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CAM practitioners in integrative practice in New South Wales, Australia: A descriptive study
Complementary Therapies in Medicine (2008) 16, 42—46
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
CAM practitioners in integrative practice in New South Wales, Australia: A descriptive study Sandra Grace a, Subramanyam Vemulpad a,∗, Anna Reid b, Robyn Beirman a a
Department of Health and Chiropractic, Macquarie University, 2109 NSW, Australia Centre for Professional Development, Macquarie University, Sydney, NSW 2109, Australia Available online 30 January 2007
b
KEYWORDS Complementary and alternative medicine; CAM; Integrative practice; Primary contact; Diagnosis; Qualitative research; Clinical training; Grounded theory
Summary Objectives: The aim of this study was to examine the role of complementary and alternative medical (CAM) practitioners in integrative practices where general practitioners (GPs) and CAM practitioners were co-located. Design: This study used grounded theory, a qualitative methodology from the interpretive paradigm. Setting: A total of 23 integrative practitioners (10 general practitioners and 13 naturopaths) were interviewed. The informants were drawn from 16 integrative practices and one nonintegrative general medical practice. Results: In 11 out of 16 integrative practices the CAM practitioners yielded their primary contact role to the GPs. CAM practitioners were restricted to expanding the range of treatment options available to patients. However, the role of the CAM practitioners was influenced by the level of CAM training the GP(s) in the practice had undertaken. The more CAM training the GPs had undertaken, the more CAM practitioners were enlisted as diagnosticians as well as treatment providers. Conclusion: CAM practitioners in integrative practices had an accessory role to the GPs in the practice, deferring diagnosis and assessment activities to the GPs. However, where GPs had significant training in CAM, the CAM practitioner’s role included both treatment and diagnostic activities. © 2007 Published by Elsevier Ltd.
Introduction Models of primary health care that combine Western and complementary medicine include integrative practices
∗
Corresponding author. Tel.: +61 2 98509385; fax: +61 2 98509389. E-mail address: [email protected] (S. Vemulpad). 0965-2299/$ — see front matter © 2007 Published by Elsevier Ltd. doi:10.1016/j.ctim.2006.12.001
where Western medical doctors and complementary and alternative medicine (CAM) practitioners share practice space.1,2 Such practices provide an opportunity to examine the extent to which an integrated or co-management approach to health care has evolved. Naturopaths in Australia receive a generalist training in CAM which usually involves 4 years of private college or university training in biomedical sciences, Western herbal medicine, nutrition, and either homoeopathy, counselling or massage therapies.3 They could be regarded as the ‘general
CAM practitioners in integrative practice in New South Wales, Australia practitioners’ of CAM. Naturopaths are entitled to practice as primary contact practitioners, that is, first contact practitioners who have the knowledge and skills to assess patients, to provide on-going treatment for all aspects of a patient’s health care and/or to direct patients for appropriate care.4—6 Most naturopaths establish independent practices, either alone or with other CAM practitioners. A few establish practice with general practitioners (GPs).7 The aim of this study was to examine the role of CAM practitioners in integrative practices where GPs and CAM practitioners were co-located.
Methodology This research used a qualitative approach that generates data in the form of transcribed interview texts. The results of the study are presented using a form consistent with the methodology known as Grounded Theory.8 In this case meaning is sought directly from the data, and insights are developed from the patterns that emerge from the data.9,10 In a grounded methodology the research data is presumed to contain social patterns that ‘emerge’ through iterative reading and comparison. A ‘constant comparison’ is applied that focuses on the essential elements of ‘time, place and people’.11 It implies that the physical contexts of the participants in the study provide an important analytic contribution to the possible data set. In this research we use a ‘constant comparative’ analytic technique in conjunction with purposive theoretical sampling.9 Data, in the form of interview transcripts, were coded and analysed simultaneously so that specific incidents, concepts and theories were examined in relation to each other. At the same time the participant group was expanded from a selection of co-located practitioners. In this sense there is no random selection; rather, the participants are selected on the basis of their ability to contribute experience to the phenomenon being examined. In this study, a shared concept of mutual behaviour and values is critiqued through the participation of health professionals who are co-located, and where the different locations afford an opportunity to examine essential areas of conceptual difference and commonality. The model that has emerged from this research provides a means of interpreting the interactions and activity of co-located CAM and medical practitioners. From initial interviews a working definition of the role of CAM practitioners was developed using the participants’ own descriptions. The research team then critiqued the data using perspectives developed from previous literature and knowledge of the field to formulate and test the initial participants’ descriptions of their CAM roles. Subsequent interviews focused on the clarification of CAM roles and redefinition of the emerging theory. The on-line telephone directory, http://www. yellowpages.com.au, the most comprehensive directory where both doctors and naturopaths advertise, was used to locate practices in New South Wales (NSW) where naturopaths and GPs shared the same premises. The study was limited to NSW as demographic studies showed that more naturopaths practice in NSW than in any other state.7,12 Only 19 such practices were found representing 0.14% of listed medical practices and 16.9% of listed naturopathic practices in NSW. A letter was sent inviting
