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HMCL221
www.endeavour.edu.au
Session 05a
Introduction to
Complementary Medicine
Clinical Practice
© Endeavour College of Natural Health www.endeavour.edu.au 2
Session 5
Therapeutic Relationship:
• Healing presence
• Placebo effect
• Boundaries and ethics
© Endeavour College of Natural Health www.endeavour.edu.au 3
Session 5
Therapeutic Relationship:
• Guiding patient expectations
• Patient values
• Social and ethnic diversity
considerations
© Endeavour College of Natural Health www.endeavour.edu.au 4
Session 5
Other clinical considerations:
• Professionalism
• Professional responsibility/liability
• Time management
© Endeavour College of Natural Health www.endeavour.edu.au 5
Session 5
Other clinical considerations:
• Financial considerations
• Different clinical approaches:
group visits, community
acupuncture, etc.
© Endeavour College of Natural Health www.endeavour.edu.au 6
Session 5
Tutorial activity
Online discussion of the therapeutic
relationship and other clinical considerations
in a complementary medicine consultation.
© Endeavour College of Natural Health www.endeavour.edu.au 7
Healing Presence
Quality possessed by practitioner,
which inspires healing in others.
Aura of knowledge and experience recognisable as
wisdom, which the practitioner projects engendering
confidence in the practitioner’s ability and skill.
© Endeavour College of Natural Health www.endeavour.edu.au 8
Healing Presence
Watch this video:
Healing Presence
Key Concepts:
o Practitioners who inspire self-healing in others
o Generates meaning in the relationship
o Non-specific effect
o A state of Being, Empathy, active listening and deep
caring
o “Words can be medicine”- words generate the world
around us
© Endeavour College of Natural Health www.endeavour.edu.au 9
Healing Presence
What characterises Healing Presence?
Reading
HMCL221 SN05 Reading-Fostering a Healing Presence
Attributes and Belief Systems of Person(s) that
Characterize Healing Presence (page 4)
o Therapeutic Relationship
o Empathy
o Compassion
o Charisma
o Spirituality
o Intention
(McDonough-Means, Kreitzer, & Bell, 2004)
© Endeavour College of Natural Health www.endeavour.edu.au 10
Healing Presence
Attributes and Belief Systems of Person(s) that
Characterize Healing Presence (page 4) cont’d
o Transpersonal Communication
o Healee psychology
o Optimism
o Expectancy and Belief
o Surrounding physical environment
(McDonough-Means, Kreitzer, & Bell, 2004)
© Endeavour College of Natural Health www.endeavour.edu.au 11
Discussion Forum
Tutorial Participation Activity
Look through the questions posed in the reading Fostering
a Healing Presence under the section Questions for
Consideration on page 9. Choose any two questions and
provide your opinion of possible answers to the questions
or conclusions that could be made.
HMCL221
www.endeavour.edu.au
Session 05b
Introduction to
Complementary Medicine
Practice
© Endeavour College of Natural Health www.endeavour.edu.au 13
Placebo
Oxford Dictionary definition
Placebo
noun (plural placebos)
1. A medicine or procedure prescribed for the
psychological benefit to the patient rather than for any
physiological effect.
2. A substance that has no therapeutic effect, used as a
control in testing new drugs.
© Endeavour College of Natural Health www.endeavour.edu.au 14
Placebo
Science can’t explain the
placebo effect.
Watch this video and be prepared
to be amazed:
The Placebo Effect
© Endeavour College of Natural Health www.endeavour.edu.au 15
ConclusionsWe could hypothetically conclude when combining what we
have learnt about Healing Presence with Placebo that:
Greater Healing Presence perceived in a
practitioner may lead to greater patient confidence
in the practitioner’s ability and therefore due to the
effect of placebo increase healing outcomes for
the patient.
© Endeavour College of Natural Health www.endeavour.edu.au 16
Professional Boundaries
o Are essential to a good practitioner–patient
relationship
o Protect both patients and practitioners
o Recognised in most Codes of Conduct for health
practitioners
BUT…
In reality, it may sometimes be difficult to decide at what
point the fine line of professional boundaries has been
over stepped and where it might become necessary for
a practitioner to terminate the relationship with a
patient.
