THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 16, Number 11, 2010, pp. 1185–1190 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2009.0402
Interprofessional Collaborations in Integrative Medicine Sandra Grace, PhD, MSc(Chiro), DipEd, and Joy Higgs, AM, PhD
Objectives: Little is known about the implementation of integrative medicine (IM) in Australian health care and the nature of interprofessional collaborations that have been established in IM. The aim of this research was to examine the relationships among general medical practitioners (GPs) and complementary and alternative medicine (CAM) practitioners and their respective roles in co-located integrative practices. Design: This research adopted hermeneutic phenomenology as an effective methodology for revealing people’s experiences of IM and the meanings they attached to these experiences. Three (3) data collection methods were used: cumulative case studies, focus groups, and key informant interviews. Data analysis consisted of constant comparison of data from multiple sources to identify patterns and meta-themes. Settings/location: The setting for this research was Australian IM clinics where GPs and CAM practitioners were co-located. Results: Three (3) practice styles were identified among IM practitioners in this research: (1) mutually empowering when GPs and CAM practitioners regarded each other as peers, (2) GP-directed with varying levels of autonomy afforded CAM practitioners, and (3) limited collaboration where patients were offered mainstream medicine and CAM, which GPs performed themselves. Conclusions: IM practice styles differed in terms of interprofessional power-sharing and roles assigned to CAM practitioners. Practice styles where CAM practitioners were highly valued and able to exercise high levels of professional autonomy were perceived as making effective use of the available CAM workforce. Both GP-directed and intragrative practice styles (where GPs practiced CAM themselves without referral to CAM practitioners) were perceived by many GPs and CAM practitioners as enhancing patient safety.
ntegrative medicine (IM) encompasses a range of possible practice styles such as co-location, referral networks, and direct or intragrative medicine (where practitioners with training in both mainstream medicine and complementary and alternative medicine [CAM] practice their own personal style of integration).1–4 Much debate has focused on barriers to integration such as perceived safety and efficacy of CAM,5–9 the attitude of key medical personnel toward the value of IM,10 limited interpersonal and interprofessional communication,11–13 and the lack of shared vision among practitioners.14 However, the growing acceptance of this emerging model of health care is evident in the shift in debate from the legitimacy of CAM within health care to the effectiveness of IM delivery.15–17 There is also a growing trend for general medical practitioners (GPs) to refer for CAM services, although with a preference for referring to GPs with CAM training and not to nonmedically trained CAM practition-
ers.18–20 This referral practice has been rationalized in terms of the state funding that some CAM therapies (e.g., acupuncture) attract when carried out by GPs and not by nonmedically trained practitioners.20 This research focused on IM delivery in Australian practices where GPs and CAM practitioners were co-located. The aim of this research was to examine interprofessional relationships among GPs and CAM practitioners and their respective roles in co-located IM practices. Materials and Methods To understand peoples’ experiences of IM and the meanings and significance they attach to these experiences, a qualitative research strategy was appropriate. This research drew on van Manen’s21 hermeneutic phenomenology as an effective methodology for revealing people’s experiences of interprofessional relationships in IM practice. Phenomenological research examines the nature of human phenomena
The Education for Practice Institute, Charles Sturt University, New South Wales, Australia.
