Integrative and complementary practices: interest of the academic community and challenges of medical education

Introduction: Traditional Complementary and Alternative Medicine (TCAM) encompass therapeutic resources of complex medical systems from different medical rationalities. This field of practice has gained greater visibility in recent times, with the increase in demand for health care that prioritizes a more comprehensive approach of human beings, encouraging the health professionals themselves to seek better training. Objective: To evaluate the interest, the degree of knowledge and the attitude of students and teachers of the medical course towards the TCAM and the challenges for their effective teaching. Method: This is a cross-sectional, descriptive study with a quantitative approach, which was carried out with 214 individuals, 21 of which were teachers and 193 students attending the first to the twelfth semesters of the medical course at a health education institution in Recife-PE. An online survey was used to assess the study participants regarding their learning sources and the level of interest on this topic, as well as the Portuguese version of the Integrative Medicine Attitude Questionnaire (IMAQ). The data were submitted to descriptive statistical analysis (frequency and percentage), using software R, version 3.4.3. and LibreOffice. Result: Among the study participants, 57.14% of teachers and 35.42% of students were aware of the Nacional TCAM Policy (PNPIC, Política Nacional de Práticas Integrativas e Complementares), 85.71% of the teachers and 91.7% of students considered TCAM to be crucial for Brazilian Unified Health System (SUS). Most considered the teaching of TCAM an important subject for the undergraduate medical course (90.48% of teachers and 89.58% of students). The best known practices were yoga, phytotherapy and TCM/acupuncture and there was greater interest to learn yoga and TCM/acupuncture. Conclusion: A large number of students and teachers have never had contact with TCAM. However, most are willing to recommend them to patients and family members and are willing to learn about the topic. Thus, it is recommended that more studies be performed on this topic and that it can corroborate for their inclusion in health courses’ curriculum.


INTRODUCTION
Integrative and complementary health practices comprise a heterogeneous set of therapeutic practices, knowledge and resources that encompass medical systems from different medical rationalities. This field is called Traditional/ Complementary and Alternative Medicine (TCAM) by the World Health Organization (WHO) and involves approaches that seek to stimulate natural mechanisms for health recovery and disease prevention through techniques that emphasize user embracement and a comprehensive view of the human being in their physical, mental, social and spiritual scope 1 .
In the late 1970s, the WHO created the Traditional Medicine Program to create policies in the area 2 . Since then, there is an effort to encourage Member States to implement public policies for the rational use of TCAM in health care systems, as well as the development of studies to better understand its safety and quality 1 . It was from this perspective that, in 2006, in Brazil, the National Policy on Integrative and Complementary Practices (PNPIC) was created in the Brazilian Unified Health System (SUS). The PNPIC, working with 29 currently regulated practices, legitimized the public offering of activities that were already used by the population 3 .
The PNPIC in SUS still has little support, such as low financial incentives, few investments in professional training, poor evaluation and monitoring. However, it is recognized by the WHO that the TCAM are effective in areas such as mental health, prevention and treatment of non-communicable diseases and improvement in the quality of life of people with chronic diseases, as well as the aging population. Even with all the challenges, the search for these techniques has been increasing. The pursuit of a balanced health through interventions focused on a holistic view is growing, especially when building a health system that seeks, in one of its three basic principles, comprehensive care 4 .
It is essential to highlight the reality of the TCAM in Recife, state of Pernambuco, Brazil, where the institution evaluated in this study is located. The history of work in the area precedes the PNPIC itself, being a pioneer in providing these practices linked to the Family Health Strategy, such as the Professor Guilherme Abath Comprehensive Health Care Unit (UCIS), founded in 2002, and which is currently the field of medical residency practice in family health, as well as the Municipal Policy of Integrative and Complementary Practices in Health in Recife, created in 2012, which further strengthens the presence of these practices in the local health network 5,6 .
Considering the scarcity of studies and the population's growing interest in these practices, it is important that this topic be taken to the academic environments. The practical reality, however, goes against the population's growing demand for alternative therapies: there are many physicians who are unable to answer questions raised by patients about the use of TCAM, or about their mechanisms of action, indications, drug interactions or even adverse effects of these therapies 7 .
To understand the challenges of teaching TCAM, the prejudice and lack of information present in medical education adopted in Brazil call for attention. Despite the changes achieved with the National Curriculum Guidelines (NCGs), medical education is still influenced by the Flexner reform from early 20 th century North America, which favored medical training associated to laboratory diagnoses, performance of exams and procedures and fragmentation of knowledge in search of more efficient training. Due to the mercantilization of health, this model spread throughout the West and, therefore, TCAM were excluded from undergraduate schools, as they were considered "non-scientific" 8  Even with a medical curriculum that does not meet the need for the teaching on the subject, it was observed that, overall, medical students have favorable attitudes towards TCAM and wish to learn more on this subject. Additionally, they also consider the offer of TCAM in health services to be important and many students believe in the possibility of integrating them to the conventional Medicine 10 .
Therefore, this study aimed to assess the interest, level of knowledge and attitude of medical students and teachers towards TCAM and the challenges for their effective teaching.  The study population consisted of the students and teachers of the abovementioned medical course from the 1 st to the 12 th semesters, with a total of 1,084 students regularly enrolled in the institution, in any academic stage of the course, and a total of 88 teachers working in academic activities of the analyzed semesters (data from 2019). The non-probabilistic sample was defined by convenience, and consisted of 214 individuals, of which 21 were teachers and 193 students.
The study included people over 18 years of age, students who were enrolled in that medical course during the study period, and who were attending any of the course semesters, from the 1 st to the 12 th academic semesters; and teachers from that course, during the current period of this study. Students on a leave of absence were excluded from the analysis.
A questionnaire was used for data collection, The IMAQ is an instrument that originated from the need to have a self-applicable, reliable and psychometrically capable way of measuring the attitude of students towards Integrative Medicine to provide educators with a useful tool to sensibly implement, evaluate and review Complementary Medicine curricula. In 2015, the questionnaire was validated for the Portuguese language 9 , which is the version used in this study. It uses the modified Likert scale format, containing 7 points, ranging from -3 to +3, with -3 being equivalent to Strongly disagree and +3 Strongly agree. This instrument has a structure divided into two factors: the first is related to being open to new ideas and paradigms, containing 21 items -which is called "Openness" -and the second is related to the health professional's introspection values and the doctor-patient relationship -a factor called "Relationship" -containing 8 items.
Therefore, the IMAQ contains a total of 29 items and scores negatively or positively.
The online survey was constructed using LimeSurvey and emails were sent to the entire academic community of the course. Another strategy used to increase the number of respondents was contact through a messaging application.
The creation of the database and its analysis were   Would recommend TCAM to patients and/or family members 193 100

