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Interdisciplinary Relationship Models
for Complementary and Integrative Health:
Perspectives of Chinese Medicine Practitioners
in the United States
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 paradigmatic
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
1Pacific College of Oriental Medicine, New York, NY.
2Albert Einstein College of Medicine, Bronx, NY.
3University of Minnesota, Minneapolis, MN.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 00, Number 00, 2018, pp. 1–8 JACM
ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2018.0268
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Introduction
Integrative 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
patients inclusive of traditional and complementary medicine
(T&CM), in addition to biomedicine. Different models for
the way in which biomedicine and T&CM are utilized together
have been proposed.2–5 Some have examined the way
in which teams of clinicians with differing medical training
work together, and they describe degrees of integration between
biomedicine and T&CM.2,3 Others have focused on
broader epistemological, social, and philosophical barriers in
considering what models could and have existed,4,5 and they
better address the tensions and contradictions inherent in such
a union.
Wiese et al.5 differentiate between models based on the
degree of autonomy that T&CM practitioners have within
biomedical settings. They differentiate between models
where T&CM is delivered or prescribed by biomedical
professionals (selective incorporation), where care is provided
by multidisciplinary and interprofessional collaborative
teams (integration), and a patient-centered model where
choice of care is decided by the consumer (pluralism).
Kaptchuk and Miller4 also propose three models—
opposition, integration, and pluralism. They discuss how the
relationship between biomedicine and T&CM is moving
away from opposition, which they describe as the rejection
of T&CM by biomedicine, and toward integration. Integration
is described as the polar opposite of opposition,
in which hospitals and biomedical clinics have amalgamated
biomedicine and T&CM in a holistic approach to the
treatment of disease and promotion of wellness. Integration
refers to an approach in which different medical systems are
used together without specific regard to differences in paradigms
and treatment approaches. The authors propose that
the practical, epistemological, and philosophical differences
between biomedicine and T&CM defy integration, and they
deny patients the integrity of either. Pluralism, in which
distinct health care models co-exist in parallel, is presented
as a preferable model because it ‘‘encourages cooperation,
research, and open communication and respect between
practitioners despite the possible existence of honest disagreement,
and preserves the integrity of each of the treatment
systems involved.’’
Many scholars believe4–7 that pluralism is the most likely
model that will allow true integration. However, historical,
social, and political factors provide significant challenges
for pluralism to become a predominant model within
mainstream health care.5–7 The issues raised by Kaptchuk
and Miller,4 and their thesis of fundamental incompatibility
between biomedicine and T&CM, have been echoed
by others.6–9 Adams et al.,6 using a critical social science
perspective, examined the impact of the complex power
relations that occur when biomedicine and T&CM are used
together, along with the interprofessional dynamics between
practitioners of different medical disciplines and their
adoption of inclusionary/exclusionary strategies. Based on
their research findings, they conclude that the integration of
biomedicine and T&CM is much more complex than is
often recognized, and it is significantly hampered by fundamental
incompatibilities between the paradigms of the
different medical systems. Drawing on anticolonial analysis,
Hollenberg and Muzzin7 argue that rather than integrating,
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
without recognition and respect for the origin. They propose
that biomedicine is an extension of Euroscience, which has a
long history of appropriation and assimilation of indigenous
knowledge. Through the devaluation of nonbiomedical
knowledge, the superiority of biomedical scientific evidence,
and the domination of the biomedical worldview, they conclude
that biomedicine is not integrating with T&CM, but
rather co-opting it.
Various international organizations are striving to better
understand and define how best to combine biomedicine
and T&CM. The WHO has developed a global strategy to
foster appropriate integration, regulation, and supervision of
T&CM into health care systems.10 The European Union
CAMbrella project identified six needed research areas for
facilitating T&CM use, one of which is research into different
models for T&CM integration.11 Identifying optimal
models for using biomedicine and T&CM together is important
because it impacts patient care, the effectiveness of
biomedicine and T&CM, clinicians’ satisfaction and autonomy,
and the general work environment. As insurance
coverage broadens for T&CM therapies in the United States,
biomedical settings will employ greater numbers of T&CM
practitioners. Devising an optimal approach to combining
different medical disciplines and creating an infrastructure
for effective and harmonious clinician interaction, both hierarchically
and regarding patient care decisions, will be
critically needed.
Regardless of the chosen model for combining biomedicine
and T&CM, what manifests in medical settings, and
with patients independently seeking multiple approaches,
depends on the attitudes, beliefs, and perspectives of
clinicians and administrators. These are powerful causative
factors underlying power dynamics, inclusionary/exclusionary
strategies, and the tendency for appropriation and assimilation.
Interprofessional education to establish a knowledge base
about other health care disciplines,12 and training in
evidence-based healthcare13 to engender treatment choices
based on evidence do not necessarily change perspectives,
attitudes, and beliefs. Such cultural change issues are
significant challenges for both biomedicine and T&CM
practitioners,14–16 and it has been suggested that we need
to find a new common language to facilitate truly integrated,
interprofessional, patient-centered care.17
Studies aimed at understanding the perspectives, attitudes,
and beliefs of T&CM practitioners about combining
biomedicine with T&CM are lacking in the literature. These
studies are necessary because they provide insight into what
issues need to be addressed when bringing T&CM practitioners
into mainstream medical settings. Addressing such
issues will directly impact how clinicians of different health
care disciplines work together, and whether their interactions
function to improve patient care, or antagonistically
interact to potentially confuse patients and detract from
optimal care. The small number of qualitative studies in the
literature indicate that significant tensions exist between
biomedical and T&CM practitioners when working together
in biomedical settings,18,19 and experiences of biomedical
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dominance exist among T&CM practitioners in private
practice.20–22
This article presents findings from a qualitative research
study of 31 experienced Chinese medicine practitioners, in
private practice for an average of 11 years. They were asked
to read Kaptchuk and Miller’s4 paper, which discusses three
models for the relationship between biomedicine and
T&CM—opposition, integration, and pluralism. The practitioners
were asked to present an argument as to which of the
three approaches they thought was the most ethical model for
the relationship between biomedicine and T&CM. To the
author’s knowledge, this is the first study to specifically
examine T&CM practitioners’ perspectives and opinions
about different possible models for combining biomedicine
with T&CM.
Methods
This study was undertaken and reported in accordance
with current qualitative research quality standards and
guidelines.23,24 The study was approved by the Institutional
Review Board at Pacific College of Oriental Medicine
(PCOM). Informed consent was obtained from all
participants after the course was completed and students
had received their grades.
Sampling and setting
A purposive sampling approach was used.25 Thirty-three
Chinese medicine practitioners were invited to participate in
this study. These practitioners were students who were
registered in the synchronous online 3-credit (42 h) course
Evidence Informed Practice (EIP) in the fall 2015 trimester
at PCOM. This course was part of a 15-credit academic
program for Chinese medicine practitioners who had a license
to practice acupuncture in the United States, and who
had previously graduated from an accredited master’s program
at PCOM. The degree enabled them to upgrade their
qualifications to the doctoral level. This particular cohort
of doctoral students was chosen because there was a high
proportion of very experienced Chinese medicine practitioners.
This was the first cohort to undertake the doctoral
upgrade program. The program is approved by the U.S.
Accreditation Commission for Acupuncture and Oriental
Medicine. PCOM is regionally accredited by the Western
Association of Schools and Colleges.
Data source
In week 10 of the 14-week EIP course, the students
(experienced Chinese medicine practitioners) were required
to engage in an online forum as one of the assessment items
worth 5% of their overall course grade. The assignment
required the students to read Kaptchuk and Miller,4 titled
What is the most ethical model for the relationship between
mainstream and alternative medicine: opposition, integration
or pluralism? Via an online forum in the learning
management system Moodle, the students were asked ‘‘to
present an argument as to which approach—opposition,
integration or pluralism—you think is the most ethical
model for the relationship between mainstream and alternative
medicine.’’ The assignment required them to post an
initial response of two or more paragraphs in length. They
then were required to respond to at least two posts of their
classmates, and to respond to classmates who responded to
their initial posts. Only the students participated in the forum;
the professor (B.A.) did not participate or discuss the
forum with the students until after the completion deadline.
Thirty-one of the 33 students in the EIP course gave informed