43
practitioners to participate and this was followed with a phone call. Practitioners represented a range of practice styles (urban/country, diverse socio-economic regions, and number of practitioners). Two practitioners did not respond to follow-up phone messages. All other invited practitioners agreed to participate in the research. In total, 13 naturopaths and 10 GPs were interviewed from 16 integrative practices and one non-integrative Western medical practice. All interviews were audio-taped with the informants’ consent and transcripts of the interviews forwarded to the informants for verification. All interviews were conducted by the same researcher. Initially responses were sought from practitioners about their choice of integrative practice, the profile of the practice and their contribution to it, integrative practitioners’ training, and referral patterns. Interviews were continued until redundancy of information or theoretical saturation occurred.9 Further informants were selected according to their likely contribution to the refinement or expansion of the concepts and theory that were being developed. Theoretical saturation occurred after a further four 1 h conversational interviews were conducted. Validity was established by a continual process of checking, questioning, and theoretically interpreting at every step of the research from design to reporting. Cross-checks were imposed on the informants’ stories. One method was triangulation, in this case checking concepts emerging from the interview data with descriptions of integrative medicine in primary care practices in the UK13,14 and Australia.15 Checks were also made with clinic advertising material and unsolicited data such as comments written on returned transcripts. Three elements of analysis guided the development of the grounded theory. Firstly, concepts were derived from the data, then categories were described within each concept, and finally generalised relationships between concepts and categories were developed.16
Results GPs’ perceptions of the role of CAM practitioners in integrative practice Seven of the 10 GPs in the study considered themselves the key providers of health care, responsible for directing and monitoring the health care of the patients in the practice. Deficiencies in training of naturopaths were identified by six GPs as potentially limiting naturopaths’ ability to recognise disease and consequently to know when to refer patients for Western medical treatment. ‘‘I have spent years under the supervision of other doctors seeing a lot of people. So if somebody walks in I can tell you if they’re sick or not. . .And what I’ve always had a problem with in naturopathy is not the courses—the course content is fantastic—it’s the clinic. What we really need is a big, centrally based naturopathy hospital and clinic, where people can work under supervision and just see lots and lots of people.’’ (GP 2) The GPs in the study referred patients to CAM practitioners to provide a broader range of treatment options than would have been available in non-integrative prac-
44
S. Grace et al.
tices. The GPs recognised the important role CAM could play as a first treatment approach, especially in the management of chronic and non-life threatening conditions.16 Where possible, CAM treatments were used first because of their relatively inexpensive and non-invasive treatment approaches. ‘‘In general practice there were a lot of situations where I felt loath to use pharmaceuticals and at a loss to do anything else. It was fine for acutely ill people where conventional medicine is absolutely fantastic but (for) a lot of the grumbly things, for the minor things like colds and coughs, it just wasn’t suitable.’’ (GP 2) One GP who had studied Western herbal medicine described how she saw the unique contribution CAM could make to health care, particularly to health maintenance and promotion, and to illness prevention. ‘‘In medicine there’s no concept of normalising, optimising, or restoring. If I give a patient a medical drug, it merely shifts their symptoms to another area that is not normal either. So we move and treat symptoms. With herbal medicine it’s the ability to give the patient something that’s going to prompt the body, nudge the body to come back to where it knows it can be.’’ (GP 1) Referral for CAM treatment also occurred when GPs thought that Western medicine had been ineffective. The following quotation shows how a GP referred patients for CAM when they had reached an impasse. ‘‘I think the majority of clients we refer are the ones we can’t fix. We get somebody else to look at them. The hard ones.’’ (GP 4) In some cases it was not that the case was complex, but that there were few, or no, pharmaceuticals available or pharmaceutical treatment had undesirable side-effects. ‘‘With the great majority of herbal medicines you’re not doing harm and I think a lot of the pharmaceutical medicines are doing harm as well as good and sometimes the harm is greater than the good. People would come in with these problems, like arthritis, and the side-effects of the drugs were as bad as the condition in many ways.’’ (GP 2) All of the GPs in the study thought that their medical training lacked information on CAM. They acknowledged the importance of nutritional influences on health and often referred patients to CAM practitioners for nutrition advice. ‘‘I thought about nutrition. It’s the one thing they didn’t teach me in medicine. It must be important. Why didn’t they teach me? I had 1 h of nutrition in my 6-year course. Eight years with the hospital work. One hour of nutrition.’’ (GP 3)
CAM practitioners’ perceptions of their role in integrative practice Nine of the 13 CAM practitioners in the study accepted the primary contact role of the GPs. Fig. 1a represents the role of CAM practitioners in integrative practice: that of provid-
Figure 1 (a) A model of co-location where GPs are perceived as the primary health care providers. (b) A model of co-location where GPs have undertaken significant CAM training.
