Education in Traditional and Non Conventional Medicine : A Growing Trend in Italian Schools of Medicine

Traditional and Non-Conventional Medicines (TM/NCM) are slowly gaining ground in Italy despite the opposition of biomedicine which dominates the health and education system. The latest research indicates that: more than 50% of general practitioners recommend homeopathic medicines to their patients; 14.5% of the Italian population has recourse to Non Conventional Medicines; 16.2% of the sample has recourse to homeopathic medicines. Given this trend, this first-ever survey/census investigates the actual role of the Italian University in promoting an academic education in Traditional and Non-Conventional Medicines. Although in 2004 and in 2011 the Italian Permanent Conference of the Presidents of MD Schools of Medicine assumed an official position of stigmatisation of TM/NCM, many Italian Schools of Medicine have activated various types of courses. The authors analyse the TM/NCM training schemes offered on the websites of private and public Italian Schools of Medicine in the academic year 2011-2012. An ad-hoc questionnaire was likewise mailed to all the Italian Schools of Medicine, consisting of eight questions concerning the quality and quantity of both undergraduate and postgraduate education programmes in Traditional and Non-Conventional Medicine (Elective Courses (undergraduate), High Education Courses (post-graduate), eventual Specializations, Masters Courses, Doctorates and other kinds, such as CME, etc.). The authors have also reconstructed a geographical map of the different types education programme in Traditional and Non-Conventional Medicine, highlighting the more virtuous Italian University Centres and Regions in this connection. Citation: Tognetti Bordogna M, Gentiluomo A, Roberti di Sarsina P (2013) Education in Traditional and Non Conventional Medicine: A Growing Trend in Italian Schools of Medicine. Altern Integ Med 2: 131. doi:10.4172/2327-5162.1000131


