INTRODUCTION

In addition to standard conventional medical care, more than one-third of Americans also use complementary and alternative medical (CAM) therapies for their routine health care needs.1–4 CAM therapies are those not considered part of conventional medicine, such as herbal medicine and acupuncture.5 The combination of conventional medicine and CAM practices in one clinical setting is often now referred to as integrative medicine (IM). The precise definition of IM is still evolving. The National Center for CAM, a division of the National Institute of Health, defines IM as the combination of mainstream medical therapies and CAM therapies for which there is some evidence of safety and effectiveness.5 Snyderman and Weil6 go beyond this definition and define it as a form of medicine that cannot be understood as simply the additive use of conventional and CAM therapies. They define IM as medical care focused on health and healing, rather than illness, with an emphasis on the centrality of the patient–physician relationship. In their definition, IM includes lifestyle choices that promote health and active participation by patients. IM practitioners view the patient as a physical being, a spiritual being, and a community member and act as guides rather than commanders. IM centers often provide for more time with the patient whether this is during a one-hour massage or a one-hour primary care office visit with an MD.7 Academic centers and private clinics that provide IM are becoming commonplace in most major cities in the United States.8 Many CAM therapies, although included in this model, have not been scientifically proven to have therapeutic benefits.

It is not clear why people choose IM care, rather than a usual clinic, for their primary care needs. To help understand this trend we conducted focus groups with regular users of IM. Our goals were to identify factors that contributed to the choice of IM for primary care needs and to assess the values and beliefs of some regular IM users.

METHODS

Study Participants and Recruitment

We conducted six focus groups of patients from an integrative care clinic in Cambridge, MA, in April and May 2005. The Marino Center for Progressive Health is a nonprofit IM clinic affiliated with Mount Auburn Hospital, Cambridge, MA; it provides approximately 33,000 patient visits annually. The majority of its patients are insured and use the Marino Center for primary care. CAM services offered at the center include acupuncture, chiropractic therapy, craniosacral therapy, herbal medicine, massage, mind–body medicine, and traditional Chinese medicine. Visits to primary care physicians (PCP) are covered by health insurance; CAM practices are paid for out of pocket. Patients self-refer to our clinic through word of mouth, health insurance databases, or referrals from Mount Auburn Hospital. The center employs 12 medical doctors, two mental health care providers, four registered nurses, three physical therapists, and five CAM practitioners. All staff members are board certified or licensed in their respective specialties. At the Marino Center, new patients are seen for 60 minutes, and 30–45-minute follow-up visits are the norm.

Focus groups were held at Mount Auburn Hospital to avoid contextual bias of meeting at the center. Following standard focus group methodology, groups were gender-specific to encourage communication about the private issues of health care. Focus groups had an average of six participants per group (range five to seven). The New England Institutional Review Board, an independent institutional review board, approved the study, and all participants provided written informed consent.

We recruited participants using flyers in patient areas and through encounters with PCPs. Patients were eligible to participate if they had a PCP at the center, used some form of CAM therapy regularly, were 18–80 years old, were English-speaking, and were able to provide written informed consent. Participants received a $50 incentive.

Conducting the Focus Groups

An ethnographer and expert in CAM/IM (B. O’Connor) led the groups using a detailed guide of open-ended questions (available from the authors on request). The same guide was used to query all focus group participants. Domains covered include perception of what IM means, how participants chose to seek care at an IM center, general ideas of health and illness, use of CAM, beliefs about the therapeutic encounter, and history of personal medical conditions. The final number of focus groups was determined by information saturation, using concurrent data analysis. Saturation occurs when additional information no longer generates new understanding.9 All focus groups lasted 90 minutes and were audiotaped. All data were held as strictly confidential. Identifiers were removed during audiotape transcription and only deidentified transcripts were reviewed during analysis.

