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.

We recruited patients randomly using the Madison telephone listings. Our inclusion criteria required that they were aged 18 years or older, used both alternative and conventional medicine in the past year, and were willing to meet for an unpaid hourlong interview. Out of 237 phone numbers randomly chosen from the telephone book, 29 were disconnected, and 58 went unanswered after at least 3 attempts. Of the remaining 150, 25 fit inclusion criteria, 19 agreed to an interview, and 17 were actually interviewed. The location of the interview was open to the participants’ choice and included home, office, and a public place, such as a restaurant or library. The semistructured format allowed free-flowing interviews aimed at probing health beliefs, choices, and practices. We were specifically interested in how patients thought about both alternative and conventional health services, how and why they made their health care choices, and how they personally valued various aspects of CAM and conventional medicine that came to light during the interview. Although our initial goal was to interview 20 patients, we stopped after 17 because we felt we had reached the point of data saturation (we ceased to learn new things with our interviews).

Results

During the 37 interviews in the practitioner and patient categories, a number of points emerged. Issues contrasting conventional and alternative health care rose to prominence during the interviews. Respondents noted differences of style, cost, training, institutional structure, and philosophy, orientation, and world-view. Vague, subtle, implicit, and subjective differences were described as well as obvious, clear, and objective differences. Among the medley of points that surfaced, a number of issues were raised repeatedly. After discussion and deliberation we organized that data into 4 major thematic categories: holism, empowerment, access, and legitimization. Nearly every idea, talking point, or issue that we noted—several hundred in all—fit comfortably within at least one of these major themes. Some of the more salient ideas and issues are shown in Table 3. A number of points, issues, or subthemes related to more than one of the themes and provided important interconnections or overlaps.

Holism

Patients and practitioners of alternative therapy stressed the importance of a grounded integrated whole-person approach. Patients noted that they preferred to be treated as whole people rather than as composites of numerous biomedical attributes. Practitioners stressed the multidimensional nature of their work and contrasted their integrated approach from what they considered the mechanistic reductionist methods of biomedicine. One practitioner said, “I think conventional medicine tries to fix a problem…rather than get to the heart of the issue.” One patient described it as “healing and staying healthy in a proactive sense.” Another said it was “amazing, your mind and body working together.” The importance of incorporating emotional, physical, psychological, and social factors in both diagnosis and therapy was repeatedly stressed.

Empowerment

Our participants told us that conventional biomedical practitioners often disempower their patients by acting in condescending, disparaging, chauvinistic, or paternalistic manners. In contrast, alternative healers were characterized as facilitating rather than directing the healing process, relying on self-empowerment and personal responsibility for health. One patient said, “I have to be part of the process for it to work.” Another defined conventional medicine as: “You broke it, so let’s fix you.” A third, describing her interaction with conventional physicians said, “And every time I bring it up they blow it off. So I didn’t get very far when I voiced my concerns.” A fourth went so far as to say, “I think the doctors’ way of being is phasing out because people are getting more responsible for their health care.” Most respondents felt that personal empowerment was important for health and told us that alternative healers tend to focus on personal empowerment more than their conventional biomedical counterparts.

Access

The thematic category we called “access” combines issues of insurance coverage with physical, economic, and social availability. As a whole, patients noted that conventional health care was relatively accessible because it was paid for by insurance that was usually available through employment. Additionally, conventional medicine was noted to be physically available in most areas; CAM services were often harder to locate and visit. Alternative medicine was described as expensive from an out-of-pocket perspective and less economically accessible from the patient’s point of view. Several patients noted that they tried conventional methods before moving on to alternative healing. When asked why, one said “I thought I would exhaust the route of things that are free.” Another noted the relative high cost of alternative therapy by saying, “So basically out of sheer monetary restraints, I’ll go back to the physician.” Alternative providers were in consensus that “Most people pay out of pocket…. It is a detriment for people to pay out of pocket.”

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 studies^12,35-37 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.’”

