Of the 143 accredited medical schools in North America in 2007, 16 met our inclusion criteria as having an academic PIM program (see Figure ). The reasons for starting a PIM program were varied. One hospital wished to be a leader in the field, while several programs were initiated in response to philanthropic interest. Programs experienced a variety of support from upper administrative and hospital management, ranging from “benign neglect” to “very supportive”. Two of the programs were the second ones to be initiated by a given individual: of these, one closed after the “champion” left, but the other remains active. The first program was initiated in 1991, the most recent, at the time of data collection, in 2007.
Location of included academic pediatric integrative medicine programs.
All programs provided clinical services, and 75% had both an outpatient and inpatient service. The most common conditions addressed by the inpatient services were cancer (64%), chronic pain (50%), and gastrointestinal or other chronic illness (28.5% each). The most commonly addressed outpatient conditions were cancer (57%), mental health (50%), and chronic pain or abdominal pain or headaches (42.8% each). Abdominal pain, mental health issues, and headaches were more commonly addressed in outpatient (42.9%, 50%, 42.9%) than inpatient services (14.3%, 0%, 7%). Two of the programs dealt solely with pain. Most programs served all children (0–16 or 0–21). One outpatient program did not see children under 3 and another saw primarily adolescents. Two programs continued to see chronically ill patients after they had become adults.
Referral experiences varied between centers. For example, self-referrals were accepted by 86% of outpatient vs. 57% of inpatient services. In one case, pediatric referral was required in order to create dialogue with physicians around CAM and to insure that patient load could be accommodated. Physician referral was preferred in the inpatient settings. One service only accepted physician referral because they did not want to be perceived as going behind any physician’s back, while another accepted self-referral if the patient’s insurance accepted it.
The gatekeeper model of having one person make care decisions predominates in both the inpatient and outpatient settings. Only one program had a team approach to inpatient care, while four programs had this for outpatient care.
The range of CAM services offered in inpatient or outpatient settings varied (see Table
). The most comprehensive inpatient oncology service provided acupuncture, acupressure, massage therapy, reflexology, aromatherapy, Reiki, herbal counseling, nutrition and yoga to all interested patients without contraindications. CAM practitioners who provided inpatient services included: massage therapists, acupuncturists, and a naturopath, a music therapist, an art therapist, and a yoga instructor. However, most inpatient services offered CAM therapies through conventional health care providers, who were not always licensed in the CAM modality that they provided. Some outpatient clinics offered on-site CAM services, but often patients were referred to CAM practitioners in the community who had been vetted is some manner. Acupuncture/acupressure, mind-body and energy therapy were the most commonly offered modalities in both inpatient and outpatient services. Energy therapy was available in 64% of inpatient programs but only 29% of the outpatient services. Further details are available in Table
Complementary and alternative therapies offered by pediatric integrative medicine programs in North America
Most common complementary and alternative therapies offered on site at 16 Pediatric Integrative Medicine programs*
Since their inception, the 16 programs had identified a total of only three adverse events: (i) a patient wanted only massage therapy but energy work (e.g. reiki) was also provided; (ii) minor bruising from acupuncture; and (iii) one patient had a post-traumatic stress flashback post hypnotherapy.
Personnel, policies and credentials
Nine programs operated with between 1 and 11 FTE divided among MDs, RNs, psychologists, nutritionists and CAM providers. Seven programs had less than 1.0 FTE clinical personnel, usually an MD.
There was a wide variability in methods for credentialing both conventional and complementary practitioners to provide CAM. Credentialing of acupuncturists, massage therapists and other CAM professionals varied substantially across the programs and between inpatient and outpatient services. Sometimes credentialing was an internal hospital process; other times it was external, for example, through state licensure. In one inpatient program the CAM provider came in under the auspices of a family “visitor”, but this meant that they could not chart their visit. In another case, an inpatient program with a physician provider of CAM was put on hold for six months in order for the physician to obtain the proper CAM credentials. Outpatient programs often referred patients to community providers vetted by the program’s physician or through word of mouth.
Programs stated the importance of making sure that the CAM providers were comfortable working within the conventional system and had some pediatric experience or formal training with children, and that the modalities chosen reflected the community’s interests.
