Volume 97, Issue 1, October 2014, Pages 135–139
Reflective Practice
Integrating family medicine and complementary medicine in cancer care: A cross-cultural perspective ☆
Abstract
In
this paper, we describe the case study of a 27 year-old Arab female
patient receiving palliative care for advanced breast cancer who was
referred to complementary medicine (CM) consultation provided within a
conventional oncology department. We explore the impact of the
integrative CM practitioners’ team of three family physicians and one
Chinese medicine practitioner on the patient's well-being and
specifically on the alleviation of her debilitating hot flashes and
insomnia. This quality of life improvement is also affirmed by comparing
the Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself
Concerns and Well-being (MYCAW) questionnaires administered at the
initial and follow-up assessment sessions. In conclusion, we suggest
that family physicians trained in evidence-based complementary medicine
are optimal integrators of holistic patient-centered supportive care.
The inclusion of trained CM practitioners in a multi-disciplinary
integrative team may enhance the bio-psycho-social-spiritual
perspective, and provide additional practical therapies that improve the
quality of life of patients confronting cancer.
Keywords
- Doctor–patient communication;
- Supportive care;
- Family medicine;
- Integrative medicine;
- Complementary Alternative Medicine;
- Cross-cultural
1. Exposure to integrative oncology training
In
October 2012, two of the authors, Jamal and Erez, joined a 270-h
integrative oncology training program designed for family physicians
interested in acquiring complementary medicine-based supportive care
skills. Jamal, an Arab-Muslim family physician directing a palliative
care unit, and Erez, a Jewish family physician working in a semi-urban
community clinic, had recently joined the weekly 5-h training sessions
offered by the integrative oncology program (IOP) operated within an
oncology outpatient facility of the largest health maintenance
organization in northern Israel.
The
IOP, established in 2008 with the aim of improving the quality of life
(QOL) of patients receiving chemotherapy within the conventional
oncological care setting, offers its services free of charge to patients
referred by the oncology service providers (oncologist, nurse, or
psycho-oncologist) with specific QOL concerns [1].
The IOP director is also a family physician in charge of a
multi-disciplinary team of 17 physicians and paramedical practitioners
with dual training in complementary medicine (CM) and conventional care
(nurses, social worker, physiotherapist, occupational therapist, and a
dietary consultant) as well as CM practitioners who completed an
integrative oncology training program.
Jamal
and Erez participated in an IOP training program designed for
specialists in family medicine who choose to focus their continuing
medical education (5 weekly hours) in a specialized clinic which
integrates CM within cancer supportive care. Prior to joining the IOP
training, family physicians need to have concluded a 26-h introductory
course on CM offered by several academic institutions in Israel (e.g.
family medicine residency programs and CME courses) [2].
The two-year IOP training program objectives include gaining knowledge
of CM efficacy and safety in cancer supportive care, acquiring practical
therapeutic skills (e.g. acupressure for nausea relief) and adopting
attitudes in favor of a non-judgmental evidence-based approach.
Throughout the entire training program, clinical and psychotherapeutic
supervision is provided by the IOP director and psycho-oncologist.
The
training program took place early on Tuesday mornings, starting with a
clinical staff meeting in which Jamal and Erez, the two male family
physicians, met with Eran, the IOP director (also male), and Pesi, a
traditional female Chinese practitioner who recently joined the team as
part of her specialized training in integrative oncology, which is a
mandatory prerequisite for CM practitioners who wish to join the IOP
team.
2. Shadya, in between hot flashes and breast cancer pain
Shadya,
a 27-year-old married woman and mother of 5, was diagnosed with breast
cancer following a diagnostic work-up initiated by her family physician.
One year prior to cancer diagnosis, Shadya felt engorgement in her left
breast and attributed it to milk accumulation although she was not
lactating at the time. Several months later she consulted her family
physician, who referred her to a breast care clinic. Left breast
invasive ductal cancer was diagnosed at stage III T3N2MO. Further
diagnostic workup suggested liver metastases. Shadya's oncologist
prescribed palliative chemotherapy with docetaxel once every two weeks
with the aim of minimizing local breast pain and attenuating disease
progression. Shadya was referred to IOP consultation by her
psycho-oncologist who assessed a need for integrative supportive care.
