JACM

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 00, Number 00, 2018, pp. 1–8
ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2018.0268

Interdisciplinary Relationship Models

for Complementary and Integrative Health:
Perspectives of Chinese Medicine Practitioners
in the United States
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Belinda J. Anderson, PhD,1,2 Sai Jurawanichkul, MSTOM,1 Benjamin E. Kligler, MD,2

Paul R. Marantz, MD,2 and Roni Evans, PhD3

Abstract
Objectives: The combination of biomedicine and traditional and complementary medicine (T&CM) is often
referred to as integrative medicine. However, the degree to which the medical disciplines are integrated varies
between medical settings, and it is believed by some to be impossible due to epistemological and paradig-
matic differences. Clinicians’ perspectives are important determinants of how different medical disciplines
are used together. This study explores the perspectives of experienced Chinese medicine practitioners when
asked about the most ethical model (opposition, integration, or pluralism) for the relationship between
biomedicine and T&CM.
Design: Thirty-one Chinese medicine practitioners, undertaking a doctoral upgrade program at the Pacific
College of Oriental Medicine, participated in this study. Participants were asked to read a publication discussing
three models (opposition, integration, and pluralism) for the relationship between biomedicine and T&CM and
then discuss, via an online forum within Moodle learning management system, the most ethical model. An
inductive content analysis of the forum posts was undertaken to identify common themes, followed by member
checking.
Results: The data were found to contain six major and six minor themes. There was a clear preference
for pluralism. The Chinese medicine practitioners expressed reservations about the integrative model,
and, above all, cared about the quality of patient care. Much dialogue occurred around issues related to a
power imbalance within health care, and possible cooptation issues. Paradigmatic differences and a lack
of compatibility between biomedical research models and the practice of Chinese medicine were seen
as problematic to the validity of research findings. Interprofessional education was viewed as critical
for the development of respect, shared patient care, and referrals between clinicians from different
disciplines.
Conclusions: This study provides insight into the issues associated with combining biomedicine and T&CM
that are perceived by Chinese medicine practitioners. Such insights are important for the development and
management of clinical settings that provide complementary and integrative health care, especially as the
provision of insurance coverage for T&CM increases.

Keywords: complementary and integrative medicine, traditional and complementary medicine, pluralism, Chinese medicine,
acupuncture, qualitative, education

1
Pacific College of Oriental Medicine, New York, NY.
2
Albert Einstein College of Medicine, Bronx, NY.
3
University of Minnesota, Minneapolis, MN.

1
 2 ANDERSON ET AL.

