Demographics
Forty-five percent of the study participants were conventional health care providers (
n = 274), including oncology doctors (
n = 32), family physicians (
n = 124) and nurses (
n = 118). Half of the oncologists reported that they were male, and the majority of the family physicians, nurses, acupuncturists, massage therapists and reflexologists/zone therapists were female (Table
2).
Table 2
Sex according to profession
Oncology doctor | 32 | (5.3) | 7 | (21.9) | 16 | (50.0) | 9 | (28.1) |
Family physician | 124 | (20.5) | 63 | (50.8) | 56 | (45.2) | 5 | (4.0) |
Nurse | 118 | (19.5) | 70 | (59.3) | 0 | (0.0) | 48 | (40.7) |
Conventional health care provider with dual training | 1 | (0.2) | 1 | (100) | 0 | (0.0) | 0 | (0.0) |
Acupuncturist | 212 | (35.0) | 126 | (59.4) | 30 | (14.2) | 56 | (26.4) |
Massage therapist | 128 | (21.1) | 75 | (58.6) | 17 | (13.3) | 36 | (28.1) |
Reflexologist/zonetherapist | 42 | (6.9) | 29 | (69.0) | 3 | (7.1) | 10 | (23.8) |
Forty-seven individuals had dual training in conventional health care and complementary therapy (Table
3). More than half of the respondents (52%) were complementary therapists (
n = 316). They were trained as acupuncturists (
n = 212), massage therapists (
n = 128) and reflexologists/zone-therapists (
n = 42). The majority of the complementary therapy participants were trained in several modalities, so the reported numbers exceed the total number of participants in each provider group.
Table 3
Characteristics of the participants (n = 606)a
Age, years | 0.003b
|
Mean age | 439 | (48.2) | 133 | (45.5) | 52 | (50.4) | 28 | (50.7) | 226 | (48.9) | |
Level of education | <0.0001d
|
Compulsory | 2 | (0.4) | | (0.0) | | (0.0) | | (0.0) | 2 | (0.8) | |
Middle level | 45 | (9.6) | | (0.0) | | (0.0) | | (0.0) | 45 | (18.5) | |
University up to 4 years | 143 | (30.4) | | (0.0) | 28 | (50.0) | 14 | (45.2) | 101 | (41.6) | |
University more than 4 years/PhD | 280 | (59.6) | 140 | (100) | 28 | (50.0) | 17 | (54.8) | 95 | (39.1) | |
Professiona
| |
Oncology doctor | 32 | (16.2) | 32 | (100) | | | | | | | |
Family physician | 124 | (59.6) | 121 | (97.6) | | | 3 | (2.4) | | | |
Nurse | 118 | (41.5) | | | 91 | (100) | 27 | (93.1) | | | |
Conventional health care provider with dual training | 1 | (0.6) | | | | | 1 | (100) | | | |
Acupuncturist | 212 | (57.5) | | (0.0) | | (0.0) | 38 | (17.9) | 174 | (82.0) | |
Massage therapist | 128 | (46.7) | | (0.0) | | (0.0) | 9 | (75.0) | 119 | (73.0) | |
Reflexologist/zonetherapist | 42 | (22.5) | | (80.0) | | (0.0) | 3 | (7.1) | 36 | (92.8) | |
Clinical practice | <0.0001d
|
Full time health provider | 287 | (71.9) | 121 | (89.0) | 38 | (77.6) | 18 | (72.0) | 110 | (58.2) | |
Part time health provider | 92 | (23.1) | 11 | (8.1) | 10 | (20.4) | 5 | (20.0) | 66 | (34.9) | |
Other (students or retired persons) | 20 | (5.0) | 4 | (2.9) | 1 | (2.0) | 2 | (8.0) | 13 | (6.9) | |
Patient visits per week | <0.0001c
|
1–19 patients | 132 | (33.9) | 11 | (8.3) | 27 | (57.4) | 4 | (16.0) | 90 | (48.6) | |
20–39 patients | 121 | (31.1) | 28 | (21.2) | 17 | (36.2) | 5 | (20.0) | 71 | (38.4) | |
40 or more patients | 136 | (35.0) | 93 | (70.5) | 3 | (6.4) | 16 | (64.0) | 24 | (13.0) | |
Cancer patient visits per week | <0.0001d
|
1–19 cancer patients | 362 | (92.1) | 126 | (92.6) | 31 | (64.6) | 23 | (92.0) | 182 | (98.9) | |
20 and more patients | 31 | (7.9) | 10 | (7.4) | 17 | (35.4) | 2 | (8.0) | 2 | (1.1) | |
Location | 0.004c
|
Rural area | 119 | (29.9) | 57 | (41.9) | 7 | (14.6) | 3 | (12.0) | 52 | (27.5) | |
Small city, village (up to 50,000 inhabitants) | 153 | (38.4) | 44 | (32.4) | 23 | (47.9) | 12 | (48.0) | 74 | (39.2) | |
Large city (>50,000 inhabitants) | 126 | 31.7) | 35 | (25.7) | 18 | (37.5) | 10 | (40.0) | 63 | (33.3) | |
A significant difference was found between the provider groups in age, with medical doctors and complementary therapists being, on average, younger than the other groups (p = 0.003). A significant difference was also found between the groups regarding education. More than four years of education was reported by 100% of the medical doctors, 55% of the primary health care providers with dual training, and 50% of the nurses, compared to only 39% of the complementary therapists (p < 0.0001).
