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Available online at www.sciencedirect.com

European Journal of Integrative Medicine 5 (2013) 410–417

Original article

Integrative medical practitioners and the use of evidence

Karen F. Willis a,∗, Jo-Anne Rayner b

a Faculty of Health Sciences, The University of Sydney, 75 East St, Lidcombe, NSW 2141, Australiab School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia

Received 18 October 2012; received in revised form 15 May 2013; accepted 15 May 2013

bstract

ntroduction: Increasing numbers of general medical practitioners in Australia define themselves as integrative practitioners, incorporating bothllopathic and complementary and alternative medicine (CAM) in an environment where evidence-based medicine is the hallmark of best practicen medicine.

ethodology and approach: We conducted semi-structured qualitative interviews with 23 self-identified integrative medical practitioners in twotates of Australia. Participants were recruited from publicly available lists of self-identified integrative medical practitioners – the local telephoneisting and the website of their professional organisation. Interviews explored how doctors define and use evidence in their practice. We undertook

thematic analysis of the interview transcripts with particular exploration of the key ideas that emerged about their use of evidence.esults: These practitioners are sceptical about the dominance of the evidence-based medicine movement, and push to reclaim their autonomyased on the indeterminancy of individual cases. They acknowledge that an understanding of clinical benefit may not be scientifically evidencednd utilise discourses of experience and safety in discussing their clinical practice.

onclusions: Our findings provide further insights into how medical practitioners work within their own profession, their relationships with otherare providers (specifically CAM practitioners), their views about their non-integrative medical peers and their resistance to prescribed ways oflinical practice.

2013 Elsevier GmbH. All rights reserved.

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eywords: Integrative medicine; Complementary and alternative medicine (CA

ntroduction

General practice in medicine is an area of professional workhat is fraught with ambiguity. Lacking the prestige of med-cal specialisation, dealing with the day-to-day health crisesf patients, and subject to increased scrutiny by regulatorygencies, general practitioners (GPs) are often represented asorking at the ‘coalface’ of medicine. The contemporary expec-

ation of work at the coalface is the application of scientificnowledge to the healing of illness or the curing of disease. Thathe everyday reality of general practice does not accord with a

cientific model of health and healing is encapsulated by Mayt al. [1] when they identify that a reductionist, scientific modelf healing has ‘poor utility’ in three areas of general practice:

∗ Corresponding author. Tel.: +61 2 93519256.E-mail addresses: Karen.willis@sydney.edu.au (K.F. Willis),

.rayner@latrobe.edu.au (J.-A. Rayner).

erteoocg

876-3820/$ – see front matter © 2013 Elsevier GmbH. All rights reserved.ttp://dx.doi.org/10.1016/j.eujim.2013.05.001

ociology; Public health; Evidence; Professions

he management of chronic illness; the diffuse symptoms thatrise from the social and psychological character of the patient’sorld; and in preventative health care, with its focus on identi-

ying and managing risk prior to the development of illness. Asay and colleagues argue: ‘A problem for medicine as a gen-

ral field is what to do with the patient’s subjective experiencef illness, and how to connect it with medical knowledge andractice’ [1].

Evidence based medicine (EBM) has arguably changed theay that scientific medicine is conceptualised. EBM provides

guide to assessment and use of evidence, with the strongestvidence found at Level 1, comprising systematic reviews andandomised controlled trials (RCTs), then cohort and case con-rol studies at Levels 2 and 3 respectively, and lowest forms ofvidence, Levels 4 and 5 obtained from case series and expertpinion [2]. While the focus on EBM suggests a unified body

f knowledge, rather than a plurality of practices and contextsontributing to the construction of medical knowledge [3], therowth of evidence-based practice has not resolved differences

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etween scientific evidence, subjective experience or the tacitnowledge that is seen as vital to practising the ‘art of medicine’4].

One area that has caused extensive debate about evidences Complementary and Alternative Medicines (CAM). CAMan be defined as systems and practices, which are outside theomain of conventional medicine, used to prevent or treat illness,nd/or promote health and wellbeing [5], and includes a broadpectrum of natural and complementary therapies, treatments,nd modalities. While CAM has, in the past, been consideredutside the conventional medical system, increasing numbersf Australian doctors believe that some CAMs are effective,ome are even considered ‘mainstream’ [6] and as such arencorporated into clinical practice [7–9]. However, among Aus-ralian medical practitioners, the use of CAM is contested. Whileome argue that it is ethical to prescribe CAM if it is doneo in the context of the healing relationship and where thereay be an ‘accumulation of knowledge’ [10], others argue that

he trend towards incorporating CAM into medical practice is ‘form of medicine that would be rejected by most of theireers’ [11].

