Background Internationally, physicians are integrating medical acupuncture into their practice. Although there are some informative surveys and reviews, there are few international, exploratory studies detailing how physicians have accommodated medical acupuncture (eg, by modifying schedules, space and processes).
Objective To examine how physicians integrate medical acupuncture into their practice.
Methods Semi-structured interviews and participant observations of physicians practising medical acupuncture were conducted using convenience and snowball sampling. Data were analysed in NVivo and themes were developed. Despite variation, three principal models were developed to summarise the different ways that physicians integrated medical acupuncture into their practice, using the core concept of ‘helping’. Quotes were used to illustrate each model and its corresponding themes.
Results There were 25 participants from 11 countries: 21 agreed to be interviewed and four engaged in participant observations. Seventy-two per cent were general practitioners. The three models were: (1) appointments (44%); (2) clinics (44%); and (3) full-time practice (24%). Some physicians held both appointments and regular clinics (models 1 and 2). Most full-time physicians initially tried appointments and/or clinics. Some physicians charged to offset administration costs or compensate for their time.
Discussion Despite variation within each category, the three models encapsulated how physicians described their integration of medical acupuncture. Physicians varied in how often they administered medical acupuncture and the amount of time they spent with patients. Although 24% of physicians surveyed administered medical acupuncture full-time, most practised it part-time. Each individual physician incorporated medical acupuncture in the way that worked best for their practice.
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Physicians around the world are integrating medical acupuncture into their practice in response to increasing demand from patients as well as promising research findings and positive results from clinical practice.1–6 A considerable volume of medical acupuncture research focuses on efficacy, which is unquestionably useful for understanding which conditions and diseases it can be used to treat. Although training is available, for example, through the British Medical Acupuncture Society (BMAS), it may be difficult for some physicians to maintain their skills. Understandably, training courses primarily focus on learning and practising new skills, rather than adaptation to practice. A few physicians have published useful insights about how they have managed to integrate medical acupuncture into their practice, while others may face significant challenges incorporating it.7–10 Not all physicians will have colleagues or mentors with whom to discuss integration, therefore research into how physicians incorporate medical acupuncture may provide a valuable source of support for physicians who want to change their practice.
Many physicians use a combination of research evidence and clinical experience to treat their patients' musculoskeletal problems and pain.7 ,11–14 Because medical acupuncture requires time and may not be covered by insurance or national health plans, busy physicians need to plan its incorporation, for example, by changing their physical space (eg, renting clinical space, adding more rooms), staffing (eg, hiring a nurse to remove needles), schedules (eg, rearranging appointments or adding extra clinics) or processes (eg, billing patients).8 ,15 Learning from their peers' experiences may influence the willingness of physicians to undertake training or help them decide whether they can feasibly integrate it into their practice.
The aim of this study was to examine how physicians have changed their practice to incorporate medical acupuncture, in order to help accelerate change for those who are considering introducing medical acupuncture but are unsure about how to do this.
This exploratory, qualitative study of physicians' experiences integrating medical acupuncture into their practice was approved by the Alberta School of Business Research Ethics Board at the University of Alberta in Edmonton, Canada (reference no. REA-1110). A convenience sample16 of 21 semi-structured in-person and telephone interviews with physicians practising medical acupuncture was conducted from 2007 to 2011. Potential participants were contacted through a local medical acupuncture course, internet searches, the websites of the International Council of Medical Acupuncture and Related Techniques (ICMART) and its various member societies including the BMAS (1150 physician members), the Australian Medical Acupuncture College (600 members) and the American Academy of Medical Acupuncture (AAMA; 1300 members) and, finally, physicians' websites. Authors of articles about integration of medical acupuncture were also approached. Snowball sampling was used, whereby physicians were asked to suggest colleagues who might be interested in participating.17 ,18 The intent was to interview a range of physicians, from those practising a few hours a week to those practising full-time, to understand the different ways that they had accommodated medical acupuncture. Physicians were invited to participate via email; those who volunteered to participate signed the consent form. The interviews were conducted in English. Some participants whose first language was not English were sent the questions in advance. One physician emailed some responses in French and these were discussed in English during the interview.
