Promoting Interactional Health Equity Through (Complementary and Integrative Health) Talk During Clinical Encounters

Abstract

Objectives

Complementary and Integrative Health (CIH) is recognized as a set of modalities to bolster health and well-being often outside of standard biomedical practice. How people discuss CIH with their biomedical providers is a microcosm for health communication more generally. In this Discussion, we propose a revision of the Street et al. (2009) conceptual framework to illustrate how CIH talk during a clinical encounter has the potential to contribute to (or detract from) interactional health equity.

Methods

We use discourse analytic techniques to re-analyze two digitally recorded biomedical encounters.

Results

Two case studies are re-analyzed to illustrate how clinician-client conversation about CIH during a clinical encounter might lead to interactional health equity.

Conclusions

Interactions with clinicians can be challenging due to differences in knowledge about biomedicine, administrative processes, and even navigating interpersonal relationships. How a clinician responds can either center a biomedical agenda in the Voice of Medicine or help ratify a patient’s agenda in the Voice of the Lifeworld. How clinicians and patients negotiate CIH talk is conceptually linked with immediate interactional outcomes.

Practice Implications

In populations in which patients/caregivers or their extended communities may already have low trust in biomedicine, a mistrustful therapeutic alliance, or history of discrimination, disattention of the Lifeworld and avoiding talk about CIH has the possibility of exacerbating inequities. Every turn at talk during a clinical encounter has the potential to foster increased social participation which, in turn, may contribute to health outcomes and influence patient and community well-being at individual, community, and institutional levels. CIH talk can open space for patients to actively participate in healthcare by incorporating the patients’ Lifeworld into the clinical encounter can contribute to interactional health equity within clinical encounters.

Introduction

Health equity is a major focus in healthcare systems and health communication research. The World Health Organization (WHO) affirms health as a fundamental right that is most equitable when the unfair, avoidable, or remediable differences in health outcomes can be addressed to contribute to everyone’s overall health and well-being regardless of identity and demographic categories [1]. While healthcare outcomes continually demonstrate unfair, avoidable, and remediable differences that are often compounded by histories of inequity in/outside healthcare, improving communication between clinicians and patients in clinical encounters is one actionable way to ratify patients’ participation which, by extension, may help improve health outcomes. Scholarship and implementation efforts focused on health equity justifiably focus on structural issues aimed to foster systemic top-down change. However, this focus should not divert the scholarly gaze from social interactions that (re)create systems into being. Social interaction, sometimes referred to as talk, consists of discrete, taken-for-granted communication events that unfold between clinician and patient during a clinical encounter. One area in which health equity is consequential is when clinicians and patients discuss Complementary and Integrative Health (CIH) during clinical encounters.

CIH has consistently been used by one-third of the United States population [2, 3] and likely more. Medical systems are blending CIH with biomedicine, including the Department of Veterans Affairs[4, 5], and the National Center for Integrative Health (NCCIH)[6, 7]. Within primary care, CIH is an important topic of medical consultations, and research shows that patients want to discuss CIH with their primary care providers[8]. In biomedical encounters, clinicians are socialized into clinical routines that presume they, and by extension, biomedicine, are the ones “in charge” of health and wellness.

A recent systematic review found that most research on talk about CIH (or CIH communication) is focused on the narrow aspect of ‘disclosure,’ or patient revelation about CIH use with a biomedical provider[9]. However, studies using audio recordings of clinical encounters of CIH talk show that talk about CIH involves more than the socio-legal notion of disclosure [10]. When a patient mentions CIH, clinicians’ responses include disattention, acknowledgement, support, disregard, discouragement, and even ridicule[11–14]. In other words, patient mentions of interest in or use of CIH are consequential interactional moments. How a clinician responds can either center a biomedical agenda or ratify a patient’s agenda, respectively captured in Mishler’s notions of the Voice of Medicine (VOM) and the Voice of the Lifeworld (VOL)[15]. Clinicians typically prioritize VOM that simultaneously de-prioritizes patients’ agendas, such as CIH talk that is rooted in the lived experience and VOL. We propose that health equity is not merely rooted in the aftermath of the encounter in the form of overall health outcomes, but in the moment-by-moment unfolding of clinical interaction.

