Constructing Agency in Treatment Decisions: Negotiating Responsibility in Cancer

Shared decision-making endorses intention to follow through treatment or vaccination recommendations: a multi-method survey study among older adults

BACKGROUND

Previous studies have shown that shared decision-making (SDM) between a practitioner and a patient strengthens the ideal of treatment adherence. This study employed a multi-method approach to SDM in healthcare to reinforce the theoretical and methodological grounds of this argument. As the study design, self-reported survey items and experimental vignettes were combined in one electronic questionnaire. This technique aimed to analyze the effects of previous experiences and the current preferences regarding SDM on the intentions to follow-through with the medical recommendations.

METHOD

Using quantitative data collected from the members of the Finnish Pensioners' Federation (N = 1610), this study focused on the important and growing population of older adults as healthcare consumers. Illustrated vignettes were used in the evaluation of expected adherence to both vaccination and the treatment of an illness, depending on the decision-making style varying among the repeated scenarios. In a within-subjects study design, each study subject acted as their own control.

RESULTS

The findings demonstrated that SDM correlates with expected adherence to a treatment and vaccination. Both the retrospective experiences and prospective aspirations of SDM in clinical encounters supported the patients' expected adherence to vaccination and treatment while decreasing the probability of pseudo-compliance. The association between SDM and expected adherence was not affected by the perceived health of the respondents. However, the associations among the expected adherence and decision-making styles were found to differ between the treatment and vaccination scenarios.

CONCLUSIONS

SDM enables expected treatment adherence among older adults. Thus, the multi-method study emphasizes the importance of SDM in various healthcare encounters. The findings further imply that SDM research benefits from questionnaires combining self-report methods and experimental study designs. Further cross-validation studies using various types of written and illustrated scenarios are encouraged.

"One a Day Keeps the Prison Away": Understanding the Experiences of Individuals Convicted of Sexual Offences Receiving Anti-Androgens for the Treatment of Problematic Sexual Arousal

Problematic sexual arousal (PSA) is an umbrella term to describe a range of clinical presentations related to excessive sexual thinking (e.g., sexual preoccupation) and sexual behavior (e.g., hypersexuality). Although such concepts are known to affect sexual recidivism among individuals convicted of sexual offences, PSA is not routinely or directly targeted in offending behavior programs in England and Wales. However, in recent years, there have been moves to incorporate pharmacological interventions for addressing this among people with sexual offence histories. Although some work to understand the experiences of those taking SSRI medication for this purpose has emerged, little is known about the experiences of service users taking anti-androgen medication. In this study, we interviewed all individuals in prison taking anti-androgens for the treatment of problematic sexual arousal following convictions for sexual offences in England at the time of data collection (N = 10). Using a phenomenologically oriented thematic analysis, we established themes pertaining to "Differing needs: Motivations for treatment," "Medication as a risk management strategy," and how the medication helped the men in their pursuit of "Discovering a 'new me'." This work contributes important knowledge to inform the development of ethical and effective prescribing of anti-androgen medication with this population and offer recommendations for both future research and the development of clinical practice.

Shared decision-making during prostate cancer consultations: Implications of clinician misalignment with patient and partner preferences

Concepts of patient-centredness and shared decision-making inform expectations that clinicians should display sensitivity to patients' expressed preferences. This study examines the organisation of treatment-related preferences expressed by patients and their partners during clinical consultations for people with localised prostate cancer. A conversation analysis of twenty-eight diagnosis and treatment consultations was conducted with data recorded from four clinical sites across England. When clinicians disaligned from expressions of preference such as directing talk away from expressions, or moving to redress perceived misunderstandings, it caused discordance in the unfolding interaction. This led to couples silencing themselves. Two deviant cases were identified that did not feature the misalignment found in all other collected cases. In these two cases, the interaction remained collaborative. These findings highlight the immediate consequences of expressions of preference being resisted, rejected, and dismissed in a context where clinicians are expected to explore expressed preferences in service of SDM. The deviant case analysis offers an alternative practice to the pattern observed across the collection, offering a comparison between misaligned sequences, and cases where social solidarity was maintained. By acknowledging couple's expressions as valid contributions, rather than acting to inform or correct them, clinicians can create opportunity spaces for discussion around treatment preferences.

