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Trials and tribulations on the road to implementing integrative medicine in a hospital setting
Ian Coulter
School of Dentistry, University of California Los Angeles; and RAND Corporation, Samueli Institute, Santa Monica, Los Angeles CA, USA
Lara Hilton
RAND Corporation, Santa Monica, Los Angeles CA, United States of America
Gery Ryan
RAND Corporation, Santa Monica, Los Angeles CA, United States of America
Marcia Ellison
Cedars-Sinai Medical Centre, Los Angeles CA, United States of America
Hilary Rhodes
School of Social Policy and Practice, University of Pennsylvania, Philadelphia PA, United States of America
Abstract
In this paper, results are reported from a five year qualitative study involving a stakeholder analysis of a hospital-based centre for integrative medicine. The objective of the study was to identify the barriers and the facilitators for creating integrative medicine in this setting. The study documented the timeline of the Centre from its very hopeful beginning to its demise.
The paper focuses on the administrative implementation process, examining the original expectations in light of the organisational culture, business model, impact of policies and regulations, and the trade-offs made between the original goals and those attained within this environment.
One of the most troubling aspects arising from this case study was that no corrective mechanism was in place for program design flexibility once previously created policies were deemed harmful to the Centre. When the major assumptions on which the Centre was founded, turned out to be false, there was no turning back and the Centre collapsed.
Keywords
sociological program evaluation, integrative medicine, sociology
Article Text
An Integrative Medicine Centre represents two distinct medical systems and philosophies. Biomedicine, with its disease focus and fairly homogeneous, vertically organised hierarchy of specialists and generalists, traces its philosophical roots and practices to rationalistic quantitative Western scientific traditions. In contrast, complementary and alternative medicine (CAM) represents a loosely organised aggregation of heterogeneous practices based on global medical systems and philosophies that approach health and illness from an individualised but holistic perspective (Kaptchuk & Miller 2005; Coulter 2004). Despite these paradigmatic differences, this ‘integration' has been occurring in some form for over a decade (Eisenberg 2006; Jonas 2005; Ruggie 2005; Coulter & Willis 2004; Singer & Fisher 2007; Cohen 2004; Collyer 2004; Barrett 2003; Dalen 1998). This case study examines an attempt to institutionalise this process of integration by establishing a hospital-based Integrative Medicine (IM) Centre.
Definition of integrative medicine
While there is no agreement about what constitutes IM, most commentators agree it has something to do with bringing CAM into some form of relationship with biomedicine. An immediate difficulty is that there is no uniform definition of CAM (Coulter & Willis 2004), let alone a consensus of what constitutes integration. The distinction between CAM and biomedicine is increasingly problematic (Coulter & Willis 2007). There is also increasing difficulty in naming the alternative to CAM. We concur with Wiseman (2004), who suggests that the term biomedicine is the least evaluative of the labels and does at least denote a medical paradigm within which the biological sciences are a core component and where explanations for disease and illness are predominantly biologically-based (Mead & Bower 2000). Further, the diversity of practices included under the rubric of CAM lessens its usefulness as an umbrella term. These practices range from very focused therapies to whole medical systems.
To call the combination of two paradigms ‘integrative' is, as Coulter and Willis (2007) have noted, problematic:
... the use of the term ‘integrative' may bear more relation euphemistically to the term ‘takeover' in much the same way as in the business world, the term ‘merger' of two companies conceals the reality of takeover and on occasions hostile takeover at that.
Institutional integration
In the United States, institutional IM is being developed in a highly individualistic manner and a body of literature documenting attempts to establish integrative centres is growing (Barrett 2003; Weeks 2001; Muscat 2000; Moore 1997: 114; Blanchet 1998).
In 2003, a national survey of 1,007 US hospitals documented that 16 percent provided IM and over one-quarter (26.7 percent) offered some form of CAM (Larson 2005). Novey (in Larson 2005), suggests the models of integration that have been implemented can be delineated into five types: a ‘virtual' model (a clinic without walls); consultatory models (which rely on referrals from staff physicians to in-house CAM providers); primary care units integrating CAM and biomedicine; fitness or wellness centres; and expensive CAM services in a retreat-like environment.