GRACE AND HIGGS
and the experiences of those who live through them, taking into account the contexts and subjective meanings participants give to particular situations. In hermeneutic phenomenology, the emphasis is placed on interpretations of phenomena that offer deep layers of meaning. The number of participants was not predetermined but evolved in response to the quality and redundancy of information that emerged from the data collection.22 The research involved three overlapping phases. In phase 1, cumulative case studies that combined data derived from several IM sites were used to examine practitioners’ perceptions about the advantages and disadvantages of IM, including referral among practitioners. As more CAM practitioners practice in NSW than in any other state and as most practice in metropolitan areas,23–25 three IM clinics in metropolitan Sydney were selected to provide maximum variation in number and diversity of medical and CAM practitioners, range of CAM services, and number of years in operation (Table 1). Data collection consisted of direct observation of the daily operations of each clinic for up to 10 days, and semistructured interviews with 11 practitioners (see Table 2 for interview guides). In phase 2, four focus groups of practitioners (two groups of CAM practitioners, one group of GPs, and one group of both CAM practitioners and GPs) provided an opportunity for in-depth discussion of issues raised in other phases, to incorporate new perspectives, and to test the credibility of emerging findings. Participants were recruited from advertisements disseminated via four seminars and from five IM practices, two of which were not involved in the case study phase. Five (5) GPs and 10 CAM practitioners who took part
in the focus groups had not previously been involved in the research. Each focus group had between 5 and 10 participants and lasted 1–2 hours. In phase 3, in-depth interviews were conducted with 6 key informants (3 GPs and 3 CAM practitioners) who were selected by purposive sampling on the basis of their standing as IM experts (number of publications, conference presentations, and/or clinical experience in IM). Each participant was interviewed up to three times for 1–1.5 hours on each occasion. This series of interviews provided an opportunity for the interviewees to express a wide range of personal insights about the practice of IM and to examine in depth emerging findings of the research. Interviews and focus groups were audiotaped and transcribed with participants’ consent. Data collection and data analysis were conducted concurrently by the researchers so that questioning and observation were progressively guided by the data. Data analysis consisted of repeatedly reviewing transcripts and field notes to identify emerging concepts. A key feature of the analysis process was constant comparison to identify conceptual similarities and themes in the data.26,27 Emerging themes were refined, expanded, or discarded throughout the data analysis process. Ultimately, a set of metathemes emerged from the combined findings from all phases of the research. Bracketing28 (acknowledging and reflecting on researchers’ own preconceptions) and triangulation29 (using multiple data collection methods, multiple perspectives, multiple data analysis reviewers, and regular peer review as external checks on the credibility of the findings) were used to reduce
Table 1. Profiles of IM Clinics in Case Study Phase Clinic Clinic 1
General medical practitioners GP1: WM, acupuncture, nutritional medicine GP2: WM, acupuncture, herbal medicine, nutritional medicine, homeopathy GP3: WM, anthroposophical medicine, herbal medicine, nutritional medicine GP4: WM, homeopathy GP5: WM, herbal medicine, nutritional medicine GP1: WM, acupuncture, herbal medicine, nutritional medicine
GP1: WM, nutritional medicine, counseling GP2: WM, nutritional medicine, environmental medicine, herbal medicine, acupuncture GP3: WM, environmental medicine, nutritional medicine, allergy testing GP4: WM, environmental medicine, naturopathic medicine GP5: WM, nutritional medicine, environmental medicine GP6: WM, bio-energetic medicine, acupuncture, homeopathy, nutritional medicine, parasitology GP7: WM, homeopathy GP8: WM, environmental medicine, nutritional medicine
CAM practitioners CAM1: psychotherapy CAM2: naturopathy CAM3: naturopathy CAM4: naturopathy CAM5: naturopathy CAM1: naturopathy CAM2: naturopathy CAM3: naturopathy CAM4: naturopathy CAM5: Reiki CAM6: remedial massage CAM1: naturopathy CAM2: acupuncture, Traditional Chinese Medicine CAM3: chiropractic CAM4: chiropractic
IM, integrative medicine; CAM, complementary and alternative medicine; WM, Western medicine.
Number of years in operation 26 years
1187 Table 2. Interview Guides
Case study phase
Sample interview guide Focus group phase
Sample interview guide Key informant phase
GPs: Reasons for GPs introducing CAM into their practices CAM practitioners: Reasons for CAM practitioners wanting to work in IM Concerns, if any, about integrating CAM and mainstream medicine (e.g., efficacy, safety, competence of practitioners, legal issues, cost-effectiveness) Are some CAMs useful for particular conditions? For particular patients? Are CAMs useful for treating obesity, problems associated with aging, for preventive medicine? Referral networks within the practice and outside the practice? Strategies, if any, adopted by practitioners/clinic to foster integration How important is an evidence base for CAM? How are Western medical and CAM diagnoses integrated? Medicalization of CAM; benefits and risks. Are patients looking for GPs who practice CAM rather than a CAM practitioner who is not medically trained? The future role of CAM practitioners? Marginalization? Role restricted to treatment? Can IM make a special contribution to preventive medicine? IM as an enhanced model of primary health care Personal experiences of IM and training in CAM What kinds of patients use IM? Assessment processes in IM; use of CAM diagnosis Models of IM IM and preventive medicine CAM service/product vs. CAM practitioner
GPs, general medical practitioners; CAM, complementary and alternative medicine; IM, integrative medicine.