Pragmatic pluralism: Mutual tolerance of contested understandings between orthodox and alternative practitioners in autologous stem cell transplantation

High-dose chemotherapy and autologous stem cell transplantation (ASCT) is used to treat some advanced malignancies. It is a traumatic procedure, with a high complication rate and significant mortality. ASCT patients and their carers draw on many sources of information as they seek to understand the procedure and its consequences. Some seek information from beyond orthodox medicine. Alternative beliefs and practices may conflict with conventional understanding of the theory and practice of ASCT, and 'contested understandings' might interfere with patient adherence to the strict and demanding protocols required for successful ASCT.The present study, conducted in Sydney, Australia, examines narrative-style interviews with 10 sequentially recruited ASCT patients and nine of their carers conducted at the time of transplant and three months later. Transcripts were read for instances of mention of alternative advice, and for instances of contested understanding of information relevant to the transplant.Patients and carer pairs expressed closely concordant views about alternative advice. Five pairs were consulting alternative practitioners. Contested understanding was expressed in four domains-understandings of the transplant itself and its underlying theory, of the relationship between the components of the 'transplant', of the nature and role of stem cells, and of beliefs about bodily function and life-style. Contested understandings of the transplant treatment were expressed as predominantly personal interpretations of orthodox informationPatients and carers seemed to recognise that alternative and conventional systems were discordant, yet they were able to separate the two, and adhere to each practice without prejudicing their medical treatment. A single case of late, post-transplant repudiation of Western medicine is discussed to emphasise some of the possible determinants of dissonance when it does occur.

Vlogging Cancer: Predictors of Social Support in YouTube Cancer Vlogs

Social support research has demonstrated the physical and psychological benefits of social support for patients, but has done little to identify successful strategies for eliciting social support. However, contemporary digital channels offer new ways to examine this issue. In particular, this study explores vlogging as a coping strategy for cancer patients and a context in which to explore predictors of online social support. A content analysis of 69 YouTube vlogs and 869 associated comments was performed. A series of multilevel binomial logistic regression analyses revealed that narrative features that position the cancer patient as protagonist-including providing an explanation of the diagnosis experience, agentive problem solving, and positive reappraisal of the situation-were associated with receiving empathic support. In contrast, moralizing pleads for audience checkups decreased the likelihood of receiving empathic support. Findings contribute to an undertheorized body of research that also has translational value for patients, doctors, and designers of supportive online spaces who might eventually recommend narrative vlogging in clinical settings.

Clinical Positioning Space: Residents' Clinical Experiences in the Outpatient Oncology Clinic

In this article, we present a case study of residents' clinical experiences and communication in outpatient oncology consultations. We apply positioning theory, a dynamic alternative to role theory, to investigate how oncology residents and patients situate themselves as persons with rights and duties. Drawing from seven qualitative interviews and six days of observation, we investigate the residents' social positioning and their conversations with patients or supervisors. Our focus is on how (a) relational shifts in authority depend on each situation and its participants; (b) storylines establish acts and positions and narratively frame what participants can expect from a medical consultation viewed as a social episode; and (c) the positioning of rights and duties can lead to misunderstandings and frustrations. We conclude that residents and patients locate themselves in outpatient conversations as participants who jointly produce and are produced by patients' and nurses' storylines about who should take responsibility for treatment.

Patient-centered care in cancer treatment programs: the future of integrative oncology through psychoeducation

ABSTRACT 

The reciprocal relationship between the mind and body has been a neglected process for improving the psychosocial care of cancer patients. Emotions form an important link between the mind and body. They play a fundamental role in the cognitive functions of decision-making and symptom control. Recognizing this relationship is important for integrative oncology. We define psychoeducation as the teaching of self-evaluation and self-regulation of the mind–body process. A gap exists between research evidence and implementation into clinical practice. The patients’ search for self-empowerment through the pursuit of complementary therapies may be a surrogate for inadequate psychoeducation. Integrative oncology programs should implement psychoeducation that helps patients to improve both emotional and cognitive intelligence, enabling them to better negotiate cancer treatment systems.

Listening to patients with cancer: using a literary-based research method to understand patient-focused care

OBJECTIVE

In spite of considerable attention, patients diagnosed with cancer continue to report poor experiences of care. The root causes of this remain unclear. This exploratory study aimed to investigate new ways of understanding the experience of patients with cancer, using a literary-based research approach.

DESIGN

Interviews were undertaken with four patients diagnosed with high-grade brain cancers at least 6 months from diagnosis and with people (n=5) identified by the patients as important in their care pathway. Interview transcripts were analysed by humanities academics as pieces of literature, where each patient's story was told from more than one person's perspective. The academics then came together in a facilitated workshop to agree major themes within the patient experiences. The themes were presented at a patient and carer event involving 70 participants to test the validity of the insights.

