Informing the model of care for an academic integrative healthcare centre : a qualitative study exploring healthcare consumer perspectives

Objectives: To engage with local primary care stakeholders to inform the model of care for a proposed academic integrative health care center incorporating evidence-informed traditional, complementary, and integrative medicine (TCIM) in Sydney, Australia. Design: In-depth semistructured interviews, informed by community-based participatory research principles, were conducted to explore primary care stakeholder preferences and service requirements regarding the proposed Western Sydney Integrative Health (WSIH) center in their local district. Setting: Telephone and face-to-face interviews at primary care clinics in Sydney. Subjects: Thirteen participants took part in the study: eight general practitioners (GPs) and five primary care practice managers (PMs). Methods: GPs were recruited through local GP newsletters, closed GP Facebook groups, and snowballing. PMs were recruited through a national PM newsletter. The semistructured interviews were audiorecorded and transcribed verbatim before conducting a thematic analysis. Results: Three main themes emerged: (1) the rationale for “why” the WSIH center should be established, (2) “what” was most important to provide, and (3) “how” the center could achieve these goals. Participants were willing to refer to the service, acknowledging the demand for TCIM, current gaps in chronic disease care, and negligible Government funding for TCIM. They endorsed a model of care that minimizes out-of-pocket costs for the underserved, incorporates medical oversight, integrates evidence-informed TCIM with conventional health care, builds trust through interprofessional communication and education, and provides sound clinical governance with a strong focus on credentialing and risk management. It was proposed that safety and quality standards are best met by a GP-led approach and evidence-based practice. Conclusions: Our findings demonstrate that participants acknowledged the need for a model of care that fits into the local landscape through integrating conventional health care with TCIM in a team-based environment, with medical/GP oversight to ensure sound clinical governance. Findings will be used with input from other stakeholder groups to refine the WSIH model of care

Shared medical appointments and mindfulness for Type 2 diabetes : a mixed-methods feasibility study

Introduction: Type 2 diabetes (T2DM) is a major health concern with significant personal and healthcare system costs. There is growing interest in using shared medical appointments (SMAs) for management of T2DM. We hypothesize that adding mindfulness to SMAs may be beneficial. This study aimed to assess the feasibility and acceptability of SMAs with mindfulness for T2DM within primary care in Australia. Materials and Methods: We conducted a single-blind randomized controlled feasibility study of SMAs within primary care for people with T2DM living in Western Sydney, Australia. People with T2DM, age 21 years and over, with HbA1c > 6.5% or fasting glucose >7.00 mmol/L within the past 3 months were eligible to enroll. The intervention group attended six 2-h programmed SMAs (pSMAs) which were held fortnightly. pSMAs included a structured education program and mindfulness component. The control group received usual care from their healthcare providers. We collected quantitative and qualitative data on acceptability as well as glycemic control (glycated hemoglobin and continuous glucose monitoring), lipids, anthropometric measures, blood pressure, selfreported psychological outcomes, quality of life, diet, and physical activity using an ActiGraph accelerometer. Results: Over a 2-month period, we enrolled 18 participants (10 females, 8 males) with a mean age of 58 years (standard deviation 9.8). We had 94.4% retention. All participants in the intervention group completed at least four pSMAs. Participants reported that attending pSMAs had been a positive experience that allowed them to accept their diagnosis and empowered them to make changes, which led to beneficial effects including weight loss and better glycemic control. Four pSMA participants found the mindfulness component helpful while two did not. All of the seven participants who contributed to qualitative evaluation reported improved psychosocial wellbeing and found the group setting beneficial. There was a significant difference in total cholesterol levels at 12 weeks between groups (3.86 mmol/L in intervention group vs. 4.15 mmol/L in the control group; p = 0.025) as well as pain intensity levels as measured by the PROMIS-29 (2.11 vs. 2.38; p = 0.034). Conclusion: pSMAs are feasible and acceptable to people with T2DM and may result in clinical improvement. A follow-up fully-powered randomized controlled trial is warranted. Clinical Trial Registration: Australia and New Zealand Clinical Trial Registry, identifier ACTRN12619000892112

Advancing medical education : connecting interprofessional collaboration and education opportunities with integrative medicine initiatives to build shared learning

Background: Improved teamwork between conventional and complementary medicine (CM) practitioners is indicated to achieve effective healthcare. However, little is known about interprofessional collaboration and education in the context of integrative medicine (IM). Methods: This paper reports the findings from a constructivist-grounded theory method study that explored and highlighted Australian medical students' experiences and opportunities for linking interprofessional collaboration and learning in the context of IM. Following ethical approval, in-depth semi-structured interviews were conducted with 30 medical students from 10 medical education faculties across Australian universities. Results: Medical students recognised the importance of interprofessional teamwork between general medical practitioners and CM professionals in patient care and described perspectives of shared responsibilities, profession-specific responsibilities, and collaborative approaches within IM. While students identified that limited interprofessional collaboration currently occurred in the medical curriculum, interprofessional education was considered a means of increasing communication and collaboration between healthcare professionals, helping coordinate effective patient care, and understanding each healthcare team members' professional role and value. Conclusions: The findings suggest that medical curricula should include opportunities for medical students to develop required skills, behaviours, and attitudes for interprofessional collaboration and interprofessional education within the context of IM. While this is a qualitative study that reflects theoretical saturation from a selected cohort of medical students, the results also point to the importance of including CM professionals within interprofessional collaboration, thus contributing to more person-centred care