Scheduling
an appointment with Shadya was no simple task. Shadya and Walid, her
husband who had recently emigrated from Jordan, lived in a rural Arab
community in northern Israel and spoke only rudimentary Hebrew. Based on
the integrative team's prior experience with barriers to integrative
care provision among patients with cancer from the Arab community,
Arabic-speaking Jamal initiated a phone call to Shadya and scheduled an
appointment for the following Tuesday.
Shadya
and Walid arrived at the meeting 50 min late, leaving only 10 min to
conduct a brief assessment of Shadya's well-being and concerns. Shadya
told Jamal and Eran that for the last 3 years she had felt that her
breast was congested, but had attributed it to lactation (even though
she was not nursing). Following the cancer diagnosis, she was advised by
relatives to change her diet by increasing salads and lemon juice and
using edible capsules containing the herb Arum Palestinum, considered in traditional Arab medicine as an anti-cancer remedy. Based on the ESAS [3] questionnaire, Jamal and Eran assessed significant insomnia, anxiety, dyspnea, pain, fatigue and nausea (see Fig. 1). When asked to write down the two most serious concerns she would like the physicians to help her with (MYCAW questionnaire) [4], Shadya rated headaches and hot flashes with the maximum severity score of 6 out of 6 (see Fig. 2).
The very short initial meeting concluded with traditional-Arab medicine
oriented recommendations regarding herbs and nutrition aimed at
improving Shadya's QOL and a 15-min acupuncture treatment conducted by
the IOP in Shadya's oncologist's office. Although she was unfamiliar
with this kind of treatment, Shadya felt a sense of safe containment in
the room which enabled her to close her eyes and relax.
- Fig. 1.
Comparison of Shadya's quality of life self-assessments (based on the ESAS questionnaire). Edmonton Symptom Assessment Scale questionnaire, which was validated in several oncology settings, has good internal consistency and correlates appropriately with corresponding QOL questionnaire measures [18]. A score of 0 reflects the best condition and 10 reflects the worst.
- Fig. 2.
Comparison of Shadya's self-assessment of concerns (based on the MYCAW questionnaire). Measure Yourself Concerns and Wellbeing questionnaire was validated in a supportive cancer care setting that includes complementary therapies [4]. A score of 0 refers to the concern not bothering the patient at all, and 6 indicates the concern greatly bothering the patient.
Next
to this initial integrative oncology assessment, Shadya's oncologist
diagnosed breast tumor and liver metastasis progression. The oncologist
switched the chemotherapy to Letrozole and LHRH agonist which yielded,
over the next 3 months, only a partial response. Parallel to the
oncologist's surveillance, Shadya and Walid scheduled weekly to biweekly
sessions with the integrative team. During the next 4 months, Erez and
Pesi joined Jamal and Eran in the provision of integrative treatment
aimed at improving Shadya's well-being and addressing her growing
emotional and spiritual concerns. During the 5 initial sessions, the
integrative treatment goals focused on improving Shadya's headaches,
breast pain, hot flashes, insomnia, fatigue, and to some extent, her
anxiety (see Table 1
summarizing treatment goals and modalities along the initial 6-week
period). The oncologist's decision to switch from chemotherapy with
docetaxel to hormonal therapy resulted in an increase in Shadya's hot
flashes and re-prioritized the integrative treatment goals aiming to
alleviate its severity, duration, frequency, and impact on sleep and
emotional distress. The integrative treatment included acupuncture, an
herbal supplement (Cimicifuga racemosa) and dietary and herbal
consultation oriented toward traditional Islamic medicine. Shadya
reported a significant improvement in her headaches following the