consent to be included in this study. All were given
participant codes (PC) for the purposes of identifying their
contributions in this publication. Twenty were female, and
11 were male. Their average length of time as licensed
acupuncturists was 11.4 years.
Data analysis
An inductive content analysis was undertaken by B.A.
and S.J. to identify themes and summarize forum content
following the phases outlined by Braun and Clarke.26 Although
students were provided with a paper outlining possible
models for the relationship between biomedicine and
T&CM, B.A. and S.J. were not deducing themes based on
the perspectives presented in this article or other papers
relevant to this general topic, but rather identifying themes
that emerged from the student’s discourse around this topic.
The data were analyzed through a pragmatic worldview
inclusive of a mixed-methods strategy.27 Themes that
emerged from the data were transformed into quantitative
data by counting the number of times a theme was mentioned,
and the number of students who mentioned each theme. This
was undertaken to permit both a qualitative description of the
themes and the identification of major and minor themes
according to how frequently they were mentioned by the
students in the online forum. Summation of theme frequency
permitted verification of the relative importance of the different
themes, which guided the discussion of relative theme
importance for this group of acupuncturists, and appropriate
connection to existing related literature.
At the time this research was undertaken, S.J. was a
Chinese medicine master’s degree student at PCOM undertaking
this research as part of a 3-credit research elective
course that was supervised by B.A. B.A. was the professor
of the EIP course. At the time of the study, she was Academic
Dean at the PCOM New York (NY) campus for 10
years, and she was also an active researcher and Chinese
medicine practitioner. The EIP course is part of the doctoral
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.
had worked closely with 9 of the 33 students taking the EIP
course as either faculty or administrators on the NY campus,
and had engaged in numerous conversations with
them, and many other students and faculty at PCOM-NY,
about integrative medicine and the types of issues raised in
these forums.
Initially, all forum posts were read by B.A. and S.J., who
then discussed the content and emergent themes. B.A. and
S.J. then independently reread the forums and each created a
list of theme categories. Microsoft Word was used to
manage the themes and data analysis. S.J. cut and pasted
direct quotes from the forums into a table arranged per her
chosen themes. B.A. highlighted quotes on a hard copy print
out of the forum discussions and identified reoccurring
themes, which she wrote in the margins. B.A. and S.J. then
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met and discussed the themes they had identified. Based on
this discussion, B.A. condensed this into six major themes
and six minor themes, and allocated forum content into
these thematic categories. S.J. examined this and conferred
as to its accuracy with her interpretation and categorization
of the forum data.
B.A. then examined her forum hard copies and counted
the number of times themes were mentioned in total, and by
individual students. All comments belonging to a theme
were included and counted toward the total number per
theme, except where more than one very similar comment
was mentioned as belonging to the same theme in a single
post by one person. B.A. then cut and pasted all forum
comments that represented the 12 themes into a table. All
forum comments were then examined by B.A. and S.J., and
a shorter list of forum comments for each of the six major
themes that was representative of all comments was created
for inclusion in this study. Member checking,27 a method to
determine the validity of the identified themes with study
participants, was undertaken by sharing data tables with
nine of the students in the class who verified that the data
analysis accurately reflected their interpretation of the forum
dialogue.
Results
Six major and six minor themes emerged from the analysis
of the forum discussions. Later, we describe each theme
and provide examples that appropriately illustrate the nature
of the discussion. In terms of the amount of forum discussion
that occurred—there were 33 initial posts, with an
average of 428 words per post, and 127 response posts, with
an average of four responses per initial post. The average
length of the response posts was 108 words.
Table 1 presents the six major and six minor themes as
defined by the number of times each theme was mentioned
(excluding instances where more than one very similar
comment was mentioned as belonging to the same theme in
a single post by the same person), and the number of students
who mentioned each theme. The number of times that
a theme was mentioned can exceed the number of students
who mentioned the theme because a single person could
have mentioned it both in their original post and in their
response to others’ posts.
Major Themes
A preference for the pluralistic model
Of the 31 students, 21 clearly stated a preference for
pluralism, 8 spoke of the strengths and weaknesses of integration
and pluralism without a clear commitment to either,
and 2 preferred the integrative model. Statements
ranged from simply stating a preference for pluralism—‘‘I
choose pluralism as our best ethical option’’ (PC 32), to
more detailed comments indicating that pluralism was seen
to be more ethical, less diluting to the profession, more
respectful, allowing of autonomy, and least damaging. For
example, ‘‘Pluralism takes into account the strengths of
each medicine and recognizes that there is validity and
strength in each medicine’’ (PC 29), and ‘‘pluralism helps
avoid a hierarchical structure within a group practice, and
reduces judgment about effectiveness and ethical norms
which might compromise ethical standards’’ (PC 32).
Opposition to the integrative model
Many of the students saw the integrative model as reducing
the effectiveness of the different medical approaches,
for example, ‘‘Integration may breakdown
constructs to fit together, but lose valuable principles and
tools’’ (PC 8). Concerns were expressed about the lack of
research evidence to support the choice of best treatment
options, for example,
‘‘Based on the available evidence, it is difficult to vote in
favor of integrative approach without sufficient integrative
research which can pinpoint exactly which alternative medicine
techniques are most helpful in treating certain conditions
or complimenting the existing mainstream medicine
practice’’ (PC 3).
Some of the students felt that integrative medicine
was more of a concept, rather than reflecting the real
ability to truly integrate very different medical practices.
For example,
Table 1. Six Major Themes and Six Minor Themes
Themes
Total No. of
comments
Total No. and % of
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)
aOut of the 31 acupuncturists who participated in this study.
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‘‘The limitations of homogenizing two incongruous perspectives
do a disservice to both. Interpreting a completely
different system using a singular language is at best incoherent,
and at worst, ineffective or harmful’’ (PC 23).
Importance of patient centeredness
There was a distinct patient-centered theme throughout
the forums. Many of the students stressed that what really
mattered in the choice of models was what was best for the
patient. For example, ‘‘The goal above all else is that the
patient gets the best care’’ (PC 17), and ‘‘In the bigger
picture, incorporating both modalities as legitimate options
for care is one way that our health care system can improve
and truly serve the patient, physically, mentally and spiritually’’
(PC 21). Some of the students felt that pluralism
allowed patients to have more choice between the various
medical approaches, and to be able to engage with medical
approaches that were more authentic, for example,
‘‘Pluralism allows for respecting patients who say they are
receiving a clinical benefit from a particular treatment, not
standing in their way if they feel it is helping and you do not
see a specific harm, but at the same time, allowing each
discipline to speak their mind to the patient’’ (PC 28).
Power imbalance and cooptation issues
A lot of forum discussion centered around the theme of
power imbalance and co-optation issues. Many of the students
saw themselves and their profession in a less powerful
position compared with biomedicine—‘‘Western Medicine
is in charge of our destiny, and that is due to their social,
economic and political influences’’ (PC 6). Profit and politics
were mentioned frequently as issues that determined the
hierarchy in U.S. health care, for example, ‘‘Medicine like
many other institutions is ultimately going to be guided by
power holders and their indigenous sense of ethical right and
wrong—possibly with motivations all too influenced by
profit’’ (PC 24). Comments about prejudice against T&CM
were frequent, and some of the students expressed concern
that Chinese medicine could be co-opted by biomedicine—
‘‘there is a lot of interest by the Western medical community
to incorporate Eastern medicine into their programs.
The demand for it has increased and they are
taking advantage of this opportunity to financially benefit/
profit by opening integrative medicine departments in
house vs referring out’’ (PC 34).
There appeared to be a general sentiment of resignation to
the truth of these issues and the difficulty of changing this
current reality.
Importance of interprofessional education
Many of the students discussed the critical need for interprofessional
education to improve the understanding of what
Chinese medicine is, and the way in which it is practiced. The
need to understand each other’s approach to medicine was also
emphasized. Many saw this as critical for the development of
respect, shared patient care, and referrals—
‘‘It seems that education is key. For there to be respect and
referrals among different modalities, we need to understand
what each modality does, and where its strengths and limitations
lie. All practitioners need to know when to refer out,
and have an idea of where to refer’’ (PC 26).
It was also suggested that interprofessional education
would foster less prejudice against T&CM by biomedicine.
Issues about scientific research methodology
and paradigms
Several students wrote about the inappropriateness of
