BMC Complement Altern Med. 2016; 16: 134.
Published online 2016 May 20. doi: 10.1186/s12906-016-1111-3
PMCID: PMC4875612
Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario M5S 3M2 Canada
Women’s
College Hospital and Department of Family and Community Medicine,
Faculty of Medicine, University of Toronto, and Women’s College
Hospital, Toronto, Ontario M5S 1B2 Canada
Heather S. Boon, Email: ac.otnorotu@noob.rehtaeh.
Corresponding author.Abstract
Background
Medical
pluralism has flourished throughout the Western world in spite of
efforts to legitimize Western biomedical healthcare as “conventional
medicine” and thereby relegate all non-physician-related forms of
healthcare to an “other” category. These “other” practitioners have been
referred to as “unconventional”, “alternative” and “complementary”,
among other terms throughout the past half century.
Methods
This
study investigates the discourses surrounding the changes in the terms,
and their meanings, used to describe unconventional medicine in North
America. Terms identified by the literature as synonymous to
unconventional medicine were searched using the Scopus database. A
textual analysis following the method described by Kripendorff 2013 was
subsequently performed on the five most highly-cited unconventional
medicine-related peer-reviewed literature published between 1970 and
2013.
Results
Five
commonly-used, unconventional medicine-related terms were identified.
Authors using “complementary and alternative”, “complementary”,
“alternative”, or “unconventional” tended to define them by what they
are not (e.g., therapies not taught/used in conventional
medicine, therapy demands not met by conventional medicine, and
therapies that lack research on safety, efficacy and effectiveness).
Authors defined “integrated/integrative” medicine by what it is
(e.g., a new model of healthcare, the combining of both conventional
and unconventional therapies, accounting for the whole person, and
preventative maintenance of health). Authors who defined terms by “what
is not” stressed that the purpose of conducting research in this area
was solely to create knowledge. Comparatively, authors who defined terms
by “what is” sought to advocate for the evidence-based combination of
unconventional and conventional medicines. Both author groups used
scientific rhetoric to define unconventional medical practices.
Conclusions
This
emergence of two groups of authors who used two different sets of terms
to refer to the concept of “unconventional medicine” may explain why
some journals, practitioner associations and research/practice centres
may choose to use both “what is not” and “what is” terms in their
discourse to attract interest from both groups. Since each of the two
groups of terms (and authors who use them) has different meanings and
goals, the evolution of this discourse will continue to be an
interesting phenomenon to explore in the future.
Background
Medical
pluralism has flourished despite efforts to legitimize Western
biomedical health care as “conventional medicine”, thereby relegating
non-physician forms of healing to an “other” category. These “other”
practitioners have been labelled as “unorthodox”, “unconventional”,
“alternative” and “complementary”, among other terms throughout history [1, 2].
The changes in these terms and their meanings are the subject of this
inquiry. By exploring the peer-reviewed medical literature discourses
with a focus on the individuals and groups that were instrumental in
these changes, this study sheds light on how conventional practitioners
and researchers understand, label and categorize “others” providing
health care to patients.
“Conventional” medicine
Numerous
terms have emerged to identify the type of medicine practised by
physicians including: “orthodox”, “allopathic”, “modern”, “scientific”,
“bio-”, “evidence-based”, “Western”, “mainstream”, and “conventional”,
each preceding the word “medicine”, and sometimes “therapy” [3, 4].
For the purpose of this study, we thought it important that a neutral
term, with minimal negative or positive connotation was employed,
considering that this study investigates the terminology itself. The
word “conventional” was chosen to frame this study because it is both
widely understood, common in the literature, and relatively neutral in
referring to the politically dominant system of medicine at any
historical time point [2].
For the purpose of this study, “conventional medicine” is defined as
“medical interventions that are taught extensively at US [and Canadian]
medical schools and generally provided at US [and Canadian] hospitals”
([5], p. 246).
“Unconventional” medicine
We
can see that there is great difficulty in defining terms which refer to
medical therapies outside the realm of conventional medicine [6].
Over the past half-century, there has not been a single, agreed upon
overarching name given to unconventional systems and their
practitioners. A variety of terms have been used to describe therapies
excluded from conventional medicine including: “irregular”,
“unorthodox”, “unscientific”, “quack”, “fringe”, “folk”, “alternative”,
“adjunctive”, “alternative and complementary”, “complementary and
alternative”, “complementary”, “integrated”, “integrative”,
“non-mainstream”, and “unconventional”, each preceding the word
“medicine” or “therapy” [1, 2].
Many of these terms, with the possible exception of the terms
“complementary” “integrated”, “integrative”, “non-mainstream”, and
“unconventional”, suggest a negative connotation associated with the
safety and/or effectiveness of these medicines [1].
