Maine Medical Center Family Medicine Residency Program
Complementary and Integrative Medicine Project

Background and Significance

National perspective
Complementary and alternative medicine has a visible presence in popular American culture. Searching for it on the Internet returns hundreds of thousands of web sites, herbal and homeopathic remedies can be found on the shelves of most drugstores and supermarkets, advertising and articles appear in many newspapers and magazines, and dozens of books are published on CAM therapies every year. CAM has been defined as practices for the prevention and treatment of disease that exist largely outside the institutions where conventional health care is taught and provided. It includes therapies that are self-administered and over-the-counter as well as those that require highly specialized practitioners.^1,2,3

Use of complementary and alternative medicine is widespread among adults in the United States. According to a survey conducted by Eisenberg et al in 1997, 42% of the adult U.S. population reported using at least one alternative therapy, up from 33% in 1990 as documented by the same group.^4,5 Indeed, the number of visits to alternative medicine practitioners in 1997 exceeded the number of visits to primary care physicians.⁵ A survey conducted by Hughes in San Francisco in 1995 revealed that 40% of adults had used at least one CAM therapy in the previous 12 months and 90% were satisfied with the outcome.⁶ From 1990-1997 the use of herbal therapies increased 380% and high dose vitamins 130%. Further, nearly 20% of people taking prescription medication reported taking herbs, high dose vitamin supplements, or both.⁵ While insurance companies are increasingly receptive to paying for CAM therapies, patients are still paying large amounts for them out-of-pocket. By extrapolating interview data, researchers have calculated that in 1997 patients paid more out-of-pocket for alternative medicine than for primary care.⁵ These statistics show that more and more patients value and are actively seeking complementary and alternative medical therapies. At the same time, they are looking for physicians trained in an allopathic model who can help them integrate conventional medicine with CAM therapies.⁷ Given their patients' interest and practices, primary care physicians have a responsibility to develop an understanding of the principles and applications of CAM.⁸

Despite the prevalence of the use of CAM therapies in the US, physicians trained in orthodox medicine do not understand CAM practices. One study of 295 family physicians in Maryland showed that less than one-half had knowledge of acupressure, herbal medicine, megavitamin therapy, art therapy, prayer, traditional oriental medicine, homeopathic medicine, electromagnetic applications, and Native American medicine. From a list of 18 therapies, the only modalities in which at least two-thirds of the respondents had training were diet and exercise, behavioral medicine, counseling, and biofeedback.⁹ A separate study of 138 physicians in New Mexico, Washington state, and Israel assessed knowledge of nine alternative therapies. The physicians were asked to use a six-point scale for each of the 9 therapies, where1 = not at all knowledgeable and 6 = very knowledgeable. The average of the means of self-assessed knowledge for the three groups was 18.9 with a possible range of 9-54.¹⁰

While the use of complementary and alternative treatments is common, the integration of these modalities with conventional medicine is not. Among the respondents in the 1997 Eisenberg study, 96% who saw a practitioner of alternative therapy for a principal condition also saw a medical doctor during the previous year. However, according to these patients, only 38% of those therapies were discussed with their medical doctor. Nearly half of the alternative therapies reported were used without consultation by either a medical doctor or a practitioner of alternative therapy.5 Despite the fact that patients report being pleased with the outcome of their CAM therapies, the possibility for harmful treatment and negative drug/herb or herb/herb interactions is great. Clearly, there is a need for professional strategies for informed dialogue between patients and medical doctors.^11,12

Lack of knowledge about CAM by medical doctors, however, does not correlate with lack of interest. Three separate studies have shown that over 50% of conventional physicians in the U.S. use or refer patients for complementary and alternative medical treatments.^9,10,13 In order for physicians to make sound clinical judgements about the effective integration of conventional medicine with alternative approaches, they need education about CAM therapies.^{1,2,5,8,11,14} Further, to practice competently, medical doctors must apply the principles of evidence-based medicine to CAM, as to any area of health care.¹⁵

Conventional physicians cannot integrate CAM approaches with allopathic medicine effectively without consultation from CAM practitioners. A professional dialogue with a shared vocabulary and common goals for patient well being must develop between these two groups. CAM practitioners must be involved as teachers, mentors and consultants. They offer thorough understanding of their particular modalities and the ability to communicate with patients about CAM.^11,12