People seek either conventional or alternative health care for a variety of reasons, from perceived health need to accessibility to perceived effectiveness.^48,49 Astin35 has shown that philosophical orientation—as defined by an interest in personal and spiritual growth and a commitment to environmentalism and feminism—is a significant predictor of use of CAM. In a national representative survey, patients within this defined group of “cultural creatives” were twice as likely to choose CAM therapies than other patients; it was a stronger statistical predictor than either education or global health status. Astin’s conclusions infer that the values of this segment of society have permeated the social matrix enough to influence health care behaviors, leading to the dramatic increase in CAM therapy during the 1990s.

Conclusions

The patients and providers interviewed for our study called for integration of the best aspects of conventional and alternative care. They suggested that the apparent strengths of CAM—especially holism and empowerment—could be used to help improve the quality of conventional health care. We suggest that some ideas and methods from CAM should be investigated and, if found deserving, either adopted or adapted by the official medical system. CAM therapists should be credentialed and incorporated into the health care team and some CAM methods should be learned by conventional providers. Our respondents felt that an integrative effort, if backed by credible evidence and implemented with high-quality standards, could help heal a powerful, but sometimes dangerous, health care system. We feel that this type of integrative effort requires regulation as well as recognition, and should include outcomes-based research. Such an endeavor should be based both on principles and on outcomes data. One such principle was clearly articulated by our respondents: All people should have access to legitimate, holistic, and empowering health care.

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.

We recruited patients randomly using the Madison telephone listings. Our inclusion criteria required that they were aged 18 years or older, used both alternative and conventional medicine in the past year, and were willing to meet for an unpaid hourlong interview. Out of 237 phone numbers randomly chosen from the telephone book, 29 were disconnected, and 58 went unanswered after at least 3 attempts. Of the remaining 150, 25 fit inclusion criteria, 19 agreed to an interview, and 17 were actually interviewed. The location of the interview was open to the participants’ choice and included home, office, and a public place, such as a restaurant or library. The semistructured format allowed free-flowing interviews aimed at probing health beliefs, choices, and practices. We were specifically interested in how patients thought about both alternative and conventional health services, how and why they made their health care choices, and how they personally valued various aspects of CAM and conventional medicine that came to light during the interview. Although our initial goal was to interview 20 patients, we stopped after 17 because we felt we had reached the point of data saturation (we ceased to learn new things with our interviews).

Results

During the 37 interviews in the practitioner and patient categories, a number of points emerged. Issues contrasting conventional and alternative health care rose to prominence during the interviews. Respondents noted differences of style, cost, training, institutional structure, and philosophy, orientation, and world-view. Vague, subtle, implicit, and subjective differences were described as well as obvious, clear, and objective differences. Among the medley of points that surfaced, a number of issues were raised repeatedly. After discussion and deliberation we organized that data into 4 major thematic categories: holism, empowerment, access, and legitimization. Nearly every idea, talking point, or issue that we noted—several hundred in all—fit comfortably within at least one of these major themes. Some of the more salient ideas and issues are shown in Table 3. A number of points, issues, or subthemes related to more than one of the themes and provided important interconnections or overlaps.

Holism

Patients and practitioners of alternative therapy stressed the importance of a grounded integrated whole-person approach. Patients noted that they preferred to be treated as whole people rather than as composites of numerous biomedical attributes. Practitioners stressed the multidimensional nature of their work and contrasted their integrated approach from what they considered the mechanistic reductionist methods of biomedicine. One practitioner said, “I think conventional medicine tries to fix a problem…rather than get to the heart of the issue.” One patient described it as “healing and staying healthy in a proactive sense.” Another said it was “amazing, your mind and body working together.” The importance of incorporating emotional, physical, psychological, and social factors in both diagnosis and therapy was repeatedly stressed.