The words “complementary”, “integrated”, and “integrative”, suggest a
certain relationship between conventional medicine and “other”
therapies, and thus these terms do not appear to refer to all therapies
not included in conventional medicine [7–10].
Similar
to the word “conventional”, the word “unconventional” was chosen to
frame this study because it is widely understood, common in the
literature, and suggests a sense of neutrality when referring to the
politically subordinated system of medicine at any point in time [2]. For the purpose of this study, “unconventional medicine” is defined as “medical interventions that are not taught extensively at US [and Canadian] medical schools and generally not provided at US [and Canadian] hospitals” ([5], p. 246).
Regardless of the terms used to describe unconventional medicine, the challenge of definition still exists [5, 11, 12].
This is partly due to multiple factors that contribute to the reality
that a large number of very different unconventional systems and
practitioners exist, and thus, any given term must encompass a wide
range of practices and beliefs [5].
Unconventional medicines arise from multiple histories, schools of
thought, and world regions. Furthermore, some previously unconventional
therapies have since been integrated into medical school curricula, at
which point they are technically excluded from the categorization as
unconventional medicine [12].
Selecting a term with a meaning that accurately accounts for all forms
of unconventional therapies and interventions is both complex and
dynamic.
Theoretical framework: scientific rhetoric boundary work
Theories
about how groups of health care practitioners form, evolve and interact
provide necessary context when aiming to understand the discourses
surrounding unconventional medicine. One such theory relevant to this
study is that of Thomas Gieryn [13],
who asserts that science is often used by those seeking to distinguish
and demarcate their work and its products from “non-scientific”
intellectual enterprises. This “boundary work” has occurred throughout
history, with a notable example being how the miasmatists of the 1800s
sought to discredit the work of John Snow, who was sceptical of the
miasmatic theory of disease. The famous London cholera outbreak of 1854
eventually lead to the acceptance of a pre-germ-theory-notion of
transmission via water, but only after many lives were unnecessarily
lost because of the refusal of the miasmatists to acknowledge that John
Snow’s data maps were compelling forms of evidence against their theory
of cholera transmission through noxious air [14].
Had John Snow not been a well-respected anaesthesiologist, whose
patients included Queen Victoria, his theory of cholera transmission
would likely never have been given a second look because of his
unorthodox epidemiologic methods and wild departure from the dominant
scientific understanding of disease that governed public health at the
time. Even today, hierarchies of evidence are taught in medical schools,
and randomised controlled trials are held out as the most compelling
forms of evidence, despite the fact they have limited applicability to
real-world settings where patients are heterogenous [15].
Gieryn’s boundary work relating to scientists argues that they
construct a social boundary in order to distinguish their intellectual
activities from those which are not “scientific” [13].
Gieryn asserts that science serves as a type of intellectual authority
because scientific knowledge has come to be widely accepted by society
as the preferred truth in describing and explaining reality. Finally, he
argues that science is more dynamic and ambiguous than scientists may
claim, for it is not a single entity, nor are boundaries constructed
similarly, but instead are created in response to challenges faced by
different obstacles lying in the way of achieving authority and material
resources [13].
Applying
Gieryn’s perspective served to focus the inquiry on exploring if, and
how, conventional practitioners utilize the rhetoric of science to
legitimize practices of their own or delegitimize practices of others.
We show that conventional practitioners’ use a scientific notion of
“effectiveness” to establish the validity of their therapies and
research methods, as a rhetorical strategy to establish their authority.
Concomitantly, conventional practitioners label unconventional
practitioners and their therapies, “unscientific”, which functions to
exclude them from conventional medicine and deny them legitimacy and
resources.
Study aim
The
overall purpose of this research study was to conduct a textual
analysis to identify the shifts in how unconventional systems (and their
practitioners) have been described over time in the peer-reviewed
literature applicable to Canada and the United States from 1970 to 2013.
The specific objectives of this study were two-fold:
- to identify changes in the naming of unconventional medicine over time in the peer-reviewed medical literature and;
- to conduct a textual analysis to explore how changes in the naming of unconventional medicine occurred and who contributed to them.
Methods
Study design: textual analysis
Textual
analysis is a specific study design derived from content analysis. The
latter comprises a group of techniques helpful in analysing and
understanding samples of text [16, 17].
Content analysis is one type of study design used in qualitative
research, which involves attention to the content of texts and
circumstantial meaning, focussing on language characteristics as
communication [16, 18–20].
