Medical Students Knowledge and Perception Regarding Complementary and Alternative Medicine

Objective The purpose of the study was to identify knowledge and perception of medical students regarding complementary and alternative medicine therapy (CAM). Background Complementary and alternative medicine (CAM) is growing field in medicine, which can be a useful resource to improve the quality of life. Medical students should be aware of these modalities available freely for the patient as over the counter medicine. Methods A crosssectional survey based study carried out on 6th and 7th year medical students (clinical years). Data was collected on self-administered questionnaire in which core elements were divided-Knowledge and Perception about CAM and Knowledge regarding Herbs used as Pain Killer. Statistical analysis was performed using SPSS (IBM SPSS Statistics 20.0). Data were expressed in frequencies, mean and percentages. Results Less than a half (44.9%) of the participants were 7th year and (55.1%) were 6th year students. Majority of the students (80.5%) were Omani 53 (45%) of study participants were below 25 years in age and 101 (85.6%) were female. No difference was observed between 6th and 7th year students (p-0.516, 95% CI-1.74-3.31), significant difference (p-0.009, 95% CI 1.25-8.44). Significant difference was observed (p-0.009, 95% CI-7.45-1.08) between Omani and non-Omani participants. Students possess adequate knowledge about CAM and positive approach in clinical practice but overall they have poor knowledge about herb as pain killer. Conclusion Students in clinical years have positive approach towards CAM and their knowledge is adequate in general but they have poor knowledge regarding herbs used as pain killer.


Introduction
Complementary and alternative medicine (CAM) is growing very fast and the use of CAM in health care is rapidly evolving [1]. CAM has been defined by the National Center for Complementary and Alternative Medicine as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine [2]. They may be grouped into categories such as natural products, mind-body, and body-based practices. CAM is a broad domain of healing resource to improve the quality of life and can be a valuable addition to the chronic pain management plan. CAM is mainly used as self-medication patients' own beliefs, and the wish for more control over one's own health [3][4]. Which could be herbs, vitamins, minerals, or other natural products, some of them have been studied for pain control. Some are called mind-body medicines [5][6]. People use CAM, especially herb as selfmedication to reduce symptoms and to improve well-being thinking that it has no side effects. Herbal Medicine is the use of preparations, which contain exclusively plant material [7].
Medical student's knowledge is limited as CAM is not formally included in undergraduate curriculum [8,9]. Although alternate medicine therapy in family Medicine rotation each disease management covers but still it is not taught as conventional medications. Family medicine is an essential component of the primary care infrastructure of the Oman health care delivery system. This primary care specialty provides first contact, ongoing, and preventive care to all patients. Both the clinical courses (year 6 and 7) run as a spiral with consolidating and sharpening the knowledge and skills acquired in year 6 with some more practical approach in year 7. Oman Medical College is aware of the importance of CAM and has taken initiatives to enhance its awareness among medical student to develop and organize strategies with a view to formulating education programs. In their pre-clinical year students learn basics of CAM and their application in clinical practice followed by assessment in that area. CAM is now included in clinical years' curriculum to teach and train the students to be an effective doctor and have competence to provide high standards of care to meet the health need of people of Oman and the region.
To strengthen and make it more effective in terms of teaching and experiential learning of CAM, few steps is already being taken. Thus, a process of needs assessment, identifying gaps in knowledge, consultations with the curricula reformers and strategic planning is thought to be effective catalysts for curricular change [9]. This study was designed to assess the knowledge and perception of medical students regarding complementary and alternative medicine.

Method
The survey of 118 medical students carried out at Oman Medical College. The questionnaire designed was divided in to 3 sections. The first section consists of demographic details of students (age, gender and year of education) and second section contains questions regarding knowledge and perception about CAM and third knowledge regarding herbs used as pain killer. All questions had five responses (strongly agree, agree, neutral, disagree, and strongly disagree).
The questionnaire was prepared and approved with ethical review committee of Oman Medical College. All students in clinical years were invited to participate. Participants were enrolled after taking written informed consent. The principal investigator (PI) ensured uniformity and two trained research assistants assisted PI in data collection.
Statistical analysis was performed using SPSS (IBM SPSS Statistics 20.0). Data were expressed in frequencies, mean and percentages.
Mean scale scores for the year of class, gender, age and citizenship were evaluated for significance difference using the paired t-test.

