Integration between orthodox medicine, homeopathy and acupuncture for inpatients: Three years experience in the first hospital for Integrated Medicine in Italy

Abstract

The hospital in Pitigliano (Tuscany) is the first hospital in Italy to put into practice a model of Integrated Medicine. This clinical setting caters for the use of complementary medicine (homeopathy and acupuncture (針灸 zhēn jiǔ)) alongside orthodox therapies (conventional medicine). The therapeutic model implicates doctors who are experts in complementary and alternative medicine (CAM; 補充與替代醫學 bǔ chōng yǔ tì dài yī xué) and the rest of the hospital personnel working together as equals. This contribution explains the difficulties, critical aspects and potential of this innovative setting.

The clinical setting for Integrated Medicine was evaluated in part through observation and in part through the analysis of approval questionnaires. The writers of the questionnaires were the orthodox medical personnel and the hospital patients.

The project is still evolving today in spite of the initial partial contrariety of some doctors in the hospital and some external doctors in the area. However, it can already be considered a positive experience, as confirmed by the high approval gained from many health workers and most of the hospital patients. Moreover, the follow-up carried out through specific surgeries dedicated to CAM is extremely positive.

Up to now 532 inpatients suffering from acute illnesses, relapse of a chronic illness or neurological or orthopaedic rehabilitation following strokes, brain haemorrhage, neurological illness or limb prosthesis operations have been treated. This work has tried to illustrate the innovative and positive experience for the Italian public health authorities so that it may also be useful to anyone who would like to promote similar initiatives within its public health Institution.

Graphical abstract

1. Introduction

Complementary medicine is not officially recognised by orthodox medicine in most of the Western countries, Italy included. This is mainly due to cultural barriers, therefore it has not been possible to set out regulations nor to find credit within the Institutions. However, the opportunity given by the Italian Regional Government to apply operational measures within the region allowed the Centre for Integrated Medicine of Pitigliano (Tuscany) to implement an innovative healthcare approach (see Appendix 1).

The Centre for Integrated Medicine of Pitigliano was founded by the Health Government of the Tuscany Region in February 2011 in order to provide assistance to patients and to carry out scientific research projects. The Centre is the first public hospital in Italy which provides inpatients with homeopathy remedies, acupuncture (針灸 zhēn jiǔ) treatment as well as Traditional Chinese Medicine (中醫 zhōng yī; TCM). The cutting-edge project entails several objectives to be achieved within the Italian public healthcare system:

• (i)to potentially establish a clinical setting between orthodox medicine and complementary and alternative medicine (CAM; 補充與替代醫學 bǔ chōng yǔ tì dài yī xué) practitioners, based on mutual agreement and close co-operation in terms of therapy and treatment;
• (ii)to test the interdisciplinary approach among inpatients;
• (iii)to verify the beneficial effects deriving from the approach regarding the improvement of the quality of life in patients suffering from chronic diseases as well as the decrease of side-effects triggered by conventional therapy;
• (iv)to verify the potential advantages of integrated medicine in terms of cost management regarding the regional healthcare system.

This contribution describes the hospital clinical setting of Integrated Medicine, the operational plan, the difficulties regarding its fulfilment, the crucial points, the opportunities and beneficial effects experienced by practitioners and patients three years after the beginning of the project. Among the tasks, CAM physicians (homeopathy, acupuncture and TCM) provide patients with Integrated Medicine, at five clinics (for outpatients) and in hospital wards, as well as at the neurological and orthopaedic Rehabilitation Centre (for inpatients) in Manciano (Tuscany). Patients at the Centre in Manciano have experienced cerebral vascular accidents or suffer from chronic neurological diseases (ALS, multiple sclerosis, Parkinson's syndromes and so on), or have undergone surgery for knee and hip implants. This represents a ground-breaking project for the Italian healthcare system whose preparatory plan lasted for two years (from 2008 to 2010) (see Appendix 1).