A semi-structured interview guide with open-ended questions was developed and tested on three physicians before the study (see online supplementary file 1). Open-ended questions can facilitate the sharing of stories and encourage participants to speak more freely about their personal experiences.19 All interviews were digitally recorded with the participant's permission. Physicians were asked questions about where they had undertaken their medical acupuncture training, how they had integrated it into their practice, and their relationships with patients. Where appropriate and as clarification, the researcher further probed participants' responses and asked additional questions.20 ,21
In addition, four participant observations were conducted in 2008 using convenience sampling.16 The author typically attended a 3–4 h morning or afternoon clinic, sat in a chair and took notes about what the physician said and did when they saw patients. Where appropriate and permitted by the physician, the researcher asked questions from the interview guide and also clarified what they said or were doing with the patient. Some physicians continued to talk with the researcher after the observations were finished. During the interviews and observations, all participants were asked if they had additional questions or information they would like to share.
The interviews were transcribed verbatim into password-protected Microsoft Word files by a professional transcriber who signed a confidentiality agreement. The researcher's notes and memos from the 20 h of participant observations were entered into Microsoft Word. Data were analysed in NVivo V.9 (QSR International, Melbourne, Australia).
The researcher read the interviews and participant observations line-by-line and wrote memos about emerging themes, items of potential interest and questions. As the first interviews were being analysed, the researcher noticed similar patterns of practice emerging and grouped these into: (1) appointments; (2) clinics; and (3) full-time practice. Open-coding was used to identify patterns within each model, first focusing on the words participants used.22 The core themes for each model were developed through interpretive coding from the open-codes.22 Constant comparison of the themes along with theoretical coding were used until a central category was identified.19 To avoid researcher bias, participants were asked for feedback about the three models as the data were analysed.
Based on the emerging patterns in the data and the researcher's memos, more detailed information about how physicians scheduled medical acupuncture appointments, the amount of time they spent with patients, and the location where they administered the acupuncture (ie, their office or a separate location) was collated. Exemplary quotes were used to illustrate the core themes and experiences of physicians in each model. Saturation was reached when no new codes or themes were found in the data. The researcher discussed the final three models with a physician practising medical acupuncture who agreed with the way they had been classified.
A total of 25 physicians participated. Twenty-one were interviewed (of 22 physicians contacted; response rate 95%) and another four engaged in participant observation. The length of the interviews ranged from 50 min to over 2 h, while participant observation of the four physicians occurred over 20 h; approximately 3.5 h was spent observing each physician (response rate 100%). In some cases, information was not available from the interviewee or participant observed and in these cases the researcher requested it by email. There was a small amount of missing data for a total of four physicians; one physician passed away, one retired, one did not respond to email, and one moved away.
Table 1 lists the characteristics of the 25 participating physicians. Seventy-two per cent were general practitioners (GPs) and 68% were male. Physicians averaged 33.8 years in practice and had worked for an average of 12.7 years before undertaking medical acupuncture training. They worked in 11 different countries on three continents: Europe (n=14), North America (n=10) and Australia (n=1). Physicians had completed training in 12 countries, including private training in China (table 2).
