Findings from a three-round Delphi study: essential topics for interprofessional training on complementary and integrative medicine

Background Integrating complementary medicine into medical care promotes patient-oriented care. A well-informed and collaborative professional healthcare team is essential for effective and patient-safe implementation of these methods. At present, the skills for patient counseling, therapy and care regarding complementary medicine vary among the professional groups involved. Professionals generally feel that they are not sufficiently qualified in this area. Curricular concepts for Complementary and Integrative Medicine (CIM) are virtually non-existent in undergraduate interprofessional training. The aim of this study is to initiate a consensus-building process between various experts (professionals, students, patient and faculty representatives) in order to identify which topics should be the focus of such a curriculum. Methods A three-round Delphi study was carried out from March 2018 to March 2019 to compile the experience and knowledge of experts in the field of integrative patient care and interprofessional education. Sixty-five experts from Germany and German-speaking Switzerland with various professional backgrounds and experiences were asked to name general content, therapy methods and treatment reasons which should be addressed in interprofessional seminars. In the subsequent rounds these were rated on a seven-point Likert scale. The ratings were assigned to relevance groups and discussed in a final workshop in July 2019. Results The response rates for the three rounds were 76% (n = 50), 80% (n = 40) 90% (n = 36); and 21% (n = 11) for the final workshop. The experts suggested that topics could be aligned along the most common treatment reasons such as insomnia, generalized pain, fatigue and back pain. However, it is important that students also receive an overview of the evidence base for different therapeutic concepts, especially in the field of classical natural medicine, acupuncture and mind-body medicine, and that they get an overview of the effects and interactions of frequently used procedures. Conclusion Consensus was reached among the various experts on the most important topics for an interprofessional CIM curriculum. The systematic evaluation of the topics in this study can help to create a curriculum that achieves a high level of acceptance among teachers, lecturers and students, and thus facilitates implementation at universities and medical faculties. Supplementary Information The online version contains supplementary material available at 10.1186/s12906-020-03140-x.


First Round
We welcome you to the first round of the Delphi survey "Development of an interprofessional curriculum on complementary and integrative medicine" Thank you very much for participating in this survey. When answering the questions, please refer to a potential seminar for Complementary and Integrative Medicine (CIM) with 30-60 teaching units of 45 min each, which is offered at a medical school for students of medicine and other healthcare professions (from the fields of nursing, therapy and diagnostics) in undergraduate education. This survey is meant to record your personal opinion on and assessment of contents and objectives for such a curriculum. Please fill in the questionnaire as completely as possible and use the free text to make comments and further additions. The survey will be conducted pseudonymously. Your evaluations and verbatim core statements from the free text answers will be included in the next survey round and in the result report, but it will not be possible to draw conclusions about your identity. In addition to the socio-demographic surveys, the survey includes one section on the addressed goals and competencies and one section on the possible curricular content. It should take about 20 to 30 minutes to complete the questionnaire. You can stop and come back to continue the questionnaire at a later time. Your results will be stored temporarily. If you have any questions, please do not hesitate to contact me. The newly mentioned competencies will be submitted for evaluation inte next survey round on a seven point likert scale.

NEXT
Your comments will be will be listed anonymously in the next survey round. The assessed competencies will be assigned to four relevance groups based on the assessments.
How should the competencies be addressed?
Drop-down-Menu: B1.1-B1.18 When answering the questions, please refer to a potential seminar for Complementary and Integrative Medicine (CIM) with 30-60 teaching units of 45 min each, which is offered at a medical school for students of medicine and other healthcare professions (from the fields of nursing, therapy and diagnostics) in undergraduate education. Below you will find a list of teaching-learning objectives and competencies based on CIM curricula already described in the literature. Please rate them with regard to their relevance on a seven-point Likert scale. Please also indicate whether these competencies should be addressed explicitly or implicitly ("between the lines").
Use the free text to justify and supplement your assessment and to list further competencies.

Classical natural medicine
The classical natural medicine methods classified as relevant will be broken down in detail in the next survey round and submitted again for evaluation (80% > scale level 5).