Introduction
The research presented here forms part of a broader analysis conducted by the first edition of the Mastercourse in "Health Systems, Traditional and Non Conventional Medicine" at the University of Milano These traditional anthropological healthcare and medical systems to some extent run counter to the dominant medical system (biomedicine). They are of increasing interest to the field of sociology (among others) as a social phenomenon which gives new impetus to the issue of doctor/ patient relations, one of the basic subjects of health sociology (WHO, 2004). Recourse to TM/NCM highlights the importance of humanising and personalising relations with the physician, who sees the patient "in his/her organic, psychological, social and relational dimension" [1]. It also legally expresses people's right to choose their own treatment and thus regain responsibility for their condition. The fact is that illness and healing are expressions of a person's biography, events endued with meaning which is restored by these traditional forms of healing [2]. Such an approach makes treatment "not a mechanical act, but a process that is strictly consistent with one's own biography" [1].
The basic ingredients of a non-conventional MD approach are dialogue, communication, active listening, attention to the patient's history, free narration of the complaint; these blend seamlessly with recording the biological parameters. The treatment provided by TM/NCM is personalized and appropriate, based on respect for the individual's unique make-up. Traditional and Non-Conventional Medicines are thus an authentic health system in which knowledge generates healing; and yet "among Italian regional welfare systems there are still great disparities in the degree to which they are included and considered legitimate" [1].
For all these reasons there is an urgent social need to rationalise the process of training such professionals in terms of safeguarding the patient, defining training standards and, especially, liaising with private facilities at this moment of legislative hiatus. There are a range of entities in present-day Italy that purport to train practitioners of TM/NCM; however, they are unable to give participants a qualification which, institutionally, only the University can bestow. Above all, there are considerable differences in syllabus, approach and hours of tuition, so that we are in danger of producing marked differences in professional status [3,4].
The 'universe' we have studied consists of 37 public universities offering 40 degree courses in Medicine, 2 Faculties in Turin and 3 in Rome; 3 private universities (Campus Biomedico; the Sacro Cuore Catholic University of Rome (and Campobasso); the San Raffaele 'Vita e Salute' University); and the Mantua University Foundation . Degree courses in Medicine are to be found throughout the peninsula, catering for 9,501 students in the year 2011-2012, the numbers varying from university to university, region to region. Access is strictly by admission examination. Only Valle D' Aosta, Trentino Alto Adige and Basilicata do not provide Faculties of Medicine in the university syllabus.
The present study is the first exploratory survey to have been conducted in Italy-a first census in the field. Its significance lies in the social importance nowadays held by Traditional and Non-Conventional Medicines for the Italian and world population. There are at least two issues that especially call for thought and make it necessary to take a hard look at university training schemes in these traditions of medicine.
The first is the demand for TM/NCM among Italians. The most recent surveys tend to separate the doctor, on the one hand, and the patient, on the other. Thus, according to the Health Monitor CompuGroup Medical-Il Sole 24 Ore Health, over half of general practitioners recommend homeopathic products to their patients, while the Eurispes Italia Report suggests that 14.5% of the Italian population resort to Non-Conventional Medicines, a figure which is as high as 16.2% in the May 2012 Doxapharma survey on consumption of homeopathic medication. The reasons for this increase are hard to fathom. The sociological literature argues that [5,6] on the one hand, these are post-modern forms of expression in that they manifest a desire for self-determination and free choice on matters of health, while on the other, they are a sign of change in the dominance of the biomedical pattern, whereby people are being encouraged to take responsibility for their own health. Or [7] they are cultural proposals tending to put "a new construction on disease and healing" [1]. The consumption factor is also connected with the increase in immigration witnessed in Italy.
As an institution, the University is meant to map the boundaries of the professions and see that they meet the individual's needs as far as possible in this age of globalization. Since the percentage of immigrants to our country is steadily growing, it becomes necessary for us to train the medical sector to respond to the needs of this part of the population, in respect of the "patient's so-called right to choose" which decisively increases his/her obligation to live responsibly [8].
The second ground for thought derives from the fact that these forms of medicine and their drug-economic dynamics are slowly penetrating some Regional Health Systems in Italy. This ties up with the current needs of Italian health management and a reappraisal of the Evidence-Based Medicine paradigm and how far it is valid (let alone infallible). Three aspects of it have been identified: "1) medical knowledge and clinical expertise; 2) (scientific) evidence via clinical trials; 3) patient preferences" [8].
At the World Congress on Traditional Medicine held in Beijing in 2008, the World Health Organization drew up the "Beijing Declaration on Traditional Medicine" which calls "for action and cooperation by the international community, governments, health workers and professionals to ensure that traditional medicine is properly used and makes a significant contribution to the health of all peoples, according to the ability, priorities and relevant legislation of the various countries" [9].
The position of the permanent conference of deans of italian schools of medicine As we know, one of the mainstays of the medical profession is the single-cycle six-year Degree course in Medicine. After passing all the exams and successfully discussing their thesis, graduates next have to sit the state examination which confers the title of physician and a right to enroll in the Order of Physicians, which lends further weight to the profession [10]. But let us note from the start, the milieu we are investigating is 'politically' influenced, first by the medical establishment and then by the Faculties of Medicine. According to the regulations and circulars that are currently in force , in Italy TM/ NCM can only be practiced by doctors of medicine, however widely such healing systems may diverge in their training from conventional or Biomedical Medicine (one thinks, for example, of Tibetan Medicine, Ayurveda or Traditional Chinese Medicine).
There is hence an official position both on defining the professional ambit in the light of the above-mentioned regulations and circulars and on the question of training: that position is set by the Permanent Conference of Deans of Degree Courses in Medicine (CPPCLM). In 2004, and again in 2011, this body expressed a formal disinclination to introduce Traditional and Non-Conventional Medicines into the Specialist Degree Course in Medicine. The 2004 conference statement reads: "we may thus conclude by firmly opting for non-inclusion of CAM as a discipline (or disciplines) in the Specialist Degree Course in Medicine, not even as a surreptitious admission under other forms of teaching (seminars, elective courses). What is indispensable in tackling this issue is that we bolster the student's methodological tools for seeking, understanding and critically analyzing information.
The 2004 and 2011 Conference draws up the following guidelines on the policy to be followed with reference to TM/NCM: "1 -Acquisition of skills pertaining to CAM is not a didactic objective of degree courses in Medicine. Hence teaching designed to develop specific skills in any kind of CAM may not be included in integrated medical degree courses, disciplines or modules until such time as there be unambiguous scientific evidence in their favor. faculties to tackle the basic issue of doctor-patient relations. That there are so many optional or elective courses geared to this objective may pave the way for introducing regular? Courses on TM/NCM. Again, the many M.A.s, Upgrade Courses, Higher-Education Training Courses and professional Catch-Up courses covering wellness, nutrition, Low Medicine, Palliative Care, Kinesiology, Hydro-Kinesitherapy, PNEI (Psycho-Neuro-Endocrine-Immunology), relaxation techniques and Musicotherapy do suggest a new awareness that the apparently infallible Evidence-Based Medicine 'movement' , raising science to a well-nigh omnipotent technique, badly needs to resuscitate the artistic, holistic side to medicine. Apart from their affinities with TM/NCM, such courses express a humanizing of the medical profession and the nonmedical health professions; they point to a new therapeutic alliance based on other communication strategies and really geared towards the patient -who is nowadays often well-informed and claims to know about his complaint.

