Patient Education and Counseling 70 (2008) 395402

www.elsevier.com/locate/pateducou

Attitudes toward integration of complementary and alternative medicine

in primary care: Perspectives of patients, physicians and
complementary practitioners
Eran Ben-Arye a,*, Moshe Frenkel a,b, Anat Klein c, Moshe Scharf d
a
Department of Family Medicine, Israel
b
The University of Texas M. D. Anderson Cancer Center, Houston, United States
c
Medicollege, International Center and College of Natural Complementary Medicine, Haifa, Israel
d
Clalit MashlimaComplementary Clalit Health Services, Haifa, Israel
Received 14 February 2007; received in revised form 11 November 2007; accepted 23 November 2007

Abstract
Objective: Our study explored the attitudes of patients toward complementary and alternative medicine (CAM) use, their family physicians role
regarding CAM, and models for CAM referral and treatment. We compared patients perspectives regarding integration of CAM into primary care
with attitudes of primary care physicians (PCPs) and CAM practitioners.
Methods: We conducted a comprehensive literature review and focus group discussions to develop a questionnaire, which we gave to three groups:
a random sample of patients receiving care at an academic family medicine clinic and PCPs and CAM practitioners employed in the largest health
maintenance organization in Israel.
Results: A total of 1150 patients, 333 PCPs, and 241 CAM practitioners responded to our questionnaire. Compared with PCPs, patients expected
their family physician to refer them to CAM, to have updated knowledge about CAM, and to offer CAM treatment in the clinic based on appropriate
training. When asked about CAM integration into medical care, more patients expected to receive CAM in a primary care setting compared to
PCPs expectations of prescribing CAM (62% vs. 30%; p = 0.0001). Patients, CAM practitioners, and PCPs expected family practitioners to
generate CAM referrals in an integrative primary care setting (85.6% vs. 82.4% vs. 62.6%; p < 0.0001). Patients supported CAM practitioners
providing CAM treatments in the primary care setting, regardless of whether the practitioner held a medical degree (MD). Also, more patients than
PCPs or CAM practitioners expected their family physician to provide CAM (28.2% vs. 14.5% vs. 3.8%; p < 0.0001).
Conclusion: Patients, PCPs, and CAM practitioners suggested that family physicians play a central role in CAM referral and, to a lesser extent,
that they actually provide CAM treatment themselves.
Practice implications: PCPs need to be aware of their present and future role in informed referral to CAM and, to a lesser degree, in providing
CAM in integrative primary care clinics. With the increasing use of CAM, patients may expect their family physician to be more knowledgeable,
skillful, and have a balanced approach regarding CAM use. In addition, practitioners should learn how to communicate effectively and better
collaborate with CAM practitioners to the benefit of their patients.
# 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Primary care; Family medicine; Integrative medicine; Complementary medicine; Alternative medicine; Doctorpatient communication

1. Introduction techniques rooted in traditional, philosophical, and empirical

The phrase complementary and alternative medicine
(CAM) encompasses a variety of therapeutic methods and
* Corresponding author at: Unit of Complementary and Traditional Medicine,
Department of Family Medicine, Clalit Health Services, 6 Hashahaf Street,
Haifa 35013, Israel. Tel.: +972 52 870 9282; fax: +972 4 851 3059.
E-mail address: eranben@netvision.net.il (E. Ben-Arye).
systems of medicine that view health and disease in the context
of the human totality of body, mind, and spirit. The
establishment of the National Center of Complementary and
Alternative Medicine by the U.S. National Institutes of Health
in 1997 marked a shift in the relationship between mainstream
conventional medicine and CAM. Medical educators have
suggested various models for the relationship between the two
systems, shifting from opposition to integration and pluralism
[1]. This phenomenon is also evident in the changing

