Defining integrative medicine (IM) has always been a challenge to the field. Over many years, definitions have ranged from care that “combines treatments from conventional medicine and [complementary/alternative medicine] CAM for which there is some high-quality evidence of safety and effectiveness” [
There is also a lack of consensus about the appropriate structures and processes of implementing IM. Some argue for a model of IM that offers patients an array of alternatives in a single clinic or multiple linked clinics, while others maintain that simply combining different modalities in the care of patients, alone, “is not integrated medicine” [
A major part of the problem with finding consensus on definitions of IM in the USA is the relative novelty of formal approaches. This is not the case in China, where IM has been meticulously planned and implemented by government in various institutional contexts over the last 60 years. As one of four integrative healthcare systems recognized by the World Health Organization (WHO) [
In this section, we briefly review the structural development of “integrative Chinese and western medicine” (中西医结合—
Starting in 1955, the central government encouraged western biomedical physicians to “broaden their knowledge” in traditional healing practices. This sparked the development of a systematic two-and-half year full-time training program called “western physicians learning Chinese medicine” in Beijing and other cities [
After completing their training, these pioneers were assigned to different working environments, including both western biomedical (WM) and Chinese medical (CM) organizations, to further develop IM. In WM settings, they worked at either newly established institutes of integrative medicine or departments of Chinese medicine within WM research institutes, hospitals, and universities. At the time, CM organizations were all newly established and included hospitals, CM colleges, and research institutions such as the China Academy of Traditional Chinese Medicine (now China Academy of Chinese Medical Sciences, CACMS), established in 1955. Within these settings, many dual-trained physicians practiced IM, while others focused exclusively on research and teaching [
In terms of training, CM colleges currently offer five-year courses for undergraduates, with roughly 30–40% of time devoted to teaching biomedicine, modern scientific principles, and experimental methodologies [
The present study utilizes an exploratory sequential mixed methods design, wherein we first collected and analyzed qualitative data and then used these findings to inform subsequent quantitative analysis [
We used a snowball sampling methodology to develop two lists of participants for interviews [
The majority of interviews with pioneers and current leaders were conducted in Mandarin Chinese, while some were conducted in English or a mixture of Chinese and English. Interviews were videotaped and recorded in audio format. The transcripts for the current research were based on recorded audio files; however researchers consulted video files for tone and expression as needed. Interviews varied in length, ranging from 30 minutes to three hours.
Interview questions were sent to interviewees well in advance of the scheduled interview for review, suggestions, and corrections. Based on the expertise of the particular interviewee, questions were tailored accordingly. Interviews opened with biographic questions. In each domain, interviewers began with broad topics and then probed each response, continuing to narrow questions until the information exhausted all responses or the topic changed.
In this mixed methods study, we utilized a “quasi-statistical approach” to qualitative coding where themes are divided into categories and then statistically examines in association with key characteristics of interviewees [
All interviews were transcribed by independent transcriptionists. A research assistant audited all transcripts in Chinese against the original audiotapes. Another research assistant audited all transcripts in English against the original audiotapes. The interviewees subsequently had the opportunity to review the edited transcript to ensure factual accuracy and, if desired, to provide additional commentary. After receiving the corrected transcripts, a research assistant created tables of contents and indices for each transcript.
In our analysis, we used an exploratory technique in which transcripts were reviewed to identify a “core statement” illustrating the key concepts in each oral author’s perspective on integrative medicine development in China. This exploratory technique, developed by Lincoln and Guba, involves grouping similar ideas or items into “piles” and then identifying and labeling the overarching themes or domains of each of the piles [
Based on content indexed by our research assistant, we extracted answers to the definition of integrative medicine. All raw materials were input into a spreadsheet and sorted into themes. Through this process, we identified four major definitions, which reflect the diversity of opinions expressed by the various types of experts. Based on the extracted answers, two investigators (Weijun Zhang and Ka-Kit Hui) independently coded the definition and approach to the interviewee, with an initial intercoder agreement kappa of 0.816 [
Even with the kappa value of 0.816, we further analyzed the code disagreement to reach full agreement between the two coders. The agreed-upon codes (D1, D2, D3, and D4) in the master coding dataset were then used as dependent variables for the subsequent analysis. Previous research has indicated that age, education, and working environment are factors affecting providers’ perception towards IM [
Statistical analyses were performed using statistical software, SAS version 9.3 (Cary, NC). The associations between the definition of IM espoused by each participant and each factor (age, original education background, type of experts, and working environment) were first evaluated individually using Fisher exact test. The effect of interactions between selected pairs of factors on the definition of IM was further investigated by examining the stratified associations in the corresponding subsets using Fisher exact tests.