Introduction different medical systems. Drawing on anticolonial analysis,

Hollenberg and Muzzin7 argue that rather than integrating,

I ntegrative medicine has become an accepted new

model in health care in the United States (US).1 In this
model, an expanded array of healing options is available to
what is really happening is appropriation. Appropriation is
the adoption of the intellectual property and traditional
knowledge of T&CM, and its use within biomedicine
patients inclusive of traditional and complementary medicine without recognition and respect for the origin. They propose
(T&CM), in addition to biomedicine. Different models for that biomedicine is an extension of Euroscience, which has a
the way in which biomedicine and T&CM are utilized to- long history of appropriation and assimilation of indigenous
gether have been proposed.2–5 Some have examined the way knowledge. Through the devaluation of nonbiomedical
in which teams of clinicians with differing medical training knowledge, the superiority of biomedical scientific evidence,
work together, and they describe degrees of integration be- and the domination of the biomedical worldview, they con-
tween biomedicine and T&CM.2,3 Others have focused on clude that biomedicine is not integrating with T&CM, but
broader epistemological, social, and philosophical barriers in rather co-opting it.
considering what models could and have existed,4,5 and they Various international organizations are striving to better
better address the tensions and contradictions inherent in such understand and define how best to combine biomedicine
a union. and T&CM. The WHO has developed a global strategy to
Wiese et al.5 differentiate between models based on the foster appropriate integration, regulation, and supervision of
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degree of autonomy that T&CM practitioners have within T&CM into health care systems.10 The European Union
biomedical settings. They differentiate between models CAMbrella project identified six needed research areas for
where T&CM is delivered or prescribed by biomedical facilitating T&CM use, one of which is research into dif-
professionals (selective incorporation), where care is pro- ferent models for T&CM integration.11 Identifying optimal
vided by multidisciplinary and interprofessional collabora- models for using biomedicine and T&CM together is im-
tive teams (integration), and a patient-centered model where portant because it impacts patient care, the effectiveness of
choice of care is decided by the consumer (pluralism). biomedicine and T&CM, clinicians’ satisfaction and au-
Kaptchuk and Miller4 also propose three models— tonomy, and the general work environment. As insurance
opposition, integration, and pluralism. They discuss how the coverage broadens for T&CM therapies in the United States,
relationship between biomedicine and T&CM is moving biomedical settings will employ greater numbers of T&CM
away from opposition, which they describe as the rejection practitioners. Devising an optimal approach to combining
of T&CM by biomedicine, and toward integration. In- different medical disciplines and creating an infrastructure
tegration is described as the polar opposite of opposition, for effective and harmonious clinician interaction, both hi-
in which hospitals and biomedical clinics have amalgam- erarchically and regarding patient care decisions, will be
ated biomedicine and T&CM in a holistic approach to the critically needed.
treatment of disease and promotion of wellness. Integration Regardless of the chosen model for combining biomedi-
refers to an approach in which different medical systems are cine and T&CM, what manifests in medical settings, and
used together without specific regard to differences in par- with patients independently seeking multiple approaches,
adigms and treatment approaches. The authors propose that depends on the attitudes, beliefs, and perspectives of
the practical, epistemological, and philosophical differences clinicians and administrators. These are powerful causative
between biomedicine and T&CM defy integration, and they factors underlying power dynamics, inclusionary/exclusionary
deny patients the integrity of either. Pluralism, in which strategies, and the tendency for appropriation and assimilation.
distinct health care models co-exist in parallel, is presented Interprofessional education to establish a knowledge base
as a preferable model because it ‘‘encourages cooperation, about other health care disciplines,12 and training in
research, and open communication and respect between evidence-based healthcare13 to engender treatment choices
practitioners despite the possible existence of honest dis- based on evidence do not necessarily change perspectives,
agreement, and preserves the integrity of each of the treat- attitudes, and beliefs. Such cultural change issues are
ment systems involved.’’ significant challenges for both biomedicine and T&CM
Many scholars believe4–7 that pluralism is the most likely practitioners,14–16 and it has been suggested that we need
model that will allow true integration. However, historical, to find a new common language to facilitate truly inte-
social, and political factors provide significant challenges grated, interprofessional, patient-centered care.17
for pluralism to become a predominant model within Studies aimed at understanding the perspectives, atti-
mainstream health care.5–7 The issues raised by Kaptchuk tudes, and beliefs of T&CM practitioners about combining
and Miller,4 and their thesis of fundamental incompatibil- biomedicine with T&CM are lacking in the literature. These
ity between biomedicine and T&CM, have been echoed studies are necessary because they provide insight into what
by others.6–9 Adams et al.,6 using a critical social science issues need to be addressed when bringing T&CM practi-
perspective, examined the impact of the complex power tioners into mainstream medical settings. Addressing such
relations that occur when biomedicine and T&CM are used issues will directly impact how clinicians of different health
together, along with the interprofessional dynamics between care disciplines work together, and whether their interac-
practitioners of different medical disciplines and their tions function to improve patient care, or antagonistically
adoption of inclusionary/exclusionary strategies. Based on interact to potentially confuse patients and detract from
their research findings, they conclude that the integration of optimal care. The small number of qualitative studies in the
biomedicine and T&CM is much more complex than is literature indicate that significant tensions exist between
often recognized, and it is significantly hampered by fun- biomedical and T&CM practitioners when working together
damental incompatibilities between the paradigms of the in biomedical settings,18,19 and experiences of biomedical
 INTERDISCIPLINARY RELATIONSHIP MODELS FOR CIH 3