Empowerment

Our participants told us that conventional biomedical practitioners often disempower their patients by acting in condescending, disparaging, chauvinistic, or paternalistic manners. In contrast, alternative healers were characterized as facilitating rather than directing the healing process, relying on self-empowerment and personal responsibility for health. One patient said, “I have to be part of the process for it to work.” Another defined conventional medicine as: “You broke it, so let’s fix you.” A third, describing her interaction with conventional physicians said, “And every time I bring it up they blow it off. So I didn’t get very far when I voiced my concerns.” A fourth went so far as to say, “I think the doctors’ way of being is phasing out because people are getting more responsible for their health care.” Most respondents felt that personal empowerment was important for health and told us that alternative healers tend to focus on personal empowerment more than their conventional biomedical counterparts.

Access

The thematic category we called “access” combines issues of insurance coverage with physical, economic, and social availability. As a whole, patients noted that conventional health care was relatively accessible because it was paid for by insurance that was usually available through employment. Additionally, conventional medicine was noted to be physically available in most areas; CAM services were often harder to locate and visit. Alternative medicine was described as expensive from an out-of-pocket perspective and less economically accessible from the patient’s point of view. Several patients noted that they tried conventional methods before moving on to alternative healing. When asked why, one said “I thought I would exhaust the route of things that are free.” Another noted the relative high cost of alternative therapy by saying, “So basically out of sheer monetary restraints, I’ll go back to the physician.” Alternative providers were in consensus that “Most people pay out of pocket…. It is a detriment for people to pay out of pocket.”

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 studies^12,35-37 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.’”

People seek either conventional or alternative health care for a variety of reasons, from perceived health need to accessibility to perceived effectiveness.^48,49 Astin35 has shown that philosophical orientation—as defined by an interest in personal and spiritual growth and a commitment to environmentalism and feminism—is a significant predictor of use of CAM. In a national representative survey, patients within this defined group of “cultural creatives” were twice as likely to choose CAM therapies than other patients; it was a stronger statistical predictor than either education or global health status. Astin’s conclusions infer that the values of this segment of society have permeated the social matrix enough to influence health care behaviors, leading to the dramatic increase in CAM therapy during the 1990s.

Conclusions

The patients and providers interviewed for our study called for integration of the best aspects of conventional and alternative care. They suggested that the apparent strengths of CAM—especially holism and empowerment—could be used to help improve the quality of conventional health care. We suggest that some ideas and methods from CAM should be investigated and, if found deserving, either adopted or adapted by the official medical system. CAM therapists should be credentialed and incorporated into the health care team and some CAM methods should be learned by conventional providers. Our respondents felt that an integrative effort, if backed by credible evidence and implemented with high-quality standards, could help heal a powerful, but sometimes dangerous, health care system. We feel that this type of integrative effort requires regulation as well as recognition, and should include outcomes-based research. Such an endeavor should be based both on principles and on outcomes data. One such principle was clearly articulated by our respondents: All people should have access to legitimate, holistic, and empowering health care.

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.

We recruited patients randomly using the Madison telephone listings. Our inclusion criteria required that they were aged 18 years or older, used both alternative and conventional medicine in the past year, and were willing to meet for an unpaid hourlong interview. Out of 237 phone numbers randomly chosen from the telephone book, 29 were disconnected, and 58 went unanswered after at least 3 attempts. Of the remaining 150, 25 fit inclusion criteria, 19 agreed to an interview, and 17 were actually interviewed. The location of the interview was open to the participants’ choice and included home, office, and a public place, such as a restaurant or library. The semistructured format allowed free-flowing interviews aimed at probing health beliefs, choices, and practices. We were specifically interested in how patients thought about both alternative and conventional health services, how and why they made their health care choices, and how they personally valued various aspects of CAM and conventional medicine that came to light during the interview. Although our initial goal was to interview 20 patients, we stopped after 17 because we felt we had reached the point of data saturation (we ceased to learn new things with our interviews).

Results

During the 37 interviews in the practitioner and patient categories, a number of points emerged. Issues contrasting conventional and alternative health care rose to prominence during the interviews. Respondents noted differences of style, cost, training, institutional structure, and philosophy, orientation, and world-view. Vague, subtle, implicit, and subjective differences were described as well as obvious, clear, and objective differences. Among the medley of points that surfaced, a number of issues were raised repeatedly. After discussion and deliberation we organized that data into 4 major thematic categories: holism, empowerment, access, and legitimization. Nearly every idea, talking point, or issue that we noted—several hundred in all—fit comfortably within at least one of these major themes. Some of the more salient ideas and issues are shown in Table 3. A number of points, issues, or subthemes related to more than one of the themes and provided important interconnections or overlaps.