Interviewees had a mean age of 67.3 years. The median age was 71 years old. 84.9 percent were male, while 15.1 percent were female. 64.4 percent of interviewees were originally trained in biomedicine, while 32.9 percent were originally trained in CM and 2.7 percent were trained in nonmedical fields. 45.2 percent of interviewees could be considered pioneers who developed and practiced IM in late 1950s and early 1960s. The other 54.8 percent could be considered current leaders (nonpioneers). 76.7 percent of interviewees were clinicians, while 23.3 percent were nonclinicians involved exclusively in research and education. 67.1 percent of interviewees were currently practicing or had recently practiced IM in a CM organization and 32.9 percent were practicing or had practiced in a WM organization. The characteristics of study participants are shown in Table
Characteristics of the interview sample (
Number of experts | Percent | |
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Age, mean = 67.3, std. dev. = 13.7 | ||
<50 years | 11 | 15.1 |
50–65 years | 21 | 28.8 |
>65 years | 41 | 56.1 |
Gender | ||
Male | 62 | 84.9 |
Female | 11 | 15.1 |
Type of practice | ||
Pioneers | 33 | 45.2 |
Colleagues and leaders | 40 | 54.8 |
Original education | ||
Western medicine | 47 | 64.4 |
Chinese medicine | 24 | 32.9 |
Nonmedicine | 2 | 2.7 |
Type of expert | ||
Clinicians | 56 | 76.7 |
Nonclinicians | 17 | 23.3 |
Working environment | ||
Western medicine | 24 | 32.9 |
Chinese medicine | 49 | 67.1 |
In our analysis, we identified four unique ways of defining IM among our interviewees, listed in Table
The four definitions used by participants in the present study.
Approach | Goal | a.k.a. | |
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D1 | Fully understand both western medicine and Chinese medicine and then blend the best medicines clinically and theoretically | To create a new medicine | Ideal or classic |
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D2 | Fully understand the strength and weakness of both western and Chinese medicine and then utilize the best parts of both, depending on evidence or not | To better serve their patients or enhance communication between both kinds of medicine | Pragmatic |
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D3 | Under the theoretical framework of Chinese medicine, utilize current technology to study patients and treatment | To improve and modernize Chinese medicine | Modernization of Chinese medicine |
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D4 | Based on their area of specialty in western medicine, study modalities and/or mechanisms of Chinese medicine in clinical practice and research | To enhance and expand the scope of understanding of studied specialty | Westernization of Chinese medicine |
The first definition used by participants emphasizes the creation of an entirely “new medicine” by blending the theories and practices of western medicine and CM. One interviewee, who was working at a CM university, uses a chemistry metaphor to describe his thinking on the subject: To use a metaphor: the gases hydrogen and oxygen in combination generate water, and once it is water, it is no longer gas, but liquid. In this instance, the form has undergone a dramatic transformation. Hydrogen and oxygen are no longer distinguishable. They have become something new. But if, to use another example, you combine green beans with soybeans, it is a mixture but you can still clearly differentiate each kind of bean…. Most people think that the highest level of integrative medicine is the formation of a new medicine, rather than a mixture or compound.