ing CAM treatments for patients following Western medical diagnosis. CAM practitioners were not usually involved in diagnostic activities. They recognised the limits of their training in Western medical diagnosis and saw the opportunity to seek advice over issues of patient care as advantageous both for themselves and for their patients. One CAM practitioner commented on her lack of confidence in performing Western medical diagnostic techniques: ‘‘Even though I had training in physical examination, I think it’s such a grey area. I’m not adequately trained. I think it’s totally unprofessional and unsafe of me to pretend. It would be better to have had no training than to be inadequately trained. (Naturopath 3)’’ Interpretation of pathology tests is integral to naturopathic diagnosis and yet referral for pathology tests by naturopaths is severely restricted by the absence of Medicare rebates for patients referred by naturopaths. CAM practitioners who were co-located with GPs were able to refer their patients to the GPs in their practices for pathology testing. In solo practices the ability of CAM practitioners to assess and monitor their patients’ health care is further restricted because many non-integrative GPs are not willing to collaborate with CAM practitioners, particularly in the area of diagnosis. ‘‘The doctors here are open to naturopaths referring to them and will do the tests we require. Often if the patients can’t come to see our doctor for practical reasons and we write a referral to doctors for tests that we require, a lot of doctors will say, ‘‘I’m not doing those tests. I don’t think they’re necessary’’. With our doctors, they understand the program that we’re running and fully agree to participate in what we need to have done. (Naturopath 9)’’
CAM practitioners in integrative practice in New South Wales, Australia Eight of the GPs in the study had undertaken CAM training. Some had very high levels of training in CAM, often equal to or exceeding that of the CAM practitioners in their practices. The findings of this study suggest that the higher the level of CAM training the GPs had undertaken, the more CAM diagnosis was used, and consequently the more CAM practitioners were likely to contribute to the diagnosis and assessment of patients. The co-location model presented in Fig. 1a is altered when GPs have had significant training in CAM. Fig. 1b represents the closer relationship between CAM practitioners and diagnostic and assessment activities when GPs had undertaken significant training in CAM.
Discussion The training deficiencies identified in this study (the lack of information on CAM in medical training and the poor development of Western medical diagnostic skills in CAM training) have been reported as barriers to integration17—19 along with lack of evidence for some CAMs,20—23 divergent philosophies,24,25 and medico-legal issues.26—30 These factors might account for the relatively small number of integrative practices in existence. In the UK CAM practitioners work in at least 20% of general practices.31 One Australia-wide study that included naturopaths, herbalists and acupuncturists found that only 4% of respondents worked in group practices with a GP or other mainstream practitioner.7 In our study, 16.9% of listed naturopaths shared premises with GP(s). The primacy of the GPs found in this study is consistent with studies examining integrative practices in other countries.32—34 This study suggests that the subordination of the CAM practitioner’s role in integrative practices is related to diagnosis (Fig. 1a). The limited ability of CAM practitioners to perform Western medical diagnosis was recognised by all practitioners in the study. However, there appears to be a growing imperative to recognise the contribution CAM can make to treatment options for patients.19,27,35—37 For those patients who are interested and potentially receptive to an alternative approach to health care (and there appears to be a large number in Australia38—47 ) the contribution that CAM diagnosis and assessment activities could make to patients’ health outcomes in integrative practices is largely unexplored. Western medical practitioners are increasingly more open to CAM and more willing to undertake CAM training.44 Our findings suggest that as Western medical practitioners undertake CAM training, they are more likely to incorporate CAM diagnostic and assessment procedures. These procedures may be provided by CAM practitioners or by Western medical practitioners who have trained in CAM. (Fig. 1b). This study was limited to integrative practices where naturopaths shared premises with GPs. Other types of integrative practise certainly exist.48—50 These include GPs who have CAM training and practice their own personal style of integrative medicine as well as the use of referral networks between GPs and CAM practitioners who are not sharing premises.
