Collecting Information About a CAM Practitioner’s Practice: A Preliminary Report of a Self-Interview Methodology

Abstract

To prepare allopathic providers to advise patients about complementary and alternative medicine (CAM) therapies, the University of Kentucky CAM curriculum integration project has identified and trained CAM practitioners to coteach, precept, and demonstrate their respective practices. This project is interested in integrating CAM practitioners as teachers into this university and has formed a multidisciplinary committee for advice. The committee has recognized the importance of increased understanding of CAM practices to enhance communication within itself and to decide to which CAM practices students should receive exposure. This article reports our attempt to create a CAM practice description, based on questions general to CAM practice and specific to a particular approach. Because there is limited existing systematic research on CAM practice characteristics, these questions may interest researchers conducting qualitative studies, especially those seeking an example of questions to ask CAM practitioners. We also believe this practice description will be of general interest.

Efforts to integrate complementary and alternative medicine (CAM) information into conventional health professions’ curricula involve interaction among practitioners of varying care cultures. Such efforts call for enhanced understanding and communication about a variety of diverse health care practices and include a need for information about the practice characteristics of CAM providers.

However, a review of the literature reveals limited systematic study of CAM practice characteristics. Reports of characteristics of specific therapies are rare, with the important exception of studies of chiropractic practice. For example, Hawk, Long, Perillo, and Boulanger (2004) have used practice-based research methods to describe preventive and primary care behaviors of chiropractors. Gherkin and colleagues (Boon et al., 2004; Cherkin et al., 2002; Sherman et al., 2005) have used survey methods extensively. One study described in the recent Institute of Medicine Report (Institutes of Medicine of the National Academies, 2005) compared data on licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians in four states to data from the National Ambulatory Care Survey regarding allopathic physician care. The researchers were able to characterize practices in terms of visit duration, insurance coverage, and conditions seen. Condition comparisons were largely nonspecific (i.e., limited to broad categories, such as musculoskeletal and wellness), and the survey was limited to licensed providers. The patient characteristics and practice characteristics of physicians using homeopathy have been described (Jacobs, Chapman, & Crothers, 1998).

Researchers using quantitative surveys face several methodological problems. Typologies of CAM modalities such as those created by the National Institutes of Health (NIH) consensus task force (National Center for Complementary and Alternative Medicine, n.d.)—that is, alternative medical systems, mind-body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies—may lack utility for survey research; the modalities are broad and the therapies listed are not exhaustive. Within therapies, there may be diversity of opinion as to what constitutes status as a CAM practitioner and what activities are typical. A lack of both public records and credentialing for many CAM therapies makes data collection difficult. These unknowns contribute to problems with operationalizing research constructs. For example, what is a reliable and valid definition of a CAM practice? Or, what qualifications are necessary to be considered a particular type of CAM practitioner? In the face of poorly operationalized constructs, qualitative studies may be helpful in understanding more details about the object of study and may contribute to building its operational definition.

For the purpose of preparing allopathic providers to advise patients about the use of CAM therapies, the University of Kentucky CAM curriculum integration project has identified and trained a cadre of CAM practitioners to coteach, precept, and demonstrate their respective practices. For purposes of learning about these practitioners, standard information has been collected, including contact information, teaching interests, student evaluations, and credentials, if they exist. However, this information may be insufficient for enhancing understanding and communication necessary for interdisciplinary collaboration, particularly when therapies and practices are unfamiliar.

This article reports the attempt to create a CAM practice description, based on a series of questions general to CAM practice as well as several questions specific to a particular approach. Because there is limited existing systematic research on CAM practice characteristics, these questions may interest researchers conducting qualitative studies, especially those who are seeking an example of questions to ask CAM practitioners. We believe this practice description will be of general interest as well. This article reports preliminary results of a strategy to collect detailed, qualitative information about CAM practitioner practices via a self-administered questionnaire. The information is being collected for use in enhancing communication and understanding among academic and community health care providers of varying care cultures who are working together on a CAM curriculum integration project funded by an R25 grant from the NIH/National Center for Complementary and Alternative Medicine. The methodology and findings presented here may be of use to researchers and educators who are interested in collecting health care practice descriptions via qualitative methods, as well as to others who are interested in a description of an herbalist’s practice.

METHODOLOGY

The practice-description questionnaire and the resulting practice description appearing below were shaped and motivated by the advisory committee (AC) for the University of Kentucky CAM curriculum integration project. The University of Kentucky was a recipient of 1 of 14 NIH five-year CAM curriculum development projects awarded to allopathic health professions schools. The project seeks to integrate CAM knowledge and interdisciplinary care skills into existing curricula of the University of Kentucky Colleges of Medicine and Health Sciences, including medical and health professions education, residency training and continuing education; enhancement of the development of critical thinking skills for learners; and the preparation of CAM practitioners to teach and precept. The University of Kentucky project is strategically incorporating CAM practitioners to coteach, precept, and demonstrate CAM therapies in selected medical school courses, including required educational experiences with CAM practitioners at practice sites in urban Lexington and rural eastern Kentucky.

