Patient and Clinician Openness to Including a Broader Range of Healing Options in Primary Care

INTRODUCTION

In the report Complementary and Alternative Medicine in the United States, the Institute of Medicine (IOM) identified the integration of complementary and alternative medicine and conventional medicine as an important area for additional research.¹ Although a high degree of interest in complementary and alternative medicine (CAM) therapies was found among practicing physicians more than a decade ago,^2–4 there has been limited uptake of an integrative approach to medicine by larger health care organizations. This lack of integration is especially noteworthy, given the increasing evidence of the safety and effectiveness of many CAM therapies¹ and the continued struggle in primary care to relieve the suffering of patients with conditions for which medical treatments are often of limited value (eg, chronic musculoskeletal pain, fibromyalgia, and lupus).

Many patients seek treatment options, particularly CAM therapies,^5–7 that are not currently offered in or through primary care, and they often are reluctant to tell their health care clinicians about their use of these treatments for fear of a negative reaction.^8–11 A more integrated and inclusive approach to healing that provides a wider range of treatment choices may improve patient satisfaction, decrease costs (by avoiding expensive tests and procedures), avoid adverse events (resulting from drug-herb interactions), and help improve health outcomes.^12,13

This study addresses several key issues highlighted in the IOM report by exploring the beliefs and attitudes of primary care patients and clinicians regarding integrating additional healing options into primary care. We undertook this project in preparation for designing a pilot program to evaluate the inclusion of additional healing options into primary care clinics in an integrated delivery system.

METHODS

We carried out our study in a large, integrated, Washington State health care system in October and November of 2008. Focus groups were held with patients (4 groups) and primary care clinicians (3 groups). The sessions were conducted by an anthropologist experienced in focus group facilitation (C.H.). The discussions explored participants’ perspectives regarding what primary care clinicians currently do or recommend that is healing, ideas about other healing options, openness to integrating these healing options into primary care, and facilitators and barriers to integrating other healing options. Participants were encouraged to share their own experiences with other healing options (see the Supplemental Appendix, Focus Group Guides, available at http://www.annfammed.org/cgi/content/full/9/5/447/DC1). The study was approved by the Group Health Institutional Review Board.

Patients and clinicians were recruited from the Seattle and Tacoma metropolitan areas. We selected a random sample of patients who had at least 1 primary care visit in the previous 12 months, stratified by sex and age. The organization has state-of-the-art data systems that allow for the identification and random selection of patients using a wide variety of variables. Letters mailed to patients invited them to participate in a discussion group to “identify ways to better meet the needs” of patients and to share “their ideas about ways to make primary care more healing.” The letter asked patients to call if they were interested in finding out more or participating in a discussion group. Patients who called were enrolled on a first-come, first-served basis. Beyond initially screening for basic comprehension of the study, there was no additional screening of patients. Patient focus groups were held in 3 locations to increase the geographic, socioeconomic, and cultural diversity of participants.

We sent e-mail invitations to all primary care clinicians—physicians, physician assistants (PAs), and registered nurses (RNs)—practicing in the health plan’s Puget Sound area clinics. All clinicians who volunteered were included in the study until the groups were filled. We obtained written consent from each participant and paid cash incentives (patients $100, clinicians $200). Focus group discussions were recorded with verbatim transcripts made in real time by a stenographer present in the room and with an audio recording. All transcripts were reviewed by a team member using the audio recording to correct errors. We gave participants unique identifiers to assess whether themes were shared by the group or repeatedly raised by the same person.

Two reviewers (C.H., S.H.) read all transcripts carefully at least once to identify codes for (1) all healing options that were mentioned by participants (options used by the facilitator to stimulate conversation were excluded), and (2) key themes. We used techniques from both immersion/crystallization¹⁴ and grounded theory (ie, constant comparison)¹⁵ to assist with the development of the initial and final codes. Both of these techniques involve reading and rereading of text to allow for the emergence or crystallization of key themes. Themes or groupings were compared and combined or separated by the coders based on similarities and differences and on frequency of occurrence. One reviewer (S.H.) coded all the transcripts using these initial codes, and a second coder (C.H.) either independently coded the material or reviewed the coding done by the primary coder. An iterative process was used to resolve differences and revise the codes. Atlas.ti software^16,17 was used to assist with coding and data analysis.

Once coding was completed, we developed coding memos on key areas of interest to summarize findings and provided example quotations. The entire team reviewed these memos, searched for nonconfirming data and suggested themes for further exploration.