scientific research models for investigating Chinese medicine
due to significant paradigm differences. Students suggested
the need for research approaches that are compatible
with the way that Chinese medicine is practiced, for example,
‘‘The biggest victory I can foresee with a foundation
of pluralism, is that not only may we all work together, but
that Chinese Medicine can test its own effectiveness without
the constraints of fitting into the Biomedical’s paradigm of
research’’ (PC 17). Concerns were expressed about reductionist
scientific methodologies, and the randomized controlled
trial in particular, as being unable to adequately
encompass a holistic medical system—
‘‘Western based science looks at the world by tearing it up
into very small pieces that can be analyzed. By doing this to
Eastern medicine, meaning and understanding are often lost.
Western medicine is interested in coming up with explanations
for things, but we don’t always have quick explanations
for how treatments work and therefore they become easily
dismissed as invalid’’ (PC 8).
Minor Themes
Pluralism requires patients to be able to advocate
for themselves
Some students argued that with a pluralistic model, patients
would need to make their own choices about which
medical approach they wanted, and concerns were expressed
about potential patient confusion and difficulty with this—
‘‘Creating an environment where the patients’ ability to be
part of the game—and accommodate them when they are sub
optimally resourced—is something our medical practices and
institutions should endeavor to be nimble and responsive to
without judgment, agenda or manipulation’’ (PC 24).
Prior education focused on the integrative model/
unaware of pluralism
Students indicated that their education has focused, almost
exclusively, on integration, and some had never heard
of the pluralistic model before—‘‘Most of us had no idea
about this term in our medical system prior to this class. We
were all stuck on integration’’ (PC 29).
Against the opposition model
Five of the students indicated that opposition was not a
model of choice for them. For example, ‘‘I do agree that
opposition (at least ongoing opposition) is unethical and
unreasonable as a strategy for functional relationship’’
(PC 15).
Pluralism maintains the integrity of Chinese medicine
Pluralism was seen to help maintain the integrity of
Chinese medicine because it did not require it to be amalgamated
with biomedicine and, thus, lose its integrity—‘‘If I
had to choose, I would choose pluralism, but this choice is
only chosen, as the least damaging to the integrity of our
medicine’’ (PC 8).
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Importance of thousands of years of anecdotal
evidence
The thousand-year history of Chinese medicine was
mentioned by several of the students, and was seen as
providing a large amount of anecdotal evidence, and also, in
their view, significantly legitimized its effectiveness—
‘‘heralded in the West is the newest technology or drug,
while heralded in the East is a lifetime of experience treating
the human mechanism’’ (PC 13).
Pluralism is also in Chinese medicine
Some felt that in many ways Chinese medicine itself
operated under a pluralistic model because of the coexistence
of many different theories and styles of practice, and
the notion that there is not one single ‘‘right’’ approach—
‘‘this pluralistic streak in our own medicine has been integral
to its continued evolution’’ (PC 15).
Discussion
This study identified six major and six minor themes.
These Chinese medicine clinicians showed a clear preference
for pluralism and were opposed to integration. Many
expressed that patient care was the most important consideration,
and that this was more important than choosing a
model. Concerns were expressed about power imbalance
issues, the possibility of co-optation, and the appropriateness
of research methodology for assessing the effectiveness
of T&CM therapies. Interprofessional education was seen as
critical to improving the knowledge and understanding of
the T&CM disciplines.
The minor themes highlighted additional important issues.
The practitioners expressed concerns for the ability of
patients to be able to advocate for themselves when faced
with a range of choices of different therapeutic approaches.
They indicated that their prior education had failed to raise
their awareness of a pluralistic model. The opposition model
was viewed as counterproductive and divisive. Pluralism
was seen as a model that would better protect the integrity of
Chinese medicine, and it helped to prevent single modalities
(like acupuncture) from being used outside of the discipline
of Chinese medicine and its theoretical foundations. A small
number of participants spoke to the long history of Chinese
medicine and the value of such a large body of anecdotal
evidence, and the fact that pluralism also exists within
Chinese medicine itself.
This study deepens our understanding of the critical issues
that act as barriers to delivering interprofessional
patient-centered care by biomedical and T&CM practitioners.
Considering that this assignment was only worth 5% of
the course grade, the amount and texture of the dialogue
strongly suggests that these practitioners felt passionately
about these issues. Further, most Chinese medicine practitioners
in the United States work in private practices, and
therefore have control over the way that they interface with
the health care system. Therefore, the perspectives of the
practitioners in this study are not significantly influenced by
being forced into any specific model for their relationship
with biomedicine.
The main reasons that the Chinese medicine practitioners
in this study preferred pluralism was because it allowed each
medical system to retain its autonomy, and it reduced the
likelihood that T&CM would become diluted and devalued
when combined with biomedicine. Some thought that this
dilution and devaluation was caused by issues associated
with the research, whereas others suggested that the vastly
different paradigms and traditions prevented integration.
Similar perspectives have been reported among practitioners
of a range of T&CM disciplines, including Chinese medicine,
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 practitioners
to have greater autonomy and equal standing within
the health care system, as well as an ability to honor their
own paradigms and worldviews.
This suggests that these are universal issues regardless of
different health care systems and other possible cultural
factors. The increasing awareness and concern about the
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
‘‘articulated’’ rather than ‘‘integrative.’’28 Integration, among
attendees, was seen to be an extension of biomedical dominance,
and associated paradigm assimilation and appropriation,
in which nonbiomedical theoretical foundations are
either ignored or translated into biomedical equivalents.7–9
Some see this as directly related to a history of colonial devaluation
of indigenous knowledge.7
This domination by biomedicine is believed to be engendered
by profit and politics.6,7 Thirty-nine percent of the
practitioners in this study spoke about this issue and saw it
as a major impediment to T&CM disciplines being permitted
equal acceptance in biomedical settings. This and
previous studies5–7,18 indicate that T&CM practitioners feel
oppressed by a system that appears to unfairly question what
they do, and that has the capacity to support or sanction their
disciplines. Such underlying attitudes, along with associated
inclusionary/exclusionary strategies,6 will need to be uncovered,
policed, and eliminated for effective and harmonious
interprofessional medical care settings to function
optimally.
The Chinese medicine practitioners in this study emphasized
the importance of interprofessional education, which
indicates that this is not just an abstract ideal, but something
that T&CM practitioners would view as a critical step toward
creating an even playing field. Fortunately, there is
currently concerted effort toward this goal in the development
of medical education competencies10,29 and incorporation
into medical and health care curricula.13 Correspondingly,
there has also been significant focus and funding by the
National Institutes of Health aimed at increasing the research
literacy of T&CM practitioners and teaching evidence-based
medicine in T&CM colleges.30
The use of appropriate research methodology and evidence
to validate T&CM therapies were important issues in
the consideration of the best model for combining biomedicine
and Chinese medicine by these practitioners.
These are contentious issues within the research and T&CM
communities.31,32 Chinese medicine is a complex intervention
in which several different modalities (acupuncture,
herbal medicine, cupping, moxabustion etc.) are frequently
used in a single treatment. Most of the research has focused
only on acupuncture in randomized controlled trials. Such
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trials do not resemble real-world practice and are often inconsistent
with the paradigms of Chinese medicine.32 This is
because they lack Chinese medicine differential diagnosis,
test acupuncture as a single modality, do not individualize
treatments, and often include placebo controls. The splitting
apart of complex medical interventions, and testing individual
modalities outside of their theoretical foundations,
often results in reduced effectiveness outcomes.8,33 Indeed,
this is part of the argument against the use of randomized
controlled trials for testing the efficacy of complex interventions.
31,34,35 Acupuncture placebo controls are not inert,
36 and, consequently, many of these trials have failed to
show a statistically significant difference between real and
placebo treatments, leading to the conclusion that acupuncture
is just a placebo.37
These methodological issues have had a very detrimental
impact on Chinese medicine practitioners’ perceptions of
the quality and value of research.21,38,39 Many feel that
acupuncture randomized controlled trials do not provide
clinically relevant information. Placebo controlled trials are
also seen as a disservice to the profession. Reference to this
is seen in this comment by one of the study participants—
‘‘in the mainstream media, or the journaled ‘‘evidence’’ of
all the sham acupuncture trials that seem to me to only try to
disprove acupuncture from the outset with bias due to the
utilization of sham needling’’ (PC 14).
The practitioners in this study expressed a preference for
