Introduction

‘Complementary and alternative medicine’ (CAM) is an overarching term that encapsulates a diverse range of modalities considered to be outside the scope of orthodox medicine. According to the National Center for Complementary and Alternative Medicine in the US¹ and the National Institute of Complementary Medicine in Australia,² both of which are leading authorities in CAM research, these therapies can be divided into five distinct categories, including whole medical systems (such as naturopathy, homeopathy, Western herbalism, Ayurveda, indigenous and traditional Chinese medicine (TCM)); energy medicine (including therapeutic touch, flower essences and Reiki); biologically based interventions (such as nutrients, plant and animal products); manipulative therapies (including massage, chiropractic, osteopathy and reflexology), and mind–body interventions (such as tai chi, yoga, meditation and progressive relaxation).

Given the recent trend towards integrative medicine, the line separating CAM from orthodox medicine is becoming less distinct. This is further perpetuated by vague definitions of CAM. NCCAM,¹ for example, defines CAM as ‘a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine’. Defining CAM by what it is not is no longer appropriate given the changing face of healthcare and the integration of CAM into medical, nursing and allied health curricula. CAM is more fittingly defined as a diverse group of health-related modalities that promote the body’s innate healing ability in order to facilitate optimum health and wellbeing, while retaining a core focus on holism, individuality, education and disease prevention.

Consumer interest in these therapies has escalated over the past few decades. In fact, more than fifty per cent of the Western population,³ including the Australian,^4,5 US⁶ and Japanese populations,⁷ have used CAM at least once over a 12-month period. Biologically based interventions, such as nutrient supplements and herbal medicines, and manipulative therapies, such as massage and chiropractic, are among those demonstrating the highest level of use. Over the same period, close to ten per cent of UK adults,⁸ twelve per cent of US adults,⁶ and twenty-three⁹ to forty-four per cent of Australians⁵ have consulted a CAM practitioner; chiropractic and osteopathy were the most commonly used services.The growing interest in CAM across the globe can be attributed to a number of factors. Although earlier studies signalled consumer dissatisfaction with orthodox medicine as a leading cause of CAM use,³ more recent reports indicate that an aspiration for active healthcare participation, greater disease chronicity and severity, holistic healthcare beliefs, and an increase in health-awareness behaviour are more likely to predict CAM use.^10–12 These transformations in consumer attitude and health behaviour have parallelled changes in the way many CAM specialties practise.

The shift towards evidence-based practice, along with issues concerning education and regulation, are now shaping the future of many system-based modalities, particularly naturopathy, Western herbalism and TCM. These changes suggest that the aforementioned specialties may be in the process of professionalisation, that is, transforming from occupation to profession. Unification of the CAM profession, controlled entry into the vocation (i.e. occupational closure), closer alignment to the mainstream scientific-evidence-based practice paradigm, and the development and standardisation (or codification) of knowledge are all essential criteria for the professionalisation of CAM occupations.^13,14 Although codification involves claiming a unique body of knowledge, it also requires an understanding of how that knowledge can be applied to practice.¹⁵ Clinical decision-making models play a pivotal part in this translational process. This chapter will therefore introduce the reader to a decision-making framework for complementary and alternative medicine (DeFCAM), and demonstrate how this framework may facilitate the application of CAM knowledge into clinical practice. The uptake of such a model may also help to espouse the ongoing development of CAM and enhance the professionalism of CAM practitioners.

CAM philosophy

The practice of CAM is guided by the art, science and principles of each profession. Even though the art and science of the CAM therapies are distinctly different from each other, many of these professions share similar philosophies. Some of the core principles underlying these philosophies that are shared by therapies such as naturopathy, Ayurveda, TCM, chiropractic, osteopathy, Western herbalism and homeopathy,^16–24 are as follows:

These principles are central to understanding the unique approach of CAM. More importantly, these principles serve to inform clinical decision making, particularly decisions relating to the assessment and treatment of an individual patient (including the identification of the underlying cause of the condition and the provision of holistic care). Even so, these doctrines are neither systematic nor process oriented and, as such, are unable to methodically direct practitioners through the CAM consultation or decision-making process. For graduates of CAM, the absence of a clear framework could make transition from student to clinician difficult. One way to facilitate this transition is by bridging the gap between the philosophical foundations of CAM and the requirements of modern-day clinical practice (i.e. avoiding client harm by adopting the best available evidence, formulating client-centred treatment goals, evaluating care to ensure balance has been restored), through the provision of a CAM-specific clinical decision-making framework.

Clinical decision-making models

Over the past few decades, a number of decision-making models have emerged within the healthcare sector. The general aim of these frameworks was to guide practitioners through the process of decision making in often complex clinical environments. Examples of some of the more common models used in clinical practice are highlighted in Table 1.1. Many of these frameworks were originally designed to improve documentation in the healthcare sector rather than guide clinical decision making. SOAP, DAP, OHEAP and SNOCAMP, for example, while providing a simple, systematic and consistent approach to documentation in the clinical environment, provide very little direction for practitioners in the management of client problems. Fortunately, several models have since emerged that attempt to address this problem.

Table 1.1 Clinical decision-making models used in the healthcare sector

One of the earliest participative decision-making frameworks to surface in orthodox medicine was that developed by Ballard-Reisch (1990).²⁵ Originally designed for physicians, the eight-stage participative decision-making model aimed to provide a more client-centred and structured approach to client care. Although the need for a participative approach was timely and well justified, the stages of the model lacked sufficient description. There is also little evidence to indicate that, to date, this process has been accepted or taken up by the wider medical community. This is not to say that other participative models have not been adopted by physicians, only that the use of such frameworks has not been well published.

A well-documented decision-making framework is the nursing process. This model has been widely accepted by the nursing community and is recognised internationally and integrated into most nursing curricula.²⁶ In essence, the process provides a client-centred framework for nursing practice ‘by which nurses use their beliefs, knowledge, and skills to diagnose and treat the client’s response to actual and potential health problems’.²⁶

The benefits that the nursing process delivers to the nursing profession have been recognised by other disciplines, including the dietetics community, which has led to the subsequent development of the nutrition care process.^27,28 It is not surprising, therefore, that there is considerable overlap between the two processes. In fact, there are many similarities between most decision-making models, including the Prion²⁹ clinical reasoning model, Nagelkerk³⁰ diagnostic reasoning process and the aforementioned frameworks. The key themes that arise from all of these models are assessment, diagnosis, planning, implementation and evaluation.

Another concept that is implied in the Ballard-Reisch model²⁵ but not explicitly stated in any other decision-making process, yet a component that is critical to all client–practitioner interactions, is rapport. Incorporating rapport into a clinical decision-making framework, together with the five themes listed above, would in effect create a more complete, systematic and structured approach to the management of client problems. DeFCAM is therefore one of only a few, if not the only known model to adequately capture all of these themes within one process. Although the development of such a model could be perceived by some as merely following the trends of other professions, there is in fact real merit for the CAM profession in adopting such a framework, which the following section alludes to.