Charateristics of participants
A total of 20 GPs participated in the study. Ten participants were between 41 and 50 years old, five between 51 and 60 and another five between 61 and 70 years. Eight GPs were female, twelve male. Four practices were based in cities or suburbs, ten in towns and six in villages. Fourteen participants had been specialized as GPs for more than 10 years, and 18 were either the only practice owner or a joint partner. Nine had an additional qualification in at least one CAM therapy (6 acupuncture, 5 naturopathy, 5 homeopathy, 2 chirotherapy) and eight an additional qualification in emergency medicine.
While several participants considered themselves skeptical towards CAM, all prescribed at least herbal remedies in their clinical practice. Based on their general tendencies in the interview, we considered only one participant a true skeptic (i.e., generally believing that CAM treatments do not have any effects over placebo and trying to avoid such treatments as far as possible) and four as clearly convinced CAM providers (i.e., firmly believing that the CAM treatments used have specific effects). The remaining participants seemed to be highly pragmatic in their views on CAM, ranging from rather skeptical to very open.
The basis is conventional medicine - CAM is a supplementary tool
One important indirect argument made by participants legitimizing the use of CAM was that they use these treatments largely as a practical supplement when conventional medicine does not provide satisfactory solutions. Most participants (including convinced CAM providers) explicitly emphasized that conventional medicine is the basis of their clinical practice.
Complementary medicine is a very good supplement, but only up to a certain point. The core should be conventional medicine, around which other things from here and there can be used as complements. It’s a good compromise, that's how I see it. The basis is conventional medicine, to which other things can be added. (17)
Two GPs using CAM intensively and in a convinced manner in their clinical practice even stated that, for them, being competent in conventional medicine is a precondition to apply these modalities.
My thinking was I have to be able to practice conventional medicine properly in order to justify my use of other things. (11)
The limits of evidence and science in general practice
At the same time, participants reported that conventional medicine with its focus on evidence and science leaves many problems in primary care unanswered (see our article on therapeutically indeterminate situations  for details). In the following quote, a participant who originally specialized in internal medicine explained why CAM modalities are “dispensable” in specialized care but can be helpful in general practice, despite classifying himself as rather skeptical. The last phrase of the quote is also an example of how participants started to question their own positions during the interviews which addressed issues rarely discussed openly.
I’m sure that if I had a specialist practice as an internist, where you really get referrals with clear questions, complementary medicine is dispensable, or a very small niche, as in irritable bowel syndrome or whatever, or with palpitations and things like that at the cardiologist, where you might try something, but otherwise rarely. But with us [in general practice], I think, because it's such a diffuse, unsorted patient population, I find that you do actually need it. Well, right now I'm sticking my neck out in favor of complementary medicine although I told you at first that I don’t use it at all, so I’m not sure I belong in this interview any more. (13)
Participants using CAM more frequently argue that the quality of evidence in general practice is often weak.
It's just that if you go a little deeper into evidence-based medicine, you'll see that even in conventional medicine, the evidence is sometimes astonishingly thin. (03)
These participants also tend to address concerns regarding unclear or implausible mechanisms of action for CAM treatments by pointing to gaps in mechanistic knowledge in conventional medicine and the fact that current knowledge is often incomplete and sometimes falsified by new research.
It is often the case with conventional drugs, too, that one doesn’t really understand the mechanism of action, or only vaguely what’s happening. And every few years there's something new, new knowledge. (06)
In general, science with its empirical principles based on populations rather than individuals was not considered to be the only guide for daily work in general practice.
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.
… it is always about the individual patient and their problem … (16)
To have practical solutions in as many situations as possible and in order to be able to take account of the preferences of patients, participants aimed to have broad toolkits.
The benefit is that I simply have a broader repertoire … Where conventional medicine has its gaps or where the patient has other ideas, I still have therapeutic alternatives. (03)
They judged the different therapies by their contribution to the potential solution of the patient’s problem. The means to reach the therapeutic goals were considered secondary. In some situations CAM could become an alternative instead of a supplement for more convinced CAM providers.
In my opinion, one has a therapeutic goal in each case. And I stick to it. And I do my best to achieve it. And it doesn’t matter how I achieve it. So, if the man can walk again, because the pain in the hip has diminished, then the therapeutic goal has been reached. It doesn’t matter whether the hip has been replaced or if I’ve used acupuncture it or recommended something else. (04)
Complementary medicine is sometimes even the better tool for me, not so as to avoid patients going somewhere else, but because in my eyes I can better help them with this kind of medicine. For that reason, I would even prefer complementary medicine in certain cases. (14)
Participants often prescribed CAM treatments to avoid conventional treatments with a higher risk of side effects, but also stressed that the use of CAM itself must not harm the patient.