Vohra et al (2005) studied nine IM programs in North America. Twelve key themes related to successful integration were identified. In contrast to the focus on implementation factors for success, Barrett (2003) used a literature review to identify potential barriers and facilitators to the successful institutional integration of CAM. In the United Kingdom, the Prince of Wales brought together a steering committee and working groups to examine the issue of integrative health care (Dalen 1998). None of these studies, however, delineates what constitutes ‘successful' integration.
Methods
In order to examine how a Centre for Integrative Medicine (or IM Centre) fits into a larger medical centre and community of stakeholders, a case study methodology was utilised (Yin 1984). Case studies provide in-depth information about how programs work (or do not work) within the larger social and organisational contexts in which they are embedded (also Jinnett et al 2002).
We utilised both qualitative and quantitative data collection and analysis techniques. Most data came from structured and semi-structured interviews with six stakeholder groups:
1) Key hospital administrators
2) Non-CAM clinicians within the hospital (attending physicians)
3) Non-CAM clinicians in the community (private attendings)
4) CAM providers in the IM Centre
5) CAM providers in the adjacent community; and
6) Patients.
To complement our qualitative data, we collected quantitative data from patient files and structured patient questionnaires. Finally, to place our case study in a larger framework, we held a one-day workshop with key personnel from across the country who were directors of other IM programs (successful and unsuccessful). ...continues...
References
Barrett B (2003) Alternative, complementary, and conventional medicine: Is integration upon us? Journal of Alternative and Complementary Medicine 9(3): 417-427.
Becker H (1958) Problems of inference and proof in participant observation, American Sociological Review 26(6): 652-660.
Bernard HR (2006) Research Methods in Anthropology: Qualitative and Quantitative approaches, AltaMira Press: Lanham MD.
Blanchett KD (1998) University Centre for complementary and alternative medicine at Stony Brook, Journal of Alternative and Complementary Therapies 4: 327-332.
Cohen MM (2004) CAM practitioners and ‘regular' doctors: Is integration possible? The Medical Journal of Australia 180(12): 645-646.
Collyer FM (2004) The corporatisation and commercialisation of complementary and alternative medicine: Studies in social context, in Tovey P, Easthope G and Adams J (eds) The Mainstreaming of Complementary and Alternative Medicine, Routledge: London, pp.81-89.
Coulter I, Hays R and Danielson C (1994) 'The chiropractic satisfaction questionnaire, Topics in Clinical Chiropractic 1: 40-43.
Coulter ID and Willis EM (2004) The rise and rise of complementary and alternative medicine: A sociological perspective, The Medical Journal of Australia 180(11): 587-589.
Coulter ID (2004) Integration and paradigm clash: The practical difficulties of integrative medicine, in Tovey P, Easthope G and Adams J (eds) The Mainstreaming of Complementary and Alternative Medicine, Routledge: London, pp.103-122.
Coulter ID and Willis E (2007) Explaining the growth of complementary and alternative medicine, Health Sociology Review 16(3-4): 214-225.
Dalen JE (1998) ‘Conventional' and ‘unconventional' medicine: Can they be integrated? Archives of Internal Medicine 158: 2179-2181.
de Vries H, Weijts W, Dijkstra M and Kok G (1992) The utilisation of qualitative and quantitative data for health education program planning, implementation, and evaluation: A spiral approach, Health Education Quarterly 19(1): 101-115.
Edgerton RB and Langness L (1974) Methods and Styles in the Study of Culture, Chandler & Sharp: San Francisco.
Eisenberg DM, Kaptchuk TJ and Arcarese D (1993) Alternative Medicine: Implications for Clinical Practice and Research, Harvard Medical School Dept. Medicine Elective ME549 J.
Eisenberg DM (2006) ‘David M Eisenberg MD: Integrative medicine research pioneer', interview by Karolyn A Gazella and Suzanne Snyder, Alternative Therapies in Health and Medicine 12(1): 72-79.