The AC consists of a diverse group of community CAM practitioners—including a licensed massage therapist, chiropractor, herbalist, holistic nurse, and acupuncturist—and University faculty from both the University of Kentucky Colleges of Medicine and Health Sciences. The AC has been charged with providing recommendations about CAM content to be incorporated into the curriculum, exploring evidentiary problems associated with potential differences in “ways of knowing” between conventional and CAM communities, and addressing issues such as fairness and communication as allopathic and CAM communities attempt to work together in a meaningful effort.

The AC identified a need for CAM practice descriptions at its Spring 2004 annual retreat. The theme of the retreat was “Finding Common Ground.” During the retreat, the project participants received a report from the anthropologist on the AC about barriers to the integration process. Several important issues were discussed after this report, and the AC reached the conclusion that understanding the respective views and modalities of CAM providers was key and decided that they should work to understand other practitioners’ perspectives. It was suggested that practice descriptions be developed to increase mutual understanding of practices among CAM and conventional providers as well as to provide educational content for trainees. That is, AC members expressed the need to learn more about respective practices to enhance their work together, with the aim of producing better curriculum content recommendations.

AC participants then discussed what information they wished to learn about each other’s modality and practice and volunteered to respond to project inquiries. Individual committee members raised questions of particular interest to them and there was discussion and agreement about areas of common interest. A coauthor and AC member with a rural holistic nursing practice (H.P.) compiled the list of questions into a written questionnaire (Table 1) and modified them specifically for an herbalist’s practice. Reported below are the responses of one respondent, an herbalist, who is a member of the AC and a coauthor (A.B.). The questions remain in their original form except that the final question was added post hoc to clarify differences perceived by the practitioner of his practice from conventional medical practices.

TABLE 1.

Self-Interview Questionnaire

What is the most common reason folks seek your services?

What conditions do you have most success with?

What/who do you especially enjoy working with?

How long are your sessions and what do they cost?

Are sessions only in person or available by phone and/or e-mail also?

Do you have many heath professionals that call you with questions? If so, do you charge for these services?

What do you offer?

Do you advise about supplements as well as herbs?

Do you advise about drug/herb/supplement interactions? Are there good references for this or would it be better to consult with you?

What kind of education/training do you have?

What is your vision for yourself and your work?

Are you making your own products? Tea? Tinctures? Other?

How do you differentiate your practice from that of conventional medicine, to your clients and other providers?

The project has received Institutional Review Board approval from the University of Kentucky to conduct research on its integration efforts bringing CAM and “conventional” participants together to work on curriculum integration, including participants’ perceptions and experiences of the integration process.

What Is the Most Common Reason Folks Seek Your Services?

[Author’s note: Mr. Bentley indicates in a later answer that he treats conditions rather than diseases.] People present to me for just about any reason, or sometimes for no reason at all. A few examples from this week include a child (13 months old) with a persistent ear infection that hasn’t responded to antibiotics, a woman (30 years old) with a urinary tract infection, a man (75 years old) experiencing pain from breaking two lumbar vertebrae, and a man who wanted to know if his large supplement regimen made sense. For some people, it’s their primary or only form of care; and for some, it’s complementary to other modalities. I see a lot of people who have conditions that are not easily treated by conventional means—like autoimmune diseases.

What Conditions Do You Have Most Success With?

The conditions I have the most success with are those in which the patient is willing to take charge of his own health and make a solid effort to get better. I have a much harder time helping people who just want to take one or two supplements and not change anything else in their lives, but it is generally possible to help them to some degree.

What/Who Do You Especially Enjoy Working With?

I especially enjoy working with people who are new to the world of natural health and complementary/alternative therapies. There are so many things that a person can do to improve her health, versus the standard American diet and lifestyle, and it is amazing to see that transformation take place.

That being said, I am perpetually awed by the diversity of human life and conditions. A while back, I saw a man with ringworm on his scalp, which is unusual because he was white with straight hair, and head ringworm likes to grow on African-type hair follicles. I almost wanted to say ”Oh, that’s really neat,” but that would have seemed inappropriate.

How Long Are Your Sessions and What Do They Cost?

The first session costs $50 and takes about an hour, sometimes longer. After that, sessions cost $35 each and take around half an hour.

Are Sessions Only in Person or Available by Phone and/or E-mail Also?

