Terms and their contexts
Similar to the Delphi survey respondents, the focus group participants quickly reached the consensus that different CAM-related terms have different purposes and that their use is highly contextual. As one participant put it, “The purpose of a term is to identify something, and so terms may shift because of the focus of the discussion.” (Focus Group [FG] participant 2) Thus, the focus group participants were given the task of clarifying terms according to context.
In light of the Delphi results, two umbrella terms were discussed (CAM and IHC), as well as the names of the specific disciplines subsumed under these labels. Even though participants generally agreed that we lack optimal definitions for these two umbrella terms and that all terms that have so far been introduced are to some extent problematic, CAM and IHC remained the most popular and accepted terms by far. The names of the specific disciplines were also deemed adequate in certain contexts. When debating whether CAM’s practice and research communities should come up with one or more terms to replace CAM, the general consensus was that a change in terminology would be a step backwards. As one focus group participant said: “Language and power are closely intertwined. If we let go of the term CAM, it will be detrimental for the field.” (FG participant 6) Another added: “[In the USA,] if NCCAM lets go of CAM, the CAM disciplines, in particular, will be gone. It designates the CAM disciplines. It’s about research, it’s about enabling, it’s about professional development, it’s about boundaries, you know… it’s about inclusion. The fear is if you use IHC [over CAM], you will lose the focus. […] It’s an enfranchising term.” (FG participant 7) On the other hand, a few participants remarked on a strong tendency for certain European governments to avoid using the term CAM. This might illustrate that, as one participant put it, “the golden age of the CAM term is fading out” in Europe.
The usefulness of umbrella terms was discussed at length. Most participants agreed that such terms, in particular CAM, were convenient especially, “when you’re studying or researching a group of disciplines or therapies. […] We’re not going to identify each one of them. That’s the context in which we use the term CAM.” (FG participant 5) Other participants provided examples from different settings. A participant concluded: “We need a global term to refer to the field.” (FG participant 7) Participants also acknowledged that the term CAM represents a “brand.” One commented: “As the director of a graduate program, any of the other terms don’t help me, because nobody knows what we’re talking about whereas CAM, they do! And they say, oh yes, that’s all the other stuff.” (FG participant 5) A consensus emerged on the benefits of using the term CAM after one participant questioned the group: “By hanging together under an umbrella term, does that actually help the individual disciplines? Or is it better to seek independence by saying “I’ll take my chances, I’m an acupuncturist, I want to study acupuncture, I want to leave the CAM term and I’ll live by myself on an acupuncture term, and hope that funding agencies will fund me.” That’s the question? […] My feeling is at this stage, around the globe, there is more benefit to hanging together.” (FG participant 5)
On the other hand, one participant cautioned that some practitioners and researchers have abused umbrella terms, using them as catchall terms to lump together any therapies or practitioners that do not qualify as biomedicine. For example, he explained that this strategy has provided those practitioners and researchers with ammunition to claim that CAM is ineffective. As one of the forum participants underscored, “I do not think that meditation is the same as chiropractic or herbs or homeopathy. When things are all lumped, criticisms of one are lobbed against all, muddying the discussion.” (Forum participant 14) Therefore, efforts should be made to define the scope of the research question and to refrain from using umbrella terms when another term that specifically refers to the discipline’s name could be used.
In parallel, participants were much in agreement that the use of umbrella terms should be restrained in the practitioner-patient dialogue for sake of clarity. If used, an umbrella term should be used only when referring to a group or practitioners or therapies, which is usually uncommon in the context of such a therapeutic relationship. One participant stressed the importance of referring to the discipline’s name by saying: “What makes it alternative for practitioners and researchers [and thus justifies the use of an umbrella term] is the theory; for the patient, it’s the needles, the herbs, etc.” (FG participant 8)
Of note, a majority of the focus group participants had major concerns about using the term “integrative medicine” as an alternative to “integrative healthcare,” and so the latter was employed for the discussion. Participants agreed that although “medicine” is a powerful word, its use is often limited to or associated with biomedicine. For this reason, participants believed that “healthcare” was a more inclusive term when used along with the term “integrative” and therefore was more adequate for the discussion. As one participant commented: “There are issues around the terminology medicine. That’s one of the things that has come through the discussions in multiple disciplines, nursing being one of the forefront disciplines in the discussion, that medicine is limited to practitioners or professionals who have a medical license. So broadening the term to [the term] healthcare does make sense.” (FG participant 3)
As alluded to in the Delphi survey, it became clear during the first session that the context of use should indicate which term to use. Focus group participants chose to add ‘philosophy’ to the original list of contexts compiled by the Delphi survey respondents. This context refers to the values and beliefs attached to the system within which practitioners and patients interact. Table
1 shows which terms are appropriate for which context, as determined by the participants. Participants had difficulty agreeing on which terms should be used in the contexts of practitioner-patient interactions and practitioner-practitioner interactions. Reference to the discipline’s specific name was favoured over the other two available options. Nevertheless, when an umbrella term is necessary, participants suggested the term CAM should be considered.
Table 1
Context of use of CAM-related terms
Education of conventional and CAM practitioners | | | X |
Policy making | | X | |
Philosophy | | X | |
Research (grant, publication) | X* | | X |
Practitioner-patient interaction | X* | | X |
Practitioner-practitioner interaction | X* | | X |
Definitions proposed
Overall, the participants agreed that despite their deficiencies, the terms CAM and IHC remain the best options. However, the definitions need to be revisited and clarified. In an effort to facilitate this process, the Delphi survey respondents were invited to enumerate features that should be included in new or revamped definitions of the terms CAM and IHC. These key concepts included: (1) therapeutic intent of the therapy or product (to distinguish, for example, between church going as a routine and praying specifically for a cure); (2) the use of purposefully identified regulated, licensed and well-established groups of practitioners and disciplines; (3) existence of a body of knowledge that suggests therapy might work; (4) patient-centeredness; (5) safety of the therapy or product when delivered and used as indicated; and (6) specific to IHC, a reference to the concept of collaborative work.
These concepts were presented to the focus group participants, who were then asked to assemble a new definition for CAM and IHC. Participants quickly devised a definition for IHC; the only point of uncertainty was whether the term CAM should be included in the definition. A slightly greater proportion of participants thought CAM should not be mentioned in the definition. Finding an acceptable definition for CAM, on the other hand, was more of a challenge. Despite vigorous discussion, the participants were unable to agree upon a comprehensive definition. Both definitions were subject to critiques and were subsequently modified over the course of the six weeks that the forum was open. The three authors performed interpretative analysis of the comments and made iterative modifications to the definitions. The resulting definitions are presented in Table
2.
Table 2
Suggested definitions
CAM: A broad range of therapeutic interventions developed and practiced by trained healthcare professionals and disciplines who have created bodies of knowledge that are used for education and training. These interventions are based on three important principles: (1) to treat the whole person; (2) to see the individual as a facilitator of health; (3) to see the body as having the inherent ability to heal itself. |
Integrative healthcare: A system of healthcare that is patient-centered and collaborative, encompassing a diversity of therapeutic options [including CAM] that have been found to be safe, effective and informed by available evidence to achieve optimal health and healing. |