pluralism because it preserves the integrity of Chinese
medicine by permitting it to stay as a whole discipline and
not become fragmented by exclusively using one modality
or aspect of the discipline. The more recent focus on wholesystems
research approaches that better encompass the
complexity of acupuncture therapy, such as pragmatic40 and
comparative effectiveness41 trials, has increased the relevancy
of the research for Chinese medicine practitioners.
38,39 This and other studies41 indicate that such research,
along with case studies,17 will need to be recognized as
legitimate evidence to justify treatment decision making in
settings where biomedical and T&CM practitioners are cotreating
and sharing responsibility for patient care.
The themes that arose when discussing the most ethical
model for T&CM and biomedicine by this group of experienced
Chinese medicine practitioners accurately encompass
the key issues that need to be addressed in creating an
interprofessional patient-centered health care environment.
Pluralism permits different disciplines to function autonomously,
but it relies on knowledge, respect, and communication
between practitioners. The participants in this study
identified important barriers—power struggles, the generation,
and use of appropriate evidence to inform patient care
and patient education. Addressing such issues through active
participation of all stakeholders (practitioners, patients, administrative,
and support staff) will be needed to create a
health care system that offers patients the best that our
health care system can provide.
This study has limitations. The forums were undertaken
in the 10th week of the 14-week term, and the students
taking this course would have thus been exposed to the
professor’s (B.A.) opinions and perspectives. This was a
graded assignment (worth 5% of their total grade), and,
therefore, the students may have tended to express what they
thought would be agreeable to the professor. The students
were asked ‘‘to present an argument as to which approach—
opposition, integration or pluralism—you think is the most
ethical model for the relationship between mainstream
and alternative medicine.’’ The word ‘‘ethical’’ can be
interpreted in many ways, and such multiplicity may have
influenced the students’ responses. This may have also
been why many of the students mentioned the importance
of a patient-centered approach. A codebook with operational
definitions to identify themes was not used, which
may have led to inconsistencies between B.A. and S.J., and
inaccuracies in the quantitative evaluations. Identifying
themes in forum dialogue and transforming qualitative
forum dialogue into quantitative data involving quantifying
the number of times themes are mentioned, while accounting
for redundancy (repeated themes in a single forum
post), involved the subjective analysis of the investigators,
and could, therefore, be biased by their perspectives and
interpretations.
Conclusions
This study provides insight into the perspectives of Chinese
medicine practitioners toward different models for
combining biomedicine and T&CM. The issues highlighted
by this study will need to be addressed to provide optimal
patient care as greater numbers of T&CM practitioners are
employed in biomedical settings.
Acknowledgments
The authors thank Dr. Corbin Campbell of Teachers
College, Columbia University for her insightful feedback on
the article. Research reported in this publication was supported
by the National Center for Complementary and Integrative
Health of the National Institutes of Health (NIH),
United States, under Award numbers K07AT007186 and
R25AT003582. This publication was also supported in part
by the CTSA Grant 1 UL1 TR001073-01, 1 TL1 TR001072-
01, and 1 KL2 TR001071-01 from the National Center for
Advancing Translational Sciences, United States (NCATS),
a component of the NIH. The content is solely the responsibility
of the authors and does not necessarily represent the
official views of the NIH.
Disclosure Statement
No competing financial interests exist.
References
1. National Center for Complementary and Integrative
Medicine. Online document at: https://nccih.nih.gov/health/
integrative-health, accessed November 22, 2018.
2. Boon H, Verhoef M, O’Hara D, Findlay B. From parallel
practice to integrative health care: A conceptual framework.
BMC Health Serv Res 2004;4:1–5.
3. Mann D, Gaylord S, Norton S. Moving toward integrative
care: Rationales, models, and steps for conventional-care
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4. Kaptchuk TK, Miller GM. What is the most ethical model
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INTERDISCIPLINARY RELATIONSHIP MODELS FOR CIH 7
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5. Wiese M, Oster C, Pincombe J. Understanding the
emerging relationship between complementary medicine
and mainstream healthcare: A review of the literature.
Health 2010;14:326–342.
6. Adams J, Hollenberg D, Lui C, Broom A. Contextualizing
integration: A critical social science approach to integrative
health care. J Manip Physiol Ther 2009;32:792–798.
7. Hollenberg D, Muzzin L. Epistemological challenges to
integrative medicine: An anti-colonial perspective on the
combination of complementary/alternative medicine with
biomedicine. Health Sociol Rev 2010;19:34–56.
8. Bell IR, Caspi O, Schwartz GE, et al. Integrative medicine
and systemic outcomes research. Arch Intern Med 2002;
162:133–140.
9. Benjamin PJ, Phillips R, Warren D, et al. Response to a
proposal for an integrative medicine curriculum. J Altern
Complement Med 2007;13:1021–1033.
10. World Health Organization Traditional Medicine Strategy
2014–2023. Online document at: http://www.who.int/
medicines/publications/traditional/en
11. Fischer F, Lewith G, Witt CM, et al. A research roadmap
for complementary and alternative medicine—What we
need to know by 2020. Forsch Komplementmed 2014;21:
e1–e16.
12. Sierpina V, Kreitzer MJ. Interprofessional education and
integrative healthcare. Explore 2014;10:265–266.
13. Kreitzer MJ, Sierpina V, Maiers M, et al. Ways of knowing:
Integrating research into CAM education and holism
into conventional health professional education. Explore
2008;4:278–281.
14. Evans R, Maiers M, Delagran L, et al. Evidence informed
practice as the catalyst for culture change in CAM. Explore
(NY) 2012;8:68–72.
15. Perlman A, Stagnaro-Green A. Developing a complementary,
alternative, and integrative medicine course: One
medical school’s experience. J Altern Complement Med
2010;16:601–605.
16. Coomarasamy A1, Khan KS. What is the evidence that
postgraduate teaching in evidence based medicine changes
anything? A systematic review. BMJ 2004;329:1017.
17. Kligler B, Weeks J. Finding a common language: Resolving
the town and gown tension in moving toward
evidence-informed practice. Explore (NY) 2014;10;
275–277.
18. Hollenberg D. Uncharted ground: Patterns of professional
interaction among complementary/alternative and biomedical
practitioners in integrative health care settings. Soc Sci
Med 2006;62:731–744.
19. Geist-Martin P, Bollinger BJ, Wiechert KN, et al. Challenging
integration: Clinicians’ perspectives of communicating
collaboration in a center for integrative medicine.
Health Commun 2016;31:544–556.
20. Hsiao AF, Ryan GW, Hays RD, et al. Variations in provider
conceptions of integrative medicine. Soc Sci Med 2006;62:
2973–2987.
21. Jackson S, Scambler G. Perceptions of evidence-based
medicine: Traditional acupuncturists in the UK and resistance
to biomedical modes of evaluation. Sociol Health Illn
2007;29:412–429.
22. Wiese M, Oster C. ‘Becoming accepted’: The complementary
and alternative medicine practitioners’ response to
the uptake and practice of traditional medicine therapies by
the mainstream health sector. Health 2010;14:415–433.
23. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting
qualitative research (COREQ): A 32-item checklist
for interviews and focus groups. Int J Qual Health Care
2007;19:349–357.
24. O’Brien BC, Harris IB, Beckman TJ, et al. Standards for
reporting qualitative research: A synthesis of recommendations.
Acad Med 2014;89:1245–1251.
25. Patton MQ. Qualitative Research and Evaluation Methods,
3rd ed. Thousand Oaks, CA: Sage, 2002.
26. Braun V, Clarke V. Using thematic analysis in psychology.
Qual Res Psychol 2006;3:77–101.
27. Creswell JW, Creswell JD. Research Design: Qualitative,
Quantitative, and Mixed Methods Approaches, 5th ed. Los
Angeles, CA: Sage, 2017.
28. Weeks J. Articulated Medicine: Pan America Health
Organization Reengages Traditional and Complementary
Medicine Efforts. J Altern Complement Med 2017;23:
745–746.
29. Kligler B, Brooks AJ, Maizes V, et al. Interprofessional
competencies in integrative primary healthcare. Glob Adv
Health Med 2015;4:33–39.
30. Kreitzer MJ, Sierpina VS. NCCAM awards grants to CAM
institutions to enhance research education. Explore (NY)
2008;4:74–76.
31. Langevin HM, Wayne PM, Macpherson H, et al. Paradoxes
in acupuncture research: Strategies for moving forward.
Evid Based Complement Alternat Med 2011;2011:180805.
32. Luo J, Xu H, Liu B. Real world research: A complementary
method to establish the effectiveness of acupuncture. BMC
Complement Altern Med 2015:22;15:153.
33. Craig P, Dieppe P, Macintyre S, et al. Developing and
evaluating complex interventions: The new Medical Research
Council guidance. BMJ 2008;337:a1655.
34. Richardson J. The use of randomized control trials in
complementary therapies: Exploring the issues. J Adv Nurs
2000;32:398–406.
35. Cohn S, Clinch M, Bunn C, Stronge P. Entangled complexity:
Why complex interventions are just not complicated
enough. J Health Serv Res Policy 2013;18:40–43.
36. Zhang CS, Tan HY, Zhang GS, et al. Placebo devices as
effective control methods in acupuncture clinical trials: A
systematic review. PLoS One 2015;10:e0140825.
37. McGeeney BE. Acupuncture is all placebo and here is why.
Headache 2015;55:465–469.
38. Kaptchuk TJ, Chen KJ, Song J. Recent clinical trials of
acupuncture in the West: Responses from the practitioners.
Chin J Integr Med 2010;16:197–203.
39. Hansen K. Attitudes to evidence in acupuncture: An interview
study. Med Health Care Philos 2012;15:279–285.
40. MacPherson H. Acupuncture research: Time to shift from
theoretical to practical questions. J Altern Complement
Med 2006;12:837–839.
41. Witt CM, Aickin M, Cherkin D, et al. Effectiveness guidance
document (EGD) for Chinese medicine trials: A consensus
document. Trials 2014;15:169.
Address correspondence to:
Belinda J. Anderson, PhD
Pacific College of Oriental Medicine
110 William Street, 19th Floor
New York, NY 10038
E-mail:

In today’s health care system, delivery processes involve numerous interfaces and patient handoffs among multiple health care practitioners with varying levels of educational and occupational training. During the course of a 4-day hospital stay, a patient may interact with 50 different employees, including physicians, nurses, technicians, and others. Effective clinical practice thus involves many instances where critical information must be accurately communicated. Team collaboration is essential. When health care professionals are not communicating effectively, patient safety is at risk for several reasons: lack of critical information, misinterpretation of information, unclear orders over the telephone, and overlooked changes in status.1

Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death. Medical errors, especially those caused by a failure to communicate, are a pervasive problem in today’s health care organizations. According to the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, JCHAO), if medical errors appeared on the National Center for Health Statistic’s list of the top 10 causes of death in the United States, they would rank number 5—ahead of accidents, diabetes, and Alzheimer’s disease, as well as AIDS, breast cancer, and gunshot wounds.1 The 1999 Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System, revealed that between 44,000 and 98,000 people die every year in U.S. hospitals because of medical errors.2 Even more disturbing, communication failures are the leading root cause of the sentinel

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events reported to the Joint Commission from 1995 to 2004. More specifically, the Joint Commission cites communication failures as the leading root cause for medication errors, delays in treatment, and wrong-site surgeries, as well as the second most frequently cited root cause for operative and postoperative events and fatal falls.1