I have done sessions by phone and e-mail before, but I do not like doing them, nor do I feel they are nearly as effective. I like to be able to physically observe someone, feel that person’s pulse and look at his tongue, see his face, hear his voice, and observe any irregular signs that he may have. None of this would be easy to do over the phone or by e-mail.

Do You Have Many Health Professionals That Call You With Questions? If So, Do You Charge for These Services?

Yes, they do, and no, I do not. Except health care professionals within drug companies trying to develop new drugs who want extensive information about how a particular herb works and is traditionally used. This has only happened a couple times.

What Do You Offer?

Most of the time, when people come in, I try to build a thorough history with them, figure out what their diet and habits are like that might be contributing to or ameliorating their condition, and any specifics that might let me know exactly what is going on inside them. As you know, I do not offer diagnosis or treatment of diseases. I offer assessment of conditions and treatment of individuals, supporting healthy functioning of their bodies and minds. The tool I use most for assessment is simple communication. I also use observation of pulse and tongue signs, observation of signs on the body (such as appearance of an injury), simple empirical tests (like holding a tuning fork to the ear and then pressing the handle to the person’s head and asking which sounded louder), and occasionally microscopy (such as looking at blood cells) and other techniques. Again, this isn’t used to diagnose diseases—just to figure out what is or isn’t happening in the body.

Based on all of this, I will recommend herbs that people can use to strengthen deficient areas, tone down excesses, and support the normal functioning of the body’s organs and systems.

Sometimes, I will use an intervention that requires direct application by a practitioner. The most common treatment of this sort for me to use is moxabustion, burning herbal incense near acupuncture points or injury sites to stimulate the body’s innate healing mechanisms and help the flow of Qi in the body. There are two other techniques called cupping (applying a warmed glass cup to areas of the body, essentially for the same purpose) and Guasha, which uses the same points but stimulates them by scraping the skin with the smooth edge of something. (I use a jade spoon, which is traditional in Xinjiang, where I learned this.)

Do You Advise About Supplements As Well As Herbs?

Not especially. I keep myself as informed as possible about anything my patients might be taking, be it herbs, supplements, over-the-counter and prescription drugs, vaccines, specialized diets, medical surgical and diagnostic procedures, other forms of therapy, etc. But the interventions I recommend to people are pretty much botanical preparations and procedures, changes in diet, and exercises.

My approach to supporting the functions and structures of the human body tends toward the theory that complex, multisubstance things like herbs are going to be more in line with what the human system is designed to process than single-substance remedies like vitamin C. So, for instance, if someone takes plain zinc for prostate health, it may be that the zinc promotes healthy testosterone levels (provided they can digest it). If they take saw palmetto berries, they’ll not only get zinc (in a natural and bioavailable form), they will also get a wide spectrum of antioxidants, some anti-inflammatory compounds, enzymes, and the catechins typically thought of as being the “active principle” in saw palmetto. Each of these things (and many others) has been demonstrated to have a beneficial effect on prostate health.

Often, this means that in taking the herbs, people are getting a moderate dose of a few substances and a miniscule dose of dozens if not hundreds of complementary substances, which all work together to produce a net effect. I consider this a more stable approach than taking a large dose of a single substance.

Additionally, with a lot of the substances out there, I feel that they are basically untested drugs: concentrated substances, made in a lab or isolated from living things, without much history of use to back their safety and effectiveness. So I would not necessarily be comfortable recommending the latest supplement.

Do You Advise About Drug/Herb/Supplement Interactions? Are There Good References for This or Would It Be Better to Consult With You?

I have not found any references yet that I felt were trustworthy. The main reason is that people do not seem to be accounting for the pharmacology of herbs. If there are documented interactions, most references will include them (although some reports of interactions are highly questionable). Conversely, interactions that could be readily predicted by knowing how herbs work are frequently not included. So, yes, I do advise people about herb/drug interactions.

What Kind of Education/Training Do You Have?

I got my primary training from my father—who got it from his father, who got it from his mother, who was from an Irish family that produced a long line of prominent healers in post-medieval Europe and who ultimately got their start at a school in Connachta (northwest Ireland) called Scoil na Sidhe. Later, 1 traveled around the world studying traditional healing ways in several different areas, including central Asia/western China, the Silk Road countries, Lapland, a few Native American reservations, and the primarily Gaelic-speaking areas of Ireland. Now, I self-educate vigorously and keep in touch with the community of herbalists around the country. We share ideas and discussions via HerbalHall, which is an invitation-only e-mail Listserv.

What Is Your Vision for Yourself and Your Work?

