Content uploaded by Grace Sandra
Author content
All content in this area was uploaded by Grace Sandra on Mar 07, 2015
Content may be subject to copyright.
Integrative Medicine:
Enhancing Quality in Primary Health Care
Sandra Grace, PhD, and Joy Higgs, PhD
Abstract
Objectives: Integrative medicine (IM) is an emerging model of health care in Australia. However, little is known
about the contribution that IM makes to the quality of health care. The aim of the research was to understand the
contribution IM can make to the quality of primary care practices from the perspectives of consumers and
providers of IM.
Design: This interpretive research used hermeneutic phenomenology to understand meanings and significance
that patients and practitioners attach to their experiences of IM. Various qualitative research techniques were
used: case studies; focus groups; and key informant interviews. Data sets were generated from interview
transcripts and field notes. Data analysis consisted of repeatedly reading and examining the data sets for what
they revealed about experiences of health care and health outcomes, and constantly comparing these to allow
themes and patterns to emerge.
Setting: The setting for this research was Australian IM clinics where general medical practitioners and CAM
practitioners were co-located.
Results: From the perspective of patients and practitioners, IM: (1) provided authentically patient-centered care;
(2) filled gaps in treatment effectiveness, particularly for certain patient populations (those with complex, chronic
health conditions, those seeking an alternative to pharmaceutical health care, and those seeking health pro-
motion and illness prevention); and (3) enhanced the safety of primary health care (because IM retained a
general medical practitioner as the primary contact practitioner and because IM used strategies to increase
disclosure of treatments between practitioners).
Conclusions: According to patients and practitioners, IM enhanced the quality of primary health care through its
provision of health care that was patient-centered, effective (particularly for chronic health conditions, non-
pharmaceutical treatments, and health promotion) and safe.
Introduction
Accepted principles of quality in health care in-
clude focusing all health care interactions on the patient,
customizing treatment approaches to individual patient
needs and values, and providing effective, safe and equitable
health care.
1–4
Several quality performance frameworks, in-
cluding the National Framework for Assessing Performance
5
in the United Kingdom and Healthcare Effectiveness Data
and Information Set (HEDIS)
6
in the United States, have been
developed in the past decade to measure structures, pro-
cesses, and outcomes of health care. Campbell et al.
7
draw a
distinction between quality of health care provided to indi-
viduals and that provided to populations. According to
Campbell, indicators of quality, such as access and effective-
ness, are most meaningful in the context of health care pro-
vision to individuals, whereas equity, efficiency, and cost are
relevant in the provision of health care to populations. This
article focuses on quality of health care provided to individ-
uals in primary care settings.
The increasing use and prevalence of complementary and
alternative medicine (CAM)
8–10
raise crucial questions in
relation to health care quality, particularly in relation to
the effectiveness and safety of CAM and the informed use
of CAM approaches by non-CAM practitioners. Several
books provide catalogues of integrative treatments for many
health conditions,
11–13
but studies dealing with resultant
health benefits or with issues of health service delivery are
scarce.
14–16
Several contexts of integrative medicine (IM)
exist in Australia, including co-location of CAM and main-
stream medical practitioners in metropolitan practices and
isolated examples in hospital settings and in remote and
The Education for Practice Institute, Charles Sturt University, Sydney, New South Wales, Australia.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 16, Number 9, 2010, pp. 945–950
ªMary Ann Liebert, Inc.
DOI: 10.1089/acm.2009.0437
945
rural communities.
17–19
The setting for the current research
was IM practices in Sydney, New South Wales, Australia.
This setting was chosen because more CAM practitioners
practice in metropolitan NSW has than any other region of
Australia.
20–22
Other models of IM such as referral networks
for CAM services
23–26
are beyond the scope of this research.
Health services research has provided much information
on structures and processes of care that can improve out-
comes for patients.
27
Increasingly, patient-based outcomes
are being used to complement traditional metrics such as
clinic audits and patient-satisfaction surveys. The aim of this
research was to understand the contribution IM can make to
the quality of primary health care through a deep under-
standing of lived experiences and perceptions of IM health
care from the perspective of health care consumers and
providers.
Materials and Methods
This interpretive research used hermeneutic phenome-
nology (a research strategy that examines people’s lived ex-
periences of human phenomena, in this case, health care).
