Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies

BACKGROUND: Many people use complementary or alternative medicine (CAM). It is estimated that over 50% of patients that require health care use CAM either in conjunction with, or separate from, conventional health care. Despite the popular use of CAM, patients do not always inform their conventional medicine health carers of their CAM use. The medical practitioner is in most cases the first health care professional a person contacts concerning a health care matter, and needs to have a full history of a health problem to understand and provide optimum care. This literature review aims to provide an understanding of the degree to which patients disclose their use of CAM to their medical practitioners, and their reasons for not doing so. METHOD: A comprehensive literature search identified 12 studies published between 1993 and 2002 that examined what percentage of consumers did not disclose to their medical practitioners their use of CAM, and their reasons for not doing so. RESULTS: The rate of non-disclosure of those using CAM is as high as 77% in some studies. The main reasons patients provided for not disclosing their use of CAM to their medical practitioners were concerns about a negative response by the practitioners, the belief that the practitioner did not need to know about their CAM use, and the fact that the practitioner did not ask. DISCUSSION: The pre-conceptions patients have that influence their non-disclosure may be based on three issues. First, beliefs and concerns that influence their decision-making, second personal experiences in their consultations with medical practitioners, and third, the desire for more control over their health care. Medical practitioners need to acknowledge the concerns and beliefs of patients in making their health care decisions, and work with patients so that the use of CAM is acknowledged and the patients' needs, beliefs and concerns respected.     

Components Necessary in a Successful Nurse Practitioner-Physician Collaborative Practice

In recent years, collaborative practice has gained much attention from nurse practitioners in primary health care settings. This is because many nurse practitioners feel that nurse practitioners and physicians can complement each other's roles. Together, they can provide more comprehensive, quality primary health care than either profession can provide by itself. Nurse practitioners and physicians working together to care for a common group of patients may have varying degrees of collaboration in their practice. This article discusses some elements and components necessary to maximize the quality and extent of collaboration.     

Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice

In the United Kingdom nurse practitioners are assuming responsibilities traditionally considered to be within the domain of general practitioners. Important amongst these is the referral of patients to medical consultants in secondary care, a responsibility commonly associated with the general practitioner's role as 'gatekeeper' to health care. This paper describes a study designed to identify issues raised by the challenge that a developing nursing role presents to interprofessional working at the interface between primary and secondary care. When invited to comment, study participants (nurse practitioners, nurse educators, medical consultants and general practice registrars) related nursing referrals to issues associated with professional boundary changes, namely: teamwork, regulation of practice, communication, professional conflict and professional relationships. This paper discusses the views of primary and secondary care practitioners about who should take responsibility for the referral of patients in the light of concerns raised about professional competence and accountability. Individual nurse practitioners and their colleagues have found pragmatic ways to manage their work however, although UK government policy supports development of advanced clinical nursing, there remains much work to be done to provide the professional and legal infrastructure to support the role.     

The Acute Care Nurse Practitioner in Collaborative Practice

Nurse-physician relationships remain, for the most part, hierarchical in nature. A hierarchical structure allows the person at the top, most notably the physician, the highest level of authority and power for decision making. Other health care providers are delegated various tasks related to the medical plan of care. One role of nonmedical health care providers, including nurses, is to support the medical plan of care and increase the productivity of physicians. Medical centers have house staff, usually interns and residents, who work collaboratively with the attending physicians in care delivery. At one medical center, a shortage of medical house staff for internal medicine prompted the development and evaluation of an alternative service. The alternative service utilized master prepared, certified nurse practitioners on a nonteaching service to provide care for selected types of medical patients. Physicians consulted with nurse practitioners, but retained decision-making authority concerning patient admission to the service. This paper describes the development and evaluation of an alternative service based on a collaborative practice model and the role of nurse practitioners working under such a model. Discussion includes suggestions for process guideline development for organizations that want to improve collaborative practice relationships between unit nursing staff, nurse practitioners, and physicians.     

Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice

In the United Kingdom nurse practitioners are assuming responsibilities traditionally considered to be within the domain of general practitioners. Important amongst these is the referral of patients to medical consultants in secondary care, a responsibility commonly associated with the general practitioner's role as 'gatekeeper' to health care. This paper describes a study designed to identify issues raised by the challenge that a developing nursing role presents to interprofessional working at the interface between primary and secondary care. When invited to comment, study participants (nurse practitioners, nurse educators, medical consultants and general practice registrars) related nursing referrals to issues associated with professional boundary changes, namely: teamwork, regulation of practice, communication, professional conflict and professional relationships. This paper discusses the views of primary and secondary care practitioners about who should take responsibility for the referral of patients in the light of concerns raised about professional competence and accountability. Individual nurse practitioners and their colleagues have found pragmatic ways to manage their work however, although UK government policy supports development of advanced clinical nursing, there remains much work to be done to provide the professional and legal infrastructure to support the role.     

