Integrating complementary and alternative medicine into primary healthcare in Canada: Barriers and opportunities Kevin D. Willison, MA ABSTRACT Many of the ideological orientations within the framework of primary healthcare (PHC) mirror orientations inherent in the practices of complementary and alternative medicine (CAM). Both seek improved outcomes for their clients, especially those with chronic disease, and both are oriented towards disease management, rehabilitation, and self-care to enhance health and wellness. With PHC reform in full swing in countries such as Canada, addressing its link to CAM is more important than ever. In fact, given the ideological similarities between these complex and evolving paradigms, PHC reforms have real potential to encourage CAM use even further. Since the prevalence of CAM use in cancer patients is well-documented, its link with PHC reform is an important and timely issue. Key word: primary healthcare, CAM, cancer, integrative medicine INTRODUCTION The term primary healthcare (PHC) has been interpreted in different ways. At its core, PHC is defined as a set of universally accessible services that promote health, prevent disease, and provide diagnostic, curative, rehabilitative, supportive, and palliative services. At the heart of PHC reform is the goal to establish a holistic health and social-service system that emphasizes health promotion and disease and injury prevention.1–5 Of interest here is the potential role of complementary and alternative medicine (CAM), alongside PHC, to bring about these goals. Forms of CAM are commonly used by many patients for preventive and treatment purposes.6–8 However, current research on the potential relationship between CAM and health promotion is severely lacking.9 Among the growing Canadian provincial and national documentation regarding the goals and initiatives of PHC reform, little is being said about the potential of CAM for improving healthcare outcomes for Canadians.10–13 This is Institute for Human Development, Life Course and Aging, University of Toronto (KDW), Toronto, Ontario, Canada. true despite the fact that the demand for and use of CAM is growing at a phenomenal rate14,15 and has increased within the last 30 years in all industrialized countries.16,17 GOAL SIMILARITIES OF PHC AND CAM The goal of PHC reform is to reduce the use of the hospital system where possible. CAM is commonly defined as therapeutic practices that fall outside the boundaries of conventional biomedicine.9 Although CAM is more often used as an adjunct to mainstream healthcare rather than as a replacement for it,8 research indicates that CAM use also has the potential to reduce hospital visits.18,19 Another goal of primary healthcare is to improve health outcomes, especially for patients with chronic illnesses. CAM is often used by those with chronic disease, who frequently attribute its use to their physical or mental improvement.20–31 Good, or at least improved, physical and mental health is an important dimension of quality of life,4 and rapid deterioration can occur in individuals with chronic illness if no treatment is provided. Therefore, it becomes crucial to identify the treatable components of a functional problem to provide appropriate, cost-effective therapeutic interventions,32 and the effect of CAM on health outcomes and patient perceptions of quality of life should not be overlooked given its prevalence. Moreover, PHC reform is committed to providing holistic healthcare. CAM is intrinsically aligned with this goal. Public preference for more natural, holistic, less technological, and more cost-effective healthcare is growing along with CAM use.33,34 A further tenet of PHC reform is the development of a multidisciplinary approach to patient care. Despite the struggle many CAM practitioners face in achieving acceptance for their practices,35 particular types of CAM are gaining increased credibility in mainstream healthcare.9,28,36,37 To aid in this integration process, attention needs to be paid to the similarities in goals of both traditional medicine and CAM and how together they might further the goal of improving health outcomes and reducing hospital use in patients (Table 1). JOURNAL OF CANACER INTEGRATIVE MEDICINE, SUMMER 2005, VOLUME 3, NUMBER 2 1 Table 1. Similarities in outcome goals between mainstream primary healthcare (PHC) and complementary and alternative medicine (CAM) Goals/attributes of CAM Goals/attributes of PHC Proactive approach to care Proactive approach to care Wellness promotion Wellness promotion Holistic orientation Holistic orientation Multidisciplinary in scope Multidisciplinary in scope Home or community-based Reducing hospital use Patient-/client-focused Patient-/client-focused Emphasis on self-care Emphasis on self-care BARRIERS TO INTEGRATING CAM WITH PHC A number of barriers currently hinder the integration of CAM with PHC. First, Canada lack sufficient resources to approach the problem. Recurrent obstacles such as fragmentation of care and services, inefficient use of healthcare providers, lack of emphasis on health promotion, and poor information sharing exacerbate this problem.38 Moreover, as PHC services are rooted in