© Endeavour College of Natural Health www.endeavour.edu.au 17
Professional Boundaries
Professional boundaries are integral to Good Practice. Good
practice involves a practitioner:
o Maintaining professional boundaries.
o Never using professional position to establish or pursue an
exploitative or other inappropriate relationship with anybody
under their care. This includes those close to the patient, such
as their carer, guardian or spouse or the parent of a child
client.
o Avoiding expressing personal beliefs to clients in ways that
exploit their vulnerability or that are likely to cause them
ddistress.
(Medical Board of Australia, 2009)
© Endeavour College of Natural Health www.endeavour.edu.au 18
Examples of CAM practitioners Code of
Conduct & Ethics
o ANTA
http://www.australiannaturaltherapistsassociation.com.au
/downloads/anta_codeofethics.pdf
o ATMS
http://www.atms.com.au/uploads/pdf/New_ATMS_Code
%20of%20Conduct.pdf
o NHAA
http://www.nhaa.org.au/index.php?option=com_content&
view=article&id=81&Itemid=76
© Endeavour College of Natural Health www.endeavour.edu.au 19
General Code of Professional
Ethics in Clinico Always respect the rights and dignity of the clinic
client;
o Always maintain the utmost standard of
professional competence and behaviour;
o Ensure that all information about the consultation
and treatment being offered to the client is
understood. All consultation, assessment and
treatment must be carried out with the informed
consent of the clinic client;(Endeavour Clinic Handbook, 2014)
© Endeavour College of Natural Health www.endeavour.edu.au 20
General Code of Professional
Ethics in ClinicContinued…
o Always ensure client confidentiality and
privacy;
o Take care to ensure a high standard of
hygiene and promote safe practices.
(Endeavour Clinic Handbook, 2014)
© Endeavour College of Natural Health www.endeavour.edu.au 21
Patient Expectations
o Meeting or failing to meet the care patients hope for is an
important predictor of patient satisfaction.
o Identification and clarification of patient expectations is
an essential part of the consultation process.
o Unrealistic patient expectations need to be identified and
discussed with the patient by the practitioner in the early
stages of the practitioner-patient relationship and also as
they arise throughout the treatment process.
o Unmet expectations may increase the likelihood of
complaint or even claim against a practitioner.
© Endeavour College of Natural Health www.endeavour.edu.au 22
Patient Expectations
Patient expectations of doctors:
1. Confident - “The doctor’s confidence gives me confidence.”
2. Empathetic - “The doctor tries to understand what I am feeling &
experiencing, physically and emotionally, and communicates that
understanding to me.”
3. Humane - “The doctor is caring, compassionate, and kind.”
4. Personal - “The doctor is interested in me more than just as a
patient; he/she interacts with me, and remembers me as an
individual.”
5. Forthright - “The doctor tells me what I need to know in plain
language.”
6. Respectful - “The doctor takes my input seriously and works with
me.”
7. Thorough - “The doctor is conscientious and persistent.”
(Bendapudi et al., 2006)
© Endeavour College of Natural Health www.endeavour.edu.au 23
Patient Expectations
o Managing unrealistic patient expectations
• Most issues of patient dissatisfaction and complaints regarding
health care result from poor communication between practitioner
and patient.
• Establishment of a sound patient-practitioner relationship
(therapeutic relationship) and clear, open communication are the
keys to preventing/minimising unmet expectations.
• “What are you hoping to achieve from this appointment?” (What
are your expectations?) can be a relevant question for a
practitioner to ask in the first consultation.
(www.fluenceportland.com, n.d.)
© Endeavour College of Natural Health www.endeavour.edu.au 24
Discussion Forum
Draw on your knowledge about Healing Presence and the
influence Placebo Effect may have on Healing Presence.
Discuss on the Forum how Healing Presence may effect
Professional Boundaries and Patient Expectation.
In particular take into consideration a patient’s needs,
wants and vulnerabilities when they are not well and how
that may influence how they may interact with a practitioner
who portrays characteristics of Healing Presence. Provide
possible positive and negative interactions between the
patient and practitioner.
HMCL221
www.endeavour.edu.au
Session 05c
Introduction to
Complementary Medicine
Practice
© Endeavour College of Natural Health www.endeavour.edu.au 26
Patient Values
Patient values and beliefs are linked to
culture and heritage and are therefore
best discussed under Social and Ethnic
Diversity coming up next.