Family medicine is a natural discipline for the study of complementary and alternative medical practices. From a financial standpoint, family physicians are increasingly responsible for regulating referrals to subspecialists. The gatekeeper role has extended from referrals to subspecialists to referrals to practitioners of CAM therapies as insurance companies increased coverage for those services. Philosophically, family medicine has at its foundation a patient-centered, family-focused, community-oriented approach. Family physicians are taught to view patients holistically, including consideration of the biological, psychological and social components of each person.¹⁶ This biopsychosocial approach is compatible with the principles of CAM therapies. In addition, family physicians have an ongoing, longitudinal relationship with their patients, making the limitations of biomedicine in solving all health problems apparent.10 Family practice physicians will not have to shift their paradigm far to comprehend and embrace CAM approaches to health care.

Among the national organizations promoting CAM education for primary care physicians is the Society for Teachers of Family Medicine (STFM). One of the recommendations of the STFM Group on Alternative Medicine is to include alternative medicine training in all family practice residencies.8 This group acknowledges one of the challenges of incorporating a CAM curriculum within a residency program is having faculty members who feel comfortable precepting residents on this topic. For this reason, they advocate the development of faculty as a first step. Their guidelines for resident education focus on residents acquiring a reasonable knowledge base to allow effective communication with patients about alternative therapies. They provide a framework of attitudes, knowledge, and skills from which to design a CAM curriculum. National experts also agree about the need to clarify which therapies are based on evidence and which ones require more research before a determination can be made.2,7,8 Both the principles and applications of CAM remain largely unproven by traditional scientific methods.8 However, more and more research involving CAM is being done with results published in scientific literature each year. The rate of increase in citations tagged "alternative medicine" in the National Library of Medicine's Medline is 12% per year, nearly twice that of conventional medical literature.1 Therefore, skills in critical appraisal are crucial to a project proposing to teach family practice faculty and residents about CAM therapies.

Local perspective
As is true in the rest of the United States, we at the MMCFPRP need to bridge the gap between our patients' use of CAM therapies and our knowledge about CAM as conventional health care providers. Two surveys regarding CAM have been conducted within the past two years at the MMCFPRP. Both surveys included adult outpatients, faculty, residents, and nursing staff at our two outpatient sites, or FPCs. Patients in our survey reported that 54% of them are using CAM therapies, while most providers thought that fewer than 25% are using such therapies. Patients indicated their most commonly used CAM therapies are herbal remedies, massage therapy and chiropractic care. More than three-fourths of the patients who use CAM therapies said they have not discussed these therapies with their primary care physician, thinking their doctor lacks knowledge or interest in the subject. Indeed, 72% of the providers at the MMCFPRP reported some discomfort discussing CAM therapies with patients; 96% of those cited lack of knowledge as the reason for their discomfort.

Further mirroring nationwide statistics, there is interest among both patients and providers at MMCFPRP in integrating conventional medicine with CAM therapies. Seventy-eight percent of patients in our survey reported they would like to have alternative treatments available at the FPCs. One patient stated, "I hope this survey is indicative of a plan to broaden practice with alternative healers!" Another patient responded, "I definitely would be pleased to know the doctors here are knowledgeable in alternative healing methods." One hundred percent of the faculty, residents and nursing staff said they think integrating CAM into medical practice would be useful. The entire group of providers also reported they would like to include evidence-based CAM in the residency curriculum. Comments from providers included, "CAM is in the community to stay, so the more we know about it the better," and "I would love to know more. Patients love it when you talk to them about alternative therapies." Resident and faculty physicians reported greatest interest in learning more about acupuncture, herbal remedies, hypnosis, manipulative therapies, and yoga/meditation.

The demographics of Portland, Maine are shifting. The city becomes more culturally diverse each year as the immigrant and refugee population increases. The Portland Press Herald, our daily newspaper, recently reported that 48 languages are spoken in Portland. In part due to our proximity to downtown and affordable housing areas, the patients of the Portland FPC are also increasingly culturally diverse. With this growth in cultural diversity has come an increase in culturally specific medical beliefs held and CAM therapies used by our patients. The resident physicians at the MMCFPRP need knowledge, skills, and accurate information about CAM therapies to provide optimum health care for the patients they serve now and for those they will care for in other communities after they complete their residency training.

