Multidisciplinary co-operation is the ideal expression of Medical Marriage, where doctors and complementary practitioners work together as a team, providing care, support, health and welfare for patients, practitioners and doctors alike. It is the best guarantee for excellence, efficiency and safety of care provision, allowing for ongoing education, peer supervision and self-reflection – the cornerstones of good practice.

To refer patients to another health care professional – if that practitioner will be better suited to help them to improve their health – is the only ethical thing to do. Structures of professional relationships and communication need to be established which will allow access and movement across the boundaries of orthodox and complementary medicine. This has to become the norm within modern health care systems if patients are to be provided with the support they clearly want.

When patients hear about multidisciplinary co-operation for the first time, their reaction is often, ‘It’s about time!’ It seems obvious to most people that co-operation is the best way to serve patients. However, from within the confines of whichever paradigm a practitioner operates, it may’seem like an uneasy marriage. Historically the two health care systems have developed in opposing camps and often disrespect has dominated the relationship.

The vision of Medical Marriage asserts that all parties will benefit from a mutually respectful co-operation and integration of health care models. Each system can compensate for the weaknesses in the other. For example, holism is concerned with psychosomatic conditions and prides itself on treating the mind and spirit. How often does the body in fact come last, leaving people without relief from their symptoms, or in danger of having potentially serious symptoms overlooked? Medically trained professionals, on the other hand, have an extensive knowledge of body systems and pathologies, which allows them to address physical problems, but the mind and spirit may be ignored in the overriding desire to alleviate symptoms.

A medical specialist can intervene in the most dire situations, providing, for instance, a liver transplant to save a life. The GP is a generalist with broad-based clinical experience and the ability to co-ordinate care with all specialists. Similarly, complementary practitioners have access to a body of knowledge largely unavailable to medically trained professionals. Partnership is the obvious way to provide the best care for patients, with the option for practitioners to refer patients on to the specialist who is most suited to addressing the presenting problems.

Fig.l: The model of integrated health care, as proposed by the working group on multidisciplinary co-operation at the Medical Marriage conference 1996 at Findhorn

The Contribution of Complementary Medicine

The many different complementary approaches offer a wide variety of treatment options, which allows flexibility and diversity to tailor patients’ health care to their own preferences. The complementary approaches are often very gentle and work with the person’s own body wisdom, facilitating the self-healing of which it is capable.

The practitioners of complementary therapies place high emphasis on patient contact and allow long consultation times, which give the patient the feeling of being listened to and respected. Physical touch is often used, which apart from the specific therapeutic effect also gives comfort and induces relaxation.

Complementary therapies are engaged in health enhancement, as they offer tools and services which are very useful for stress management. It seems perfectly normal for someone undergoing some stressful situation to go and have a massage when they would not dream of going to their GP, who would have nothing to offer in such a case. Complementary therapies will bring people into a health centre who are not ill. One does not have to have symptoms to seek treatment from a complementary therapist.

Complementary therapies are in the transition zone between disease care and health enhancement. Someone who has been ill may use complementary therapies – alongside or instead of orthodox treatment – to assist their return to full health, and continue, perhaps less frequently, the same treatments once they are better. The complementary therapy is used ongoingly as a preventative measure or for health enhancement.

Complementary therapies at times can offer an explanation for a presenting problem when orthodox medicine is not able to find a clinical diagnosis. This can give reassurance as well as providing a means of addressing the problem therapeutically. For example, a woman with a herpes lesion on her upper lip would have been given orthodox medical treatment to suppress the symptom. However, a homoeopath, on questioning the woman, noted that she had suffered from genital herpes 20 years previously, which had been suppressed at the time with drug treatment. The Homoeopathy assessment in this case was entirely favourable for, in the homoeopathic model, the lesion was a recurrence of an old symptom in a milder form, indicating that the woman’s body was throwing off the old suppressive drug treatment and was now processing the herpes virus. It indicated that she was in excellent health, and the remedy given was simply to speed up the process, so the lesion disappeared within three days, without, from a homoeopathic viewpoint, the body being compromised by suppressive drug treatment.

The Benefit for Complementary Practitioners

One of the benefits of Medical Marriage to practitioners in the complementary field is the potential increase in professional choice, as they are able to work within the mainstream system as well as outwith it. In mainstream medicine, they are available for patients with complaints which, in the present structure, they may not often see, but for whom their modality may be very effective. This applies in particular to problems experienced by deprived sectors of the population.