Conceptual Framework

Street et al. [16] proposed a model in which a direct communication pathway associated with immediate health outcomes and an indirect communication pathway associated with health outcomes across a temporal cascade of proximal, intermediate, and distal outcomes. Our reimagining of the Street et al’s model addresses outcomes associated with the indirect communication pathway in the aftermath of the clinical encounter. Although the original model conceptualizes multifaceted relationships between communication and health outcomes, outcomes associated with social interaction are incorporated only after the end of the encounter in proximal outcomes. This means the social interaction outcomes that unfold moment-by-moment during the clinical encounter are largely unaddressed. In Figure 1, we revise Street et al.’s model to add interactional outcomes.

Figure 1. An Integrated Model of Complementary and Integrated Health (CIH) Communication and Health Outcomes.

Street et al. (2009) proposed a communication model identifying how communication contributes to proximal, intermediate, and distal (or overall) health outcomes. We amend the original model proposing interactional outcomes during the clinical encounter as a conceptual precursor to the Street et al. health outcome continuum.

Figure 1 presents the clinical encounter as a chain of events that unfolds patients’ Lifeworlds and includes the social determinants of health, previous experiences of health and illness, and prior experiences of health care, including medical encounters. While often unknown to clinicians, collectively these factors influence the interaction during clinical encounters. We characterize interactional outcomes as small, taken-for-granted interactional actions that unfold turn-by-turn between clinician and patient during clinical encounters best studied using digitally recorded interaction. Other examples of interactional outcomes during clinicial encounters include how clinicians solicit additional concerns[17], announce bad news[18], reassure patients[19, 20], and respond to CIH talk[11, 12, 14]. We propose that clinical interactions may be more equitable when clinicians are mindful of how they use the VOM and how they attend to the patient’s VOL.

This Discussion presents a refined conceptual framework where social interaction is the conceptual root of other health outcomes that originate within the clinical encounter that we illustrate in the following two case studies.

Case Studies

We use discourse analytic techniques as applied to the study of health communication in biomedical encounters[21]. We re-analyzed two previously published examples of dyadic healthcare interaction [12, 14] to examine how clinicians and patients might promote interactional health equity when discussing CIH during clinical biomedical encounters.

Case Study 1: Clinicians, Biomedicine, and the Lifeworld

Case 1 is a previously published [14] interaction between an oncologist at a large academic medical center, Dr. Scott, and Mr. Tate, an older man with stage 4 cancer, and his spouse and caregiver, Mrs. Tate. The cancer has metastasized and is growing into Mr. Tate’s brain tissue. In addition to chemotherapy, Mr. Tate is also undergoing focused radiation treatments. The following excerpt comes from a routine follow-up interaction. In this extract, Dr. Scott has just completed reviewing the most recent scans and moves into a physical exam.

During the exam, Mrs. Tate informs Dr. Scott of a potentially serious event – what she names as a grand mal seizure and several smaller seizures witnessed within a short period after the most recent radiation treatment. Next, Mrs. Tate describes two mind-body CIH modalities – acupressure and guided imagery meditation – to help Mr. Tate positively cope with and, potentially, mitigate seizure severity. Mr. Tate affirms the CIH modalities have helped. The mind-body CIH modalities the Tates mention carry extremely low risk of an adverse event relative to other strategies for seizures, including medication. More importantly, the couple conveys a snapshot of their Lifeworld outside the clinic [22] where they actively navigate the ebbs and flows of a serious, ongoing illness, including unexpected and unanticipated side-effects.

Dr. Scott’s primary visual and embodied orientation is the ongoing physical examination, and he does not verbally respond to the Tates. Instead of pausing to ask more about the seizure or CIH strategies to mitigate severity, Dr. Scott disattends the couple’s talk, defined as a response in which a clinician does not give an overt verbal response to a patient’s or caregiver’s contribution at a place where a response would be expected [13]. In 229 observed encounters between English-speaking patients and oncologists, 45% of patient-initiated CIH talk were similarly responded to as the participant in Case 1[14]. This interactional moment has potential for enacting health equity. Street et al. [16] describe enhancing the therapeutic alliance and enhancing patients’ (and caregivers’) ability to manage emotion as two domains relevant to this interaction. However, rather than leaning into a potentially emotional and medically uncertain topic important for both the patient and caregiver, Dr. Scott disattends both the reported medical event and the couple’s CIH solutions to manage it. In other words, Dr. Scott’s communication interactionally inhibits further interaction. As Dr. Scott completes the exam, he moves away from Mr. Tate to the computer in the corner of the exam room, logs into the electronic medical record, and initiates a new, unrelated sequence addressing another symptom.