dominance exist among T&CM practitioners in private then were required to respond to at least two posts of their
practice.20–22 classmates, and to respond to classmates who responded to
This article presents findings from a qualitative research their initial posts. Only the students participated in the fo-
study of 31 experienced Chinese medicine practitioners, in rum; the professor (B.A.) did not participate or discuss the
private practice for an average of 11 years. They were asked forum with the students until after the completion deadline.
to read Kaptchuk and Miller’s4 paper, which discusses three Thirty-one of the 33 students in the EIP course gave in-
models for the relationship between biomedicine and formed consent to be included in this study. All were given
T&CM—opposition, integration, and pluralism. The practi- participant codes (PC) for the purposes of identifying their
tioners were asked to present an argument as to which of the contributions in this publication. Twenty were female, and
three approaches they thought was the most ethical model for 11 were male. Their average length of time as licensed
the relationship between biomedicine and T&CM. To the acupuncturists was 11.4 years.
author’s knowledge, this is the first study to specifically
examine T&CM practitioners’ perspectives and opinions
Data analysis
about different possible models for combining biomedi-
cine with T&CM. An inductive content analysis was undertaken by B.A.
and S.J. to identify themes and summarize forum content
Methods following the phases outlined by Braun and Clarke.26 Al-
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though students were provided with a paper outlining pos-

This study was undertaken and reported in accordance sible models for the relationship between biomedicine and
with current qualitative research quality standards and T&CM, B.A. and S.J. were not deducing themes based on
guidelines.23,24 The study was approved by the Institu- the perspectives presented in this article or other papers
tional Review Board at Pacific College of Oriental Medi- relevant to this general topic, but rather identifying themes
cine (PCOM). Informed consent was obtained from all that emerged from the student’s discourse around this topic.
participants after the course was completed and students The data were analyzed through a pragmatic worldview
had received their grades. inclusive of a mixed-methods strategy.27 Themes that
emerged from the data were transformed into quantitative
Sampling and setting data by counting the number of times a theme was mentioned,
A purposive sampling approach was used.25 Thirty-three and the number of students who mentioned each theme. This
Chinese medicine practitioners were invited to participate in was undertaken to permit both a qualitative description of the
this study. These practitioners were students who were themes and the identification of major and minor themes
registered in the synchronous online 3-credit (42 h) course according to how frequently they were mentioned by the
Evidence Informed Practice (EIP) in the fall 2015 trimester students in the online forum. Summation of theme frequency
at PCOM. This course was part of a 15-credit academic permitted verification of the relative importance of the dif-
program for Chinese medicine practitioners who had a li- ferent themes, which guided the discussion of relative theme
cense to practice acupuncture in the United States, and who importance for this group of acupuncturists, and appropriate
had previously graduated from an accredited master’s pro- connection to existing related literature.
gram at PCOM. The degree enabled them to upgrade their At the time this research was undertaken, S.J. was a
qualifications to the doctoral level. This particular cohort Chinese medicine master’s degree student at PCOM un-
of doctoral students was chosen because there was a high dertaking this research as part of a 3-credit research elective
proportion of very experienced Chinese medicine practi- course that was supervised by B.A. B.A. was the professor
tioners. This was the first cohort to undertake the doctoral of the EIP course. At the time of the study, she was Aca-
upgrade program. The program is approved by the U.S. demic Dean at the PCOM New York (NY) campus for 10
Accreditation Commission for Acupuncture and Oriental years, and she was also an active researcher and Chinese
Medicine. PCOM is regionally accredited by the Western medicine practitioner. The EIP course is part of the doctoral
Association of Schools and Colleges. upgrade program offered by the PCOM San Diego campus,
where B.A. had no administrative or Dean-related activities
because her Dean role was specific to the NY campus. B.A.
Data source
had worked closely with 9 of the 33 students taking the EIP
In week 10 of the 14-week EIP course, the students course as either faculty or administrators on the NY cam-
(experienced Chinese medicine practitioners) were required pus, and had engaged in numerous conversations with
to engage in an online forum as one of the assessment items them, and many other students and faculty at PCOM-NY,
worth 5% of their overall course grade. The assignment about integrative medicine and the types of issues raised in
required the students to read Kaptchuk and Miller,4 titled these forums.
What is the most ethical model for the relationship between Initially, all forum posts were read by B.A. and S.J., who
mainstream and alternative medicine: opposition, integra- then discussed the content and emergent themes. B.A. and
tion or pluralism? Via an online forum in the learning S.J. then independently reread the forums and each created a
management system Moodle, the students were asked ‘‘to list of theme categories. Microsoft Word was used to
present an argument as to which approach—opposition, manage the themes and data analysis. S.J. cut and pasted
integration or pluralism—you think is the most ethical direct quotes from the forums into a table arranged per her
model for the relationship between mainstream and alter- chosen themes. B.A. highlighted quotes on a hard copy print
native medicine.’’ The assignment required them to post an out of the forum discussions and identified reoccurring
initial response of two or more paragraphs in length. They themes, which she wrote in the margins. B.A. and S.J. then
 4 ANDERSON ET AL.

