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‘You just got to eat healthy’: The topic of CAM in the general practice consultation

Kevin Dew
School of Social and Cultural Studies, Victoria University of Wellington, New Zealand

Elizabeth Plumridge
Department of Primary Health Care and General Practice, University of Otago, New Zealand

Maria Stubbe
Department of Primary Health Care and General Practice, University of Otago, New Zealand

Tony Dowell
Department of Primary Health Care and General Practice, University of Otago, New Zealand

Lindsay Macdonald
Department of Primary Health Care and General Practice, University of Otago, New Zealand

George Major
Department of Primary Health Care and General Practice, University of Otago, New Zealand

Abstract

New Zealand research suggests that CAM use by GPs has decreased, while referral to CAM practitioners by GPs has increased, and that patients often do not tell their health practitioners when they are using CAM.

The New Zealand Medical Council has developed guidelines for GPs who use CAM. However, there is no research in New Zealand that looks at how patients and GPs respond to CAM issues in the consultation.

This paper uses data collected for two research projects on doctor-patient interaction. For this research, consultations between 105 patients and nine GPs were video-recorded. In this data set, all doctors but one were ‘orthodox' and to some degree reserved judgement on CAM, albeit remaining cautious in how they made this evident. Patients on the other hand demonstrated a variety of strategies to get CAM on the agenda, and GPs were careful to couch any criticism in such a way as to protect the ‘face' of patients.

Keywords

sociology, complementary and alternative medicine, doctor-patient interaction

Article Text

In New Zealand there has been a trend of increasing referral by GPs to CAM therapy, with nearly 95% of GPs doing so, but a decreasing number of GPs practising some form of CAM, with only 20% doing so (Poynton et al 2006). New Zealand research suggests that only one-third of patients who use CAM disclose this to their medical practitioner (Nicholson 2006). The New Zealand Health Practitioners Competency Assurance Act (2003), which covers general practitioners and other medical practitioners, states that a practitioner cannot be found guilty of a disciplinary offence ‘merely because that person has adopted and practised any theory of medicine or healing if, in doing so, the person has acted honestly and in good faith' (Medical Council of New Zealand 2005). The Medical Council of New Zealand's guidelines for medical practitioners who use CAM places the onus on the practitioners ‘to inform the patient not only of the nature of the alternative treatment offered but also the extent to which that is consistent with conventional theories of medicine ...' (Medical Council of New Zealand 2005). Underpinning this, and indeed all practice of doctors, is the Hippocratic Oath to ‘prescribe regimens for the good of my patients ... and never do harm to anyone'. This can be applied to CAM as to all aspects of medicine.

Early sociological analyses of CAM emphasised the ways in which it was dominated by biomedicine. Willis (1983) used case studies to illustrate different forms of dominance, for example through subordination of occupations to medicine or limitation placed on what other professionals could practice. Larkin (1983) traced the way in which modern medicine evolved through eliminating competing healers such as herbalists and controlling emergent ones. The marginalisation of the therapeutic practices of indigenous peoples through the process of colonisation has been studied (Goldberg 1993). The growing popularity of alternative therapies since the 1960s, particularly in Anglophone countries, has been of sociological interest (Saks 2001). Reasons put forward for this rise in popularity include dissatisfaction with orthodox medicine (Sharma 1992), particularly in relation to the treatment of chronic conditions (Kelner & Wellman 1997); a growing public interest in health care generally (Northcott & Bachynsky 1993); interest from the market, particularly the pharmaceutical industry (Collyer 2004); and a reflection of postmodern values such as the rejection of scientific and professional authority (Siahpush 1998).

Willis (1994) argued that complementary medicine and orthodox medicine are becoming less incommensurable. According to Coulter (2004), medicine has been extraordinary for its capacity to turn yesterday's heresy into today's healthcare - but he points out that there are paradigmatic differences between CAM and biomedicine - giving rise to the possibility that biomedicine itself may be transformed by CAM (also see Coulter & Willis 2007). In contrast, Dew (1998) has suggested that CAM may be transformed by forms of accountability, such as EBM and quality assurance programmes, that have taken hold in biomedicine. These positions are not necessarily incompatible, as mutual transformation is a possibility.

This paper does not try to settle the dispute about the reasons for interest in CAM, but provides insights into the relationship between CAM and orthodox medicine in contemporary times. As Tovey and colleagues (2004) state:

To understand the contemporary forms and contents of CAM there is a need to step back from the often hurriedly established demands of policy-makers, and to explicitly include in analyses reference to how the arena is marked by complexity and contingency, diversity and dispute and is in a state of constant change.

Although there is research looking at CAM use by practitioners and patients using interview data (Dew 2001; Tovey & Broom 2007), and a great deal of research using data from naturally-occurring physician-patient consultations that looks at a range of other issues (for recent examples see Heritage & Maynard 2006a); there are no examples in the extant literature of studies that explore CAM issues using naturally occurring interactional data. This paper is unique in using such data to explore interactional issues in relation to two topics: GP responses to patient-initiated CAM talk; and the different explicatory work undertaken by GPs who use CAM and orthodox GPs in relation to causation.

The data analysed for this paper was originally collected as part of two related projects exploring clinical decision-making and tracking the interactions of individual patients with health professionals as they move through the primary and secondary care systems in New Zealand. The research questions on the information sheets to doctors and patients were of a general nature, stating that the research aimed to explore aspects of clinical decision-making and communication in the consultation. Ethical approval for the research was obtained from the Central Regional Ethics Committee. Video recordings were made of 105 consultations with nine GPs. The GPs were recruited from a mix of central city and suburban practices. All nine consultations where CAM issues were identified have been used for this paper.

All consultations collected were fully transcribed using a modified conversation analysis format (for conventions, see below), based on a set of widely-used conventions originally devised by Gail Jefferson (ten Have 1999). The point of such a detailed form of transcription is to identify such conversational features as overlaps in talk, pauses and changes in intonation to allow a close examination of how and what issues are ‘recognised' and ‘attended to' by clinicians. Following Heritage and Maynard (2006b: 1), the approach taken in this paper assumes that:

... physician and patient - with various levels of mutual understanding, conflict, cooperation, authority, and subordination - jointly construct the medical visit as a real-time interactional product.

By analysing actual interactions, various socio-medical dilemmas can be identified and also the interactional resources deployed by the interactants in response to such dilemmas.

The paper is divided into two sections, the first looks at interactions involving orthodox GPs, and the second at interactions involving a GP who uses CAM alongside conventional therapies, described here as an integrative medicine GP.

Orthodox GP CAM talk

In this data set there are seven cases where patients raise issues that are CAM related, and GPs respond to these in a variety of ways. In effect, however, they ‘reserve judgement' on CAM to the extent necessary to protect the ‘face' of their patients (cf: Goffman 1963). ...continues...

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