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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 10, Number 6, 2004, pp. 939–945 © Mary Ann Liebert, Inc.

Spirituality and Choice of Health Care Practitioner

JUDITH J. PETRY, M.D., F.A.C.S., 1 and ROBERT FINKEL, D.P.E. 2

ABSTRACT

Background: Patients who include a complementary and alternative medicine (CAM) practitioner in their health care represent a small percentage of the population identified as CAM users. Their choice may be mo- tivated by intangible personality or worldview characteristics. Objective: A prospective study was designed to determine if a patient’s choice of conventional or alternative health care practitioner was related to total score on an instrument for scaling psychospiritual characteristics. Design: A sequential convenience sample of patients attending five different health care practices in New England. Setting: A family practitioner (FP) who uses CAM. (1) A FP clearly not identified with CAM. (3) A chiro- practor. (4) A naturopath, and (5) A homeopath. Outcome measures: Total scores on the Spiritual Involvement and Beliefs Scale (SIBS), plus item scores of five separate questions and two factors. Results: With 210 respondents, SIBS scores in Practice 2 were significantly lower than in practice 1 (p 0.004), 3 (p 0.001), 4 (p 0.018), and 5 (p 0.02). This pattern remained over the five question scores and two factors. Conclusion: Patients who chose a physician associated with CAM, or an alternative practitioner (chiropractor, naturopath, or homeopath) for their direct health care scored higher on a psychospiritual testing instrument (SIBS) than those who chose a conventional physician.

INTRODUCTION

T he choice to consult with a complementary or alterna- tive medical practitioner in search of treatment repre-

sents a greater commitment, both behaviorally and finan- cially than does the self-care use of complementary and alternative medicine (CAM) modalities practiced by a large percentage of the U.S. population. Estimates of actual vis- its to CAM practitioners, based on random population sur- veys, have been 6.5%–26% of the U.S. population (Druss and Rosenheck., 1999; Eisenberg et al., 1993, 1998; Foster et al., 2000; Palinkas and Kabongo, 2000; Paramore, 1997). A variety of intangible qualities may influence the deci- sion to consult a CAM practitioner. Spirituality has been suggested as one of these influences. To date there have been

no reports of the use of standardized measures of spiritual- ity in the assessment of individual choice to consult with a CAM provider. We designed the present study to answer the question: Does spirituality as measured by a standardized instrument differ between those people who choose an al- ternative provider and those who choose a conventional medical provider? The decision to seek out CAM practitioners may be ini- tiated by a sense of desperation, or a “push” away from con- ventional medicine (Astin, 1998; Furnham and Smith, 1988); or by a pull toward an alternative ideology (Kelner and Wellman, 1997; Pawluch et al., 2000). Little is known about the underlying motivation of individuals in their pur- poseful inquiry into alternative choices. Since several researchers have pointed out the increas-

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ingly apparent fact that users of CAM providers are not a homogenous group (Caspi et al., 2004; Furnham et al., 1995), it seems worthwhile to explore the reasons for their choice in the quest for a patient-centered model of health care (Leckridge, 2004). In an effort to define and understand the population of individuals who choose to consult a CAM medical provider for their health care needs, investigators have explored de- mographics, diagnoses, insurance status, and a variety of nonstandardized attitudinal questions. As Caspi et al. (2004) pointed out, the foci of these attempts at the characteriza- tion of a subgroup that distinguishes between CAM self-care and CAM provider-directed care have been who the patients are, and why they chose an alternative provider. The results of those investigators who addressed the “who” question are quantifiable characteristics of the CAM provider user population that are consistent with self-care CAM users: predominantly white, female, of upper income level, more highly educated, insured, live in the Western United States, more likely to have specific diagnoses, more likely to have psychiatric morbidity, and have no religious affiliation (Astin,1998; Furnham and Forey, 1994; Owens et al., 1999; Wolsko et al., 2002). The results of addressing the “why” question are some unique but difficult to quantify, observations on the CAM provider user population: they consider themselves “risk takers” (Sturm, 2000), “unconventional” (McGregor and Peay, 1996), are more comfortable with uncertainty (Caspi et al., 2004), desire a treatment that is congruent with their belief system (Caspi et al., 2004), have higher health con- sciousness and awareness, have a more optimistic outlook on health (Furnham and Forey, 1994), value an emphasis on treating the whole person (Vincent and Furnham, 1996), are more likely to consider spirituality an impor- tant factor in their lives (Kelner and Wellman, 1997), wish to treat causes of illness, not just symptoms (Mitzdorf et al., 1999), are more involved with their own health care decisions (London et al., 2003), stress the importance of emotional well-being (Furnham and Beard, 1995), and de- sire health care that makes sense “spiritually” (Caspi et al., 2004). In order to quantify one of these identified characteris- tics of CAM provider users, we selected a short, easily ad- ministered measure of spirituality (Spiritual Involvement and Beliefs Scale [SIBS]), developed for use in a general medical practice population (Hatch et al., 1998); and ad- ministered it to a convenience sample of patients attending one of five health care practices. The practices were located in rural New England and consisted of a conventional gen- eral practice that did not utilize CAM (Non-CAM), a gen- eral medical practice characterized by the use of CAM, a chiropractic practice, a naturopathic practice, and a lay homeopathic practice. The study was intended as a pilot study to future research.