The majority of the medical doctors and nurses worked full time (89% and 78%, respectively). These numbers were significantly greater than those for the complementary therapists; 58% worked full time, while 35% worked part time (p < 0.0001).
Seventy percent of the medical doctors and 64% of the conventional health care providers with dual training had 40 or more patient visits per week, compared to only 13% of the complementary therapists and 6% of the nurses (p < 0.0001). More than 90% of the medical doctors, providers with dual training and the complementary therapists had between 1 and 19 cancer patient visits per week; by comparison, 35% of the nurses had 20 or more cancer patient visits (p < 0.0001).
The largest proportion of medical doctors (42%) practiced in rural areas. The largest proportion of nurses (48%), providers with dual training (48%) and complementary therapists (39%) worked in small towns (p = 0.004).
Communication with cancer patients about treatments
Overall, the communication of health care providers with their cancer patients about treatment modalities followed provider specialty. Responses to the questions were frequently distributed in two opposite ends of the scales, with conventional providers on one end and the providers with dual training and the complementary therapists on the other end (Table
4).
Table 4
Communication with patients (n = 606)a
How often do you ask your cancer patients it they use CT? | .000c
|
Never | 53 | (13.3) | 29 | (21.0) | 9 | (15.8) | 1 | (4.0) | 14 | (7.8) | |
Sometimes | 152 | (38.0) | 84 | (60.9) | 33 | (57.9) | 6 | (24.0) | 29 | (16.1) | |
Often/always | 195 | (48.8) | 25 | (18.1) | 15 | (26.4) | 18 | (72.0) | 137 | (76.1) | |
How often do you ask your patients about what outcome they expect from CT? | .000c
|
Never | 36 | (8.9) | 23 | (16.9) | 4 | (7.1) | 1 | (3.8) | 8 | (4.3) | |
Sometimes | 148 | (36.5) | 71 | (52.2) | 34 | (60.7) | 8 | (30.8) | 35 | (18.7) | |
Often/Always | 221 | (54.6) | 42 | (30.9) | 18 | (32.2) | 17 | (65.3) | 144 | (77.0) | |
Do your cancer patients expect the following outcomes from CT? | |
cure the cancer | 131 | (21.7) | 86 | (57.0) | 35 | (38.5) | 1 | (2.1) | 9 | (2.8) | .000b
|
slow the progression of cancer | 174 | (28.8) | 92 | (60.9) | 40 | (44,0) | 3 | (6.4) | 39 | (12.3) | .000b
|
strengthen the immune system | 243 | (40.2) | 71 | (47.0) | 37 | (40.7) | 19 | (40.4) | 116 | (37.7) | .209b
|
symptoms relief | 274 | (45.3) | 80 | (53.0) | 32 | (35.2) | 22 | (46.8) | 140 | (44.3) | .057b
|
reduce adverse effects of chemo therapy | 236 | (39.0) | 58 | (38.4) | 27 | (29.7) | 22 | (46.8) | 129 | (40.8) | .172b
|
improve physical and emotional well being | 272 | (45.0) | 65 | (43.0) | 28 | (30.8) | 22 | (46.8) | 157 | (49.7) | .014b
|
provide hope and a sense of control | 171 | (28.3) | 59 | (39.1) | 29 | (31.9) | 11 | (23.4) | 72 | (22.8) | .002b
|
I do not ask my patients about this | 23 | (3.8) | 13 | (8.6) | 3 | (3.3) | 0 | (0.0) | 7 | (2.2) | .006c
|
How do you advice your cancer patients if they ask you about CT? | .000c
|
Discourage use | 14 | (3.6) | 10 | (7.4) | 2 | (3.6) | 0 | (0.0) | 2 | (1.1) | |
Encourage use | 100 | (25.6) | 3 | (2.2) | 4 | (7.3) | 11 | (42.3) | 82 | (47.1) | |
Neither | 177 | (45.4) | 81 | (60.0) | 30 | (54.5) | 10 | (38.5) | 56 | (32.2) | |
Other | 99 | (25.4) | 41 | (30.3) | 19 | (34.5) | 5 | (19.2) | 34 | (19.5) | |
How do you advise your cancer patients if they ask you about conventional treatment? | .002c
|
Discourage use | 2 | (0.5) | 0 | (0.0) | 0 | (0.0) | 0 | (0.0) | 2 | (1.1) | |