Education in TM/NCM in Italy: a nutshell summary
Pace the official position of the Permanent Conference of Deans of Degree Courses in Medicine, this study detects that a number of universities are not toeing the line. They refer to Article 33 of the Italian Constitution and hence the freedom to teach and the "autonomy to establish by-laws within the limits of State law", and have provided specific under-and post-graduate training in TM/NCM. Indeed, our inquiry found evidence of marked attention and considerable interest by certain universities.
In the academic year 2011-2012 a number of Elective Courses were run (ADEs, ADOs, and seminars) on traditional forms of medicine; post-graduate training amounted to 17 Masters and 5 Upgrade Courses.
What have not been run are any Higher Training Courses or PhDs in traditional medicine. However, one should note that a teaching module of a Turin University PhD Programme in Biomedical Science and Oncology includes "Clinical evidence of high-quality Phytotherapeutic preparations in Gynaecology".
Again, we found no researchers, associate, extraordinary or ordinary professors specifically pertaining to TM/NCM. The private universities do not seem to be investing in TM/NCM training which could, in reality, be an eye-catching addition to the national scene.

Education in TM/NCM within university programmes
In looking at the above Faculties' training programmes, one is hard put to make out individual university policies on TM/NCM, especially if one analyses the websites which are in various cases lacking in precision.
Our review of the training area shows from the ministerial tables relating to the total number of training credits that every Faculty has independently chosen to liberalise its number of free credits, raising them in some cases to as many as ten within the MSc course in Medicine. Again, the reformed version of the degree course, as we said, includes not just elective courses (monographic and in-house) but also Optional Didactic Activities (ADOs) as well as Elective Didactic Activities (ADEs). In some cases these last two kinds of training scheme are being used by Faculties, such as the Turin "San Luigi Gonzaga", to inform the medical undergraduate about TM/NCM. They normally count for 1 or 2 credits and take seminar form.
The CPPCLM finds that an extra teaching effort needs to be made to strengthen student training in methodology and drug therapy, instill the concept of health and the role of lifestyles, and foster an ability to detect the individual's socio-cultural and spiritual leanings, seize teaching opportunities for narrative medicine, build up an ability to listen and create a helpful counseling relationship" [11].