I see that a massive change is taking place right now in health care, and part of that change is wider acceptance and understanding of herbal medicine. Having the good fortune to be an herbalist at the time when this is happening, I feel that it is up to me to help foster this shift in awareness. I am planning on taking on an apprentice whenever she gets around to it, and suppose I’ll eventually be working with a few other herbalists who have apprenticed under me— but that is a few years off. I also have plans to start a small herbal/pharmaceutical company making extracts from plants (some of which will be labeled as drugs and others as supplements). I have pretty much done the paperwork to make the company official and just need to build a place to make them on the farm in Rockcastle County. I have considered expanding my teaching practice and organizing it into some sort of “program” for people wanting to become herbalists. But there are other decent programs already out there, so this becomes less likely as my clinical practice gets busier and busier. (Maybe when the kids are grown.)

So, 10 years ago, I would not have envisioned my practice growing to the level it has today. Ten years or 20 years or more from now, who knows what the world may be like.

Are You Making Your Own Products? Tea? Tinctures? Other?

I make most of the products I use in my practice from plants that I gather or that I have gathered or grown for me. Primarily I use tinctures, because they are readily absorbed, easy to use, and have a good shelf life, but I also make teas, salves, oil extracts, glycerin extracts, vinegar extracts, sterile aqueous extracts, capsules, poultices, tablets, powders, and just about anything else.

How Do You Differentiate Your Practice From That of Conventional Medicine, to Your Clients and to Other Providers?

While the most readily apparent difference might be that an herbalist recommends herbs rather than drugs, there is in fact a very significant difference in terms of the therapeutics of herbal and conventional medicine. Herbalists seek to treat individuals not on the basis of what diseases or conditions they might have, but rather in terms of which structures and functions of their bodies need to be supported. Assessment is focused not on diagnosing a disease but on gaining an understanding of which aspects of the anatomy and physiology are deficient or excessive. This can be very different even for two people with the same medically diagnosed condition. For example, a person who has been diagnosed by her doctor as having hypertension may have an excess of emotional stress, or she may need herbs to support kidney function.

DISCUSSION

This example of a CAM practitioner self-interview suggests that the process of practitioners responding to a written questionnaire can be successful in producing an informative practice description. This method, therefore, may be of use to researchers who wish to collect qualitative information about practice characteristics. One aspect of the method that affects the generalizability of these results and may limit applicability of this method in other settings is the unique relationship of the CAM practitioner respondent to the project. In this instance, the CAM respondent is a coauthor and member of the AC. His openness may be related to the trust and commitment that he feels to the project as well as his ability to contribute editorially to the conclusions. Researchers using this method should be prepared to discuss risks to the respondents that may come from such openness about their practices, especially if those practices are considered controversial. However, CAM practitioners may feel that the benefits that come from the opportunity to describe their practice in the literature or otherwise encourage qualitative study may outweigh any risks they face personally.

In its next step, the University of Kentucky project will use this interview as an example interview in a planned project activity to modify the self-interview guide, based on AC input. The modified interview guide will be used to collect similar self-interviews from our complete cadre of CAM practitioners.

Based on the results of this single pilot self-interview, the authors have already noted areas in which the self-interview questionnaire could be improved. These include more information about the day-to-day operations of the practice, including record keeping and number of patients or clients seen; description of practice environment; impressions of the success and viability of the practice; and referral patterns. These and other areas of omission and of needed clarification, as well as additional suggestions for improvement, will be brought up for discussion at the next meeting of the AC. All of these potential modifications will be developed by consensus of the AC, with the goal of increasing knowledge and understanding of CAM practitioners’ practices.

When collected, these self-interviews will be compiled into a pamphlet that will be distributed to all AC members, meeting their requests to have this information about their respective practices. A next step will be to query the AC as to their perception of the usefulness of the questionnaire. With individual permissions, the project will publish the self-interview information on the University of Kentucky project Web site. Students who have clinical experiences with various practitioners would then be expected to review the Web site before their field experiences with practitioners. The University of Kentucky project plans to apply this method more systematically in an analysis of the practices of eight licensed massage therapists and nine chiropractic physicians who are currently teaching third-year medical students at the University of Kentucky.

Biography

Biographical Data. William G. Elder, PhD, is an associate professor in the University of Kentucky, Department of Family Practice and Community Medicine, and director of the Department’s complementary and alternative medicine curriculum integration efforts. Hunter Purdy, RN, HN-BC, serves as a holistic nurse consultant and educator at WaysMeet in Berea, Kentucky. WaysMeet is a collective of health practitioners and workshop facilitators whose work is “guided by the belief in the healing potential that exists in each person and the conviction that all persons need support through education and community as they move toward wellness.” Andrew Bentley is a clinical herbalist practicing in Lexington, Kentucky. He also works with University of Kentucky faculty to introduce herbal medicine into various medical school courses.