The
goal of conducting a textual analysis is to identify hidden meanings,
as well as unquestioned patterns and accentuations of texts, where the
intent of the researcher is to acquire a deeper understanding of the
context in which the text is written. Hence, textual analysis views a
text as a “cultural artifact”, and identifies why written work is
produced, in addition to the intended audience of the text being
analyzed. Textual analysis focusses on repeated patterns, placing,
striking imagery, style, and tone, as examples of items which enable
researchers utilizing this study design to elicit “the structures of
meanings and the configurations of feelings on which this public
rhetoric is based” [21].
This study adopted a six-stage textual analysis model based on Klaus
Krippendorff’s components of content analysis: unitizing, sampling,
coding, reducing, inferring, and narrating [22].
Unitizing
guides the researcher in deciding what type of data should be collected
and analyzed. For this study, this was limited to the peer-reviewed
literature as these articles serve to communicate discussions and
controversies concerning researchers’ and practitioners’ understanding
of unconventional medicine.
The next step, sampling, involved identifying an appropriate sample of peer-reviewed articles [22],
retrieved from the Scopus searches. Sampling allows the researchers to
limit observations and analysis, in cases where it is impractical to
analyze all texts relevant to the study [22]. In this study, it facilitated a focus on the most commonly used terms.
Coding
refers to bridging the gap between texts and the researcher’s reading
of them. In this stage, coding categories were developed from the data
guided by the theories of professions discussed in the Theoretical
Framework section above. According to Krippendorff [22],
“researchers can avoid simplistic formulations and tap into a wealth of
available conceptualizations” by deriving categories from established
theories. Coding is an iterative process. Codes are created and revised
as additional data are collected.
Reducing the data
helps researchers to efficiently represent large volumes of data,
ultimately reducing the diversity of text to what matters through
summarizations [22].
Following the initial collection and coding of text excerpts, all
excerpts were examined to question if they were grouped into the most
appropriate categories to explain the data, and to explore if the
categories could be grouped into themes. Original categories or themes
may have been removed, merged or split during this review. This process
was repeated until all categories and themes had been satisfactorily
developed and all excerpts were adequately indicative of each category
or theme.
Inferring refers to identifying what unobserved phenomena mean, or refer to, supported by evidence found within the text [22].
This involved examining how the texts in each article were organized
and presented and what specific “angle” the authors’ were taking.
Additionally, the general “mood” of the text was taken into account,
where careful attention was paid to concepts either depicted
prominently, unimportantly or omitted altogether, allowing the
researcher to identify authors’ presuppositions and subtexts [23].
Lastly,
narrating makes the researcher’s findings understandable to everyone
else. This stage involved describing the practical significance of the
results and how the contributions made by our study impacted the
existing literature previously published within this subject area [22].
Data collection
On
September 11, 2014, a series of advanced searches of the Scopus
database were conducted, encompassing all terms previously identified as
being used to represent unconventional medicine synonyms in the
literature [1, 2]. These terms are provided in Table 1.
Screening of Commonly Used Search Terms for Year of Use Pertaining to Unconventional Medicine
The Scopus database is very comprehensive in its coverage of scientific, technical, medical, and social scientific literature [25],
which makes it particularly ideal in recovering unconventional
medicine-related peer-reviewed articles. Scopus is the largest database
of peer-reviewed literature, currently housing 53 million records,
including coverage of the entire MEDLINE and EMBASE databases [24]. Scopus is also more comprehensive with regards to its cited reference countsthan Web of Science [25].
Preliminary
Scopus searches identified five terms as the most commonly-used:
“alternative”, “unconventional”, “complementary”, “complementary and
alternative” and “integrated/integrative”. These terms were chosen
because a sufficient quantity of articles were cited highly enough to
suggest that the papers associated with each term were influential and
could be used to establish general trends associated with the changes
and meanings of the respective terms. The final Scopus search using
these five terms, excluding duplicates, yielded 7012 articles.
Articles
were selected for further review in this study if they met all of the
following inclusion criteria: (1) they were obtained from the
peer-reviewed literature and; (2) they were applicable to the Canadian
or American health care setting; and (3) they were published in English.
For criteria (2), this includes Canadian or American publications, and
also any other English-language publications as they may have influenced
the North American health care system (e.g., are highly-cited in the
Canadian or American literature). We limited our sample for close
analysis to the 20 most highly-cited articles (and sources they used for
their definitions of terms) per search term, because a high number of
citations suggests that these articles have had the most influence and
impact in shaping the discourse. See Fig. 1. These 100 articles are shown in Table 2.
Overview of the Search, Screening and Analysis of Articles in Study
The 20 Most Highly-Cited Peer-Reviewed Articles for Five Commonly-Used Unconventional Medicine-Related Search Terms
Data analysis
Each
article was coded with the goal of obtaining phrases, sentences, or
paragraphs of text that supported the developing categories and themes
and investigated the debates present in the sample [22].