Thus the rise of the ‘Integrative Medical’ practitioner is onehat deserves further attention. There are definitional debatesbout integrative medicine and definitions are contested [12].he Australian Integrated Medicine Association (AIMA) [13]efines integrative medical practice as:

medicine that reaffirms the importance of the relationshipbetween practitioner and patient, focuses on the whole per-son, is informed by evidence, and makes use of all appropriatetherapeutic approaches, health care professionals and disci-plines to achieve optimal health and healing.

Others [14] identify integrative medicine as incorporating aolistic approach that may include a range of practices suchs diet and lifestyle advice as well as CAM modalities. Thisuggests that not all doctors who identify as practicing integra-ive medicine necessarily utilise CAM modalities [15]. Coultert al. [16] point to the lack of empirical evidence for integrativeedicine as a new form of practice. One Australian study of inte-

rative practices pointed to the ‘accessory’ role that co-locatedAM practitioners played alongside their medical counterparts,

uggesting that within integrative medical practice the hierarchyf knowledge still favours biomedicine [17] although this mayary according to the training and experience of the medicalractitioner [18].

The trend towards acceptance and/or use of CAM by medicalractitioners can partially be explained by consumer pressures.n 2004, there were an estimated 1.9 million consultations withaturopaths and western herbal medicine practitioners, at a costf AUD 85 million excluding the costs of medicines [6]. In010, it was claimed that two in three Australians have usedAM over the last 12 months, spending over AUD 3.5 millionach year [19]. As elsewhere, Australians are increasingly using

AM as a health care option for a variety of chronic conditions,ith women the primary users [20–22]. Medical practitionersave responded to these trends by adapting the services thathey provide.

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Integrative Medicine 5 (2013) 410–417 411

Sociologists have argued that incorporation of CAM intoedical practice may also be a strategy to maintain occupational

erritory and authority over health and healing [23]. This per-pective draws on traditional understandings of medicine as theominant profession in health, and the ‘medical dominance’ the-is [24], thus, integrative medicine is a way of ‘co-opting’ CAMractices [25]. Medical practitioners are at an advantage relativeo their non-medical CAM counterparts, as their consultationseven if not all the therapies they provide) are subsidised byustralian national medical insurer, Medicare. Theorists from

his perspective argue that while professionalising is a constantrocess, with many more players seeking a stake in health care,edicine is not so much in decline as ‘adaptive’ to contempo-

ary conditions [24,26]. Saks [27] argues the medical responseo occupational challenges by CAM practitioners may take twoorms – either incorporation of specific practices within theirwn repertoires of practice or maintaining dominance throughelegated authority to CAM practitioners in subordinated orimited roles. Similarly, Easthope [28] argues that integrationf specific practices will continue and is an adaptive strategy byedical practitioners in the face of consumer and global industry

ressures.Other writers suggest that integrative medical practice may

e about boundary work within medicine. Easthope et al. [29]uggest that there is a hierarchy of accepted medical practicesanging from being deemed as ‘normal practice’, to formalecognition by the state, and finally, inclusion in medical cur-iculum. Further, they argue ‘lower status practitioners are moreikely than higher status practitioners to accept an ‘alterna-ive’ therapy as normal practice’ [29]. For GPs, identifications an ‘integrative medical practitioner’ may also be about thee-assertion of clinical authority [30,31], especially in the cur-ent environment where autonomy is perceived as under threat,ue to a combination of government intervention and con-umer demands. Adams [32] points to integrative practitioners’se of CAM as a response to the perceived constraints ofvidence-based medicine. He locates his finding as one of manyntra-professional debates about the work of general practice,hich is viewed as both an ‘art’ and a science’ with a reliancen the importance of intuitive decision making.

