Dilemma of integration with Western medicine - views of Traditional Chinese Medicine practitioners in a predominant Western medical setting

Navigating the path: a qualitative exploration of New Zealand general practitioners' views on integration of care with acupuncturists

BACKGROUND

Increasingly, many patients believe that a combined approach of complementary and alternative medicine (CAM), including acupuncture, and conventional medicine is better than either on its own, and more patients now have the desire to discuss CAM with well-informed general practitioners (GPs). However, to our knowledge, the interaction and collaboration between GPs and acupuncturists specifically in relation to shared care have not been investigated. This research explored interprofessional communication between GPs and acupuncturists in New Zealand. This article specifically reports the GPs' viewpoints.

METHODS

This study was part of a larger mixed-methods research project. Semi-structured interviews of 14 purposively sampled GP participants were conducted and analysed using thematic analysis.

RESULTS

The data analysis identified both facilitators of and barriers to integrative health care. Facilitators included the willingness of GPs to engage in communication and a recognition of the importance of patient choice. Barriers included the limited opportunities for sharing information and the lack of current established pathways for communication or direct referrals. GPs also highlighted the confusion around scopes of practice in terms of the different styles of and approaches to acupuncture.

CONCLUSION

This research contributes to the body of knowledge concerning interprofessional communication and collaboration between GPs and acupuncturists and suggests that while there are significant barriers to collaboration, there is also the potential to impact provider satisfaction and patient well-being. It provides context within a New Zealand health care setting and also provides additional insights regarding acupuncture, specifically through the disaggregation of specific CAM modalities.

Is Traditional Chinese Medicine "Mainstream" in China? Trends in Traditional Chinese Medicine Health Resources and Their Utilization in Traditional Chinese Medicine Hospitals from 2004 to 2016

Background

Traditional, complementary, and alternative medicine (TCAM) has attracted increasing attention in developed countries, but its mainstream status in China, the home of TCAM, is unclear. Over the period of 2004-2016, we analyze the health resources and health resource utilization of traditional medicine in traditional Chinese medicine (TCM) hospitals in China.

Methods

Over 2004-2016, we obtained data from all TCM hospitals in all Chinese provinces to create a hospital-based, longitudinal dataset. TCM health resources and their utilization were measured by two outcome variables: (1) primary outcome variables comprising the proportion of TCM physicians, TCM pharmacists, revenue from TCM drugs, and TCM prescriptions and (2) the secondary outcome variables, as proxies of westernization for TCM hospitals, comprising the number of medical equipment above RMB 10,000 and the proportion of surgery in inpatient visits. We used linear regression models with hospital-fixed effects to analyze time trends for the outcome variables.

Results

The number of public TCM hospitals remained stable from 2004 to 2016, while the number of private TCM hospitals increased from 294 in 2004 to 1560 in 2016. There was a small percentage increase in the proportion of TCM physicians (0.280%), TCM pharmacists (0.298%), and revenue from Chinese medicines (0.331%) and TCM prescriptions (1.613%) per hospital per year. Chinese drugs accounted for less than a half of the total drug prescriptions, and accordingly, just one-third of the drug revenue was from Chinese medicines at TCM hospitals. The proportions of physicians, pharmacists, revenue from Chinese drug sales, and traditional medicine prescriptions never reach the 60% benchmark target for mainstream in TCM hospitals. As proxies for Western medicine practices in TCM hospitals, the number of medical equipment above RMB 10,000 rapidly rose by over 13 percent per hospital per year, but the proportion of inpatient surgeries declined by 0.830 percentage points per hospital per year, reflecting a mixed trend in the use of Western medicine practices.

Conclusion

For the 2004-2016 period, traditional medicine, although making progress towards the mainstream benchmark of 60% TCM services, was still not mainstream at TCM hospitals.

Why are we hiding? A qualitative exploration of New Zealand acupuncturists views on interprofessional care

BACKGROUND

In recent years more health service users are utilising complementary and alternative medicine (CAM), including acupuncture, for the management of their health. Currently general practitioners (GPs), in most cases, act as the primary provider and access point for further services and also play an important role in integrated care management. However, the interaction and collaboration between GPs and acupuncturists in relation to shared care has not been investigated. This research explored interprofessional communication between GPs and acupuncturists in New Zealand. This article reports specifically the acupuncturists' viewpoints.

