Integrative/collaborative Medicine – Philosophical Underpinnings

So I did it again, signed up for the next module with the Northern College of Acupuncture on my journey to earning an MSc in Advanced Complimentary Medicine.

For this module I think I will use this blog to reflect on my learning so that when it comes to ‘reflective diary time’ all my work will already be done.

It looks like this module is building on the last. The first reflection they are asking me to make is: –

  1. What is my research topic?
  2. How might I go about researching this?
  3. What is my choice of paradigm and methodology?
  4. How would I approach this research topic with a different paradigm?

My research topic is related to how clients perceive the intervention of hypnotherapy and acupuncture used concomitantly, how they perceive their problem and the outcome. I want to know about their lived experience of the problem and the intervention.

It follows on then that my world view is constructivist, interpretative, I’m a relativist. Ontologically there is no reality apart from the reality perceived from an individual view point. Therefore, epistemogically then, how can we obtain knowledge about it if it doesn’t exist, let alone – methodologically measure it?  I have to say I sway towards the critical realist stance that this cannot be taken out of the context of society. It depends on the culture we are born into as to our world view. I recognise that there is a power factor here too, we are not all equal, some models/societies/ disciplines/research approaches/genders dominate over others.

To get back to my research interests, I will go about finding out about my clients’ experience from a qualitative angle, research-in-action, practitioner as researcher. I will inevitably affect the outcome, all experience is subjective, we cannot measure it out of the context of society, so I don’t need to control for that. My clinic will be my case study, I will be my case study, field notes, observation and unstructured interviews will be my methods of data collection.

If I was approaching this from a positivist angle I would need to control for everything, my question would be based on efficacy – is hypnoacupuncture more effective than usual treatment for headache for example. I would need a large number of participants and the control group would need to be matched to the intervention group. I would need to remove all possible variables which might confound the outcome, remove the person from society, maybe get robots to do the treatment to control for the therapeutic relationship, I’m getting sarcastic now!

Maybe my approach will change over the course of this module, watch this space for learning outcome one – I need to refine and focus my research question even further in light of new knowledge.

Next up on the e-learning is to read Howick (2013) paper on Placebo Use in the United Kingdom and then make the following notes:-

  1. Is this coming from a positivist or interpretivist approach? Positivist. A survey of GP’s in the UK regarding placebo usage, utilising statistical analysis to interpret the data.
  2. What assumptions do the authors appear to have made in terms of the nature of the knowledge they wish to gain? Assumptions are made about what constitutes a placebo. Can a placebo be so easily defined, if it works then is it really a placebo since it has had a therapeutic outcome. For example, if positive suggestion is a placebo most practitioners use this in all consultations, it is taught as basic communication skills. If positive suggestion is purely placebo then so is hypnotherapy. Practitioners are asked to categorise their complex consultations in a tick box exercise with no room for the complexities of individual consultations. Assumptions are made that the GP’s can remember all their consultations, some doing over 100 in a week – impossible.

What is gained or lost from the picture based on the approach and methodology taken? The patient perspective is missing, this is all about the GP and their practice. How does the patient feel about being given a placebo, what does the patient perceive as a placebo. Given antibiotics for a sore throat may be a welcome gesture when nothing else has worked.

I’m not sure how useful an exercise this was and what it contributes to future practice, the outcome in terms of improving practice was not discussed. Also the GP perspective is lost, there is no room for discussion, one box must be ticked and it might not quite fit!

 

Next mandatory guided activity: –

Slide 19

 

Look at the words in the blue boxes. Spend about 20 minutes thinking and making notes about how EBM and patient-centred medicine might approach them. Take into consideration the following:

  • What differences and similarities are apparent?
  • Why do you think these differences exist?
  • How does either approach affect the patient?
  • What parallels can you see with these approaches when looking at your discipline?

I need to pick one or two words and discuss them on the forum.

I can’t help thinking that there is a word missing ‘NURSE’

The nurse bridges the gap between EBM and PCM. The nurse treats the whole person, the individual in front of them, equipped with the knowledge of current guidelines in the area of concern. The nurse involves and educates the patient so that they can achieve an effective and informed decision about their care. The nurse in the ‘bridge’.

The distinction between EBM and PCM is power. There is a power struggle between the two approaches EBM is the dominant medical, illness/doctor orientated approach, PCM is the ‘soft’, may I say feminine, approach, with lower status due t this, like the distinction between quantitative an qualitative research. PCM represents the patient, how they feel and experience the illness. The nurse bridges the gap.

Some patients want to be told what to do and trust the medical practitioner implicitly to put their best interests at heart, they hand over power to the practitioner. If this person is asked their opinion and give treatment options to consider they are at risk of thinking the practitioner is not sure what to do. To use the other extreme as an example, the other patient may want to know all the options and be treated as an equal in the decision making, they respect the practitioner’s skill and knowledge but also have a voice of their own which  they know how to use!

There is a conceptual  bridge too and it is not difficult to see, it is called informed consent. It is a negotiation between practitioner and  individual patient utilising knowledge of current best practice with the aim of positive outcome for the patient. If litigation is a worrying aspect to patient choice of treatment, as long as it is documented (and signed) that the patient has had all options available explained and offered and has chosen to opt out then the clinician is covered.

My two words I choose are NHS and litigation. Practitioners in the NHS have to be guided by the evidence for fear of litigation. It is when the patient chooses to diverge from the NHS when treatment has failed that they receive truly patient centred care. They choose to pay for ‘care’ on sometimes anecdotal evidence since the so called, dominant, positivist approach to EBM has failed them. Sometimes it is ‘care’ that they require, not medicine. If this is classed as placebo but it works for the patient is it ethically wrong?

My practice is evidence based but patient centred, without the patient there is no practice!

On to the next quest:-

Spend 30 – 60 minutes reading and collecting your thoughts on the Anderson (1999) paper A Case Study in Integrative Medicine: Alternative Theories and the Language of Biomedicine.

Ths is case study about  patient with back pain that did not respond to conventional approach to treatment. 6 alternative practitioners examined, diagnosed and offered a management plan from their philosophical stance on the problem.

Consider the following:

  • What challenges does this paper highlight in a collaborative setting? 

The main problem is language and discourse and power. Each discipline has a different philosophical approach to the illness/patient. This particular case study did not appear to be patient centred at all, they all seemed to adopt the dominant medical model discourse to describe and label the problem.

  • How is language used here to express or share power in this example?

It appears the practitioners naturally used the dominant medical language and approach without conscious thought. Showing how powerful the culture of medicine can be. There was definitely a hierarchy with the patient at the bottom, having treatment prescribed without dialogue with the patient on her views and understanding of the problem and treatment options.

  • How do you think this impacts the patient?

This seriously impacts on the patient as she was treated as an inanimate, unthinking subject to be discussed and not involved at all in her treatment plan. There was no social context discussed, how was the illness impacting on her life, were there any psychological reasons for her hanging on to the pain, maybe there were advantages to be had from this – no-one discussed or considered that aspect it was viewed from the  narrow medical angle alone.

So far so good, now I have to go on the forum and discuss my thoughts, not too confident at sticking my neck out just yet!
Attended the video conference and it was fine, I did have to think and speak out as there were only 2 students and 3 tutors – private tuition, brilliant. Great module so far, lets hope it continues.

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