0738-3991/$ see front matter # 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2007.11.019
396 E. Ben-Arye et al. / Patient Education and Counseling 70 (2008) 395402
terminology for non-conventional medicine from alternative
medicine to complementary medicine suggesting a lesser
degree of opposition. The term integrative medicine not only
implies tolerance of mainstream medicine toward CAM but
also calls for a dialogue between the two systems in clinical
practice, research, and education [2]. Some scholars use the
term integrative medicine to refer to the merging of CAM
with conventional biomedicine [3], while others conceptualize
it as being different from combination medicine (CAM plus
conventional medicine) and emphasize its synergistic potential
in advancing a patient-centered bio-psycho-socio-spiritual
paradigm [4].
Integrating CAM into national health care systems has been
suggested in North America, Europe, and Australia [5,6]. In
2002, the White House Commission on Complementary and
Alternative Medicine Policy recommended integration into
the nations health care system of those complementary and
alternative health care practices and products determined to be
safe and effective [7]. In the U.K. in 2001, the House of Lords
report on complementary medicine recommended integrating
CAM with conventional medicine [8], and the Prince of Wales
has also advocated integrating various CAM modalities into the
U.K. National Health System [9]. Integration of conventional
medicine and CAM (or traditional medicine) has been evident
in clinical practice and medical education in China for decades
and has been growing in developing countries such as India and
Cuba [1012].
We decided to look at CAM use in Israel because Israel
has an ethnically diverse population that used, until the past
four decades, a variety of traditional medicine modalities.
Nevertheless, as modernity prevails, ethnic characteristics
are fading [13]. Israels population of 7.1 million [14] uses
complementary therapies extensively. In 2005, the number of
registered CAM practitioners involved in CAM professional
societies was 3500 (out of 10,000 trained CAM practitioners)
[15], and 1.4 million CAM treatments were administered,
45% of which were administered by the four health
maintenance organizations (HMOs). All four of Israels
HMOs offered CAM treatments under medical surveillance
through administratively separate agencies. Shmueli and
Shuval showed that between 1993 and 2000, CAM use grew
among the Israeli Jewish urban population aged 4575 years
[16]. The increase in CAM use was accompanied by a
growing volume of CAM research in Israel, with a significant
number of publications from family medicine departments
[17,18]. These two tendencies of increased CAM use and
research along with the rise in CAM reimbursement by
managed care organizations and insurance providers in the
US and Europe [1921], emphasize the need to study the
feasibility of CAM integration in Israel in general and in
primary care in particular.
Researchers have described various obstacles in establishing
integrative care clinics and suggested different models for
integration in hospital and primary care settings [3,22,6,23,24].
Frenkel and Borkan [25] and Bell et al. [4] suggested
employing integrative clinical models for primary health care,
emphasizing the holistic approach common to CAM and
conventional medicine. However, articles on this topic are
limited to theoretical discussion of the possibilities of CAM
integration. Our study aimed to fill the gap between theory and
real-life clinical practice by exploring patients, physicians
and CAM practitioners attitudes about integrating CAM into
primary care. The authors intended to study the three groups
viewpoints concerning the following questions: How do
patients, conventional clinicians and CAM practitioners
perceive an integrative care model, and where should it be
based (primary, secondary, or tertiary care setting)? Who
should refer patients to CAM and who should provide the
treatment? How do patients and physicians envision the role of
the family practitioner in this integrative process? Do they
envision adding CAM treatments to the family practitioners
arsenal of prescribed medication and optional referrals? Or,
does integration mean adjoining the CAM practitioner to the
clinics medical team?
2. Methods
2.1. Study participants
We designed a three-arm study of patients, primary care
physicians (PCPs), and CAM practitioners. All study sites were
a part of Clalit Health Services (CHS), which is the largest of
the four HMOs in Israel and serves approximately 60% of
Israels population [26]. The Minister of Health in Israel and the
Medical Director of the CHS Haifa district supported the study.
A Helsinki Committee (a local institutional review board)
approved the study protocol.
The following three populations participated in the study:
 Patients receiving care at a large university-based primary
care clinic in Kiryat Motzkin, a city in northern Israel with a
population of 40,000 people of moderate to high socio-
economic status (7 on a 10-point scale) [27]. The clinic
operates under the aegis of the CHS, serves a population of
15,700 clients (12,500 of which are adults), and employs 40
staff members. We included patients from only one clinic
because of the clinics large size and because the
demographic characteristics of the patients were representa-
tive of the Jewish urban population. A pilot study of 60
patients verified that CAM use among the clinic patients was
comparable to a previous report on CAM use in primary care
CHS clinics in Israel [28].
 PCPs working in CHS clinics who were connected to the CHS
e-mail network or employed in the CHS Haifa and Western
Galilee district.
 Physicians and CAM practitioners employed by an agency
that was part of CHS that offers self-paid, reduced-price
CAM services at 40 clinics throughout Israel.
2.2. Study design
We designed the study based on teaching and research
experience with PCPs, CAM students/practitioners, and
patients at both conventional and CAM clinics in Israel and
 E. Ben-Arye et al. / Patient Education and Counseling 70 (2008) 395402 397