Physicians discussed how their practice had gradually changed over time as they integrated medical acupuncture. While four physicians had left their position to practise full-time, most administered it part-time. The following narrative illustrates how a physician's practice had evolved over 15 years and is followed by three quotes representing physicians' journeys to incorporation:
This physician initially began administering medical acupuncture during a patient's regular appointments and did not charge. He found that this was not enough time, thus he began to hold a half-day clinic in another location and charged patients. This was still not enough time to meet patient demand. He worked 50% in general practice and 50% doing medical acupuncture for 5 years. Then he moved into research full-time while practising medical acupuncture on the side. Currently, this physician administers medical acupuncture one half-day twice a week and patients pay a fee. (GP 11)
“…time and money [prevented me from taking formal training]. Then the kids were out of the house, there was more time, I was rising up in the ranks and [my] salary increasing, then that was not an obstacle… I thought if I do this training, I want to make it work… I have more patients than I can see, granted I don't work full time…the patients have charts that are an inch high. People come with photocopies of their western tests and we go through those and then do an interview about Traditional Chinese Medicine. I could not do my practice if I were not a physician.” (Geneticist)
“I stopped work as a regular anesthesiologist and worked only with chronic pain problems… I also started acupuncture research—it took ten years [to write] my thesis…then I started my own clinic. …I worked half time at the hospital and half time at my own clinic…then after five years or so, I worked full time in my own [private pain] clinic. …years later the hospital wanted me to come back and work…one day a week. …patients wanted [acupuncture] and then the hospital wanted it. They wanted me to come and…train doctors, physiotherapists and nurses… I was the main teacher and [continued] for about ten years. Then…I took those courses so I [hold] them now in my private clinic.” (Anaesthetist 1)
“Maybe 10 years ago I was shyer with colleagues to say, “Well, I do acupuncture”. It's part of my truth now so I just say it and I think there's been more of a global acceptance so I'm not finding the resistance. And mostly what I'm hearing is people saying, “Oh, I wanted to take the course. I just haven't found the time”. It's just, “Yeah, I'd like to take the course”. Mostly what I'm hearing…it's not the voodoo that it used to be.” (GP 3)
While many physicians had started practising mid-career, a handful had begun very early on in their career. Three physicians talked about their early influences:
“…my father, who is a medical doctor…said to me, “I think you have to do acupuncture so that patients can have the medicine that they need. …if you can balance the autonomic nervous system then it would help my patients”. …if you have your own practice for acupuncture then you are like a specialist and you can say when you want to see patients and when not… I started full time in '77… [Today], the more people are helping me, the more patients, the bigger the practice is growing… Formerly it was only for pains but now it is for emotions, for everything they are coming. If they don't feel so good, if they are disappointed at their work and they want to be strengthened.” (GP 7)
“I started [in the 1970s] with my Japanese master… I felt since I was an anesthesia pain specialist it would be important to formalize with the UCLA program before [I integrated it in 1997]. …even though I was very interested in acupuncture, I was also very interested in medicine. And I felt even at a young age that integrating the two would be the best approach and I think that's shown to be the case. …the patients have been glad I do what I do. Certainly the last 10, 20 years have been much easier in terms of the acceptance of acupuncture. Whereas early on I was probably considered a quack, now my colleagues—they're generally kind of interested.” (Anaesthesist 2)
“I…[spent] four months in China learning acupuncture… We ended up with about 30 other people… It was run in English. We learned all the acupuncture points and Traditional Chinese syndromes… We were the first formal WHO sponsored course in China for Western doctors… I had a vision of [starting a complementary medicine research group] ever since I'd been in China, which was approximately 20 years after.” (GP 10)
Some felt that medical acupuncture involved more than needling patients. Some physicians mentioned that they teach. Others volunteered with associations, conducted research and wrote books. A few said they regularly trained in China. One physician discussed how he had got involved in teaching:
“…while I was still a medical acupuncture student, my teachers asked me if I was interested in teaching in the future. And I thought about it and told them that I would be interested. So later on I met [GP 8] who was [my teacher]. And we talked more about it and I wanted to try to teach because I thought I would get better myself—I had to learn the [material] better to teach it to other people.” (GP 9)
Two physicians talked about their volunteer work with associations:
“…most of the [volunteer] work [with ICMART] has been without pay. It's an idealistic purpose or idealistic goal to bring medical acupuncture to the people and to improve our medicine, to widen the thinking in medicine. That's the idea behind [it].” (GP 6)
“…along the way I got drawn into the American Academy of Medical Acupuncture and its leadership structure…first as a board member and then Vice President and then I've been asked to be President starting next April.” (GP 18)