RESULTS

Insights into the key issues for patients with cancer could be grouped into six themes: accountability; identity; life context; time; language; rigour and emotion. Patients often held a different perspective to the traditionally held medical views of what constitutes good care. For example, patients did not see any conflict between a doctor having scientific rigour and portraying emotion.

CONCLUSIONS

One key feature of the approach was its comparative nature: patients often held different views from those traditionally held by physicians of what constitutes health and good outcomes. This revealed aspects that may be considered by healthcare professionals when designing improvements. Proposals for further testing are discussed, with a particular emphasis on the need for sensitivity to individual differences in experiences.

The Sociology of Traditional, Complementary and Alternative Medicine

Complementary and alternative medicine (CAM) and traditional medicine (TM) are important social phenomena. This article reviews the sociological literature on the topic. First, it addresses the question of terminology, arguing that the naming process is a glimpse into the complexities of power and history that characterize the field. Second, focusing on the last 15 years of scholarship, it considers how sociological research on users and practitioners of TM/CAM has developed in that time. Third, it addresses two newer strands of work termed here the 'big picture' and the 'big question'. The big picture includes concepts that offer interpretation of what is happening at a societal level to constrain and enable observed patterns of social practice (pluralism, integration, hybridity and activism). The big question, 'Does it work?', is one of epistemology and focuses on two developing fields of critical enquiry - first, social critiques of medical science knowledge production and, second, attempts to explain the nature of interventions, i.e. how they work. Finally, the article examines the role of sociology moving forward.

Positive patient experiences in an Australian integrative oncology centre

Background

The purpose of this study was to explore the experiences of cancer patients’ utilising complementary and integrative therapies (CIT) within integrative oncology centres across Western Australia.

Methods

Across four locations 135 patients accessed CIT services whilst undergoing outpatient medical treatment for cancer. Of the 135 patients, 66 (61 ± 12 y; female n = 45; male n = 21) agreed to complete a personal accounts questionnaire consisting of open-ended questions designed to explore patients’ perceptions of CIT. All results were transcribed into nVivo (v9) and using thematic analysis, key themes were identified.

Results

Of the 66 participants, 100% indicated they would “recommend complementary therapies to other patients” and 92% stated “CIT would play a significant role in their future lifestyle”. A mean score of 8 ± 1 indicated an improvement in participants’ perception of wellbeing following a CIT session. Three central themes were identified: empowerment, support and relaxation. Fourteen sub-themes were identified, with all themes clustered into a framework of multifaceted views held by cancer patients in relation to wellbeing, role of significant others and control.

Conclusions

Exploration of patients’ experiences reveals uniformly positive results. One of the key merits of the environment created within the centres is patients are able to work through their cancer journey with an increased sense of empowerment, without placing them in opposition to conventional medical treatment. In order to effectively target integrative support services it is crucial to explore the experiences of patients in their own words and use those forms of expression to drive service delivery.

An oasis in the hospital: the perceived benefits of a cancer support center in a hospital setting offering complementary therapies

AIMS

The aim of this study was to explore and describe the experiences of persons attending a cancer support center, providing emotional support to cancer patients through self-selected complementary therapies offered free of charge through qualified volunteer therapists. A grounded theory methodology was used. Sources of data were 16 semistructured interviews with persons attending the center. Interviews were digitally recorded and transcribed verbatim. Analysis was conducted using the constant comparative method.

FINDINGS

The overarching theme that emerged in this study was the benefits attributed to attendance at the cancer support center. The center was described as an "oasis" in the hospital, and three aspects relating to this were identified: (a) facilitating comfort, (b) increasing personal control, and (c) helping make sense of the cancer experience.

CONCLUSION

A drop-in center offering complementary therapies appeared to enable coping with the diagnosis and treatment of cancer by facilitating comfort and increasing perceptions of personal control. The center also helped some participants to make sense of their experience with cancer. This research has provided a unique insight into the ongoing emotional needs of cancer patients, and directions for further development and research into the provision of holistic care for patients within a hospital setting.

The role of complementary and alternative medicine (CAM) routines and rituals in men with cancer and their significant others (SOs): a qualitative investigation

PURPOSE

Complementary and alternative medicine (CAM) is frequently used in cancer patients, often with contribution of the significant others (SOs), but without consultation of healthcare professionals. This research explored how cancer patients integrate and maintain CAM use in their everyday life, and how SOs are involved in it.

METHODS

In this qualitative study, male participants were selected from a preceding Australian survey on CAM use in men with cancer (94 % response rate and 86 % consent rate for follow-up interview). Semistructured interviews were conducted with 26 men and 24 SOs until data saturation was reached. Interview transcripts were coded and analyzed thematically, thereby paying close attention to participants' language in use.

