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Department of Nursing, Physiotherapy and Occupational Therapy
The meaning of acupuncture in Western
healthcare assistance: The perspective of
health professionals trained in
acupuncture in Spain.
El sentido de la acupuntura en la asistencia sanitaria
occidental: La perspectiva de los profesionales
sanitarios formados en acupuntura en España.
DOCTORAL THESIS
Supervised by Dra. Beatriz Rodríguez Martín
ESTHER GARCÍA ESCAMILLA
Madrid, Spain, 2015
Departamento de Enfermería, Fisioterapia y Terapia Ocupacional
El sentido de la acupuntura en la
asistencia sanitaria occidental: La
perspectiva de los profesionales
sanitarios formados en acupuntura en
España
The meaning of acupuncture in Western healthcare
assistance: The perspective of health professionals
trained in acupuncture in Spain.
TESIS DOCTORAL
Dirigida por la Dra. Beatriz Rodríguez Martín
ESTHER GARCÍA ESCAMILLA
Madrid, España, 2015
AGRADECIMIENTOS
A todas las personas que han participado desinteresadamente en esta investigación y que me han aportado indirectamente fuerza y luz en estos años:
- Los participantes por compartir conmigo sus historias de vida - Beatriz, mi directora, por sus ánimos y disponibilidad, y haber sabido encauzar este
trabajo - Juan por ayudarme con las revistas y recordarme que somos seres de agua luminosa,
gracias por tus hermosas y firmes palabras - Fidela por dar con los participantes que precisamente necesitaba y proporcionarme las
preciosas traducciones del Nei Jing en español - María, Aaron y Richad por sus infinitas correcciones de la lengua inglesa - Al Dr. José Luis Padilla Corral y la Escuela Neijing por ser mi REFERENTE en esta vida - A Hermenegilda y María Luisa Monterde por su ejemplo y su BELLEZA - Agradezco la MARGARITA que me mostró este camino de la MTC y otras muchas
cosas más - A Ottavio per la sua generosità - A mi madre, por ser un PILAR de constancia y amor - A mi padre, por su manera taoísta de vivir - A mi hermana, por su LUZ - A mi hermano por recordarnos siempre que las cosas pueden ser de otro modo. - A mis queridas amigas artistas, Estherova y Lucía por su SINTONÍA - Otra vez María, por estar ahí desde el principio, todavía hoy, gracias - A Elena, por nuestro reencuentro - A Belén, por esa lejanía que hace retornar - A Juan Sebastián, por recordarme cada día las cosas simples y bellas de la VIDA.
1
ÍNDICE DE CONTENIDOS
ÍNDICE TABLAS ........................................................................................................... 3
ÍNDICE FIGURAS ......................................................................................................... 4
PRESENTACIÓN ......................................................................................................... 5
ABREVIATURAS .......................................................................................................... 7
IDEOGRAMAS ............................................................................................................. 8
INTRODUCCIÓN .......................................................................................................... 9
Acupuntura y Medicina Tradicional China ............................................................... 11
Acupuntura y pluralismo asistencial ........................................................................ 22
La acupuntura como medicina en sí misma ............................................................ 23
Creciente interés social, sanitario e internacional por la acupuntura ....................... 23
Evidencia científica sobre la efectividad de la acupuntura ....................................... 25
Sobre los mecanismos de acción de la acupuntura ................................................. 27
Integración de la acupuntura en la asistencia sanitaria occidental ........................... 28
Importancia de la perspectiva de los profesionales sanitarios sobre la acupuntura . 31
Desarrollo de la investigación .................................................................................. 33
PLANTEAMIENTO Y OBJETIVOS ............................................................................. 45
PLANTEAMIENTO .................................................................................................. 47
OBJETIVOS ............................................................................................................ 48
MANUSCRITOS ......................................................................................................... 51
MANUSCRITO I. Integration of acupuncture into conventional medicine from health
professionals’ perspective: A thematic synthesis of qualitative studies. ................... 53
MANUSCRITO II. What led health professionals to study and practise acupuncture in
Spain? ........................................................................................................................ 73
MANUSCRITO III. Collaboration between acupuncture and Western medicine: The
perspective of health professionals trained in acupuncture in Spain ........................ 95
ABSTRACTS OF MANUSCRIPTS (RESUMEN DE LOS MANUSCRITOS) .............. 115
Manuscript I........................................................................................................... 117
Manuscrito I........................................................................................................... 118
Manuscript II.......................................................................................................... 119
Manuscrito II.......................................................................................................... 120
2
Manuscript III ........................................................................................................ 121
Manuscrito III ......................................................................................................... 122
CONCLUSIONS OF THE STUDY (CONCLUSIONES DEL ESTUDIO)..................... 123
CONCLUSIONS .................................................................................................... 125
CONCLUSIONES ................................................................................................. 129
APORTACIONES CIENTÍFICAS DEL ESTUDIO ...................................................... 133
BIBLIOGRAFÍA ......................................................................................................... 137
APÉNDICE ............................................................................................................... 153
3
ÍNDICE TABLAS
Tabla 1…………………………………………………………………………… 17
Tabla 2…………………………………………………………………………… 20
Tabla 3…………………………………………………………………………… 35
Tabla 4…………………………………………………………………………… 41
Tabla 5…………………………………………………………………………… 57
Tabla 6…………………………………………………………………………… 58
Tabla 7…………………………………………………………………………… 59
Tabla 8…………………………………………………………………………… 67
Tabla 9…………………………………………………………………………… 63
Tabla 10………………………………………………………………………….. 81
Tabla 11………………………………………………………………………….. 82
Tabla 12………………………………………………………………………….. 83
Tabla 13………………………………………………………………………… 114
4
ÍNDICE FIGURAS
Figura 1…………………………………………………………………………... 37
Figura 2…………………………………………………………………………... 43
Figura 3…………………………………………………………………………... 44
Figura 4…………………………………………………………………………... 60
5
PRESENTACIÓN
El impacto de las enfermedades crónicas y degenerativas en la población mundial es motivo de
gran preocupación en la actualidad. En muchas ocasiones este impacto se ha relacionado con el
envejecimiento de la población pero hoy sabemos que el estilo de vida es su causa fundamental.
Como estilo de vida no sólo entendemos los hábitos higiénicos, la actividad física y la
alimentación. Existen otros condicionantes que influyen en la manera que tenemos de vivir y
adaptarnos al medio que nos rodea como puede ser el clima, las características geográficas del
lugar donde se habita, la exposición a determinados agentes atmosféricos, la calidad del aire, la
clase social, el trabajo que se realiza, el nivel de desarrollo del país donde se reside, el nivel de
opresión o libertad que se goza o sufre. Así como, el ánimo, el carácter con el que se vive, los
impactos emocionales, la interpretación que se hace del acontecer o la esperanza que se tiene de
futuro.
Por otra parte, hablando de salud la clave siempre será la prevención, lo que nos lleva de nuevo
a pensar en el estilo de vida.
Sabemos que la acupuntura es valorada a nivel mundial para el tratamiento de enfermedades
crónicas y degenerativas y que, gran parte de las personas que recurren a esta medicina, buscan
tratamiento para este tipo de afecciones porque no se encuentran satisfechas con lo que les
ofrece la medicina alopática convencional. Además, la acupuntura se fundamenta en una
filosofía que conlleva una forma de entender el mundo y un estilo de vida radicalmente
diferente a la occidental donde el consumismo, la superficialidad, la desigualdad y la
competitividad están a la orden del día.
En este contexto el estudio social de la acupuntura se convierte en un tema relevante. Por ello
nos preguntamos por qué podría tener sentido su integración en una sociedad y en una cultura a
la que no pertenece. Dado que, a pesar de su vigencia histórica y la evidencia que existe sobre
su efectividad, su uso sigue siendo controvertido en gran medida por valoraciones poco
fundamentadas, hemos profundizado en el tema a través de las perspectivas de profesionales
sanitarios con formación y experiencia en acupuntura.
Este estudio fue diseñado y ejecutado por Esther García Escamilla con la guía y supervisión de
Beatriz Rodríguez Martín. Fue llevado a cabo sin ninguna financiación.
A continuación se presentan los resultados de esta investigación integrados en tres artículos
científicos que tratan sobre:
6
- Las percepciones de los profesionales sanitarios sobre la integración de la acupuntura en
la medicina convencional en países occidentales.
- Las motivaciones en profesionales sanitarios para estudiar y practicar acupuntura en
España.
- Las percepciones de profesionales sanitarios formados en acupuntura y con experiencia
en su práctica, sobre la colaboración entre acupuntura y medicina occidental en España.
IMPLICACIÓN DE LA DOCTORANDA:
- Diseño del estudio.
- Búsqueda y captación de participantes
- Recogida de datos a través de entrevistas en profundidad
- Transcripción de los datos
- Análisis de los datos
- Elaboración de los artículos incluidos en la presente tesis.
7
ABREVIATURAS
ACTH: Hormona adrenocorticotropa
CAM: Complementary and Alternative Medicines
ECA: Ensayos Clínicos Aleatorizados
EEUU: Estados Unidos
MTC: Medicina Tradicional China
MTN: Medicinas Tradicionales y Naturales
NHS: National Health System
OMS: Organización Mundial de la Salud
RCT: Randomised Control Trial
RU: Reino Unido
SNA: Sistema Nervioso Autónomo
TCM: Traditional Chinese Medicine
UK: United Kingdom
USA: United States of America
WHO: World Health Organization
8
IDEOGRAMAS
QI: Energía vital, soplo, aliento.
TIAN: Cielo, celeste, hombre celeste, hombre estelar
LING: Espíritu, espíritu de la humanidad
SHEN: Psiquismo, manera de ser, manera de estar
DAO: ruta, sentido, camino
ZHĒN CI: acupuntura
9
INTRODUCCIÓN
10
Introducción
11
Acupuntura y Medicina Tradicional China
1. Filosofía y Medicina Tradicional China
Para hablar de Medicina Tradicional China (MTC) es necesario desmontar algunas
presuposiciones que pueden existir y que de hecho se manifiestan en su propio nombre. La
MTC surgió en principio como un estilo de vida más que como una medicina, no sólo pertenece
al acervo cultural chino y no es un conocimiento estrictamente tradicional (1)
.
La procedencia geográfica y temporal de la MTC es incierta. Su origen se ubica en lo
que hoy se identifica con Corea y Vietnam, y se fundamenta en una visión energética del ser
humano que se extendió por el continente asiático (2)
. Las similitudes entre la MTC y otros
sistemas terapéuticos orientales como el Ayurveda y el Shiatsu y la importancia que todavía hoy
tiene esta medicina en las dos Coreas y Vietnam, evidencian que este conocimiento no es legado
exclusivo del pueblo chino (3)
.
Por otra parte, la MTC no representa un saber anclado en el tiempo, sino que ha
continuado desarrollando recursos terapéuticos y adaptándose creativamente a las necesidades
sanitarias que ha ido experimentando el hombre. Prueba de ello es el trabajo de la Doctora
Youyou Tu, Premio Nobel de Medicina 2015, quien descubrió y probó la efectividad de la
artemisina, principio activo extraído de la Artemisia Annua L., para el tratamiento de la malaria
a partir del estudio de la tradición médica china. Concretamente se inspiró en un libro datado
entre el 284 y el 346 d.C (A handbook of prescriptions for emergencies by Ge Hong) (4)
.
Además, sabemos que la MTC ha realizado valiosas aportaciones a la medicina occidental, las
cuales han permitido el desarrollo de fármacos para el tratamiento de la leucemia, la enfermedad
de Alzheimer y las enfermedades cardiovasculares y cerebrovasculares, entre otras (4)
.
El contenido de los textos más antiguos de medicina china hace referencia a aspectos
filosóficos y antropológicos (1)
. En concordancia a una particular concepción del hombre y del
universo, se desarrolló una ética, es decir, unas pautas de comportamiento recogidas por la
filosofía Taoísta, que iban a permitir al ser humano no enfermar y conservar la salud,
constituyendo el pilar fundamental de la MTC, la prevención (5)
. Por ello, más que una medicina
representa un estilo de vida (1)
. La autoría de dichos textos se atribuye a tres emperadores
legendarios. Su estudio siempre ha abierto el interrogante entre mito y realidad por la manera
particular del pueblo chino de contar la historia relacionando el acontecer con figuras
legendarias, con un pasado remoto (5)
.
La tradición nos habla de FUSHI, El Emperador Blanco, al que se le atribuye el I
Ching, Libro de las Mutaciones o Libro del Cambio (6)
. Esta obra recoge la dinámica
Introducción
12
cosmovisión de la tradición china que parte de la premisa de que todo es cambio,
transformación y movimiento. SHEN NONG sería El Emperador Rojo, conocido como el
fundador de la agricultura y descubridor del poder medicinal de las plantas. Y HUANG DI, El
Emperador Amarillo, al que se le atribuye la creación del calendario, los carros, las canoas y la
navegación, así como el Huang Di Nei Jing o Tratado de lo Interno del Emperador Amarillo,
también conocido como Canon de Medicina del Emperador Amarillo (dividido en el Ling Shu o
Eje vital y Su Wen o Preguntas sobre la seda blanca) (7,8,9)
.
Huang Di Nei Jing representa el primer tratado sobre la ciencia médica china. Algunas
fuentes lo datan entre el 2.697 y el 2.595 a.C. (periodo en el que se ha situado el reinado del
Emperador Amarillo) mientras que otras lo ubican entre el siglo V y II a.C. (Periodo de los
Estados Combatientes, época de gran inestabilidad política y social en la historia de China, en la
que este saber pudo recogerse de forma escrita por temor a que se perdiera). Su contenido
proviene de una tradicional oral desarrollada y actualizada con el tiempo. En él se recoge la
visión energética del hombre, la fisiología, la fisiopatología y las bases diagnósticas y
terapéuticas en que se fundamenta la MTC (8)
.
La visión de la MTC que se presenta a continuación es legado del Doctor José Luis
Padilla Corral, cuyo cuidadoso estudio de los textos de la tradición china ha permitido rescatar y
actualizar este conocimiento, así como su transmisión particularmente en lengua española (1,10)
.
Su visión ha sido contrastada y corroborada a lo largo de este trabajo con la de otros autores
(8,11,12,13,14,15). Como iremos ilustrando, la concepción tradicional china del hombre y el universo
posee un carácter relativo (establece conceptos que adquieren una connotación diferente
dependiendo de dónde o en qué se referencie lo que se está explicando) y simbólico (1)
.
Como decíamos, la filosofía Taoísta permea todos los textos antiguos de MTC. El Dao
De Jing constituye el máximo exponente de esta filosofía, obra atribuida a Lao Tze. Apenas
existe información sobre su autor aunque se ha hipotizado que vivió alrededor del s.VI a.C. (16)
.
Esta obra sienta las bases de la idea de salud de la MTC en la que la enfermedad es explicada
por la pérdida de conexión del hombre con su entorno entendido en sentido amplio: lo que le
rodea, los demás y uno mismo (5,16)
. La palabra Dao, traducida como sendero, vía o camino,
alude a su filosofía, la cual transmite la manera en que el hombre ha de posicionarse en el
universo y comportarse para ser feliz, disfrutar la vida y prevenir la enfermedad. En este
sentido, el ser humano es concebido como un ser que se referencia continuamente porque la
posición que toma y ocupa cualquier cosa siempre se define con respecto a algo (1)
.
El concepto del Wu Wei, El no hacer, recoge la idea taoísta de vivir. Este concepto, más
que un comportamiento pasivo, conlleva una actitud profundamente pacifista basada en el
respeto por el acontecer y la actividad natural. Esto implica la adopción de una actitud
Introducción
13
contemplativa que permita la observación y comprensión de los fenómenos naturales sin la
intervención del juicio de valor, no oponerse a los ritmos de la Naturaleza, buscar la satisfacción
natural y tranquila de las necesidades, no buscar el reconocimiento personal ni la supremacía
sobre los demás, evitar el acumular, no apegarse a nada ni a nadie, y permitir que el devenir siga
su curso porque todo es movimiento y cambio (2,5,16)
. Desde esta visión, lo único eterno es el Dao
que representa el devenir del universo a través de la dinámica del Yin y el Yang, conceptos
opuestos y complementarios en constante transformación, que representan básicamente los
movimientos de contracción y expansión del universo (1)
(“El frío extremo dará
origen al calor, y el calor extremo dará origen al frío” (9)
). Ambos conceptos van a
representar los parámetros con que abordar la comprensión y tratamiento de la
enfermedad, son conceptos relativos y van a cambiar en función de a qué nos
estemos referenciando (1)
(“El Yin y el Yang son la vía del Cielo y la Tierra, son los grandes
esquemas de todas las cosas” (8)
).
El Yang representa lo que se expande, es un principio activo relacionado con el calor, lo
que está en alto, lo luminoso, lo creativo, el cielo, lo sutil, lo inmaterial, lo no estructurado. El
Yin representa lo que se contrae, es un principio pasivo ligado al frío, lo que está en lo bajo, lo
oscuro, la tierra, lo estructurado, lo duro, lo ya formado. Son siempre parámetros relativos a qué
nos estemos referenciando. Por ejemplo, en el cuerpo humano, el pecho es yang con respecto a
la cadera porque se ubica en una posición más alta, pero es yin con respecto a la cabeza. De la
misma manera las caderas son yin con respecto al pecho, pero son yang con respecto a las
rodillas que se sitúan anatómicamente más abajo.
Como nos recuerda su símbolo, dentro del Yin está el Yang y viceversa. Por ejemplo, el
día es yang porque implica claridad y actividad y la noche es yin porque es oscura y representa
un tiempo de pasividad y descanso. Sin embargo, la mañana es yang dentro del yang (momento
más luminoso y activo del día) y la tarde es yin dentro del yang (es menos luminosa y anuncia el
cese de la actividad). El primer periodo de la noche es yin dentro del yin (momento más oscuro)
mientras que según se acerca el alba la oscuridad va desapareciendo por lo que se considera
yang dentro del yin (14)
. Como vemos, cualquier proceso de expansión va a conllevar un proceso
de contracción (la aparición de la claridad implica que cese la oscuridad y viceversa) (1)
.
Además, cuando un fenómeno llega a su máxima expresión, se transforma en su opuesto. Por
ejemplo, cuando la noche alcanza su máximo de oscuridad, culmina y comienza a avanzar hacia
el día (“El Tao es grande porque se aleja, al alejarse se expande y su expansión le hace
retornar”) (1)
.
Yin-Yang
Introducción
14
2. Visión energética del ser humano.
Dentro del modelo antropológico de la MTC, el ser humano como parte del universo,
comparte y participa de una energía cósmica, “una Fuerza Inconmensurable que da origen y
entretiene a todas las cosas” (1)
. Esta energía o Qi, también traducida como soplo o aliento
anima todo el universo y recorre el cuerpo humano a través de unos canales energéticos que,
internamente, ponen en relación todas las partes del organismo y dimensiones de la
persona (cuerpo, mente, espíritu), al tiempo que conectan al individuo con el
entorno (1)
. Estos canales aparecen descritos en el Huang Di Nei Jing, y se
corresponden con estructuras no materiales que se relacionan con las distintas
partes y funciones del cuerpo, así como con aspectos psíquicos y espirituales (7,17)
. De este
modo, la MTC establece una visión unitaria del ser humano en la que estructura física,
psiquismo y espíritu conforman un todo indivisible ligado al universo (1)
.
La visión antropológica de la MTC se basa en un modelo analógico en el que el hombre
es considerado como un microcosmos dentro de un macrocosmos, y como proyección de este
último se desenvuelve siguiendo su misma dinámica: el movimiento y la transformación entre el
Yin y el Yang (1)
. El ser humano integra el universo en sí mismo, por lo que todo lo que existe
fuera de sí está contenido en su interior, de manera que la comprensión del mundo le lleva a la
comprensión de sí mismo y viceversa (11)
. Además, todos los fenómenos del universo estarían
interconectados a través de la misma fuerza creativa o Qi, de modo que todo repercute en todo
(1).
La MTC concibe al ser humano como una entidad energética, un ser de luz, que viaja
por el universo y en un momento dado se conforma, se estructura y se manifiesta en este plano
de existencia que llamamos vida, momento en el cual el hombre se sitúa entre el cielo y la tierra,
y a partir de ahí transcurre sus existencia. Una vez que el periodo que conocemos como vida
finaliza, esa entidad se desestructura y continua su camino por el universo. Siguiendo este
planteamiento, el ser humano, como ser energético, representa una entidad de luz, y su primera
manifestación es el agua, de donde surge la vida. Por lo tanto, la vida sería una configuración de
agua luminosa posicionada entre el cielo y la tierra. Las distintas formas en que se organiza esa
agua dan lugar al resto de elementos que componen cualquier estructura. Según
este esquema estos elementos son: agua, madera, fuego, tierra y metal, los cuales,
en el hombre, representan ciertos aspectos físicos, funcionales, psíquicos y
espirituales al mismo tiempo (1)
.
Desde esta visión el ser humano posee un espíritu y es fruto de una herencia y una
interrelación. Su existencia se mantiene a través de la alimentación, la respiración y la
Qi
Tian
Introducción
15
interacción con el entorno (lo que le rodea, los demás y uno mismo). Y se relaciona y expresa a
través de un psiquismo, un ánimo (1)
.
El espíritu hace referencia a los aspectos creativos de la persona y se manifiesta en las
vocaciones, ideales y proyectos de cada uno (Energía Yuan). La herencia proviene de nuestros
antepasados y nos da el sustrato físico (Energía Zong). La sexualidad, entendida como
mecanismo íntimo de interrelación, permite que el espíritu se aposente en una estructura física a
través de la concepción y ocurra la vida como tal (Energía Jing). El ideograma chino
de espíritu, LING, no nos habla de un espíritu individual sino del espíritu de la
humanidad. Según esta visión, todos venimos con un proyecto que se corresponde
con un proyecto colectivo, una función a desarrollar que se manifiesta en una
vocación o un ideal, y que nos conecta con la humanidad y el universo. Por tanto, representa una
idea esencialmente solidaria en la que el espíritu de cada uno cobra sentido en relación a los
demás (1)
.
La respiración y la alimentación permiten que la vida se mantenga (Energía Yong), así
como los procesos de relación y homeostasis (Energía Wei) (1)
. El psiquismo de la persona se
identifica con el carácter de cada uno, con el ánimo. El ideograma que hace referencia a este
concepto, el SHEN, significa manera de estar, manera de expresarse. El SHEN se manifiesta en
unos sentimientos, afectos y emociones, en una manera de afrontar la vida. Para la concepción
antropológica de la MTC el psiquismo de cada persona se conforma a partir de la
relación entre la herencia, el espíritu y la experiencia vivencial de cada uno. Por
ello, es influido por su alimentación, su respiración y su relación con el entorno,
además de por unas características subjetivas y creativas (1,18)
.
El SHEN constituye un concepto muy importante dentro de la concepción de la MTC ya
que considera que si la esfera psíquica y afectivo-emocional de la persona está en equilibrio va a
ser muy difícil que enferme y, si lo hace, podrá reponerse sin gran dificultad (19,20)
. Además, cada
elemento del organismo cumple una función fisiológica al tiempo que regula un área de la
experiencia psíquica. El órgano más importante es el corazón porque alberga el psiquismo de la
persona, su ánimo, y recibe y organiza los sentimientos generados por el resto del organismo.
De este modo si el psiquismo que el corazón recibe es adecuado, generará alegría mientras que
si no lo es se experimentará tristeza (1)
.
Recapitulando, desde esta perspectiva, el ser humano se referencia (ocupa una
posición), se relaciona (con el entorno, los demás y uno mismo) e integra el universo dentro de
sí mismo (por lo que todo lo que existe en el mundo se corresponde con un aspecto de su
existencia). Partiendo de estas premisas, la MTC configura un modelo explicativo simbólico, en
el que cada parte de la estructura humana se relaciona con una orientación, una época del año,
Ling
Shen
Introducción
16
un elemento, un sabor, un color, un canal de energía, una estructura física, una función
fisiológica y un psiquismo, como puede observarse en la tabla que se presenta a continuación
(Tabla 1) (1)
.
Introducción
17
Tabla 1. Tabla de correspondencias de la MTC
(Fuente propia)
Correspondencias Reino Mutante del
Agua
Reino Mutante de la
Madera
Reino Mutante del
Fuego
Reino Mutante de la
Tierra
Reino Mutante del
Metal
Orientación Norte Este Sur Centro Oeste
Energía celeste Frío Viento Calor/Fuego Humedad Sequedad
Elemento Agua Madera Fuego Tierra Metal
Época del año Invierno Primavera Verano Períodos
interestacionales Otoño
Sabor Salado Ácido Amargo Dulce/Insípido Picante
Color Negro Verde/Azul Rojo Amarillo Blanco
Órgano Riñón Hígado Corazón Bazo-páncreas Pulmón
Entraña Vejiga Vesícula biliar Intestino delgado Estómago Intestino grueso
Parte del cuerpo Hueso, médula ósea Músculos, tendones Vasos sanguíneos Tejido conjuntivo Piel, vello
Proyección Orejas, cabello Uñas, ojos Lengua, mirada Boca, labios Nariz
Sentido Oído Vista Olfato Gusto Tacto
Olor Putrefacto Transpiración Quemado Perfumado Rancio
Planeta regente Mercurio Júpiter Marte Saturno Venus
Sonido Gemido Grito Sonrisa Canto Lamento
Psiquismo Responsabilidad Decisión, generosidad Alegría, regocijo Reflexión Recuerdo
Psiquismo alterado Miedo,
irresponsabilidad
Cólera, ira, violencia,
rencor, celos, envidia Tristeza Obsesión, irreflexión Melancolía
Introducción
18
3. Concepción de la salud y estilo de vida
La concepción de la salud de la MTC deriva de la concepción energética, unitaria y
relacional del ser humano (1)
. En este sentido, las causas de enfermedad obedecen a factores
climatológicos (frío, calor, fuego, humedad, sequedad y viento), factores emocionales (miedo,
ira, tristeza, obsesión y melancolía), la herencia y aspectos relacionados con la higiene, el
descanso, la alimentación, la respiración, la sexualidad, la moral y la espiritualidad, siendo el
equilibrio y el término medio las claves para mantener la salud
(1,12,18,21).
Esta visión presta especial atención al estilo de vida en un sentido amplio. Por una parte,
tiene en cuenta el lugar donde la persona se desenvuelve cotidianamente y los agentes
climáticos a los que se expone sin considerarlos como positivos o negativos ya que en principio,
todos son necesarios para la homeostasis. Por otra parte, incluye aspectos relacionados con el
comportamiento, el ánimo y el modo en que la persona interpreta lo que le sucede (22)
. De
manera que los trastornos de convivencia, de relación, afectivos y emocionales producen un
desequilibrio de la mente, el ánimo y el espíritu de la persona, influyendo en el deterioro del
cuerpo, la sangre y la energía. Cuando esto sucede, la persona pierde la sintonía con el entorno,
los demás y uno mismo, se debilita y los factores ambientales pueden causarle enfermedad (23)
.
Así, la comprensión de la esfera psico-afectiva y emocional constituye un elemento clave en el
abordaje de la enfermedad desde la perspectiva de la MTC (24)
.
Además, como ser unitario, para vivir una vida saludable, el ser humano ha de sentirse
integrado, es decir, ha de sentirse parte de su entorno, que es amado y que tiene una función que
desarrollar, al tiempo que ha de experimentar una vivencia de sí mismo no dividida en la que
pensamiento, sentimiento y acción se integren de una manera coherente y consecuente. Así
mismo, es importante que desarrolle sus proyectos, su vocación, su ideal y su creatividad (1)
.
La MTC también considera que el ser humano es influido por la herencia, la
alimentación, la calidad de su respiración y de su descanso, el desarrollo de su vida sexual así
como la manera en que vivencia su relación con el entorno, con uno mismo y con los demás. En
este sentido se recomienda comer con moderación, mantener un equilibrio entre el ejercicio y el
reposo, llevar una vida sexual equilibrada, no fatigarse, no experimentar cambios bruscos de
estado de ánimo y desarrollar actividades creativas (5,25)
.
De acuerdo con la filosofía taoísta, para conservar la salud la MTC aconseja vivir de
manera pacífica y tranquila, sin apegos, con dedicación y sin buscar
reconocimiento personal o éxito, de acuerdo con el ritmo de las estaciones, y el
suceder de la noche y el día. Comportarse de dicha manera significa seguir la vía
del Dao, vivir en sintonía con el universo y prevenir la enfermedad (9,16,2)
. En este Dao
Introducción
19
sentido, el Huang Di Nei Jing proporciona pautas de comportamiento según el período del año y
del día con el fin de preservar y recuperar la salud (Tabla 2) (2,12)
.
Como explica Carl Jung, dentro de la concepción tradicional china del mundo, el azar
no existe (6)
. La enfermedad no ocurre por casualidad sino que obedece a unas causas adaptativas
en las que la persona no se ha relacionado armónicamente con el entorno lo que produce que su
energía se desequilibre. La dinámica interna entre el Yin y el Yang se desestabiliza y se produce
un desequilibrio en la energía y la sangre del paciente (12)
. En esa medida, la enfermedad es
concebida como un proceso adaptativo y de aprendizaje (26)
.
Introducción
20
Tabla 2. Pautas de comportamiento según la estación de la MTC
(Fuente propia)
ESTACIÓN FUNCIÓN ACTIVIDAD ACTITUD RITMO
PRIMAVERA Nacimiento
- Momento de iniciar
- Nuevos propósitos
- Despliegue
- Generosidad
- Decisión
- Actitud relajada
Levantarse y acostarse temprano
VERANO Crecimiento - Momento de expresar - Evitar la violencia
- Estar alegre
Levantarse temprano, acostarse
tarde
OTOÑO Cosecha
- Momento de recogimiento
- Reunión de las experiencias
- Aprendizaje
- Tolerancia
- Perdón
- Indulgencia
Levantarse y acostarse temprano
INVIERNO Ocultamiento - Momento de letargo
- Reclusión - Estar como ausente
Acostarse y no levantarse antes de
que amanezca
Introducción
21
4. Abordaje terapéutico de la MTC
Las técnicas de diagnóstico de la MTC se basan en el análisis de la sintomatología, el estado
anímico, el pulso, la lengua, el color de la tez y olor del paciente, la palpación del cuerpo y la
observación de la constitución física (12)
. A través de estas técnicas se interpreta la situación energética
de la persona y se establece un tratamiento dirigido al restablecimiento de su equilibrio energético y,
en consecuencia, del propio sistema regenerativo, homeostático y curativo del propio organismo (1)
.
La MTC contempla la enfermedad y la sanación como un proceso holístico que engloba
distintas dimensiones del ser humano estableciendo tratamientos que tienen en cuenta los aspectos
físicos, psicológicos, relacionales y espirituales del ser humano (12, 13,26)
.
El carácter relativo de los parámetros de explicación de la MTC propicia un abordaje y
tratamiento individual, flexible y plural de la enfermedad (1)
. Al igual que el Yin y el Yang, los
conceptos de macrocosmos y microcosmos también constituyen conceptos relativos aplicables al
estudio de cualquier fenómeno de la naturaleza. Así, la MTC considera ciertos microsistemas dentro
de la estructura humana como pueden ser la espalda, la oreja, la mano o el pie donde estarían
representados todos los aspectos y partes de la persona. Esto explica, desde esta visión, cómo es
posible establecer un diagnóstico a partir de la observación del rostro y la lengua o de la palpación de
la espalda.
Como se ha argumentado previamente, el Qi recorre el cuerpo a través de unos canales
energéticos que permiten que todo el organismo esté interconectado formando una unidad. Además, a
lo largo del cuerpo se identifican una serie de puntos de energía o resonadores donde la energía vibra o
resuena de una manera especial conectando al individuo con el exterior y viceversa. Cuando esta
energía vital se desestabiliza, la persona enferma (12)
. La MTC ha desarrollado varios técnicas
terapéuticas que permiten movilizar y armonizar la energía: el Qi Qong (movimientos acompañados
por la respiración), el tuina (masaje), la acupuntura (aplicación y manipulación de agujas a lo largo del
cuerpo), la moxibustión (aplicación de calor), la digitopuntura (presión realizada con las manos) y la
fitoterapia (que contempla el uso de sustancias vegetales, animales y minerales). Todo ello
acompañado por las recomendaciones oportunas sobre el estilo de vida que van a permitir restablecer
la salud y prevenir la enfermedad (27)
.
5. La acupuntura
La acupuntura consiste en la aplicación y manipulación de agujas metálicas a lo largo de los
resonadores o puntos de acupuntura con la intención de reequilibrar la energía o Qi del paciente (27)
. La
evidencia arqueológica muestra que ya en el paleolítico se practicaba alguna forma de acupuntura con
Introducción
22
agujas de piedra, de bambú, de hueso y de barro (la utilización de estas últimas se ha mantenido hasta
el s. XX), así como cauterizaciones (9)
. Las primeras agujas metálicas fueron descubiertas en un tumba
que data del siglo II a.C. Sin embargo, investigaciones arqueológicas sugieren que la moxibustión es
anterior a la acupuntura. En la actualidad, ambas técnicas se aplican conjuntamente
de manera que, en general, cuando se habla de acupuntura se engloba también la
moxibustión. En el ideograma chino de acupuntura (Zhēn Ci) aparece representado
tanto el fuego como el metal, lo que evidencia la íntima relación entre ambas técnicas (9)
.
Acupuntura y pluralismo asistencial
Históricamente la población ha venido utilizando instancias asistenciales y terapéuticas
diferentes a las oficialmente reconocidas como el curanderismo, la automedicación, el autocuidado así
como las denominadas medicinas complementarias y alternativas (CAM siguiendo las siglas de este
término en inglés Complementary and Alternative Medicine). El National Center for Complementary
and Alternative Medicine propone una definición, muy citada en la literatura al respecto, que entiende
las CAM como “un conjunto diverso de sistemas, prácticas y productos médicos y de atención de la
salud que no se consideran actualmente parte de la medicina convencional” (29)
. La acupuntura queda
recogida bajo esta nomenclatura, así como la homeopatía, el Ayurveda, el naturismo, distintas terapias
manipulativas, la meditación y un largo etcétera(28)
.
La búsqueda de otras terapias no es un fenómeno exclusivo de los pacientes, sino que estudios
previos muestran que los profesionales sanitarios también recurren a este tipo de instancias
terapéuticas buscando respuestas a ciertos problemas de salud (30)
. En este sentido, sabemos que la
medicina occidental ha integrado técnicas y sustancias medicinales provenientes de otras tradiciones
sanadoras. Así, al igual que al principio poníamos en cuestión el término MTC, también es necesario
poner en cuestión el término medicina occidental porque no da cuenta del legado que recoge de otras
culturas (4,31)
. Al respecto, en Europa existen evidencias del uso médico de la acupuntura y la
fitoterapia china a inicios del siglo XIX (32)
.
La Organización Mundial de la Salud (OMS) propone una definición de las CAM más
detallada: “prácticas, enfoques, conocimientos y creencias sanitarias diversas que incorporan
medicinas basadas en plantas, animales y/o minerales, terapias espirituales, técnicas manuales y
ejercicios aplicados de forma individual o en combinación para mantener el bienestar, además de
tratar, diagnosticar y prevenir las enfermedades” y las reconoce como Medicinas Tradicionales y
Naturales” (3,33)
.
Zhēn Ci
Introducción
23
La acupuntura como medicina en sí misma
La acupuntura es la técnica más conocida y utilizada de la MTC en Occidente, donde se
considera como una medicina en sí misma porque su utilización se fundamenta en la teoría, la
fisiología, la fisiopatología y las formas de diagnóstico y tratamiento de la MTC. Además, en
occidente, su aplicación se acompaña generalmente de consejos terapéuticos sobre el estilo de vida y
de otras técnicas como la moxibustión, el masaje y la digitopuntura (27)
.
Creciente interés social, sanitario e internacional por la
acupuntura
En las últimas décadas, la acupuntura ha cobrado un interés creciente en los países
occidentales, lo que es evidenciado por el uso creciente de la acupuntura por parte de la población y de
los profesionales sanitarios, el incremento de publicaciones en torno a su efectividad y su presencia
mediática (34)
. Asimismo, organismos internacionales como la OMS recomiendan su utilización en la
práctica clínica y algunos países europeos han desarrollado legislación para su empleo así como para
su integración en los sistemas nacionales de salud (3,33,35)
.
1. Aumento del interés de la población por la acupuntura en países
occidentales
La prevalencia de uso de la acupuntura por parte de la población en países occidentales se
sitúa en el 14.5% en Alemania (36)
, el 6.3% en Estados Unidos (EEUU) (37)
, el 8.1% en Canadá (38)
y el
1.8% en Italia (39)
. Entre los países mencionados, Alemania es el único donde los tratamientos de
acupuntura son cubiertos por el sistema público de salud lo que podría explicar que presente un
porcentaje más alto (40)
.
Recientes estudios muestran que la población occidental acude a la acupuntura principalmente
para tratar dolencias del sistema musculo-esquelético, afecciones crónicas y problemas de salud para
los que no han encontrado una respuesta efectiva en los tratamientos médicos convencionales (36-38,41)
.
La población también recurre a la acupuntura para mejorar la función del sistema inmunitario, el
bienestar general y con fines preventivos (36,37)
. Otros de los motivos más destacados son el deseo de
evitar el consumo de fármacos y su abordaje holístico del proceso salud-enfermedad (36-38,41)
. En este
sentido los pacientes resaltan que la acupuntura, en comparación con la medicina convencional, se
centra más en el estilo de vida, los factores ambientales, los factores medioambientales y los sistemas
credenciales que dan significado a la realidad estableciendo una relación terapeuta-paciente con mayor
contenido psicosocial (34,42)
. Además, entre los beneficios relacionados con la acupuntura, los pacientes
destacan aspectos relacionados con un mayor bienestar físico y emocional, transformaciones
Introducción
24
personales a nivel cognoscitivo, la sensación de libertad frente a la enfermedad o el dolor, mayor
control y conexión con el cuerpo y las emociones, disponer de más energía y evitar o reducir el
consumo de medicamentos (43,44)
.
En España un 7.4% población utiliza la acupuntura (45)
, acercándose a la cifra que presentan
EEUU y Canadá al respecto. Esta similitud podría relacionarse con el hecho de que ni en España ni en
estos países la acupuntura es sufragada por el Sistema Nacional de Salud (40)
. La prevalencia del uso de
la acupuntura recae sobre mujeres de mediana edad y aumenta a medida que ascendemos en la escala
social y en el nivel de estudios (46,47)
. Estos datos deben ser analizados con precaución porque son las
mujeres en general las que recurren con más frecuencia a los servicios sanitarios en España y, teniendo
en cuenta que la acupuntura no suele encontrarse integrada en el Sistema Sanitario Público, es lógico
que acudan a este tipo de servicios con más incidencia a medida que disponen de más recursos
económicos (48)
. Los beneficios que la población española reporta haber encontrado en la acupuntura se
relacionan con su abordaje holístico, su capacidad para prevenir y curar tanto problemas físicos como
emocionales y la ausencia de efectos secundarios (45)
.
Además, observamos una tendencia al alza en la prevalencia de uso de la acupuntura por parte
de la población. En EEUU se registraron 8.19 millones de usuarios en el 2002 mientras que en el 2007
esta cifra superó los 14 millones. Asimismo, en España, la Encuesta Nacional de Salud (ENS) muestra
un incremento en el uso de las CAM en general desde el 2003 al 2011 (49)
.
2. Aumento del interés de los profesionales sanitarios por la acupuntura
Estudios recientes muestran un gran interés terapéutico por la acupuntura por parte de los
profesionales sanitarios y estudiantes de medicina en países occidentales. Desde este ámbito se
considera que la acupuntura incluye conceptos y métodos que pueden mejorar la medicina occidental
por lo que debería incluirse en el currículo académico de los profesionales sanitarios e incrementarse
los fondos destinados a la investigación sobre la efectividad de la acupuntura (50,51)
. Entre el 40 y el
83% de los profesionales sanitarios recomiendan la acupuntura a sus pacientes en países occidentales y
consideran su inclusión en el Sistema Nacional de Salud principalmente para el tratamiento del dolor y
reducir gastos (50,52,53)
.
Sabemos que la acupuntura es la medicina complementaria más valorada por la profesión
médica (50-52)
. Aproximadamente 80.000 médicos practican la acupuntura en los países miembros de la
Unión Europea, si bien hay que considerar que esta actividad no se registra sistemáticamente (54)
. En
España no existe un registro oficial que contabilice el número de profesionales sanitarios que practican
la acupuntura, sin embargo, una variedad de instituciones ofrecen cursos en esta materia (55)
.
Actualmente se imparten cursos de postgrado en acupuntura en universidades y organismos colegiados
como la Universidad Complutense de Madrid, la Universitat de Barcelona, la Universidad de
Introducción
25
Zaragoza, el Colegio de Médicos de Madrid, la Universidad de Valencia en colaboración con el
Colegio de Médicos de dicha ciudad o la Universidad de Santiago de Compostela. Además, existen
centros privados que ofrecen cursos en acupuntura reconocidos a nivel internacional como la Escuela
Nei Jing con presencia en otros países europeos, Estados Unidos (EEUU) y América del Sur (10)
.
Se ha observado cierta diversidad en la forma en la que los profesionales sanitarios incorporan
la acupuntura en su práctica clínica (27)
. Encontramos profesionales que la incluyen como una simple
técnica obviando su base teórica (fisiología, fisiopatología, formas de diagnóstico) de modo que se
remiten a estimular puntos de acupuntura clásicamente utilizados para determinadas dolencias (56)
.
Otros profesionales incorporan el cuerpo teórico en que se fundamenta la acupuntura, abrazando
incluso su cosmovisión. En cualquier caso, la práctica de la acupuntura nunca se disocia totalmente de
su base tradicional porque el uso y funciones de sus puntos se conocen a partir de ella (27)
.
3. Reconocimiento internacional
A nivel internacional, la OMS destaca el papel de la acupuntura como elemento clave para
mejorar la calidad y la universalidad de la asistencia sanitaria internacional, especialmente en los
países con mayores necesidades económicas. Así, contempla y propone la inclusión de la acupuntura
en los sistemas nacionales de salud como recurso para cubrir necesidades sanitarias derivadas de la
falta de recursos económicos y de respuestas terapéuticas satisfactorias de la medicina alopática, ya
sea por la ineficacia de ciertos tratamientos como por sus efectos secundarios (3,33)
. En este sentido la
OMS enfatiza el papel de la acupuntura para dar respuesta al aumento de enfermedades crónicas y
debilitantes tales como las enfermedades coronarias, el cáncer, la diabetes o los trastornos mentales.
Siendo en este tipo de patologías donde la población muestra mayor insatisfacción con la medicina
alopática (3)
.
Asimismo, la Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura
reconoce la acupuntura y la moxibustión como patrimonio cultural inmaterial de la humanidad dando
cuenta de la relevancia de este legado para la sociedad (57)
.
Evidencia científica sobre la efectividad de la acupuntura
Más allá de la vigencia milenaria histórica de la acupuntura y de los resultados positivos
revelados por su práctica, son numerosos los esfuerzos científicos por producir medicina basada en la
evidencia que corroboren su efectividad. Al respecto son destacables las publicaciones sobre la
efectividad de la acupuntura en revistas internacionales como The International Journal of
Acupuncture (58)
, Evidenced-based Complementary and Alternative Medicine (59)
y Evidenced-based
Integrative Medicine (60)
, así como los trabajos de la Fundación Cochrane (61)
. Además, una revisión
sistemática realizada por la OMS revela la efectividad de la acupuntura en el tratamiento de una gran
Introducción
26
variedad de problemas de salud como la depresión, la artritis reumatoide, problemas neurológicos,
ciertas afecciones de la sangre, el asma, la rinitis alérgica, el cólico biliar y el cólico renal (62)
. Tras esta
revisión se han publicado varios ensayos clínicos aleatorizados (ECA) que demuestran además la
eficacia de la acupuntura en el tratamiento del dolor y de afecciones del sistema inmunitario
(63,64,65,66,67), así como casos clínicos que reportan resultados eficaces del empleo de la acupuntura en
problemas ginecológicos, obstétricos, cardiovasculares, endocrinos, dermatológicos y oftalmológicos
(68,69).
Por otra parte, existen estudios que corroboran la eficacia de los tratamientos que combinan la
acupuntura con la medicina convencional en el tratamiento del dolor, cáncer, problemas articulares y
en pediatría (70-74)
. Estos trabajos evidencian mejoras en la sintomatología física de los pacientes, en su
estado emocional, en su calidad de vida y en la relación médico-paciente, así como una reducción de
los efectos secundarios de los tratamientos alopáticos con los que se conjugó la terapia acupuntural (70-
74).
A pesar de lo anterior, la efectividad de la acupuntura sigue siendo un tema controvertido.
Algunos ECA no hayan resultados positivos en el tratamiento del dolor (75)
y ciertas revisiones
sistemáticas concluyen que la acupuntura no presenta evidencia científica suficiente debido a que los
ECA que evalúan su efectividad se han llevado a cabo con muestras pequeñas. Otra de las debilidades
señaladas de este tipo de estudios es la dificultad de cegar las investigaciones a pesar de los esfuerzos
por realizar punturas simuladas (76,77,78)
.
Sin embargo, como resalta Rupert Sheldrake, la comunidad científica exige índices de
evidencia más altos para reconocer la efectividad de las CAM que para comercializar tratamientos
farmacológicos (79)
. Además la práctica clínica demuestra que el modelo de ECA es inadecuado para
medir la eficacia de la acupuntura, así como basar los resultados de su aplicación solamente en
indicadores clínicos sin incluir el estudio de casos e indicadores subjetivos. En este sentido, se ha
enfatizado la necesidad de investigar los resultados de la acupuntura en su práctica real e recoger la
experiencia de los pacientes y terapeutas (43,80,81)
.
Por otra parte, gran parte de los estudios realizados sobre la efectividad de la acupuntura no
evalúan tratamientos acupunturales establecidos en función de la fisiopatología y las formas de
diagnóstico en que se basa esta medicina, lo que explica que los resultados de los ECA sobre la
utilidad de la acupuntura no coincidan con los resultados hallados por la experiencia clínica (82)
.
Esto evidencia que la acupuntura es sometida a una exigencia científica para ser reconocida
mucho mayor que muchos fármacos que ya se comercializan. Además, está siendo evaluada de manera
parcial con métodos y técnicas no adecuadas, lo que pone de manifiesto la necesidad de replantear el
diseño de las investigaciones sobre su efectividad.
Introducción
27
Sobre los mecanismos de acción de la acupuntura
Resulta muy difícil comprender los mecanismos de acción de la acupuntura, desde la
perspectiva mecánico-materialista occidental (83)
. Como se ha argumentado previamente, la visión
unitaria del ser humano de la tradición china explica que ejercicios físicos y de respiración produzcan
efectos a nivel emocional y de conciencia, que mejorando un aspecto de la persona (físico, emocional,
relacional, espiritual) se puedan sanar otros, o que actuaciones en una parte del cuerpo tengan
consecuencias en otra parte más alejada o en la globalidad del organismo (1,13)
. Asimismo, la
concepción energética del ser humano explica cómo sin la necesidad de introducir ninguna sustancia
química en el organismo, éste sea capaz de poner en movimiento determinados mecanismos de
homeostasis, regeneración y curación (1)
. Sin embargo, estas explicaciones no convencen mucho al
occidental por lo que se han realizado numerosos estudios con la intención de conocer cómo la
acupuntura es capaz de producir respuestas en el organismo (67,84)
.