Analyzing the Focus Groups

Focus group audiotapes were transcribed conversationally by an outside company and later reviewed by three investigators (A.M. McCaffrey, G.F. Pugh, and B. O’Connor) to identify major themes. Two investigators (A.M. McCaffrey and B. O’Connor) then reread each transcript, manually coding instances of each theme and identifying illustrative quotations. Any differences of opinion about the meaning of specific passages were discussed and resolved. Only themes that recurred are presented herein; areas described were mentioned a minimum of seven discrete times or were said with concordance of the group (as described by the moderator). Quotes offered by participants are provided as illustrations of the factors that emerged during the focus group discussions.

RESULTS

A total of 37 patients from an IM center participated in six focus groups (Table 1). Participants reported an average of 4.9 medical problems (Table 2) and used an average of 6.8 CAM therapies each (Table 3). Two broad themes emerged from the analysis of focus group discussions, beliefs of IM users and important elements in the patient/provider IM encounter in IM (Table 4).

Table 1 Characteristics of Focus Groups
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Table 2 Medical Problems Reported by Participants
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Table 3 Complementary and Alternative Therapies used by Participants
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Table 4 Motivation and Values of Users of Integrative Medicine (IM)
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IM Users’ Belief Systems

Focus group members believed the combined approach of CAM and conventional medicine provides better care than either approach alone, particularly when all options are considered in a nonhierarchal way. They do not shun conventional medicine nor do they assume that all modes of CAM are worthwhile. Participants want their providers to consider all options of both conventional and CAM treatments:

I really like that things are integrated and there are all these different options. There are pharmaceuticals as an option and there is homeopathy and herbal supplements, but all of them are considered as valid options depending on what works for you.

I like seeing a doctor who is aware of the bigger picture. Even if she decides or recommends a conventional treatment, at least I know they’re aware of alternative health thinking...that gives me more confidence in the treatment, even if their treatment might end up being the same [conventional].

Participants have a broad view on health; they believe that health is a combination of physical health, emotional health, lifestyle, and spiritually. They feel that this broad or holistic view on health and well-being is not acknowledged by conventional medicine but is embraced by IM.

It’s exercise; its diet; it’s outlook; it’s how I am physically feeling in my body, and how I’m emotionally relating to other people—if I’m attuned or not particularly connected with the world.

When I am feeling good, I think it’s mental and it’s physical and it’s spiritual; it all of it together.

Many participants comment that general nutrition and the use of supplements are important to health.

Most doctors don’t make the connectionbetween nutrition and health. You literally are what you eat. If you eat crappy food, then you’re going to become crappy.

Participants do not want prescription medications except as a last resort and feel that conventional medicine overemphasizes prescription medicines. This may be because of a combination of factors including distrust in conventional medicine, fear of side effects from medicines, and an underlying belief that the body can heal itself given the right nutrition, rest, and time.

There is a tendency for doctors either to recommend drugs or surgery. I would experience negative side effects and have to be seen by someone else in order to deal with those. It was kind of a cycle that ensued.

I do not like to take medicine unless absolutely necessary.

...it’s a chronic condition. I’m sure I’ll probably have it the rest of my life; but if I can use less medication, rather than more, that’s really my goal.

IM and A Pragmatic Approach to Problem Solving

Patients viewed IM care as a pragmatic approach to problem solving. Often participants described suffering from illness that conventional medicine provided few options for care.

I was diagnosed with MS and I was a total mess; and there is no cure. So my doctor really had nothing to tell me, there was nothing he could do...I’ve been going for acupuncture and massage therapy, and I get vitamins and Chinese herbs. I’m doing so much better, it’s really amazing.

I was having severe headaches everyday for two years and I went and had a full physical...At the end of the physical I said ‘what about my headaches?’ and the answer was ‘there can be many reasons for headaches and there is nothing we can do for you’. So I decided to try something else.

The IM Encounter

A second theme was that patients view the IM encounter as having elements not always present in conventional medical visions. Our subjects want the opportunity to discuss CAM use with their PCP, be respected for their beliefs, and be given guidance on its use.