RESULTS

A major theme associated with high CAM use was "CAM routines and rituals," as it was identified that men with cancer practiced CAM as (1) functional routines, (2) meaningful rituals, and (3) mental/spiritual routines or/and rituals. Regular CAM use was associated with intrapersonal and interpersonal benefits: CAM routines provided men with certainty and control, and CAM rituals functioned for cancer patients and their SOs as a means to create meaning, thereby working to counter fear and uncertainty consequent upon a diagnosis of cancer. SOs contributed most to men's uptake and maintenance of dietary-based CAM in ritualistic form resulting in interpersonal bonding and enhanced closeness.

CONCLUSIONS

CAM routines and rituals constitute key elements in cancer patients' regular and satisfied CAM use, and they promote familial strengthening. Clinicians and physicians can convey these benefits to patient consultations, further promoting the safe and effective use of CAM.

Networks of knowledge or just old wives’ tales?: A diary-based analysis of women’s self-care practices and everyday lay expertise

Complementary and alternative medicine is increasingly popular in Australia and particularly among women. While existing research provides some understanding of women’s engagement with complementary and alternative medicine and biomedicine, there has been comparatively little examination of the day-to-day character of their experiences. In this study, we utilise solicited diaries with women aged 60–65 years drawn from the 1946–1951 cohort of the Australian Longitudinal Study on Women’s Health to capture the temporal dimension of their therapeutic engagement. Focusing on 30 active complementary and alternative medicine users, we explore women’s experiences of managing their health, illness and well-being over a 1-month period. The themes that emerge from their diaries illustrate the day-to-day enactment of lay expertise through informal knowledge networks, practices of self-trialling and experimentation and the moralities underpinning self-care. The diaries provide unprecedented temporal insight into the (often problematic) enactment of lay expertise at the nexus of complementary and alternative medicine and biomedicine. They also point to the value of longitudinal techniques of data collection for augmenting more traditional sociological ways of exploring therapeutic pluralism.

Resisting medications: moral discourses and performances in illness narratives

Adherence research has been dominated by attitudinal approaches that isolate individual statements made in interviews and then assign a fixed attitude to the individual who made that statement. Despite much sociological research having raised questions about the notion of fixed attitudes, little research has theorised the process by which individual utterances about medicine-taking are produced as a form of resistance to medications within interviews. Using Goffman's concept of performance as a starting point, this article offers an alternative framework for conceptualising adherence presentations when provided in the form of a rhetorical narrative. Through the presentation of case material taken from interviews with participants who had not taken prophylactic asthma medications as prescribed, we develop Goffman's concept of performance to theorise the production of adherence talk in two important ways. First, individual performances can be seen to be shaped by how moral discourses of illness management transfer across contexts. Second, performances are subject to inequalities in the resources interactants have access to. An extended definition of Goffman's concept of performance is thus offered, arguing that the 'meaning' of individual performances is produced by a combination of which moral discourses interactants orientate to and which discourses are used to categorise individuals.

Bodies of knowledge: Nature, holism and women’s plural health practices

The proliferation of complementary and alternative medicine (CAM), and women’s high level of engagement with these practices, has presented sociology with a range of questions regarding gender, embodiment and identity work in the context of contemporary medical pluralism. The current study, drawing on 60 qualitative interviews with women from the Australian Longitudinal Study on Women’s Health (ALSWH), examines how a group of Australian women negotiate CAM and biomedicine in a range of health and illness contexts. Selected from the mid-aged cohort of this national study, here we explore their accounts of engagement with CAM and biomedicine, unpacking their logics underpinning, and rhetorical practices surrounding, their therapeutic engagement. The results provide significant insight into: the importance of ideas about nature, holism and strengthening; perceptions of the harshness and softness of medicines for women’s bodies; and, the relative importance of scientific proof vis-a-vis individual subjectivities. Ultimately, their accounts illustrate gendered and embodied strategies of strategic integration, and importantly, border crossing. We conclude that while women’s engagement with CAM and biomedicine may be indeed be gendered in character, we suggest a rethinking of gender-based resistance (to biomedicine) or gender-alignment (to CAM) arguments; the notion of women as designers would more adequately capture the landscapes of contemporary medical pluralism.

Lifestyle and self-care advice within traditional acupuncture consultations: a qualitative observational study nested in a co-operative inquiry

OBJECTIVES

The study objective was to develop methodology for observational research within traditional acupuncture consultations in community-based practice, and to explore how traditional acupuncturists communicate with patients about lifestyle and self-care.