the possibility of misinterpretation. This research was approved by the University of Sydney’s Human Research Ethics Committee. Results This research identified a range of interprofessional relationships that empowered CAM practitioners to varying degrees. The participants in this research were engaged in the following modes of collaboration: Mutual empowerment: Interprofessional collaborations as equal partnerships Equal power-sharing relationships among GPs and CAM practitioners were evident in this research, although in a limited number of cases. It appeared that high levels of CAM training and self-confidence on the part of the CAM practitioner accompanied significant power-sharing among practitioners. CAM practitioners retained their primary contact role in these partnerships, and patients initially consulted the practitioner of their choice (GP or CAM), who assessed and either treated or referred them. In the following excerpts, 2 practitioners who practiced in this style express their respect for practitioners of other disciplines. They appear to be more committed to treatment options that could benefit patients than to the primacy of their respective disciplines. One of the important things in integrative health care is recognizing that different practitioners have very different experiences and expertise and if you want to help people the most, you want to benefit from everybody’s expertise. You want to be able to maintain a conversation with other practitioners, particularly if it’s for the benefit of a patient. You want to be able to speak their language and certainly be able to appreciate that their language is very important, as important as your language is.…So we must not be obstinate
and think that our own discipline is more important or less important. GP 1 If you work together it doesn’t matter where the patient goes first. For example, if they come to me after a motor vehicle accident and really need an adjustment, then I can see that and I can assess who they need to see and refer them. So everyone needs to know what everyone else does and when it is most appropriate to get the patient to have certain treatments.…Most chronic illnesses might need two or three things simultaneously. What’s the priority or what’s the best simultaneous combination of therapy for the patient? Education, understanding, and no feeling of competition.…If I were this patient, what would I need? And if I can’t help them, I think, who can? CAM practitioner 1
GP-directed collaboration: Interprofessional collaborations as unequal partnerships When GPs took on the role of the sole primary contact practitioners in the practices, several secondary referral possibilities arose: Referral could be to other GPs who practiced CAM or to CAM practitioners. When patients were referred to CAM practitioners, referral could be more or less prescriptive: (1) referral with a high level of autonomy for CAM practitioners (i.e., referral for CAM diagnosis and treatment); or (2) referral with a low level of autonomy for CAM practitioners (i.e., referral with GPs directing the course of treatment). High level of autonomy for CAM practitioners within GP-directed care. In this type of interprofessional partnership, patients were initially assessed by GPs using Western medical diagnosis. Patients whose conditions were considered suitable for CAM were then referred to CAM practitioners who carried out assessments using the tools of
1188 their CAM specialty. GPs who referred patients in this nonprescriptive way were acknowledging the competence of CAM practitioners to perform CAM assessment and treatment. In the following example, the patient has been referred to a naturopath. Assessment in this case includes ‘‘a full case history’’ to obtain information over and above the initial medical assessment and blood tests. To begin with they go to see Dr.…He can order any blood tests that need to be done. When they come to see me, I’ll go through a full case history with them to make sure that we have all the information we need. CAM practitioner 2
In the second excerpt, referral for general osteopathy, which didn’t specify treatment, gave autonomy to the CAM practitioner to work within his own expertise. I would just buzz the practitioner and say, ‘‘I’m sending soand-so to you’’, or I’d write a note in the file and then I would ask the patient to come back again in about a month’s time when they’d had two or three visits to the other practitioners. I’d ask them to come back to see me and tell me what they’d prescribed for them and how many treatments they’d had and if they felt any better. GP 2