PETRY AND FINKEL

MATERIALS and METHODS

Design

Between 1999 and 2001 a prospective sequential conve- nience sample of patients keeping appointments in five dif- ferent health care practice settings were invited by the re- ceptionist in each practice to fill out a brief instrument designed to measure spiritual involvement. The surveys were anonymous. The only demographic data requested were age and gender. Participation was strictly voluntary. No record was kept of the number of patients who were not offered the survey, or the number who refused to complete the survey.

Measurement instrument

SIBS was designed to fill a void in the objective evalua- tion of spirituality in order to facilitate scientific inquiry into the relationship between spirituality and medical care. The original intention was to make it “comprehensive and widely applicable.” The instrument is applicable across religious traditions and assesses actions as well as beliefs. It is short (39 items), easily scored, and has good reliability and va- lidity (Hatch et al., 1998). The scale has been slightly mod- ified since its original description. In the course of devel- oping a revised version of the SIBS; Hatch and colleagues identified two substantial factors that they labeled Factor 1:

Core spirituality (Connection, meaning, faith, involvement and experience)”, and Factor 2: Spiritual perspective/exis- tential (R. Hatch, personal communication, January 3, 2003).

Practice settings

Patients utilizing five different practices were included in the study: (1) a family practitioner who was identified in the community as someone who used CAM and/or referred to alternative practitioners; (2) family practitioners who were clearly not identified with CAM; (3) a group chiropractic practice; (4) a group naturopathic practice; and (5) an inde- pendent nonphysician homeopathic practitioner. Patients in the first practice were asked whether they chose their physi- cian because he or she used CAM, or not, and whether they would consider the use of CAM along with their conven- tional medical care. Those in the third, fourth, and fifth prac- tices were asked whether they also used a conventional med- ical practitioner, and whether they had told their medical practitioner that they were also consulting an alternative practitioner.

Data analysis

We were interested in whether differences in scoring could be identified across the practice groups. The order of data was ordinal. It was determined that the scores were dis-

SPIRITUALITY AND CAM CHOICE

tributed in a non-normal fashion. The cases were unpaired. Therefore, a Mann-Whitney–Wilcoxon test was selected as appropriate. On an initial investigation, the individual scores that appeared to be the most discriminatory were those as- sociated with five questions: Number 16, “In times of de- spair, I can find little reason to hope”; Number 19, “I have had a spiritual experience that greatly changed my life”; Number 23, “I have joy in my life because of my spiritual- ity”; Number 33, “In difficult times, I am still grateful”; and Number 39, “How spiritual a person do you consider your- self?”. Total scores on the SIBS, item scores of the five ques- tions, as well as of the two factors were compared between groups. A Mann-Whitney U was calculated between the groups defined by the conventional and alternative practices, and between various practices.

RESULTS

Instruments were completed by 210 subjects (169 fe- males, 40 males) in the five practice settings (Table 1). Fifty- four percent (54%) were between 30–49 years of age (Table 2). The number of surveys by practice were 1: n 49, 2:

n 47, 3: n 57, 4: n 28, 5: n 29. Forty-nine (49) subjects were seeking a conventional practice, 161 were not. In practice 1, 73.5% chose the practice in part because of the physician’s use of CAM. Only 4 subjects at either prac- tice 1 or 2 indicated that they would not consider CAM use (4.2%). In practice 3, 84% also used a conventional physi- cian and 87.1% had informed their physician of their chiro- practic use. In practice 4, 75% also used a conventional physician; and 67.9% informed their physician of their naturopathy use. In physician 5, 86% also used a conven- tional physician, and 76% had informed their physician of their use of homeopathy (Table 3).