Encourage use | 309 | (78.2) | 117 | (86.7) | 42 | (77.8) | 21 | (84.0) | 129 | (71.3) | |
Neither | 46 | (11.6) | 5 | (3.7) | 6 | (11.1) | 4 | (16.0) | 31 | (17.1) | |
Other | 38 | (9.6) | 13 | (9.6) | 6 | (11.1) | 0 | (0.0) | 19 | (10.5) | |
Only 18% of the medical doctors and 26% of the nurses asked their cancer patients
often/always if they used complementary therapies, while 76% of the complementary providers and 72% of the providers with dual training asked
often/always (
p < 0.0001) (Table
4). Thirty-one percent of the medical doctors and 32% of the nurses
often/always asked their patients about what outcome they expected from complementary therapies. Significantly more of the providers with dual training (65%) and the complementary therapists (77%)
often/always asked about this (
p < 0.0001).
The contrast was striking between conventional providers and complementary therapists in the outcomes they believed their patients expected from complementary therapy. The majority of medical doctors believed that curing the cancer (57%) and slowing the progression of cancer (61%) were outcomes patients expected from complementary therapies, while, respectively, less than 3% and 7% of providers with dual training and 3% and 13% of complementary therapists believed that (p < 0.0001). Fewer between-group differences were found in patients’ expecting a stronger immune system, where less than half of each group thought patients expected this, and symptom relief, where between a third and a half of providers believed patients expected this. Similarly, about 40% of each group thought reducing the adverse effects of chemo therapy was expected by patients using complementary therapies. More complementary therapists and providers with dual training reported that improved physical and emotional wellbeing was an outcome expected by patients using complementary therapies than did providers with conventional training (p = 0.014). In contrast, more conventional providers (39% of medical doctors and 32% of nurses) thought patients using complementary therapies expected these therapies to provide hope and a sense of control, compared with only 23% of dual trained providers and complementary therapists (p = 0.002).
A total of 157 participants responded to an open-ended question about what else might improve communications between conventional health care providers and complementary therapists. Of these were (n = 27) medical doctors, (n = 8) nurses, (n = 17) providers with dual training and (n = 106) complementary therapists. One complementary therapist added:
Occasionally strengthening the immune system, but it depends on whether the aim is to strengthen the patient’s immune system. This must be discussed with the oncologist. All patients [visiting my clinic] are informed that acupuncture can NOT heal the cancer itself (CT therapist).
A medical doctor added:
I don’t have cancer patients who use complementary therapies (MD).
If patients asked for advice about complementary therapies, most medical doctors and nurses neither encouraged nor discouraged its use (60% and 54%, respectively) (Table
4). In contrast, when asked by patients about complementary therapy use, providers with dual training and complementary therapists tended to encourage their patients to use complementary therapies (42% and 47%, respectively (
p < 0.0001). Seventy-eight percent of
all participants encouraged their patients to use conventional cancer treatment when asked, though dual providers and complementary therapists were somewhat more likely to neither encourage nor discourage use (
p = 0.002).