This strategy was appropriate for the goal of understanding
meanings that patients and practitioners attach to their ex-
periences of IM. In hermeneutic phenomenology the em-
phasis is placed on interpretations that potentially provide
deep layers of meaning.
28
Three data collection methods
(cumulative case studies, focus groups, and key informant
interviews) were used to explore processes and outcomes of
IM through the interpretations of core stakeholders’ experi-
ences of IM. In particular, patients’ and practitioners’ per-
ceptions were sought about their health care experiences,
including assessment and treatment choices, health out-
comes, congruence with beliefs and values, collaborative
practices, and power sharing.
Data analysis was conducted concurrently with, and
subsequent, to data collection, so that questioning and ob-
servation were progressively guided by the emerging data.
The number of participants was not predetermined but
rather evolved in response to the quality and extent of rep-
etition of information collected. Over the period of data col-
lection, a large and information-rich data set was collected.
Redundancy of information became evident over the final
few weeks of data collection, when previously identified
ideas and themes continued to reemerge.
Case studies
Cumulative case studies that combined data derived from
several real-life contexts at different times were used to re-
flect the multiple perspectives available from a diversity of
styles of co-located IM practice.
29,30
Three IM clinics in
Sydney, Australia, were selected by maximum variation
sampling, based on their profiles as reflected by mission
statements, advertising material, and number and diversity
of medical and CAM practitioners (Table 1). The daily op-
erations of each clinic were observed for 10 days and semi-
structured interviews were conducted with 22 patients, 5
general medical practitioners (general practitioners; GPs)
who had CAM training, and 6 non–conventionally medically
trained CAM practitioners. The written authority of the
practice managers was obtained before participants were
recruited. Flyers calling for participants and an information
sheet were displayed in the clinic reception areas.
Focus groups
Flyers inviting participants to join focus groups were
displayed at four practitioner seminars (an IM seminar, a
CAM seminar, and two mainstream medicine seminars), and
at two IM clinics not previously involved in the research.
Table 1. Diagnostic and Treatment Approaches Available in Three IM Clinics in Sydney (Case Study Phase)
Clinic General Medical Practitioners (GPs) CAM practitioners
1 GP1: WM, acupuncture, nutritional medicine CAM1: Psychotherapy
GP2: WM, acupuncture, herbal medicine, nutritional medicine, homeopathy CAM2: Naturopathy
GP3: WM, anthroposophical medicine, herbal medicine, nutritional medicine CAM3: Naturopathy
GP4: WM, homoeopathy CAM4: Naturopathy
GP5: WM, herbal medicine, nutritional medicine CAM5: Naturopathy
2 GP1: WM, acupuncture, herbal medicine, nutritional medicine CAM1: Naturopathy
CAM2: Naturopathy
CAM3: Naturopathy
CAM4: Naturopathy
CAM5: Reiki
CAM6: Remedial massage
3 GP1: WM, nutritional medicine, counseling CAM1: Naturopathy
GP2: WM, nutritional medicine, environmental medicine, herbal medicine,
acupuncture
CAM2: Traditional Chinese
Medicine, Acupuncture,
GP3: WM, environmental medicine, nutritional medicine, allergy testing CAM3: Chiropractic
GP4: WM, environmental medicine, naturopathy CAM4: Chiropractic
GP5: WM, nutritional medicine, environmental medicine
GP6: WM, bioenergetic medicine, acupuncture, homeopathy, nutritional medicine,
parasitology
GP7: WM, homeopathy
GP8: WM, environmental medicine, nutritional medicine
IM, integrative medicine; GPs, general practitioners; CAM, complementary and alternative medicine; WM, Western medicine.
946 GRACE AND HIGGS
This recruitment strategy was designed to increase the var-
iability of IM clinics (e.g., ratio of CAM practitioners to GPs
and range of CAM modalities offered in the clinics) that
participants had experienced. Four (4) patients, 5 GPs, and
10 CAM practitioners who were not previously involved in
the research were recruited. All were either patients using IM
or practitioners of IM. Flyers inviting participants to focus
groups were also displayed in the reception areas of the IM
clinics that were used to gather case studies. Six (6) focus
groups were conducted to incorporate additional perspec-
tives to those gained during the interviews and to test the
credibility of emergent findings. Each focus group had be-
tween 5 and 10 participants and lasted from 1–2 hours.
