gms | German Medical Science

Despite some very critical views of complementary medicine in the media [1], [http://www.spiegel.de/spiegel/print/index-2010-28.html] (last viewed on 02.12.2013), [http://www.zeit.de/ 2010/50/index, last viewed on 02.12.2013], interest amongst the public in complementary medical treatments, including homeopathy, has been steadily increasing in recent decades [2]. For patients with statutory health insurance, there are growing possibilities of recovering the costs of integrated care incurred by individual complementary medical procedures. The cost of some prescription medicines such as those which fall under anthroposophic medicine, homeopathy and herbal medicine can also be claimed [http://www.aerztezeitung.de/news/article/683357/tk-zueckt-geldbeutel-rezeptfreie-arzneien. html] (last viewed on 02.12.2013). In 2010 there were approximately 32,000 alternative practitioners in Germany with a CAM interest [http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/&p_aid=i&p_aid=35521390&nummer=85&p_sprache=D&p_indsp=-&p_aid=97191314] (last viewed on 02.12.2013). In 2011 6933 doctors with additional training in homeopathy were added to their number [http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/&p_aid=3&p_aid=35521390&nummer=612&p_sprache=D&p_indsp=-&p_aid=73019886] (last viewed on 02.12.2013). The integration of complementary medicine into medical education in Germany is still inadequate and does not reflect the increased patient demand; this is also true in other parts of Europe [3], [4]. Only six of the 36 medical schools in Germany possess professorships in CAM [5]. Since 1993 homeopathy has been a taught and examined subject in many medical studies, and since 2003 in the medical licensing regulations [6] there has existed the cross-cutting field 12: "Rehabilitation, physical medicine, naturopathic treatment" (cf. the importance of complementary medical content for medical profession development, [7]). Other forms of integration of homeopathy and complementary medical procedures have also been established [8], for example, as clinical electives [9]]. At the Institute of General Practice, University of Magdeburg, the course in homeopathy has been offered since the winter semester of 2008/2009. It accompanies an elective in Traditional Chinese Medicine in the summer semester, both requiring four hours of study per week (56 total hours).

The homeopathy elective course takes place over three weekends in Magdeburg and in Köthen as a block with a total of 56 hours (four hours per week). Due to the interactive and hands-on nature of the event, the number of participants is limited to a maximum of 15 students. In the first year it was offered to fifth year students, but following the results of the first group discussion, the event has been open to students from their third year of study. The elective is conducted by Dr. Krémer, who is a specialist in anaesthesia. She has worked since 1995 in an established practice in Berlin as a GP and has an additional qualification in homeopathy. She has many years of experience as a lecturer in this context. The seminar concept with the learning objectives (see Table 1 [Tab. 1]) was developed jointly by the Institute for General Practice and Dr. Krémer.

The following teaching methods are utilised: introductory lectures followed by discussion; performance of practical exercises; student presentations on a self-chosen topic. The student's presentation and the written report form the basis of the performance record. In addition, each year there is a one-day excursion to Köthen, the origin of homeopathy, including a visit to the European Library for homeopathy used by students for literature research. To test the effect of a homeopathic remedy itself, students have the option of taking an undisclosed drug for three days, and then for a week to note any occurring somatic effecs, to determine if the characteristics of taking the medicine occur in a blind test.

As part of the evaluation of the course, the students were asked about their motivation to participate, their prior expectations of the seminar and their opinions on the seminar concept. As well as this, their learning experiences were sought, especially in comparison to the conventional medical approach, and how homeopathy might impact their future career plans.

The survey method was a qualitative approach – a group-discussion guided by specific questions. This was carried out at the end of the event: in 2008/ 09 with 14 students (11 women), in 2010/11 with 5 students (2 women), and in 2011/12 with 11 students (10 women); organizational reasons unfortunately precluded group-discussions in 2009/10. Questions were modified or supplemented based on the evaluation of previous group-discussions, in addition to questions that were used in all year groups (questions 1 to 5, see Table 2 [Tab. 2]). This is in the sense of an iterative approach. Hence in 2011/2012 questions 6-8 were used in addition, sharpening the focus on professionnal formative elements and the acquiring of medical basic skills.

The content of the group-discussions were: motivation for participation, evaluation of the seminar concept, points of view regarding the concepts of homeopathy and conventional medicine; the course of the discussions was fairly fluid (see Table 2 [Tab. 2]).

Two facilitators led the group discussions, which lasted about 60-80 minutes. The discussions were digitally recorded and fully transcribed. Evaluation was made on the basis of Mayring's qualitative content analysis [10].