Instead of responding to the patient’s specific concern and solutions, the clinician prioritizes routine medical work. As an interactional outcome, this case demonstrates that disattention prioritizes the VOM and bypasses an opportunity for cultural humility that respects the couple’s Lifeworlds. Instead of disattending, the clinician could have minimally acknowledged the announced side-effect and CIH solution without disrupting the flow of the clinical encounter. When a patient/caregiver announces something worrisome or describes a low-risk strategy for bolstering physical, emotional, mental, or spiritual well-being, they are extending an invitation to a piece of their unique Lifeworld that is deeply contextualized.

As a potential moment of interactional health equity, clinicians can minimally acknowledge patients’ or caregivers’ CIH mentions without disrupting the flow of the clinical encounter. Tervalon & Murray-García [23] characterize cultural humility as “a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations” (p. 117). Self-reflection about the clinician’s role to promote a safe therapeutic environment and trusting therapeutic alliance for well-being might start with the cultural humility to understand how interactional outcomes may have repercussions for healing for individuals, communities, and larger society[24].

Case Study 2: Patient Participation through Lifeworld

When patients/caregivers initiate CIH talk, they may be informing clinicians, soliciting advice or further discussion about those modalities or about CIH in general. Regardless of the intention, when patients initiate CIH talk they communicate something about their treatment preferences and the values that exist in an otherwise private Lifeworld.

Case 2 is a previously published [13] extended interaction that includes a Chinese American patient who speaks in English to his English-speaking primary care provider (PCP) about several health issues that include diabetes, blood pressure, and a recent colonoscopy. Over the course of the encounter the patient announces taking multiple nutritional supplements. However, the PCP does not respond to the patient’s first or even second mention of common supplements (bolded in Table 2). Only when the patient continues with less common supplements does the clinician respond. In this excerpt, the patient pursues a response from the clinician to create an opportunity for interactional health equity about his CIH use.

Table 2.

Case 2: Magnesium, Broccoli Extract, Cacao Nibs, Vitamin D

114	DR:	((DR typing throughout))
115	PT:	I didn’t drink enough liquid [((chuckles)) or ate enough veggies
116	DR:	[ok um ok so no- n:::o u::m blood mixed
		in the sto::ol or an:y mucus? Any stool that’s got kinda like mu- mucus around it?
117	PT:	mucus around the sto:ol. How [wo
118	DR:	[you know like mixed in like float:y kinda looks like a little (0.5)
		gobbly (.8) °you [know°
119	PT:	[not that I’m aware of usually it’s more diarrhea like ((chuckles))
120	DR:	sometimes it’s diarrhea? (0.8) [mkay
121	PT:	[because I take a lot of magnesium
122	D:	Ok
123	PT:	[aye ehum:::m
124	DR:	[ok. Uh Yeah uh (0.8) u:::m=
125	PT:	=I do wanna know my A.1.c::. cause I’ve taken a different type of s[upplement
126	DR:	[mmhmm
127	PT:	it’s called uh (0.5) ah broccoli extract I was reading about it it’s supposed to lower A1c levels
128	DR:	hm o:k ((DR typing in background))
129	PT:	so it’s natural (0.6) so instead of eating a lot of bro^ccoli I iust take the pill=
130	DR:	=YOU TAKE THE PILL (.5) hm (0.3) ok:ay= ((DR continues typing))
131	PT:	=((chuckles or inhales)) ss it’s called sulf-or-a-phane. That’s a broccoli extract (1.0)
		you have to eat a who::le lotta broccoli to get it ((1.2 DR continues typing))
132	DR:	e::::o:kay I ^generally go for eating the real stuff rather than the extract though (0.3)
		((chuckles))
		.hhh [u:::m
133	PT:	[o^::h.
134	DR:	that’s usually a better thing to do (0.2) OK s:::o let’s se::e he::re. A::1::c:: (0.2) °6.6° we can do one right no::w if you want?