© Endeavour College of Natural Health www.endeavour.edu.au 27
Social and Ethnic Diversity
Key Concepts:
o Social Norms
o Cultural Diversity
o Cultural Desire
o Cultural Awareness
o Cultural Competency
o Heritage
o Cultural Care
© Endeavour College of Natural Health www.endeavour.edu.au 28
Social Norms
o The idea of norms provides a key to understanding
social influence in general and conformity in particular.
o Social norms are the accepted standards of behaviour of
social groups – ranging from friendship and work group,
health care settings and governments etc.
o Behaviour which fulfils these norms is called conformity,
and most of the time roles and norms are powerful ways
of understanding and predicting what people will do.
o Norms provide order in society.
(http://alearningaday.com/2
012/03/on-day-care-centre-
norms.html, n.d.)
© Endeavour College of Natural Health www.endeavour.edu.au 29
Cultural Diversity Australian PopulationTOP 10 COUNTRIES OF BIRTH FOR THE OVERSEAS-BORN
POPULATION
Country of birth Persons Proportion of all
overseas-born
Median age Sex ratio(a)
'000 % years
United Kingdom 1 101.1 20.8 54 101.7
New Zealand 483.4 9.1 40 102.8
China(b) 319.0 6.0 35 79.8
India 295.4 5.6 31 125.2
Italy 185.4 3.5 68 104.7
Vietnam 185.0 3.5 43 84.6
Philippines 171.2 3.2 39 60.6
South Africa 145.7 2.8 39 96.9
Malaysia 116.2 2.2 39 83.5
Germany 108.0 2.0 62 90.6
Born elsewhere overseas 2 183.8 41.2 44 95.6
Total overseas-born 5 294.2 100 45 96.1
(a) Number of males per 100 females.
(b) Excludes Special Administrative Regions and Taiwan Province.
(ABS, 2013)
© Endeavour College of Natural Health www.endeavour.edu.au 30
Cultural Desire
o Cultural desire is defined as the motivation to become engaged in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and seeking cultural encounters.
o It stands in contrast to the feeling of "having to" participate in this process.
© Endeavour College of Natural Health www.endeavour.edu.au 31
Cultural Desire
o Cultural desire includes a genuine passion to be
open and flexible with others, to accept
differences and build on similarities, and to be
willing to learn from others as cultural
informants. This type of learning is a life-long
process which has been referred to as cultural
humility.
© Endeavour College of Natural Health www.endeavour.edu.au 32
Cultural Competence
o Cultural desire is the pivotal and key construct of cultural competence, for it is the healthcare provider’s desire that evokes the entire process of cultural competence.
o Cultural competence refers to an ability to interact effectively with people of different cultures and socio-economic backgrounds.
o Cultural desire involves the concept of caring.
o It has been said that people don't care how much you know, until they first know how much you care.
(Campinha-Bacote, 2003)
© Endeavour College of Natural Health www.endeavour.edu.au 33
Cultural Knowledge and Awareness
o Cultural knowledge is the familiarisation with selected cultural characteristics, history, traditions, values, belief systems and behaviors of the members of other ethnic groups.
o Cultural knowledge is not stereotyping, it is ongoing learning, understanding and accepting other’s culture, race ethnicity, nationality, religion, customs or belief systems.
(Adams, 1995)
© Endeavour College of Natural Health www.endeavour.edu.au 34
Cultural Knowledge and Awareness
o Cultural intelligence is a person's capability to function effectively in situations characterised by cultural (or social) diversity.
o Cultural intelligence is a critical capability that enhances individual and organisational effectiveness. It also enhances interpersonal interactions in a wide range of social contexts.
© Endeavour College of Natural Health www.endeavour.edu.au 35
Cultural Care
o Cultural Care is the provision of health care
across cultural boundaries that takes into
consideration the context in which the client lives
as well as the situations in which the client’s
health problems arise.
(Jarvis, 2012)
© Endeavour College of Natural Health www.endeavour.edu.au 36
Cultural Competence Cultural Care
o Culturally sensitive implies that caregivers possess
some basic knowledge of the constructive attitudes
toward the diverse cultural populations found in the
setting in which they are practising.
o Culturally appropriate implies that the caregivers apply
the underlying background knowledge that must be
possessed to provide a given person with the best
possible health care.