General Practitioners: Allies or Enemies of Primary Health Care

In this paper the thesis is advanced that the general practitioners can either be a powerful ally or a major roadblock in the development of primary health care in the spirit of the Alma-Ata Declaration. The role they will play depends on their interpretation of, and attitudes towards, the concept. In the first part of the paper, four common interpretations of primary health care (primary health care as a set of activities; as a level of care; as a strategy; and as a philosophy) are described. The second part identifies common misconceptions — traps into which the general practitioners may fall when taking their stand on primary health care. In the third part, a blueprint for transforming the current systems of primary medical care systems into primary health care systems is outlined. The final section suggests some concrete actions to be taken by the general practitioners in implementing this blueprint.     

General practitioners: allies or enemies of primary health care

In this paper the thesis is advanced that the general practitioners can either be a powerful ally or a major roadblock in the development of primary health care in the spirit of the Alma-Ata Declaration. The role they will play depends on their interpretation of, and attitudes towards, the concept. In the first part of the paper, four common interpretations of primary health care (primary health care as a set of activities; as a level of care; as a strategy; and as a philosophy) are described. The second part identifies common misconceptions - traps into which the general practitioners may fall when taking their stand on primary health care. In the third part, a blueprint for transforming the current systems of primary medical care systems into primary health care systems is outlined. The final section suggests some concrete actions to be taken by the general practitioners in implementing this blueprint.     

The Importance of Oral Cancer Screenings by Nurse Practitioners

One person dies every hour from oral cancer complications, but if nurse practitioners were proficient in providing a 5-minute, comprehensive oral screening examination during routine care, many cases could be prevented or detected early. This training may decrease the incidence and prevalence of oral cancer and increase professional and public awareness. This procedure should be a shared medical and dental responsibility for patients that have medical coverage but no dental insurance. Nurse practitioners are focused on health promotion and prevention, so they are the ideal practitioner to oversee nurses working with the new requirements for long-term care.     

Nurse practitioner-led prostate biopsy in the United Kingdom

As prostate cancer detection rates increase, multi-professional health care teams with nurse practitioners are adopting some roles that have predominantly been in the medical domain. This article reports the development of nurse practitioners undertaking prostate biopsies in the United Kingdom and presents an audit demonstrating the safety of nurse practitioners conducting this procedure.     

Mental Health Nurse Incentive Program: contributing to positive client outcomes

Mental health conditions are likely to affect almost half of the population at some stage in their lives. Despite the magnitude and potentially serious consequences of mental illness and disorders, access to services is a significant problem. In 2007, the Mental Health Nurse Incentive Program (MHNIP) was implemented to improve access to mental health care in Australia. Mental health nurses are engaged under the MHNIP to work with general practitioners, psychiatrists, and other mental health professionals to treat clients experiencing a mental health condition. This paper presents findings from a qualitative exploration of nurses working under the MHNIP in Australia. In-depth interviews were conducted with 10 nurses currently working under the MHNIP to gain an understanding of their roles and their perceptions of the effectiveness of this new programme. Data were analysed using NVivo. Four major themes emerged: developing the role, a holistic approach, working collaboratively, and benefits to clients. The findings suggest that mental health nurses have the potential to make a significant contribution to enhancing access to, and the quality of, mental health care through flexible and innovative approaches.     

Residency programs for primary care nurse practitioners in federally qualified health centers: a service perspective

A number of social forces are converging to shape the coming health care and professional practice environment for nurse practitioners (NPs) and the public they serve. Two major innovations of the 1960s, NPs and community health centers, have reached their fourth decade since their inception. These forces have traveled parallel and overlapping paths in their mission to provide high quality health care. Today the current federally qualified community health centers (FQHCs) are a major component of the nation's safety net for the medically underserved, special populations, and the uninsured throughout the United States. Nurse practitioners in the FQHC settings are responsible for highly complex care across lifecycles, with a focus on the treatment and management of disease along with prevention and health promotion. The author suggests that FQHC-based formal residency programs in primary care at either the post-master's or post-doctoral level are the next step in the evolution of both FQHCs and NP preparation. Possible funding mechanisms through changes in federal graduate medical education legislation are explored.     