The statements were coded, on the basis of the categories in the Guide, as well as any further obtained inductively from the material of the group discussions. Analysis of the material was carried out by two social scientists independently. Following the analysis, results were discussed in the research group and validated by recourse to the transcripts until a uniform analysis was apparent. With this procedure, an attempt was made to achieve the highest possible standards in terms of the criteria for qualitative research.

The results can be divided into several main categories and sub-categories (see Table 3 [Tab. 3]).

Both students who had already some experience with homeopathy (themselves or in their families and friends), as well as students with no previous access to homeopathy attended the course. It is striking that some students opt for this elective who are rather critical of homeopathy: “I 'm even more critical now of the whole subject, because before, I had only read a little something about it” (2/E/2).

A common desire was to provide to patients general information on homeopathy, and to be able to form their own opinions on it. Many students had an interest in getting to know the history, theoretical basis and mode of action of homeopathy and thereby to establish a reference for practice as well.

Another basic desire was wanting to know more medical approaches in addition to conventional medicine. Reasons included limitations of conventional medicine or negative experiences thereof (eg lack of time during patient contact, rigorous rejection of alternative approaches by doctors or teachers). The elective course offered another "viewpoint on people and on medicine" (3/H/3).

The seminar concept is consistently positively evaluated by the students, as it provides good insight into the effectiveness and operation of homeopathy. The design as a block seminar is experienced as stressful, but at the same time regarded as important to aid the understanding homeopathy and it's contrariness to conventional medicine, (which is both necessary and useful). A balanced combination of theory and practice was positively evaluated by the students. In addition to editing and discussing patient cases, students valued their own ingestion of a homeopathic medicinal product as an important experience.

The students consistently evaluate the lecturer as very positive. Her professional background, particularly its conventional medical training, is thought to be significant. Her suggestion, that conventional and complementary medicine should be seen, rather than as two mutually exclusive alternatives, but as integrated, was greatly appreciated by the students. For the students this included both the limitations of conventional medicine as well as homeopathy. Overall, the teacher was considered a relevant figure, illustrating the connection between conventional medicine and homeopathy practised in personal union - clearly authenticity and credibility play a central role here. To the students, it is important that the teacher had not "(...) wanted to convert (...) that everyone was free to form their own thoughts and to form their own opinion and that was just good" (3/A/14).

The high practical relevance of the seminar was assessed positively by the students, as the whole concept of homeopathy is viewed by some as very different to the conventional medical approach. By taking an unknown homeopathic remedy, the students reflected on the resulting autogenous sensual sensations: "So one has noticed it immediately, I would never have thought so, that it would clearly and quickly give symptoms" (3/A/12). An initial irritation with respect to the homeopathic approach was experienced by some students in the seminar. However, it was also understood that it was important to engage with the unknown thinking and working of homeopathy: "(...) it was necessary to think in another style (...) I was really, really suspicious at the beginning. But I mean: Ok, if you let yourself get involved" (3/A/11).

Dealing with different traditions of thought of homeopathy and conventional medicine is experienced by some students as problematic and leads them to view homeopathy partly as "not satisfactory" (2/A/3), because homeopathy isn't able to tie to conventional medical training. For some individual students after the seminar doubts remained: "I am still a little critical" (1/C/9).

When comparing the two approaches and their active principles on certain dimensions students particularly found striking that homeopathy usage is advocated much earlier, for example it may be taken to treat mood disorders that would not be, in the classical clinical picture, yet considered serious.

In addition to this early approach of homeopathic treatment diagnosis and treatment played a central role for the students. In contrast to their previous experiences in conventional medicine, the lengthy history taking was valued. Also diagnosis and treatment are associated in homeopathy with more time, where practitioners may adopt an attitude of trying, waiting and if necessary correcting. In conventional medicine, the students usually view the opposite approach, and the long-term effect of homeopathy was questioned: "(...) there is a quick treatment which may then bring a short-term improvement, but then the question is whether there was any long term improvement for the best" (2/E/18).

Another important difference between the two approaches for students is the specific patient orientation in homeopathy: it is not the disease but the sick person at the centre. Critical impressions in this context are reflected in the recent medical education: "you noted that you have been previously trained to lead, not to respond to the patient (...), and it was even bad, if you have allowed somehow too long for history taking (...)" (3/C/6).

In this context the students also discussed that the patient was considered in a far more comprehensive manner in homeopathy than would be the case in conventional medicine, with more symptoms considered, guiding them to specific diseases. Using this increased patient orientation and more comprehensive perception of the patient experience, the students searched for the "primary", which is tailored to the individual patient illness problem: "Because sometimes the symptom is not the disease" (3/A/6). This individualized approach of homeopathy is experienced in contrast to their current medical education as: "(...) the first time in medical school away from evidence-based medicine back towards the individual" (1/D/3).