Gieryn’s
theory was used to guide the coding process, including both the
development of the content categories, and the subsequent acquisition of
phrases, sentences or paragraphs of text that supported these themes
developed from these categories. Gieryn’s [13]
perspective highlighted the need to investigate whether and how authors
may use the rhetoric of science to their advantage (or disadvantage) in
labelling and describing the concept of unconventional medicine. For
example, in introducing or changing a term, did the author(s) appear to
refer to science as an intellectual authority in order to distinguish a
group or practice as (more) scientific than a competitor?
All
text excerpts were first categorized into topics organized into series
of themes, and following this, different excerpts within the same theme
were re-read again to screen for duplication of ideas. Duplicated ideas
were then reduced, resulting in all remaining texts to be indicated of a
larger volume of texts, used as exemplars in interpreting the findings
of the textual analysis [22].
Results
The
five most commonly-used terms in articles published between 1975 and
2013 were as follows, from most to least used in article titles:
“complementary and alternative”, “complementary”, “alternative”,
“integrated/integrative”, and “unconventional”. The order of the first
instances of these terms being used with respect to the meaning of
unconventional medicine, is as follows: “alternative” (1975) [26], “unconventional” (1980) [27], “complementary” (1984) [28], “complementary and alternative” (1994) [29], and “integrated/integrative” (1995) [30].
No
articles recovered from Scopus that had titles including one of the
five commonly used unconventional medicine-related terms were published
prior to 1975. “alternative” was the solely used term between 1975 and
1983, and remained the predominantly used term until 1990 and again
between 1997 and 1999. The use of the term “complementary” increased in
the early to mid-1990s, and its use has remained relatively consistent
up until 2013. The use of the combination term “complementary and
alternative” increased sharply beginning in 2000, and continues to be
the most commonly used term up to 2013. The use of the term
“integrated/integrative” began in the mid 1990s, and its use has since
slowly increased each year. “Unconventional” is a term used generally
less frequently than the other four terms, though its use has been
continuous between 1980 and 2013. Its use experienced a small rise
between the mid-1990s until the early 2000s. The number of publications
associated with these unconventional medicine-related terms tracked per
year is shown in Fig. 2. There were no significant changes in the meaning of individual terms over time in the literature analysed.
Number of Publications with Unconventional Medicine-Related Terms in Title per Year from 1975–2013
During
the textual analysis, we found that the meanings associated with the
terms “alternative”, “unconventional”, “complementary” and
“complementary and alternative” differed greatly from the term
“integrated/integrative”. While the first four terms were often used by
authors interchangeably and possessed similar definitions, the use of
the term “integrated/integrative” stood out as unique. These first four
terms were characterized by being defined by “what is not”, including
being listed or grouped as items not part of conventional medicine, directly being categorized as therapies or interventions not taught/used in conventional medicine, used to treat therapy demands that are not met by conventional medicine, and therapies lacking in
research on safety, efficacy and effectiveness. In contrast, the fifth
term was characterized oppositely as by “what is”, including a new model
or system of healthcare, the combination of conventional and
unconventional medicine, accounting for the whole person, and
preventative maintenance of health.
Importantly,
it should be noted that all themes identified in this study were
evaluated by the year in which the respective article was published. No
significant changes in the appearance or disappearance of any of the
“what is not” or the “what is” themes or subthemes occurred over this
study’s timeframe. However, it should be noted that all peer-reviewed
articles from which subthemes were extracted were published in 1993 or
later. The two major themes each containing four subthemes are the focus
of this section.
“Alternative”, “unconventional”, “complementary” and “complementary and alternative” medicine: an analysis of terms defined by “what they are not”
Defining
terms by “what is not” comprises one of two major themes within this
study. The definitions of four terms – “alternative”, “unconventional”,
“complementary” and “complementary and alternative” – can generally be
described as “what is not” definitions. Authors using any or all of
these terms in their articles consistently defined them as something
that was not within the realm of conventional medicine. While
defining by “what is not” served as an overarching theme, within it
there were four subthemes that emerged upon evaluating the texts
relevant to this group of authors.
The first
sub-theme that emerged was the fact that many authors either defined or
used these terms in reference to a list or group of therapies or
interventions:
“The most common CAM [complementary and alternative medicine] interventions/therapies included in the surveys, in order of most common inclusion, were chiropractic care, acupuncture, herbal medicine, hypnosis, massage therapy, relaxation techniques, biofeedback, and homeopathic treatment. CAM interventions/therapies such as chelation therapy, energy therapies, qi gong, tai chi, yoga, high-dose vitamins, and spirituality/prayer for health purposes were less commonly included.” ([31], p. 64)
While
not typically definitions themselves, such lists and/or groups of items
often defined the parameters of these therapies in studies. These lists
or groups of therapies were often accompanied with a given definition,
explaining the reasoning behind what was selected for inclusion in the
list.