Se ha comprobado que los puntos de acupuntura son lugares que presentan una menor
resistencia eléctrica cutánea lo que se ha planteado que a través de ellos puedan penetrar en el cuerpo
impulsos electromagnéticos procedentes del entorno, recorrer el organismo a través de vías capaces de
transmitir la energía eléctrica y escapar del cuerpo nuevamente a través de esos mismos puntos,
manteniendo una interrelación constante entre medio e individuo (85)
. Además, en estos puntos han sido
detectadas estructuras anatómicas nerviosas desde donde se deduce que el efecto producido por las
agujas pueda entrar en contacto con el sistema nervioso autónomo (SNA) a través de distintas
conexiones sinápticas, generando un efecto físico. De esta manera, a través de las agujas se estimularía
la liberación de distintos neurotransmisores (serotonina, ACTH, dinorfinas, encefalinas, beta
endorfinas), sustancias que actúan sobre el dolor, el sistema inmunológico, el sistema endocrinológico
y emocional (86)
.
Por otra parte, estudios como los liderados por The Hearthmath Institute demuestran que la
dinámica del SNA y las relaciones entre cerebro y corazón, son especialmente sensibles a los cambios
en el estado emocional (87,88)
. Específicamente emociones negativas, como la frustración, la ansiedad o
el enfado, producen ritmos cardíacos erráticos y desordenados así como una menor sincronización
entre la rama simpática y parasimpática del SNA. Mientras que emociones positivas como el aprecio,
el amor o la compasión generan un mayor orden y coherencia en los ritmos cardíacos, reflejando
mayor sincronización entre las dos ramas del SNA. La relación entre las emociones y el organismo se
produciría a través de los campos electromagnéticos que conectan todo el organismo, siendo el
corazón el órgano que genera el mayor impulso electromagnético del cuerpo siendo capaz de permear
y mandar una señal sincronizada a todas las células. Además sabemos que la dimensión emocional,
mental y física interrelaciona con la información genética (ADN) a través de los campos
Introducción
28
electromagnéticos que conectan todo el organismo, influyendo en procesos vitales celulares tales
como la réplica del ADN o la producción de proteínas y encimas (88)
. De esta manera se demuestra
cómo el epigenoma influye en el genoma modificándolo de manera positiva o negativa. El impacto
que ejerce el entorno, las creencias, pensamientos y emociones también ha sido explicado a nivel
celular a través de los trabajos del biólogo Bruce Lipton (89)
.
Por otra parte, siguiendo los presupuestos de la MTC, la relación que la persona tiene consigo
misma constituye otro aspecto importante a la hora de explicar el proceso de salud-enfermedad. Así,
es conocido el impacto de los sentimientos que uno experimenta hacia sí mismo en el estado de salud,
como por ejemplo la autoestima, debido a sus repercusiones en el sistema inmunitario y cardiovascular
(90).
Todo ello podría explicar ciertos aspectos de la efectividad de la acupuntura y corroboraría la
importancia otorgada por la MTC a los aspectos emocionales, morales, espirituales y ambientales que
rigen los procesos de enfermedad y sanación.
Finalmente, a pesar de la tendencia hacia la especialización en la medicina occidental (y en
general en todas las ramas de conocimiento en el mundo occidental), desde diversos sectores se
reconoce la necesidad de incluir un enfoque holístico (90)
como evidencia el desarrollo de enfoques más
integradores como la psiconeuroendocrinoinmunología (PNIE) (11)
. Sabemos que el proceso de
especialización permite un conocimiento cada vez más detallado de las partes más pequeñas, pero
presenta limitaciones para dar explicaciones inclusivas que indaguen en la complejidad de los
fenómenos, promoviendo a un conocimiento muy detallado pero reduccionista (91)
.
Integración de la acupuntura en la asistencia sanitaria occidental
La OMS contempla la inclusión de la acupuntura en la asistencia sanitaria occidental en base a
la percepción de que existen aspectos de la medicina alopática que pueden ser completados y
mejorados por la acupuntura debido a su enfoque y a sus recursos terapéuticos (3,33)
. Además, su
incorporación en el sistema sanitario se plantea con el objetivo de abaratar costes y reducir su presión
sobre los recursos económicos debido al alto coste de ciertos tratamientos e intervenciones
convencionales (3,33)
. En este sentido es necesario definir en qué sentido y cómo la acupuntura puede
contribuir a superar los límites que presentan la biomedicina y la práctica sanitaria convencional.
Estudios previos muestran que el uso de la acupuntura por parte de la población en países
occidentales, suele venir acompañado de una crítica al modelo biomédico dominante y, en muchos
casos, de preguntas en torno a la salud y la enfermedad que no encuentran respuesta dentro de este
paradigma (34)
. La concepción del proceso del salud-enfermedad de la biomedicina, basada en técnicas
como la alopatía, la cirugía, las radiaciones y las terapias genéticas o nanociencia, se fundamenta en
Introducción
29
un modelo filosófico y antropológico que entiende que la única realidad que existe es la materia, y que
ésta es de naturaleza mecánica (83)
. Así, la enfermedad es explicada por la presencia de algún agente
tóxico externo o por el mal funcionamiento mecánico del organismo, descuidando ciertos aspectos que
influyen en el proceso salud-enfermedad como el contexto social y relacional de cada individuo, sus
emociones, sentimientos, afectos, ideales y proyectos (92)
.
En la actualidad, existe una gran preocupación por la subordinación de la medicina a intereses
económicos y de la industria farmacéutica, así como por la iatrogénesis médica (79,93-95)
. Estudios
previos han comprobado que la acupuntura, aplicada por profesionales adecuadamente formados, no
produce efectos secundarios ni representa ningún peligro (96)
.
Por otra parte, las personas que acuden a la acupuntura presentan predominantemente una
tipología de enfermedades que no han encontrado una respuesta y un tratamiento eficaz en el sistema
médico convencional, como sucede en el caso de enfermedades crónicas, degenerativas, terminales,
psicosomáticas o en el tratamiento del dolor. Estas personas buscan una relación médico-paciente con
mayor contenido psicosocial y terapias que eviten la iatrogénesis, así como enfoques distintos sobre la
manera de entender la salud y la atención sanitaria que den más importancia a los estilos de vida, a los
factores medioambientales, a los sistemas credenciales que dan significado a la realidad y que estén
más orientados a la mejora de la calidad de vida de los pacientes (34,42)
.
En el contexto social actual, marcado por el incremento de enfermedades crónicas y
degenerativas debido en gran medida al estilo de vida occidental (caracterizado por el sedentarismo, el
estrés, la exposición a agentes contaminantes, la falta de sentido en la vida, la cosificación de las
relaciones humanas, la primacía de los valores económicos y la percepción de la vida bajo los
parámetros éxito/fracaso y tener/carecer), se plantean opciones como la acupuntura que además de
recursos terapéuticos aportan un enfoque vital diferente (97-101)
.
A todo ello se une la valoración de la inclusión de la acupuntura en la asistencia sanitaria,
recogida por la OMS en sus Estrategias sobre Medicina Tradicional (3,33)
, como recurso para reducir
costes debido al no requerimiento de alta infraestructura o de mayor inversión económica para su
aplicación (73,102)
. Al respecto, ciertas investigaciones apuntan resultados positivos en la relación coste-
efectividad de los tratamientos acupunturales (103-106)
.
1. Experiencias de integración de la acupuntura en la sanidad pública
Existen varias experiencias de sistemas sanitarios públicos que desarrollan modelos integrados
donde medicina occidental y medina tradicional y complementaria colaboran con el objetivo de dar
una asistencia sanitaria de calidad y de cobertura universal, destacando el modelo sanitario chino,
vietnamita y cubano (3)
. China y Vietnam integran la acupuntura como medicina tradicional ya que
forma parte de su propio legado cultural, al igual que la República Popular Democrática de Corea y la
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30
República de Corea. En Cuba, sin embargo, la acupuntura es considerada una medicina
complementaria porque no pertenece a su acervo cultural (3)
. En todos estos modelos la acupuntura ha
sido y es un elemento clave para la asistencia sanitaria tanto en Atención Primaria como Hospitalaria,
permitiendo a la sanidad pública (3,107-109)
:
Ir más allá del diagnóstico y tratamiento de enfermedades, sirviendo de base para el
desarrollo de programas de promoción de la salud, prevención de la enfermedad y
rehabilitación debido a su concepción de la salud, recomendaciones sobre la dieta, estilo
de vida y ejercicios físicos acompañados de la respiración como el Qi Qong.
Implementar tratamientos sin efectos secundarios evitando las consecuencias de la
iatrogénesis médica relacionadas con ingresos hospitalarios, reducción de la calidad de
vida o la generación de nuevas patologías.
Extender la protección social a la salud en zonas con carencia total o insuficiencia de
infraestructuras sanitarias aumentando los recursos terapéuticos para asistir a los sectores
más pobres. De esta manera la acupuntura, junto a otras MTN, ha permitido trascender los
límites impuestos por la medicina moderna la cual ha sufrido un proceso de centralización
urbano debido al alto de grado de tecnificación y su elevado coste económico.
Formar en asistencia sanitaria básica a personas en barrios y comunidades dotando a la
población de recursos sencillos y no dañinos, con los que abordar problemas de salud
básica y cotidiana. (En China la formación de miembros de la población en MTC desde
1965, los llamados médicos descalzos, ha proporcionado a las comunidades recursos
diagnósticos, tratamientos y elementos para la promoción de la salud (109)
).
Ampliar la gama de posibilidades terapéuticas.
Mejorar la eficiencia en términos económicos del sistema sanitario permitiendo el ahorro
de medicamentos y evitando ingresos hospitalarios. (La introducción de la analgesia por
acupuntura en cirugía durante los años 2001 y 2002 permitió ahorrar 4.8 millones de
dólares al Sistema Sanitario Cubano (107)
).
2. Marco normativo sobre el empleo de la acupuntura en países occidentales
En países occidentales, la acupuntura es practicada por profesionales con diferente formación
en la materia, estilos de práctica, actitudes ante la acupuntura y formación sanitaria. De igual manera,
encontramos un marco normativo muy heterogéneo, no sólo entre países sino incluso entre regiones de
un mismo país (35,40)
.
En países como EEUU, Reino Unido (RU), Noruega, Suecia y Finlandia tanto médicos como
otros profesionales sanitarios y profesionales sin formación sanitaria oficial pueden practicar la
acupuntura. Sin embargo, en otros países como Alemania, la legislación sólo permite practicar la
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31
acupuntura a médicos y profesionales parasanitarios oficialmente reconocidos (los denominados
heilpraktiker) (40)
.
En cuanto a la cobertura ofrecida por los seguros sanitarios nacionales y privados en relación a
la acupuntura, la situación es también muy heterogénea. En Austria, Alemania y Francia, los seguros
sanitarios nacionales cubren el uso de tratamientos acupunturales en el caso de ciertas patologías como
el dolor lumbar y cervical. En EEUU, RU, Suiza y Holanda, Alemania, Austria y Francia existen
seguros privados que incluyen la acupuntura para el tratamiento de diferentes problemas de salud
dependiendo del seguro (40,110)
.
En España, no existe una regulación estatal específica sobre acupuntura aunque el Real
Decreto 1277/2003 reconoce la posibilidad de administrar tratamientos de acupuntura y otras terapias
naturales en unidades de terapias no convencionales (U.101) integradas en centros sanitarios, bajo la
responsabilidad de un médico, siendo las comunidades autónomas las encargadas de autorizar estos
centros (45)
. Pero, en general, los profesionales sanitarios pueden practicar la acupuntura dentro del
ejercicio de sus profesiones, como cualquier tratamiento que consideren necesario. Sin embargo, los
practicantes no pertenecientes a ninguna profesión sanitaria regulada deben adscribirse al epígrafe 841
del Impuesto sobre Actividades Económicas, lo que regula solamente a efectos impositivos y no en
términos de competencias profesionales (111)
.
Aunque el Sistema Sanitario Español no provee de manera sistemática tratamientos
acupunturales, es posible encontrar iniciativas de este tipo a lo largo del Sistema Sanitario Público. En
el año 2005 se registraron 12 unidades en Andalucía donde se practicaba regularmente la acupuntura
tanto en ámbito hospitalario como en Atención Primaria (45)
. Sin embargo, también existen
profesionales que practican la acupuntura de manera no sistemática ni registrada, por lo que no es
posible conocer el uso real que se hace de ella a lo largo del Sistema Nacional de Salud.
Ante la ausencia de regulación y la creciente demanda por parte de la población, la OMS
elaboró una guía con directrices sobre capacitación básica y seguridad en acupuntura dirigida a países
en los que el Sistema Nacional de Salud ofrezca sólo atención médica occidental careciendo de
normativa y legislación al respecto. Dicha guía establece un plan de estudios básicos y directrices
sobre seguridad en el ejercicio de la acupuntura (112)
.
Importancia de la perspectiva de los profesionales sanitarios sobre
la acupuntura
Como se ha señalado anteriormente, las limitaciones de los ECA para producir evidencia sobre
la efectividad de la acupuntura ponen de manifiesto la necesidad de incluir las percepciones de los
pacientes y de los profesionales sanitarios al respecto.
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32
Teniendo en cuenta que la acupuntura no pertenece a nuestro acervo cultural, conocer, desde
el punto de vista de profesionales sanitarios formados en la materia, en qué medida la práctica de la
acupuntura tiene sentido en la sociedad occidental, podría revelar claves para la mejora de la asistencia
sanitaria en España y países de nuestro entorno. Así como contribuir a alcanzar una colaboración
efectiva entre la medicina alopática y la acupuntura incrementando de este modo los recursos
terapéuticos a disposición de la población.
Existen algunos estudios cuantitativos que evidencian la importancia otorgada por
profesionales sanitarios y estudiantes de medicina a la acupuntura y a su integración en la medicina
occidental (50-53)
. Sin embargo, no explican qué necesidades de la población podría cubrir la acupuntura
y en qué sentido, cómo podría contribuir a la mejora de la calidad de vida de los pacientes, por qué los
profesionales sanitarios consideran importante su inclusión o por qué buscan recursos terapéuticos
pertenecientes a otros paradigmas.
Por otra parte, las investigaciones previas que analizan el punto de vista de los profesionales
sanitarios sobre la integración de la acupuntura en la medicina occidental, indagan en sus percepciones
sobre las CAM en general y no consideran la acupuntura en su particularidad. La nomenclatura CAM
engloba una gran variedad de prácticas con dispares características y modos de aplicación por lo que
cada terapia debería ser estudiada por separado (30)
.
Sería especialmente relevante recoger la experiencia clínica de los profesionales sanitarios
formados en acupuntura que además tengan experiencia en la práctica de la acupuntura. Conocer en
qué situaciones ellos han comprobado que es efectiva y, dadas la dificultades encontradas en la
integración entre biomedicina y acupuntura (debido a la preeminencia del paradigma biomédico y las
diferencias conceptuales entre ambas medicinas) (91,113,114)
, analizar cómo individualmente integran
ambas medicinas tanto a nivel conceptual como práctico.
Un estudio reciente recogió la valoración sobre la acupuntura de médicos expertos en la
materia y con una amplia experiencia en su práctica en Austria. Los resultados de este estudio, en
consonancia con otro estudio similar realizado en Alemania, revelaron una valoración de la acupuntura
muy positiva en el tratamiento de un amplio número de patologías (69)
. La acupuntura fue considerada
muy efectiva como tratamiento único en casos de: cefaleas y trastornos del aparato locomotor, dolor
en general, problemas ginecológicos y obstétricos, trastornos psicosomáticos, infecciones de las vías
respiratorias, trastornos internos del tracto abdominal, depresión, angustia, pánico, trastornos
pediátricos, problemas oftalmológicos y adicciones (69)
.
Además, sería útil conocer la experiencia de fisioterapeutas y profesionales de enfermería, que
debido al rol sanitario que ejercen, están más involucrados en la asistencia y seguimiento diario de los
pacientes. De este modo podrían conocerse los beneficios de la integración de la acupuntura en la
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33
asistencia sanitaria en su globalidad (beneficios relativos a la calidad de vida de los pacientes y su
bienestar general, así como las transformaciones que puedan experimentar a nivel adaptativo,
emocional y de conciencia (13,34,43,44)
).
Desarrollo de la investigación
1. Delimitación del objeto de estudio
La importancia que ha ido adquiriendo la acupuntura en occidente evidencia la necesidad de
abordar su estudio desde un punto de vista social (33,62,115)
. Las primeras búsquedas bibliográficas
revelaron que este fenómeno había sido indagado desde el punto de vista de los pacientes y de su
efectividad, pero que apenas existían investigaciones que analizaran el punto de vista de los
profesionales sanitarios, a pesar de que se había señalado la importancia de conocer su perspectiva (30)
.
Para evitar la intromisión de cualquier idea preconcebida, se formuló una pregunta de investigación
que permitiera acotar un área de investigación abarcable para el investigador, sin restringirla
demasiado (116)
:
¿Cuáles son las percepciones de los profesionales sanitarios sobre el uso de la acupuntura en
España?
Profundizando un poco más a través de la literatura existente, se comprendió la relevancia de
preguntar a profesionales sanitarios con formación en acupuntura y experiencia en su práctica, ya que
esto podía revelar claves para la mejora de la calidad de la asistencia sanitaria, lo que supuso acotar la
pregunta de investigación un poco más:
¿Cuáles son las percepciones de los profesionales sanitarios formados en acupuntura y con
experiencia en su práctica sobre el uso de la acupuntura en España?
2. Metodología cualitativa
Dado el carácter subjetivo del objeto de estudio, se eligió una metodología cualitativa la cual
permite conocer la perspectiva de los actores sociales implicados en una realidad social a través del
significado que ellos mismos dan a su experiencia, dentro del contexto en que se encuentran inmersos
(116). Como existían pocas publicaciones que abordaran este tema y concretamente, en España no se
encontró ninguna, la metodología cualitativa también iba a permitir explorar este fenómeno
recogiendo la diversidad de puntos de vista que pudieran darse (117)
.
Los presupuestos y recomendaciones de la Teoría Fundamentada (Grounded Theory)
porpuestas por Strauss y Corbin, guiaron la investigación ya que el objetivo del estudio era ir más allá
de la descripción del fenómeno desarrollando teorías explicativas (116)
. Además, la Teoría
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34
Fundamentada establece una serie de propuestas metodológicas que contribuyen a evitar la intromisión
de ideas preconcebidas o juicios de valor que puedan distorsionar el análisis de la realidad. Para ello
esta metodología recomienda (116)
:
Partir de un nivel menor de abstracción a uno mayor desarrollando la investigación de
manera inductiva.
No establecer hipótesis teóricas previas al desarrollo del estudio. Permitir que la teoría
emerja a partir de las relaciones conceptuales que van surgiendo del análisis e
interpretación de los datos.
Desarrollar simultánea e interactivamente los procesos de recolección, análisis e
interpretación de los datos.
Aplicar el método de comparación constante a lo largo de toda la investigación. Esto
implica comparar:
Los datos entre sí
Los resultados del proceso de análisis e interpretación de los datos con los
mismos datos
Así como con la bibliografía existente
Y con situaciones hipotéticas que construya el investigador a modo de
“experimentos teóricos”.
3. Técnicas de acceso al objeto de estudio
Los datos fueron recogidos a través de entrevistas en profundidad. Dado que los actores
sociales interpretan sus vivencias en un proceso de interrelación consigo mismos y con su contexto
social, la utilización de una pregunta abierta propició que los participantes reconstruyeran el proceso
por el que fueron formando sus perspectivas (116)
. Así cada participante comenzó su discurso
respondiendo a una pregunta sobre qué le había llevado a la acupuntura a lo largo de su recorrido
profesional y desarrollo personal. Y se les pedía que incluyeran información sobre dónde se habían
formado y su experiencia laboral. De esta manera, los participantes fueron reconstruyendo libremente
el proceso por el que habían ido formando sus puntos de vista y tomando sus decisiones, con la menor
intervención posible por parte del entrevistador.
En los casos en los que los participantes no manifestaban espontáneamente sus percepciones
sobre la colaboración entre la acupuntura y la medicina convencional, se incluía una pregunta al
respecto. Sin embargo, a medida que se desarrollaba el estudio y aparecían incógnitas más concretas
sobre el objeto de investigación, se fue creando una lista de temas relevantes en constante elaboración.
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35
Tabla 3. Lista de temas para las entrevistas
Lista de temas
Formación académica
Formación en acupuntura
Experiencia profesional
Datos demográficos (edad actual, edad con la que comenzaron a estudiar acupuntura, tiempo practicando
medicina occidental, tiempo practican acupuntura)
Motivaciones para estudiar acupuntura
Manera personal de practicar la acupuntura
Percepciones sobre la acupuntura
Forma de integrar ambas medicinas
Percepciones sobre la colaboración entre acupuntura y medicina convencional
Percepciones sobre la integración de la acupuntura en la asistencia sanitaria pública
Visión comparada entre acupuntura y medicina occidental
A qué se refiere la esfera espiritual
Barreras percibidas para la práctica de la acupuntura
Factores que favorecen la práctica de la acupuntura
Preferencia personal entre acupuntura y medicina occidental
Formación en otras medicinas complementarias
Respuesta a preguntas personales encontradas en el estudio de la acupuntura
Por qué estudiar/practicar acupuntura entre las medicinas complementarias que existen
4. Descripción del proceso de investigación
Fueron realizadas un total de 28 entrevistas en profundidad. La primera entrevista tuvo lugar
el 31 de abril del 2013 y la última el 13 de Julio del 2015. El tiempo mínimo de duración de cada una
fue de 20 minutos y el máximo de 60 minutos. Se llevaron a cabo en un ambiente tranquilo, y se
registraron digitalmente. Ante la imposibilidad de concretar una cita presencial, en ocho ocasiones se
realizaron vía telefónica o por videoconferencia. Cada participante recibió información sobre los
objetivos de la investigación y la manera en la que iban a tratarse los datos, y firmaron un
consentimiento previamente a la entrevista.
Los criterios de inclusión para participar en las entrevistas fueron: ser médico, profesional de
enfermería o fisioterapeuta (porque son los profesionales sanitarios más involucrados en el estudio y
práctica de la acupuntura en España) (45)
, haber recibido formación en acupuntura y tener experiencia
en su práctica. Los participantes debían haber seguido un programa de formación basado en las
recomendaciones de la OMS sobre formación básica y seguridad en la práctica de la acupuntura (112)
.
Se aplicaron los criterios sobre formación mínima en acupuntura (200 horas) establecidos para
médicos al resto de participantes para asegurar que sus discursos estuvieran fundamentados.
La técnica de muestreo teórico permitió ir seleccionando participantes que, dadas sus
características, podrían aportar nueva información o aclarar aspectos identificados en el análisis de
discursos previos. Siguiendo las recomendaciones de la Teoría Fundamentada, una vez realizada la
primera entrevista, se transcribió, y se comenzó el análisis identificando conceptos, elaborando
memorias en las que se iban relacionando los conceptos que emergían, y formulando preguntas
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36
teóricas como por ejemplo, “¿pensaría lo mismo una persona de otro sexo o con experiencia laboral
en otro ámbito?, ¿qué opinarían profesionales formados en otras escuelas?, ¿qué diferencias existen
entre las personas que integran ambas medicinas en la asistencia pública y las que lo hacen en
centros privados?, ¿por qué eligieron la acupuntura entre las medicinas complementarias que
existen?”. Los interrogantes que el análisis e interpretación generaban, iban señalando qué
características debía a priori reunir el siguiente participante y cómo dirigir su entrevista. Y así
sucesivamente.
El muestreo fue completado con la técnica de muestreo bola de nieve. La combinación de
ambas técnicas de muestreo permitió seleccionar participantes de diferentes edades, sexos,
procedencias, formación y experiencia profesional (Tabla 4), aumentando las posibilidades de recoger
perspectivas diferentes que pudieran añadir, aclarar y detallar la información. El proceso de
recolección de datos terminó cuando el análisis e interpretación de los discursos recogidos a través de
las entrevistas no aportaba más conceptos, ni más detalles sobre los conceptos ya identificados, ni más
relaciones entre estos conceptos. El tema de las motivaciones de los profesionales sanitarios para
estudiar y practicar la acupuntura se saturó en la entrevista nº 17 pero la investigación continuó porque
el análisis de nuevas entrevistas seguía aportando información al tema sobre la colaboración entre
ambas medicinas. Una vez concluido el análisis de la entrevista nº 23 esta información comenzó a
repetirse. Aun así se realizaron 5 entrevistas más para corroborarlo.
Aunque no estaba incluido en los criterios de inclusión, durante la investigación se presentó la
oportunidad de entrevistar a una veterinaria-acupuntora responsable de una consulta de rehabilitación
y fertilidad y profesora de medicinas complementarias en una universidad pública (esta entrevista fue
la nº 15). Su análisis no se incluye en la presentación de resultados de esta investigación (la cual
incluye 27 entrevistas) pero, siguiendo la técnica de muestreo teórico, fue relevante comparar las
motivaciones e inquietudes entre un profesional de la salud dedicado al ámbito animal y los
profesionales dedicados al ámbito humano porque cabía la posibilidad que pudiera generar nuevos
interrogantes. En este sentido, futuros estudios podrían continuar esta línea e indagar de un modo más
profundo estas cuestiones.
El análisis de los datos comenzó con el proceso de codificación que permitió ordenar los datos
al tiempo que comenzar a interpretarlos y acceder a un primer nivel de abstracción. Todas las
entrevistas fueron transcritas literalmente y analizadas a través del software para análisis cualitativo
Atlas.Ti versión 5.2. Esta herramienta facilitó la administración y clasificación de una gran cantidad
de datos, así como el análisis minucioso de cada entrevista, línea por línea, a partir del cual se fueron
identificando los conceptos que emergían de los discursos, buscando sus propiedades y características,
comparándolos entre sí y etiquetándolos, es decir, se les atribuía un código o nombre que representara
las características que recogía ese concepto. Nombrar implica una abstracción de la realidad, conlleva
Introducción
37
establecer una definición que permite clasificar e identificar objetos que comparten esa definición y
los que no la comparten. Estos conceptos tenían sentido dentro del contexto en el que el participante
estaba inmerso (codificación abierta) con lo cual ya en este primer momento surgían relaciones entre
los conceptos y el contexto que era necesario recoger a través de memorias. La interpretación de los
discursos recogidos iba demando ciertos conocimientos o información por lo que se recurría a la
literatura para investigar sobre ciertas medicinas complementarias como la homeopatía, el Reiki y la
medicina antroposófica, sobre temas de salud pública, sobre los “médicos descalzos”, sobre los
sistemas sanitarios de otros países o sobre la concepción de la enfermedad y el cuerpo en la medicina
occidental.
Continuando con el análisis y la interpretación de los datos, poco a poco fueron emergiendo
similitudes y relaciones entre los códigos lo que permitía agruparlos en conceptos más abstractos o
categorías, elaboradas de la misma manera, estableciendo similitudes y relaciones entre sus
características. Periódicamente se volvía sobre los códigos re-etiquetándolos con nombres más claros
o más representativos, o englobando distintos códigos en uno sólo porque se apreciaba que se referían
al mismo concepto y no tenía sentido recoger una misma idea con nombres diferentes.
Las explicaciones teóricas surgieron de las relaciones que se iban identificando entre los
conceptos que formaban cada categoría y su contexto. A través de las memorias se establecieron
proposiciones y esquemas. Entonces, cada categoría servía a modo de eje en torno al cual los
conceptos incluidos en ella se relacionaban entre sí explicándola en sus distintas dimensiones
(codificación axial). Estas relaciones no eran consideradas concluyentes sino que se establecían a
modo de hipótesis que se comparaban con el análisis y la interpretación de nuevos datos (para lo que
era necesario entrevistar más profesionales y recoger nuevos discursos) y con la literatura existente.
Finalmente, en un proceso de abstracción mayor, fueron emergiendo relaciones entre las
categorías (codificación selectiva), se fueron articulando oraciones que explicaban las percepciones de
los participantes y, de nuevo, eran tratadas como posibilidades o hipótesis, y se realizaban más
entrevistas para explicarlas con más detalle, consolidarlas o transformarlas. Así, las categorías se iban
integrando y explicaban, a partir de las relaciones identificadas entre ellas, las percepciones de los
profesionales sanitarios sobre la acupuntura.
Por ejemplo, una de las categorías que emergió del discurso que explicaba las motivaciones de
los profesionales sanitarios para estudiar y practicar acupuntura fue “la búsqueda de una medicina más
humana”. Esta categoría se explicaba en función de las vivencias y el contexto en el que había
trascurrido la experiencia profesional de los participantes y se ilustra en el siguiente diagrama (Figura
1):
Introducción
38
Durante todo el desarrollo de la investigación se elaboraron esquemas de este tipo
acompañados de memorias en las que se relacionaban los conceptos y categorías mediante
proposiciones.
Finalmente se construyó una explicación teórica a partir de las relaciones entre las categorías
emergentes, sobre las motivaciones de los profesionales sanitarios para estudiar y practicar acupuntura
y sus percepciones relacionadas con la colaboración entre ambas medicinas, que se ilustra en los
diagramas de códigos recogidos en las Figuras 2 y 3.
La fiabilidad y validez de esta investigación se basaron en la coherencia interna del estudio
siguiendo las recomendaciones de Morse (118)
, por lo que:
De acuerdo con el carácter subjetivo del objeto de estudio (percepciones) se eligió una
metodología cualitativa y el enfoque de la Teoría Fundamentada lo que permitió
conocer el contexto, las emociones y las interacciones/acciones que influyeron las
perspectivas de los participantes.
La recolección de los datos finalizó una vez saturada la información.
El proceso de recolección, análisis e interpretación de los datos se llevó a cabo de
manera dinámica y dialéctica.
Las entrevistas fueron transcritas completamente y analizadas minuciosamente dentro
del contexto en que los participantes construyeron sus discursos. Esto fue facilitado
por la manera de enfocar las entrevistas, ya que los participantes explicaban el
proceso y contexto que les había llevado a la acupuntura.
Búsqueda
de una
medicina
más
humana
Burocratización
de la asistencia
sanitaria
Excesiva
especialización
médica
Sometimiento
de la medicina a
intereses
económicos
Fragmentación
de la persona
Cosificación de
la persona
Insatisfacción
Frustración
Desilusión
Agresividad de la
medicina
convencional
Distanciamiento
entre profesional
sanitario y
paciente
Dificulta la
comprensión del
proceso de
enfermedad
Deteriora la
calidad de la
asistencia
sanitaria
Daños colaterales
en la salud del
paciente
Genera problemas
de conciencia
Considera al
paciente en su
globalidad
Acupuntura
No ocasiona
daños al
paciente
Figura 1. Motivación para estudiar y practicar acupuntura: Búsqueda de una medicina más humana
Sentimientos
Introducción
39
El método de comparación constante guio el proceso de análisis e interpretación de los
datos.
Para aumentar la validez del estudio y evitar sesgos se utilizaron las siguientes técnicas de
triangulación (119)
:
Triangulación de datos: la muestra incluyó profesionales con distintas características
con el objetivo de recoger la máxima variedad de puntos de vista.
Muestreo triangulado: se combinó la técnica de muestreo teórico con un muestreo en
forma de bola de nieve.
Triangulación de investigadores: el análisis e interpretación de los datos fue revisado
por otra investigadora y consensuado por un tercer profesional.
5. Revisión sistemática.
Durante esta investigación, además del trabajo de campo con las entrevistas a los profesionales
sanitarios, se realizó una revisión sistemática de la literatura existente sobre las percepciones de los
profesionales sanitarios sobre la integración de la acupuntura en la medicina convencional en países
occidentales. En dicha revisión se identificaron estudios publicados en español, italiano e inglés, hasta
enero del 2015, que analizaran el fenómeno objeto de estudio. Los artículos incluidos fueron hallados
en las bases de datos de PubMed, Web of Science CINAHL, SCOPUS y Cochrane Library, a través de
una estrategia de búsqueda completada con búsquedas manuales.
Tras la búsqueda de los artículos, se realizó una síntesis temática de los 18 estudios que
cumplieron los criterios de inclusión siguiendo las propuestas de Thomas y Harden (120)
. En un primer
momento, se apartó la pregunta de investigación y se procedió a la en identificación, en cada artículo,
de los distintos aspectos que analizaban estas investigaciones sobre la acupuntura en general desde el
punto de vista de los profesionales sanitarios (conceptos claves). Esta fase fue especialmente delicada
porque 12 de los 18 estudios incluían el punto de vista de los participantes sobre varias CAM al mismo
tiempo, por lo que hubo que seleccionar cuidadosamente lo que hacía referencia a la acupuntura. Poco
a poco se fueron agrupando estos aspectos clave, clasificándolos según las distintas áreas relativas a la
acupuntura que iban explicando y se fueron estableciendo relaciones entre ellos (temas descriptivos).
Finalmente, lo temas volvieron a ser interpretados a la luz de la pregunta de partida, es decir, qué
explicaban sobre la integración de la acupuntura en países occidentales desde el punto de vista de los
profesionales sanitarios.
A través de este trabajo fue posible conocer qué se había estudiado hasta el momento sobre la
acupuntura y qué podía ser explicado, a partir del análisis conjunto de los aspectos abordados por cada
investigación sobre el fenómeno de la integración de la acupuntura en países occidentales desde la
Introducción
40
perspectiva de los profesionales sanitarios. La síntesis temática dio como resultado una serie de temas
que explicaban distintos aspectos sobre este fenómeno:
Percepciones y conceptualizaciones de los profesionales sanitarios en las que se
fundamenta su visión sobre la integración de la acupuntura en la medicina
convencional:
- Medicina complementaria
- Medicina holística
- Medicina empírica
- Oportunidad para el desarrollo personal
- Aproximación centrada en el paciente
Motivaciones para practicar acupuntura
Situaciones en las que recomendar la acupuntura
Elementos que posibilitan la integración de la acupuntura
- Facilitadores para su implementación
Investigación
Conocimiento y formación
Comunicación entre profesionales
- Barreras para su implementación
Preeminencia del paradigma biomédico
Rigidez de la organización de la asistencia sanitaria
Falta de reconocimiento y apoyo institucional
Conocer la importancia de estas áreas y sus relaciones con respecto a la integración de la
acupuntura en la medicina occidental, nos permitió alcanzar un nivel mayor de sensibilización con
estos aspectos y prestar más atención a estos temas durante el desarrollo de las entrevistas (121)
.
Además, facilitó la comparación constante de la información que se iba recogiendo e interpretando en
España, con los hallazgos de los estudios realizados en otros países occidentales, estableciendo
similitudes, particularidades, diferencias e interrogantes.
Otra investigadora realizó búsquedas paralelas en las bases de datos y revisó el análisis e
interpretación del estudio. Un tercer investigador consensuó posteriormente los resultados de la
revisión.
Introducción
41
SEXO
EDAD
EDAD CUANDO
ESTUDIÓ
ACUPUNTURA
PROCEDENCIA FORMACIÓN
ACADÉMICA
FORMACIÓN EN
ACUPUNTURA
PROFESIÓN EN EL
MOMENTO DE LA
ENTREVISTA
PROVINCIA
DONDE
TRABAJA
PRÁCTICA DE LA
ACUPUNTURA
FORMACIÓN EN
MEDICINAS
COMPLEMENTARIAS
Mujer 62 37 España Médico > 500 horas Médico de urgencias
(centro rural)
Madrid Centro público
(esporádicamente)
No
Mujer 57 52 España Profesional de.
Enfermería
> 500 horas Enfermera de urgencias
(centro rural)
Madrid Familiares y amigos Reiki, Tai Chi, gimnasia
energética
Mujer 48 30 Colombia Médico > 500 horas Médico-Acupuntora Madrid Centro privado No
Mujer 58 España Médico > 500 horas Médico-Acupuntora Madrid Centro privado No
Mujer 53 25 España Médico > 500 horas Médico-Acupuntora Madrid Centro privado No
Mujer 61 España Médico > 500 horas Médico-Acupuntora Madrid Centro privado No
Mujer 30 27 España Fisioterapeuta 300 horas Fisioterapeuta Madrid Centro privado Osteopatía
Mujer 53 30 España Médico > 500 horas No trabaja (realiza la
residencia)
Madrid Espagiría, flores de Bach
Hombre 71 25 Colombia Médico > 300 horas Médico (medicina integral) Madrid Centro privado Plantas medicinales, terapia
neural
Mujer 51 42 España Profesional de
Enfermera
> 500 horas Enfermera de urgencias
(centro hospitalario)
Madrid Familiares y amigos Meditación, gimnasia energética
Hombre 52 35 España Profesional de
Enfermería
> 500 horas Enfermero en Atención
Primaria (centro
rural)/Acupuntor
Cuenca Esporádicamente en
centro público. Centro
privado
Meditación, plantas naturales,
masaje
Hombre 65 21 Italia Médico > 500 horas Médico-acupuntor Madrid Centro privado y
público
No
Hombre 55 45 España Médico > 500 horas Médico atención primaria Madrid Centro público No
Mujer 44 29 España Profesional de
Enfermería
> 500 horas Acupuntora Cuenca Centro privado Homeopatía, dietética,
fitoterapia
Mujer 64 29 España Veterinaria > 500 horas Veterinaria consulta
reproducción/rehabilitación
(centro hospital)
Madrid Centro público Medicina biorreguladora,
oligoterapia, homeopatía, flores
de Bach
Hombre 47 38 Rusia Médico > 200 horas Médico-acupuntor Madrid Centro privado No
Hombre 58 España Médico > 500 horas Médico general Madrid Centro público No
Mujer 62 55 España Profesional de
Enfermera
300 horas Enfermera en neonatología Madrid No practica No
Mujer 32 30 España Fisioterapeuta > 200 horas Fisioterapeuta Barcelona Centro privado No
Tabla 4. Características de los participantes
Introducción
42
Mujer 57 55 España Médico > 200 horas Médico dentista centro de
atención primaria
Madrid No practica No
Hombre 40 35 España Fisioterapeuta > 200 horas Fisioterapeuta-Acupuntor León Centro privado No
Mujer 33 25 España Fisioterapeuta > 200 horas Fisioterapeuta-Acupuntora Madrid Centro privado No
Hombre 48 26 España Profesional de
Enfermería
> 200 horas Enfermero (centro
hospitalario)
Alicante Centro público Flores de Bach, reflexología
podal, cromoterapia
Mujer 67 32 España Profesional de
Enfermería
> 500 horas Acupuntora Cuenca Centro privado Reflexología podal, medicina
antroposófica
Mujer 32 22 Brasil Fisioterapeuta > 500 horas Acupuntora Cuenca Centro privado No
Hombre 50 Alemania Fisioterapeuta > 500 horas Fisioterapeuta-acupuntor Cuenca Centro privado y
público
Reflexología podal
Mujer 47 43 España Profesional de
Enfermería
200 horas Terapeuta medicinas
complementarias y
esteticista
Alicante Centro privado Flores de Bach, quiropraxia,
aromaterapia
Mujer 40 37 España Fisioterapeuta > 300 horas Fisioterapeuta (centro
geriátrico)
Albacete Centro público No
Introducción
43
MOTIVACIONES DE
LOS PROFESIONALES
SANITARIOS POR LA
ACUPUNTURA
BÚSQUEDA
DE UNA
MEDICINA
MÁS HUMANA
ADQUIRIR
RECURSOS
TERAPÉUTICOS
ADICIONALES
EFICACIA Y GRAN
ALCANCE CURATIVO DE
LA ACUPUNTURA
ATRACCIÓN POR LA
FILOSOFÍA EN QUE
SE FUNDAMENTA LA
ACUPUNTURA
MOTIVACIONES
DE TIPO
LABORAL
INFLUENCIA
EXTERNA
Medicina
no
dañina
Considerar
pacientes en
su globalidad
Mayor
colaboración
entre
profesionales
HUMANA
Visión
holística
Visión
energética
Visión
humanista
Cosmovisión de
la Medicina
Tradicional China
Visión
optimista
Evitar
fármacos
Simplicidad de los
tratamientos
Comprensión holística
del paciente
Tratamientos
efectivos Tratamiento
enfermedad
crónica Tratamiento ante falta de
opciones terapéuticas
convencionales
Esfera
física
Esfera
emocional
Esfera
relacional
Esfera
espiritual Otros
profesionales
sanitarios
Publicaciones
científicas
Independencia
laboral
Otra manera de
organizar la
asistencia
terapéutica
Tratamiento enfermedad
neurológica
Figura 2. Motivaciones de los profesionales sanitarios por el estudio y práctica de la acupuntura
Introducción
44
Percepciones sobre la
colaboración entre
acupuntura y medicina
occidental
Beneficios de la
colaboración
Factores clave
para la
colaboración
Barreras para
la
colaboración
Potencial de la acupuntura
para complementar la
medicina convencional
Mejorar la calidad de
vida de los pacientes
Tratamiento de los efectos
secundarios
Bajar dosis de la
medicación Potenciar tratamientos
convencionales
Visión humanista y holística
Aportación de otros
elementos curativos
Qi Qong
Consejos sobre
el estilo de vida
Meditación
Ejercicios de
respiración
Preeminencia del
paradigma biomédico
Barreras
institucionales
Falta de comunicación
entre profesionales
Actividad reducida a
dispensar recetas
Intereses de la industria
farmacéutica
Percepción de la acupuntura como
una amenaza para la práctica
sanitaria convencional
Prejuicios
Minusvalorización
de la acupuntura
Desvalorización
de la acupuntura
Inflexibilidad de la
organización de
la asistencia
sanitaria
Falta de soporte y
reconocimiento
de la acupuntura
Capacidad de la acupuntura para
actualizarse
Aplicar tratamientos acupunturales
fundamentados en los
presupuestos de la MTC
Traducir
conceptos entre
ambos
paradigmas
Sesiones clínicas/Trabajo en
equipo/Comunicación entre
profesionales
Crear cultura de
acupuntura
Reconocimiento institucional de la
acupuntura
Figura 3. Percepciones de los profesionales sanitarios sobre la
colaboración entre acupuntura y medicina convencional
Evitar medicación y
tratamientos invasivos
45
PLANTEAMIENTO Y OBJETIVOS
46
Planteamiento y objetivos
47
PLANTEAMIENTO
1. Existe un aumento exponencial de personas que sufren enfermedades de crónicas en todo el
mundo (100,101)
. Sabemos que el desarrollo de estas enfermedades está relacionado con el estilo
de vida de la población y que afectan a más personas a medida que descendemos en la escala
social (100)
.
La OMS estima que en el 2020 las enfermedades crónicas serán responsables del
66.7% de la mortalidad a nivel mundial (en 1990 el 40.7% de las defunciones fueron
causadas por enfermedades crónicas) (100)
.
En España el 60% de las defunciones están causadas por enfermedades crónicas tales
como: cáncer, enfermedades cardíacas, enfermedades cerebrovasculares,
enfermedades crónicas de las vías respiratorias inferiores y diabetes (101)
.
La esperanza de vida al nacer libre de enfermedad crónica en España se sitúa en 26.2
años para las mujeres y 31.3 para los hombres (122)
(esta cifra ha sufrido un radical
descenso desde el 2003, año en el que se situó en 37.9 años para las mujeres y 40.9
años para los hombres) (123)
.
Existe evidencia científica que muestra la efectividad de la acupuntura en el
tratamiento de enfermedades crónicas y en la mejora de la calidad de vida (62,63,68,124-
130).
Sabemos que la acupuntura concede especial importancia al estilo de vida a la hora de
entender y abordar la enfermedad (12)
.
2. En la actualidad los Sistemas Sanitarios ejercen una gran presión sobre los recursos
económicos debido al alto coste de ciertos tratamientos convencionales y a la alta prevalencia
de estilos de vida que no favorecen la prevención de enfermedades (3,33,101)
.
Frente a esto, estudios previos muestran los beneficios que puede aportar la
integración de la acupuntura en los sistemas sanitarios al no requerir el despliegue de
mayor inversión económica ni infraestructura para su aplicación (42,105)
.
Sabemos que la prevención es el pilar básico de la MTC y la acupuntura se engloba
dentro de esta medicina (5,12)
.
3. Existe una seria preocupación por parte de los profesionales sanitarios y los pacientes por los
efectos secundarios de los fármacos e intervenciones médicas, así como por la subordinación
de la medicina a intereses económicos (34,93,94)
.
Cada vez son más los profesionales sanitarios que buscan en la acupuntura otras
opciones terapéuticas (50,52)
.
Planteamiento y objetivos
48
4. En la actualidad, asistimos a una búsqueda por parte de profesionales sanitarios y de la
población de respuestas a preguntas en torno al proceso de salud-enfermedad no contestadas
por el modelo médico imperante en nuestras sociedades (34,42,83)
.
La acupuntura proporciona explicaciones más centradas en los factores
medioambientales, psico-emocionales y afectivos, así como en los sistemas
credenciales que influyen en el proceso de salud-enfermedad (131)
.
5. La investigación cualitativa representa una herramienta metodológica que permite la
comprensión de la realidad social en su contexto y su globalidad, entendiendo el punto de
vista de las personas implicadas (132)
. Se ha evidenciado la necesidad de investigar
cualitativamente el fenómeno de la integración de la acupuntura desde el punto de vista de los
profesionales sanitarios con el objetivo de:
completar los resultados de los estudios cuantitativos existentes sobre la utilidad de la
acupuntura
y explicar la importancia otorgada a la acupuntura por parte de profesionales sanitarios
señalada por estudios cuantitativos (81)
.
OBJETIVOS
1. Conocer las concepciones de los profesionales sanitarios en países occidentales sobre la
integración de la acupuntura en la medicina convencional.
2. Comprender qué motivaciones encuentran los profesionales sanitarios para estudiar y practicar
la acupuntura en España.
3. Comprender las percepciones y concepciones de los profesionales sanitarios que practican la
acupuntura en España sobre la colaboración entre medicina occidental y acupuntura.
4. Identificar en qué aspectos la acupuntura puede mejorar la calidad terapéutica y asistencial en
los países occidentales.
Los resultados de este trabajo de investigación se presentan en tres artículos científicos donde se
responde a las preguntas planteadas en los objetivos del estudio:
El objetivo 1 se aborda en el manuscrito I: “Integration of acupuncture into conventional
medicine from health professionals’ perspective: A thematic synthesis of qualitative studies”
(Perspectiva de los profesionales sanitarios sobre la integración de la acupuntura en la
medicina convencional: Una síntesis temática de estudios cualitativos).
El objetivo 2 se trata en el manuscrito II: “What led health professionals to study and practise
acupuncture in Spain?” (¿Qué lleva a un profesional sanitario al estudio y práctica de la
acupuntura en España?)
Planteamiento y objetivos
49
El objetivo 3 se responde en el manuscrito III: “Collaboration between acupuncture and
Western medicine: The perspective of health professionals trained in acupuncture in Spain”
(La colaboración entre la acupuntura y la medicina occidental: La perspectiva de profesionales
sanitarios formados en acupuntura en España).