As the interaction begins, the patient describes his bowel movements (line 119) as potentially affected by the magnesium he takes (line 121), the first mention of CIH use. The patient’s motivation for using magnesium is not articulated nor is there a question stated. In response, the clinician minimally acknowledges the announcement, defined as a brief verbal response[14], such as ‘okay’ (line 122, 124), before shifting to another activity. As in Case 1, the clinician sidesteps the opportunity to inquire about the magnesium the patient is taking and thus inhibits further CIH talk.

Without a substantive response from the clinician, the patient shifts to a next topic, his 6-month blood sugar level A1c (lines 125, 127). In contrast from the first CIH mention (line 121), the patient announces three significant aspects of the less common CIH. First, he names the nutritional supplement by its common, recognizable name, broccoli extract (line 125); second, he explains that he has been reading about the supplement (line 127); and finally, he describes the reason he is taking it, to lower blood sugar levels (line 127). These three elements inform the clinician not only that the patient is actively using a CIH supplement, but also why. Together, they suggest that the patient works to inform himself about ways to participate actively in his health and communicating these actions to the clinician, which Street et al. [16] identify as patient knowledge and shared understanding. Finally, the patient actively participates in the encounter by asking the clinician to investigate whether his actions are improving his long-term blood sugar levels, displaying knowledge of clinical procedures to assess efficacy of his actions, and being explicit about what information he desires, in an effort to potentially reach a high quality decision [16].

While the clinician does not display recognition of the patient’s actions because she appears to be primarily engaged in typing into the electronic health record (lines 128, 130, 132), she does respond by minimally acknowledging the patient’s announcement (line 126). Unlike the prior attempt, the patient does not move to the next activity. Rather, he continues his turn by explaining that the supplement is “natural” (line 129) and explicitly explaining that the supplement is more convenient for him than eating the fresh vegetable. At the patient’s turn completion, the clinician responds with a more than minimal turn that is both louder and a verbatim repeat, “=YOU TAKE THE PILL (.5) hm (0.3) ok:ay= (line 130). Here the clinician acknowledges the patient’s mention, demonstrating hearing and understanding its content, but sidesteps - or possibly delays -- taking a negative stance. Clinician acknowledgement of a patient CIH mention can facilitate continued CIH talk[11, 14], and the patient continues with a fourth part explaining his knowledge of the supplement stating its chemical name (line 131) and repeating the perceived benefit of taking the supplement as possibly more nutritious than “eat[ing] a who::le lotta broccoli” (line 131).

Finally, after multiple turns to explain the supplement and his reason for taking it (lines 129, 131), the clinician responds with a direct counter-recommendation: “I generally go for eating the real stuff rather than the extract though…that’s usually a better thing to do” (lines 132, 134). Although the clinician ultimately disagrees with the patient’s CIH usage, the clinician’s tone is neither confrontational nor does the patient appear to receive the news negatively. Rather, the clinician could be seen as following the NCCIH’s recommendations to eat whole foods and vegetables over individually isolated supplements[25]. In other words, the clinician uses the patient’s CIH mention to educate him about the claims of the benefits of broccoli extract and the (VOM) value of evidence-based nutrition for maintaining health more generally. However, disagreement about CIH does not necessarily decrease the therapeutic alliance between patient and clinician, but could serve to enhance it through increased information exchange and increased patient empowerment and agency [16].

Disclosure of CIH in clinical encounters has been found to lead to more patient-centered encounters[26]. In their model, Street et al. [16] discuss sharing knowledge and empowering patients to make their own health decisions. PCPs have biomedical knowledge that help patients make sense of their current health status and choices, including recommendations for treatments, CIH use, and other health behaviors. However, some clinicians avoid CIH talk with patients due to lack of knowledge with discussing CIH modalities, [27] and patients avoid CIH out of fear of a negative reaction even though studies show that most clinicians react positively to patient disclosure [8]. Throughout this episode, the patient demonstrates himself as both engaged and knowledgeable effectively navigating both VOL and VOM. He clearly described his own health (lines 117, 119) and produces an extended description of a CIH nutritional supplement that includes identifying its common and scientific names, its function, and advantages (lines 125, 127, 131). Most importantly, he persists in pursuing a substantive response from the clinician about his interest in and use of CIH as part of his Lifeworld.