The above-mentioned aspects were noted as particularly characteristic of homeopathy by the students (patient orientation, holism, take your time, etc.). Despite the personal union of the lecturer who integrated conventional and homeopathic medicine, a doctor dichotomous picture was felt to exist. They experienced this in the seminar with the doctor image as a partnership, so the patient will take on a higher level of responsibility, "so that the patient is held responsible for themselves. Indeed that was now, that is now, a theme that I was particularly impressed with" (2/A/15). Although the doctor image was perceived by the students as a positive enrichment of their previous medical role, the faesibility of this in everyday practice was also critically examined.

Regarding the possible future use of homeopathy in the professional arena, the group discussions followed a wide range of different anticipated usage pattern, and can be graded in summary as follows:

• Extensive use of homeopathy as a distinct approach later
• Integrate homeopathy into conventional medical practice
• Offer homeopathy as an option to interested patients
• Not use homeopathy as an approach, but take on individual aspects (eg patient orientation)
• Not use homeopathy itself, but advise patients on options
• Homeopathy of no relevance to future jobs
• Homeopathy is not of any interest.

Overall, the knowledge of theory and practice of homeopathy was viewed positively by the students, regardless of whether they wanted to work with homeopathy in later professional life or not: “(...) then I take still very, very much with me, for conventional medicine and, as well, it is almost a pity that (...) those things that play a big role in homeopathy, come up short in our other studies (...)" (2/A/19). A key point here is that the high level of patient orientation, as well as the holistic and individualized view of the patient is an important learning experience for them to adopt as later physician behaviour: "The holistic approach of homeopathy (...) is a very central point and you can definitely take (...) and that's one thing (...), which is very relevant for clinical use later" (1/C/10).

Even if the students view positively their homeopathy experiences (especially the patient orientation and holistic perspective) and would like to integrate it into their studies and professional life, they feared limiting factors, as soon as they have to take more responsibility in the supply chain "(...) it may remain, just in the practical year, (...). So, that you just might leave it there and then maybe prescribe the wrong medication, that's actually almost logical somehow" (3/C/7).

Other anticipated problems:

• difficulty working with colleagues critical of homeopathy;
• lack of knowledge of patients regarding homeopathic treatment options;
• limited possibilities of combining conventional medicine and homeopathy in clinical practice due to the different time patterns;
• structure of the German health care system as an obstacle for greater patient orientation;
• problems combining the individualized approach of homeopathy and evidence-based conventional medicine, "you can certainly in conventional medicine use drugs, which are always tested for the general public, but that does not make it right" (3/D/6).

Against the students' background, the long-term effects of the homeopathy course in concrete everyday work were viewed critically: "So you have become aware of this, but if you can maintain this sensitivity now, I do not know" (3/D/7).

The elective homeopathy at the University of Magdeburg represents a new and innovative aspect to the curriculum, which has been successfully established in the last five years and well accepted by a heterogeneous group of students. In particular, the combination of theory and practice, and the preparation of the compounds as well as the possible integration of conventional medicine and homeopathy are positively evaluated by students.

The student responses concerning basic medical skills were that they were practised and deepened: more time for history-taking, case observation and illness course are appreciated – especially with respect to individual patient orientation. Symptoms are not only taken as a sign of a specific disease, but in terms of the patient-oriented and holistic approach, the individuality of the patient and the illness are both further emphasised. In general practice, the patient perspective is particularly relevant, where people experience themselves as sick (within the meaning of illness) and in the sense of the hermeneutic principle of treatment (in the sense of disease). Especially in general practice, this is conceived as a chain of interpretive, hermeneutic actions, as a common understanding between doctor and patient [11].

It is not the disease but the person as a patient in a dialogue with his doctor who is central. The attitude of trying, waiting and possibly correcting is presented and practiced in the elective. Patient orientation, in which the holistic and individualized views of the patient, is used as an important learning experience for many students. The doctor -patient relationship is experienced as a partnership, for which the patient undertakes a greater degree of responsibility.

It is interesting that the positive evaluation of the seminar is independent of whether the students were critical of the homeopathic approach or not. There were also students, who viewed the insight into homeopathy as positive, but due to a perceived discrepancy between conventional medical training and the homeopathic approach do not want to use it as a future treatment.

Here, the lecturer had a special role to play in this, to challenge many prejudices associated with the topic. She challenged the students own professional development, which took place in the conventional medical context, and identified numerous common factors. Equally, her critical openness, lack of dogmatism and authenticity facilitated the students grappling with the somewhat controversial subject of homeopathy. A fundamental difference, as perceived by the students between homeopathy and conventional medicine, is the perception of the people or patients. Thus, evidence-based medicine can in part be perceived as opposed to individualized medicine, although in the original concept, the external evidence was only one pillar next to the individual patient's wishes and the individual doctor's expertise [12]. One could ask how these three ever became disconnected in medical education.