Instrument scores

SIBS scores in practice 2 (conventional) were significantly lower than in practice 1 (p 0.004), 3 (p 0.001), 4 (p 0.018), and 5 (p 0.02). These disparities held true for the five question scores as well. There were no differences be- tween scores on the SIBS or the five questions between prac-

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TABLE 1. SELECTION OF PROVIDER ACCORDING TO GENDER OF RESPONDENTS a

Setting

Female

Male

#1 CAM–MD #2 Non-CAM MD #3 Chiropractor #4 Naturopath #5 Homeopath

44 (89.8%)

5 (10.2%)

32 (69.6%)

14 (30.4%)

49 (86%)

8 (14%)

25 (89.3%)

3 (10.7%)

19 (65.5%)

10 (34.5%)

a (One non-CAM [complementary and alternative medicine] M.D. respondent did not indicate gender.)

tice 3 (chiropractor) and 4 (naturopath). There were no dif- ferences between practice 1 (CAM-MD) and 5 (homeopath). Question 19 on the SIBS (“I have had a spiritual experience that greatly changed my life.”) ranked significantly higher in practice 3 and 4 compared to practice 1 or 2. On question 19, practice 5 was not different from 1, but was higher than 2 at a level that approached significance (p 0.063) (Fig. 1). On Factors 1 (Core spirituality) and 2 (Spiritual perspec- tive/existential), the mean ranks for the Non-CAM MD were 34.7 and 31.1 versus 44.6 and 50.3 for the homeopath (p 0.057, .000); were 41.7 and 42.6 versus 61.3 and 60.6 for the chiropractor (p 0.001, 0.002); were 35.0 and 34.9 ver- sus 46.3 and 43.2 for the naturopath (p 0.011, 0.107); were 41.8 and 37.4 versus 54.9 and 59.1 for the CAM-MD (p 0.021, 0.000) (Fig. 2 and 3). When the scores from all the practices other than that of the homeopath were pooled and compared to the scores from that practice, the mean rank for the pool on question 11 (“I find inner peace when I am in harmony with nature”) was 100.60 versus 121.22 for the homeopath (p 0.065); and on Q21R (the score for the negatively worded “I don’t take time to appreciate nature”) was 100.32, versus 126.59 for the homeopath (p 0.021). In summary, the findings were that those patients who chose their health care practitioner based on the practi- tioner’s use of CAM modalities scored significantly higher on a measure of spirituality (SIBS) than those who chose a family practitioner not associated with CAM. When indi- vidual questions were evaluated between groups, patients choosing CAM practitioners scored higher on questions re-

TABLE 2. SELECTION OF PROVIDER ACCORDING TO AGE GROUP

Setting

10–19 yrs.

20–29

30–39

40–49

50–59

60–69

70–79

80–89

#1 CAM–MD #2 Non-CAM MD #3 Chiropractor #4 Naturopath #5 Homeopath

 

7

22

10

5

3

1

1

3

14

4

12

5

4

2

3

1

14

19

15

5

3

 

10

8

7

2

1

2

4

11

8

2

2

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PETRY AND FINKEL

TABLE 3. NUMBER OF SURVEYS COLLECTED FOR EACH PRACTICE SETTING a

Setting

# Surveys

# Using MD also

# Informing MD

#1 CAM–MD #2 Non-CAM MD #3 Chiropractor #4 Naturopath #5 Homeopath

49

47

57

46 (81%)

45 (79%)

28

21 (75%)

19 (68%)

29

25 (86%)

22 (76%)

a Number and percentage of respondents in non-M.D. settings who also use M.D. for health care and number who informed M.D. of complementary and alternative medicine use. There were 5 missing responses for M.D. notification under chiropractic, 6 missing responses under naturopathy, and 1 missing response under homeopathy. CAM, complementary and alternative medicine.

lated to spiritual experiences that changed their lives, the joy in their lives related to their spirituality, gratitude, and the degree of spirituality that they ascribed to themselves. When compared on the basis of the major factors of “Core spirituality” and “Spiritual perspective/existential” the pa- tients who selected the family practitioner not associated with CAM scored significantly lower than those who se- lected any of the other practitioners. Strikingly, those indi- viduals consulting the homeopath appear to be markedly dis- tinguished from all of the others; perhaps by a transpersonal integration of nature in their search for meaning.