1.1. Integrated medicine: treatment techniques and typology

Starting in the ‘90s the concept of combining orthodox or conventional medicine and CAM when treating patients within the health service, (integrative medicine or integrated medicine and Integrative Health Care) has spread throughout the western world, and this collaboration has taken place in various forms according to, in primis, the culture and governing body of the country where it has been developed.^{1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16}

The Centres which offer Integrated Medicine can be divided into three typologies:

• (i)healthcare services provided by single practitioners who apply different treatment techniques. These techniques are mainly used individually. The first typology entails treatment differentiation and does not have practitioners involved who work together.
• (ii)healthcare services provided by practitioners, within the Centre, who are specialised in more than one discipline. They perform integrated medicine individually, however they do not co-operate together and for this reason this cannot be considered a Centre of Integrated Medicine.
• (iii)interdisciplinary therapeutic treatment provided by a team of professional practitioners specialised in several disciplines. They work together on each medical case and mutually agree on what therapeutic treatment is the most suitable and appropriate for each patient (interdisciplinary approach). This is the most significant feature which distinguishes an authentic Centre for Integrated Medicine. The Centre of Pitigliano belongs to this third typology.²

1.2. The Centre for Integrated Medicine at the Hospital in Pitigliano

Patients: Mainly elderly people (30% are over 65) suffering from chronic diseases which are caused by several factors and characterised by two or more co-existing medical conditions. The relapse of chronic diseases or the intensification of disorders relating to a primary illness are among the first causes which lead patients to be admitted to hospital (Table 1). The Clinics for Integrated Medicine provide healthcare services to patients from the Province of Grosseto (48%), but also to patients from other Tuscan provinces (40%) as well as other regions (12%). At the Rehabilitation Centre in Manciano patients from other Italian hospitals are admitted in order to begin a rehabilitation programme lasting for three weeks or longer (Table 2).

Table 1.

Reasons for hospital admittance to the hospital in Pitigliano. Period 2011–2013.

Reason for admittance %
Cardio circulatory problems	12.3%
Abdominal medical syndromes	15%
Neurological syndromes	10.3%
Respiratory syndromes	20.3%
Endocrine/metabolic syndromes	2%
Painful osteo-arthritic syndromes	20%
Syndromes of multi-organ disfunction	9.5%
Oncogenic diseases	10,60%

No. patients treated with IM 242; Gender Male: 134; Female: 108.

Table 2.

Reasons for admittance to the Rehabilitation Centre in Manciano. Period 2011–2013.

Reasons for admittance %
Neurological Rehabilitation after stroke and brain haemorrhage	51.2%
Rehabilitation after limb prosthesis surgery or vertebral stabilisation	28.93%
Rehabilitation due to degenerative neurological illness (multiple sclerosis, SLA, Parkinson's disease)	19.87%

No. patients treated with IM 290; Gender Male: 130; Female: 160.

1.3. Organisation of the Centre

General information – Each Centre for Integrated Medicine belonging to the third typology differs from the others based on its project specifications. In the Centre in Pitigliano the project was developed over a 2-year period, from 2008 to 2010, by a scientific committee appointed by the governing bodies of the Tuscany Region and led by a team of practitioners specialised in Integrated Medicine (see Appendix 1). The task of the Committee was to study how the Centre could be recognised and accredited from a legal and institutional perspective, focussing on the necessary measures and actions to implement CAM within a hospital structure. The study has led to: the modification of the informed consent model in order to adapt it to integrated treatment (orthodox medicine, homeopathy, acupuncture and TCM); the expansion of the regional healthcare codes by introducing specific codes for CAM; the addition on the medical chart of a space where homeopathy, acupuncture and TCM treatments (detailed anamnesis, semiological criteria, specific diagnosis based on the CAM typology) can be registered; the addition of information concerning the integrated treatment that the patient has received in order to inform the family doctor; drafting of new codes for patients’ discharge and medical chart filing for legal purposes, by registering the specific codes related to the CAM treatments.

Location – In order to build the Centre, the structure of the hospital was modified. CAM clinics destined for outpatients and their waiting areas were changed, taking into account the criteria used by the Royal London Hospital for Integrated Medicine and the Glasgow Centre for Integrative Medicine.

