Explore (NY). 2008 (Jan); 4 (1): 18–24 ~ FULL TEXT
Michael J. Garner, MSc, Michael Birmingham, PhD, Peter Aker, MSc, DC, David Moher, PhD,
Jeff Balon, DC, MD, Dirk Keenan, DC, and Pran Manga, PhD
Carlington Community and Health Services,
Ottawa, Ontario, Canada.
BACKGROUND: The use of complementary and alternative medicine has been increasing in Canada despite the lack of coverage under the universal public health insurance system. Physicians and other healthcare practitioners are now being placed in multidisciplinary teams, yet little research on integration exists.
OBJECTIVE: We sought to investigate the effect of integrating chiropractic on the attitudes of providers on two healthcare teams.
DESIGN: A mixed methods design with both quantitative and qualitative components was used to assess the healthcare teams. Assessment occurred prior to integration, at midstudy, and at the end of the study (18 months).
SETTING: Multidisciplinary healthcare teams at two community health centers in Ottawa, Ontario, participated in the study.
PATIENTS/PARTICIPANTS: All physicians, nurse practitioners, and degree-trained nurses employed at two study sites were approached to take part in the study.
INTERVENTION: A chiropractor was introduced into each of the two healthcare teams.
MAIN OUTCOME MEASURES: A quantitative questionnaire assessed providers' opinions, experiences with collaboration, and perceptions of chiropractic care. Focus groups were used to encourage providers to communicate their experiences and perceptions of the integration and of chiropractic.
RESULTS: Twelve providers were followed for the full 18 months of integration. The providers expressed increased willingness to trust the chiropractors in shared care (F value = 7.18; P = .004). Questions regarding the legitimacy (F value = 12.33; P < .001) and effectiveness (F value = 11.17; P < .001) of chiropractic became increasingly positive by study end.
CONCLUSION: This project has demonstrated the successful integration of chiropractors into primary healthcare teams.
Key words: Primary care, chiropractic, community health centers
From the FULL TEXT Article:
Complementary and alternative medicine (CAM) usage has been
increasing in the general Canadian population, despite the fact that
most CAM treatments fall outside the standard coverage of the
publicly financed health insurance system.  Scientific evidence
demonstrating the potential role of CAM in primary healthcare is
also increasing. [2, 3] These changes have resulted in courses on CAM
being included in the curricula of many North American medical
schools. [4, 5] Despite the increase in utilization, evidence for its use,
and education in CAM, the integration of CAM into primary
healthcare settings and teams is rare.
One type of integration that has been examined previously is
that of nurse practitioners into primary care practices. [6, 7] The
creation of an educational environment within the primary care
setting is important for increasing the use of nurse practitioners. 
Practitioners feel less anxiety about role overlap when a collaborative
treatment approach is used,  although physicians continue
to find it difficult to work as members of a team with other
kinds of practitioners.  Even with these difficulties in collaborating
and concerns about liability and responsibility, referrals to
CAM providers from physicians are increasing in the United
States,  Canada,  and the United Kingdom. 
In Ontario, providers who were once able to work independently
are being positioned within multidisciplinary teams. It is
important to understand how physicians work and integrate
with nonconventional healthcare providers. Community health
centers (CHCs) currently care for clients by using multidisciplinary
healthcare teams. These teams serve as a readily available
location for the exploration of the integration of nonconventional
practitioners with conventional healthcare providers. In
both the United States and Canada, CHCs are mandated to treat
marginalized populations who have limited access to health services,
including services not subsidized by the provincial healthcare
plan. [13, 14] Just before the start of the study, chiropractic was
delisted from the provincial healthcare plan, making this treatment inaccessible to the majority of CHC clients who do not have private healthcare insurance and who could not afford to
attend otherwise. Previously, the provincial healthcare plan partially
covered the cost of this service. Although chiropractors
and medical doctors work concurrently in the Ontario healthcare
system, there has yet to be a meaningful integration of these
two professions. The present study was undertaken to investigate
introducing chiropractic care, and the effect this integration had
on the practice and attitudes of multidisciplinary primary care
teams in Ottawa, Canada.
