The Integrative Medicine Team—Is Biomedical Dominance Inevitable?

Abstract

Introduction:

As traditional, complementary, and alternative medicines (TCAM) continue to find their way into mainstream medical practice, questions arise about the future of integrative medicine (IM). Concern has been voiced that the biomedical profession will dominate IM and many of the core principles and philosophies governing the practice of TCAM will be lost.

Methods:

Using mixed methods, an IM primary care clinic in Sydney, Australia, was compared to the IM models discussed in the literature.

Results:

Commercial concerns greatly influenced the team's development and the services provided by the practice under study. Questions arose as to whether the clinic was simply incorporating TCAM or truly integrating it. Further analysis of the data revealed evidence of biomedical dominance.

Conclusions:

Given the current health care system in Australia, it seems likely that the biomedical doctor will continue to occupy a central logistical and leadership role in this clinic's IM team.

Introduction

I n response to growing consumer demand for traditional, complementary, and alternative medicines (TCAM), the biomedical professions are integrating more TCAM in their clinical practices.¹ Professional bodies and researchers have proposed a range of definitions for and approaches to integrative medicine (IM); however, a final definition is likely to emerge and settle only as the practice of IM develops.^1

–7

IM teams and health care models

Given the diversity of descriptions of IM, it is not surprising that clinics claiming to offer IM also provide health care using different team arrangements and service models.

Boon et al.,⁸ in discussing team arrangements, proposed a continuum of seven team-oriented health care practices: parallel, consultative, collaborative, coordinated, multidisciplinary, interdisciplinary, and integrative (Table 1). As the team becomes more integrative, there is less reliance upon biomedical models and a greater diversity in healing philosophies; care is patient-centered and holistic; the team becomes more complex and is nonhierarchical, and roles are less defined; and communication with the patient and between practitioners increases, with more consensus-based decision making.

Table 1.

Continuum of Seven Team-Oriented Health Care Practices ^a

Parallel	Independent practitioners working in the same premises.
Consultative	Expert advice is provided to another practitioner upon request.
Collaborative	Patient information is shared on a case-by-case basis between independent practitioners who are caring for the same patient.
Coordinated	A case manager coordinates communication between the team of practitioners and the patient.
Multidisciplinary	A team leader directs the services provided by the team of practitioners.
Interdisciplinary	The team members, usually through regular face-to-face meetings, jointly make decisions about patient care.
Integrative	Interdisciplinary, nonhierarchical blending of biomedicine and traditional, complementary, and alternative medicines. The patient and practitioners have shared goals and values.

Adapted from Boone et al. ⁸

A recent review of IM health care models identified three general approaches to service provision⁹:

1. Selective incorporation in which either the biomedical doctor provides selected TCAM therapies or TCAM practitioners provide services under the guidance of the biomedical doctor.

2. Integrative medicine in which multidisciplinary teams collaborate to provide a comprehensive range of TCAM services alongside biomedical services.

3. Patient-centered pluralism in which patients choose the level of integration and potential disagreements between the different paradigms and philosophies of healing are allowed.

Biomedical dominance

In all westernized countries, health care services are organized by professional authority, with biomedical doctors commanding the highest rank. To do so, the profession must maintain autonomy, authority, and dominance over health care.¹⁰ A significant body of work in the field of health sociology suggests that “medical dominance” is structurally embedded into society.^11,12 It is supported by the socialization of students training for their professional roles, the competition between professions claiming jurisdiction over specialized knowledge (social closure), the co-option of elements from other professional domains, and the marketing to and acceptance of professional authority by the layperson that is often backed by government legislation and funding.^10,12

–15

There is continuing debate about whether the neoliberal economic reforms of the past few decades have significantly weakened biomedical dominance.^10,13,14 Certainly, the freer capitalistic market has coincided with a rise in patient demand for TCAM, legislative changes legitimizing TCAM, insurance funding for TCAM, and changes in consumer expectations and behavior.^1,10 As part of this process, there is evidence that both the biomedical professions and TCAM practitioners are absorbing elements of each other. However, it is not clear if the motivation is to integrate and find common ground or to promote their own professional legitimacy.¹⁶