Clinical setting – The team of professionals working in the Pitigliano Hospital and the Rehabilitation Centre of Manciano is comprised of practitioners specialised in orthodox medicine (internal medicine, orthopaedics, neurology, surgery and radiology). The addition of five professional practitioners specialised both in orthodox medicine and homeopathy, acupuncture and TCM to the regular team of physicians was the main requirement for the building of the Centre for Integrated Medicine; moreover each CAM treatment is followed by a tutor who monitors whether the treatment is properly implemented. This pattern does not often occur in Centres for Integrated Medicine as practitioners from different medical backgrounds are part of the team; we noted that this factor may have a negative effect on the efficiency of the team and therefore we decided to experiment this particular clinical medical setting which we considered necessary for team cooperation (vide infra). The Integrated Medicine team is led by a specialised practitioner with long medical experience in orthodox and integrated medicine and a great deal of experience as a hospital doctor, who was appointed by the governing bodies of the Tuscany Region. This practitioner monitors the correct application of therapeutic treatments as well as being in charge of the development of the project (in terms of scientific objectives and healthcare purposes). Furthermore she works closely with the local health Authority (ASL 9 Grosseto).

The project has been outlined by a scientific Committee which has taken into account the principles of integration within the medical disciplines promoted by the Italian Society of Homeopathy and Integrated Medicine since 1999.^{17, 18} The project is regularly monitored by the Head Physicians of the hospitals in Pitigliano and Manciano together with the Doctor in charge of the project who liaises between the clinical setting of Integrated Medicine, the scientific Committee, the General Administration of the Health Authority of ASL 9 Grosseto, the Department of Health of the Tuscany Region and the local Board of Bio-ethics.

Co-operation with the hospital orthodox physicians – The project entails close co-operation between the physicians and other hospital personnel at the Pitigliano Hospital and the Rehabilitation Centre of Manciano according to a clinical setting model which foresees co-operation on equal footing, (inter pares)^{19, 20}: this was the most difficult aspect of the project.

Formation and training of the healthcare providers – The premise at the activation of this particular clinical setting was that orthodox physicians do not usually specialise in CAM; in 2009 the Faculty of Medicine of the University of Siena launched a two-year specialisation programme in Integrated Medicine for physicians and chemists majoring in homeopathy, acupuncture, TCM and phytotherapy with a view to increasing knowledge of CAM. A further one-year specialisation programme was created for the remaining healthcare providers (healthcare assistants, physiotherapists, obstetricians) in the field of Integrated Medicine and complementary therapy. Moreover, the Centre for Integrated Medicine in Pitigliano was appointed by the University of Siena as the reference centre for practical training and it offers practical internships to the students attending the two programmes. Furthermore, the CAM professional team of experts has organised in past years several accredited workshops and conferences within the healthcare training field with the main focus on homeopathy, acupuncture and TCM. The events have been attended by physicians and healthcare providers from the hospital of Pitigliano and Manciano and by healthcare personnel who work in other health structures within the ASL 9 territory.

Information and interaction with practitioners on the territory – Several initiatives have been promoted in order to inform family doctors and paediatricians about the innovations provided by the Centre. The results will be shown in a specific section at a later stage.

Apparatus of the hospital wards – The hospital has been supplied with homeopathic drug products and equipped with acupuncture stations; the healthcare providers have been trained and informed about how to use homeopathic drugs and how to handle the needles for the acupuncture treatments. Further training has been provided on how to prepare homeopathic galenic drugs: the personnel in charge of the preparation of this medicine is monitored by a specialised chemist who attended the Master's degree course in Integrated Medicine (University of Siena). At the opening of the Centre the team of practitioners specialised in homeopathy and acupuncture prepared therapeutic protocols.

Scientific research activity – In 2009 the Tuscany Regional Board of Bio-ethics expressed positive opinion on CAM research within the regional Public Health Service. The Board of Bio-ethics at the ASL9 (Grosseto) also approved scientific research at the CAM Centres of Pitigliano and Manciano.

Setting assessment – The features which make up the hospital clinical setting of Integrated Medicine have been measured partly through observation and partly through anonymous questionnaires handed out to the healthcare providers at the hospitals of Pitigliano and Manciano (Table 3) and to the inpatients at the hospital of Pitigliano and the rehabilitation centre in Manciano (Table 4). In detail, the following outcome has been assessed: the acceptance level of the setting among the healthcare personnel, the difficulties encountered during the setting-up of the project, and the usefulness perceived by the healthcare personnel and inpatients. The results are depicted in the following section.

Table 3.

Health personnel questionnaire.

