Quality in Primary Care Open Access

Keywords

family medicine, homeopathy, patient– physician interaction, qualitative research

Background

Homeopathy enjoys a high regard among patients that shows no sign of diminishing.[1–3] In terms of research on the specific effectiveness of treatment methods, homeopathy is one of the areas of complementary and alternative medicine (CAM) that has been relatively well investigated, although the methodological quality of the studies often leaves a lot to be desired.[4] Authors who view the evidence base more positively have also come to the conclusion that it is not clear whether homeopathy is superior to the placebo as a treatment concept.[5]

At the forefront of the attitude of conventional (academic) medicine towards homeopathy is the fact that there is no definitive evidence of additional benefit over and above the placebo effect.[6] According to Shang et al, it is the treatment setting from which patients are most likely to benefit: ‘Context effects can influence the effects of interventions, and the relationship between patient and carer might be an important pathway mediating such effects’.[4] However, this rather sobering assessment has not damaged the popularity of the concept.

Even observational studies of high methodological quality cited as evidence of the benefit of homeopathy are, principally for methodological reasons, limited in terms of their significance. They essentially come to the conclusion that patients feel better under longterm homeopathic treatment, but that it remains unclear whether this can be ascribed to a specific effect of homeopathy.[7,8] It is particularly interesting that a recent randomised controlled trial (RCT) in patients with rheumatoid arthritis suggested that non-specific elements of a homeopathic treatment were responsible for the improvement in symptoms measured here.[9] Irrespective of this ongoing controversy regarding the specific benefit of homeopathy, it seems important to come to a better understanding of the significance that patients attach to its use.

A series of Anglo-American studies has attempted to investigate the motives behind patients’ use of homeopathy.[10,11] These studies differentiated between homeopathy-specific and non-homeopathy-specific motives.[12] In the former, the search for the ‘right’ medication is of significance; whereas in the latter, it may be the experience of a greater (or different form of) empathy on the part of the therapist. The aspect of empathy is of particular interest as a recent study by Mercer et al of a large group of patients in 26 Scottish general practices has shown that ‘the patients’ perception of the doctors’ empathy is of key importance in patient enablement in general practice consultations in both high and low deprivation areas’.[13] Whereas the motivations of patients to use homeopathy have generally been investigated less well, there is a broad debate regarding patient pReferences for CAM in general.

In 2000, there was a discussion in the British Journal of General Practice[14] as to why patients used complementary medical practitioners; the study found that patients in the conventional system were dissatisfied with the manner of communication and explanatory models for their disease, they feared the side effects of pharmacotherapy and they criticised the lack of a holistic treatment approach. CAM, by contrast, was associated with the strengthening of the patient’s own self-healing powers. Patients also valued the time that alternative therapists made available to them. The appreciation and psychological support given to them by their therapists was of particular importance to patients – both men and women – with chronic conditions. Ten years later, Ernst and Hung[15] essentially confirmed these assessments, but also stated that research into patient expectations was lacking.

Homeopathic treatment has been investigated significantly less well in terms of the patient perspective. Even in Germany, the homeland of homeopathy, there are currently no methodologically appropriate studies that investigate the question of how patients describe their view of homeopaths (or homeopathic medical practitioners) in the light of general experiences with medicine (for a view of German homeopaths, see Frank;[16] for the view of German patients towards herbal medicine, see Joos et al).[17] If one wishes to pursue the question of what lessons family medicine should draw from the high levels of homeopathy use, this type of research becomes even more important. Although some writers call for the direct integration of alternative medicine,[18–20] others reject this completely.[21] In general, a better patient-centred approach is seen as important.

Against this background, we considered it to be useful to investigate the motivation, attitudes and experiences of patients who had been in long-term contact with homeopathic medical practitioners in Germany using a qualitative study appropriate for this research situation. Other providers of homeopathic services (in Germany primarily Heilpraktikers – nonmedical practitioners) were not included in the study.

Methods

The central research question was: ‘How do male and female patients experience the medical care they receive from office-based male and female homeopathic medical practitioners, what experiences have they had from this medical care and how does this compare with conventional medical services?’ Questionnairebased, semi-structured, face-to-face interviews were used. The survey method of the expert interview as described by Meuser and Nagel[22,23] was chosen because of the wish to address the interview partners as user-oriented experts in relation to the healthcare system. The analysis was based on the summary qualitative content analysis approach as described by Mayring.[24,25]

The areas of focus of the interview guide, which were developed based on the literature, were as follows:

•experiences with homeopathic medicine/current assessments

•homeopathic medicine versus conventional medicine

•communication and interaction

•significance of health and illness.