Thus the challenge is to understand what the move to ‘inte-rative medical practice’ really means – whether it is about aew way of practice or a co-option of CAM. Baer and Coulter23] argue that the term integrative medicine requires scrutiny,s ‘it has been developed largely by those to claim who practiset’. While the definition is important in terms of developmentf a sociological approach to this topic, it is also interesting toxamine why medical practitioners choose to label themselvess ‘integrative’. There has been less exploration about what iteans in terms of the intraprofessional boundary work to self-

efine as an integrative medical practitioner in a context wherehe dominant mode of practice is focused on EBM.

ethod

The research on which this paper is based, sought to explorehe reasons why medical practitioners identify their clinical

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ractice as ‘integrative’. We were particularly interested inhe way that such identification may be an expression ofhe position of the GP within a medical field in which theyccupy an ambiguous position, particularly in the context ofBM. Using a qualitative, interpretive approach we undertookemi-structured interviews with medically registered doctors inwo states of Australia (Victoria and Tasmania). Doctors wereligible for inclusion in the study if they self-identified as prac-ising integrative medicine by being listed on either the publiclyvailable AIMA Website, or the electronic telephone listings ofoctors offering complementary or integrative medicine. Theseources were used to identify doctors practising both states. Werote to the identified doctors providing information about the

tudy and inviting them to participate. This was followed upne week later with a phone call to their practice. Of 43 doctorsnvited to participate, 23 agreed to be interviewed.

The doctors were diverse in terms of geographic location,ender and type of practice: 14 were women and nine wereen; number of years in clinical practice ranged from four years

o 35; most (n = 18) had undertaken their medical education inustralia; 17 practiced in metropolitan areas and five in regional

reas; eight doctors were in sole practice, eight were in a groupractice with other medical doctors, and seven were in groupractices that included other health occupations (for example,ther health professionals or CAM practitioners). This diver-ity in the sample provides rich information about the practicef integrative medicine. Ethics approval was obtained from theniversity Human Research Ethics Committee (FHEC90/15).Topics covered in the interview included participants’ philo-

ophical approach to medicine, their definition of integrativeedicine practice, their use of evidence in their practice, and

heir use of CAM in their clinical practice. Seven interviewsere conducted face-to-face. The remaining 16 conducted via

he telephone at the doctor’s request. All interviews were digi-ally recorded and transcribed verbatim. We followed principlesf thematic analysis, a primarily inductive technique for generat-ng findings from interview data [33]. Following a close readingf the transcripts, initial coding (tagging of text relating to eachxpressed idea) was undertaken using Nvivo8 software. We thenxamined the coded text to identify similarities and differencesn the ideas expressed, and from the patterns in the data thatecame evident, we generated the key themes about the use ofvidence. During the analytical process of investigating the pat-erns across the data we identified three different categories ofractice within the self-definition of ‘Integrative Medical’ prac-itioner, enabling us to explain our findings about the differentiews, and use of, evidence in decision making.

esults

We began by examining how doctors drew on CAM inheir everyday practice and this examination revealed thathree groups of practitioner were evident [18]. We categorised

pproximately one third of doctors as ‘Integrative Medicalractitioners’ – as their medical practice comprised the usef both conventional treatments and CAM for therapeuticffect. The most common CAM modalities practised by these

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Integrative Medicine 5 (2013) 410–417

octors were acupuncture, homoeopathy and herbal medicine. second group were categorised as ‘Specialist’ doctors’. Theyid not view themselves as GPs (some did no general practice)nd tended to practise one form of CAM – most commonlyind-body or lifestyle medicine. They generally referred

o themselves as ‘consultants’ or ‘specialists’. Less easy toategorise was a third group of participants, whom we labelleds the ‘Good Doctors’. These participants did not use or practiceAM in their medical practice, but would accept the use ofAM by the patients who consulted them, were in their terms,

low prescribers of pharmaceuticals’ and strongly believed innd provided nutritional or lifestyle advice to their patients. Ineparating this last group of participants from the integrativeedicine category, we took the view that lifestyle advice and

dvice regarding, for example, vitamins, is part of orthodoxeneral practice, unlike the provision of a therapeutic modalityuch as acupuncture, herbal medicine or homoeopathy.

