Integrating a Complementary Medicine Service Within a General Surgery Department: From Contemplation to Practice

Abstract

This article describes experience in developing a complementary and alternative medicine (CAM) service within a general surgery department in a public academic hospital in Israel. A framework is suggested for integrating CAM services within a hospital, based on the authors' experience, along three themes: the organizational structure of such a service, communication with the conventional team, and self-appraisal using a research-based documentation and assessment process. With the anticipated increase in CAM utilization within medical institutions, it is hoped this article will provide foundations for successful integration of other such services.

Introduction

T he use of complementary and alternative medicine (CAM), a group of diverse medical and health care practices and products that are not generally considered part of conventional medicine, is increasing steadily in the Western world.¹ Interest in CAM grows proportionally with the chronicity of illness and its burden on life.² CAM use is commonly driven by patient demand rather than it being offered by the medical system.³ In recent years, there has been a growing interest in providing CAM within both community and hospital settings. However, the provision of CAM for hospitalized patients has been reported mostly in the context of clinical trials,⁴ whereas the integration of CAM as an actual service for the care of hospitalized patients has been reported seldom in the medical literature.⁵

A large proportion of patients attending hospitals are familiar with CAM use prior to their admission.⁶ Some continue to use CAM (specifically herbs and food supplements) while hospitalized,⁷ and studies indicate that hospitalized patients reflect patterns of CAM use that are similar to the general population.⁸ Based on the relatively short period of stay in most hospital departments, it may be assumed that patient awareness of, and preference for, CAM does not change significantly during hospitalization.

Yet, hospitalization can pose dilemmas for patients regarding CAM use. On the one hand, patients may wonder about the legitimacy of CAM within the hospital setting and hesitate to disclose their use to physicians and nurses. On the other hand, they might encounter limitations of conventional care during hospitalization and be interested in adding CAM therapies.⁷ Thus, offering CAM to hospitalized patients might well have practical benefits, and also promote ethical principles of patient autonomy, beneficence, and nonmaleficence, and respect for medical pluralism.⁹

These observations motivated a group of clinicians and researchers to establish a CAM service within a general surgery department in a public academic hospital in Israel. This article describes the process of developing that service.

Developing an Integrative Surgical Program

Based on the authors' experience, the development of an integrative surgical program can be broken down into four phases: contemplation, crystallization, formation, and implementation, which will be discussed in the following sections.

Contemplation

The first phase of contemplation was aimed to assess the need for inpatient CAM services, and included professional brainstorming discussions and conversations with patients.

One-on-one brainstorming discussions about the concept of inpatient CAM services were held with various hospital stakeholders, including physicians from diverse specialties, nurses, and administrators. Integrative physicians and CAM practitioners outside the hospital were also consulted. The main topics of discussion were the pros and cons of such a service, general logistics, and organizational ramifications.

Input was also sought from patients participating in an independent study on CAM use that was being conducted in the hospital at the time. Patients who appeared to be relatively informative during their research interviews were selected and approached for an additional conversation, during which they were asked about their perceptions regarding a hospital-based CAM service. Patients were requested to reflect upon such a service in terms of its role in patient care, financial aspects (e.g., willingness to pay), and what would amount to optimal communication between the conventional medical team and CAM practitioners in their view.

The authors talked with professionals and patients until it was felt that suggestions and ideas were starting to repeat themselves (i.e., until reaching saturation). Patients and staff perceptions regarding a CAM service at the hospital are presented in Table 1. At the end of this process, there appeared to be general agreement with the notion that inpatient CAM services would be accepted by both hospital staff and patients, although some estrangement was to be expected initially. Other questions were left to be discussed in the next phase of crystallization, including some regarding the practical aspects of a CAM service.

Table 1.

Patients and Staff Perceptions Regarding a Complementary and Alternative Medicine (CAM) Service at the Hospital

Theme	Patients	Hospital staff
Interest in CAM service	“I used CAM in the past for my arthritis condition and it helped. If it can also help hospitalized people, why not?”	Any service that contributes to our patients should be considered.
	“This sounds like a good idea. If they [doctors and CAM practitioners] work together we will benefit.”	Although we do not feel informed enough about CAM, patient preferences are a strong motivator to include such a service.
What type of treatments should be included?	“It really depends what helps. It's for the doctors to decide.”	Selection of CAM treatments depends on the medical condition and on the findings that support the treatments' safety and effectiveness. In addition, it is best to avoid esoteric treatments in order to avoid opposition.
	“There should be a mix of treatments available so that people can choose.”
Finance	“People are willing to pay a reasonable sum for treatments that help them.”	Outpatient services should break even. In-patient services should be free of charge.
	“The hospital should subsidize the treatments so they will be available to all.”
Communication	“It's obvious that all parties should be informed about my care.”	All services at the hospital are documented and all parties are notified via standard procedures. CAM services should not be an exemption.
	“If I'm getting massage, I'm not so sure why the doctor needs to know that. He's got enough on his head.”