El objetivo 4 se trata de manera transversal en todos los manuscritos.
50
51
MANUSCRITOS
52
53
MANUSCRITO I. Integration of acupuncture into conventional
medicine from health professionals’ perspective: A thematic
synthesis of qualitative studies.
La integración de la acupuntura en la medicina convencional desde la
perspectiva de los profesionales sanitarios: Una síntesis temática.
54
Integration of acupuncture into conventional medicine
55
Introduction
Complementary and Alternative Medicine (CAM) includes a variety of practices and therapeutic
products developed outside of mainstream Western medicine such as acupuncture, homeopathy,
Ayurveda, naturopathy and meditation (29)
. Due to the disparity of characteristics and ways of
application, each therapy should be considered separately.
Acupuncture, one of the principal techniques of Traditional Chinese Medicine (TCM), has been
recognised by the World Health Organization as an effective therapy for a variety of conditions (62)
.
Furthermore, some countries such as Austria and Germany offer acupuncture for the treatment of
some types of chronic pain by the state-regulated health insurance carriers (69,133)
. Likewise,
acupuncture is currently available in the UK’s National Health System (134)
.
Recently there has been an increasing interest in the study, practice and recommendation of
acupuncture among health professionals and medical students (50-53)
. Some of the reasons are lack of
responses to conventional treatment, absence of available treatments, lack of adverse effects of
acupuncture, request of the patients, belief of health professionals in its efficacy, and existence of
documented evidence (52)
.
Although some health practitioners recognised that knowledge and research in acupuncture are
important, the lack of knowledge expressed by healthcare workers is noteworthy. Moreover, the
limited communication regarding acupuncture usage between health professionals and patients was
highlighted (50,51,135)
. Previous studies underline the need to further analyse certain issues concerning
integration of acupuncture into conventional medicine. These issues include diseases that may be
treated by acupuncture, risks or adverse effects related to its practice, how to achieve the integration,
which kind of professionals may provide it, and the cost related to the integration (50,53)
. Regarding
acupuncture effectiveness, there are still some challenges to be taken up, including the small size of
existing research (76-78)
and the inconvenience of the outcomes to evaluate its effectiveness. The
importance of including the perspective of patients to assess the benefits of acupuncture treatments
(43,80) has been also highlighted. Nevertheless, there is still some controversy about the effectiveness of
acupuncture. While certain studies show the effectiveness of acupuncture for treating different pain
conditions (64-66,74)
. On the other hand, cost-effective research in acupuncture is almost an unexplored
field (103)
. Another traditional weakness of the acupuncture research, such as the impossibility of
conducting double-blind acupuncture clinical trials, is being overcome (136)
.
According to recent surveys, the use of CAM among the general population was reported to be 42.3%
in Germany (137)
, 38.3% in the United States of America (138)
and 44% in the United Kingdom (139)
.
Regarding acupuncture, the reported prevalence of use is 14.5% in Germany (36)
and 6.3% in the
United States of America (37)
. Reasons for visiting an acupuncturist were for specific health problems
Integration of acupuncture into conventional medicine
56
or ineffectiveness of the previous medical treatment. The most frequently reported condition was
musculoskeletal complaint followed by back pain. Acupuncture was also used for general wellness,
enhanced energy and improved immune function (37,137)
. The fact that acupuncture does not require a
complex infrastructure and major economic investment are further benefits associated with
acupuncture (73)
.
It is believed that the increased interest of health professionals in acupuncture is linked to the
limitations of conventional medicine to address some health problems. This is due to the lack of
available and effective treatments and their side effects for certain disorders (52)
. The general
population might share these reasons (37,137)
.
Although the viewpoint of the health professionals may affect the use of the acupuncture by the
general population, few studies have deeply analysed relevant issues regarding the collaboration
between acupuncture and Western medicine from the perspectives of health professionals (140,141)
.
Even though the effectiveness of acupuncture in addressing some health disorders is still a
controversial issue, the evidence provided by the tradition and the experience confers relevance (142)
. In
addition, some recent evidences support the benefits of acupuncture integration into conventional
medicine setting, particularly improvements in physical and emotional symptoms, increased quality of
life levels and reduction of drug side effects (70-72,74)
. In order to provide a better understanding of this
phenomenon, we summarised and analysed the qualitative studies aimed to examine the conceptions
of health professionals related to the integration of acupuncture into conventional medicine.
Methods
Search Strategy. A systematic search of the following electronic databases (publications until January
2014) was conducted: PubMed, Web of Science, SCOPUS, CINAHL and The Cochrane Library. We
searched for qualitative studies exploring the integration of acupuncture into conventional medicine
from the perspective of health professionals. Some of the search terms used were “complementary and
alternative medicine”, “acupuncture”, “Traditional Chinese Medicine”, “integrative medicine”,
“practice complementary and alternative medicine”, “practice acupuncture”, “physicians”, “nurses”,
“physiotherapists”, “health professionals”, “motivations”, “perceptions”, “conceptualizations”,
“attitudes”, “views” and “Qualitative Research”. These terms were combined in different ways in the
included electronic databases (Table 5). Furthermore, manual searches in other sources such as grey
literature, were undertaken in order to obtain more results. The search strategy was conducted
independently and subsequently agreed by two reviewers (EGE, BRM). Any disagreement over the
selected studies was referred to a third reviewer (VMV). We also scanned reference lists of the found
studies.
Integration of acupuncture into conventional medicine
57
We considered as exclusion criteria studies that were not conducted in Western countries, secondary
studies, and studies not published in English, Spanish or Italian.
Table 5. Search Strategies
Methodology for the synthesis. For the qualitative synthesis, we used a thematic synthesis approach
aiming to find out relevant themes about acupuncture integration into conventional medicine grounded
in the perspective of participants. This synthesis was conducted in three stages according to the
methods proposed by Thomas and Harden (120)
. In the first stage, we extracted key concepts to capture
the meaning and context of each study. At this point, we put out our review question and started with
the thematic analysis in order to find out all the relevant issues about acupuncture from the perspective
of participants. In a second stage, we organised the key concepts into related areas to develop
“descriptive themes”. In the last stage called “going beyond the content” of the original studies, we
concluded five “analytical themes” examining the “descriptive themes” in the light of the review
question. This can explain some keys to the collaboration between acupuncture and conventional
medicine (Table 6).
DATABASE SEARCH STRATEGY
PUBMED
(((((Acupuncture Therapy OR Complementary Medicine OR integrative medicine OR Traditional
Chinese Medicine OR "practice acupuncture"))) AND (health personnel OR physicians OR nurs*
OR physiotherapist)) AND (perception OR motivation OR attitude OR conceptualization OR view))
AND Qualitative Research)
COCHRANE
LIBRARY PLUS
(Acupuncture Therapy or Complementary Medicine or Traditional Chinese Medicine or integrative
medicine or "practice acupuncture" or "practice complementary and alternative medicine") and
(health personnel or health professional or nurs* or physician or physiotherapist) and (motivation* or
perception* or attitude*) and (Qualitative Research)
SCOPUS (acupuncture OR complementary and alternative medicine” OR “practice acupuncture” OR “practice
complementary and alternative medicine”) AND (“health professional” OR physician OR nurs* OR
physiotherapist)AND (Qualitative Research)
CINAHL
(((acupuncture OR Traditional Chinese Medicine OR Complementary and Alternative Medicine)
AND (health professional OR physician OR *nurse OR physiotherapist)) AND (qualitative research
OR qualitative study))
ISI OF
KNOWLEADGE
((acupuncture OR Traditional Chinese Medicine OR complementary and alternative medicine OR
integrative medicine) AND (qualitative research OR qualitative study)
Integration of acupuncture into conventional medicine
58
Table 6. Relevant themes related to acupuncture integration into conventional medicine
Quality appraisal. The use of checklists for the evaluation of the quality of qualitative studies has
been much criticised. Generally, there is a lack of consensus about how quality should be assessed
(120). We developed a “sensitivity analysis” to observe a possible impact of study quality on the
findings of the review. For this purpose, we identified the concepts of quality within the context of the
aim of our review (health professionals’ point of view) and created a checklist to discuss the quality of
the studies based in other synthesis (143)
. The list included eight questions about the appropriateness of
the research design and the quality of the analysis. The quality appraisal was conducted independently
Analytical themes Descriptive themes
Perceptions and conceptions of acupuncture that underlay health
professionals views about integration
- Perception of acupuncture as a
complementary medicine:
Supplement (effectiveness gap of
Western medicine, contraindications
and shortages)
Accompaniment (drugs and medical
proceeds side effects)
Added benefits (quality of life).
- Perception of acupuncture as a holistic
medicine.
- Perception of acupuncture as an empiricist
medicine: evidence provided by experience.
- Patient centered approach.
- Self-development opportunity.
Why practice
acupuncture
Motivations to practice acupuncture - Perspective of nurses: opportunity to develop
in a personal and professional way because of
the emphasis on care and holistic healing.
- Perspective of physicians: personal
experiences, knowledge and convictions.
- Patients’ demands.
In which
conditions
practice or
referrer
acupuncture
Recommendation of acupuncture to patients - Absent of conventional treatments.
- Lack of efficacy of conventional treatments.
- Contraindications of conventional treatments.
What make
possible the
integration of
acupuncture into
conventional
medicine
Facilitators for
integration of
acupuncture into
conventional medicine
Health
professionals’
knowledge and
training
- Integration of acupuncture into academic
curricula.
- Creation of communication spaces between
health professionals and acupuncturists.
- Major institutional support.
Encouragement of research in these therapies.
Investigation to
provide evidence
of acupuncture’s
effectiveness
- To be aware of the importance of the
research.
- More funding to support it.
- To give priority to qualitative approaches in
order to understand holistically acupuncture
benefits.
Barriers to integrate acupuncture into
conventional medicine
- Primacy of biomedical model.
- Time constraints.
- Lack of compensation.
- Lack of funding.
- Lack of institutional support.
- Lack of scientific evidence.
- Lack of recognised teaching.
Integration of acupuncture into conventional medicine
59
and subsequently agreed by two reviewers (EGE, BRM). Any disagreement was referred to a third
reviewer (VMV). However, we did not use the results of these questions as a criterion for exclusion.
Due to the few published articles found, we considered all articles that answer the research aims
including poor quality articles which support the findings of the more developed articles (144)
. We
examined the appropriateness of the research design to the research question. Furthermore, we revised
the coherence regarding to methods, sampling, literature, analysis strategy, and presentation (118)
.
(Table 7).
Table 7. Quality appraisal of included articles
Article Is there a
clear
statement
of the
research
aims?
Is a
qualitative
methodology
appropriate?
Is a
theoretical
perspective
explicit?
Is the
sampling
strategy
clear an
appropriate?
Is the
analysis
sufficiently
rigorous?
Did the
researcher
consider
reflexivity?
Did the
researcher
describe the
triangulation
process?
Are
negative
cases
presented
or
sought?
Hansen,
2012
Y Y N Y Y N N N
Schroer et
al, 2009
Y Y N Y Y Y Y N
Marian et al,
2006
Y Y Y Y Y N Y Y
Johannessen,
2009
Y Y Y Y N N Y N
Johannessen,
2011
Y Y Y Y N N Y N
Joos et al,
2008
Y Y N Y Y N Y Y
Cant et al,
2011
Y Y Y Y Y N Y N
Frank and
Stollberg,
2004
N Y N Y Y N Y N
Adams,
2001
Y Y N Y Y N Y N
Verhoef et
al, 2010
Y Y N Y Y N Y Y
Berger et al,
2012
Y Y N N Y N Y Y
Rayner et al,
2011
Y Y N Y Y N - Y
Grace and
Higgs, 2010
Y Y N Y Y N Y Y
Bertrand,
2012
Y Y Y Y Y N Y Y
Hsiao et al,
2006
Y Y N Y Y N Y Y
Schiff et al,
2012
Y Y N Y N N N N
Bishop et al,
2012
Y Y N Y N N N N
Hughes et al,
2006
Y Y N Y Y Y N N
Y: Yes (The study met the criteria) N: No (The study did not meet the criteria)
Integration of acupuncture into conventional medicine
60
Data extraction. The data was extracted independently and subsequently agreed by two reviewers
(EGE, BRM). Duplicate studies were removed.
We provide a structured summary of each study listing authors, publication date, context, type of
therapy, methodology, data collection and sampling techniques, outcome measures, and main
conclusions. We respected original studies wording (Table 9) in order to preserve context.
Any disagreement was referred to a third reviewer (VMV). It was not necessary to obtain additional
information from the authors of original studies.
ENTREQ statement’s recommendations were taken into account to perform the analysis (145)
.
Results
The database search retrieved 1167 potentially relevant articles. 1102 of them were excluded due to a
preliminary screening based on abstract and titles. The full-text examination of the remaining 65
articles excluded 50 of them that did not meet inclusion criteria. Finally, to those 15 selected relevant
papers, three other studies that were found by hand searching in other sources of information were
added (Figure 1). Characteristics of the included studies are presented in Table 9.
Figure 4. Flow diagram
The principal data collection techniques within the included studies were the semi-structured and the
in-depth interview (11 and four respectively). Other techniques were participant observation (two),
18 papers included in the
systematic review
50 papers excluded:
- Based in other researches
- Not published in English, Italian or Spanish
- Did not report the Complementary and
Alternative Medicines considered - Did not include acupuncture as object of
analysis
- Did not follow a qualitative approach - Did not consider the perspectives of
health professionals.
68full-textpapersreviewed
1102 excluded
references after
title and abstract
review
3 papers identified from
manual search.
1167 referencesidentified in PubMed,
Web of Science, SCOPUS, CINAHL y
The Cochrane
Integration of acupuncture into conventional medicine
61
case study (two), focus group (two), open-ended questionnaires (one), documents analysis (one), and
mixed qualitative and quantitative techniques (one).
Regarding triangulation methods, eight studies involved multiple researchers, four used more than one
method for gathering data, one adopted more than one theoretical scheme in the interpretation of the
phenomenon, and one applied a multiple strategy to validate the results. Non-triangulation method is
specified in four articles. All the investigations showed congruence between question formulation,
data collection strategies and analysis (118)
. The studies that present more developed analysis provide
further details. Therefore, these studies contributed most to the thematic synthesis.
In relation to the setting characteristics, most of the studies included health professionals practising
acupuncture and took place in sites where the relation between acupuncture and biomedicine is
favourable. Five studies were conducted in fields of primary care (141,146-149)
, four in integrative
medicine centres (151-154)
, two in hospitals (155,156)
and seven of them did not specify the field (140,142,156-
160). We found documentation of integration in the treatment of depression
(141), rheumatoid arthritis
(158), and pain management
(140). Acupuncture was also used as support during pregnancy and childbirth
(154) and before and after surgery
(155). Regarding the country of origin, five studies were conducted in
the United Kingdom (140,141,146,154,158)
, three in Germany (147,148,157)
, two in Norway (159,160)
, two in
Australia (150,152)
and two other studies in the United States of America (151,156)
. Israel, Denmark,
Canada and Switzerland provided one study each to this review(149,153,155)
. The investigations
conducted in the public sector were carried out in the United Kingdom (146,154)
and Israel (155)
, while the
studies conducted in the private sector took place in the United States of America (151)
, Norway (159,160)
and Canada (153)
. Investigations performed jointly in both sectors were carried out in the United
Kingdom (140,158)
and Germany (147,157)
. Not all the articles included information about the sector (public
or private) in which they were conducted. No studies carried out in Mediterranean countries were
found.
Concerning the characteristics of the sample, six articles merely included the viewpoint of physicians
(141,146,148,149,152), three of nurses
(156,159,160) and nine comprised of different health-related professionals
(140,142,147,150,151,153,154,155,158). Among the nine studies which included the point of view of different
health-related professionals, eight compared the perspectives between health professionals and CAM
practitioners with non-conventional health-related training (140,142,147,150,151,153,155,158)
. Most of the
investigations considered different CAM therapies, whereas acupuncture or TCM were considered
exclusively in six studies (140,141,142,156-158)
.
Based on the perspective of health professionals, the thematic analysis revealed the following relevant
issues regarding the acupuncture integration into conventional medicine (Table 6):
Integration of acupuncture into conventional medicine
62
Perceptions of acupuncture among health professionals. Perceptions concern our beliefs about,
understanding and interpretation of a phenomenon, and our expectations. Thus, people create a
representation or interpretation of their experiences that affects their opinions, practices and
behaviours (161,162)
. Therefore, we analysed perceptions of health professionals about acupuncture that
may influence the way they think about integration (Table 8):
Complementary medicine. Some health professionals stated that acupuncture completes conventional
medicine by adding something that cannot be provided by Western medicine. Accordingly,
acupuncture was perceived as a supplement that covers the effectiveness gap of conventional
treatments and possible contraindications (drug allergies, adverse effects, polypharmacy, pregnancy)
(142,155,157). In the view of participants, acupuncture also compensates conventional medicine shortages
providing preventive and individualistic treatments, a patient-centred approach (140,147,148)
and other
reasons of the health-illness process which include social, emotional, and spiritual dimensions of
human beings (141,159,160)
. Acupuncture was conceived as a conventional medicine accompaniment
offering treatments for the side effects of medication and medical procedures (155)
. In one study, nurses
and midwives stated that acupuncture may counteract the increased technical and bureaucratic nature
of modern nursing and midwifery (154)
. Some health professionals highlighted the added benefits of
acupuncture related to care, wellbeing and quality of life (154)
. Acupuncture not only represented a way
to save time and work over longer periods, but also to work safely (146,148)
.
Due to the conception of acupuncture as a supplement to Western medicine, some participants
considered it as an alternative. We found no evidence of the perception that acupuncture could replace
Western medicine, but rather that the term alternative was used to refer to the possibility of reinforcing
conventional medicine (140,141,151,156)
.
Holistic medicine. Some health professionals used the word “holistic” referring to acupuncture in
order to highlight the importance conferred to physical, mental, emotional, social, and spiritual
dimensions of human beings (152,153,158,159,160)
. The holistic approach of acupuncture encouraged some
participants to adopt its practice because it allowed them to treat the whole person (the totality is more
than the sum of its parts) in opposition to conventional medicine, which is purely focused on
symptoms (142,151,152)
. As a consequence, some participants considered that they treat a person and not a
patient (159)
. They also found that they were focused on the healing process, care and life style (140,155)
.
Empirical medicine. Participants perceived acupuncture as an empirical medicine because the
evidence of its efficacy is provided by experience (personal experiences and tradition-experiences
collected during the years) (153,158)
. Some of them also highlighted that the results they observed when
treating patients were more successful than those carried out by RCTs (142)
.
Integration of acupuncture into conventional medicine
63
Self-development opportunity. In the specific context of nursing care, which is usually subordinated
to the authority of physicians, acupuncture was perceived by nurses as an opportunity to develop their
professional competences related to the care and healing process (154,159,160)
.
Patient-centred approach. Some participants perceived acupuncture as a patient-centred approach
due to the holistic conception of patients and the individualization of treatments. Accordingly, certain
health professionals conceived that the patient-centred approach could improve the patient-
practitioner relationship because patients were often more aware and actively engaged in the healing
process (140,147,148,160)
. Due to the improvement in the patient-practitioners relationship, health
professionals showed satisfaction in their practice (147,159)
.
Table 8. Health professionals' perceptions of acupuncture related to integration
Health professionals’ perceptions of acupuncture related to integration of acupuncture into conventional
medicine
Acupuncture as
supplement of
Western medicine
Compensates Western
medicine shortages
Effectiveness gap of conventional treatments
Conventional treatments contraindications
Complete Western
medicine
Holistic medicine
Preventive approach
Patient-centered approach
Counteract the technical and bureaucratic nature of Western medicine
Acupuncture as
accompaniment of
Western medicine
Treatment for medical procedures side effects
Treatment for drugs side effects
Self-development opportunity
Added benefits of
acupuncture to
Western medicine
Work safe
Save time
Save work
Quality of life
Wellbeing
Care
Knowledge and training. According to the participants, increased knowledge and training of
acupuncture among health professionals would encourage cooperation between conventional medicine
and acupuncture (148,151,154)
. It would allow health professionals to understand the therapeutic range of
this practice, while improving their disposition to recommend it (150)
. Furthermore, they considered that
familiarization with the language of acupuncture would enable communication between both
Integration of acupuncture into conventional medicine
64
disciplines (155)
. Identified key elements to facilitate cooperation between health professionals and
acupuncture practitioners were: integration of these medicines into academic curricula (148)
, creation of
communication spaces between health professionals and acupuncture practitioners (155)
, major
institutional support and encouragement of research in these therapies (148,151,154)
. Consequently,
increased training of acupuncture practitioners in conventional medicine was noted as an important
aspect to facilitate bidirectional communication between health professionals and acupuncture
practitioners (150)
.
Investigation. Participants considered that the evidence produced by research would encourage
physicians to recommend acupuncture to patients (141,142,148,153,154)
. In this way, they considered it is
necessary to be aware of the importance of having more funding to support the research (148,153,154)
.
Some health professionals also underlined the importance to give priority to qualitative approaches in
order to understand holistically the benefits of acupuncture (142,153,158)
. They also pointed out the
limitations of randomised control trials (RCT) to assess the effectiveness of acupuncture, due to the
individual nature of the treatments and the impossibility to blind the studies (142,148,158)
.
Barriers. The main obstacles to integrate acupuncture into the conventional medical practice
perceived by participants were: primacy of the biomedical model (148,159,160)
, time constraints (140,146,147)
,
lack of economical compensation, funding, institutional support, scientific evidence, and recognised
teaching (148,153,154)
. Particularly, time constraints affect the development of a close professional-patient
relationship (158)
. Nurses (subordinated to medical authority) required the recognition of situations to
practice CAM (159,160)
.
Recommendation. Participants mainly referred and practiced acupuncture in chronic diseases and in
cases where a lack of efficacy or contraindications for conventional treatments was observed (adverse
effects, drug interactions and allergies) (141,149,156,157)
. Otherwise, acupuncture was not suggested for
acute problems (156)
.
Motivations. The reasons of participants to practice acupuncture were identified to be mainly intrinsic.
Whilst nurses underlined the opportunity to develop their selves in a personal and professional way
due to the emphasis on care and holistic healing (159,160)
, physicians associated their motivations with
convictions, experiences on the effectiveness of acupuncture and personal knowledge (149,152)
. Demand
of patients was also an important influence on the practice of acupuncture (141,148,149,154,157)
.
Taking into account that the aim of this study was to find out relevant issues regarding the acupuncture
integration into conventional medicine based on the perspectives of health professionals, our findings
provides an explanation for: which perceptions and conceptions underlie the views of participants on
acupuncture (perceptions), the reasons why some health professionals practice acupuncture
(motivations), the situations in which they may refer to or practice acupuncture (recommendations)
Integration of acupuncture into conventional medicine
65
and the elements which make the integration of acupuncture into conventional medicine possible
(facilitators- knowledge and investigation- and barriers) (Table 5). Through the synthesis, we
established relationships between these concepts grounded in the data. The perceptions of health
professionals explain which beliefs, understandings and interpretations of acupuncture influence the
way they think about integration. Acupuncture knowledge and the evidence provided by research
(which are facilitators for the integration of acupuncture into conventional medicine), support the
recommendations of acupuncture by healthcare providers. This also motivates them to practice it and
collaborate with acupuncture practitioners. Similarly, knowledge and evidence (which is a form to
increase knowledge), would provide the possibility of transcending the barriers which impede
collaboration between acupuncture and conventional medicine. In order to achieve this goal, the most
relevant issue is to increase and improve the acupuncture knowledge among healthcare providers. This
fact may contribute to the integration of acupuncture into Western medicine, which should be
encouraged by institutional support. The idea of cooperation between both medicines was grounded in
the perception of acupuncture as a complementary therapy, which may supplement and add benefits to
conventional treatments. Moreover, “working together” was recognised by the participants as the key
condition for the successful integration of acupuncture (150,151,157)
.
Integration of acupuncture into conventional medicine
66
Table 9. Summary of included articles
AUTHOUR,
YEAR
STUDY
SETTING TYPE OF THERAPY METHOLOGY
DATA
COLLECTION SAMPLING PARTICIPANTS
OUTCOME
MEASURES CONCLUSIONS
Hansen,
2012.
Denmark.
(Field is not
specified)
Evidence in
acupuncture.
Acupuncture. Interpretative
(Template
Analysis and
Grounded
Theory).
Semi-structured
interviews.
Snow ball
sampling.
12 participants: 4
physicians practising
acupuncture, 4
acupuncturists with
others healthcare-related
training, 4 acupuncturists
with no conventional
healthcare- related
training
(7 female and 5 males).
Perceptions of concept
of evidence and the
use of RCT in
acupuncture among
practitioners.
The evidence based on
experience was the most
prominent.
RCT should consider the
individuality of acupuncture
treatments in the design.
Social science research methods
could assess the efficacy of
acupuncture.
Schroer et al,
2009.
United
Kingdom.
Primary care.
Treatment of
depression.
Acupuncture. Interpretative
(Framework
approach).
In-depth
interviews.
Criterion and
convenience
sampling.
30 participants:
10 acupuncture patients,
10 acupuncturist
physicians (9 GPs and 1
psychiatrist).
Circumstances in
which physicians
would be willing to
refer acupuncture for
depression.
Physicians selected to refer
acupuncture patients not
satisfied with conventional
treatments and explanatory
models.
Marian et al,
2006.
Switzerland.
Primary care.
TCM, anthroposophic
medicine, homeopathy,
neural therapy and
phytotherapy.
Mixed Method:
cross-sectional
survey, 636
questionnaires)
and content
analysis
(inductive and
deductive
construction of
analytic categories
as from 175
questionnaires).
Open-ended
questionnaires.
Representative
sampling.
GPs providing
complementary or
conventional primary
care.
Physicians’
motivations to practice
CAM in relation to
their philosophy of
care.
Physicians emphasised the
incorporation of holistic values
into medical practice. Moreover,
physicians’ motivations to
practice CAM were associated to
their own values and knowledge.
An assessment of risk-benefits
related to conventional/CAM
treatments and patient situations
determined the practice of CAM.
Integration of acupuncture into conventional medicine
67
Johannessen,
2009.
Norwey.
Nursing.
Private sector.
Acupuncture/ TCM,
kinesiology,
homeopathy, spiritual
healing, reflexology,
aromatherapy,
rosentherapy, Bach
flower essences, Ma-Uri
massage, psychodrama
therapy, craniosacral
therapy, nutrition,
bioresonance,
naturopathy,
phytotherapy, Ayurveda,
and anthroposophic
medicine.
Etnography.
Interviews and
participatory
observation.
Convenience
sampling.
18 nurses (females):
minimum of 1-year
experience working in
the public health service
and offered CAM in
private practice.
Motivations of nurses
to leave the
Norwegian health care
service in order to
practice CAM.
Independent practice of CAM
offers nurses the opportunity to
develop their clinical skills due
to the emphasis in care and
holistic healing, in an egalitarian
and autonomous environment.
Johannessen,
2011.
Norwey.
Nursing.
Private sector.
Acupuncture/ TCM,
reflexology,
homeopathy, healing,
anthroposophycal
nursing, color therapy,
psychodrama,
aromatherapy/massage,
diet and herbs, Reiki,
Ma-Uri massage, Bach
flowers medicine, Rosen
therapy, craniosacral
therapy and Ayurveda.
Etnography.
Interviews and
participatory
observation.
Convenience
and snow ball
sampling.
20 nurses (female)
practising CAM.
Motivations of nurses
to practise CAM in
relation to the
concepts of self-
development and self-
realization.
Nurses’ motivations to practise
CAM were related to the
philosophy of CAM: the
development of self is perceived
to be therapeutic and the illness
as an opportunity for self-
development.
Joos et al,
2008.
Germany.
Primary care.
Acupuncture,
naturopathy,
homeopathy,
chiropractic and
balneology.
Interpretative.
Content Analysis
(Mayring).
Focus group. Convenience
sampling.
17 GPs. Attitudes of GPs
related to the
integration of CAM
into the healthcare
system.
GPs perceived a need for
increased funding for research,
better education and
remuneration in order to
improve the integration of CAM
Integration of acupuncture into conventional medicine
68
in primary care.
Cant et al,
2011.
United
Kingdom.
Hospital.
Nursing and
midwifery.
Public sector.
Acupuncture,
aromatherapy,
reflexology, massage,
yoga, hypnosis, Bach
flower remedies and diet
therapy.
Interpretative.
Thematic analysis.
In-depth
interviews, case
study and semi-
structured
interviews.
Snowball
sampling.
12 nurses and 15
midwives (26 females
and 1 male) practising
CAM in public hospitals.
Nurses and midwives’
perceptions of the
integration of CAM
into their hospital
practice.
Integration of CAM into hospital
practice was perceived by nurses
and midwifes to be
unsystematic, underfunded and
individualised. Barriers
identified to integration were:
medical authority, lack of
funding and institutional
support, relative fragility of the
evidence base, unsystematic
nature of the training and
credentials.
Frank and
Stollberg,
2004.
Germany.
Public and
private sector.
Acupuncture. Interpretative.
Content analysis
(Mayring), cross-
case and
individual
analysis.
Semi-structured
interviews.
Random
sampling.
14 physicians practising
acupuncture (7 worked
within the public system
and 7 privately).
Physicians’
perceptions of the
degree in which they
integrate acupuncture
into biomedical model.
Acupuncture tends to become a
medical specialization adapted to
individual patients’ demands.
Adams,
2001.
United
Kingdom.
Primary care.
Public sector.
Acupuncture,
homeopathy,
hypnotherapy,
neurolinguistic
programming.
Interpretative.
Thematic analysis
(Rice and Ezzy).
In-depth
interviews.
Convenience
sampling.
25 GPs practising CAM
in NHS surgeries (11
female and 14 males, >5
years of experience as
physicians).
Perceptions of the
integration of CAM
into the public health
among physicians
taking into account the
consultation time
constraints.
Physicians develop a “brief”
style CAM consultation in order
to adapt CAM into the public
health and related lengthier
consultations to shorter duration
of treatments.
Verhoef et al,
2010.
Canada.
IM.
Private sector.
TCM, naturopathy,
quiropraxia, mind-body
and massage therapies.
Interpretative.
Content analysis.
Semi-structured
interviews.
Convenience
sampling.
25 participants: IM
practitioners (physicians
and CAM practitioners)
clinic directors and
managers.
Perceptions of the
inclusion of outcomes
research programs in
integrative health care
clinics among
professionals.
Barriers to conducting outcomes
research in IM clinics identified
by participants were: lack of
resources, organization, time,
staff interest, and training.
IM clinics required outcomes
Integration of acupuncture into conventional medicine
69
research programs able to
document the patients’
experiences.
Berger et al,
2012.
Germany.
Primary care.
Public sector.
Acupuncture,
homeopathy,
naturopathy.
Interpretative.
Content analysis
(Mayring) and
thematic coding
(Strauss).
Semi-structured
interviews.
Quota sampling. 30 participants: 10 GPs,
10 GPs practising CAM
and 10 nonmedical CAM
practitioners (19 female
and 11 male).
Comparison of
physicians and CAM
practitioners’
perceptions regarding
to the health
professional-patient
relationship.
Professionals who practice CAM
perceived a more participative
health professional-patient
relationship.
GPs considered the sanitary
protocols as obstacles for
achieve a patient-centered
medicine.
Rayner et al,
2011.
Australia.
IM.
Acupuncture,
homeopathy, herbal
medicine, mind-body
medicine and lifestyle
medicine.
Interpretative.
Thematic analysis.
Semi-structured
interviews.
Convenience
sampling.
23 physicians practising
IM (14 female and 9
male).
Motivations of
physicians to work in
IM and to incorporate
CAM into their
practice.
The holistic and patient-centered
approach focusing on lifestyle of
IM and CAM motivated
physicians to work in these
fields.
Grace and
Higgs, 2010.
Australia.
IM.
Acupuncture, nutrition,
homeopathy, herbal
medicine,
anthroposophical
medicine, environmental
medicine, naturopathy,
bioenergetic medicine,
Reiki, chiropractic.
Hermenetuic
phenomenology
(van Manen)
Case study, semi-
structured
interviews, focus
group and in-
depth interviews
with key
informants.
Convenience
and purposive
sampling.
GPs and CAM
practitioners.
Perceptions of
collaborations’ forms
among GPs and CAM
practitioners.
Mutual knowledge between GPs
and CAM practitioners’
practices enable deeper
cooperation between
conventional medicine and
CAM therapies.
Bertrand,
2012.
United States.
Nursing.
Context of
Triage process.
TCM. Interpretative.
Symbolic
interactionism.
Semi-structured
interviews.
Purposive
sampling.
20 nurses (female) who
had personally tried
TCM.
Perception of aspects
that influence in
nurses’
recommendations of
TCM.
Nurses perceived their role in
each situation, the condition of
each patient and their training as
influential aspects in their
recommendation of TCM.
Hsiao et al,
2006.
United States.
IM.
Academic
Acupuncture,
chiropractic.
Interpretative.
Grounded Theory.
Semi-structured
interviews.
Purposive and
snowball
sampling.
50 participants: 13
physicians, 13 physician
acupuncturists, 12
Perceptions of IM
practice among
professionals.
Relevant factors in developing
an IM identified were: open-
minded perspective on other
Integration of acupuncture into conventional medicine
70
context and
private practice
chiropractors and 12
acupuncturists (33 male
and 17 female).
healing traditions, cooperation
between professionals and
combination of conventional
treatments with CAM.
Schiff et al,
2012.
Israel.
Public hospital.
Surgery service.
Acupuncture,
reflexology, guided
imagery, breathing
techniques.
Interpretative.
Thematic analysis.
Consultation
reports.
Consecutive
sampling.
304 consultation reports
between conventional
health professionals and
CM practitioners,
registered in the hospital
electronic consultant
charting system.
Analysis of integration
of CM into
conventional medicine
through
communication
patterns between
conventional and
complementary health
providers.
CM practitioners began to adopt
a biomedical language whilst
health providers began to
employ a more holistic, psycho-
emotional and symptomatic
terminology understanding the
therapeutic potential of CM.
Bishop et al,
2012
United
Kingdom.
Private and
public sector.
Context of pain
management.
Acupuncture. Interpretative.
Inductive thematic
analysis (Bram
and Clarke).
Semi-structured
interviews.
Purposive
sampling.
16 acupuncturists among
physiotherapists, nurses,
physicians and CAM
practitioners: 7 work
privately, 3 in the public
sector and 6 in both (14
female and 1 male).
Similarities and
differences between
private and public
acupuncture practice
identified by
acupuncturists.
Time constraints identified in the
public sector affect the
professional-patient relationship
While private practice is
constrained by patients’
financial resources.
Hughes et al,
2006.
United
Kingdom.
Private and
public sector.
Context of
rheumatoid
arthritis.
Acupuncture. Interpretative.
Grounded Theory.
Semi-structured
interviews.
Theoretical
sampling.
19 participants: 10 health
professional
acupuncturists and 9
non-health professional
acupuncturists.
Perceptions of treating
patients with
rheumatoid arthritis
among acupuncturists
and the impact of their
affiliation to a
traditional or Western
theoretical base.
Limited divergence was found in
the treatments outcomes
between traditional and Western
acupuncture practice. Besides
alleviating rheumatoid pain,
benefits of acupuncture were
related to improving the quality
of life.
RCT: Randomised Control Trials CAM: Complementary and Alternative Medicine GP: General Practitioner
IM: Integrative Medicine TCM: Tradtional Chinese Medicine CM: Complementary Medicine
Integration of acupuncture into conventional medicine
71
Discussion
As far as we know, this is the first systematic review of qualitative studies examining and synthesising
the integration of acupuncture into conventional medicine from the perspective of health professionals.
Our study is focused on the manner in which acupuncture is being integrated and the barriers to its
practice reported by the literature. Our findings reveal that the integration of acupuncture and
conventional medicine is produced by the adaptation of acupuncture to the conventional medicine in
both, public and private sector (146,154,155,157)
, despite the formal and conceptual heterogeneity in which
it is performed (157,158)
.
Another important finding reveals that the motivations of health professionals for the incorporation of
acupuncture are based on their own convictions (159,160)
and personal knowledge and experience
(149,152,156) rather than scientific evidence. This fact contradicts the importance conferred by literature to
the evidence-based practice of acupuncture by health professionals and can contribute to the
publication bias (30)
. Additionally, some studies included in this review suggest that RCT have some
limitations in the assessment of the effectiveness of acupuncture in terms of physical, emotional,
social, and spiritual outcomes (27,43,163)
. These limitations to provide evidence supporting acupuncture
practice are being overcome using research methods and techniques of social science (43,153)
.
As previous studies have pointed out, barriers to integrate acupuncture into conventional medicine are
the primacy of the biomedical paradigm, excessive bureaucracy and the subordination of medicine to
economic interests (79,89,94,95)
. These obstacles are evidenced by the time constraints and the lack of
funding, institutional support, scientific evidence, and recognised teaching programs in acupuncture
(140,146-148,153,154,159).
Acupuncture is considered by some participants as a supplement to Western medicine because it
completes and complements conventional medicine with a holistic approach of the health-illness
process. The holistic approach of acupuncture has been highlighted by Patterson and Britten (13)
. They
defined acupuncture as a complex intervention due to the interconnections and cyclical reinforcements
of improvements in social, emotional, physical and spiritual dimensions of patients.
The perception of acupuncture as a supplement to Western medicine is consistent with other studies
showing the benefits of acupuncture in collaboration with conventional medicine. Cooperation
between acupuncture and the pharmacological treatment of knee osteoarthritis was revealed to be
more effective than pharmacological treatment alone (74)
. Benefits of acupuncture as a complementary
therapy into paediatric pain and cancer patient care, was also evidenced (70,71,72)
. Advantages related to
improvements in physical and emotional symptoms, quality of life and physician-patient relationship
were shown (70,71,72,74)
. Gain control over patient well-being and reduced drug side effects were also
reported (70)
.
Integration of acupuncture into conventional medicine
72
The benefits of complementary therapies integration into conventional medicine have also been
demonstrated. Some examples are meditation, touch and mind-body therapies, relaxation therapy,
music therapy and massage. The use of herbs and dietary supplements in conjunction with prescription
medication was revealed to be problematic due to the potential herb-drug interaction (70,71)
.
The serious concern about adverse drug reactions and medical iatrogenesis -third leading cause of
death worldwide (93,94)
- and the search for different explanations of illness, motivates health
professionals to enrich their view of the health-illness process considering other paradigms (34,142)
.
According to previous studies, our findings suggest the lack of adverse effects (96)
and its holistic
approach, that includes physical, social, emotional, and spiritual factors which influence the health-
illness process, as facilitators for integration of acupuncture (13)
. This highlights the need for a
constructive dialogue between both medicines promoted by major knowledge of health professionals
about acupuncture. The adaptive capacity of TCM may facilitate this dialogue (146,157)
.
Our results are relevant because they highlight the importance of overcoming the biomedical paradigm
and the conventional healthcare model. This study synthesised the contributions of existing qualitative
investigations in this area, enables a broader description and allows a more complete understanding of
the range of existing challenges.
Conclusions of this study are limited due to the few published qualitative studies concerning the
integration of acupuncture into conventional medicine from the perspective of health professionals.
We found another limitation related to the heterogeneity in characteristics of the analysed
investigations. Most of the studies of this review included health professionals who practise
acupuncture and took place in sites where the relation between acupuncture and biomedicine is
favourable. This fact could bias the results, but it allowed us to know the perceived barriers and
obstacles by health professionals for the effective integration of acupuncture.
Given the limitations of conventional treatments (drugs side effects, drug resistance, lack of
treatments, medical iatrogenesis, and supremacy of economic interests), more research is needed to
analyse the perspectives of acupuncture among health professionals and to document the holistic
benefits associated with acupuncture. Furthermore, the point of view of different health professionals
such as nurses, midwives and physiotherapists, who are comparatively underrepresented in the
analysed studies, must be taken into account. It is also necessary to carry out more investigations in
Mediterranean countries in order to incorporate more points of view. Finally, comparative studies
between countries in which acupuncture is a predominant therapy and those in which it is a minority
practice could be useful in order to explore ways in which cooperation between both medicines could
be fostered
73
MANUSCRITO II. What led health professionals to study and practise
acupuncture in Spain?
¿Qué conduce a un profesional sanitario a la acupuntura en España?
74
Health professionals’ perceptions to study and practise acupuncture
75
Introduction
Acupuncture is the best known and widest spread practice of Traditional Chinese Medicine (TCM) in
the Western world (40)
. This confers special relevance to the experiences and circumstances of life to
explain the health-illness process. From this approach, human beings form a whole in which physical,
emotional, social and spiritual dimensions are indissoluble (1)
. Acupuncture has been recognised by the
World Health Organization (WHO) as an effective therapy for a variety of conditions such as
depression, rheumatoid arthritis, neurological disorders, asthma, allergic rhinitis, biliary and renal
colic, blood disorders, dysentery and gout. It was also acknowledged for the treatment of pain and
drugs and postoperative side effects (62)
.
An increasing interest of Western health professionals and medical students for acupuncture has been
reported in the last few years (50-53)
. The European Parliament considers acupuncture practitioners as a
health workforce and highlights the need for further research in acupuncture considering also the
perspectives of health providers (35,55,164)
. According to the Complementary and Alternative Doctors
Alliance, approximately 80.000 physicians practise acupuncture in Europe (40)
. The main reasons for
this interest are adverse drug reactions, medical iatrogenesis and search for different explanations of
illness (165)
. Other reported motivations include patients’ lack of responses to conventional treatment,
absence of treatments and personal request of patients (52)
. In this line, some health professionals
conceive acupuncture as a complementary therapy that may supplement and add benefits to
conventional treatments such as pre/postoperative patient care, depression and rheumatoid arthritis
(165).
Biomedical trained health professionals approach acupuncture in a variety of ways (157)
. In some cases,
acupuncture is incorporated into the biomedical practice as a simple technique rejecting the
metaphysical explanations in which it is founded. On other occasions, health professionals embrace
TCM concepts including its metaphysical and anthropological vision. Although between the two lies a
complex array of forms, they are never entirely disassociated from traditional knowledge (27)
.
Estimations of the prevalence of use of acupuncture among the population in the United States of
America (USA) and Germany are 6.3% and 14.5% respectively. The discrepancy in relation to these
estimates can be explained by the behaviour of the health insurances in each country. The National
Health Insurance and private insurance companies covered acupuncture treatments in Germany but not
in the USA (40)
. In Spain, where acupuncture treatments are also not covered by the public and private
insurances, these figures reached 7.4%, similar to USA (45)
. Benefits associated with acupuncture by
the Spanish population were to treat human beings from a holistic point of view, prevent and cure
physical and emotional diseases and the absence of side effects. Compatibility with and supplement of
conventional treatments were also emphasised (45)
.
Health professionals’ perceptions to study and practise acupuncture
76
In Spain, there is not a state regulation regarding acupuncture practice neither an official register of
health professionals practising it. Health centres should be registered as a Non-conventional Therapy
Unity in order to provide acupuncture treatments and other natural therapies, under the responsibility
of a physician. On the other hand, non regulated health professional practitioners must be registered in
the Economic Activities Tax, which regulates their situation only for fiscal purposes (55,111)
. Although
these treatments are not systematically funded by the National Health Insurance, the current legislation
supports its use within the National Health System (NHS). Thus, there is a variety of initiatives to
practise acupuncture among the Public Health System (55)
. Moreover, a variety of institutions offer
training in acupuncture, such as university postgraduate programs, collegiate organisations and private
teaching centres (55)
. Some offer training in acupuncture founded in the Chinese tradition and
permeated by Taoism philosophy, such as The Nei Jing School, spread around the world, which does
not specifically require students to have health professional training (10)
. Others offer courses from a
more biomedical approach only for university graduated health professionals, such as health
professional colleges and university programs (55)
. Nevertheless, we did not find any school entirely
disassociated from the TCM or Western medicine concepts.
Previous quantitative studies have reported that the current interest of health professionals in
acupuncture could be due to different factors: patients’ lack of response to conventional treatments,
absence of conventional treatments, request of the patients, adverse drugs reactions and search for
different explanations of the health-illness process (50,52,53)
. Nevertheless, there are few studies that
explore in detail the motivations of health professionals to study and practise acupuncture in Western
countries. These motives have been recently collected in a qualitative systematic review (165)
.
Accordingly, nurses underline the opportunity to develop themselves in a personal and professional
way due to the emphasis on care and holistic healing (159,160)
, while physicians associate their
motivations with convictions, individual experiences on the effectiveness of acupuncture and personal
knowledge (149,152)
. Existing research in the area includes different therapies with a disparity of
characteristics and ways of application which hinders the understanding of acupuncture particularities.
Moreover, it involves solely North-western European countries (165)
The aim of this study was to map and understand the motivations of health professionals to study and
practise acupuncture in Spain in order to reveal keys that may improve the quality of health care.
Methodology
Design
We used in-depth interviews and Grounded Theory Dimensional Analysis to collect, analyse and
interpret the data in our effort to investigate the motivations of health professionals to study and
practise acupuncture. This inductive method was chosen to obtain a theoretical explanation by
Health professionals’ perceptions to study and practise acupuncture
77
analysing the health professionals’ conceptualisations of their motivations grounded in their
experiences. According to this methodology, data collection, analysis and theory are reciprocal with
each one (116,167,121)
. This allows the analysis of the data within the context and the identification of
concepts that explain the behaviour of participants.
Sample and date collection
We conducted 27 in-depth interviews with health professionals who had studied and practised
acupuncture. In particular, we interviewed physicians, nurses and physiotherapists because they are
the health experts most involved in this practice in Spain (55)
. A theoretical sampling guided the
sampling process in order to ensure that each new case was appropriate for providing new concepts
and clarifying relationships and logic among constructs. We used a snowball sampling in order to
triangulate this process. Interviews were audio-taped and transcribed verbatim for subsequent analysis.
All participants signed an informed consent after receiving a detailed explanation of the study
provided by the main researcher (EGE). The data collection process was guided by the analysis until
the point of data saturation was reached, meaning that no new analytical concepts emerge by
broadening the sample (117)
.
The inclusion criterion was to sample physicians, nurses and physiotherapists trained in acupuncture
based on the World Health Organization recommendations on basic training and safety in acupuncture
(112). We applied the recommendations of limited training for physicians (not less than 200 hours) to
nurses and physiotherapists to ensure that the conceptions of our participants were well-founded. We
selected informants of both sexes, different age groups and professional backgrounds in an effort to
provide the broadest possible information. This maximised opportunities to discover dissimilarities
among concepts and to enrich categories in terms of their properties and dimensions. Table 10 shows a
brief description of the characteristics of participants.