	Yes	No
Did you know about Complementary Medicine before the Centre of Integrated Medicine opened?	69%	31%
	Yes	No
Did you already know about Integrated Medicine?	9%	91%
	Easy	Difficult	Indifferent
What impact did the new model of Integrated Medicine in the hospital have on you?	58%	18%	24%
	Curiosity	Acceptance	Indifference	Refusal
What was your first reaction to the model of Integrated Medicine?	63%	30%	7%	0%
	Yes	No	No reply
Did your attitude change after taking part in a health course setting of Integrated Medicine on Integrated Medicine	55%	40%	5%
If yes, in what way?
More positive concerning its usefulness	73%
Less positive concerning its usefulness	1%
No reply 26%	26%

Total questionnaire: 65: Doctors: 16; Health personnel: 49.

Table 4.

Questionnaire for inpatients.

	No.	%
No. anonymous questionnaires distributed	532	99%
No. anonymous questionnaires returned compiled correctly	485	91%
	Yes	No
Before your visit to the Hospital Centre of Integrated Medicine did you know about Integrated Medicine?	21%	69%
	Easy	Difficult	Indifferent
What impact did the new model of Integrated Medicine in the Hospital have on you?	92%	0%	8%
	Better	Worse	Indifferent
Do you think that the Complementary Medicine therapies, with regard to your symptoms, made you feel:	93%	0%	7%
	Physical	Psychological	Both
If you feel better is it at a: Physical level; Psychological level; Both	93%	16%	84%
No. eligible inpatients: 537
	M	F	TOT
No. inpatients treated in the period 2011–2013 Gender: Male (M) Female (F)	264	268	532

2. Results

The clinical setting of Integrated Medicine, which is at present at an experimental stage, is ambitious, given the cultural background of CAM (補充與替代醫學 bǔ chōng yǔ tì dài yī xué) experiments within the Public Health Service all over the world. Indeed, it entails that the patient be shared by orthodox and CAM physicians according to a model of collaboration implicating mutual trust (collaboration inter pares). In order to carry out the project of health integration according to the principles of Integrated Medicine preset by the Scientific Committee, the following points of the project have been considered fundamental:

2.1. Cultural exchange among healthcare personnel

The Tuscany Region authorised the realisation of a clinical setting for Integrated Medicine in a small hospital with the objective of verifying its feasibility in a limited, and therefore more suitable environment which was more appropriate to cultural exchange between healthcare personnel from very different backgrounds. At the opening of the Integrated Medicine Centre none of the healthcare professionals working at the hospital, including the Director, had specific knowledge of CAM. The healthcare project aroused the immediate curiosity and willingness of the nursing staff (Table 3) and it was welcomed with enthusiasm by local people even though the population is composed mainly of elderly people with low income and without a specific cultural education regarding the therapeutic opportunities offered by CAM (Table 4). On the other hand, while the orthodox physicians at the Hospital of Pitigliano had shown little enthusiasm and at times a hostile attitude too, definitely less complex was the acceptance of all the health personnel at the Centre in Manciano. It is likely that a small rehabilitation centre (holding 21 beds) where patients have a two or three-week stay is more inclined to experiment complementary therapies of support, given the particular typology of patients (after strokes (中風 zhòng fēng), cerebral haemorrhage or arthroplastic operations etc.), the continuity of care and the typology of the healthcare services (such as rehabilitation), compared to a hospital ward which manages urgencies.

2.2. The interdisciplinary approach to treatment

The prime precondition for a health initiative of Integrated Medicine is the trust and mutual respect between professionals who are expert in orthodox medicine and in CAM. However, this precondition is not foregone, since orthodox medicine was developed in the Academy, and was structured and evolved with the approval of the establishment and of the dominant doctrine while CAM is still today marginalised.^{21, 22, 23, 24, 25, 26, 27} It follows that trust and respect regarding CAM are values which still need to be achieved rather than being readily accepted. In order to achieve the objective of sharing the therapeutic path of the inpatients a mutual agreement for a daily 30-min briefing before the start of the health care activity in the wards was arranged between the Health Project Manager of Integrated Medicine and the Head Physician of the Internal Medicine Unit in the Hospital. During the briefing both the teams of CAM and orthodox practitioners discuss the inpatients and decide who could benefit from integrated treatment. Only at this point do the doctors inform the patients of the additional therapeutic opportunity and if the patient gives his/her approval then Integrated Treatment with homeopathy and acupuncture (針灸 zhēn jiǔ) commences prior informed consent. The initiative of a daily briefing for the physicians has led to a place for dialogue; although it was initially believed to be compulsory by the orthodox practitioners it has, over time, evolved towards a more spontaneous interpersonal relationship thanks to the self-confidence and mutual trust which have developed in the field: this is due to the positive therapeutic results achieved using integrated treatment. Moreover, the orthodox and CAM physicians share the visit to the inpatients using diagnostic criteria used both in orthodox and CAM medicine.¹ The official institution of an integrated medicine examination of the inpatients has permitted the sharing of a semiotic approach between the orthodox and CAM physicians, thus simplifying the use of the new Integrated Medical Records.