One physician discussed his research:
“…fortunately…I have enough funding at the moment… It's coming from a combination of charity, NHS, and MRC… I have some degree of sustainability over the next five years. And I also have financial reserve…. [We're studying] symptom management in cancer, expectations and beliefs influencing outcome from acupuncture and a variety of studies looking at [brain] imaging in acupuncture.” (GP 10)
Common among physicians was the belief that medical acupuncture could help patients. However, they viewed ‘helping’ in different ways. Some wanted to help as many patients as possible (eg, through group clinics or short appointments) while others spent more time with individual patients (from 30 min to 2 h). Some felt limited by their practice with respect to how much they could help. The following quote is from a physician in a setting where demand for medical services was high, and is followed by a second quote illustrating how a physician felt unable to help patients in the way he would have liked to:
“…basically in order for me to do more acupuncture—I would have to cut back on my family practice which is the same as saying that I would have to cut back on patients. I'd have to tell patients to find other doctors. So that's actually the biggest problem with actually expanding acupuncture is what do I do with my regular family practice?” (GP 17)
“…there have been drastic changes over the course of my career. I began to feel less and less like a real doctor, especially over the last five or so years when I was doing family medicine. …the hospital owned the practice and there were these bean counters…saying “You really need to see more patients” and “You need to document to a level to support a higher billing code”. In other words, “You need to make more money for us”. I think that kind of pressure really interferes with healing relationships. But now I feel like I'm back to where I was twenty five years ago: I can help my patients, I can spend the time, I can do whatever's necessary… When I was doing primary care…I didn't have the time [to help patients]…literally was just running from one patient to the next, which is a horrible situation.” (GP 18)
Other physicians felt that being connected with patients was central to helping them:
“In acupuncture, I'm…putting my needles in with my hands on and listening to the patient. And there's a huge amount of human contact. Being present with the patient and evaluating the patient at a deep level helps with the healing. And Chinese medicine is full of that…[it's] sort of triggering the healing instincts in you.” (GP 2)
“…there's some people who haven't experienced it and are open to it, and those are really fun ones because they'll come in with a problem and I just put in one needle really quick. “If you don't mind, I'd like to try something…I'm just gonna put [the needle] in and let's see what happens”… If it helps, that's good. It is so delicious because it creates this other link of trust [with patients]… For me, that's what I love about medicine.” (GP 3)
Although there was variation, there were many commonalities in how physicians have incorporated medical acupuncture. The core concept of helping formed the basis for how these commonalities were classified into three models: (1) appointments; (2) clinics; and (3) full-time practice. While it may be argued that there are negligible differences between having individual appointments and grouping appointments into clinics, the physicians with whom the models were discussed felt that they could be separated. Therefore, in tables 3 and 4, physicians who both administered medical acupuncture during appointments (model 1) and held weekly clinics (model 2) are included separately.
Model 1: incorporating medical acupuncture into appointments
Eleven physicians (44%) in seven different countries administered medical acupuncture through appointments (table 3). Two physicians administered it when necessary during regular appointments and nine had dedicated appointment slots. Five used multiple rooms. One physician used eight rooms and hired a nurse to remove the needles, but did not comment about any training and safety issues associated with this. Because they had limited time with patients, some physicians said that they used quicker techniques such as ‘battlefield acupuncture’—ear acupuncture for relieving pain, which was developed for use in war zones where there is limited access to medical care.23
The main reasons physicians gave for incorporating medical acupuncture into appointments were efficiency and time constraints. Using existing appointments is considered efficient because it does not take extra time and many physicians can still see the same number of patients each day. Because they had busy practices with little extra time, many physicians tried to fit medical acupuncture into their existing appointment structure. Two discussed how they had efficiently integrated it:
“I often see patients in regular 10 minute appointments… I'll assess the patient in a regular spot, so I have 10 minutes to explain the treatment to them. I put a website together and it explains more about what I do in the practice… I ask patients to look at the website.” (GP 12)
“I occasionally put in 1–2 needles when I see a patient. I don't provide it for a fee. It's my patient visiting, and while I'm chatting to them I put the needles in—so that's just where it's at right now.” (GP 4)
