Original Article · Originalarbeit Forsch Komplementmed 2015;22:36–41 DOI: 10.1159/000375182
Published online: February 3, 2015
Complementary Medicine for Cancer Patients in General Practice: Qualitative Interviews with German General Practitioners Anne Dahlhaus a, b, c Andrea Siebenhofer a, b, c Corina Guethlin a a
Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany c German Cancer Consortium (DKTK), Heidelberg, Germany
Keywords Cancer · Complementary medicine · Primary care · Qualitative study · General practice
Schlüsselwörter Krebs · Komplementärmedizin · Grundversorgung · Qualitative Studie · Hausarzt
Summary Background: The aim of this study was to investigate how general practitioners react when their cancer patients show interest in complementary medicine, and how their reaction is related to their knowledge in the field. Methods: We conducted semi-structured interviews with 10 German general practitioners. Interviewees came from 5 different federal states and varied in terms of urban/rural setting, single/joint practice, additional certifications, gender and length of professional experience. Interviews were electronically recorded, transcribed and then analysed using qualitative content analysis according to Mayring. Results: General practitioners feel largely responsible for providing information on complementary medicine to their cancer patients. However, uncertainty and a lack of knowledge concerning CAM lead mainly to reactive responses to patients’ needs, and the general practitioners base their recommendations on personal experiences and attitudes. They wish to support their cancer patients and thus, in order to keep their patients’ hopes up and maintain a trusting relationship, sometimes support complementary medicine, regardless of their own convictions. Conclusion: Although general practitioners see themselves as an important source of information on complementary medicine for their cancer patients, they also speak of their uncertainties and lack of knowledge. General practitioners would profit from training in complementary medicine enabling them to discuss this topic with their cancer patients in a proactive, open and honest manner.
Zusammenfassung Hintergrund: Die Studie beleuchtet den Umgang von Hausärzten mit den komplementärmedizinischen Anliegen ihrer Krebspatienten und setzt die Reaktionen der Ärzte in Verhältnis zu ihrem Kenntnisstand über Komplementärmedizin. Methoden: Wir führten semistrukturierte Interviews mit 10 deutschen Hausärzten durch. Die interviewten Ärzte kamen aus 5 verschiedenen Bundesländern und variierten in Bezug auf die Lage ihrer Hausarztpraxis (städtisch/ländlich), Einzel-/Gemeinschaftspraxis, Zusatzqualifikationen, Geschlecht und Berufserfahrung. Die Interviews wurden elektronisch aufgezeichnet, transkribiert und dann mittels qualitativer Inhaltsanalyse nach Mayring ausgewertet. Ergebnisse: Die Hausärzte fühlen sich zuständig dafür, ihre an Krebs erkrankten Patienten mit Informationen zur Komplementärmedizin zu unterstützen. Allerdings führen Unsicherheit und unzureichendes Wissen dazu, dass Hausärzte eher reaktiv auf Patientenanliegen reagieren und ihre Empfehlungen vor allem auf persönlichen Erfahrungen und Einstellungen basieren. Einzelne Hausärzte befürworten Komplementärmedizin unabhängig ihrer eigenen Überzeugung, um ihre Krebspatienten zu unterstützen, deren Hoffnung aufrechtzuerhalten und die vertrauensvolle Beziehung zum Patienten zu wahren. Schlussfolgerung: Obwohl sich Hausärzte als wichtige Informationsquelle zur Komplementärmedizin für ihre an Krebs erkrankten Patienten wahrnehmen, beklagen sie Unsicherheit und unzureichendes Wissen in diesem Bereich. Eine entsprechende Fort- und Weiterbildung könnte dabei helfen, dass Hausärzte komplementärmedizinische Themen mit ihren Krebspatienten proaktiv, offen und ehrlich diskutieren.
