Models of Integrative Practice

Integrative Medicine: Define

Integrative medicine at a structural, organisational level

Integrative medicine could be described as a partnership in the health management of body, mind and spirit. It is a partnership between the health care providers and those seeking the care. The care approach/medicine is negotiated between the partners to ensure the best possible management plan for that individual utilising both complementary and bio-medicine appropriately. The individual is offered responsibility for their own health management and is an equal partner in  the relationship.

Integrative medicine requires a collaborative relationship between health care providers and the structures that govern them. For integrative care to succeed, practitioners require to maintain their professional boundaries but also have an extensive knowledge and understanding of their partners’ disciplines in order to integrate effectively. This enables the safety of boundaries between disciplines, otherwise these would become blurred and there would be no structure or definitive process for groups nor individuals.

Integrative medicine at an individual level

Boon et al (2009)

http://www.jmptonline.org/article/S0161-4754(09)00269-3/pdf

argue that integrative medicine can also be viewed at an individual level. One practitioner negotiating the appropriate balance of bio-medicine and complementary medicine for the benefit of the individual.

This makes total sense to me, sometimes it is difficult to maintain the boundaries of both complementary and bio-medicine when the clinician practices both, in fact, it’s impossible.

These boundaries are not fixed anyway they are fluid and dynamic. Even for the purely CAM practitioner or the pure medic, there are grey areas between the two disciplines, they are not as separate as we perceive them to be.

As CAM practitioners we utilise biomedical terminology as a common language to which  we can all relate in order to label, frame and define the problem. Medics utilise, in consultation, the power of body language and use of language and active listening skills to negotiate the way forward with their patients. Medicine as a discipline recognises that the patient is a bio-psycho-social being who does not exist in a sterile vacuum.

Reflections

As I was reading the articles, this really made me think about my own research. I am in a prime position to attempt to integrate, or at least collaborate my CAM skills (acupuncture and hypnotherapy) within the GP practices at which I work as a locum Nurse Practitioner. All the GP’s are supportive and do refer to me when required. Funding is the issue.

It would be great to have a discussion with the practice manager and the senior partner, who is also a member of the commissioning group in our area. Perhaps even a pilot scheme, looking at people with chronic headache and migraine as acupuncture is still recommended for these conditions in the NICE guidelines. Hypnotherapy is also recommended by NICE for irritable bowel syndrome. Outcome measures, patient satisfaction, number of GP consultations before and after, medication changes, financial implications.

Unfortunately my timing is not good as the NHS is currently, as depicted by the media, at breaking point.

It’s disheartening also to see the integrated health scheme in an Arizona primary care setting

https://ihc.arizona.edu/index.html 

did not last although it was deemed efficacious and acceptable to the patients and practitioners. Also the Prince of Wales Foundation for Integrated Health Care has come to a sticky end. It appears funding is a big issue here too.

I note the Glastonbury Health Centre (primary care)

http://www.glastonburyhealthcentre.nhs.uk/integrated_medicine.htm

boast an ‘extensive complementary service’ in their description of their support for integrated (not integrative) medicine. Yet they only have 2 CAM practitioners, neither of whom are mentioned in their list of team members. It appears a while since their ‘integrated medicine’ web page was updated too as they mention this service is funded by Somerset PCT and in collaboration with the Prince of Wales Foundation for Integrated Health Care. The former is now Somerset Clinical Commissioning Group as from 2013 and the latter folded in 2010.

I feel a common thread going through this can be identified as a generative mechanism, this being ‘accessibility of resources’. Who has the power to access resources, mainly financial ones. Who has the power to define which resources can be accessed, by whom and when.

Feedback form tutor: –

What a great reflection on the nitty-gritty- very impressive! It is a particular issue, this ‘communication’ business – because you are right to note that we need to have a good understanding of each other’s work and to ‘enable’ communication, you have to have some knowledge – and that is a really tricky issue. How much knowledge can/would/could a GP have of TCM? I found that many had very little understanding of even something as straightforward as massage therapy – which was assumed to be massage for relaxation, so even there you can have significant misunderstandings when communicating.

