Practitioner-client relationships in integrative medicine clinics in Australia: a contemporary social phenomenon

How do patients integrate complementary medicine with mainstream healthcare? A survey of patients' perspectives

BACKGROUND

Complementary medicines (CM) are widely consumed by Australians. However, CM is not included in policy and planning of patient-centred models of healthcare. This study aimed to explore how patients themselves manage to integrate CM with mainstream healthcare.

METHODS

An online survey was distributed through snowball sampling via professional networks and targeted advertising in social media to Australian consumers of CM. Data were managed in Excel and analysed using descriptive statistics in IBM SPSS v23 and Stata v13.

RESULTS

A total of 379 consumers of CM therapies or products completed the survey. The mean age was 51 years, 83% were female and 34% reported having a chronic disease. CM consumers consulted a wide range of healthcare providers. Almost all (97%) had seen a general medical practitioner (GP) within the past year. Overwhelmingly, participants (95%) reported that they themselves were the primary managers of their own healthcare, either on their own (60%) or in collaboration with a CM practitioner (19%) or GP (16%). Approximately 60% of participants reported that they freely discussed their visits to CM practitioners with their GP. Among those, however, males with chronic disease were less likely to disclose CM practitioner consultations (X²₍₁₎ = 4.1, p =  0.04) and over-the-counter pharmaceutical consumption (X²₍₁₎ = 3.8, p =  0.05) to GPs than males without chronic disease. Small numbers in some subgroup analyses suggested that further, larger studies on patient perspectives should particularly target males with chronic disease. Most respondents (83%) valued free choice of health practitioner as extremely or very important (83%). A sense of practitioner community was extremely or very important to the majority (76%) of participants.

CONCLUSION

CM consumers see themselves as primary managers of their healthcare. They want more communication between healthcare providers, which could support them in the safe integration of their total healthcare options. Healthcare policy and planning should recognise the totality of influences on patient health, including the range of CM practitioners and products used by some healthcare consumers.

Naturopathy in Australia: Where are we now? Where are we heading?

Naturopathy is the general practice of natural therapies. It emphasizes prevention, treatment, and promotion of optimal health through therapeutic modalities which encourage the self-healing process of the body. Formalized in the 19th century by the hydrotherapy and nature cure movement in Austria and Germany, naturopathy was introduced to Australia at the turn of the 20th century. It became popular since the 1970s due to social and cultural change characterized by the post-modern philosophy, as well as government policies highlighting individual responsibility and freedom of choice. Naturopathy is one of the most popular forms of complementary medicine in Australia today with naturopaths received 4.9 million consultations annually. Naturopathic consultations are sought for a variety of conditions and, in some areas, as a form of primary care, especially by middle-aged women who have a higher education level and a higher annual income. The number of Australian naturopaths was estimated to be over 4000 in 2017 and expects to grow to over 4600 by 2022, although this number is likely to be an underestimation. Australian naturopaths, as a predominantly female profession, work mainly in private clinical practice with nutritional medicine, herbal medicine, homeopathy, as well as massage therapies being the most common modalities used. There are also signs of greater integration with community pharmacies and integrative medicine clinics in major cities. The Bachelor's degree programs in Naturopathy has just become the only accredited entry-level qualification since late 2015. Currently, there are only 5 private colleges offering naturopathic education, a far cry from the 40 over in mid-2000. The profession continues to be self-regulated. There is no barrier of entry to practice and unqualified practitioners of naturopathy can potentially do harm to the public. The registration of naturopaths remains unresolved due to fragmented representation under many professional associations, disunity among the profession, and objections by certain health care lobbyists. There is a dearth of research demonstrating efficacy of the whole practice of naturopathy in Australia, which has directed the government's decision to withdraw it from private health insurance coverage from 2019. Moving forward, the whole system research of naturopathy in Australia will be in focus with the recent establishment of a practice-based research network and an international research consortium. With increasing scrutiny from evidence-based medicine, the present and future challenge to Australian naturopaths is centered on the integration of both scientific and traditional evidence to form the foundation of a person-centered, evidence-informed practice.