Table 10. Main characteristics of participants (N=27)
Characteristics Variables Woman Man
Health profession
Physician 7 5
Nurse 6 2
Physiotherapist 5 2
Age
30-40 4 1
41-50 4 3
51-60 6 3
>60 4 2
Acupuncture training
200-300 hours 4 2
300-500 hours 4 1
>500 hours 11 5
Acupuncture practice
Public sector 2 2
Private sector 11 3
Public and private sectors
0 4
Friends and family 3 0
Do not currently practice 2 0
Health professionals’ perceptions to study and practise acupuncture
78
After providing participants information about the study, we made an appointment. All interviews
took place in a quiet and private environment and were conducted by the main researcher (EGE). Each
one started out with an open-ended question about their professional and personal background up to
the point where they started to practise acupuncture. Through them, we could gather real-life stories of
participants which allowed us to understand the emotions, conceptions and contexts that influenced
their decisions. Although the interviewer had a topic list that could emerge openly throughout the
interviews (Table 11), she intervened as little as possible in order to let participants freely express their
own history. The topic list was refined and guided by the theoretical sampling. Interviews were
conducted between April 2013 and July 2015 and lasted from 35 to 60 minutes. All of them were
audio-taped using a digital recorder, rendered anonymous and literally transcribed.
Table 11. Topic list of interviews
Topic list
Health professional training
Acupuncture training
Work experience
Professional motivations to study acupuncture
Personal motivations to study acupuncture
Way of acupuncture practice
Conception about the collaboration between acupuncture and conventional medicine
Comparative view of acupuncture and conventional medicine
Perceptions of acupuncture philosophy
Perceived barriers to acupuncture practicing
Preferences between acupuncture and conventional medicine
Training in other complementary medicines
Reasons to study and practice acupuncture among other complementary medicines
Data analysis
Data collection, analysis and interpretation were simultaneously undertaken in an interactive process.
Each transcript was analysed before a subsequent interview took place in order to assess the point
where data saturation was reached (117)
. Transcripts were analysed line by line to identify concepts that
explained the motivations of health professionals to study and practise acupuncture. To do this, we
used the qualitative software program Atlas.Ti 5.2.
The identified concepts were labelled and classified into categories using an open, axial and selective
coding process. We started by creating tentative labels for chunks of data just based on the meaning
that emerged from the data (open coding). After that we identified relationships among the open codes
(axial coding). Finally we figured out core variables that included a set of data and selectively coded
any data that related to the core variables (selective coding). The constant comparison method was
used to identify the latent pattern in the perspective of participants. This also implied continually going
back and forth among the interview transcriptions, analytical memoranda and review literature. Each
code was continuously compared with all other codes in order to identify similarities, differences and
Health professionals’ perceptions to study and practise acupuncture
79
general patterns. Themes and categories gradually emerged from a minor level of abstraction to a
major one (116)
.
Based on this, we constructed categories which explained the motivations of health professionals to
study and practice acupuncture (Table 12).
Table 12. Codes and categories of health professionals’ motivations to acupuncture
Health professionals’ motivations to study and practice acupuncture
Searching for a more humane medicine
Medical specialisation
Bureaucratisation of healthcare assistance
Capitalisation of conventional medicine
Rejection of time restrictions
Dehumanisation of medicine
Searching for a non-harmful medicine
Avoid aggressive treatments and drugs adverse effects
Lack of control of drugs side effects
Lack of treatment for emotional-affective dimensions
Absence of contraindications
Lack of emotional care
Dehumanisation of care
Dehumanisation of language medicine
Inability to understand the whole person
Acquire therapeutic resources
Lower cost of acupuncture treatments
Simplicity of acupuncture application
Confined activity to prescribing drugs
Efficacy
Holistic benefits
Dissatisfaction with healing potential of conventional
medicine
Acquire therapeutic resources
Integral knowledge
Widen knowledge
Efficacy and far-reaching potential of acupuncture
Effectiveness
Integral treatment
Acupuncture as a complementary therapy
Acupuncture as an alternative therapy
Treatment for conditions
Treatment of pain
Treatment of chronic diseases
Treatment of psychosomatic illnesses
Treatment of rare diseases
Treatment of immune system disturbances and allergies
Treatment of psychological disturbances
Treatment of emotional sphere
Treatment of neurological disturbances
Treatment of digestive problems
Treatment of gynaecological conditions
Treatment of functional diseases
Health professionals’ perceptions to study and practise acupuncture
80
Attraction to acupuncture philosophy
Attraction for Chinese philosophy
Searching for something else
Energetic approach
Response to questions about life and death
Style of life
Vision of the transcendent one
Humanistic approach
Holistic approach
Importance of individualised treatments
Importance of life history
Importance of health professional-patient relationship
Importance of experiences and circumstances of life
Influence of other recognised professionals or sources of
information
Influence of relevant sources of information
Influence of colleges
Work-related motivations
Help others
Competitive work environment
Exploitative working conditions
Professional independence
Bad working conditions
Rejection of hierarchical healthcare organisation
Time constrictions
Rigour
We carried out a variety of strategies in order to ensure the reliability and validity of the analysis, such
as ensuring methodological coherence, sampling sufficiency, developing a dynamic relationship
between sampling, data collection and analysis, thinking theoretically, and theory development (118)
.
According to the aim of the study, we chose a methodological approach (Grounded Theory) and a data
collection technique (in-depth interviews) that allowed us to understand the phenomenon (motivations
of health professionals to practise acupuncture) in the light of the meanings attributed by the social
actors. Through them, we could also understand the context, emotions, actions/interactions that
influence their conceptualisations. Sampling continued until the point of data saturation was reached.
Interviews were literally transcribed and analysed in the full context. We examined the transcriptions
line-by-line and interpreted them one by one. The analysis was led by the constant comparative
method and an interactive relationship between data, analysis and interpretation.
We used data and investigator triangulation techniques to increase the validity and to mitigate biases
in the study. The sample included participants of different ages, genders and backgrounds. Theoretical
sampling was also triangulated using a snowball sampling. The data was analysed independently and
then agreed by two researchers from different disciplines (EGE: Sociology, BRM: Nursing and
Anthropology) who inspected the phenomenon from multiple perspectives. Any disagreement was
referred to a third researcher (VMV: Medicine).
Health professionals’ perceptions to study and practise acupuncture
81
Results
Six main categories emerged from the analysis of the motivations of participants to study and practise
acupuncture: searching for a more humane medicine, acquire additional therapeutic resources, efficacy
and far-reaching healing potential of acupuncture, attraction to acupuncture philosophy, external
influences (other professionals and recognised sources of information), and work-related motivations.
For a better understanding, we include the most representative verbalisations after translating them
from Spanish to English. As meanings may be distorted during the translation process, we provide an
accurate translation of the quotations respectful to the original meaning rather than a strict literal one.
Translations were corroborated by a bilingual translator and an English mother tongue corrector. We
also include a table with the emergent themes, categories and codes (Table 12).
Searching for a more humane medicine.
Participants considered that some aspects of biomedical and conventional healthcare are dehumanised.
They reflected on the aggressiveness of some treatments and procedures and the high-specialised,
bureaucratised and capitalised context in which conventional medicine is immersed and expressed
their dissatisfaction and disappointment regarding this issue. Therefore, participants were looking for
a non-harmful medicine which considers the patients as whole human beings. In this regard, they
expressed serious concerns about drug side effects, adverse drug reactions and medical iatrogenesis
and highlighted the lack of side effects of acupuncture treatments.
You realise that you do more harm than good because, as conventional medicine stands, the
way a research is conducted and the diagnosis procedures are harmful and invasive. The way
to treat is also invasive. It has many side effects. (…) That was how I started, searching for a
new way to practice medicine that wasn’t so harmful. But I have found acupuncture as a
useful resource in order to palliate, relieve, improve, and above all without major damage
being done (Female, Physician, 53 years)
I realised that people experienced or could experience side effects. This terrified me. I thought
“Well, I am prescribing a medication that causes different effects across people. Medication
can suit some people well or produces a set of symptoms or improvements. Other people don’t
improve and have different symptoms. Sometimes these symptoms became worse instead of
better and they experience things which they didn’t before taking the medication”. You enter
in a vicious circle in which you don’t control anything because it depends on the medication
and how it fits to the person. (Female, Physician, 58 years)
Health professionals’ perceptions to study and practise acupuncture
82
Participants pointed out that the healthcare assistance is immersed in a highly bureaucratised context
which produces an enlargement of the distance between health professionals and patients and impedes
the understanding of the health-illness process.
I think it is a lack of closeness. There is not enough individual knowledge of the patient. Lots
of moments are lost in data, papers and protocols. One has to see the patient, another as well,
you have to send him to one professional, then to another. The patient gets lost in between.
(Female, Physician, 58 years)
I was working in the out-patient department, which was the same type of the NHS. I thought,
“This is not the medicine I want to practise” because the patient was not actually treated but
there were a lot of forms, institutional paperwork and statistics that were actually false. The
quality of care, the humane treatment of people, absolutely lost. (Female, Physician, 48)
Participants also highlighted that the excessive specialisation of the biomedical approach and the
healthcare assistance cause a fragmentation of the person.
Each specialist is dedicated to his/her area but where do you put all together? And something
that drew my attention, especially in older people, is the quantity of drugs that they take
because each specialist prescribes medication. It seems mad to me divide one person so much.
What I like about acupuncture is that it looks at the patient as a totality. (Female, Nurse, 57
years)
In this line, they considered that the biomedical approach does not focus on the person but on the
disease. It divides individuals into painful or diseased parts, which results in a reification of the
patients. In their opinion, the illness of the body is more of concern than the whole human being and
its circumstances of life. Therefore, patients are treated far away from a preventive approach.
There is still a trend to mark people not as a person but as injuries. (Female, Nurse, 62 years)
It is important to reassure the people. Talk with them, see how the person is and not only pay
attention to the heart problem, do an electrocardiogram and check the ST segment elevation,
but look at the person itself. What is happening to him, why does he need to smoke right after
leaving the hospital (…) We have to get further in these kind of things but we do not. We do
not solve the emotional problem that is causing him another heart attack two days later.
(Female, Nurse, 51 years)
They pointed out that the trend to reify patients is also evidenced by the medical language.
One learns pathology in Western medicine. A man with cirrhosis, “Ah, I have seen very
beautiful cirrhosis!”, “I have seen very typical cirrhosis!” That is the language used among
Health professionals’ perceptions to study and practise acupuncture
83
physicians, “You must see the cancer I have seen!” How can you see a cancer when it is a
man or a woman? (Female, Physician, 48 years)
On the other hand, participants wished to transcend the conventional barriers between disciplines
and the high-specialised healthcare assistance. Physicians would like to be more involved in the
implementation of treatments and nurses and physiotherapists would like to contribute more in the
decision-making about clinical diagnosis and care.
I realised that I was a technocrat. I applied some techniques, which basically consisted of
implementing the pharmacological treatments prescribed by physicians. I actually could do
little for the patient. (Male, Nurse, 48 years)
Each specialist only deals with their own respective field. For example if you comment to a
digestive system specialist, “I have palpitations sometimes”, he would do a report and send
you to the cardiologist. He does not deal with that because he doesn’t know how. (Female,
Physician, 58 years)
Moreover, participants also pointed out that the dependence of healthcare assistance on economic
matters results in a deterioration of the healthcare quality. In this regard, time constraints and the lack
of empathy in dealing with patients because of these issues were stressed.
The more patients you see, the better. Medicine has become a lucrative activity. (Female,
Physician, 48 years)
At a certain point, I could not deal with. I could not work. I had to see too many patients. That
is inhumane. Firstly, the person is not well treated, does not have good life quality and leaves
without being cured. You remain with a feeling of anger and thinking, “Oh my God, I have not
done my job”. And you morally say “My God, where are we!” (Female, Physiotherapist, 30
years).
Acquire additional therapeutic resources.
Another motivation of health professionals was the wish to learn new therapeutic resources.
Participants pointed out the limitations of current drugs and physiotherapy treatments. They felt that
they were short of therapeutic resources, which generated a sense of frustration among them because.
Physicians considered their own activity confined to dispensing prescriptions and treating symptoms.
They found in acupuncture a way to actually help and feel fulfilled through their professional practice.
We physicians are here to serve people. Many times you have a patient, you are constantly
prescribing him medication, each week, and he keeps coming. Patients are treated but not
cured. There is medication for every condition but actually it doesn’t work much. For me, it
Health professionals’ perceptions to study and practise acupuncture
84
was if I would find a way out because I saw a possibility to actually help through acupuncture.
(Male, Physician, 47 years)
In any case, you learn different techniques. But even with that I saw I was short in many cases.
You have the feeling that you can go further but you don’t have enough knowledge. (Female,
Physiotherapist, 32 years)
Our participants turned to acupuncture in the expectation of avoiding medication and treating
patients in a holistic manner. They considered acupuncture a great finding in their professional life.
What most surprised me at the beginning was the quantity of drugs that people needed. I
thought “if there is a different treatment in which people don’t depend on pills...” That seemed
to me very important. (Female, Nurse, 57 years)
This was a great discovery. I thought, “This actually is a comprehensive treatment” (Female,
Physician, 58 years)
As noted above, participants highlighted the lack of side effects and contra-indications as an important
motivation in the practice of acupuncture. Moreover, they underlined the simplicity of acupuncture
implementation, which does not require a complex infrastructure and major economic investment.
I found something that did well without harming. (Female, Physician, 53 years)
The inefficacy of conventional treatments and their side effects in many of the diseases that I
treated was what pushed me to study different things [acupuncture and other natural
therapies]. To me, the ease of applying acupuncture in some places and the cost of more
expensive medications represented further reasons. (Male, Physician, 71 years)
The possibilities of Western medicine and acupuncture to co-exist and complement each other
motivated them to study and practice acupuncture. In this line, some participants maintained that
knowing both medicines gives them an “expanded view” of health. Participants explained that
acupuncture concepts may be transferred and understood in biomedical terms and vice versa. They
also emphasised that both approaches may complement each other.
We have reached such a melting point that we can raise hypothesis to work energetically
based on scientific knowledge because magically it is possible interpret science’s discoveries
in terms of energy. It is logical because in the end both are talking about the same. (…) We
collaborate with that [the conventional treatment]. If you are undergoing in vitro fertilization
treatment, we work to bring the maximum quantity of blood and energy to the reproductive
system. If you have any allergy, we activate the body’s defensive system in a way that the
antihistamine will be more effective and the intakes less. (Female, physician, 53 years)
Health professionals’ perceptions to study and practise acupuncture
85
Some participants received an acupuncture training based on the metaphysical assumptions of TCM
and others lacked of these conceptions, but all of them handled traditional concepts. Beyond the
personal way to combine both medicines of each participant, they highlighted the importance of
considering acupuncture as a medicine, not merely as a technique. They considered that practicing
acupuncture implies a holistic view of the patient and handling TCM concepts. They emphasised the
importance to conduct a complete Chinese medical history before diagnosing and establishing a
treatment.
With the time we realised that we are talking about similar things but with different language.
(...) One of the particular things of TCM is the holistic view of the person. I mean, you cannot
treat a headache with a formula. We get used to treat a headache with salicylic acid, a health
condition with a drug. Therefore, it does not matter what influence in this headache. You are
focused on remove pain… the Chinese say this is treating the branch but not the root of the
problem. You can do the same with acupuncture. There are points that are, say, analgesic.
But, usually a Chinese medical history should be done. (Male, physician, 58)
There are many courses and people who practise acupuncture handling few concepts. I think
this is very serious. I think it is not given enough importance to acupuncture which is a
medicine itself. I would not prescribe drugs because I do not know enough about it. I believe
this is a similar point. (Female, physiotherapist, 34 years)
Besides the controversies over acupuncture integration in Western medicine settings, participants
argued that it is important to use all the knowledge available in order to help patients.
I perfectly coexist with my two medicines. Furthermore, I don’t have the feeling that they are
mutually exclusive, but rather I think there are complementary. (...) I have seen many
acupuncturists saying that only acupuncture works in many conferences and things like that. I
said, well, if only acupuncture works, every health professional would be an acupuncturist.
But there are problems that acupuncture does not solve. And the same, there are things that
Western medicine does not cure. (Female, physician, 53 years)
I do not like call it [acupuncture] an alternative medicine. I always mention all of them as
complementary medicines because I think the more weapons we have in order to fight disease,
the better. (Female, physician, 63 years)
If I do not know it, I should have to learn it and study because we are in this world and it is
important to know Western medicine although we practise acupuncture. (Female, nurse, 67
years)
Health professionals’ perceptions to study and practise acupuncture
86
On the other hand, participants pointed out that all dimensions of human beings influence each other
in an interactive way. For example, emotions have an impact on the physical body and vice versa. In
this regard, some of them turned to acupuncture searching for new therapeutic resources which enable
them to treat different health problems at the same time in order to obtain better results.
I realised that other factors influence the musculoskeletal system problems, for example the
stress. Usually when we see a patient, there are many issues and more things that are going
on. For example, the person can suffer pressure at work and digestive problems due to the
prescribed medicine... What interested me was the possibility to handle also these matters to
obtain better results in the physiotherapy treatment. (Male, Physiotherapist, 40 years)
Efficacy and far-reaching healing potential of acupuncture.
Participants approached acupuncture through a variety of personal and professional experiences. The
curative potential of acupuncture was one of the most mentioned reasons to study and practise it.
Besides experimenting acupuncture by themselves, participants met its effectiveness thorough a family
member or even through patients. They found out not only the therapeutic value of acupuncture in the
treatment of physical conditions, but also in the treatment of emotional, psychological and spiritual
dimensions of people. Moreover, acupuncture was considered as a useful technique for the treatment
of chronic diseases or in cases in which no efficient therapeutic remedies exist.
I experienced a great difference once I have started and continued the [acupuncture]
treatment. It was effective. I improved a lot physically and emotionally. As I was studying
Medicine, I decided that it was a very useful and effective therapy. Since I had benefited from
it, I wanted that more people could also do it. (Male, Physician, 65 years)
I was also interested in acupuncture because I realised that the number of chronic patients are
rising. (Male, Nurse, 52 years)
Participants argued that acupuncture is relegated to treat incurable or difficult to cure diseases. In this
regard, they expressed a high degree of satisfaction, feeling proud and fulfilled.
I am very happy because, apart that it is my job, it is a huge satisfaction for me. I treat
pathologies that are incurable with the current treatments such as migraines, chronic
constipation, seasonal allergies, any type of pain, fibromyalgia, anxiety... Half of Spanish
workforce takes anxiolytics because of the circumstances in which they are living. This causes
the need for more and more because a person gets used to everything after a period of time.
The next drug has to be more powerful, the dose has to be higher and this is of course more
aggressive. (Male, Physician, 47 years)
Health professionals’ perceptions to study and practise acupuncture
87
People tried everything before seeking an acupuncture treatment. Acupuncture is the last
considered resource. That is why our satisfaction treating patients is double. (Male,
Physician, 58 years)
Another identified reason that brought participants to acupuncture, was the interest in the emotional,
social and spiritual dimensions that affect the illness process. As we noted above, they sought to
overcome the fragmented vision of human beings.
I realised that everything was related to emotions, to the ability to express and understand
why something happened to you. Chinese medicine also was in the same line. (Female, Nurse,
51 years)
I started to study acupuncture because it is very holistic. This covers all aspects: physical,
emotional, psychical… (Female, Nurse, 44 years).
People think that acupuncture works for the treatment of migraine, pains, arthrosis, rheumatic
problems… Very limited things… But actually any pathology can be treated by acupuncture.
The spiritual part which involves the ideals, vocations, expectations, dreams, affections, loves
and the searching for something else that each person has is also treatable by TCM.
Conventional medicine cannot treat it. TCM makes a change of perspective possible and there
are acupuncture points that facilitate this psychical change. (Female, Physician, 48 years).
Attraction to the acupuncture philosophy.
Some participants searched for something else in both their personal and professional lives. They
thought there might be immaterial aspects that influence the health beyond the physical dimension of
human beings. Therefore, they were attracted by the energetic vision of acupuncture.
I was just in this spiritual search, like “there is something more, I do not believe that life is
reduced to birth, growth, reproduction, death, work very hard to get money and nothing else”.
I was bored and I thought “This is not what I am looking for”. I started to look for other
things (…) I searched for the human spiritual dimension where the human beings are
something more”. (Female, Physician, 48 years)
I realised that something escaped me, something that I needed in both my personal and
professional life… deepening a bit more in the human being. I realised we are not only a
conglomerate of muscles and bones, but something else. (Female, Nurse, 62 years)
I agreed with this philosophy, because while working, we always ask ourselves questions.
When you are with a dying man, you always question your philosophy about life and death.
When you are with someone who has a pain or suddenly the person heals and nobody knows
Health professionals’ perceptions to study and practise acupuncture
88
how it has happened, you think, “Well, what has happened?” And you make questions and do
research in these kinds of things that are unconventional which do not fall into the statistics or
into the regular conventional medicine approach. (Male, Nurse, 52)
Others were attracted to TCM philosophy which, permeated by Taoist philosophy, constitutes the
foundation of acupuncture. In some cases, we found that participants considered the discovery of this
new approach as a revelation and embraced the TCM worldview. It proposes a style of life, an
anthropological model and an explanation of the health-illness process different from the Western
point of view.
I felt aligned with the totalitarian vision of the human being placed in the universe and the
vision transmitted by the [Chinese] tradition of what is the life, how must that be lived, why we
get sick, what we have to do to do not get sick and be immortal. This is what the Nei Jing says,
which is the basic text of Chinese tradition, in its first chapter. (Female, nurse, 67 years)
Furthermore, we found health professionals who embrace completely traditional Chinese philosophy
ethical proposes adopting a dedicated and altruist lifestyle to serve people through the practice and
teaching of TCM.
There are people who do not understand the style of life I adopted because it goes beyond
acupuncture. I think the different way of life is what people reject the most. In the world we
live, a life dedicated to serve others, without objectives, without seeking to earn money,
without have a salary, is not understandable. (Female, Nurse, 67 years)
At one point continuing with my PhD studies did not make sense to me because I saw clearly
that I was directing to TCM. The school [in which she studied] not only promotes a
profession, but a way to live the life. I saw it was a new way to take life. (Female, Physician,
53 years)
Participants underlined that the vision of TCM about the health-illness process attracted them because
it highlights the importance of the style of life. They were looking for an explanation that takes into
account the social, emotional and spiritual dimensions of human beings beyond the biomedical
paradigm.
The most attractive aspect to me was that there is not a patient-illness approach, but a person
involved in certain circumstances which have an impact… and then the pathology appears. It
is not a pathology that a person has, but a person with certain circumstances that lead to
something. (Female, Physiotherapist, 32 years)
The Chinese Medicine approach is very different. The human being is treated like a person
who develops a certain pathology or disease at some point. The person is seen as a whole and
Health professionals’ perceptions to study and practise acupuncture
89
it is questioned why this person with a certain style of life, has developed a disease. Then the
cirrhosis of this person is not the same as the cirrhosis of another person, although the disease
of cirrhosis may be the same. (Female, Physician, 48 years)
They emphasised the positive conception of human beings in which, in opposition to the Western
approach, the body is not imperfect or decadent. In this way, some participants expressed that Western
medicine normalises the experience of some pains and accepts certain health problems without going
into detail. Therefore, TCM’s optimistic approach prompted them to study acupuncture.
The doctor just said to the person “It is like this. Menstrual pains happen by default, you have
to experience them”. The same happens with headaches “We have already tried all drugs at
our disposal and there is no way to remove this ache, so you have to stand it”, or “You are
admitted to the hospital each time you suffer a headache”. I looked for other things and I
realised there were other alternatives. (Male, Nurse, 52 years)
From the Western medicine approach it is natural that human beings get sick and die. From
the TCM approach what is natural is that the human being is designed and kept healthy. It is
also planned that it has a long life, even being immortal. Those are two completely different
views: one is based in sickness and death and the other one in health and long life. (Female,
Physician, 48 years)
External influences (other professionals or recognised sources of information).
Participant motivations were also influenced by recognised sources of information or professionals,
that in their opinion, conferred credibility to acupuncture. This could happen as a result of a course, a
medical publication or the experience of other professionals.
I took a course on pain management here in the hospital. In the afternoon we had the surprise
of having Dr. Padilla among us [well-known physician and acupuncturist] who gave a talk
about pain. This man has founded the Nei Jing School and for many years, he had been
working with acupuncture building up a deep expertise. (Male, Nurse, 52 years)
She [another colleague] told me about her point of view, based on her experiences and on the
patients that she had treated. This seemed so curious and interesting to me, that I said “Well,
can’t I learn this?” (Female, Physician, 53 years)
In the medical journal Jano, I found an advertisement for acupuncture lessons given by Dr.
Van Nghi [well known physician and acupuncturist]. (Female, Physician, 63 years)
In some cases, the experience and life-view of other health professionals deeply marked our
participants who experienced a great change in their life conception.
Health professionals’ perceptions to study and practise acupuncture
90
The fact of entering the school and knowing the Master [well-known physician and
acupuncturist] changed my life completely. It changed every aspect of my life. I mean my
perception of everything. On a personal level, it made my life turn around. (Female, Physcian,
58 years)
Work-related motivations.
Participants expressed a disappointment with the dependence of health assistance on economical
issues linked to a deterioration of patients’ healthcare and their working conditions. In this line, they
stressed the time constraints in conventional settings. They saw in the practice of acupuncture a way to
achieve personal and professional fulfilment.
That is why it attracted me… this fulfilled the expectation I had when I was younger to help
others. I saw Western medicine was not… it was very focused on business and economic
benefits. (Female, Physician, 48 years)
Some participants looked for an independent labour and a different way to organise work and
healthcare assistance.
What I do not like of the NHS is time restrictions. The advantage I saw in having my own
acupuncture practice was that I could manage my time. I could decide to earn less money and
not having a boss who may tell me “This consultation is from a private insurance and you
must see 15 patients this afternoon”. If I consider that a patient needs 1 hour, it takes 1 hour.
(Female, Physician, 53 years)
Discussion
As far as we are concerned, it is the only study carried out to ascertain the motivations of health
professionals to study and practice acupuncture in Spain. It is also one of the few qualitative
investigations about this topic. We provide an explanation of this phenomenon in terms of health
professionals’ experiences and circumstances regarding their healthcare practice. Our results show that
health professionals were attracted to acupuncture because of the TCM worldview (a philosophical
approach) and therapeutic benefits of acupuncture (a practical approach). In consequence, our
participants chose between acupuncture training based on Chinese metaphysical worldview or
acupuncture approach lacking these assumptions, but all of them handled traditional concepts such as
Yin/Yang and the Five Element theories (1,131)
.
We found that motivations of health professionals to study and practise acupuncture are founded in a
search for a non-harmful medicine and a humanistic approach which means that the circumstances and
experiences of life became a central aspect influencing the health-illness process. This search is guided
Health professionals’ perceptions to study and practise acupuncture
91
by their vocation to help others. The dissatisfaction with their healthcare practice underlay this search
which is explained in a context of bureaucratisation, specialisation and capitalisation of medicine. In
this context, participants consider that human beings are reified and the medicine dehumanised. A
disappointment with the healing potential of the conventional treatments was also emphasised together
with the aggressiveness and side effects of certain conventional treatments. Additionally, the search
and attraction to another explanatory model of the illness-process, which takes the emotional,
psychological, social and spiritual dimensions of human beings into account, is pointed out. Health
professionals look for safe and effective therapeutic resources, a holistic approach for the health-
illness process, and a way to transcend the traditional division between disciplines.
Our study reveals the possibility to translate concepts between acupuncture and conventional medicine
as a key for their integration. Despite the difficulties of integrating both paradigms due to each
different worldview and the dominance of biomedicine paradigm explained by the devaluation,
subjugation, degradation and adaptation of non-Western knowledge by Western culture (31,91,113)
, our
results show the possibility to integrate acupuncture and biomedical concepts in order to collaborate
and improve the health. In this regard, it is appreciable the labour of professionals who investigate the
acupuncture tradition and establish bridges between both medicines (68,167,168)
. Although health
professionals in this research study and approach acupuncture from different views, all of them share
the perception of acupuncture as a complete medicine, not merely as a technique, and highlight the
importance of traditional Chinese concepts to practise acupuncture. Moreover, the results show how
philosophy and practice are interconnected because applying acupuncture treatments involves
embracing a holistic approach and TCM concepts (27)
. This does not support the Western medical
acupuncture tendency to avoid completely the traditional Chinese knowledge. This is not interested in
acupuncture diagnosis and consequently treatment. It uses formula of classical/recognised points to
treat similar conditions (56)
.
In line with previous studies, our findings showed that modern medicine can neglect the humane
dimension including the social and relational context, the personal development, as well as feelings
and emotions experienced by any person (83,89,92)
. The high-specialised healthcare assistance model
ruled by the biomedical paradigm results in a fragmentation and reification of human beings, which
are not considered as a whole person, but in terms of painful or sickness parts (92)
. The dysfunctional
consequences of the ongoing specialisation have been pointed out. The process of specialisation fails
to understand each phenomenon in a more inclusive context and it also impedes the collaboration
between disciplines (90)
. In this regard, our study reveals that acupuncture may be a useful approach to
achieve an integrative healthcare because it enables professionals to transcend the traditional division
between professionals and disciplines.
Health professionals’ perceptions to study and practise acupuncture
92
Moreover, the mechanistic vision of human beings in which the biomedical approach is based,
explained illness in terms of external toxic agents or malfunctioning of the organism (83)
(Goswami,
2008). Healthcare professionals seek to overcome this approach, which is consistent with other studies
that underline the motivation of health professionals to enrich their vision of health considering other
paradigms (165)
. In this concern, our results support other studies that relate the benefits of acupuncture
not just to improvements in physical symptoms, but also in the emotional state, quality of life and
well-being (70-72,74)
.
From the isolated and unsystematic experiences of acupuncture integration into the Spanish NHS, we
may deduce that other Western countries are more practical and open towards including different
paradigms at the institutional level. For example Germany, where 77% of the clinics dedicated to pain
management use acupuncture and the United States of America, where 20% of hospitals offer
complementary therapies (169,170)
. Furthermore, most of the participants of this study have practised
Western medicine among the NHS and acupuncture in the private sector. Generally, they do not
practice acupuncture in Western medicine settings but in acupuncture clinics. This may be explained
by the pre-eminence of the biomedical paradigm in the Spanish healthcare assistance. According to the
results of integrative medicine social research, we found that acupuncture practice in conventional
settings is relegated to cases in which Western medicine does not offer effective treatments (91,165)
.
Findings of this study are consistent with other studies, showing that there is a serious concern about
the adverse drug reactions and medical iatrogenesis among health professionals, as well as about the
limitations of medicine due to its subordination to economic interests (79,93,94,165)
. The lack of
acupuncture’s adverse effects and the lack of conventional and satisfactory treatments for some
conditions are also underlined as reasons for the interest of health professionals in acupuncture (37,52)
.
Nevertheless, participants highlight that the healing potential of acupuncture treatments goes beyond
these fields.
In contrast with certain studies, we do not find the demand of patients (141,148,149,154,157)
and the scientific
evidence (52)
as main reasons for the interest of the health professionals in acupuncture. All participants
highlight the importance of the effectiveness of acupuncture treatments, although it is perceived by
their own experience rather than by the scientific evidence (142)
.
Despite the fact that our results cannot be extrapolated to other realities with different characteristics
from the studied sample, the findings show an analytic wealth by including participants with different
demographic features. However, the context of bureaucratisation, specialisation and capitalisation of
medicine in which the analysed speeches became meaningful, is spread around the world (79,89,92)
.
Therefore, our findings may provide keys to improve the quality of healthcare not just for Spain. The
lack of critical approaches to acupuncture is another limit of our study. Nevertheless, it provides
constructive keys for the collaboration between acupuncture and Western medicine.
Health professionals’ perceptions to study and practise acupuncture
93
Our findings are relevant because they evidence the need to revise the Western Healthcare Assistance
Model and the biomedical paradigm. Participants emphasise the potential of acupuncture to complete
the fragmented and objectified view of human beings because it allows them to understand the
experiences and circumstances of life that influence the health-illness process. This establishes the
basis for a preventive medicine while providing non harmful therapeutic resources and establishing a
close health-professional relationship.
Motivations of health professionals to study and practise acupuncture highlight the need for further
research in order to find ways to facilitate and establish constructive dialogues between acupuncture
and conventional medicine. This may help to include the acupuncture humanistic approach and
therapeutic benefits into Western healthcare assistance. The relevance of overcoming the biomedical
approach in the Spanish clinic practice which emerged in this study implies an enrichment of everyday
practice with other perspectives and therapies while giving more emphasis to the life experiences and
circumstances of patients. It is also necessary to promote qualitative research on acupuncture
effectiveness to distinguish its holistic benefits (43)
. It would be helpful to conduct cost-effective
investigations in order to assess the economic benefits of acupuncture integration in Western
countries, which experience increases in chronic diseases related to Western life style and ageing
population. The impact of the economic crisis represents another problem, especially in Mediterranean
countries (97,171)
. Moreover, it would be interesting to address critical approaches of health
professionals to acupuncture practice.
Conclusion
The motivations of health professionals to study and practise acupuncture are based on a search for a
more humane medicine and therapeutic resources in a context of excessive specialisation,
bureaucratisation and capitalisation of Western medicine. A serious concern about adverse drug
reactions and medical iatrogenesis among health professionals, accompanies this search. Moreover,
acupuncture offers the possibility to transcend the biomedical paradigm, which produces a reification
of human beings, and improves the healthcare assistance by facilitating the cooperation between
disciplines and professions.
The results may contribute to the development of health programs considering the point of view of
health professionals practising acupuncture. The inclusion of lifestyle considerations as a feature of
acupuncture may be relevant for the everyday clinical practice and for the establishment of preventive
programs. It considers not only the conditions in which we live but also how we are living our lives
(perceptions and conceptions of events, expectations, vocations, ideals, affections, meanings we
ascribe to our world, and the emotional and cognitive state in which we experience the life).
94
95
MANUSCRITO III. Collaboration between acupuncture and
Western medicine: The perspective of health professionals trained
in acupuncture in Spain
La colaboración entre la acupuntura y la medicina occidental: La
perspectiva de profesionales sanitarios formados en acupuntura en España
96
Collaboration between acupuncture and Western medicine
97
Introduction
Acupuncture comes from Traditional Chinese Medicine (TCM) and is one of the most popular
complementary therapies in the Western world (40)
. It is based on a unitary conception of the human
being and provides holistic treatments (1,13)
. The insertion and manipulation of needles along specific
body points is often used in conjunction with other techniques such as moxibustion (heat stimulation),
acupressure (finger pressure), massage and lifestyle counselling (27)
.
The World Health Organization (WHO) recognised its effectiveness and recommends the inclusion of
acupuncture into the National Health Systems (NHS) in order to reduce the pressure of the high costs
of some conventional treatments. It is also contemplated in response to increasing chronic and
degenerative diseases (3,33,105)
.
Benefits of acupuncture in collaboration with conventional medicine have been evidenced in the
treatment of knee osteoarthritis, paediatric pain and cancer. These advantages were related to
improvements in physical and emotional symptoms, quality of life and physician-patient relationship.
Gain control over patient well-being, improvement of the immune system and reduction of drug side
effects were also reported (67,70-72,74)
.
Austria and Germany offer acupuncture for the treatment of some types of chronic pain by the state
regulated health insurance carriers (69,133)
. It is also currently available in the United Kingdom NHS
(134). In Germany, 77 per cent of clinics dedicated to pain management use this therapy, and in the
United States of America, 20 per cent of hospitals offer complementary therapies including
acupuncture (169,170)
.
In Spain, 7.4 per cent of the population use acupuncture due to its holistic and preventive approach,
the absence of side effects and the possibility to complement conventional treatments (45)
. In principle,
this therapy is not included in the service portfolio of the NHS, but there are some initiatives to
practise it in some hospitals and primary health care settings, particularly in the Andalusia
Autonomous Community (55)
. Regarding the regulatory framework, Spanish health centres registered
as Non-conventional Therapy Units may provide acupuncture treatments under the responsibility of a
physician (55)
.
The European Parliament considers acupuncture practitioners as a health workforce and highlights the
need to further research in acupuncture considering the perspectives of health providers (35,164)
. In this
regard, perceptions of Western health professionals practising acupuncture about its integration into
conventional medicine have been recently collected in a systematic review. Accordingly, the idea of
cooperation between both medicines is grounded in the perception of acupuncture as a complementary
therapy, which may supplement and add benefits to conventional treatments due to its holistic
Collaboration between acupuncture and Western medicine
98
approach. Health professionals highlight the need to improve knowledge of acupuncture among
healthcare providers in order to support the recommendations of acupuncture and facilitate
constructive dialogues between both medicines. They also highlight the importance of increasing the
investigation on acupuncture effectiveness considering also qualitative studies and outcome measures.
Reported barriers to integrate acupuncture into conventional medicine are the primacy of the
biomedical paradigm and the subordination of medicine to economic interests. Health professionals
particularly refer to acupuncture in the case of chronic diseases and in cases where a lack of efficacy
and contraindications for conventional treatments are observed (165)
.
Instead of a real integration between both medicines, acupuncture is generally adapted to the
conventional medicine practice and paradigm. The integration of acupuncture into the Western
healthcare practice tends to be problematic due to conceptual differences between the two approaches
and the dominance of the biomedical paradigm (147,113,114)
. Therefore, we refer to the collaboration in
order to reveal constructive and practical keys for an improvement of the healthcare assistance and
also to avoid giving more importance to Western medicine over acupuncture or vice versa.
Existing research in this area involves mainly North-western European countries. Further analysis of
health professionals’ perceptions of the collaboration between acupuncture and Western medicine may
reveal keys which can improve the quality of healthcare. This may also facilitate an effective and
universal healthcare assistance. It would be especially relevant in countries which experienced an
increase of chronic diseases such as Spain. This increase is the result of the Western lifestyle and the
absences of preventive healthcare resources (100,101,171)
.
The aim of this study was to understand the perceptions and conceptualisations of health professionals
training in both medicines, concerning the collaboration between acupuncture and Western medicine
in Spain.
Methods
Design
This article is part of a larger study which examines the collaboration of acupuncture and Western
medicine through the perspective of trained health professionals in both medicines. We used in-depth
interviews and Grounded Theory Dimensional Analysis to collect, analyse and interpret the data. This
inductive method was chosen to obtain a theoretical explanation by analysing health professionals’
conceptualisations. According to this methodology, data collection, analysis and theory stand in
reciprocal relationship with each other (116,121,166,)
. This allows the analysis of the data within the
context and the identification of concepts which explain the point of view of participants.
Collaboration between acupuncture and Western medicine
99
Sample and data collection
We conducted 27 in-depth interviews with health professionals who had studied and practised
acupuncture. In particular, we interviewed physicians, nurses and physiotherapists because they are
the health professionals most involved in this practice in Spain (55)
. A theoretical sampling guided the
sampling process in order to ensure that each new case was appropriate for providing new concepts
and clarifying relationships and logic among constructs. We also used the snowball technique to
triangulate this process. Interviews were audio-taped and transcribed verbatim for subsequent analysis.
The data collection process was guided by the analysis until the point of data saturation was reached,
meaning that no new analytical concepts emerge by broadening the sample (117)
.
The inclusion criteria was to sample physicians, nurses and physiotherapists trained in acupuncture
based on the World Health Organisation recommendations on basic training and safety in acupuncture
(112). We applied the recommendations of limited training for physicians (not less than 200 hours) to
nurses and physiotherapists because this allowed us to ensure that the conceptions of our participants
were well-founded. We selected informants of both sexes, different age groups and professional
backgrounds in order to provide the fullest possible information (Table 10). This maximised
opportunities to discover dissimilarities among concepts and to make denser categories in terms of
their properties and dimensions.
All participants received a detailed and complete explanation of the study and signed an informed
consent before conducting the interview, which took place in a quiet and private environment. We also
conducted eight telephone interviews. Each one started out with an open-ended question about their
professional and personal background before starting to study acupuncture. Through them, we could
gather real-life stories of participants which allowed us to understand their perceptions of the
collaboration between acupuncture and Western medicine. Although the interviewer (EGE) had a
topic list that could emerge openly throughout the interviews (Table 11), the intervention was kept to a
minimum in order to let participants express freely. The topic list was refined and guided by the
theoretical sampling. Interviews were conducted between April 2013 and July 2015 and lasted from 20
to 60 minutes. All of them were audio-taped using a digital recorder, rendered anonymously and
literally transcribed.
Data analysis
Data collection, analysis and interpretation were simultaneously undertaken in an interactive process,
meaning that each transcript was analysed before a subsequent interview took place in order to assess
the point where data saturation was reached (117)
. Transcripts were analysed line by line in order to
identify concepts that explained the motivations of health professionals to study and practise
acupuncture. We drew upon the qualitative software program Atlas.Ti 5.2.
Collaboration between acupuncture and Western medicine
100
The identified concepts were labelled and classified into categories using an open, axial and selective
coding process. We started by creating tentative labels for chunks of data based on the meaning that
emerged from it (open coding). After that, we identified relationships among the open codes (axial
coding). Finally, we figured out core variables that included a set of data and selectively coded any
data that related to them (selective coding). The constant comparison method was used for the
identification of the latent pattern in the perspective of participants. This also implied continually
going back and forth among the interview transcriptions, analytical memoranda and review literature.
Each code was continuously compared to all other codes in order to identify similarities, differences
and general patterns. Themes and categories gradually emerged from a minor level of abstraction to a
major one (116)
.
Based on this, we constructed categories which explained the motivations of health professionals to
study and practice acupuncture (Table 13).
Rigour
We carried out a variety of strategies in order to ensure the reliability and validity of the analysis such
as ensuring methodological coherence, sampling sufficiency, developing a dynamic relationship
between sampling, data collection and analysis, theoretical thinking, and theory development (118)
.
According to the aim of the study, we chose a methodological approach (Grounded Theory) and a data
collection technique (in-depth interviews) that allowed us to understand the phenomenon (health
professionals’ perceptions of the collaboration between acupuncture and Western medicine) in the
light of the meanings attributed by social actors. Through them, we could also understand the context,
emotions, actions/interactions that influence their conceptualisations. Sampling continued until the
point of data saturation was reached. Interviews were literally transcribed and analysed in the full
context. We examined the transcriptions line by line and interpreted them one by one. The analysis
was led by the constant comparative method and an interactive relationship between data, analysis and
interpretation (118)
.
We used data and investigator triangulation techniques to increase the validity and to mitigate biases
in the study. Sample included participants of different ages, genders and backgrounds. Theoretical
sampling was also triangulated using snowball sampling techniques. Data was analysed independently
and then agreed by two researchers from different disciplines (EGE: Sociology, BRM: Nursing and
Anthropology) who inspected the phenomenon from multiple perspectives. Any disagreement was
referred to a third researcher (VMV: Medicine).
Collaboration between acupuncture and Western medicine
101
Results
Participants of this study received acupuncture training based on TCM medicine concepts such as Yin-
Yang, Zang-Fu and Five Elements theories. Some of them also embraced metaphysical,
anthropological and ethical assumptions of TCM, which are permeated by Taoism Philosophy.
Participants used to combine acupuncture treatments with other TCM resorts such as massage,
moxibustion, acupressure, Qi Qong and counseling. Some participants complemented their practice
with other natural therapies such as homeopathy, neural therapy, Reiki and Bach flowers. However,
these therapies were generally applied on the basis of acupuncture diagnosis.
Four main categories emerged from the analysis of health professionals’ perceptions of collaboration
between acupuncture and Western medicine: styles of practice, benefits of the collaboration between
acupuncture and conventional medicine, key factors for the cooperation and barriers to practise
acupuncture in conventional healthcare settings. For a better understanding, we include the most
representative participants’ verbalisations after translating them from Spanish to English. We provide
an accurate translation of the quotations respecting the original meaning rather than a literal
translation. Translations were corroborated by two correctors of English language. We also include a
table with the emergent themes, categories and codes (Table 13).
Styles of practice
We identified three types of practice depending on how health professionals combine both medicines
in their professional practice.
Practice in private acupuncture centres. Acupuncture represented the main activity for health
professionals practising in this context, who in general did not use conventional medicine treatments.
Most of our participants fall into this category. They considered that acupuncture approach gives them
a greater understanding of the health-illness process and the possibility to avoid the aggressiveness of
conventional medicine treatments. Nevertheless, they used Western diagnostic tests to support
acupuncture diagnosis and recommended conventional treatments if necessary.
When you completely understand TCM, you see things clearer than from a Western medicine
perspective. I always say, for example, if there is a urinary tract infection, we do the
[acupuncture] treatment but if it still hurts, “you must go to the doctor to get the prescription
for the medicine you need” because although I can, I do not use to prescribe. (Female,
physician, 61 years)
I have found in TCM a resource to palliate, improve, relieve, and above all avoid harm, which
basically was what I rejected from Western medicine. (Female, physician, 53 years)
Collaboration between acupuncture and Western medicine
102
Practice in conventional healthcare centres. In this case, participants’ main activity was the
conventional medicine but they also included acupuncture treatments when Western treatments were
not available or did not produce satisfactory results. Therefore, acupuncture was considered as a last
resort in line with the predominance of the biomedical approach.
We receive patients referred from the pain control unit, with rare pathologies, allergic
processes. They asked if I can help (...). Problems that were very long-standing and have
become chronic (Male, Physician, 58 years)
I propose acupuncture to patients with whom I have tried all type of physiotherapy treatments
that I know. They do not improve with them, so I suggest acupuncture (Female,
physiotherapist, 42 years)
In this context, we also found out a particular but marginal way to practise among nurses and
physiotherapists as a result of biomedicine and medical dominance. This involved the disguised
acupressure practice in healthcare assistance in order to avoid conflicts with physicians and managers
who were not open to acupuncture practice.
I cannot practise acupuncture in my workplace. As I cannot use needles there or offer this
treatment openly, I slyly massage some acupoints. (Female, nurse, 53 years)
Practice in integrative medicine centres. Few participants worked in centres with an integrative
perspective of medicine which implied the combination of biomedicine and acupuncture treatments. In
this case, health professionals, especially physiotherapists, combined conventional and acupuncture
treatments at the same time or chose between the two, depending on what was considered most
appropriated for the patient. They did not consider one approach more important than the other.
We apply acupuncture instead of other analgesic physiotherapy treatments as one part of the
integration. But in other patients, who experience more problems apart of muscular ones, such
as digestive disorders, sleep disturbances, stress, and anxiety, physiotherapy would become a
supportive technique and the principal one would be acupuncture. I apply treatments in a
consistent and flexible manner (Male, physiotherapist, 40 years)
Benefits of the collaboration between acupuncture and conventional medicine.
Participants perceived acupuncture as a complementary medicine because it may supplement and
improve the approach to health-illness process and treatments of Western medicine. In this line,
they highlighted the conception of acupuncture as an aid element due to its efficacy and far-reaching
potential. The vision of human beings and the health-illness process in which acupuncture is founded
was also pointed out.
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103
The advantages of acupuncture collaboration with conventional medicine were related to the
improvement in quality of life, decrease of medication and aggressive treatments, avoidance of
intoxications in polymedicated patients and enhancement of conventional treatments.
I consider acupuncture as a complementary treatment because it also enhances drug
treatments. We can decrease medication dosage and sometimes even stop it because it is no
longer needed. (Male, physician, 65 years)
We have been able to explain Western concepts from an energetic approach and give them an
energetic focus. Thus, we can cooperate in such a way that the patient is able to better endure
chemotherapy by improving body’s defence. We can support and we work in this way (…) “If
you are receiving an in vitro treatment, we work to improve the quantity of blood and energy
available in your reproductive system. If you have an allergy, we can work on your immune
system in such a way that antihistamines are more effective and you can reduce the dosage.