Key informants
Key informants were selected by purposive sampling
based on their reputations as experts (indicated by relevant
publications, conference presentations, public media profiles,
and clinical experience in IM). Three (3) GPs and 3 CAM
practitioners were recruited. Each participant was inter-
viewed three times for up to 1.5 hours on each occasion. This
series of interviews enabled interviewees to express personal
perspectives and perceptions of integrative health care and
allowed indepth discussions of the emerging findings of the
research.
All interviews were audiotaped for transcription with the
participants’ permission. NVIVO software was used for
data management. Data analysis consisted of repeatedly
reexamining the data for what it revealed about experiences
of health care and health outcomes. A key feature of the
data analysis was constant comparison. Tesch
31
describes
this as a process seeking ‘‘to discern conceptual similarities,
to refine the discriminative power of the categories, and to
discover patterns.’’ First-order analysis of the data consisted
of identifying key words and phrases used by participants.
Next, associated ideas were abstracted from the first-order
analysis to form second-order constructs. Repeated reading
of the data enabled common concepts or higher-order
themes to be identified. Emerging themes were refined,
expanded, or discarded throughout the data analysis pro-
cess. Ultimately, the findings from all phases of the research
were fused to form metathemes. The quality of this research
was ensured by authentic, credible, and transparent use of
the methodology. Every stage of the research was con-
ducted ethically and rigorously (e.g., exploring outliers and
potential rival explanations, and the use of triangulation,
including multiple data sources, multiple data analysts, and
member checks).
Results
From the perspective of patients and practitioners in this
research, IM is a patient-centered, effective, and safe model
of primary health care.
Patient-centered care
IM practitioners in this research strove to implement pa-
tient-centered care. This was manifest in the value attributed
to patients’ knowledge and experience and in attempts to
tailor practices to patients’ values and preferences. As one
interviewee noted:
It’s very important that you meet a person in [that
person’s] value system ….I encourage people to tell
me what they think. (CAM practitioner 1)
Patient-centered care was also evident in the acknowledg-
ment of diverse origins of ill health and multiple treatment
approaches. Patients were viewed in the wide contexts of
their family circumstances, communities, cultures, physical
environments, and, sometimes, spiritual beliefs. One
patient’s first encounter with an IM GP exemplified this
patient-centered approach:
[The doctor] said: ‘‘Tell me about your life.’’ It wasn’t
just: ‘‘What’s wrong with you?’’ (Patient 1)
The opportunity to discuss health issues and to ask questions
was highly valued by patients and was facilitated by long
consultation times. Decisions about health care were often
made into a joint enterprise between patients and practi-
tioners. Key features of IM were the wide range of diagnostic
and treatment choices, including conventional biomedicine,
CAM, and self-management options, how these interven-
tions were combined and sequenced, and choice of practi-
tioners. CAM diagnostic techniques were often used to
identify subclinical indicators and diverse origins of disease
processes. In the following interview excerpt, physical causes
of dysfunction as well as life circumstances were considered
relevant to the individual’s health and were taken into ac-
count. The embodied condition that has traditionally been
the focus in mainstream medicine was replaced by a focus on
the whole person; as shown in this example:
I listen to [my patients] and then we discuss how they
can approach their condition[s]. Take a really simple
example. They’ve been to see another doctor who said:
‘‘Your blood pressure is up. You have to go on tablets,’’
and a lot of people don’t want to go onto medication.
I’ll say: ‘‘Have you had any investigation into where
your hypertension is coming from?’’ We will do the
work-up on hypertension, a conventional medical
work-up. And occasionally you will get a surprise that
there is something underneath it such as [a] kid-
ney [condition] or some other problem that [a pa-
tient hasn’t] actually been tested for. Then we look at
the results. and we might start with diet or cholesterol,
or we might start with some of the complementary
support, stress management, maybe work with haw-
thorn. I look at what else is going on in their lives.