Conclusion In integrative practices in NSW, 9 out of 13 CAM practitioners yielded their primary contact role to the GPs in the
45
practice. When the GPs referred to CAM practitioners, they referred for CAM treatment. The CAM practitioners provided an expanded range of treatment options to patients. CAM practitioners did not usually contribute to the assessment and diagnosis of patients. Rather, CAM practitioners referred to GPs in their practices for Western medical diagnosis. From our study a model of co-location emerged where GPs were perceived as the key health care providers. In such practices, the role of CAM provider is restricted to providing further treatment options to patients. However, this model of co-location changes when GPs have significant training in CAM. The higher the level of CAM training the GP has undertaken, the greater the CAM practitioners’ role. In this case CAM practitioners contribute to diagnostic and assessment activities as well as treatments.
References 1. Rees L, Weil A. Integrated medicine. Br Med J 2001;322: 119—20. 2. Peters D. Integrating complementary therapies in primary care: a practical guide for health professionals. Edinburgh: Churchill Livingstone; 2002. 3. Grace S, Vemulpad S, Beirman R. Training in and use of diagnostic techniques among CAM practitioners: an Australian study. J Altern Complement Med 2006;12:695—700. 4. Simpson L, Lee PR. Primary care: an idea in search of a paradigm? Am Family Physician 1993;47:323—6. 5. Donaldson M, Yordy K, Vanselow N, editors. Defining primary care. Washington: National Academy Press; 1994. 6. Kranz KC. An overview of primary care concepts. Top Clin Chiropractic 1995;2:55—65. 7. Hale A. Survey of ATMS: acupuncturists, herbalists and naturopaths. J Aust Trad Med Soc 2002;8:143—9. 8. Thorne S, Joachim G, Paterson B, Canam C. Influence of the research frame on qualitatively derived health science knowledge. Int J Qualitative Meth 2002;1:1—47. 9. Taylor SJ, Bogdan R. Introduction to qualitative research methods. The search for meanings. 2nd ed. New York: John Wiley & Sons; 1984. 10. Crabtree BF, Miller WL, editors. Doing qualitative research. Research methods for primary care volume 3. Newbury Park: Sage Publications; 1992. 11. Glaser B. Conceptualization: on theory and theorising using grounded theory. Int J Qualitative Meth 2002;1:1—31. 12. Bensoussan A, Myers SP, Wu SM, O’Connor K. Naturopathic and Western herbal medicine practice in Australia—–a workforce survey. Complement Ther Med 2004;12:17—27. 13. Peters D, Chaitow L, Harris G, Morrison S. Integrating complementary therapies in primary care. Edinburgh: Churchill Livingstone; 2002. 14. Rakel D. Integrative medicine. Philadelphia: Saunders; 2003. 15. Hunter A. Working in a multidisciplinary clinic: the pleasures and the pitfalls. Conference of Complementary Health Users Group, Melbourne; 1993. 16. Pandit N. The creation of theory: a recent application of the grounded theory method. The qualitative report 1996; 2(4). Online document at www.nova.edu/ssss/QR/QR24/pandit.html. Accessed 19/10/2006. 17. Berman BM, Singh BK, Lao L, Sing BB, Ferentz KS, Hartnoll SM. Physician’s attitudes toward complementary or alternative medicine: a regional survey. J Am Board Family Pract 1995;8:361—6. 18. Owen D, Lewith GT. Complementary and alternative medicine (CAM) in the undergraduate curriculum: the Southampton experience. Med Educ 2001;35:73—7.
