Integrative Health Care: Perspectives From an Acupuncturist and Public Health Researcher

Over the last decade, the phrase "complementary and alternative medicine," or CAM, has become commonplace. There are many reasons why CAM has become more popular. The rise of consumer movement and the accompanying distrust of experts have often been cited by health researchers as to why patients are choosing CAM (Hauge and Lavin, 1983; Goldstein, 1999; Kronenfield and Schneller, 1997). More and more people are able to explore alternatives in health care, due to the increase in access to information, especially with the use of the Internet. The Internet now offers consumers a means of doing their own research on health care alternatives prior to seeing their primary or Western care provider. Furthermore, talk shows like "Oprah" also influence consumers, especially women, to choose certain health products and alternatives.

With the rise of CAM users, there has been recognition of the need for research and the funding to make research possible. Acupuncture has had access to much of these research funds because it is also a modality that physicians use frequently in practice (Helms, 1995). As acupuncture needles "pierce the skin and create a micro-injury," there is an immediate physiological, measurable response in the body, and scientific research likes to deal in measurable responses. This does not, however, negate the "qi" theory of acupuncture: energy flows through the body which, if disrupted, causes disharmony, presenting in illness or disease, or the energy is disrupted through injury. Frequently, the way in which acupuncture studies are conducted is being researched. "Sham" acupuncture, which uses a control group that receives acupuncture at unrecognized traditional points, involves piercing the skin, thus causing a physiological effect. It is now becoming practice to use "blunted" needles that do not pierce the skin, but produce the same sensation as an acupuncture needle.

Although acupuncture has not been fully proven, research has shown that acupuncture does cause measurable physiological responses in the body, such as increasing the production of endorphins (Helms, 1995). Similarly, there are chemical changes that occur with certain medications that cause desired results in patients' symptoms. Even with drugs, however, we don't always know how and why a drug works. Because we don't fully understand the concept of qi or the meridian system of acupuncture, it shouldn't be discounted as a viable treatment option and/or integrative modality. Why should acupuncture be scrutinized more than pharmaceuticals? Seeking explanations of efficacy is often the goal of health-related research.

In my opinion, everyone believes that they can treat the patient most effectively based on their expertise, be it TCM, homeopathy or Western medicine. Until we can fully understand and appreciate each others' disciplines, patients may continue to encounter obstacles in receiving the most appropriate treatments for their condition(s). Fortunately, there are practitioners breaking the communication barrier and placing their patients' health care needs before their egos - a process being called "integrative health care" (IHC).

Perspectives From Research on Integrative Health Care

In trying to better understand this new form of health care, I spoke with Daniel Hollenberg, a PhD candidate in the Department of Public Health Sciences at the University of Toronto. Daniel has researched integrative health care as part of a doctoral thesis: "A Critical Analysis of Integrative Health Care in Canada: A Multi-Site Case Study Analysis." His research explores three different initiatives in IHC by drawing upon interviews with patients and practitioners, observation of the clinical environment, and document analysis.

The focus of his research is not on the modalities themselves, but the actual integration of multiple modalities. In each of the three sites he investigated, all had traditional Chinese medicine (TCM) as one significant component among other multidisciplinary approaches.

Regarding practitioners, Daniel noted, "... there was a lot of learning on an interdisciplinary level including Western health care practitioners expanding their understanding, acceptance and world view toward a deeper appreciation of illness, disease and wellness to include physical, psychological and spiritual dimensions."

The biggest problem he observed, however, was that over time, consumers could not consistently access CAM therapies. Patients from a lower socioeconomic status could not afford privatized CAM treatments, or if they could, they were unable to sustain treatment for a significant length of time. As he noted, this impacts the continuity of care, as the CAM modalities in the clinics were not covered under public health insurance in Canada. (There are some exceptions, such as chiropractic care; however, this modality isn't fully covered by OHIP, the Ontario Health Insurance Plan.)

Daniel observed: "... while there was progress in developing an integrative model of care, there remained many challenges pertaining to the practitioners' understanding of modalities from diverse health care paradigms, which sometimes caused problems in the development of fully integrative clinical guidelines." Biomedical and paramedical practitioners also maintained an economic and professionally dominant position over the CAM practitioners in the IHC settings.

An Acupuncturist's Perspective on IHC

Before moving to Toronto, I practiced as an acupuncturist in an IHC setting in Pennsylvania. I found that IHC practices were becoming increasingly more common. When I asked the physicians who invited me to work with them why they were interested in acupuncture, massage therapy, shiatsu, naturopathy and chiropractic, their answer was that their patients were requesting these services. They found that IHC benefited their patients and also provided additional revenue to the practice.

As an acupuncturist, I found the benefits to patients increased, more often than not, with the combinations of the different CAM treatments available. One example was a young female patient who suffered from temporomandibular joint dysfunction (TMJD). The patient had to withdraw from her final semester at a university due to her debilitating pain. Symptomatic and eventually functional relief were achieved through a combination of pain medication, botox injections, acupuncture, chiropractic adjustments and physiotherapy. The treatments began with botox and pain medications. The patient was able to reduce medication and resolve trigger points and pain in the major TMJ muscles through the acupuncture treatments. During our biweekly patient staff meetings, the team decided to add chiropractic treatments. She was then able to reduce the acupuncture treatments. Eventually, physiotherapy was added to her regimen and the chiropractic treatments were decreased to a "PRN" (as needed) basis.

As the patient was an artist, this greatly helped her functional capacity to return to normal. Raising her arms to paint at an easel greatly stressed the upper back and neck muscles that were involved in reproducing her pain as a result of the TMJD. The final result was that the patient was able to complete her studies and continue treating herself with a home exercise program.

The key points I am trying to raise here are that teamwork and communication with all practitioners were keys to successful patient treatment, and that IHC does work.

In the United States, in contrast to Canada, IHC is performed more often than not in a physician's office or group practice. This may be due to the fact that acupuncture as one form of CAM is nationally recognized and licensed according to each state. Currently, only three Canadian provinces have regulated acupuncture; however, they have not developed standardized acupuncture educational guidelines.

Acupuncture is one of the "lucky" CAM modalities in that through research, it has proven effective as a stand-alone or integrated modality, especially in treating pain (NIH Consensus Statement, 1997). Knowing that acupuncture is able to receive monies for viable research, it is my hope that it will become more integrated into mainstream Canadian health care, much like physiotherapy and massage therapy. Hopefully, acupuncture will soon become a regulated profession in Ontario. An acupuncture advisory committee has been in place with the Ministry of Health and Long-Term Care. I believe this is one treatment modality that is long overdue the recognition it deserves.

References

• Goldstein MS. Alternative Healthcare: Medicine, Miracle of Mirage? Philadelphia: Temple University Press, 1999.
• Hauge MR, Lavin B. Consumerism in Medicine: Challenging Physician Authority. Beverly Hills: Sage, 1983.
• Helms J. Acupuncture Energetics: A Clinical Approach for Physicians. Medical Acupuncture Press, 1995.
• Kronenfield JJ, Schneller. The growth of a buyer and consumer practitioners model in health care: the impact of managed care on changing models of the doctor-patient relationship. Presented at the Annual Meeting of the American Sociological Association, Toronto, Canada, August 1997.
• NIH Consensus Statement. www.nih.gov/news/pr/nov97/od-05.htm.