Another benefit to practitioners would concern the back-up of medical care: not only is it available as an emergency measure but the practitioner can be assured that they can call on a doctor to get a medical point of view on their patient’s situation. Should medical care become necessary for the patient, it will be given in a way that respects and integrates the contribution of complementary care.

With the rapprochement of the two health care systems, complementary practitioners gain access to research resources which will advance the academic understanding of the different disciplines and further their acceptance and validation.

The Contribution of Contemporary Medicine

For a health care system which integrates the holistic paradigm, the role of contemporary medicine needs to be redefined. Even if complementary therapies become the first line of treatment in many cases, there is no suggestion within the model of Medical Marriage that contemporary medicine should be relegated to playing second fiddle. It obviously has a valid and essential part to play in the overall scheme of health care. This is most clear in cases where orthodox intervention is called for: in accidents and emergencies; when surgical intervention is needed; in the replacement of body parts or functions (for example insulin dependent diabetes); and when chemical drug treatment is the only successful avenue.

Contemporary medicine’s role in diagnosis remains crucial, ensuring that a serious condition is not overlooked and appropriate treatment is not delayed. Most of the complementary modalities do not diagnose; some professional associations actually impose in their code of practice on the practitioner that they refrain from making a diagnosis.[1] Others, such as homoeopathy or traditional Chinese medicine, have a frame of reference for diagnosis which is foreign or unknown to many people. Medical diagnosis provides the background information necessary for the patient to decide on which health care approach they want to choose; a doctor’s clinical judgement can assist them in creating a coherent treatment plan.

The importance of the family doctor – who is a partner to the patient in their health care – is greater than ever. With more information and options available, patients want the reassurance of one health care professional who can hold the overview of their care and give unbiased advice, who knows them well, is familiar with all the different aspects of their lives, who ideally knows their living circumstances and the other members of their family and is connected with all the specialist practitioners who have to be drawn in when needed. That practitioner has to have the breadth of clinical experience which allows them to accompany the patient in all life situations – from birth to death and everything in between. The GP is trained and suited to this role in a way that a complementary practitioner cannot be.

The curriculum for the future GP has to be extended to include the theory and basic practice of complementary therapies and most importantly the skills of relationship- centred care.[2]

The knowledge orthodox practitioners possess is extensive and one of the foundation stones of the multidisciplinary partnership. While some complementary therapists have a good grounding in anatomy and physiology, others have less. In the same way that doctors do not need to learn all complementary therapies to which they want to have access for their patients, neither do complementary therapists need to study pathology and pharmacology, etc. to the same depth a doctor has; they simply need to be willing to work together in partnership.

The medical profession has much to teach complementary therapists in the way of cross-discipline communication. Historically they co-operate and communicate as best they can via letters and phone-calls, keeping one another informed of their specialist treatments, a process which few complementary therapists have adopted at this point.

Benefits for the Doctor

Multidisciplinary co-operation offers relief to doctors from one of the biggest burdens within orthodox medicine. Doctors often reach a point of helplessness, particularly with patients with chronic disease, with stress-induced symptoms or with terminal illness when orthodox medicine has little to offer. This helplessness gets compounded by the expectations of both patient and doctor that the doctor should know how to help. The phrase ‘You can’t just do nothing’ or ‘Doctor, you have to do something’ is a burden under which doctors labour. In many instances, for the sake of taking action – of doing something rather than nothing – this leads to a prescription being written, which serves no one in the long run.

In a multidisciplinary team, doctors can draw on supportive therapies which will not necessarily cure the symptom but will allow patients to cope better with their situation. They can work together with practitioners who have a completely different approach to health care and who therefore do not feel the same limitations. In holistic health care the focus can be on the improvement of health and life quality whatever the presenting problem. This can be achieved through lifestyle modulation, improved diet, nutritional supplementation, exercise, stress management or through support in the form of massage, relaxation or counselling. The patients play a more active role in their self-care. They are active partners with the health care professionals and determine, to a large degree, the different components of their care plan. All of this reduces stress and increases job satisfaction for the doctor, while providing the patient with safe, effective treatments and follow-up supervision.

The Role of the Doctor

There are two different roles attributed to doctors in the model of multidisciplinary co-operation. One is that of the specialist, such as a gynaecologist or an oncologist, who provides expert care much as they do today. The other is the role of the general practitioner which, in Medical Marriage, will be considerably expanded. Co-operating GPs have to embrace the holistic paradigm in health care, engage in a new relationship with patients and have a foundation knowledge of complementary therapies. They can then act as both gatekeeper and care co-ordinator for their patients.