(GP 1)
Effective health care
The findings of this research suggest that IM is particu-
larly suited to certain patient populations: those with chronic
or complex health conditions such as rheumatoid disease
and chronic fatigue; those looking for alternatives to phar-
maceutical management of their conditions; and those who
are well and who are interested in maintaining and pro-
moting their health. For these groups, neither mainstream
medicine nor CAM alone had provided satisfactory health
care. Changes in physical health assessments were supported
by many strong testimonials to the effectiveness of IM. Pa-
tients reported improvements in physical conditions and
feelings of well-being, as the following demonstrates:
ENHANCING QUALITY IN PRIMARY HEALTH CARE 947
I was sick for 2 years and went to numerous doctors,
[and] had numerous blood tests to try to find the an-
swer. The first doctor was an infectious diseases spe-
cialist who took vials of blood but couldn’t find
anything wrong. Then I came here, and, as soon as I
started treatment, I started getting better. They ran
tests and sent a urine test to America ….they showed
very high levels of mercury and a number of other
things. They gave me some medicine, double-checked
the test results, and they indicated the same thing, and
I started the treatment. It’s been a relief because I was
really, really sick. I was sleeping 15 hours a day on
weekends. I’d go to work and give up. As soon as I
had my first treatment—the first was one was great—
as soon as I had the infusion I started feeling better.
(Patient 2)
For GPs, IM opened up new ways of approaching health
care. As one GP noted:
When I practiced in the conventional framework, there
were too many occasions when I didn’t know why a
person responded the way [he or she] did or I didn’t
know why [the patient] didn’t respond the way I ex-
pected. Since I’ve been learning nutritional medicine
and looking at diets and supplementation, I’ve got a
much better handle on why things go wrong. You may
not be able to reverse things completely but you can
always optimize the person’s health with that more
holistic perspective. (GP 2)
Safe health care
Participants reported that IM provided strategies for
overcoming their concerns about the efficacy of CAM and
the competence of CAM practitioners. Patients perceived
that GPs’ training provided them with the necessary skills to
identify legitimate CAM practices from the available array.
The very practice of CAM (or association with it) by GPs
enhanced the credibility of CAM’s efficacy. IM practitioners
in this research stated that that they practiced evidence-
based medicine (EBM) in their clinics every day. These
practitioners achieved this by accepting experience-based
evidence as being equally legitimate as biomedical evidence.
In this research, the dominant model of IM positioned GPs
as the gatekeepers and monitors of patients’ health care. This
arrangement was preferred by most patients and GPs and
many CAM practitioners. It was also promoted by govern-
ment subsidies. For example, pathology tests ordered by
CAM practitioners did not qualify for an Australian gov-
ernment medical rebate, whereas the same tests ordered by
medical practitioners did qualify. In this gatekeeper model of
health care, concerns that are sometimes raised about the
competence of CAM practitioners were allayed by patients’
first contact being with a GP who exercised ultimate control
over the provision of CAM. Perception of the high level of
diagnostic skills of GPs determined the patient’s choice of
practitioner in the following case:
The thing that I really love about my doctor is that he
uses a holistic approach. He uses homoeopathy. I go to
him because he’s got that medical background. Even
though I have a natural therapies background myself,
and know that they have a huge amount to offer, and
that, in a lot of cases, it’s the natural therapies that
actually make the difference over conventional medi-
cine, I still think there’s a lot in the (area of ) diagnostic
study that naturopaths don’t get. I prefer to see the
doctor. I think it’s a safety thing. (Patient 3)
Many CAM practitioners also valued the Western medical
diagnostic skills of GPs, as one practitioner put it:
[A]lthough I’m qualified in naturopathy I wouldn’t
profess to know as much as a half-baked doctor would
know. The gap in knowledge I think is quite huge.
How can you have the same diagnostic skills? (CAM
practitioner 2)
IM also went some way toward overcoming safety con-
cerns arising from patients’ failure to disclose the full range
of their treatment. It is common for individual practitioners
not to be aware of treatment patients are receiving from
other sources. In the IM clinics in this research, shared
spaces, practice meetings, and informal conversations maxi-
mized communication among practitioners. Sharing patient
files was a simple and effective way of monitoring and co-
ordinating patients’ treatment when they were consulting
more than 1 practitioner in the clinic. Without such proce-
dures, there could be no guarantee that practitioners would
be fully cognizant of their patients’ previous and even cur-
rent treatment within the practice.