© 2015 S. Karger GmbH, Freiburg 1661–4119/15/0221–0036$39.50/0 Fax +49 761 4 52 07 14 [email protected] www.karger.com
Accessible online at: www.karger.com/fok
Dr. Anne Dahlhaus Institute of General Practice Goethe-University Frankfurt Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany [email protected]
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/4/2016 8:50:11 PM
b
Introduction
Methods
‘It is well known that cancer patients, in particular, often attach considerable importance to complementary medicine. What questions do your patients regularly ask in connection with complementary medicine?’ ‘As a general practitioner, do you offer complementary medicine? What options do you offer?’ ‘Do you think there are specific points in time when the subject of complementary medicine is of particular importance to cancer patients? When are they?’ ‘What do you think? Are you, as a general practitioner, confronted with complementary medicine more or less than other groups of medical professionals?’ ‘As far as complementary medicine is concerned, in what areas do you, your patients, and their relatives require information? Where are the gaps in your knowledge?’ ‘When you hear that a general practitioner has said: “Sometimes, (the use of CAM) reflects my feeling of powerlessness, and is aimed at giving the patient a positive perspective and to maintain his trust in our relationship.” What are your immediate thoughts?’
Fig. 1. Examples of interview questions on complementary care of cancer patients in general practice.
Data Collection The interviews were conducted by a physician and a student of educational science. Both were trained and supervised by a psychologist with experience in qualitative research. The semi-structured interview guideline was developed, pretested and adapted by the psychologist and the physician. It was made up of open-ended questions on CAM in general practice (fig. 1). To further elucidate the role of CAM, the final question in the interview guideline confronted the interviewees with the following comment made by one GP in the pre-test: ‘Sometimes, (the use of CAM) reflects my feeling of powerlessness, and is aimed at giving the patient a positive perspective and to maintain his trust in our relationship’. The interviewed GPs were asked to spontaneously comment on the statement. The interviews were electronically recorded, transcribed verbatim and anonymised. Consent was obtained verbally prior to the start of the interviews and afterwards in written form. The duration of the interviews ranged from 19 to 31 min. Analysis All interviews were analysed using Mayring’s qualitative content analysis [19]. Most of the categories were applied deductively (mostly from interview questions). However, when a new theme emerged, some of the sub-categories (such as GP attitudes to CAM) were developed inductively. To develop the coding scheme, the first 5 interviews in each series were coded by the 2 interviewers independently of one another and then discussed under the supervision of the psychologist. Then, a final code set was generally agreed and all interviews were then re-analysed using the final coding scheme. For publication, the citations were translated into English by a native speaker.
Sampling and Recruitment Recruitment for the study took place within the context of a larger qualitative study that included several thematic series. From April 2011 to June 2012, 154 GPs were invited by fax to participate in a semi-structured telephone interview on oncology in general practice. The participants were identified via the online search function of the German Association of Statutory Health Insurance Physicians as well as from a list of research and training practices affiliated with the Institute of General Practice at the University of Frankfurt, Germany. The sample varied regarding additional qualifications (palliative medicine, etc.), urban/rural setting, single/joint practice, gender and years of professional experience. In total, we conducted 56 interviews in 4 separate series on the topics ‘general role and involvement of GPs in cancer care (series 1)’, ‘palliative medicine for cancer patients/psychosocial care (series 2)’, ‘multimorbidity/complementary medicine in cancer patients (series 3)’ and ‘cancer patient pathways/ cancer patient management (series 4)’. Quotes in this manuscript originate from the third series that took place in June and July 2012 and consisted of 10 interviews with GPs on the use of CAM in cancer care. As this was an interview study with physicians, the Ethics Committee of the University Hospital Frankfurt/Main waived formal ethical approval but granted its general approval of the study. The study was conducted in accordance with the ethical standards laid out in the revised version of the Declaration of Helsinki of 1975 and its amendments of 1983, 1989 and 1996 [18].