METHODS

This study formed part of a larger mixed methods trial investigating barriers and facilitators to communication and collaboration between acupuncturists and general practitioners in New Zealand. Semi structured interviews of 13 purposively sampled acupuncture participants were conducted and analysed using thematic analysis.

RESULTS

The data analysis identified both facilitators and barriers to integrative care. Facilitators included a willingness to engage, and the desire to support patient choice. Barriers included the limited opportunities for sharing of information and the lack of current established pathways for communication or direct referrals. The role evidence played in integrative practice provided complex and contrasting narratives.

CONCLUSIONS

This research contributes to the body of knowledge concerning communication and collaboration between GPs and acupuncturists, and suggests that by facilitating communication and collaboration, acupuncture can provide a significant component of integrated care packages. This research provides context within a New Zealand health care setting, and also provides insight through the disaggregation of specific provider groups for analysis, rather than a grouping together of CAM as a whole.

Holistic Integrative Medicine

Many people engaging in medical science asked me, “You’ve been working on the exploration of Holistic Integrative Medicine (HIM) for quite a while. What is the progress you have made in your research? Have you got your article published? May I be your first reader?” Each time I was confronted with such a situation, I felt embarrassed and speechless. Just as an old saying goes, it is easy to put the boat along with the current but it is difficult to sail against the current [1].

Development of Evidence-Based Chinese Medicine Clinical Service Recommendations for Cancer Palliative Care Using Delphi Approach Based on the Evidence to Decision Framework

Objectives: Existing evidence supports the use of certain Chinese medicine (CM) interventions for symptom management among palliative cancer patients. However, evidence-based service recommendations tailored to the local context are needed for CM planning and implementation. In response, we aimed to establish consensus on CM clinical service recommendations for cancer palliative care among Hong Kong experts. Methods: Seven CM interventions showing statistically significant favorable results in existing systematic reviews (SRs) and overviews of SRs were subjected to a GRADE-ADOLOPMENT-based 2-round Delphi survey. Twelve Hong Kong experts in cancer palliative care, including conventionally trained physicians, CM practitioners, and nurses (n = 4 from each category), were invited to participate. Use of the Evidence to Decision framework within the GRADE-ADOLOPMENT approach enabled experts to consider aspects of problem priority, benefits, harms, equity, acceptability, and feasibility when making CM recommendations in cancer palliative care. Results: Three evidence-based CM interventions reached positive consensus as service recommendations, namely: (1) acupuncture for reducing fatigue among palliative cancer patients; (2) acupressure for reducing fatigue among palliative cancer patients; and (3) moxibustion for reducing nausea and vomiting among patients receiving chemotherapy. Median rating of recommendation ranged from 2.5 to 3.0 (interquartile range = 0.00-1.00) on a 4-point Likert-type scale, and the percentage agreement ranged from 83.4% to 91.7%. Conclusions: The GRADE-ADOLOPMENT approach facilitates a consensus-based process of reaching 3 evidence-based CM recommendations for cancer palliative care. Future studies may develop tailored strategies to implement these recommendations in the Hong Kong health system.

Morbidity pattern of traditional Chinese medicine primary care in the Hong Kong population

Primary care manages >90% of illnesses requiring medical services in Hong Kong, in which 9,513 registered Chinese medicine practitioners (CMPs) provide 8.2% of the consultations. This is the first study aimed to determine the morbidity pattern in different Traditional Chinese Medicine (TCM) primary care settings in Chinese population. 55,312 patients’ encounters were classified by the International Classification of Primary Care-2 (ICPC-2) from 260 of CMPs. Mean patient age was 50.5 years, with more females than males (67.0% vs 33.0%). Most patients consulted CMPs for chronic (64% vs 33.7%) rather than acute conditions. Among the 30% of patients, hypertension (49.5%) or diabetes (18.5%) were the most common co-morbidity. The most common problems presenting to CMP were respiratory (24.9%), musculoskeletal complaints (22.7%), cough (11.7%), and lower back pain (6.6%). To our knowledge, this was the first study permitting direct comparison with that presenting to Western medicine (WM) primary care by ICPC-2 systems. The results confirmed the role of CMP in primary care for musculoskeletal or chronic illnesses that they may have also received conventional WM treatment. We recommend greater effort and more resources should be invested to promote interdisciplinary communication to ensure safety and synergy of TCM and WM in primary care.