When integrating biomedicine with TCAM, there is the possibility that biomedical doctors will control the process as in other health care services.¹⁷ Although only a small number of studies have been published, biomedical dominance has also been observed in the IM setting.^3,9 There is a tendency for biomedical doctors to control patient care and use biomedical language as the main form of communication between practitioners.^18,19 Research confirms the significant impact biomedical practitioners' attitudes and knowledge of TCAM have on the style of IM practiced and the level of integration.^7,20,21

The pressure to only include evidence-based TCAM^2,5,22 further demonstrates the tendency of the biomedical profession to incorporate TCAM into orthodox medicine rather than truly integrate the two. A concern raised about the evidence-based approach to integration is that the biomedical professions are cherry-picking rather than truly integrating the different healing modalities.^17,23

Objectives

In response to the research on and debate about what constitutes an IM team and the impact of biomedical dominance, this article presents some of the findings from a case study of an IM clinic.

The results were evaluated in light of the following questions: (1) What model of health care is provided by the clinic by what type of IM team? (2) Are there signs of biomedical dominance?

Methods

The findings discussed in this article come from a case study of the first 4 years of an IM primary care clinic in Sydney, Australia.²⁴ A mixed method approach was used to collect and analyze the data. The results and conclusions presented in this article are mostly drawn from a staff questionnaire but also include a review of the minutes taken of staff meetings, the authors' personal knowledge of the clinic's history and background, and other quantitative data routinely collect by the clinic. Although both quantitative and qualitative data were collected, the synthesis of the data was qualitative using both inductive and abductive theory building.²⁵

Fourteen practitioners (six biomedical doctors including the medical director, three psychologists, a dietitian, two naturopaths, a traditional Chinese medicine practitioner, and a shiatsu practitioner) and one manager completed an anonymous questionnaire with both quantitative and qualitative questions. The questionnaire was constructed by the first author as part of a team building exercise in the clinic.²⁴ In the questionnaire, the 15 respondents were asked to read the article by Boon et al. ⁸ and comment about what style of team arrangement they thought the clinic was mostly providing. A description of patient-centered care was also given,²⁶ which accompanied questions about the provision of patient-centered care. Other questions asked about team building, communication, trust, and interreferrals among practitioners. The review of IM health care models⁹ had not been published at this stage, so these models were not specifically discussed. The quantitative and qualitative results of the questionnaire were analyzed and presented at a staff meeting for further discussion. The minutes of this meeting, along with written notes taken during and shortly after the meeting were coded on paper. In an attempt to further explore the issues raised by practitioners, the analysis also drew on the other data collected about the clinic.

The question of whether there were signs of biomedical dominance did not arise until the data analysis began. It was not specifically addressed in the questionnaire, nor was it formally discussed by practitioners in staff meetings. Drawing on principles from Grounded Theory, both the qualitative and quantitative data were re-examined and recoded using a cyclical iterative and recursive process to generate and test the hypothesis of whether there was biomedical dominance and to explore related issues.²⁵ Unfortunately, limited resources prevented further in-depth exploration; for example, with practitioner and patient interviews, or another staff questionnaire.

Results

The IM team and health care model

All practitioners stated in the questionnaire that they were committed to the concept of working in an IM team. Yet there were considerable differences in opinion about the team as defined by Boon et al. ⁸ (Fig. 1). Despite small numbers, there was no qualitative difference in the responses from the different practitioner groups.

FIG. 1.

Practitioner views about the style of health care they considered to be most commonly practiced in the clinic.⁸ Some practitioners selected more than one option (n=15).