Complementary medicine teaching in Australian medical curricula : the student perspective

Background: Use of complementary medicine in Australia is increasing. Despite documented high use, however, perspectives of complementary medicine teaching inclusion within health professions education are poorly documented and understood. Aim: This paper explores medical students' perspectives of complementary medicine teaching from the curriculum of Australian medical programs. Methods: A constructivist grounded theory methodological approach was used to generate, construct, and analyse data. Thirty second-year to final-year medical students from 10 medical school education faculties in Australian universities participated in semi-structured interviews over a five-month period in 2013. Findings: Students from all represented medical schools highlighted perspectives of complementary medicine offerings in both the preclinical and clinical curriculum. Across the curriculum, a wide range of perspectives were related to both complementary medicine teaching and learning aspects incorporating social and ethical issues, evidence of clinical efficacy and safety, and evidence-based principles involving critical application and appraisal. Discussion: The findings demonstrate diverse perspectives of complementary medicine teaching not necessarily synonymous with learning. While all students highlighted some form of complementary medicine teaching and/or learning, perspectives varied between schools and across jurisdictions in terms of context and content. Clinical exposure to informal complementary medicine learning in clerkship was extensive relative to formal didactic teaching in the preclinical curriculum. Educational exposure to complementary medicine was shown to positively affect medical student attitudes towards complementary medicine. Conclusion: A coordinated policy towards integration of complementary medicine teaching in Australian medical curricula is recommended. Impetus for open debate regarding what level of complementary medicine teaching and/or learning is sufficient in medical and other health professions education is required

Learning and adaptation with regard to complementary medicine in a foreign context : intercultural experiences of medical students from different cultural backgrounds

Little is known about challenges and transition that medical students from different cultural backgrounds face with regard to complementary medicine (CM). This paper explores such students’ experiences and perspectives of socio-cultural and academic difference with regard to CM and experiences of intercultural relations. Using a constructivist grounded theory approach, 30 in-depth qualitative interviews were conducted with medical students across 10 Australian medical schools. The data were rigorously analysed through a systematic process of coding, categorisation and theoretical development. The findings indicate that students adapted considerably to the host culture. Students with Western backgrounds integrated better socio-culturally and academically compared to students with non-Western backgrounds. Although nationality represented cultural identity, students’ construction of cultural difference was informed by their perception of diverging value systems within the specific educational environment. These values were, in turn, reflected in students’ reported behaviours, attitudes, and levels of engagement in socio-cultural and academic aspects of university life. Adaptation employed by students was evidenced largely due to their conflicting sense of responsibility towards familial culture regarding CM and focus on fitting in. While students’ tendency to gravitate towards cultural peers was evident, most students adapted to their host environment regarding CM to fit into normal intercultural encounters during medical school. In conclusion, students’ intercultural contact with regard to CM was both complex and problematic. At a time of significant diversification within the higher education student body, this paper highlights the role medical education institutions can play in fostering intercultural and academic guidance and support

Resourcing the clinical complementary medicine information needs of Australian medical students : results of a grounded theory study

The aim of this study was to identify Australian medical students’ complementary medicine information needs. Thirty medical students from 10 medical education faculties across Australian universities were recruited. Data were generated using in-depth semi-structured interviews and constructivist grounded theory method was used to analyze and construct data. Students sought complementary medicine information from a range of inadequate sources, such as pharmacological texts, Internet searches, peer-reviewed medical journals, and drug databases. The students identified that many complementary medicine resources may not be regarded as objective, reliable, differentiated, or comprehensive, leaving much that medical education needs to address. Most students sought succinct, easily accessible, evidence-based information to inform safe and appropriate clinical decisions about complementary medicines. A number of preferred resources were identified that can be recommended and actively promoted to medical students. Therefore, specific, evidence-based complementary medicine databases and secondary resources should be subscribed and recommended to medical schools and students, to assist meeting professional responsibilities regarding complementary medicines. These findings may help inform the development of appropriate medical information resources regarding complementary medicines

What do medical specialists think about a proposed academic, integrative health centre in Australia? : a qualitative study