The high level of patient orientation, accompanied by a partnership - style doctor - patient relationship, a holistic orientation, the emphasis on individuality and subjectivity (cf. to distinguish [13]) and the personal responsibility of the patient in homeopathy, was for the students an impressive experience. Regardless of whether they want to continue to work in homeopathy or not, this experience was regarded by them as positive and important for their subsequent medical education.

The learning experiences of students in the homeopathy elective are not tied exclusively to this approach and its use. Rather, in the seminar, important aspects of the doctor - patient relationship are conveyed, which are discussed in the context of regular medical studies from the perspective of students. This complementary perspective on the patient and the work of a physician / doctor could be an important starting point to reflect on the homeopathic approach and related behaviours in medical school. The acceptance of the complementarity of various medical approaches could create opportunities to improve the teaching of medical basic skills in medical education.

Back in 2001, Swayne pointed to the possible contribution of homeopathy to the core curriculum of medical studies: comprehensive medical history, learning and emphasis on the subjectivity and individuality of the patient, focusing on self-healing and the integration of physical, psychological, social and spiritual dimensions of life and health [14].

The results presented here must be considered in the context of potential limitations. Firstly, the results should be seen in the context of voluntary participation in an optional subject, which is clearly a positive selection bias of interested students. It can be assumed that a fundamental, though possibly critical, interest in the subject of homeopathy was present in all participants. Had this event been compulsory, eg "rehabilitation, physical therapy, naturopathic treatment" offered as part of the cross-cutting field 12, the results would certainly have been more wide-ranging and perhaps critical. In this respect it would be interesting to interview students after their attendance of the cross-cutting field 12, for their impressions, evaluations and comments concerning complementary medical procedures. Limitations also arise due to the size of the surveyed student numbers, which stood at a total of 30 students, as well as the variable group size (between five and 14 students). Furthermore, the survey of students was carried out immediately after the homeopathy elective course, so no statements about the medium or even long-term effects of the seminar visit could be made. It would be interesting to survey students, for example, after a year, or at the end of their studies. The special role of the teacher as a mentor should be noted when evaluating the statements of the students: her central position was significant so it can be assumed that the lecturer herself was an important factor in the assessment of the seminar, as well as the evaluation of homeopathy by the students.

The hermeneutic case principle is especially important in general practice, as well as the consideration of the subjective side of disease, and a holistic and individualized view of the suffering and the plight of the sick. This can be learnt in a professional setting which may then make deficits in the training of medical basic skills more obvious.

The results of the elective course support efforts to better integrate homeopathic approaches and complementary medical procedures in general in medical teaching and research, as a means to teach and train basic medical professional skills.

There are already today various efforts to integrate those approaches into the study of medicine, for example, by the GMA Committee Integrative Medicine and Pluralism [https://gesellschaft-medizinische-ausbildung.org/ aktivitaeten/ausschuesse/integrative-medizin.html, last viewed on 22.01.2014] as well as in the student context, for example, the university working groups forum for naturopathy and complementary medicine [15].

Internationally, a possible contribution to the integration of complementary medicine in the study of medicine is also often discussed. The Scottish Deans ' Medical Curriculum Group (2007) highlights the following aspects in medical education: a discussion of the availability of CAM therapies; which ones are used; to what extent can conventional and alternative approaches be combined; therapeutic principles for the treatment and relief of symptoms, and an understanding of CAM for health care [16]. In the U.S., the issue of integration of CAM content is also a hot topic. For example, Wetzel et al discuss ten practical steps for the inclusion of CAM in medical education [17].

In order to achieve the best possible patient care, different approaches from different medical specialties should be combined and integrated as part of medical school teaching. The differences between the approaches should not be central nor should any apparent inconsistencies; rather the links and connections between conventional medical and complementary medical approaches should be emphasised. In this sense a form of integrative medicine as a "healing - oriented medicine which re-emphasizes the relationship between patient and physician, and integrates the best of complementary and alternative medicine with the best of conventional medicine" should develop to promote the best of what is already known in medical education ([18], p 851).

Initiatives such as the "Dialogue Forum for pluralism in medicine" with the aim of integrating different therapeutic approaches [19] should be encouraged not only in order to meet the needs of patients, but also those of medical students.

For teaching and research, accompanying financial support was granted by the Homeopathic Foundation and Carstens-foundation for which we are most grateful.

The authors declare that the have no competing interests.