A total of 14 interviews (7 with female GPs) were conducted. They took place at the GPs practice or via videoconference, depending on participants’ preferences, and lasted between 31 and 65 min (mean: 49 min). The mean age of the participants was 47.5 (Range: 38–60). Seven GPs practiced in the canton of Vaud, four in the canton of Fribourg and three in the canton of Neuchâtel. The analysis of the interviews generated four main themes: perceptions of CM; recommending CM; discussing CM during the consultation; and needs for the future.
Perceptions of CM
What is CM?
Participants underlined that the term CM encompassed a wide variety of therapies that are more or less recognized or evidence-based, and mostly unfamiliar to them.
“The problem is that well, I don’t know all the complementary medicine methods. Most of the time I have no idea.” (GP 2).
All expressed uncertainty regarding how to define CM and whether a given modality should be considered conventional, complementary, or outside these two categories (notably approaches considered “esoteric” or pseudoscientific). Some CM, like osteopathy, meditation or hypnosis, were considered almost conventional by some GPs, in the sense that they would easily or commonly recommend them to their patients or consider doing so. Some herbal medicine treatments, that are reimbursed by the mandatory health insurance, were also often considered conventional medicine.
“Then there are perhaps some [modalities] that are [considered CM] without my knowing it, because it’s true that everything that has to do with relaxation, meditation, sophrology, yoga, I don’t know if it’s a [complementary] medicine (…) these are things that appeal to me a little more (…) because common sense tells me that I want to believe in it, and I find that it’s the continuation of my medicine. They’re not that complementary.” (GP 10).
When asked how they would define CM, participants mostly mentioned elements that defined what it is not: not reimbursed by the mandatory health insurance, not taught in medical schools, not practiced by the GPs themselves. As one participant put it:
“I don’t have a very precise or exhaustive definition. I’d say perhaps a little naively (…) something that’s not part of conventional, usual medicine. But what is really complementary? Is it a decision from health insurances to include [CM] or not [in their reimbursement plans]? Or is it more of a clinical decision? Do we expect a certain degree of validation or not? And then, there’s what I’m used to prescribe or practice, and then there’s what I’m also not familiar with, and which, by definition, I don’t practice, I don’t prescribe (…). Anyway, I don’t think I have a clear picture of these possible definitions, which may exist somewhere.” (GP 8).
Openness towards CM
All but one participant spontaneously expressed being open to CM in general to a certain degree. Their attitude ranged from explicit enthusiasm to cautious support of patients’ preferences. Most GPS observed that many patients commonly use CM and that these should therefore be taken into consideration, despite their own opinion towards a particular CM.
“It’s a reality brought to us by the patients. We realize that it’s widely used, that many patients find it beneficial, if you like. So, we can’t ignore this reality.” (GP 6).
In general, participants considered CM as a useful complement to conventional medicine as it may provide alternative tools and approaches to care, thus broadening the range of treatments available to patients.
“Sometimes you have to experiment with a lot of things until the patient finds what suits him/her. And that’s why I think it’s good that there are quite a few different ways of approaching certain problems and several different types of medicine, because there are some that suit some people and others that suit others.” (GP 4).
Only one GP expressed clear reservations regarding CM. These reservations were mainly directed towards a perceived tendency to treat all CM on equal terms, although some are sustained by scientific evidence, while others are not.
“(…) I have a fair amount of reservations (…) because I have the impression that there’s a movement going on now where if you’re not open to complementary medicine (…) you’re seen as a retrograde. Whereas I, who am certainly far too Cartesian, believe in what works, in what has been scientifically proven, if possible, even if by far not everything in my allopathic medicine has been scientifically proven. (…) So there you have it, I’ve got a problem with that, that these medicines are considered to be different, so they’re treated differently. Maybe the traditional scientific approach doesn’t apply to them, but I find that there is now a kind of tolerance which (…) I don’t like.” (GP 10).
Skepticism of CM
Almost all GPs also expressed skepticism towards CM to a greater or lesser extent. This skepticism was either related to specific therapies or to CM therapists’ behaviors considered as problematic by GPs. When related to specific therapies, skepticism was primarily directed towards lesser-known CM, those that lacked scientific evidence or were not perceived as plausible.
“I’m a bit blocked when it comes to things that are a bit too esoteric or things like that. When things get a bit too far out of hand. I need to have my feet firmly on the ground.” (GP 4).
Concerns were raised regarding the insufficient training and tendency of some therapists to overstep their competencies.
“For me, that’s perhaps the biggest pitfall of complementary medicine: there are quite a few therapists who know no limits. And in my profession, I try to really respect my limits. And I’m quite struck by the fact that some therapists have no limits. (…). So, what I’m trying to say is that (…) my fear is that they go beyond the spectrum of their skills. I think they really do have skills, but they should stop at those skills.” (GP 11).
