Scientic Worldview Differences Between Allopathic Medical Degree and East Asian Medicine Degree Students

Background Integrative medicine has become a new healthcare model due to the growing evidence base for complementary and integrative therapies. However, some question whether complementary and integrative therapies can truly be integrated with biomedicine due to differences in underlying paradigms and theoretical bases. This study aimed to explore differences in scientic worldviews between students studying East Asian medicine and those completing an allopathic medical degree using the validated Thinking about Science Survey Instrument (TSSI). Methods 122 medical students from Albert Einstein College of Medicine (Einstein) and 48 East Asian medicine students from the Pacic College of Health and Science (Pacic College) participated in this study. Participants completed the TSSI, a 60-item Likert-scale instrument that quantitatively measures the sociocultural resistance to, and support for science. Item and category means were compared for each group using the two-sample t-test. Results Einstein students were generally supportive of science and Pacic College students were generally supportive of/positively neutral to science. Einstein students more strongly armed the relationship of science in relation to the categories of Epistemology, Public Health, Emotion and Aesthetics, the Economy, and Public Policy. Pacic College students more strongly armed the relationship between science and the category Race and Gender. There were no differences in the categories of Environment and Resource, Science for All, and Religion and Morality. Conclusion This study suggests that there are differences underlying the scientic worldviews of Einstein and Pacic College students, particularly with regard to Epistemology and Public Health. Such differences may be related to the different theoretical knowledge bases and ways of viewing health within the two disciplines. Our study also suggests that both groups may be receptive to the value of other paradigms. Providing courses that focus on different therapeutic approaches and paradigms during medical training may foster interprofessional understanding and collaboration between providers of different medical disciplines.


Introduction
Over the past several decades there has been a growing interest in complementary and integrative health (CIH), an approach that encompasses many practices, interventions and products outside the origin of conventional Western medicine (biomedicine). 1 The National Institutes of Health (NIH), National Center for Complementary and Integrative Health (NCCIH) categorizes CIH approaches into "mind-body practices" (e.g. acupuncture, yoga, chiropractic, etc.) and "natural products" (e.g. herbs, vitamins, supplements etc.), and refers to them collectively as Complementary Health Approaches (CHAs). 1 The healthcare model in which CIH and biomedicine are practiced together is called integrative medicine.
There have been many interprofessional education initiatives in biomedical and CIH institutions. In 2000, the NCCIH, through the R25 grant mechanism (the Complementary and Alternative Medicine [CAM] Educational Project), funded 15 biomedical institutions to incorporate CIH into their degree programs. 2 A second round of NIH R25 educational grants (the CAM Practitioner Research Education Project Grant Partnership) enabled nine CIH institutions to implement research and evidence-based medicine (EBM) into their degree programs, in partnership with a research-intensive institution. 3 One such interprofessional education initiative is the interprofessional education student exchange program partnership between Albert Einstein College of Medicine (Einstein) and Paci c College of Health and Science (Paci c College; formerly Paci c College of Oriental Medicine). 4 Participating students engage in interprofessional learning activities inclusive of lectures, clinical observerships, and dissection laboratory classes.
Despite the public demand 5,6 and rise in popularity of integrative medicine, some question whether the vastly different paradigms of CIH and biomedicine can truly be integrated. 7 CIH is derived from prescienti c theories and philosophies, while biomedicine is based on bioscience. 8 Since biomedicine is the dominant medicine in the US, some argue that CIH cannot maintain its integrity if it becomes coopted and "reconstructed on a scienti c foundation." 8,9 Previous studies have indicated that although CIH students found science and the scienti c method valuable, they were wary of its relevance to clinical practice. 10,11 In particular, they viewed the scienti c method's reductionist approach, such as the randomized controlled trial (RCT), as incapable of assessing a holistic medical system such as East Asian medicine. 9 Issues have also been raised about the value of CIH education in medical degree programs. One study reported that CIH education was thought to be valuable due to providing a more holistic perspective to patient care. 12 However, questions arise as to which CIH therapies should be incorporated into an already dense medical curriculum, especially considering the inconsistencies in scienti c evidence supporting the e cacy and effectiveness of the various CIH therapies. 2 Another concern is to extent to which medical students would be expected to incorporate CIH education into their clinical practice. 2 This nuanced relationship led us to inquire about allopathic medical degree and East Asian medicine students' basic views of science and its relationships with areas such as epistemology (knowledge) and health, and how such views may differ between these two groups. Understanding students' perspectives is especially important as they represent the future of our healthcare system. Through this study, we aim to provide a quantitative narrative on how these two groups may value science differently in the context of important socio-cultural issues, and how these differences can be overcome as we face increasing integration of different healthcare disciplines.