2.3. Acceptance of the patients

It is important to underline the extraordinary fact that 99% of the inpatients immediately accepted integrative treatment in spite of being mainly elderly with a not specific cultural education regarding the therapeutic opportunities offered by CAM (Table 4). Indeed, the patients had heard that complementary medicines and the fact that they were dispensed in the hospital was sufficient to guarantee their trust in the integrated treatment, without conflict or hesitation.

2.4. The professional relationship with General Practitioners (GPs)

It has been experienced to date that to attain a true sharing of patients between orthodox and CAM physicians GPs also need to be engaged in this specific clinical setting. In order to reach this collaboration the CAM service in the hospital made available a telephone and email service for the family physicians (Gps) and paediatricians. At present, however, this aspect of the integrated clinical setting remains still embryonic due to its difficult realisation; in fact the territorial dispersion of the GPs weakens the setting-up of a relationship and therefore a longer time is needed for a collaboration. Moreover, as can be clearly seen from the questionnaires compiled by 1500 outpatients, those who were sent by their GPs or paediatricians were only 8% of the total cases treated in the Integrated Medicine Clinic (Table 5). In spite of the numerous cultural initiatives to involve these physicians the percentage has not improved during the three-year period experimentation.

Table 5.

Questionnaire for outpatients.

	Favourable	Indifferent	Contrary	Don't Know
1. Do you know your Family Doctor's opinion on complementary medicine?	29%	22%	5%	44%
2. Where did you hear about the Hospital Centre of Integrated Medicine in Pitigliano? Multiple answers.
Word of mouth (friends, acquaintances, relatives, etc.)	53%
Personal knowledge	18.50%
Newspapers, radio, TV, internet, etc.	10%
ASL 9 informative material	10%
Family doctor	8%
Pharmacist	0,10%
Specialist Doctor (neurologist, homeopathic doctor, acupuncturist, psychologist)	0,30%
Another professional (physiotherapist, osteopath, naturopath)	0,10%

No. questionnaires examined: 1550.

2.5. Time factor

In our view, a reciprocal relationship and open-mindedness represent prime factors for the realisation of an Integrated Medicine clinical setting within a hospital. In this sense, on the basis of the experience achieved over a period of more than three years, we believe that there should be a certain period of time to elaborate the natural and obvious doubts produced by the orthodox physicians, in order that the project may mature. It must be said that this Public Health Project was decided by the Health Ministry of the government of the Tuscan Region although nobody had any cultural background concerning Integrated Medicine. We have learnt from this experience that foreseeing errors that may occur and the flexibility to accept change in relational strategy may be the successful means to solve the typical frustration found when participating in a health project built outside classic institutional rules. On the other hand, the knowledge of being part of an emerging healthcare project financed with the objective of verifying its feasibility and utility for the Public Health Service could be sufficient motive to encourage responsibility, curiosity, modesty and enthusiasm on the part of the protagonists of a new medical perspective (Table 3). Indeed, if Integrated Medicine is an emerging model in Italy, it can only be developed through an experimental path, since it cannot be adopted from analogous pre-existing health scenarios.

2.6. Mutual trust

Having highlighted the preconditions of the work, the integrated medicine model defines itself step by step through the clinical medical setting established in the hospital wards through the close, continuous collaboration between the various physicians. The scenario which is outlined in Pitigliano is a small hospital unit and therefore, in our opinion, particularly suitable for a strong inter-disciplinary collaboration between physicians. Since most of the inpatients are afflicted by chronic illnesses, generally not easy to cure using orthodox medicine alone, this type of setting is an ideal substratum for this training in Integrated Medicine.

