Clinical articleOriginal researchIntegrating Complementary and Alternative Medicine Into Conventional Primary Care: The Patient Perspective
Introduction
Complementary and alternative medicine (CAM) is becoming increasingly popular worldwide with healthcare consumers, patients, healthcare providers, medical researchers, and educators.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Therapies include acupuncture, chiropractic manipulation, herbal medicine and dietary supplements, nutraceuticals, homeopathy, mind-body techniques, spirituality and faith healing, massage therapy, Therapeutic Touch, and a number of others.2, 5 According to the World Health Organization, CAM is a growing health system with economic importance worldwide. In Africa, up to 80% of the population uses CAM to help meet their healthcare needs.13 In Asian and Latin American populations, CAM is used as a result of historical circumstances and cultural beliefs.13 In Western Europe and Australia, 20% to 70% of the population regularly uses CAM.6, 10
In 1992, it was estimated that at least one in three Americans used a CAM therapy and that the number of annual visits to CAM providers exceeded the number of visits to all primary care physicians.5 A study of family practice patients in southern Texas revealed that CAM use was even higher—58% of responders used CAM.14 The U.S. Centers for Disease Control and Prevention stated that 62% of adults used some form of CAM therapy during a 12-month period in 2003-2004. This trend suggests a continuing demand for CAM therapies that will affect healthcare delivery in the foreseeable future.2
Patients use CAM primarily for common problems encountered in the primary care setting, such as back or neck pain, a head cold, anxiety, or depression.2 Many forms of CAM are appropriate in the early stages of disease or chronic illness, the stages most commonly treated by primary care physicians.11 In the past few years, however, CAM has been gradually entering the conventional medical system through integrative medicine clinics. There are no reliable data on the number of these clinics across the United States, but their numbers are increasing.15 Most of the information about US integrative medicine centers comes from established centers affiliated with hospitals around the country, not from primary care settings.12 Sporadic initiatives have been seen but are limited in the primary care setting,16, 17, 18, 19 and there is no consensus concerning the integration of CAM into conventional medical care.
The World Health Organization, the White House Commission on Complementary and Alternative Medicine Policy report, the Institute of Medicine of the National Academies, and the National Center of Complementary and Alternative Medicine of the National Institutes of Health have independently concluded that determining how to safely and effectively integrate CAM into traditional medical systems is a high priority for research.13, 20, 21, 22, 23 Yet, despite this interest among the general public and within US governmental bodies, it is still not clear how patients perceive CAM therapies or how they would like these therapies to be integrated into their conventional medical care.
With the current emphasis on patient-centered care, evaluation of the patients' perspective is essential. Some of the following questions come to mind and remain unanswered: What do patients really want? How would they prefer to integrate CAM into their healthcare? Where would they like to obtain this service? Who is the preferred provider of these services?
Most studies of CAM have evaluated its trends and its use in different geographic locations 5, 6, 8, 24, 25, 26 and in specific patient populations (eg, pediatric patients, psychiatric patients, HIV/AIDS patients, and atopic dermatitis patients).4, 27, 28, 29 Other studies have evaluated the attitudes of physicians, medical students, and medical educators toward the use of CAM.7, 30, 31 Some studies have investigated the reason that patients want to include CAM in their healthcare, and others have dealt with patients' barriers to disclosing their use of CAM to their medical providers.32, 33
It is not well understood how patients perceive the process of integrating therapies and the practical implications of integrating CAM into their conventional care. To address this gap in knowledge, we prepared a questionnaire and evaluated the answers of patients who had been treated at one location in southern Texas.
Section snippets
Methods
To evaluate patients' interest in integrating CAM into the primary care clinic, experienced research assistants administered a survey to a convenience sample of 502 patients. Our survey was conducted at a large university-based family medicine clinic in southern Texas, staffed by both family medicine residents and faculty physicians. This clinic has approximately 35,000 visits a year. Patient sources, from Galveston and surrounding counties, include a very diverse population in terms of
Results
The 502 patients in this study were a random sample of the adult patient population treated at the family medicine clinic. In this study group, 68.7% of participants were women, and the average age was 53 years (range, 18-89 years; SD, 14.77 years); ethnic breakdown was African American, 24.3%, Caucasian, 67.5%, and Hispanic 8.2%; 31.4% had high school education or less, 34.7% had some college education, 19.1% were college graduates, and 14.5% had a graduate school degree (Table 1).
Health
Discussion
This study replicated the findings of multiple previous reports on the extent of CAM usage among US adults and on the distribution of the most frequently used therapies.2 We found it reassuring that general usage patterns of CAM in this study population mirrored those of the overall US population, a measure of external validity. But the main issue that this study highlighted was the patients' perspective on integrating CAM into the conventional medical setting.
The process of integrating CAM
Conclusion
The use of CAM is widespread. However, patients would like their family physician to provide and supervise these therapies in the primary care setting. A considerable number of patients believed that natural practitioners should be part of a family practice clinic and are willing to pay out of pocket for some of these services.
These findings should provide the basis for multicenter, cross-cultural studies, which may further clarify the patient perspective on this integration process so that
Acknowledgments
This work could not have been completed without the enthusiasm, support and help of research assistants Mary Jane Simmons and Alma Salazar.
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The opinions expressed are those of the authors and not necessarily those of the National Institutes of Health, National Center for Complementary and Alternative Medicine, Texas Academy of Family Physicians, or Health Resources and Services Administration Academic Administrative Units.
This study was supported in part by the National Institutes of Health and National Center for Complementary and Alternative Medicine CAM Education Project IR25AT00586-01, the Texas Academy of Family Physicians, and Health Resources and Services Administration Academic Administrative Units grant D12HP00169.