The MMCFPRP is completing a faculty development project in medical informatics and the use of EBM. As a result of this project, our faculty members are knowledgeable and comfortable accessing and managing electronic sources of medical information. We believe these skills will be invaluable in gathering information about CAM therapies. They have gained skills in critical appraisal through this project, enabling them to be sophisticated consumers of the medical literature. These skills will be particularly useful as they teach residents and care for patients regarding selection and safe use of effective CAM therapies.

The MMCFPRP will implement a systematic, coordinated educational program that provides residency program residents and faculty members with an orientation to complementary and alternative medicine, advances knowledge and skills in CAM treatment and patient communication, facilitates collaborative relationships with CAM practitioners, and builds positive attitudes about the value of integrating CAM with conventional medicine as part of routine patient care.

Past Experience/Environment
Residency and Institution

It is important to describe the characteristics of MMC and the MMCFPRP as they pertain to the objectives of this project.

MMC is a 607-bed tertiary care center located in Portland, Maine's largest city. A community-based hospital, it is a teaching affiliate of the University of Vermont College of Medicine and offers residencies in ten specialties and seven fellowships, with 195 total house staff. An infrastructure exists through our active department of medical education for cross-specialty faculty development. The residency program directors of the primary care specialties of internal medicine, pediatrics and family medicine have collaborated to develop curricula in mutually important areas. The institution is clear in its commitment to medical education, as reaffirmed in its most recent strategic plan. One of the three components of MMC's mission is to "educate tomorrow's caregivers." Education about complementary and alternative medicine is critical for primary care physicians, and we expect that our curriculum will serve as a model for similar initiatives in the institution's other residency programs.

The MMCFPRP was founded in 1974. Our vision statement emphasizes our focus on excellence and on innovation: "We are a premier family practice residency program, exemplary and innovative in clinical education and in health care delivery." Indeed, our innovative efforts have led to the development, with grant funding, of four separate curricular areas over the last five years: rural health, community-oriented primary care, quality improvement, and informatics and EBM. Through our recent focus on EBM, we have honed our skills in critical appraisal of the medical literature. Our faculty and residents alike are discerning readers and will be sophisticated consumers of information about CAM. These abilities are critical to learning about and promoting complementary and alternative medicine with its many skeptics among the more traditionally trained physician community.

The residency's mission blends education for family practice residents with delivery of comprehensive health care. Specifically, the mission of the MMCFPRP is to:

• Promote a scholarly environment
• Foster a balance of personal and professional growth
• Enhance patient and family health

We are devoted to providing a superior educational experience for family practice residents and students as well as comprehensive, high quality health care to patients, families, and our community. In fulfilling our mission, we are committed to continuous quality improvement.

We have described essential principles upon which our program is based: Our goal is to train tomorrow's caregivers to be lifelong learners, well versed in evidence-based medicine. A formal curriculum responsive to ever changing educational needs is the backbone of our residency program. In addition, ongoing faculty and staff development and department-wide research activities are vital components of our program.

Family practice emphasizes the influence of family and community on an individual's health. We strive to anticipate and respond to each patient's health care needs in a manner that enhances continuity through the coordinated delivery of clinical services, patient and family education, and appropriate use of community services.

To fulfill our mission in our current medical environment, we must ensure that family physicians clearly understand principles and practice of complementary and alternative medicine as they coordinate care and use of community services.

In the year 2000, our residency program will educate 21 family practice residents, twelve women and nine men, at three levels of training. They care for patients in three sites: MMC and the residency's two FPCs in Falmouth and Portland. Continuity of care is provided at each FPC, as residents care for a panel of patients throughout the three years of residency. Residents spend one to four half-days weekly seeing patients and learning in the FPC. Ambulatory medicine teachers or "preceptors" help residents with assessment of patients and development of plans of care. Each half-day session at the FPC includes a short didactic presentation, emphasizing clinical knowledge, skills and attitudes appropriate to outpatient medicine. In addition to learning during patient care in the hospital and outpatient settings, residents attend teaching conferences each Tuesday morning. The Tuesday sessions include didactic and case-based presentations and procedural workshops. The final major settings for education in our program are resident rotations in the offices of community specialists. In these outpatient office settings, they learn in-depth about facets of medicine important in primary care, such as dermatology and gynecology, usually during a two- to six-week block rotation.