Fielding NG and Lee RM (1991) Using Computers in Qualitative Research, Sage: Newbury Park CA.
Hsiao AF, Hays RD, Ryan GW, Coulter ID, Andersen RM, Hardy ML, Diehl DL, Hui KK and Wenger NS (2005) 'A self-report measure of clinicians' orientation toward integrative medicine, Health Services Research 40(5 Pt 1): 1553-1569.
Jinnett K, Coulter ID and Koegel P (2002) Cases, contexts and care: The need for grounded network analysis, Social Networks and Health 8: 101-110.
Jonas WB (2005) 'Wayne B Jonas MD: Supporting the scientific foundation of integrative medicine', Interview by Karolyn A Gazella and Suzanne Snyder, Alternative Therapies in Health and Medicine 11(5): 68-74.
Kaptchuk TJ and Miller FG (2005) Viewpoint: What is the best and most ethical model for the relationship between mainstream and alternative medicine: Opposition, integration, or pluralism? Academic Medicine 80(3): 286-290.
Larson L (2005) Integrating integrative medicine: A how-to guide, Trustee 58(10): 14-16, 21-22, 1.
Lincoln YS and Guba EG (1985) Naturalistic Inquiry, Sage: Newbury Park CA.
Mead N and Bower P (2000) Patient-centredness: A conceptual framework and review of the empirical literature, Social Science and Medicine 51(7): 1087-1110.
Miller WL and Crabtree BF (1992) Primary care research: A multimethod typology and qualitative road map, in Crabtree BF and Miller WL (eds) Doing Qualitative Research, Sage: Newbury Park CA, pp.17-28.
Moore NG (1997) 'Psychiatry and alternative medicine: Constructing a rationale for integration, Alternative Therapies in Health and Medicine 3(2): 24, 26-27.
Morse JM (1994) 'Designing funded qualitative research, in Denzin NK and Lincoln YS (eds) Handbook of Qualitative Research, Sage: Thousand Oaks CA, pp.220-235.
Muhr T (1997) ATLAS.ti: The Knowledge Workbench, Scientific Software Development: Berlin.
Muscat M (2000) Beth Israel's Centre for Health and Healing: Realizing the goal of fully integrative care, Alternative Therapies in Health and Medicine 6(5): 100-101.
Patton MQ (1990) Qualitative Evaluation and Research Methods, Sage: Newbury Park CA.
Pfaffenberger B (1988) Microcomputer Applications in Qualitative Research, Sage: Newbury Park.
Ruggie M (2005) Mainstreaming complementary therapies: New directions in health care, Health Affairs (Millwood) 24(4): 980-990.
Ryan G and Bernard HR (2000) Data management and analysis methods, in Denzin N and Lincoln Y (eds) Handbook of Qualitative Research, Sage: Thousand Oaks, pp.769-802.
SAS Institute (for 1999) SAS Institute Inc, SAS OnlineDoc.
Singer J and Fisher K (2007) The impact of co-option on herbalism: A bifurcation in epistemology and practice, Health Sociology Review 16(1): 18-26.
Spradley JP (1979) The Ethnographic Interview, Holt, Rinehart & Winston: New York.
Tashakkori A and Teddlie C (1998) Mixed Methodology: Combining Qualitative and Quantitative Approaches, Sage: Thousand Oaks CA.
Vohra S, Feldman K, Johnston B, Waters K and Boon H (2005) Integrating complementary and alternative medicine into academic medical centres: Experience and perceptions of nine leading centres in North America, BMC Health Services Research 5: 78.
Weeks J (2001) Major trends in the integration of complementary and alternative medicine, in Faass N (ed) Integrating Complementary Medicine into Health Systems, pp.4-11.
Wiseman N (2004) Designations of medicines, Evidence-Based Complementary and Alternative Medicine 1(3): 327-329.
Yin RK, Bateman PG and Moore GB (1983) Case Studies and Organizational Innovation: Strengthening the Connection, Cosmos: Washington DC.
Yin RK (1984) Case Study Research: Design and Methods, Sage: Thousand Oaks CA.
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