Influence of GPs’ own beliefs and experiences
GPs acknowledged that their personal beliefs and experiences had an influence on their perception of CM, whether positive or negative. For example, having personally tested a particular therapy impacted GPs’ perceptions of that therapy.
“I think a lot of it is personal experience. As a child and young adult, before I started my studies, I was treated with homeopathy, and it didn’t work at all. I was treated with acupuncture and that helped a lot. I’ve never been treated with essential oils, but for me they’re based on plants, so I think that’s fine. So I think that quite a lot of my opinions are based on my personal experiences.” (GP 4).
Similarly, some GPs underlined that they did not need to precisely understand the mechanism of this or that CM as long as it made some sense to them or at least appealed to them to some extent, as explained by one GP who was asked why he would recommend osteopathy more often than other CM.
“Maybe because I understand [osteopathy] a bit more, because it seems more mechanical, more physical, closer to what I do, and to the way we’ve learnt to reason. It makes more sense to me. Maybe that’s why I’m going to recommend it more. I think that’s it. It appeals to me more. And I get the impression that the training is a bit clearer, that it’s more validated than others I know less about. (…) Acupuncture also requires training, it can also lead to certification and so on. Obviously. But I’m a bit less familiar with it. Maybe I don’t know as much about it.” (GP 1).
Recommending CM
In practice, the extent to which GPs actually recommended CM to their patients varied greatly between participants. Herbal medicine, osteopathy or acupuncture was commonly recommended by most GPs to some extent. However, for other CM, usage varied from merely discussing CM in the consultation to regularly recommending a variety of different CM. GPs’ behaviors in this context were influenced by different elements.
Reasons for recommending CM
Indications to use CM differed between GPs depending on which CM they were familiar with, if any. Some CM were used as first line treatments, mainly in patients presenting with benign to mild ailments (e.g., stress, anxiety, common colds, respiratory tract infections). This was particularly the case for herbal medicine, although others were also cited, such as shiatsu and yoga.
“So yes, I’m quite keen on using that [herbal medicine]. Moreover, when the disorder isn’t severe enough. Typically for sleep disorders, a classic example, rather than prescribing benzo[diazepine], whose long-term consequences we know, I’ll suggest herbal medicine instead. And then see with the patients whether it works or not but at least give them a trial period.” (GP 9).
A few participants considered that CM may be an interesting option for minor conditions in cases where patients are reluctant to use conventional treatments or when they want to leave the consultation with a prescription.
Other most cited reasons for recommending CM included chronic conditions, such as chronic pain, and functional disorders. In these cases, CM was often used as a second line treatment or as a last resort when everything else has failed.
“I’m sometimes open to it [CM] in situations where I feel that my medicine has exhausted its possibilities, where people have chronic pain, ailments that we don’t understand. I say to myself “In this case, we have to get out of my own medicine because (…) there’s nothing that works. We need to change the way we look at the problem”. And that means not trying another part of my medicine but trying another medicine. (…). So here I can suggest something [a CM]. (…) But that’s it, I think about it in these situations, not directly to treat back pain or pneumonia at the first consultation.” (GP 10).
Barriers and facilitators
Participants identified several barriers and facilitators to recommending CM.
Knowledge and training
Most GPs underlined that it was easier to recommend CM for which they had at least some basic knowledge or had personally experienced.
“And that’s why I recommend osteopathy and acupuncture. Because I’ve tried it myself and got to know it.” (GP 4).
Conversely, lack of training or knowledge was considered a major barrier, as GPs were reluctant to recommend CM without being certain of their efficacy or when unsure about the indications.
“The problem is that I lack training. Because I come from a scientific background. And then you hear all sorts of things. Patients come with questions (…). And frankly, with the need to keep up to date with the latest scientific advances [in the biomedical field], I’m not yet able to do that for complementary medicine too. So sometimes I find it hard to answer questions or I find it hard to really recommend something or say ‘well, you see, scientifically it’s proven’. And that’s what I miss. (…). So I have a few notions, hypnosis for example for quitting smoking, little things like that. But because I’m not trained enough, it’s not yet part of the advice I give to people.” (GP 1).
Efficacy
Personal beliefs regarding the efficacy of CM, as well as availability of scientific evidence were cited as important reasons for recommending CM.
“[With] phytotherapy, there’s an active substance. Some of them have been studied, perhaps not like the latest [conventional] drugs from [pharmaceutical companies], but there you go. In any case, there is an active substance. In my opinion, this is not the case with homeopathy. So, this is a good example of what I believe in and use. (…) So, I believe in phytotherapy and I use it. I don’t believe in homeopathy, and I don’t use it.”. (GP 10)
Financial aspect
The financial aspect was seen as a barrier to recommending CM. Indeed, GPs did sometimes hesitate to recommend CM that are not covered by the mandatory health insurance to patients who do not have supplemental insurance.