conventional medicine, there is a strong adherence to a biomedical approach to healthcare and resistance to change. Canadian healthcare practices remain predominantly organized around family physicians and general practitioners working alone or in small-group practices.39 This isolation impedes innovation as well as exposure to CAM therapy practices and information.40 Although the biomedical model has resulted in significant gains in the treatment of acute disease, its overemphasis on cure misses the mark when it comes to treating those with chronic (long-term, incurable) illness. It neglects the psychosocial needs of individuals, thus creating a void that CAM could potentially fill.41 The philosophical differences between CAM and PHC as it is currently practiced make integration of these diverse practice paradigms problematical but not impossible. Innovative solutions are needed to resolve this problem. One such solution is an interpretive approach to setting treatment priorities. This would include stakeholder participants reflecting and resolving competing values and assumptions.42 Whatever solutions are used in furthering integration, patience will undoubtedly be needed to achieve tangible results. Another obstacle is that many CAM professions lack the consistent and uniform licensing and credentialing proce- 2 dures found in more traditional healthcare professions, which contributes to general skepticism towards its efficacy.43 Of particular concern is the need to create a rigorous scientific research base regarding CAM interventions.41 The lack of acceptance of CAM modalities by PHC practitioners and others may be the direct result of insufficient evidence as to its benefits and contraindications. Evidence of CAM’s efficacy and safety need to be determined both through expanded eclectic research and clinical trials.44,45 Researchers have found that CAM practitioners who are more formally organized are more likely to recognize the value of scientific research in promoting mainstream acceptance of their practices.46,47 More important, the lack of efficacy research feeds the perception that CAM lacks the credibility required for public funding.48 Lack of research also creates an ethical dilemma for physicians with regard to providing referrals to CAM services.49 Given the above considerations, integrating PHC and CAM is by no means without obstacles. Success can be gauged, however, through structural and service integration markers.50 The former occurs between providers, while the later addresses how services actually get integrated on the frontlines of care. Structural integration can be achieved through the development of common definitions, standards, and protocols; integrating information systems for improved sharing of information; identifying common objectives; aligning incentives; and facilitating funding transfer. DISCUSSION Berwick Stewart is quoted as saying, “Every system is perfectly designed to produce the results it gets.”51 Current healthcare systems in all industrialized countries are poorly JOURNAL OF CANACER INTEGRATIVE MEDICINE, SUMMER 2005, VOLUME 3, NUMBER 2 designed to attend to the unique healthcare needs of individuals with chronic illness. CAM is associated with a sense of physical and mental improvement and enhanced quality of life in the growing number of patients who use it, and research indicates that CAM may potentially reduce hospital stays.18–31 Yet resistance to integrating CAM into traditional healthcare remains. it is possible that further research and revamped healthcare policies will improve the dialogue between PHC and CAM professionals and lead to their enhanced cooperation. Such a dialogue could improve comprehensive care and create a positive paradigm shift wherein the needs of vulnerable populations such as cancer patients and those with long-term chronic illnesses may be better and more cost-effectively met.30,35,52 Skeptics of healthcare initiatives such as holistic, community-based health promotion may see such efforts as a display of hostility towards physical decline53 or as a way to place full responsibility for health squarely on the individual.54 Although these are important considerations, they should not be used to hinder progress in developing and promoting programs and alternatives for those with chronic illness who seek them.55 CONCLUSION ACKNOWLEDGMENTS The ongoing encouragement and support of Qing Zhu, MSc, is greatly appreciated. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. More research regarding the efficacy of CAM is needed to promote its integration and acceptance. Little attention has been paid to date as to what factors determine consumer choice of CAM practices, although this is changing.23,30,56–58 With the increase in CAM use in general, so is there an increased need for research examining the correlates of such use.14,15,59 No single model for PHC delivery can meet all of the identified needs of the current system; e.g., quality, effectiveness, access, continuity, productivity, and responsiveness.60 However, integrating CAM into the PHC model may improve the system’s ability to meet these needs. 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