The type of medical practice varied between these threeroups: those who perceived themselves to be most outside theainstream of medical practice (usually the ‘Specialist’ group)

enerally operated solo practices; those who we defined asGood Doctors’ generally worked in a group practice with otherPs who did not define themselves as integrative; and those who

ctively practised integrative medicine were most likely to workn group practices with either other integrative medical practi-ioners, allied health professionals and/or CAM practitioners,lthough two doctors in this group worked as sole practitioners.n reporting the findings below, we have assigned pseudonymsnd delineated participant categories using IM (Integrative Med-cal practitioner); GD (Good Doctor); and SP (Specialist).

mportance of, and scepticism towards, evidence

Doctors in this study had clear views of EBM as being abouthe application of Level 1, scientific knowledge to their clinicalecisions, in a way that did not allow for the flexibility requiredn individual decision making. This is consistent with Pope’s34] argument that a difficulty for the EBM movement is ‘thats has helped to sustain the idea that evidence and practice areiametrically opposed’. While there was some overlap betweenhe three groups of doctors identified above, there were somehemes that were more predominant according to how they wereategorised.

Integrative Medical practitioners (and one participant fromhe ‘Good Doctor’ group) were more likely to discuss themportance and use of evidence, but emphasised that clinicalxperience and intuition also contributed to their decision-aking. Anna (IM) for example, stated that evidence “plays a

ig role [in deciding on treatment options] but at the same timey experience plays in a bigger role”. These doctors saw them-

elves as no different to the majority of their medical peers.s Diana (IM) reiterated, “All doctors still practice that way.

sn’t it interesting that its anecdotal, but that we still go, ‘well I

emember that helped this person with this thing, so let’s try it”.

Leo (GD) stated the importance of scientific evidence to hislinical practice:

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“I very much try and stay within a realm that has somesort of scientific evidence. I know there are modalities that Ifind quite interesting, and I know of people who get amaz-ing results, but I don’t use them as they just don’t havethe evidence to support them. . . and they’d be disparagedcompletely from a mainstream perspective”.

Helen’s (IM) view of the application of evidence was alsondicative of other participants’ views:

“The way that medicine works is that if people tell you itworks you keep doing it, and if people tell you it doesn’twork you don’t. So regardless of evidence-based whatever,the practicality and when you’re on the frontline you learn alot from your patients”.

Participants in the IM and the GD groups described the grow-ng evidence for various CAM and their strategies for keepingp to date with this growing evidence. As Frances (IM) stated:

“My evidence comes from medical journals. . .. When itcomes to herbs, I try to keep as up to date as I can. . . andsome herbs are very well known, and other herbs have beenused for thousands of years do have some evidence. [Thereis] not a huge amount of evidence, but if they’re not going tointeract with what other things people are using and if theyseem the appropriate herb and if they have got some studieson them, then I will use them”.

The importance of trust in evidence was also highlighted.eo’s (IM) comments are indicative:

“I like to always put things into that evidence-basedperspective. . . but in most cases the evidence isn’t Level 1evidence. . . .It really boils down to the confidence that you oryour practitioner have in that medicine achieving the outcomethat’s desired. . . .When you think about it, trust is probablyat the core of everything, both not only in health care but withother things in life. If you trust your practitioner, even thoughthey may not have a huge range of research up there, you’reprobably still likely to do what they say”.

Throughout all groups, doctors critiqued the idea of evidence,sking critically ‘what is evidence’, and arguing that clinicalractice and patient experience also constituted ‘evidence’. Asiona (GD) said:

“Well I think evidence is obviously important, and I think it’snot even debatable that evidence is not important. The pointis how do you define evidence, and if you actually look at thedefinition of evidence its two things. It’s both the researchand it’s also clinical experience”.

Brett (IM) made the point that it is difficult to translate theesearch context into the clinical setting: “In applying [researchndings] to individual cases it is important to remember that it’slways going to be an artificial sort of situation, any researchontext and to keep that in mind”. In relation to the use of

AM, Kevin (IM) argued: “Absence of evidence is not absencef effect”. Some doctors critiqued what they saw as the dou-le standard applied to CAM, where anecdotal evidence was

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Integrative Medicine 5 (2013) 410–417 413

eemed as an unacceptable form of evidence yet accepted as theeginning of an evidence-base in conventional medicine. PeterGD) argued: “There is a lot of stuff we do in medicine wherehere is no double-blinded randomised controlled trial. . . I don’think you necessarily need the certain levels that some people

ight demand”.Similarly, Nella (IM) stated:

“Well, see Level 5 evidence is the opinion of somebody, anexpert in the field, who has lots of years’ experience. Now,I believe that is evidence. But it is not Level 1. And mostof what I do is probably Level 2, which is an observationalstudy with no placebo. But then, when, often I’ll see journalarticles where they had a small study group with no placebo,and they said, ‘that is evidence’. . . (laughs)”.