This project was implemented in two CHCs in Ottawa, Ontario,
Carlington Community and Health Services and South-East
Ottawa Centre for a Healthy Community, from July 2004 until
March 2006. All physicians, nurse practitioners and degree-trained
nurses employed at the two study sites were approached
to participate in the study. Each center hired a chiropractor, who
was integrated as a part-time member of the healthcare team and
received salary and full benefits. Chiropractic services were available
to all clients of either center free of charge. The chiropractors
were selected on a variety of criteria, both to ensure a similar
practice philosophy as that found at CHCs as well as personalities
that would be a good fit with the other members of the
healthcare team. Ethics approval for the study was obtained
from the Ottawa Public Health Department Ethics Review
This study used a mixed methods design with quantitative and
qualitative components, using questionnaires and focus groups
to assess the healthcare teams. Providers were assessed at baseline
(prior to integration), nine months later, and at study end (18
months) by using focus groups and quantitative questionnaires.
Focus groups were used to broaden and complement the information
gathered by the quantitative questionnaires. Focus group
sessions and questionnaire administration were performed on
the same morning. After the first two focus group sessions, educational
sessions were run to expose providers to chiropractic
treatment by demonstrations and presentations of the published
evidence on chiropractic. These sessions were run by members
of the research team (J.B., P.A., M.J.G.) and the chiropractors
hired for the integration.
The questionnaire was developed to ascertain providers’ opinions,
experiences with collaboration, and perceptions of chiropractic
care. Each question used a seven-point Likert scale,
ranked from strongly agree to strongly disagree for response. The
questionnaire used was designed specifically for use in this study
because the integration of chiropractors into medical settings
had not been evaluated previously. The questionnaire was pilottested
before the study began with providers at a CHC in Ottawa,
similar to the two study CHCs, to insure clarity of the
Provider Focus Groups
One member of the research team (M.J.G.) moderated the focus
groups, which lasted between 60 and 90 minutes. Group sessions
were recorded using nonconcealed microphones. The focus
groups served as a forum for providers at both centers to communicate
their experiences and perceptions of the integration
and of chiropractic. At the initial session, we discussed chiropractic
and its role in primary healthcare, along with perceptions
and concerns about the study and the introduction of a new
provider into the CHC. The second and final focus groups
centered on how the providers’ views had or had not changed
regarding chiropractic and how this influenced clinical practice
and the success (or failure) of the integration. At the end of the
study period, face-to-face interviews were performed with each
of the chiropractors to assess the success of the collaboration
from their point of view.
Change in response over the three time periods was assessed by
repeated measures analysis of variance, with the general linear
model procedure in SAS version 9.1 (SAS Institute Inc., Cary,
NC). Post hoc analyses were performed on all statistically significant
main effects. Quantitative questionnaires were based on
those used elsewhere.  The focus group audiotapes were transcribed
for analysis. The Spencer and Ritchie qualitative framework
served as a guide for the qualitative analysis.  Analysis
involved an initial search for recurrent themes, focusing on the
impact of the integration. This process involved familiarization
with the data, identification of themes, then examining changes
in provider’s perceptions and attitudes over the course of the
study. This study was done in accordance with the Ottawa Public
Health Ethics Review Board and received ethics approval in
Twelve providers were followed for the full 18 months of integration.
Eight other providers were eligible for inclusion at the
beginning of the study: three left their job; four took new positions
at the centers, and one nurse refused involvement in the
study. The results reported only pertain to the twelve providers
followed for the full 18-month integration. The mean age of the
providers was 44.1 years, and they all had worked at their centers
between two and five years (Table 1). Each chiropractor had
been in practice more than 5 years and had prior experience
working in at least one multidisciplinary medical setting.
Provider attitudes toward collaboration with the chiropractor
changed over time (Table 2). The healthcare team expressed
increased willingness to trust the chiropractor in shared-care
cases (F-value = 7.18; P = .004) and had greater respect for the
chiropractor’s knowledge and skills (F-value = 6.14; P = .008).
For other questions of collaboration, the providers were generally
neutral in their attitudes at baseline, and there were no
significant changes over the study period.
Attitudes Toward Chiropractic
We observed a shift during the integration in the attitude of
healthcare providers toward chiropractic (Table 3). General
questions regarding both the legitimacy of chiropractic as a
form of healthcare (F value = 12.33; P < .001) and the effectiveness
of chiropractic (F value = 11.17; P < .001) moved
from neutral responses to increasingly more positive responses.