We interviewed 10 GPs from 5 different German federal states. Further characteristics of the interview partners are displayed in table 1. GPs are important contact persons for cancer patients that are interested in CAM. Many of the interviewed GPs perceive themselves to be a primary contact for cancer patients having questions related to CAM:
CAM for Cancer Patients in General Practice
Forsch Komplementmed 2015;22:36–41
Results
37
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/4/2016 8:50:11 PM
Following a cancer diagnosis, the use of complementary and alternative medicine (CAM) is popular among patients [1]. CAM is used by cancer patients to improve general well-being by reducing side effects and toxicity, to increase the body’s resistance and to help prevent further cancers or recurrence [1, 2]. Despite advances in conventional cancer therapies, it would appear that patients have a substantial level of unmet physical, social, emotional and spiritual needs, and that such unmet needs probably encourage patients to use CAM [3]. General practitioners (GPs) have been shown to play an important role in sequential, parallel and shared cancer therapy [4] by providing continuous, patient-centered, holistic care [5, 6], and supporting their cancer patients emotionally [7]. Research has shown that GP involvement in the care of cancer patients can improve patient outcomes, satisfaction with care, quality of life and a sense of psychosocial well-being [8, 9]. GPs use CAM more often than specialists [10, 11], and as many as two thirds of breast cancer patients that use CAM employ alternative therapies or procedures under the guidance of their GP [12]. Patients, GPs and CAM practitioners agree that GPs play a central role in CAM referrals and, to a lesser extent, they actually provide CAM themselves [13]. A considerable number of GPs that advise their patients in the use of CAM report having no special CAM training [14]. They admit lacking knowledge required to make appropriate recommendations on matters pertaining to CAM and express the need for more information on the subject [15, 16]. However, at the same time, they seem to be one of the main sources of information on CAM for cancer patients [17]. This raises questions concerning the reaction of GPs to their patients’ interest in CAM, what advice they give and how their behaviour is related to their knowledge in the field.
Table 1. Characteristics of interview partners
General practitioner (GP)
Singlehanded/joint practice
Urban/rural setting*
Gender
Additional certification
Specialty area
Professional experience
GP1 GP2
joint practice single-handed practice
large town rural town
female female
none palliative medicine
family medicine family medicine
29 years 5 years
GP3
single-handed practice
rural town
male
none
family medicine
41 years
GP4
single-handed practice
rural town
male
none
family medicine
5 years
GP5
single-handed practice
medium-sized town
male
nutritional medicine
internal medicine
10 years
GP6
joint practice
large town
female
physical therapy, naturopathic medicine, nutritional medicine
family medicine
10 years
GP7
joint practice
medium-sized town
female
nutritional medicine
family medicine
28 years
GP8
single-handed practice
medium-sized town
female
none
family medicine
5 years
GP9
joint practice
medium-sized town
male
none
internal medicine
7 years
GP10
joint practice
large town
female
none
internal and family medicine
29 years
*Classification
of urban/rural setting refers to number of inhabitants: rural town
Published online: February 3, 2015
Complementary Medicine for Cancer Patients in General Practice: Qualitative Interviews with German General Practitioners Anne Dahlhaus a, b, c Andrea Siebenhofer a, b, c Corina Guethlin a a
Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany German Cancer Research Center (DKFZ), Heidelberg, Germany c German Cancer Consortium (DKTK), Heidelberg, Germany
Keywords Cancer · Complementary medicine · Primary care · Qualitative study · General practice
Schlüsselwörter Krebs · Komplementärmedizin · Grundversorgung · Qualitative Studie · Hausarzt
Summary Background: The aim of this study was to investigate how general practitioners react when their cancer patients show interest in complementary medicine, and how their reaction is related to their knowledge in the field. Methods: We conducted semi-structured interviews with 10 German general practitioners. Interviewees came from 5 different federal states and varied in terms of urban/rural setting, single/joint practice, additional certifications, gender and length of professional experience. Interviews were electronically recorded, transcribed and then analysed using qualitative content analysis according to Mayring. Results: General practitioners feel largely responsible for providing information on complementary medicine to their cancer patients. However, uncertainty and a lack of knowledge concerning CAM lead mainly to reactive responses to patients’ needs, and the general practitioners base their recommendations on personal experiences and attitudes. They wish to support their cancer patients and thus, in order to keep their patients’ hopes up and maintain a trusting relationship, sometimes support complementary medicine, regardless of their own convictions. Conclusion: Although general practitioners see themselves as an important source of information on complementary medicine for their cancer patients, they also speak of their uncertainties and lack of knowledge. General practitioners would profit from training in complementary medicine enabling them to discuss this topic with their cancer patients in a proactive, open and honest manner.