The strongest statements about the EBM movement camerom the group categorised as ‘Specialists’. Participants in thisroup claimed that the “pendulum has swung too far to evidence-ased medicine”; “there is too much hype about evidence-basededicine”; that “things that matter don’t come from trials”;

nd that “you can find evidence for or against any health mat-er”. They were critical not only of the push to EBM, but ofhe construction of knowledge. Gary’s (SP) critique of scien-ific knowledge was indicative of this critique, given that theseoctors argued they were dealing at the level of the individual:

“It’s very difficult to prove things as a double blind trial ina hundred or a thousand people when you’re talking aboutvery real anecdotes of the healing process happening in anindividual in a given life. . . The fact that you cannot verifythat sort of approach in a scientific thing, doesn’t make it nottrue”.

Similarly, Andrew’s (SP) approach indicated the importancef the influence of the practitioner in determining the course ofreatment, rather than just the evidence:

“I don’t do any prescriptive stuff at all. I don’t prescribea herb, I don’t prescribe medication. I don’t do anything.Mine is TOTALLY mind work. . . .Even if you and I did thesame, exact same sort of technique, we would bring to itsomething completely different. . . .And so I bring to it notjust my clinical experience, but my life experience, because,you know, you can’t do any of this work without havingjourneyed yourself”.

Cameron (SP), also a mind-body specialist, argued againsthe use of evidence and the reliance on acquired common-sensend wisdom – what may also be called ‘tacit knowledge’:

“What they have now is another notion called ‘evidence free’medicine. Like, you shouldn’t go with the evidence, youshould go with the wisdom, with the common sense, andapproach the patient [with the intent] that there should not beharm, because evidence keeps changing”.

Embedded within doctors’ sceptical views about evidenceas the role of the pharmaceutical companies in knowledge con-

truction, funding, and influence over clinical medicine. This isncapsulated in Fiona’s (GD) comment: “The biggest piece of

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vidence that I would want to know is: who paid for this, andhat questions have been asked”. Carol (IM), along with manyther doctors, argued that such reliance affected the construc-ion of evidence and inevitably disadvantaged evidence aboutAM: “So, when I see some pharmaceutical company comingut with research that says, “Vitamin D doesn’t work” I justhink ‘of course’ it was set up not to work”.

For some doctors, medical education was compromised dueo the influence of pharmaceutical involvement in the construc-ion of evidence and the “drug culture of medicine” (Ingrid GD),hich ultimately lead to the “deskilling” of medical practition-

rs. This sentiment was powerfully captured in a comment byina (SP):

“I don’t consider myself to be alternative at all. . . [Betweengraduating and now] medicine was hijacked by the marketi.e., big pharma. And they have seduced the government, thecolleges, the universities, general practice, everybody. AndGPs, in my opinion, have been deskilled. . . And in the past Ithink you will find GPs did a lot more. I consider myself tobe old fashioned, not alternative”.

arm, safety and evidence

Doctors drew on notions of harm and safety in their decisionsbout evidence and the use of CAM, and it was here that aierarchy of treatments indicated by evidence of harm/safetymerged. For IM practitioners Belinda, Diana and Anna, thereas clear evidence of safety of acupuncture but less evidence forotanical or herbal medicine. As Anna (IM) said, when decidinghich modality to use:

“Evidence plays a big role but in the same time my expe-rience plays in a bigger role. . . if my experience is great inresults then evidence is really for scientific purpose. I don’tneed that evidence to decide to use acupuncture as a treat-ment modality, ok. So that’s my approach to acupuncture.To some other areas of complementary medicine, definitely Iwould look for evidence, especially for herbs and somethingthat patients need to take internally because they can harmpeople”.