Experiences of pregnant women receiving osteopathic care

The state of women's health during pregnancy and in the post-natal period can have profound and long-term effects on their own health and that of their children. Women are increasingly seeking complementary and alternative therapies during pregnancy. The aim of this study was to explore the experiences of women who received osteopathic treatment during pregnancy.

METHOD

This phenomenological study used semi-structured interviews with pregnant patients who were undergoing osteopathic care in northern NSW and south-east Queensland, Australia. Data were analysed thematically.

RESULTS

Osteopathic care provided symptom relief, particularly for low back and pelvic pain. Participants wanted a natural childbirth with minimal medical intervention if possible. Osteopathic care was perceived as helping prepare women's bodies for birth and in so doing helped alleviate anxieties associated with childbirth and with entering the mainstream medical system.

CONCLUSIONS

Pregnant women receiving osteopathic care reported experiencing physical and mental health benefits both during pregnancy and in the post-natal period.

Interface, interaction and integration: how people with chronic disease in Australia manage CAM and conventional medical services

OBJECTIVES

To understand the extent to which conventional and complementary health care are integrated for CAM users with chronic conditions.

METHODS

In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia.

RESULTS

Many participants reported regular, frequent and long-term use of CAM therapies to maintain their health or assist in the management of their chronic condition. They generally managed the interface between convention and complementary health care on their own, as the perceived or expressed negative attitudes of some doctors, or the belief that the doctor did not need to know, were barriers to the disclosure of CAM use. For a smaller group, there was interaction between conventional and CAM providers, which limited the extent of uncertainty and conflicting information being (mis)interpreted by consumers.

CONCLUSIONS

Greater interaction between CAM and medical providers would be beneficial to consumers. Structural barriers, related to financing and service organization, need to be addressed. Attitudinal shifts of some health-care practitioners also need to be addressed, in the context of workforce development.

Room for improvement: complementary therapy users and the Australian health system

CONTEXT

People with chronic conditions who are often in contact with the health-care system are well placed to reflect on how services meet their needs. Some research characterizes people who use complementary and alternative medicines (CAMs) as a distinct group who opt out of the mainstream health system. However, many CAM users are people with chronic or terminal health conditions who concurrently use mainstream health-care services. The difference in perspectives between people with chronic conditions who do or do not use CAM has received little attention by researchers.

OBJECTIVE

To explore the views of CAM users with chronic conditions and identify their perspectives on the health system.

DESIGN AND SETTING

In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia.

RESULTS

One in four CAM practitioner users was partly motivated to use CAM as a result of their dissatisfaction with the mainstream health system. In general, their dissatisfaction mirrored the concerns of the general population. This included the perceived lack of a humanistic or person-centred approach, which was central to problems relating to individuals' clinical encounters as well as to health system design.

DISCUSSION AND CONCLUSION

Participants' concerns suggest room for improvement in the Australian health system to better reflect patients' needs. A systems approach is needed to reorient health-care practitioners to modify the organization of care because of the incentives embedded in the structure of the health-care system.

A gentle ethical defence of homeopathy

Recent discourses about the legitimacy of homeopathy have focused on its scientific plausibility, mechanism of action, and evidence base. These, frequently, conclude not only that homeopathy is scientifically baseless, but that it is "unethical." They have also diminished patients' perspectives, values, and preferences. We contend that these critics confuse epistemic questions with questions of ethics, misconstrue the moral status of homeopaths, and have an impoverished idea of ethics-one that fails to account either for the moral worth of care and of relationships or for the perspectives, values, and preferences of patients. Utilitarian critics, in particular, endeavour to present an objective evaluation-a type of moral calculus-quantifying the utilities and disutilities of homeopathy as a justification for the exclusion of homeopathy from research and health care. But these critiques are built upon a narrow formulation of evidence and care and a diminished episteme that excludes the values and preferences of researchers, homeopaths, and patients engaged in the practice of homeopathy. We suggest that homeopathy is ethical as it fulfils the needs and expectations of many patients; may be practiced safely and prudentially; values care and the virtues of the therapeutic relationship; and provides important benefits for patients.