RESULTS

DISCUSSION

A first step toward integrated medicine is the initiation of an open dialog between patients and their conventional health care clinicians about other healing options. Our study is one of only a few attempts to explore patient and clinician openness to integrating a broader range of healing options into primary care in the United States. Both published studies we could find focused on CAM therapies. Frenkel and Borkan¹⁹ assessed practitioners’ ideas about integration of CAM into primary care in the United States. They highlighted a number of barriers similar to those identified in our study, including the need for improved knowledge of the evidence base for CAM therapies. More recently, Ben-Arye et al²⁰ surveyed Israeli patients and found that more than 95% supported integration of CAM into primary care and more than 90% expected their physician to be knowledgeable about CAM therapies and to “refer them to a CAM practitioner when it was appropriate and safe.”

Our focus groups revealed that both patients and clinicians were open to expanding healing options in primary care. Both groups could identify a wide variety of healing options they did not consider part of standard care. There was broad agreement among patients that clinicians should recommend options which have evidence of effectiveness, although there is substantial variation in the level of evidence they required. Clinicians were particularly concerned that options they recommend be safe.

Patients had clear expectations of how clinicians should introduce recommendations for new options. They wanted the recommendation to be presented as an option, not an order. They also wanted it to be added care, not to replace standard diagnosis and treatment. They wanted practical information about the treatment and referrals to trusted practitioners. Clinicians and patients were most familiar with exercise, massage, nutrition, spirituality/religion, recreational activities and lifestyle change, and therapeutic activities (eg, pet therapy, art therapy). These options might take priority for integration into primary care. Interestingly, nutrition, exercise, and general lifestyle changes (which included such activities as gardening, volunteering, dancing, etc) are conventional treatments of proven value but have not been effectively integrated into medical care. Most of the remaining healing options identified are more closely associated with complementary and alternative medicine.

These findings suggest that integrating open discussion and referrals to additional healing options into primary care may be both feasible and desirable, especially for patients whose conditions are not responding to standard medical treatments (eg, chronic pain, irritable bowel disorder, chronic fatigue). Several barriers would need to be addressed, however. Clinicians need better information regarding the nature, effectiveness, and safety of healing options. They also need current, reliable information on practitioners and resources in their communities.

There are also a number of challenges that, although not raised by the clinicians in our study, clearly need to be addressed in any considerations of how to integrate other healing options into our current health care system. These challenges include the fast pace of most health care encounters and the lack of clinician time, concerns about the cost of providing access to other healing options, lack of evidence that providing other healing options would be more cost-effective, and the lack of proven business models for providing integrated care.

This exploratory study has a number of limitations: a self-selected sample, biases generated by the context of the study, and limitations of the questions asked. Our participants were drawn from patients in 1 large health care system with traditions of patient advocacy, community involvement, emphasis on prevention, and clinical research. All patient participants had established relationships with primary care clinicians. In addition, our population is more educated, predominantly white, and less religious than populations in some other regions of the United States. The clinician participants were highly experienced, most with more than 25 years of practice experience. The invitation letter stated our interest in healing and health care and might have attracted biased participants. Our community has high rates of CAM use,²¹ including among patients who regularly see medical doctors. Also, our health care system provides benefits for CAM treatments, as mandated in Washington State.

Although our specific findings may not be generalizable to other groups or populations, they provide important themes and insights into the issue of integrating health care that could be tested in other settings. Furthermore, our findings are consistent with research conducted by Frenkel and Borkan,¹⁹ Shelley et al,⁹ and Ben-Arye et al,²⁰ all of whom found, through a variety of sources including patient self-report, that patients are interested in or already using CAM healing options (a major subset of the options we studied). We identified themes regarding safety and the need for clinicians to be open and flexible about other healing options, similar to those identified by Shelly et al. Consistent with the findings of Ben-Arye et al, we found that most patients are open to having their primary care clinicians recommend other healing options. Furthermore, these findings, while exploratory, may provide guidance to clinicians interested in discussing additional healing options with their patients.

Further research will be needed to clarify the safety, clinical effectiveness, and cost-effectiveness of specific healing options and of the integration of various packages of such options into primary care. In the meantime, this study suggests that increasing dialog between patients and clinicians and making additional healing options available to patients, particularly those who do not respond well to conventional treatments, is viewed as desirable and acceptable by many patients and primary care clinicians.