In addition to our residency program, the Department of Family Practice at MMC sponsors a primary care sports medicine fellowship. The fellows may be graduates of residencies in pediatrics, family medicine, internal medicine or emergency medicine. Along with their faculty, they staff four sports medicine clinics weekly, seeing an average of 50 patients per week with musculoskeletal problems. Although sports injuries constitute a large part of the practice of the Sports Medicine Clinics, more chronic conditions, including chronic pain, are prevalent. Local primary care physicians are the major referral base for the Sports Medicine Clinic.

Family Practice Centers
The FPC in Portland has traditionally served the area's underserved and indigent. It is designated as an underserved site for the State of Maine; patients include those from census tracts 1-14, a low-income population including homeless and refugees. We also serve patients from the Casco Bay Islands, a Federal health care shortage area. The six faculty, nurse practitioner, five RNs and 16 residents who practice in our Portland site have 34,000 patient encounters annually. Of our patients, 40% are insured by Medicaid, 15% by Medicare, 20% by managed care companies; 10% receive uncompensated care. The patient population is ethnically and culturally diverse, reflecting the increasing diversity in Portland's population as a whole. We have a large immigrant and refugee population, with patients from Southeast Asia, Somalia and Latin American countries. The cultural diversity is reflected in the many different medical belief systems and traditions we encounter in our practice. Some of the most common diagnostic categories seen in our practice which are amenable to CAM therapies include depression, chronic pain, otitis media, asthma, allergy, headaches, hypertension and hypercholesterolemia.

In 1999, we built a new FPC in Portland to house patient care facilities; offices for faculty and residents; a state-of-the-art "Learning Resource Center" for staff, patients and community; observation-therapy rooms with one way mirrors; 20 exam rooms; X-ray, laboratory and physical therapy facilities; and community conference rooms.

The second FPC is in Falmouth, a suburb of Portland about six miles from MMC. The facility opened in January 1997. It houses the practices of private attending physicians and residents in the disciplines of family practice, pediatrics, internal medicine, obstetrics and gynecology, as well as a Learning Resource Center. Primary care interdisciplinary education was a major impetus for developing the model of care in this facility.

Our FPCs are ideal settings for collaborative practices, for resident and medical student education. Their many resources will support the aims of this project. Both of our FPCs were designed to accommodate collaborative practices, with exam rooms available to practitioners who provide services to FPC patients on a limited basis. A podiatrist, a nutritionist and counselors currently see patients in our FPCs on a weekly to monthly basis. All exam tables are adjustable for manipulation. Some of the exam rooms in each site are equipped with video cameras to tape physician-patient interactions. We have computers available in close proximity to practice areas, facilitating the use of computer-based decision support and EBM programs to assist in patient care. Our observation/therapy rooms provide excellent opportunities for learners to observe teachers demonstrating new techniques with patients and for learners to then be observed using their new skills. The staff members of the Learning Resource Centers are active in coordinating community educational programs each year, providing individual patients with educational resources, and in promoting hands-on demonstrations which invite patients and community members into the FPCs for a specific purpose (e.g., skin screening for melanoma).

Grant-supported experience in curriculum development
We have had extensive experience in incorporating new curricula into the MMCFPRP. From 1994-1997, we developed new curricula in community-oriented primary care (COPC), rural health, and quality improvement with support from a Bureau of Health Professions grant. Initial efforts were grant funded, but we have sustained our efforts beyond the grant period, and all the areas are now integral parts of our curriculum. These initiatives included faculty and staff development, working with a multidisciplinary task force for each area, and incorporation of the curricular theme into resident education and into our clinical practice at the Family Practice Center. We provide a detailed description of the process we used for one component of the grant, COPC, as an example of our capacity to attain goals and sustain efforts in curricular change.