Five-year outcomes of western mental health training for Traditional Chinese Medicine practitioners

BACKGROUND

There are increasing expectations for primary care practitioners to deal with mental health problems. In Hong Kong, 15 % of the general public consult Traditional Chinese Medicine (TCM) practitioners regularly for their primary health care needs. This study investigated the 5-year outcomes of a western mental health training course for TCM practitioners in Hong Kong.

METHOD

Structured questionnaire surveys were conducted to compare the TCM practitioners' confidence and engagement in mental health care before and after the Course. The data collected during 2011-2015 were analyzed.

RESULTS

A total of 151 TCM practitioners returned both pre- and post-Course questionnaires, with a response rate of 95.6 %. After the course, there were significant increases in the proportions of participants being confident of recognizing patients with psychological problems (62.9 % before the course vs 89.4 % after), diagnosing common mental health problems (47.7 % vs 77.5 %), and managing them (31.2 % vs 64.3 %). Overall, 66.9 % of the participants reported some increase in their confidence in recognizing patients with psychological problems, diagnosing or/and managing patients with common mental health problems. Qualitative responses illustrated the major improvements were increased awareness of mental symptoms, better understanding of classification of mental disorders and management approaches. On the other hand, barriers included difficulties in understanding medical terms in English, consultation time constraints, and a lack of formal referral system to psychiatrists.

CONCLUSIONS

The Course has positive impact on TCM practitioners in handling mental health patients. The findings are useful for designing similar trainings on complementary and alternative medicine practitioners in other countries.

Differences in antibiotic use between patients with and without a regular doctor in Hong Kong

BACKGROUND

Literature shows that continuity of care from a primary care physician is associated with better patient satisfaction and preventive care. This may also have an effect on patients' use of antibiotics. This study investigated the differences in antibiotic use between patients with and without a regular doctor in a pluralistic health care system.

METHODS

A cross-sectional telephone questionnaire survey using randomly selected household phone numbers was conducted in Hong Kong. Several key areas about antibiotic use were compared between the respondents with a regular doctor and those without.

RESULTS

The response rate was 68.3 %. Of the 2,471 respondents, 1,450 (58.7 %) had a regular doctor, 942 (38.1 %) without, and 79 (3.2 %) did not give a clear answer. The respondents with a regular doctor were more likely to report that they always finished the full course of antibiotics (74.2 % vs 62.4 %), as well as using antibiotics for their last upper respiratory tract infections (17.4 % vs 10.1 %). The association with antibiotic use remained significant in the multivariable logistic regression analysis after adjusting for other confounding factors (P < 0.001, OR = 1.76, 95 % CI:(1.27, 2.48)).

CONCLUSIONS

While patients with a regular doctor, compared to those without, were more likely to report finishing the full course of antibiotics, they also had nearly twice the chance of reporting antibiotic use for upper respiratory tract infections. This challenges the common belief of the benefits in having a regular doctor.

Capitalizing on synergies-a discourse analysis of the process of collaboration among providers of integrative health care

Background

Integrative health care (IHC) combines therapies and providers from complementary and conventional health care. Previous studies on IHC have shown power relations between providers but few studies have explored how the interaction develops over time. The objective of this study was to explore the development of IHC collaboration and interaction among participating providers during a series of consensus case conferences for managing patients with back and neck pain.

Methods

This qualitative study was conducted within a pragmatic randomized controlled clinical trial in primary care. Patients' treatment plans were developed based on IHC provider consensus conferences (n = 26) of which 15 (5 of the first, 5 in the middle, and 5 of the last in the clinical trial) were selected for analysis. Findings were derived by means of discourse analysis, focusing on the participants’ use of subject positions during the conferences.

Findings

The IHC team in this study gradually formed a group identity, moving their subject positions from individual treating subjects to members of a team and were able to make consensus-based decisions about patients’ individual treatment plans. In the discourse, the IHC team identified collaborative shortcomings and problematized the provision of IHC. They were able to capitalize on the synergies in their collaboration and developed a shared vision of IHC provision.

Conclusions

The process of IHC collaboration involved the gradual formation of an IHC team identity, which facilitated interdisciplinary, non-hierarchical consensus-based decision-making in the team. The discourse further suggests that a reform of some legal and organizational health sector barriers might be needed to realize sustainable implementation of IHC services in Sweden.