Methods
This paper presents data on the range of training offered by universities since the University possesses the constitutional right to educate, has the function of propounding and producing knowledge, and confers qualifications attained by attending courses that are open to high-school leavers [12]. This being so, it is socially important to understand how Italy's Medical Faculties stand with regard to these traditional medicines which revive the notion of medicine as an art, focus on the person and not the disease, and consider the patient not just in anatomical-physiological terms, but as an amalgam of body, emotion, mind and spirit.
To analyse the range of training on offer, we sent out a semistructured questionnaire to the Medical Faculties of Italy, and sifted the websites of the various faculties. The questionnaire comprised eight questions seeking to know what the Faculty offered in terms of TM/ NCM in its various forms (Elective Courses, First and Second level Masters , Upgrade Courses , Post-graduate Specialization Schools , PhDs , Other training [seminars, etc.]). For such courses Faculties were asked to specify the number of credits, the number of theory lessons and practicals, the name of the reference person and the syllabus. The questionnaire also inquired after research projects promoted and the existence of regular TM/NCM teaching staff.
One of the critical facts to emerge is that scarcely more than onethird of the Medical Faculties responded to the survey -a lack of compliance for which there may be three explanations.
The first regards the transition which the Italian academic world is currently going through following Law 240/210 which is revolutionizing the university system, especially the Faculties of Medicine as it transforms them into Schools of Medicine. The second may be a purely marketing decision. Faculties are very likely reluctant to provide too ready information on their own prospectuses in order not to play into the hands of other universities. If so, the danger is that courses will overlap and competition among universities will suffer, instead of stimulating a better and more diversified range of options. The third reason is that some universities may be diffident about their own training schemes or else convinced that these have already been clearly defined.
The information we gathered from the questionnaire was supplemented by data from the portals of the various medical faculties. Here we came across websites that had not been updated or were not user-friendly; some faculties even referred users to the Ministry of Education, the University and Research for the tuition options on offer: this was the case with the Second University of Naples which gave no details of its training schemes, though these included A.D.E.s (Elective Didactic Activities) and A.D.O.s (Optional Didactic Activities).
Note that our survey only covered courses (under-or post-graduate) that explicitly referred to TM/NCM and were hence specifically geared to promoting such forms of medicine and training practitioners in them.
Nonetheless, our website analysis did bring to light a real effort by By analysing the questionnaires, and consulting two search engines and websites, we have reached the breakdown of elective courses shown in Table 1. Table 1 simply sets out the tuition as stated in returned questionnaires and from the Bologna University website which clearly proposes to run the above courses and gives specific information about them. Other seats of learning, like Turin University and Milan State University, offer a range of tuition concerning TM/NCM, much of it aimed at other health worker categories (nurses and obstetricians), but without clarifying the teachers, programmes or effective implementation. For this reason they are left out of Table 1.  Figure 1 shows, together these amount to nearly half of what is on offer (45.5%, to be precise).
It will be noticed that there is a certain correspondence between the interest shown in TM/NCM by some Regional Health Systems and the attention of the universities in those regions for university training therein. Areas "like Lombardy, Tuscany and Campania, which approve a number of launch-operations and experiments, as well as setting up specific bodies to study and monitor NCM" [1] prove to be the same regions as provide the biggest post-graduate training in TM/NCM (though Latium is an exception). "Is this just chance, or is there liaison between regions and universities on these subjects?" an interesting question which we might address in a specific future research project.

Mastercourses in TM/NCM run by Italian Schools of Medicine
Seventeen masters were put on in the Italian academic year 2011-2012 ( Figure 3).
Of these, 58.8% were level-II, access to which was for five-year single-cycle (or specialist) graduates ( Table 3). The remaining 41.2%, level-I Masters, are offered to professions that require a three-year degree ( Table 2).
The first point to emerge from Table 3

Sardinia) possess universities that offer Masters in Traditional and
Non-Conventional Medicines. Tuscany and Latium clearly stand out in that on their own they amount to 53% of all the training on offer, as our Figure 2 shows.
Our research also shows the most 'virtuous' universities to be the Rome group (First and Second University) and Naples' Federico II, which on their own represent half of the training on offer and suggest a commitment by the Centre-South to training in Traditional and Non-Conventional Medicine.
In the academic year 2011-2012 first-ever Masters were put on in "Health Systems, Traditional and Non-Conventional Medicines" (Milan-Bicocca), "Antalgic Acupuncture" (Sassari) "Acupuncture and Traditional Chinese Medicine in Gynaecology and Obstetrics" (Naples).

Upgrade Courses run by Italian medical faculties
As mentioned, in 2011-2012 there were not only Masters but 5 Upgrade Courses in TM/NCM run by Italian universities (Table 4).
What emerges from Table 4 is: 1. The failure of the South to offer Upgrade Courses in TM/NCM, whereas the North seems to be heavily investing in this kind of postgraduate training.
2. The most 'virtuous' region is Lombardy, which accounts for 57.1% of what Italy as a whole has to offer in terms of Upgrade Courses. One should mention en passant that Pavia University's proposed Upgrade Course in "Coordinators of integrated medicine" did not get off the ground because the minimum number of enrolments was not reached.

