BACKGROUND: The use of various forms of complementary and alternative medicine (CAM) has become widespread. We investigated this use in Madison, Wisconsin.
METHODS: We conducted semistructured in-depth interviews focused on the knowledge, attitudes, and behaviors of a random sample of 17 patients who had used both CAM and conventional therapies during the past year. Participants were recruited using telephone listings. Twenty alternative practitioners were selected to represent the major modalities. The topics discussed included healing philosophy, choices of therapeutic methods, and ideas concerning concurrent use of differing therapeutic modalities. An 8-member multidisciplinary team analyzed the transcripts individually and in group meetings.
RESULTS: Four major themes emerged from the interview data: (1) holism, (2) empowerment, (3) access, and (4) legitimization. Both patients and providers distinguished between the socially legitimized and widely accessible but disempowering and mechanistic attributes of conventional medicine and the holistic and empowering but relatively less accessible and less legitimate nature of alternative healing. There was a strong call for integrating the best aspects of both.
CONCLUSIONS: Practitioners and users of alternative therapies in the Madison area confirmed both the alternative and complementary natures of unconventional health care, called for more integrated and accessible health care, and provided insights that could be useful in bridging the gap between conventional and alternative medicine.
The use of complementary and alternative medicine (CAM) is on the rise. Various CAM modalities, including acupuncture, Chinese medicine, homeopathy, massage, naturopathy, spiritual healing, and the use of herbal medicines and supplements compete with, provide an alternative to, or complement the more conventional forms of medicine available in hospitals and licensed physicians’ offices. There is an emerging literature on various aspects of this growing phenomenon with hundreds of articles and dozens of texts already on the market.1-7 The Journal of the American Medical Association and associated Archives journals chose alternative medicine for their 1998 theme issue. The boundaries of CAM are being defined and redefined.8-13 A fair amount of research has explored physicians’ attitudes and practices regarding this increasingly prevalent phenomenon.14-18 However, very little is known about how patients think about and choose among the many alternatives or how alternative practitioners situate themselves in this process.19-22 To map out this relatively unknown but clearly expanding social territory we conducted, transcribed, and reviewed 37 in-person semistructured long interviews with providers of alternative therapies and people who use those therapies. Our respondents provided us with coherent and intriguing depictions of the many issues involved. Perhaps most important, our participants highlighted a number of ideas and issues that together form themes defining and demarcating “complementary”, “alternative”, and “conventional” health care.
Methods
Our goal was to investigate the knowledge, attitudes, and practices of patients and providers of complementary and alternative therapies. Eisenberg and colleagues23 defined complementary and alternative medicine as “unconventional.” In their framework, CAM therapies are those that are not taught in US medical schools or widely available in hospitals and licensed physicians’ offices. Our operational definition of CAM was consistent with that definition. Our inclusion criteria were focused on issues of reimbursement. Therapies such as herbal medicine, homeopathy, and mind-body medicine are not generally reimbursable, while most therapies prescribed by physicians are covered by third-party payers. We considered osteopathy and chiropractic as conventional medicine but included acupuncture in the alternative category. These broad definitions were not rigid. Instead, we let patients and providers describe to us their definitions and understandings of “complementary” and “alternative.” CAM therapies represented in our study are listed in Table 1. As a qualitative interview-based study, our research was designed to be exploratory, descriptive, integrative, multirelational, and hypothesis-generating. We followed the standard qualitative research method of formal multidisciplinary review of transcribed in-person long interviews.24-26 Each transcribed interview was reviewed by each member of an 8-person multidisciplinary research team, using a standardized worksheet. Transcriptions were reviewed individually and then discussed in 4 face-to-face group meetings. The research team consisted of an anthropologist and family physician research fellow, a faculty family physician, a biocultural anthropologist, a medical-education nurse and the faculty coordinator for an alternative medicine course for medical students, an alternative psychotherapist, 2 premedical students, and the research assistant interviewer who recently graduated in sociology and women’s studies.
Alternative therapy providers were recruited using a key informant sampling method. We began by generating a near-complete list of alternative providers in the Madison, Wisconsin, area. We used telephone listings, informal interviews with knowledgable informants, and looked for notices and business cards posted at pharmacies, health food stores, and alternative healing centers. Once we felt confident that our list was sufficiently comprehensive (approximately 150 individuals), we sampled the CAM providers to include a wide representation of healing modalities. Following informed consent procedures approved by our institutional review board, 20 healers were recruited and interviewed using a semistructured format aimed at understanding the nature of practice, philosophy of healing, and attitudes and practices with regard to patients’ use of conventional medicine. Examples of the questions asked are listed in Table 2. The interviews were semistructured, and the interviewer was allowed flexibility to explore ideas brought up by the respondent.