Legitimization
Our respondents differentiated between the officially recognized nature of conventional medicine and the less legitimated but increasingly recognized status of CAM. They also differentiated between official or legal legitimacy and legitimacy originating from credible evidence. Practitioners and patients believed in the effectiveness of the modes they used. Referring to the evidence base of alternative medicine, one patient said, “It is just as sound as conventional medicine. It’s just that there haven’t been enough studies yet.” However, one practitioner claimed that “What I teach (and practice) is research based and backed up by studies.” A patient, however, felt that the evidence of effectiveness was often “anecdotal and that doesn’t work in health care.” Both patients and practitioners noted the current lack of standards and felt that standardization (and legitimization) should occur. One said, “They (alternative practitioners) are not under any regulated umbrella, and I think there are a lot of exaggerated claims about what they can do for you.” Another put it more bluntly, “I think there are many quacks out there without review and standards, and people are skeptical of them.”
Discussion
Alternative, complementary, or unconventional therapies are increasingly prevalent throughout the industrialized world.27-33 In the United States, Eisenberg and coworkers estimated that in 1990 approximately 34% of Americans used an unconventional therapy, and made an estimated 425 million visits to alternative practitioners.23 By 1997, those figures had climbed to 42% of Americans using an unconventional therapy, and 629 million visits to CAM providers.34 Other studies12,35-37 provide similar estimates. The number of visits to CAM providers clearly outnumbers the number of visits to primary care physicians, estimated at 388 million in 1997. It is an interesting situation, considering the relatively high (estimated at $27 billion in 1997) out-of-pocket costs of alternative medicine and the greater credibility and legitimacy of conventional medicine. The literature provides few insights. A number of hypotheses have been proposed, but few have been tested.18-20,22 Socioeconomic indicators are mildly predictive at best. There is a slight positive association with education, income, and female gender and a moderate negative association with African American ethnicity, but overall these are poor predictors, with odds ratios ranging from 1.2 to 1.4.19,22,23,34,35 Dissatisfaction with conventional medicine does not seem to significantly predict CAM use. In contrast, most patients who use CAM continue to utilize and appreciate conventional medicine, although they often do not tell their physician about their unconventional choices.
Our research project was designed to begin to map out the attitudinal and behavioral territory of CAM and between alternative and conventional medicine. 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. They believe conventional medicine has legitimate strength in both diagnosis and treatment but often fails to take account of the complexity of the whole person. Many noted that because of its power, conventional medicine can easily do harm. One practitioner described conventional medicine as “like using a boulder to kill an ant.” Another used a velocity metaphor in describing the difference, “Chinese medicine has a top speed of 30 miles per hour and if your disease is going 45 to 50, you need to go to an allopathic (conventional) physician because they can go 120.”
Of the 4 thematic categories identified, access is perhaps the most complex, because it includes health system issues (eg, insurance coverage) and patient-provider communication issues (eg, language, culture, and socioeconomic accessibility). Alternative therapies cost less to society than conventional ones. A person paying out of pocket will receive more provider time per dollar with an alternative practitioner than with most conventional providers. However, for the majority of people in the United States who have health care coverage, conventional medicine costs very little out of pocket, certainly less than the $25 to $50 per hour charged by many alternative providers. So we are left with the contradictory situation in which the direct costs to patients using the relatively expensive official health care system are often less than the price that alternative healers charge. However, for the substantial minority that lack insurance coverage (15% to 20% of the United States), conventional medicine is often beyond their financial reach, perhaps increasing the relative accessibility of alternative medicine.
The incorporation of a more holistic and empowering healing philosophy can be seen as a natural step in the growth of medicine, a step that has already been taken by many persons. This type of healing strategy is consistent with the adoption of the biopsychosocial model, a theory-based health care strategy first proposed by Engel in the 1970s.38-40 In conventional health care, family physicians have perhaps most embraced holism, humanism, and biopsychosocial medicine.41-45 Our results can also be seen as consistent with the behavioral model of health care developed by Andersen and colleagues.46 This behavioral model postulates that choices of health care arise from predisposing characteristics (health beliefs and social structure) interacting with enabling resources (access), as well as health needs.47 The behavioral model has been applied to alternative health care by Kelner and Wellman,21 who after analyzing in-depth interviews with 300 patients concluded that “the choice of type of practitioner(s) is multidimensional and cannot solely be explained either by disenchantment with medicine or by an ‘alternative ideology.’”