Integration of CAM research, education, and clinical care delivery
in academic health science centers is occurring in many US
institutions. Canadian initiatives are few in number, and limited in
scope. Given the increasing demand for CAM services, this is an
important area for future growth in all North American medical centers.
The existing programs have important information to share regarding
credentialing, medico-legal issues and billing for clinical programs;
identifying researchers and research projects for a successful research
program; and strategies for implementing educational initiatives and
establishing a functional administrative structure. It is important to
note that most of the centers visited do not yet have all three
"pillars" of clinical care, research and education, with various
reasons for this. Some started with clinical care, others will add that
last. Most have learned that research and education are important
components and are working to expand these areas within their programs.
We demonstrate that CAM has been successfully integrated in nine
North American academic medical centers. Centers displayed diverse
implementation strategies and had made different arms (research,
clinical and education) operational at different times. Some had a
separate integrative hospital-based clinic consisting of CAM and
conventional providers for broad patient care needs; others had a
narrow, highly specialized patient care approach, such as for acute and
chronic pain (e.g., dental pain, osteomyelitis,
rheumatoid/osteoarthritis, etc.). Each site varied in available funding
and the strength of its affiliation to a University.
An integrative medicine program fits with the core values and
beliefs of many academic medical centers. For example, 29 renowned
academic medical institutions in North America have recently joined to
form The Consortium of Academic Health Centers for Integrative Medicine
[16].
Their mission is to help advance medicine and healthcare through
rigorous scientific studies, new models of clinical care, and
innovative educational programs that integrate biomedicine, the
complexity of human beings, the intrinsic nature of healing and the
rich diversity of therapeutic systems.
While advocates of integrative medicine may speak of "evidence-based" CAM [17]; integration within academic medical centers may foster double standards for the inclusion of CAM therapies [18].
For instance, "evidence-based medicine" for some narrowly refers to the
practice of taking randomized controlled trials as the strongly
preferred form of evidence for medical practice; however, we observed
that each of the integrative clinical programs have, like most of
conventional medicine, taken care to allow a role for other factors
(i.e., clinical experience, clinical state and circumstances of
patient, patient preference) beyond evidence from randomized controlled
trials [19,20].
Indeed, "as a distinctive approach to patient care, EBM involves two
fundamental principles. First, evidence alone is never sufficient to
make a clinical decision. Decision makers must always trade the
benefits and the risks, inconvenience, and costs associated with
alternative management strategies, and in doing so consider the
patient's values. Second, EBM posits a hierarchy of evidence to guide
clinical decision making" [21].
The fundamentals of "integration" will sometimes require clinicians to
ignore unbridgeable epistemological practices and beliefs between
conventional and CAM [18].
Our study has three major limitations. First, while every attempt
was made to engage the centers to allow us to sit in on a case
conference, unfortunately this was not possible. The centers that had
been in existence for the longest period of time no longer held them,
although they agreed they were an important component for sites new at
providing integrative care. The centers that were more recently formed
still held these team meetings, but did not give permission for outside
observers to attend. Therefore, we were not able to directly observe
the functioning of the multidisciplinary teams. However, one of us (KF)
previously trained for a short period of time at a site which held case
conferences and was therefore able to contribute that experience to our
larger understanding. Second, one of ten leading integrative programs
in North America was not assessed due to time constraints. This may
have led to the omission of further potentially useful information,
although we had already reached saturation from the nine sites visited.
Of note, our intent was not to identify specific subspecialty programs
(e.g. integrative oncology centers); thus our findings may not be
generalizable to such centers. Third, one of the investigators (SV)
intended to, and now has, set up an integrative medical center at an
academic institution which may have biased the collection and
interpretation of interview data. Having two investigators
independently record and interpret field notes at each site helped to
both ensure reliability and overcome this limitation.
Our study also had several strengths. As far as we are aware, this
is the first qualitative analysis of the experiences and perceptions of
site leaders (e.g. clinical directors, research directors) at multiple
integrative academic medical centers. The key themes we present should
be used to help guide academic centers wishing to integrate CAM. Our
team was multidisciplinary in its research and clinical expertise and
reflected a variety of points of view (e.g. health services research,
qualitative research, family medicine, pediatrics, pharmacy as well as
naturopathy). Our recommendations are based on the experiences of nine
of ten highly recommended integrative medical centers in North America,
and have been applied in the development of Canada's first academic
pediatric integrative medicine program (CARE Program, Stollery
Children's Hospital, Edmonton, Canada).
CAM is a widespread patient driven initiative. Academic institutions
have an opportunity to develop new initiatives in integrative medicine
that could help healthcare providers and patients meet their
information needs, enable more evidence-based decision-making,
facilitate the development of new knowledge, and enhance health
outcomes. For academic centers wishing to build such initiatives, our
findings illustrate integration is timely and feasible in a variety of
different ways and in a variety of settings.
Answers to all your Biology Questions