The interviewees were recruited by means of a short newspaper article and also by approaching homeopathic medical practitioners who received a number of information letters that they were requested to pass on to their patients. If they were interested in taking part in the project, patients were asked to contact the researchers. The sample was based on the following inclusion criteria:

• treatment for at least 12 months for a chronic condition by a conventional medical practitioner with a certified additional qualification in classic homeopathy

•gender

•age

•social environment.

Apart from the original intention to recruit approximately equal numbers of men and women, all other sample criteria were met.

To sum up, this was an opportunistic sample taking into account specific inclusion criteria (preliminary sampling).[26,27]

The interviews, which lasted on average between 60 and 90 minutes, were conducted between January and April 2009 and took place in the homes of the interviewees. All interviews were transcribed word for word and in their entirety and pseudonyms were used. Informed consent was obtained for recording the discussion, interview analysis and presentation of the results. The analysis of the interviews was performed by three healthcare researchers and social scientists with the involvement of a multidisciplinary (medicine, health sciences, social sciences) research workshop/interpretation group.

Results

Twenty-one women aged from 31 to 75 years and five men aged from 29 to 50 years were interviewed. The interviews, held in German were transcribed word for word in German. For reasons of anonymity and for ease of translation, sections of the interviews quoted in this article that were spoken in dialect were converted into standard German. Men were difficult to recruit, which may have reflected the greater reluctance of men to talk about health-related matters.

The results are presented with the overriding aim of investigating interviewees’ experiences of homeopathy and developing a wider framework of understanding. These reported experiences are presented under two selected areas of focus: first, how patients talk about the development of the relationship with their homeopathic medical practitioners; and second, what importance they attach to the selection of homeopathic medications (the ‘globules’). These reports are then interpreted in terms of the development of the doctor–patient relationship. This forms the foundation of the subsequent discussion that explores whether and, if so, what conclusions family physicians can draw in the light of what has been discovered about the patient perspective.

Contact with the homeopathic medical practitioner

Almost irrespective of whether the contact with the homeopathic medical practitioner came about more by chance, whether it was an expression of deep dissatisfaction with conventional medicine, or whether it was a result of family tradition, it proved to be very important that during the initial contact ‘genuine interest’ on the part of the homeopathic medical practitioner was experienced in terms of the individual patient and his or her symptoms.

If he then asks, how are you doing? ... how have things been recently? ... and so on, then I get the impression that he is really interested and not asking out of politeness, ... And it’s incredibly easy to talk to him because he is so open and so on. Yes, a really friendly manner, very, very interested too. (W11/340–346)

One patient reported that she felt in good hands in terms of everything that was important to her and that, above all, there was sufficient time during the initial consultation:

•.. She (the doctor) really takes time, she listens to everything, she also perhaps listens to things all around the subject, to perhaps what else there has been, why this and that are like they are, perhaps something has changed in this period of my life, or, or something else has happened. And with her you really feel in good hands. You know,

you, you, you really have the feeling that she cares for you all round, which is as it should be. (W2/177–184)

Patients mentioned that they often missed precisely this openness in their everyday healthcare and then did not have the courage to describe their concerns as they had originally planned:

You know, I sometimes feel that doctors are not looking at me properly at all, not really taking notice of me properly at all, (...) instead they are involved in their hustle and bustle, you know ... in what they’ll be doing with the next patient or in something else I don’t know what. So that I am so pressured that I’m not even able to put my question at all (...). (W13/726–736)

Patients found the initial homeopathic consultation, which tended to last one to two hours, unusual when viewed against the background of their experiences in the traditional healthcare sector, which was characterised by a lack of time. However, they then came to realise that homeopathic medical practitioners were able in this way to gain a more comprehensive insight into their patients than was the case with traditional family practitioners:

•.. You ask yourself why she (the doctor) asks such strange questions. And what’s the point of that, why I have my foot outside the bed covers or prefer to eat hot or cold food. But she obviously wants to get to know the person. And the people then also take time and then enquire about things. (W12/70–75)