2.7. The interdisciplinary approach among CAM physicians

Up to now our attention has been focused on the process of collaboration between CAM practitioners and orthodox medical colleagues as an indispensable factor of our project which foresees the interdisciplinary approach to medical treatment; however, the concurrent presence of expert CAM physicians (homeopaths, acupuncturists) favours the realisation of an interdisciplinary approach within complementary medicine. The inpatients in Pitigliano and Manciano undergo homeopathic, acupuncture and TCM (中醫 zhōng yī) consultations at the same time. Moreover this model of integration between doctors expert in CAM (in this case doctors expert in homeopathy, acupuncture and MTC) is fairly new and as yet there is little published literature. It is interesting to observe how the cultural exchange among CAM clinical systems is simpler because some methodological preconditions already exist, in particular the CAM practitioners generally share various items such as: a global vision of the person, the individuality of the therapeutic approach, the trust in self-recovery of the body, the search for a close relationship between physician and patient and the respect and trust in the professionalism of each CAM physician. In our opinion the little literature available regarding not only the integration between CAM therapy and orthodox medicine in the hospital, but also among the disciplines belonging to CAM is a further confirmation of the still embryonic phase of the comprehension of the particularity and potentiality of Integrated Medicine. Each physician expert in CAM at the Centre has had long practical experience in complementary medicine. Mutual trust between CAM physicians in this clinical setting took place immediately thanks too to the innovation of the health model and to the perception of the professional and cultural responsibility implied. The methods of approach concerning inpatients were agreed between the CAM physicians and their tutors at the start of the project, while the most demanding clinical cases and the problems experienced in the wards are discussed in a weekly meeting between the CAM team and the Health Project Manager.

3. Discussion

Our model of Integrated Medicine is aimed at the sharing of the inpatient between CAM (補充與替代醫學 bǔ chōng yǔ tì dài yī xué) and orthodox practitioners and the rest of the healthcare professionals, and its purpose is to realise an interdisciplinary approach to Care. This implies comparison between different learnings of medicine.

Moreover, the model of medical assistance based solely on academic thinking, where biomedicine defines and codes from its dominant position the methodology and practice that must be followed is in a stage of re-arrangement. Although this re-arrangement will be different in each country depending on individual cultural and legislative situations, in most cases these integrated health assistance models foresee the use of new techniques in therapy in addition to those already in use provided by orthodox medicine. These new models are, therefore, defined as integrative health assistance (Integrated Health Care or IHC models), a term introduced in the USA and in Great Britain where this model took its first steps before extending into many western countries.⁴ If the traditional orthodox model is considered by its critics reductionist and mechanistic, CAM is based on the holistic principle of the inseparable mind-body system both in the state of well-being and suffering. The CAM system adopts therapeutic techniques that require more scientific and efficiency trials but they are welcomed by an increasing number of patients especially if they are afflicted by chronic illnesses where biomedicine is not always able to propose sufficient therapy. These considerations are thought to be the cause of the origin of the proposal of a new therapeutic model which includes both CAM and biomedicine philosophies, which we have defined as Integrated Medicine. The IHC model cannot, due to its own nature, always be the same, as it often refers to the fusion or simply to the coexistence of biomedicine with the traditional therapeutic methodologies of any given population. Therefore, the proposals and realisations of the IHC model are different depending on where they occur.²⁸ The number of complementary medicines and disciplines that can be integrated into the therapeutic path is as high as the sector of application is wide, from preventive medicine, to the encouragement of healthy living practices and to the management of acute and chronic illnesses, oncology and palliative care.^{29, 30, 31, 32, 33, 34} The integration of CAM therapies started in the late 90s when the first articles appeared in scientific literature.³ Since then health facilities offering so-called integrative therapy have started to grow and at the same time the number of articles on this topic have grown. Nevertheless, still today the phenomena is in the phase of definition, in expectation of a satisfying clarification as to the necessary requirements for the predisposition of an integrative or integrated medicine clinical setting within the public health system. Moreover, if the experiences of CAM integration within the public health system have actually matured from the late 90s to the present day, from a cultural point of view it is reasonable to believe that it is not yet possible to arrive at operational standards shared internationally. In addition, there are the intricate legislative implications that underlie the attitude of each national health government regarding the investments and support provided to CAM, which represent the consequence of the cultural substratum of each population. It is plausible to hypothesise that such an approach is not separate from the difficulty that orthodox medicine has experienced when being confronted with other medical cultures developed on epistemological and methodological presuppositions different from those established by the Academy. Therefore, the difficulty and sense of frustration are understandable at the beginning of a cultural exchange in medicine which is a precondition of an interdisciplinary approach to treatment as we have interpreted Integrated Medicine in the project described herein. Although over the last decade there has been a great deal of talk of Integrated Medicine and Integrative Medicine in scientific literature, including the numerous articles published regarding the possible strategies in order to carry out adequate scientific research in order to document the effectiveness, safety, costs, social and economic impact,^{35, 36, 37, 38, 39, 40} of various CAM therapies, there have not been very many models of Integrated Medicine on trial in state hospitals. The clinical setting of Integrated Medicine in experimentation in the Hospital of Pitigliano is the first in Italy based in a hospital where there are homeopathy and acupuncture (針灸 zhēn jiǔ) therapies available not only for outpatients but also for inpatients, with the intention of studying both a model of integrated assistance and its use in terms of cost, efficacy and effectiveness. The typology of the health project has entailed the realisation of a clinical setting which is not the addition of further therapeutic resources but rather to assess the possibility of preparing a therapeutic pathway for each patient which is shared as much as possible.

