Missing Options for the Healthcare Consumer

Here's my research paper from last semester's English Research Writing class.  

Susan Fullmer

Professor Dan Wilber

Eng 102

7 May 2015

Missing Options for the Healthcare Consumer:

Are Allopathic Health Care Providers and Complementary Alternative Medicine Providers

Part of the Same Discourse Community?

Introduction

According to Bruce Herzberg, an English professor at Bentley College, “Discourse operates within conventions defined by communities. . .  academic English now uses the notion of ‘discourse communities’ to signify a cluster of ideas:  that language use in a group is a form of social behavior, that discourse is a means of maintaining and extending the group’s knowledge and of initiating new members into the group, and that discourse is epistemic or constitutive of the group’s knowledge.” (Herzberg 1).  A linguistics professor at The University of Michigan, John Swales, uses Herzberg’s definition to produce several intriguing questions.  He states, “It points us towards asking how a particular discourse community uses its discoursal conventions to initiate new members or how the discourse of another reifies particular values or beliefs. . . how do we recognize such communities in the first place?” (Swales 218).

In considering these definitions of discourse communities I have focused my attention on health care practitioners from two different healthcare systems.  The first is the allopathic, or western, medical system, which is most used in the United States.  The second is the complementary alternative medicine (CAM) form of healthcare that is practiced worldwide and has a growing usage in the United States.

What is CAM?

CAM is a health care system and philosophy that many western medical professionals do not consider mainstream or even credible.  Some CAM treatments have been studied using the rigours of conventional medical testing and have been shown to be safe and effective such as massage, osteopathy and chiropractic.  On the other end of that spectrum are lesser studied alternative therapies that are also widely used such as acupuncture, herbal medicines, homeopathy, healing crystals, and Reiki and other body energy modalities (Stoneman 1).    

John Swales talks about six defining characteristics that are necessary to identify a group of individuals as a discourse community.  I will focus on his second characteristic which is as follows:  A discourse community has mechanisms of intercommunication among its members.  He points out that the participatory mechanisms will vary according to the community meetings, telecommunications, correspondence, newsletters, conversations and so forth.  But this criteria produces a negative answer to the case of “The Cafe Owner Problem”, an example of a particular discourse community.  This group occupies the same professional roles and interact with the same clientele, they respond to the same kind of messages for the same purposes and they have similar skills.  Yet, as cafe owners working long hours in their own establishments, they never interact with one another.  Do they form a discourse community?  Though they may share similar traits can they be a community if they neither admit to nor recognize that such a community exists?  Can others assign community membership to them if they see them as such, for example, their patrons? (Swales page 221)  Could this example be applied to healthcare providers from two medical traditions who may not acknowledge their own membership in a common discourse community?  And what if other individuals such as their patients see them as one group?  Does that then make all providers of healthcare members of one discourse community?  And if they are seen by others as being part of the same community, would there be benefits if the providers knew and acknowledged this?  My goal in this paper is to explore the possible existence of a discourse community whose members would consist of allopathic practitioners and CAM practitioners.

Literature Review

I looked at journals that are mainstream to both healthcare traditions when searching for information about my subject and also to specifically look for conversations between the members of this possible discourse community.  For the allopathic side of the conversation I wanted to be sure to include the Journal of the American Medical Association (JAMA), which has the largest circulation of any weekly medical journal in the world for western medicine.  Consequently, I searched the widely read Journal of Alternative and Complementary Medicine, among other peer reviewed journals about CAM.  I familiarized myself with definitions of discourse communities by reading Bruce Herzberg and John Swales.

Methods

While researching this paper I considered John Swales’ six characteristics that define a group of individuals as a discourse community.  I focused on the second characteristic which states, “A discourse community has mechanisms of intercommunication among its members” (Swales 221).  Using articles from peer reviewed journals, I did a rhetorical analysis of case studies regarding the use of CAM in the United States and around the world.  I also observed what, if any, conversations are happening between medical providers from both western and alternative health care.  Among other sources, I looked specifically at journals from both health care systems such as The Journal of American Medical Association (allopathic) and The Journal of Alternative and Complementary Medicine (CAM).

Findings

Are People Using CAM?