46 19. Cohen MM. CAM practitioners and ‘‘regular’’ doctors: is integration possible? Med J Aust 2004;180:645—6. 20. Trevelyan J. Complementary therapies on the NHS: current practice, future developments (Part 1). Complement Ther Nurs Midwifery 1995;4:82—4. 21. Berman B. Cochrane complementary medicine field. Online document at: http://compmed.umm.edu/compmed/ cochrane/cochrane.htm. Accessed 13/10/2003. 22. Giordano J, Garcia M, Boatwright D, Klein K. Complementary and alternative medicine in mainstream public health: a role for research in fostering integration. J Altern Complement Med 2003;9:441—5. 23. Dwyer JA. Good medicine and bad medicine: science to promote the convergence of ‘‘alternative’’ and orthodox medicine. Med J Aust 2004;180:647—8. 24. Teicher LA. Nursing the human: not the machine. Aust J Holist Nurs 1996;3:41—4. 25. Bell I, Baldwin C, Schwartz G, Russek L. Integrating belief systems and therapies in medicine. Integr Med 1999;1:95—105. 26. Sherman RP, Ladenheim J. Truly informed consent. What MDs should reveal about alternatives to medical treatment. J Am Chiropractic Assoc 1995;32:45—7. 27. Nisselle PE. Alternative medicine and the law. Mod Med Aust 1999;42:123—5. 28. Gruner J. The ethics of complementary medicine. Monash Bioethics Rev 1999;19:13—27. 29. Young R, Worswick D, Stoffell B. Complementary medicine in intensive care: ethical and legal perspective. Anaesth Intensive Care 2001;29:227—38. 30. Kerridge IH, McPhee JR. Ethical and legal issues at the interface of complementary and conventional medicine. Med J Aust 2004;181:164—6. 31. Zollman C, Vickers A. Complementary medicine and the doctor. Br Med J 1999;319:1558—61. 32. Scherwitz LW, Cantwell M, McHenry P, Wood C, Stewart W. A descriptive analysis of an integrative medicine clinic. J Altern Complement Med 2004;10:651—9. 33. Shuval JT, Mizrachi N. Changing boundaries: modes of coexistence of alternative and biomedicine. Qualitative Health Res 2004;14:675—90. 34. Hollenberg D. Uncharted ground: patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings. Soc Sci Med 2005;62:731—44. 35. Brophy E. Does a doctor have a duty to provide information and advice about complementary and alternative medicine? J Law Med 2003;10:271—84.
S. Grace et al. 36. Brophy E. Medico-legal implications of complementary medicine. Holistic healthcare in practice. In: Cohen M, editor. Proceedings of the ninth international holistic health conference. Noosa, Qld: Australian Integrative Medicine Association; 2003. p. 24—38. 37. Weir M. Obligation to advise of options for treatment-medical doctors and complementary and alternative medical practitioners. J Law Med 2003;10:296—307. 38. Bensoussan A, Myers P. Towards a safer choice: the practice of traditional Chinese medicine in Australia. Sydney: Faculty of Health, University of Western Sydney, Macarthur; 1996. 39. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996;437: 569—73. 40. Kermode S, Myers SP, Ramsay L. Natural and complementary therapies utilization on the North Coast of NSW, Australia. J Holist Nurs 1998;5:7—13. 41. Easthope G, Tranter B, Gill G. Normal medical practice of referring patients for complementary therapies among Australian general practitioners. Complement Ther Med 2000;8:226—33. 42. Welch SA. The use of complementary medicines by inpatients at St Vincent’s Hospital Sydney. Aust J Hosp Pharm 2001;31:111—3. 43. Leach M. An examination of factors influencing natural therapy use in the Royal District Nursing Service. Aust J Holist Nurs 2002;9:41—9. 44. Pirotta M, Farish SJ, Kotsirilos V, Cohen MM. Characteristics of Victorian general practitioners who practise complementary therapies. Aust Family Physician 2002;31:1133—8. 45. Bensoussan A, Myers S, Wu SM, O’Connor K. A profile of naturopathic and western herbal medicine practitioners in Australia. Sydney: CompleMED, University of Western Sydney; 2003. 46. Coulter ID, Willis EM. The rise and rise of complementary and alternative medicine: a sociological perspective. Med J Aust 2004;180:587—9. 47. Maclennan AH, Myers SP, Taylor AW. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. Med J Aust 2006;184:27—31. 48. Ryan K. Medical homoeopathy. Br Med J 1998;316:2—7. 49. Bodeker G, Chaudhury RR. Lessons on integration from the developing world’s experience. Commentary: challenges in using traditional systems of medicine. Br Med J 2001;322:164—7. 50. Kaptchuk TJ, Miller FG. Viewpoint: what is the best and most ethical model for the relationship between mainstream and alternative medicine: opposition, integration, or pluralism? Acad Med 2005;80:286—90.