Difficulties in provider-patient communication
Only 16% of the medical doctors and 18% of the nurses were
very comfortable answering questions about complementary therapies, compared to 60% of the providers with dual training and 71% of the complementary therapists (
p < 0.0001) (Table
5). The majority of the medical doctors, nurses and providers with dual training were
very comfortable answering their patients’ questions about conventional cancer treatment (55%, 70% and 50%, respectively), compared to only 34% of the complementary providers (
p < 0.0001).
Table 5
Difficulties in provider-patient communication (n = 606)a
How comfortable are you to answer question about CT? | .000b
|
Not at all | 32 | (6.9) | 16 | (11.3) | 8 | (11.8) | 1 | (3.3) | 7 | (3.2) | |
Moderately | 219 | (47.4) | 103 | (72.5) | 48 | (70.6) | 11 | (36.7) | 57 | (25.7) | |
Very | 211 | (45.7) | 23 | (16.2) | 12 | (17.6) | 18 | (60.0) | 158 | (71.2) | |
How comfortable are you to answer question about conventional cancer treatment? | .000b
|
Not at all | 34 | (7.4) | 4 | (2.8) | 1 | (1.4) | 1 | (3.3) | 28 | (12.7) | |
Moderately | 210 | (45.5) | 60 | (42.0) | 20 | (29.0) | 14 | (46.7) | 116 | (52.7) | |
Very | 218 | (47.2) | 79 | (55.2) | 48 | (69.6) | 15 | (50.0) | 76 | (34.5) | |
How difficult do you find patients using CT? | .000b
|
Not at all | 250 | (63.3) | 52 | (38.5) | 33 | (57.9) | 20 | (80.0) | 145 | (81.5) | |
Moderately | 137 | (34.7) | 81 | (60.0) | 24 | (42.1) | 4 | (16.0) | 28 | (15.7) | |
Very | 8 | (2.0) | 2 | (1.5) | 0 | (0.0) | 1 | (4.0) | 5 | (2.8) | |
How difficult do you find patients using conventional medicine? | .000b
|
Not at all | 318 | (79.1) | 83 | (62.9) | 44 | (78.6) | 21 | (84.0) | 170 | (91.9) | |
Moderately | 75 | (18.8) | 48 | (36.4) | 12 | (21.4) | 3 | (12.0) | 12 | (6.5) | |
Very | 5 | (1.3) | 1 | (0.8) | 0 | (0.0) | 1 | (4.0) | 3 | (1.6) | |
Thirty-nine percent of the medical doctors found patients’ use of complementary therapies not at all difficult, compared to 58% of the nurses. More than 80% of the providers with dual training and complementary therapists found this not at all difficult.
Medical doctors (n = 41), nurses (n = 19), providers with dual training (n = 5) and complementary therapists (n = 34) wrote additional comments. Several of the medical doctors expressed that it depended entirely on the modality their patients wanted to use. One added:
My advice depends on my knowledge and experience with the modality of my patient’s choice (MD).
Moreover:
I recommend conventional treatment, and if they want to use complementary therapies in addition, they should discuss this with the specialist health service (MD).
Several added comments like this:
I advise them to consider the cost-benefit and adverse effects carefully (MD).
Some nurses (n = 6) and complementary therapists (n = 7) wrote that they advised the patients to talk with their conventional health care provider. For example, one said:
I strongly recommend that they consult their oncologists and follow their advice! (Nurse).
Several medical doctors had a positive attitude toward patient use of complementary modalities, but they qualified their advice with negative connotations. They stated:
If harmless, I support their choice (MD).
If they don’t get fleeced for money and feel that it helps, it’s OK (MD).
I’m open to anything that works, and, as long as it’s not outrageous, go ahead! (MD).
The nurses and providers with dual training supported the patients regardless of their choice:
I listen to them, explain the effect they experience and take it further from there (Physician with dual training).
Moreover, several wrote:
I support my patients whatever they choose (Nurse).
While the majority of providers in each group found their patients use of conventional medicine not at all difficult, slightly fewer of the medical doctors (63%) and nurses (79%) reported this acceptance than did providers with dual training (84%) and complementary therapists (92%) (p < 0.0001). Medical doctors (n = 30), nurses (n = 12) and complementary therapists (n = 36) wrote additional comments that illuminated the quantitative responses. Medical doctors (n = 17) discussed the pros and cons of conventional cancer treatment with their patients. They wrote statements like:
It depends entirely on the cancer type. If the cancer isn’t curable, I often recommend forgoing conventional therapy, as adverse effects are often worse than living with the disease (MD).