“The weak point for osteopathy is that it is not reimbursed. And there’s a clear economic barrier for some patients. (…). So I can prescribe osteopathy, but if they don’t go for it, well, it’s not an effective treatment. So you also have to adapt a little to the patient’s environment – and, ultimately, to their financial resources and possibilities. So sometimes we say we won’t do osteo[pathy] because the patient can’t afford it.” (GP 8).
Trust
In addition, most GPs felt that they needed to be able to trust CM therapists to send them patients. GPs either trusted therapists that they personally knew, or therapists with extensive and recognized training.
“I’m of the opinion that if I recommend hypnosis, it has to be done by a psychologist who specializes in hypnosis, because you need to have some background. I mean, it’s one thing to say that you can relax a little. But to really be able to do a more substantial treatment, you need to have good training behind you.” (GP 2).
Most GPs acknowledged that they often lacked a network of trusted and adequately trained CM therapists to refer patients to.
“Sometimes there are situations where I say to myself ‘maybe complementary medicine could be an asset’, but I don’t necessarily know who to refer to. Because then, for me, the problem – unlike perhaps a specialist, a cardiologist and so on – is knowing who to refer to, whether he or she’s really good in this field or not. It’s not the same academic training either.” (GP 3).
To constitute a referral network for CM, participants mostly relied on discussions with and recommendations from other colleagues, and from their own experience of being treated with CM. Positive feedback from patients about their CM therapist could also lead GPs to recommend that therapist to other patients.
“Well, patients tell me about their experiences [with CM]. ‘I’ve been to so and so, it’s done me good’. Then I say, ‘What does this person do?’ I’m interested. (…) In particular [there is] a therapist in [town] who does a bit of hypnosis, a bit of herbal medicine and a bit of energy medicine, all mixed. And I’ve had two or three patients who’ve come back from her with real improvements. And when someone comes in for the tenth time with the same complaint, and I know it’s nothing serious, (…) I say ‘Why not?” Then I refer them. And in the end people decide whether they want to go or not. So yes, I sometimes refer people like that.” (GP 13).
Discussing CM during the consultation
Approaching the subject
When asked whether they proactively enquired about their patients’ use of CM during consultations, most GPs admitted to not systematically doing so. Among them, some preferred to enquire about the type of treatments or therapies used by their patients in general.
“I’m not asking the question specifically. I’m asking the question, but have you done other things? Have you thought about doing something different? That’s more like it, without suggesting anything. Because sometimes it comes naturally, sometimes not. I don’t approach it like that, I just approach it a little.” (GP1).
GPs also felt that it was usually their patients who brought up the subject. Some GPs acknowledged however that their patients might not necessarily have the courage to spontaneously talk about their use of CM for fear of being judged by their GP.
“It’s true that people [patients], and this is also the problem, (…) don’t always dare tell us [that they use CM]. For fear, perhaps, of our judgement. They may think we’re going to judge them or tell them it’s no good. And sometimes you can tell by the way they tell us, that they tell us a little bit as if they were at fault, when in fact that’s not the case at all.” (GP 3).
GP’s role in CM conversations
GPs reported that their patients seldom come with specific demands for CM but that they mostly recount what CM they use alongside their conventional treatment and sometimes ask for advice regarding these treatments. When patients did talk about their CM use, GPs expressed that they generally supported the initiatives taken by their patients or at least would not discourage them, in cases where they were skeptical about the type of CM used. Some highlighted the importance of supporting patients’ autonomy and choices and to be able to admit to not knowing about a particular CM.
“I’m far away from this practice of medicine where we’re all-powerful, etc., because I fundamentally believe that people, firstly, are free to make the choices they want. And secondly, they’re not my patients, they belong to themselves. So, in fact, I’m very happy when they talk to me about it spontaneously because it’s just part of things. And I’m quite happy to encourage them to go down that road, even though I always tell them that I don’t know anything about it, so I can’t give them any sound advice. On the other hand, as long as it’s the right thing for them, I’ll go for it, there’s no problem.”. (GP 9)
Nevertheless, GPs felt it was their responsibility to accompany their patients in their treatment choices while ensuring that they do not put themselves in danger medically.
“I find it really interesting when patients talk to us about it [CM], because we have our general practitioner’s perspective, plus we know people, they’re our patients, and we can say ‘OK, he’s not taking any risks, he can go’ (…). On the contrary, we tell people ‘But be careful, you have high cholesterol, you smoke, you could have a heart attack. You can’t lower your cholesterol by going to the kinesiologist’, simple things like that. So our role (…) is more to check a little whether the patient is taking risks or not by turning to complementary medicine, because often it’s the patient’s choice.” (GP 13).