However, almost every interviewee who espouses this view agrees that the new medicine has to go through multiple stages of development in order to actualize. One interviewee, who had been trained in western biomedicine and worked in a biomedical organization, explains: There are three distinct phases in the process of integrating Chinese and Western medicine(s). First, the basic compatibility of the medicines needs to be recognized by both sides. Second, an allowance must be made for this compatibility. [Because] modern Western medicine pays attention to local pathology, and focuses on removing it or attacking it, and Chinese medicine strives to treat the whole, focusing on regulating the internal system. Chinese medicine thus can supplement modern Western medicine in exactly the ways it needs to be supplemented. But Chinese medicine lacks the kind of rapid treatment that is found in modern Western medicine. So this complementarity is deserving of theoretical research… Therefore, [third] there is hope for developing new understandings of diseases and further creating a new therapeutic system that blends the strengths of both Chinese and Western medicines.
The second definition expressed by interviewees does not mention the creation of a new medicine. Instead, the approach associated with this definition argues that integrative practitioners need to understand both Chinese and western medicines, including the strengths and weaknesses of both approaches as well as the way each can be explained with each other. The first goal here is to meet patients’ need for healing, regardless of approach, as one clinician who espoused this definition argues: I wish I could give my patients the best treatments for relieving their suffering. If an approach is effective, safe, and reasonable theoretically, I think I will use it regardless of whether it is western medications or [CM] herbs.
Another goal encompassed within this definition is for researchers and clinicians to translate or explain each medical system to the other for better understanding. One pioneer and clinician, who worked in a CM organization, said, Chinese medicine and Western medicine are two very different medical systems…. we can consider the mechanism of so-called “calming the liver and subduing yang” in the treatment of hypertension within the context of Western medicine. We can combine the strengths, and explain it theoretically such that Westerners can easily understand what “calming the liver subduing yang” means… if you study the effects of “settling the liver and extinguishing wind” in the nervous system, in the endocrine system, or even the effect on angiotensin levels, then communication will be much easier.
The third definition emphasizes the view that clinical practice and research should primarily follow the theories of Chinese medicine. This approach utilizes current technology to study patients and treatments with the overarching goal of improving Chinese medicine. As one interviewee, who graduated from a CM university and is currently working at a CM organization, stated: Regardless of whether you are developing Chinese medicine or western medicine, you have to deal with how to utilize modern technology to enhance, enrich, and to develop certain specialties. Especially for Chinese medicine, a traditional medicine with a few thousand years of history… it has its own methodology. Therefore, whatever you are developing, modernization of Chinese medicine or integrative medicine, I think you should not ignore the principles of Chinese medicine. You have to follow these principles, utilizing modern technology and absorbing some of the methods from modern sciences to enrich Chinese medicine.
The fourth definition is described as the westernization of Chinese medicine. The approach here is that clinicians and researchers approach one of many modalities and/or mechanisms of Chinese medicine from a biomedical perspective. As one interviewee, a neuroscientist and acupuncture researcher working at a leading medical University in China, said: To be honest, I did not spend two years to learn Chinese medicine like my predecessors… so I only scratched the surface. With help from my teachers, I started a project that I had never tried before. I studied the involvement of the hypothalamus area with acupuncture analgesia in rabbits, first using electrophysiological methods, and then using neuropharmacological methods. By combining these two methods, I investigated the effects of acupuncture needling on electrical activity in the hypothalamus, and how pain is reduced when two competing signals- pain and needling- are produced together.
Overall, all interviewees were more likely to define integrative medicine as D2 (pragmatic approach, 50.7%) and less likely to define it as D4 (westernization of CM, 8.2%).
Overall, there were no significant differences between the definitions espoused by pioneers and current leaders; age alone was not associated with definition. However, no subject under 50 years expressed D1 (the creation of a new medicine).
Figure
The definition differences between clinician and nonclinician.
Those interviewees with an initial education in western medicine were less likely to define IM as D3 (improving CM with current technology) than those with an initial education in CM. Only those with initial education in biomedicine expressed D4 (westernization of CM). However, there was no significant difference between groups when defining IM (Fisher exact test
Figure
The definition differences between WM and CM working environment. WM-O: western medicine organizations. CM-O: Chinese medicine organizations.
Among those with an initial education in biomedicine, more than 70% of clinicians expressed D2 (pragmatic combination), while nonclinicians were roughly evenly distributed among the other three definitions and were a little more likely to have D4 (westernization of CM), followed by D1 (new medicine) and D3 (improving CM with current technology) (Fisher exact test
The definition differences between subgroups in education background and practice type. WM-C: clinician whose original education was in western medicine. WM-nonC: nonclinicians whose original education was in western medicine. CM-C: clinician whose original education was in Chinese medicine. CM-nonC: nonclinicians whose original education was in Chinese medicine.