SUBMIT
In the following, some teaching content are listed. Please assess their relevance for an interprofessional CIM curriculum on a seven-point Likert scale. In addition, you have the possibility to indicate if you cannot or do not want to assess the content due to lack of knowledge and/or for other reasons.
Please use the free-text fields to justify or supplement your assessments and to list further possible teaching content.
Your comments will be listed in the next survey round. The newly listed content will be submitted for evaluation in the second round of questioning. The assessed content will be assigned to four relevance groups (very relevant -not relevant). You will then have the opportunity to agree or disagree with the assignment and to add further comments.

Second Round
We welcome you to the second round of the Delphi survey "Development of an interprofessional curriculum on complementary and integrative medicine" Thank you very much for participating in the first survey round. The present questionnaire was designed on the basis of your weightings, suggestions and constructive criticism. All comments were fully incorporated into the second survey wave. A compilation of all quotations can be found in the attached result report. Part A of this second survey contains questions on teaching methods, Part B: questions on competencies, Part C: questions on role competencies and Part D: questions on curricular content.
When answering the questions, please refer to a potential seminar for Complementary and Integrative Medicine (CIM) with 30-60 teaching units of 45 min each, which is offered at a medical school for students of medicine and other healthcare professions (from the fields of nursing, therapy and diagnostics) in undergraduate education. This survey is meant to record your personal opinion on and assessment of contents and objectives for such a curriculum. Please fill in the questionnaire as completely as possible and use the free text to make comments and further additions. The survey will be conducted pseudonymously. Your evaluations and verbatim core statements from the free text answers will be included in the next survey round and in the result report, but it will not be possible to draw conclusions about your identity.
It should take about 30 minutes to complete the questionnaire.
You can stop and come back to continue the questionnaire at a later time. Your results will be stored temporarily.
If you have any questions, please do not hesitate to contact me.

Others
If you think the statement is correct, please tick the box on the left.

Others
From the following list, select the learning setting that you think is best suited for an interprofessional CIM seminar! (CIM=Complementary and integrative medicine)

NEXT
In the first survey round, some methodological-didactic aspects for an interprofessional complementary and integrative medical curriculum were taken up. Since the development of a teaching and learning program cannot be carried out without without taking teaching methods into consideration (assessment drives learning), your comments and suggestions from the first survey wave will be taken up and discussed at the beginning of this survey wave.
When answering the questions, please refer to a potential seminar for Complementary and Integrative Medicine (CIM) with 30-60 teaching units of 45 min each, which is offered at a medical school for students of medicine and other healthcare professions (from the fields of nursing, therapy and diagnostics) in undergraduate education.
Select from the following list the structural orientation of the contents of an interprofessional CIM curriculum that best suits your needs.
CIM-contents should primilary be oriented on therapy options.
CIM basic knowledge should be offered as a compulsory module for all students in the medical and health professions. In addition, there should be the opportunity to deepen individual areas in elective modules. CIM should be offered voluntarily, extracurricular modules with certificate degree.
CIM should be offered as a curricularly anchored elective module for all students in the medical and health professions. CIM should be offered as a compulsory basic module for all students in the medical and health professions in the curriculum of the main study programme.
CIM should not be offered as an independent interprofessional module but integrated more strongly into existing modules. CIM should not be taught at universities and colleges.
No answer CIM-contents should primilary be oriented on disease patterns. CIM-contents should primilary be oriented on reasons for seeking care.

No answer
If you think the statement is correct, please tick the box on the left.
CIM-contents should primilary be oriented on health care service processes. CIM-contents should primilary be oriented on International Clssification of Functioning, Disability and Health (ICF).
Please select from the following list for which fields of activity an interprofessional CIM seminar should primarily qualify.
If the statement is only partially true or under certain conditions, you can write a comment on the right.

I agree Free-text field
Interprofessional CIM care is relevant to the field of prevention and health promotion. Interprofessional CIM care is relevant for the support of self-and lay therapy and care. Interprofessional CIM care cannot be implemented in the (present and future) care reality and is therefore not relevant.
Please select from the following list which teaching methods should be primarily used in a CIM curriculum.
If the statement is only partially true or under certain conditions, you can write a comment on the right.
CIM knowledge should be acquired by self-directed learninig (problem-oriented learning).