Crystallization

The unresolved questions that emerged in the initial phase of contemplation were discussed thoroughly in the second phase of crystallization. Four (4) perspectives were taken as major themes for modeling: institutional, conventional staff, CAM practitioner, and practical aspects of time and cost.

The hospital has 450 beds and is affiliated academically with the Bruce Rappaport Faculty of Medicine, Technion Institute. From the institutional perspective, three leading issues arose at meetings with the hospital administrators: financial, ethical, and clinical. The hospital is part of Israel's public health care system, so that hospital services are covered by national health insurance. This means that patients do not pay out-of-pocket for any of the services that are provided during hospitalization. It was felt that charging money for “extra” CAM services would be unethical since it would create inequality between patients. The management decided, therefore, that inpatient CAM services would be free of charge. In order to avoid incurring heavy expenses for the hospital, a modest pilot in one department was thought to be appropriate. Another institutional concern was that having a CAM service might expose the hospital to the criticism of providing supposedly unscientific medicine. This was addressed by resolving to provide “mainstream” CAM treatments (e.g., acupuncture and hypnosis), for which an evidence base exists for certain indications and which are regulated partially by law in Israel.

As for the perspective of the conventional staff, the introduction of a new service may interrupt routine and thus generate opposition. Also, a new service needs physical space and other facilities (computers, etc.). In a busy and crowded hospital this may trigger “territorial wars.” It was therefore crucial to establish partnerships with the conventional staff and allow enough preparation in order to avoid these hurdles. Plans were made so that interference with daily routine was minimized, and facilities were allocated in addition to those of the department (i.e., iPADs as working stations). Subjective factors, such as friendship with senior staff, are important in the selection of the department to house the CAM service, so as to form alliances with colleagues who are open to such transformation and ready to endorse it. It has been the experience of many pioneers in the field of integrative medicine that openings into mainstream medical establishments occur when joining forces with personal friends who have gained positions of influence in their institution. This was also the case with the choice of the general surgery department as the site of the pilot service, when a long-time friend and proponent became its director. The support he provided was invaluable and facilitated a smooth and uneventful process throughout the pilot.

CAM practitioners provide yet another perspective. They are seldom trained and exposed to treatment in acute-care settings, where patients present with complex and challenging manifestations of disease, rather than a chronic stable phase. Exposing practitioners first to a single department will help focus their professional preparation. Having the ability to foresee a defined set of clinical scenarios (e.g., managing postoperative pain, nausea, and vomiting) allows appropriate training and improves quality of care and risk management.

Creating a systematic CAM service within the hospital was not a viable option initially, because of time and budget constraints. Some hospitals in Israel provide CAM services in their outpatient settings. Often, practitioners work in these settings voluntarily with the motive of gaining clinical experience. The authors objected to such an approach for moral and professional reasons. Integration should be in all aspects, and therefore volunteer work was not a consideration. Practitioner salaries were matched to those of allied health practitioners in the public service in Israel. Because the CAM treatments provided by our service did not require significant investment in space (treatments are provided in the patient's bed) and equipment (i.e., acupuncture needles and reflexology cream), 90% of the service's cost was spent on practitioner salaries. In terms of logistics, 2 practitioners working 5 hours daily was considered sufficient to address patient needs in multiple loci of the surgery stations (surgery department, induction/surgery preparation room, and so on). Consequently, the cost of providing CAM care on an initially small scale was a relatively minor expense out of the hospital's overall budget, and the increment was justified as an excellent public relations activity for the hospital in the context of improved service to patients. Eventually, the hospital management decided to allocate money from internal funds to pay for practitioners' salaries and equipment in the pilot program, while strategic plans to create a comprehensive and financially sustainable service were left to be considered at a later stage.

Formation

After deciding to develop a CAM service within the general surgery department—a complementary-integrative surgery service (CISS)—the question arose as to the scope of the service. A literature search was conducted in order to characterize the problems that patients undergoing surgery report as being treated suboptimally with standard conventional care.^10,11 Concomitantly, interviews were conducted with surgeons and nurses in the surgery ward to learn what medical conditions they viewed as having suboptimal treatment with conventional care, and what they would consider to be significant contributions of a CAM service.

