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Older patients are increasingly likely to be under the simultaneous care of both physicians and alternative practitioners, often for treatment of the same condition. In the majority of cases, however, alternative care is not integrated with biomedical care; indeed, most patients do not inform their physicians of their concurrent use of complementary and alternative medicine (CAM). Because of the increased use of CAM in recent years, this is a critical juncture at which to study healthcare relationships in which the patient is treated by practitioners from different medical systems who are usually not in contact with and often not aware of one another. The purpose of this paper is to (a) review the limited literature that addresses healthcare relationships among patients, physicians, and alternative practitioners; (b) suggest that understanding all 3 sides of the patient-physician-CAM practitioner triangle creates a more comprehensive and realistic view of current healthcare practices; and (c) propose that qualitative research methodologies can provide unique and essential understandings of these emerging healthcare relationship configurations. An ongoing qualitative research study of older women with breast cancer and their interactions with their physicians and alternative practitioners is described as an example.
Practitioners’ relationships with their patients, their patients’ communities, and other practitioners are central to healthcare and are the vehicle for putting into action a paradigm of health that integrates caring, healing, and community.1
Researchers in the burgeoning field of doctor-patient communication are increasingly recognizing the significance of relationship-centered healthcare. To learn the extent of corresponding research on healthcare relationships and complementary and alternative medicine (CAM),2 the PubMed database of English-language bibliographic information was searched. The most fruitful search strings were “alternative medicine and physician-patient relations” (71 results) and “alternative medicine and interprofessional relations” (43 results).
To put the amount of published information into perspective, physician-patient relations in the context of CAM represent .08% of the literature on general physician-patient relations; interprofessional relations in the context of CAM represent .07% of the literature on general interprofessional relations. These figures are misleading because they include only a handful of original research articles—the remainder of the publications are reviews, editorials, and letters.
The majority of studies of alternative medicine that are even tangentially related to healthcare interactions have been quantitative investigations that emphasize the prevalence of CAM use (eg, Eisenberg et al3) or the attitudes of physicians toward their patients’ use of CAM (eg, Astin et al4). The few studies that address healthcare relationships in the context of CAM limit their focus either to patient–physician communication or physician-CAM practitioner communication. Also, these investigations tended to survey either patients or practitioners and therefore did not address both of the participants or the interactive nature of the dyads. Patient-physician studies indicate that patients feel it is important to discuss CAM with their physicians,5 but the majority of patients who use CAM do not discuss it with their physicians.6-11 Also, though patients often rely on their physicians to foster communication regarding CAM,6,7 many physicians are not interested in initiating these conversations.6 When discussions of CAM use do occur in the context of biomedical care, they are more poorly integrated into the therapeutic encounter than are discussions of biomedical treatment with alternative practitioners.7 Not surprisingly, patients’ discomfort with biomedical relationships contrasts with their greater satisfaction with CAM practitioner communication.12,13
Literature on physician–CAM practitioner relationships is even more limited and is dominated by studies of communication between general practitioners and chiropractors. Evidence suggests that chiropractors and general-practice medical physicians are beginning to complement each other's care, primarily in rural areas.14 Still, much of the contact between physicians and chiropractors is characterized by superficial interactions. Greater awareness appears to be associated with increased levels of interprofessional acceptance and respect.15-20 Physician referrals to CAM practitioners are correlated with physicians’ perceived level of understanding of the treatment.21,22 Physicians, however, are less comfortable than chiropractors with sharing patient-care responsibilities23 and there is a marked lack of coordination of care for shared patients.24
Practically no studies in the medical literature focus on patients’ relationships with CAM practitioners—the notable exception is a study of communication in chiropractic.12 Finally, no published studies—quantitative or qualitative—investigate concurrent relationships among patients of any age using CAM, their physicians, and their CAM practitioners.
In the contemporary United States, older patients are more likely than ever to be under the care of both physicians and CAM practitioners,25,26 often for treatment of the same condition. Recent studies indicate, however, that in the vast majority of cases, alternative care is not integrated with biomedical care—indeed, most patients do not inform their physicians of their concurrent use of alternative modalities.3,7 Furthermore, there are strong indications that parallel use of biomedical and CAM therapies in older patients will continue to escalate.27,28 The growing interest in the use of CAM for chronic conditions,28,29 the predicted expansion of the aged population over the next decades, and the aging of the baby-boom cohort that is already using CAM30 will result in an increase in patients’ concurrent visits to biomedical and CAM practitioners. This is a critical juncture at which to study the virtual triangle of patient, physician, and CAM practitioner. The triangle gives the illusion of being complete, but, in reality, it is only 2-sided: it reflects the relationships between patient and physician and between patient and CAM practitioner, but not between physician and CAM practitioner (see Figure). This is an emerging configuration of healthcare relationships in which the patient is treated by practitioners from different medical systems who are usually not in contact with, and often not aware of, one another.