The second theme related to a major reason
as to why these therapies were found on these lists of groups. The best
example of this is the definition of the term “unconventional therapies”
provided in Eisenberg et al.’s ([5], p. 246) study which is also the most highly-cited definition among the 80 papers [1, 32–43]:
Medical interventions neither taught widely at U.S. medical schools or generally available in US hospitals.” (emphasis added)
The third subtheme involved describing these as therapies that were being used to meet demands not met by conventional medicine. One good example of this is yet another highly-cited definition [40, 44–47] provided by Ernst et al. ([48], p. 506):
“Diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine” (emphasis added)
The
fourth subtheme captured the notion that there is a lack of academic
research surrounding the safety, efficacy and/or effectiveness of
unconventional therapies. Authors defined “complementary”,
“alternative”, complementary and alternative” or unconventional”
medicine as therapies not having sufficient evidence for use:
“Providers, methods and modes of diagnostics, treatment and/or prevention, for which, without sound evidence, specificity, sensitivity and/or therapeutic efficacy is commonly claimed in respect to a definite medical problem.” (emphasis added) ([49], p. 315)
Many
authors who used these four terms made clear that they felt there was a
need to rigorously evaluate unconventional therapies. Many included a
call for increased research and funding to be devoted to the study of
this subject area, to ensure that unconventional medicines met a certain
standard of safety and efficacy:
“In light of these observations, we suggest that federal agencies, private corporations, foundations, and academic institutions adopt a more proactive posture concerning the implementation of clinical and basic science research, the development of relevant educational curricula, credentialing and referral guidelines, improved quality control of dietary supplements, and the establishment of postmarket surveillance of drug-herb (and drug supplement) interactions.” ([37], p. 1575)
“Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.” ([32], p. 841
“Integrated/integrative” medicine: an analysis of terms defined by “what is”
In
contrast, authors who used the term “integrated/integrative”, only
defined it in a way that it could exist independently, as opposed to by
defining it by something that is “not”, and therefore, we argue that
these authors defined this term by “what is”.
There
were also four subthemes that could be identified from among this group
of authors solely using the term “integrated/integrative”.
The
first subtheme involves promoting a new model or system of healthcare.
The authors who used this term advocated for fundamental changes to the
conventional healthcare system. For example:
“Integrative medicine is not a radical movement, but it can produce major change. Its point is to position medicine in such a way that it can continue to build on its fundamental platform of science and at the same time reposition itself to create a health care system that more broadly focuses on the well-being of patients as well as practitioners.” ([9], p. 397)
The
second theme related to the thoughtful combination of conventional and
unconventional therapies. Largely, the authors who wrote about
“integrated/integrative” medicine believed that numerous and
positively-perceived aspects of unconventional medicines could
complement conventional ones to form a novel, ameliorated healthcare
system. Their language often included a criticism of the reductionist
form of conventional medicine-based research, and the need to adopt
research strategies that would showcase the optimal therapeutic ability
of unconventional therapies. For example:
“The challenge is to sort through all the evidence about all healing systems and try to extract those ideas and practices that are useful, safe, and cost-effective. Then we must try to merge them into a new, comprehensive system of practice that has an evidence base and also address consumer demands. The most appropriate term for this new system is integrative medicine.” (emphasis added) ([50], p. 442)
“We believe that the health care system must be reconfigured to restore the primacy of caring and the patient-physician relationship, to promote health and healing as well as treatment of disease, and to take account of the insufficiency of science and technology alone to shape the ideal practice of medicine. The new design must also incorporate compassion, promote the active engagement of patients in their care, and be open to what are now termed complementary and alternative approaches to improve health and well-being.” (emphasis added) ([9], p. 396)
“A published case study of communication has shown that IM [integrative medicine] panel members representing a wide range of theories of health and healing were able to communicate easily with one another, when they limited themselves to the scientific language of biomedicine.” (emphasis added) [51]
The
third theme in this category is that of accounting for the whole
person. This idea was discussed frequently in these articles, and
involved taking into account the different “dimensions” of a patient,
including their biological, psychological, sociological and spiritual
factors, as a practitioner in this new integrative medical model.