GPs also sometimes tried to draw their patients’ attention to certain factors that might indicate that they are being taken advantage of, such as the costs and numbers of therapy sessions proposed by their CM therapist.
“I also try to question them a little and stimulate their critical thinking, because they’re often quite vulnerable people, I find, who go a bit left and right. Some are very solid and have one or two points of reference [for CM], but sometimes it’s also people with syndromes that are a bit mysterious, where conventional medicine doesn’t provide a precise enough answer for them. So they look for answers elsewhere, and sometimes the risk is that they get lost (…), that they waste money, energy and time. I don’t think I’m being very paternalistic in this surveillance (…)”. (GP 6)
Requests for laboratory analysis
Most GPs spontaneously evoked a specific situation where patients visit a CM therapist and then come to their GP with demands for a long list of laboratory analysis requested by their therapist. These demands were mostly considered as problematic.
“Sometimes (…) we’re asked to sign laboratory orders for endless lists of analyses that I’ve never done, even when I’ve worked in hospital, even in intensive care, we’ve never checked these things, and then they should be checked… Maybe I’m reaching the limits of my knowledge, but sometimes I think it’s all nonsense.” (GP 10,)
GPs would sometimes agree to prescribe those analyses, to maintain the therapeutic relationship with their patients or when they felt able to interpret the results themselves too. However, in most cases, these requests were dismissed as signing prescriptions with no clear purpose would engage GPs professional responsibility.
“And then, generally speaking, I accept some of the analyses, but I accept the ones I’m capable of interpreting. Because in fact, if I ask for an analysis that I’m not capable of interpreting, and that analysis is abnormal, I’m in an uncomfortable position.” (GP 11).
That same participant, along with others, also underlined GPs responsibility in controlling healthcare costs, as these analyses may be very expensive and would be reimbursed by the basic health insurance if prescribed by a physician.
“It’s also a question of health insurances. It’s the problem of our expensive healthcare system, where people know they can be reimbursed. But it’s us doctors who are the guarantors of that responsibility [of signing something, for the patient to be reimbursed]. And we are responsible for controlling healthcare costs, especially GPs.” (GP 11).
Needs for the future
The needs expressed by the participants echo the barriers and facilitators to the recommendation of CM mentioned above, notably regarding training. As stated above, most GPs felt they lacked training or information regarding CM. They also acknowledged that it would take time to try to learn more about CM, whether through training or information seeking.
“I’ve got patients who use complementary medicine quite a lot and in many situations it’s a help, it’s a plus, I think, that has its place. Now, personally, I don’t really know much about it, and I don’t really have the time or energy to go further and understand things. I don’t practice anything, I don’t have any little practice of this or that, nothing at all, apart from a little bit of herbal medicine, and then that’s really it.” (GP 7).
Training
All GPs confirmed that teachings about CM were almost absent during their pre-graduate training. However, training needs regarding CM differed between participants. Some relied on learning by experience, through discussions with colleagues, patients or CM therapists. Some contemplated getting proper training in one CM or the other (e.g., hypnosis or phytotherapy). Finally, others advocated introductory courses, in post-graduate or continuous education, that would allow GPs to have an overview of the different CM used by the population.
“We’re not all going to specialize in homeopathy or whatever, but perhaps we should have a little more basic knowledge of these different branches, just to know that they exist. And then, what can we do or achieve in terms of therapeutic results? Or what are the indications? To broaden the picture a bit, that could be very complementary to a GP’s practice.” (GP 8).
A few GPs mentioned how such training would be particularly interesting for the practice of general medicine.
“Typically, it [training in CM] seems to me to be of little interest to a cardiologist or a neurologist. For me, in general practice, we’re more concerned with supporting our patients and looking after their health in general. (…) And in health, I think that using complementary medicine can be useful. And also, because our role is really that of gatekeepers and guides, advocates and companions to our patients.” (GP 11).
Information
Needs also differed regarding information about CM. Even if they sometimes sought more information when confronted with CM unknown to them, mostly through Internet searches, GPs underlined they lacked the time to systematically look for information in these cases. Information on CM was mostly gained through colleagues and patients themselves. Most GPs identified the need for a tool that would centralize information on CM and be easily accessible. GPs wished it would contain scientific information on treatment efficacy, indications and scope of action of the different CM.
“That’s what I need. I need to know where to find information (…) that I can refer to. As for urinary tract infections, there are antibiotics, but for urinary tract infections there are also other things that work. There might be this plant or that plant and all that. And you can use it safely, knowing that it will still be effective. (…) That’s what I need. People who have terrible, raging osteoarthritis, and we know that a certain plant can also help.” (GP 1).
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