Originally published in Massage Bodywork magazine, February/March 2005.
Copyright 2005. Associated Bodywork and Massage Professionals. All rights reserved.
Scientific research articles are generally full of terms like univariate analysis, paired t-test, and p value. Sound Greek to you? Trying to read and understand the technical jargon and empirical process can be intimidating, especially for those of us who are more comfortable with the "art" of healing than its statistics. The thought of actually participating in said research as part of a study team can also be daunting, considering the lack of training most practitioners have had in this area.
With the growing importance of research in complementary and alternative medicine (CAM) to support acceptance and validation within the healthcare field, practitioners are increasingly becoming involved in scientific studies, either as administrators of treatment or advisors. In part, this trend is rooted in the policy of the National Institutes of Health's (NIH) National Center for Complementary and Alternative Medicine (NCCAM), which requires multidisciplinary committees, combining both academic faculties and CAM practitioners, for its funded research centers and education grants.1
But also relative to this is the increasing interest of practitioners to explore more universal application of their trade or specialty through proven results. In contrast, most community-based practitioners have received limited exposure or course work in scientific study, leaving them lacking in research knowledge and skills.
To address this issue, Suzanna Zick, N.D., M.P.H., and Rita Benn, Ph.D., at the CAM Research Center (CAMRC), University of Michigan in Ann Arbor, developed and implemented a seven-session research methods course titled "Research Your Passion in CAM." Their evaluation results, utilizing quantitative and qualitative measures, were published in Alternative Therapies in Health and Medicine, May/June 2004. Overall, the course was a great success, as documented by both scientific data and the students' enthusiasm.
Zick says that with NCCAM's new policies, providers are encouraged to extend their role beyond committee advisors to be principle investigators and actual practitioners within the studies. But of course, not every practitioner will have the inner passion required for this rigorous path. Benn, director of CAMRC's Integrative Medicine Education Program, says the ideal student for this course will be open-minded, coming in with a desire to learn rather than focused on proving a point. "Somebody who has an interest in wanting to understand the effectiveness of their particular practice," she says, "has a good amount of experience and a way of looking at the world a little more scientifically. We had two goals: To expose them to the world of research so they could understand what they might read about effectiveness; the other was to have them want to develop a study, to show a long-term commitment and interest." Building the Bridge
Applying for the course was, in a sense, a rite of initiation into that demanding world of commitment and interest. In addition to resumes, recommendation letters, experience requirements, and course fee, applicants were requested to submit in writing their motivation for participation, personal and professional goals related to the course, and a research question to be developed in their coursework. An eclectic group of 11 students was chosen, representing diverse CAM professions. Equally diverse were their ages (from 24 to 62), and levels of experience and education.2
The course was presented in half-day sessions over a period of four months. The first portion laid the groundwork for understanding the language and process of research design, conducting literature searches and critically evaluating these materials, and the process of hypothesis generation and grant proposal. From here, students moved into specifics of grant writing, funding, and implementation of their project.3
Lecture and group discussion were combined with in-class presentations and homework assignments, complemented by guest speakers from academia and a panel of practitioners with clinical trial experience. Zick and Benn, using a mixed-methods evaluation design, combined structured and semi-structured questionnaires to evaluate results. Quantitative data reflected a high rating of effectiveness of the course, with substantial increase of understanding in areas of research design, terminology and methodology, literature review, and grant writing.4
Through a qualitative analysis of open-ended questions, the instructors' review and discussion of responses identified "a core set of themes that captured the quality of the practitioners' experiences."5
Using a process called "member checking," the team verified these results by presenting the themes and accompanying transcribed responses back to a sample of four participants for confirmation. In addition to themes of acquiring a new language and increased confidence in ability to pursue research, a third focus, that of the dilemma in applying scientific research to CAM, reflects a common concern voiced throughout CAM studies.6
Building on their successful outcome, Zick and Benn are in the planning stages for another course offering, incorporating changes based on study results. Although the schedule isn't set yet, they're considering expanding the course length, allowing more time for adequate coverage and assimilation of material. The two-part format will be restructured with basic subjects covered in the first half and emphasis on more fully developing research proposals in the latter portion.7From Practitioner to Researcher
With their increased knowledge of the basics of research, students became more discriminating in their literature critiques. Zick says a common trend for many of us is to make the most of positive results, while being almost illogical in our critique of negative results. As students became more adept in the language and process of studies, they were better able to think it through. "Maybe this is right, maybe this is why it was not right," Zick says. They were reading and digesting the entire report rather than just the highlights. "They were able to see how deep biases get imbedded in the discussion section, both good and bad, and how conclusions don't always match up." Students were also inspired to carry this experience back to their practice, scheduling time to actually do literature searches and more appropriately discerning applicability of results within their modalities.