I had been seeing a chiropractor, and I started seeing an acupuncturist, and I realized there were all of these other aspects of my life and my health that I wanted to be talking to a doctor about.

I had developed a thyroid problem and I had done various alternative treatments elsewhere. Every time I would go in for follow up [my doctor] would say ‘so what have you tried, what are you doing?’. I said I had been doing the acupuncture [and she said]’okay, so you are not doing anything.’ She would totally discredit what I was saying...I felt that I needed to be seeing someone who understands my point of view on this and how I want to treat my body, and respect that.

I liked the fact that it was integrative; both that I was going to get a doctor who was traditionally trained, and was open to alternatives at that same time.

Participants describe looking for providers to help them make sense of symptoms not well understood by conventional medicine and to provide treatment options for these symptoms. Often a constellation of symptoms is described in the CAM world as diagnosis that conventional medicine does not acknowledge.

For the first time I felt like the various and seemingly disparate symptoms I was coming in with actually made sense to my healthcare provider and fit within a framework that that person understood, and also within a treatment model that that person understood, and then could be used to help make me better—which it is, and I am.

My first allergist in the area told me that nothing was wrong. I would go into adrenal crisis that would last for months, and I couldn’t work for months, and would have these horrendous symptoms, and he would say there was nothing wrong.

The adrenal crisis this patient is referring to is not due to adrenal insufficiency as understood by conventional medicine but to “low adrenal function” as described in the alternative literature and deemed to be because of chronic stress.10 Symptoms include fatigue, insomnia, reduced resistance to infection, and sensitivity to allergens. The existence of this syndrome is controversial and provides an example of a CAM diagnosis.

I got very ill with candidiasis and found Doctor R [at the Marino Center] who right away was able to diagnose what I had and was very quickly able to help me and he told me that most physicians don’t even know that there is such a thing and they will not come up with that diagnosis.

Candidiasis or yeast overgrowth syndrome describes a controversial syndrome where Candida albicans, normally present in small amounts in the body, is believed to overgrow in the gut and cause allergic reactions. Symptoms include fatigue, irritability, constipation, diarrhea, abdominal bloating, mood swings, depression, anxiety, dizziness, weight gain, difficulty concentrating, muscle and joint pain, cravings for sugar or alcoholic beverages, psoriasis, hives, respiratory and ear problems, menstrual problems, infertility, impotence, bladder infections, and “feeling bad all over.”11

Integrative medical encounters are generally longer, usually one hour or more for the first visit. Participants believe it is important to spend time with practitioners and are drawn to this model of care.

I think the biggest thing is that there is time. There is individual, one-on-one time.

Being listened to by the provider is crucial to good care and is distinct from time spent. This is the most cited desire of patients pursuing IM care.

I think the quality of listening is very important. My experience [with IM] has been that the doctors listen, and they make suggestions, and they listen back to how you feel about the suggestions.

I am beginning to think that progressive medicine is finding a doctor who will listen.

Participants want their questions invited, their self knowledge and education credited and the opportunity for shared decision making.

Doctors have said things in the past that left me feeling like I am not supposed to know anything, because you cause more problems for them. [IM] is the opposite of that, and I think that’s the one main benefit.

My experience has been that if you have ideas, like an herbal thing or something like that might be helpful and you suggest it to [IM doctors], they’ll take it seriously as a possibility. They may let you experiment with it if they feel it’s safe.

In the past, in [conventional] medicine, only the doctors go to lectures, to learn new cutting edge things. But we’re all trying to find out what’s on the cutting edge now. We’re our own physicians.

I am developing an awareness of what my body needs and what my mind needs and what my spirit needs, and the toolbox of how to get so that I can feel well one day.

Availability of insurance coverage was cited by a majority of participants as a key element in selecting an IM center. Availability of a range of treatment options in one location was also a strong selection criterion.

I knew there was going to be a good balance of getting care that was covered by my insurance that went with my beliefs based on my experience of things that worked and helped. I got it and I stayed.

