An Online Program Shapes Doctors’ Minds—and Hearts

An Online Program Shapes Doctors’ Minds—and Hearts**

By Victoria Maizes MD

Nearly 14 years ago, the Arizona Center for Integrative Medicine at the University of Arizona College of Medicine embarked on an experiment in online education that would have a major impact on the medical profession.

To meet the growing demand for training in integrative medicine—a healing-oriented practice that takes account of the whole person and makes use of all appropriate therapies—the center began offering the content of its residential fellowship online. What was at the time a radically new delivery system for medical education went on to have radical results: While only four doctors a year had taken part in the residential fellowship, which required two years of on-site study at the College of Medicine, some 1,000 fellows have now graduated from the online program.

At a time when online higher education is often seen as second best, it is worth exploring some of the elements that have led to the program’s success and allowed many doctors and other practitioners to seek specialized training they might not otherwise have received.

While many people conflate integrative medicine with complementary or alternative medicine, the actual definition is more complex. Integrative medicine emphasizes the therapeutic relationship between practitioner and patient, covers all aspects of a patient’s lifestyle, and is informed by medical evidence.

Our residential fellowship program, the first of its kind in the nation, was developed in 1997 by Andrew Weil, the center’s founder and director, and a national advisory group of educators. It immersed fellows (I was one of them) in the study of nutrition and mind-body influences on health, traditional Chinese and Ayurvedic medicine, homeopathy, osteopathy, botanicals, and other forms of healing. We deepened our understanding of patients’ spiritual needs, participated in healing ceremonies, and reflected for two days each month on how our training had shaped us as human beings.

While transformational, the residential fellowship was neither scalable, as only four doctors could be trained each year, nor sustainable, as it depended on philanthropic funding. Given our center’s mission to transform medical education and health care in America, we had to deal with both of those limitations.

In 2000 we adapted the curriculum developed for the residential fellowship and created a 1,000-hour, two-year program taught primarily online. We included three weeklong residential blocks (spaced 11 months apart) to build a learning community and to teach subjects that could not be taught online.

For a majority of learners, the fellowship serves to restore them to the ideals that originally brought them to medicine.

Our fellows are mostly primary-care doctors, but we also train many specialists, along with nurse practitioners and physician assistants. Tuition ($15,000 annually) sustains the program, meeting one challenge. While passionate naysayers depict online learning as a dismal “one size fits all” scenario, where classes lack student-teacher interaction and foreshadow the demise of an intellectual life, we discovered that for a majority of learners, the fellowship serves to restore them to the ideals that originally brought them to medicine.

A year into the program, during their second residential week, fellows speak of the marked personal changes in their own diets and meditation and exercise practices, and their ability to more effectively counsel patients on making lifestyle changes. During their final residential week, fellows frequently say they feel closer to their community of fellows than they have ever felt to other physicians. Many say they have been reinspired to practice medicine. Attrition, a problem in many online programs, is less than 5 percent.

The content is developed by experts, including faculty and alumni of the integrative-medicine center and nationally known scientists and clinicians, and is peer reviewed by external reviewers. All courses are reviewed annually for changes in science.

A team of full-time instructional web designers creates a broad menu of interactive learning experiences, allowing fellows, for example, to share reflections, rank the quality of scientific articles, and calculate the nutrients in a meal. Clinical relevance is addressed by giving fellows access to online “patient waiting rooms,” from which they choose virtual patients based on real cases and prepare treatment plans. They can also see the treatment plans of their classmates and of faculty members. These activities and others assure that fellows are not simply reading on the web but interacting individually and collectively.

Threaded course dialogues, designed to foster connections, are asynchronous to meet the needs of students spanning time zones around the globe. Each held over a 10-day period to maintain focus and intensity, they are moderated by a multidisciplinary team of five or more experts. For example, the nutrition module is moderated by a nutritionist and four integrative physicians (with combined advanced training in nutrition, dietary supplements, and Ayurvedic medicine). Fellows may also connect informally, including at online “water coolers” where they can plan to meet up at conferences or take part in special-interest groups.

During the residential weeks we provide a confidential healing space, allowing participants to share, for example, intimate details of painful professional experiences such as the death of a favorite patient, a medical mistake, or their own stories of burnout. Rituals like creating a personal prayer flag honor the role of physician as healer, and are incorporated into the residential weeks.

Eight years into our new online fellowship, we had gone from educating four to 130 physicians a year. But if we truly wanted to transform medical education, we had to scale further. We had to move training in integrative medicine from an elective fellowship undertaken by midcareer professionals to a required part of conventional training. So beginning in 2008, we initiated another online project—a curriculum to meet the needs of the thousands of physicians who graduate from medical school each year and enter residency training. With support of the U.S. Education Department and forward-thinking philanthropists, we developed our Integrative Medicine in Residency program, a 200-hour online curriculum designed to be embedded into existing residency programs.

For a pilot project we recruited eight family-medicine programs across the country. All agreed that their residents would complete the entire 200 hours as a compulsory part of their curriculum. We also required participating programs to appoint faculty members trained in integrative medicine to mentor and evaluate residents.

Five years into this curriculum project, we have data showing that our participating residents’ knowledge of integrative medicine improves and that they enjoy learning online.

Because it is online, the Arizona program could potentially train primary-care physicians across the nation.

The residency project has also proved to be scalable; over the past three years we have added 39 additional residency programs (with a total of 1,286 residents, some of whom have since graduated) and expanded into other fields of medicine. Licensing fees paid by the residency programs cover the cost of maintaining and updating the curriculum, making the online integrative-medicine curriculum financially sustainable.

While we don’t yet know whether our program is transformational, we have a robust evaluation system in place. We measure those qualities you would wish for in your physician, such as empathy and compassion, and those that you would hope your doctor would never experience, including burnout, anxiety, and depression. And given the busy schedules of practicing physicians and the 80-hour workweek limit imposed on residents by national accreditors, online education provides an excellent way to deal with time challenges.

Many other educational programs have also succeeded online. The University of Minnesota Center for Spirituality and Healing offers online courses in meditation, spirituality in health care, and mind-body medicine, among others. The Institute for Integrative Nutrition has taught nutrition and health coaching online for many years.

Success in an online program often depends on the level of commitment: It must be a high priority for college leaders, and must include faculty who are determined to become effective online instructors. Our center has created a national model for integrative medical education which, because it is delivered online, could potentially train primary-care physicians across the nation. It fills an important gap in medical education.

Rather than labeling online education second best, it is time we looked carefully at the educational needs of learners, the unique strategies for pedagogical success, and the niches that online learning can serve best.

Victoria Maizes is a physician, executive director of the Arizona Center for Integrative Medicine, and a professor of medicine and public health at the University of Arizona.

**This article was first published by The Chronicle of Higher Education on April 21, 2014