43.8% of Upgrade Courses are the work of Milano Statale
University.
The decision to run a Masters or an Upgrade Course is by no means a light one. In the first case a proper academic qualification must be issued, and a certificate in the second. To offer a Masters evidently means a conscious open commitment to training in TM/NCMs.

The most popular TM/NCM in the post-graduate arena
Various specific TM/NCM programmes are mentioned in connection with certain Masters, but when we analysed the various post-graduate course titles it became clear that the greatest attention and credit attached to training in Acupuncture (36.4%).
There are many possible explanations: that this practice enjoys greater legitimacy through meriting numerous publications on Pub Med, especially for the treatment of headache, and hence has a safer and more scientific reputation; its approach is more practical and somewhat more allopathic, closer to western practice; it has already found its way into various Regional health Systems. Acupuncture is offered free of charge at certain major health facilities like Turin's 'Sant' Anna Hospital.
It is also interesting to note the focus on Acupuncture and not on Traditional Chinese Medicine of which it is just one application, along with Qi Gong, diet, Tuina, Moxa and Chinese Phytotherapy.

Other kinds of university education in TM/NCM
To complete this panorama of the TM/NCM-connected training on offer by Italian universities for the academic year 2011-2012, one should list a few other training schemes. These are workshops, residential events, meetings, conferences-significant chinks of light, in short, onto a world that is still in the formation. Apart from affording professional training and updating, these are important in that they create synergy and networks, as well as catalyzing the media as to this new forma mentis which is on the way in.

Future outlook
The increase in TM/NCM training on offer is evidence of Academe's    growing interest in such forms of medicine [13]. But many other reasons may underlie this. We conjecture that one is economic, since such courses bring in considerable revenue for individual universities. Another is marketing-related: the programmes differentiate the various universities and bring visibility; they arouse interest throughout the country and create partnerships with private concerns with an interest in legitimising TM/NCM (associations, companies importing, distributing and producing homeopathic products, etc.) [14], yet another reason is the prestige and distinction a university may gain by investing in this field. The increase may also be consistent with past prospectuses-training policy on which universities feel they cannot backtrack [15]. Lastly, it may be a practical response to overtures by regional policy, since we have noted the direct link between regions that are sensitive to the issue and universities in those areas presenting a 'virtuous' response, especially where training is sponsored by firms producing on behalf of TM/NCM and where doctors of TM/NCM have formed a Roll within their professional Council [16].

Level-I Mastercourses by region
For the moment we cannot say with any certainty which of these reasons have caused the increase. There is definitely an increasing trend; witness the level-I Masters in "Osteopathic Science" being put on by University of Milano-Bicocca for the academic year 2012-2013, and a repeat of the Upgrade Course for "Coordinators of integrated medicine" at Pavia.
Again, in October 2012 Siena University inaugurated its first professional Catch-Up Course lasting 16 hours and entitled "Clinicalpractical Full Immersion in Integrated Medicine", the aim being to "provide the clinical-practical specialist update needed by professionals to use the methods of Integrated Medicine correctly".
To complete this multiple and varied picture, we must mention a Masters in Naturopathy being put on by Rome's "San Raffaele" Telecommunications University, a "legally-recognized non-state university issuing official qualifications of the same legal validity as traditional university qualifications". Again, "La Sapienza" Universitylends its patronage to a course of Osteopathy run by the Chinesis Association.
Evidence of various universities' increasing open-mindedness about TM/NCM, and hence the growing social acceptance of these subjects, is to be found in the number of post-graduate courses that subdivide into modules, some carrying a certain weight, connected with Non-Conventional Medicines. Among these are: 1. A level-I Masters in "Posturology" offered by Rome's "Sapienza" University within which is a 20-credit module called Manual Therapy and Osteopathy.