Interfaces between different healing traditions in our medically pluralistic society31 have increased with the development of patient empowerment and medical consumerism, as well as recent changes in the organization of healthcare delivery, including managed care.32,33 Research findings regarding the prevalence of use and the cost of CAM treatments have drawn both popular and scientific attention.3,34,35 The health needs of America's aging population are providing a growing market for medical care. The aging of the baby-boom cohort, in particular, is changing the nature of healthcare in the United States. The focus on the individual, the notion of personal responsibility for healthcare, new forms of spirituality, relatively high levels of education, and increasing cultural and ethnic diversity provide for a growing acceptance of medical pluralism.36 The current market for CAM is being created by middle-aged and older individuals who are investing to improve their healthcare, together with individuals who have chronic illnesses and diseases such as cancer who are not adequately treated by conventional medicine.36,37 A recent study projected that “the per capita supply of alternative medicine clinicians (chiropractors, naturopaths, and practitioners of Oriental medicine) will grow by 88 percent between 1994 and 2010, while physician supply will grow by 16 percent.”38
Among the most frequently cited reasons for the increased consumer use of CAM are the following:
Many patients are responding to the changing medical environment by taking advantage of multiple and concurrent healthcare options. The emic, or insider's, perspective elicited by ethnographic research reveals an intricate framework of logic underlying patients’ health behavior. Patients’ integration of biomedical and CAM therapies is not desperate and haphazard, as historically depicted in the biomedical literature; patients’ healthcare practices involve deliberate and complex strategizing. Research in women with breast cancer indicates that individuals combine disparate elements—from what may appear to be mutually exclusive health traditions—into a syncretic whole.48
To learn the intricacies of contemporary healthcare relationships, it is important to understand how patients seek and maintain concurrent therapeutic relationships with physicians and CAM practitioners. Biomedical and alternative health traditions may only appear to be irreconcilable—their apparent inconsistencies are either not viewed as such or are deemed insignificant by the patient.48
In 1997, an estimated 15 million adults in the United States took prescription medications concurrently with herbal remedies, high-dose vitamins, or both (18.4% of all prescription users).33 The extent to which patients disclose their use of CAM to their physicians, however, remains low. Despite the apparent trend toward greater acceptance of some CAM treatments, the majority of people in the United States (and 67% of San Francisco women with breast cancer7) do not discuss their CAM use with their physicians; only 38.5% of CAM therapies used in 1997 were disclosed to physicians.3 The prevailing attitude of the conventional medical establishment “is evidenced by 70 percent of non-conventional therapy users not informing the conventional physician, a legacy of doctor-patient relations that is surely not in the best interests of the patient.”42 The consequences of ineffective relationships and interactions are clear: patient dissatisfaction, inaccurate understanding (and diagnosis), lack of adherence, and negative outcomes in physical, psychosocial, and economic terms.44,49
Although the culture of biomedicine is increasingly accepting of a variety of different healing modalities, enthusiasm among many biomedical practitioners remains guarded. Interest in CAM is growing among physicians, but the reaction to the resurgence of CAM is so negative in some quarters50 that a number of organizations and journals have been established largely to discredit alternative therapies.45,51,52 One problematic outcome of this mixed reception is that patients assume the entire burden of managing the interactions of 2 healthcare domains when they feel unable or choose not to discuss their concurrent treatment use.44 A study of women's breast cancer treatment choices revealed that discussions of patients’ CAM use are more poorly integrated into the medical encounter than are discussions of biomedical treatments with CAM practitioners.7 Of the women being simultaneously treated by CAM practitioners, 46% chose not to tell their physicians because they anticipated a negative response, thought that CAM use was not relevant to their biomedical treatment course, or simply had a different understanding of the roles of physicians and CAM practitioners in developing and implementing patients’ personal healing strategies. Additionally, women who desired a more integrated approach to their healthcare focused their efforts on the CAM practitioner, not the physician.7 Researchers suggest that older cohorts may have a different perception of the expected and proper role of the patient in healthcare relationships,53 but in general, patients’ views of patient-physician and patient–CAM practitioner relationships remain poorly understood, especially the perspectives of older, ethnically diverse women.32, 54