One practitioner wrote:

P1: I think the team generally works together on a client's health needs mostly by sharing client notes… I do work in a collaborative manner especially on difficult and complicated cases and in this process, it becomes a collaborative/consultative process. This, however, depends on availability of practitioners for a quick face-to-face meeting… [With a biomedical doctor with little IM experience, collaboration was limited whilst the biomedical doctor was] gaining more confidence/understanding in natural therapies and becoming more willing to refer.

Attempting to define the IM team prompted much discussion about the practice of IM. Practitioners commented in the staff meeting that the clinic also provides conventional primary care and is not a specialized IM clinic. Therefore, not all clinical presentations warrant a team approach and different types of teamwork would be appropriate for different clinical presentations. There was general agreement in the staff meeting that selecting only one of Boon and colleagues' categories to describe the clinic's team had limited usefulness.

Aside from a lack of clinical need for a team approach for all patients attending the clinic, other contributing factors limiting a team approach and its development were

• practitioners not having an in-depth understanding of each other's modalities

• high staff and practitioner turnover rates

• infrequent staff meetings

• lack of interest and incentives for practitioners to meet and discuss cases

• minimal, if any payment for case conferencing

• busy practitioners who were not available for face-to-face conferencing

• practitioners, who all work part-time, not being in the clinic at the same time

Similar to the practitioners' varied opinions about the clinic's team arrangements, the results of the questionnaire found differing views about other important aspects that influence teamwork. Although everyone felt confident with the clinical competency of the other practitioners, their views were mixed when asked about effective communication and cross referrals.

Comments about difficulties with communication among practitioners mostly focused on practical issues such as technical challenges with electronic messaging systems and a lack of face-to-face contact with other practitioners due to the reasons just listed. Consequently, there was a heavy reliance upon the integrated clinical records, instant messaging, emails, and ad hoc corridor conversations.

Data were not collected by the clinic to track referral patterns. Management observed that the business model of the clinic required at least half the practitioners to be biomedical doctors.²⁴ One reason given was that the biomedical doctors were an important referral source for the less busy TCAM and allied-health practitioners. Comments from the staff questionnaire suggested that referrals within the clinic were mostly between the biomedical doctors and the TCAM and allied-health practitioners. The TCAM and allied-health practitioners rarely cross-referred to each other. It was not clear from the data why this was the case; however, the following quote from a TCAM practitioner who also claimed to refer patients to other practitioners conjectured that some practitioners may not have seen any extra benefit in referring and consider their therapeutic system to be holistic and complete.

P2: There is always going to be an element of believing that one's own practice can engender the cure [for the patient] and outside help [from other practitioners in the clinic] is not necessary.

Added to this was evidence that not all practitioners were comfortable with the other philosophies of healing and therapies provided by practitioners in the clinic.

P1: Some practitioners are open-minded and others need [scientific] evidence and are not open about some healing methods.

Patient preferences played a significant role in the development of the clinic.²⁴ The directors and practitioners in the clinic trialed different IM services such as implementing specialty health programs in which a group of practitioners worked together as an integrated team and offered joint consultations with more than one practitioner. However, there was little patient demand for these integrated health care services. In some cases, patients even felt overserviced and one practitioner commented:

P3: The problems I encounter include: with some patients, a sense of being referred to too many practitioners.

The clinic's business model meant that patients rather than practitioners mostly made the final decision about the level of integration. Many patients self-referred and chose which practitioners to consult. Even if the practitioner recommended a highly integrated team approach, the patient ultimately made the decision.

All the practitioners stated in the questionnaire that they and the other practitioners mostly provided patient-centered care.²⁶ However, the following comments demonstrate that practitioners did not always understand or use the patient-centered model:

P4: There are times when a directive approach is needed. The model suggests that the patient can direct their healing needs and process. This [biomedical doctor] can't get the optimum outcome, in that an expert needs to direct the process, i.e. a doctor.

P5: For the most part I would say that the patients I have seen who have seen other practitioners at the clinic feel well attended to. Sometimes I have heard a complaint of not being heard and at other times I have felt the practitioner may have been concentrating on a treatment of the symptom or disease rather than the patient's special circumstances.