A Masters in Palliative Care put on by Turin University's San
Luigi di Orbassano Faculty of Medicine, which contains a module on TM/NCM.
3. An Upgrade Course in "Functional Biological Medicine" at the University of Pescara-Chieti, "designed to develop advanced specialist knowledge of the main aspects of so-called "non-conventional medicines", as recognized by the Italian Federation of Medical Rolls, the approach being to integrate them into the rudiments of so-called "conventional medicine". Part of this consists of contact lessons on points of Phytotherapy, Pharmacology and Homo-toxicology.
4. An Upgrade Course in the "Rational and Critical Foundations and Therapeutic use of Medicinal Plants and Dietary Supplements", run by Milan's "State" University and including among its subjects "Phytotherapeutic preparations: cultivating, harvesting and preserving medicinal herbs".

Discussion and Conclusions
Our survey shows quite clearly that the Italian University is taking a growing and increasingly concrete interest in Traditional and Non-Conventional Medicines. One may argue that, in terms both of information and of training, some Italian universities are consciously making room for these traditions of healing and are beginning to come into line with international practice where "teaching on NCM within the university curriculum is now widespread. Over 90% of British universities offer courses on this subject [15], as do 83% of American colleges [14]. As for European universities, a recent survey found that diverse courses on NCM are being held in about 40% of the institutes that agreed to take part in the survey [17][18][19][20].
The Italian National Health System is in the grip of a deep crisis heavily conditioned by the necessity of balancing its books, with increasingly tight protocols, exhausting racing against time and cuts to resources penalizing the end-users [10,21,22]. Hospital administrations are becoming task-masters, forcing personnel to accept taxing hours and work stress. TM/NCM may be one way out: it is relatively economical to implement in terms of hospital budgets, and also revives the age-old medical art based on touch, observation of the whole and empathy between doctor and patient. Biomedicine has indeed made extraordinary strides in treating acute conditions above all, but in its advanced technological state it has become alienated from the patient, creating a gap that reduces the art of medicine to a piecemeal view of the person. A profitable blend of Biomedicine and Traditional/Non-Conventional Medicine would also fit the definition of health drawn up at Alma Ata in 1978 by the World Health Organization: "a state of complete physical, psychic and social well-being and not just the absence of disease". Integrating the approaches might pave the way for "Organizational Wellness" [23], meaning a "factor preventing the 'risk of error' in welfare work which, by its very nature, entails constant handling of uncertainty, the unexpected and emotions running high" [24].
The University of the Globalized World cannot afford not to train and inform its professional cadres about TM/NCMs which are treating over three billion people at extremely low cost, especially in view of the increasing demand for them and of WHO recommendations. Health worker professionalism must constantly be enhanced for the sake of patient protection. The Italian University is going through a period of transition and reform, out of which appropriate room might be apportioned to these anthropological health traditions. The road to a fertile relationship among the traditions may already have been embarked on. Thus, we may scan the international horizon for terms of comparison, making allowance for variations in course characteristics, focus, subjects covered and teaching approaches [25]. One such is the CAM-MS Program in Physiology run by the Georgetown University: this "was created in response to (1) a nation-wide consumer interest in CAM that led National Institutes of Health to fund initiatives to incorporate CAM into health professions education, (2) the progressive clinical integration of various CAM modalities, and (3) the resulting demand for well-informed and properly trained healthcare providers and scientists. The development of a scientifically rigorous educational program in CAM, and the subsequent linkage to leading academic institutions in all the health professions, is helping to provide a cadre of informed individuals who are embarking on careers in the health professions with an enriched perspective on healthcare and renewed enthusiasm" [12].
Such enthusiasm is the result of a "Person-centred medicine which adopts a unitary and systemic approach; accommodates the complexity of natural phenomena and human nature; studies the relations of man to his environment, how body and psyche interact, what spiritual integrity means in a human being; and stresses active patient responsibility for keeping healthy and being healed" [16].
Some 'take-home' messages • Despite the negative official attitude of the Deans, many universities are not toeing the line • The poor response rate to the questionnaire may reflect the current institutional muddle, as well as caginess about over-frank disclosure in a competitive university scenario • There is some correspondence between interest in TM/NCM by certain Regions (especially in the Centre-South) and 'virtuous' university syllabuses within those Regions • This survey shows Acupuncture to be the most popular TM/NCM branch, perhaps because it is closest to biomedicine Crisis in biomedicine, with its funding cuts and stressful workloads, militates in favor of TM/NCM as a more economical, humanized and harmonious alternative.