Low level of autonomy for CAM practitioners within GPdirected care. In this practice style, patients were initially diagnosed by GPs, who referred them to CAM practitioners for CAM treatment that the GPs themselves specified. CAM practitioners were not given the option of performing CAM assessments independently. In the following excerpt, the naturopath is not called upon to make her own assessments using CAM diagnostic tools. I’d organize all the pathology and whatever tests they needed done and the person would have to come back to see me to discuss the results of those tests before any referral. Then we’d get a very clear picture of what was going on. Depending on what the needs were, it might be a digestive problem and I’d refer them to the naturopaths to talk about their diet. GP 2
According to some CAM practitioners, restricting them to providing treatments prescribed by GPs did not make the best use of their skills. The practitioner in the following excerpt tries to educate the GPs in the practice about her skills in Traditional Chinese Medicine. Dr.…sent him to me to have herbal treatment for gallstones. But diagnosing him [using Traditional Chinese Medicine] I could see a lot of other problems, chronic ones, so I sent her a note saying that longer term I would like to treat these. I think in that way they will start to understand what Chinese medicine is about.…We can add to the management of the other practitioners. We always treat patients holistically, so I can’t just isolate a certain symptom. So I tell [the doctors], if you want me to only treat one specific part of the condition I will, but you should let me treat the patient holistically. CAM practitioner 3
CAM practitioners varied in their responses to being directed in this way. Some CAM practitioners found this practice restrictive and demeaning; others appreciated a directive for specific treatment because it removed the responsibility associated with primary contact assessment.
GRACE AND HIGGS I always would refer that to a GP even though I had the [diagnostic] training. I’m not adequately trained. I think it’s totally unprofessional and unsafe of me to pretend. CAM practitioner 4
This practice style where GPs directed patients’ health care was supported by the GPs involved as a means of enhancing patients’ safety. Any concerns by the GP over the competence of CAM practitioners to identify patients requiring referral (as expressed in the following excerpt) were allayed by patients having first contact with GPs, who exercised ultimate control over the provision of CAM. A lot of CAM practitioners are very well intentioned. They’ve completed courses, but they don’t know about pathology. They might have studied some, but they have never studied the whole range of pathology. They’ve never seen really sick people. They have never been into a hospital and seen someone die of kidney failure. They have only seen the walking unwell. They see a particular sort of person. GP 3
Noninclusive practice: Limited or no interprofessional collaboration GPs with CAM training clearly valued CAM but often found no need for the services of CAM practitioners. In this practice style, IM was delivered exclusively by these intragrative GPs, who either selected parts of CAM (often those with biomedical evidence) to use in treatment or practiced CAM according to its holistic philosophy. Many CAM practitioners expressed concern that this noninclusive practice style resulted in the diminution of their role in the health care system. There is definitely a sense that you are not a peer. They may like you and respect your work but you’re certainly not a peer, and the hierarchy is clear and the pecking order is unspoken but it’s there. You do share patients but at the doctor’s discretion. The doctor really has the patient and when you share patients they are really the doctor’s patients and you might play a peripheral role. CAM practitioner 5
According to some CAM practitioners, their skills sometimes exceeded those of the GPs in their CAM specialty, and by not referring to CAM practitioners, patients could miss out on expertise available to them. None of the doctors I work with would ever refer to me for Chinese herbal medicine even though I’ve had years of training. They would look up a book and recommend the herbs themselves rather than refer to me.…Prescribing herbs, homeopathy, or nutrition, if they have any skills at all, even a little bit, they would prefer to use those skills in an incompetent manner instead of referring to someone who has a full range of skills in them. CAM practitioner 5 Patients are attracted to doctors who practice alternative medicine, so they often go there first. Then the doctors use orthodox medicine and either send patients to us or the doctors just do the treatment themselves. I do find it a bit of a concern. I’m trained in nutritional medicine, herbal medicine, and homeopathy. I find those three tools are such big tools that they alone are hard enough to have a good grasp of and I know that medical training is so rigorous and so demanding. I just question the idea of one person doing everything. I think