DESIGN

This was a mixed-method qualitative study, using audio-recording of consultations followed by telephone interviews of patients. The study was nested within a cooperative inquiry. As co-researchers, group members participated in framing the research questions, deciding methods to be used, and discussing the emergent findings.

SETTINGS

Four (4) experienced traditional acupuncture practitioners, registered with the British Acupuncture Council, contributed to the co-operative enquiry and recorded consultations in three clinics in Somerset.

SUBJECTS

Subjects comprised a convenience sample of patients attending 21 consultations. A purposive subsample of patients was selected for interview.

RESULTS

Audio-recording was challenging to some practitioners who felt that it might result in infrequent, but nevertheless worrying, withholding of personal information by patients. Patients, however, reported that they were generally positive about the audio-recording. Each consultation was analyzed as a trajectory in which eight categories of talk interwove with each other and with periods of physical examination, needling, and silence. Trajectories showed where talk about self-care ("self-care talk") appeared in the consultations, the content of such talk, and who initiated it. The data confirmed that self-care advice arises from, and is explained in terms of, each person's individual Chinese Medicine diagnosis. The identification of different types of talk and the way that "self-care talk" is interwoven throughout the consultation emphasized the integral nature of self-care support and advice in the practice of traditional acupuncture. Some patients had difficulty putting self-care advice into practice, even when they were intellectually committed to it, suggesting that practitioners may need to follow up more carefully on the advice they have given.

CONCLUSIONS

Self-care in traditional acupuncture consultations is integral, interactive, and individualized. This study has mapped out a potential agenda for research into self-care in traditional acupuncture consultations and illustrates the exciting opportunities that open up when observational and interview data are combined.

Putting the pieces together: endometriosis blogs, cognitive authority, and collaborative information behavior

OBJECTIVE

A discourse analysis was conducted of peer-written blogs about the chronic illness endometriosis to understand how bloggers present information sources and make cases for and against the authority of those sources.

METHODS

Eleven blogs that were authored by endometriosis patients and focused exclusively or primarily on the authors' experiences with endometriosis were selected. After selecting segments in which the bloggers invoked forms of knowledge and sources of evidence, the text was discursively analyzed to reveal how bloggers establish and dispute the authority of the sources they invoke.

RESULTS

When discussing and refuting authority, the bloggers invoked many sources of evidence, including experiential, peer-provided, biomedical, and intuitive ones. Additionally, they made and disputed claims of cognitive authority via two interpretive repertoires: a concern about the role and interests of the pharmaceutical industry and an understanding of endometriosis as extremely idiosyncratic. Affective authority of information sources was also identified, which presented as social context, situational similarity, or aesthetic or spiritual factors.

CONCLUSIONS

Endometriosis patients may find informational value in blogs, especially for affective support and epistemic experience. Traditional notions of authority might need to be revised for the online environment. Guidelines for evaluating the authority of consumer health information, informed by established readers' advisory practices, are suggested.

Patient decision-making about complementary and alternative medicine in cancer management: context and process

Objective

In this paper, we set out to describe the personal and social contexts of treatment decisions made by cancer patients concerning complementary and alternative medicine (cam) and also the process through which cancer patients reach cam decisions throughout the cancer trajectory.

Methods

We selected and reviewed a variety of cam decision-making models published in the past 10 years within the Canadian health literature.

Results

The cam decision-making process is influenced by a variety of sociodemographic, disease-related, psychological, and social factors. We reviewed four main phases of the cam decision-making process:

Immediately following diagnosis, cancer patients become interested in taking stock of the full spectrum of conventional and cam treatment options that may enhance the effectiveness of their treatment and mediate potential side effects. Information about cam is then gathered from numerous information sources that vary in terms of credibility and scientific legitimacy, and is evaluated. When making a decision regarding cam options, patients attempt to make sense of the diverse information obtained, while acknowledging their beliefs and values. The cam decision is often revisited at key milestones, such as the end of conventional treatment and when additional information about disease, prognosis, and treatment is obtained.

Conclusions

The cam decision-making process is a dynamic and iterative process that is influenced by a complex array of personal and social factors. Oncology health professionals need to be prepared to offer decision support related to cam throughout the cancer trajectory.

Cancer survivorship in the age of YouTube and social media: a narrative analysis

Background

As evidenced by the increasing popularity of YouTube (www.youtube.com), personal narratives shared through social media are an area of rapid development in communication among cancer survivors. Identifying the thematic and linguistic characteristics of YouTube cancer stories can provide a better understanding of this naturally occurring communication channel and inform social media communication efforts aiming to use personal stories to reach individuals with serious illnesses.