Traditional medical education emphasizes the importance of error-free practice, utilizing intense peer pressure to achieve perfection during both diagnosis and treatment. Errors are therefore perceived normatively as an expression of failure. This atmosphere creates an environment that precludes the fair, open discussion of mistakes required if organizational learning is to take place. In the early 1990s, Donald Berwick wrote about patients needing an open communication system instead of experiencing adverse events stemming from communication failures.3 More than a decade later, this concept still has profound implications on our method of health care delivery. As such, this chapter will review the literature on the important role of communication and team collaboration in helping to reduce medical errors and increase patient safety.

Research Evidence Go to: What Are Communication and Team Collaboration?

Webster’s Dictionary defines communication as “the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs.” It is important to consider that communication is not just verbal in form. One study states that 93 percent of communication is more affected by body language, attitude, and tone, leaving only 7 percent of the meaning and intent based on the actual words said.4 Whereas the spoken words contain the crucial content, their meaning can be influenced by the style of delivery, which includes the way speakers stand, speak, and look at a person.1 However, critical information is often transmitted via handwritten notes, e-

mails, or text messages, which can lead to serious consequences if there is miscommunication.

Collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for patient care.5, 6 Collaboration between physicians, nurses, and other health care professionals increases team members’ awareness of each others’ type of knowledge and skills, leading to continued improvement in decisionmaking.7

Effective teams are characterized by trust, respect, and collaboration. Deming8 is one of the greatest proponents of teamwork. Teamwork, he believes, is endemic to a system in which all employees are working for the good of a goal, who have a common aim, and who work together to achieve

 

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that aim. When considering a teamwork model in health care, an interdisciplinary approach should be applied. Unlike a multidisciplinary approach, in which each team member is responsible only for the activities related to his or her own discipline and formulates separate goals for the patient, an interdisciplinary approach coalesces a joint effort on behalf of the patient with a common goal from all disciplines involved in the care plan. The pooling of specialized services leads to integrated interventions. The plan of care takes into account the multiple assessments and treatment regimens, and it packages these services to create an individualized care program that best addresses the needs of the patient. The patient finds that communication is easier with the cohesive team, rather than with numerous professionals who do not know what others are doing to mange the patient.9 Table 1 is a compilation of some of the components found in the literature of a successful teamwork model.10–14

Table 1

Components of Successful Teamwork

It is important to point out that fostering a team collaboration environment may have hurdles to overcome: additional time; perceived loss of autonomy; lack of confidence or trust in decisions of others; clashing perceptions; territorialism; and lack of awareness of one provider of the education, knowledge, and skills held by colleagues from other disciplines and professions.15 However, most of these hurdles can be overcome with an open attitude and feelings of mutual respect and trust. A study determined that improved teamwork and communication are described by health care workers as among the most important factors in improving clinical effectiveness and job satisfaction.16

Extensive review of the literature shows that communication, collaboration, and teamwork do not always occur in clinical settings. For example, a study by Sutcliff, Lewton, and Rosenthal17 reveals that social, relational, and organizational structures contribute to communication failures that have been implicated as a large contributor to adverse clinical events and outcomes. Another study shows that the priorities of patient care differed between members of the health care team, and that verbal communication between team members was inconsistent.16 Other evidence shows that more than one-

fifth of patients hospitalized in the United States reported hospital system problems, including staff providing conflicting information and staff not knowing which physician is in charge of their care.18 Over the past several years, we have been conducting original research on the impact of physician

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and nurse disruptive behaviors (defined as any inappropriate behavior,

confrontation, or conflict, ranging from verbal abuse to physical or sexual

harassment) and its effect on staff relationships, staff satisfaction and

turnover, and patient outcomes of care, including adverse events, medical

errors, compromises in patient safety, poor quality care, and links to

preventable patient mortality. Many of these unwanted effects can be traced

back to poor communication and collaboration, and ineffective teamwork.19– 22

Unfortunately, many health care workers are used to poor communication and teamwork, as a result of a culture of low expectations that has developed in many health care settings. This culture, in which health care workers have come to expect faulty and incomplete exchange of information, leads to errors because even conscientious professionals tend to ignore potential red flags and clinical discrepancies. They view these warning signals as indicators of routine repetitions of poor communication rather than unusual, worrisome indicators.23

Although poor communication can lead to tragic consequences, a review of the literature also shows that effective communication can lead to the following positive outcomes: improved information flow, more effective interventions, improved safety, enhanced employee morale, increased patient and family satisfaction, and decreased lengths of stay.1, 24–26 Fuss and colleagues27 and Gittell and others28 show that implementing systems to facilitate team communication can substantially improve quality.

Effective communication among staff encourages effective teamwork and promotes continuity and clarity within the patient care team. At its best, good communication encourages collaboration, fosters teamwork, and helps prevent errors.

Barriers to Effective Communication

Health professionals tend to work autonomously, even though they may speak of being part of a team.29 Efforts to improve health care safety and quality are often jeopardized by the communication and collaboration barriers that exist between clinical staff. Although every organization is unique, the barriers to effective communication that organizations face have some common themes. Table 2 indicates some common barriers to interprofessional collaboration that we have learned from our research and focus groups with hospitals across the country.

Table 2

Common Barriers to Interprofessional Communication and Collaboration

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The barriers indicated in Table 2 can occur within disciplines, most notably between physicians and residents, surgeons and anesthesiologists, and nurses and nurse managers.30, 31 However, most often the barriers manifest between nurses and physicians. Even though doctors and nurses interact numerous times a day, they often have different perceptions of their roles and responsibilities as to patient needs, and thus different goals for patient care. One barrier compounding this issue is that because the United States is one of the most ethnically and culturally diverse countries in the world, many clinicians come from a variety of cultural backgrounds. In all interactions, cultural differences can exacerbate communication problems.1 For example, in some cultures, individuals refrain from being assertive or challenging opinions openly. As a result, it is very difficult for nurses from such cultures to speak up if they see something wrong. In cultures such as these, nurses may communicate their concern in very indirect ways. Culture barriers can also hinder nonverbal communication. For example, some cultures ascribe specific meaning to eye contact, certain facial expressions, touch, tone of voice, and nods of the head. Issues around gender differences in communication styles, values, and expectations are common in all workplace situations. In the health care industry, where most physicians are male and most nurses are female, 32 communication problems are further accentuated by gender differences. A review of the organizational communication literature shows that a common barrier to effective communication and collaboration is hierarchies.33–37 Sutcliff and colleagues’ research17 concurs that communication failures in the medical setting arise from vertical hierarchical differences, concerns with upward influence, role conflict, and ambiguity and struggles with interpersonal power and conflict. Communication is likely to be distorted or withheld in situations where there are hierarchical differences between two communicators, particularly when one person is concerned about appearing incompetent, does not want to offend the other, or perceives that the other is not open to communication. In health care environments characterized by a hierarchical culture, physicians are at the top of that hierarchy. Consequently, they may feel that the environment is collaborative and that communication is open while nurses and other direct care staff perceive communication problems. Hierarchy differences can come into play and diminish the collaborative interactions necessary to ensure that the proper treatments are delivered appropriately. When hierarchy differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can hinder communication and give the impression that the individual is unapproachable.1, 38