met and discussed the themes they had identified. Based on have mentioned it both in their original post and in their
this discussion, B.A. condensed this into six major themes response to others’ posts.
and six minor themes, and allocated forum content into
these thematic categories. S.J. examined this and conferred Major Themes
as to its accuracy with her interpretation and categorization
of the forum data. A preference for the pluralistic model
B.A. then examined her forum hard copies and counted Of the 31 students, 21 clearly stated a preference for
the number of times themes were mentioned in total, and by pluralism, 8 spoke of the strengths and weaknesses of in-
individual students. All comments belonging to a theme tegration and pluralism without a clear commitment to ei-
were included and counted toward the total number per ther, and 2 preferred the integrative model. Statements
theme, except where more than one very similar comment ranged from simply stating a preference for pluralism—‘‘I
was mentioned as belonging to the same theme in a single choose pluralism as our best ethical option’’ (PC 32), to
post by one person. B.A. then cut and pasted all forum more detailed comments indicating that pluralism was seen
comments that represented the 12 themes into a table. All to be more ethical, less diluting to the profession, more
forum comments were then examined by B.A. and S.J., and respectful, allowing of autonomy, and least damaging. For
a shorter list of forum comments for each of the six major example, ‘‘Pluralism takes into account the strengths of
themes that was representative of all comments was created each medicine and recognizes that there is validity and
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for inclusion in this study. Member checking,27 a method to strength in each medicine’’ (PC 29), and ‘‘pluralism helps
determine the validity of the identified themes with study avoid a hierarchical structure within a group practice, and
participants, was undertaken by sharing data tables with reduces judgment about effectiveness and ethical norms
nine of the students in the class who verified that the data which might compromise ethical standards’’ (PC 32).
analysis accurately reflected their interpretation of the forum
dialogue.
Opposition to the integrative model
Results Many of the students saw the integrative model as re-
ducing the effectiveness of the different medical ap-
Six major and six minor themes emerged from the anal-
proaches, for example, ‘‘Integration may breakdown
ysis of the forum discussions. Later, we describe each theme
constructs to fit together, but lose valuable principles and
and provide examples that appropriately illustrate the nature
tools’’ (PC 8). Concerns were expressed about the lack of
of the discussion. In terms of the amount of forum discus-
research evidence to support the choice of best treatment
sion that occurred—there were 33 initial posts, with an
options, for example,
average of 428 words per post, and 127 response posts, with
an average of four responses per initial post. The average ‘‘Based on the available evidence, it is difficult to vote in
length of the response posts was 108 words. favor of integrative approach without sufficient integrative
Table 1 presents the six major and six minor themes as research which can pinpoint exactly which alternative med-
defined by the number of times each theme was mentioned icine techniques are most helpful in treating certain condi-
(excluding instances where more than one very similar tions or complimenting the existing mainstream medicine
practice’’ (PC 3).
comment was mentioned as belonging to the same theme in
a single post by the same person), and the number of stu- Some of the students felt that integrative medicine
dents who mentioned each theme. The number of times that was more of a concept, rather than reflecting the real
a theme was mentioned can exceed the number of students ability to truly integrate very different medical practices.
who mentioned the theme because a single person could For example,

