Integrating CAM and biomedicine in primary care settings: physicians' perspectives on boundaries and boundary work.

In this article, we present the results of a study that was conducted among 15 family physicians who had incorporated complementary and alternative medicine (CAM) into their clinical work in Israel. We aimed to explore the types of boundaries those physicians encountered, how these boundaries were contoured, and under what circumstances they were crossed. We conducted in-depth interviews with the physicians in 2008, and found that epistemological and cognitive boundaries did not pose a problem for them. However, with regard to the organizational boundary, the participants indicated that it was necessary to use a variety of strategies before they could utilize their CAM skills. Many of the participants indicated that the epistemological differences between the biomedical and CAM paradigms, such as the absence of evidence-based medicine in CAM practices, are not important. The ease with which boundaries were crossed in the complex social context described here is characteristic of postmodern societies. On the whole, the integrative physicians interviewed can be viewed as "postmodern" professionals who reject the impermeability of many long-established boundaries and hierarchies.

Touching ethics: assessing the applicability of ethical rules for safe touch in CAM--outcomes of a CAM (complementary and alternative medicine) practitioner survey in Israel.

INTRODUCTION: Recently, ethical guidelines regarding safe touch in CAM were developed in Israel. Publishing ethical codes does not imply that they will actually help practitioners to meet ethical care standards. The effectiveness of ethical rules depends on familiarity with the code and its content. In addition, critical self-examination of the code by individual members of the profession is required to reflect on the moral commitments encompassed in the code. METHODS: For the purpose of dynamic self-appraisal, we devised a survey to assess how CAM practitioners view the suggested ethical guidelines for safe touch. We surveyed 781 CAM practitioners regarding their perspectives on the safe-touch code. RESULTS: There was a high level of agreement with general statements regarding ethics pertaining to safe touch with a mean rate of agreement of 4.61 out of a maximum of 5. Practitioners concurred substantially with practice guidelines for appropriate touch with a mean rate of agreement of 4.16 out of a maximum of 5. Attitudes toward the necessity to touch intimate areas for treatment purposes varied with 78.6% of respondents strongly disagreeing with any notion of need to touch intimate areas during treatment. 7.9% neither disagreed nor agreed, 7.9% slightly agreed, and 7.6% strongly agreed with the need for touching intimate areas during treatment. There was a direct correlation between disagreement with touching intimate areas for therapeutic purposes and agreement with general statements regarding ethics of safe touch (Spearman r=0.177, p<0.0001), and practice guidelines for appropriate touch (r=0.092, p=0.012). CONCLUSION: A substantial number of practitioners agreed with the code, although some findings regarding the need to touch intimate area during treatments were disturbing. Our findings can serve as a basis for ethical code development and implementation, as well as for educating CAM practitioners on the ethics of touch.

Integrative pediatric care: parents' attitudes toward communication of physicians and CAM practitioners.

OBJECTIVE: In this study, we explored parents' perspectives toward complementary and alternative medicine (CAM) use by their children and its impact on parent-doctor and doctor-CAM-practitioner communication. PATIENTS AND METHODS: We designed a 2-arm study of parents who approached either conventional primary care or CAM clinics with their children to consult physicians or practitioners regarding their child's health. RESULTS: A total of 599 parents responded to our questionnaire (319 in 5 conventional clinics [83.9% response rate] and 280 in 21 CAM clinics [71.2% response rate]). Parents in conventional clinics reported less use of CAM by their children within the previous year (35.3% vs 73.7%; P < .0001) but used more traditional and homemade remedies (46.4% vs 12.7%; P < .0001). Both parent groups largely supported informing their child's physician regarding CAM use and expected the physician to initiate a CAM-related conversation and to refer their child to a CAM practitioner. The 2 groups' respondents largely supported communication between the child's physician and the CAM practitioner by the use of a referral/medical letter. Compared with respondents in CAM clinics, parents in conventional clinics were more supportive of CAM integration in a pediatric primary care setting and envisioned a more dominant role of physicians regarding CAM referral and a significant role of physicians in providing CAM. CONCLUSIONS: Parents who are referred to conventional and CAM clinics express distinctive attitudes toward CAM integration in pediatric care. Parents perceive physician-CAM practitioner communication as highly important and instrumental in promoting their children's health and safety.

Bridging the physician and CAM practitioner communication gap: suggested framework for communication between physicians and CAM practitioners based on a cross professional survey from Israel.

OBJECTIVE: Our study aimed to develop a framework to improve communication between physicians and CAM practitioners regarding mutual patients. METHODS: Following a modified Delphi process, we developed preliminary recommendations regarding communication between physicians and CAM practitioners. We then surveyed 473 physicians and 781 CAM practitioners regarding their opinions on these recommendations. RESULTS: High reliability and validity of the survey were found among the physicians and CAM practitioners (Cronbach's alpha score of .94 and .83, respectively). Physicians and CAM practitioners considered communication regarding mutual patients important (80% and 97%, respectively; P<.001). A medical/referral letter was the preferred communication mode. Physicians and CAM practitioners concurred on four elements that should be included in such a referral letter: conventional-CAM diagnosis with coherent terminology, possible conventional-CAM treatment interactions, description of the treatment plan and its goals, and quality issues regarding CAM supplements. CONCLUSIONS: A practical framework for advancing physician-CAM practitioner communication is feasible, and may be applied in daily medical care with the goal of bridging the patient-physician-CAM practitioner communication gap. PRACTICE IMPLICATIONS: Communication between physicians and CAM practitioners regarding mutual patients is important. Establishing a framework for the mode and content of such communication is feasible.

Development of ethical rules for boundaries of touch in complementary medicine--outcomes of a Delphi process.

The practice of complementary medicine (CAM) often involves touch. The unique philosophy of many CAM therapies, and the setting in which treatments are provided create a therapeutic space which may be less clearly defined than in conventional settings - a space in which the boundaries between professional touch and personal/intimate touch may become easily obscured. Thus, complementary therapists need clear definitions and firm boundaries in order to maintain therapeutic efficacy and commitment. The aim of the process described in this article, was to develop ethical guidelines for boundaries of touch that will promote the safety and protection of the public which use CAM. Through a modified Delphi process, a diverse group of CAM practitioners, physicians, ethicists, legal consultants, health policy specialists, and representatives from the public, developed Ethical Rules for Boundaries of Touch in CAM. These guidelines may be implemented in ethical codes of professional CAM organizations, and also serve as a foundation for curriculums in ethics in CAM schools.