The Gatekeeper

As gatekeeper in primary health care, GPs assess patients’ needs and help them in making decisions regarding the next steps in their health care. This entails advice being given on the theoretical and practical background of the different orthodox and complementary modalities and knowing which approaches are appropriate choices in a given condition. Doctors working within multidisciplinary teams will naturally be very familiar with the disciplines practised by their colleagues while also needing to be aware of additional complementary practitioners in the local area.

Gatekeepers require the skills of clinical judgement as they meticulously collect relevant information, draw the appropriate conclusions and conscientiously communicate with the specialist practitioners to whom they are referring patients. They have to be able to create rapport with the patients; to be sensitive to their individual requirements; to provide information as diverse as pathophysiology and contact addresses of self-help organisations; to discuss options and give time for patients to reach their own decisions. The task of the gatekeeper is complete once patients have reached a decision regarding their next steps.

The Care Co-ordinator

The care co-ordinator fulfils the function of the gatekeeper and, beyond that, stays in touch with patients’ progress. In situations where a patient sees several practitioners concurrently, patient and care co-ordinator meet on a regular basis to review progress. It is important to assess whether all necessary aspects are covered and the best combination of modalities is being used. The role of the care co-ordinator is to make suggestions from the perspective of the outside observer who may see things in a more detached way.

A case report by Cornelia, acting as care co-ordinator:

Jane, 34 years old, was suffering from severe respiratory problems due to sarcoidosis. She had had extensive diagnostic investigations and was on systemic steroids as well as inhalers. Clinically she was still unwell and her lung capacity and spirometry were severely reduced. The specialists were recommending more invasive treatments, such as laser surgery. She felt disempowered and violated by the medical establishment and wrote: ‘How can I protect myself from being an ‘interesting case’ for the medical world?’

She wanted to explore complementary approaches to improve her symptoms and work with the emotional trauma caused by the condition and the medical interventions. She also wanted to unravel any emotional or thought patterns which might have caused the illness or be perpetuating it. 

Through the first consultations with the case co-ordinator she had access to the specialist’s reports and discussed them in detail; she also evaluated the complementary therapies she was receiving; and established a positive co-operative relationship with a new GP.

The following health care professionals were involved in her care:

consultant in thoracic medicine
general practitioner
medical doctor in the role of case co-ordinator
classical homoeopath
bodyworker- using biodynamic massage
spiritual healer and psychic.

The consultant in thoracic medicine wanted to repeat some of the earlier investigations to monitor the development. The patient was very frightened of the procedures. After expressing her fears and making sure she had friends and support available for the time of the hospitalisation, she agreed to co-operate with the specialist’s recommendation for further assessment and treatment. This assessment showed no improvement under high doses of systemic steroid. Having come to the end of the therapeutic line, the consultant suggested a trial with azathioprin but offered little hope that it would have positive results. At this point he was able to support her when she asked to have the steroids reduced, as she wanted to try classical homoeopathy. He continued to monitor her and, in co-operation with the GP, gradually reduced the steroids over time, ensuring that the lung function did not deteriorate any further.

In the following 15 months her clinical situation improved steadily and she now feels more in charge and satisfied with her care. She continues treatments with the homoeopath and sees the GP regularly.

This case demonstrates the value of the care co-ordinator being an advocate for the patient. Co-operation ensues once all different health care professionals involved are confident that the contribution they are making in the care for the patient is respected.

The Requirements of Working in Multidisciplinary Co-operation

Establishing co-operation across the boundaries of different paradigms is not easy as those involved are lacking even the basics of a shared language and understanding of each other’s ways of working. Working together with colleagues who have the same training and therefore speak the same language and operate under the same paradigm is difficult enough. There is tremendous complexity within modern Western medicine and also enormous variety within complementary therapies. Co-operation under these circumstances cannot be taken for granted. It needs focused attention and requires the development of structures which facilitate the co-operation. The training of the different health care professions will have to expand to include enough information about the other disciplines that an understanding and common language can be developed.

At present the expectation is that the health care professionals in mainstream medicine co-operate and communicate with each other for the benefit of the patient. In reality this communication is sometimes effective but very often not. Patients complain that surgeons and physicians do not talk to each other but use their treatments parallel as if one does not affect the other. It is generally accepted, for example, that the difference in culture between general medicine and surgery hampers communication.