(Female, physician, 53 years)
As noted above, participants appreciated the integrated conceptual frame and the therapeutic resources
offered by acupuncture. In this regard, they considered acupuncture not only as a technique but as a
complete medicine able to treat any condition.
The WHO has developed a list of pathologies that are able to be treated with acupuncture:
headache, pain, arthrosis, rheumatic problems… very limited things… and nothing else. But
actually all pathologies are able to be treated with acupuncture. (Female, physician, 48 years)
It is the only medicine that existed in China before, so everything can be treated by
acupuncture. (Female, physician, 63 years)
Physiotherapists emphasised the advantages of joining the physical therapy and acupuncture
treatments, especially in rehabilitation programs and in neurological conditions, whilst nurses pointed
out the benefits of including acupuncture treatments into the day to day healthcare practice such as
preventing complications and providing relieve.
In the case of neurological problems, I am referring to motion exercises, body exercises. We
obtain a faster body response if we apply both treatments [conventional physiotherapy and
acupuncture treatments]. (Female, physiotherapist, 32 years)
You can use them [acupuncture and other complementary therapies] individually in patients
with headache, vomiting, nausea. You can always use them in this kind of situations. I have
always done it. When it is said “apply medicine if pain”, I always use other techniques and
when the pain is relieved I do not use medicines. (Male, nurse, 48 years)
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In addition, participants pointed out that acupuncture approach gives them a humanistic and holistic
vision of the health-illness process which explains and emphasises the impact of lifestyles and
people’s life experiences on the disease process. This vision allows them to consider the sickness as a
process which is influenced by the whole life experience of the person. Therefore, they felt more able
to counsel and help patients to become aware of the importance of conditions and perceptions of life
for the health.
I am interested in the person, not in the sickness itself. This is one of the differences: it is a
more global vision of the person, more humanistic. I have to contemplate the life history of the
person to understand how the disease has been developed. It is not just about applying some
needles, but also about giving another vision of the process, helping the person to see a
possible reason of the disease, what he/she can do to recover or to change the style of life. I
mean, it is not only about using some acupoints or some drugs, but about what the person can
do to rethink his/her way of life or to recover the health. (Female, physician, 48 years)
Participants considered that these aspects were of key importance to the doctor-patient relationship. In
this regard, participants expressed that this relationship has been deteriorated because conventional
medicine has developed a technological way to approach patients. The contact with the patient was
highlighted from the TCM perspective, which includes listening to the symptoms, how the patient
feels, how the disease appeared, observation of the person (complexion, tongue, pulse, face,
expression) and palpation of the body, which was also the old way to conduct a diagnosis in the
conventional medicine.
At the end, we do with TCM the same as physicians did when all of these devises or this
technology didn’t exist yet. They had to do a diagnosis based on what they saw, taught and
asked. Well, TCM keep doing it. In my opinion, TCM makes you go back to being a real
physician in the sense that you must have contact, spend more time, and touch the patient.
(Male, physician, 58 years)
Participants explained that the contributions of acupuncture go much further than its therapeutic
resources and holistic approach. They perceived the philosophy and the way to understand life and
human beings in which acupuncture is founded as a healing element. The healing resources proposed
by this philosophy for the personal development and healing such as Qi Qong, meditation, breathing
exercises, prayer and creative activities were also pointed out.
The teaching transmitted by the Chinese tradition is actually much broader. It requires a lot of
individual and spiritual work. It promotes many other things and healing resources at the
service of the health and the immortality of the being, such as any other creative activity:
theatre, singing, dance, music, painting, writing, poems, cooking, plants, minerals... any
Collaboration between acupuncture and Western medicine
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available resource can be a healing resource. Everything will depend on the intention with
which it is used. (Female, nurse, 67)
Participants considered that taking both approaches is very enriching and results in an amplification of
their knowledge which is very useful to assess and advise people they treat.
When I see a patient I see the Western and the Eastern part and, therefore, I expand the
perspective to guide the patient a little bit more. They ask a lot, “Well, do you think I need a
surgery because that is what they told me”. So I can guide them: “We can wait a bit” or
“Let’s see” or “Yes, it is better that you have surgery”. (Female, physician, 48 years)
Chinese medicine used to have a holistic perception of patients and could relate all aspects. It
could refer different pathologies to the climate, emotions... This is a much more complete
approach. Chine medicine could understand why a patient becomes ill. University education
just gives us a specialized view of the patient and from this point of view, it is impossible to
understand why the patient became sick. (Male, nurse, 48 years)
Key factors for the cooperation
The recognition of the complementarities between acupuncture and biomedicine was pointed out
as a relevant key factor for the cooperation. In this line, participants conceived acupuncture as an
updated medicine. New concepts of science and medicine could be translated into acupuncture
terminology. They emphasised that it is still possible to understand new illness processes and deduce
treatments from its theoretical frame.
We have reached one point in which we can raise the hypothesis to work energetically. This is
based on scientific knowledge because surprisingly it is possible to interpret science’s
discoveries in terms of energy. This has led a research framework in our centre in which we
assimilate scientific knowledge and give it an energetic focus. (Female, physician, 53 years)
When we move one part of the body, everything moves because everything is interconnected.
The key idea is that the Qi is everywhere in the body, which allows to link Eastern energetic
ideas to Western mechanical ones. It is better when I merge both ideas from West and East.
They make a joint, one part and another part. (Male, physiotherapist, 50 years)
There are a lot of publications founded in traditional books or sources, in ancient ones (...)
and based on these, more and more research work is being conducted in order to find out
where acupuncture works at all levels. (Male, physicians, 65 years)
Although participants contemplate acupuncture as an alternative option in cases in which conventional
treatments are not effective or do not exist, they refused the terminology “alternative” and prefer
Collaboration between acupuncture and Western medicine
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“complementary”. They conceived the last one more inclusive because it expresses the possibility to
joint efforts aimed to improve the health.
When there are not more Western medicine treatments, you think in other options. There are
very complicated situations such as tumours or autoimmune pathologies where drugs have
many side effects and you do not see any other way out. (Male, physician, 55 years)
I do not like to call it [acupuncture] an alternative medicine. I always mention all of them as
complementary medicines because I think the more weapons we have in order to fight disease,
the better. (Female, physician, 63 years)
In this concern, participants pointed out that acupuncture treatments should be implemented on the
basis of TCM theories and diagnosis in order to achieve a real cooperation and get better results.
Completing a Chinese clinical history was also required for an effective collaboration between both
medicines.
One of the particular things of TCM is the holistic view of the person. I mean, you cannot treat
a headache with a formula. We get used to treat a headache with salicylic acid, a health
condition with a drug. Therefore, it does not matter what influences this headache. You are
focused on removing the pain… Chinese people say this is treating the branch but not the root
of the problem. You can do the same with acupuncture. There are points that are analgesic.
But, usually a Chinese medical history should be done. To complete a diagnosis I have to ask
about every feature of each symptom because each one explains something about the problem.
(Male, physician, 58 years)
Another important point was related to the conventional healthcare assistance practice. The
existence of interdisciplinary work teams and clinical sessions was pointed out as facilitators for the
collaboration between acupuncture and Western medicine, because they allow health professionals to
joint knowledge and efforts. The inclusion of a social approach into the health assistance was also
identified as an enabling factor for their cooperation. They considered that the collaboration would
have more sense when health professionals include a global approach to the patient, considering all
human dimensions that influence in the health-illness process (physical, emotional, social,
psychological and spiritual).
We work in an interdisciplinary team where there is a physiotherapist, a health visitor, a
nurse and a geriatrician. That is what I like the most of my work, I do not depend on an
orthopaedic specialist, I depend on a geriatrician. The physician of the nursing home is
geriatrician and a geriatrician has a more global vision of the person than an orthopaedic
surgeon, who divides by specialities or anatomic parts. (Female, physiotherapist, 42 years)
Collaboration between acupuncture and Western medicine
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Participants perceived that a culture of acupuncture is emerging gradually as a result of experiences
of acupuncture implementation into conventional settings, which facilitate the collaboration between
both medicines in conjunction with the increment of acupuncture knowledge among health
professionals.
At some level, we are creating a culture of acupuncture. The pain unit consults us in order to
use this resource. The physiotherapy department refer us to certain pathologies. Some
colleagues come to be treated. (Male, physician, 58 years)
Participants also emphasised the importance of the recognition of acupuncture at institutional level.
In this line, the evidence provided by clinical outcomes and the fact that this medicine has been
maintained over time, were mentioned as strong supports for acupuncture practising.
There must be a reason why this way of work and help it is maintained and why it is still useful
and keeps answering now, 7000 or 8000 years since we know there are vestiges of this
practice. It is neither due to what acupuncturists of twentieth century say. There have been
many generations not only of acupuncturists but of transmitters of this vision of life, human
being, illness and way to heal. (Female, nurse, 67 years)
The public demand was another identified aspect for the inclusion of acupuncture into conventional
medicine as well as the political will.
Public pressure is important because the demand is increasing in a geometric proportion
(Male, physician, 65 years)
Participants mentioned the importance of some international initiatives for acupuncture recognition
such as “The WHO Traditional Medicine Strategy: 2014-2023” and the inclusion of acupuncture in the
list of Intangible Cultural Heritage of the United Nations Educational, Scientific and Cultural
Organization (UNESCO).
The WHO published a report last year saying that the state members of the WHO have to
promote natural therapies and incorporate them into the health legislation. Thus, there is a
big support to include this kind of therapies into public health services. (Male, nurse, 48
years)
Barriers to practise acupuncture into conventional healthcare settings
Participants perceived that the pre-eminence of biomedical paradigm limits the cooperation between
acupuncture and biomedicine. As noted above, they considered that acupuncture is underestimated in
mainstream medicine because its healing potential is not valued and is diminished. They pointed out
that the trivialisation of acupuncture is evidenced by the existing stereotypes and prejudices in this
Collaboration between acupuncture and Western medicine
108
field such as the conception of acupuncture as a beauty treatment or a witchcraft practice. They
thought that this evidence the lack of acupuncture knowledge among health professionals.
People ask you trivial things, “look I have here spare tires here, do you think they would be
gone if you put me some needles?” (Female, physician, 58 years)
Well, the conference was a complete success. Only 8 out of 200 people stayed in the room. I
mean, (he laughed) only the people who were interested in this topic, in this way to talk, in this
way to approach, stayed there. The rest were typical, let’s say, conventional physicians and
nurses. All these things seemed to them as witchcraft. (Male, nurse, 52 years)
Participants considered that the dominance of the mechanistic and materialistic vision results in a
rejection of the energetic and spiritual approach of humans beings. In this regard, the consideration of
acupuncture as a non scientific medicine was interpreted as another barrier. However, participants
emphasised that acupuncture is founded in the experience, supported by theoretical knowledge and
empirically verifiable.
Medical professionals are educated in a different way, everything they have seen is highly
specialised, very concrete, considered from a materialistic point of view, and they scarcely
study the importance of the emotional aspect. So they have to see results of what you do first.
(Male, nurse, 48 years)
When you deeply study it [acupuncture] and see that it has a structure, a logic, a methodology
and it is fairly robust, you change your mind. Many meta-analysis, important studies in which
is evidenced the efficacy of acupuncture in a range of pathologies emerge, although this is not
on the agenda of most of physicians. (Male, physician, 58 years)
On the other hand, participants experienced difficulties to implement acupuncture treatments in
conventional settings due to institutional barriers, such as the inflexible work organisation and the
lack of institutional support. They explained that the highly specialised and bureaucratised context, in
which healthcare assistance is immersed, impedes the collaboration between both medicines. They
considered that this is evidenced by time constraints and the rigidity of protocols which make the
implementation of non-conventional treatments difficult. The highly specialised development of the
biomedicine and the healthcare assistance were seen as obstacles to adopt a holistic approach because
they avoid the global conception of human beings.
In this public outpatient centre, there was no possibility [to acupuncture practice] because
there was neither time nor other options. You have limited time of consultation which is
already stipulated. (Female, physician, 58 years)
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109
Each specialist is dedicated to his/her area but where do you put all together? (Female, nurse,
57 years)
In this line, participants explained that the lack of time to achieve clinical sessions hinders the
communication among health professionals, which impedes the continuity of acupuncture treatments.
They also considered that the highly hierarchical organisation of conventional settings interfere in this
communication.
I have to register my treatments and the nurse who works after me does not understand what I
have done. There is not continuity and communication. (Male, nurse, 47 years)
Therefore, they perceived their own activity reduced to dispensing drugs and treating symptoms,
mentioning the economic interests of pharmaceutical companies as barriers for the inclusion of
acupuncture into Western societies.
I realised that I was a technocrat. I applied some techniques which basically consisted of
implementing the pharmacological treatments prescribed by physicians. I actually could do
little for the patient. (Male, nurse, 48 years)
I would like that it [acupuncture] could be applied, but a change in the mentality of doctors,
legislation, politic concepts, economic interest of pharmaceuticals and prescribing of
medicaments is needed. (Female, physiotherapist, 34 years)
Moreover, some participants perceived that acupuncture suffers a closure in mainstream medicine
because some health professionals conceive it as a threat for their activity.
Sometimes there are also problems with Eastern medicine because it seems they are stealing
your job, but I say, “This is not necessary, we can work together in order to make things
better. (Female, physiotherapist, 32 years)
The integration has been a very slowly and difficult thing. There has been a lot of opposition
and many detractors in the medical field due to a lack of knowledge and competition. We have
been treated very contemptuously. (Male, physician, 65 years)
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Table 13. Perceptions of health professionals of the collaboration between acupuncture and Western medicine
Categories Subcategories Codes
Styles of
practice
Practice in private
acupuncture private
Acupuncture as a principal practice
Use of Western diagnosis tests to support acupuncture diagnosis
Practice in conventional
healthcare centres
Acupuncture as a supportive Western medicine therapy Acupuncture as a last resort
Acupuncture as disguised practice
Practice in integrative
medicine centres
Combination of biomedicine and acupuncture treatments
Equal consideration of both medicines
Benefits of the
collaboration
between
acupuncture
and
conventional
medicine
Acupuncture
supplements and
improves Western
medicine treatments
Potential treatment for any condition Improvement of conventional treatments
Treatment of drugs side effects
Treatment of conventional procedures side effects (diagnosis tests, surgical operations)
Treatment of pain
Treatment of chronic diseases
Treatment of psychosomatic illnesses
Treatment of rare diseases
Treatment of psychological disturbances Treatment of emotional sphere
Treatment of functional diseases
Amplification of health professionals knowledge Improvements in patients’ quality of life
Holistic treatment
Contribution of holistic
and humanistic vision of
acupuncture to
conventional medicine
Energetic vision Treatment from the origin of the disease
Further consideration of the impact of the lifestyle on the health/illness
process Further consideration of the impact of life experience on the health/illness
process
Improvement in the health professional-patient relationship
Further acupuncture
healing proposals
Personal development proposals (Qi Qong, meditation, breathing exercises, prayer and creative activities)
Lifestyle changes
Key factors
for the
cooperation
Recognition of the
complementarities
between acupuncture
and biomedicine
Updated medicine
Translation of concepts between both medicines
Consideration of acupuncture as a complete medicine
Inclusion of TCM theories, diagnosis and clinical history in order to achieve a real cooperation
Consideration of acupuncture as a complementary medicine instead of an
alternative one
Changes in conventional
healthcare assistance
practice
Inclusion of interdisciplinary work teams Implementation of clinical sessions
Social approach to patients
Global approach to patients
Creation of “culture of
acupuncture”
Improvement of health professionals knowledge in acupuncture
Conduction of experiences in acupuncture integration
Institutional factors International initiatives for acupuncture recognition
Political will Recognition of acupuncture (scientific, historical and empirical evidence)
Increase of public demand for acupuncture
Barriers to
practice
acupuncture
in
conventional
healthcare
settings
Pre-eminence of
biomedical paradigm
Lack of acupuncture knowledge among health professionals
Consideration of acupuncture as a non-scientific medicine
Underestimation of the acupuncture healing potential
Impossibility of acupuncture treatment continuity
Institutional barriers Lack of clinical sessions Hierarchical organisation of healthcare settings
Lack of institutional support and recognition
Rigidity of healthcare work organisation (high medical specialisation, time constraints and inflexible protocols)
Economic interest of pharmaceutical companies
Personal barriers Conception of acupuncture as a threaten activity among some physicians
Collaboration between acupuncture and Western medicine
111
Discussion
As far as we are concerned, this is the first study which examines the perceptions of health
professionals regarding the collaboration between acupuncture and Western medicine in Spain. It is
also one of the few qualitative studies about this topic. Our findings reveal that health professionals
trained in both medicines consider that taking both approaches results in amplification of health
professionals’ knowledge and in improvement of the healthcare assistance. In this regard, acupuncture
was valued not only because of its therapeutic resources but also for its proposals for personal
development and healing such as lifestyle recommendations, Qi Qong, meditation, breathing
exercises, prayer, and creative activities. Barriers to acupuncture and Western medicine collaboration
were related to the dominance of the biomedicine paradigm. However, acupuncture has been revealed
as a new avenue of cooperation between professionals and a way to transcend the traditional division
between disciplines.
We consider that the most relevant key factors for the collaboration between both medicines found out
by our study are the capacity of acupuncture to be updated and the possibility to transfer concepts
between both visions. In this regard, the labour of professionals who investigate the acupuncture
tradition and establish treatments for current and new diseases based in this medicine is appreciable
(27,68,167,168). This shows how acupuncture is not stagnant and represents a vast source of knowledge.
We emphasise that participants do not refuse or underestimate the value of biomedicine and point out
a way to supply, improve and transcend the limits of the Western healthcare assistance.
Barriers to collaboration between both medicines revealed by this study are consistent with other
researches, showing that the pre-eminence of the biomedical paradigm and the inflexibility of Western
medicine settings results in an impossibility to apply no conventional treatments (,113,114,146)
. The lack of
acupuncture knowledge, communication between professionals, teamwork and holistic approach are
also relevant factors (165)
. Our study reveals that acupuncture represents a new avenue of cooperation
between professionals and a way to transcend the traditional division between disciplines. This is
explained by its holistic approach and its capacity to involve professionals in all of the stages of the
healthcare assistance including diagnosis, treatment and care.
Conventional medicine and biomedical paradigm are under intense critical spotlight because they do
not provide answers to many of the health-illness processes experienced by the population. The
serious concern about drugs side effects and the subordination of medicine to economic interests also
constitutes relevant points (31,79,83,93,94)
. In line with previous studies, results of our study draw attention
to the fragmentised vision of human beings in which Western medicine is based, which is evidenced
by the vast medical specialisation. This is founded to be failed for the understanding of the health-
illness process because it does not address all aspects that influence the health (90,92,172)
. Furthermore,
the mechanistic and materialistic vision of health, which explains the illness in terms of external toxic
Collaboration between acupuncture and Western medicine
112
agents or malfunctioning of the organism, reduces the activity of health professionals to dispensing
drugs and treating symptoms (83,92)
.
Participants of this study value acupuncture not only as a technique but as a complete medicine which
does not support the tendency of Western medical acupuncture to ignore TCM physiology,
physiopathology and diagnosis (56)
. In contrasts, health acupuncture knowledgeable professionals
highlight that the unified conception of human beings of acupuncture may transcend the fragmented
vision of the biomedical approach providing consistent holistic treatments. This has been pointed out
previously (173)
. Acupuncture approach may also restore the importance of the lifestyle and the way in
which we are living the life including our conceptions and perceptions of events, expectations,
vocations, ideals, affections, meanings we ascribe to our world and the emotional and cognitive state
in which each individual experiences the life (1,13)
. These aspects establish the basis for a preventive
approach. Furthermore, as a recent study supports, acupuncture represents a no-harmful avenue of
research (96)
.
Although acupuncture is considered by the WHO and the European Commission as a relevant resource
to provide healthcare in countries that experience economical problems and increase of chronic
diseases (33,3,164)
, complementary therapies are generally not included in the university curricula of
health professionals in Spain (173)
. There are Spanish health professionals who already have acquired
this knowledge in private institutions and academic postgraduate courses, but they are not fully
applying acupuncture treatments because many healthcare settings do not allow them. Therefore, the
population is missing its benefits (55)
.
Despite of the fact that our results cannot be extrapolated to other realities with different
characteristics from the studied sample, the findings show an analytic wealth by including participants
with different demographic features. As biomedicine and the Western organisation of the healthcare
assistance are spread around the world (79,89,92)
our results may provide key factors to improve the
quality of healthcare not just in Spain. Another limit of the study is the lack of critical approaches to
acupuncture collaboration with biomedicine. Nevertheless, these findings provide constructive critics
to the current situation of Western healthcare assistance, especially regarding Spain.
Results of this study pointed out the relevance to further qualitative research on acupuncture
effectiveness, in order to improve healthcare assistance. It is also necessary to enrich the point of view
of health professional about the health-illness process through other paradigms. Conventional
healthcare institutions should also reveal the knowledge and capacities of their health professionals,
which may allow them to make use of the resources at its disposal.
Collaboration between acupuncture and Western medicine
113
Conclusion
Barriers to acupuncture and Western medicine collaboration are related to the dominance of
biomedicine paradigm and the rigidity of healthcare organisation. However, our study reveals the
possibility to build bridges between both medicines. Science and biomedicine can be understood and
translate into acupuncture concepts. Therefore, acupuncture is not stagnant and represents a vast
source of knowledge and research. It also proposes sources for personal development and healing such
as meditation, breathing exercises, prayer, lifestyle recommendations and creative activities.
Collaboration of acupuncture and Western medicine may contribute to improve the quality of the
healthcare assistance providing new ways of cooperation between professionals and healing resources.
Acupuncture is considered not only as a technique but as a complete medicine. It is a valuable
resource to transcend the biomedical paradigm and improve the healthcare assistance due to the
unified conception of human beings and its holistic treatments.
114
115
ABSTRACTS OF MANUSCRIPTS (RESUMEN DE
LOS MANUSCRITOS)
116
Abstract
117
Manuscript I
Integration of acupuncture into conventional medicine from health professionals’
perspective: A thematic synthesis of qualitative studies.
Abstract
Introduction: Acupuncture is a prominent Complementary Medicine. Although health professionals’
conceptions of acupuncture may affect its utilisation and integration within conventional medicine,
these aspects have not been well studied. The aim of this review was to analyse the integration of
acupuncture into conventional medicine from the perspective of health professionals.
Methods: We conducted a systematic review and a thematic synthesis of qualitative studies that
analysed the integration of acupuncture into conventional medicine grounded in participants’
perspectives. A systematic search was undertaken in PubMed, Web of Science, Cochrane Library
Plus, Scopus and CINAHL.
Results: This review included 18 articles: 6 analysed the viewpoint of physicians, 3 of nurses and 9
comprised different health-related professionals. Most of these studies included healthcare
professionals practising acupuncture and took place in sites where the relation between acupuncture
and biomedicine is favourable. The most used research techniques were convenience sampling, semi-
structured interviews and interpretative approach. The holistic approach of acupuncture and its lack of
adverse effects were highlighted by the analysed studies. This led to health professionals encouraging
its integration into conventional medicine. The main obstacles perceived for the integration were lack
of knowledge and institutional support. In general, acupuncture has been adapted to the biomedical
model (often practiced in an unsystematic and individual manner), and it is conceived as a supplement
of Western medicine.
Conclusions: “Working together” and overcoming the biomedical model are recognised by the
participants as key conditions for successful integration of acupuncture.
Resumen
118
Manuscrito I
Perspectiva de los profesionales sanitarios sobre la integración de la acupuntura en la
medicina convencional: Una síntesis temática de estudios cualitativos.
Resumen
Introducción: Dentro de las medicinas complementarias, la acupuntura es una de las más destacadas.
Aunque la opinión de los profesionales sanitarios sobre la acupuntura puede influir en su utilización e
integración en la medicina convencional, no se ha indagado en sus puntos de vista. El objetivo de esta
revisión fue analizar la integración de la acupuntura en la medicina occidental desde la perspectiva de
los profesionales sanitarios.
Metodología: A través de una revisión sistemática llevada a cabo en las bases de datos de PubMed,
Web of Science, Cochrane Library Plus, Scopus and CINAHL, se identificaron 18 artículos que
analizaban la integración de la acupuntura desde el punto de vista de distintos profesionales sanitarios.
Muchos de estos estudios incluyeron la perspectiva de profesionales sanitarios que practicaban la
acupuntura. Predominó el muestreo de conveniencia, la aproximación metodológica interpretativa y
las entrevistas semi-estructuradas.
Resultados: La acupuntura fue concebida como un complemento para la medicina occidental. La
acupuntura se integra en la práctica asistencial convencional a partir de su adaptación al modelo
biomédico predominante, de forma asistemática y a través de iniciativas individuales. Las aportaciones
de la acupuntura a la medicina convencional más destacadas fueron su enfoque holístico y la ausencia
de efectos secundarios. La falta de conocimiento y apoyo institucional fueron percibidos como los
principales obstáculos para su práctica.
Discusión: Las claves para una efectiva integración de la acupuntura se basan en el trabajo en equipo
entre profesionales y la superación del modelo biomédico.
Abstract
119
Manuscript II
What led health professionals to study and practise acupuncture in Spain?
Abstract
Introduction: Acupuncture is the widest spread practice of Traditional Chinese Medicine in the
Western world. This confers special relevance to the experiences and circumstances of life to explain
the health-illness process. Recent research has reported an increasing interest of Western health
professionals in its practice. The aim of this study was to map and understand the motivations of
health professionals to study and practise acupuncture in Spain.
Methods: A total of 27 in-depth interviews were conducted with Spanish health professionals training
in and practising acupuncture. Participants were selected following a theoretical sampling. Grounded
Theory Dimensional Analysis guided this research in order to obtain a theoretical explanation of the
motivations of health professionals to study and practise acupuncture.
Results: Their motivations were focused on six categories: humanisation of medicine, acquiring
additional therapeutic resources, efficacy and far-reaching healing potential of acupuncture, attraction
to acupuncture philosophy, external influences (other professionals and relevant sources of
information) and work-related motivations.
Conclusions: Our results show that health professionals were attracted to acupuncture because of the
TCM worldview (a philosophical approach) and therapeutic benefits of acupuncture (a practical
approach). Acupuncture offers the possibility to improve the healthcare assistance by transcending the
reification of human beings resulting from the pre-eminence of the biomedical paradigm and
facilitating cooperation between disciplines. Participants consider acupuncture as a complete
medicine, not merely as a technique, and highlight the importance of traditional Chinese concepts to
practise it.
Resumen
120
Manuscrito II
¿Qué lleva a un profesional sanitario al estudio y práctica de la acupuntura en España?
Resumen
Introducción: La acupuntura en la parte de la Medicina Tradicional China más difundida en
occidente. Desde este enfoque, las circunstancias y vivencias de cada persona adquieren una
importancia fundamental a la hora de explicar el proceso salud-enfermedad. Recientes investigaciones
evidencian un creciente interés de los profesionales sanitarios en la acupuntura. El objetivo de este
estudio fue comprender las motivaciones de los profesionales sanitarios para estudiar y practicar la
acupuntura en España.
Metodología: Se llevaron a cabo 27 entrevistas en profundidad a profesionales sanitarios con
formación en acupuntura y experiencia en su práctica. Los participantes fueron selecciones a través de
un muestreo teórico. El Análisis Dimensional de la Teoría Fundamentada guio el desarrollo de esta
investigación con el objetivo de obtener explicaciones teóricas sobre las motivaciones de los
profesionales sanitarios para estudiar y practicar acupuntura en España.
Resultados: Las motivaciones de los participantes se articularon en seis categorías: búsqueda de una
medicina más humana, adquirir recursos terapéuticos adicionales, eficacia y gran potencial sanador de
la acupuntura, atracción por la filosofía en que se fundamenta la acupuntura, influencias externas
(otros profesionales y fuentes de información reconocidas) y motivaciones de tipo laboral.
Discusión: Nuestros resultados muestran que la visión del mundo de la MTC (motivación intelectual)
y los beneficios terapéuticos (motivación práctica) de la acupuntura, atrajeron a los profesionales
sanitarios hacia su estudio y práctica. La acupuntura ofrece la posibilidad de mejorar la asistencia
sanitaria superando la cosificación de las personas generada por el paradigma biomédico y facilitando
la cooperación entre disciplinas. Los participantes consideran la acupuntura no sólo como una técnica
sino como una medicina, y enfatizan la importancia de practicarla en función de las bases teóricas
establecidas por la MTC.
Abstract
121
Manuscript III
Collaboration between acupuncture and Western medicine: The perspective of health
professionals in Spain.
Abstract
Introduction: Acupuncture is one of the most popular complementary therapies in the Western world.
Its inclusion into conventional healthcare settings is being internationally considered. The aim of this
study was to understand the perceptions and conceptualisations of health professionals about the
collaboration between acupuncture and Western medicine in Spain.
Methods: A total of 27 in-depth interviews was conducted with Spanish health professionals who
were trained in and practice acupuncture. Participants were selected following a theoretical sampling.
Grounded Theory Dimensional Analysis guided this research in order to obtain a theoretical
explanation of the perceptions and conceptualisations of participants.
Results: Four main categories emerged from the analysis of health professionals’ perceptions
regarding the collaboration between acupuncture and Western medicine: styles of practice, benefits of
the collaboration between acupuncture and conventional medicine, key factors for this cooperation and
barriers to the practice of acupuncture into conventional healthcare settings.
Discussion: Our results showed that health professionals trained in both medicines consider that
taking both approaches results in the amplification of health professionals’ knowledge and the
improvement of the healthcare assistance. Acupuncture contributions to conventional medicine were
valued not only because of its therapeutic properties but also for its proposals for personal
development (lifestyle recommendations, Qi Qong, meditation, breathing exercises, prayer, and
creative activities). Barriers to acupuncture and Western medicine collaboration were related to the
dominance of the biomedicine paradigm. However, acupuncture has been revealed as a new avenue of
cooperation between professionals and a way to transcend the traditional division between disciplines.
Resumen
122
Manuscrito III
La colaboración entre la acupuntura y la medicina convencional: La perspectiva de
profesionales sanitarios formados en acupuntura en España.
Resumen
Introducción: La acupuntura es una de las medicinas complementarias más populares en el mundo
occidental. Su inclusión dentro de los sistemas sanitarios está siendo considerada internacionalmente.
El objetivo de este estudio fue comprender las percepciones y conceptualizaciones de los profesionales
sanitarios sobre la colaboración entre la medicina occidental y la acupuntura en España.
Metodología: Se realizaron 27 entrevistas a profesionales sanitarios españoles con formación en
acupuntura y experiencia en su práctica. Los participantes fueron seleccionados siguiendo un muestreo
teórico. El Análisis Dimensional de la Teórica Fundamentada guió esta investigación con el propósito
de extraer explicaciones teóricas sobre las percepciones y conceptualizaciones de los participantes.
Resultados: Las percepciones de los profesionales sanitarios sobre la colaboración entre acupuntura y
medicina occidental se articularon en torno a cuatro categorías principales: estilos de práctica,
beneficios de la colaboración ente medicina occidental y acupuntura, factores claves para la
cooperación y barreras para la práctica de la acupuntura en centros sanitarios convencionales.
Discusión: Nuestros resultados muestran que los profesionales sanitarios con formación en acupuntura
consideran que el conocimiento y práctica de ambas medicinas se traduce en una mayor comprensión
del proceso de salud-enfermedad y repercute en la mejora de la asistencia sanitaria. Las aportaciones
de la acupuntura no fueron sólo valoradas por su potencial terapéutico sino también por sus propuestas
sobre desarrollo personal (Qi Qong, meditación, ejercicios de respiración, oración y actividades
creativas), propuestas consideradas como beneficiosas para el conjunto de la población. Los
obstáculos para la colaboración entre acupuntura y medicina occidental identificados por los
participantes se relacionaron con la dominación del paradigma biomédico. Sin embargo, la acupuntura
representa una vía de cooperación entre profesionales sanitarios y una forma de trascender la visión
tradicional entre disciplina
123
CONCLUSIONS OF THE STUDY
(CONCLUSIONES DEL ESTUDIO)
124
Conclusions
125
CONCLUSIONS
Objective 1:
Participants consider that acupuncture is able to supplement Western medicine by providing
therapeutic resources to treat health problems for which there is no effective remedy or when
allopathic treatments present contraindications for patients. Side effects of drugs and
conventional procedures can also be treated with acupuncture.
Participants believe that acupuncture is capable to complete the biomedicine conception of the
health-illness process by providing a holistic vision of the human being.
Nowadays, the integration of acupuncture into Western medicine is problematic, due to the
pre-eminence of the biomedical paradigm and the inflexible organisation of conventional
healthcare settings.
Participants highlight the need to further research on the effectiveness of acupuncture using
research methods and techniques of social science (life stories, interviews, case studies) to
assess the holistic benefits of acupuncture.
Objective 2:
Motivations of participants to study and practise acupuncture are accompanied by a critical
reflection on Western medicine and the healthcare assistance in Spain:
- Participants consider that there is a lack of therapeutic resources to treat health
problems such as pain, chronic and degenerative disorders, emotional affections,
psychosomatic illnesses and neurological disorders.
- Participants emphasised that the high medical specialisation, the excessive
bureaucratisation of healthcare assistance and the subordination of medicine to
economic interests, results in a fragmentation and reification of patients. This impedes
the understanding of the health-illness process and produces the deterioration of the
healthcare assistance.
- There is a serious concern among health professionals about the aggressiveness of
certain treatments, diagnostic tests and ways to conduct research in biomedicine.
- Participants believe that the biomedical paradigm is reductionist and it does not
account for emotional, affective, social and spiritual aspects, which influence the
health-illness process.
Conclusions
126
Participants decide to study and practise acupuncture because of the far-reaching potential of
acupuncture treatments, its holistic approach to the health-illness process and the lack of side
effects.
Participants find in acupuncture a way to overcome the excessive medical specialisation
because it involves professionals in all stages of healthcare assistance, such as diagnosis,
treatment, patient follow-up, rehabilitation and care of patient. This facilitates the
communication between health professionals.
Objective 3:
Participants consider that taking both Western medicine and acupuncture approaches increases
the available knowledge and therapeutic resources to help patients.
Participants emphasise that acupuncture is not a stagnant medicine but it is constantly updated
and establishes treatments for new health problems based in traditional Chinese knowledge.
Participants do not consider acupuncture and biomedicine as opposed, but as complementary.
The key factor for the success collaboration between both medicines is the possibility to
translate concepts between them.
The pre-eminence of the biomedical paradigm and the inflexible organisation of the healthcare
assistance in Spain are pointed out as the main barriers to the collaboration between both
medicines. Participants believe that acupuncture is still viewed with prejudices and it is
dismissed, despite of its historical permanence and the evidence of its effectiveness provided
by scientific research.
Participants emphasised that it is important to establish acupuncture treatments on the basis of
the TCM theoretical frame. This is the key for the effectiveness of acupuncture.
Objective 4:
The usefulness of acupuncture in Western medicine is valued because of:
The far-reaching potential of acupuncture treatments and its lack of side effects.
Its capacity to increase the effectiveness of conventional treatments.
Acupuncture provides treatment for the side effects of drugs and conventional interventions.
Acupuncture is an optional treatment in cases in which there is not remedy or when
conventional treatments show contraindications for the patient.
Conclusions
127
Benefits of acupuncture are related to improving the quality of life.
Acupuncture is also valued for its proposals for personal development and healing such as
lifestyle recommendations, Qi Qong, meditation, breathing exercises, prayer and creative
activities.
Acupuncture approach restores the importance of the human dimension conferring special
importance to psychological, affective, emotional, creative and vocational aspects of the
person in order to understand the health-illness process.
The acupuncture holistic view of the patient may facilitate overcoming the extreme division
between medical specialities.
Collaboration between healthcare professionals can be promoted by the study of acupuncture
because it provides ways to establish diagnosis and treatments approachable by health
professionals with different backgrounds.
Acupuncture promotes the implication of health providers in the health-illness process which
may result in an improvement of the relationship between patients and health professionals.
128
Conclusiones
129
CONCLUSIONES
Conclusiones sobre el objetivo 1:
Los participantes consideran que la acupuntura puede complementar la medicina occidental
proporcionando recursos terapéuticos en problemas de salud para los que no existen
tratamientos alopáticos o en los casos en los que éstos presenten contraindicaciones, así como
para el tratamiento de los efectos secundarios producidos por ciertos medicamentos e
intervenciones médicas.
Los participantes estiman que la acupuntura puede completar la comprensión del proceso de
salud y enfermedad de la medicina occidental proporcionando una visión holística del ser
humano.
En la actualidad la integración de la acupuntura en la medicina occidental es problemática
debido a la pre-eminencia del paradigma biomédico, el exceso de burocratización y la falta de
flexibilidad con que se organiza la asistencia sanitaria.
Los participantes destacan la necesidad de investigar la efectividad de la acupuntura
incluyendo métodos de evaluación pertenecientes a las ciencias sociales (entrevistas, historias
de vida, estudio de casos) que puedan mostrar de los beneficios de su aplicación en su
globalidad.
Conclusiones objetivo 2:
La motivación de los participantes por el estudio y la práctica de la acupuntura viene
acompañada por una reflexión crítica sobre la medicina occidental y la asistencia sanitaria en
España:
- Consideran que en el ámbito de la medicina occidental existe una falta de recursos
terapéuticos en situaciones tales como el tratamiento del dolor, enfermedades crónicas
y degenerativas, problemas emocionales, enfermedades psicosomáticas o afecciones
neurológicas.
- Perciben que la alta especialización médica, la excesiva protocolización de la
asistencia sanitaria y la subordinación de la medicina a intereses económicos,
producen una cosificación y fragmentación del paciente, lo que impide la
comprensión de los distintos aspectos que influyen en el proceso de salud-
enfermedad, produciendo un deterioro en la calidad asistencial.
Conclusiones
130
- La agresividad de las formas de tratamiento, diagnóstico e investigación de la
biomedicina, causa en los participantes una seria preocupación.
- Consideran que el paradigma biomédico es reduccionista y no da cuenta de la
dimensión afectiva, relacional, emocional y espiritual que influye en el proceso de
salud-enfermedad.
Los participantes deciden estudiar acupuntura y practicarla debido al potencial de sus recursos
terapéuticos, por su abordaje holístico del proceso salud-enfermedad y por no ocasionar
efectos secundarios.
Los participantes encuentran en la acupuntura una manera de superar la excesiva
especialización médica porque permite a cada profesional implicarse simultáneamente en el
diagnóstico, tratamiento, seguimiento, rehabilitación y cuidado del paciente. Aspecto que
favorece la comunicación entre profesionales.
Conclusiones objetivo 3
Los participantes consideran que la colaboración entre acupuntura y medicina occidental se
traduce en una amplificación de conocimientos y de recursos terapéuticos a disposición de los
pacientes.
Los participantes enfatizan que la acupuntura no es una medicina estancada sino que se
actualiza constantemente y encuentra formas con las que abordar problemas de salud nuevos,
basándose en sus esquemas tradicionales de comprensión del proceso de salud-enfermedad.
La acupuntura y la biomedicina no son consideradas visiones contrapuestas, sino que pueden
complementarse. La clave es saber traducir conceptos entre ambas medicinas.
La pre-eminencia del paradigma biomédico y la inflexibilidad de la organización asistencial en
España son identificados como las principales barreras para la colaboración entre ambas
medicinas. Los participantes señalan que la acupuntura, a pesar de su vigencia histórica y la
evidencia que existe sobre su efectividad, es contemplada con perjuicios y minusvalorada.
Los participantes enfatizan que la acupuntura es una medicina y que no tiene sentido
desproveerla de su base teórica porque a partir de ella se fundamenta su efectividad.
Conclusiones objetivo 4
Los participantes valoran la utilidad de la acupuntura en la medicina occidental por:
Proporcionar recursos terapéuticos efectivos sin efectos secundarios.
Conclusiones
131
Su capacidad para potenciar la efectividad de los medicamentos alopáticos.
Tratar los efectos secundarios de los fármacos y otros procedimientos convencionales.
Ofrecer recursos terapéuticos ante la ausencia de tratamientos conocidos o contraindicaciones
de los mismos.
Reportar beneficios relacionados con la mejora de la calidad de vida.
Proveer propuestas sanadoras y de desarrollo personal útiles para el diseño de programas de
prevención de la salud. Por ejemplo, recomendaciones sobre el estilo de vida, ejercicios físicos
acompañados por la respiración, meditación o el desarrollo de actividades creativas.
Recuperar la dimensión humana al conferir especial importancia a las dimensiones psico-
afectivas y emocionales así como a la esfera creativa y vocacional de cada persona a la hora de
abordar el proceso-salud enfermedad.
Permitir superar la extrema división entre especialidades médicas y profesiones sanitarias al
establecer una comprensión holística del paciente y formas de diagnóstico y tratamiento
abordables por distintos profesionales sanitarios (médicos, profesionales de enfermería y
fisioterapeutas entre otros), por lo que su estudio puede facilitar la colaboración entre
profesionales de distintos ámbitos.
Mejorar la relación terapeuta-paciente favoreciendo la implicación de los profesionales
sanitarios en el proceso de salud-enfermedad.
132
133
APORTACIONES CIENTÍFICAS DEL ESTUDIO
134
135
Artículos científicos
García-Escamilla E, Rodríguez-Martín B and Martínez-Vizcaíno V Integration of acupuncture into
conventional medicine from Health Professionals’ perspective: a thematic synthesis of qualitative
studies. Health: The Interdisciplinary Journal for the Social Study of the Health, Illness and
Medicine; 2015. DOI: 10.1177/1363459315574116.
García-Escamilla E, Rodríguez-Martín B and Martínez-Vizcaíno V What led a health profesional to
study and practise acupuncture in Spain? Remitido para su publicación en Health: The
Interdisciplinary Journal for the Social Study of Health, Illness and Medicine; 2015. En proceso
de revisión por pares. Referencia: Health-15-0223.
García-Escamilla E, Rodríguez Martín B and Martínez-Vizcaíno V. Collaboration between
acupuncture and Western medicine: The perspective of health professionals trained in
acupuncture in Spain. Remitido para su publicación en Qualitative Health Research; 2015.
Referencia: QHR-2015-0857.
Comunicaciones a congresos
García Escamilla E y Rodríguez Martín B. “Percepciones de los profesionales sanitarios sobre la
acupuntura”. VI Congreso Internacional de Educación y Salud: Una Mirada Transcultural”. Del 7
al 9 de Noviembre de 2013 (Comunicación oral).
García Escamilla E y Rodríguez Martín B. “¿Cuáles son las motivaciones de los profesionales
sanitarios para estudiar y practicar acupuntura en España?” XIX Encuentro Internacional de
Investigación en Cuidados. Del 17 al 20 de Noviembre de 2015 (Póster). Premio al mejor
póster.
Otras aportaciones
García Escamilla E y Rodríguez Martín B. Percepciones de los profesionales sanitarios sobre la
acupuntura. En: Soriano Ayala E, González Jiménez AJ y Cala VC, coordinadores. Retos
Actuales de Educación y Salud Transcultural. Universidad de Almería. Almería; 2014 ISBN: 978-
84-16027-23-1.
García Escamilla E y Rodríguez Martín B ¿Cuáles son las motivaciones de los profesionales para
estudiar y practicar acupuntura en España? Libro de Ponencias INVESTEN. XIX Encuentro
Internacional de Investigación en Cuidados; 2015. p. 544-45
136
137
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Integration of acupuncture into conventional medicine from health professionals’ perspective: A thematic synthesis of qualitative studies
Esther García-Escamilla, Beatriz Rodríguez-Martín and Vicente Martínez-VizcaínoHealth and Social Research Centre, University of Castilla-La Mancha, Spain
AbstractAcupuncture is a prominent Complementary Medicine. Although health professionals’ conceptions of acupuncture may affect its utilisation and integration within conventional medicine, these aspects have not been well studied. The aim of this review was to analyse the integration of acupuncture into conventional medicine from the perspective of health professionals.We conducted a systematic review and a thematic synthesis of qualitative studies that analysed the integration of acupuncture into conventional medicine grounded in participants’ perspectives. A systematic search was undertaken in PubMed, Web of Science, the Cochrane Library Plus, Scopus and CINAHL.This review included 18 articles: 6 analysed the viewpoint of physicians, 3 of nurses and 9 comprised different health-related professionals. Most of these studies included healthcare professionals practising acupuncture and took place in sites where the relation between acupuncture and biomedicine is favourable. The most used research techniques were convenience sampling, semi-structured interviews and interpretative approach. The holistic approach of acupuncture and its lack of adverse effects were highlighted by the analysed studies. This led to health professionals encouraging its integration into conventional medicine. The main obstacles perceived for the integration were lack of knowledge and institutional support. In general, acupuncture has been
Corresponding author:Esther García-Escamilla, Health and Social Research Centre, University of Castilla-La Mancha, Santa Teresa Jornet Street, Cuenca 16071, Spain. E-mail: [email protected]
574116 HEA0010.1177/1363459315574116HealthGarcía-Escamilla et al.research-article2015
Article
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2 Health
adapted to the biomedical model (often practised in an unsystematic and individual manner), and it is conceived as a supplement of Western medicine.‘Working together’ and overcoming the biomedical model are recognised by the participants as key conditions for successful integration of acupuncture.
Keywordsacupuncture, health professionals, nurses, physicians, thematic synthesis
Introduction
Complementary and Alternative Medicine (CAM) includes a variety of practices and therapeutic products developed outside of mainstream Western medicine such as acu-puncture, homeopathy, Ayurveda, naturopathy and meditation (National Center for Complementary and Alternative Medicine, 2014). Due to the disparity of characteristics and ways of application, each therapy should be considered separately.
Acupuncture, one of the principal techniques of Traditional Chinese Medicine (TCM), has been recognised by the World Health Organization (WHO, 2002) as an effective therapy for a variety of conditions. Furthermore, some countries such as Austria and Germany offer acupuncture for the treatment of some types of chronic pain by the state-regulated health insurance carriers (Endres et al., 2007; Ots, 2010). Likewise, acupunc-ture is currently available in the UK National Health System (Thomas et al., 2003).
Recently, there has been an increasing interest in the study, practice and recommenda-tion of acupuncture among health professionals and medical students (Bjerså et al., 2012; Chaterji et al., 2007; Fanì et al., 2014; Van Haselen et al., 2004). Some of the reasons are lack of responses to conventional treatment, absence of available treatments, lack of adverse effects of acupuncture, request of the patients, belief of health professionals in its efficacy and existence of documented evidence (Van Haselen et al., 2004).
