On the edges of medicine – a qualitative study on the function of complementary, alternative, and non-specific therapies in handling therapeutically indeterminate situations

Abstract

Background In routine practice, general practitioners (GPs) see many patients for whom treatment might not be necessary, or evidence-based treatments are not available, yet often a treatment is prescribed. We denote such situations as therapeutically indeterminate. We aimed to investigate 1) whether therapeutically indeterminate situations play a role in the accounts of GPs in their practical work; 2) the role of complementary and alternative medicine (CAM) modalities or non-specific therapies, and of other strategies used in handling therapeutically indeterminate situations; and 3) factors associated with preferences for specific strategies. Methods We performed semi-structured, individual face-to-face interviews with 20 purposively sampled, experienced GPs from Bavaria, Germany. A grounded theory approach was used for data analysis. Results Participants reported that therapeutically indeterminate situations recur often in their daily practice. Professionally legitimate strategies such as empathetic consultations without providing a treatment intervention did not seem to suffice for coping with all of these situations. CAM treatments were used frequently, but motives varied. While some participants were convinced that these treatments were active and effective, others were uncertain or had doubts and used them as a relational tool, as a non-specific treatment or as a beneficial placebo. Conventional drugs were also used in a non-specific manner or despite doubts regarding the risk-benefit ratio. The extent to which GPs felt responsible for offering solutions in therapeutically indeterminate situations seemed to influence their preference for specific strategies. Conclusion Our results demonstrate the important role of CAM and the somewhat smaller role of non-specific therapies for German general practitioners in dealing with therapeutically indeterminate situations. The concept of therapeutically indeterminate situations may be helpful in better understanding why many general practitioners treat patients in situations where treatment does not appear to be clearly indicated. Electronic supplementary material The online version of this article (10.1186/s12875-019-0945-4) contains supplementary material, which is available to authorized users.

How German general practitioners justify their provision of complementary and alternative medicine – a qualitative study

“…As the methods of our study have been described in detail elsewhere [15], we only give a relatively brief description below. After providing informed consent, purposefully sampled experienced GPs providing first-line primary care in Bavaria, Germany, participated in problem-oriented interviews (performed between July 2015 and December 2016).…”

“…The problem is that people are always different, that ... all science ultimately forgets the individual, and so the actual individual case. (15) Helping individual patients without doing harm Participants felt primarily committed to helping the presenting patient.…”

“…So what matters is the outcome and not necessarily knowing how it works ... we see that it works, and then I can administer it as long as it doesn't harm the patient. (15) I do have my doubts and wonder what it is that works … but then I often see these amazing reactions, and then I say, there must be something in it.…”

“…We have performed a qualitative study among experienced German GPs to better understand why they use CAM treatments as well as other professionally questionable interventions (for example, antibiotics in patients with the common cold). In an earlier article [15] we described our findings suggesting that GPs generally use such strategies to manage "therapeutically indeterminate situations". Such situations are characterized by two sets of conditions: "firstly, there is a desire for medical treatment, either by the patient or the physician, or both.…”

“…Such situations are characterized by two sets of conditions: "firstly, there is a desire for medical treatment, either by the patient or the physician, or both. Secondly, either such a treatment is not (unambiguously) necessary from a medical perspective, a professionally accepted treatment is not available, or an existing effective treatment is not acceptable to the patient" (p2 [15]). Therapeutically indeterminate situations occur frequently in patients with minor illnesses, medically unexplained symptoms, or long-lasting complaints associated with chronic diseases.…”