Texas. We conceptualized a collaboration of conventional and
CAM researchers in study design.
First, we developed three sets of questionnaires after
conducting a comprehensive literature review and holding
meetings in the Complementary and Traditional Medicine
Unit at the Department of Family Medicine in Haifa. To
refine the questions, we administered the questionnaires
to three focus groups (a patient focus group, a PCP group,
and a CAM practitioner group). The focus groups
consisted of male and female patients of various ages and
education levels and with various health statuses and CAM
experiences.
We refined the questionnaires a second time by adminis-
tering pilot questionnaires to a sample of 60 patients in the
clinic, 30 PCPs, and 30 CAM practitioners. We analyzed the
data from these preliminary pilot questionnaires to further
refine the questionnaires and came up with a broad and
understandable definition of CAM: therapies often named
alternative, complementary, natural, folk/traditional medicine,
which are not usually offered as part of the medical treatment in
the clinic. Added to this definition was a list of CAM
modalities: herbal medicine, Chinese medicine (including
acupuncture), homeopathy, folk and traditional medicine, diet/
nutritional therapy (including nutritional supplements), chir-
opractice, movement/manual healing therapies (massage,
reflexology, yoga, Alexander and Feldenkreis techniques,
etc.), mindbody techniques (meditation, guided imagery,
relaxation), energy and healing therapies, and naturopathy. The
final version of the questionnaires consisted of 8 questions
about participants demographics and 15 questions about their
attitudes toward CAM, which included 13 multiple-choice
questions (MCQs) and 2 questions that used a Likert-like scale.
To administer the survey, research assistants approached
1300 patients receiving treatment at a family medicine clinic
from April to June 2005. Any patient over the age of 18 years
who came to the clinic seeking administrative, medical
(nurse or physician), or pharmaceutical service was asked to
fill out the questionnaire. Patients were given the option of
filling out the questionnaire themselves or having the
questions read to them in Hebrew or Russian with the
research assistant recording the answers. This dual-option
strategy was chosen in order to limit language bias.
Questionnaires were posted and e-mailed to 2532 PCPs
and 450 CAM practitioners employed in CHS. We employed
both e-mail and postal routes in order to overcome the
possibility of non-active or non-used e-mail addresses. A
web-based system was used to distribute questionnaires via
e-mail in such a way that respondents remained anonymous.
We then input the survey data into a computer for further
analysis.
2.3. Statistical analysis
We evaluated the data using SPSS software, version 12
(SPSS Inc., Chicago, IL, USA). A p value less than 0.05 was
regarded as statistically significant. We performed t-test and
analysis of variance and Pearsons Chi-squared to determine
whether a significant difference existed between patients, PCPs,
and CAM practitioners in terms of age, years of education and
sex.

Table 1
Characteristics of patients, PCPs, and CAM practitioners
Characteristic Patients (n = 1150) PCPs (n = 333) CAM practitioners (n = 241)
Sex, no. (%)a
Men 418 (37%) 187 (58%) 95 (41%)
Women 704 (63%) 134 (42%) 137 (59%)
Mean age  S.D. (median) (years) 50.3  18.2 (53) 47.7  7.2 (48) 40.2  9.4 (38)
Education  S.D. (years) 13  2.9
Medical specialties, no. (%) b
Specialist 265 (80%)c
Family medicine 105 (32%)
Internal medicine 47 (14%)
Pediatrics 9 (3%)
CAM modality, no. (%) b
Movement/manual healing 124 (51%)d
Traditional Chinese medicine 88 (37%)
Naturopathy 29 (12%)
Homeopathy 10 (4%)
Herbal medicine 9 (4%)
Chiropractic 8 (3%)
Healing 4 (2%)
Meditation 3 (1%)
Note: Data analysis were performed by t-test.
a
1122/1150 patients, 321/333 PCPs, and 232/241 CAM practitioners reported their sex.
b
Respondents reporting any kind of medical or CAM specialty, which included one or more of the fields specified in the table.
c
Eighty-eight physicians (27.3%) reported having studied CAM, with experience ranging from basic introductory courses to full programs. Twenty-four physicians
(7.7%) reported practicing CAM. Fifty-two percent reported having used CAM treatments over the past year.
d
Thirty-one (13%) of the CAM practitioners were physicians.
398 E. Ben-Arye et al. / Patient Education and Counseling 70 (2008) 395402