Table 1. Six Major Themes and Six Minor Themes

Total No. of Total No. and % of
Themes comments students who mentioneda
Major themes
A preference for the pluralistic model 23 21 (68)
Opposition to the integrative model 21 15 (48)
Importance of patient centeredness 18 17 (55)
Power imbalance and co-option issues 23 12 (39)
Importance of interprofessional education 13 10 (32)
Issues about scientific research methodology and paradigms 10 7 (23)
Minor themes
Pluralism requires patients to be able to advocate for themselves 6 4 (13)
Prior education focused on the integrative model/unaware of pluralism 5 5 (16)
Against the opposition model 5 5 (16)
Pluralism maintains the integrity of Chinese medicine 3 3 (10)
Importance of thousands of years of anecdotal evidence 3 2 (6)
Pluralism is also in Chinese medicine 3 2 (6)
a
Out of the 31 acupuncturists who participated in this study.
 INTERDISCIPLINARY RELATIONSHIP MODELS FOR CIH 5

‘‘The limitations of homogenizing two incongruous per- It was also suggested that interprofessional education
spectives do a disservice to both. Interpreting a completely would foster less prejudice against T&CM by biomedicine.
different system using a singular language is at best inco-
herent, and at worst, ineffective or harmful’’ (PC 23). Issues about scientific research methodology
Importance of patient centeredness and paradigms

There was a distinct patient-centered theme throughout Several students wrote about the inappropriateness of
the forums. Many of the students stressed that what really scientific research models for investigating Chinese medi-
mattered in the choice of models was what was best for the cine due to significant paradigm differences. Students sug-
patient. For example, ‘‘The goal above all else is that the gested the need for research approaches that are compatible
patient gets the best care’’ (PC 17), and ‘‘In the bigger with the way that Chinese medicine is practiced, for ex-
picture, incorporating both modalities as legitimate options ample, ‘‘The biggest victory I can foresee with a foundation
for care is one way that our health care system can improve of pluralism, is that not only may we all work together, but
and truly serve the patient, physically, mentally and spiri- that Chinese Medicine can test its own effectiveness without
tually’’ (PC 21). Some of the students felt that pluralism the constraints of fitting into the Biomedical’s paradigm of
allowed patients to have more choice between the various research’’ (PC 17). Concerns were expressed about reduc-
medical approaches, and to be able to engage with medical tionist scientific methodologies, and the randomized con-
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approaches that were more authentic, for example, trolled trial in particular, as being unable to adequately
encompass a holistic medical system—
‘‘Pluralism allows for respecting patients who say they are
receiving a clinical benefit from a particular treatment, not ‘‘Western based science looks at the world by tearing it up
standing in their way if they feel it is helping and you do not into very small pieces that can be analyzed. By doing this to
see a specific harm, but at the same time, allowing each Eastern medicine, meaning and understanding are often lost.
discipline to speak their mind to the patient’’ (PC 28). Western medicine is interested in coming up with explana-
tions for things, but we don’t always have quick explanations
Power imbalance and cooptation issues for how treatments work and therefore they become easily
dismissed as invalid’’ (PC 8).
A lot of forum discussion centered around the theme of
power imbalance and co-optation issues. Many of the stu- Minor Themes
dents saw themselves and their profession in a less powerful Pluralism requires patients to be able to advocate
position compared with biomedicine—‘‘Western Medicine for themselves
is in charge of our destiny, and that is due to their social,
economic and political influences’’ (PC 6). Profit and poli- Some students argued that with a pluralistic model, pa-
tics were mentioned frequently as issues that determined the tients would need to make their own choices about which
hierarchy in U.S. health care, for example, ‘‘Medicine like medical approach they wanted, and concerns were expressed
many other institutions is ultimately going to be guided by about potential patient confusion and difficulty with this—
power holders and their indigenous sense of ethical right and ‘‘Creating an environment where the patients’ ability to be
wrong—possibly with motivations all too influenced by part of the game—and accommodate them when they are sub
profit’’ (PC 24). Comments about prejudice against T&CM optimally resourced—is something our medical practices and
were frequent, and some of the students expressed concern institutions should endeavor to be nimble and responsive to
that Chinese medicine could be co-opted by biomedicine— without judgment, agenda or manipulation’’ (PC 24).