Integrating complementary and alternative medicine into mainstream healthcare services: the perspectives of health service managers

Background

Complementary and alternative medicine (CAM) is increasingly included within mainstream integrative healthcare (IHC) services. Health service managers are key stakeholders central to ensuring effective integrative health care services. Yet, little research has specifically investigated the role or perspective of health service managers with regards to integrative health care services under their management. In response, this paper reports findings from an exploratory study focusing exclusively on the perspectives of health service managers of integrative health care services in Australia regarding the role of CAM within their service and the health service managers rational for incorporating CAM into clinical care.

Methods

Health service managers from seven services were recruited using purposive and snowball sampling. Semi-structured interviews were conducted with the health service managers. The services addressed trauma and chronic conditions and comprised: five community-based programs including drug and alcohol rehabilitation, refugee mental health and women’s health; and two hospital-based specialist services. The CAM practices included in the services investigated included acupuncture, naturopathy, Western herbal medicine and massage.

Results

Findings reveal that the health service managers in this study understand CAM to enhance the holistic capacity of their service by: filling therapeutic gaps in existing healthcare practices; by treating the whole person; and by increasing healthcare choices. Health service managers also identified CAM as addressing therapeutic gaps through the provision of a mind-body approach in psychological trauma and in chronic disease management treatment. Health service managers describe the addition of CAM in their service as enabling patients who would otherwise not be able to afford CAM to gain access to these treatments thereby increasing healthcare choices. Some health service managers expressly align the notion of treating the whole person within a health promotion model and focus on the relevance of diet and lifestyle factors as central to a CAM approach.

Conclusions

From the perspectives of the health service managers, these findings contribute to our understanding around the rationale to include CAM within mainstream health services that deal with psychological trauma and chronic disease. The broader implications of this study can help assist in the development of health service policy on CAM integration in mainstream healthcare services.

CAM practitioners in the Australian health workforce: an underutilized resource

BACKGROUND

CAM practitioners are a valuable but underutilizes resource in Australian health care. Despite increasing public support for complementary and alternative medicine (CAM) little is known about the CAM workforce. Apart from the registered professions of chiropractic, osteopathy and Chinese medicine, accurate information about the number of CAM practitioners in the workforce has been difficult to obtain. It appears that many non-registered CAM practitioners, although highly qualified, are not working to their full capacity.

DISCUSSION

Increasing public endorsement of CAM stands in contrast to the negative attitude toward the CAM workforce by some members of the medical and other health professions and by government policy makers. The marginalisation of the CAM workforce is evident in prejudicial attitudes held by some members of the medical and other health professions and its exclusion from government policy making. Inconsistent educational standards has meant that non-registered CAM practitioners, including highly qualified and competent ones, are frequently overlooked. Legitimising their contribution to the health workforce could alleviate workforce shortages and provide opportunities for redesigned job roles and new multidisciplinary teams. Priorities for better utilisation of the CAM workforce include establishing a guaranteed minimum education standard for more CAM occupation groups through national registration, providing interprofessional education that includes CAM practitioners, developing courses to upgrade CAM practitioners' professional skills in areas of indentified need, and increasing support for CAM research.

SUMMARY

Marginalisation of the CAM workforce has disadvantaged those qualified and competent CAM practitioners who practise evidence-informed medicine on the basis of many years of university training. Legitimising and expanding the important contribution of CAM practitioners could alleviate projected health workforce shortages, particularly for the prevention and management of chronic health conditions and for health promotion.

The health professional-patient-relationship in conventional versus complementary and alternative medicine. A qualitative study comparing the perceived use of medical shared decision-making between two different approaches of medicine

OBJECTIVE

To explore differences between conventional medicine (COM) and complementary and alternative medicine (CAM) regarding the attitude toward and the perceived use of shared decision-making (SDM) from the health professional perspective.

