Attitudes toward integration of complementary and alternative medicine in primary care: Perspectives of patients, physicians and complementary practitioners
Introduction
The phrase “complementary and alternative medicine (CAM)” encompasses a variety of therapeutic methods and techniques rooted in traditional, philosophical, and empirical systems of medicine that view health and disease in the context of the human totality of body, mind, and spirit. The establishment of the National Center of Complementary and Alternative Medicine by the U.S. National Institutes of Health in 1997 marked a shift in the relationship between mainstream conventional medicine and CAM. Medical educators have suggested various models for the relationship between the two systems, shifting from opposition to integration and pluralism [1]. This phenomenon is also evident in the changing terminology for non-conventional medicine from “alternative medicine” to “complementary medicine” suggesting a lesser degree of opposition. The term “integrative medicine” not only implies tolerance of mainstream medicine toward CAM but also calls for a dialogue between the two systems in clinical practice, research, and education [2]. Some scholars use the term “integrative medicine” to refer to the merging of CAM with conventional biomedicine [3], while others conceptualize it as being different from “combination medicine” (CAM plus conventional medicine) and emphasize its synergistic potential in advancing a patient-centered bio-psycho-socio-spiritual paradigm [4].
Integrating CAM into national health care systems has been suggested in North America, Europe, and Australia [5], [6]. In 2002, the White House Commission on Complementary and Alternative Medicine Policy recommended integration “into the nation's health care system of those complementary and alternative health care practices and products determined to be safe and effective” [7]. In the U.K. in 2001, the House of Lords’ report on complementary medicine recommended integrating CAM with conventional medicine [8], and the Prince of Wales has also advocated integrating various CAM modalities into the U.K. National Health System [9]. Integration of conventional medicine and CAM (or traditional medicine) has been evident in clinical practice and medical education in China for decades and has been growing in developing countries such as India and Cuba [10], [11], [12].
We decided to look at CAM use in Israel because Israel has an ethnically diverse population that used, until the past four decades, a variety of traditional medicine modalities. Nevertheless, as modernity prevails, ethnic characteristics are fading [13]. Israel's population of 7.1 million [14] uses complementary therapies extensively. In 2005, the number of registered CAM practitioners involved in CAM professional societies was 3500 (out of 10,000 trained CAM practitioners) [15], and 1.4 million CAM treatments were administered, 45% of which were administered by the four health maintenance organizations (HMOs). All four of Israel's HMOs offered CAM treatments under medical surveillance through administratively separate agencies. Shmueli and Shuval showed that between 1993 and 2000, CAM use grew among the Israeli Jewish urban population aged 45–75 years [16]. The increase in CAM use was accompanied by a growing volume of CAM research in Israel, with a significant number of publications from family medicine departments [17], [18]. These two tendencies of increased CAM use and research along with the rise in CAM reimbursement by managed care organizations and insurance providers in the US and Europe [19], [20], [21], emphasize the need to study the feasibility of CAM integration in Israel in general and in primary care in particular.
Researchers have described various obstacles in establishing integrative care clinics and suggested different models for integration in hospital and primary care settings [3], [22], [6], [23], [24]. Frenkel and Borkan [25] and Bell et al. [4] suggested employing integrative clinical models for primary health care, emphasizing the holistic approach common to CAM and conventional medicine. However, articles on this topic are limited to theoretical discussion of the possibilities of CAM integration. Our study aimed to fill the gap between theory and real-life clinical practice by exploring patients’, physicians’ and CAM practitioners’ attitudes about integrating CAM into primary care. The authors intended to study the three groups’ viewpoints concerning the following questions: How do patients, conventional clinicians and CAM practitioners perceive an integrative care model, and where should it be based (primary, secondary, or tertiary care setting)? Who should refer patients to CAM and who should provide the treatment? How do patients and physicians envision the role of the family practitioner in this integrative process? Do they envision adding CAM treatments to the family practitioner's arsenal of prescribed medication and optional referrals? Or, does integration mean adjoining the CAM practitioner to the clinic's medical team?
Section snippets
Study participants
We designed a three-arm study of patients, primary care physicians (PCPs), and CAM practitioners. All study sites were a part of Clalit Health Services (CHS), which is the largest of the four HMOs in Israel and serves approximately 60% of Israel's population [26]. The Minister of Health in Israel and the Medical Director of the CHS Haifa district supported the study. A Helsinki Committee (a local institutional review board) approved the study protocol.
The following three populations
Results
Questionnaires were offered to three groups of participants: adult patients receiving care at a primary care clinic, PCPs, and CAM practitioners. Of these, 88% of the patients (1150/1307), 13% of the PCPs (333/2532), and 54% of the CAM practitioners (241/450) responded. The respondents’ characteristics are summarized in Table 1.
Discussion
Our study found that patients supported the option of receiving CAM in a primary care setting. Patients also expected PCPs to be more active in prescribing CAM. In contrast, PCPs assumed that patients expected PCPs to be merely passive listeners about patients’ CAM use. A similar discrepancy was evident when we asked patients and PCPs who should provide CAM in an integrative primary care clinic. We also looked at the role of the CAM practitioner and found that more CAM practitioners and
Conflict of interest
The authors have no conflicts of interest.
Acknowledgements
We would like to thank Dr. Chen Shapira, medical director of CHS, Haifa district, for her generous support and encouragement, Ms. Ronit Leiba for the statistical analysis, Dr. Adva Lear, medical director of the Herman Clinic and the staff members in the clinic for their support and collaboration with the team of researchers, the research team from the International Center and College of Natural Complementary Medicine: Ms. Dalia Vardi, Ms. Danit Steinberg, Ms. Ira Videtski, Mr. Uri Meir Chizik,
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