In the early 1990's it was clear that residents would need knowledge, skills and attitudes that allowed them to view healthcare more broadly. Education in COPC and population-based care was essential in preparing residents for the challenges in their future practices. The faculty was committed to educating themselves and to developing and implementing a COPC curriculum over the grant period. Dr. Skelton, program director of this proposed project, led the initiative in COPC. The following description of our work with COPC provides a clear review of the process we used to reach our goals.

Community-oriented primary care is an approach to primary care in which emphasis shifts from the individual patient to populations or communities. The COPC process includes four steps: definition of a community, identification of a community health need, development of a program to address the need and monitoring of the programs effect.¹⁷ For the COPC arm of the project, we had two objectives: 1) education of residents in the principles and practice of COPC; and 2) integration of COPC into practices at the FPC. We worked on faculty development and curriculum design in the first year of grant funding, then expanded to educate residents in the last two grant years. We describe the process below:

Year One:
We convened a task force comprised of our program director for the grant, two faculty members, two residents, our FPC head nurse, a public health nurse practitioner, our educational coordinator, and a MMC nursing systems specialist. The program director for this proposed project chaired the COPC task force. The task force chair attended a two-day conference on COPC, which enhanced her knowledge of COPC and allowed her to discuss COPC with national experts and enthusiasts. Their enthusiasm for this model and their experience with its integration into residency education and practice were powerful in stimulating the chair in her leadership role at the MMCFPRP.

Task force members educated themselves about COPC by reading, through discussions with a national consultant, and by participating in a half-day workshop. We conducted focus groups with community members and health care providers to explore their opinions about community health needs and about primary care physician education in COPC. Residency faculty members were educated in a half-day session, presented in part by task force members. In the spring of the year, the task force coordinated an additional one-day conference on COPC. MMCFPRP faculty, residents and interested community physicians in all primary care disciplines attended the conference. Having completed their own and initial faculty education, the task force finished year one by designing a COPC curriculum for residents. Resident COPC projects were the centerpiece of that curriculum. The task force worked as a group to complete two projects, both as a demonstration for residents and to better understand the process of COPC.

Year two:
In year two, the task force and faculty shifted efforts to the education of family medicine residents and key FPC staff. We presented a five-session introduction to COPC for residents and staff. The goals of these interactive sessions were to introduce participants to the broader view of health care espoused by COPC and to the four-step process of COPC, and to spark enthusiasm for inclusion of COPC in the curriculum and in the FPC. We presented two additional interactive sessions for staff members who were not able to attend the longer course. We then introduced the curriculum, which consisted of introductory sessions, reading and completion of projects. Residents entering the second year of training in the second project year began planning COPC projects with faculty advisors. Finally, in year two, we began to develop a Community Advisory Council for our FPC. The task force read about community advisory councils and talked with others who used this model about the role of the council and its structure.

Year three:
In year three, the Community Advisory Council began its work. Comprised of community members and FPC patients, it met monthly. The council advised the practice leaders on areas of importance to the community and to patients, enhancing our ability to proactively serve as a resource for community health. Examples of initiatives we have undertaken on their advice include a program to treat head lice in school children and a monthly health column for the neighborhood newspaper. In the fall of year three, our consultant returned to help us evaluate our progress, modify our curriculum and encourage us in our efforts. He discussed COPC with faculty and residents who had not been in the program at the time of his initial visit. This visit was important in helping us clarify our long-term objectives and our methods in sustaining our efforts in COPC. In the spring of the third project year, the first of the resident projects were presented in a grand rounds format. Two of the first projects presented were screening pregnant FPC patients for domestic violence and addressing health care needs of people who live on islands off the coast of Maine in the winter months. The graduating residents discussed their projects with community physicians, faculty and other residents. In this format, they both modeled the curricular process for other residents and inspired community family physicians to incorporate the COPC approach in their own practices.

Grant support for COPC curriculum development ended over three years ago. At this time, the COPC curriculum is well integrated with the rest of the residency curriculum. We teach introductory sessions annually to new residents and new faculty. Resident projects are ongoing and are presented in our grand rounds series each spring. The projects have led to sustained changes in FPC practice and development of relationships with new community partners. Faculty remains committed to COPC both through their own projects and practice and by serving as advisors for resident projects. The Community Advisory Council is entering its fifth year of work and continues to be an important guiding body for our FPC.