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A convenience sampling technique was used. The annual Einstein-Paci c College interprofessional exchange program allows students from the respective institutions to participate in a non-graded elective. These include Einstein students in their rst year of the four-year medical degree program, and Paci c College students in their nal year of the three year and eight-month Master's degree program. This cohort of 170 Einstein and 109 Paci c College students were invited to participate in the study.

IRB and Survey Implementation
Use and implementation of these surveys was approved by the Einstein and PCOM institutional review boards, and informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations. The surveys were implemented using Einstein's Research Electronic Data Capture (REDCap) system. A link to the survey was emailed to the Einstein and Paci c College students, followed by two reminder emails one week apart. Survey participation was voluntary with no penalty for non-participation. Students were offered a $10 amazon gift card for completing the survey as well as being entered into a lottery to win an Apple iPad.

Survey and TSSI
This study utilized the Thinking about Science Survey Instrument (TSSI). The TSSI was preceded by demographic questions and questions that allowed participant tracking. The TSSI is a validated tool intended to quantitatively measure how subjects value science with regard to other socio-cultural aspects of society. 13 It was originally developed to measure pre-service elementary teacher's attitudes towards science, with the concern that the public at large, including elementary teachers, resist the paradigm of science, and view science incongruently with their personal beliefs about other areas of life. 13 In addition to the original population, the TSSI has also been used to study attitudes towards science held by the general U.S. public 14 and undergraduate university students. 15,16 The TSSI consists of 60 items containing a statement expressing a particular view about science in relation to other areas of culture and society. Question responses use a standard 5-point Likert agree/disagree scale. Each of the sixty items measures the respondent's view against a "common image of science," 13 and falls into one of nine categories representing different aspects of society. The creator of the TSSI stated that "these categories are not intended to represent an authoritative scienti c worldview, but a scienti c worldview version commonly found in both the popular media and the literature of science and science education." 13 Twenty-seven items required reverse scoring to create consistency when included as part of a category because they contain negatively worded questions for the resistance to science. Reversed questions have been indicated with 'R' in the results table, with the items presented with their original wording. While reverse scoring was used for analyses performed within categories, individual item means re ect the scores assigned to the item as worded (i.e., non-reversed).

Data Analysis
For each survey item, mean scores were computed for the Einstein and Paci c College students and compared using the two-sample t-test. 17 Analyses at the survey category level (nine categories) were also performed by rst averaging for each participant their scores across all the items in that category to generate a category score, and then performing a two-sample t-test between the Einstein and Paci c College groups of the category scores. A two-sided p < 0.05 was considered statistically signi cant.