Holistic health care can only be provided if the professionals involved in a patient’s care communicate with each other clearly and know enough about each other’s work to assess what respective contribution each can make to the care of the patient. The communication structures which would best serve that co-operation have yet to be evolved since the only system operating on a large scale at present involves letters exchanged by doctors, hospitals and specialists. It is a frequent experience that this system does not work as well as it could. In the complementary field, letter writing is a little practised art and it would be helpful if practitioners would establish the routine of using this tool for co-operation.

Co-operation is easiest when colleagues know one another personally, having worked together in the past, creating a shared history. They then know and respect each other as professionals and as people; they are familiar with each other’s area of expertise and methods of work, and what their strengths and weaknesses are. Personal rapport makes co-operation a positive and nourishing experience for all involved. Respect for other practitioners means accepting them as health care professionals who are doing their best and are contributing to the patients’ care to the best of their abilities. In reality, there are very few ‘bad’ practitioners – either in the complementary or in the orthodox field. All practitioners are human and therefore have their limitations and weaknesses. It makes co-operation that much easier if all are aware of these without making them barriers to professional co-operation. Personal relationships are the best safeguard for assessing the competence of a fellow practitioner and for establishing co-operation which benefits the patients.

Co-operation will require individuals to open their minds and increase their knowledge of each other’s work, world view and culture. This can be an exciting exploration and truly enlightening for all concerned.

Conferences, seminars and exhibitions will help health care professionals from all fields to meet one another, establishing trust and confidence which are essential for co-operation.

Case Conferences

Case conference meetings in multidisciplinary health care provide three major benefits:

• new perspectives on a patient’s care;
• regular updating on the care of patients seen by more than one practitioner;
• personal and professional support for the practitioners.

When health care professionals from different backgrounds come together to discuss a patient’s case, in the best scenario the perfect health care strategy can be identified and offered to the patient. While the reality in mainstream medicine can be that case conferences are a lifeless chore, they remain the most effective and immediate way to share information about patients.

A multidisciplinary case conference brings together a group of health carers with different perspectives applying themselves to the patient’s story, highlighting considerations and making observations which were not previously thought of. In the dynamics of a well functioning group, so-called group wisdom can occur, which is more than the sum of the expertise of the individuals present. In such cases there is great potential for service to the patient.

The multidisciplinary perspective allows greater understanding of the presenting situation. This is particularly so when practitioners of different paradigms are included in the team. Some presenting situations are not easily understood with a Western world view, whereas an understanding from the Eastern paradigm, for instance traditional Chinese medicine, might allow a cohesive picture to emerge, as in the following example:

A man suffered two minor injuries in a fortnight: one a cut on his left index finger requiring six stitches, the other a fall which caused strain in his left shoulder. Within the Ayurvedic system, the index finger and shoulder both relate to the heart chakra, so these minor accidents suggested stress affecting matters of the heart. When questioned further, it emerged that the patient was about to divorce his wife of 25 years, and his children were about to leave home. He was not expressing his feelings about these intense changes. In addition, within the polarity therapy framework, the heart chakra relates to the air element; when asked about his life, the patient said he felt as if a hurricane was sweeping through it. His mind was employing symbolic images relating to air and his body was demonstrating symptoms which, if left without intervention to relieve his emotional stress, might have created serious physical problems.

Supervision

Case discussion in a group of health carers can, in addition, provide individual practitioners with supervision for their work. Supervision is a concept which is essential in health care. All practitioners should have a period of time after they complete their training when they work under the supervision of a more experienced colleague. This allows them to apply and expand the knowledge they acquired during their training. They gain confidence and acquire experience at the same time. Later in professional life not everybody has the opportunity of regular supervision. When a practitioner can talk freely about difficult cases or interactions with patients which did not feel positive, there is much learning to be gained and stress can be managed before it builds up. Conversely, practitioners can receive nourishment and inspiration when they share a ‘good’ case, where the relationship with the patient is working well and the treatment is successful.

There are basically two kinds of supervision. Technical supervision occurs when a more experienced practitioner of the same discipline is present. Peer supervision can be helpful in many areas of professional conduct, and can include practitioners with differing training backgrounds. Many questions arising in a case do not have to do with the technique of the modality used but with the practitioner-patient relationship, with ethical or organisational questions of professional practice. In fact, practitioners of other modalities may be able to bring in perspectives which would not have been thought of if only colleagues from the same disciplines were part of the discussion.