Although it may have been experienced as disconcerting, the ‘homeopathic manner’ of asking questions formed a framework or basis for a controlled convergence between patient and doctor. The manner of the consultation, particularly the detailed questions to promote discussion, also contributed to an active and therefore also individually experienced participation by the patient. In this way the detailed style of questioning, which is a key component of the consultation, is designed to contribute to the building of trust. It is to be assumed that the confidence to answer detailed questions and the use of detailed questions as an instrument of building trust were interlinked:

Yes, we don’t worry about it because we really, this is our trusted doctor. I think that if some stranger asked the question, as I said before, it would seem strange, you know that, that he simply needs it for the patient history and. They are you know, you know, not every – these may be everyday questions but a bit strange for outsiders, that’s how it is. (W22/287–293)

During the course of the treatment relationship, the issue of time underwent a reversal of which the interviewee was mostly unaware. In fact, once a trusting doctor–patient relationship was formed, patients greatly appreciated it if during the course of the treatment they could briefly phone the doctor:

I can then phone and tell Mr X (doctor) that my daughter has earache in her left ear and her nose is running and which are the best globules to give. (W14/735–737)

In other words, patients did not expect that their homeopathic medical practitioner had unlimited time for them once a ‘fit’ (i.e. a stable relationship of trust) had been built up. Even longishwaiting times were felt to be appropriate, although these occurred less frequently in the practices of homeopathic medical practitioners than in conventional medicine.Afurther component of the ‘fit’ was that patients felt no inhibitions in relating everything that was important to them, i.e. with no fear of not being taken seriously:

I really have the feeling with many conventional medical practitioners that only their side is right and that everything else is just humbug and rubbish and sentimentality or whatever. (W12/972–975)

Without denying the importance or competence of conventional physicians in general or even feeling that they are replaceable, the criticism by interviewees of conventional medicine consistently stemmed from the feeling of not having experienced the appropriate level of respect in the doctor–patient relationship:

I don’t know how many hospitals we were in, we travelled round the whole of Germany and dealt with doctors and. (...). And they really are a quite peculiar species. Of these very, very many doctors (...) perhaps there were two good human doctors who were able to explain things to you so that you could understand. All the others really floated around like demigods. (W16/329–339)

Another significant finding was that interviewees frequently stated how important the combination of conventional and alternative medicine was to them. Traditional medicine remained important to them to ensure that nothing was overlooked and that they benefited from the successes of medicine:

•.. I find it an optimal combination, a doctor who does homeopathy. Who does both, I mean sometimes you perhaps need a different medication, but that is easy, he knows about it all, I mean he has studied it. (W18/1108– 1112)

A different view of the value of homeopathy and conventional medicine can be seen in the following quote:

With homeopaths I have now found ... that they have a sort of different way of treating people. That they are more friendly, more interested, and tend to think more holistically. And with conventional medical practitioners I have sometimes found that although they may be good in terms of the subject matter, they don’t have the right personal touch when dealing with patients. And I can live with that, I think, very well, if a doctor is good in terms of his subject matter, he can be awkward in his dealings with people ... (W11/491–503)

Patients therefore made use of both forms of medicine. They were prudent not to abandon the conventional medicine that they often criticised since they were well aware of its benefits.

The final relevant finding here is the stability of the relationship between the interviewees and their homeopathic medical practitioners, which allowed an extraordinarily paternalistic medical role of the homeopath to be accepted and even valued in the relationship. If the relationship was right, patients clearly accepted the therapeutic recommendations of their homeopathic medical practitioners without question:

No, when she says it’s necessary now, then it’s necessary now, that’s it. And I think that’s come about simply from this, from this very good, from these consultations, from the, because she has asked in detail why I came to her and what sort of method I want and what is important to me. And therefore she knows exactly what I want, and that’s just how she goes about it. And that’s the good thing about her. (W2/622–629)

The role of the globules

The following section shows the importance of the globules (a major component of homeopathic medication) within the longer term (existing) relationship between homeopathic medical practitioners and their patients. At the centre of the patient perspective was the search for a substance that was ‘right’ for them. Individualised therapy following a detailed description of the symptoms taking into account the personality of the patient are the ingredients for a confidenceinspiring prescription of globules:

It is always a matter of finding a remedy that exactly matches the individual person. And in homeopathy that is of course incredibly difficult because there are a few thousand different remedies. And when you find the right one, it’s like the lottery, like all six numbers in the lottery. Then you can again do a lot, bring things together as they should be in the human body. And that is always the aim, that you are always trying to find this remedy. (W17/141– 149)

Analogous to the establishment of trust on initial contact with a homeopathic medical practitioner, the experience of intensive, sometimesmonth-long searches for the ‘right’ medication was decisive in terms of the attitude to the globules (and to this form of medical consultation and treatment). Once the interviewees had found that a specific individualised remedy helped them, a fundamentally opposite attitude may develop in the further course of their relationship to homeopathy, namely the addition of the globules to the ‘homeopathic medicine chest’ (W11/723–724) that was then used for similar symptoms or other people.