Demographics
Demographic data is shown in Table 1. The response rate was 72% (n = 122) for Einstein students and 44% (n = 48) for Paci c College students. There were distinct differences between the two groups with respect to gender, age, and prior education. The Einstein students had a relatively even distribution of male and female students, whereas the Paci c College students were predominantly female. The latter group was also generally older than the former. Most students at both institutions held a bachelor's as their highest degree, although Paci c College contained more diversity among the remaining degree possibilities. TSSI Survey Table 2 shows the nine TSSI categories and their corresponding item means for the two student groups, ordered by smallest p-value. The criteria for alignment with the model (supportive of science) is a score between 3.51 and 5.00, whereas neutral to the model is between 2.51 and 3.50, and against the model (resistance to science) is between 1.00 and 2.50. Of the 60 items within the nine broad TSSI categories, 22 showed statistically signi cant differences between the Einstein and Paci c College students.  Figure 1 visually depicts the data in Table 2. The pale grey shaded area is the neutral range. The area above the neutral range represents scores that are consistent with the model (greater sociocultural support for science), and below as inconsistent with the model. From this gure, it is evident that neither group is 'anti-science' in any of the TSSI categories, with the majority of scores being above neutral or on the positive end of the neutral range. The nine categories and their items will be discussed in more detail below, by order of the category with the greatest statistically signi cant difference between the student groups.
Epistemology Category ("Science is a superior, exemplary form of knowledge that produces highly reliable and objective knowledge about the real world." 13 ) In the Epistemology category Einstein students were neutral (M = 3.07, SD = 0.64), and Paci c College students were barely neutral (M = 2.61, SD = 0.71), scoring signi cantly lower than the Einstein students (p-value < .0001). In ve of nine items in the Epistemology category the two groups showed signi cant differences (Table 2), and Einstein students scored higher on all ve of these items.
Public Health Category ("The conquering of disease and physical a iction and the great advances in public health are made possible by science and will not continue without science." 13 ) In the Public Health category Einstein students showed a signi cantly greater level of agreement (M = 3.93, SD = 0.58), compared to Paci c College students who bordered the upper neutral zone (M = 3.49, SD = 0.55; p-value < .0001). The students exhibited signi cant differences in all four Public Health items (Table 2).
Emotion and Aesthetics Category ("Scientists are often passionate about their work but the work of science best proceeds on the basis of objective reason and empiricism. There is a beauty to science. Indeed, "elegance" is often required of scienti c ideas." 13 ) In the Emotion and Aesthetics category Einstein students scored above the neutral zone with a mean of 3.80 (SD = 0.50), whereas Paci c College students were neutral with a mean of 3.49 (SD = 0.49), and the difference was signi cantly different (p-value = 0.0004). Among the four items in this category, three were signi cantly different ( Table 2).
Economy Category ("Modern industrial, commercial, and information-based economies depend on the scienti c developments for increasing production, wealth and general public welfare." 13 ) Both groups aligned with the model (Einstein M = 4.16, SD = 0.42, Paci c College M = 3.92, SD = 0.41), although the difference was signi cant (p-value = 0.0008). This is the highest ranked category for the Einstein students and the second highest ranked for the Paci c College students. Two out of the 10 items in this category showed signi cant differences between the two groups ( Table 2).
Public Policy Category ("Science acts in the public interest. Science should thus be supported by public funds, however, the science community is more than capable of policing scienti c activity." 13 ) In the Public Policy category both groups were neutral (Einstein M = 3.29, SD = 0.36, Paci c College M = 3.10, SD = 0.38), although Einstein students scored signi cantly higher (p-value = 0.0027). Among the 10 items in this category, four were signi cantly different between the two student groups ( Table 2). Religion and Morality Category ("People make moral choices about the use of scienti c ndings but science itself is morally neutral. Science is also neutral with regard to religion. The importance of science, however, is such that science must be protected from the intrusive activities of some religions." 13 ) In the Religion and Morality category both groups scored in the negative range of neutral, with a mean of 2.68 (SD = 0.72) for Einstein and 2.60 (SD = 0.54) for Paci c College. The mean difference for the category, and for all of the seven items was not signi cantly different between the two student groups (pvalue = 0.5211).