Discussion
Participants in this study perceived IM as promoting ac-
cepted criteria for quality in health care, namely that IM was
patient-centered, effective and safe. Concerns about the efficacy
of CAM and the competence and training of CAM practi-
tioners have been major barriers to the integration of CAM
and mainstream health care.
32–34
The findings of this study
suggest that IM may reduce or overcome these concerns.
Concerns about efficacy of CAM
This research raises the issue of dissonance between in-
creasing patient preference for CAM and its relatively lim-
ited base of biomedical evidence. The paucity of biomedical
research has been attributed to the limited number of CAM
researchers, lack of funding, and the unsuitability of
empirico-analytical approaches to CAM therapies (e.g., dif-
ficulties measuring responses to energetic healing or identi-
fying placebo controls in massage and touch therapies).
Innovative research designs are required. For example, Jonas
et al.,
35
proposed an integrated evaluation model for the
study of whole-systems health care in cancer. In this model,
observational data are collected and combined with selected
information from sociologic, anthropologic, and behaviorial
research, and from cellular and molecular biology. Coulter
36
argued that health services research of the sort that charac-
terizes the present study (e.g., participant observation stud-
ies, indepth interviewing, and focus group studies) is the best
available research paradigm for exploring perceptions of
clinical effectiveness.
Concerns about the competence of CAM practitioners
Participants in this research often preferred to have GPs as
the monitors and gatekeepers of patients’ health care; this
948 GRACE AND HIGGS
was seen as a safety strategy for the use of CAM. There is
no consistent understanding of what constitutes primary
contact practitioner training in diagnostic skills for non–
conventional medically trained practitioners either within
the health care system or within CAM training institutions. A
uniformly accepted standard is needed, one that applies
equally to all non–conventional medical health care practi-
tioners who practice primary contact medicine. Until the
general public can be assured that all CAM practitioners
have the diagnostic skills required for primary contact
(which requires the ability to diagnose and prescribe treat-
ment, including the ability to identify and refer patients for
assessment of serious medical conditions) the gatekeeping
role of GPs will be required in the interest of public safety.
The use of hermeneutic phenomenology in this research
was intended to provide deep understanding of issues of
significance to particular people in particular situations. The
results may be used to inform individuals and groups in
similar situations to the research settings. Maximum varia-
tion sampling was used to expand the transferability of the
findings to similar contexts. To minimize the risk of bias, the
current researchers acknowledged and reflected on their own
preconceptions throughout the prolonged interaction with
the original data. Triangulation (such as using multiple data
sources and multiple data collection methods) encompassed
a wide variety of perspectives and was sufficiently extensive
to ensure that no major ideas or themes were omitted. The
use of multiple data analysis reviewers and regular external
and participant checks supported the credibility of the in-
terpretations. Moreover, these results may generate topics for
wider consideration and stimulate further research on the
implementation and value of IM health care.
Conclusions
According to patients and practitioners, IM enhanced the
quality of primary health care through its provision of patient-
centered, effective, and safe health care. For patients with
chronic health conditions and for those wanting non-
pharmaceutical treatments, IM filled treatment effectiveness
gaps and provided strategies for health promotion and illness
prevention. Concerns that are sometimes raised about safety
in relation to the primary contact role of CAM practitioners
were perceived as alleviated by the gatekeeping role of the GPs.
Disclosure Statement
No competing financial conflicts exist.
References
1. Audet A-M, Davis K, Schoenbaum SC. Adoption of patient-
centred care practices by physicians. Arch Intern Med
2006;66:754–759.
2. Bezold C. The future of patient-centered care: Scenarios,
visions, and audacious goals. J Altern Complement Med
2005;11(suppl1):S77–S84.
3. Davis K, Schoenbaum SC, Audet A-M. A 2020 vision of
patient-centred primary care. J Gen Intern Med 2004;20:
953–957.
4. Institute of Medicine. Crossing the Quality Chasm: A New
Health System for the 21st Century: National Academy of
Sciences, 2001. Online document at: www.nap.edu./books/
0309072808/html/
5. National Health Service (NHS) Executive. The New NHS
Modern and Dependable: A National Framework for As-
sessing Performance. Online document at: www.open
.gov.uk/doh/newnhs/consult.htm Accessed December 29,
2009.