Dissatisfaction with Conventional Medicine

Many of the focus group participants describe being dissatisfied with conventional medicine. They describe being rushed, not being listened to, being dismissed as a complainer, and even feeling traumatized by conventional medicine:

I am pretty medical phobic because I had such traumatic experience with conventional doctors; I have found that they don’t listen to you carefully and they tell you that it’s your imagination, when you’re having a problem that they are not familiar with.

DISCUSSION

Our data suggest that many of the qualities patients are looking for in integrative medical care are universally shared: they value a strong therapeutic relationship with a primary care provider who is a good listener and provides time, knowledge, and understanding. IM users are dissatisfied with many aspects of conventional medicine. They want to speak openly about CAM use and obtain guidance on its use from knowledgeable physicians. They want the opportunity to try alternative approaches to problems poorly treated by conventional medicine, and openness to contested diagnoses. They hold a holistic model of health (mind, body, and spirit all play a role) and are convinced that the combination of CAM and conventional medicine is superior to either approach alone. They strongly prefer to avoid prescription medicines whenever possible and to wish discussing the role of nutrition and supplements in health maintenance.

The illnesses described by our participants are consistent with previous studies of common conditions associated with CAM use, particularly back problems, allergies, digestive problems, and fatigue.1–3 Many of these illnesses are not well treated by conventional medicine, supporting the pragmatic use of integrative approaches. CAM therapies reported by our participants are consistent with national surveys on CAM use with supplements, relaxation techniques, chiropractic, herbal therapies, and massage being among the most commonly used.1–3

Most users of CAM do not discuss its use with their medical doctor.1,2 Data suggest this lack of communication is because of a perceived inability by MDs to understand and incorporate CAM.4,12 Our data support this rationale. Participants in our study want to avoid pharmaceuticals except as last resort. This is consistent with a recent study on the use of CAM therapies by patients with IBS.13 Participants note that nutrition and vitamin supplementation are important to health. The use of medicinal diets, dietary supplements, and vitamins at high doses is a departure from mainstream nutrition taught in conventional schools.

The study subjects value time spent with provider during which they felt heard, questions were invited, self knowledge appreciated, and opportunities for shared decision making were encouraged. Previous patient satisfaction studies on quality care emphasize effective communication and involvement in decision making as essential to quality care.14,15 In addition, previous studies of CAM use by patients report similar goals of having more control in the decisions about their medical care.13,16

As postmodern society changes, faith in the ability of science and technology (including medicine) to solve the problems of living has declined.17 Since the late 1960s and early 1970s, societal trends toward increasing individualism and self-determination have influenced health care. Many people are less willing to accept the pronouncements of traditional authorities, such as doctors, without question and many individuals seek greater levels of control over most aspects of their lives.18,19 As policymakers debate on how to reform the current health care system, this new trend in medical care is important to understand and should be taken into account in market-driven service provision.

Our study has a number of limitations. We studied a self-selected, volunteer sample of patients from one health center, which limits the generalizability of our results. Our qualitative methods do not allow us to determine the exact proportion of patients who held any given attitude or their hierarchical ordering of importance. However, the themes we have reported are those that recurred independently in each focus group, enhancing our confidence that these themes accurately reflect the general attitude of patients choosing IM for their primary health care. We do not know whether other analysts would have identified different factors in our transcripts, although we control for this possibility by having multiple raters review each transcript.

CONCLUSION

We found that users of IM have both universal and unique reasons for seeking care. Users of IM believe that a combination of CAM and conventional medicine is superior to either alone and, like most patients, are looking for a strong therapeutic relationship with their providers. Conventional practitioners should consider gaining some knowledge of CAM practices so that they can provide more guidance and open dialog about what other practices their patients use for health concerns. Much of the draw of IM may be because of the current conditions in mainstream medicine—perceived shorter visit times, increased reliance on pharmaceuticals and technology, and less personal interaction. This research is a necessary step towards designing interventions and systems of care to improve patient satisfaction.