Nurse Practitioner Political Strength Through Unification

If nurse practitioners are to achieve their goal of serving as the principal providers of primary health care and having a major voice in health policy decisons, they must increase their political effectiveness. Of all the problems that nurse practitioners face today, this is one of the most serious. This article identifies some of the reasons why nurse practitioners have failed to achieve maximum political effectiveness, such as lack of national stancardization of the role, titling confusion, and the lack of research to demonstrate that the nurse practitioner is the most appropriate and cost effective primary health care provider. Next, the consequences of the above are explored. Finally, some solutions are proposed, the most important of which is the establishment of a strong national nurse practitioner organization to serve as the voice of all nurse practitioners.     

The patient-centred interview: the key to biopsychosocial diagnosis and treatment

The article reports on some ideas and experiences gained from a holistic approach to working with patients and introduces a viewpoint that includes opinions on how postmodernism, the biopsychosocial model and a patient-centred interviewing style can change traditional, biomedical-oriented medicine. During the past 10 years, we have been instructing medical students in the use of this patient-centred interviewing model and have trained experienced general practitioners (GPs) in adopting it in 2-year family-oriented continuing medical education courses. We believe that doctors and other health care providers, particularly in primary care settings, need a comprehensive concept of human health and illness, and that skill in patient-centred interviewing is the product of a deep learning process. In conclusion, we have learned that a successful patient-centred interview helps the GP to better understand the patient and helps to explain the data that the patient presents. Patient-centred orientation and interviewing also change the communication between doctor and patient in a direction which supports the patient's and his/her family members' own resources in the healing process.     

Comments on complementary and alternative medicine in Europe

Despite the advances in Western medicine, up to one in three people in populations served by this medical system are seeking some form of unorthodox care each year, and Europe is no exception. Patients have driven this change, to the point where complementary and alternative medicine (CAM) is the second biggest growth industry in Europe. Often patients have to rely on the growing numbers of CAM practitioners with a variable standard of care that ranges from excellent to dangerous. Many practitioners work without regulation or even work illegally. Many orthodox health care professionals have shared their patients' concerns. Over the last 15 years, these practitioners have moved from silent interest to open enquiry and growing use. For example, approximately one in five of Scotland's general practitioners have received basic training in integrating homeopathy with orthodox practice. The demand for CAM is in part a search for a broader range of therapies, but is also a call for a different approach to care, with less emphasis on drugs, and a more whole-person approach. Mostly, people look to CAM when orthodoxy has failed. But CAM is also increasingly becoming a first-line intervention for some, because of the worry about the side effects of conventional treatments and a perception that orthodoxy has become dehumanized. With some exceptions, research is still in its early stages and lacks infrastructure. Patient satisfaction, empirical clinical outcome, and cost are beginning to be emphasized over mechanism of action or explanatory models. Recent official reports are calling for national and European-level enquiry and response. Future development is likely to emphasize integrative care. The challenge is to create better medical systems, with a whole-person emphasis, calling on a broader range of approaches than is currently orthodox. We seem to need a reunion of the art and science of medicine.     

The patient-centred interview: the key to biopsychosocial diagnosis and treatment

The article reports on some ideas and experiences gained from a holistic approach to working with patients and introduces a viewpoint that includes opinions on how postmodernism, the biopsychosocial model and a patient-centred interviewing style can change traditional, biomedical-oriented medicine. During the past 10 years, we have been instructing medical students in the use of this patient-centred interviewing model and have trained experienced general practitioners (GPs) in adopting it in 2-year family-oriented continuing medical education courses. We believe that doctors and other health care providers, particularly in primary care settings, need a comprehensive concept of human health and illness, and that skill in patient-centred interviewing is the product of a deep learning process. In conclusion, we have learned that a successful patient-centred interview helps the GP to better understand the patient and helps to explain the data that the patient presents. Patient-centred orientation and interviewing also change the communication between doctor and patient in a direction which supports the patient's and his/her family members' own resources in the healing process.     

Decision-making in primary care: outcomes from a study using patient scenarios

BACKGROUND: Various documents emphasize the importance of new roles and new ways of working to modernise delivery of health service and improve the public's health. In particular nurse practitioners are seen as crucial in the modernization process. AIM: This paper reports the outcomes of a study conducted in 1998 to ascertain the differences, if any, in the decision-making processes of nurse practitioners and general practitioners for diagnosis and treatment when given the same patient scenarios. METHODS: Information processing theory together with 'think aloud' approach were used to understand the cognitive processes of the 22 participants, 11 general practitioners and 11 nurse practitioners, in the study. A reference model was developed for each of the six scenarios of the study; three medical photographs were also used. The data were analysed using NUD*IST computer software. RESULTS: The outcomes of each scenario are presented and comparisons are made with general practitioners. The results show that there were more similarities than differences in the decision-making processes of the two groups. Hypothesis evaluation appears to be the critical component in the decision-making process. Explanations given by the two groups at the end of their 'think aloud' procedure justify their diagnoses and treatment/management plans. CONCLUSIONS: The research adds to existing evidence that encourages health care providers to use nurse practitioners more flexibly and to develop service-based approaches to the delivery of health care as set down in government policies. It also adds to the body of literature using information processing theory because it demonstrates that the two groups use similar decision-making processes to arrive at similar diagnoses and treatment options.     