acupuncture treatments but no improvement in the severity of the hot
flashes and insomnia. The unsuccessful treatment of these symptoms
influenced the integrative practitioners to change the therapeutic
setting. With Shadya's consent, Walid was invited into the room and
asked if he was willing to participate in the therapy process. He was
instructed by Erez to apply gentle acupressure on Shadya's legs by
mirroring the physicians’ manual application, which he could carry on
doing at home. At the same time, Pesi inserted acupuncture needles and
instructed Shadya through guided imagery which was simultaneously
translated by Jamal, who modified the text with Arabic metaphors and
idioms that resound better with the young Muslim patient. A metaphor of
cooling air emitted from a ventilator was suggested. The acupressure
applied by Erez and Walid on the feet was supplemented by a gentle touch
applied by Pesi on Shadya's chest. Nine days later Shadya and Walid
entered the room with broad smiles and reported a daily practice of the
“breathing and imagining a cooling ventilator” at home and acupressure
occasionally provided by Walid. Interim assessment revealed significant
improvement of the two leading concerns on MYCAW scales (headaches: from
6 to 1; hot flashes: from 6 to 2) as well as improvement of anxiety,
insomnia, dyspnea, and fatigue on ESAS questionnaires. Nevertheless,
breast pain emerged as the new leading concern, a pain that was regarded
by Shadya as a “marker” for the progression of her disease. During the
next sessions, Shadya expressed her deepest fear of “losing my five
children” who had been transferred temporarily to the care of two foster
families in her village. Pesi, Erez, and Jamal decided to modify the
acupuncture/acupressure and guided imagery modalities, adding a
recommendation to complement the daily practice of guided imagery at
home with writing a journal of her thoughts and fears. As time
progressed, Shadya felt less left breast pain and the CT scan confirmed a
partial response to the treatment. The oncologist was asked, as part of
the integrative treatment impact assessment, to fill in a 4-item
questionnaire. On the first question, relating to overall symptom
severity change during the time in which the patient received
integrative care, the oncologist scored the change as +2 meaning
moderate improvement [the scale ranges from −3 (significant worsening)
to 0 (no change) and +3 (significant improvement)]. The second question
asked Shadya's [female] oncologist to assess the integrative treatment's
contribution to her ability to treat the patient (score varies from
1 = very slight to 7 = very much). Relating to Shadya's integrative
care, the oncologist scored this contribution as 5 on a 7-point scale.
An identical score of 5 on a 7-point scale was also assessed concerning
the oncologist's satisfaction with her communication with the
integrative physician. Finally, on the fourth question, the oncologist
stated that she would recommend to her colleagues that they refer other
patients with similar clinical status to integrative medicine treatment.
- Table 1. Treatment modalities provided to Shadya along the initial 6 weeks following the 1st assessment.
- * Clinical outcome is graded by the degree of improvement: H, high; M, moderate; L, low; NC, no change.
Shadya's
personal journal had gradually increased in volume and her husband
continued driving her the long distance from their village to the
oncology center in Haifa, eager for the next appointment. Shadya and
Walid continued the integrative treatment and attended 7 more
appointments during the next 4 months. At that time, tumor progression
was diagnosed based on tumor marker elevation and CT-scan findings.
Following her oncologist's recommendation, Shadya received one
chemotherapy cycle with Fluorouracil, Leucovorin, and Vinorelbine but
then decided to seek palliative care at another medical center near her
village.