In order to understand the possibility of this common discourse community of healthcare providers, we must first understand the growing use of complementary alternative medicine.  The article, “Integrating Traditional Practices into Allopathic Medicine” reports that there has been an increased use in CAM in developed nations over the last several decades.  An estimated 80% of people in Africa and Asia successfully use primary medical care for what in the United States is considered “alternative medicine” (Guan 1) .  Though critics of CAM might like to attribute these remedies to “snake-oil and quackery,” the fact is that they are routinely prescribed in modern healthcare systems around the world.  This includes some publicly funded healthcare programs such as the National Health Service in the United Kingdom. (Stoneman page 1)

Why Do People Use CAM?

When researchers first started looking at the reasons why people used CAM they assumed they were dissatisfied with conventional medicine.  A famous and groundbreaking study in 1998 from the Journal of The American Medical Association called, “Why Patients Use Alternative Medicine” started with this hypothesis.  On the contrary, what they found is that people were generally pleased with their health care but sought CAM for a variety of other reasons.  One of these reasons was a shifting paradigm of the importance of a spiritual factor in health.  Many people said they sought CAM because it better aligned with their philosophy of holistic health - the health of body, mind, and spirit.  They reported that they wanted their health practitioners to have the same kind of health care philosophy (Astin 1, 9).  Swales noted that communities reifies the particular values and beliefs of it’s members.  As patients seek health care providers that support and reflect their own holistic health beliefs, it seems that some find them from both western and alternative traditions.

The article, “The Economic Evaluation of Complementary and Alternative Medicine:  The growing importance of including naturopathic doctors in health care reform” also found that patients are finding alternative health care more congruent with their values, beliefs and philosophical feelings towards health and life.  Additionally, their research showed that patients find CAM therapies when conventional medicine cannot cure their chronic medical conditions.  It also showed that they seek health care alternatives when western medicine and pharmaceuticals become too expensive.  The researchers point out that as CAM use increases, so does interest in its cost-effectiveness and how it would compare with allopathic medicine.  They state that there have been published research studies that do indicate that CAM may have a cost-savings aspect due to components such as inexpensive treatments, lower technology interventions, and emphasis on preventative measures which can dramatically decrease healthcare costs over the lifetime of the consumer (Tais 1, 6).  

This paradigm shift towards a system that focuses on wellness and prevention for which CAM exceeds was discussed by the CHP Group in their published work, “Complementary and Alternative Medicine:  Integrating Evidence-Based and Cost-Effective CAM Into the Health Care System.”  They cite that current health care costs are astronomical and that chronic conditions such as diabetes and hypertension are a large part of that cost.  They continue by saying that many chronic conditions are preventable and even reversible but instead a growing number of Americans are choosing to ignore the obvious benefits and healthy lifestyle choices and are turning instead to pharmaceuticals to “fix” the problem.  The article points out that CAM’s focus is on prevention, wellness, and positive lifestyle changes.  CAM has great success in treating chronic conditions and is cost effective, therefore should play a major role in health care (The CHP Group page 3).  Are details such as “treatments” and “cost saving measures” similar between western and CAM traditions?  If not, would that make a big enough difference to exclude them from a common discourse community as discussed by Swales?     

Who uses CAM?

Western medicine therapies follow a strict requisite of evidential standards based on randomized controlled trials.  But do some users of alternative therapies tend to accept the idea that the lack of this scientific approach does not undermine the use of some of the more controversial CAM treatments?  Researchers in the United Kingdom wanted to know which of these two viewpoints reflects that of the general public.  The writers’ intention was to investigate public use of and beliefs about the efficacy of the prominent and controversial CAM therapy, homeopathy.  They wanted to know if there is a sub-group who are at ease in combining support for science and conventional medicine with the use of CAM treatments (Stoneman 1).

Their results suggest that over 40% of the British public maintain positive evaluations of both homeopathy and conventional medicine together.  From this information they suggest that the simultaneous support for controversial CAM treatments and conventional medicine can, in part, be explained by a lack of scientific knowledge but also may be attributed to concerns about the regulation of medical research.  The researchers note that some CAM users report a growing distaste for conventional medicine, which is overly-dependent on the synthetic, pharmacological remedies.  They argue that CAM treatments can be used with great effect (Stoneman 5).

This controversy led to a recent UK Parliamentary Select Committee recommendation that homeopathy should not be funded, and regulatory licenses allowing homeopathic products to be sold as medicines should be withdrawn.  Again, their reasoning is that there is little to no evidence to support the contention that homeopathy can be used as a safe and effective treatment, let alone a replacement for a conventional treatment.  These sentiments are strongly voiced within the prominent public and scientific discourse community, but what about the general public (Stoneman 1)?