6. National Committee for Quality Assurance. What is HEDIS?
Online document at: www.ncqa.org/tabid/187/Default.aspx
Accessed December 27, 2009.
7. Campbell SM, Roland MO, Buetow SA. Defining quality of
care. Soc Sci Med 2000;51:1611–1625.
8. George J, Ioannides-Demos LL, Santamaria NM, et al. Use of
complementary and alternative medicines by patients with
chronic obstructive pulmonary disease. Med J Aust 2004;
181:248–251.
9. Coulter ID, Willis EM. The rise and rise of compelmentary
and alternative medicine: A sociological perspective. Med J
Aust 2004;180:587–589.
10. MacLennan AH, Wilson DH, Taylor AW. The cost of CAM. J
Complement Med 2003:2:43–48.
11. Kligler B. Integrative Medicine: Principles for Practice.
Berkshire: McGraw-Hill, 2004.
12. Yuan C-S, Bieber EJ, eds. Textbook of Complementary and
Alternative Medicine. New York: Parthenon Publishing
Group, 2003.
13. Peters D, Chaitow L, Harris G, Morrison S. Integrating
Complementary Therapies in Primary Care. Edinburgh:
Churchill Livingstone, 2002.
14. Anderson R. A case study in integrative medicine: Alter-
native theories and the language of biomedicine. J Altern
Complement Med 2000;5:165–173.
15. Eisenberg D, Post D, Davis R, et al. Addition of choice of com-
plementary therapies to usual care for actue low back pain: A
randomised controlled trial. Spine 2007:5:151–158.
16. Scherwitz L, Cantwell M, McHenry P, et al. A descriptive
analysis of an integrative medicine clinic. J Altern Comple-
ment Med 2004;10:651–659.
17. Caldicott P. Setting up an integrative medicine clinic. In:
Cohen M, ed. 13th International Holistic Health Conference
Integrative Medicine Perspectives. Leura, New South Wales:
Australasian Integrative Medicine Association Inc; 2007:
79–82.
18. Easthope G, Tranter B, Gill G. General practitioners’ atti-
tudes towards complementary therapies. Soc Sci Med 2000;
51:1555–1561.
19. SolarisCare Foundation. SolarisCare Integrated Care for
Cancer: History at a Glance. Perth: SolarisCare Foundation,
2010. Online document at: http://solariscare.org.au/home/
history Accessed August 24, 2010.
20. Bensoussan A, Lewith GT. Complementary medicine re-
search in Australia: A strategy for the future. Med J Aust
2004;181:331–333.
21. Hale A. 2002 National survey of remedial therapists. J Aust
Trad Med Soc 2002:119–124. vol 8?
22. Hale A. 2002 Survey of ATMS: Acupuncturists, herbalists
and naturopaths. J Aust Trad Med Soc 2002;8:143–149.
23. Bensoussan A, Myers SP, Wu SM, O’Connor K. Naturo-
pathic and Western herbal medicine practice in Australia:
A workforce survey. Complement Ther Med 2004;12:17–27.
24. Grace S, Vemulpad S, Reid A, Beirman R. CAM practitioners
in New South Wales, Australia: A descriptive study. Com-
plement Ther Med 2008;16:42–46.
25. Hall K, Giles-Corti B. Complementary therapies and the
general practitioner: A survey of Perth GPs. Aust Fam
Physician 2000;29:602–606.
ENHANCING QUALITY IN PRIMARY HEALTH CARE 949
26. Pirotta M, Farish SJ, Kotsirilos V, Cohen M. Characteristics
of Victorian general practitioners who practise complemen-
tary therapies. Aust Fam Physician 2002;31:1133–1138.
27. Rogers SO. Evaluation of the impact of health services re-
search on quality of care. Surgery 2009;145:635–638.
28. van Manen M. Researching Lived Experience: Human Sci-
ence for an Action Sensitive Pedagogy, 2nd ed. London:
Althouse Press, 1997.
29. Yin RK. Case Study Research: Design and Methods, 3rd ed.
Thousand Oaks, CA: Sage, 2003.
30. Burns RB. Introduction to Research Methods, 4th ed.
Frenchs Forest: Longman, 2000.