By study end, the providers were indicating that
chiropractic care for low back pain was safer than anti-inflammatory
medication (F value = 18.08; P < .001). Initial skepticism
about the efficacy and safety of chiropractic dissipated
by the end of the study (F value = 15.21; P = .001). Questions
regarding experiences with the chiropractor and patient outcomes
moved from neutral to positive over the course of the
study (F value = 15.69; P = .001). The providers also indicated
that the presence of the chiropractor on the healthcare
team impacted their practice in a positive way and influenced
their understanding of chiropractic (mean response at 18
months, 1.33). Post hoc analysis of variables that changed
significantly over the study revealed that the most of the
change occurred between baseline and nine months, as opposed
to the second half of the study.
Table 4 A
Table 4 b
Analysis of the focus group data revealed a shift within the medical
teams from negative and limited views of chiropractic to a generally
positive attitude toward having a chiropractor on the healthcare
team (Table 4). The providers’ understanding of the scope of the
chiropractor’s role increased markedly over the course of the study.
The providers at both sites referred conditions of increasing complexity
over the study, particularly the referral of chronically disabled
individuals; a typical comment was “Well, I definitely don’t
see as many musculoskeletal people after the initial visit.” The
healthcare team expressed that patient response to chiropractic care
was almost always positive. It is noteworthy that there were no
negative outcomes observed in the study at either center, as seen in
the following representative comment: “I have only had positive
feedback from many of my clients; they have always had some sort
of change in their outcome and they have always had some sort of
positive thing to say.”
Providers’ understanding of chiropractic changed over the course
of the study period, from seeing it as a largely unknown practice to
understanding both the science and the actual practice of chiropractic.
Initially, the providers did not think the introduction would
impact their practice. By the end of the study period, the change in
caseload because of the additional treatment option chiropractic
provided, and relief to the healthcare team stemming from referring
difficult cases — those for whom the conventional medical treatment
options had been ineffective — to the chiropractor proved to
have a positive impact on the providers’ individual and group practice.
A representative comment was “We are able to give the patient
hope and encouragement, and actually, I have a lot of patients that
it (chiropractic) has helped with their pain reduction and certainly
has taken the burden off of me psychologically a little bit and time
wise as well.” It is important to note that the providers remained
skeptical about chiropractors in general and would only consider
referring to other chiropractors if they were demonstrated to be
similar in skill and practice methodology to the integrated chiropractor.
The focus groups also elucidated the factors that were important
to the successful integration of a chiropractor into a
multidisciplinary healthcare team (Table 5). The main factors
were the personality of the chiropractor, the healthcare provider’s
understanding of chiropractic care, and the practice
characteristics, such as team meetings and how the clinic is
physically set up.
Post-integration interviews with the chiropractors revealed that
the integration was ultimately a success. Both chiropractors remarked
that the length of time and amount of effort to gain the
trust of the doctors and nurses on the healthcare team was large.
However, once interpractitioner trust had been established, the
collaborative practice that ensued was beneficial to the chiropractor
as a professional and increased the scope of care provided
to his/her patients.
Our results indicate that integrating chiropractic care into an
established conventional medical setting, specifically a CHC,
can be achieved with a high degree of comfort, as reported by
healthcare providers and patients alike. These data are in sharp
contrast to other published opinions. Kelner and colleagues 
saw the integration of CAM as a distant possibility that would be
extremely difficult to achieve. They did not favor this kind of
integration and raised doubts about the competence of the
CAM providers as well as the feasibility of working together. The
collaboration observed in this study involved referrals back and
forth between the chiropractor and the medical doctors, case
collaboration on the treatment of certain patients, and seeking
advice and diagnostic opinions from each other.
During the initial assessment, we observed the providers’
doubts about the competence of the chiropractors and the concerns
about collaboration. Over the course of the study, these
concerns dissipated and were replaced by a largely positive view
of collaboration and working with chiropractors as equal team
members. Although concern about chiropractic in general remained,
the providers did state that they would be comfortable
with a different chiropractor who shared the same abilities and
practice methodology as the integrated chiropractor.
We found that interprofessional education was useful in reducing
both the concerns about chiropractic and the team’s
reluctance to collaborate with the chiropractor. The providers
indicated that presentation of peer-reviewed research on chiropractic
and the demonstrations of chiropractic treatments were
useful in dispelling misconceptions and concerns toward the
safety and efficacy of chiropractic and manipulation. The importance
of interprofessional education has been previously
stated as very important for addressing collaboration problems. 