In this study the following questions were used to determine the public's opinion of science and conventional medicine.  1. What is your belief in the importance of science in the core educational curriculum of all young people?  2.  Do you have faith in science’s ability to improve human health and longevity through technological innovation?  3.  Do you have a positive orientation toward the primary “face” and first port of call within the conventional medical system?  They did find some support for the idea that CAM users are associated with a lack of scientific knowledge, but mostly this was attributed to a group of people that did not believe in both conventional and alternative therapies.  Their analyses confirmed that a large proportion of the general public have used CAM treatments at some time in their lives. This of course reinforces conventional medical arguments that the public health is negatively affected by this wide spread use of untested CAM treatments.  Conversely, only one third of the population sided with the “conventional” orientation that expresses optimism and trust in western medicine and science while rejecting alternative medicine.  However, the largest sub-group identified was characterised by those that support both conventional medicine and science along with CAM as well as the efficacy of homeopathy (Stoneman 2, 5).  

Given that western medicine has a foundation of empirical evidenced based practice, could they be considered members of the same health care discourse community, as a system that seemingly does not use the same standards for all its treatments?  If CAM funded similar experiments to the lesser studied alternative treatments would they show conclusive evidence of their efficacy?  Would this lead to a more inclusive membership, including both health care systems according to western practitioners?  

Are There Negative Outcomes from a Divided Health Care Community?

What happens when a potential discourse community is divided or its members do not acknowledge the entire group?  Can this cause harm?  One unfortunate outcome from the intersection of patients desiring CAM and their western providers who either will not speak about it or are not educated enough to speak about it, is discussed in the article, “Integrating Traditional Practices into Allopathic Medicine.”  It states that patients in this situation tend to self prescribe without their allopathic practitioner’s knowledge or consent.  It is estimated that one in three Americans fall into this category.  Their studies show that if a conversation about CAM is started it is usually by the patient.  Unfortunately the patient often does not have the medical understanding to know all the proper questions to ask in these situations.  An example of a negative outcome from this scenario would be a dangerous drug-herb interaction due to the mixing of incompatible herbs and pharmaceuticals. (Guan 1,2).  It behooves the conventional practitioner to initiate these questions and conversations, yet they do not.  

Robbie had been feeling anxious to the point that he was concerned that it was affecting his ability to focus at work and school.  He finally decided to see if his allopathic doctor could help with the situation.  His doctor said there was certainly something that could be done and promptly prescribed Xanax which is a common pharmacological treatment for panic and anxiety disorders.  What his doctor did not mention was that Xanax is a very addictive drug.  After some time Robbie realized that he was unable to stop taking the medication.  He worked for a year to wean himself off of the Xanax.  Perhaps because this treatment is effective for symptoms but is not curative, his anxiety is still a problem. (Robbie)

Besides neglecting to educate Robbie on the addictive properties of the prescribed medication, the western medical provider made another serious omission during that initial discussion on anxiety.  He neglected to mention complementary alternative medicine (CAM).  Had he been given those options Robbie may have been told about current therapies such as meditation, massage, yoga, acupuncture, a plant named Kava, and a  variety of relaxation techniques.  According to the Anxiety and Depression Association of America, these have been proven to have a great success rate in the treatment of anxiety, and they are non invasive and non addictive. (Complementary and Alternative Treatment 1)

What benefits would there be from a united community of western and CAM practitioners?  If practitioners from both traditions acknowledged themselves to be on the same team, would this help unify the medical care offered in the United States?  It is important to remember that each health care system has its own strengths and weaknesses.  While CAM is known for its preventative focus, western medicine exceeds in emergent situations such as urgent care or the acute need for surgery.  However, what happens when those strengths and weakness are not considered or even known?  What are the ramifications of the absence of conversation between CAM and western medicine, and could this be inconvenient or even dangerous to the patient?

