Health care practitioners from 25 different IHC Canadian clinics, four of which also took part in the qualitative phase of the project (the fifth clinic that was involved in Project I closed prior to the administration of the survey). The distribution of the responding clinics across the different MTHP groups of models as selected by the respondents is presented in Table . Overall statistical comparisons of the models according to the MTHP framework constructs (philosophy and values, structure, process, and outcomes) are presented in Table . Pairwise comparisons between groups of models as well as qualitative findings are discussed in the sections below.
Distribution of clinic models as perceived by the survey respondents
The survey measured the extent to which the practitioners believed in the benefits of interprofessional collaboration. This was used to verify whether diversity of health care philosophy and involvement of each team member increase when moving along the continuum (hypothesis Philosophy and values 1). This hypothesis was supported as respondents identifying themselves as being from group C clinics scored significantly higher on the beliefs in benefits measurement scale than the respondents from the group A models (p = 0.031). However, the overall difference was no longer significant when the respondents who chose not to pick a model of practice were added to the sample (p = 0.094). Similarly, no statistically significant difference was found between groups in the respondents' perception of their knowledge of each other's healing approach (p = 0.889).
Qualitative analysis of the data also revealed differences between models of practices in terms of the philosophy of the interviewees towards IHC, especially with regards to how they defined the practice and envisioned the place of IHC in the current Canadian health care system. In contrast to interviewees who classified their collaboration model as group A, a majority of the participants from more highly integrated practices (group B or C) emphasized that they were practicing health care according to a patient-centered approach where the multiple facets of wellness were considered, a notion that the former group did not bring up in discussions.
"Oftentimes your standard medical conventional treatment for certain ailments will treat the symptoms but, peripheral things [also] need to be addressed. [...] I think our current health care system is overwhelmed and I think that a lot of times we're doing damage control, but not in this clinic. I feel that the patients that walk into this clinic get the most cutting-edge care you can get because you get both sides of the coin without any animosity and that's what needs to happen for our medical system to progress. The doctors and naturopaths and osteopaths and chiropractors need to put their egos aside and work together for the betterment of the patients because that's what it's about." (Multidisciplinary clinic, Complementary and Alternative Medical practitioner [CAM1])
Similarly, the director of a group C clinic described his model of practice as follows: "[Our model is] effective and more real than the conventional model and is more attuned to complex multi-factorial chronic symptoms. [...] Every patient gets 5 acupuncture sessions, everybody gets 3 hellerwork sessions, everybody gets 6 counselling sessions and so on. What we do within those sessions is unique to the individual. (Integrative clinic, Biomedical practitioner [BM1])
Our results validated the second hypothesis pertaining to the Philosophy and values set on the reliance on a biomedical model. For example, in many instances participants in a group C model pointed out that their clinics were not offering two different kinds of medical health care services, but rather blended approaches to health care where the practitioners serve as guides for the patient's healing process.
Furthermore, we found that the terminology related to "evidence-based medicine", a concept often associated with the biomedical scientific culture, was common in the discussion with the interviewees from clinics similar to the group A models, but specifically from the group B models. These participants alluded to the fact that evidence-based medicine was central to the clinic's ethos. Some CAM interviewees associated an evidence-based clinical approach with rigidity and criticized it either as a limitation for their own practice or likened it to shackles for their conventional medicine colleagues. However, the interviewees in group C seemed to have a more open-minded view of evidence-based practice:
The important thing is that [the staff] have reasonable training in conventional work so they are not kind of wishy washy, New age-type-grounded, but that they also have to explore their own healing, for one reason or another, because it is only through the experience of process or finding their own healing that you ever understand the holistic perspective. [...] The only kind of learning you can do in regular medicine is to see something you have not seen before. What you learn [in integrative medicine] is to get rid of everything you ever learned. The only thing you learn is that everything you ever learned needs to be trashed. (Integrative clinic, BM1)
The first hypothesis referring to the structure construct corresponds to trust and respect among the team members (hypothesis Structure 1). Interpersonal trust between colleagues was found to be the lowest within respondents from the group A models when compared both to those from group B (p = 0.045) and to those from group C (p = 0.014). No significant difference was found between groups B and C (p = 0.720).
Different perspectives on structure emerged from the qualitative data. The relative simplicity of the structure of the visited clinic identified as collaborative was striking. As one interviewee expressed it:
"We are 4 people sharing the expenses of one centre, that's all. We share the business expenses, we share the rent, other than that we do not have any dependency. I don't even know when they come and when they go. [...] We do not work for each other." (Consultative clinic, BM2)
In contrast, participants from a group C model described the barriers met with regards to the clinic management of space and time (hypothesis Structure 2) as well as sustainability of the particular health care services offered to the clientele:
"We have a nutritionist on staff. If we do not refer to our nutritionist then she is sitting there in a room not making any money for the clinic and nothing works. So paying for the rent or the space and being a not-for-profit clinic, we have to make sure that we do not go under budget and just break even." (Interdisciplinary clinic, CAM1)
"I think [working within a collaborative setting] is more time consuming, because you basically increase your load of patient care since you not only work a full day of patients, you also possibly help with other patients. (Interdisciplinary clinic, CAM2)
With regards to the business plans of the different clinics approached for Project I, we also noted contrasting methods of reimbursement for the delivery of care. In the single consultative clinic (group A), CAM practitioners saw their fees reimbursed from patients' insurance plans and personal payments; whereas the physicians only invoiced the government for their services. In the three clinics corresponding to group B of the MTHP framework, we observed a mixture of reimbursement methods within each clinic. Even physicians sometimes invoiced the patients directly, especially when the care provided was not considered conventional medicine. In the group C clinic, all practitioners were paid directly by the patients or their insurance plans, whenever possible.