Furthermore, many of these authors claimed that by accounting for each
of these factors, a clinician’s quality of practice would also improve:
“Integrative medicine represents a higher-order system of systems of care that emphasizes wellness and healing of the entire person (bio-psycho-socio-spiritual dimensions) as primary goals, drawing on both conventional and CAM approaches in the context of a supportive and effective physician-patient relationship.” (emphasis added) ([52], p. 133)
“All factors that influence health, wellness and disease are taken into consideration, including mind, spirit and community, as well as body. These multiple influences on health have been firmly documented in the literature but are not often recognized as important in medical practice. Conventional medical care tends to focus on the physical influences on health. An integrative approach also addresses the importance of the nonphysical (eg, emotions, spirit, social) influences on physical health and disease.” (emphasis added) ([53], p. 279)
Lastly,
the fourth theme associated with the term “integrative/integrated” is
regarding the preventative maintenance of health. The final theme
commonly discussed by this group of authors involved the idea that,
instead of waiting to treat disease once it developed, the focus of
healthcare should be shifted towards addressing preventative health in
both patients and healthcare providers:
“In addition to providing the best conventional care, integrative medicine focuses on preventive maintenance of health by paying attention to all relative components of lifestyle, including diet, exercise, stress management, and emotional well-being.” (emphasis added) ([9], p. 396).
Authors
highlighted that preventative maintenance of health also included the
teaching of physicians to care for themselves. These authors advocated
for medical schools to encourage their students to follow healthy
lifestyles.
Discussion
The
purpose of conducting this analysis was to explore how the meanings
associated with unconventional medicine-related terms have changed over
time in the peer-reviewed literature. We had expected to find an
evolution in use of these terms and their meanings over time. Instead, a
key finding was that four out of five terms selected for further
analysis – “alternative”, “unconventional”, “complementary” and
“complementary and alternative” – were frequently defined and/or used
interchangeably. While the use and definition of the fifth term,
“integrated/integrative”, was so unique that it would be incorrect to
categorize it as synonymous with the other terms as we had originally
assumed when embarking on the study. In addition to this dichotomy
between “what is not” versus “what is” in unconventional
medicine-related terminology, another key area of relevance relates to
Thomas Gieryn’s [13]
scientific boundary work described earlier in this paper. These two key
findings make up the two major points of discussion in the next
section.
The divide between “what is” vs. “what is not”
The
first key finding relates to the existence of two distinct groups of
authors in the literature including those who use terms defined by “what
is not” (i.e. “alternative”, “unconventional”, “complementary” and
“complementary and alternative”), and those who use the term defined by
“what is” (i.e. “integrated/integrative”). More importantly, a key
difference in stance is what separates these two groups of authors.
Those
defining terms by “what is not” generally did not seek to make changes
in the sociopolitical positioning of unconventional medicine. In
addition to not focussing attention on which of the four terms they
used, these authors aimed to position themselves as a group who viewed
and evaluated unconventional therapies “objectively”. These authors
frequently explained that their reason for conducting research into
unconventional therapies was to fill in knowledge gaps in the
conventional medicine community. “What is not” authors often advocated
for greater scientific research of unconventional therapies with a
stated goal of determining the safety and efficacy, among other aspects,
of such therapies.
In contrast, those defining terms
by “what is” sought to evaluate certain unconventional therapies that,
if deemed to have sufficient evidence for their use, should then be
offered within an integrative medical model. The “what is” group of
authors were explicit in stating that their goal lies in reforming the
current conventional healthcare system in two major ways: revising
medical education and changing the way medicine is practiced. Authors in
this group also advocated for teaching medical students and
practitioners how to lead more healthy lifestyles during their training
and practice respectively. “What is” authors also engaged in an
interesting form of advocacy, as they made claims that their proposed
changes in conventional healthcare would serve as a solution to global
health crises. By addressing an issue that has been highlighted in major
reports including those published by the Lancet Commission and the
World Health Organization, among other influential sources, these
authors argued that their suggested reforms of the healthcare system are
needed to keep pace with population demands in health care [54, 55].
Stakeholders
(such as funding bodies, academic journals and unconventional
medicine-related care centres or educational institutions) interested in
attracting authors with an interest in this field appear to have
adjusted their language to appeal to both groups. For example, the
National Center for Complementary and Alternative Medicine (NCCAM)
(formerly named as the Office of Alternative Medicine (OAM)), changed
its name to the National Center for Complementary and Integrative Health
(NCCIH) in December 2014 [56].