Objective

The objective of our study was to provide an in-depth description of authentic personal cancer stories. Through a linguistically based narrative analysis of YouTube stories, the analysis explicates the common attributes of these narratives.

Methods

Informed by narrative theories, we conducted an iterative, bottom-up analysis of 35 YouTube videos identified by the search terms “cancer survivor” and “cancer stories”. A list of shared thematic and linguistic characteristics was identified and analyzed.

Results

A subnarrative on the cancer diagnosis was present in 86% (30/35) of the stories under analysis. These diagnostic narratives were characterized by dramatic tension, emotional engagement, markers of the loss of agency or control, depersonalized reference to the medical personnel, and the unexpectedness of a cancer diagnosis. The analysis highlights the themes of story authenticity and emotional engagement in this online communication medium.

Conclusions

Internet advances have enabled new and efficient exchange of personal stories, including the sharing of personal cancer experience among cancer survivors and their caregivers. The analytic results of this descriptive study point to the common characteristics of authentic cancer survivorship stories online. Furthermore, the results of this descriptive study may inform development of narrative-based communication, particularly in maintaining authenticity and emotional engagement.

Prostate cancer support groups, health literacy and consumerism: are community-based volunteers re-defining older men's health?

In this article we describe the connections between prostate cancer support groups (PCSGs) and men's health literacy and consumer orientation to health care services. The study findings are drawn from participant observations conducted at 16 PCSGs in British Columbia, Canada and 54 individual interviews that focused on men's experiences of attending group meetings. Men's communication and interactions at PCSGs provide important insights for how men talk about and conceptualize health and illness. For example, biomedical language often predominated at group meetings, and men used numbers and measures to engage with risk discourses in linking prostate cancer markers to various treatment options and morbidity and mortality rates. Many groups afforded opportunities for men to interact with health care providers as a means to better understand the language and logic of prostate cancer management. The health literacy skills fostered at PCSGs along with specific group-informed strategies could be mobilized in the men's subsequent clinical consultations. Consumer discourses and strategies to contest power relations with health care professionals underpinned many men's search for prostate cancer information and their commitment to assisting other men. Key were patients' rights, and perhaps responsibility, to compare diverse health products and services in making decisions across the entire trajectory of their prostate cancer. Overall, the study findings reveal PCSGs as having the capacity to contest as well as align with medical expertise and services facilitating men's transition from patient to informed health care consumers. The processes through which this occurs may direct the design of older men's health promotion programs.

The experience of using complementary therapies after a diagnosis of cancer: a qualitative synthesis

This article describes a qualitative synthesis of published research on cancer patients' experiences of complementary therapies. We conducted a systematic search for qualitative studies on this subject published between 1998 and 2007. Twenty-six refereed journal articles met the inclusion criteria. These 26 articles were repeatedly read by the research team and key concepts emerging from them were identified. Differences and variations were examined in association with treatment, therapy type and by stage of cancer (early stage, mid-treatment, advanced cancer, palliative care and long term 'survivors'). Six overarching concepts were located, which describe the key aspects of patients' experiences of the use of complementary and alternative medicine after a diagnosis of cancer: Connection; Control; Well-being; Transformation; Integration; and Polarization. These are described in a 'line of argument' synthesis, and differences associated with treatment type and stage of disease are noted. The findings are presented in a table showing the six concepts according to treatment type and stage; as a composite story; and in a diagrammatic model showing the individual, practitioner and organizational levels. The synthesis identified various specific ways in which complementary therapies supported cancer patients, as well as occasional negative effects. The most notable barrier was the perceived polarization of complementary therapies and biomedicine; patients reported better experiences in integrated settings.

Giving patients responsibility or fostering mutual response-ability: family physicians' constructions of effective chronic illness management

Current visions of family medicine and models of chronic illness management integrate evidence-based medicine with collaborative, patient-centered care, despite critiques that these constructs conflict with each other. With this potential conflict in mind, we applied a critical discursive psychology methodology to present discursive patterns articulated by 13 family physicians in Ontario, Canada, regarding care of patients living with multiple chronic illnesses. Physicians constructed competing versions of the terms "effective chronic illness management" and "patient involvement." One construction integrated individual responsibility for health with primacy of "evidence," resulting in a conceptualization consistent with paternalistic care. The second constructed effective care as involving active partnership of physician and patient, implying a need to foster the ability of both practitioners and patients to respond to complex challenges as they arose. The former pattern is inconsistent with visions of family medicine and chronic illness management, whereas the latter embodies it.