The amount of time physicians spent with patients varied. The majority spent 10–15 min (range 5–30 min) per patient, which may have comprised a regular visit inclusive of medical acupuncture or just needling. Some administered medical acupuncture a few times a week while others had multiple appointments per day. For example, the anaesthetist who was interviewed saw up to eight patients per hour. Unfortunately, physicians did not comment about whether a few hours a week was enough to maintain their skill level. One study reported that physicians averaged 8 h/week.24 A few physicians also booked appointments at specific times and/or on specific days of the week. Many said they preferred longer appointments because they wanted to talk with/spend more time with patients, because patients need time to change, and because needling per se takes time. One GP discussed how he had set up appointments:
“I devoted one half day a week, I'd just do acupuncture patients [then]. That's not turned out to be enough time, so…two other days a week I'll do an acupuncture patient as the last patient of the day so I'm not rushed and I can take my time.” (GP 17)
Model 2: incorporating medical acupuncture through clinics
Eleven physicians (44%) from four countries had regular medical acupuncture clinics (table 4). Physicians' schedules for clinics varied from daily to weekly and from 4 to 16 h/week. Some clinics were held in their regular office while others rented space in a different location. Those who rented space usually held half-day clinics once or twice a week and often needed to pay additional staff and charge a fee to cover costs. Some physicians who held clinics also booked medical acupuncture appointments in their regular practice (model 1). For example, one GP rented a space for his weekly clinics but also had specific appointments in his regular practice. Those who used their regular office tended to use fewer rooms and see fewer patients. Most physicians said they would spend more time with patients on the first visit and less time on subsequent visits.
The main reasons that physicians gave for holding clinics were: not being able to incorporate medical acupuncture into appointments; wanting to help a larger number of patients; not having enough rooms in their office; and greater efficiency. For example, the geneticist offered clinics in the evenings and on weekends because he could not offer medical acupuncture in his regular position (see first quote below). In the second quote a physician described how he had changed his clinic scheduling.
“I see patients for ten or more sessions and I see them for longer when they come, there is more sharing…so you get to know the patient better because you spent more face time with them. I would see patients over a period of a year and I would see them for two hours at a time, so those are things that do not happen in my day practice.” (Geneticist)
“After I took the Helms course, I very rapidly began offering acupuncture as either an alternative therapy or, if something else had failed, as an initial therapy if that was [a patient's] preference as well. So within my pain management clinic hours I began scheduling for acupuncture patients and it grew pretty rapidly.” (GP 16)
Below is a quote from a physician who held group clinics with nurses so he could see as many patients as possible without taking too much time away from his demanding practice. This is followed by a narrative highlighting how a second physician, directly observed while conducting clinics in a large health system, was concerned about efficiency:
“…apart from seeing patients in regular appointments…I have a clinic where I see up to 25 patients in two hours on a Tuesday and I use about four rooms. And we also have a clinic for knee arthritis run by two nurse acupuncture specialists where we have a group therapy…which is great because the patients teach each other and it adds an element of the treatment which you just don't get if you're treating people on their own. It's not something that you see very often.” (GP 12)
She is vexed with the patient booking process because sometimes there are gaps between patients and she doesn't like wasting her time. She'd rather have a full lot of patients and be busy instead of having to wait for them to arrive. The issue is that new patients get a double time slot and if they cancel, these two time slots are left empty rather than filling them with two regular patients. Unfortunately, this is the [system's] way of doing things. (GP 15)
Model 3: incorporating medical acupuncture full-time
One female and five male physicians (24%) from five countries practised full-time, usually privately (table 5). All these physicians indicated that they had initially tried appointments and clinics but subsequently decided to practise full-time. Financial concerns were less salient since many physicians were at a later career stage, had paid off loans/mortgages, and did not have dependants at home. They also had enough paying patients to support a full-time practice, which they had developed over decades or shorter periods. One physician had an assistant remove the needles so he could see more patients, although he did not comment about the safety issues that might be associated with this practice. Two GPs had administered medical acupuncture full-time for most of their career. One shared his experience with moving to full-time practice:
“…we would book people every fifteen minutes [but] I found that wasn't enough for acupuncture. So for a new patient I would allow half an hour and a subsequent visit I'd cut back to twenty minutes. But I was running late most of the time. What I found is that the more time you spend with people, give them a chance to relax and talk, then all of a sudden the hidden truths come out. Once I built up the [medical acupuncture] practice I left the group, I went out on my own and allocated more time for consultations. I have been doing full time acupuncture since 1996.” (GP 1).