Objectives: This qualitative study aimed to explore medical specialists’ perspectives on a proposed academic integrative healthcare (IHC) centre to be established in their local district. Methods: A convenience sample of medical specialists were recruited via direct email invitations that was augmented with snowball sampling until data saturation was reached. The in-depth, semi-structured interviews were conducted via telephone, audio recorded and transcribed verbatim, followed by a thematic analysis. Results: Eight participants took part in the study. Three main themes emerged: 1) the benefits of an academic setting, 2) sound clinical governance, and 3) specialists in the field of TCIM. Underpinning the three themes was the belief that patients were at risk of harm due to haphazard, unsupervised use of unproven traditional, complementary and integrative medicine (TCIM). It was anticipated that an academic centre would address these issues with appropriate risk management protocols, effective interprofessional communication and by upholding the principles of evidence-based practice to ensure safe and coordinated patient-centered care. Opportunities from collaborations within secondary care included centre being recognized as specialists in the field of TCIM, conducting research and bidirectional learning. Conclusions: The findings demonstrated that medical specialists acknowledged the need for a TCIM model of care that interfaces with the local secondary care landscape through the implementation of sound safeguards, credentialed practitioners, and evidence-based practice to adequately protect patients and clinicians. The findings will be amalgamated with the input from other stakeholder groups via a community-based participatory research framework to refine the model of care

Coverage of cancer services in Australia and providers' views on service gaps : findings from a national cross-sectional survey

Background: In response to the increasing cancer prevalence and the evolving health service landscape across the public and private health sectors in Australia, this study aimed to map cancer services and identify factors associated with service provision and important service gaps. Methods: A prospective, cross-sectional survey was conducted throughout 2016. Extensive search strategies identified Government or privately-owned, hospital or community-based healthcare organisations with dedicated cancer services. One nominated staff member from each organisation answered a purpose specific online/paper questionnaire. Descriptive statistics, standardised rates, and single level and multilevel multinomial logistic regression were used to analyse the data. Analysis was augmented with a qualitative descriptive analysis of open-ended questions. Results: From the 295 eligible organisations with a cancer service in Australia, 93.2% participated in the survey. After adjusting for remoteness, for-profit companies were significantly more likely than Government operated services to provide only one or two types of cancer services (e.g. radiotherapy) in a limited range of settings (e.g. day hospital with no in-patient or home care) (p < 0.001) and less likely to provide comprehensive cancer services (p < 0.001). After adjusting for ownership and the respondent’s role in the organisation, respondents located in remote regions of Australia were more likely to identify cancer services that are dependent upon specialist medical practitioners as the most important service gaps in their region (p = 0.003). Despite 76.0% of organisations across Australia offering some type of supportive care or survivorship services, providers identified this group of services as the most pressing service gaps in major cities, rural and remote regions alike (standardised rate: 47.9% (95%CI: 43.6–57.4%); p < .000). This included the need for improved integration, outreach and affordability. Conclusions: The broad range of cancer services, settings and ownership identified by this survey highlights the complexity of the Australian healthcare system that cancer survivors must navigate and the challenges of providing comprehensive cancer care particularly in rural and remote regions. Whilst the significant role of supportive care and survivorship services are increasingly being recognised, the findings from this survey support calls for innovative service models and funding mechanisms that expand the focus from preventing and treating cancer to supporting cancer survivors throughout the cancer continuum and promoting the delivery of integrated and equitable cancer care across the public and private sectors

Hospital policies on complementary medicine : a cross-sectional survey of Australian cancer services

It has been reported that about 60% of patients commencing chemotherapy in Australia with curative intent and 47% of those receiving radiotherapy also use complementary medicine.1,2 Ingestible products are frequently used, but are often not discussed with the medical team, which increases the risk of interactions and other undesirable effects. Opportunity costs are another problem; while complementary medicine is typically used by people with cancer for supportive care and wellbeing, some use it to help treat cancer

Integrative medicine in general practice in Australia : a mixed-methods study exploring education pathways and training needs

Background: Globally, a substantial proportion of general practitioners (GPs) incorporate integrative medicine (IM) into their clinical practice. Objective: This study aimed to map the IM education and training pathways and needs of a cohort of Australian GPs who are members of the Royal Australian College of General Practitioners’ IM Specific Interest Network, which is a group of GPs with interest in IM. Methods: We conducted a mixed-methods study comprising of an online, cross-sectional survey supplemented with in-depth semi-structured interviews. Data from the survey and interviews were initially analysed separately and then combined. Results: Eighty-three (83) of 505 eligible GPs/GPs in training (16.4%) participated in the survey, and 15 GPs were interviewed. Results from the two datasets either converged or were complementary. Almost half (47%) of survey respondents had undertaken formal undergraduate or postgraduate IM education, a short course (63%), informal education (71%) or self-education (54%), in at least one of 20 IM modalities listed. Interviewees affirmed there was no single education pathway in IM. Survey respondents who identified as practicing IM were significantly more likely to have IM education, positive attitudes towards IM, particularly natural products, and higher self-rated IM knowledge and competencies. However, knowledge gaps were identified in professional skills domains of population health and context, and organisational and legal dimensions of applied IM practice. Interviewees also highlighted a range of professional and systemic barriers to the practice of IM, education, and training. There was broad support for recognition of IM as a sub-specialty through formalised postgraduate training and accreditation. Most survey respondents (62%) expressed interest in post-fellowship recognition of GPs with advanced skills in IM. Conclusion: Our findings demonstrate that it is important to define best practice in IM for GPs in Australia and provide a standardised pathway towards recognition of advanced skills in IM