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Staff who witness poor performance in their peers may be hesitant to speak up because of fear of retaliation or the impression that speaking up will not do any good. Relationships between the individuals providing patient care can have a powerful influence on how and even if important information is communicated. Research has shown that delays in patient care and recurring problems from unresolved disputes are often the by-product of physician-

nurse disagreement.39 Our research has identified a common trend in which nurses are either reluctant or refuse to call physicians, even in the face of a deteriorating status in patient care. Reasons for this include intimidation, fear of getting into a confrontational or antagonistic discussion, lack of confidentiality, fear of retaliation, and the fact that nothing ever seems to change. Many of these issues have to deal more with personality and communication style.40 The major concern about disruptive behaviors is how frequently they occur and the potential negative impact they can have on patient care. Our research has shown that 17 percent of respondents to our survey research in 2004–2006 knew of a specific adverse event that occurred as a result of disruptive behavior. A quote from one of the respondents illustrates this point: “Poor communication postop because of disruptive reputation of physician resulted in delayed treatment, aspiration, and eventual demise.”19

Leaders in both medicine and nursing have issued ongoing initiatives for the development of a cooperative rather than a competitive agenda to benefit patient care.5, 39, 41, 42 A powerful incentive for greater teamwork among professionals is created by directing attention to the areas where changes are likely to result in measurable improvements for the patients they serve together, rather than concentrating on what, on the surface, seem to be irreconcilable professional differences. The fact that most health professionals have at least one characteristic in common, a personal desire to learn, and that they have at least one shared value, to meet the needs of their patients or clients, is a good place to start.

Practice Implications Go to: Known Benefits of Communication and Team Collaboration

A large body of literature shows that because of the complexity of medical care, coupled with the inherent limitations of human performance, it is critically important that clinicians have standardized communication tools and create an environment in which individuals can speak up and express concerns. This literature concurs that when a team needs to communicate complex information in a short period of time, it is helpful to use structured communication techniques to ensure accuracy. Structured communication techniques can serve the same purpose that clinical practice guidelines do in assisting practitioners to make decisions and take action. Research from

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aviation and wilderness firefighting is useful in health care because they all

involve settings where there is a huge variability in circumstances, the need to

adapt processes quickly, a quickly changing knowledge base, and highly

trained professionals who must use expert judgment in dynamic settings.

Research shows that in these disciplines, the adoption of standardized tools

and behaviors is a very effective strategy in enhancing teamwork and reducing risks.1, 17, 43–54, 60, 61

Crew Resource Management (Aviation)

Experts in aviation have developed safety training focused on effective team management, known as Crew Resource Management (CRM). Improvements in the safety record of commercial aviation may be due, in part, to this training. Realizing that 70 percent of commercial flight accidents stemmed from communication failures among crew members, CRM sought to standardize communication and teamwork. The concept originated in 1979, in response to a NASA workshop that examined the role that human error plays in air crashes. CRM emphasizes the role of human factors in high-stress, high-risk environments. John K. Lauber, a psychologist member of the National Transportation Safety Board, deemed CRM as “using all available sources—information, equipment, and people—to achieve safe and efficient flight operations.”44, 45 CRM encompasses team training as well as simulation, interactive group debriefings, and measurement and improvement of aircrew performance. This represents a major change in training, which had previously dealt with only the technical aspects of flying. It considers human performance limiters (such as fatigue and stress) and the nature of human error, and it defines behaviors that are countermeasures to error, such as leadership, briefings, monitoring and cross-checking, decisionmaking, and review and modification of plans. From a practical standpoint, CRM programs typically include educating crews about the limitations of human performance. Trainees develop an understanding of cognitive errors and how stressors (such as fatigue, emergencies, and work overload) contribute to the occurrence of errors. Operational concepts stressed include inquiry, seeking relevant operational information, advocacy, communicating proposed actions, conflict resolution, and decisionmaking. CRM is now required for flight crews worldwide.

The development and implementation of CRM in aviation over the last 25 years offers valuable lessons for medical care. Sexton and colleagues51 compared flight crews with operating room personnel on several measures, including attitudes toward teamwork. This landmark study included more than 30,000 cockpit crew members (captains, first officers, and second officers) and 1,033 operating room personnel (attending surgeons, attending anesthesiologists, surgical residents, anesthesia residents, surgical nurses, and anesthesia nurses). Questionnaires were sent to crew members of major airlines around the world (over a 15-year period). The operating room

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participants were mailed an analogous questionnaire, administered over a period of 3 years at 12 teaching and nonteaching hospitals in the United States, Italy, Germany, Switzerland, and Israel.

The Sexton study and other analyses suggest that safety-related behaviors that have been applied and studied extensively in the aviation industry may also be relevant in health care. Study results show successful CRM applications in several dynamic decisionmaking health care environments: the operating room, labor and delivery, and the emergency room.26, 31, 55, 56 As with aviation, the medical application of CRM has required tailoring of training approaches to mirror the areas in which human factors contribute to mishaps. In anesthesiology, 65–70 percent of safety problems (accidents or incidents) have been attributed at least in part to human error. In response, several anesthesiologists from the Veterans Affairs Palo Alto Health Care System and Stanford University developed Anesthesia Crisis Resource Management (ACRM), modeled on CRM.55 Kaiser Permanente, a nonprofit American health care system providing care for 8.3 million patients, has also adopted CRM with successful results.54 In response to the occurrence of a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) Regional Hospital developed and implemented a patient safety program called Medical Team Management (MTM) that was modeled on the aviation industry’s CRM program and focused on communication, teamwork, and reporting to determine the impact of a patient safety program on patterns of medical error reporting.57 This study was a retrospective review of 1,102 incident reports filed at Eglin USAF Regional Hospital in Florida between 1997 and 2001. Collected data from the comparison periods (1998 and 2001) were statistically analyzed using the chi-square test. This study indicates that, since the implementation of MTM, there has been a statistically significant increase in the number of reports filed at Eglin USAF Regional Hospital and a decline in the severity of incidents. These findings suggest that since the implementation of MTM, there have been changes in the patterns of error reporting, and with training, staff are able to prevent more serious incidents. Table 3 highlights the application of a CRM model to medicine.

Table 3

Application of a CRM Model to Medicine

Kaiser Permanente, SBAR (Situation, Background, Assessment, Recommendation) Tool, 2002

Doctors and nurses often have different communication styles in part due to training. Nurses are taught to be more descriptive of clinical situations, whereas physicians learn to be very concise. Standardized communication

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tools are very effective in bridging this difference in communication styles.

Michael Leonard, physician coordinator of clinical informatics at Kaiser Permanente, along with colleagues, developed a technique called SBAR (Situation-Background-Assessment-Recommendation). This technique has been implemented widely at health systems such as Kaiser Permanente.1, 17, 58 Many other hospitals have embraced the SBAR communication tool or a similar tool created by the Studer Group (see Table 4).59 For example, the Queen’s Medical Center in Honolulu has incorporated the SBAR tool as a key component of its patient safety program. The SBAR technique provides a framework for communication between members of the health care team about a patient’s condition. SBAR is an easy-to-remember tool used to create mechanisms useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations between members of the team for what will be communicated and how, which is essential for information transfer and cohesive teamwork. Not only is there familiarity in how people communicate, but the SBAR structure helps develop desired critical-thinking skills. The person initiating the communication knows that before they pick up the telephone, they need to provide an assessment of the problem and what they think an appropriate solution is. Their conclusion may not ultimately be the answer, but there is clearly value in defining the situation. Table 5, Guidelines for Communicating with Physicians Using the SBAR Process explains how to carry out the SBAR technique in detail. The guidelines use the physician team member as the example; however, they can be adapted for use with all other health professionals.