o Culturally competent implies that the caregiver
understand and attends to the total context of the
individual’s situation, including awareness of immigration
status, stress factors, other social factors, and cultural
similarities and differences. (Jarvis, 2012)
© Endeavour College of Natural Health www.endeavour.edu.au 37
Guide for Cultural Care - RESPECT
o R = realise that you must know and understand your
heritage and that of the client
o E = examine your client within the context of their
cultural boundaries
o S = select questions that are not complex, and do not
ask too rapidly
o P = pace questions throughout physical examination
o E = encourage your client to discuss their understanding
of health and illness to you
o C = check for your clients understanding of your
recommendations
o T = touch your client within the boundaries of his or her
heritage (Jarvis, 2012)
© Endeavour College of Natural Health www.endeavour.edu.au 38
Cultural Competence Checklist
o http://www.asha.org/uploadedFiles/Cultural-
Competence-Checklist-Personal-Reflection.pdf
(www.flickr.com, n.d.)
© Endeavour College of Natural Health www.endeavour.edu.au 39
Demographic Risk Factors
o Tobacco smoking
o Excessive alcohol
o Poor diet and nutrition
o Physical inactivity
o Excessive sun
exposure
o Insufficient
vaccination
o Unprotected sexual
activity
Demographic factors include age, sex and population
subgroups. Examples of demographic risk factors
include:
© Endeavour College of Natural Health www.endeavour.edu.au 40
Health Disparity
o A health disparity is an unusual and disproportionate
incidence and/or prevalence of a specific health
condition in a population group, such as:
• High incidence of diabetes among Indigenous Australians
• High incidence of kidney failure among Indigenous Australians
• Obesity prevalence is higher among lower SES
(Office of Public
Engagement, University
of Minnesota, n.d.)
© Endeavour College of Natural Health www.endeavour.edu.au 41
National Health Priority Areas
o Australian Institute of Health and Welfare
http://www.aihw.gov.au/national-health-priority-areas/
• Cancer
• Cardiovascular disease
• Diabetes
• Obesity
• Arthritis and Musculoskeletal Problems
• Mental health
• Dementia
© Endeavour College of Natural Health www.endeavour.edu.au 42
Demographic Profile of CAM Users
o In terms of their health, CAM users tend to have more
than one medical condition, but might not be more likely
than non-users to have specific conditions such as
cancer or to rate their own general health as poor.
o The estimated use of CAM among Australian population
varies. It is widely known that more than 50% of people
in their experience with cancer use some form of CAM
therapy.
o The evidence suggests that people who visit a
naturopath or herbalist tend to be female, of middle age
and have higher education and income. (Bishop & Lewith, 2010; Chi-Wai Lui et al., 2012)
HMCL221
www.endeavour.edu.au
Session 05d
Introduction to
Complementary Medicine
Practice
© Endeavour College of Natural Health www.endeavour.edu.au 44
Professionalism
o The old model of medical professionalism
valued qualities such as
• Detachment
• Paternalism
• Restricted communication with patients
• Ethically grounded in beneficence
© Endeavour College of Natural Health www.endeavour.edu.au 45
Professionalism
o New medical professionalism encompasses:
• Empathy
• Emotional engagement
• Open communication
• Patient-centredness
• Ethically grounded in patient autonomy.
© Endeavour College of Natural Health www.endeavour.edu.au 46
Professional Responsibility/Liability
o A professional practitioner is obligated to provide care or
service that meets the standard of practice for his/her
profession – i.e. It is their responsibility.
o Professional Liability is the legal obligation of health care
professionals or their insurers to compensate patients for
injury or suffering caused by acts of negligence, as a
result of the practitioner not meeting their professions
standard of practice.
© Endeavour College of Natural Health www.endeavour.edu.au 47
Time Management
A patient’s time is valuable and is to be respected.
Schedule patients efficiently
Manage flow and time of consultation
© Endeavour College of Natural Health www.endeavour.edu.au 48
Time Management
Timely management of SOAP Consultation process.
o Introductions 3-5 mins
o Case taking 30-40 mins
o Examination 5-10 mins
o Assessment 5-10 mins
o Treatment/Treatment Planning/Prescription 10-30 mins
o Strategising case management with the patient 5-10mins
© Endeavour College of Natural Health www.endeavour.edu.au 49
Financial Considerations
o Health care must be of value to patients and take into
consideration cost containment and customer safety,
convenience, service and satisfaction while being financially
viable to provide by the practitioner.
Patient Value
Patient health outcomes : Cost of delivering the outcomes
o Access and affordability of health care closes health
disparities.