DISCUSSION
The profile analysis identifies a majority of female participants, which is in line with the national scenario of the feminization of medical work 11  in addition to the lack of knowledge about the care that the population already has access to and tends to increasingly seek 13 .
In order to have a health network that ideally encompasses TCAM, training for this purpose is necessary, linking the teaching-service-community. Nevertheless, the participants have favorable attitudes towards the inclusion of the topic in undergraduate school, since most consider the TCAM as essential and support a greater inclusion of their teaching in the curriculum, which is also recommended by researchers 13  As for the data related to the IMAQ, it can be observed that the positive total mean score, with a standard deviation that does not show extreme variations between minimum and maximum values, reinforces the existence of favorable attitudes towards more holistic approaches. Considering the factors of this instrument separately, in relation to openness to new ideas and paradigms, it can be said that despite the positive average value, it is still has smaller significance in relation to the maximum possible value, a fact that is associated with the resistance towards topics that deviate from the exclusively biomedical approach. Regarding the introspection factor and the doctor-patient relationship, the IMAQ demonstrates that, proportionally, there are more positive attitudes in comparison to the openness to topics such as TCAM.
It is important to emphasize that the results obtained from the assessed population cannot be taken as a representation of the entire universe of the target population, due to the selection bias identified during the questionnaire application. As this is a survey-type study applied through an online questionnaire on a virtual platform provided by the educational institution, there was the technological advantage of repeatedly distributing the questionnaire to all students and teachers, however, the restricted virtual format made the initially designed questionnaire become longer, a contributing factor to the non-response rate 17,18 , as well as discrepancies between the number of respondents from different periods of the course. Thus, the data analyzed here are representative only of the studied population and should not be extrapolated or taken as a concrete reality for the general public.
The assessment of knowledge, interests and attitudes of teachers and students about TCAM is a field that is little explored by health professionals in the medical education process. The results presented in this research are consistent with previous studies 14 that showed little knowledge of TCAM by health professionals and students. This is linked to the perpetuation of prejudice originated from the medical education reforms of the last century and the lack of learning on the topic throughout undergraduate school 13,15 , as consequence of the Flexner Report and its historical influence on Brazilian education. Currently, with the increasing inclination to break away from the disease-