Discussion
This study evaluated and compared the scienti c worldview differences between medical degree and East Asian medicine students. Our results indicate that, of the nine categories, Einstein students were overall supportive of science, whereas Paci c College students were supportive of/positively neutral to science. Einstein students more strongly a rmed the relationship of science in relation to the categories of Epistemology, Public Health, Emotion and Aesthetics, the Economy, and Public Policy. Paci c College students more strongly a rmed the relationship between science and the category of Race and Gender.
There were no differences in the categories of Environment and Resource, Science for All, and Religion and Morality.
Several important trends were seen in the demographic data. The Einstein students were almost evenly distributed between male and female whereas the Paci c College students were predominantly female.
These numbers similarly re ect the gender distribution in their respective institutions. 18,19 The Einstein students were more than twice as likely to have studied the natural sciences before matriculating to medical school, as compared to the Paci c College students. This difference is most likely due to the basic science prerequisite coursework needed to apply to a United States (US) medical school, a requirement not shared in US East Asian medicine schools. This would likely have imparted greater scienti c knowledge for Einstein students and may explain why they are more supportive of science overall. The Paci c College students were generally older than the medical students, possibly because the students surveyed included 1st year medical students and senior year East Asian medicine degree students. Another possible explanation for this may be that many students of East Asian medicine in the US pursue this eld as a second career and/or have completed graduate school training, therefore matriculating at Paci c College at a later age than most medical students who pursue a medical degree immediately after completing their undergraduate degree.
Both groups of students endorsed the crucial role science plays in facilitating many advancements and improvements to society, as re ected in their a rmations that "scienti c knowledge is useful" (item 51) and that "there are many good things we can do today because of scienti c knowledge" (item 25). As upcoming healthcare professionals, both groups appreciated the value science has in regard to public health, a rming that "scienti c research makes important contributions to medicine and the improvement of public health" (item 48). For the Paci c College students, this suggests that subscribing to a paradigm that is different than biomedicine does not equate to anti-science beliefs, and counters the stereotype that has sometimes been used to describe CIH practitioners as "quacks." 20 There appears to be fundamentally different epistemological perspectives between the two groups of students, as suggested by the differences in the Epistemology category. These distinctions likely arise from the different theoretical knowledge base of the two disciplines. East Asian medicine builds from three conceptual principles -yin and yang, the ve elements and qi. 21,22 These abstract and immaterial principles contrast heavily with biomedicine, which builds on the natural sciences, such as biology and biochemistry.
These contrasting worldviews have established vastly different methodologies in obtaining knowledge. The methods of biomedicine "seeks to discover the objective truth about the natural world via framing hypotheses and subjecting them to rigorous experimental tests under controlled conditions." 8 The randomized controlled trial (RCT), which has undoubtedly made important contributions to modern medicine, is the representative method of assessing therapeutic interventions, because of its design to reduce bias. Einstein students support this model, a rming that "Scienti c knowledge is the most objective form of knowledge" and therefore "Science is the best source of reliable knowledge" (Epistemology, items 17 and 34). This has important implications because studies have shown that medical students and physicians rely on the results of RCTs and mechanistic studies to form an opinion about CIH. 23,24 Historically East Asian medicine had relied upon information on the lowest tiers of the evidence hierarchy 25 such as classical texts and expert opinion and experience to inform their practice. To meet modern scienti c scrutiny, many RCTs have been conducted to study East Asian medicine interventions, but they have often provided inconclusive and disappointing results due to methodological designs that fail to study the interventions in their original context. 26 Acupuncture RCTs have also struggled to produce an inert placebo-control, which brings into question whether they achieved the goal of minimalizing therapeutic effects. 27 This may explain why the largest signi cant mean difference in Epistemology was on item 33, "The methods of science are the most reliable source of true, factual knowledge." Our results may suggest that Paci c College students don't think the preferred methods of science can wholly encapsulate the complexities of East Asian medicine. Alternative methodologies such as mixed-methods, whole-system approaches, and pragmatic clinical trials have been recommended to more accurately assess CIH interventions. 28,29 The fact that the Einstein students scored in the neutral range in the Epistemology category suggests that although they believe science is the most ideal method of knowledge creation (items 17,34,33), it has limitations (items 2,44,27). This suggests that Einstein students may have awareness of and/or may even potentially be open to other worldviews, a notion presented in previous studies. In one medical school where students undertook a mandatory CIH course, the students appeared "willing to challenge their pre-existing beliefs about medicine." 