In 1995, medical folklorist Bonnie O'Connor noted that “the medical literature expresses a number of primary concerns about alternative therapies: that they are incorrect and unfounded; that they will cause direct harm; that they will delay or replace use of conventional medicine, thus causing indirect harm; and that they are perpetrated by quacks and frauds motivated by profiteering impulses.”55,56 The older patient, in particular, has been portrayed as more vulnerable to “quackery” due to naiveté, gullibility, or eccentricity.17,57,58 In recent years, a more balanced portrayal of the effects of CAM use has appeared with greater frequency in the medical literature. Increasingly, CAM therapies are being depicted as having varied, not monolithic effects; that is, some “have demonstrable beneficial effects; some can be harmful under certain conditions; and others may interact with pharmacologic therapies in clinically significant ways.”44
Most of the earlier literature on the use of CAM cancer therapies focuses on the patient's perspective, leaving physicians’ views to be inferred largely from anecdotal comments and editorials in medical journals.59 More recently, surveys have been conducted on physicians’ attitudes toward CAM, as well as CAM practitioners’ views.12,60-64 One meta-analysis suggests that many physicians are either referring to or practicing some of the more prominent and well-known forms of CAM and that even more believe that these therapies may be useful or efficacious.29 Although existing studies clarify some aspects of physicians’ and CAM practitioners’ understandings of their relationships with patients, little is known about how either type of healthcare practitioner responds to patients’ wishes to integrate care or the precise ways in which these goals are ascertained and achieved. Yet respectful discussion
... sheds light on patients’ worldviews, values, explanatory models, lifestyles, health beliefs, and goals for care—all of which are clinically relevant and contribute to the ongoing development of effective and mutually rewarding doctor-patient relationships. The very process of the discussion can, in fact, enhance these relationships bilaterally by promoting a model of negotiation and informed empowerment, rather than one of parentalism and acquiescence.44
In the present environment of medical consumerism and managed care, attention has turned toward methods of ensuring patient satisfaction. Seeking ways to improve the delivery of healthcare, studies have focused on the traditional cornerstone of the healthcare system: the therapeutic dyad of patient and physician. In practice, however, many studies of healthcare interactions have had a more limited view. Researchers too often “focus on either patients or physicians, neglecting the relational aspects of the encounter. Any interaction between 2 persons is reflexive.”53 McCormick, Inui, and Roter note, “We often ask patients whether they feel well understood and supported by clinicians, but we are unaware of approaches to evaluating medical care in which both parties are asked to evaluate one another's commitment, understanding, and mutual support of the work at hand.”65 In 1994, the PEW-Fetzer Task Force on Advancing Psychosocial Health Education asserted that
Healthcare is an activity that involves many people—patients, families, caregivers, organizational managers, community leaders, etc.—within a complex matrix of personal, professional, and community relationships. It is not a grand machine, a complex of physical facilities, advanced pharmaceuticals, surgical techniques, or an administrative system, however wonderfully conceived. It is instead an essentially human activity, undertaken and given meaning by people in relationships with one another and their communities, both public and professional.1
Understanding all 3 sides of the patient-physician-CAM practitioner triangle, as well as recognizing the potential to add a new integrative dimension to those relationships, may create a more comprehensive and realistic view of current healthcare practices.
Some of the questions that need to be asked are simply revisions of inquiries health researchers have conducted for years, updated for new contexts. For example, under what circumstances are different systems of healthcare simultaneously engaged? What are the perceived strengths and deficiencies of relationships with practitioners from different healthcare systems?
Many questions, however, are entirely new formulations. The current state of healthcare relationships should be assessed from the perspectives of different kinds of patients. For example, to what extent are older women with breast cancer comfortable assuming sole or primary responsibility for managing the interface between different systems of healthcare? Do older breast cancer patients find the recently developed concepts of relationship-centered medicine and integrative care to be significant and relevant to their healthcare needs? Information also must be gathered on biomedical and CAM practitioners’ views and understandings. For example, how are features of healthcare delivery under managed care perceived to affect physician-patient interactions? How do biomedical and CAM practitioners address patients’ interest in integrative medicine? What is the extent of physicians’ and CAM practitioners’ professional contact with each other?
Clearly the study of this emerging healthcare phenomenon necessitates the formulation of new research questions. The study of the virtual triangle of healthcare relationships and communication requires the inclusion of previously underutilized qualitative research methods.
