Patient and Clinician Openness to Including a Broader Range of Healing Options in Primary Care

The article published by Hsu et al. illuminates the role of complementary and alternative medicine (CAM) in daily discussion with patients in primary care. In this well designed qualitative study comparing patients' and physicians' perspectives, the authors suggest that integrating open discussion and referral to additional healing options in primary care may be both feasible and desirable. In the discussion section, the authors refer to the challenges inherent in implementing CAM integration in real-life practice. These challenges include the clinician's time constraints, considerations of cost-effectiveness, and an absence of proven business models for providing integrated care.

As a family physician working in a primary care clinic operated within the largest health maintenance organization in Israel (Clalit Health Services, serving over 4 million clients), I am fully aware of the challenge of integrating CAM in a mere 10-minute appointment with patients seeking holistic care. Most of the 1800 clients who have chosen my colleagues and me to be their family physicians in the integrative primary care clinic (named Alluma, literally translated means "sheaf of wheat") in northern Israel, expect from us far more than openness to CAM. Most patients joined the clinic seeking a physician that offers the best possible family medicine practice integrated with practical CAM-based skills. These range from educated triage and referral to professional CAM practitioners to counseling about best-evidenced practices for specific ailments, and providing prescriptions for herbs, nutritional supplements, and other CAM remedies based on efficacy, safety and cost considerations.

Along our journey as integrative physicians, we have learned of the vast differences in patients' perspectives towards the concept of integration. Some patients interpret CAM as alternative care and expect us to be non-judgmental and open to their health belief models, even if we do not necessarily agree with their reluctance to use antibiotics or their children's immunization status. Other patients relate to CAM in the context of traditional medicine and expect us to be more attentive to cross-cultural perspectives and to offer nutritional and herbal therapies that resonate with Jewish and Arabic traditional medicine. Most of our patients perceive CAM as complementary to family medicine and look for practical tips for improving their cough or lower back pain. As we grow with our patients, we have witnessed the upgrading process that has metamorphosed alternative, traditional, and complementary into an integrative model of care. From my own perspective as a dual practitioner trained in family practice and complementary medicine, I feel that the term integrative care may be interpreted in many ways. After all, most of my colleagues largely support patient-centered care based on a holistic bio-psycho-social-spiritual model that does not require CAM flavoring in order to be defined as integrative. Nonetheless, in the context of CAM integration within primary care, the term integrative has unique implications: the ability of the family physician to act not only as an empathic listener to patients who seek advice but to actively serve as a gatekeeper regarding CAM and, in certain cases, as a navigator who integrates practical complementary skills with a holistic family medicine perspective.

In 2011, we are facing a third generation process in which more and more patients expect their physicians to move from the previous alternative and complementary concepts to an integrative agenda and to act as coordinators and caregivers of CAM as an integral part of their practice. At the same time, many physicians may feel they lack the required knowledge and skills for what might appear to be a weird realm of witchcraft and placebo. Other physicians with a more sympathetic attitude towards CAM, including those trained in it, may still ponder how integration is feasible in the busy beehive-like practices which many of us encounter daily. Thus, the main questions that need to be addressed are the following: Do we really perceive CAM as significant a component of our clinical practice as other clinical areas of expertise and specialty? How do we understand our role as CAM integrators? Which CAM-related skills should we add to our training programs? Should training be limited to knowing about CAM or be upgraded to more advanced skills such as a learning-efficient strategy-search in Medline using CAM-related keywords or how to provide erudite advice regarding herbal use or referral indications to an acupuncturist? To what extent are we willing to assimilate CAM within our own family practice or become integrative complementary medicine-oriented family practitioners? What are the possible benefits and disadvantages of this integrative process and is it intended to better meet patients' expectations and well-being only? To what extent may a CAM-driven integrative process also have implications for our own personal growth and our experience with burnout?

Clarissa Hsu and her colleagues balance their study well by referring to their study limitations and to the need for further research. In addition to this act of modesty and scientific precaution, they also conclude the article with the sentence starting with: "In the meantime,…" and suggest that their current findings support the need for dialogue between patients and clinicians and for making additional healing options available to patients. Indeed, we urgently need to act, at least on an educational level, in residency programs and CME-accredited courses, to bridge the gap between physicians' theoretical knowledge and their attitude towards their practical ability to provide elementary but skilled CAM consultation.

My own limitations and bias as an Israeli family practitioner working within the cross-cultural community in northern Israel may hinder my advice to practitioners working in Seattle or any other community in the US. As a teacher in the department of family medicine at the Technion's Faculty of Medicine in Haifa, and as co-founder of its complementary and traditional medicine unit, I realize that CAM integration is a lengthy step-by-step process that should be seeded and nurtured starting from pre- graduate studies up to the higher level of continuous education and faculty development. CAM may offer us, as learners, its charm and wisdom and at the same time challenge us with both evidence- and ethics-based perspectives. It also may serve, however, to help us, along our own individual and professional journey, to contemplate the healing language of the "other" and become more present, mindful and attentive to ourselves and to our patients.

Eran Ben-Arye, MD

Complementary and Traditional Medicine Unit, Director; Department of Family Medicine, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel and Clalit Health Services, Haifa and Western Galilee District, Israel

Integrative Oncology Program, Director; The Oncology Service, Lin Medical Center, Clalit Health Services, Haifa and Western Galilee District, Israel

Competing interests:   None declared