(Bishop & Lewith, 2010)
© Endeavour College of Natural Health www.endeavour.edu.au 50
CAM practitioners contribute to
value-based health care
• Patient-centred
• Individualised care according to level of
self-efficacy – achievable steps
• Goal based
• Evidence-based
• Education focussed
• Culturally sensitive and competent
• Patient empowerment
• Supportive of change
• Most importantly - realistic, ethical, safe
© Endeavour College of Natural Health www.endeavour.edu.au 51
Different Clinical Approaches
o Individual Practitioner Multi-modality Clinic
o Clinical Specialist – e.g. specialising in women’s health
o Multi-practitioner multimodality practice
o Integrated Health Practice – Conventional and
Complementary Medicine practitioners
o Multiple roomed or cubicle practice e.g. acupuncture
o Community Clinic – price conscious provision of services
to lower socio economic groups.
o Mobile practice
© Endeavour College of Natural Health www.endeavour.edu.au 52
Multimodality Holistic Clinic
https://www.wellnationclinics.com.au/
© Endeavour College of Natural Health www.endeavour.edu.au 53
Integrated Health Practice
Conventional and Complementary Medicine
practitioners e.g. http://niim.com.au/
o Integrative General
Practice
o Medical Specialists
o Complementary Medicine
o Family Medicine
o Anti-Ageing Medicine
o Psychiatry Services
o Psychology and
Counselling Services
o Naturopathy
o Osteopathy
o Exercise Physiology
o Acupuncture & Chinese
Medicine
o Myotherapy
© Endeavour College of Natural Health www.endeavour.edu.au 54
Multiple roomed or cubicle practice
e.g. acupuncture
(http://www.citycollegeofacupuncture.com/cpd.html, n.d.)
© Endeavour College of Natural Health www.endeavour.edu.au 55
Community Clinic
o Leichhardt Women’s Community Health Centre provides
low-cost and affordable medical, allied and
complementary health care and education to improve
women’s health. It is a non-government and not for
profit. http://www.lwchc.org.au/
o In Community Acupuncture, the cost of a treatment is
less because the acupuncturist's time and space are
shared. Groups of five or six people receive acupuncture
simultaneously. http://www.chrispickrell.com/rcac/
© Endeavour College of Natural Health www.endeavour.edu.au 56
Mobile practice
(http://www.ahh.net.au/mobile-massage-brisbane/, n.d.)
© Endeavour College of Natural Health www.endeavour.edu.au 57
Good Luck in your
Mid-semester Exam
Quiz
© Endeavour College of Natural Health www.endeavour.edu.au 58
References
Australian Bureau of Statistics (ABS). (2013). 2071.0 - Reflecting a Nation:
Stories from the 2011 Census, 2012–2013. Retrieved from
http://www.abs.gov.au/ausstats/[email protected]/mf/2071.0
Adams, D.L. (1995). Health issues for women of colour: A cultural diversity
perspective. Thousand Oaks: SAGE Publications.
Bendapudi, N.M., Berry, L.L., Frey, K.A., Parish, J.T., & Rayburn, W.L.
(2006). Patients’ perspectives on ideal physician behaviours.
Mayo Clinic proceedings. Mayo Clinic, 81(3), 338–344.
Bishop, F.L., & Lewith, G.T. (2010). Who uses CAM a narrative review of
demographic characteristics and health factors associated with
CAM use. Evidence-based Complementary and Alternative
Medicine, 7(1), 11–28.
Campinha-Bacote, J. (2003). Many faces: Addressing diversity in health
care. Online Journal of Issues in Nursing, 8(1), 3.
© Endeavour College of Natural Health www.endeavour.edu.au 59
References Jarvis, C. (2012). Physical examination & health assessment (6th ed.). St
Louis, MO: Elsevier Saunders.
McDonough-Means, S.I., Kreitzer, M.J., & Bell, I.R. (2004). Fostering a
healing presence and investigating its mediators. Journal of
Alternative and Complementary Medicine (New York, N.Y.),10(1),
S25–S41.
Medical Board of Australia. (2009). Good medical practice: A code of
conduct for doctors in Australia. Retrieved from
http://www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx
Porter, M.E. (2014). Value-based health care delivery. Institute For
Strategy And Competitiveness, Harvard Business School.
Retrieved from
http://www.hbs.edu/faculty/Publication%20Files/3_13615129-
eeec-4987-bf1a-1261ff86ae69.pdf
© Endeavour College of Natural Health www.endeavour.edu.au 60