Although some health practitioners recognised that knowledge and research in acu-puncture are important, the lack of knowledge expressed by healthcare workers is note-worthy. Moreover, the limited communication regarding acupuncture usage between health professionals and patients was highlighted (Bjerså et al., 2012; Chaterji et al., 2007; Sewitch et al., 2008). Previous studies underline the need to further analyse certain issues concerning integration of acupuncture into conventional medicine. These issues include diseases that may be treated by acupuncture, risks or adverse effects related to its practice, how to achieve the integration, which kind of professionals may provide it and the cost related to the integration (Bjerså et al., 2012; Fanì et al., 2014). Regarding acu-puncture effectiveness, there are still some challenges to be taken up, including the small size of existing research (Deare et al., 2013; Manheimer et al., 2012; Paley et al., 2011) and the inconvenience of the outcomes to evaluate its effectiveness. The importance of including the perspective of patients to assess the benefits of acupuncture treatments (Paterson et al., 2009; Verhoef et al., 2006) has also been highlighted. Nevertheless, there is still some controversy about the effectiveness of acupuncture While certain studies show the effectiveness of acupuncture for treating different pain conditions (Linde et al., 2009; Smith et al., 2011; Trinh et al., 2006; Vas et al., 2004; Vickers et al., 2012) or
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García-Escamilla et al. 3
improving immune function (Arranz et al., 2006), other researchers found no evidence (Ernst and Lee, 2010; Matthews et al., 2014). Furthermore, some systematic reviews conclude that there is no consistent evidence about the effectiveness of acupuncture due to the inappropriateness of the designed studies (Deare et al., 2013; Manheimer et al., 2012; Paley et al., 2011; Paterson et al., 2009; Verhoef et al., 2006). On the other hand, cost-effective research in acupuncture is almost an unexplored field (Herman et al., 2005). Another traditional weakness of the acupuncture research, such as the impossibil-ity of conducting double-blind acupuncture clinical trials, is being overcome (Takakura and Yajima, 2007).
According to recent surveys, the use of CAM among the general population was reported to be 42.3 per cent in Germany (Bücker et al., 2008), 38.3 per cent in the United States (Barnes and Bloom, 2008) and 44 per cent in the United Kingdom (Hunt et al., 2010). Regarding acupuncture, the reported prevalence of use is 14.5 per cent in Germany (Bücker et al., 2008) and 6.3 per cent in the United States (Zhang et al., 2012). Reasons for visiting an acupuncturist were for specific health problems or ineffectiveness of the previous medical treatment. The most frequently reported condition was musculoskeletal complaint, followed by back pain. Acupuncture was also used for general wellness, enhanced energy and improved immune function (Burke et al., 2006; Zhang et al., 2012). The fact that acupuncture does not require a complex infrastructure and major economic investment is a further benefit associated with acupuncture (Hernández et al., 2008).
It is believed that the increased interest of health professionals in acupuncture is linked to the limitations of conventional medicine to address some health problems. This is due to the lack of available and effective treatments and their side effects for certain disorders (Van Haselen et al., 2004). The general population might share these reasons (Burke et al., 2006; Zhang et al., 2012).
Although the viewpoint of the health professionals may affect the use of the acupunc-ture by the general population, few studies have deeply analysed relevant issues regard-ing the collaboration between acupuncture and Western medicine from the perspectives of health professionals (Bishop et al., 2012; Schroer et al., 2009).
Although the effectiveness of acupuncture in addressing some health disorders is still a controversial issue, the evidence provided by the tradition and the experience confers relevance (Hansen, 2012). In addition, some recent evidences support the benefits of acupuncture integration into conventional medicine setting, particularly improvements in physical and emotional symptoms, increased quality of life levels and reduction of drug side effects (Deng and Cassileth, 2009; Deng et al., 2004; Kemper et al., 2000; Vas et al., 2004). In order to provide a better understanding of this phenomenon, we sum-marised and analysed the qualitative studies aimed to examine the conceptions of health professionals related to the integration of acupuncture into conventional medicine.
Methods
Search strategy
A systematic search of the following electronic databases (publications until January 2014) was conducted: PubMed, Web of Science, Scopus, CINAHL and the Cochrane Library. We searched for qualitative studies exploring the integration of acupuncture into
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4 Health
conventional medicine from the perspective of health professionals. Some of the search terms used were ‘complementary and alternative medicine’, ‘acupuncture’, ‘Traditional Chinese Medicine’, ‘integrative medicine’, ‘practice complementary and alternative medicine’, ‘practice acupuncture’, ‘physicians’, ‘nurses’, ‘physiotherapists’, ‘health pro-fessionals’, ‘motivations’, ‘perceptions’, ‘conceptualizations’, ‘attitudes’, ‘views’ and ‘Qualitative Research’. These terms were combined in different ways in the included electronic databases (see Table 1). Furthermore, manual searches in other sources such as grey literature were undertaken in order to obtain more results. The search strategy was conducted independently and subsequently agreed by two reviewers (E.G.-E., B.R.-M.). Any disagreement over the selected studies was referred to a third reviewer (V.M.-V.). We also scanned reference lists of the found studies.
We considered as exclusion criteria studies that were not conducted in Western coun-tries, secondary studies and studies not published in English, Spanish or Italian.
Methodology for the synthesis
For the qualitative synthesis, we used a thematic synthesis approach aiming to find out relevant themes about acupuncture integration into conventional medicine grounded in the perspective of participants. This synthesis was conducted in three stages according to the methods proposed by Thomas and Harden (2008). In the first stage, we extracted key concepts to capture the meaning and context of each study. At this point, we put out our review question and started with the thematic analysis in order to find out all the relevant issues about acupuncture from the perspective of participants. In a second stage, we organised the key concepts into related areas to develop ‘descriptive themes’. In the last stage called ‘going beyond the content’ of the original studies, we concluded five ‘ana-lytical themes’ examining the ‘descriptive themes’ in the light of the review question. This can explain some keys to the collaboration between acupuncture and conventional medicine (see Table 2).
Quality appraisal
The use of checklists for the evaluation of the quality of qualitative studies has been much criticised. Generally, there is a lack of consensus about how quality should be assessed (Thomas and Harden, 2008). We developed a ‘sensitivity analysis’ to observe a possible impact of study quality on the findings of the review. For this purpose, we iden-tified the concepts of quality within the context of the aim of our review (health profes-sionals’ point of view) and created a checklist to discuss the quality of the studies based in other synthesis (Smithson et al., 2012). The list included eight questions about the appropriateness of the research design and the quality of the analysis. The quality appraisal was conducted independently and subsequently agreed by E.G.-E. and B.R.-M. Any disagreement was referred to V.M.-V. However, we did not use the results of these questions as a criterion for exclusion. Due to the few published articles found, we con-sidered all articles that answer the research aims including poor quality articles which support the findings of the more developed articles (Atkins et al., 2008). We examined the appropriateness of the research design to the research question. Furthermore, we
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García-Escamilla et al. 5
revised the coherence regarding methods, sampling, literature, analysis strategy and presentation (Morse et al., 2002) (see Table 3).
Data extraction
The data were extracted independently and subsequently agreed by E.G.-E. and B.R.-M. Duplicate studies were removed.
We provide a structured summary of each study listing authors, publication date, con-text, type of therapy, methodology, data collection and sampling techniques, outcome measures and main conclusions. We respected original studies’ wording (see Table 4) in order to preserve context.
Any disagreement was referred to V.M.-V. It was not necessary to obtain additional information from the authors of original studies.
Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement’s recommendations were taken into account to perform the analy-sis (Tong et al., 2012).
Results
The database search retrieved 1167 potentially relevant articles; 1102 of them were excluded due to a preliminary screening based on abstract and titles. The full-text exami-nation of the remaining 65 articles excluded 50 of them that did not meet inclusion
Table 1. Search strategies.
Database Search strategy
PubMed (((((Acupuncture Therapy OR Complementary Medicine OR integrative medicine OR Traditional Chinese Medicine OR ‘practice acupuncture’))) AND (health personnel OR physicians OR nurs* OR physiotherapist)) AND (perception OR motivation OR attitude OR conceptualization OR view)) AND Qualitative Research)
Cochrane Library Plus
(Acupuncture Therapy or Complementary Medicine or Traditional Chinese Medicine or integrative medicine or ‘practice acupuncture’ or ‘practice complementary and alternative medicine’) and (health personnel or health professional or nurs* or physician or physiotherapist) and (motivation* or perception* or attitude*) and (Qualitative Research)
Scopus (acupuncture OR ‘complementary and alternative medicine’ OR ‘practice acupuncture’ OR ‘practice complementary and alternative medicine’) AND (‘health professional’ OR physician OR nurs* OR physiotherapist) AND (Qualitative Research)
CINAHL (((acupuncture OR Traditional Chinese Medicine OR Complementary and Alternative Medicine) AND (health professional OR physician OR *nurse OR physiotherapist)) AND (qualitative research OR qualitative study))
ISI Web of Knowledge
((acupuncture OR Traditional Chinese Medicine OR complementary and alternative medicine OR integrative medicine) AND (qualitative research OR qualitative study)
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6 Health
Table 2. Relevant themes related to acupuncture integration into conventional medicine.
Analytical themes Descriptive themes
Perceptions and conceptions of acupuncture that underlay health professionals’ views about integration
- Perception of acupuncture as a complementary medicine
Supplement (effectiveness gap of Western medicine, contraindications and shortages)
Accompaniment (drugs and medical proceeds side effects)
Added benefits (quality of life) - Perception of acupuncture as a holistic medicine - Perception of acupuncture as an empiricist
medicine: evidence provided by experience - Patient-centred approach - Self-development opportunityWhy practise acupuncture
Motivations to practise acupuncture - Perspective of nurses: opportunity to develop in a personal and professional way because of the emphasis on care and holistic healing
- Perspective of physicians: personal experiences, knowledge and convictions
- Patients’ demandsIn which conditions to practise or refer acupuncture
Recommendation of acupuncture to patients
- Absence of conventional treatments.- Lack of efficacy of conventional treatments- Contraindications of conventional treatments
What makes possible the integration of acupuncture into conventional medicine
Facilitators for integration of acupuncture into conventional medicine
Health professionals’ knowledge and training
- Integration of acupuncture into academic curricula- Creation of communication spaces between health
professionals and acupuncturists- Major institutional support- Encouragement of research in these therapies
Investigation to provide evidence of acupuncture’s effectiveness
- To be aware of the importance of the research- More funding to support it- To give priority to qualitative approaches in order
to understand holistically acupuncture benefitsBarriers to integrate acupuncture into conventional medicine
- Primacy of biomedical model- Time constraints- Lack of compensation- Lack of funding- Lack of institutional support- Lack of scientific evidence- Lack of recognised teaching
criteria. Finally, to those 15 selected relevant papers, 3 other studies that were found by hand-searching in other sources of information were added (see Figure 1). Characteristics of the included studies are presented in Table 4.
The principal data collection techniques within the included studies were the semi-structured interview and the in-depth interview (11 and 4, respectively). Other techniques were participant observation (2), case study (2), focus group (2), open-ended question-naires (1), documents analysis (1) and mixed qualitative and quantitative techniques (1).
Regarding triangulation methods, eight studies involved multiple researchers, four used more than one method for gathering data, one adopted more than one theoretical scheme in the interpretation of the phenomenon and one applied a multiple strategy to validate the results. Non-triangulation method is specified in four articles. All
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García-Escamilla et al. 7
the investigations showed congruence between question formulation, data collection strategies and analysis (Morse et al., 2002). The studies that present more developed analysis provide further details. Therefore, these studies contributed most to the thematic synthesis.
In relation to the setting characteristics, most of the studies included health profes-sionals practising acupuncture and took place in sites where the relation between acu-puncture and biomedicine is favourable. Five studies were conducted in fields of primary care (Adams, 2001; Berger et al., 2012; Joos et al., 2008; Marian et al., 2006;
Table 3. Quality appraisal of included articles.
Article Is there a clear statement of the research aims?
Is a qualitative methodology appropriate?
Is a theoretical perspective explicit?
Is the sampling strategy clear and appropriate?
Is the analysis sufficiently rigorous?
Did the researcher consider reflexivity?
Did the researcher describe the triangulation process?
Are negative cases presented or sought?
Hansen (2012)
Y Y N Y Y N N N
Schroer et al. (2009)
Y Y N Y Y Y Y N
Marian et al. (2006)
Y Y Y Y Y N Y Y
Johannessen (2009)
Y Y Y Y N N Y N
Johannessen (2011)
Y Y Y Y N N Y N
Joos et al. (2008)
Y Y N Y Y N Y Y
Cant et al. (2011)
Y Y Y Y Y N Y N
Frank and Stollberg (2004)
N Y N Y Y N Y N
Adams (2001)
Y Y N Y Y N Y N
Verhoef et al. (2010)
Y Y N Y Y N Y Y
Berger et al. (2012)
Y Y N N Y N Y Y
Raynera et al. (2011)
Y Y N Y Y N – Y
Grace and Higgs (2010)
Y Y N Y Y N Y Y
Bertrand (2012)
Y Y Y Y Y N Y Y
Hsiao et al. (2006)
Y Y N Y Y N Y Y
Schiff et al. (2012)
Y Y N Y N N N N
Bishop et al. (2012)
Y Y N Y N N N N
Hughes et al. (2006)
Y Y N Y Y Y N N
Y: Yes (the study met the criteria); N: No (the study did not meet the criteria).
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8 Health
Tab
le 4
. Su
mm
ary
of in
clud
ed a
rtic
les.
Aut
hor
(yea
r)T
ype
of t
hera
py
stud
y se
ttin
gM
etho
dolo
gyD
ata
colle
ctio
nSa
mpl
ing
Part
icip
ants
Out
com
e m
easu
res
Con
clus
ions
Han
sen
(201
2)D
enm
ark
(Fie
ld is
not
sp
ecifi
ed)
Evid
ence
in
acup
unct
ure
Acu
punc
ture
Inte
rpre
tativ
e (T
empl
ate
Ana
lysi
s an
d G
roun
ded
The
ory)
Sem
i-st
ruct
ured
in
terv
iew
s
Snow
ball
sam
plin
g12
par
ticip
ants
: 4
phys
icia
ns p
ract
isin
g ac
upun
ctur
e, 4
ac
upun
ctur
ists
with
ot
her
heal
thca
re-
rela
ted
trai
ning
, 4
acup
unct
uris
ts w
ith
no c
onve
ntio
nal
heal
thca
re-r
elat
ed
trai
ning
(7
fem
ales
an
d 5
mal
es)
Perc
eptio
ns
of c
once
pt o
f ev
iden
ce a
nd
the
use
of R
CT
in
acu
punc
ture
am
ong
prac
titio
ners
The
evi
denc
e ba
sed
on e
xper
ienc
e w
as t
he
mos
t pr
omin
ent.
RC
T s
houl
d co
nsid
er
the
indi
vidu
ality
of
acup
unct
ure
trea
tmen
ts
in t
he d
esig
n.So
cial
sci
ence
res
earc
h m
etho
ds c
ould
as
sess
the
effi
cacy
of
acup
unct
ure.
Schr
oer
et a
l. (2
009)
Uni
ted
Kin
gdom
Prim
ary
care
Tre
atm
ent
of
depr
essi
on
Acu
punc
ture
Inte
rpre
tativ
e (F
ram
ewor
k ap
proa
ch)
In-d
epth
in
terv
iew
sC
rite
rion
and
co
nven
ienc
e sa
mpl
ing
30 p
artic
ipan
ts:
10 a
cupu
nctu
re
patie
nts,
10
acup
unct
uris
t ph
ysic
ians
(9
GPs
an
d 1
psyc
hiat
rist
)
Cir
cum
stan
ces
in
whi
ch p
hysi
cian
s w
ould
be
will
ing
to r
efer
ac
upun
ctur
e fo
r de
pres
sion
Phys
icia
ns s
elec
ted
to r
efer
acu
punc
ture
pa
tient
s no
t sa
tisfie
d w
ith c
onve
ntio
nal
trea
tmen
ts a
nd
expl
anat
ory
mod
els.
Mar
ian
et a
l. (2
006)
Switz
erla
ndPr
imar
y ca
reT
CM
, ant
hrop
osop
hica
l med
icin
e,
hom
eopa
thy,
neu
ral t
hera
py a
nd
phyt
othe
rapy
Mix
ed M
etho
d:
cros
s-se
ctio
nal
surv
ey, 6
36
ques
tionn
aire
s)
and
cont
ent
anal
ysis
(in
duct
ive
and
dedu
ctiv
e co
nstr
uctio
n of
ana
lytic
ca
tego
ries
as
from
175
qu
estio
nnai
res)
Ope
n-en
ded
ques
tionn
aire
sR
epre
sent
ativ
e sa
mpl
ing
GPs
pro
vidi
ng
com
plem
enta
ry
or c
onve
ntio
nal
prim
ary
care
Phys
icia
ns’
mot
ivat
ions
to
prac
tise
CA
M in
re
latio
n to
the
ir
philo
soph
y of
car
e
Phys
icia
ns e
mph
asis
ed
the
inco
rpor
atio
n of
ho
listic
val
ues
into
m
edic
al p
ract
ice.
M
oreo
ver,
phy
sici
ans’
m
otiv
atio
ns t
o pr
actis
e C
AM
wer
e as
soci
ated
w
ith t
heir
ow
n va
lues
an
d kn
owle
dge.
An
asse
ssm
ent
of
risk
-ben
efits
rel
ated
to
con
vent
iona
l/CA
M
trea
tmen
ts a
nd p
atie
nt
situ
atio
ns d
eter
min
ed
the
prac
tice
of C
AM
.
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García-Escamilla et al. 9
Aut
hor
(yea
r)T
ype
of t
hera
py
stud
y se
ttin
gM
etho
dolo
gyD
ata
colle
ctio
nSa
mpl
ing
Part
icip
ants
Out
com
e m
easu
res
Con
clus
ions
Joha
nnes
sen
(200
9)N
orw
ayN
ursi
ngPr
ivat
e se
ctor
Acu
punc
ture
/TC
M, k
ines
iolo
gy,
hom
eopa
thy,
spi
ritu
al h
ealin
g,
refle
xolo
gy, a
rom
athe
rapy
, Ros
en
ther
apy,
Bac
h flo
wer
ess
ence
s, M
a-U
ri m
assa
ge, p
sych
odra
ma
ther
apy,
cr
anio
sacr
al t
hera
py, n
utri
tion,
bi
ores
onan
ce, n
atur
opat
hy,
phyt
othe
rapy
, Ayu
rved
a, a
nd
anth
ropo
soph
ical
med
icin
e
Ethn
ogra
phy
Inte
rvie
ws
and
part
icip
ator
y ob
serv
atio
n
Con
veni
ence
sa
mpl
ing
18 n
urse
s (fe
mal
es):
min
imum
of 1
-yea
r ex
peri
ence
wor
king
in
the
pub
lic h
ealth
se
rvic
e an
d of
fere
d C
AM
in p
riva
te
prac
tice
Mot
ivat
ions
of
nurs
es t
o le
ave
the
Nor
weg
ian
heal
thca
re s
ervi
ce
in o
rder
to
prac
tise
CA
M
Inde
pend
ent
prac
tice
of
CA
M o
ffers
nur
ses
the
oppo
rtun
ity t
o de
velo
p th
eir
clin
ical
ski
lls
due
to t
he e
mph
asis
in
car
e an
d ho
listic
he
alin
g, in
an
egal
itari
an
and
auto
nom
ous
envi
ronm
ent.
Joha
nnes
sen
(201
1)N
orw
ayN
ursi
ngPr
ivat
e se
ctor
Acu
punc
ture
/TC
M, r
efle
xolo
gy,
hom
eopa
thy,
hea
ling,
an
thro
poso
phic
al n
ursi
ng,
colo
ur t
hera
py, p
sych
odra
ma,
ar
omat
hera
py/m
assa
ge, d
iet
and
herb
s, R
eiki
, Ma-
Uri
mas
sage
, Bac
h flo
wer
s m
edic
ine,
Ros
en t
hera
py,
cran
iosa
cral
the
rapy
and
Ayu
rved
a
Ethn
ogra
phy
Inte
rvie
ws
and
part
icip
ator
y ob
serv
atio
n
Con
veni
ence
an
d sn
owba
ll sa
mpl
ing
20 n
urse
s (fe
mal
e)
prac
tisin
g C
AM
Mot
ivat
ions
of
nurs
es t
o pr
actis
e C
AM
in r
elat
ion
to t
he c
once
pts
of
self-
deve
lopm
ent
and
self-
real
izat
ion
Nur
ses’
mot
ivat
ions
to
pra
ctis
e C
AM
w
ere
rela
ted
to t
he
philo
soph
y of
CA
M:
the
deve
lopm
ent
of
self
is p
erce
ived
to
be
ther
apeu
tic a
nd t
he
illne
ss a
s an
opp
ortu
nity
fo
r se
lf-de
velo
pmen
t.Jo
os e
t al
. (2
008)
Ger
man
yPr
imar
y ca
reA
cupu
nctu
re, n
atur
opat
hy,
hom
eopa
thy,
chi
ropr
actic
and
ba
lneo
logy
Inte
rpre
tativ
eC
onte
nt
Ana
lysi
s (M
ayri
ng)
Focu
s gr
oup
Con
veni
ence
sa
mpl
ing
17 G
PsA
ttitu
des
of G
Ps
rela
ted
to t
he
inte
grat
ion
of
CA
M in
to t
he
heal
thca
re s
yste
m
GPs
per
ceiv
ed a
ne
ed fo
r in
crea
sed
fund
ing
for
rese
arch
, be
tter
edu
catio
n an
d re
mun
erat
ion
in
orde
r to
impr
ove
the
inte
grat
ion
of C
AM
in
prim
ary
care
.
Tab
le 4
. (C
ontin
ued)
(Con
tinue
d)
at UNIVERSIDAD CASTILLA LA MANCH on March 23, 2015hea.sagepub.comDownloaded from
10 Health
Aut
hor
(yea
r)T
ype
of t
hera
py
stud
y se
ttin
gM
etho
dolo
gyD
ata
colle
ctio
nSa
mpl
ing
Part
icip
ants
Out
com
e m
easu
res
Con
clus
ions
Can
t et
al.
(201
1)U
nite
d K
ingd
omH
ospi
tal
Nur
sing
and
m
idw
ifery
Publ
ic s
ecto
r
Acu
punc
ture
, aro
mat
hera
py,
refle
xolo
gy, m
assa
ge, y
oga,
hy
pnos
is, B
ach
flow
er r
emed
ies
and
diet
the
rapy
Inte
rpre
tativ
eT
hem
atic
an
alys
is
In-d
epth
in
terv
iew
s,
case
stu
dy
and
sem
i-st
ruct
ured
in
terv
iew
s
Snow
ball
sam
plin
g12
nur
ses
and
15 m
idw
ives
(26
fe
mal
es a
nd 1
mal
e)
prac
tisin
g C
AM
in
publ
ic h
ospi
tals
Nur
ses’
and
m
idw
ives
’ pe
rcep
tions
of
the
inte
grat
ion
of
CA
M in
to t
heir
ho
spita
l pra
ctic
e
Inte
grat
ion
of C
AM
in
to h
ospi
tal p
ract
ice
was
per
ceiv
ed b
y nu
rses
and
mid
wiv
es
to b
e un
syst
emat
ic,
unde
rfun
ded
and
indi
vidu
alis
ed. B
arri
ers
iden
tifie
d to
inte
grat
ion
wer
e m
edic
al a
utho
rity
, la
ck o
f fun
ding
and
in
stitu
tiona
l sup
port
, re
lativ
e fr
agili
ty o
f th
e ev
iden
ce b
ase,
un
syst
emat
ic n
atur
e of
the
tra
inin
g an
d cr
eden
tials
.Fr
ank
and
Stol
lber
g (2
004)
Ger
man
yPu
blic
and
pr
ivat
e se
ctor
Acu
punc
ture
Inte
rpre
tativ
eC
onte
nt
anal
ysis
(M
ayri
ng),
cros
s-ca
se
and
indi
vidu
al
anal
ysis
Sem
i-st
ruct
ured
in
terv
iew
s
Ran
dom
sa
mpl
ing
14 p
hysi
cian
s pr
actis
ing
acup
unct
ure
(7
wor
ked
with
in t
he
publ
ic s
yste
m a
nd 7
pr
ivat
ely)
Phys
icia
ns’
perc
eptio
ns o
f the
de
gree
in w
hich
th
ey in
tegr
ate
acup
unct
ure
into
bi
omed
ical
mod
el
Acu
punc
ture
ten
ds
to b
ecom
e a
med
ical
sp
ecia
lisat
ion
adap
ted
to in
divi
dual
pat
ient
s’
dem
ands
.
Ada
ms
(200
1)U
nite
d K
ingd
omPr
imar
y ca
rePu
blic
sec
tor
Acu
punc
ture
, hom
eopa
thy,
hy
pnot
hera
py, n
euro
lingu
istic
pr
ogra
mm
ing
Inte
rpre
tativ
eT
hem
atic
an
alys
is (
Ric
e an
d Ez
zy)
In-d
epth
in
terv
iew
sC
onve
nien
ce
sam
plin
g25
GPs
pra
ctis
ing
CA
M in
NH
S su
rger
ies
(11
fem
ales
and
14
mal
es, >
5 ye
ars
of e
xper
ienc
e as
ph
ysic
ians
)
Perc
eptio
ns o
f th
e in
tegr
atio
n of
CA
M in
to
the
publ
ic
heal
th a
mon
g ph
ysic
ians
tak
ing
into
acc
ount
the
co
nsul
tatio
n tim
e co
nstr
aint
s
Phys
icia
ns d
evel
op
a ‘b
rief
’ sty
le C
AM
co
nsul
tatio
n in
ord
er
to a
dapt
CA
M in
to
the
publ
ic h
ealth
an
d re
late
d le
ngth
ier
cons
ulta
tions
to
shor
ter
dura
tion
of
trea
tmen
ts.
Tab
le 4
. (C
ontin
ued)
at UNIVERSIDAD CASTILLA LA MANCH on March 23, 2015hea.sagepub.comDownloaded from
García-Escamilla et al. 11
Aut
hor
(yea
r)T
ype
of t
hera
py
stud
y se
ttin
gM
etho
dolo
gyD
ata
colle
ctio
nSa
mpl
ing
Part
icip
ants
Out
com
e m
easu
res
Con
clus
ions
Ver
hoef
et
al.
(201
0)C
anad
aIM Pr
ivat
e se
ctor
TC
M, n
atur
opat
hy, q
uiro
prax
ia,
min
d-bo
dy a
nd m
assa
ge t
hera
pies
Inte
rpre
tativ
eC
onte
nt
anal
ysis
Sem
i-st
ruct
ured
in
terv
iew
s
Con
veni
ence
sa
mpl
ing
25 p
artic
ipan
ts:
IM p
ract
ition
ers
(phy
sici
ans
and
CA
M p
ract
ition
ers)
, cl
inic
dir
ecto
rs a
nd
man
ager
s
Perc
eptio
ns o
f th
e in
clus
ion
of o
utco
mes
re
sear
ch
prog
ram
mes
in
inte
grat
ive
heal
thca
re
clin
ics
amon
g pr
ofes
sion
als
Barr
iers
to
cond
uctin
g ou
tcom
es r
esea
rch
in IM
clin
ics
iden
tifie
d by
par
ticip
ants
wer
e la
ck o
f res
ourc
es,
orga
nisa
tion,
tim
e, s
taff
inte
rest
, and
tra
inin
g.IM
clin
ics
requ
ired
ou
tcom
es r
esea
rch
prog
ram
mes
abl
e to
do
cum
ent
the
patie
nts’
ex
peri
ence
s.Be
rger
et
al.
(201
2)G
erm
any
Prim
ary
care
Publ
ic s
ecto
r
Acu
punc
ture
, hom
eopa
thy,
na
turo
path
yIn
terp
reta
tive
Con
tent
an
alys
is
(May
ring
) an
d th
emat
ic c
odin
g (S
trau
ss)
Sem
i-st
ruct
ured
in
terv
iew
s
Quo
ta
sam
plin
g30
par
ticip
ants
: 10
GPs
, 10
GPs
pr
actis
ing
CA
M
and
10 n
onm
edic
al
CA
M p
ract
ition
ers
(19
fem
ales
and
11
mal
es)
Com
pari
son
of p
hysi
cian
s an
d C
AM
pr
actit
ione
rs’
perc
eptio
ns
rega
rdin
g th
e he
alth
pr
ofes
sion
al–
patie
nt
rela
tions
hip
Prof
essi
onal
s w
ho
prac
tise
CA
M
perc
eive
d a
mor
e pa
rtic
ipat
ive
heal
th
prof
essi
onal
-pat
ient
re
latio
nshi
p.G
Ps c
onsi
dere
d th
e sa
nita
ry p
roto
cols
as
obst
acle
s fo
r ac
hiev
e a
patie
nt-c
entr
ed
med
icin
e.R
ayne
ra e
t al
. (2
011)
Aus
tral
iaIM
Acu
punc
ture
, hom
eopa
thy,
her
bal
med
icin
e, m
ind-
body
med
icin
e an
d lif
esty
le m
edic
ine
Inte
rpre
tativ
eT
hem
atic
an
alys
is
Sem
i-st
ruct
ured
in
terv
iew
s
Con
veni
ence
sa
mpl
ing
23 p
hysi
cian
s pr
actis
ing
IM (
14
fem
ales
and
9
mal
es)
Mot
ivat
ions
of
phys
icia
ns t
o w
ork
in IM
and
to
inco
rpor
ate
CA
M
into
the
ir p
ract
ice
The
hol
istic
and
pa
tient
-cen
tred
ap
proa
ch fo
cusi
ng o
n lif
esty
le o
f IM
and
CA
M
mot
ivat
ed p
hysi
cian
s to
w
ork
in t
hese
fiel
ds.
Tab
le 4
. (C
ontin
ued)
(Con
tinue
d)
at UNIVERSIDAD CASTILLA LA MANCH on March 23, 2015hea.sagepub.comDownloaded from
12 Health
Aut
hor
(yea
r)T
ype
of t
hera
py
stud
y se
ttin
gM
etho
dolo
gyD
ata
colle
ctio
nSa
mpl
ing
Part
icip
ants
Out
com
e m
easu
res
Con
clus
ions
Gra
ce a
nd
Hig
gs (
2010
)A
ustr
alia
IMA
cupu
nctu
re, n
utri
tion,
ho
meo
path
y, h
erba
l med
icin
e,
anth
ropo
soph
ical
med
icin
e,
envi
ronm
enta
l med
icin
e,
natu
ropa
thy,
bio
ener
getic
med
icin
e,
Rei
ki, c
hiro
prac
tic
Her
men
etui
c ph
enom
enol
ogy
(van
Man
en)
Cas
e st
udy,
se
mi-
stru
ctur
ed
inte
rvie
ws,
fo
cus
grou
p an
d in
-dep
th
inte
rvie
ws
with
key
in
form
ants
Con
veni
ence
an
d pu
rpos
ive
sam
plin
g
GPs
and
CA
M
prac
titio
ners
Perc
eptio
ns o
f co
llabo
ratio
ns’
form
s am
ong
GPs
and
CA
M
prac
titio
ners
Mut
ual k
now
ledg
e be
twee
n G
Ps a
nd
CA
M p
ract
ition
ers’
pr
actic
es e
nabl
e de
eper
co
oper
atio
n be
twee
n co
nven
tiona
l med
icin
e an
d C
AM
the
rapi
es.
Bert
rand
(2
012)
Uni
ted
Stat
esN
ursi
ngC
onte
xt o
f T
riag
e pr
oces
s
TC
MIn
terp
reta
tive
Sym
bolic
in
tera
ctio
nism
Sem
i-st
ruct
ured
in
terv
iew
s
Purp
osiv
e sa
mpl
ing
20 n
urse
s (fe
mal
e)
who
had
per
sona
lly
trie
d T
CM
Perc
eptio
n of
as
pect
s th
at
influ
ence
nur
ses’
re
com
men
datio
ns
of T
CM
Nur
ses
perc
eive
d th
eir
role
in e
ach
situ
atio
n,
the
cond
ition
of e
ach
patie
nt a
nd t
heir
tr
aini
ng a
s in
fluen
tial
aspe
cts
in t
heir
re
com
men
datio
n of
T
CM
.H
siao
et
al.
(200
6)U
nite
d St
ates
IM Aca
dem
ic
cont
ext
and
priv
ate
prac
tice
Acu
punc
ture
, chi
ropr
actic
Inte
rpre
tativ
eG
roun
ded
The
ory
Sem
i-st
ruct
ured
in
terv
iew
s
Purp
osiv
e an
d sn
owba
ll sa
mpl
ing
50 p
artic
ipan
ts:
13 p
hysi
cian
s,
13 p
hysi
cian
ac
upun
ctur
ists
, 12
chir
opra
ctor
s an
d 12
acu
punc
turi
sts
(33
mal
es a
nd 1
7 fe
mal
es)
Perc
eptio
ns o
f IM
pr
actic
e am
ong
prof
essi
onal
s
Rel
evan
t fa
ctor
s id
entif
ied
in d
evel
opin
g an
IM w
ere
open
-m
inde
d pe
rspe
ctiv
e on
oth
er h
ealin
g tr
aditi
ons,
coo
pera
tion
betw
een
prof
essi
onal
s an
d co
mbi
natio
n of
con
vent
iona
l tr
eatm
ents
with
CA
M.
Tab
le 4
. (C
ontin
ued)
at UNIVERSIDAD CASTILLA LA MANCH on March 23, 2015hea.sagepub.comDownloaded from
García-Escamilla et al. 13
Aut
hor
(yea
r)T
ype
of t
hera
py
stud
y se
ttin
gM
etho
dolo
gyD
ata
colle
ctio
nSa
mpl
ing
Part
icip
ants
Out
com
e m
easu
res
Con
clus
ions
Schi
ff et
al.
(201
2)Is
rael
Publ
ic h
ospi
tal
Surg
ery
serv
ice
Acu
punc
ture
, ref
lexo
logy
, gui
ded
imag
ery,
bre
athi
ng t
echn
ique
sIn
terp
reta
tive
The
mat
ic
anal
ysis
Con
sulta
tion
repo
rts
Con
secu
tive
sam
plin
g30
4 co
nsul
tatio
n re
port
s be
twee
n co
nven
tiona
l hea
lth
prof
essi
onal
s an
d C
M p
ract
ition
ers,
re
gist
ered
in t
he
hosp
ital e
lect
roni
c co
nsul
tant
cha
rtin
g sy
stem
Ana
lysi
s of
in
tegr
atio
n of
CM
in
to c
onve
ntio
nal
med
icin
e th
roug
h co
mm
unic
atio
n pa
tter
ns b
etw
een
conv
entio
nal a
nd
com
plem
enta
ry
heal
th p
rovi
ders
CM
pra
ctiti
oner
s be
gan
to a
dopt
a b
iom
edic
al
lang
uage
whi
le h
ealth
pr
ovid
ers
bega
n to
em
ploy
a m
ore
holis
tic,
psyc
ho-e
mot
iona
l an
d sy
mpt
omat
ic
term
inol
ogy
unde
rsta
ndin
g th
e th
erap
eutic
pot
entia
l of
CM
.Bi
shop
et
al.
(201
2)U
nite
d K
ingd
omPr
ivat
e an
d pu
blic
sec
tor
Con
text
of p
ain
man
agem
ent
Acu
punc
ture
Inte
rpre
tativ
eIn
duct
ive
them
atic
an
alys
is (
Bram
an
d C
lark
e)
Sem
i-st
ruct
ured
in
terv
iew
s
Purp
osiv
e sa
mpl
ing
16 a
cupu
nctu
rist
s am
ong
phys
ioth
erap
ists
, nu
rses
, phy
sici
ans
and
CA
M
prac
titio
ners
: 7
wor
k pr
ivat
ely,
3
in t
he p
ublic
sec
tor
and
6 in
bot
h (1
4 fe
mal
es a
nd 1
mal
e)
Sim
ilari
ties
and
diffe
renc
es
betw
een
priv
ate
and
publ
ic
acup
unct
ure
prac
tice
iden
tifie
d by
acu
punc
turi
sts
Tim
e co
nstr
aint
s id
entif
ied
in t
he p
ublic
se
ctor
affe
ct t
he
prof
essi
onal
–pat
ient
re
latio
nshi
p w
hile
pr
ivat
e pr
actic
e is
co
nstr
aine
d by
pat
ient
s’
finan
cial
res
ourc
es.
Hug
hes
et a
l. (2
006)
Uni
ted
Kin
gdom
Priv
ate
and
publ
ic s
ecto
rC
onte
xt o
f rh
eum
atoi
d ar
thri
tis
Acu
punc
ture
Inte
rpre
tativ
eG
roun
ded
The
ory
Sem
i-st
ruct
ured
in
terv
iew
s
The
oret
ical
sa
mpl
ing
19 p
artic
ipan
ts: 1
0 he
alth
pro
fess
iona
l ac
upun
ctur
ists
an
d 9
non-
heal
th
prof
essi
onal
ac
upun
ctur
ists
Perc
eptio
ns o
f tr
eatin
g pa
tient
s w
ith r
heum
atoi
d ar
thri
tis a
mon
g ac
upun
ctur
ists
an
d th
e im
pact
of
the
ir a
ffilia
tion
to a
tra
ditio
nal
or W
este
rn
theo
retic
al b
ase
Lim
ited
dive
rgen
ce w
as
foun
d in
the
tre
atm
ent
outc
omes
bet
wee
n tr
aditi
onal
and
Wes
tern
ac
upun
ctur
e pr
actic
e.
Besi
des
alle
viat
ing
rheu
mat
oid
pain
, be
nefit
s of
acu
punc
ture
w
ere
rela
ted
to
impr
ovin
g th
e qu
ality
of
life
.
RC
T: r
ando
mis
ed c
ontr
ol t
rial
s; C
AM
: com
plem
enta
ry a
nd a
ltern
ativ
e m
edic
ine;
GP:
gen
eral
pra
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; IM
: int
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CM
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se M
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CM
: com
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med
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Tab
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. (C
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Schroer et al., 2009), four in integrative medicine centres (Grace and Higgs, 2010; Hsiao et al., 2006; Raynera et al., 2011; Verhoef et al., 2010), two in hospitals (Cant et al., 2011; Schiff et al., 2012) and seven of them did not specify the field (Bertrand, 2012; Bishop et al., 2012; Frank and Stollberg, 2004; Hansen, 2012; Hughes et al., 2006; Johannessen, 2009, 2011). We found documentation of integration in the treatment of depression (Schroer et al., 2009), rheumatoid arthritis (Hughes et al., 2006) and pain management (Bishop et al., 2012). Acupuncture was also used as support during pregnancy and child-birth (Cant et al., 2011) and before and after surgery (Schiff et al., 2012). Regarding the country of origin, five studies were conducted in the United Kingdom (Adams, 2001; Bishop et al., 2012; Cant et al., 2011; Hughes et al., 2006; Schroer et al., 2009), three in Germany (Joos et al., 2008; Frank and Stollberg, 2004; Berger et al., 2012), two in Norway (Johannessen, 2009, 2011), two in Australia (Grace and Higgs, 2010; Raynera et al., 2011) and two other studies in the United States (Bertrand, 2012; Hsiao et al., 2006). Israel, Denmark, Canada and Switzerland only provided one study each to this
1167 referencesidentified in PubMed, Web of Science, SCOPUS, CINAHL y The
Cochrane
3 papers identified from manual search.
1102 excluded references after title and abstract review
68full-textpapersreviewed
50 papers excluded:- Based in other researches
- Not published in English, Italian or Spanish
- Did not report the Complementary and Alternative Medicines considered
- Did not include acupuncture as object of analysis
- Did not follow a qualitative approach- Did not consider the perspectives of
health professionals.
18 papers included in the systematic review
Figure 1. Flow diagram.
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García-Escamilla et al. 15
review (Marian et al., 2006; Schiff et al., 2012; Verhoef et al., 2010). The investigations conducted in the public sector were carried out in the United Kingdom (Adams, 2001; Cant et al., 2011) and Israel (Schiff et al., 2012), while the studies conducted in the pri-vate sector took place in the United States (Hsiao et al., 2006), Norway (Johannessen, 2009, 2011) and Canada (Verhoef et al., 2010). Investigations performed jointly in both sectors were carried out in the United Kingdom (Bishop et al., 2012; Hughes et al., 2006) and Germany (Berger et al., 2012; Frank and Stollberg, 2004). Not all the articles included information about the sector (public or private) in which they were conducted. No studies carried out in Mediterranean countries were found.
Concerning the characteristics of the sample, six articles merely included the view-point of physicians (Adams, 2001; Frank and Stollberg, 2004; Joos et al., 2008; Marian et al., 2006; Raynera et al., 2011; Schroer et al., 2009), three of nurses (Bertrand, 2012; Johannessen, 2009, 2011) and nine comprised different health-related professionals (Berger et al., 2012; Bishop et al., 2012; Cant et al., 2011; Grace and Higgs, 2010; Hansen, 2012; Hsiao et al., 2006; Hughes et al., 2006; Schiff et al., 2012; Verhoef et al., 2010). Among the nine studies which included the point of view of different health-related pro-fessionals, eight compared the perspectives between health professionals and CAM prac-titioners with non-conventional health-related training (Berger et al., 2012; Bishop et al., 2012; Grace and Higgs, 2010; Hansen, 2012; Hsiao et al., 2006; Hughes et al., 2006; Schiff et al., 2012). Most of the investigations considered different CAM therapies, whereas acupuncture or TCM was considered exclusively in six studies (Bertrand, 2012; Bishop et al., 2012; Hansen, 2012; Hughes et al., 2006; Schroer et al., 2009).
Based on the perspective of health professionals, the thematic analysis revealed the following relevant issues regarding the acupuncture integration into conventional medi-cine (see Table 2).
Perceptions of acupuncture among health professionals
Perceptions concern our beliefs about, understanding and interpretation of a phenome-non, and our expectations. Thus, people create a representation or interpretation of their experiences that affects their opinions, practices and behaviours (Johansson et al., 2014; Petrie and Weinman, 1997). Therefore, we analysed perceptions of health professionals about acupuncture that may influence the way they think about integration (see Table 5).
Complementary medicine. Some health professionals stated that acupuncture completes conventional medicine by adding something that cannot be provided by Western medi-cine. Accordingly, acupuncture was perceived as a supplement that covers the effective-ness gap of conventional treatments and possible contraindications (drug allergies, adverse effects, polypharmacy, pregnancy) (Bertrand, 2012; Cant et al., 2011; Schroer et al., 2009). In the view of participants, acupuncture also compensates conventional medicine shortages providing preventive and individualistic treatments, a patient- centred approach (Berger et al., 2012; Bishop et al., 2012; Joos et al., 2008) and other reasons of the health-illness process which include social, emotional and spiritual dimen-sions of human beings (Johannessen, 2009, 2011; Schroer et al., 2009). Acupuncture was conceived as a conventional medicine accompaniment offering treatments for the side
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effects of medication and medical procedures (Schiff et al., 2012). In one study, nurses and midwives stated that acupuncture may counteract the increased technical and bureau-cratic nature of modern nursing and midwifery (Cant et al., 2011). Some health profes-sionals highlighted the added benefits of acupuncture related to care, well-being and quality of life (Cant et al., 2011). Acupuncture represented a way not only to save time and work over longer periods but also to work safely (Adams, 2001; Joos et al., 2008).
Due to the conception of acupuncture as a supplement to Western medicine, some participants considered it as an alternative. We found no evidence of the perception that acupuncture could replace Western medicine, but rather that the term alternative was used to refer to the possibility of reinforcing conventional medicine (Bertrand, 2012; Bishop et al., 2012; Hsiao et al., 2006; Schroer et al., 2009).
Holistic medicine. Some health professionals used the word ‘holistic’ referring to acu-puncture in order to highlight the importance conferred to physical, mental, emotional, social and spiritual dimensions of human beings (Hughes et al., 2006; Johannessen, 2009, 2011; Raynera et al., 2011; Verhoef et al., 2010). The holistic approach of acupunc-ture encouraged some participants to adopt its practice because it allowed them to treat the whole person (the totality is more than the sum of its parts) in opposition to conven-tional medicine, which is purely focused on symptoms (Hansen, 2012; Hsiao et al., 2006; Raynera et al., 2011). As a consequence, some participants considered that they treat a person and not a patient (Johannessen, 2009). They also found that they were focused on the healing process, care and lifestyle (Bishop et al., 2012; Schiff et al., 2012).
Table 5. Health professionals’ perceptions of acupuncture related to integration.
Health professionals’ perceptions of acupuncture related to integration of acupuncture into conventional medicine
Acupuncture as supplement of Western medicine
Compensates Western medicine shortages
Effectiveness gap of conventional treatmentsConventional treatments contraindications
Complete Western medicine Holistic medicinePreventive approachPatient-centred approach
Counteract the technical and bureaucratic nature of Western medicine
Acupuncture as accompaniment of Western medicine
Treatment for medical procedures side effectsTreatment for drugs side effectsSelf-development opportunity
Added benefits of acupuncture to Western medicine
Work safeSave timeSave workQuality of lifeWell-beingCare
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Empirical medicine. Participants perceived acupuncture as an empirical medicine because the evidence of its efficacy is provided by experience (personal experiences and tradition experiences collected during the years) (Hughes et al., 2006; Verhoef et al., 2006). Some of them also highlighted that the results they observed when treating patients were more successful than those carried out by randomised control trials (RCTs) (Hansen, 2012).
Self-development opportunity. In the specific context of nursing care, which is usually subordinated to the authority of physicians, acupuncture was perceived by nurses as an opportunity to develop their professional competences related to the care and healing process (Cant et al., 2011; Johannessen, 2009, 2011).
Patient-centred approach. Some participants perceived acupuncture as a patient-centred approach due to the holistic conception of patients and the individualisation of treat-ments. Accordingly, certain health professionals conceived that the patient-centred approach could improve the patient–practitioner relationship because patients were often more aware and actively engaged in the healing process (Berger et al., 2012; Bishop et al., 2012; Johannessen, 2011; Joos et al., 2008). Due to the improvement in the patient–practitioner relationship, health professionals showed satisfaction in their practice (Berger et al., 2012; Johannessen, 2009).
Knowledge and training
According to the participants, increased knowledge and training of acupuncture among health professionals would encourage cooperation between conventional medicine and acupuncture (Cant et al., 2011; Hsiao et al., 2006; Joos et al., 2008). It would allow health professionals to understand the therapeutic range of this practice, while improving their disposition to recommend it (Grace and Higgs, 2010). Furthermore, they considered that familiarisation with the language of acupuncture would enable communication between both disciplines (Schiff et al., 2012). Identified key elements to facilitate cooperation between health professionals and acupuncture practitioners were integration of these medicines into academic curricula (Joos et al., 2008), creation of communication spaces between health professionals and acupuncture practitioners (Schiff et al., 2012), major institutional support and encouragement of research in these therapies (Cant et al., 2011; Hsiao et al., 2006; Joos et al., 2008). Consequently, increased training of acupuncture practitioners in conventional medicine was noted as an important aspect to facilitate bidirectional communication between health professionals and acupuncture practitioners (Grace and Higgs, 2010).