El enfermo de cáncer: una aproximación a su representación social

Esta investigación tiene como objetivo el análisis de la representación social del cáncer y de los enfermos oncológicos en la población española. Para ello se entrevistaron a 200 sujetos elegidos mediante muestreo al azar. El método utilizado fue la realización de entrevistas estructuradas que contenían asociaciones libres de palabras ante términos estimulo y preguntas semicerradas. Las respuestas obtenidas son analizadas a partir de análisis descriptivos y análisis de contenido. Los resultados nos indican que existe una representación social del cáncer y del enfermo oncológico y que parte de ella sufre variaciones en función de la pertenencia a determinadas categorías o grupos sociales. Estos resultados son relevantes en el contexto sanitario ya que dicho conocimiento permite a los sanitarios analizar su comunicación con el paciente y poder llevar a cabo un trato diferenciado del enfermo de cáncer, no por su pertenencia social a un grupo de enfermos determinado sino por sus peculiaridades personales lo que incrementa la efectividad de la acción profesional.

Agency and communication challenges in discussions of informed consent in pediatric cancer research

In this article we examine the discourse of four focus groups we conducted at a pediatric research hospital in which we queried teenage patients, parents, nurses, and physicians about their perceptions of the informed consent process in research. Autonomy, as the goal of informed consent, is a murky concept, with some ethicists questioning the possibility that it can ever be attained. We argue that it might be more productive to consider agency, which we define as language and action that are constructed, negotiated, and maintained through effective communication. Our goal was to understand how individuals rhetorically constructed agency in discussions of informed consent experiences. After transcribing and coding the focus group interviews, we identified six aspects of agency in participants' discourse: (a) defining roles, (b) seeking information, (c) providing information, (d) supporting others, (e) making decisions, and (f) claiming agency for self. Examining these aspects of agency indicated that efforts to improve the informed consent process must address: (a) status differentials, (b) role definitions, (c) information flow, and (d) relationships.

Cancer Patients' Experiences of Using Complementary Therapies: Polarization and Integration

Objective

The use of complementary therapies by people with cancer is commonplace. In a recent synthesis of 26 qualitative studies of patients' experiences of complementary therapy use after a diagnosis of cancer, the emergent theme of ‘polarization’ was the most notable barrier to a positive experience of complementary therapies. In this paper, we explore the two synthesis concepts of ‘polarization’ and ‘integration’, and their relationship to health service policies and guidelines on integrated services.

Methods

A systematic literature search and a meta-ethnography to synthesize key concepts.

Results

The majority of patients who used complementary therapies after a diagnosis of cancer wanted to be certain that the therapies were not interfering with their conventional cancer treatment. They valued the therapies in wider terms including: taking ‘a niche of control’, relieving symptoms, improving wellbeing, and promoting reconnection and social interaction. The emergent theme of ‘polarization’ suggested that conventional physicians who are perceived to be poorly informed or negative about complementary approaches induce patient anxiety, safety concerns, and difficulties in access. They may compromise their therapeutic relationship and, rarely, they may trigger patients to abandon conventional medicine altogether. In contrast, integrated advice and/or services were highly valued by patients, although some patients preferred their complementary health care to be provided in a non-medicalized environment.

Conclusions

Our findings suggest that the current polarized situation is unhelpful to patients, detrimental to therapeutic relationships and may occasionally be dangerous. They indicate that complementary therapies, in a supportive role, should be integrated into mainstream cancer care.

Informing evidence: claimsmaking in midwives' and clients' talk about interventions

Communication for informed choice is particularly challenging in clinical settings such as direct-entry midwifery, where the care model embraces diverse therapies and forms of knowledge. We identified three discursive moves (explanation, invocation, and evaluation) that Ontario midwives and clients used in making claims about proposed interventions. The analysis was informed by an understanding of communication as an interactionally situated and socially constructed interpretive practice. Both midwives and women called on the authority of biomedical discourse, but they also turned to sources such as women's wisdom to support their cases. The flexible use of these moves afforded participants considerable latitude in accepting or rejecting forms of evidence as authoritative. However, strategies designed to empower clients in making choices could unintentionally serve to enhance the authority of the care provider. Talk about interventions brings into view both the knowledge systems and the broader relations within which regulated midwifery practice operates.