The literature search and staff interviews identified areas where the conventional standard of care was unsatisfactory and complementary assistance would be appreciated, such as pain control and postoperative bowel dysfunction. There was also assessment from staff responses to interviews whether any specific therapy would trigger opposition from conventional caregivers. In addition, treatments that might present safety issues, such as herbal prescription, were deferred for further consideration at a later phase.

The next step was to conduct yet another literature review so as to appraise whether CAM has potential in treating those conditions that had been identified as candidates for CISS. It was found that potential symptoms for CAM intervention included the following: pain management, postoperative nausea and vomiting, insomnia, anxiety, bowel movement, and fatigue. The main CAM therapies that were reported as potentially beneficial included touch therapies, such as reflexology^12,13 and massage,¹⁴ aromatherapy,^15,16 music therapy,^17
–19 hypnosis,^20,21 guided imagery,^22,23 and acupuncture.^24,25 Articles were reviewed and categorized by subjects to create a “service library” for practitioner education. Consequently, it was chosen initially to incorporate acupuncture, hypnosis, guided imagery, and reflexology for supportive care in the surgery ward within the CISS pilot. These therapies are used frequently in ambulatory community settings in Israel, and physicians and patients are more familiar with them. In addition, the availability of practitioners played a role; hence, although certain other therapies (e.g., music therapy) were considered highly appropriate, the scarcity of therapists precluded their inclusion. Further questions arose with regard to the composition of the CISS team. In Israel there is no legal regulation of most CAM practices, and there are no agreed-upon standards for verifying credentials. In addition, CAM training curricula are not standardized, and in any event they are mostly oriented toward outpatient care. These circumstances made practitioner selection especially challenging. Practitioner qualifications were therefore defined as including all of the following: 5 years of practical experience in their CAM modality; multiple CAM expertise; excellent communication skills; proven leadership initiative (i.e., experience in planning and successfully carrying out a team project); didactic capability; and, last but not least, unpretentious practitioners with an appreciation of conventional medicine and respect for the institutional context. These characteristics were considered crucial for building cross-disciplinary working relations in terms of patient care and to preempt conflicts with conventional medical staff. It was also intended for the service to develop a strong academic orientation, and therefore CAM practitioners were sought who would be oriented toward research. Research experience was not a prerequisite since it would have extremely limited the availability of practitioners. There was a plan, however, to provide research mentoring at a later stage. Competence of potential practitioners was assessed by reviewing school curricula and individual curriculum vitae, asking referees about the characteristics described above, and conducting personal interviews in a hospital committee.

After identifying and recruiting the CAM practitioners for the integrative team, a series of orientation meetings was held. The goal was to consolidate the CISS team by (1) familiarizing all members with the various treatment modalities, so that acupuncturists, for instance, would understand the scope of practice and basic techniques of mind–body therapists, and vice versa; (2) addressing indications and contraindications in surgery patients (e.g., not leaving needles in sedated patients, or the effectiveness of hypnosis in reducing anxiety prior to surgery); and (3) developing appropriate treatment approaches for specific conditions that are prevalent in the surgery department, such as nausea or insomnia. Practitioners were also introduced to common medical procedures and medical language and terminology used daily in the surgery department, in order to enhance professional communication with the conventional medicine team. Safety and quality assurance protocols were also structured (for example, whether and how to provide acupuncture to patients receiving anticoagulants, or the appropriateness of hypnosis in patients with active psychiatric conditions). Practitioners toured the various stations of surgery patients in the hospital (outpatient clinic, surgery ward, induction room, surgery theater, postanesthesia care unit, and so on). They also went through standard recruitment procedures for all new hospital personnel.

In parallel, the conventional staff was prepared through holding individualized meetings with key nurses and physicians in the surgery department to assess their attitudes toward CAM and its potential role in an integrative service. Staff meetings were then convened at which presentations were given on the nature of the service and each treatment modality, emphasizing indications and contraindications. After the service became active, more one-on-one meetings were held with selected physicians and nurses who seemed less receptive or tolerant of its various aspects.

Implementation

Communication is a crucial element for integration on three levels: among the CAM practitioners, with the conventional medical staff, and most of all with the patients.