I love your foray into the issue of ‘boundaries’ – a very complex picture which you give a good airing! There are also issues of what is known in sociological circles as ‘professional exclusion’ – so these then hark back to the power issues we started thinking about under the theory of Generative Mechanisms, but just for example, there are many territorial struggles between massage therapy and physiotherapy, conceptual struggles between what has become known as ‘medical acupuncture’ and TCM acupuncture, power struggles between professions within the medical world (eg; sports medicine and physiotherapy) and even misunderstandings between CAM practitioners about whose therapy might be the most appropriate in any given situation. So you are quite right to question how these boundaries are erected in the first place (through professional training?), and how they are maintained – for both good (eg integrity of the profession) and not so good reasons (eg pure power/territorial struggles).

Under reflections, you mention the possibility of doing some preliminary investigations into collaboration into your own situation, so hold onto that thought and start thinking about how that might fit into your assignments during this module. We can discuss this more fully on Friday, but just be thinking about some tiny, tiny piece of the puzzle, for example would a meeting with the Practice Manager be possible as an exploratory start? In my research I found the PM to be more key than the lead GP with one lead GP even saying to me, ‘Well, I’ll ask my PM if that would work’ – interesting to someone on the outside!

The barriers you mention are real – for sure! And many of the larger attempts have sadly either, as you say, gone under or are significantly reduced and very much under the control of the NHS, so where does that leave the model debate – ‘equal but separate’? But you are quite right, according much of the research (mine included), that funding is a major issue – not surprising, but it changes how you think about solutions, so good to take on board.

Just thinking about my philosophical underpinnings when it comes to research as I’m also thinking about models of integration and collaboration. (multi-tasking perhaps?)

I know I am a relativist. I know critical realism is the ‘glue’ in between positivism and constructivism. I know there are cultural mechanisms at play that affect how we behave in certain situations but we all have agency and are not totally controlled by the structures and organisations, we can choose how we respond. May be the ‘sick’ person chooses to remain ‘sick’ as this ‘illness’ is serving them well in society e.g extra financial benefits, more attention, extra help, unable to work for a living, more compensation. A different individual, in the same culture with the same generative mechanisms at play may choose to seek to ‘shake off’ this ‘illness’, seen as getting in their way to achieving their goals and aspirations, their earning potential, their relationship dynamics. We are thinking, feeling individuals, our realities are relative to our experiences and how we view the generative mechanisms at play. We may not even be able to articulate or identify the mechanisms but we still have choices in how we respond.

To relate this then to models of collaborative and integrative medicine. From a critical realism perspective, within the open system of society, there generative mechanisms at play that apparently affect how we are affected by given situations. The models then give a structure as to how collaboration and integration can be achieved – they are ideals, they are generalist and steer away from the particular. They do take in to consideration individual perspectives when qualitative research is utilised i.e participant interviews , (Gaboury et al. / Social Science & Medicine (2009) 1–9), but individual differences cannot fully be accommodated by these models, tending then towards a more positivist outcome.

(The way forward with my research would be to investigate ‘expectation’ client and practitioners, maybe as a generative mechanism and the effect this has on ‘outcome’). I know about the greater generative mechanisms, I prefer to look at the specifics at an individual level. Where did that expectation come from? Is there a common theme at play? Is it gender or social position dependent,etc?)

I have looked at 2 other models of integrative and collaborative medicine, one is explicit and based on  McGrath, J. E. (1964). Social psychology: A brief introduction. New York: Holt, Rinehart and Winston) and found in the Gaboury et al (2009) paper as mentioned above. There is a suggestion on 3 mechanisms to be considered when looking at healthcare professionals ‘inter-professional’ behaviour, that is, input, process and output. This was quite a useful model in that it enabled a structure for the research too. The paper identified structures at individual and structural levels, identifying personal clinician perspectives affecting collaboration and integration of services. Finances, time constraints, communication, assumed power, interdisciplinary education were all identified. Therefore from a critical realist point of view, this model is quiet useful, despite it being developed prior to the emergence of critical realism.