3. On being a family physician in an integrative oncology setting
Contemplating Shadya's journey may take us along different paths and perspectives. Prima facie,
the story is about a young patient encountering a life-threatening
illness who is referred by her oncology care provider to receive
complementary medicine treatment offered within a conventional oncology
center. But our story is more than a complexity of patient's and
therapists’ narratives, and calls for a wider perspective. Although the
setting of care is different from family medicine's conventional
practice, Erez, Jamal, and Eran met Shadya and her husband as three
family physicians dually trained, or being trained, in complementary
medicine-oriented supportive cancer care. The unique family medicine
training, which includes a bio-psycho-social-spiritual orientation,
communication skills, and a non-judgmental attitude toward the patient's
health beliefs, enabled the three to approach the patient and her
caregiving husband in this remarkable integrative oncology setting. The
self-acknowledgment of their limitations in providing efficacious
treatment to Shadya also enabled the three family practitioners to work
together with Pesi, the non-MD Chinese medicine practitioner, in a form
of intimate multi-disciplinary teamwork that took place in the same
room. This four-member integrative team faced not only Shadya's concerns
of headaches and hot flashes but also the deepest levels of existential
fear of death and the imminent threat of separation from her husband
and five young children. The lack of uniformity within the four-member
team (in age, gender, cultural-religious affiliation, and training in
conventional and complementary medicine) facilitated a better
recognition of the barriers to the treatment and contributed to their
seeking, and ultimately finding, an innovative strategy to overcome
these obstacles. The challenge of improving Shadya's hot flashes best
illustrates the advantage of this multi-approach team. At first, the
team approached this specific concern by suggesting the use of Cimicifuga racemosa herbal capsules, based on preliminary research on their efficacy, tolerability and safety in breast cancer patients [5], [6] and [7].
This recommendation was also considered appropriate based on Shadya's
affiliation with traditional herbal medicine which was supplemented with
recommended use of local herbs recognized in the Arab community.
Unfortunately, this evidence-based and culturally oriented approach did
not relieve Shadya's hot flashes, first induced by the chemotherapy and
later on by the hormone treatment she received. At that time, the team
approached the unrelieved concern with a second line of integrative
treatment. The preference of acupuncture to relieve Shadya's vasomotor
and sleep disturbances was again supported by evidence-based research [8] and [9]
but was also based on Shadya's experience of headache alleviation
following acupuncture. Acupuncture was now targeted to improve the
bothersome hot flashes and consequent insomnia. Where the herbs did not
work, the acupuncture needles seemed to induce quality of life
enhancement. This progression was further augmented by guided imagery,
another CM modality studied in patients with breast cancer experiencing
vasomotor symptoms [10] and [11].
However, healing and palliation were not merely limited to the
evidence-based arena but also derived from integration of therapeutic
modalities and personnel with diverse backgrounds. The needle insertion
performed by Pesi was combined with guided imagery translated by Jamal
into Shadya's explicit and symbolic vocabulary, while Erez instructed
her husband in acupressure techniques. The cultural barriers we
witnessed with Shadya and her husband were bridged not only by language
translation competence but also by the ability of the entire
practitioners’ team to attune the treatment dynamics to the health
belief models of the patient and her care providers, One of the outcomes
of this process was evident when Pesi recommended that Shadya write a
reflective diary. Indeed, Shadya's diary, although unrevealed to us or
to her husband, may be regarded as another therapeutic modality to
facilitate patients’ awareness and expression, as reported by Bolton in
research titled “Writing is a way of saying things I can’t say” focusing
on explorative writing by cancer patients receiving palliative care [12].
We
suggest that effective elements of integrative treatments include
synergism of evidence-based complementary medicine modalities, a
patient-centered bio-psycho-socio-cultural-spiritual approach, and
effective communication among the multi-disciplinary team of care
providers (see Table 2
specifying approaches practiced by the medical team to overcome
treatment barriers). In Shadya's case, the desired synergism was
apparently achieved by the non-specific effects of the integrative
treatment (care providers’ empathy, therapeutic rapport based on
cross-cultural aspects, the spouse's involvement in acupressure
treatment at home) as well as specific effects (acupuncture, massage and
guided imagery). The acupressure/massage technique which Erez taught
Walid, Shadya's husband, illustrates the complexity of integrative
intervention. On the one hand, literally as well as metaphorically,
efficacy of caregivers’ instruction in massage and touch therapy is
evidence-based and may improve cancer patients’ satisfaction, quality of
life, and quality of caregiver-patient relationship [13].