3. Results Table 2
Patients and PCPs assessment of CAM efficacy and safety (on a 5-point scale)

Questionnaires were offered to three groups of partici- Patients PCPs p Value

pants: adult patients receiving care at a primary care clinic, Total number of respondents 1024 329 0.0001
PCPs, and CAM practitioners. Of these, 88% of the patients Mean level of efficacy 3.4619 2.9392
(1150/1307), 13% of the PCPs (333/2532), and 54% of the Median 3 3
CAM practitioners (241/450) responded. The respondents
Number of CAM users 472 170 0.0001
characteristics are summarized in Table 1.
Mean level of efficacy 3.6589 3.1647
Median 4 3
3.1. CAM use during the past year
Total number of respondents 1021 325 0.0001
We first analyzed the personal practices and attitudes of Mean level of safety 3.6249 3.3692
patients compared to those of PCPs A considerable number of Median 4 3
participants in both groups reported having used CAM Number of CAM users n = 473 n = 167 0.0001
treatments in the previous year (patients 44.8% vs. PCPs Mean level of safety 3.8436 3.5509
52.0%; p = 0.02). Fig. 1 shows that more patients than PCPs Median 4 4
reported use of diet therapy, including nutritional supplements
Note: Data analysis was performed by Pearsons Chi-squared test.
(43.6% vs. 34.3%; p = 0.039), folk/traditional medicine (29.2%
vs. 19.2%; p = 0.009), energy healing (13.0% vs. 4.1%;
p = 0.0006) and naturopathy (12.8% vs. 6.4%; p = 0.024). expectations to what PCPs believed were patients expecta-
PCPs reported significantly more use of homeopathy (18.0% tions regarding the physicians role in CAM. Patients
vs. 10.5%; p = 0.015) and consultation with CAM practitioners had significantly higher expectations of their family
(26.4% vs. 43.0%; p < 0.0001) than patients did. physician compared to PCPs expectations on the following
topics: referral to CAM based on efficacy and safety aspects
3.2. Subjective assessment of CAM efficacy and safety (40.4% vs. 25.3%; p < 0.0001), updated knowledge about
CAM (25.7% vs. 16.0%; p < 0.0001), and feasibility of
Patients and PCPs scored CAM efficacy and safety on a 5- offering CAM treatment in the clinic based on appropriate
point scale (Table 2). Compared to PCPs, patients rated CAM as training (14.9% vs. 3.0%; p < 0.0001). Compared to patients,
more efficacious and safe. In both groups, those who used CAM PCPs thought that patients expected PCPs only to listen to
attributed significantly more efficacy and safety to CAM use them on topics regarding CAM (9.4% vs. 35.8%;
than did those who did not use CAM. The same discrepancies in p < 0.0001).
the efficacy and safety score were noticed between both patients
and PCPs who used CAM. 3.4. Level of care

3.3. Expectations about the family physician Patients and PCPs perspectives on the integration of CAM
into a primary care clinic were also compared. Table 3 shows
Patients and PCPs reported their expectations of a family that more patients than PCPs expected to receive CAM in a
physician regarding CAM. Fig. 2 compares patients primary care clinic (62.0% vs. 29.8%; p = 0.0001), while more

Fig. 1. Patients and primary care physicians self-reports on CAM use and consultations with CAM practitioners in the previous year.
 E. Ben-Arye et al. / Patient Education and Counseling 70 (2008) 395402 399

Table 3
If CAM were included in the medical service, where would you prefer to receive CAM treatment?
Preferred site of care Number of respondents (%) p Value
a
Patients (n = 1074) PCPs (n = 333)
Primary care clinic 666 (62.0%) 99 (29.8%) 0.0001
Specialist clinic in a secondary care center 228 (21.2%) 163 (49.1%) 0.0001
Hospital clinic 18 (1.7%) 3 (0.9%) NSb
Private care 103 (9.6%) 28 (8.4%) NS
Health food store 6 (0.6%) 3 (0.9%) NS
Note: Data analysis was performed by Pearsons Chi-squared test.
a
1074/1150 patients responded to this question.
b
NS: not significant.

