Why do general practitioners (GPs) seem so open to complementary therapies? The nature of family medicine is a clue: GPs deal mostly with acute disease, which would get better on its own, and with a great deal of chronic degenerative disease like arthritis and heart failure. True, they witness some (but not a great deal of) catastrophic disease like cancer and coronaries, but far more long-term relapsing disorders: asthma, digestive or skin problems; conditions where tissues are sound yet organs malfunction, often because of a 'stress-related' component.
Why do general practitioners (GPs) seem so open to complementary therapies? The nature of family medicine is a clue: GPs deal mostly with acute disease, which would get better on its own, and with a great deal of chronic degenerative disease like arthritis and heart failure. True, they witness some (but not a great deal of) catastrophic disease like cancer and coronaries, but far more long-term relapsing disorders: asthma, digestive or skin problems; conditions where tissues are sound yet organs malfunction, often because of a 'stress-related' component. And a significant amount of GP time is taken up with patients' problems of daily living and their social crises, sometimes manifesting as bodily illness. Understandably we struggle with this array of suffering, knowing that health care is only partly a matter of science and that biomedicine has no 'cure' for ordinary unwellness and distress. Many patients still expect doctors to provide such a cure nonetheless, so it is disappointing that 30 years of pharmaceutical progress have delivered so few significant new treatments for common diseases.
Much discussion of integration of complementary and alternative and mainstream practice tends to focus on the needs, expectations and problems of medical professionals who are integrating CTs. But there are other issues relating particularly to the needs (and anxieties) of the complementary and alternative medicine (CAM) practitioner who intends to get involved in an integration project. Working collaboratively at close quarters with the medical profession can entail some loss of autonomy (for that is the nature of teamwork); and perhaps the acceptance of the doctor as the 'gatekeeper' would be high on the list of initial difficulties encountered.
Why then might complementary practitioners (CPs) want to work in the mainstream? Once again the issues are not just about effectiveness. Some experienced CPs having realized their own therapy is not a total 'alternative', want to reassess conventional medicine's strengths as well as its weaknesses; discover at first hand the worth and limitations of other CTs; treat a wider case mix and gain access to the state sector. This makes the idea of working in a group very interesting, compelling even. Although few have as yet been able to turn curiosity into the reality of teamwork, we predict that CPs and GPs will find ways to work together and that, for it to happen, all the members will have to be dear on why they are doing so and how best to go about it.
Successful integration entails a gradual acclimatization to what is in many ways a foreign environment, where the CAM practitioner will encounter language difficulties and perspectives quite different from those of the safe, self-directed world of independent private-sector CAM practice. What is more, working in an NHS setting usually involves a financial sacrifice. Why then might a CAM practitioner want to collaborate with a GP or work in a clinical setting with mainstream practitioners and therapists? The trade-off needs to make professional sense. One major reason why CAM practitioners choose to provide their particular skill or approach in a GP setting is for personal and professional development.
Yet, becoming enmeshed in teamwork is one of the first culture shocks involved; the tensions and challenges this involves, as well as the safety net it offers, mean abandoning the purely self-directed style of operation most CAM practitioners enjoy in private work. The integration exercise at Marylebone has involved the personal and professional growth of doctors as well as CAM therapists and practitioners. In fact, we suspect that the most critical factor for co-workers hoping to integrate their approaches is the availability of time for the sort of well organized group reflection where strongly held belief systems, and the therapeutic practices which flow from these, can be examined together.
Mainstream practice provides clinical challenges as well as opportunities to evaluate the relevance, practicability and effectiveness of one's own skills and approaches and those of others. CAM practitioners in private practice usually work solo, and if they interact with mainstream practitioners at all, it is only through occasional cross-referrals. However, when working in a team of GPs, counsellors and other CAM practitioners, detailed discussion of patients' individual needs and exploring therapeutic choices is possible. In this setting CAM practitioners will also be asked for evidence and explanations of what they do. Learning to discuss treatment approaches and clinical choices in a coherent way, using jargon-free language comprehensible to people from other disciplines, can be a profoundly educational experience. Multidisciplinary team-working requires co-workers to develop relationships with colleagues and build mutual confidence that patients will be safely cared for. Learning to understand the needs, methods and perspectives of other healthcare disciplines is an impetus for professional growth; for pre-existing prejudices slowly melt with the realization of our common aims.
The integration exercise calls for an ability to reflect honestly on the concepts and methods of one's own particular discipline while learning to appreciate the views and methods of others who see the world differently. Whether a team intends complementary therapies to be provided by conventional or by non-medically qualified practitioners, the need to plan and manage the project carefully will be paramount, because the decision to bring CTs into mainstream medical practice is a great challenge for any practice. We have therefore designed this book to help all practitioners discover their own best approach. 1t is based on our experience at Marylebone Health Centre (MHC) in central London, where we have been developing an integrated system since the mid-1980s. Our experience and the experience of other practices, have shaped this book, which has been 5 years in the writing.