I agree Free-text field
CIM content/knowledge should be presented in a structured way in the classical lecture format.

2nd Delphi Round: Teaching Methods (Part A)
Real patients and/or acting patients should be involved in the seminars as often as possible.
Students shoud try out simple procedures and CIM methods for themselves (experience-oriented learning).
Students shoud discuss ethical questions and contradictory statements regarding CIM. Students should share their own experiences, opinions and attitudes with regard to CIM.
CIM content should be presented as complex case studies (case-oriented learning).

I agree
Others: B1.10 The competency "Students are able to be familiar with the skills of all professions involved in CIM care" is partly relevant, as it is a prerequisite for appreciative cooperation and communication. B1.5 The competency "Students are able to assess CIM methods with regard to their evidence on the basis of corresponding literature research" is partly relevant and should be taught rather explicitly. However, not only CIM databases should be used for research.
B1.12 The competency "Students are able to recognize how their specific occupational roles contribute to provide the necessary patient care when working in interprofessional teams" is partly relevant and depends on the CIM action possibilities in the respective care situation. B1.8 The competency "Students are able to independently apply selected methods to patient care" is not relevant. However, independent of this, practical exercises in the module can deepen the learning content and promote critical assessment.
B1.18 The competency "Students are able to handle their own health carefully with awareness" is partly relevant and should be addressed rather implicitly.

Free-text field
If you do not agree or only partially agree with the statement or would like to add something, please use the free text field behind the statement.
If you fully agree with the statement, please tick the respective box on the left side of the page.
In the following, competencies are arranged in descending hierarchical order according to the relevance assessment already carried out, but retains its original numbering from the first survey wave. Please indicate whether you agree with the groupings and hypotheses.
B1.16 The competency "Students are able to show openness to the wishes and attitudes of the patient and treat them respectfully" is very relevant as a cornerstone of evidence-based medicine even independently of CIM and forms the basis of all therapeutic action.
B1.15 The competency "Students are able to respect and consider patient perspectives and subjective experiences of illnes" is very relevant independently of CIM. However, students should already have knowledge of treatment methods and therapy options. B1.1 The competency "Students are able to classify CIM terms and methods correctly" is relevant and, as a solid knowledge base, is a prerequisite for the other contents of the CIM curriculum. This competence should therefore be taught explicitly. B1.2 The competency "Students are able to form their own opinion about the respective procedures" is relevant, but the formation of opinion should be based on scientific principles. B1.11 The competency "Students are able to discuss CIM in the interprofessional healthcare team" is relevant, but should be taught rather implicitly.
B1.3 The competency "Students are able to reflect and explain their beliefs and attitudes towards CIM" is very relevant and should be explicitly taught in a CIM curriculum.
B1.9 The competency "Students are able to recognize their own possibilities and limitations in the interprofessional healthcare team" is relevant and serves to avoid exceeding the competency and to recognize the necessity of interprofessional cooperation. B1.6 The competency "Students are able to assess CIM methods with regard to their evidence on the basis of corresponding literature research" is relevant independently of CIM, but here it forms the basis for a critical approach to CIM. B1.7 The competency "Students are able to critically evaluate publications on CIM" is relevant and should be taught explicitly as a prerequisite for professional action. B1.13 The competency "Students are able to respect different therapeutic perspectives and practices" is relevant independently of CIM and should be taught explicitly as a prerequisite for interprofessional care. B1.17 The competency "Students are able to advise patients and relatives on CIM in an interprofessional team" is relevant and serves to identify knowledge gaps in one's own profession on the one hand and to be able to react to the variety of methods and needs used by patients on the other hand. B1.14 The competency "Students are able to inquire and recognize the physical, psychological and social care needs of a patient" is relevant, but requires the ability to evaluate different options for action. B1.4 The competency "Students are able to expand their knowledge of CIM procedures" is partly relevant, since students usually have little previous knowledge of the procedures.
How should the competencies be addressed?

NEXT
Below is a list of the competencies and teaching-learning objectives proposed in the first survey round. You now have the opportunity to assess the relevance on a seven-point Likert scale. Please also indicate whether these competencies should be addressed explicitly or implicitly ("between the lines").