Nurse practitioner research: issues in practice and theory

Since the inception of the nurse practitioner role, numerous studies have focused on the characteristics of NPs, including their educational preparation, their practice settings, demographic characteristics of clients, cost analysis, and the quality of services within a medical context. The two major conclusions of the majority of these studies have been that the delivery of health care by nurse practitioners has been fully accepted by patients, and that nurse practitioners are competent in the delivery of quality care. A brief historical overview of nurse practitioners is presented; the major methodological and conceptual issues of nurse practitioner research are reviewed. Views on practice issues and nursing theory development are shared, and directions for future nurse practitioner research are explored.     

A primer on referring patients for psychotherapy

Forty percent of the mental health care in this country is provided by primary care practitioners alone, and another 20% is provided by primary care practitioners working with mental health professionals. Primary care physicians can serve a valuable role by educating their patients about various forms of psychotherapy. Finding a good "fit" between patient and therapist is crucial to a good outcome. We discuss which psychotherapeutic techniques are appropriate for various emotional problems and the advantages and disadvantages of each.     

Collaborating with medicine? Perceptions of Australian naturopaths on integrating within the conventional medical system

Complementary and alternative medicine (CAM) is an increasingly prevalent part of contemporary health care. Whilst there have been some attempts to understand the dynamics of CAM integration in the health care system from the perspective of conventional care providers and patients, little research has examined the view of CAM practitioners. This study aims to identify the experiences of integration within a conventional healthcare system as perceived by naturopaths. Qualitative semi-structured interviews were conducted using a purposeful sample of 20 practising naturopaths in South East Queensland, Australia to discuss their experiences and perceptions of integrating with conventional medical providers. Analysis of the interviews revealed five broad challenges for the integration of CAM according to naturopaths: competing paradigms between CAM and conventional medicine; co-option of CAM by conventional medical practitioners; the preservation of separate CAM and conventional medical worlds by patients and providers due to lack of formalised relations; negative feedback and biases created through selective or limited experience or information with CAM; and indifferent, reactive and one-sided interaction between CAM and conventional medical providers. Naturopaths support the integration of health services and attempt to provide safe and appropriate care to their patients through collaborative approaches to practice. The challenges identified by naturopaths associated with integration of CAM with conventional providers may impact the quality of care of patients who choose to integrate CAM and conventional approaches to health. Given the significant role of naturopaths in contemporary health-care systems, these challenges require further research and policy attention.     

Attitudes and knowledge of primary care professionals towards evidence-based practice: a postal survey

OBJECTIVES: To describe the attitudes, awareness and use of evidence across key professional groups working in primary care. METHODS: A postal questionnaire was sent to all lead/chairs, general managers, clinical governance leads, lead nurses, lead pharmacists and public health practitioners working in local health care cooperatives in Scotland. RESULTS: 289 (66.1%) health care professionals responded, ranging from 51% of general managers to 80% of lead nurses. All professional groups supported evidence-based practice. General practitioners (GPs) were less likely to agree that they had the skills to carry out literature reviews or appraise evidence compared to nurses and public health facilitators (36% vs. 75% vs. 80%; 51% vs. 64% vs. 70%). Access to the internet and bibliographic databases was good for all groups but GPs used a narrower spectrum of evidence-based journals, relying mainly on medical literature. Only nurses and public health practitioners appeared to have any understanding of qualitative research terms. Public health practitioners were also least likely to view guidelines or protocols developed by others as the best source of evidence for primary care. The major perceived barrier to practising evidence-based practice was time. Consequently the most important facilitator was protected time, but increased resources (financial and staff) and training were also cited. Professional groups other than GPs perceived inter-professional boundaries as a barrier and suggested multi-professional teamworking and learning as potential supports for evidence-based practice. CONCLUSIONS: While all professional groups welcome and support evidence-based practice, there are clear differences in the starting point and perspectives across the groups. These need to recognized and addressed to ensure that learning the skills of evidence-based practice and implementing evidence are effective. This will also enhance the ability of primary care organizations to develop robust mechanisms for supporting key aspects of clinical governance.