Zusammenfassung Hintergrund: Die Studie beleuchtet den Umgang von Hausärzten mit den komplementärmedizinischen Anliegen ihrer Krebspatienten und setzt die Reaktionen der Ärzte in Verhältnis zu ihrem Kenntnisstand über Komplementärmedizin. Methoden: Wir führten semistrukturierte Interviews mit 10 deutschen Hausärzten durch. Die interviewten Ärzte kamen aus 5 verschiedenen Bundesländern und variierten in Bezug auf die Lage ihrer Hausarztpraxis (städtisch/ländlich), Einzel-/Gemeinschaftspraxis, Zusatzqualifikationen, Geschlecht und Berufserfahrung. Die Interviews wurden elektronisch aufgezeichnet, transkribiert und dann mittels qualitativer Inhaltsanalyse nach Mayring ausgewertet. Ergebnisse: Die Hausärzte fühlen sich zuständig dafür, ihre an Krebs erkrankten Patienten mit Informationen zur Komplementärmedizin zu unterstützen. Allerdings führen Unsicherheit und unzureichendes Wissen dazu, dass Hausärzte eher reaktiv auf Patientenanliegen reagieren und ihre Empfehlungen vor allem auf persönlichen Erfahrungen und Einstellungen basieren. Einzelne Hausärzte befürworten Komplementärmedizin unabhängig ihrer eigenen Überzeugung, um ihre Krebspatienten zu unterstützen, deren Hoffnung aufrechtzuerhalten und die vertrauensvolle Beziehung zum Patienten zu wahren. Schlussfolgerung: Obwohl sich Hausärzte als wichtige Informationsquelle zur Komplementärmedizin für ihre an Krebs erkrankten Patienten wahrnehmen, beklagen sie Unsicherheit und unzureichendes Wissen in diesem Bereich. Eine entsprechende Fort- und Weiterbildung könnte dabei helfen, dass Hausärzte komplementärmedizinische Themen mit ihren Krebspatienten proaktiv, offen und ehrlich diskutieren.
© 2015 S. Karger GmbH, Freiburg 1661–4119/15/0221–0036$39.50/0 Fax +49 761 4 52 07 14 [email protected] www.karger.com
Accessible online at: www.karger.com/fok
Dr. Anne Dahlhaus Institute of General Practice Goethe-University Frankfurt Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany [email protected]
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/4/2016 8:50:11 PM
b
Introduction
Methods
‘It is well known that cancer patients, in particular, often attach considerable importance to complementary medicine. What questions do your patients regularly ask in connection with complementary medicine?’ ‘As a general practitioner, do you offer complementary medicine? What options do you offer?’ ‘Do you think there are specific points in time when the subject of complementary medicine is of particular importance to cancer patients? When are they?’ ‘What do you think? Are you, as a general practitioner, confronted with complementary medicine more or less than other groups of medical professionals?’ ‘As far as complementary medicine is concerned, in what areas do you, your patients, and their relatives require information? Where are the gaps in your knowledge?’ ‘When you hear that a general practitioner has said: “Sometimes, (the use of CAM) reflects my feeling of powerlessness, and is aimed at giving the patient a positive perspective and to maintain his trust in our relationship.” What are your immediate thoughts?’
Fig. 1. Examples of interview questions on complementary care of cancer patients in general practice.
Data Collection The interviews were conducted by a physician and a student of educational science. Both were trained and supervised by a psychologist with experience in qualitative research. The semi-structured interview guideline was developed, pretested and adapted by the psychologist and the physician. It was made up of open-ended questions on CAM in general practice (fig. 1). To further elucidate the role of CAM, the final question in the interview guideline confronted the interviewees with the following comment made by one GP in the pre-test: ‘Sometimes, (the use of CAM) reflects my feeling of powerlessness, and is aimed at giving the patient a positive perspective and to maintain his trust in our relationship’. The interviewed GPs were asked to spontaneously comment on the statement. The interviews were electronically recorded, transcribed verbatim and anonymised. Consent was obtained verbally prior to the start of the interviews and afterwards in written form. The duration of the interviews ranged from 19 to 31 min. Analysis All interviews were analysed using Mayring’s qualitative content analysis [19]. Most of the categories were applied deductively (mostly from interview questions). However, when a new theme emerged, some of the sub-categories (such as GP attitudes to CAM) were developed inductively. To develop the coding scheme, the first 5 interviews in each series were coded by the 2 interviewers independently of one another and then discussed under the supervision of the psychologist. Then, a final code set was generally agreed and all interviews were then re-analysed using the final coding scheme. For publication, the citations were translated into English by a native speaker.