Biomedical dominance

Although practitioners never raised the issue of biomedical dominance in staff meetings, throughout the questionnaire TCAM and allied-health practitioners alluded to frustration with biomedical dominance of the clinic's health care model:

P5: I think that the model at the clinic is still very GP [general practice] focused. I think that the GP still dominates the process and operates as the primary health care provider.

P2: There is still a sense of hierarchy that does not sit as comfortably with the integrated team model.

Further to this, there were many signs suggesting biomedical dominance in the clinic:

• the clinic is owned and led by a biomedical doctor

• the clinical governance and accreditation systems are only for the biomedical doctors

• the computer software was designed for biomedical doctors

• clinic meetings uses biomedicine as the default language

• biomedical doctors charge the highest consultation fees

• the financial survival of the clinic requires at least half the practitioners to be biomedical doctors

• biomedical doctors can practice or prescribe various components of other practitioners' modalities without any formal training or accreditation but not vice versa

• in shared cases, the final authority for management decisions mostly rests with the biomedical doctor and/or the patient, but rarely with a nonmedical practitioner.

On the last point, while answering the questionnaire, a TCAM practitioner raised the question of accountability within the team.

P7: Accountability—doctors are medico-legally accountable. Who are the CM practitioners accountable to? The doctors? Themselves? The clinic?

When the question of accountability was discussed in staff meetings, based on the advice of the practitioners' indemnity insurers, there was general agreement that the biomedical doctor was medico-legally accountable for the care provided by an IM team, especially if the team included an unregistered health practitioner. At the time of this study, aside from osteopaths and chiropractors, Australian statutory law did not regulate other TCAM practitioners, thus limiting legal recourse by aggrieved patients.

Over the first 4 years of the clinic, it became clear that biomedical doctors have an important role in the economic survival of the clinic.²⁴ The financial pressures of having to attract biomedical doctors to the clinic meant that management often had to balance the desire for equity across the team with the need to provide extra benefits. For example, biomedical doctors were guaranteed access to the limited parking. This comment from an allied-health practitioner demonstrates the discontent these difficult decisions often generated:

P6: Well it's not an equal team. The doctors are at the top. You can see this all the way down to who gets a car space—only the doctors.

Discussion

In the evolution of health care services in western countries, TCAM and IM are unusual—patients, as empowered consumers, have mostly driven the demand, often ignoring the advice of the biomedical professions. Demand appears to be growing, and as more biomedical practitioners start to use and integrate TCAM, the definition of IM and the development of IM teams and health care models will continue to evolve.¹ In the case of this clinic, commercial and social pressures strongly influenced its efforts to provide IM and the development of the team.²⁴

Rather than imposing a health care model on the team, the directors allowed the clinic to evolve naturally. The advantage of this approach was the clinic was able to respond to market demands and become financially viable. However, having to survive in the real world placed considerable stressors on the IM team that reduced their capacity to develop a truly integrative model.

Questions arose as to whether this clinic had a fully integrated cohesive team or was simply housing practitioners under the one roof with in-house referrals and shared care for some patients. Certainly, there was expressed frustration from some practitioners about the need for a more cohesive equal IM team. There was evidence to suggest the team was fluctuating between the seven team-oriented health care practices described by Boon et al. ⁸ The team's orientation was influenced by the patient's clinical needs and preferences and the practitioners who were involved in the patient's care.

The comments from practitioners about the practice of IM were in line with previous research that observed the level of integration between TCAM practitioners and biomedical doctors correlated with the biomedical doctor's knowledge of TCAM.²⁰ The comments suggested that the biomedical doctors with training in other medical systems practiced more integratively within the team. It was not clear if all biomedical doctors in the clinic require a minimum level of TCAM knowledge to practice as effective IM team members, and for that matter, if all practitioners need to be well versed in each other's therapeutic approaches and languages.⁶ A lack of experience with integrating different therapeutic paradigms may also help explain the low referrals between the different TCAM and allied-health practitioners.