In learning to communicate within the CISS team, cross-disciplinary talk was emphasized. Team meetings and patient conferences were conducted in such a way as to introduce the philosophy and practice of each treatment modality to all CISS team members. Moreover, practitioners were encouraged to see patients together, and to explore the benefits of combined treatments. The rationale for this process was to facilitate a thorough understanding of the language of different CAM practices, and the strengths and weaknesses of each modality in diverse clinical scenarios. Through this process, we expected practitioners to enrich their treatment approaches, by learning from and incorporating other treatment modalities. Indeed, hypnotherapists began using acupressure points and breathing techniques to facilitate trance states, while acupuncturists and reflexologists reported better relaxation responses when using simple guided imagery techniques, following focused training and supervision by the psychologist who provides hypnosis at our service.

Daily collaboration and communication with the medical team was conducted on multiple levels. Practitioners joined the medical rounds and brought the attention of physicians to patients who might benefit from CAM. They accompanied nurses and physicians on their daily routines (nurse care, surgery room, outpatient clinic, and so on) in order to learn the biomedical language and mode of care. In addition, the option of a CISS consultation was added to the hospital's electronic consultation system. Thus, consultations could be ordered by the head nurse and by physicians in the surgery department after the morning round, in the same way they might order a consultation from other hospital specialists. Practitioners would then prioritize treatments according to predefined service guidelines. As an example, patients undergoing surgery the same day of the consultation request, and patients experiencing moderate to severe symptoms would receive treatments before patients who were planned for discharge. Since the treatments were provided in the standard rooms of the department that host 4 patients per room, it was very common to receive requests from room neighbors to receive treatments also. In such cases, the practitioners would ask the head nurse to open a new consultation request. Consequently, an average of 7 consultations were opened early every morning and a similar number of consultations were opened throughout the day.

Communicating with patients in a hospital setting may be challenging for CAM practitioners. It is different from the ambulatory setting, where CAM practitioners usually encounter the self-selection of patients. Individuals who opt for CAM therapies in the community often have a general sense and positive view of CAM. On the other hand, hospitals serve a diverse and multicultural population, and offering CAM services there is not obvious. Even the terminology of CAM can confuse patients and trigger hesitance, if not resistance. It was surprising to discover that some 20% of patients did not understand what was meant by CAM. Many patients were unfamiliar with acupuncture, guided imagery, and reflexology. CISS handouts were therefore developed in several languages, and the existence and nature of the CISS was communicated at all the “stations” surgery patients pass through (both outpatient and inpatient) with the assistance of surgery department staff, including medical personnel. CISS practitioners regularly informed each other about general communication barriers, and difficulty with particular patients, by means of an electronic practitioner log. Over time, specific key words and sentences emerged as the best facilitators of effective communication.*

Research

From the very conception of the service, there was a commitment to developing a strong CISS research orientation, for different reasons. CAM skeptics will find it hard to argue against a service that is committed to research. In an academic hospital, in particular, research is considered a value, and commitment to that value speaks for the professionalism and seriousness of the service. Therefore, an outcomes database was developed for ongoing collection of data from participants and nonparticipants of CAM in the surgery department. In addition, CISS was a pilot service, so there was interest in studying and learning from its multifaceted aspects, as detailed in the following:

1. A unique software program was developed and utilized from day 1 of the service, in order to gather electronic data on the effectiveness and safety of CAM treatments and synchronize them with the hospital data of conventional care. Patient-reported outcomes are documented pre- and post-CAM intervention, based on a modified Edmonton Symptom Assessment System, and Measure Yourself Concerns and Wellbeing questionnaires. The control group consisted of patients receiving standard care who were either reluctant to use CAM but willing to cooperate and complete questionnaires, or interested in CAM treatments but unable to receive them due to limitations on the availability of CAM practitioners. Furthermore, practitioners document the CAM diagnosis and treatment rationale in the research database. This, as the authors understand it, is a pivotal concept in research on the effectiveness and safety of integrative care from both a methodological perspective (conducting subgroup analysis and comparing outcomes according to CAM diagnosis), and an ethical stance that places value on medical pluralism. Outcomes data are now available for over 700 patients, with the ability to analyze treatment effectiveness in terms of symptom control for each treatment modality, as well as length of stay, and medication use in the treatment group and control group.

2. Communication and collaboration between CAM practitioners and conventional health care personnel were assessed using textual analysis of consultation reports. The themes that emerged were reflected back to the practitioners in order to optimize communication with the conventional personnel. Among other things, the following were assessed: the number of referrals to the service, who initiated the referral, whether appropriate indications and contraindications for referral were used, and so on. Practitioners also documented in a diary the nature and impact of their experience interacting with conventional personnel. These data will be analyzed using qualitative research methodology in order to learn about the barriers and facilitators of the integrative process as perceived by the CISS team.

