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The increasing demand for alternative and complementary medical treatment requests further discussions on the integration of CAM into conventional primary health care. The existent controversy concerning safety, lack of proof of effectiveness of the alternative therapy and in certain cases the absence of a regulatory body [1] [2] [3], have in the past raised heated discussions against the integration of CAM. But the increased interest of the public is impacting on the `conventional´ consultations, resulting in alterations of many a general practitioners stance toward CAM [3]. Patients´ quest for more autonomy in their health management, a fear of adverse reactions and the awareness of limitations to the allopathic treatment, has led patients to self-medication with alternative remedies and to dispense on private visits to CAM practitioners, outside the health system [3] [4]. Beyond that it is the congruence of the alternative approach to patients´ most personal beliefs and values, and the knowledge of a safe and effective treatment that is at the same time cautious of the patients´ orientation toward leading a healthy life [5] that has increased the awareness and acceptance of CAM therapies. General practitioners have recognized this trend, since they are often the first contact patients turn to for information regarding alternative therapies, and have attempted to adapt to this new tendency. Many that would in the past have had inadequate knowledge of the alternative and complementary methods have done training, permitting them to provide sufficient information about the alternative treatments available and the possible effects to the patients´ specific ailment [1] [2] [3].

One major step toward the integration of CAM is communication. This applies both to the practitioner-patient relationship and the cooperation between general practitioner and CAM-provider [3] [5] [6]. The need for collaboration between the two strands of health care practice is evident and could permit understanding and acceptance, resulting in an efficient service meeting patient requests [6].  Referral to CAM-practitioners usually occurs where a wider range of treatment options is sought to be available to patients, and where allopathic treatment has been ineffective or has brought forth adverse reactions and side-effects [1]. For the general practitioner to be able to respond significantly to patients´ interrogations, about alternative and complementary methods of treatment, requires handing the power of individual and personal decision making, back to the patient. As such it is assured that the ethical principle of autonomy is met and one essential point for successful integration of CAM into health care is fulfilled [2] [6]. Non-maleficience is another ethical factor that is thoroughly questioned when discussing integration as there is a lack of agreement over the scientific evidence of available CAM therapies [1] [7]. Available evidence of the effectiveness of CAM practice has already suggested a legitimate incorporation into primary health care but is still questioned due to the differences to conventional practice such as conception and interpretation, context of health and ailment, as well as the deviation in the relationship to science [2].To the general practitioner the CAM therapies are often still a challenge, because here practice is taking place in a zone that lies outside of the boundaries of conventional health care, in an area where the general practitioners training may not fully permit him to accept and understand the restricted but growing scientific body of evidence available [3] [7].

It has also been questioned if integration of CAM into conventional health care is, beyond questioning the feasibility of it, at all to be aspired [2]. Profound alterations could occur if evidence-based CAM treatments were fully integrated. By repressing CAM into the boundaries of conventional practice, CAM may be altered in its foundations, becoming standardized, resulting in the loss of it as an alternative option, and a merging of the two health strands beyond the identifiable features of CAM-practice [2]. Pro integration stands another factor, that of the financial aspect. CAM practice has been identified as being potentially cost saving in the long term, since expensive conventional treatments could be avoided and repeat consultations may be reduced. Arguments opposing this are of increased NHS spending on CAM, fearing the possibility of reduction of monetary funding and expenditure on other sectors of medical care [3]. Constituting a major factor opposing integration is the scientific evidence and the lack of research into CAM therapies [1] [2] [3] [5] [6] [7]. Ernest et al [6] go as far as to claim no reliable risk-benefit assessment can be undertaken in CAM to confidently confirm beneficence is greater than the risks possibly associated to CAM treatment. Controversy here exists, as funding for further research that could provide evidence for the safety and efficacy of CAM, usually goes into other sectors of medical research where existent evidence already promises efficient results for the justification of the research to be conducted [6].

In summary there needs to be said that for a successful integration of CAM into conventional health care practice, general practitioners are required to have a basic knowledge, from reliable source, of the CAM therapies that are available [1] [2] [3] [5]. There is the requirement for clear guidelines concerning referral and administrative issues [5]. Referral and cooperation with CAM practitioners has to be reliable, safe and efficient [1] [6]. From the point of view of the CAM practitioner, he needs to continually expand his knowledge in his field and should be prepared to seek assistance and advice on medical issues outside of his field from a general practitioner [1] [5].  For the cooperation of both the CAM provider and the general practitioner there is the need of intensive communication [3]. Conventional diagnosis prior to CAM treatment is an advisable feature of integration [1] and the interaction should result in CAM complementing general practice and vice versa conventional treatment supporting CAM for a successful integration to take place [5].

[Many thanks to Ian Townsend, University of Central Lancashire, U.K., for his assistance with this assignment]

References:

[1] Grace, S., Velmupad, S., Reid, A.,Beirman, R. 2007 CAM practitioners in integrative practice in New South Wales, Australia: A descriptive study [Online] last accessed 27.01.09 at URL http://www.sciencedirect.com

[2] Kerridge, I., McPhee, J. 2004 Ethical and legal issues at the interface of complementary and conventional medicine [Online] last accessed 26.01.09 at URL http://www.mja.com.au

[3] Maha, N., Shaw, A. 2007 Academic doctors’ views of complementary and alternative medicine (CAM) and its role within the NHS: an exploratory qualitative study [Online] last accessed 06.02.09 at URL http://www.biomedcentral.com

[4] Dumoff, A. 2004 Legal issues presented by integrative health care practice [Online] last accessed 27.01.09 at URL http://www.sciencedirect.com

[5] Frenkel, M., Borkan, J. 2003 An approach for integrating complementary-alternative medicine into primary care [Online] last accessed 07.02.09 at URL  http://fampra.oxfordjournals.org

[6] Ernst, E., Cohen, M., Stone, J. 2003 Ethical problems arising in evidence based complementary and alternative medicine [Online] last accessed 21.12.08 at URL http://jme.bmj.com

[7] Adams, K., Cohen, M., Eisenberg, D., Jonsen, A. 2002 Ethical Considerations of Complementary and Alternative Medical Therapies in Conventional Medical Settings [Online] last accessed 26.01.09 at URL http://www.annals.org

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