Qualitative science provides unique theories and methods to investigate the emerging relationships among older patients and their biomedical and CAM practitioners. As anthropologist Claire Cassidy explains, qualitative research methodologies display a high degree of “model fit” with integrative medicine; that is, they comprise “research design and techniques [that] fit the explanatory model/s of the study population/s.”66 If a paradigm is a basic set of beliefs that guide actions, then a paradigmatic confluence between research method and research topic can help to ease the investigative endeavor. A brief overview of qualitative research follows for those unfamiliar with this form of inquiry and the characteristics that make it particularly suitable for the study of emerging healthcare relationships, as well as the full range of CAM systems, modalities, practices, theories, and beliefs.
Qualitative research crosscuts disciplines, fields, and subject matters. To oversimplify, qualitative inquiry involves an interpretive, naturalistic approach to the world:
The word qualitative implies an emphasis on the qualities of entities and on processes and meanings that are not experimentally examined or measured (if measured at all) in terms of quantity, amount, intensity, or frequency. Qualitative researchers stress the socially constructed nature of reality, the intimate relationship between the researcher and what is studied, and the situational constraints that shape inquiry.”67
In addition, such researchers emphasize the value-laden nature of inquiry and seek answers to questions that focus on the way social experience is created and given meaning. In contrast, quantitative studies emphasize the measurement and analysis of causal relationships between variables, not processes. Many proponents of quantitative studies claim that their research is conducted within a value-free framework.66 Thus, qualitative and quantitative inquiry reflect commitments to different styles of research, different epistemologies, and different forms of representation. “Qualitative researchers use ethnographic prose, historical narratives, first-person accounts, still photographs, life histories, and biographical and autobiographical materials, among others. Quantitative researchers use mathematical models, statistical tables and graphs, and usually write about their research in impersonal, third-person prose.”67
There is no single, unified qualitative research method. “Those undertaking qualitative studies have a baffling number of choices of traditions”68 —one typology delineates 28 different approaches.69 Some of the most frequently used methods include biography, phenomenology, grounded theory, ethnography, and case study. In practice, various methods may be integrated in a single study. For example, in the ongoing qualitative study described at the end of this article, the methodological approach combines elements of phenomenology, ethnography, and grounded theory. This hybrid methodology permits the study of the meanings individuals derive from experiences, the description and analysis of culture-sharing groups, and the systematic collection of data for the generation of theory. Additionally, “methodology is inevitably interwoven with and emerges from the nature of particular disciplines ... and particular perspectives.”70(p163) The conceptual framework underlying this research is informed by developments in medical anthropology, the anthropology of aging, and medical folkloristics. These developments are grounded in the literature on patient-practitioner interaction,71-74 the experience of illness,75-77 biomedicine as a cultural system,78,79 medical pluralism,55,80,81 and relationship-centered and integrative medicine.1,82
The potential contributions of a qualitative approach to this research endeavor will be summarized in terms of a (nonexhaustive) sampling of pertinent characteristics: perspective, depth and detail, flexibility, and context sensitivity.
To grasp the intent of qualitative inquiry, it is necessary to understand the importance of acquiring an inside, or emic, understanding. Qualitative researchers “study things in their natural settings, attempting to make sense of, or to interpret, phenomena in terms of the meanings people bring to them.”83 Ethnographic methods (eg, open-ended, semistructured interviews or participant observation), in particular, are appropriate for the detailed investigation of patient-practitioner relationships in the context of CAM. These methods include rich descriptions and fine-grained analyses of individuals’ assumptions, knowledge, and values. Participants’ subjective views are valued as expert and their conceptualizations and models are integrated into research design. Through the use of in-depth, semistructured interviews, for example, qualitative researchers encourage informants to describe their beliefs and practices using their own logic and terminology. Qualitative researchers are committed to an emic, ideographic position, which directs their attention to the specifics of particular cases. This type of data collection results in rich personal accounts of meanings, relationships, and processes—critical information for determining participants’ understandings of their relationships to each other in the healthcare encounter. Although both qualitative and quantitative researchers are concerned with the individual's point of view, qualitative investigators think they can get closer to the actor's perspective through detailed interviewing or observation.