Four physicians, including the one above, had left their full-time position to practise privately. One detailed his path:
“I started out doing half a day a week and as things got busier I was doing two half days a week seeing just acupuncture patients… I felt very supported by [my workplace]… The greatest difficulty had to do with reimbursement. …the hospital does the billing…Medicare [and Medicaid do] not cover acupuncture. …the hospital didn't have the provision to work with [patients]… I really felt strongly that if someone wanted to try it and would benefit, we shouldn't be depriving them of the treatment. In my private practice now if someone [has]…a financial constraint I have the ability to say “Okay, you pay me what you can afford and I'll just adjust the rest”, but I didn't have that freedom in [my workplace].” (GP 18)
The main reasons that physicians decided to practise full-time were opportunity and demand from patients. Some also indicated that moving into full-time practice had been part of their pre-retirement plan. One physician shared how he had decided to take advantage of an opportunity to practise full-time. Since he had been nearing retirement, he decided to leave his full-time position and practise from home:
“I wrestled with whether I should [go into private practice] or not… I'm getting close to retirement age—this would be a good way to try to slow down… My intention was to have a small practice and spend plenty of time with my patients… I resigned my full time position…the practice is now quite busy, busier than I had expected and the hours are pretty long. So it's not like, semi-retirement yet but there is a potential for slowing down.” (GP 18)
One of the physicians who had built her practice over several decades even returned following retirement because of high demand:
“I became an acupuncturist at a rehabilitation centre, after I [trained in] Switzerland… I had 30 hours a week for work medicine and 30 more hours, sometimes more, for acupuncture… [I got involved when] one of the rehab doctors called me and asked, “You give acupuncture?” I said, “Yes”. “Will you please come, I have a case for you”. …the week after he phoned back again… After a few months like that…the director of the centre said “You are coming regularly now, we have to pay you”… I worked there 27 years and then I retired for 3 months. Then they phoned me, “Will you please come back?” So I'm still working there.” (GP 5)
All full-time physicians charged patients, often to cover the costs of administering the acupuncture and their time. Some health systems and insurance companies fund physician-administered medical acupuncture. One GP said he got involved with the Australian Medical Acupuncture College and lobbied the federal government so that “patients could get rebates from the government [for] doctors practicing acupuncture … we managed to get Medicare for medical acupuncture”.
This exploratory study has examined the ways that international physicians have integrated medical acupuncture into their practice. Physicians were both interviewed and observed. Although a few physicians have published their personal experiences about integrating medical acupuncture,7–10 this study has investigated in greater detail the different ways that international physicians have accomplished this, and identified three principal models of acupuncture provision. Participating physicians had trained with a variety of organisations around the world, typically in their home countries. After completing their training, many of these physicians had experimented with different ways of integrating medical acupuncture into their work. For example, some had begun with appointments before proceeding to dedicated clinics or moving into full-time practice, while others had held clinics from the outset.
While most previous studies have focused on physicians in a single country,14 ,24 ,25 this study's participants were international. In comparison, a UK study found that 44% of physicians were female, early in their career (having been practising for 7 years on average), and working in a National Health Service (NHS) setting or private practice.14 Another study of US physicians found that they were equally likely to be male or female, early in their career (having been practising for 5 years on average), and that most were in private practice.25 Both studies found that GPs in private practice who undertook medical acupuncture training in their early career continued to practise. Two-thirds of the present study's physicians, mainly GPs, were mid-career (having been practising for an average of 13.8 years) before they had integrated acupuncture into their practice. A survey has indicated that 60% of medical acupuncture professionals are GPs.25 The present study had a higher proportion of GPs (72%) and males (68%) than other published studies. Although some associations regularly survey their members (eg, AAMA and BMAS), it is not possible to compare their surveys directly with this study because they do not publish their results.24
The practice changes that physicians had made so they could help their patients could be categorised into three main models: (1) appointments; (2) clinics; and (3) full-time practice. Some physicians combined more than one model (eg, offered both appointments and regular clinics), depending on how they organised their practice. The variety within each model suggests that physicians individualise integration according to their own needs and practice limitations. For example, physicians varied in how often they saw medical acupuncture patients and the time spent with them. Most physicians integrated medical acupuncture part-time, while some chose to practise full-time. This study found that physicians who could not practise medical acupuncture in their current workplace had explored other options such as opening a private clinic or renting external space. Some physicians had made considerable changes to their practice to accommodate medical acupuncture.