Prior to making a decision on its new name, the NCCIH invited public
comment allowing anyone with an interest to contribute to the idea of
their proposed name change. This appears to deliberately signal openness
to funding studies from individuals in both the “what is not” and “what
is” groups. It should be noted that this strategy of including
terminology used by both groups is not unique to the NCCIH, as the
deliberate combination of terms is also increasingly being seen in
peer-reviewed journal names (i.e., Journal of Complementary and
Integrative Medicine [http://www.degruyter.com/view/j/jcim], Alternative and Integrative Medicine [http://esciencecentral.org/journals/alternative-integrative-medicine.php]), practitioner associations (i.e., Association of Complementary and Integrative Physicians of British Columbia [http://www.acpbc.org/]) and research/practice centres (i.e., Australian Research Centre in Complementary and Integrative Medicine [http://www.uts.edu.au/research-and-teaching/our-research/arccim], Mayo Clinic’s Complementary and Integrative Medicine Program [http://www.mayo.edu/research/centers-programs/complementary-integrative-medicine/complementary-integrative-medicine-program/overview]), that exist in this field.
The use of scientific rhetoric for legitimacy
The second key finding revolves around scientific rhetoric, which relates to Gieryn’s [13]
scientific boundary work. Despite differences that exist between both
groups of authors, each focussed on the importance of science in
defining medicine that was not “conventional”. Authors defining terms by
“what is not” used scientific rhetoric to identify the importance of
further research addressing the safety and efficacy of these therapies.
For example, Eisenberg et al. called for academic institutions to
implement further “clinical and basic science research” regarding
unconventional therapies ([37],
p. 1575), while Angell and Kassirer stated that unconventional medicine
has not been “scientifically tested”, and argue that such therapies
should undergo “scientific testing” equally rigorous to that required
for conventional medicines [32, p. 839, 841] thus ruling them “out” of
the realm of conventional medicine for now.
Authors
defining terms by “what is” used this rhetoric to describe their
integration strategy, which depended upon scientific evidence. Snyderman
and Weil explained that the point of integrative medicine is to align
medicine so as to allow for it to continue building on its “fundamental
platform of science” ([9],
p. 397). Bell et al. argued elsewhere in their article that it is
mandatory that integrative medicine be based in “good science”, and that
integrative medicine values “scientific evidence” as a way of enhancing
the public’s understanding of good health as a society ([52],
p. 135). Finally, Sundberg et al. explained with regard to an
integrative medicine clinic involved in their study, that integrative
medicine members comprised of many different theories of health/healing,
could easily convey information with one other, when they restricted
communication to the “scientific language of biomedicine” [51].
Thus, rather than focusing on scientific rhetoric to rule therapies
“out”, they leverage scientific notions of validity and legitimacy to
justify the integration of unconventional therapies into conventional
medicine, thereby ruling them “in.” This is a subtle difference in
rhetorical strategy, but it signifies a different project altogether,
and one of which many users of these terminologies may not be aware.
Study limitations
The
primary limitation that should be addressed in this study is with
regards to potentially unaccounted for, yet influential, discourses
emerging in the most recent years of this study’s timeframe. The nature
of the peer-reviewed publication process involves a lag time between
authors reading influential work, incorporating it into their studies,
and ultimately citing/publishing this work. To combat this limitation,
efforts were made to search both the online and grey literature sources
to determine whether any discourses surrounding unconventional
medicine-related terms appeared to influence the time period
corresponding with the years including and directly preceding 2013. No
new themes were identified using this strategy.
Study implications
From
a theoretical standpoint, our study serves as a compelling example of
Gieryn’s perspective on scientific boundary work. We have demonstrated
that scientific rhetoric is evident in the discourses of both “what is
not” and “what is” author groups, which demarcate their work within a
conventional medicine framework from that of work performed by members
of unconventional medicine. Through applying Gieryn’s theory, we
identify two distinct ways in which conventional practitioners have
constructed boundaries to demarcate their work and research.
This
study provides an analysis of the labelling regarding unconventional
medicine-related terms, potentially facilitating more nuanced use of
these key terms by the stakeholders invested in the field of
unconventional medicine. This study has illuminated a tension in the
texts published in the medical literature about unconventional medicine
in which two groups of authors leverage scientific rhetoric, but to very
different ends. Additionally, our findings can help to explain why
academics or practitioners who work in an environment primarily
categorized by supporters of “what is not” language but who use “what
is” language (or vice-versa) may face criticism from their colleagues,
or a lack of traction, with regards to their research or practice goals
within the field of unconventional medicine. Lastly, this study suggests
that authors looking to continue (or begin) publishing their work in
this field, should recognize that these five commonly-used
unconventional medicine-related terms are not synonymous in meaning or
definition.
Future directions
This
study was designed to analyse discourses within the peer-reviewed
medical literature, so it was not surprising that the majority of texts
were dominated by the voice of conventional medical practitioners and
researchers. This was the case in both the “what is not” and “what is”
groups of articles. This study was not designed to adequately capture
the voices of unconventional medicine members, which were almost
completely non-existent in the peer-reviewed literature.