This interaction is unusual because in the published analysis the authors argue that the patient’s continued pursuit of the clinician may invite the clinician to recommend against continued use[9]. Because the patient persistently raises his CIH use, he may ultimately be recruiting the clinician as a consultant to manage his ongoing CIH use – a different but equally important – interactional outcome consistent with making high quality decisions [15]. As Street et al. [16] note, patients have a right to understand scientific risks and benefits of treatment options to make informed decisions about medical care, and clinicians must understand patients’ values, preferences, and beliefs and about CIH modalities that can support their health.

Discussion and Conclusions

(1). Discussion

The two case studies suggest how clinicians and patients negotiate CIH talk during clinical encounters contributes to interactional outcomes as a precursor to other health outcomes. We chose instances where the clinician disagreed or disattended to patient CIH talk because agreement is not a prerequisite for equitable CIH talk. Instead, we argue that how clinicians and patients navigate CIH talk is itself an interactional outcome. Figure 1 highlights the patient’s Lifeworld as a site of knowledge and experience that the patient brings into the clinical encounter. While these case studies cannot determine which aspects of CIH talk may lead to specific health outcomes, future research can use this model to investigate which aspects of interaction might be intervened upon that may ultimately lead to discrete health outcomes and, ultimately, to improved health equity through social interaction [28].

Second, we assert that communication during the clinical encounter is worth close examination because immediate, interactional outcomes are possible precursors to the proximal, intermediate, and overall health outcomes associated with Street et al.’s indirect communication pathway[16]. Because interactional outcomes are dyadically (or triadically) constructed between clinicians and patients, our re-framing of the model challenges future research to question how communication processes unfold through careful examination of the language and interaction used during clinical interactions, rather than taking traditional clinician and patient characteristics at face value, such as race, ethnicity, or other identity categories. While we have treated CIH talk separately from examination of social identities and how they might contribute to inequity, we recognize that future research could explore the intersections of racial/ethnic, gender identity, sexuality, age, disability and other social identities in conversations about CIH and other ways people bolster their health and well-being in their Lifeworlds. If talk can contribute to in/equity, in/equitable talk can affect health equity in other future clinical encounters as well as outside the clinical realm in people’s Lifeworlds. As a result, interactional outcomes have a conceptual relationship with population-level health outcomes and, by extension, health equity.

(2). Conclusion

When writing about integrative health equity, Chao and Adler [29] remind readers that “our collective future depends on all people in all communities having an equitable opportunity for optimal wellness” (p. 2). Although they specifically address access to CIH, our case studies and conceptual model in Figure 1 suggest that clinicians’ responses may serve a gatekeeping function to patients’ access to biomedical information about and decision making around CIH use.

(3). Practice Implications

One pathway for access to CIH may be in the form of asking about and receiving accurate information from trusted sources to manage CIH and biomedical care. How patients initiate and how clinicians respond to CIH talk or other important areas in a patient’s Lifeworld is an interactional outcome that can contribute to interactional health equity within clinical encounters.

Table 1.

Case 1: Acupressure, Guided Imagery

Mrs. Tate:	I wanted to let you know that after the last whole-brain radiation, (Mr. Tate) had a series of grand mal seizures, but before that I recognized he had
some	littler ones before that big one.
Mr. Tate:	I can feel when the seizures come on.
Mrs. Tate:	((nodding)) When they do, I massage a couple acupuncture points that are good for calming down the nervous system.
Mrs. Tate demonstrates pressing points on her own hand for Dr. Scott, who briefly looks up from his current activity, the continued physical examination.
Mrs. Tate:	I hold that point and tell him to think of a happy place. It really helps.
Mr. Tate:	((nodding enthusiastically)) It really does help to minimize the seizure severity.

Highlights.

• Health equity is often structural but also includes an interactional dimension

• Complementary and Integrative Health (CIH) is widely used and discussed

• Clinical encounters create opportunities to ratify patient participation in CIH talk

• Interactional health equity requires balancing Voices of Medicine and Lifeworld

• Interactional outcomes have a conceptual relationship to health equity and outcomes