INTERPROFESSIONAL COLLABORATIONS it’s a bit much to expect someone to be a very good doctor and a very good herbalist and a very good acupuncturist. I think it is much more valuable if we just work together as a team. CAM practitioner 6
Discussion The finding in this research that the most common partnership arrangement was of GPs as gatekeepers and monitors of patients’ health care is consistent with findings from other studies.30–33 According to practitioners in this research, this relationship overcame concerns about the level of diagnostic skills of CAM practitioners. Many CAM practitioners in this research acknowledged the superior Western medical diagnostic skills of GPs. When GPs functioned as the gatekeepers and monitors of patients’ health care, CAM practitioners were relieved of the responsibility associated with being primary contact practitioners. That CAM training institutions sometimes fall short of preparing their graduates for their primary contact role was further demonstrated in this research by CAM practitioners’ high referral rates for medical assessment and by their tendency to consult GPs in the practices about their patients’ health before proceeding with CAM treatment. Australian CAM educators and curriculum designers urgently need to review training in relation to primary contact practice. Collaborations in IM in this research can be described in terms of the value placed by GPs on CAM practitioners themselves as opposed to the value they placed on CAM as a product or service. In some practice styles (e.g., mutually empowering collaborations), CAM practitioners were highly valued and able to exercise high levels of professional autonomy. In others (e.g., intragrative medicine), CAM services or products appeared to be valued more highly than the capacity of CAM practitioners to deliver them. To date, the focus of CAM training for members of the medical profession has been on the selective application of CAM products for diagnosed conditions (for example, the use of (biomedical) evidence-based supplements such as omega-3 fatty acids and glucosamine in the treatment of osteoarthritis).34 In contrast, there is a deficiency in the sort of training that could enable deeper collaboration between GPs and CAM practitioners. Without such training, the increasing value of CAM as a product may outstrip the status of CAM practitioners, who consider themselves the experts in CAM. In qualitative research, findings relate to particular contexts at particular times and cannot be generalized. This research reports on the implementation of IM in Australian practices where GPs and CAM practitioners were co-located. The concepts of power-sharing among practitioners identified in this research may be transferable to similar health care settings. Conclusions IM practice styles differed in terms of interprofessional power-sharing and roles assigned to CAM practitioners. Highly collaborative practices where CAM practitioners were able to exercise high levels of autonomy were perceived by some practitioners as making the most effective use of the available CAM workforce. GP-directed care mediated varying levels of autonomy for CAM practitioners. In some cases, patients were referred in
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Address correspondence to: Sandra Grace, PhD, MSc(Chiro), DipEd The Education for Practice Institute Charles Sturt University 16 Masons Drive North Parramatta 2151 New South Wales Australia E-mail: [email protected]
This article has been cited by: 1. Gray Bimbi, Orrock Paul. 2014. Investigation into Factors Influencing Roles, Relationships, and Referrals in Integrative Medicine. The Journal of Alternative and Complementary Medicine 20:5, 342-346. [Abstract] [Full Text HTML] [Full Text PDF] [Full Text PDF with Links] 2. Keonie Moore. 2014. Metabolic syndrome: A case report for collaborative care. Advances in Integrative Medicine 1, 44-47. [CrossRef] 3. Yael Keshet, Eran Ben-Arye, Elad Schiff. 2013. The use of boundary objects to enhance interprofessional collaboration: integrating complementary medicine in a hospital setting. Sociology of Health & Illness 35:10.1111/shil.2013.35.issue-5, 666-681. [CrossRef] 4. Elad Schiff, Eran Ben-Arye, Samuel Attias, Gideon Sroka, Ibrahim Matter, Yael Keshet. 2012. Perceiving integration of a complementary medicine service within a general surgery department through documentation of consultations: A thematic analysis. Patient Education and Counseling 89, 430-433. [CrossRef]