Follow-up
studies should seek to understand discourses generated by
unconventional practitioners and patients. This may involve evaluating
other forms of media unconventional medicine practitioners use to
produce their discourses. It will be important to explore how
unconventional medicine practitioners describe themselves and how
patients are interpreting the differing discourses of unconventional
medicine.
Furthermore, this study
focused on the peer-reviewed literature. Future studies should attempt
to understand discourses found in forms of media inclusive of the grey
literature or the internet to determine whether our results are
comparable. By doing this, such information obtained may help to explain
whether both “what is not” and “what is” authors engage, if at all,
using similar or different discourses outside of the realm of
peer-reviewed media. Understanding what and who leads the creation of
discourses surrounding the naming of unconventional medicine members
found in other forms of media may also help uncover key information
associated with the dynamics between and within practitioners and
researchers of both conventional and unconventional medical professions.
Conclusions
This
study identified a dichotomy between two groups of conventional
medicine practitioners. The first group described the terms
“alternative”, “unconventional”, “complementary” and “complementary and
alternative” as therapies that are not taught/used in conventional medicine, meet needs not addressed in conventional medicine, and have not
been shown to be safe or effective. The second group defined the term
“integrated/integrative” medicine as a new model of health and wellness
that advocates combination of conventional and evidence-based
unconventional therapies, accounts for the whole person and promotes the
preventative maintenance of health in both patient and practitioner.
From
a practical standpoint, this research has served to crystallize a
debate that has been played out in the texts written by both groups of
authors. Very different language use between these two author types
suggests the possibility of a growing intra-professional split among
this group of seemingly homogeneous conventional medicine members. This
study will sensitize its audience to a greater awareness of naming
surrounding unconventional medicine-related terms and how they may be
interpreted by others within their field. This study can help to explain
why academics or practitioners who work in an environment primarily
consisting of supporters of “what is not” language but who use “what is”
language (or vice-versa) may face criticism from their colleagues, or a
lack of traction, with regards to their research or practice goals
within the field of unconventional medicine. Lastly, this study’s
finding of a clear dichotomy in language and meaning associated with
“what is not” versus “what is” language provides a service to authors
looking to continue (or begin) publishing their work in this field,
helping them to identify that these five commonly-used unconventional
medicine-related terms are not simply synonymous in meaning or
definition.
While both groups
incorporate scientific rhetoric into their discourses, each seeks to
advance their own distinct agenda. The “what is not” group fundamentally
attempts to study the field of unconventional medicine as objective,
academic researchers. In contrast, the “what is” group are activists
with an interest in reforming the present model of conventional
healthcare training and delivery. This divide between these two groups
of authors within conventional medicine will require ongoing
investigation as the discourses change over time.
Ethics approval and consent to participate
This study involved the peer-reviewed literature only; it did not require ethics approval or consent to participate.
Acknowledgements
The
authors wish to acknowledge liaison librarian Gail Nichol for her help
with the use of Scopus, among other peer-reviewed literature search
tools and databases.
Funding
JYN
was funded by an Ontario Graduate Scholarship jointly awarded by the
University of Toronto and the Province of Ontario for the 2014–2015
academic year.
Abbreviations
| CAM | Complementary and Alternative Medicine |
| NCCAM | National Center for Complementary and Alternative Medicine |
| NCCIH | National Center for Complementary and Integrative Health |
| OAM | Office of Alternative Medicine |
Footnotes
Competing interests
The author(s) declare that they have no competing interests.
Authors’ contributions
JYN:
made substantial contributions to the design of the study, collected
and performed the analysis of the data, drafted the manuscript, and gave
final approval of the version to be published. HSB: made substantial
contributions to the design of the study, the collection of data as well
as the interpretation and analysis of the data, extensively revised the
manuscript critically, and gave final approval of the version to be
published. AKT: made contributions to the design of the study as well as
the interpretation and analysis of the data, revised the manuscript
critically, and gave final approval of the version to be published. CRW:
made contributions to the design of the study as well as the
interpretation and analysis of the data, revised the manuscript
critically, and gave final approval of the version to be published.
Authors’ information
JYN is a graduate student at the Leslie Dan Faculty of Pharmacy, University of Toronto and is supervised by HSB.
HSB is a Professor and the Dean of Leslie Dan Faculty of Pharmacy, University of Toronto.
AKT is an Assistant Professor at the Leslie Dan Faculty of Pharmacy, University of Toronto.
CRW
is Vice-President Education at Women's College Hospital and Associate
Professor at the Department of Family and Community Medicine, Faculty of
Medicine, University of Toronto
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