4. Conclusions

In the present contribution we have endeavoured to describe the characteristics of an innovative clinical setting of Integrated Medicine in Italy, the principle difficulties encountered and the solutions adopted to solve them. We hope that this article is useful to health professionals who wish to define a common strategy of integration, and at the same time that it may provide useful information to those who are aiming to adopt similar health initiatives. On our part, albeit with great difficulty on the part of orthodox physicians, we were able to demonstrate that:

• (i)it is possible to realise a clinical setting of Integrated Medicine based on a close collaboration between orthodox and CAM (補充與替代醫學 bǔ chōng yǔ tì dài yī xué) physicians;
• (ii)this model of health assistance is very much appreciated by the patients;
• (iii)the perception of the well-being of the patients who receive integrated treatment in the hospital is enhanced.

We are convinced that a small hospital has simplified the realisation of such a health project through the establishment of a stronger collaboration between the individuals involved in the setting. The coexistence and collaboration among the physicians, both orthodox and complementary, are very much appreciated by the patients, who declare that they have more trust in the orthodox medicine offered in the hospital since the introduction of homeopathic and TCM (中醫 zhōng yī) therapies. Moreover, we consider the appreciation on the part of elderly and very elderly patients, who have little knowledge of CAM due to the local cultural background, an added value In our opinion, it would be important that this new health model be imported into larger sanitary structures in Italy, and for this reason we hope that our particular experience, which did not fail⁴¹ and is continually growing, may be an example for similar future initiatives.

Author contributions

All research done by the authors.

Financial support

No.

Conflict of interest

None.

Appendix 1.

The Tuscany Region has been providing Complementary Medicine services as components of its public healthcare system since 1996. Three regional centres for homeopathy, acupuncture (針灸 zhēn jiǔ), TCM (中醫 zhōng yī) and phytotherapy have been operating since 1999 in Tuscany. The patients can benefit from the service by paying a ticket which is similar to the one paid for other healthcare services provided by orthodox medicine. The Regional Law n° 9 approved in 2007 recognises four complementary medicines (manual medicine, acupuncture, homeopathy and phytotherapy) as “official” medicines of the regional healthcare service, which may be applied to the population within the public healthcare facilities of the Region. Currently there are more than one hundred outpatient clinics which provide complementary medicine services located around Tuscany. Law No. 9 permitted the setting-up of the first hospital for Integrated Medicine in Italy, and it provides CAM (homeopathy and acupuncture and TMC) to inpatients too. The scientific Committee, appointed by the Tuscany Region, drafted and developed a research project from 2008 to 2010. The Committee is composed of delegates of the healthcare system governing bodies of Tuscany; physicians with great experience in homeopathy, phytotherapy, acupuncture and TCM; the Deans of the Faculties of Medicine of the Universities of Florence and Siena; an expert in legal medicine; the Administration of the local health Authority ASL 9; the Head Physician of internal medicine of the Hospital of Pitigliano and the Medical Director of the Royal London Hospital for Integrated Medicine; and it is co-ordinated by a Doctor specialised in Integrated Medicine nominated by the Tuscany Region. In 2010 the project was approved through appropriate norms adopted by the Tuscany Region that consented the opening of the hospital centre for Integrated Medicine in order to provide inpatients and outpatients with CAM assistance and to carry out scientific research.