DISCUSSION

There is a growing consensus in conventional medicine that the relationship between spirituality and health can no longer be ignored. Our study adds more data to the body of knowledge regarding the role of spirituality in health care. We suggest that spirituality, as measured by one standard- ized and validated instrument, differs with an individual’s choice of health care provider. Persons with higher scores for spirituality on this instrument make different health care provider choices than those with lower scores.

Yet, the very definition of the construct that we measured is an elusive one. The medical literature includes an ongo- ing struggle to define spirituality in a measurable and use- ful way. Current definitions vary widely and many are so vague as to be useless. Some authors have equated spiritu-

ality with meaning. “Spirituality

meaning and purpose in life” (Post et al., 2000). Other de- finitions have involved belief in a higher power. Hungel- mann et al. (1996) found a definition of spirituality among elders as: “A sense of harmonious interconnectedness be- tween self, others, nature, and Ultimate Other, which exists throughout and beyond time and space.” Participants in The First American Samueli Symposium at- tempted to arrive at a consensus definition of spirituality; “The feelings, thoughts, experiences, and behaviors that arise from a search for that which is generally considered sacred or holy. Spirituality is usually, though not universally, considered to involve a sense of connection with an absolute, imminent, or transcendent spiritual force, however named, as well as the conviction that meaning, value, direction, and purpose are valid aspects of the universe” (Dossey, 2003). The author ad- mits that this definition is not the “final word.” To highlight its complexity, it is worth quoting MacDon- ald’s (2000) extensive summary of the literature on the “con-

pertains to ultimate

of the literature on the “con- pertains to ultimate FIG. 1. Differential effect of provider on

FIG. 1. Differential effect of provider on total score. Compari- son of total Spiritual Involvement and Beliefs Scale (SIBS) scores for each practice setting. CAM, complementary and alternative medicine.

FIG. 2. Differential effect of provider on core spirituality. Mean scores of factor 1, core spirituality, for each practice setting. CAM, complementary and alternative medicine.

SPIRITUALITY AND CAM CHOICE

SPIRITUALITY AND CAM CHOICE FIG. 3. Differential effect of provider on spiritual perspective. Mean scores of

FIG. 3. Differential effect of provider on spiritual perspective. Mean scores of Factor 2, Spiritual Perspective, for each practice setting. CAM, complementary and alternative medicine.

tent domain” of spirituality: “(a) Spirituality is a multidi- mensional construct that includes complex experiential, cog- nitive, affective, physiological, behavioral, and social com- ponents; (b) Spirituality is inherently an experiential phenomenon/construct that includes experiences labeled spir- itual, religious, peak, mystical, transpersonal, transcendent, and numinous; (c) Spirituality is accessible to all people and qualitative and quantitative differences in the expressions of spirituality can be measured across individuals; (d) Spiritual- ity is not synonymous with religion but reflects a construct domain that includes intrinsic religiousness; and (e) Spiritu- ality includes paranormal beliefs, experiences, and practices.” The nursing community, which helped to bring to light the importance of spirituality in medical care, has recently sounded warnings that attempts to clarify the multidimen- sional aspects of the subject may result in a “blanket defin- ition” that is “so broad in meaning that it loses any real significance” (McSherry and Cash, 2004). Although Mac- Donald’s (2000) thesis on spirituality may seem to lend cre- dence to the caution, he was able, after extensive testing and evaluation of a long list of spiritual measurement instru- ments (not including SIBS), to categorize spirituality in five discrete dimensions: (1) cognitive orientation towards spir- ituality, (2) experiential/phenomenological dimension of spirituality, (3) existential well-being, (4) paranormal be- liefs, and (5) religiousness. Although he does not offer a de- finition of spirituality, he notes that most of his five ele- ments are found in available instruments that assess spirituality. Our intention to answer a question regarding the spiritu- ality of a population of patients required that we choose an instrument that would measure some aspect of that construct. The SIBS was developed specifically for use in a general medical practice. It was intended to be widely applicable across religious traditions, to assess actions as well as be- liefs, and to be easily administered. Because we were ob- serving unconventional actions taken by individuals in their

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health care choices, the assessment of actions based on be- liefs was important to us. That the survey was relatively short and easy to take was also important, as patients were

filling out the survey while they waited for their provider appointment.