Sampling and Recruitment Recruitment for the study took place within the context of a larger qualitative study that included several thematic series. From April 2011 to June 2012, 154 GPs were invited by fax to participate in a semi-structured telephone interview on oncology in general practice. The participants were identified via the online search function of the German Association of Statutory Health Insurance Physicians as well as from a list of research and training practices affiliated with the Institute of General Practice at the University of Frankfurt, Germany. The sample varied regarding additional qualifications (palliative medicine, etc.), urban/rural setting, single/joint practice, gender and years of professional experience. In total, we conducted 56 interviews in 4 separate series on the topics ‘general role and involvement of GPs in cancer care (series 1)’, ‘palliative medicine for cancer patients/psychosocial care (series 2)’, ‘multimorbidity/complementary medicine in cancer patients (series 3)’ and ‘cancer patient pathways/ cancer patient management (series 4)’. Quotes in this manuscript originate from the third series that took place in June and July 2012 and consisted of 10 interviews with GPs on the use of CAM in cancer care. As this was an interview study with physicians, the Ethics Committee of the University Hospital Frankfurt/Main waived formal ethical approval but granted its general approval of the study. The study was conducted in accordance with the ethical standards laid out in the revised version of the Declaration of Helsinki of 1975 and its amendments of 1983, 1989 and 1996 [18].
We interviewed 10 GPs from 5 different German federal states. Further characteristics of the interview partners are displayed in table 1. GPs are important contact persons for cancer patients that are interested in CAM. Many of the interviewed GPs perceive themselves to be a primary contact for cancer patients having questions related to CAM:
CAM for Cancer Patients in General Practice
Forsch Komplementmed 2015;22:36–41
Results
37
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/4/2016 8:50:11 PM
Following a cancer diagnosis, the use of complementary and alternative medicine (CAM) is popular among patients [1]. CAM is used by cancer patients to improve general well-being by reducing side effects and toxicity, to increase the body’s resistance and to help prevent further cancers or recurrence [1, 2]. Despite advances in conventional cancer therapies, it would appear that patients have a substantial level of unmet physical, social, emotional and spiritual needs, and that such unmet needs probably encourage patients to use CAM [3]. General practitioners (GPs) have been shown to play an important role in sequential, parallel and shared cancer therapy [4] by providing continuous, patient-centered, holistic care [5, 6], and supporting their cancer patients emotionally [7]. Research has shown that GP involvement in the care of cancer patients can improve patient outcomes, satisfaction with care, quality of life and a sense of psychosocial well-being [8, 9]. GPs use CAM more often than specialists [10, 11], and as many as two thirds of breast cancer patients that use CAM employ alternative therapies or procedures under the guidance of their GP [12]. Patients, GPs and CAM practitioners agree that GPs play a central role in CAM referrals and, to a lesser extent, they actually provide CAM themselves [13]. A considerable number of GPs that advise their patients in the use of CAM report having no special CAM training [14]. They admit lacking knowledge required to make appropriate recommendations on matters pertaining to CAM and express the need for more information on the subject [15, 16]. However, at the same time, they seem to be one of the main sources of information on CAM for cancer patients [17]. This raises questions concerning the reaction of GPs to their patients’ interest in CAM, what advice they give and how their behaviour is related to their knowledge in the field.
Table 1. Characteristics of interview partners
General practitioner (GP)
Singlehanded/joint practice
Urban/rural setting*
Gender
Additional certification
Specialty area
Professional experience
GP1 GP2
joint practice single-handed practice
large town rural town
female female
none palliative medicine
family medicine family medicine
29 years 5 years
GP3
single-handed practice
rural town
male
none
family medicine
41 years
GP4
single-handed practice
rural town
male
none
family medicine
5 years
GP5
single-handed practice
medium-sized town
male
nutritional medicine
internal medicine
10 years
GP6
joint practice
large town
female
physical therapy, naturopathic medicine, nutritional medicine
family medicine
10 years
GP7
joint practice
medium-sized town
female
nutritional medicine
family medicine
28 years
GP8
single-handed practice
medium-sized town
female
none
family medicine
5 years
GP9
joint practice
medium-sized town
male
none
internal medicine
7 years
GP10
joint practice
large town
female
none
internal and family medicine
29 years
*Classification
of urban/rural setting refers to number of inhabitants: rural town