Similarly Diana (IM) viewed acupuncture as safe, andbotanicals” as having less evidence of safety:

“I usually tell patients that it’s one of the things we know thatis really quite safe, so we’ve got a lot of evidence for safetyof acupuncture. So when the safety of it is assured than I’mmore likely to choose it rather than something like a botanicalwhere we’re still unsure about the safety”.

Drawing on the notion of risk, Belinda (IM) argued that:If it’s very, very, very low risk associated with that treatmenthan it’s still quite safe to use it. Therefore evidence again isery important, but it wouldn’t stop me, from possibly advising

atients to try [a therapy without evidence]”. Delia (IM) statedhat: “Well. . . to me, evidence is results. If you are not doingnything detrimental to somebody and you repeatedly get goodesults, well, then to me, that is evidence”.

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Integrative Medicine 5 (2013) 410–417

For Peter (GD), when discussing the provision of lifestyledvice as part of his clinical practice, evidence was less impor-ant due to the lack of harm:

“Oh, I don’t necessarily need double-blind randomised con-trolled studies. I mean (laughs) you need some level of, atleast anecdotal evidence, but you know, look most things thatare around, like the nutritional stuff and certainly the lifestylestuff, it is pretty basic. I think there is enough evidence thatthey are not doing any harm, and that they, definitely, morethan likely of very good use”.

ithin, outside or on the borderlands – relationshipsith/in medicine

Ideas about evidence were also indicative of doctors’ relation-hips with conventional medicine – both in how they believedhey were viewed by their medical peers (as Frances (IM) said

“they think I’m a ‘nutter”!) and in how they saw their peersho did not choose to embrace integrative practice. While theoctors we categorised as SP considered themselves as ‘outside’edicine, doctors categorised as IM in particular were keen to

dentify as GPs. As Diana (IM) said, “I’m quite a conventionaloctor at heart”. Similarly Helen (IM) said:

“I guess I’ve never really seen myself as being a radicalperson. I’ve seen that people who choose to be fully conven-tional are often very frustrated and disappointed and theirpatients are also, in not being able to do more and to givemore options”.

This approach of staying ‘within medicine’ was also evidenthen doctors discussed their referral practices. Most referralractices were limited to other medically trained practitioners oro non-medical practitioners where the participant had personalxperience of care or who were highly recommended by thosehey trusted. Doctors also mentioned their caution in referringo non-medically trained practitioners.

However, while clearly situating their place in medicine, doc-ors saw themselves as different to GPs who did not embraceAM. They identified a range of reasons why their conven-

ional peers did not take up integrative medical practice. Thesexplanations were all located in a ‘deficit’ model of reasoninghere GPs were lacking in the qualities (either personal or struc-

ural) needed to take on integrative practice and were referencedgainst the positive attributes of integrative practice as a betterodel of practice. For example, Leo (GD) stated:

“The whole Medicare system [is] working against you. . . .Iactually make a lot less than other GPs I know, because Ispend a lot of time with people (emphasis added)”.

Integrative medicine also requires additional study, accordingo Helen (IM) and required to confidence to practice “differ-ntly”. Conventional doctors were regarded as “information

oor” about the advantages of CAM. For example, Brett (IM)aid: “I don’t think medical practitioners are getting the infor-ation about alternative medicine from the appropriate sources.hey’re reading it from very bigoted reports”. This led to a

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ack of familiarity, said Peter (GD) and “if they are not familiarith the stuff themselves. . . I guess it is more of a knowledge

hing”. Attitudinal barriers were also mentioned: “I think it’s thePs attitude, so their beliefs already. And I think a lot of thoseeliefs are coloured by a sense of rejection, in that they feel ashough someone’s gone to complementary medicines rejectingheir advice, or fear of the unknown” (Diana IM). Similarly,arol (IM) and Andrew (SP), referred to a medical “attitude oflosed-mindedness” towards CAM, and Brett (IM) argued thatt was an “attitude of arrogance that was based on fear that CAM

ay be shown to work”.Whereas these doctors saw themselves as open to new ways

f thinking, they saw those who did not practice in this way (bothPs and specialists) as resistant to new information. Matthew

GD) explained his view about the lack of evidence for someurgical procedures and how he tried to provide information foratients:

“I’ll print it [information] out and say [to the patient], ‘looktake this to the orthopaedic surgeon’. . . But I suspect mostorthopaedic surgeons would get fairly irritated with a patientwho came in with this information. . . Well, a lot of surgeonsare very dominant type of people”.