Investigation
Participants considered that the evidence produced by research would encourage physi-cians to recommend acupuncture to patients (Cant et al., 2011; Hansen, 2012; Joos et al., 2008; Schroer et al., 2009; Verhoef et al., 2010). In this way, they considered it is neces-sary to be aware of the importance of having more funding to support the research (Cant et al., 2011; Joos et al., 2008; Verhoef et al., 2010). Some health professionals
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also underlined the importance to give priority to qualitative approaches in order to understand holistically the benefits of acupuncture (Hansen, 2012; Hughes et al., 2006; Verhoef et al., 2010). They also pointed out the limitations of RCTs to assess the effec-tiveness of acupuncture, due to the individual nature of the treatments and the impossi-bility to blind the studies (Hansen, 2012; Hughes et al., 2006; Joos et al., 2008).
Barriers
The main obstacles to integrate acupuncture into the conventional medical practice per-ceived by participants were primacy of the biomedical model (Johannessen, 2009, 2011; Joos et al., 2008), time constraints (Adams, 2001; Berger et al., 2012; Bishop et al., 2012), lack of economical compensation, funding, institutional support, scientific evi-dence and recognised teaching (Cant et al., 2011; Joos et al., 2008; Verhoef et al., 2010). Particularly, time constraints affect the development of a close professional–patient rela-tionship (Hughes et al., 2006). Nurses (subordinated to medical authority) required the recognition of situations to practice CAM (Johannessen, 2009, 2011).
Recommendation
Participants mainly referred and practised acupuncture in chronic diseases and in cases where a lack of efficacy or contraindications for conventional treatments were observed (adverse effects, drug interactions and allergies) (Bertrand, 2012; Frank and Stollberg, 2004; Marian et al., 2006; Schroer et al., 2009). Otherwise, acupuncture was not sug-gested for acute problems (Bertrand, 2012).
Motivations
The reasons of participants to practise acupuncture were identified to be mainly intrinsic. While nurses underlined the opportunity to develop their selves in a personal and profes-sional way due to the emphasis on care and holistic healing (Johannessen, 2009, 2011), physicians associated their motivations with convictions, experiences on the effective-ness of acupuncture and personal knowledge (Marian et al., 2006; Raynera et al., 2011). The demands of patients was also an important influence on the practice of acupuncture (Cant et al., 2011; Frank and Stollberg, 2004; Joos et al., 2008; Marian et al., 2006; Schroer et al., 2009).
Taking into account that the aim of this study was to find out relevant issues regarding the acupuncture integration into conventional medicine based on the perspectives of health professionals, our findings provide an explanation for which perceptions and con-ceptions underlie the views of participants on acupuncture (perceptions), the reasons why some health professionals practise acupuncture (motivations), the situations in which they may refer or practise acupuncture (recommendations) and the elements which make possible the integration of acupuncture into conventional medicine (facilita-tors – knowledge and investigation – and barriers) among the view of health profession-als (see Table 3). Through the synthesis, we established relationships between these concepts grounded in the data. The perceptions of health professionals explain which
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beliefs, understandings and interpretations of acupuncture influence the way they think about integration. Acupuncture knowledge and the evidence provided by research (which are facilitators for the integration of acupuncture into conventional medicine) support the recommendations of acupuncture by healthcare providers. This also motivates them to practise it and collaborate with acupuncture practitioners. Similarly, knowledge and evi-dence (which is a form to increase knowledge) would provide the possibility of tran-scending the barriers which impede collaboration between acupuncture and conventional medicine. In order to achieve this goal, the most relevant issue is to increase and improve the acupuncture knowledge among healthcare providers. This fact may contribute to the integration of acupuncture into Western medicine, which should be encouraged by insti-tutional support. The idea of cooperation between both medicines was grounded in the perception of acupuncture as a complementary therapy, which may supplement and add benefits to conventional treatments. Moreover, ‘working together’ was recognised by the participants as the key condition for the successful integration of acupuncture (Frank and Stollberg, 2004; Grace and Higgs, 2010; Hsiao et al., 2006).
Discussion
As far as we know, this is the first systematic review of qualitative studies examining and synthesising the integration of acupuncture into conventional medicine from the per-spective of health professionals. Our study is focused on the manner in which acupunc-ture is being integrated and the barriers to its practice reported by the literature. Our findings reveal that the integration of acupuncture and conventional medicine is pro-duced by the adaptation of acupuncture to the conventional medicine in both the public and private sectors (Adams, 2001; Cant et al., 2011; Frank and Stollberg, 2004; Schiff et al., 2012), despite the formal and conceptual heterogeneity in which it is performed (Frank and Stollberg, 2004; Hughes et al., 2006).
Another important finding reveals that the motivations of health professionals for the incorporation of acupuncture are based on their own convictions (Johannessen, 2009, 2011) and personal knowledge and experience (Bertrand, 2012; Marian et al., 2006; Raynera et al., 2011) rather than scientific evidence. This fact contradicts the importance conferred by literature to the evidence-based practice of acupuncture by health profes-sionals and can contribute to the publication bias (Astin et al., 1998). Additionally, some studies included in this review suggest that RCTs have some limitations in the assess-ment of the effectiveness of acupuncture in terms of physical, emotional, social and spiritual outcomes (Birch, 2007; Kaptchuk, 2002; Verhoef et al., 2006). These limitations to provide evidence supporting acupuncture practice are being overcome using research methods and techniques of social science (Verhoef et al., 2006, 2010).
As previous studies have pointed out, barriers to integrate acupuncture into conven-tional medicine are the primacy of the biomedical paradigm, excessive bureaucracy and the subordination of medicine to economic interests (Illich, 1975; Lipton, 2005; Null et al., 2011, Sheldrake, 2012). These obstacles are evidenced by the time constraints and the lack of funding, institutional support, scientific evidence and recognised teaching programmes in acupuncture (Adams, 2001; Berger et al., 2012; Bishop et al., 2012; Cant et al., 2011; Johannessen, 2009; Joos et al., 2008; Verhoef et al., 2010).
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Acupuncture is considered by some participants as a supplement to Western medicine because it completes and complements conventional medicine with a holistic approach of the health-illness process. The holistic approach of acupuncture has been highlighted by Paterson and Britten (2004). They defined acupuncture as a complex intervention due to the interconnections and cyclical reinforcements of improvements in social, emo-tional, physical and spiritual dimensions of patients.
The perception of acupuncture as a supplement to Western medicine is consistent with other studies showing the benefits of acupuncture in collaboration with conventional medicine. Cooperation between acupuncture and the pharmacological treatment of knee osteoarthritis was revealed to be more effective than pharmacological treatment alone (Vas et al., 2004). Benefits of acupuncture as a complementary therapy into paediatric pain and cancer patient care were also evidenced (Deng and Cassileth, 2009; Deng et al., 2004; Kemper et al., 2000). Advantages related to improvements in physical and emo-tional symptoms, quality of life and physician–patient relationship were shown (Deng and Cassileth, 2009; Deng et al., 2004; Kemper et al., 2000; Vas et al., 2004). Gain con-trol over patient well-being and reduced drug side effects were also reported (Deng and Cassileth, 2009).
The benefits of complementary therapy integration into conventional medicine have also been demonstrated. Some examples are meditation, touch and mind-body therapies, relaxation therapy, music therapy and massage. The use of herbs and dietary supplements in conjunction with prescription medication was revealed to be problematic due to the potential herb–drug interaction (Deng and Cassileth, 2009; Deng et al., 2004).
The serious concern about adverse drug reactions and medical iatrogenesis – third leading cause of death worldwide (Gøtzsche, 2014; Null et al., 2011) – and the search for different explanations of illness motivate health professionals to enrich their view of the health-illness process considering other paradigms (Ballvé, 2003; Schroer et al., 2009). According to previous studies, our findings suggest the lack of adverse effects (Zhang et al., 2010) and its holistic approach, which includes physical, social, emotional and spiritual factors that influence the health-illness process as facilitators for the integration of acupuncture (Paterson and Britten, 2004). This highlights the need for a constructive dialogue between both medicines promoted by major knowledge of health professionals about acupuncture. The adaptive capacity of TCM may facilitate this dialogue (Adams, 2001; Frank and Stollberg, 2004).
Our results are relevant because they highlight the importance of overcoming the biomedical paradigm and the conventional healthcare model. This study synthesises the contributions of existing qualitative investigations in this area, enables a broader descrip-tion and allows a more complete understanding of the range of existing challenges.
Conclusions of this study are limited due to the few published qualitative studies concerning the integration of acupuncture into conventional medicine from the perspec-tive of health professionals. We found another limitation related to the heterogeneity in characteristics of the analysed investigations. Most of the studies of this review included health professionals who practise acupuncture and took place in sites where the relation between acupuncture and biomedicine is favourable. This fact could bias the results, but it allowed us to know the perceived barriers and obstacles by health professionals for the effective integration of acupuncture.
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Given the limitations of conventional treatments (drugs side effects, drug resistance, lack of treatments, medical iatrogenesis, supremacy of economic interests), more research is needed to analyse the perspectives of acupuncture among health professionals and to document the holistic benefits associated with acupuncture. Furthermore, the point of view of different health professionals such as nurses, midwives and physiothera-pists, who are comparatively underrepresented in the analysed studies, must be taken into account. It is also necessary to carry out more investigations in Mediterranean coun-tries in order to incorporate more points of view. Finally, comparative studies between countries in which acupuncture is a predominant therapy and those in which it is a minor-ity practice could be useful in order to explore ways in which cooperation between both medicines could be fostered.
Acknowledgements
We are very grateful to Dr. María Moreno and Aaron Peche for the formal revision and linguistic correction of the manuscript. We also thank Richard Lindley and Samuel C Dennis for their help with the English language. We are immensely grateful to Neijing School for transmiting the knowledge needes to develop this work. We also appreciate Javier Ale’s critical review of the manuscript.
Declaration of conflicting interests
There is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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Author biographies
Esther García-Escamilla has a BSc in Sociology and an MSc in Health and Social Research. She is currently a researcher at Health and Social Research Centre (CESS), University of Castilla-La Mancha (UCLM). Her research work is focused on Qualitative Research in Traditional Chinese Medicine. She has participated in qualitative projects relating regional and national calls.
Beatriz Rodríguez-Martín has a PhD in Health and Social Research, an MSc in Health and Social Research, a BSc in Social Cultural Anthropology and is a Registered Nurse. She is Professor (Assistant) of Gerontology and Research Methods at the University of Castilla-La Mancha (UCLM); Faculty of Occupational Therapy, Speech Therapy and Nursing; and researcher at Health and Social Research Centre (CESS), University of Castilla-La Mancha (UCLM). Her research work has focused on Qualitative Research in Health, Patient Health Experience, Public Health and Health-Related Quality of Life. She participates in national and international research projects and has written several scientific articles.
Vicente Martínez-Vizcaíno, MD, PhD, Director of the Health and Social Research Centre, University of Castilla-La Mancha, Cuenca, Spain, and Professor of Research Methods in Health Sciences, has supervised two PhD theses using qualitative methods and at this moment is promot-ing mixed studies that combine both qualitative and quantitative research approaches. He also collaborates as associate researcher at the Universidad Autónoma de Chile.
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What led health professionals to study and practise
acupuncture in Spain?
Journal: Health
Manuscript ID Health-15-0122.R1
Manuscript Type: Original Manuscript
Keywords: Complementary and alternative medicine, Grounded theory, Sociology of health in developing countries
Abstract:
Acupuncture is the widest spread practice of Traditional Chinese Medicine in the Western world. This confers special relevance to the experiences and circumstances of life to explain the health-illness process. Recent research has reported an increasing interest of Western health professionals in its
practice. The aim of this study was to map and understand the motivations of health professionals to study and practise acupuncture in Spain. A total of 27 in-depth interviews were conducted with Spanish health professionals training in and practising acupuncture. Participants were selected following a theoretical sampling. Grounded Theory Dimensional Analysis guided this research in order to obtain a theoretical explanation of the motivations of health professionals to study and practise acupuncture. Their motivations were focused on six categories: humanisation of medicine, acquiring additional therapeutic resources, efficacy and far-reaching healing potential of acupuncture, attraction to acupuncture philosophy, external influences (other professionals and relevant sources of information) and work-related motivations.
Our results show that health professionals were attracted to acupuncture because of the TCM worldview (a philosophical approach) and therapeutic benefits of acupuncture (a practical approach). Acupuncture offers the possibility to improve the healthcare assistance by transcending the reification of human beings resulting from the pre-eminence of the biomedical paradigm and facilitating cooperation between disciplines. Participants consider acupuncture as a complete medicine, not merely as a technique, and highlight the importance of traditional Chinese concepts to practise it.
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What led health professionals to study and practise acupuncture in Spain?
Key words: health professionals, acupuncture, motivations, qualitative research, in-depth interview
Abstract
Acupuncture is the widest spread practice of Traditional Chinese Medicine in the Western world. This
confers special relevance to the experiences and circumstances of life to explain the health-illness
process. Recent research has reported an increasing interest of Western health professionals in its
practice. The aim of this study was to map and understand the motivations of health professionals to study
and practise acupuncture in Spain.
A total of 27 in-depth interviews were conducted with Spanish health professionals training in and
practising acupuncture. Participants were selected following a theoretical sampling. Grounded Theory
Dimensional Analysis guided this research in order to obtain a theoretical explanation of the motivations
of health professionals to study and practise acupuncture.
Their motivations were focused on six categories: humanisation of medicine, acquiring additional
therapeutic resources, efficacy and far-reaching healing potential of acupuncture, attraction to
acupuncture philosophy, external influences (other professionals and relevant sources of information) and
work-related motivations.
Our results show that health professionals were attracted to acupuncture because of the TCM worldview
(a philosophical approach) and therapeutic benefits of acupuncture (a practical approach). Acupuncture
offers the possibility to improve the healthcare assistance by transcending the reification of human beings
resulting from the pre-eminence of the biomedical paradigm and facilitating cooperation between
disciplines. Participants consider acupuncture as a complete medicine, not merely as a technique, and
highlight the importance of traditional Chinese concepts to practise it.
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Introduction
Acupuncture is the best known and widest spread practice of Traditional Chinese Medicine (TCM) in the
Western world (CAMDOC Alliance, 2010). This confers special relevance to the experiences and
circumstances of life to explain the health-illness process. From this approach, human beings form a
whole in which physical, emotional, social and spiritual dimensions are indissoluble (Padilla, 2001).
Acupuncture has been recognised by the World Health Organization (WHO) as an effective therapy for a
variety of conditions such as depression, rheumatoid arthritis, neurological disorders, asthma, allergic
rhinitis, biliary and renal colic, blood disorders, dysentery and gout. It was also acknowledged for the
treatment of pain and drugs and postoperative side effects (WHO, 2002).
An increasing interest of Western health professionals and medical students for acupuncture has been
reported in the last few years (Bjersa et al, 2012; Chaterji et al, 2007; Fanì et al, 2014; Van Haselen et al,
2004). The European Parliament considers acupuncture practitioners as a health workforce and highlights
the need for further research in acupuncture considering also the perspectives of health providers
(European Commission 2008 and 2012, Ministerio de Sanidad, Política Social e Igualdad Pública, 2011).
According to the Complementary and Alternative Doctors Alliance, approximately 80.000 physicians
practise acupuncture in Europe (CAMDOC Alliance, 2010). The main reasons for this interest are adverse
drug reactions, medical iatrogenesis and search for different explanations of illness (García-Escamilla et
al, 2015). Other reported motivations include patients’ lack of responses to conventional treatment,
absence of treatments and personal request of patients (Van Haselen et al, 2004). In this line, some health
professionals conceive acupuncture as a complementary therapy that may supplement and add benefits to
conventional treatments such as pre/postoperative patient care, depression and rheumatoid arthritis
(García-Escamilla et al, 2015).
Biomedical trained health professionals approach acupuncture in a variety of ways (Frank and Stollberg,
2004). In some cases, acupuncture is incorporated into the biomedical practice as a simple technique
rejecting the metaphysical explanations in which it is founded. On other occasions, health professionals
embrace TCM concepts including its metaphysical and anthropological vision. Although between the two
lies a complex array of forms, they are never entirely disassociated from traditional knowledge
(Kaptchuk, 2002).
Estimations of the prevalence of use of acupuncture among the population in the United States of
America (USA) and Germany are 6.3% and 14.5% respectively (Bücker et al, 2008; Zhang et al, 2012).
The discrepancy in relation to these estimates can be explained by the behaviour of the health insurances
in each country. The National Health Insurance and private insurance companies covered acupuncture
treatments in Germany but not in the USA (CAMDOC Alliance, 2010). In Spain, where acupuncture
treatments are also not covered by the public and private insurances, these figures reached 7.4%, similar
to USA (Observatorio de las Terapias Naturales, 2008). Benefits associated with acupuncture by the
Spanish population were to treat human beings from a holistic point of view, prevent and cure physical
and emotional diseases and the absence of side effects. Compatibility with and supplement of
conventional treatments were also emphasised (Observatorio de las Terapias Naturales, 2008).
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In Spain, there is not a state regulation regarding acupuncture practice neither an official register of health
professionals practising it. Health centres should be registered as a Non-conventional Therapy Unity in
order to provide acupuncture treatments and other natural therapies, under the responsibility of a
physician. On the other hand, non regulated health professional practitioners must be registered in the
Economic Activities Tax, which regulates their situation only for fiscal purposes (Alonso, 2008;
Ministerio de Sanidad, Política Social e Igualdad Pública, 2011). Although these treatments are not
systematically funded by the National Health Insurance, the current legislation supports its use within the
National Health System (NHS). Thus, there is a variety of initiatives to practise acupuncture among the
Public Health System (Ministerio de Sanidad, Política Social e Igualdad Pública, 2011). Moreover, a
variety of institutions offer training in acupuncture, such as university postgraduate programs, collegiate
organisations and private teaching centres (Ministerio de Sanidad, Política Social e Igualdad Pública,
2011). Some offer training in acupuncture founded in the Chinese tradition and permeated by Taoism
philosophy, such as The Nei Jing School, spread around the world, which does not specifically require
students to have health professional training (Escuela Neijing, 2015). Others offer courses from a more
biomedical approach only for university graduated health professionals, such as health professional
colleges and university programs (Ministerio de Sanidad, Política Social e Igualdad Pública, 2011).
Nevertheless, we did not find any school entirely disassociated from the TCM or Western medicine
concepts.
Previous quantitative studies have reported that the current interest of health professionals in acupuncture
could be due to different factors: patients’ lack of response to conventional treatments, absence of
conventional treatments, request of the patients, adverse drugs reactions and search for different
explanations of the health-illness process (Bjersa et al, 2012; Fanì et al, 2014; Van Haselen et al, 2004).
Nevertheless, there are few studies that explore in detail the motivations of health professionals to study
and practise acupuncture in Western countries. These motives have been recently collected in a
qualitative systematic review (García-Escamilla et al, 2015). Accordingly, nurses underline the
opportunity to develop themselves in a personal and professional way due to the emphasis on care and
holistic healing (Johannessen 2009, 2011), while physicians associate their motivations with convictions,
individual experiences on the effectiveness of acupuncture and personal knowledge (Marian et al, 2006;
Raynera, 2011). Existing research in the area includes different therapies with a disparity of
characteristics and ways of application which hinders the understanding of acupuncture particularities.
Moreover, it involves solely North-western European countries (García-Escamilla et al, 2015).
The aim of this study was to map and understand the motivations of health professionals to study and
practise acupuncture in Spain in order to reveal keys that may improve the quality of health care.
Methodology
Design
We used in-depth interviews and Grounded Theory Dimensional Analysis to collect, analyse and interpret
the data in our effort to investigate the motivations of health professionals to study and practise
acupuncture. This inductive method was chosen to obtain a theoretical explanation by analysing the
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health professionals’ conceptualisations of their motivations grounded in their experiences. According to
this methodology, data collection, analysis and theory are reciprocal with each one (Bowen, 2006;
Rodríguez-Martín et al, 2013; Strauss and Corbin, 1998). This allows the analysis of the data within the
context and the identification of concepts that explain the behaviour of participants.
Sample and date collection
We conducted 27 in-depth interviews with health professionals who had studied and practised
acupuncture. In particular, we interviewed physicians, nurses and physiotherapists because they are the
health experts most involved in this practice in Spain (Ministerio de Sanidad, Política Social e Igualdad
Pública, 2011). A theoretical sampling guided the sampling process in order to ensure that each new case
was appropriate for providing new concepts and clarifying relationships and logic among constructs. We
used a snowball sampling in order to triangulate this process. Interviews were audio-taped and transcribed
verbatim for subsequent analysis. All participants signed an informed consent after a detailed explanation
of the study provided by the main researcher (EGE). The data collection process was guided by the
analysis until the point of data saturation was reached, meaning that no new analytical concepts emerge
by broadening the sample (Silverman, 2011).
The inclusion criterion was to sample physicians, nurses and physiotherapists trained in acupuncture
based on the World Health Organization recommendations on basic training and safety in acupuncture
(WHO, 1999). We applied the recommendations of limited training for physicians (not less than 200
hours) to nurses and physiotherapists to ensure that the conceptions of our participants were well-
founded. We selected informants of both sexes, different age groups and professional backgrounds in an
effort to provide the broadest possible information. This maximised opportunities to discover
dissimilarities among concepts and to enrich categories in terms of their properties and dimensions. Table
1 shows a brief description of the characteristics of participants.
After providing participants information about the study, we made an appointment. All interviews took
place in a quiet and private environment and were conducted by the main researcher (EGE). Each one
started out with an open-ended question about their professional and personal background up to the point
where they started to practise acupuncture. Through them, we could gather real-life stories of participants
which allowed us to understand the emotions, conceptions and contexts that influenced their decisions.
Although the interviewer had a topic list that could emerge openly throughout the interviews (see Table
2), she intervened as little as possible in order to let participants freely express their own history. The
topic list was refined and guided by the theoretical sampling. Interviews were conducted between April
2013 and May 2015 and lasted from 35 to 60 minutes. All of them were audio-taped using a digital
recorder, rendered anonymous and literally transcribed.
Data analysis
Data collection, analysis and interpretation were simultaneously undertaken in an interactive process.
Each transcript was analysed before a subsequent interview took place in order to assess the point where
data saturation was reached (Silverman, 2011). Transcripts were analysed line by line to identify concepts
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that explained the motivations of health professionals to study and practise acupuncture. To do this, we
used the qualitative software program Atlas.Ti 5.2.
The identified concepts were labelled and classified into categories using an open, axial and selective
coding process. We started by creating tentative labels for chunks of data just based on the meaning that
emerged from the data (open coding). After that we identified relationships among the open codes (axial
coding). Finally we figured out core variables that included a set of data and selectively coded any data
that related to the core variables (selective coding). The constant comparison method was used to identify
the latent pattern in the perspective of participants. This also implied continually going back and forth
among the interview transcriptions, analytical memoranda and review literature. Each code was
continuously compared with all other codes in order to identify similarities, differences and general
patterns. Themes and categories gradually emerged from a minor level of abstraction to a major one
(Strauss and Corbin, 1998).
Based on this, we constructed categories which explained the motivations of health professionals to study
and practice acupuncture (see Table 3).
Rigour
We carried out a variety of strategies in order to ensure the reliability and validity of the analysis, such as
ensuring methodological coherence, sampling sufficiency, developing a dynamic relationship between
sampling, data collection and analysis, thinking theoretically, and theory development (Morse et al,
2002). According to the aim of the study, we chose a methodological approach (Grounded Theory) and a
data collection technique (in-depth interviews) that allowed us to understand the phenomenon
(motivations of health professionals to practise acupuncture) in the light of the meanings attributed by the
social actors. Through them, we could also understand the context, emotions, actions/interactions that
influence their conceptualisations. Sampling continued until the point of data saturation was reached.
Interviews were literally transcribed and analysed in the full context. We examined the transcriptions line-
by-line and interpreted them one by one. The analysis was led by the constant comparative method and an
interactive relationship between data, analysis and interpretation.
We used data and investigator triangulation techniques to increase the validity and to mitigate biases in
the study. The sample included participants of different ages, genders and backgrounds. Theoretical
sampling was also triangulated using a snowball sampling. The data was analysed independently and then
agreed by two researchers from different disciplines (EGE: Sociology, BRM: Nursing and Anthropology)
who inspected the phenomenon from multiple perspectives. Any disagreement was referred to a third
researcher (VMV: Medicine).
Results
Six main categories emerged from the analysis of the motivations of participants to study and practise
acupuncture: searching for a more humane medicine, acquire additional therapeutic resources, efficacy
and far-reaching healing potential of acupuncture, attraction to acupuncture philosophy, external
influences (other professionals and recognised sources of information), and work-related motivations. For
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a better understanding, we include the most representative verbalisations after translating them from
Spanish to English. As meanings may be distorted during the translation process, we provide an accurate
translation of the quotations respectful to the original meaning rather than a strict literal one. Translations
were corroborated by a bilingual translator and an English mother tongue corrector. We also include a
table with the emergent themes, categories and codes (see Table 3).
Searching for a more humane medicine.
Participants considered that some aspects of biomedical and conventional healthcare are dehumanised.
They reflected on the aggressiveness of some treatments and procedures and the high-specialised,
bureaucratised and capitalised context in which conventional medicine is immersed and expressed their
dissatisfaction and disappointment regarding this issue. Therefore, participants were looking for a non-
harmful medicine which considers the patients as whole human beings. In this regard, they expressed
serious concerns about drug side effects, adverse drug reactions and medical iatrogenesis and highlighted
the lack of side effects of acupuncture treatments.
You realise that you do more harm than good because, as conventional medicine stands, the way
a research is conducted and the diagnosis procedures are harmful and invasive. The way to treat
is also invasive. It has many side effects. (…) That was how I started, searching for a new way to
practice medicine that wasn’t so harmful. But I have found acupuncture as a useful resource in
order to palliate, relieve, improve, and above all without major damage being done (Female,
Physician, 53 years)
I realised that people experienced or could experience side effects. This terrified me. I thought
“Well, I am prescribing a medication that causes different effects across people. Medication can
suit some people well or produces a set of symptoms or improvements. Other people don’t
improve and have different symptoms. Sometimes these symptoms became worse instead of better
and they experience things which they didn’t before taking the medication”. You enter in a
vicious circle in which you don’t control anything because it depends on the medication and how
it fits to the person. (Female, Physician, 58 years)
Participants pointed out that the healthcare assistance is immersed in a highly bureaucratised context
which produces an enlargement of the distance between health professionals and patients and impedes the
understanding of the health-illness process.
I think it is a lack of closeness. There is not enough individual knowledge of the patient. Lots of
moments are lost in data, papers and protocols. One has to see the patient, another as well, you
have to send him to one professional, then to another. The patient gets lost in between. (Female,
Physician, 58 years)
I was working in the out-patient department, which was the same type of the NHS. I thought,
“This is not the medicine I want to practise” because the patient was not actually treated but
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there were a lot of forms, institutional paperwork and statistics that were actually false. The
quality of care, the humane treatment of people, absolutely lost. (Female, Physician, 48)
Participants also highlighted that the excessive specialisation of the biomedical approach and the
healthcare assistance cause a fragmentation of the person.
Each specialist is dedicated to his/her area but where do you put all together? And something
that drew my attention, especially in older people, is the quantity of drugs that they take because
each specialist prescribes medication. It seems mad to me divide one person so much. What I
like about acupuncture is that it looks at the patient as a totality. (Female, Nurse, 57 years)
In this line, they considered that the biomedical approach does not focus on the person but on the disease.
It divides individuals into painful or diseased parts, which results in a reification of the patients. In their
opinion, the illness of the body is more of concern than the whole human being and its circumstances of
life. Therefore, patients are treated far away from a preventive approach.
There is still a trend to mark people not as a person but as injuries. (Female, Nurse, 62 years)
It is important to reassure the people. Talk with them, see how the person is and not only pay
attention to the heart problem, do an electrocardiogram and check the ST segment elevation, but
look at the person itself. What is happening to him, why does he need to smoke right after
leaving the hospital (…) We have to get further in these kind of things but we do not. We do not
solve the emotional problem that is causing him another heart attack two days later. (Female,
Nurse, 51 years)
They pointed out that the trend to reify patients is also evidenced by the medical language.
One learns pathology in Western medicine. A man with cirrhosis, “Ah, I have seen very beautiful
cirrhosis!”, “I have seen a very typical cirrhosis!” That is the language used among physicians,
“You must see the cancer I have seen!” How can you see a cancer when it is a man or a woman?
(Female, Physician, 48 years)
On the other hand, participants wished to transcend the conventional barriers between disciplines and the
high-specialised healthcare assistance. Physicians would like to be more involved in the implementation
of treatments and nurses and physiotherapists would like to contribute more in the decision-making about
clinical diagnosis and care.
I realised that I was a technocrat. I applied some techniques, which basically consisted of
implementing the pharmacological treatments prescribed by physicians. I actually could do little
for the patient. (Male, Nurse, 48 years)
Each specialist only deals with their own respective field. For example if you comment to a
digestive system specialist, “I have palpitations sometimes”, he would do a report and send you
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to the cardiologist. He does not deal with that because he doesn’t know how. (Female,
Physician, 58 years)
Moreover, participants also pointed out that the dependence of healthcare assistance on economic matters
results in a deterioration of the healthcare quality. In this regard, time constraints and the lack of empathy
in dealing with patients because of these issues were stressed.
The more patients you see, the better. Medicine has become a lucrative activity. (Female,
Physician, 48 years)
At a certain point, I could not deal with. I could not work. I had to see too many patients. That is
inhumane. Firstly, the person is not well treated, does not have good life quality and leaves
without being cured. You remain with a feeling of anger and thinking, “Oh my God, I have not
done my job”. And you morally say “My God, where are we!” (Female, Physiotherapist, 30
years).
Acquire additional therapeutic resources.
Another motivation of health professionals was the wish to learn new therapeutic resources. Participants
pointed out the limitations of current drugs and physiotherapy treatments. They felt that they were short
of therapeutic resources, which generated a sense of frustration among them because. Physicians
considered their own activity confined to dispensing prescriptions and treating symptoms. They found in
acupuncture a way to actually help and feel fulfilled through their professional practice.
We physicians are here to serve people. Many times you have a patient, you are constantly
prescribing him medication, each week, and he keeps coming. Patients are treated but not cured.
There is medication for every condition but actually it doesn’t work much. For me, it was if I
would find a way out because I saw a possibility to actually help through acupuncture. (Male,
Physician, 47 years)
In any case, you learn different techniques. But even with that I saw I was short in many cases.
You have the feeling that you can go further but you don’t have enough knowledge. (Female,
Physiotherapist, 32 years)
Our participants turned to acupuncture in the expectation of avoiding medication and treating patients in a
holistic manner. They considered acupuncture a great finding in their professional life.
What most surprised me at the beginning was the quantity of drugs that people needed. I thought
“if there is a different treatment in which people don’t depend on pills...” That seemed to me
very important. (Female, Nurse, 57 years)
This was a great discovery. I thought, “This actually is a comprehensive treatment” (Female,
Physician, 58 years)
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As noted above, participants highlighted the lack of side effects and contra-indications as an important
motivation in the practice of acupuncture. Moreover, they underlined the simplicity of acupuncture
implementation, which does not require a complex infrastructure and major economic investment.
I found something that did well without harming. (Female, Physician, 53 years)
The inefficacy of conventional treatments and their side effects in many of the diseases that I
treated was what pushed me to study different things [acupuncture and other natural therapies].
To me, the ease of applying acupuncture in some places and the cost of more expensive
medications represented further reasons. (Male, Physician, 71 years)
The possibilities of Western medicine and acupuncture to co-exist and complement each other motivated
them to study and practice acupuncture. In this line, some participants maintained that knowing both
medicines gives them an “expanded view” of health. Participants explained that acupuncture concepts
may be transferred and understood in biomedical terms and vice versa. They also emphasised that both
approaches may complement each other.
We have reached such a melting point that we can raise hypothesis to work energetically based
on scientific knowledge because magically it is possible interpret science’s discoveries in terms
of energy. It is logical because in the end both are talking about the same. (…) We collaborate
with that [the conventional treatment]. If you are undergoing in vitro fertilization treatment, we
work to bring the maximum quantity of blood and energy to the reproductive system. If you have
any allergy, we activate the body’s defensive system in a way that the antihistamine will be more
effective and the intakes less. (Female, physician, 53 years)
Some participants received an acupuncture training based on the metaphysical assumptions of TCM and
others lacked of these conceptions, but all of them handled traditional concepts. Beyond the personal way
to combine both medicines of each participant, they highlighted the importance of considering
acupuncture as a medicine, not merely as a technique. They considered that practicing acupuncture
implies a holistic view of the patient and handling TCM concepts. They emphasised the importance to
conduct a complete Chinese medical history before diagnosing and establishing a treatment.
With the time we realised that we are talking about similar things but with different language.
(...) One of the particular things of TCM is the holistic view of the person. I mean, you cannot
treat a headache with a formula. We get used to treat a headache with salicylic acid, a health
condition with a drug. Therefore, it does not matter what influence in this headache. You are
focused on remove pain… the Chinese say this is treating the branch but not the root of the
problem. You can do the same with acupuncture. There are points that are, say, analgesic. But,
usually a Chinese medical history should be done. (Male, physician, 58)
There are many courses and people who practise acupuncture handling few concepts. I think this
is very serious. I think it is not given enough importance to acupuncture which is a medicine
itself. I would not prescribe drugs because I do not know enough about it. I believe this is a
similar point. (Female, physiotherapist, 34 years)
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Besides the controversies over acupuncture integration in Western medicine settings, participants argued
that it is important to use all the knowledge available in order to help patients.
I perfectly coexist with my two medicines. Furthermore, I don’t have the feeling that they are
mutually exclusive, but rather I think there are complementary. (...) I have seen many
acupuncturists saying that only acupuncture works in many conferences and things like that. I
said, well, if only acupuncture works, every health professional would be an acupuncturist. But
there are problems that acupuncture does not solve. And the same, there are things that Western
medicine does not cure. (Female, physician, 53 years)
I do not like call it [acupuncture] an alternative medicine. I always mention all of them as
complementary medicines because I think the more weapons we have in order to fight disease,
the better. (Female, physician, 63 years)
If I do not know it, I should have to learn it and study because we are in this world and it is
important to know Western medicine although we practise acupuncture. (Female, nurse, 67
years)
On the other hand, participants pointed out that all dimensions of human beings influence each other in an
interactive way. For example, emotions have an impact on the physical body and vice versa. In this
regard, some of them turned to acupuncture searching for new therapeutic resources which enable them to
treat different health problems at the same time in order to obtain better results.
I realised that other factors influence the musculoskeletal system problems, for example the
stress. Usually when we see a patient, there are many issues and more things that are going on.
For example, the person can suffer pressure at work and digestive problems due to the
prescribed medicine... What interested me was the possibility to handle also these matters to
obtain better results in the physiotherapy treatment. (Male, Physiotherapist, 40 years)
Efficacy and far-reaching healing potential of acupuncture.
Participants approached acupuncture through a variety of personal and professional experiences. The
curative potential of acupuncture was one of the most mentioned reasons to study and practise it. Besides
experimenting acupuncture by themselves, participants met its effectiveness thorough a family member or
even through patients. They found out not only the therapeutic value of acupuncture in the treatment of
physical conditions, but also in the treatment of emotional, psychological and spiritual dimensions of
people. Moreover, acupuncture was considered as a useful technique for the treatment of chronic diseases
or in cases in which no efficient therapeutic remedies exist.
I experienced a great difference once I have started and continued the [acupuncture] treatment.
It was effective. I improved a lot physically and emotionally. As I was studying Medicine, I
decided that it was a very useful and effective therapy. Since I had benefited from it, I wanted
that more people could also do it. (Male, Physician, 65 years)
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I was also interested in acupuncture because I realised that the number of chronic patients are
rising. (Male, Nurse, 52 years)
Participants argued that acupuncture is relegated to treat incurable or difficult to cure diseases. In this
regard, they expressed a high degree of satisfaction, feeling proud and fulfilled.
I am very happy because, apart that it is my job, it is a huge satisfaction for me. I treat
pathologies that are incurable with the current treatments such as migraines, chronic
constipation, seasonal allergies, any type of pain, fibromyalgia, anxiety... Half of Spanish
workforce takes anxiolytics because of the circumstances in which they are living. This causes
the need for more and more because a person gets used to everything after a period of time. The
next drug has to be more powerful, the dose has to be higher and this is of course more
aggressive. (Male, Physician, 47 years)
People tried everything before seeking an acupuncture treatment. Acupuncture is the last
considered resource. That is why our satisfaction treating patients is double. (Male, Physician,
58 years)
Another identified reason that brought participants to acupuncture, was the interest in the emotional,
social and spiritual dimensions that affect the illness process. As we noted above, they sought to
overcome the fragmented vision of human beings.
I realised that everything was related to emotions, to the ability to express and understand why
something happened to you. Chinese medicine also was in the same line. (Female, Nurse, 51
years)
I started to study acupuncture because it is very holistic. This covers all aspects: physical,
emotional, psychical… (Female, Nurse, 44 years).
People think that acupuncture works for the treatment of migraine, pains, arthrosis, rheumatic
problems… Very limited things… But actually any pathology can be treated by acupuncture. The
spiritual part which involves the ideals, vocations, expectations, dreams, affections, loves and
the searching for something else that each person has is also treatable by TCM. Conventional
medicine cannot treat it. TCM makes a change of perspective possible and there are acupuncture
points that facilitate this psychical change. (Female, Physician, 48 years).
Attraction to the acupuncture philosophy.
Some participants searched for something else in both their personal and professional lives. They thought
there might be immaterial aspects that influence the health beyond the physical dimension of human
beings. Therefore, they were attracted by the energetic vision of acupuncture.
I was just in this spiritual search, like “there is something more, I do not believe that life is
reduced to birth, growth, reproduction, death, work very hard to get money and nothing else”. I
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was bored and I thought “This is not what I am looking for”. I started to look for other things
(…) I searched for the human spiritual dimension where the human beings are something more”.
(Female, Physician, 48 years)
I realised that something escaped me, something that I needed in both my personal and
professional life… deepening a bit more in the human being. I realised we are not only a
conglomerate of muscles and bones, but something else. (Female, Nurse, 62 years)
I agreed with this philosophy, because while working, we always ask ourselves questions. When
you are with a dying man, you always question your philosophy about life and death. When you
are with someone who has a pain or suddenly the person heals and nobody knows how it has
happened, you think, “Well, what has happened?” And you make questions and do research in
these kinds of things that are unconventional which do not fall into the statistics or into the
regular conventional medicine approach. (Male, Nurse, 52)
Others were attracted to TCM philosophy which, permeated by Taoist philosophy, constitutes the
foundation of acupuncture. In some cases, we found that participants considered the discovery of this new
approach as a revelation and embraced the TCM worldview. It proposes a style of life, an anthropological
model and an explanation of the health-illness process different from the Western point of view.
I felt aligned with the totalitarian vision of the human being placed in the universe and the vision
transmitted by the [Chinese] tradition of what is the life, how must that be lived, why we get sick,
what we have to do to do not get sick and be immortal. This is what the Nei Jing says, which is
the basic text of Chinese tradition, in its first chapter. (Female, nurse, 67 years)
Furthermore, we found health professionals who embrace completely traditional Chinese philosophy
ethical proposes adopting a dedicated and altruist lifestyle to serve people through the practice and
teaching of TCM.
There are people who do not understand the style of life I adopted because it goes beyond
acupuncture. I think the different way of life is what people reject the most. In the world we live,
a life dedicated to serve others, without objectives, without seeking to earn money, without have
a salary, is not understandable. (Female, Nurse, 67 years)
At one point continuing with my PhD studies did not make sense to me because I saw clearly that
I was directing to TCM. The school [in which she studied] not only promotes a profession, but a
way to live the life. I saw it was a new way to take life. (Female, Physician, 53 years)
Participants underlined that the vision of TCM about the health-illness process attracted them because it
highlights the importance of the style of life. They were looking for an explanation that takes into account
the social, emotional and spiritual dimensions of human beings beyond the biomedical paradigm.
The most attractive aspect to me was that there is not a patient-illness approach, but a person
involved in certain circumstances which have an impact… and then the pathology appears. It is
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not a pathology that a person has, but a person with certain circumstances that lead to
something. (Female, Physiotherapist, 32 years)
The Chinese Medicine approach is very different. The human being is treated like a person who
develops a certain pathology or disease at some point. The person is seen as a whole and it is
questioned why this person with a certain style of life, has developed a disease. Then the
cirrhosis of this person is not the same as the cirrhosis of another person, although the disease
of cirrhosis may be the same. (Female, Physician, 48 years)
They emphasised the positive conception of human beings in which, in opposition to the Western
approach, the body is not imperfect or decadent. In this way, some participants expressed that Western
medicine normalises the experience of some pains and accepts certain health problems without going into
detail. Therefore, TCM’s optimistic approach prompted them to study acupuncture.
The doctor just said to the person “It is like this. Menstrual pains happen by default, you have to
experience them”. The same happens with headaches “We have already tried all drugs at our
disposal and there is no way to remove this ache, so you have to stand it”, or “You are admitted
to the hospital each time you suffer a headache”. I looked for other things and I realised there
were other alternatives. (Male, Nurse, 52 years)
From the Western medicine approach it is natural that human beings get sick and die. From the
TCM approach what is natural is that the human being is designed and kept healthy. It is also
planned that it has a long life, even being immortal. Those are two completely different views:
one is based in sickness and death and the other one in health and long life. (Female, Physician,
48 years)
External influences (other professionals or recognised sources of information).
Participant motivations were also influenced by recognised sources of information or professionals, that
in their opinion, conferred credibility to acupuncture. This could happen as a result of a course, a medical
publication or the experience of other professionals.
I took a course on pain management here in the hospital. In the afternoon we had the surprise of
having Dr. Padilla among us [well-known physician and acupuncturist] who gave a talk about
pain. This man has founded the Nei Jing School and for many years, he had been working with
acupuncture building up a deep expertise. (Male, Nurse, 52 years)
She [another colleague] told me about her point of view, based on her experiences and on the
patients that she had treated. This seemed so curious and interesting to me, that I said “Well,
can’t I learn this?” (Female, Physician, 53 years)
In the medical journal Jano, I found an advertisement for acupuncture lessons given by Dr. Van
Nghi [well known physician and acupuncturist]. (Female, Physician, 63 years)
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In some cases, the experience and life-view of other health professionals deeply marked our participants
who experienced a great change in their life conception.
The fact of entering the school and knowing the Master [well-known physician and
acupuncturist] changed my life completely. It changed every aspect of my life. I mean my
perception of everything. On a personal level, it made my life turn around. (Female, Physcian,
58 years)
Work-related motivations.
Participants expressed a disappointment with the dependence of health assistance on economical issues
linked to a deterioration of patients’ healthcare and their working conditions. In this line, they stressed the
time constraints in conventional settings. They saw in the practice of acupuncture a way to achieve
personal and professional fulfilment.
That is why it attracted me… this fulfilled the expectation I had when I was younger to help
others. I saw Western medicine was not… it was very focused on business and economic benefits.
(Female, Physician, 48 years)
Some participants looked for an independent labour and a different way to organise work and healthcare
assistance.
What I do not like of the NHS is time restrictions. The advantage I saw in having my own
acupuncture practice was that I could manage my time. I could decide to earn less money and
not having a boss who may tell me “This consultation is from a private insurance and you must
see 15 patients this afternoon”. If I consider that a patient needs 1 hour, it takes 1 hour.
(Female, Physician, 53 years)
Discussion
As far as we are concerned, it is the only study carried out to ascertain the motivations of health
professionals to study and practice acupuncture in Spain. It is also one of the few qualitative
investigations about this topic. We provide an explanation of this phenomenon in terms of health
professionals’ experiences and circumstances regarding their healthcare practice. Our results show that
health professionals were attracted to acupuncture because of the TCM worldview (a philosophical
approach) and therapeutic benefits of acupuncture (a practical approach). In consequence, our participants
chose between acupuncture training based on Chinese metaphysical worldview or acupuncture approach
lacking these assumptions, but all of them handled traditional concepts such as Yin/Yang and the Five
Element theories (Moss, 1999: Padilla 2001).
We found that motivations of health professionals to study and practise acupuncture are founded in a
search for a non-harmful medicine and a humanistic approach which means that the circumstances and
experiences of life became a central aspect influencing the health-illness process. This search is guided by
their vocation to help others. The dissatisfaction with their healthcare practice underlay this search which
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is explained in a context of bureaucratisation, specialisation and capitalisation of medicine. In this
context, participants consider that human beings are reified and the medicine dehumanised. A
disappointment with the healing potential of the conventional treatments was also emphasised together
with the aggressiveness and side effects of certain conventional treatments. Additionally, the search and
attraction to another explanatory model of the illness-process, which takes the emotional, psychological,
social and spiritual dimensions of human beings into account, is pointed out. Health professionals look
for safe and effective therapeutic resources, a holistic approach for the health-illness process, and a way
to transcend the traditional division between disciplines.
Our study reveals the possibility to translate concepts between acupuncture and conventional medicine as
a key for their integration. Despite the difficulties of integrating both paradigms due to each different
worldview and the dominance of biomedicine paradigm explained by the devaluation, subjugation,
degradation and adaptation of non-Western knowledge by Western culture (Adam et al, 2009; Hollenberg
and Muzzin, 2014; Vandana Shiva, 1997), our results show the possibility to integrate acupuncture and
biomedical concepts in order to collaborate and improve the health. In this regard, it is appreciable the
labour of professionals who investigate the acupuncture tradition and establish bridges between both
medicines (Maciocia, 2007; Padilla, 2006; Van Nghi, 1987). Although health professionals in this
research study and approach acupuncture from different views, all of them share the perception of
acupuncture as a complete medicine, not merely as a technique, and highlight the importance of
traditional Chinese concepts to practise acupuncture. Moreover, the results show how philosophy and
practice are interconnected because applying acupuncture treatments involves embracing a holistic
approach and TCM concepts (Kaptchuck, 2002). This does not support the Western medical acupuncture
tendency to avoid completely the traditional Chinese knowledge. This is not interested in acupuncture
diagnosis and consequently treatment. It uses formula of classical/recognised points to treat similar
conditions (Adrian White, 2015).
In line with previous studies, our findings showed that modern medicine can neglect the humane
dimension including the social and relational context, the personal development, as well as feelings and
emotions experienced by any person (Goswami, 2008; Le Breton, 2008; Lipton, 2005). The high-
specialised healthcare assistance model ruled by the biomedical paradigm results in a fragmentation and
reification of human beings, which are not considered as a whole person, but in terms of painful or
sickness parts (Le Breton, 2008). The dysfunctional consequences of the ongoing specialisation have been
pointed out. The process of specialisation fails to understand each phenomenon in a more inclusive
context and it also impedes the collaboration between disciplines (Kaplan, 2007). In this regard, our study
reveals that acupuncture may be a useful approach to achieve an integrative healthcare because it enables
professionals to transcend the traditional division between professionals and disciplines.
Moreover, the mechanistic vision of human beings in which the biomedical approach is based, explained
illness in terms of external toxic agents or malfunctioning of the organism (Goswami, 2008). Healthcare
professionals seek to overcome this approach, which is consistent with other studies that underline the
motivation of health professionals to enrich their vision of health considering other paradigms (García-
Escamilla et al, 2015; Yeh et al, 2008). In this concern, our results support other studies that relate the
benefits of acupuncture not just to improvements in physical symptoms, but also in the emotional state,
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quality of life and well-being (Deng et al, 2004; Deng and Cassileth, 2009; Kemper et al, 2000; Vas et al,
2004).