Almost all nonclinicians working in WM organizations expressed D4 (westernization of CM), excluding one who expressed D1 (new medicine), while those working in CM organizations were about equally split between D1 and D3 (Fisher exact test
The definition differences between subgroups in practice types and working environment. WM-O-C: clinicians working in WM organizations. WM-O-nonC: nonclinicians working in WM organizations. CM-O-C: clinicians working in CM organizations. CM-O-nonC: nonclinicians working in CM organizations.
We also tried to analyze the two-way interactions of practice types, original education background, and working environment. There was no nonclinician with an educational background in CM who worked in a WM organization; only two nonclinicians had been educated originally in Chinese medicine and worked in CM organizations; and only two clinicians who had been educated originally in Chinese medicine worked in western medicine organizations.
The term “integrated Chinese and western medicine” (
There are key differences between definitions two, three, and four, however. The second definition represents a pragmatic approach to IM that is less concerned with ideal goals and more focused on immediate application in a clinical context. It provides guidance to practitioners, such that they know when, where, what, and how to use each medicine appropriately [
The third definition also takes a pragmatic stance on the development of IM, prioritizing classical CM theories and clinical methodologies at the same time as recognizing the value of approaching CM with modern technology in order to improve upon it. In the third definition, however, there is a clear prioritization of classical and traditional terminology, theory, and practice. CM is made better with biomedical technology, in this approach, to the extent that its core features remain undisturbed [
In the fourth definition—the westernization of CM—we see a different type of pragmatic approach to understanding how CM and biomedicine relate to one another. This approach emphasizes the study of CM methods vis-à-vis their effects on the biomedical body. The terminology, theory, and practice used here are overwhelmingly biomedical. In contrast to the third definition, the values and knowledge of CM here are subordinated to those of biomedicine [
The differentiation between the third and fourth definitions may seem subtle, given that both use methodologies in western medicine and modern science to assist in studying Chinese medicine [
From our results, it is clear that, in clinical environments where practitioners are required to think on their feet in the care of patients, the definition of IM quickly moves from an idealized vision of a “new medicine” into a pragmatic approach that uses CM and biomedicine alongside one another in whatever way most benefits the patient. This is also inspired, to a large extent, by the rising demands of patients for combined approaches to care [
The present results suggest that practical implementation of IM research in China demands a distinct approach to the definition of IM that prioritizes either western biomedicine or CM. Unlike clinicians, researchers have to seek research funds from various related government agencies. Overarching government funding priorities thus inevitably have impact on how nonclinician researchers understand IM. From this perspective, the government’s support for analyzing effective properties of various CM treatments using modern scientific concepts and techniques, along with the adoption of international research standards for randomized controlled trials (RCT), has clearly had an impact on the ways in which nonclinician researchers define IM. Depending on where their funding sources come from, researchers are more apt to choose definitions three or four.
Structural limitations and institutional set-up play an important large, if not sometimes larger, role in how IM is implemented in China or elsewhere. Our results suggest that working environment is a key factor influencing the definitions and approaches of individual practitioners of IM. This relates to health policy and regulation at a systems level, working environment at an organizational level, and interaction with peers at an individual level.