The medical establishment was thus seen as ‘other’ to theseoctors, an “old boys club” (Brett IM), and one that had noteen welcoming to doctors who may be drawn to integrativeedicine. For example, Fiona (GD) argued that people from

ifferent cultural backgrounds and women are more likely toractice using CAM, adding:

“The other thing I think that would be a factor is the factthat they’re marginalized a bit and so you tend to havepeople attracted to those sort of things who might notbe given the same kind of easy passage in the old boys’networks”.

Thus, doctors differentiated their practice from what theyermed ‘the mainstream’. In doing so, they argued that they didot make as much money as their peers, but that their practiceas more rewarding for them and their patients, and further

hat their type of practice was responding to a deficit withinonventional medicine. Mathew (GD) powerfully encapsulatedhese sentiments:

“I’m not just another sausage machine that is replicated allover [town name] you know. And I think the benefit to patientsis that I think they feel that they are getting – I am value addingfor them – because I’m not only using the conventional, but Ithink it is also I think hoping to build bridges for people thathave been somewhat alienated and lost – have lost trust withthe medical profession”.

When discussing their relationship with ‘conventional’ ormainstream’ medicine, doctors used language that ‘othered’heir medical colleagues who were not seen as open to integra-

ive practice (in the following quotes this use of language is inold). For example, Elias’ (GD) use of ‘the mainstream’ is usedo signal practices of lesser value.

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Integrative Medicine 5 (2013) 410–417 415

“I think there’s a problem with an evidence base and what themainstream calls [evidence]. . . The mainstream only wantto see one way – a double blind control, randomised controlstudy. There’s no other evidence whatsoever. . .. it becomesa monopolised sort of a medical dictatorial way of saying,“this is the only way of doing things”.

Similarly, Leo’s (GD) comments indicated his value witheference to difference from ‘the mainstream’:

“I’m seen as not quite being in the mainstream. . . Peoplewho don’t want to take drugs, or something or they don’t likedoctors, but they will come and see me, because they haveheard that I’m a bit different”.

Again, a point of difference was the use of evidence for someoctors: “I think I have a much greater reliance on evidence thanour average GP” (Gina, SP). According to Matthew (GD),Most GPs wouldn’t have all that information at their fingertipseally. They wouldn’t be able to or feel confident to log intoubmed or the Cochrane databases”.

In differentiating themselves from the mainstream, these doc-ors argued that they were part of a new way of practicing

edicine that should not be ignored by the profession. IngridGD) said, integrative medicine “is taking over conventionaledicine to some extent” and there was a majority view that

onventional medicine had to become at least open to, if notractising, alternative approaches. Gary (SP) argued:

“Doctors need to understand at the very least, even if theydon’t use those approaches themselves, about the dangersand the interactions and know that at least a broad sense ofwhat those things are about”.

Consumer demands were recognised as important in bring-ng about change: Belinda (IM) stated “CAM is so widely usedy people that we should try to stop ignoring it – I’m talkingbout medical people here”; Olivia (GD) believed, “Medicine isvolving so quickly that we’ve got to keep up with the changes”;nd Fiona (GD) noted that increased medical knowledge washerefore vital: “Doctors will become more and more embar-assed about being asked about things they don’t know”.

While most of the commentary was about resistance by con-entional medicine, there were some cases where they saw theainstreaming of different approaches. For example Peter (GD)

tated: “This area is just growing and growing. GPs are com-ng around to the nutritional things I recommend, and they areecommending it as well. And it is just basically in the last yeart has become more mainstream”.

In an echo of the theoretical approach that views integrativeractice as co-option, these doctors argued that “CAM shoulde located within medicine” (Elias, GD) and at the very least,s Brett (IM) argued, medical training was needed to practiceAM: “To do this [CAM] without medicine is sort of half baked.

t has to have a very solid grounding in anatomy, biochem-stry, you know, pharmacology”. Similarly, Belinda (IM) argued

er medical knowledge was “necessary to offer evidence-basedpproach to it and to stop people wasting their time and money

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16 K.F. Willis, J.-A. Rayner / European Jour

n other therapists that don’t give as good advice”; and GarySP) said:

“I don’t examine my patients because it is not the way Iapproach it. . . .but my medical training is very importantin being able to recognise those sorts of situations that mayappear as nebulous symptoms and may appear to be a psycho-somatic sort of a symptom, but in fact there’s some underlyingproblem”.

iscussion and conclusion

The decision to become an IM practitioner has previouslyeen conceptualised as a search for clinical autonomy withinureaucratic and professional constraints or as a co-option ofAM, but it is also about the cultural dimensions of knowledgeonstruction [3]. For example, international surveys [35–37]uggest that IM is a multi-dimensional construct that incorpo-ates provider attitudes to bio-medicine and CAM, and theirnowledge and practice. We have previously reported thathe notions informing the practice of medical doctors whoelf-identify as IM practitioners include holism, vitalism, andmpowerment [12], indicating that medical knowledge is notimply about the use of an EBM approach, but is contextualisedithin prevailing views about health and healthism.Our analysis suggests that integrative medical practice

an also be conceptualised as resistance within conventionaledicine, particularly to dominant interests such as the phar-aceutical industry. Thus, the notion of evidence represents a

ontested territory upon which relationships within medicine arelayed out. While there is some reclaiming of clinical autonomy,here is scepticism of medicine’s relationship with the pharma-eutical industry and the incapacity of conventional medicine torovide solutions to contemporary health problems.

The different territory on which ideas about evidenceecomes particularly clear when we analyse how the IM prac-itioners define and discuss the use of evidence. Resistance toBM is less for those doctors we clearly defined as true IMractitioners, that is, those who practise using a range of tech-iques both conventional and CAM. The group of practitionersho are ‘Good Doctors’ are those who most clearly ‘straddle theivide’ between conventional and CAM; while those we haveeemed ‘Specialist Practitioners’ are most critical of conven-ional medicine, and provide the strongest account of resistanceo the ways of thinking within a medical framework and the usef evidence. Tilburt et al.’s [38] cross sectional study of medicalnd CAM practitioners’ knowledge about CAM evidence mayrovide insights into our findings. As with our study, they foundhat all groups of practitioners deem clinical experience to bemportant in decision making. They also found that increased

edical education is likely to be an indicator of confidence toraw on evidence, with medical specialists in their study mostonfident of all the groups in interpreting research. However,

ncreased evidence may also mean increased capacity to cri-ique dominant forms of knowledge. As most of our participantsad undertaken additional education [18], they were all confi-ent in their use of evidence, but were not necessarily accepting

Integrative Medicine 5 (2013) 410–417

hat scientific medicine or the research on which it was basedrovided the answers they needed in their clinical practice.

Similarly, we found that the level of engagement with bothAM and conventional medicine also shapes confidence toractice and views about evidence. Those who are most clearlyractising integrative medicine, incorporating both CAM andonventional modalities, into a clinical practice framework, areost comfortable with their position within the medical profes-

ion. Those who we categorised as ‘Good Doctors’ are morembivalent about their practice role because they work within

framework of conventional medical practice, even if they per-eive themselves as practising differently from the mainstream.hose categorised as ‘Specialist’ are most likely to work at theargins of medical practice, are less likely to be embeddedithin an integrative framework that incorporates both CAM and

onventional medicine, and are most critical of evidence-basededicine.The study is limited by the small sample size and the self-

elected nature of the participants. We do not know whetherhose medical doctors who self-identify as integrative but whoid not participate in this study are more or less likely to use evi-ence to guide clinical practice compared to the medical doctorsho did participate. Recruiting medical practitioners to partici-ate in research is known to be difficult [39]. While we wouldave preferred to undertake all the interviews face-to-face, par-icipation was dependent on the doctors’ availability after hoursnd their preference for a telephone interview. While we do notelieve that this markedly affected the data collected, it was lessasy to build rapport with the doctors, particularly at the end of ausy day. Despite these limitations, the study results provide fur-her insights into how medical doctors negotiate and transgressrofessional boundaries, their relationships with CAM providersnd their peers, and their views on the utility of evidence-basededicine to guide clinical practice.

unding

The study was funded by the Faculty of Health Sciences, Larobe University, Australia.

onflict of interest

The authors have no conflict of interest.

cknowledgements

We thank the doctors who gave their time to participate inhe study and Rebekah Burgess for her assistance in recruitingarticipants.

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