The successful integration of COPC into the curriculum and sustained change in our view of health care can be attributed to shared vision by faculty; to the step-wise education of residency program experts, our multi-disciplinary task force, faculty and residents; and to broad-based curricular development. Though not described in detail here, the two other components of the grant-supported project, rural health and quality improvement, similarly met their objectives.

Currently, we are working with a Health Resource Services Administration grant on faculty development in informatics and EBM. We have used much the same model for this project: convening a multidisciplinary task force, including a medical librarian, information services specialists, faculty, residents, community physicians, and faculty from other primary care residency programs; educating ourselves about informatics and EBM; and then planning a resident curriculum. The faculty development portion of each project has included designating a faculty leader to become a resource to the rest of the residency program. This faculty leader acquired advanced knowledge and skills in the content area through advanced training at a national level and through his collaboration with a national consultant. The faculty leader was then responsible for introducing the subject matter to the rest of the faculty, residents and staff through workshops in Portland. He and the project coordinator reinforced skills and knowledge introduced in the workshops on a longitudinal basis, coaching residents and faculty in EBM and informatics during patient care sessions at the FPCs. An ongoing relationship for the key faculty member with the national consultant or with local experts has been critical in maintaining momentum and problem solving when difficulties arise. As the faculty development project draws to a close, we are shaping a curriculum for residents in informatics and EBM.

Curriculum development/refinement process
In addition to grant-supported curricular development, we have extensive experience in curriculum development, review and refinement. The curriculum development and review process for MMCFPRP, devised with the advice of two educational consultants, one of whom is the faculty coordinator for this project, is now well established and easily extended to new curricula. For development of new curricula, a subcommittee is convened. It consists of community family physicians, residents, faculty, a curriculum consultant and specialists in the curricular area of interest, e.g., surgeons for surgery. The subcommittee is responsible for reviewing national guidelines and publications about curricula in that content area, determining which knowledge, skills and attitudes should be learned by residents and outlining the experiences which will help them attain those objectives. They provide a list of resources for the educational experience, including books, journals, computer software and tapes. Finally, they develop tools for evaluation of the educational experience. The curriculum committee as a whole (comprised of faculty, residents, education coordinator and educational consultants) reviews each element of the residency program on a regular basis, modifying as necessary, and reconvening a subcommittee if major changes are warranted. In this way, we maintain a dynamic and constantly improving educational experience for our residents.

Each element of the curriculum is taught in an integrated manner: in a block rotation of two to six weeks' duration and longitudinally through other educational experiences. For example, residents learn about the care of older adults during block rotations on the Family Practice Inpatient Service, during a one-month geriatrics rotation, during Tuesday teaching conferences, during the one-month orientation to residency, and as they care for the elderly as outpatients in their homes and in the FPCs. For all of our curricular content areas, we have developed overarching themes, many of which have direct application to CAM:

• Problem solving
• Wellness/prevention
• Life stages
• Physician/patient partnership
• Family
• Biopsychosocial focus
• Ethics
• Patient education
• Community
• Consultation
• Evidence-based medicine
• Research

Faculty development faculty resources
Our emphasis on innovation and adoption of new curricular areas as we perceive significant shifts in practice of medicine requires that our faculty pursue professional growth at a rapid rate. We support our faculty in continuing medical education in several ways. Each has a budget for conferences and travel outside of the residency program. These funds support them as they learn new skills and reinforce those learned in the past. We hold quarterly faculty "educational salons", two-hour seminars in which faculty members teach each other about a new area of interest. Our department has an annual morning-long educational symposium for residents, faculty and community physicians, and we participate in an annual statewide faculty meeting in which the four Maine family practice residency programs share their ideas and innovations. In addition, faculty members regularly attend and present at the national and regional conferences of the Society of Teachers of Family Medicine.