2nd Delphi Round: Competencies (Part B)
highly relevant (at least 80% of the respondents rated it with a 6 or 7 on the Likert scale) relevant (at least 80% of the respondents rated it with a 5-7 on the Likert scale) partly relevant (at least 80% of the respondents rated it with a 4-7 on the Likert scale) not relevant (remaining topics) In the first wave of the survey, competencies were assessed on a seven-point Likert scale (1=not at all relevant to 7=very relevant). In the evaluation these were classified into the following four categories: Furthermore, the free-text fields were evaluated and hypotheses were derived. The hypotheses and the newly listed competencies are now presented to you for evaluation.
In the following, competencies are arranged in descending hierarchical order according to the relevance assessment already carried out, but retains its original numbering from the first survey wave. Please indicate whether you agree with the groupings and hypotheses. If you fully agree with the statement, please tick the respective box on the left side of the page. If you do not agree or only partially agree with the statement or would like to add something, please use the free text field behind the statement.
C1.3 The competency "Graduates behave in an appreciative manner in interprofessional cooperation and thus contribute to good patient care" is one of the most important sub-competency for an interprofessional CIM curriculum. C1.8 The competency "Graduates work together with various health professions and disciplines in an appropriate, appreciative and efficient manner" is also very relevant. Here you can justify the assessments made on the CanMEDS sub-competencies of the communicator and/or list which aspects you consider particularly important. Please indicate the corresponding competency number (C2.1-C2.6). C3.5 Graduates know and consider strategies for error and risk management. C3.6 Graduates know and consider the needs of people with disabilities. C3.7 Graduates know and consider the characteristics, tasks, responsibilities and development of the profession. C3.8 Graduates are familiar with the basics of the economic framework and health policy. C3.9 Graduates contribute to quality assurance. C3.10 Graduates consider their own health and well-being as a prerequisite for a professional career. C3.11 Graduates are capable of self-knowledge, self-reflection, self-criticism and self-development. C3.12 Graduates deal with various forms of uncertainty. C3.13 Graduates know the prerequisites and measures to establish trust. C3.14 Graduates are able to deal with role-related challenges. C3.15 Graduates consider cultural, contextual and everyday aspects in their actions.

Sub-competencies
Here you can justify the assessments made on the CanMEDS sub-competencies of the professional and/or list which aspects you consider particularly important. Please indicate the corresponding competency number (C3.1-C3.15). Here you can justify the assessments made on the CanMEDS sub-competencies of the Scholar and/or list which aspects you consider particularly important. Please indicate the corresponding competency number (C5.1-C5.10).

Sub-competencies: Medical Expert
partly relevant (at least 80% of the respondents rated it with a 4-7 on the Likert scale)

2nd Delphi Round: CanMEDS Role Competencies (Part C)
In the first survey roun, role competencies were assessed on a seven-point Likert scale (1=not at all relevant to 7=very relevant). In the evaluation these were classified into the following four categories: Competencies in medical education are nationally and internationally oriented to the CanMEDS. This competency model was developed for physicians by the Royal College of Physicians and Surgeons of Canada in 2005 and is based on different roles that can be assumed by the respective professions in healthcare.
highly relevant (at least 80% of the respondents rated it with a 6 or 7 on the Likert scale) relevant (at least 80% of the respondents rated it with a 5-7 on the Likert scale)

NEXT
In the first survey round, the other CanMEDs roles were evaluated: Scholar, Communicator, Health Advocate, Leader, Professional and Medical Expert.
The Communicator was rated as very relevant and the Professional, Medical Expert and Scholar as relevant for a CIM curriculum. The sub-competencies of these four role competencies are now presented one after the other for evaluation.
Furthermore, the free-text fields were evaluated and hypotheses were derived. The hypotheses and the newly listed Role competencies are now presented to you for evaluation.