12 In another study that explored physicians' views, those who had positive views of CIH often had a history of exposure to CIH, which likely prompted a shift in their worldview, with one physician stating that CIH "described human nature in a way that I could recognize." 30 The Paci c College students' neutrality in the Public Health category may be related to their perception that the holistic aspects of East Asian medicine are not fully compatible with the more reductionist approach of biomedicine. The emotional, spiritual and cultural determinants of health are central to East Asian medicine. In many ways this is conceptually similar to the biopsychosocial model of care. 31 Although the Einstein students a rmed the Public Health category overall, they expressed neutrality to the statement "Scienti c knowledge is the single most important factor in the improvement of medicine and public health" (Public Health, item 8), and this item had the highest degree of variance in this category. This variability may re ect the gradual societal acceptance of the biopsychosocial model and the social determinants of health, and the fact that Einstein endorses this model and introduces it early in their medical curriculum. Previous studies have shown that medical students and physicians were aware of CIH as a distinct model of care that embraces holistic, self-care and behavioral change. 12,32 The Einstein students were also more opposed to the statement that "Common sense contributes more to good health than does scienti c knowledge" (Public Health, item 9). This could suggest that while common sense can contribute to good health, it may cause physicians to miss important diagnoses if taken in lieu of more sophisticated procedures such as imaging and blood tests.
The remaining categories contain other important group-and item-level distinctions concerning the contextual valuation of science. Taken as a whole, our data suggests that Einstein students are generally more favorable of science with regard to broader areas of society indirectly related to medicine. One exception is in Race and Gender category, where the Paci c College students perceived the scienti c community to be friendlier towards women and minorities than the Einstein students. This view may be a re ection of their comparably limited exposure to the eld of academic medicine.
An unexpected nding in the Science for All category was that Paci c College students more strongly a rmed that university-level students should study at least some science. Previous studies on Paci c College students have shown they highly valued scienti c research to elevate the profession and improve patient care. 33 This utilization of scienti c research could explain their advocacy for university-level scienti c education.
There are several limitations to this study. The speci c institutions from which the participants were sampled may not represent all allopathic medical and East Asian medicine institutions in the US. Another limitation concerns the low response rate in Paci c College students (44%), compared to that of Einstein students (72%). In general, the Paci c College students are older and therefore may have lower rates of computer and internet literacy/usage, possibly leading to lower response rates. 34 It is also known that response rates tend to be higher when the participants nd the survey topic interesting. 34,35 Since the TSSI deals with scienti c worldviews, it is possible that Paci c College non-respondents were not interested in the topic. This may have produced data indicating a more positive scienti c worldview perceived by the Paci c College students. Overall, Einstein respondent demographics did not greatly differ from the entire class of 2020, so we can't point to evidence of response bias. However, there is not enough information from Paci c College non-responders to infer a lack of non-response bias.
We did not provide the opportunity for free responses, which would have justi ed and clari ed the answers chosen by the students. Gathering more qualitative data on these areas could perhaps be undertaken in a future study. Lastly, this study was undertaken before the coronavirus pandemic, which very likely would have impacted the results of the study.

Conclusions
This study suggests that there are differences underlying the scienti c worldviews of Einstein and Paci c College students, which may be a re ection of the paradigms their respective medicines hold, and which can present a barrier to integration. The creator of the TSSI argued that if there is resistance to a paradigm, that "in-paradigm" education efforts, such as enforcing more scienti c education in hopes of increasing interest, enthusiasm and approval of science, is ineffective. 13 Studies on East Asian medicine students support this theory. In several US East Asian medicine institutions, more research education was negatively correlated with research interest. 10,11 Despite the difference in worldviews, neither group of students hold extreme views for or against science, and therefore may be receptive to learning other perspectives besides their own. Worldview consciousness is an important clinical skill to facilitate communication and receptiveness, and to reduce implicit bias. 36 To foster this skill, courses on different beliefs, cultures and worldviews should be taught early in medical school curriculum to encourage collaboration and communication between biomedical and CIH students. 4,36 List Of Abbreviations Category means of allopathic medical degree students and East Asian medicine degree students. Legend: Category means of medical degree students (n=122), represented as grey columns and East Asian medicine degree students (n=48), represented as white columns and ordered by smallest p-value.