The stability of our faculty has been a key element in the success of incorporation of new curricular areas. We have had some additions to our faculty, but in the last ten years not a single faculty member has chosen to leave our program. The knowledge and skills the faculty gain will, therefore, be a resource for years to come; the enthusiasm of the current faculty for developing a curriculum in complementary and alternative medicine will be sustained. Our current faculty of 14 is half women and half men. They have all endorsed our efforts to develop a curriculum in this key area, and several already have advanced training in areas of complementary and alternative medicine. Jacquelyn Cawley, DO, serves as medical director for the FPCs and includes osteopathic manipulative therapy (OMT) in her practice. William Dexter, M.D. , and Mark Bouchard, M.D. , who serve on the faculty of both the residency program and the sports medicine fellowship have both pursued training, become certified in and now practice OMT. Our two behavioral science faculty members, George Dreher, M.D. and Julie Schirmer, MSW, have both had thorough training in mind-body medicine. Dr. Dreher uses guided imagery in his practice, has extensive experience in meditation and some familiarity with hypnosis, biofeedback and yoga as therapeutic modalities. Ms Schirmer's education has consisted of reading and conferences with Herbert Benson, M.D. , Joan Borysenko, PhD, Harry Golan, M.D. and others. She uses meditation routinely in practice, particularly in the treatment of anxiety and depression. She has taught guided imagery for smoking cessation, post-operative pain control and athletic performance anxiety. Hypnosis has been useful in her therapy with patients as well. To further her growing interest, Jennifer Childs-Roshak, M.D. recently completed a course in evidence-based complementary and alternative medicine. Though we have a solid starting point and much interest, we acknowledge that current faculty resources are inadequate to integrate this curricular component into our residency program.

Institutional experience with CAM
A CAM Task Force was appointed by MMC's medical staff in 1998 to determine whether provision of CAM services in the hospital and ambulatory setting should be addressed, and, if so, which services should be considered. The Task Force was headed by the Chief of the Department of Family Practice and was comprised of a group with diverse backgrounds in health care including physicians of many specialties, nurses, occupational and physical therapists and a chaplain. The Task Force held six meetings over four months in 1998, with attendance of 90+% of the members at each meeting. The Task Force made the following recommendations:

1. MMC should formally address the provision of CAM services, based on the widespread and growing use of CAM services, level of current use and availability of CAM services in MMC and increasing requests for CAM services by patients and providers.
2. Four services should be considered for initial approval: relaxation strategies, therapeutic touch, massage therapy and acupuncture.
3. A permanent institutional committee should be established to address several pertinent issues and tasks related to provision of CAM services.

Unfortunately, despite continued interest and patient demand for CAM services, the only significant change in CAM services since 1998 has been the establishment of a division of osteopathic manipulative medicine within the department of Family Practice. The members of this division provide manipulative medicine services on a consultative basis at Maine Medical Center. The institutional and patient interest and the groundwork done by the Task Force on CAM provide an opportunity for development and expansion of services in this area.

Portland community/CAM presence
The Portland community has a large number of complementary and alternative medicine practitioners, including several who have worked with our residents on an intermittent or elective basis. In the department of family medicine's division of osteopathic manipulative medicine, one physician is accredited and practices acupuncture and another practices homeopathy. The Greater Portland community of 150,000 currently supports 29 acupuncturists, several homeopathic practitioners, three specialists in biofeedback, 11 hypnotists, and over a hundred practitioners of manipulative medicine, including chiropractic and osteopathic manipulative medicine, and an equal number of massage therapists. To date, there is limited intercourse between the practitioners of complementary medicine and the more traditional medical community, including MMC's teaching programs.

Collaboration within program and in the community
Our residency program emphasizes a collaborative model, both in education and in our practice, within our FPCs and between the FPCs and the community. Both our Portland and Falmouth FPCs are organized into 3 teams, each of which includes faculty and resident physicians, RNs, medical assistants and receptionists. Each team member provides care to patients at the highest level of his or her ability and training. Our team approach to care in the FPC also includes podiatrists, nutritionists, a clinical pharmacist, physical therapists, exercise physiologist, mental health practitioners and a health educator. We collaborate with community health nurses, public health nurses, and our community health educators to provide the best care possible for our patients and to teach our residents how to function as physicians within a collaborative healthcare model. The Community Advisory Council for our Portland FPC helps us proactively incorporate new services in our Center to meet community health needs. As outlined above, we use a multidisciplinary collaborative process to develop new curricula.