As one of four integrative healthcare systems recognized by the WHO [
Besides widespread national health policies, other guidelines and plans deriving from the SATCM also influence how clinical practice and research are conducted in both CM and CM-primary IM organizations. For example, due to the privatization of the healthcare market, utilization of CM decreased by over 40% in the 1990s, especially in urban areas [
The balancing of high level government demands for integration and modernization can prove challenging within specific institutions, especially given the overall sentiment that overt westernization of CM is politically incorrect [
IM units at WM organizations are usually staffed by graduate students that were trained in their department or institutes [
The results did not support the hypothesis that age and pioneer status comprised a significant factor in individuals’ definitions of IM. This runs contrary to expectations that pioneers may espouse a more idealistic definition of IM reflecting their training in the 1950s and 1960s. However, this result also suggests the importance of such pioneers’ experience in framing their understanding of IM. Given their repeated frustrations in instantly developing a new medicine [
Surprisingly, our result suggested that educational background of dual-trained IM experts is not a significant factor influencing the definition of IM. This differs from the results obtained in a Korean study, which demonstrated that educational background determines the way integration is understood and put into practice [
The present study carries several implications. In the USA, where we are currently wrangling with the issue of how to apply IM in real clinical settings, the present study suggests that we have a great deal to learn from Chinese clinicians who have been dealing with this very issue for more than 60 years. Though policy and practice in the west will certainly be different than those in China, many of the pitfalls and advantages to the ways in which certain policies have been actualized in practice in China can provide a guiding light to thinking through the way we implement IM in the west.
Specifically, as the development of integrative approaches to care is being supported by organizations such as the WHO [
In research, our results demonstrate that researchers examined in this study supported D4 (the westernization of Chinese medicine) when working in WM organizations, either because funding sources demanded such an approach or because they were influenced by the institutions in which they found themselves working. Similar demands and pressures exist for IM researchers in the west. The classic RCT was naturally adopted in clinical trials of Chinese medicine. However, researchers who are working in CM organization supported D3 (modernization of Chinese medicine). From our perspective, the modernization of Chinese medicine requires research designs to represent the principles of Chinese medicine, including whole systems and pattern differentiation (pattern diagnosis). The development of innovative approaches, such as whole systems research (WSR), offer promising opportunities for research to appropriately capture and measure the complexities of care in IM and other forms of CAM [
Finally, our study also directs us towards the awareness that it would also be helpful, in trying to avoid some of the pitfalls that have made the practice of IM in China so fraught with controversy, to involve leaders other than MD specialists in the establishment of IM systems. Generalists as well as CAM specialists should thus also play a significant role in the development of policies and practices shaping IM’s development in the west [
Limitations of the present study include the fact that the snowball sampling for identifying interviewees yielded a small sample and skewed distribution, which prevented formal statistical tests of interaction effects. A larger caveat consists of the difficulties involved with attributing one exclusive definition to each participant. Many of the IM definitions shared in the course of our interviews move between the ideal and the practical in the sense of a desired future versus the realities of everyday practice in different settings. This truth is notwithstanding; we argue that the delineation of these definitions in the Chinese context holds value in that it allows us to distinguish the overarching approaches used to combine CM and biomedicine in China. From a conceptual standpoint, this delineation invites a dialogue regarding how various definitions do indeed impact the research and the practice of IM in any country.
The present study provides a glimpse into the thinking of dual-trained IM experts in a WHO recognized integrative healthcare system. The value of such perspectives does not necessarily lie in its demonstration of some unchanging truth claim that IM holds in China. Instead, because these ideas come from individuals with dual-training and a great deal of experience designing and implementing IM research and practice, this study offers the opportunity to think through the meaning of some of the different directions that IM research and clinical practice may lead in the United States and other western countries. In the USA, researchers and clinicians are well aware of the fact that idealized notions of creating a “new medicine” with IM are often compromised in various ways in the design of specific research studies and clinical systems. While idealized definitions are often the starting point, practical applications of IM are complex processes that develop over time and must be applied by individuals with adequate training in multiple domains. The suitable definition is likely to emerge and settle only as the practice of IM develops.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Research for this paper was partly sponsored by funding from the Annenberg Foundation, the Gerald Oppenheimer Family Foundation, the Panda Charitable Foundation, and Xiangxue Pharmaceutical. The invaluable help in conducting interviews from Shirley Casper Wong and Cherry Zeng, the constructive consultation of questionnaire design from Teresa Barnett and Marcia Meldrum, the management assistance from Sue Fan and Rosana Chan, the statistical assistance from Fei Yu, and the coding and transcription work of Luge Yang, Jing Zhang, Elaine Ho, and Sara Wing are gratefully acknowledged. The authors would also like to thank generous supports from the Chinese Association of Integrative Medicine and interview subjects who participated in this project.