If new complaints occurred, they could then take these globules either after consulting with the doctor or independently. There were also reports of the practice of passing on globules to friends and family because of the conviction that they were helpful with certain symptoms. An extreme manifestation of this behaviour was related by a patient, who gave an acquaintance globules from her cabinet following a collapse, which, although it appeared worrying, quickly passed.

Reassurance about giving the globules was given by the emergency doctor who saw no reason for therapeutic intervention. After he left, the acquaintance then took the medication:

And then she (the acquaintance) said she was in favour of homeopathy and I then gave her a tablet. And you could really see it, she then sucked on it and about five or ten minutes later the colour had returned to her face again. And I found that really good. (W11/177–182)

Here it was not seen as a contradiction that an individually selected remedy was found to be effective with a different person in a completely different situation. In the context of the patient’s own medical history, the globules had a significance that did not appear to indicate the need for critical reflection on the subject of ‘individual therapy versus universal remedy’. Although the interviewees were well aware of the public and scientific debate about the lack of proof of effectiveness of the globules, they immunised themselves against this criticism by pointing to positive experiences in the use of globules with young children and animals:

I know there is a lot of criticism that it actually can’t work because there is nothing in it. On the other hand, there are trials with animals where there can actually be no placebo effect and it works. My niece has a horse and the horse had problems with its eyes and it was given the same eye drops that I take and they worked. (W11/743–749)

I don’t know why it works, I don’t know how it works, but it does work. And in particular with our children who in fact were given it as infants. (...) A six-month old child, when they get globules on their tongue, they can’t say, I’m now getting something on my tongue and then it works. (W4/859–866)

A third significant aspect of the patient perspective related to experienced and/or feared side effects of traditional pharmacotherapy. The spectrum of reported experiences includes antibiotics:

What might happen if I take antibiotics seven or eight times during the year, well, my kidneys would be unhappy and my liver and what have you, well, it’s not exactly healthy. (FW2/332–334)

The fear of side effects also related to specific medications prescribed for serious conditions (in this case rheumatoid arthritis) such as methrotrexate to which ‘horrendous side effects’ were ascribed:

Then there is the cancer drug Methrax, Methrax, whatever, I can’t remember now what it’s called. And to be honest I treat it with respect. I treat it with respect and would be afraid of getting more health problems than I have now. Actually, it’s enough for me and I want to make sure that I can somehow keep things under control. (W23/ 243–248).

And in terms of positive effects, the interviewees not only mentioned experiences bordering on ‘miracle’ cures, for example with allergic conditions.

And practically at a stroke it was gone. And that naturally totally convinced me. (W14/49–50)

They also mentioned the conviction that, in contrast to allopathy, globules were able to mobilise the body’s own forces:

So the greatest benefit for me is that the medicine has no side effects. And that the body can be instructed, or however you want to say it, to mobilise its self-healing forces. Those are the two greatest benefits of all for me. (W14/585–588)

Globules were seen as a counter-concept to a drug therapy that was felt to be externally imposed and dangerous and which was only accepted if there is absolutely no alternative. Globules fulfilled the wish for individuality and safety. For ‘experienced’ patients they opened up the possibility of becoming pro-active themselves with a homeopathic home pharmacy and exercising a degree of independence over their own or others’ disease processes.

Discussion

There were two key findings from participants reporting on long-term experiences with medical doctors who also practised homeopathy. First, there was a high level of appreciation for the communication with homeopathic medical practitioners who were seen as consistently treating patients with respect. During the extensive initial consultation, a ‘fit’ is created in the doctor–patient relationship which allows an initial level of trust to develop with the effect that the patient is subsequently not unsettled by abbreviated advice or paternalistic attitudes. The homeopathic medical practitioner becomes the preferred support companion for the disease and how it is experienced. Second, patients were impressed by the search for the ‘right’ medication and this was seen as practically free from side effects and promoting selfhealing forces. Homeopathy thereby became a meta metaphor for natural medicine, in contrast to allopathy where side effects, which can sometimes be severe, are often experienced. In each case, homeopathy appeared to this group of patients as the ideal individualised form of medicine.