‘‘there is a lot of interest by the Western medical com- Prior education focused on the integrative model/
munity to incorporate Eastern medicine into their pro- unaware of pluralism
grams.The demand for it has increased and they are
taking advantage of this opportunity to financially benefit/ Students indicated that their education has focused, al-
profit by opening integrative medicine departments in most exclusively, on integration, and some had never heard
house vs referring out’’ (PC 34). of the pluralistic model before—‘‘Most of us had no idea
about this term in our medical system prior to this class. We
There appeared to be a general sentiment of resignation to were all stuck on integration’’ (PC 29).
the truth of these issues and the difficulty of changing this
current reality. Against the opposition model

Importance of interprofessional education

Five of the students indicated that opposition was not a
model of choice for them. For example, ‘‘I do agree that
Many of the students discussed the critical need for inter- opposition (at least ongoing opposition) is unethical and
professional education to improve the understanding of what unreasonable as a strategy for functional relationship’’
Chinese medicine is, and the way in which it is practiced. The (PC 15).
need to understand each other’s approach to medicine was also
Pluralism maintains the integrity of Chinese medicine
emphasized. Many saw this as critical for the development of
respect, shared patient care, and referrals— Pluralism was seen to help maintain the integrity of
‘‘It seems that education is key. For there to be respect and Chinese medicine because it did not require it to be amal-
referrals among different modalities, we need to understand gamated with biomedicine and, thus, lose its integrity—‘‘If I
what each modality does, and where its strengths and limi- had to choose, I would choose pluralism, but this choice is
tations lie. All practitioners need to know when to refer out, only chosen, as the least damaging to the integrity of our
and have an idea of where to refer’’ (PC 26). medicine’’ (PC 8).
 6 ANDERSON ET AL.