Many physicians stated that they had gradually phased medical acupuncture into their practice, usually starting with a few appointments or a clinic, until they could establish a schedule that worked for them. As demand grew, many physicians had decided to make other changes; some had quit their regular jobs to administer medical acupuncture full-time, while others had added extra or longer appointments/clinics or worked extra hours. One physician had hired a nurse to remove the needles so that he could see more patients, but such adaptations were less common.26 Almost two-thirds of physicians charged patients. As previously documented,8 ,15 many physicians had reservations about charging patients but had found them willing to pay for the service. In short, each physician had tailored the incorporation of medical acupuncture to his or her particular needs, within the limitations of their practice.
Because this was an exploratory qualitative study, the physicians who voluntarily participated may not adequately represent the entire population of medical acupuncture providers. The participants were also different from other studies; for example, they had often integrated medical acupuncture mid-career and there was a higher percentage of males. The sample size was small and participants were from many different countries. In addition, the participants may have had more successful medical acupuncture practices and therefore differ from others with less successful practices or those who have not integrated acupuncture after training. The models developed from the participants' responses and observations may not capture all the ways that medical acupuncture is incorporated into physicians' practices. Hence, it may not be possible to generalise from this study's results.
Participants were limited to those who spoke and understood English. Although a few non-native English speakers were sent interview questions in advance, some mentioned they were less comfortable expressing themselves in English. Observed participants may have acted differently due to the Hawthorne effect.27 As many participants were identified via the internet, those who did not have websites or who were not listed on websites such as ICMART are likely to have been missed. Physicians with websites may be more likely to have established medical acupuncture practices rather being than new practitioners. Thus, the study sample may have been biased towards recognised or known practitioners. Additionally, the sampling methods may not have adequately captured physicians practising in traditional health settings or those without a website.
Future studies are needed to validate the three models and to improve generalisability. Researchers could contact medical acupuncture associations and request to interview and observe participants through their membership lists, being mindful to stratify sampling by country and type of physician to ensure greater generalisability. Conducting an international survey with medical acupuncture associations could capture useful information from a variety of physicians. As four participants were observed for 20 h, there could be value in conducting in-depth ethnography of physicians as they practise. International researchers could interview participants in their own language or use a translator in the future. Finally, as this study had a higher than expected proportion of males, researchers may want to explore if there is a relationship between gender and choices regarding medical acupuncture practice.
The participants in this exploratory qualitative study have provided an international perspective about the changes they have made to integrate medical acupuncture into their practice. The three main models reflect how physicians have found different ways to incorporate medical acupuncture and suggest that physicians phase it in according to their individual needs and practice. Within each model, there is variation in how often physicians administer medical acupuncture and how much time they spend with patients. The most common practice adaptations include using a combination of appointments and clinics. Although some physicians have left their positions to administer medical acupuncture full-time, most have integrated it part-time, demonstrating that it is possible for them to use it in their practice.
I extend my gratitude to the physicians who volunteered to participate in this study, to the Editor, and to the peer reviewers for their helpful feedback.
Funding Social Sciences and Humanities Research Council of Canada (Doctoral Fellowship), Alberta Heritage Foundation for Medical Research (Health Research Studentship) and Alberta Institute for American Studies.
Competing interests None declared.
Patient consent Obtained.
Ethics approval This research was approved by the Alberta School of Business Research Ethics Board at the University of Alberta in Edmonton, Canada (reference no. REA-1110).
Provenance and peer review Not commissioned; externally peer reviewed.
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