When considering the clinic's IM health care model, it varied between selective incorporation, integrative medicine, and patient-centered pluralism as outlined in the Introduction.⁹ Further in-depth research may find one of the models predominates.

Evidence of biomedical dominance in the clinic was consistent with other research that suggests allied-health and TCAM practitioners would prefer a less hierarchical system.²¹ The questionnaire was anonymous and questions about biomedical dominance were not specifically addressed by the questionnaire, nor discussed with practitioners. As such, it was not clear from the data whether the biomedical doctors had a different opinion and if there were any other differences between the practitioner groups. Given the structural embeddedness that helps perpetuate the biomedical dominance of multidisciplinary teams,¹¹ it is not surprising that the biomedical doctors did not comment and perhaps were unaware of their dominance of the team.

Similar to other research, the tendency that we described of biomedical doctors to dominate the multidisciplinary team appeared to be as a result of both internal factors within the clinic and external factors.¹¹

The biomedical doctors were in greatest demand at the clinic²⁴ and this reinforced their dominant position over both allied-health and TCAM practitioners. There was evidence that common strategies used by professions to safeguard their positions such as social closure and co-optation were at play. For example, the clinic's infrastructure was designed primarily to support the biomedical doctors, biomedicine was the default language used by the practitioners in the clinic, and the biomedical doctors provided some TCAM and allied-health services but not vice versa.

Including biomedical doctors in an Australian IM team inherently creates market forces that selectively empower them.^10,11 Australian regulation further enables social closure by excluding TCAM and allied-health practitioners from providing many health care services. Access to pharmaceuticals and investigations in Australia is mostly restricted to services requested by biomedical doctors. The Australian health care system uses the general practitioner as the gatekeeper to other biomedical specialties. Coupled with the lack of communication and established referral patterns between TCAM practitioners and biomedical specialists and hospitals, co-ordination of patient care necessitates the general practitioner taking at the very least a central logistical role in the clinic's team.

Not only did social factors outside the clinic create a market advantage for the biomedical doctors, it also created other pressures that may have contributed towards the imbalance within the team. For example, there was external pressure on biomedical doctors to maintain control of a patient's management for fear of medical negligence or retribution by the medical board if they endorse non–evidence-based therapies or accepted an alternate TCAM diagnosis. To what extent the team is affected by these external pressures requires further exploration. In particular, are the biomedical doctors aware of and willing to relinquish their dominant position, and do the other practitioners want to assume more responsibility and control over their patients' care.

Conclusions

In establishing an IM clinic, the directors were faced with considerable challenges on all levels that strongly influenced the types of services offered by the clinic and the development of its team. As found in other research, there were signs of biomedical dominance that negatively affected the development of a truly equal, integrative team. However, given the persistent structural embeddedness supporting biomedical dominance, it is unlikely that the clinic will be able to radically change the status quo. For the time being, biomedical doctors will have at the very least, a significant impact on the clinic's health care model and maintain some kind of directing leadership role.

Perhaps of greatest interest should be patients' views and preferences, along with further exploration about the factors driving their choices. Some indication of patient preference was already known simply by watching consumer behavior and from the positive results from a patient satisfaction survey.²⁴ However, more information is needed about patients' views to determine whether they are seeking a patient-centered pluralistic health service model; what their experiences and outcomes are with different styles of IM; and how these compare with conventional biomedical primary care.

Footnotes

Author Disclosure Statement

Kerryn Phelps is an owner and medical director of the clinic. Aside from indirect financial benefit from improving the reputation of the clinic through publishing research, Phelps has no competing financial interests. No competing financial interests exist for the other three authors.

References

Coulter

, Willis

. The rise and rise of complementary and alternative medicine: a sociological perspective. Med J Aust, 2004; 180,11:587–589.

Templeman

, Robinson

. Integrative medicine models in contemporary primary health care. Complement Ther Med, 2011; 19:84–92.