Fig. 2. Patients expectations of their family physician regarding CAM.

PCPs supported a specialist clinic in a secondary medical
setting (21.2% vs. 49.1%; p = 0.0001).
3.5. Referral and treatment in an integrative family
medicine clinic
Figs. 3 and 4 illustrate patients, PCPs, and CAM
practitioners outlooks as to the appropriate model of CAM
integration in a family medicine clinic setting. As shown in
Fig. 3, patients and CAM practitioners supported a referral by a
family physician significantly more than PCPs did (85.6% vs.
82.4% vs. 62.6%, respectively; p < 0.0001). PCPs and CAM
practitioners were more supportive of direct self-referral to
CAM than patients (27.1% vs. 23.1% vs. 12.6%; p < 0.0001).
Fig. 4 shows each groups perspectives regarding the
characteristics of the practitioner offering CAM treatment in a

Fig. 3. Who should refer to CAM treatment in your primary care clinic? Fig. 4. Who should offer CAM treatment in your primary care clinic?
400 E. Ben-Arye et al. / Patient Education and Counseling 70 (2008) 395402
theoretical integrative family medicine clinic. Both PCPs and
CAM practitioners attributed the task to a CAM practitioner
without a medical degree (MD), followed by an MD CAM
practitioner and then a family physician trained in CAM.
Nevertheless, more PCPs than CAM practitioners supported the
role of a family physician in CAM treatment (14.5% vs. 3.8%;
p < 0.0001), and fewer PCPs than CAM practitioners
supported the role of a non-MD CAM practitioner (40.9%
vs. 85.0%; p < 0.0001). Patients highly ranked the place of an
MD CAM practitioner in providing CAM in their family care
clinic but supported the option that their family physician
provide CAM more than PCPs or CAM practitioners (28.2% vs.
14.5% vs. 3.8%; p < 0.0001).
4. Discussion and conclusion
4.1. Discussion
Our study found that patients supported the option of
receiving CAM in a primary care setting. Patients also expected
PCPs to be more active in prescribing CAM. In contrast, PCPs
assumed that patients expected PCPs to be merely passive
listeners about patients CAM use. A similar discrepancy was
evident when we asked patients and PCPs who should provide
CAM in an integrative primary care clinic. We also looked at
the role of the CAM practitioner and found that more CAM
practitioners and patients supported the family physicians role
in referral to CAM. There was also a discrepancy between
CAM practitioners and PCPs on whether MD or non-MD CAM
practitioners should be included in the clinic team.
How to create collaborative teamwork between physicians
and CAM practitioners (both MD and non-MD) is one of the
puzzling areas in integrative medicine research. We studied this
theme in a subset questionnaire administered to PCPs and
CAM practitioners and found that the majority of both groups
expressed an interest in clinical practice collaboration,
preferred using a medical letter to communicate with each
other, and expected to consult with each other about mutual
patients to formulate treatment plans [30]. While integration is
becoming more accepted and is currently being developed and
practiced in the treatment of lower back and neck pain, multiple
sclerosis [31], AIDS, and cancer, including hospice and
palliative care [24,32], several studies have described various
limitations of integration in theory and practice. Bell et al. [4]
specifically argued that combination medicine [CAM added
to conventional medicine] is not integrative, and Hollenberg
[24] examined two integrative health care settings in Canada
and found that when attempts were made to integrate
biomedicine and CAM, dominant biomedical patterns of
professional interaction continued to exist. In contrast to this
conventional-dominant integrative model, Sundberg et al. [29]
proposed an integrative model, the core of which was a patient-
centered interdisciplinary approach, adapted to Swedish
primary care based on a non-hierarchical mix of conventional
and complementary therapies.
Hsiao et al. [33] performed a qualitative study to identify key
domains and develop a conceptual model of integrative
medicine at the provider level. The authors conducted semi-
structured, in-depth interviews with physicians and CAM
practitioners and concluded that dual-trained MD CAM
practitioners have greater orientation toward integrative
medicine. Our study found that patients, PCPs, and CAM
practitioners view differently the issue of who should provide
CAM in integrative primary care setting. Future studies will
need to clarify the possible role of dual-trained CAM
practitioners as therapists in primary care clinics and examine