Discussion
The use of herbal medicine is very common in the Arab world including Oman and their consumption is increasing at a rapid pace worldwide due to the wide spread belief that these preparations are natural and therefore, safe. This trend is also observed among the general practitioners who are now more interested and inclined towards the use of herbal drugs for the treatment of some common ailments [10]. In Oman, herbal remedies are considered as over the counter (OTC) drugs and thus are easily available through pharmacies. This is reported in literature that medical students and general practitioner both have an opinion that CAM should be included in the curriculum [11].
Our survey based study of medical student's knowledge and perception regarding CAM shows appreciable knowledge and perception (Table 2). Literature also support same evidence and students had positive attitude regarding CAM and its importance to help conventional medicine. This can benefit in future medical practice evidence-based principles have been utilized to effectively teach medical students about [12].
The highest area of agreement in this study was when the participants admitted that the use of CAM should be asked about during a regular history taking, patients should inform/consult their doctors about their use of CAM. Literature reports about appreciable CAM knowledge among medical student and recommended curricular review in medical education [13]. Majority of students in this study agreed that relaxation techniques increase wellbeing and thus may contribute to controlling pain and Hijama is a popular method used in Oman. Participants exhibited appreciable knowledge, interest and attitudes toward CAM. This may suggest that they are not well equipped with knowledge of the efficacy and safety of CAM, and hence are afraid to advise and encourage their patients who suggest the use of CAM. Nevertheless, most students agree that patients should inform doctors about CAM use and that it should be inquired about during history taking. This is in accordance with earlier literature, since these are the sources which increase one's general knowledge. A previous study reported that nursing students have more positive attitude than medical students .The results showed that student's attitudes are in line with their interests and limited knowledge [14].
Nearly one-third of participants agreed that CAM therapies not tested in a scientific manner should be discouraged and clinical care should integrate the best of conventional and CAM practices. Health care professionals should be able to advise their patients about commonly used CAM methods. Half of them stated that a formal training or mandatory CAM course should be included in medical undergraduate curriculum. This has been reported in literature Studies have shown that medical students would like more instruction about alternative medical therapies before they can provide advice to patients. Medical schools in the western countries are increasingly offering courses addressing alternative medicine in the curriculum [15].
In this study, student's knowledge regarding CAM and herbs as pain killer was not adequate although they exhibited positive attitude towards it. Most participants admitted to be unsure in response to most questions raised. The study has shown that students at different level have different level of knowledge (Table 3). There is a need for integrative curriculum [16,17]. Both lectures and direct shadowing appear to be the favorable methods for students. In one of the U.S. institutions, a 3-week elective CAM rotation that integrated rotation and lectures has improved student's positive attitudes and their knowledge [18].
This study agreed with previous studies which revealed that students though possessed inadequate knowledge about CAM most of them believed that it should be used in conjunction with conventional medicine and that, if given adequate training, they would incorporate it in their future medical practice, also will help them make relevant changes in the medical curriculum [19,20]. Study participants seems very enthusiastic about CAM, however their knowledge is not appropriate regarding the use. CAM learning method is also assessed in publish articles [21]. Literature reports medical student's attitude and knowledge similar to the observation of this study [22].
Another study published from Oman showed the respondent's community pharmacists have a belief on the effectiveness and safety of herbal products reflecting a positive attitude towards dispensing herbal medicines but their knowledge about the side effects and herb-drug interaction was found to be inadequate for an effective advising and patient counseling. Pharmacists were more knowledgeable on specific therapeutic indications of herbal products rather than on other areas such as drug-herb interaction or side effects [23,24]. House hold survey on medication published from Oman, overall results suggest an inappropriate use of medicines among the sampled population. Selfmedication with herbal medicines is common entity [25,26].

Conclusion
Students in clinical years have positive approach towards CAM and their knowledge is adequate in general but they have poor knowledge regarding herbs used as painkiller. Complementary therapy can be a valuable addition to the chronic pain management plan in primary care and students should learn how to apply them in clinical practice with appropriate clinical judgment and awareness of the clinical evidence supporting their use and also showing their limitations.

Study Limitation
This study is conducted in one medical college so the result regarding medical student's knowledge about CAM cannot be generalized. We need more studies at different medical colleges at different level.

Disclosure Statement
No competing financial interests exist.