From the isolated and unsystematic experiences of acupuncture integration into the Spanish NHS, we may
deduce that other Western countries are more practical and open towards including different paradigms at
the institutional level. For example Germany, where 77% of the clinics dedicated to pain management use
acupuncture and the United States of America, where 20% of hospitals offer complementary therapies
(Flaherty and Takahashi, 2004; Grant, 2014). Furthermore, most of the participants of this study have
practised Western medicine among the NHS and acupuncture in the private sector. Generally, they do not
practice acupuncture in Western medicine settings but in acupuncture clinics. This may be explained by
the pre-eminence of the biomedical paradigm in the Spanish healthcare assistance. According to the
results of integrative medicine social research, we found that acupuncture practice in conventional
settings is relegated to cases in which Western medicine does not offer effective treatments (Adams,
2009; García-Escamilla et al, 2015).
Findings of this study are consistent with other studies, showing that there is a serious concern about the
adverse drug reactions and medical iatrogenesis among health professionals, as well as about the
limitations of medicine due to its subordination to economic interests (García-Escamilla et al, 2015;
Gøetze, 2014; Null et al, 2011; Sheldrake, 2012). The lack of acupuncture’s adverse effects and the lack
of conventional and satisfactory treatments for some conditions are also underlined as reasons for the
interest of health professionals in acupuncture (Van Haselen et al, 2004; Zhang et al, 2010). Nevertheless,
participants highlight that the healing potential of acupuncture treatments goes beyond these fields.
In contrast with certain studies, we do not find the demand of patients (Cant et al, 2011; Frank and
Stollberg, 2004; Joos et al, 2008; Marian et al, 2006; Schroer et al, 2009; Yeh et al, 2008) and the
scientific evidence (Van Haselen et al, 2004) as main reasons for the interest of the health professionals in
acupuncture. All participants highlight the importance of the effectiveness of acupuncture treatments,
although it is perceived by their own experience rather than by the scientific evidence (Hansen, 2012).
Despite the fact that our results cannot be extrapolated to other realities with different characteristics from
the studied sample, the findings show an analytic wealth by including participants with different
demographic features. However, the context of bureaucratisation, specialisation and capitalisation of
medicine in which the analysed speeches became meaningful, is spread around the world (Le Breton,
2008; Lipton, 2005; Sheldrake, 2012). Therefore, our findings may provide keys to improve the quality of
healthcare not just for Spain. The lack of critical approaches to acupuncture is another limit of our study.
Nevertheless, it provides constructive keys for the collaboration between acupuncture and Western
medicine.
Our findings are relevant because they evidence the need to revise the Western Healthcare Assistance
Model and the biomedical paradigm. Participants emphasise the potential of acupuncture to complete the
fragmented and objectified view of human beings because it allows them to understand the experiences
and circumstances of life that influence the health-illness process. This establishes the basis for a
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preventive medicine while providing non harmful therapeutic resources and establishing a close health-
professional relationship.
Motivations of health professionals to study and practise acupuncture highlight the need for further
research in order to find ways to facilitate and establish constructive dialogues between acupuncture and
conventional medicine. This may help to include the acupuncture humanistic approach and therapeutic
benefits into Western healthcare assistance. The relevance of overcoming the biomedical approach in the
Spanish clinic practice which emerged in this study implies an enrichment of everyday practice with other
perspectives and therapies while giving more emphasis to the life experiences and circumstances of
patients. It is also necessary to promote qualitative research on acupuncture effectiveness to distinguish its
holistic benefits (Verhoef el al, 2006). It would be helpful to conduct cost-effective investigations in order
to assess the economic benefits of acupuncture integration in Western countries, which experience
increases in chronic diseases related to Western life style and ageing population. The impact of the
economic crisis represents another problem, especially in Mediterranean countries (Silva et al, 2015;
WHO, 2011). Moreover, it would be interesting to address critical approaches of health professionals to
acupuncture practice.
Conclusion
The motivations of health professionals to study and practise acupuncture are based on a search for a
more humane medicine and therapeutic resources in a context of excessive specialisation,
bureaucratisation and capitalisation of Western medicine. A serious concern about adverse drug reactions
and medical iatrogenesis among health professionals, accompanies this search. Moreover, acupuncture
offers the possibility to transcend the biomedical paradigm, which produces a reification of human
beings, and improves the healthcare assistance by facilitating the cooperation between disciplines and
professions.
The results may contribute to the development of health programs considering the point of view of health
professionals practising acupuncture. The inclusion of lifestyle considerations as a feature of acupuncture
may be relevant for the everyday clinical practice and for the establishment of preventive programs. It
considers not only the conditions in which we live but also how we are living our lives (perceptions and
conceptions of events, expectations, vocations, ideals, affections, meanings we ascribe to our world, and
the emotional and cognitive state in which we experience the life).
Acknowledgements
We are very grateful to PhD. María Moreno and Aaron Peche for the formal revision and linguistic
correction of the manuscript. We are immensely grateful to Neijing School for thoroughly transmitting
the knowledge needed to develop this work. We would also like to thank participants for their dedicated
collaboration in the study.
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Table 1. Main characteristics of participants (N=27)
Characteristics Variables Woman Man
Health profession Physician 7 5
Nurse 6 2
Physiotherapist 5 2
Age 30-40 4 1
41-50 4 3
51-60 6 3
>60 4 2
Acupuncture training 200-300 hours 2 2
300-500 hours 7 2
>500 hours 9 5
Acupuncture training
approach
East Asian approach lacking of
TCM worldview
6 4
East Asian approach embracing
TCM worldview
11 5
Acupuncture practice Public sector 2 2
Private sector 11 3
Both sectors 0 4
Friends and family 3 0
Do not practice 1 0
TCM: Traditional Chinese Medicine
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Table 2. Topic list
Topic list
University formation as health professional
Training in acupuncture
Work experience
Professional motivations to study acupuncture
Personal motivations to study acupuncture
Way of acupuncture practice
Conception about the collaboration between acupuncture and conventional medicine
Comparative view of acupuncture and conventional medicine
Perceptions of acupuncture philosophy
Perceived barriers to acupuncture practicing
Preferences between acupuncture and conventional medicine
Training in other complementary medicines
Reasons to study and practice acupuncture among other complementary medicines
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Table 3. Codes and categories
Health professionals’ motivations to study and practice acupuncture
Searching for a more humane medicine
Medical specialisation
Bureaucratisation of healthcare assistance
Capitalisation of conventional medicine
Rejection of time restrictions
Dehumanisation of medicine
Searching for a non-harmful medicine
Avoid aggressive treatments and drugs
adverse effects
Lack of control of drugs side effects
Lack of treatment for emotional-affective
dimensions
Absence of contraindications
Lack of emotional care
Dehumanisation of care
Dehumanisation of language medicine
Inability to understand the whole person
Acquire therapeutic resources
Lower cost of acupuncture treatments
Simplicity of acupuncture application
Confined activity to prescribing drugs
Efficacy
Holistic benefits
Dissatisfaction with healing potential of
conventional medicine
Acquire therapeutic resources
Integral knowledge
Widen knowledge
Efficacy and far-reaching potential of
acupuncture
Effectiveness
Integral treatment
Acupuncture as a complementary therapy
Acupuncture as an alternative therapy
Treatment for conditions
Treatment of pain
Treatment of chronic diseases
Treatment of psychosomatic illnesses
Treatment of rare diseases
Treatment of immune system disturbances
and allergies
Treatment of psychological disturbances
Treatment of emotional sphere
Treatment of neurological disturbances
Treatment of digestive problems
Treatment of gynaecological conditions
Treatment of functional diseases
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Attraction for Chinese philosophy
Searching for something else
Energetic approach
Response to questions about life and death
Style of life
Vision of the transcendent one
Humanistic approach
Holistic approach
Importance of individualised treatments
Importance of life history
Importance of health professional-patient
relationship
Importance of experiences and
circumstances of life
Influence of other recognised professionals or
sources of information
Influence of relevant sources of information
Influence of colleges
Work-related motivations
Help others
Competitive work environment
Exploitative working conditions
Professional independence
Bad working conditions
Rejection of hierarchical healthcare
organisation
Time constrictions
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Collaboration between acupuncture and Western medicine:
The perspective of health professionals trained in
acupuncture in Spain.
Journal: Qualitative Health Research
Manuscript ID Draft
Manuscript Type: Research Article
Keywords: Holistic Care, Theory Development < Methodology, Sociology, Illness and Disease
Regions, Cultures, and Peoples:
Europe, Europeans
Methods: Grounded Theory < Research Strategies
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Collaboration between acupuncture and Western medicine: The perspective of health professionals
trained in acupuncture in Spain.
Key words: qualitative research, in-depth interview, acupuncture, health professionals, integrative
medicine, perceptions
Abstract:
The inclusion of acupuncture into conventional healthcare settings is being internationally considered.
The aim of this study was to understand the perceptions health professionals’ perceptions of the
collaboration between acupuncture and Western medicine in Spain.
A total of 27 in-depth interviews was conducted with Spanish health professionals who were trained in
and practice acupuncture. Grounded Theory Dimensional Analysis guided this research.
Four main categories emerged from the analysis of health: styles of practice, benefits of the collaboration
between acupuncture and conventional medicine, key factors for the cooperation and barriers to practice
of acupuncture into conventional healthcare settings.
Health professionals trained in acupuncture consider that taking both approaches results in the
improvement of the healthcare assistance. Acupuncture was valued because of its therapeutic properties
and proposals for personal development. Barriers to acupuncture and Western medicine collaboration
were related to the dominance of the biomedicine paradigm.
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Introduction
Acupuncture comes from Traditional Chinese Medicine (TCM) and is one of the most popular
complementary therapies in the Western world (CAMDOC Alliance, 2010). It is based on a unitary
conception of the human being and provides holistic treatments (Padilla, 2001; Paterson and Britten
2004). The insertion and manipulation of needles along specific body points is often used in conjunction
with other techniques such as moxibustion (heat stimulation), acupressure (finger pressure), massage and
lifestyle counselling (Kaptchuk, 2002).
The World Health Organization (WHO) recognised its effectiveness and recommends the inclusion of
acupuncture into the National Health Systems (NHS) in order to reduce the pressure of the high costs of
some conventional treatments. It is also contemplated in response to increasing chronic and degenerative
diseases (Kim et al, 2012; WHO, 2002, 2013).
Benefits of acupuncture in collaboration with conventional medicine have been evidenced in the
treatment of knee osteoarthritis, paediatric pain and cancer. These advantages were related to
improvements in physical and emotional symptoms, quality of life and physician-patient relationship.
Gain control over patient well-being, improvement of the immune system and reduction of drug side
effects were also reported (Arranz, 2006; Deng and Cassileth, 2009; Deng et al., 2004; Kemper et al.,
2000; Vas et al., 2004).
Austria and Germany offer acupuncture for the treatment of some types of chronic pain by the state
regulated health insurance carriers (Endres et al., 2007; Ots, 2010). It is also currently available in the
United Kingdom NHS (Thomas et al., 2003). In Germany, 77 per cent of clinics dedicated to pain
management use this therapy, and in the United States of America, 20 per cent of hospitals offer
complementary therapies including acupuncture (Flaherty and Takahashi, 2004; Grant, 2014).
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In Spain, 7.4 per cent of the population use acupuncture due to its holistic and preventive approach, the
absence of side effects and the possibility to complement conventional treatments (Observatorio de las
Terapias Naturales, 2008). In principle, this therapy is not included in the service portfolio of the NHS,
but there are some initiatives to practise it in some hospitals and primary health care settings, particularly
in the Andalusia Autonomous Community (Ministerio de Sanidad, Política Social e Igualdad Pública,
2011). Regarding the regulatory framework, Spanish health centres registered as Non-conventional
Therapy Units may provide acupuncture treatments under the responsibility of a physician (Ministerio de
Sanidad, Política Social e Igualdad Pública, 2011).
The European Parliament considers acupuncture practitioners as a health workforce and highlights the
need to further research in acupuncture considering the perspectives of health providers (European
Commission 2008, 2012). In this regard, perceptions of Western health professionals practising
acupuncture about its integration into conventional medicine have been recently collected in a systematic
review. Accordingly, the idea of cooperation between both medicines is grounded in the perception of
acupuncture as a complementary therapy, which may supplement and add benefits to conventional
treatments due to its holistic approach. Health professionals highlight the need to improve knowledge of
acupuncture among healthcare providers in order to support the recommendations of acupuncture and
facilitate constructive dialogues between both medicines. They also highlight the importance of
increasing the investigation on acupuncture effectiveness considering also qualitative studies and outcome
measures. Reported barriers to integrate acupuncture into conventional medicine are the primacy of the
biomedical paradigm and the subordination of medicine to economic interests. Health professionals
particularly refer to acupuncture in the case of chronic diseases and in cases where a lack of efficacy and
contraindications for conventional treatments are observed (García-Escamilla et al, 2015).
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Instead of a real integration between both medicines, acupuncture is generally adapted to the conventional
medicine practice and paradigm. The integration of acupuncture into the Western healthcare practice
tends to be problematic due to conceptual differences between the two approaches and the dominance of
the biomedical paradigm (Adams et al, 2009; Hollenberg and Muzzin, 2014; Lam and Sun, 2013).
Therefore, we refer to the collaboration in order to reveal constructive and practical keys for an
improvement of the healthcare assistance and also to avoid giving more importance to Western medicine
over acupuncture or vice versa.
Existing research in this area involves mainly North-western European countries. Further analysis of
health professionals’ perceptions of the collaboration between acupuncture and Western medicine may
reveal keys which can improve the quality of healthcare. This may also facilitate an effective and
universal healthcare assistance. It would be especially relevant in countries which experienced an increase
of chronic diseases such as Spain. This increase is the result of the Western lifestyle and the absences of
preventive healthcare resources (Gutiérrez et al, 2013; Silva et al, 2015; WHO, 2005).
The aim of this study was to understand the perceptions and conceptualisations of health professionals
training in both medicines, concerning the collaboration between acupuncture and Western medicine in
Spain.
Methodology
Design
This article is part of a larger study which examines the collaboration of acupuncture and Western
medicine through the perspective of trained health professionals in both medicines. We used in-depth
interviews and Grounded Theory Dimensional Analysis to collect, analyse and interpret the data. This
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inductive method was chosen to obtain a theoretical explanation by analysing health professionals’
conceptualisations. According to this methodology, data collection, analysis and theory stand in
reciprocal relationship with each other (Bowen, 2006; Rodríguez-Martín et al, 2013; Strauss and Corbin,
1998). This allows the analysis of the data within the context and the identification of concepts which
explain the point of view of participants.
Sample and data collection
We conducted 27 in-depth interviews with health professionals who had studied and practised
acupuncture. In particular, we interviewed physicians, nurses and physiotherapists because they are the
health professionals most involved in this practice in Spain (Ministerio de Sanidad, Política Social e
Igualdad Pública, 2011). A theoretical sampling guided the sampling process in order to ensure that each
new case was appropriate for providing new concepts and clarifying relationships and logic among
constructs. We also used the snowball technique to triangulate this process. Interviews were audio-taped
and transcribed verbatim for subsequent analysis. The data collection process was guided by the analysis
until the point of data saturation was reached, meaning that no new analytical concepts emerge by
broadening the sample (Silverman, 2011).
The inclusion criteria was to sample physicians, nurses and physiotherapists trained in acupuncture based
on the World Health Organisation recommendations on basic training and safety in acupuncture (WHO,
1999). We applied the recommendations of limited training for physicians (not less than 200 hours) to
nurses and physiotherapists because this allowed us to ensure that the conceptions of our participants
were well-founded. We selected informants of both sexes, different age groups and professional
backgrounds in order to provide the fullest possible information (see Table 1). This maximised
opportunities to discover dissimilarities among concepts and to make denser categories in terms of their
properties and dimensions.
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All participants received a detailed and complete explanation of the study and signed an informed consent
before conducting the interview, which took place in a quiet and private environment. We also conducted
eight telephone interviews. Each one started out with an open-ended question about their professional and
personal background before starting to study acupuncture. Through them, we could gather real-life stories
of participants which allowed us to understand their perceptions of the collaboration between acupuncture
and Western medicine. Although the interviewer (EGE) had a topic list that could emerge openly
throughout the interviews (see Table 2), the intervention was kept to a minimum in order to let
participants express freely. The topic list was refined and guided by the theoretical sampling. Interviews
were conducted between April 2013 and July 2015 and lasted from 20 to 60 minutes. All of them were
audio-taped using a digital recorder, rendered anonymously and literally transcribed.
Data analysis
Data collection, analysis and interpretation were simultaneously undertaken in an interactive process,
meaning that each transcript was analysed before a subsequent interview took place in order to assess the
point where data saturation was reached (Silverman, 2011). Transcripts were analysed line by line in
order to identify concepts that explained the motivations of health professionals to study and practise
acupuncture. We drew upon the qualitative software program Atlas.Ti 5.2.
The identified concepts were labelled and classified into categories using an open, axial and selective
coding process. We started by creating tentative labels for chunks of data based on the meaning that
emerged from it (open coding). After that, we identified relationships among the open codes (axial
coding). Finally, we figured out core variables that included a set of data and selectively coded any data
that related to them (selective coding). The constant comparison method was used for the identification of
the latent pattern in the perspective of participants. This also implied continually going back and forth
among the interview transcriptions, analytical memoranda and review literature. Each code was
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continuously compared to all other codes in order to identify similarities, differences and general patterns.
Themes and categories gradually emerged from a minor level of abstraction to a major one (Strauss y
Corbin, 1998).
Based on this, we constructed categories which explained the motivations of health professionals to study
and practice acupuncture (see Table 3).
Rigour
We carried out a variety of strategies in order to ensure the reliability and validity of the analysis such as
ensuring methodological coherence, sampling sufficiency, developing a dynamic relationship between
sampling, data collection and analysis, theoretical thinking, and theory development (Morse et al, 2002).
According to the aim of the study, we chose a methodological approach (Grounded Theory) and a data
collection technique (in-depth interviews) that allowed us to understand the phenomenon (health
professionals’ perceptions of the collaboration between acupuncture and Western medicine) in the light of
the meanings attributed by social actors. Through them, we could also understand the context, emotions,
actions/interactions that influence their conceptualisations. Sampling continued until the point of data
saturation was reached. Interviews were literally transcribed and analysed in the full context. We
examined the transcriptions line by line and interpreted them one by one. The analysis was led by the
constant comparative method and an interactive relationship between data, analysis and interpretation
(Morse et al, 2002).
We used data and investigator triangulation techniques to increase the validity and to mitigate biases in
the study. Sample included participants of different ages, genders and backgrounds. Theoretical sampling
was also triangulated using snowball sampling techniques. Data was analysed independently and then
agreed by two researchers from different disciplines (EGE: Sociology, BRM: Nursing and Anthropology)
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who inspected the phenomenon from multiple perspectives. Any disagreement was referred to a third
researcher (VMV: Medicine).
Results
Participants of this study received acupuncture training based on TCM medicine concepts such as Yin-
Yang, Zang-Fu and Five Elements theories. Some of them also embraced metaphysical, anthropological
and ethical assumptions of TCM, which are permeated by Taoism Philosophy. Participants used to
combine acupuncture treatments with other TCM resorts such as massage, moxibustion, acupressure, Qi
Qong and counseling. Some participants complemented their practice with other natural therapies such as
homeopathy, neural therapy, Reiki and Bach flowers. However, these therapies were generally applied on
the basis of acupuncture diagnosis.
Four main categories emerged from the analysis of health professionals’ perceptions of collaboration
between acupuncture and Western medicine: styles of practice, benefits of the collaboration between
acupuncture and conventional medicine, key factors for the cooperation and barriers to practise
acupuncture in conventional healthcare settings. For a better understanding, we include the most
representative participants’ verbalisations after translating them from Spanish to English. We provide an
accurate translation of the quotations respecting the original meaning rather than a literal translation.
Translations were corroborated by two correctors of English language. We also include a table with the
emergent themes, categories and codes (see Table 3).
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Styles of practice
We identified three types of practice depending on how health professionals combine both medicines in
their professional practice.
Practice in private acupuncture centres. Acupuncture represented the main activity for health
professionals practising in this context, who in general did not use conventional medicine treatments.
Most of our participants fall into this category. They considered that acupuncture approach gives them a
greater understanding of the health-illness process and the possibility to avoid the aggressiveness of
conventional medicine treatments. Nevertheless, they used Western diagnostic tests to support
acupuncture diagnosis and recommended conventional treatments if necessary.
When you completely understand TCM, you see things clearer than from a Western medicine
perspective. I always say, for example, if there is a urinary tract infection, we do the
[acupuncture] treatment but if it still hurts, “you must go to the doctor to get the prescription for
the medicine you need” because although I can, I do not use to prescribe. (Female, physician, 61
years)
I have found in TCM a resource to palliate, improve, relieve, and above all avoid harm, which
basically was what I rejected from Western medicine. (Female, physician, 53 years)
Practice in conventional healthcare centres. In this case, participants’ main activity was the conventional
medicine but they also included acupuncture treatments when Western treatments were not available or
did not produce satisfactory results. Therefore, acupuncture was considered as a last resort in line with the
predominance of the biomedical approach.
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We receive patients referred from the pain control unit, with rare pathologies, allergic
processes. They asked if I can help (...). Problems that were very long-standing and have become
chronic (Male, Physician, 58 years)
I propose acupuncture to patients with whom I have tried all type of physiotherapy treatment
that I know. They do not improve with them, so I suggest acupuncture (Female, physiotherapist,
42 years)
In this context, we also found out a particular but marginal way to practise among nurses and
physiotherapists as a result of biomedicine and medical dominance. This involved the disguised
acupressure practice in healthcare assistance in order to avoid conflicts with physicians and managers
who were not open to acupuncture practice.
I cannot practise acupuncture in my workplace. As I cannot use needles there or offer this
treatment openly, I slyly massage some acupoints. (Female, nurse, 53 years)
Practice in integrative medicine centres. Few participants worked in centres with an integrative
perspective of medicine which implied the combination of biomedicine and acupuncture treatments. In
this case, health professionals, especially physiotherapists, combined conventional and acupuncture
treatments at the same time or chose between the two, depending on what was considered most
appropriated for the patient. They did not consider one approach more important than the other.
We apply acupuncture instead of other analgesic physiotherapy treatments as one part of the
integration. But in other patients, who experience more problems apart of muscular ones, such
as digestive disorders, sleep disturbances, stress, and anxiety, physiotherapy would become a
supportive technique and the principal one would be acupuncture. I apply treatments in a
consistent and flexible manner (Male, physiotherapist, 40 years)
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Benefits of the collaboration between acupuncture and conventional medicine.
Participants perceived acupuncture as a complementary medicine because it may supplement and
improve the approach to health-illness process and treatments of Western medicine. In this line,
they highlighted the conception of acupuncture as an aid element due to its efficacy and far-reaching
potential. The vision of human beings and the health-illness process in which acupuncture is founded was
also pointed out.
The advantages of acupuncture collaboration with conventional medicine were related to the
improvement in quality of life, decrease of medication and aggressive treatments, avoidance of
intoxications in polymedicated patients, and enhancement of conventional treatments.
I consider acupuncture as a complementary treatment because it also enhances drug treatments.
We can decrease medication dosage and sometimes even stop it because it is no longer needed.
(Male, physician, 65 years)
We have been able to explain Western concepts from an energetic approach and give them an
energetic focus. Thus, we can cooperate in such a way that the patient is able to better endure
chemotherapy by improving body’s defence. We can support and we work in this way (…) “If
you are receiving an in vitro treatment, we work to improve the quantity of blood and energy
available in your reproductive system. If you have an allergy, we can work on your immune
system in such a way that antihistamines are more effective and you can reduce the dosage.
(Female, physician, 53 years)
As noted above, participants appreciated the integrated conceptual frame and the therapeutic resources
offered by acupuncture. In this regard, they considered acupuncture not only as a technique but as a
complete medicine able to treat any condition.
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The WHO has developed a list of pathologies that are able to be treated with acupuncture:
headache, pain, arthrosis, rheumatic problems… very limited things… and nothing else. But
actually all pathologies are able to be treated with acupuncture. (Female, physician, 48 years)
It is the only medicine that existed in China before, so everything can be treated by acupuncture.
(Female, physician, 63 years)
Physiotherapists emphasised the advantages of joining the physical therapy and acupuncture treatments,
especially in rehabilitation programs and in neurological conditions, whilst nurses pointed out the benefits
of including acupuncture treatments into the day to day healthcare practice such as preventing
complications and providing relieve.
In the case of neurological problems, I am referring to motion exercises, body exercises. We
obtain a faster body response if we apply both treatments [conventional physiotherapy and
acupuncture treatments]. (Female, physiotherapist, 32 years)
You can use them [acupuncture and other complementary therapies] individually in patients
with headache, vomiting, nausea. You can always use them in this kind of situations. I have
always done it. When it is said “apply medicine if pain”, I always use other techniques and when
the pain is relieved I do not use medicines. (Male, nurse, 48 years)
In addition, participants pointed out that acupuncture approach gives them a humanistic and holistic
vision of the health-illness process which explains and emphasises the impact of lifestyles and people’s
life experiences on the disease process. This vision allows them to consider the sickness as a process
which is influenced by the whole life experience of the person. Therefore, they felt more able to counsel
and help patients to become aware of the importance of conditions and perceptions of life for the health.
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I am interested in the person, not in the sickness itself. This is one of the differences: it is a more
global vision of the person, more humanistic. I have to contemplate the life history of the person
to understand how the disease has been developed. It is not just about applying some needles,
but also about giving another vision of the process, helping the person to see a possible reason
of the disease, what he/she can do to recover or to change the style of life. I mean, it is not only
about using some acupoints or some drugs, but about what the person can do to rethink his/her
way of life or to recover the health. (Female, physician, 48 years)
Participants considered that these aspects were of key importance to the doctor-patient relationship. In
this regard, participants expressed that this relationship has been deteriorated because conventional
medicine has developed a technological way to approach patients. The contact with the patient was
highlighted from the TCM perspective, which includes listening to the symptoms, how the patient feels,
how the disease appeared, observation of the patient (complexion, tongue, pulse, face, expression) and
palpation of the body, which was also the old way to conduct a diagnosis in the conventional medicine.
At the end, we do with TCM the same as physicians did when all of these devises or this
technology didn’t exist yet. They had to do a diagnosis based on what they saw, taught and
asked. Well, TCM keeps doing it. In my opinion, TCM makes you go back to being a real
physician in the sense that you must have contact, spend more time, and touch the patient. (Male,
physician, 58 years)
Participants explained that the contributions of acupuncture go much further than its therapeutic resources
and holistic approach. They perceived the philosophy and the way to understand life and human beings in
which acupuncture is founded as a healing element. The healing resources proposed by this philosophy
for the personal development and healing such as Qi Qong, meditation, breathing exercises, prayer and
creative activities were also pointed out.
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The teaching transmitted by the Chinese tradition is actually much broader. It requires a lot of
individual and spiritual work. It promotes many other things and healing resources at the service
of the health and the immortality of the being, such as any other creative activity: theatre,
singing, dance, music, painting, writing, poems, cooking, plants, minerals... any available
resource can be a healing resource. Everything will depend on the intention with which it is
used. (Female, nurse, 67)
Participants considered that taking both approaches is very enriching and results in an amplification of
their knowledge which is very useful to assess and advise people they treat.
When I see a patient I see the Western and the Eastern part and, therefore, I expand the
perspective to guide the patient a little bit more. They ask a lot, “Well, do you think I need a
surgery because that is what they told me”. So I can guide them: “We can wait a bit” or “Let’s
see” or “Yes, it is better that you have surgery”. (Female, physician, 48 years)
I realised that Chinese medicine used to have a holistic perception of patient and can relate all
aspects. It could refer different pathologies to the climate, emotions... This is a much more
complete approach. Chine medicine could understand why a patient becames ill. University
education just gives us a specialized view of the patient and from this point of view, it is
impossible to understand why the patient became sick. (Male, nurse, 48 years)
Key factors for the cooperation
The recognition of the complementarities between acupuncture and biomedicine was pointed out as a
relevant key factor for the cooperation. In this line, participants conceived acupuncture as an updated
medicine. New concepts of science and medicine could be translated into acupuncture terminology. They
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emphasised that it is still possible to understand new illness processes and deduce treatments from its
theoretical frame.
We have reached one point in which we can raise the hypothesis to work energetically. This is
based on scientific knowledge because surprisingly it is possible to interpret science’s
discoveries in terms of energy. This has led a research framework in our centre in which we
assimilate scientific knowledge and give it an energetic focus. (Female, physician, 53 years)
When we move one part of the body, everything moves because everything is interconnected. The
key idea is that the Qi is everywhere in the body, which allows to link Eastern energetic ideas to
Western mechanical ones. It is better when I merge both ideas from West and East. They make a
joint, one part and another part. (Male, physiotherapist, 50 years)
There are a lot of publications founded in traditional books or sources, in ancient ones (...) and
based on these, more and more research work is being conducted in order to find out where
acupuncture works at all levels. (Male, physicians, 65 years)
Although participants contemplate acupuncture as an alternative option in cases in which conventional
treatments are not effective or do not exist, they refused the terminology “alternative” and prefer
“complementary”. They conceived the last one more inclusive because it expresses the possibility to joint
efforts aimed to improve the health.
When there are not more Western medicine treatments, you think in other options. There are
very complicated situations such as tumours or autoimmune pathologies where drugs have many
side effects and you do not see any other way out. (Male, physician, 55 years)
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I do not like to call it [acupuncture] an alternative medicine. I always mention all of them as
complementary medicines because I think the more weapons we have in order to fight disease,
the better. (Female, physician, 63 years)
In this concern, participants pointed out that acupuncture treatments should be implemented on the basis
of TCM theories and diagnosis in order to achieve a real cooperation and get better results. Completing a
Chinese clinical history was also required for an effective collaboration between both medicines.
One of the particular things of TCM is the holistic view of the person. I mean, you cannot treat a
headache with a formula. We get used to treat a headache with salicylic acid, a health condition
with a drug. Therefore, it does not matter what influences this headache. You are focused on
removing the pain… Chinese people say this is treating the branch but not the root of the
problem. You can do the same with acupuncture. There are points that are analgesic. But,
usually a Chinese medical history should be done. To complete a diagnosis I have to ask about
every feature of each symptom because each one explains something about the problem. (Male,
physician, 58 years)
Another important point was related to the conventional healthcare assistance practice. The existence
of interdisciplinary work teams and clinical sessions was pointed out as facilitators for the collaboration
between acupuncture and Western medicine, because they allow health professionals to join knowledge
and efforts. The inclusion of a social approach into the health assistance was also identified as an enabling
factor for their cooperation. They considered that the collaboration would have more sense when health
professionals include a global approach to the patient, considering all human dimensions that influence in
the health-illness process (physical, emotional, social, psychological and spiritual).
We work in an interdisciplinary team where there is a physiotherapist, a health visitor, a nurse
and a geriatrician. That is what I like the most of my work, I do not depend on an orthopaedic
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specialist, I depend on a geriatrician. The physician of the nursing home is geriatrician and a
geriatrician has a more global vision of the person than an orthopaedic surgeon, who divides by
specialities or anatomic parts. (Female, physiotherapist, 42 years)
Participants perceived that a culture of acupuncture is emerging gradually as a result of experiences of
acupuncture implementation into conventional settings, which facilitate the collaboration between both
medicines in conjunction with the increment of acupuncture knowledge among health professionals.
At some level, we are creating a culture of acupuncture. The pain unit consults us in order to use
this resource. The physiotherapy department refers us patients with certain pathologies. Some
colleagues come to be treated. (Male, physician, 58 years)
Participants also emphasised the importance of the recognition of acupuncture at institutional level. In
this line, the evidence provided by clinical outcomes and the fact that this medicine has been maintained
over time, were mentioned as strong supports for acupuncture practising.
There must be a reason why this way of work and help it is maintained and why it is still useful
and keeps answering now, 7000 or 8000 years since we know there are vestiges of this practice.
It is neither due to what acupuncturists of twentieth century say. There have been many
generations not only of acupuncturists but of transmitters of this vision of life, human being,
illness and way to heal. (Female, nurse, 67 years)
The public demand was another identified aspect for the inclusion of acupuncture into conventional
medicine as well as the political will.
Public pressure is important because the demand is increasing in a geometric proportion (Male,
physician, 65 years)
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Participants mentioned the importance of some international initiatives for acupuncture recognition, such
as “The WHO Traditional Medicine Strategy: 2014-2023” and the inclusion of acupuncture in the list of
Intangible Cultural Heritage of the United Nations Educational, Scientific and Cultural Organization
(UNESCO).
The WHO published a report last year saying that the state members of the WHO have to
promote natural therapies and incorporate them into the health legislation. Thus, there is a big
support to include this kind of therapies into public health services. (Male, nurse, 48 years)
Barriers to the practice of acupuncture into conventional healthcare settings
Participants perceived that the pre-eminence of biomedical paradigm limits the cooperation between
acupuncture and biomedicine. As noted above, they considered that acupuncture is underestimated in
mainstream medicine because its healing potential is not valued and is diminished. They pointed out that
the trivialisation of acupuncture is evidenced by the existing stereotypes and prejudices in this field such
as the conception of acupuncture as a beauty treatment or a witchcraft practice. They thought that this
evidences the lack of acupuncture knowledge among health professionals.
People ask you trivial things, “look I have these spare tires here, do you think they would be
gone if you put me some needles?” (Female, physician, 58 years)
Well, the conference was a complete success. Only 8 out of 200 people stayed in the room. I
mean, (he laughed) only the people who were interested in this topic, in this way to talk, in this
way to approach, stayed there. The rest were typical, let’s say, conventional physicians and
nurses. All these things seemed to them as witchcraft. (Male, nurse, 52 years)
Participants considered that the dominance of the mechanistic and materialistic vision results in a
rejection of the energetic and spiritual approach of humans beings. In this regard, the consideration of
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acupuncture as a non scientific medicine was interpreted as another barrier. However, participants
emphasised that acupuncture is founded in the experience, supported by theoretical knowledge and
empirically verifiable.
Medical professionals are educated in a different way, everything they have seen is highly
specialised, very concrete, considered from a materialistic point of view, and they scarcely study
the importance of the emotional aspect. So they have to see the results of what you do first.
(Male, nurse, 48 years)
When you deeply study it [acupuncture] and see that it has a structure, a logic, a methodology
and it is fairly robust, you change your mind. Many meta-analysis, important studies in which is
evidenced the efficacy of acupuncture in a range of pathologies emerge, although this is not on
the agenda of most physicians. (Male, physician, 58 years)
On the other hand, participants experienced difficulties to implement acupuncture treatments in
conventional settings due to institutional barriers, such as the inflexible work organisation and the lack
of institutional support. They explained that the highly specialised and bureaucratised context, in which
healthcare assistance is immersed, impedes the collaboration between both medicines. They considered
that this is evidenced by time constraints and the rigidity of protocols which make the implementation of
non-conventional treatments difficult. The highly specialised development of the biomedicine and the
healthcare assistance were seen as obstacles to adopt a holistic approach because they avoid the global
conception of human beings.
In this public outpatient centre, there was no possibility [to acupuncture practice] because there
was neither time nor other options. You have limited time of consultation which is already
stipulated. (Female, physician, 58 years)
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Each specialist is dedicated to his/her area but where do you put all together? (Female, nurse,
57 years)
In this line, participants explained that the lack of time to achieve clinical sessions hinders the
communication among health professionals, which impedes the continuity of acupuncture treatments.
They also considered that the highly hierarchical organisation of conventional settings interfere in this
communication.
I have to register my treatments and the nurse who works after me does not understand what I
have done. There is not continuity and communication. (Male, nurse, 47 years)
Therefore, they perceived their own activity reduced to dispensing drugs and treating symptoms,
mentioning the economic interests of pharmaceutical companies as barriers for the inclusion of
acupuncture into Western societies.
I realised that I was a technocrat. I applied some techniques which basically consisted of
implementing the pharmacological treatments prescribed by physicians. I actually could do little
for the patient. (Male, nurse, 48 years)
I would like that it [acupuncture] could be applied, but a change in the mentality of doctors,
legislation, politic concepts, economic interest of pharmaceuticals and prescribing of
medicaments is needed. (Female, physiotherapist, 34 years)
Moreover, some participants perceived that acupuncture suffers a closure in mainstream medicine
because some health professionals conceive it as a threat for their activity.
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Sometimes there are also problems with Eastern medicine because it seems they are stealing
your job, but I say, “This is not necessary, we can work together in order to make things better.
(Female, physiotherapist, 32 years)
The integration has been a very slowly and difficult thing. There has been a lot of opposition and
many detractors in the medical field due to a lack of knowledge and competition. We have been
treated very contemptuously. (Male, physician, 65 years)
Discussion
As far as we are concerned, this is the first study which examines the perceptions of health professionals
regarding the collaboration between acupuncture and Western medicine in Spain. It is also one of the few
qualitative studies about this topic. Our findings reveal that health professionals trained in both medicines
consider that taking both approaches results in amplification of health professionals’ knowledge and in an
improvement of the healthcare assistance. In this regard, acupuncture was valued not only because of its
therapeutic resources but also for its proposals for personal development and healing such as lifestyle
recommendations, Qi Qong, meditation, breathing exercises, prayer, and creative activities. Barriers to
acupuncture and Western medicine collaboration were related to the dominance of the biomedicine
paradigm. However, acupuncture has been revealed as a new avenue of cooperation between
professionals and a way to transcend the traditional division between disciplines.
We consider that the most relevant key factors for the collaboration between both medicines found out by
our study are the capacity of acupuncture to be updated and the possibility to transfer concepts between
both visions. In this regard, the labours of professionals who investigate the acupuncture tradition and
establish treatments for current and new diseases based in this medicine is appreciable (Kaptchuck, 2002;
Maciocia, 2007; Padilla, 2006; Van Nghi, 1987). This shows how acupuncture is not stagnant and
represents a vast source of knowledge. We emphasise that participants do not refuse or underestimate the
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value of biomedicine and point out a way to supply, improve and transcend the limits of the Western
healthcare assistance.
Barriers to collaboration between both medicines revealed by this study are consistent with other
researches, showing that the pre-eminence of the biomedical paradigm and the inflexibility of Western
medicine settings results in an impossibility to apply non conventional treatments (Adams et al, 2009;
Hollenberg and Muzzin, 2014; Lam and Sun, 2013). The lack of acupuncture knowledge, communication
between professionals, teamwork and holistic approach are also relevant factors (García-Escamilla et al,
2015). Our study reveals that acupuncture represents a new avenue of cooperation between professionals
and a way to transcend the traditional division between disciplines. This is explained by its holistic
approach and its capacity to involve professionals in all of the stages of the healthcare assistance
including diagnosis, treatment and care.
Conventional medicine and biomedical paradigm are under intense critical spotlight because they do not
provide answers to many of the health-illness processes experienced by the population. The serious
concern about drug side effects and the subordination of medicine to economic interests also constitutes
relevant points (Goswami, 2008; Gøetze, 2014; Null, 2011; Sheldrake, 2012; Shiva et al; 1997). In line
with previous studies, results of our study draw attention to the fragmentised vision of human beings in
which Western medicine is based, which is evidenced by the vast medical specialisation. This is founded
to be failed for the understanding of the health-illness process because it does not address all aspects that
influence the health (Freidin, 2010; Kaplan, 2007; Le Breton, 2008). Furthermore, the mechanistic and
materialistic vision of health, which explains the illness in terms of external toxic agents or
malfunctioning of the organism, reduces the activity of health professionals to dispensing drugs and
treating symptoms (Goswami, 2008; Le Breton, 2008).
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Participants of this study value acupuncture not only as a technique but as a complete medicine which
does not support the tendency of Western medical acupuncture to ignore TCM physiology,
physiopathology and diagnosis (White, 2015). In contrasts, health acupuncture knowledgeable
professionals highlight that the unified conception of human beings of acupuncture may transcend the
fragmented vision of the biomedical approach providing consistent holistic treatments. This has been
pointed out previously (Freidin, 2010). Acupuncture approach may also restore the importance of the
lifestyle and the way in which we are living the life including our conceptions and perceptions of events,
expectations, vocations, ideals, affections, meanings we ascribe to our world and the emotional and
cognitive state in which each individual experiences the life (Padilla, 2001; Patterson and Britten, 2004).
These aspects establish the basis for a preventive approach. Furthermore, as a recent study supports,
acupuncture represents a no-harmful avenue of research (Zhang et al, 2010).
Although acupuncture is considered by the WHO and the European Commission as a relevant resource to
provide healthcare in countries that experience economical problems and increase of chronic diseases
(European Commission, 2008; WHO, 2005, 2013), complementary therapies are generally not included in
the university curricula of health professionals in Spain (Fernández-Cervilla et al, 2013). There are
Spanish health professionals who already have acquired this knowledge in private institutions and
academic postgraduate courses, but they are not fully applying acupuncture treatments because many
healthcare settings do not allow them. Therefore, the population is missing its benefits (Ministerio de
Sanidad, Política Social e Igualdad Pública, 2011).
Despite of the fact that our results cannot be extrapolated to other realities with different characteristics
from the studied sample, the findings show an analytic wealth by including participants with different
demographic features. As biomedicine and the Western organisation of the healthcare assistance are
spread around the world (Le Breton, 2008; Lipton, 2005; Sheldrake, 2012) our results may provide key
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factors to improve the quality of healthcare not just in Spain. Another limit of the study is the lack of
critical approaches to acupuncture collaboration with biomedicine. Nevertheless, these findings provide
constructive critics to the current situation of Western healthcare assistance, especially regarding Spain.
Results of this study pointed out the relevance to further qualitative research on acupuncture
effectiveness, in order to improve healthcare assistance. It is also necessary to enrich the point of view of
health professionals about the health-illness process through other paradigms. Conventional healthcare
institutions should also reveal the knowledge and capacities of their health professionals, which may
allow them to make use of the resources at its disposal.
Conclusion
Barriers to acupuncture and Western medicine collaboration are related to the dominance of biomedicine
paradigm and the rigidity of healthcare organisation. However, our study reveals the possibility to build
bridges between both medicines. Science and biomedicine can be understood and translate into
acupuncture concepts. Therefore, acupuncture is not stagnant and represents a vast source of knowledge
and research. It also proposes sources for personal development and healing such as meditation, breathing
exercises, prayer, lifestyle recommendations and creative activities.
Collaboration of acupuncture and Western medicine may contribute to improve the quality of the
healthcare assistance providing new ways of cooperation between professionals and healing resources.
Acupuncture is considered not only as a technique but as a complete medicine. It is a valuable resource to
transcend the biomedical paradigm and improve the healthcare assistance due to the unified conception of
human beings and its holistic treatments.
Acknowledgments
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We are very grateful to PhD. María Moreno and Aaron Peche for the formal revision and linguistic
correction of the manuscript. We are immensely grateful to Neijing School for thoroughly transmitting
the knowledge needed to develop this work. We would also like to thank participants for their dedicated
collaboration in the study.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-profit
sectors.
Declaration of conflicting interests
Authors declare that it no conflict of interest.
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Table 1. Main characteristics of participants (N=27)
Characteristics Variables Woman Man
Health profession
Physician 7 5
Nurse 6 2
Physiotherapist 5 2
Age
30-40 4 1
41-50 4 3
51-60 6 3
>60 4 2
Acupuncture training
200-300 hours 4 2
300-500 hours 4 1
>500 hours 11 5
Acupuncture practice
Public sector 2 2
Private sector 11 3
Public and private sectors 0 4
Friends and family 3 0
Do not currently practice 2 0
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Table 2. Topic list
Topic list
University formation as health professional
Training in acupuncture
Work experience
Professional motivations to study acupuncture
Personal motivations to study acupuncture
Way of acupuncture practice
Conception about the collaboration between acupuncture and conventional medicine
Comparative view of acupuncture and conventional medicine
Perceptions of acupuncture
Perceived barriers to acupuncture practising
Perceived facilitators to acupuncture practising
Preferences between acupuncture and conventional medicine
Training in other complementary medicines
Reasons to study and practice acupuncture among other complementary medicines
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Table 3. Perceptions of health professionals of the collaboration between acupuncture and Western medicine
Categories Subcategories Codes
Styles of
practice
Practice in private
acupuncture private
Acupuncture as a principal practice
Use of Western diagnosis tests to support acupuncture diagnosis
Practice in conventional
healthcare centres
Acupuncture as a supportive Western medicine therapy
Acupuncture as a last resort
Acupuncture as disguised practice
Practice in integrative
medicine centres
Combination of biomedicine and acupuncture treatments Equal consideration of both medicines
Benefits of the
collaboration
between
acupuncture
and
conventional
medicine
Acupuncture
supplements and
improves Western
medicine treatments
Potential treatment for any condition
Improvement of conventional treatments
Treatment of drugs side effects
Treatment of conventional procedures side effects (diagnosis tests, surgical
operations)
Treatment of pain
Treatment of chronic diseases
Treatment of psychosomatic illnesses Treatment of rare diseases
Treatment of psychological disturbances
Treatment of emotional sphere Treatment of functional diseases
Amplification of health professionals knowledge Improvements in patients’ quality of life
Holistic treatment
Contribution of holistic
and humanistic vision of
acupuncture to
conventional medicine
Energetic vision
Treatment from the origin of the disease Further consideration of the impact of the lifestyle on the health/illness
process
Further consideration of the impact of life experience on the health/illness
process
Improvement in the health professional-patient relationship
Further acupuncture
healing proposals
Personal development proposals (Qi Qong, meditation, breathing exercises,
prayer and creative activities)
Lifestyle changes
Key factors
for the
cooperation
Recognition of the
complementarities
between acupuncture
and biomedicine
Updated medicine
Translation of concepts between both medicines
Consideration of acupuncture as a complete medicine
Inclusion of TCM theories, diagnosis and clinical history in order to achieve a
real cooperation Consideration of acupuncture as a complementary medicine instead of an
alternative one
Changes in conventional
healthcare assistance
practice
Inclusion of interdisciplinary work teams Implementation of clinical sessions
Social approach to patients
Global approach to patients
Creation of “culture of
acupuncture”
Improvement of health professionals knowledge in acupuncture
Conduction of experiences in acupuncture integration
Institutional factors International initiatives for acupuncture recognition
Political will
Recognition of acupuncture (scientific, historical and empirical evidence)
Increase of public demand for acupuncture
Barriers to
practice
acupuncture
in
conventional
healthcare
settings
Pre-eminence of
biomedical paradigm
Lack of acupuncture knowledge among health professionals
Consideration of acupuncture as a non-scientific medicine
Underestimation of the acupuncture healing potential
Impossibility of acupuncture treatment continuity
Institutional barriers Lack of clinical sessions
Hierarchical organisation of healthcare settings
Lack of institutional support and recognition
Rigidity of healthcare work organisation (high medical specialisation, time constraints and inflexible protocols)
Economic interest of pharmaceutical companies
Personal barriers Conception of acupuncture as a threaten activity among some physicians
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