Supervision is the best guarantee for high standards of professional practice, good service to the patients and increased job satisfaction.

The Joys of Fruitful Team Work

Synergy means that the whole is more than the sum of the parts. In a synergistic team all partners are respected for their unique contribution. The more different aspects are represented in the team, the more colourful and enriching the co-operation can be. The synergy which can come about from such a pooling of information and perspective can be truly uplifting for all involved. People who are part of a well¬functioning team are able to work more effectively, be accessible to patients without the threat of burn-out, and maybe take more professional risks leading to better results – knowing that positive team co-operation is available to give them personal, as well as professional, support.

To create a well-functioning team takes dedication and the attention of each individual in the group. Time needs to be allocated to nourish the bonds between members, to enhance the personal connections and to address any conflicts which may occur at a personal level, as well as through conflicts in the different roles within the team. From the individual, a dedication to personal development, as well as the willingness to contribute constructively to the collective are essential. Group dynamics is a relatively new science of how to harness the potential of such teams. It gives clear guidelines on how to nourish the collective and the individual within the collective.

Aspirations such as seeing beyond the personality, fully owning one’s feelings and always speaking in ‘I’ statements – rather than in a generalised form, which can cause lack of clarity or avoidance – are useful in creating a cohesive group. Positive skills such as active listening and giving someone full attention when they are speaking will ensure effective communication and a feeling of safety and acceptance in the group. The group bonding will be nourished by social events and celebrations, and at other times by shared silence or group meditation. Inviting a group facilitator into the group during times of conflict or change can be productive in allowing the process to unfold more gracefully.

Challenges to Co-operation

It would not be realistic only to sing the praise of multidisciplinary teamwork without addressing the challenges it poses both personally and professionally. There are many hurdles in attitude, behaviour and expectations to be overcome, as in any relationship, if the ideal of Medical Marriage is to be attained.

Disrespect

Historically, the orthodox and ‘alternative’ health care systems have existed in uneasy tandem, each at least partially ignorant of the other and at worst mutually hostile and denigrating. Doctors often considered alternatives as quackery, and a waste of money; irrelevant for health care, if not dangerous. In 1986 the BMA published a report on alternative medicine and predicted that it was a fad which would pass – it was nothing with which doctors need concern themselves.[3] Complementary practitioners fuelled the polarity by judging the orthodox medical system as the source of all patients’ problems. Possibly as a response to not feeling respected by the doctors, many developed an attitude of disrespect for the medical profession and its role in health care.

The burden of the original culture difference is still relevant when exploring the question of professional co-operation. Simple and small issues such as dress code can, in many cases, influence whether confidence and rapport can be established.

Righteousness and Judgements

Righteousness in both camps – orthodox and complementary – is a hindrance which is considerable. It may reflect on the individuality of the people who choose to become health care professionals, that there is a pervading feeling that one’s own discipline is the best (and perhaps the only) approach; that what anyone else is doing is suspicious, or less effective. These attitudes, although they often stem from a deep sense of care and compassion for patients and a desire to provide the best treatment, are, however, detrimental to positive professional relationships and support the ongoing illusion of separate camps.

The list of judgements or prejudices gets fed by many different aspects – professional training, the media, individual experiences – some of which are firsthand and many secondhand or hearsay. To maintain a positive attitude of co-operation, it is important to search for a balance, to consider that there are at least two sides to any story. In an ideal world, people would be able to listen to both sides, have understanding and compassion for both and reach their own assessment with an openness of both mind and heart.

Complementary therapies as professions are young and immature, with much of the arrogance that goes with youth and zeal. The medical profession, on the other hand, is moving towards maturity, and there is a notable lessening of the arrogance, an increased willingness to accept limitations, to change and grow and develop in new areas of understanding without overlooking others on the way. Co-operation from both sides fosters humility.

Misunderstanding

This point is illustrated by a personal experience from Cornelia’s student days.