3. Also investigated were the sociological and anthropological aspects of developing an integrative service within a conventional institution, using grounded theory methods of participant observation and in-depth interviews with patients, medical personnel, hospital administrators, and CAM practitioners.²⁶

Every new service needs time to become well coordinated and efficient both within and without. It took time for the CISS staff to familiarize themselves with the routine of the CISS and the surgery department. A great amount of emphasis was given to collaborative work with the conventional team. Over time, referrals grew in volume and the indications for referral reflected a better understanding of the nature, effectiveness, and safety of various CAM treatments. Soon after feeling confident in a particular “surgery station,” practitioners were encouraged to familiarize themselves with a different station. Consequently, effective collaboration and a sense of clinical competence were gained throughout the activities of CISS. Feedback from patients and staff regarding treatment success encouraged staff to refer more patients, and increased the confidence of CAM practitioners to actively recommend appropriate treatments on daily rounds. Consequently, treatments are now provided to 15%–20% of the patients in the department. Preliminary analysis of outcome data shows improvement of at least 30% across all symptoms. This, of course, should be confirmed later on with increasing numbers of treatments.

Discussion

This article presents a narrative of conceiving, designing, and establishing a CAM service for hospitalized patients. The service is unique in terms of the integration of CAM in a medical institution through close collaboration and cross-disciplinary communication with medical staff, as well as its research base. Although this narrative may reflect the authors' own personal style and preferences, the particular characteristics of their hospital, and the specific context of the local health system, it is believed this process can inform, empower, and inspire others who wish similarly to integrate CAM in their hospital services.

This article describes in detail the various elements of each developmental phase in the establishment of the integrative surgical service, so as to allow consideration of the pros and cons of the authors' approach and experience. The CISS has recently celebrated 1 year of activity. The practice has 5 CAM practitioners who are working side by side with the conventional caregivers to provide symptomatic relief for patients in the surgery department. Although some medical personnel have chosen not to collaborate, there has been no major objection to the service. Practitioners provide patients with CAM treatments in the outpatient clinic before surgery, and throughout their hospitalization in the surgery department, induction room just before surgery where anxiety peaks, and in the postanesthesia care unit. Currently, due to clinical and resource considerations, the authors are working in the surgery theater only with patients who do not undergo general anaesthesia.

Reflecting on the process retrospectively, the authors would have done some of the things differently. For example, there was a degree of initial resistance to the service by some nurses. It turned out that CAM treatments interfered with their daily chores and were seen as a nuisance: They were used to taking temperature and blood pressure at certain times of the day, and finding a patient with acupuncture needles forced them to postpone this task. Better planning and coordination of the CISS activities would have prevented such friction.

In hindsight, the authors recommend the gradual and gentle implementation of CAM integration, since it carries with it conceptual, personal, and organizational changes. Such a service needs to be followed closely with reflection, and accompanied by research on patient outcomes as well as on sociological and organizational aspects, so as to facilitate the acceptance of integrative hospital care and its influence on wider circles. There is no doubt that this service, as well as similar ones worldwide, will generate a revolution in medicine. Such a revolution should be carefully prepared in order for it to be a success.

Conclusions

This article has shared the evolution and first steps of integrating CAM care within the surgery service in a hospital in Israel. The authors are encouraged by both the clinical work and the institutional support. The challenges may well be different in other institutions, but it is hoped some of the conceptual and practical stages presented here may serve as inspirational stepping stones for readers and trigger the pioneering of more inpatient CAM-integrated services.

Footnotes

Acknowledgments

The authors would like to thank the following people for their support in the development of CISS: Dr. Amnon Rofe, Mr. Erez Shimko, Dr. Ibrahim Matter, Ms. Rachel Voytiz, Ms. Ofra Grimberg, Ms. Ilana Peterfreund, Ms. Michal Katz, Ms. Shlomit Grimberg, and Ms. Sarah Ben Shlush. We also thank Dr. Carmel Shalev for her comments on the manuscript. The article is a follow-up to the UK–Israeli CAM–Integrative Medicine workshop that was held at Bnai Zion Medical Center, Israel in March 2011 with the support of the Israeli Society for Complementary Medicine, the UK College of Medicine, the Technion-Israel Institute of Technology, and the Academic Study Group for Israel and the Middle East.

Disclosure Statement

No financial conflicts exist.

*

The lessons learned are culturally specific and difficult to translate from Hebrew into English. For example, the word for ‘complementary’ medicine (mashlima) is the same as for ‘supplementary’ health insurance (mashlim), so that patients thought they would have to pay for the CISS.

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