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
CAM practitioners in integrative practice in New South Wales, Australia: A descriptive study Sandra Grace a, Subramanyam Vemulpad a,∗, Anna Reid b, Robyn Beirman a a
Department of Health and Chiropractic, Macquarie University, 2109 NSW, Australia Centre for Professional Development, Macquarie University, Sydney, NSW 2109, Australia Available online 30 January 2007
b
KEYWORDS Complementary and alternative medicine; CAM; Integrative practice; Primary contact; Diagnosis; Qualitative research; Clinical training; Grounded theory
Summary Objectives: The aim of this study was to examine the role of complementary and alternative medical (CAM) practitioners in integrative practices where general practitioners (GPs) and CAM practitioners were co-located. Design: This study used grounded theory, a qualitative methodology from the interpretive paradigm. Setting: A total of 23 integrative practitioners (10 general practitioners and 13 naturopaths) were interviewed. The informants were drawn from 16 integrative practices and one nonintegrative general medical practice. Results: In 11 out of 16 integrative practices the CAM practitioners yielded their primary contact role to the GPs. CAM practitioners were restricted to expanding the range of treatment options available to patients. However, the role of the CAM practitioners was influenced by the level of CAM training the GP(s) in the practice had undertaken. The more CAM training the GPs had undertaken, the more CAM practitioners were enlisted as diagnosticians as well as treatment providers. Conclusion: CAM practitioners in integrative practices had an accessory role to the GPs in the practice, deferring diagnosis and assessment activities to the GPs. However, where GPs had significant training in CAM, the CAM practitioner’s role included both treatment and diagnostic activities. © 2007 Published by Elsevier Ltd.
Introduction Models of primary health care that combine Western and complementary medicine include integrative practices
∗
Corresponding author. Tel.: +61 2 98509385; fax: +61 2 98509389. E-mail address: [email protected] (S. Vemulpad). 0965-2299/$ — see front matter © 2007 Published by Elsevier Ltd. doi:10.1016/j.ctim.2006.12.001
where Western medical doctors and complementary and alternative medicine (CAM) practitioners share practice space.1,2 Such practices provide an opportunity to examine the extent to which an integrated or co-management approach to health care has evolved. Naturopaths in Australia receive a generalist training in CAM which usually involves 4 years of private college or university training in biomedical sciences, Western herbal medicine, nutrition, and either homoeopathy, counselling or massage therapies.3 They could be regarded as the ‘general
CAM practitioners in integrative practice in New South Wales, Australia practitioners’ of CAM. Naturopaths are entitled to practice as primary contact practitioners, that is, first contact practitioners who have the knowledge and skills to assess patients, to provide on-going treatment for all aspects of a patient’s health care and/or to direct patients for appropriate care.4—6 Most naturopaths establish independent practices, either alone or with other CAM practitioners. A few establish practice with general practitioners (GPs).7 The aim of this study was to examine the role of CAM practitioners in integrative practices where GPs and CAM practitioners were co-located.
Methodology This research used a qualitative approach that generates data in the form of transcribed interview texts. The results of the study are presented using a form consistent with the methodology known as Grounded Theory.8 In this case meaning is sought directly from the data, and insights are developed from the patterns that emerge from the data.9,10 In a grounded methodology the research data is presumed to contain social patterns that ‘emerge’ through iterative reading and comparison. A ‘constant comparison’ is applied that focuses on the essential elements of ‘time, place and people’.11 It implies that the physical contexts of the participants in the study provide an important analytic contribution to the possible data set. In this research we use a ‘constant comparative’ analytic technique in conjunction with purposive theoretical sampling.9 Data, in the form of interview transcripts, were coded and analysed simultaneously so that specific incidents, concepts and theories were examined in relation to each other. At the same time the participant group was expanded from a selection of co-located practitioners. In this sense there is no random selection; rather, the participants are selected on the basis of their ability to contribute experience to the phenomenon being examined. In this study, a shared concept of mutual behaviour and values is critiqued through the participation of health professionals who are co-located, and where the different locations afford an opportunity to examine essential areas of conceptual difference and commonality. The model that has emerged from this research provides a means of interpreting the interactions and activity of co-located CAM and medical practitioners. From initial interviews a working definition of the role of CAM practitioners was developed using the participants’ own descriptions. The research team then critiqued the data using perspectives developed from previous literature and knowledge of the field to formulate and test the initial participants’ descriptions of their CAM roles. Subsequent interviews focused on the clarification of CAM roles and redefinition of the emerging theory. The on-line telephone directory, http://www. yellowpages.com.au, the most comprehensive directory where both doctors and naturopaths advertise, was used to locate practices in New South Wales (NSW) where naturopaths and GPs shared the same premises. The study was limited to NSW as demographic studies showed that more naturopaths practice in NSW than in any other state.7,12 Only 19 such practices were found representing 0.14% of listed medical practices and 16.9% of listed naturopathic practices in NSW. A letter was sent inviting