A nurse added:
I inform and explain about conventional cancer treatment, why it is recommended and support the choice they make (Nurse).
Some complementary therapists responded:
I recommend that they talk to at least two different oncologists, ask about the effects and adverse effects and what they can expect from the treatment and recommend that they follow the oncologists’ advice (CT).
I don’t give advice regarding conventional cancer treatment, but tell them to talk with their family physician (CT).
Actions that would improve communication between conventional and complementary health care providers
Respondents were queried about five different actions that could improve communications among health care providers. In general, complementary therapists and dual trained providers were the most supportive of these, with nurses and medical doctors less enthusiastic about the actions. Offering complementary providers training in conventional methods as a way to improve communication was supported by a greater proportion of providers with dual training (94%) and complementary therapists (93%) than conventional providers (medical doctors 68%, nurses 88%) (
p < 0.0001) (Table
6). Similarly, providers with dual training and complementary therapists showed greater support for providing complementary therapy training to conventional providers than did medical doctors and nurses (
p < 0.0001). Similar results were found for the use of common medical terminology (
p < 0.0001). While only about half of the medical doctors (55%) supported including complementary therapists in conventional practice and vice versa, the majority of the nurses (85%), providers with dual training (100%) and complementary therapists (99%) supported this (
p < 0.0001). When we asked what else could improve communication between conventional and complementary providers, several medical doctors added:
Table 6
Actions that would improve communication between conventional and complementary health care providers (n = 606)a
Conventional training for CT providers | .000c
|
Yes | 380 | (84.6) | 95 | (68.3) | 56 | (87.5) | 29 | (93.5) | 200 | (93.0) | |
No | 69 | (15.4) | 44 | (31.7) | 8 | (12.5) | 2 | (6.5) | 15 | (7.0) | |
CT training for conventional providers | .000c
|
Yes | 387 | (86.2) | 97 | (69.8) | 56 | (84.8) | 31 | (100) | 203 | (95.3) | |
No | 62 | (13.8) | 42 | (30.2) | 10 | (15.2) | 0 | (0.0) | 10 | (4.7) | |
Use of common medical terminology | .000b
|
Yes | 365 | (81.3) | 93 | (67.4) | 52 | (78.8) | 27 | (87.1) | 193 | (90.2) | |
No | 84 | (18.7) | 45 | (32.6) | 14 | (21.2) | 4 | (12.9) | 21 | (9.8) | |
Including a CT provider in conventional practice | .000c
|
Yes | 375 | (83.3) | 75 | (54.7) | 57 | (85.1) | 31 | (100) | 212 | (98.6) | |
No | 75 | (16.7) | 62 | (45.3) | 10 | (14.9) | 0 | (0.0) | 3 | (1.4) | |
Including a conventional provider in CT practice | .000c
|
Yes | 360 | (80.7) | 76 | (55.5) | 50 | (76.9) | 29 | (96.7) | 205 | (95.8) | |
No | 86 | (19.3) | 61 | (44.5) | 15 | (23.1) | 1 | (3.3) | 9 | (4.2) | |
Acceptance, respect and more research (MD).
Complementary therapists must have an understanding of the cause of disease that is compatible with “conventional medicine”(MD).
Complementary therapists must also realize their limitations (MD).
Evidence-based research/guidelines on complementary therapies (nurse and MD).
One of them disagreed:
Cannot see the need. We have different perspectives of the world (MD).
Several encouraged the providers to be more tolerant:
Listen to and hold each other accountable (MD).
Improve knowledge about each other’s fields. Lower the brick wall and ease the war atmosphere (MD).
When we asked for other steps that may improve communication between different health care providers, the participants added that education and cooperation may improve communication.
Acupuncturists with bachelor’s degrees can communicate better with other health personnel due to training in Western medicine (CT).
Mutual workshops, networks and seminars (provider with dual training).
Mutual assessments of the patients’ own experience with complementary therapies (MD and nurse).
Fruitful dialogue and good information both ways (providers with dual training).