Additional factors influencing the success of the integration
were positive clinical outcomes for the patients referred to
the chiropractor and the provision of chiropractic as a free service
to the clients of each CHC; these factors were significant
because many other treatments (eg, physiotherapy and massage
therapy) for musculoskeletal disorders were inaccessible by this
patient population because of cost. Also, communication between
the chiropractor and the healthcare team was facilitated
by the inclusion of the chiropractor in weekly team meetings
and other team development activities.
The post hoc analysis performed on the change in provider’s
opinions of chiropractic and collaboration revealed that the majority
of the change occurred in the first nine months of the
project. This suggests that integration of nonconventional
healthcare workers into multidisciplinary teams can occur in less
than a year, given sufficient educational and logistic support.
Previous studies indicated that a minimum of 18 months is
required for team formation. 
Negative attitudes and differences in ideology between professions
have been cited as a barrier to team functioning. [18, 19]
Previous studies have observed that the attitude toward chiropractors
in the conventional medical community is generally
poor, with only 23% considering chiropractors legitimate
healthcare providers, whereas 95% considered physiotherapists
legitimate.  The same study found that only 35% of general
practitioners surveyed thought it ethical to deal with a chiropractor.  Although the concern related to chiropractic in the
present study was not as great as that observed previously, the
providers at both sites were generally concerned about this integration.
The results of the study suggest that access to in-house
chiropractic care may improve provider perception, and that
chiropractors can be successfully integrated in a multidisciplinary
primary care setting.
There are several limitations to this study. The sample of
providers is small (N = 12) and only includes two multidisciplinary
healthcare teams. There may be unique aspects to
these teams that would prevent the results of the integration
from being generalized to other healthcare teams. In particular,
healthcare teams at CHCs collaborate as part of their
inherent culture, and they are accustomed to working with
new practitioners and treatment modalities. The sample of
medical providers was all female, which may influence the
generalizability of the results to male practitioners. The current
setting provides both chiropractic and medical care free
of charge to the client. It is unclear if the integration would be
more or less difficult in situations with different financial
agreements. In addition, the tool used for the quantitative
study was unvalidated.
The two integration sites in this study were quite similar, with
two important differences. First, the Carlington site used an
integrated medical chart where both the chiropractic records and
the medical records were in the same nonelectronic file. At the
Southeast Ottawa site, the medical and chiropractic charts were
separately maintained with limited accessibility to other team
members. This meant progress attributable to chiropractic was
difficult to ascertain, and this was identified by healthcare team
members as a barrier to integration.
The second important difference
was the presence of a volunteer chiropractic clinic at
Carlington for the five years prior to the start of this study. 
This clinic operated with a high turnover of chiropractor volunteers,
with the resulting negative opinions due to a lack of continuity
of care. This created a situation where the chiropractor
being integrated at that site had to overcome and demonstrate
the differences in clinic practices between the integrated practice
and the volunteer clinic. This caused a delay in the process, but
over the first few months as the healthcare team interacted with
the chiropractor and experienced initially positive outcomes
from patients, the integration proceeded in a similar way to the
The success of the integration of chiropractors into multidisciplinary
healthcare teams that was observed in this study should
help provide a framework for future sites attempting similar
integrations. For successful integration, it is important to first
choose a professional who is willing to put significant effort into
building relationships with the healthcare team and endure initial
skepticism. We also found that having an experienced chiropractor
(minimum of five years practice) was important to the
integration, because their practice experience and ability created
an environment where the healthcare team could be confident
in the chiropractic care given. There should also be involvement
of healthcare team members in the selection of the chiropractor
so communication styles and personality traits are such to facilitate
working with the existing team.
This project demonstrated the importance of structuring and
scheduling interactions between the established healthcare team
and the chiropractors to facilitate a successful integration. We
used formal education sessions to help dispel misconceptions
about chiropractic and had the chiropractor scheduled into
weekly clinical rounds. This integration had a positive impact on
providers’ individual practices and changed opinions and views
of healthcare practitioners toward chiropractic, resulting in conventional
and nonconventional healthcare providers working
together on a collaborative healthcare team. However, given the
small sample size and other limitations, the results may not be
generalizable to other healthcare settings.
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