The next model I have looked at is rather implicit as it is an assumption that CAM is an integral part of of service delivery in a secondary care setting.

Hypnotherapy for irritable bowel syndrome: an audit of one thousand adult patients V. Miller, H. R. Carruthers, J. Morris, S. S. Hasan, S. Archbold & P. J. Whorwell ( 2015)
This highlights my individualistic, relativist philosophy regarding ontology. Although this paper takes a ‘closed system’ positivist approach to enquiry, it does give a wonderful example of how CAM can be totally integrated with medicine. It is down to one individual – Peter Whorwell. He integrates hypnotherapy as an alternative treatment for irritable bowel syndrome (IBS) when all else has failed. The hypnotherapy service is integrated and the therapy team appear to have an equal role to play in the patient management plan. There are explicit criteria for when hypnotherapy is considered appropriate with patient negotiation also apparent in the paper. There are strict recruitment systems in place for the hypnotherapists too and they are regularly monitored for effectiveness. The interventions are unified and have strict regulation too as to how the therapy is delivered.  It is presumed then that there is continuation in patient documentation as they share the same patient notes.

The purpose of the audit of 1000 patients receiving hypnotherapy for IBS was to raise the profile and hopefully share the model of success with other service with a view to expanding the service beyond this one clinic.

The generative mechanisms of power, resources, finances, time, communication and education are all accomodated as this is one clinic sharing the same philosophy  and approach to patient care. This clinic has been functioning since 1984 hence there are temporal factors involved too, the team is well established , it  is transformative in nature, personality led, parallel system of delivery (Baer 2004) and not just an ‘additive’ (Luff and Thomas 1999) service as some other models of integrative care (e.g Glastonbury Health Centre). It is interdisciplinary and non hierarchical ( Boon et al 2009), an example of Boon et al’s definition of integrative medicine who utilises the stratification and levels of philosophy and/ or values, structure, process and outcome.

For any model of care to work it has to begin with the main players having the same philosophical approach to patient care with shared goals, the right organisational structure, plus interdisciplinary respect and partnership.

In the real world, in Primary Care in 2017, this is hardly the climate to be suggesting the ‘softer approach’ to patient care when surgeries are struggling to recruit to provide the very basics of medicine. Maybe it is the right climate to take a gamble and see and allow CAM practitioners to ‘take the strain’ of all those people with conditions that defy medical intervention. GP’s welcome a further tool in their tool box when all else has failed but I doubt they would be apply to pay for it. As well as finances, there is also the threat of litigation, they need to be confident that the practitioner to whom they are referring their patient is legitimate and has the correct qualifications and professional regulation. We can discuss all the structures and models we like but CAM practitioners do not have that cohesive regulation with which medicine is so familiar and relies upon for safety of practice.

My ideal, Utopian model is for surgeries to recruit and manage their own CAM practitioners, the practitioners being regulated by a reputable professional body of their own, ensuring continual professional development. The CAm practitioners with be equal partners of the team and have access to patient documentation to ensure a a ‘two -way’ flow in communication ( it is not practical, nor desirable for GP’s to have regular patient multidisciplinary case meetings, this is reserved for the most vulnerable and most ill patients in the practice) . We do not need to understand the brain surgeon to be able to refer, we just need to understand the patient needs and which discipline would be best suited to managing these needs.

This, then is an integrative, transformational, non-hierarchical model. Yet, professionals retain their own boundaries and identities and address their own educational needs. A system of communication and joint understanding being accomplished through joint documentation. Shared philosophical values and agreed goals for patient outcome are essential at individual, cultural and organisational levels.

From a critical realism philosophical view there would need to be a consideration of constraining and enabling mechanisms to allow this model to thrive at the levels mentioned above.

Below is the link to my first assignment: –

Philosophicalfa1im03.17