Swales brings up interesting thoughts about discourse communities, such as how they are defined and how we recognize them in the first place.  I particularly liked “The Cafe Owner Problem.”  It immediately reminded me of healthcare professionals from all forms of medical care.  They occupy the same professional roles (health care providers) and interact with the same clientele (patients).  They also respond to the same kind of messages for the same purposes and they have similar skills (to promote healing).  Yet, just like the cafe owners, many of the health care providers from these two forms of medicine don’t seem to talk to each other very much.  This is evident from the lack of CAM included in healthcare and insurance coverage currently offered the United States.  During my research I did find a gradual conversation emerging since the 1990s.  For example, I searched for CAM related articles in the Journal of the American Medical Association (JAMA).  JAMA is published by The American Medical Association, which was founded in 1847 and is the largest association of allopathic physicians in the United States.   

Stated in the article from JAMA, “Integrative Medicine and Systemic Outcomes Research Issues in the Emergence of a New Model for Primary Health Care,” “Clinicians and researchers are increasingly using the term integrative medicine to refer to the merging of complementary and alternative medicine (CAM) with conventional biomedicine. . . integrative medicine represents a higher-order system of systems of care that emphasizes wellness and healing of the entire person (bio-psycho-socio-spiritual dimensions) as primary goals, drawing on both conventional and CAM approaches in the context of a supportive and effective physician-patient relationship” (Bell 1).  The article goes on to define terms for better explaining this new medical model of integration.  But I found these types of articles in JAMA to be few.  My overall impression is that the conversation is taking place between these two healthcare styles, but it is not a loud or well known conversation.  

Conclusion

Can western medical providers and alternative medical providers be part of the same group even if they have little or no interaction?  I believe the answer is yes, all health care practitioners are from the same discourse community.  The answer must be yes when we consider this question through the rhetorical lens of John Swales’ definition as he asks, “how [does] a particular discourse community use its discoursal conventions to initiate new members or how [does] the discourse of another reifies particular values or beliefs. . . how do we recognize such communities in the first place?” (Swales 218).  This affirmative answer is especially clear when we consider the example of the cafe owners discourse community.  Regardless of the actual conversation or acknowledgement between allopathic practitioners and alternative medicine practitioners, I believe they are all part of the same discourse community.

My research has brought up questions that warrant future study.  For example, the need to look at integrative approaches to health care issues such as treatments and cost saving measures.  Could these things be improved with a united effort by all in health care?  Also, if some of the lesser studied CAM remedies were funded for empirical evidenced based research would they have positive outcomes and thereby be accepted by allopathic medicine?  And finally and perhaps most importantly, what are the possible ramifications of the absence of CAM in healthcare?  Would this eliminate healthcare consumer’s choices that could be helpful or even critical for their good health?

Works Cited

Astin, J. "Why Patients Use Alternative Medicine." JAMA: The Journal of the American Medical Association 280.19 (1998): 1659-a-661. Web.

Bell, I. R. "Integrative Medicine and Systemic Outcomes Research: Issues in the Emergence of a New Model for Primary Health Care." JAMA Internal Medicine 162.2 (2002): 133-40. Web.

"Complementary and Alternative Medicine Integrating Evidence-Based and Cost-Effective CAM Into the Health Care System." The CHP Group. The CHP Group, 2010. Web. 27 Feb. 2015.

"Complementary and Alternative Treatment." Anxiety and Depression Association of America, ADAA. N.p., n.d. Web. 06 Apr. 2015.

Guan, Amy, and Chen (Amy) Chen. "Integrating Traditional Practices into Allopathic Medicine." The Journal of Global Health (2014): n. pag.Www.ghjournal.org. Web. 10 Feb. 2015.

Herzberg, Bruce. 1986. The politics of discourse communities.  Paper presented at the CCC Convention, New Orleans, La, March, 1986.

Robbie (assumed name to protect his identity), personal interview conducted by author, Feb. 2015.

Stoneman, Paul, Patrick Sturgis, Nick Allum, and Elissa Sibley. "Incommensurable Worldviews? Is Public Use of Complementary and Alternative Medicines Incompatible with Support for Science and Conventional Medicine?" Ed. Margaret Sampson. PLoS ONE 8.1 (2013): E53174. Web.

Swales, John. “The Concept of Discourse Community.” Genre Analysis: English in Academic and Research Settings. Boston: Cambridge UP, 1990. 21-32. Print

Tais, Setareh, and Erica Zoberg. "The Economic Evaluation of Complementary and Alternative Medicine The Growing Importance of including Naturopathic Doctors in Healthcare Reform." Natural Medicine Journal 5.2 (2013): n. pag. Web.