Attitudes toward integration of complementary and alternative medicine in primary care: Perspectives of patients, physicians and complementary practitioners

Abstract

Objective

Our study explored the attitudes of patients toward complementary and alternative medicine (CAM) use, their family physicians’ role regarding CAM, and models for CAM referral and treatment. We compared patients’ perspectives regarding integration of CAM into primary care with attitudes of primary care physicians (PCPs) and CAM practitioners.

Methods

We conducted a comprehensive literature review and focus group discussions to develop a questionnaire, which we gave to three groups: a random sample of patients receiving care at an academic family medicine clinic and PCPs and CAM practitioners employed in the largest health maintenance organization in Israel.

Results

A total of 1150 patients, 333 PCPs, and 241 CAM practitioners responded to our questionnaire. Compared with PCPs, patients expected their family physician to refer them to CAM, to have updated knowledge about CAM, and to offer CAM treatment in the clinic based on appropriate training. When asked about CAM integration into medical care, more patients expected to receive CAM in a primary care setting compared to PCPs’ expectations of prescribing CAM (62% vs. 30%; p = 0.0001). Patients, CAM practitioners, and PCPs expected family practitioners to generate CAM referrals in an integrative primary care setting (85.6% vs. 82.4% vs. 62.6%; p < 0.0001). Patients supported CAM practitioners providing CAM treatments in the primary care setting, regardless of whether the practitioner held a medical degree (MD). Also, more patients than PCPs or CAM practitioners expected their family physician to provide CAM (28.2% vs. 14.5% vs. 3.8%; p < 0.0001).

Conclusion

Patients, PCPs, and CAM practitioners suggested that family physicians play a central role in CAM referral and, to a lesser extent, that they actually provide CAM treatment themselves.

Practice implications

PCPs need to be aware of their present and future role in informed referral to CAM and, to a lesser degree, in providing CAM in integrative primary care clinics. With the increasing use of CAM, patients may expect their family physician to be more knowledgeable, skillful, and have a balanced approach regarding CAM use. In addition, practitioners should learn how to communicate effectively and better collaborate with CAM practitioners to the benefit of their patients.

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?