The clinical hierarchical structure (hypothesis Structure 3) was not found to differ between models as suggested by the framework and therefore, this hypothesis could not be supported by our data. For example, group B models were the only ones with either a clinical (biomedical) director or a board of chief executive officers. However, when this topic was discussed, all interviewees confirmed that this structure was in place for management purposes and did not interfere with clinical decision making. The two clinics in groups A and C included in the interviews did not have any formal chain of command in place. However, they were the two smallest clinics, with 6 staff members each, compared with a range of 8 to 22 in the other three group B models.
The survey results verified that knowledge sharing is closely related to the MTHP continuum (hypothesis Process 1 on communication within the team). The manner in which information and knowledge is gathered and then shared among practitioners was measured using two different scales. Information sharing was found to vary between clinics according to each pair of models (p = 0.017 between groups A and B; p < 0.001 between groups A and C; and p = 0.035 between groups B and C) in the direction expected according to the framework. The second measure, knowledge gathering, was found to differ significantly only between groups A and C (p = 0.006).
The degree of acceptance of sharing authority amongst the members of the team, and particularly the clinical autonomy of the biomedical practitioners of the team compared with the CAM practitioners (hypothesis Process 2) was not found to differ significantly between groups of models (p = 0.169). However, this was only one facet of practitioner autonomy. Independence in clinical decision making was found to vary slightly among the models. From the consultative clinic visited (group A), the independency of practitioners was confirmed in many instances during the interviews: "We all do our job and that's it. We don't have anything in common." (Consultative clinic, BM1). Additionally, we found that reliance on colleagues' opinion or services between the biomedical and CAM practitioners of the consultative clinic was almost nonexistent, which demonstrated important autonomy of the practitioners but little opportunity for synergy and building of trust within the team members.
In contrast, compromising was common in daily practice for a few interviewees working in other clinic models. "For the practicality of the program, the decision might be more specific, hormone first before getting to the other stuff. So, if that was really important to me I might be upset, right? And it gets back to the whole ego and working as a group. It is just putting aside what I would normally do or see as a priority. The group would have to come together; everyone has to make that compromise." (Interdisciplinary clinic, CAM3). However, this type of comment was not found to be consistent across the interviewees as most of them considered themselves independent of their colleagues. The data suggested that the loss of autonomy would be for the sake of better answering the patients' needs:
"I think the main thing is that it's the client who does the healing, we don't. It's helping the client explore what they need to explore. It's not a case of "This is the right way to do it." We would certainly share with each other things like, "This approach might work better with this person." But it's not having a lot of, I guess investment in being right about how it should be done. I guess our main thing, in a way, is trying to support people to make it a safe enough place for them to do the degree of letting go and exploring that thing." (Integrative clinic, CAM1)
Finally, we found that the level of conflict associated with collaboration, which we used as a proxy for the respect for the diversity of opinions among team members (hypothesis Process 3), was correlated along the continuum of models. In fact, conflicts within the team members seemed to occur more frequently within the group A models when compared to the group B models (p = 0.017), or to group C models (p = 0.012).
The purpose of the MTHP framework was to delineate various models of practice that could be useful for patients and practitioners. Hence, the theoretical hypotheses related to the outcome construct focused mainly on patient health outcomes and the cost-effectiveness of care. Projects I and II did not include any of the measures related to health care or financial effectiveness of the clinics.
An important outcome from a practitioner perspective, job satisfaction, was higher for the respondents identifying themselves with group C models compared to the group A models (p = 0.050). These later respondents also reported seeing significantly less opportunity for personal growth compared to the respondents in group C (p = 0.005). These findings did not completely agree with the qualitative data since the vast majority of interviewees reported being quite satisfied with their job regardless of the clinic model assigned for the purpose of this project. Practitioners in group C described their working environment to be challenging, less stressful and frustrating, and more collegial, friendly and healthy than other health care delivery settings they have or had worked in. On the other hand, we noted that the interviewees working in a clinic in group A were less explicit in terms of the benefits of interprofessional collaboration for themselves compared to the other interviewees; rather they tended to refer more often to the positive aspects of their collaborative practice from a patients' perspective.
When asked about their intent to leave the clinic in the next year, respondents who selected a group A model to represent their clinic were not as homogeneous in their intent to stay as the other respondents. Although we observed a significant difference between groups (p = 0.040), it did not remain significant when the model was imputed for the respondents who did not chose a particular model of practice (p = 0.074). Additionally, no significant differences could be found between groups when compared in a pairwise fashion. No conflicting findings were found from analysis of the interviewees' discourse. In fact, when this theme was discussed, most interviewees emphasized that this current position compared advantageously in many respects with other health care practice models they had worked within, currently or in the past.