Khorsan

, Coulter

, Crawford

, Hsiao

. Systematic review of integrative health care research: randomized control trials, clinical controlled trials, and meta-analysis. Evid Based Complement Alternat Med, 2011; 636134.

Australasian Integrative Medicine Association. What is integrative medicine? Royal Australian College of General Practitioners and the Australasian Integrative Medicine Association joint working party. 2011. http://www.aima.net.au/resources/what_is_integrative_medicine.html

NCCAM. What is complementary medicine?2010 hnnghwaS, editor2010. http://nccam.nih.gov/health/whatiscam/

Stumpf

, Shapiro

. Bilateral integrative medicine, obviously. Evid Based Complement Alternat Med, 2006; 3:279–282.

Hsiao

, Ryan

, Hays

, Coulter

, Andersen

, Wenger

. Variations in provider conceptions of integrative medicine. Soc Sci Med, 2006; 62:2973–2987.

Boon

, Verhoef

, O'Hara

, Findlay

. From parallel practice to integrative health care: a conceptual framework. BMC Health Serv Res, 2004; 4:15.

Wiese

, Oster

, Pincombe

. Understanding the emerging relationship between complementary medicine and mainstream health care: a review of the literature. Health (London), 2010; 14:326–342.

10.

Willis

. Introduction: taking stock of medical dominance. Health Sociology Review, 2006; 15:421.

11.

Bourgeault

, Mulvale

. Collaborative health care teams in Canada and the USA: confronting the structural embeddedness of medical dominance. Health Sociology Review, 2006; 15:481–495.

12.

Freidson

. Professional dominance: the social structure of medical care. New Brunswick, NJ: Transaction Publishers, 1970.

13.

Cooper

, Bissell

, Ward

, Murphy

, Anderson

, Avery

et al. Further challenges to medical dominance? The case of nurse and pharmacist supplementary prescribing. Health (London), 2012; 16:115–133.

14.

Benoit

, Zadoroznyj

, Hallgrimsdottir

, Treloar

, Taylor

. Medical dominance and neoliberalisation in maternal care provision: the evidence from Canada and Australia. Soc Sci Med, 2010; 71:475–481.

15.

Mills

, Hallinan

. The social world of Australian practice nurses and the influence of medical dominance: an analysis of the literature. Int J Nurs Pract, 2009; 15:489–494.

16.

Broom

. Reflections on the centrality of power in medical sociology: an empirical test and theoretical elaboration. Health Sociology Review, 2006; 15:496–505.

17.

MacKenzie-Cook

. Challenging the new orthodoxy in integrative medicine. J Altern Complement Med, 2006; 12:679–683.

18.

Hollenberg

. Uncharted ground: patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings. Soc Sci Med, 2006; 62:731–744.

19.

Frenkel

, Borkan

. An approach for integrating complementary-alternative medicine into primary care. Fam Pract, 2003; 20:324–332.

20.

Grace

, Vemulpad

, Reid

, Beirman

. CAM practitioners in integrative practice in New South Wales, Australia: a descriptive study. Complement Ther Med, 2008; 16:42–46.

21.

Ben-Arye

. The role of dual-trained conventional/complementary physicians as mediators of integration in primary care. Evid Based Complement Alternat Med, 2010; 7:487–491.

22.

Adams

. General practitioners, complementary therapies and evidence-based medicine: the defence of clinical autonomy. Complement Ther Med, 2000; 8:248–252.

23.

Caspi

. Integrated medicine: orthodox meets alternative. Bringing complementary and alternative medicine (CAM) into mainstream is not integration. BMJ, 2001; 322:168.

24.

Hunter

, Corcoran

, Phelps

, Leeder

. The challenges of establishing an integrative medicine primary care clinic in Sydney, Australia. J Altern Complement Med, 2012; 18:1–6.

25.

Ezzy

. Qualitative Analysis: Practice and Innovation. London: Routledge, 2002.

26.

Hunter

. Establishing an integrative practice. J Comp Med, 2008; 7:22–26.