Table 4

Studer Group Communication Guidelines for Nurses

Table 5

Kaiser Permanente, SBAR (Situation, Background, Assessment, Recommendation) Tool, 2002

STICC (Situation Task Intent Concern Calibrate) is another type of structured briefing protocol used by the U.S. Forest Service to give direction to firefighters.1, 17, 60, 61 The following five steps are involved:

Situation: Here’s what I think we face.

 

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Task: Here’s what I think we should do.

Intent: Here’s why.

Concern: Here’s what we should keep our eye on.

Calibrate: Talk to me. Tell me if you don’t understand, can’t do it, or see something I do not.

Establishing Culture To Support Communication and Go to: Team Collaboration

The literature reviewed shows that effective teams are characterized by common purpose and intent, trust, respect, and collaboration. Team members value familiarity over formality and watch out for each other to make sure mistakes are not made. Health care teams that do not trust, respect, and collaborate with one another are more likely to make a mistake that could negatively impact the safety of patients.

One of the first crucial steps is organizational commitment and willingness to address the situation. Commitment needs to come from the top down and bottom up, making a statement about the way the organization does business. The rallying point should be around behavioral standards and their relationship to patient safety. It’s ironic that ever since the publication of the original IOM report, To Err Is Human, organizations have spent the bulk of their time and efforts in improving patient systems rather than addressing the human factor issues highlighted in the original report.2 Several recent reports have suggested that while we have made progress in the patient safety movement, we have a long way to go in meeting the IOM recommendations.62 Addressing defects in communication that affect collaboration, information exchange, appreciation of roles and responsibilities, and direct accountability for patient care are key components of any patient safety program. Clinical and administrative leaders must set the tone by establishing and adhering to behavioral standards that support agreed-

upon code of conduct practices backed by a nonpunitive culture and zero- tolerance policy.

The next step in the process is recognition and self-awareness. Organizations must be able to assess the prevalence, context, and impact of behaviors to identify potential opportunities for improvement. Doing an internal assessment will help pinpoint the seriousness of the situation and provide clues to areas that need to be addressed. Assessment information can be gained from formal methods such as incident reports, survey tools, focus groups, department meetings, task forces or committees, direct observation, suggestion boxes, and hot lines. Informal methods such as casual meetings and gossip can also provide valuable surface information and should be evaluated more deeply as to the source, relevance, and significance of the events to determine next steps. In many organizations there are still remnants

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of reluctance to address the issue head on for fear of antagonizing a prominent surgeon or staff member. With growing concerns about workforce shortages, staff satisfaction and retention, hospital reputation, liability and patient safety, and the need for compliance to the latest Joint Commission proposed standards addressing disruptive behaviors, organizations can no longer afford to take a passive approach to the situation.63–66

Creating opportunities for different groups to just get together is a highly effective strategy for enhancing collaboration and communication. These group interactions can be either formal or informal. Encouraging open dialogue, collaborative rounds, implementing preop and postop team briefings, and creating interdisciplinary committees or task forces that discuss problem areas frequently provides an upfront solution that reduces the likelihood of disruptive events. When a disruptive event does occur, some organizations have implemented a time-out, code white, or red light policy that addresses the issue in real time to prevent any further serious consequences.59

Developing and implementing a standard set of behavior policies and procedures is vital. These policies need to be consistent and universally applied. There should not be a separate policy for any one particular discipline or service. For the medical staff, the policies should become part of the medical staff bylaws with signed agreements to abide by these policies at the time of appointment and recredentialing. Included in the policies should be a standardized protocol outlining expected standards and the process for addressing disruptive behavior issues, recommendations, followup plans, and actions to be taken in the face of individual resistance or refusal to comply. Prior to implementation, make sure all employees are familiar with the existence, purpose, and intent of the policies and procedures.

For the process to unfold, the organization needs to encourage its employees to report disruptive behaviors. The organization needs to address issues related to confidentiality, fear of retaliation, and the common feelings that there is a double standard and that nothing ever gets done. Reporting mechanisms should be made easy and must be supported by the presence of a nonpunitive environment. The ideal vehicle for reporting is to address the situation in real time, but concerns about position, appropriateness, 67 receptiveness, fear, hostility, and retaliation are significant impediments. Appropriate vehicles for reporting may include reporting of the incident to a superior, filing an incident report, using a complaint or suggestion box, or reporting directly to a task force or interdisciplinary committee with assigned responsibilities for addressing these issues.59 Besides maintaining confidentiality and reducing risks of retaliation, one of the most crucial aspects of the reporting system is to give recognition and assurance that the complaints will be addressed and actions will be taken. Responses should be timely, appropriate, consistent, and provide necessary feedback and followup.

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Taking action though appropriate intervention strategies is next. On one level, generic educational programs can do a lot to spread the message and teach basic skills necessary to promote effective communication. Appropriate topics should include sessions on team dynamics, communication skills, phone etiquette, assertiveness training, diversity training, conflict management, stress management, and any other courses necessary to foster more effective team functioning and communication flow. Courses should be offered to all staff and employees at the organization: physicians, physicians in training, nurses, nursing students, and all other staff who have patient contact or play a role in the delivery of patient care. For individuals who have consistently exhibited disruptive behavior, education may need to be supported by more focused sessions and specific counseling. Another important strategy is to promote and assure competency training at all levels of the health care team. This is a key factor affecting trust and respect, which have such a strong influence on team collaboration.

Focused team training programs have been of particular value. One of the newer approaches to improving team collaboration and patient safety is through the principles learned from the aviation industry. Fostering an environment of trust and respect, accountability, situational awareness, open communication, assertiveness, shared decisionmaking, feedback, and education, interdisciplinary CRM training has brought significant 52, 53 improvements to communication flow in the perioperative setting.

Having a clinical champion or early adopter who actively promotes the importance of appropriate behavior, communication, and team collaboration can be an extremely valuable asset. Champions can come from the executive ranks or through the voluntary interest and enthusiasm of other staff members. Co-champions may be even more effective. Some organizations have reported that having a nurse and physician (or other health care professional) go through a joint training program will help foster mutual cooperation and collaboration between the different disciplines.59 Followup and feedback bring closure to the process. It is important to let people know that their input is welcomed, followup actions will be taken, and appropriate feedback will be provided.

Research Implications Go to:

The existing literature adequately outlines structured communication techniques that will help minimize medical errors. However, more research is needed on how to effectively deal with miscommunication and barriers to communication in real-time crisis situations. Also, the existing literature lacks concrete research confirming a cause-and-effect relationship between human factors and clinical outcomes of care.

Conclusions Go to:

 

 

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Effective clinical practice must not focus only on technological system issues, but also on the human factor. As shown in this chapter,good communication encourages collaboration and helps prevent errors. It is important for health care organizations to assess possible setups for poor communication and be diligent about offering programs and outlets to help foster team collaboration. By addressing this issue, health care organizations have an opportunity to greatly enhance their clinical outcomes.

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