Variations in provider conceptions of integrative medicine

Abstract

Consumers often turn to complementary and alternative medicine (CAM) and use it concurrently with conventional medicine to treat illnesses and promote wellness. However, prior studies demonstrate that these two paradigms are often not combined effectively. Consumers often do not tell physicians about CAM treatments or CAM practitioners about conventional treatments that they are using. This can lead to inefficient care and/or adverse interactions. There is also a lack of consensus about the structure and practice of integrative medicine among the various types of practitioners. This qualitative study aimed to identify key domains and develop a conceptual model of integrative medicine at the provider level, using a grounded theory approach.

Purposive sampling was used to select 50 practitioners, including acupuncturists, chiropractors, internists/family practitioners, and physician acupuncturists in private practice and at academic medical centers in Los Angeles. We conducted semi-structured, in-depth interviews with practitioners and then identified core statements that describe practitioners′ attitudes and behaviors toward integrative medicine. Core statements were free pile sorted to ascertain key domains of integrative medicine.

Four key domains of integrative medicine were identified at the provider level: attitudes, knowledge, referral, and practice. Provider age, training, and practice setting also emerged as important factors in determining clinicians’ “orientation” toward integrative medicine. “Dual-trained” practitioners, such as physician acupuncturists, exemplified clinicians with a greater orientation toward integrative medicine. They advocated an open-minded perspective about other healing traditions, promoting co-management with and making referrals to practitioners of other paradigms, and treating patients with both CAM and conventional healing modalities.

Introduction

Conventional medicine has shifted from viewing complementary and alternative medicine (CAM) with hostility to gradual incorporation of CAM (Coulter, 2004). CAM is increasingly included in conventional medical care and medical education (Wetzel, Kaptchuk, Haramati, & Eisenberg, 2003). Consumer demand and political pressure have contributed to recent interest in combining CAM and conventional medical paradigms, termed integrative medicine (Pelletier, Astin, & Haskell, 1999; Trachtman, 1994). Integrative medicine can occur at six levels: (1) consumer, (2) health care provider, (3) clinic, (4) institution, (5) professional/regulatory, and (6) health policy or system (Tataryn & Verhoef, 2001). We focus on integration at the provider level because providers play a pivotal role in the clinical encounter. Patients commonly combine CAM modalities with conventional medical treatments outside the purview of their physicians and CAM providers, yet the clinical effect of such patient-initiated “integrative medicine” may be hampered by the lack of provider supervision and even may be unsafe (Fugh-Berman, 2000). Integrative medicine without input from providers also may result in poor quality of care due to poor coordination between clinician-initiated and patient-initiated therapies (Weeks, 1996). Therapeutic benefits may be most likely to emanate from skilled providers of divergent clinical paradigms treating an interested patient according to a shared, coherent conceptual framework (Bell et al., 2002).

Yet, it is unclear what “integrative medicine” means to providers and to different provider groups. Proponents of integrative medicine, such as Andrew Weil, view it as a paradigm shift, replacing the biomedical paradigm (Weil, 2000). On the contrary, some CAM practitioners have viewed integrative medicine as conventional medicine's “co-optation” of CAM (Coulter, 2004). Still others view integrative medicine as a component of the patient-centered care movement. Although some claim that integrative medicine is more cost-effective and safe than conventional medicine or CAM alone (Pelletier et al., 1999; Weil, 2000), lack of clarity and consensus about what constitutes integrative medicine has impeded evaluation of these hypotheses. Thus, the development of a conceptual framework of integrative medicine at the provider level is necessary to understand the practice, structure, and quality of integrative medical care.

The conventional and CAM literatures do not suggest a unifying conceptual framework to operationalize integrative medicine at the provider level. We endeavored to identify the key domains and develop a conceptual model of integrative medicine at the provider level. This study also aimed to contribute to the development of a survey instrument to measure clinicians’ “orientation” toward integrative medicine.