As a young medical student I was very judgmental about doctors who were creating what I perceived to be an inhumane health care system. I considered them uncaring, hungry for prestige and money, interested only in their career, obedient to orders from superiors and managers who were even further removed from the patient, and not willing to stand up for their patients’ interest. I lumped all doctors together in one category. They were the ones who should do it ‘right’ and yet did it ‘wrong’; because I was still a student, they were the ‘faceless enemy’.[4] When I came to the point in my training when I actually worked alongside them, they started to have faces, becoming human beings with their own history, aspirations and dreams, limitations and pressures. They were not perfect by any means, but they were not all wrong either. Most of them were trying, doing their best, and sometimes they managed to achieve their aspirations though often they did not. It was important for me to know the difficult demands they were under, to see the conflicting interests, to watch the individuals struggling to get their priorities right. I observed some colleagues becoming numb under the pressures and losing contact with their inspiration and beliefs. They were generally not nourished by the work they were doing, suffered from depression and anxiety, and many were in the process of being burned out. Some would leave the job, others would stay on, out of touch with themselves and with the people around them, persevering because they could not think of anything better to do with their lives. I have seen the same happening in many other health care professions. Understanding what was happening to them entirely altered my righteous perspective.

Insecurity

Another stumbling block to co-operation and expansiveness is insecurity amongst practitioners. It is not considered professional to admit lack of knowledge or competence. Not many health care professionals feel safe or confident enough to own up to their insecurities and fears, despite the fact that everybody has them. Many are forced to hide behind a smokescreen of arrogance, mysteriousness, pretence or non-involvement. Having to maintain the image of the expert who knows everything can create one of the greatest stresses in their lives. On a professional level, this particular aspect has a dangerous side effect: it can cause practitioners not to recognise and be open about the limits of their competence. Given a positive, nourishing and accepting environment of multidisciplinary co-operation, many would be more than happy to admit that they do not know everything, and would have ways, through referral to other practitioners, of still helping patients.

Fear

Patients unwittingly slow the process of co-operation through fear and expectation of lack of acceptance. A considerable percentage (in the region of 30-40%) will not consent to having their GP informed if they consult a complementary practitioner, as they are afraid that the GP would not be supportive, that they would be ridiculed or labelled a difficult patient.[5] There are certainly some GPs who are not open to the idea that complementary therapies have a role to play in health care. However, there are many more who are exploring the possibilities for a wider choice in health care for their patients. Younger doctors especially are open-minded and keen to expand their knowledge in complementary therapies. This has been shown in many studies over the last ten years.[6] Therefore it is important to encourage patients to give their GP credit for being able and willing to support them in receiving the health care they want. In any case the more patients tell their GP that they are using complementary therapies, the more the GP will be inclined to become supportive of it – or at least wake up to the realisation that it is something that patients in their community want. From being a theoretical idea which is discussed in scientific papers, it might become real and tangible for them.[7]

Legal and Ethical Considerations

Legal and ethical considerations are one of the most prominent arguments which prevent doctors from considering co-operation with complementary practitioners. Referring to another practitioner can be considered to be delegation of duties and implies that the doctor remains responsible for the care of the patient.

The [General Medical] Council recognises and welcomes the growing contribution made to health care by nurses and other persons who have been trained to perform specialised functions, and it has no desire to either restrain the delegation to such persons of treatment or procedures falling within the proper scope of their skills… But a doctor who delegates treatment or other procedure must be satisfied that the person to whom they are delegated is competent to carry them out. It is also important that the doctor should retain ultimate responsibility for the management of these patients because only the doctor has received the necessary training to undertake this responsibility[8]

This guideline poses two major questions which have been debated a great deal in all the health care professions:

• What defines the competence of a person to cary out treatment or procedures and how can a doctor assess the competence of a practitioner of a discipline with which they are not familiar? Is it enough that they know the kind of training the practitioner had?
• How can doctors retain responsibility for the management of the patient if they refer them on to a practitioner who uses a different framework of treatment which the doctor cannot fully understand? The practitioner of, for instance, acupuncture cannot be bound by a doctor’s assessment of what is necessary or not, especially if the doctor does not have the same training as the practitioner. Retaining responsibility then becomes an empty phrase for the doctor.

If the practitioner using the complementary discipline is also medically qualified, then the referral causes no official ethical difficulty. The Professions Supplementary to Medicine Act 1960 specifies the paramedical professions to which doctors can
refer without legal or ethical problems. These include chiropodists, occupational therapists and physiotherapists. Other professions can be added to that list by the Privy Council, provided both Houses of Parliament agree. Some complementary
disciplines may be willing to consider being added to that list if permitted. Others may well feel that the identification of being a profession supplementary to medicine would compromise their contribution to health care.