the triangular patientPCPCAM practitioner perspective. One
study suggested that understanding all three sides of the
patientPCPCAM practitioner triangle creates a more
comprehensive and realistic view of current health care
practices [34]. Based on our findings, this outlook is a
fundamental requirement in establishing patient-centered
integrative care and integrating CAM into primary care.
One of the limitations of our study was that participating
patients were recruited from a single primary care clinic in Israel,
making our findings difficult to generalize across other patients
and locations. Also, various studies have suggested that there are
unique characteristics of CAM use in diverse ethnic communities
[3537]. Unlike the patients, the PCPs and CAM practitioners
who participated in our study were from clinics all over Israel.
We used a different methodology (direct administration of
questionnaires to patients versus postal and e-mail administra-
tion to PCPs and CAM practitioners) to approach the three
groups in an attempt to lessen participants reluctance, but this
may have generated a selection bias in the PCP group. The low
response rate of PCPs (333 respondents out of 2532 potential
participants) may have been caused by their low interest or
opposition to CAM, but it could also be a result of the PCPs
unfamiliarity with a new web-based system used for ques-
tionnaire collection. As shown in other e-mail-based physician
surveys, response rates to e-mail questionnaires are usually
considerably lower than to posted questionnaires (although the
quality of the data are similar) [38,39] and are affected by the
relevance of the topic to daily life in clinical practice [40,41].
The low PCP response rate in our study may indicate that PCPs
have less interest in CAM than patients or CAM practitioners. We
acknowledge that this 13% response rate has a potential for
biasing the results and may reflect the possibility that only
doctors with interest in CAM responded to the survey. An
important question to consider in our study was whether our PCP
population reflects the full range of physicians in our community
or a more CAM-favorable PCP subpopulation. The percentage of
physicians with some training in CAM in our study (27.3%) was
comparable to that in another questionnaire-based study that
involved 165 PCPs attending a routine medical continuing-
education program in Israel (25.0%) [42]. Regardless of these
potential biases, it was interesting to see the difference between
PCPs, patients, and CAM practitioners on the question of
integration in daily clinical practice.
4.2. Conclusion
In our study, patients, PCPs, and CAM practitioners
suggested that family physicians play a central role in CAM
 E. Ben-Arye et al. / Patient Education and Counseling 70 (2008) 395402
referral and, to a lesser extent, that family physicians actually
provide CAM treatment themselves. Future studies are needed
to learn the interplay and dialogue between patients and PCPs,
patients and CAM practitioners, and PCPs and CAM
practitioners. Such studies may be able to recommend reliable
and practical means of communication among the three groups.
4.3. Practice implications
PCPs need to be aware of their present and future role in
informed referral to CAM and, to a lesser degree, in providing
CAM in integrative primary care clinics. With the increasing
use of CAM, patients may expect their family physician to be
more knowledgeable, skillful, and have a balanced approach
regarding CAM use. In addition, practitioners should learn how
to communicate effectively and better collaborate with CAM
practitioners to the benefit of their patients.
Acknowledgements
We would like to thank Dr. Chen Shapira, medical director
of CHS, Haifa district, for her generous support and
encouragement, Ms. Ronit Leiba for the statistical analysis,
Dr. Adva Lear, medical director of the Herman Clinic and the
staff members in the clinic for their support and collaboration
with the team of researchers, the research team from the
International Center and College of Natural Complementary
Medicine: Ms. Dalia Vardi, Ms. Danit Steinberg, Ms. Ira
Videtski, Mr. Uri Meir Chizik, Ms. Einav Damari, Ms. Moran
Barkan, Ms. Hagit Confarti, Mr. Yoram Sendak, Ms. Riki
Caspi, Ms. Orit Zarfati, and Ms. Pnina Sneitzer, Hamichlala
Leminhal for financial support of the statistical work-up, and
Ms. Yael Bruno and Ms. Marianne Steinmetz for editing the
manuscript.
Conflict of interest
The authors have no conflicts of interest.
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