Holism

Patients and practitioners of alternative therapy stressed the importance of a grounded integrated whole-person approach. Patients noted that they preferred to be treated as whole people rather than as composites of numerous biomedical attributes. Practitioners stressed the multidimensional nature of their work and contrasted their integrated approach from what they considered the mechanistic reductionist methods of biomedicine. One practitioner said, “I think conventional medicine tries to fix a problem…rather than get to the heart of the issue.” One patient described it as “healing and staying healthy in a proactive sense.” Another said it was “amazing, your mind and body working together.” The importance of incorporating emotional, physical, psychological, and social factors in both diagnosis and therapy was repeatedly stressed.

Empowerment

Our participants told us that conventional biomedical practitioners often disempower their patients by acting in condescending, disparaging, chauvinistic, or paternalistic manners. In contrast, alternative healers were characterized as facilitating rather than directing the healing process, relying on self-empowerment and personal responsibility for health. One patient said, “I have to be part of the process for it to work.” Another defined conventional medicine as: “You broke it, so let’s fix you.” A third, describing her interaction with conventional physicians said, “And every time I bring it up they blow it off. So I didn’t get very far when I voiced my concerns.” A fourth went so far as to say, “I think the doctors’ way of being is phasing out because people are getting more responsible for their health care.” Most respondents felt that personal empowerment was important for health and told us that alternative healers tend to focus on personal empowerment more than their conventional biomedical counterparts.

Access

The thematic category we called “access” combines issues of insurance coverage with physical, economic, and social availability. As a whole, patients noted that conventional health care was relatively accessible because it was paid for by insurance that was usually available through employment. Additionally, conventional medicine was noted to be physically available in most areas; CAM services were often harder to locate and visit. Alternative medicine was described as expensive from an out-of-pocket perspective and less economically accessible from the patient’s point of view. Several patients noted that they tried conventional methods before moving on to alternative healing. When asked why, one said “I thought I would exhaust the route of things that are free.” Another noted the relative high cost of alternative therapy by saying, “So basically out of sheer monetary restraints, I’ll go back to the physician.” Alternative providers were in consensus that “Most people pay out of pocket…. It is a detriment for people to pay out of pocket.”

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 studies^12,35-37 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.’”

People seek either conventional or alternative health care for a variety of reasons, from perceived health need to accessibility to perceived effectiveness.^48,49 Astin35 has shown that philosophical orientation—as defined by an interest in personal and spiritual growth and a commitment to environmentalism and feminism—is a significant predictor of use of CAM. In a national representative survey, patients within this defined group of “cultural creatives” were twice as likely to choose CAM therapies than other patients; it was a stronger statistical predictor than either education or global health status. Astin’s conclusions infer that the values of this segment of society have permeated the social matrix enough to influence health care behaviors, leading to the dramatic increase in CAM therapy during the 1990s.

Conclusions

The patients and providers interviewed for our study called for integration of the best aspects of conventional and alternative care. They suggested that the apparent strengths of CAM—especially holism and empowerment—could be used to help improve the quality of conventional health care. We suggest that some ideas and methods from CAM should be investigated and, if found deserving, either adopted or adapted by the official medical system. CAM therapists should be credentialed and incorporated into the health care team and some CAM methods should be learned by conventional providers. Our respondents felt that an integrative effort, if backed by credible evidence and implemented with high-quality standards, could help heal a powerful, but sometimes dangerous, health care system. We feel that this type of integrative effort requires regulation as well as recognition, and should include outcomes-based research. Such an endeavor should be based both on principles and on outcomes data. One such principle was clearly articulated by our respondents: All people should have access to legitimate, holistic, and empowering health care.