Self-regulation of the professional bodies of complementary therapies is another avenue. As the General Medical Council does for medical doctors, the professions define their own code of ethics and conduct, implement a complaints procedure and hold a register of qualified practitioners. Guidelines for employment of complementary practitioners in the NHS were drawn up in 1995 and request qualification, registration and professional insurance.[9]

NHS treatment vs Private Treatment

One of the basic differences between orthodox and complementary medicine in the UK at present is that orthodox medicine is provided under the National Health Service and is therefore free at the point of delivery while complementary medicine has almost exclusively developed in the field of private medicine.

While there are many arguments for and against private health care for the patient, a challenge to co-operation between practitioners may be the fact that complementary practitioners work privately and therefore many earn less than doctors or other health care professionals within the NHS. This may put pressure on them, and may cause a conflict of interests, making them reluctant to refer on a patient.

It certainly makes complementary therapies less accessible to the population with a lower income. This leads to an air of exclusiveness around complementary medicine as it is mainly used by the educated middle class.

Research and Resources

Another great hurdle for complementary therapies is the request that they prove themselves in scientific evaluations for efficacy and effectiveness before the medical profession will consider co-operation, or health care providers contemplate purchasing services. Because complementary medicine was for so long left to the alternative field or subculture, the resources for such research have not been available. Resources are lacking not only in funding but also in academic emphasis in the training of the practitioners and the structural set-up of the training institutions. Complementary medicine in the last 30 years has been geared towards clinical work with patients. Only recently is there an awareness of the need for research, which requires a new outlook and methodology in its application to disciplines which operate under the holistic paradigm.

Education – the Core for Understanding

Education is the core for understanding between the professions. In the same way as doctors have an understanding of the many different aspects of contemporary medicine, everyone working within the model of Medical Marriage needs to have a basic knowledge of the theory, practice and application of the wide range of complementary therapies.

Studies… indicate a persistent trend among doctors of a desire for more information on more non-conventional therapies.[10]

… However it is important to distinguish here between training to practise and more general raising of awareness of basic principles and application of various techniques…. Doctors need to know more about non- conventional therapies not only for appropriate delegation of care, but also in their role as trusted advisors to their patients.[11]

The key element for both the doctor and the therapist is understanding the different spheres of influence in which they operate. It is, therefore, necessary to consider actions which can be taken to improve communications and understanding between physicians and non-conventional practitioners in order to safeguard patients’ health.[12]

Fulfilling these recommendations was one of the primary motivations for this book. The need for education applies, of course, to complementary therapists as much as to doctors.

References:

1. examples are: the Code of Practice and Ehics of The Scottish Institute of Reflexology, and the Code of Ethics of the National Federation of Spiritual Healers.
2. C P Tresolini and the Pew-Fetzer Task Force, Health Professions Education and Relationship-Centred Care, Pew Health Professions Commission, 1994.
3. British Medical Association, BMA board of science working party on alternative therapy, BMA Publications, May 1986.
4. Sam Keen, Faces of the Enemy, HarperCollins, 1991.
5. unpublished survey in Dr Cornelia Featherstone’s practice, April 1995.
6. D T Reilly and M A Taylor, Young doctors’ views on alternative medicine, BMJ, 1983; 287: 337-9.
7.  R Wharton and G Lewith, Complementary medicine and the general practitioner, BMJ, 292 (1986), 1, 498-500.
   E and P Anderson, General practitioners and alternative medicine, JRCGP, 37 (1987) 52-5.
   C Budd; B Fisher; D Parrinder; L Price, A model of co-operation between complementary and allopathic medicine in a primary care setting, BJGP, (1990) 40, 376-8.
   P Pietroni, Beyond the boundaries: relationship between general practice and complementary medicine, BMJ, 1992; 305: 564-6.
8. GMC, Professional conduct and discipline: fitness to practice, 1992; p17.
9. Anne Hayes, Guidelines for Employment of Complementary Therapists in the NHS, West Yorkshire Health Authority, 1995
10.  David T Reilly, Young doctors’ views on alternative medicine, BMJ 287 (1983), 337-9.
11. BMA, Complementary Medicine- New Apporacbes to Good Practice, Oxford Universtity Press, 1993; p48-9.
12.  ibid. p48.

***

This post was previously published as a chapter in the book Medical Marriage, the New Partnership Between Orthodox and Complementary Medicine, Dr Cornelia Featherstone and Lori Forsyth, published by Findhorn Press, 1997.