Against this background, the question of what conclusions family medicine can draw from the study is not easy to answer. On the one hand, there are a number of requirements of patient-centred medicine which have long been described as priority objectives for research and practice:[28–32]

• Doctors are aware of the patient viewpoint and are credibly interested in the patient perspective.

• Doctors demonstrate that they want to understand the individual key concerns of their patients. This applies above all to the initial contact which should demonstrate a basic approach where patients are able to present their own personal view of disease and the experience of disease without having to worry about being instantly judged.

•The organisation and processes of ambulatory healthcare explicitly provide a framework for dialogue- oriented communication.

•Doctors understand that, particularly with longterm drug treatments, the issue of unwanted effects is of enormous importance to patients.

•Doctors offer reliable ongoing support. This includes low-threshold services such as phone calls to answer questions or to attempt to clarify new problems.

From this perspective, the attempt to integrate individual components of homeopathy into the everyday activities of family medicine does not appear justified. This statement holds true irrespective of the issue of whether it is justifiable for family medicine to adopt various elements of homeopathy, such as improvement in the patient relationship, when this type of medicine is not judged as having scientific legitimacy. Of more importance is the question of how to incorporate the ‘non-specific’ motives of patients to use homeopathy into the further development of primary care. However, research into the basic requirements to be met by physicians in terms of communication competence consistently shows the importance of their genuinely appreciating patient perspectives.[33,34]

This issue is continually broached by patients and should be a part of the professional awareness of medical practitioners. Here, there is a direct link to primary care research. With regard to primary care, Marnocha talks of the direct therapeutic effect of the doctor–patient relationship and refers to the dimensions of ‘empathy, genuineness, and positive regard for the patient’ based on the teachings of Carl Rogers.[35] In a broader perspective, Stange and Ferrer see the core competences of ‘integrating, prioritizing, contextualizing, and personalizing health care’ as the centre of the generalist role of primary care physicians. They also point out the importance of a better understanding of the development of this ‘generalistic function’ through increased research.[36]

Patient-centred medicine has been demanded for decades based on the same recurring arguments and is clearly more difficult to realise, despite numerous ideal curriculum concepts and models, than is to be found in practice. There is still a need to change basic attitudes towards patients and disease, and to practise a sustainable, empathetic and open culture of communication in everyday medical life. It is important to continue to work on this aspect of care, and in particular to understand how it could be done better than previously, and this is completely independent of the relationship between conventional medicine and homeopathy. This could be the actual lesson to be learnt from the studies into the popularity of homeopathy.

In fact, irrespective of the unquestionably important debate regarding the benefit of homeopathy, what is needed is to establishhowdialogue-orientedconsultation and care can be practised on an everyday basis. It is also important to rememberthe pioneeringwork of Schwartz et al[37] in the development of the ‘patient–physician fit’, particularly as this empirical approach included the significance of the non-medical needs of patients. This discussion is by no means new and goes back to the work of Michael Balint.[38,39] It also includes more recent attempts at the radical reform of primary care.

The solution to the problems cannot be found solely in terms of training in communication competences. [40,41] It also requires ongoing reflection on the image of the medical profession and changes to the infrastructure of primary care, such as the chronic care model and the patient-centred medical home, which have now appeared on the agenda of health services research.[42,43]

The research results presented here strongly support the thesis of Stange et al [44] that greater efforts are needed to achieve the aim of a patient-centred family medicine. The comments of patients who have decided to use homeopathic medicine alongside allopathic treatment are a constant reminder to persevere with the efforts to seek ‘common ground’ between doctors and patients.[42]

Funding

The study was financed by AOK Baden-Wu¨rttemberg (Health Funds) and through in-house funds from the Health Services Research Center in Bremen. The complete version of the underlying research project can be found at www.akg.uni-bremen.de/pages/arbeitspapier Beschreibung.php?ID=28&SPRACHE=DE (accessed 29/11/13).

Ethical Approval

The project design was submitted to the Data Protection Officer at the Legal Department of the University of Bremen. Written certification was obtained stating that there are no data protection concerns relating to the project. The Legal Department/Data Protection Officer did not feel the project needed to be submitted separately to the Ethics Commission.

Peer Review

Not commissioned; externally Peer Reviewed.

Conflicts of Interest

None declared.

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