43
practitioners to participate and this was followed with a phone call. Practitioners represented a range of practice styles (urban/country, diverse socio-economic regions, and number of practitioners). Two practitioners did not respond to follow-up phone messages. All other invited practitioners agreed to participate in the research. In total, 13 naturopaths and 10 GPs were interviewed from 16 integrative practices and one non-integrative Western medical practice. All interviews were audio-taped with the informants’ consent and transcripts of the interviews forwarded to the informants for verification. All interviews were conducted by the same researcher. Initially responses were sought from practitioners about their choice of integrative practice, the profile of the practice and their contribution to it, integrative practitioners’ training, and referral patterns. Interviews were continued until redundancy of information or theoretical saturation occurred.9 Further informants were selected according to their likely contribution to the refinement or expansion of the concepts and theory that were being developed. Theoretical saturation occurred after a further four 1 h conversational interviews were conducted. Validity was established by a continual process of checking, questioning, and theoretically interpreting at every step of the research from design to reporting. Cross-checks were imposed on the informants’ stories. One method was triangulation, in this case checking concepts emerging from the interview data with descriptions of integrative medicine in primary care practices in the UK13,14 and Australia.15 Checks were also made with clinic advertising material and unsolicited data such as comments written on returned transcripts. Three elements of analysis guided the development of the grounded theory. Firstly, concepts were derived from the data, then categories were described within each concept, and finally generalised relationships between concepts and categories were developed.16
Results GPs’ perceptions of the role of CAM practitioners in integrative practice Seven of the 10 GPs in the study considered themselves the key providers of health care, responsible for directing and monitoring the health care of the patients in the practice. Deficiencies in training of naturopaths were identified by six GPs as potentially limiting naturopaths’ ability to recognise disease and consequently to know when to refer patients for Western medical treatment. ‘‘I have spent years under the supervision of other doctors seeing a lot of people. So if somebody walks in I can tell you if they’re sick or not. . .And what I’ve always had a problem with in naturopathy is not the courses—the course content is fantastic—it’s the clinic. What we really need is a big, centrally based naturopathy hospital and clinic, where people can work under supervision and just see lots and lots of people.’’ (GP 2) The GPs in the study referred patients to CAM practitioners to provide a broader range of treatment options than would have been available in non-integrative prac-
44
S. Grace et al.
tices. The GPs recognised the important role CAM could play as a first treatment approach, especially in the management of chronic and non-life threatening conditions.16 Where possible, CAM treatments were used first because of their relatively inexpensive and non-invasive treatment approaches. ‘‘In general practice there were a lot of situations where I felt loath to use pharmaceuticals and at a loss to do anything else. It was fine for acutely ill people where conventional medicine is absolutely fantastic but (for) a lot of the grumbly things, for the minor things like colds and coughs, it just wasn’t suitable.’’ (GP 2) One GP who had studied Western herbal medicine described how she saw the unique contribution CAM could make to health care, particularly to health maintenance and promotion, and to illness prevention. ‘‘In medicine there’s no concept of normalising, optimising, or restoring. If I give a patient a medical drug, it merely shifts their symptoms to another area that is not normal either. So we move and treat symptoms. With herbal medicine it’s the ability to give the patient something that’s going to prompt the body, nudge the body to come back to where it knows it can be.’’ (GP 1) Referral for CAM treatment also occurred when GPs thought that Western medicine had been ineffective. The following quotation shows how a GP referred patients for CAM when they had reached an impasse. ‘‘I think the majority of clients we refer are the ones we can’t fix. We get somebody else to look at them. The hard ones.’’ (GP 4) In some cases it was not that the case was complex, but that there were few, or no, pharmaceuticals available or pharmaceutical treatment had undesirable side-effects. ‘‘With the great majority of herbal medicines you’re not doing harm and I think a lot of the pharmaceutical medicines are doing harm as well as good and sometimes the harm is greater than the good. People would come in with these problems, like arthritis, and the side-effects of the drugs were as bad as the condition in many ways.’’ (GP 2) All of the GPs in the study thought that their medical training lacked information on CAM. They acknowledged the importance of nutritional influences on health and often referred patients to CAM practitioners for nutrition advice. ‘‘I thought about nutrition. It’s the one thing they didn’t teach me in medicine. It must be important. Why didn’t they teach me? I had 1 h of nutrition in my 6-year course. Eight years with the hospital work. One hour of nutrition.’’ (GP 3)
CAM practitioners’ perceptions of their role in integrative practice Nine of the 13 CAM practitioners in the study accepted the primary contact role of the GPs. Fig. 1a represents the role of CAM practitioners in integrative practice: that of provid-
Figure 1 (a) A model of co-location where GPs are perceived as the primary health care providers. (b) A model of co-location where GPs have undertaken significant CAM training.