31. Tesch R. Qualitative Research: Analysis Types and Software
Tools. New York: Falmer, 1995.
32. Dwyer JM. Good medicine and bad medicine: Science to
promote the convergence of ‘‘alternative’’ and orthodox
medicine. Med J Aust 2004;180:647–648.
33. Giordano J, Garcia M, Boatwright D, Klein K. Com-
plementary and alternative medicine in mainstream public
health: A role for research in fostering integration. J Altern
Complement Med 2003;9:441–445.
34. Expert Committee on Complementary Medicines in the Health
System. Complementary Medicines in the Australian Health
System: Report to the Parliamentary Secretary to the Minister
for Health and Ageing. Online document at: www.tga
.gov.au/docs/html/cmreport1.htm Accessed May 31, 2004.
35. Jonas W, Beckner W, Coulter I. Proposal for an integrated
evaluation model for the study of whole systems health care
in cancer. Integr Cancer Ther 2006;5:315–319.
36. Coulter I. The rocky road from efficacy to effectiveness: New
research directions in CAM in the US. In: Adams J, ed. Ex-
amining the Role of CAM in Health Care: Linking Re-
searchers and Practitioners. Brisbane: Network of
Researchers in Public Health and Complementary and Al-
ternative Medicine, 2009.
Address correspondence to:
Sandra Grace, PhD
The Education for Practice Institute
Charles Sturt University
16 Masons Drive
North Parramatta
Sydney, New South Wales
Australia
E-mail: sgrace@csu.edu.au
950 GRACE AND HIGGS
This article has been cited by:
1. P.J. Orrock, K. Lasham, C. Ward. 2014. Allied Health practitioners’ role in the Chronic Disease Management program: The
experience of osteopathic practitioners. International Journal of Osteopathic Medicine . [CrossRef]
2. Vivian Lin, Rachel Canaway, Bronwyn Carter. 2014. Interface, interaction and integration: how people with chronic disease in
Australia manage CAM and conventional medical services. Health Expectations n/a-n/a. [CrossRef]
3. Brigitte Franzel, Martina Schwiegershausen, Peter Heusser, Bettina Berger. 2013. Individualised medicine from the perspectives
of patients using complementary therapies: a meta-ethnography approach. BMC Complementary and Alternative Medicine 13,
124. [CrossRef]
4. Barbara F. Sharf, Patricia Geist Martin, Kevin-Khristián Cosgriff-Hernández, Julia Moore. 2012. Trailblazing healthcare:
Institutionalizing and integrating complementary medicine. Patient Education and Counseling 89, 434-438. [CrossRef]
5. Jennifer Hunter, Katherine Corcoran, Kerryn Phelps, Stephen Leeder. 2012. The Challenges of Establishing an Integrative
Medicine Primary Care Clinic in Sydney, Australia. The Journal of Alternative and Complementary Medicine 18:11, 1008-1013.
[Abstract] [Full Text HTML] [Full Text PDF] [Full Text PDF with Links]
6. E. Ernst. 2012. Bogus arguments for unproven treatments. International Journal of Clinical Practice 66, 238-240. [CrossRef]
7. Sandra Grace. 2012. CAM practitioners in the Australian health workforce: an underutilized resource. BMC Complementary and
Alternative Medicine 12, 205. [CrossRef]
8. Sunita Vohra, Soleil Surette, Deepika Mittra, Lawrence D Rosen, Paula Gardiner, Kathi J Kemper. 2012. Pediatric integrative
medicine: pediatrics' newest subspecialty?. BMC Pediatrics 12, 123. [CrossRef]
9. Jie Wang, Xingjiang Xiong. 2012. Control Strategy on Hypertension in Chinese Medicine. Evidence-Based Complementary and
Alternative Medicine 2012, 1-6. [CrossRef]
10. Edzard Ernst. 2011. Integrated medicine: smuggling alternative practices into rational medicine?. Focus on Alternative and
Complementary Therapies 16:10.1111/fct.2011.16.issue-1, 1-2. [CrossRef]
11. Nicola Robinson. 2011. Integrative medicine — Traditional Chinese medicine, A model ?. Chinese Journal of Integrative Medicine
17, 21-25. [CrossRef]