For a cold, I prefer to give the patient only a [homeopathic] remedy, which has no side effects, instead of saying, now take ibuprofen plus [brand name for acetylcysteine] plus blah blah, which … according to the evidence provides little benefit and maybe also has side effects. (07)
The main thing is not to harm the patient. Also not by losing time or whatever, you have to bear that in mind. (03)
Facilitating communication and the therapeutic relationship
The motives for using CAM to facilitate empathic communication and to develop a better relationship with patients arise in various ways in the interviews, particularly among GPs seeing many patients open to CAM therapies. For example, when talking about his “broad toolkit” the participant cited in the previous section also said that his CAM skills and experience allow him to take a more complete case history.
I am more open-minded when I speak with patients, and can take a better case history. I can better understand what other treatments the patient has already undergone, or is undergoing. (03)
The openness of the GP to CAM could increase the trust of patients skeptical toward conventional medicine when a conventional treatments are really needed:
Or when I prescribe an antibiotic they say: "If that’s what you say, then I know I really need it. If I were at the ENT [ear, nose, throat] doctor’s, I wouldn’t take it, but if you say I need it, then I really do need it, because I know that you’d prefer not to give it to me." (07)
CAM was also considered to be a means of accompanying patients with severe diseases or in difficult social situations.
Of course, a big area is the people with cancer who actually come to see me because of the mistletoe, because they’ve heard I prescribe it. And then you have to see why they actually come. … And then you have to listen carefully and look, talk to the patients … if they really want the mistletoe or if they’re just running away from their disease. And it often is the case that they’re running away. And then I try to accompany them on their way and the goal is to provide them with effective therapy. And that often means having surgery and, if necessary, doing chemotherapy and, of course, radiotherapy. But for me, the most important thing is to build trust with these patients, and to strengthen their self-confidence and courage, so that they cope with the disease, that’s the most important thing. I cannot say, “I'll give you the mistletoe and you’ll be all better”, that's not it, it's more about accompanying them on their way. (16)
Confidence in own practical experience
In general, all participants strongly trusted their personal practical experience. But while a few more skeptical GPs emphasized that personal experience is not sufficient for assessing whether a CAM treatment has specific effects, positive experiences were sufficient for the majority of participants to become open to CAM provision. These GPs judged the usefulness of CAM (as well as of conventional) treatments based primarily on what they saw in their patients. Rising doubts about the specificity of effects or the plausibility of potential mechanisms were overturned by the repeated experience of positive outcomes.
The decisive factor is the effect. 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. (14)
Appreciation of placebo effects
Whether placebo effects had a role when using CAM was not a major issue for participants. On the contrary, placebo effects were appreciated as an important and positive component of any treatment.
Of course, the placebo effect is very important. It should not be underestimated, but many conventional doctors do just that: "That's just a placebo". Placebo is really quite remarkable. (06)
Yet, when reporting on their personal use of CAM treatments participants usually implicitly or explicitly stated that they did not think that these treatments work exclusively by placebo effects (note the word “partly” in the following quote).
If the patient is happy and well, then that’s fine by me … whether it’s partly a placebo effect or not is all the same to me. (07)
Personal beliefs and the need to be authentic
If, instead, participants considered a CAM treatment to work exclusively through placebo effects, this usually had the consequence that they did not use it. The GP quoted below considered homeopathy a “great placebo”, but when trying to use it he felt as though he lost his authenticity and was lying to the patient. So he preferred using herbal remedies which were more plausible to him even if convincing clinical evidence from trials was missing.
[Homeopathy] is a great placebo. Really, there is really hardly anything in which one orients so much to the patient and ... where everything has meaning, and then one chooses the appropriate remedy. It's really astounding, how much there is to it. ... But I can’t hand on heart do something I don’t really believe in, so, yes, I've actually thought, ok, take it as a placebo … but then I really felt I was lying, playing a part, and that's not authentic. Exactly. That's why it didn’t work for me ... And with the other remedies, such as herbal remedies, there is at least an active ingredient, even if there’s no evidence from clinical trials. (13)
Based on their personal beliefs, preferences and experiences, participants made quite individual choices of CAM therapies for clinical use.
I have experience with acupuncture and Ayurveda. Therefore, I know they work. … As for homeopathy, I have no use for it. (19)
Plausibility and evidence of effectiveness – as perceived by the individual physician – influenced whether a treatment was considered acceptable or not. Herbal medicines seemed acceptable to almost all participants, while homeopathy was often discussed critically.
And then there’s homeopathy, which I haven’t talked about at all, because I never use it ... for me it’s completely irrational to think that this has any effect (laughs). And there are no significant proven effects. Although the homoeopaths always say there are. It wouldn’t occur to me. (05)
Individual strategies avoiding internal conflicts
In summary, over the years the experienced GPs in our study had developed individual strategies integrating personally selected CAM therapies to a greater or lesser extent into their daily clinical practice. These individual strategies were constructed in a manner which minimized internal conflict and supported the desire to provide good primary care.
… whether it’s morally justifiable, I have to say that personally it’s simply not an issue, because – and this applies to all medicine for me - I try to help the patient and avoid harming them, with all the means at my disposal. … The goal is to find the best possible solution for the patient. (03)