ing CAM treatments for patients following Western medical diagnosis. CAM practitioners were not usually involved in diagnostic activities. They recognised the limits of their training in Western medical diagnosis and saw the opportunity to seek advice over issues of patient care as advantageous both for themselves and for their patients. One CAM practitioner commented on her lack of confidence in performing Western medical diagnostic techniques: ‘‘Even though I had training in physical examination, I think it’s such a grey area. I’m not adequately trained. I think it’s totally unprofessional and unsafe of me to pretend. It would be better to have had no training than to be inadequately trained. (Naturopath 3)’’ Interpretation of pathology tests is integral to naturopathic diagnosis and yet referral for pathology tests by naturopaths is severely restricted by the absence of Medicare rebates for patients referred by naturopaths. CAM practitioners who were co-located with GPs were able to refer their patients to the GPs in their practices for pathology testing. In solo practices the ability of CAM practitioners to assess and monitor their patients’ health care is further restricted because many non-integrative GPs are not willing to collaborate with CAM practitioners, particularly in the area of diagnosis. ‘‘The doctors here are open to naturopaths referring to them and will do the tests we require. Often if the patients can’t come to see our doctor for practical reasons and we write a referral to doctors for tests that we require, a lot of doctors will say, ‘‘I’m not doing those tests. I don’t think they’re necessary’’. With our doctors, they understand the program that we’re running and fully agree to participate in what we need to have done. (Naturopath 9)’’
CAM practitioners in integrative practice in New South Wales, Australia Eight of the GPs in the study had undertaken CAM training. Some had very high levels of training in CAM, often equal to or exceeding that of the CAM practitioners in their practices. The findings of this study suggest that the higher the level of CAM training the GPs had undertaken, the more CAM diagnosis was used, and consequently the more CAM practitioners were likely to contribute to the diagnosis and assessment of patients. The co-location model presented in Fig. 1a is altered when GPs have had significant training in CAM. Fig. 1b represents the closer relationship between CAM practitioners and diagnostic and assessment activities when GPs had undertaken significant training in CAM.
Discussion The training deficiencies identified in this study (the lack of information on CAM in medical training and the poor development of Western medical diagnostic skills in CAM training) have been reported as barriers to integration17—19 along with lack of evidence for some CAMs,20—23 divergent philosophies,24,25 and medico-legal issues.26—30 These factors might account for the relatively small number of integrative practices in existence. In the UK CAM practitioners work in at least 20% of general practices.31 One Australia-wide study that included naturopaths, herbalists and acupuncturists found that only 4% of respondents worked in group practices with a GP or other mainstream practitioner.7 In our study, 16.9% of listed naturopaths shared premises with GP(s). The primacy of the GPs found in this study is consistent with studies examining integrative practices in other countries.32—34 This study suggests that the subordination of the CAM practitioner’s role in integrative practices is related to diagnosis (Fig. 1a). The limited ability of CAM practitioners to perform Western medical diagnosis was recognised by all practitioners in the study. However, there appears to be a growing imperative to recognise the contribution CAM can make to treatment options for patients.19,27,35—37 For those patients who are interested and potentially receptive to an alternative approach to health care (and there appears to be a large number in Australia38—47 ) the contribution that CAM diagnosis and assessment activities could make to patients’ health outcomes in integrative practices is largely unexplored. Western medical practitioners are increasingly more open to CAM and more willing to undertake CAM training.44 Our findings suggest that as Western medical practitioners undertake CAM training, they are more likely to incorporate CAM diagnostic and assessment procedures. These procedures may be provided by CAM practitioners or by Western medical practitioners who have trained in CAM. (Fig. 1b). This study was limited to integrative practices where naturopaths shared premises with GPs. Other types of integrative practise certainly exist.48—50 These include GPs who have CAM training and practice their own personal style of integrative medicine as well as the use of referral networks between GPs and CAM practitioners who are not sharing premises.
Conclusion In integrative practices in NSW, 9 out of 13 CAM practitioners yielded their primary contact role to the GPs in the
45
practice. When the GPs referred to CAM practitioners, they referred for CAM treatment. The CAM practitioners provided an expanded range of treatment options to patients. CAM practitioners did not usually contribute to the assessment and diagnosis of patients. Rather, CAM practitioners referred to GPs in their practices for Western medical diagnosis. From our study a model of co-location emerged where GPs were perceived as the key health care providers. In such practices, the role of CAM provider is restricted to providing further treatment options to patients. However, this model of co-location changes when GPs have significant training in CAM. The higher the level of CAM training the GP has undertaken, the greater the CAM practitioners’ role. In this case CAM practitioners contribute to diagnostic and assessment activities as well as treatments.
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