Importance of thousands of years of anecdotal medical system to retain its autonomy, and it reduced the
evidence likelihood that T&CM would become diluted and devalued
The thousand-year history of Chinese medicine was when combined with biomedicine. Some thought that this
mentioned by several of the students, and was seen as dilution and devaluation was caused by issues associated
providing a large amount of anecdotal evidence, and also, in with the research, whereas others suggested that the vastly
their view, significantly legitimized its effectiveness— different paradigms and traditions prevented integration.
‘‘heralded in the West is the newest technology or drug, Similar perspectives have been reported among practitioners
while heralded in the East is a lifetime of experience treating of a range of T&CM disciplines, including Chinese med-
the human mechanism’’ (PC 13). icine, in Europe, Australia, Israel, the United States, and
Canada.5,18–22 These studies indicated that a pluralistic
model was preferred because it enabled T&CM practi-
Pluralism is also in Chinese medicine tioners to have greater autonomy and equal standing within
Some felt that in many ways Chinese medicine itself the health care system, as well as an ability to honor their
operated under a pluralistic model because of the coexis- own paradigms and worldviews.
tence of many different theories and styles of practice, and This suggests that these are universal issues regardless of
the notion that there is not one single ‘‘right’’ approach— different health care systems and other possible cultural
‘‘this pluralistic streak in our own medicine has been inte- factors. The increasing awareness and concern about the
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gral to its continued evolution’’ (PC 15). deleterious aspects of the integrative model was highlighted
at the recent 2017 Pan American Health Organization
summit where attendees indicated a preference for the term
Discussion
‘‘articulated’’ rather than ‘‘integrative.’’28 Integration, among
This study identified six major and six minor themes. attendees, was seen to be an extension of biomedical domi-
These Chinese medicine clinicians showed a clear prefer- nance, and associated paradigm assimilation and appropria-
ence for pluralism and were opposed to integration. Many tion, in which nonbiomedical theoretical foundations are
expressed that patient care was the most important consid- either ignored or translated into biomedical equivalents.7–9
eration, and that this was more important than choosing a Some see this as directly related to a history of colonial de-
model. Concerns were expressed about power imbalance valuation of indigenous knowledge.7
issues, the possibility of co-optation, and the appropriate- This domination by biomedicine is believed to be en-
ness of research methodology for assessing the effectiveness gendered by profit and politics.6,7 Thirty-nine percent of the
of T&CM therapies. Interprofessional education was seen as practitioners in this study spoke about this issue and saw it
critical to improving the knowledge and understanding of as a major impediment to T&CM disciplines being per-
the T&CM disciplines. mitted equal acceptance in biomedical settings. This and
The minor themes highlighted additional important is- previous studies5–7,18 indicate that T&CM practitioners feel
sues. The practitioners expressed concerns for the ability of oppressed by a system that appears to unfairly question what
patients to be able to advocate for themselves when faced they do, and that has the capacity to support or sanction their
with a range of choices of different therapeutic approaches. disciplines. Such underlying attitudes, along with associated
They indicated that their prior education had failed to raise inclusionary/exclusionary strategies,6 will need to be un-
their awareness of a pluralistic model. The opposition model covered, policed, and eliminated for effective and harmo-
was viewed as counterproductive and divisive. Pluralism nious interprofessional medical care settings to function
was seen as a model that would better protect the integrity of optimally.
Chinese medicine, and it helped to prevent single modalities The Chinese medicine practitioners in this study empha-
(like acupuncture) from being used outside of the discipline sized the importance of interprofessional education, which
of Chinese medicine and its theoretical foundations. A small indicates that this is not just an abstract ideal, but something
number of participants spoke to the long history of Chinese that T&CM practitioners would view as a critical step to-
medicine and the value of such a large body of anecdotal ward creating an even playing field. Fortunately, there is
evidence, and the fact that pluralism also exists within currently concerted effort toward this goal in the development
Chinese medicine itself. of medical education competencies10,29 and incorporation
This study deepens our understanding of the critical is- into medical and health care curricula.13 Correspondingly,
sues that act as barriers to delivering interprofessional there has also been significant focus and funding by the
patient-centered care by biomedical and T&CM practition- National Institutes of Health aimed at increasing the research
ers. Considering that this assignment was only worth 5% of literacy of T&CM practitioners and teaching evidence-based
the course grade, the amount and texture of the dialogue medicine in T&CM colleges.30
strongly suggests that these practitioners felt passionately The use of appropriate research methodology and evi-
about these issues. Further, most Chinese medicine practi- dence to validate T&CM therapies were important issues in
tioners in the United States work in private practices, and the consideration of the best model for combining bio-
therefore have control over the way that they interface with medicine and Chinese medicine by these practitioners.
the health care system. Therefore, the perspectives of the These are contentious issues within the research and T&CM
practitioners in this study are not significantly influenced by communities.31,32 Chinese medicine is a complex interven-
being forced into any specific model for their relationship tion in which several different modalities (acupuncture,
with biomedicine. herbal medicine, cupping, moxabustion etc.) are frequently
The main reasons that the Chinese medicine practitioners used in a single treatment. Most of the research has focused
in this study preferred pluralism was because it allowed each only on acupuncture in randomized controlled trials. Such
 INTERDISCIPLINARY RELATIONSHIP MODELS FOR CIH 7

