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KTH Flashback: Patients, Doctors & the Elephant in the Room

Posted May 10 2013 10:15am

Originally posted March 30, 2009

Over the years, our practice has become increasingly specialized. Of course we continue to provide general dental services, but a large portion of our practice is made up of people with chronic illnesses and dysfunction, who want to see what role their dental and oral conditions might be playing in their health. When we first talk with these clients, we often hear stories about years spent seeing physicians and other practitioners while never gaining any insight to – let alone relief from – their myriad health problems. Some describe being told, ultimately, that their problems must be “all in their head.” Those who have dared to ask about possible “alternative” therapies have typically received withering looks or quick brush-offs about “quack medicine” – actions that both silence the individual and may be a cover-up for the fact that the practitioner just doesn’t know enough about “complementary and alternative medicine” (CAM) to have an intelligent or useful discussion about it with their patients.

The latter is suggested by a study recently published in the Annals of Family Medicine, “‘They Don’t Ask Me So I Don’t Tell Them’: Patient-Clinician Communication About Traditional, Complementary, and Alternative Medicine (TM/CAM). While the researchers found that most patients “did not expect clinicians to be experts on TM/CAM, beyond having broad awareness,”

We found that many clinicians believed their own understanding of the TM/CAM practices their patients were using was insufficient to be able to discuss the practices intelligently or to provide scientifically based medical advice to their patients should the topic come up. This perceived lack of understanding appeared to act as a barrier to the clinician in initiating discussions about TM/CAM.

While some of the medical professionals who participated in the study did describe making efforts to discuss TM/CAM with their patients, more seemed to leave the matter up to the patients – and then presumed that because patients seldom brought up the subject, few of them actually used TM/CAM in any way.

The main reason for patient reticence, the study notes, is fear of non-acceptance or judgment by their providers.

Patients’ perceptions of how their clinicians would react to their use of TM/CAM were generally the most important factor in their openness to discussions with the clinician about this topic. An accepting and nonjudgmental attitude by the clinician contributed to willingness by the patient to reveal use of TM/CAM. Many patients told stories about previous experiences during which they felt rebuked by a clinician for using TM/CAM; others avoided the discussion out of fear that the clinician would respond negatively.

[Patient] When my little boy was born, I used to give him herbs for his stomach aches. And I used to come in for his well-child check-up and I wouldn’t tell [the doctor] because…I’d be like, “she’ll get madder.” So I don’t tell them that I use herbs on the kids.

[Interviewer] And what makes you think the doctor would get mad?

[Patient] Well, when I had my first little girl they did get mad at me. They told me that I’m not supposed to give them anything for the colic.

While this study focused on care in clinics in primarily Hispanic and Native American communities, the results jibe with what we consistently hear from incoming biological clients at our practice, regardless of ethnicity, gender, class or other category. And it’s troubling. For when there are such barriers to communication,

  1. Patients and practitioners may remain ignorant of the whole array of treatment options at their disposal.
  2. Patients may find themselves at risk of negative interactions between drugs given by their doctor and homeopathic, herbal or nutritional supplements and medications they have chosen to take on their own.
  3. Negative response on the part of the practitioner practically ensures that the patient will be less forthcoming about all the actions they are taking to maintain or improve their health.
  4. Trust between practitioner and patient is eroded.

Thus, we nod in agreement with the study authors’ conclusion:

We believe that clinicians must initiate this discussion, yet in so doing they do not have to be experts in TM/CAM therapies; they simply need to show nonjudgmental interest and candor regarding limited knowledge. Such an approach was preliminarily confirmed during our video vignette process, but this model will require rigorous investigation with actual patients and clinicians. Open and nonjudgmental questioning is consistent with patient-centeredness theory, which is intended to facilitate eliciting the patient’s perspective, understanding the patient, acting in a manner consistent with patients’ values, and involving patients in medical decision making. As well, patient disclosure of TM/CAM is correlated with having a physician with a participatory decision-making style.


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