On the other hand, the outcome of the Erez–Walid interaction may also
be regarded in a gender-cultural perspective wherein two males, Erez and
Walid, represent an active “doing” pole (instructing massage), while
the two females, Shadya and Pesi, represent a more “being” pole (guided
imagery and relaxation). Nevertheless, the complexity of different
therapeutic modalities does not necessarily imply synergism, but may
also lead to a potentially inhibitory effect. Further research is needed
to clarify how different integrative oncology modalities interact,
especially concerning patient-tailored treatment. We experienced the integration
process as a non-judgmental domain where Shadya's presence met our own
inter-disciplinary dialog, encouraging us toward open-mindedness and
mindfulness. Based on our experience, we suggest that CM integration in
cancer care, as well as in other fields of medicine, is not limited only
to issues of efficacy and safety but also to those issues that center
holism in medicine: the ability to explore the complexity of our
patients’ body-mind-spirit and health-belief narratives in
asocial/cultural context, to communicate with patients as well as with
practitioners of diversified training, and to use self-reflection for
mindful practice. Thus, it is not surprising that family practitioners
and general practitioners have led a large number of ongoing integrative
oncology initiatives in the US, UK, Israel and other countries [14], [15], [16] and [17].
Indeed, family medicine training accompanied by a daily requisite for a
patient-centered perspective in the primary care clinic enables family
physicians to approach integrative challenges with optimal skills and
attitudes. We suggest further research to delve more deeply into the
potential role of family physicians as optimal integrators who can bind
CM and supportive care domains through open discourse among patients, CM
practitioners and oncology care providers.
- Table 2. Approaches practiced by the medical team to overcome barriers.
Barrier Approach practiced by the medical team Geographical distance Sessions were scheduled every 10 days instead of weekly. The team insisted on the need for regular and frequent visits. In addition, we suggested modalities that could be practiced at home (herbs, nutrition, guided imagery, journaling, and massage). Cross-cultural barriers:
I. Arab patient in a Jewish- dominant clinical setting
II. Unfamiliarity with Western-oriented integrative modalities
III. Gender-related aspects (e.g. legitimacy of touching a young female Arab patient)
IV. Time gap perceptionsInclusion of an Arab physician who called and invited the patient for initial assessment and provide care as part of the 4-member team; Inclusion of traditional Arab medicine (herbs and nutrition) in the integrative treatment; Step-by-step introduction of unfamiliar modalities (beginning with herbs, then acupuncture and touch, and only then guided imagery); Respecting gender-sensitive issues by assuring the presence of a female practitioner and Shadya's spouse; The multi-diverse background (e.g. religion, gender, age, experience) among the practitioners’ team, as well as the multiple approaches attempted, enabled better bonding and consequently increased the patient's adherence to treatment; The team needed to recognize potential cultural time-gap barriers and to address, at least in the initial session, the need for scheduling flexibility. Potential gap between patient's and providers’ expectations The patient's and caregiver's expectations and concerns are re-assessed in each session. Treatment goals are then co-formulated with the practitioners’ team regarding QOL and disease progression. Another potential expectation gap concerns patient's and providers’ definition of treatment “success”. With Shadya, we integrated multiple-CM modality approaches that might provide both short- and long-term effects. In cases where one modality had modest or no effect (e.g. the herb cimicifuga), we could “increase” the intensity of the parallel modality (e.g. acupuncture) and introduce an additional modality (e.g. guided imagery provided at the time the acupuncture needles are inserted). Caregiver and familial concerns We applied a bio-psycho-social-spiritual approach that views treatment goals as patient- as well as family-centered. Participation of the husband in treatment was envisioned in the context of his own empowerment and need for “doing” and caring. Patient's reluctance to reveal emotional-spiritual concerns This barrier may be culture-related as well as characterizing patients who expect practitioners to focus primarily on “bio-physical” concerns. With Shadya, we did focus initially on these concerns but as treatment and trust developed, we were able to relate to her deeper spiritual and existential concerns.
Conflict of interest
All
authors declare having no conflicts of interest. Furthermore, no
financial and material support was granted for the research. We confirm
all patient/personal identifiers have been removed or disguised so the
patient(s)/person(s) described are not identifiable nor can they be
identified through the details of the story.
References
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