Most of the programs had few, if any, policies and procedures in place at their onset, and a few lacked formal administrative support at the time of the interviews. Only 31% of programs reported having a policy on natural health products (NHP)/dietary supplements (DS), and these varied in what products were addressed. Existing natural health products policies included guidelines for pharmacy approval of patients’ herbal supplements as well as dietary supplement policies for outpatient/inpatient programs. Many of the programs indicated an interest in developing/obtaining institutional policies for CAM and NHPs. Clinical and administrative challenges were identified as barriers.
The 16 programs offered a variety of elective educational initiatives ranging from clinical electives for medical students and residents to community outreach presentations. Almost all (94%) described programs for residents in pediatrics and/or family medicine (25% of which were mandatory), 81% reported educational programs for medical students (19% of which were mandatory), 56% had training opportunities for fellows, and one program has a dedicated pediatric integrative medicine fellowship program. More than half (56%) offered continuing education opportunities for faculty and/or community physicians. One third (33%) provided programs for nurse and nurse practitioners, and six offered some education or training for families.
Only two programs offered research training: one mentored research projects, the other offered research-specific training in pediatric integrative medicine.
Educational strategies included: lectures, presentations (local, international, stakeholders, health professionals, general public), rounds, conferences, lunch & learns, information sheets, training at CAM schools, online educational resources, newspaper and magazine articles, and TV interviews. One quarter of PIM programs offered some online training.
Team members involved in PIM education consisted at a minimum of pediatricians, nurses, and medical students (undergraduate, graduate, and postgraduate). The inclusion of CAM practitioners was variable.
Most (81%) of the programs were interested in a collaborative pediatric training program, but identified funding and time as barriers. Two frequent comments were that: i) interest would increase with the presence of funding or ii) interest existed, but programs were already overwhelmed by current commitments.
Half of the programs had become inactive in research due to lack funding and/or time and resources. Research initiatives most commonly comprised health services research (50%) and randomized controlled trials (31%). Clinical research topics included massage therapy, antioxidants and music therapy for cancer patients; and guided imagery, hypnotherapy, Reiki, and acupuncture for chronic pain. Dietary supplements were also a frequent topic of research. No PIM program reported conducting basic research on CAM, though basic research may have been conducted in other departments in academic health centers.
Research funding was mostly obtained through peer-reviewed grants, foundations and philanthropy. Amounts ranged from tens of thousands to several million dollars. At the time of the interviews, no research funding had been obtained from industry.
Research was published in both conventional and CAM journals. Some programs emphasized the need to publish in mainstream medical journals in order to avoid “preaching to the choir” and to further educate the broader medical community on pediatric CAM.
Most PIM programs were located in an affiliated hospital or medical school and had some salaried employees. Space was a concern and/or a limiting factor for several programs. Funding came from varied sources: philanthropy, research grants, institutional, and tuition. Almost one third (31%) relied on fee-for-service income. Inpatient costs were often covered through integration into existing programs. Costs of outpatient programs were covered in a variety of ways: some by philanthropy, some modalities were covered by some insurance, some care was billed as a physician consult, and many fees were charged out-of-pocket on a sliding scale. Programs engaged in limited promotional activities; relying mostly on websites, presentations, and brochures. Two programs did no promotion: one because they could not handle more patients, the second because the administration asked them not to due to limited space and personnel. Two programs mentioned being supported by their institution’s marketing department. Only half of the programs reported engaging in strategic planning; those that did used regular business meetings, retreats, discussions with other subspecialties and developed 1–5
year plans with which to move forward.
Advice for starting pediatric integrative medicine initiatives
The most common advice offered for others considering developing an academic PIM program was to build slowly and to work within the conventional system: “utilize people already within the system and call upon them to be part of the team,” “go where you are invited.” This encompassed maintaining a strong professional reputation, not alienating potential allies by being adversarial: “no turf battles,” “avoid fights you don’t have to fight,” and basing decisions on sound evidence. It was also noted that having a champion, both within the program and within the other groups that the program dealt with (e.g., administration) was very important: “leadership vision – to be in a house that wants you.” Financial considerations were essential, and issues ranged from sustainability to the importance of looking for funding in non-traditional places, such as philanthropy. It was considered difficult to maintain the programs, particularly clinical endeavors, without additional outside support. One general piece of advice was to “Lay down some policies, guidelines, program structure before program launch.” Finally, establishing rapport through sound research was very important: “research is key – helps to gain acceptance.”