Classical natural medicine
The five tenets of classical natural medicine (hydrotherapy, balance of mind and body, exercise, nutrition and herbalism) were assessed as relevant in the first survey round. In the following, these "tenets" are now broken down into individual procedures. The procedures were assigned to the tenets, whereby it should be noted that there are also overlaps in many areas. Please rate the relevance of the respective procedures on a seven-point Likert scale. In addition, you have the option to indicate if you cannot or do not want to assess the content due to lack of knowledge and/or other reasons.

Susceptibility to infections Arterial hypertension Back Pain Climacteric complaints Complaints caused by chemotherapy
The following general curricular content was additionally suggested in the first survey round. Please rate it on a seven-point Likert scale. You also have the option to indicate if you cannot or do not want to assess the content due to lack of knowledge and/or other reasons.
Regardless of how the module is structured, the content should be deepened on the basis of concrete treatment reasons. In your opinion, which treatment reasons are particularly suitable to illustrate the indication, application and effects of CIM? Already mentioned: Infectious diseases like urinary tract infections and bronchitis Furthermore, the free-text fields were evaluated and hypotheses were derived. The hypotheses and the newly listed content are now presented to you for evaluation.
In the following, general curricular content is arranged in descending hierarchical order according to the relevance assessment already carried out, but retains its original numbering from the first survey wave. Please indicate whether you agree with the groupings and hypotheses.
If you fully agree with the statement, please tick the respective box on the left side of the page. If you do not agree or only partially agree with the statement or would like to add something, please use the free text field behind the I agree Free-text field not relevant (remaining topics) 2nd Delphi Round: Curricular Content (Part D) In the first survey round, general curricular content were assessed on a seven-point Likert scale (1=not at all relevant to 7=very relevant). In the evaluation these were classified into the following four categories: highly relevant (at least 80% of the respondents rated it with a 6 or 7 on the Likert scale) relevant (at least 80% of the respondents rated it with a 5-7 on the Likert scale) partly relevant (at least 80% of the respondents rated it with a 4-7 on the Likert scale) D4.1 As many non-classical naturopathic treatments as possible should be discussed so that the students get a good overview. D4.2 Non-classical naturopathic therapies for which a scientifically proven efficacy is available should be the main topic. D4.3 The non-classical naturopathic therapies often desired ba patients should primarily be discussed. D4.4 The non-classical naturopathic therapies that are frequently offered locally and discussed in public should be addressed primarily. D4.5 When discussing non-classical naturopathic treatments, the topic of acupuncture must be covered. D4.6 When discussing non-classical naturopathic treatments, the choice of lecturers should be made carefully in order to enable an objective and scientific approach. D4.7 Paramedical procedures should also be addressed in order to sensitise students to shalatanery. Here you can justify the assessments you have made and/or list which aspects of the listed content you consider particularly important. Please indicate the corresponding number (D.6.1-D.6.8).
You have reached the end of the interview. Is there anything else you'd like to share?
The following paramedical procedures were suggested as possible content in the first survey round. These procedures are now broken down in the following.

SUBMIT
Non-classical natural medicine is understood here to be all those traditional procedures that have either been well researched or proven by experiential healing knowledge.
Clearly distinguishable from this are paramedical procedures. These do not have a corresponding tradition and thus no correspondingly extensive experience.

Non-classical natural medicine
The following non-classical natural healing methods were suggested in the first survey round as possible additional content (in addition to acupuncture, homeopathy, Ayurveda, etc.). In the following, these procedures are now broken down.

Paramedical procedures
In the survey sound, the non-classical natural medicine methods were classified as partly relevant or not relevant, although in some cases the exemplary integration was desired. Please indicate below to what extent you agree with the statements made here. Click on the left-hand box if you fully agree with the statement. In the right box you can write a comment if you only partially agree with the statement or if you have further comments.

Third Round
We welcome you to the third round of the Delphi survey "Development of an interprofessional curriculum on complementary and integrative medicine" Thank you very much for participating in the first and second survey rounds! This third survey round is somewhat shorter and will take up a few open questions. It is very important that you work through this survey completely, because at the end you will have the opportunity to provide some personal information on how you would like to be further involved. The survey is divided into four short parts: Part A: General questions, B: Questions about treatment reasons and disease patterns, Part C: Questions about role competencies, Part D: Personal data and feedback.