trials do not resemble real-world practice and are often in- were asked ‘‘to present an argument as to which approach—
consistent with the paradigms of Chinese medicine.32 This is opposition, integration or pluralism—you think is the most
because they lack Chinese medicine differential diagnosis, ethical model for the relationship between mainstream
test acupuncture as a single modality, do not individualize and alternative medicine.’’ The word ‘‘ethical’’ can be
treatments, and often include placebo controls. The splitting interpreted in many ways, and such multiplicity may have
apart of complex medical interventions, and testing indi- influenced the students’ responses. This may have also
vidual modalities outside of their theoretical foundations, been why many of the students mentioned the importance
often results in reduced effectiveness outcomes.8,33 Indeed, of a patient-centered approach. A codebook with opera-
this is part of the argument against the use of randomized tional definitions to identify themes was not used, which
controlled trials for testing the efficacy of complex inter- may have led to inconsistencies between B.A. and S.J., and
ventions.31,34,35 Acupuncture placebo controls are not in- inaccuracies in the quantitative evaluations. Identifying
ert,36 and, consequently, many of these trials have failed to themes in forum dialogue and transforming qualitative
show a statistically significant difference between real and forum dialogue into quantitative data involving quantify-
placebo treatments, leading to the conclusion that acu- ing the number of times themes are mentioned, while ac-
puncture is just a placebo.37 counting for redundancy (repeated themes in a single forum
These methodological issues have had a very detrimental post), involved the subjective analysis of the investigators,
impact on Chinese medicine practitioners’ perceptions of and could, therefore, be biased by their perspectives and
Downloaded by Imperial College School Of Med from www.liebertpub.com at 12/09/18. For personal use only.

the quality and value of research.21,38,39 Many feel that interpretations.

acupuncture randomized controlled trials do not provide
clinically relevant information. Placebo controlled trials are Conclusions
also seen as a disservice to the profession. Reference to this
is seen in this comment by one of the study participants— This study provides insight into the perspectives of Chi-
‘‘in the mainstream media, or the journaled ‘‘evidence’’ of nese medicine practitioners toward different models for
all the sham acupuncture trials that seem to me to only try to combining biomedicine and T&CM. The issues highlighted
disprove acupuncture from the outset with bias due to the by this study will need to be addressed to provide optimal
utilization of sham needling’’ (PC 14). patient care as greater numbers of T&CM practitioners are
The practitioners in this study expressed a preference for employed in biomedical settings.
pluralism because it preserves the integrity of Chinese
medicine by permitting it to stay as a whole discipline and Acknowledgments
not become fragmented by exclusively using one modality
or aspect of the discipline. The more recent focus on whole- The authors thank Dr. Corbin Campbell of Teachers
systems research approaches that better encompass the College, Columbia University for her insightful feedback on
complexity of acupuncture therapy, such as pragmatic40 and the article. Research reported in this publication was sup-
comparative effectiveness41 trials, has increased the rele- ported by the National Center for Complementary and In-
vancy of the research for Chinese medicine practition- tegrative Health of the National Institutes of Health (NIH),
ers.38,39 This and other studies41 indicate that such research, United States, under Award numbers K07AT007186 and
along with case studies,17 will need to be recognized as R25AT003582. This publication was also supported in part
legitimate evidence to justify treatment decision making in by the CTSA Grant 1 UL1 TR001073-01, 1 TL1 TR001072-
settings where biomedical and T&CM practitioners are co- 01, and 1 KL2 TR001071-01 from the National Center for
treating and sharing responsibility for patient care. Advancing Translational Sciences, United States (NCATS),
The themes that arose when discussing the most ethical a component of the NIH. The content is solely the respon-
model for T&CM and biomedicine by this group of expe- sibility of the authors and does not necessarily represent the
rienced Chinese medicine practitioners accurately encom- official views of the NIH.
pass the key issues that need to be addressed in creating an
interprofessional patient-centered health care environment. Disclosure Statement
Pluralism permits different disciplines to function autono-
mously, but it relies on knowledge, respect, and communi- No competing financial interests exist.
cation between practitioners. The participants in this study
identified important barriers—power struggles, the genera- References
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