A convenience sample necessarily includes only those pa-

tients interested in the study topic who are also willing to take the time to fill out the instrument. We did not ask if those choosing the conventional physician as their primary care practitioner also consulted a CAM practitioner. This in- formation may have altered the results, although most likely in the direction of a lower SIBS score for the conventional practice. The percentage of female respondents in our study (80%) is high, but in keeping with gender representation in other surveys (Furnham and Smith, 1988; Vincent and Furnham,

1996). The percentage of female patients in the overall prac- tices ranged from approximately 60–85%, the highest per- cent occurring in the naturopathic practice. The figure may also be indicative of a willingness of women to participate in research.

It is not clear why the percent of patients in our study

who informed their physician of CAM provider care is higher than the figures reported by others (Eisenberg et al., 1998). Those who agreed to fill out the survey may be the same individuals who are willing to openly discuss alterna- tive provider use with their physician. It is of interest that the percent who reported naturopathic provider care to their physician was lower than those who reported chiropractic or homeopathic care. We understand that with the many measures of spiritual- ity in existence and the absence of a reliable definition of spirituality, our results on this relatively small population

are suggestive at best. They do not quantify the degree to which people include their spirituality in making health care decisions. However, persons choosing CAM practitioners for their health care possess a measurably higher level of spiritual involvement as measured by one instrument than those who do not. This level may coincide with Wilber’s “centauric sphere of consciousness” and extend to higher levels in his holarchy (Wilber, 2000). Such individuals are aware of body and mind as experiences of the self; they are on the verge of the transpersonal states. Astin’s (1998) survey of general CAM use supports this possibility. He identified 40% of respondents as utilizing some type of CAM in the past year. Those who did were more likely to have had a transformational experience that changed their world views, preferred a holistic approach to health, and could be classified as a “cultural creative”: en- vironmentalist, feminist, involved in spirituality and per- sonal growth psychology, self-actualization, self-expression, and love of the foreign and exotic (Ray, 2000). Astin sug- gested that these characteristics of alternative medicine use indicate a cultural paradigm shift in worldview and spirituality.

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Another intriguing piece of the puzzle is found in re- viewing Owens at al. (1999) discussion of the Tellegen Ab- sorption Scale administered to patients with cancer, pain pa- tients, and community controls (Owens et al., 1999). They found that higher scores on the Absorption scale correlated with use of more CAM therapies. Absorption, which was originally used as a predictor of hypnotizability, has been considered a relatively minor dimension of personality, but may be of significance in predicting CAM use. In the sim- plest terms, it indicates an ease in shifting states of con- sciousness from relaxation and rapt attention to a more activated alertness associated with artistic or mythic expe- riences and a high degree of mind–body involvement. Owens and colleagues associate absorption with the char- acteristics found in Astin’s study and most specifically find it compatible with the cultural creative construct, believing it to be the “sociological counterpart” of absorption. Perhaps the 9% of the U.S. population who are most com- mitted in choosing CAM practitioners as participants in their health care (Bausell et al., 2001; Wolsko, et al., 2002) rep- resent the small percent of individuals who have evolved to higher levels of personal growth in an ongoing cultural par- adigm shift. We propose that choosing a CAM practitioner indicates a behavioral manifestation of participation in this paradigm change.

CONCLUSION

If spirituality pertains to ultimate meaning and purpose in life, and is an internally accessed behavioral guide based on a connection and union with a higher level of con- sciousness, then conventional Western biomedicine may be woefully lacking in facilitating this resource for healing. CAM practitioners may have an advantage, at least in the perception of patients, in catalyzing the role of spirituality in healing. Their perceived role as holistic partners in health may account for their appeal to a small segment of our pre- sent culture. This may be a guiding factor in personal choice of health care practitioner and deserves the attention of con- ventional Western physicians. We conclude that there is a need for more extensive study of the more committed users of CAM.

ACKNOWLEDGMENTS

The authors thank Brattleboro Naturopathic Clinic, Brat- tleboro, VT; Sojourns Community Clinic, Westminster, VT; Saxton’s River Natural Health Care, Saxton’s River, VT; Susan Hadley, M.D., Middletown, CT; Karen McArthur, M.D., Portland, CT; and Community Health Center, Hanover, NH for their participation in data collection for this study.

PETRY AND FINKEL

Presented at Poster Session, International Scientific Con- ference on Complementary, Alternative & Integrative Med- icine Research, April 12–14, 2002, Boston, MA. No funding was sought for this study. No conflicts of in- terest exist.

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Address reprint requests to:

Judith J. Petry, M.D., F.A.C.S. P.O. Box 172 Westminster, VT 05158

E-mail: jpetry@sover.net