METHODS

Thirty guideline-based interviews with German GPs and nonmedical practitioners were conducted using qualitative analysis for interpretation.

RESULTS

The health professional-patient-relationship in CAM differs from that in COM, as SDM is perceived more often. Reasons for this include external context variables (e.g., longer consultation time) and internal provider beliefs (e.g., attitude toward SDM). German health care policy was regarded as one of the most critical factors which affected the relationship between GPs and their patients and their practice of SDM.

CONCLUSION

Differences between COM and CAM regarding the attitude toward and the perceived use of SDM are attributable to diverse concepts of medicine, practice context variables and internal provider factors. Therefore, the perceived feasibility of SDM depends on the complexity of different occupational socialization processes and thus, different value systems between COM and CAM.

PRACTICE IMPLICATIONS

Implementation barriers such as insufficient communication skills, lacking SDM training or obedient patients should be reduced. Especially in COM, contextual variables such as political restrictions need to be eliminated to successfully implement SDM.

What's in a name: integrative medicine or simply good medical practice?

OBJECTIVE

Integrative medicine, a popular movement in the USA and Europe, is taught in many US medical schools. This study describes how Australian doctors define integrative medicine, what motivates them to work in integrative medicine and the incorporation of complementary and alternative medicines (CAM) into their practice.

METHODS

Semi-structured interviews were conducted between May and December 2009 with 23 doctors in two Australian states working in integrative medicine. A thematic analysis of interview transcripts was undertaken.

RESULTS

Doctors' interpretations of the term 'integrative medicine' varied considerably. All maintained a strong belief in the usefulness of conventional medicine, while a holistic and patient-centred approach, promoting well-being, was central to their practice. Doctors' motivations for choosing an integrative approach to their practice of medicine also varied, but personal and professional experiences of alternative approaches to illness were influential in this decision. The nature of their clinical practice was also diverse; few doctors in this sample practice or professionally use CAM; a small number were happy to advise patients on the use of different modalities while even less referred to complementary practitioners.

CONCLUSIONS

The concept and practice of integrative medicine among the doctors interviewed were diverse. This has implications for the Royal Australian College of General Practitioners inclusion criteria for the membership of their integrative medicine chapter. More broadly, the findings have implications for all medical practice and the education of medical students, as much of what integrative medicine doctors do may be considered simply as 'good medical practice'.

The prevalence and experience of Australian naturopaths and Western herbalists working within community pharmacies

Background

Naturopaths and Western herbal medicine (WHM) practitioners were surveyed to identify their extent, experience and roles within the community pharmacy setting and to explore their attitudes to integration of complementary medicine (CM) practitioners within the pharmacy setting.

Method

Practising naturopaths and WHM practitioners were invited to participate in an anonymous, self-administered, on-line survey. Participants were recruited using the mailing lists and websites of CM manufacturers and professional associations.

Results

479 practitioners participated. 24% of respondents (n = 111) reported they had worked in community pharmacy, three-quarters for less than 5 years. Whilst in this role 74% conducted specialist CMs sales, 62% short customer consultations, 52% long consultations in a private room and 51% staff education. This was generally described as a positive learning experience and many appreciated the opportunity to utilise their specialist knowledge in the service of both customers and pharmacy staff. 14% (n = 15) did not enjoy the experience of working in pharmacy at all and suggested pharmacist attitude largely influenced whether the experience was positive or not. Few practitioners were satisfied with the remuneration received. 44% of the total sample provided comment on the issue of integration into pharmacy, with the main concern being the perceived incommensurate paradigms of practice between pharmacy and naturopathy. Of the total sample, 38% reported that they would consider working as a practitioner in retail pharmacy in future.

Conclusions

The level of integration of CM into pharmacy is extending beyond the mere stocking of supplements. Naturopaths and Western Herbalists are becoming utilised in pharmacies