Increased confidence in comprehension of the language and process of scientific study was exemplified by the comment of one participant: "I understood that I could actually learn the principles of research and initiate a serious research project utilizing my own CAM modality."8
In fact, four of the students carried their new-found skills into the field, undertaking the beginning steps of getting their projects off the ground. They have received continued guidance and support from the instructor team in pursuing their goals. "All of these situations show ample evidence for demonstrating that with training and support, community CAM practitioners can become researchers and contribute meaningfully to the conventional research community," investigators write. "All of these projects were generated from their own practices and experiences with their clients/patients."9
Throughout the coursework, instructors focused on encouraging students' realistic expectations of what they would be getting into and, at the same time, boosting confidence in achieving their goals. A presentation by a panel of practitioners experienced in clinical trials was especially helpful in this regard. It was a good dose of reality, Benn notes, "to show them also that it's not necessarily all that glamorous. The fun part is to create the project, then there's a lot of nitty-gritty work."
While exposing students to the realities of collaborating with academic partners, the interchange also provided inspiration. "One prime reason was to model for the student that it was possible, that there were people who were once at their level of understanding," Benn says. It allowed the students an opportunity to identify with peers who had succeeded in following through with a creative idea.
"It was really insightful for them to see the journey other practitioners had been on," Zick says, "to see the stages and that some of the stages are familiar. It might start with some high level of idealism or energy. Then reality hits about what can actually be achieved in that time -- that it's a technically difficult field -- and the change at the very end when the person realizes 'I also need to be a scientist.' This gave the students food for thought, to examine if they wanted to go through that transformation or remain a practitioner.
The practitioner panel also addressed students' feelings of intimidation at approaching more highly-trained academic faculty for support and cooperation in their projects, including concerns that they might not be respected, or "may be put down," as Benn says. The sharing of these experiences provided students encouragement in facing their fears of academia. In a wider scope, the project had a positive effect on faculty participating as guest speakers for the course. "For some academic faculty, the contact with the community practitioners was their first introduction to the field of CAM," instructors write. "They were interested in hearing the ideas of the practitioners and in helping them to think more clearly through the challenges of their research question."10The CAM Research Conundrum
A constant frustration in CAM research remains the task of matching holistic values and mind-set to the linear scientific model -- the square peg and round hole conundrum. The students' responses on open-ended questionnaires highlight this dilemma. To summarize, there were concerns about the applicability of the scientific "gold standard" to CAM. Examination of an individual component of a multifactorial entity that operates in a holistic manner ignores the synergistic process involved, as well as its potential overall benefit. While one student appreciated the positive value of identifying safe and effective practices, she notes the negative side, "in that it prevents procedures and practices not based on mathematical principles that are truly efficacious from being used in mainstream medicine."11
The slow, tedious, and costly nature of research was cited, in contrast to students' desires to implement -- without waiting for scientific data -- treatments that they and their clients already perceive as beneficial. One student also suggests the future holds a likely alteration in the paradigm for research because of the growing trend toward blending of CAM and conventional medicine.12
Echoing the thoughts of her students, Benn says, "Our present way of looking at the world is very reductionistic, and we do need to have a broader perspective." She's a proponent of mixed-methods research, not only for CAM but in general. "Once we find out that something may or not work, we need to ask why, we need to go back to the practitioner or the participants and talk." This approach was used in Zick and Benn's study and allowed them to glean important information to apply in future course offerings.
Benn encourages utilizing multiple groups, observation, and interviews, and extending the study period to further understand applicability and results. "As we get a little more sophisticated in our measurement -- the actual scales and lab devices -- we may be better attuned to see some differences." The focus should be on what works for health overall, as no single treatment will likely have universal impact within a particular condition.
In addition to opening communication between the academic community and practitioners, the team also anticipates that bridging this gap will result in creating new ways of approaching research. In their closing discussion, they write, "These are 'ways of thinking' that researchers steeped in the traditional academic and biomedical models may be less likely to intuit or formulate on their own, but which are important to maintain the integrity and uniqueness of CAM."13
The success of the methodology course underscores the importance of providing opportunities for practitioners to not only become better-informed readers of scientific literature, but also more knowledgeable and skilled participants in the field. "I think they came to appreciate that they couldn't do everything they wanted to with the scientific method," Zick says, "but they could do a lot more than they thought. There are a lot of good methods out there and different people who have the training that can put it together and get funding. It's really an issue of creativity at this point.
"I would love to encourage people who are CAM clinicians to examine whether or not there is a secret researcher in them. Even more important is to encourage those few that have that passion to not give it up. There will be barriers, but it's not impossible, and you can definitely achieve a productive research career."
Practitioners interested in applying for CAM Research Center's methodology course can contact Suzanna Zick at 734/998-7715, or e-mail firstname.lastname@example.org. Shirley Vanderbilt is a staff writer for Massage Bodywork magazine.References