Qualitative inquiry is often characterized as inductive, largely because concepts emerge from the data during the processes of interviewing and analysis. In qualitative research, data collection and data analysis begin at the same time and proceed concurrently. The likelihood of missing significant themes is greatly reduced by translating raw data into research findings, which, in turn, affect the direction of subsequent interviews in a continual, iterative process. A major strength of qualitative inquiry for the study of new and developing phenomena is that, as patterns are revealed in the data and categories of meaning are subsequently created, analysis may reveal factors that had not been predetermined by the investigator and that may generate new interpretations. Qualitative studies may ask broad, open-ended, interconnected questions that are not always specifiable as conventional hypotheses. The emerging healthcare configurations under study are particularly amenable to this methodological process. This type of research often has a holistic aim, as well. Qualitative researchers seek to understand what unifies a phenomenon, to view a complex interaction in its larger context. This context sensitivity takes the form of addressing different aspects of sociocultural and historical contexts—an important part of situating recent developments in healthcare relationships.81
An ongoing qualitative study demonstrates how this form of inquiry can broaden the conventionally limited view of the patient-physician dyad by investigating contemporary healthcare relationships. The 4-year Integrating Healthcare Relationships (IHR) study, funded by the National Institute of Aging and the National Cancer Institute, examines how emerging configurations of healthcare relationships are approached and understood by the participants (note 1). This ethnographic project encompasses 3 domains: (1) the health beliefs and healing strategies involved in older breast cancer patients seeking care concurrently from physicians and CAM practitioners; (2) patients’ understandings of and behaviors regarding their relationships with physicians and CAM practitioners; and (3) physicians’ and CAM practitioners’ understandings of and behaviors regarding their relationships with older breast cancer patients.
Rather than using quantitative research methods such as hypothesizing a particular outcome and designing and distributing a written survey, the study's qualitative methodology will allow data to emerge from the participants’ own lived experiences. This empirical, ethnographic investigation is based on data from audiotaped, in-depth interviews with linked triads of older patients, physicians, and CAM practitioners. The patient sample consists of 40 African-, Chinese-, European-, and Hispanic-American women, aged 55-84 years, who have been diagnosed with breast cancer. Women are recruited through a tumor registry case listing generated by the Northern California Cancer Center located in Union City. Participants are asked to name both the physician and the CAM practitioner with whom she has the closest ongoing relationships. The practitioner sample consists of 40 physicians and 40 CAM practitioners.
The questions asked during semistructured patient interviews cover the following domains: conceptualizations of health and illness, attitudes toward aging, current biomedical and CAM treatments and health practices, relationships with physicians and CAM practitioners, understanding of biomedicine and CAM as comparative medical systems, and characteristics of high-quality healthcare.
The domains of questions asked during the physician and CAM practitioner interviews include the preceding items, as well as the practitioners’ professional history and background, details of the general healthcare encounter, details of the patient-specific healthcare encounter, and attitudes toward and degree of engagement with other medical systems (ie, CAM for physicians or biomedicine for CAM practitioners). Through the use of qualitative research methodologies, this ongoing study of the virtual triangle should provide a framework for studying and understanding emerging healthcare relationship configurations.
A review of current literature on alternative medicine and healthcare interactions reveals a need to investigate the understudied issue of older patients under the simultaneous care of both physicians and alternative practitioners. More broadly, relationships need to be studied between and among older patients, their physicians, and their alternative practitioners. The perspective, depth and detail, flexibility, and context sensitivity that characterize qualitative inquiry can provide unique and essential understandings of the virtual triangle of healthcare relationships and communication. By understanding all 3 sides of the patient-physician–CAM practitioner triangle, as well as recognizing the potential to add a new integrative dimension to these relationships, a more comprehensive and realistic view of current healthcare practices may emerge. The IHR study will reveal older breast cancer patients’ integrative healing approaches, discover benefits and deficiencies of biomedical and CAM systems with regard to addressing patients’ needs, and suggest strategies for improving emerging healthcare relationships. It is, of course, unrealistic to expect that the different perspectives and approaches among patients, physicians, and CAM practitioners will—or even should—gradually disappear, but strategies for strengthening all sides of the therapeutic triangle undoubtedly will emerge through ongoing research.
Cancer incidence data used in this research were collected by the Northern California Cancer Center under contract N01-CN-05224/25482 with the Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, and under subcontract 0501-8701/8708-S0207 with the California Public Health Foundation.
I am deeply grateful to the women with breast cancer, as well as their healthcare practitioners, who are generously sharing their thoughts and experiences by participating in this reasearch.
1Researchers on the Integrating Healthcare Relationships (IHR) study (NIA/NCI R01 AG17973) include Shelley R. Adler, PhD, Principal Investigator; Ellen Hughes, MD, PhD, and Harriet Beinfield, LAc, Co-investigators; Paula Fleisher, MA, Research Associate, and Maia Duerr, MA, (former) Research Associate.