Intuition, subjectivity, and Le bricoleur: cancer patients' accounts of negotiating a plurality of therapeutic options

Cancer patients are now combining complementary and alternative medicine (CAM) with biomedical cancer treatments, reflecting an increasingly pluralistic health care environment. However, there has been little research done on the ways in which cancer patients juggle multiplicity in claims to expertise, models of disease, and therapeutic practice. Drawing on the accounts of cancer patients who use CAM, in this article I develop a conceptualization of therapeutic decision making, utilizing the notion of bricolage as a key point of departure. The patient accounts illustrate the "piecing together" (or bricolage) of therapeutic trajectories, drawing on intuitive, embodied knowledge, as well as formalized "objective" scientific expertise. Le bricoleur, as characterized here, actively mediates, rather than accepts or rejects CAM or biomedicine, and utilizes a combination of scientific expertise, embodied physicality, and social knowledge to make decisions and assess therapeutic effectiveness. Although these "border crossings" are potentially subversive of established biomedical expertise, the analysis also illustrates the structural constraints (and penalties) associated with bricolage, and furthermore, the interplay of a repositioning of responsibility with neoliberal forms of self-governance.

Oncology clinicians' accounts of discussing complementary and alternative medicine with their patients

The profile of complementary and alternative medicine (CAM) has risen dramatically over recent years, with cancer patients representing some of the highest users of any patient group. This article reports the results from a series of in-depth interviews with oncology consultants and oncology nurses in two hospitals in Australia. Analysis identifies a range of self-reported approaches with which oncology clinicians discuss CAM, highlighting the potential implications for patient care and inter-professional dynamics. The interview data suggest that, whilst there are a range of consultant approaches to CAM, ;risk' is consistently deployed rhetorically as a key regulatory strategy to frame CAM issues and potentially direct patient behaviour. Moreover, ;irrationality', ;seeking control', and ;desperation' were viewed by consultants as the main drivers of CAM use, presenting potential difficulties for effective doctor-patient dialogue about CAM. In contrast, oncology nurses appear to perceive their role as that of CAM and patient advocate - an approach disapproved of by the consultants on their respective teams, presenting implications for oncology teamwork. CAM education emerged as a contentious and crucial issue for oncology clinicians. Yet, while viewed as a key barrier to clinician-patient communication about CAM, various forms of individual and organizational resistance to CAM education were evident. A number of core issues for clinical practice and broader work in the sociology of CAM are discussed in light of these findings.

Exploring the temporal dimension in cancer patients' experiences of nonbiomedical therapeutics

To date, research on complementary and alternative medicine (CAM) use by cancer patients has tended to provide a "snapshot" of experience, with little attention given to the evolution of experience over time. Drawing on data from solicited diaries, this article examines individual cancer patients' temporal experiences of CAM. Our findings suggest that experiences of CAM are variable over time and space, and furthermore, that the everyday act of "doing CAM" is considerably more problematic than is often reported in face-to-face interview or survey studies. This is explored in relation to the tension between the perceived need for restrictive self-discipline alongside a sense of the emancipatory potential of CAM; the role of CAM therapists in reconceptualizing disease; and the complex interplay between CAM-derived notions of self-healing and acceptance of individual mortality. We argue that an emphasis on the temporality of cancer patients' CAM engagement is necessary to access a more nuanced understanding of the lived experiences of cancer patients.

Cancer patients' negotiation of therapeutic options in Pakistan

Cancer is the second leading cause of death in Pakistan. There is increasing evidence that patients are using a range of (biomedical and nonbiomedical) therapeutic options for cancer treatment. To date there has been no sociologically informed research into the engagement of cancer patients in Pakistan with available modalities. In this article, the authors present findings from the first such study. They purposively sampled 46 cancer patients from four hospitals in Lahore and conducted semistructured interviews with them. They argue that individuals are actively mediating therapeutic possibilities by drawing on, and at times being constrained by, personal, social, and cultural resources. It is the authors' contention that this can be conceptualized by an appreciation of individuals' active engagement with three temporally and spatially specific dimensions: structural and practical constraint; pragmatic experimentation; and cultural and religious affiliation. The negotiation (and varying power) of these dimensions is crucial to the process.

Pragmatic pluralism: Mutual tolerance of contested understandings between orthodox and alternative practitioners in autologous stem cell transplantation

High-dose chemotherapy and autologous stem cell transplantation (ASCT) is used to treat some advanced malignancies. It is a traumatic procedure, with a high complication rate and significant mortality. ASCT patients and their carers draw on many sources of information as they seek to understand the procedure and its consequences. Some seek information from beyond orthodox medicine. Alternative beliefs and practices may conflict with conventional understanding of the theory and practice of ASCT, and 'contested understandings' might interfere with patient adherence to the strict and demanding protocols required for successful ASCT. The present study, conducted in Sydney, Australia, examines narrative-style interviews with 10 sequentially recruited ASCT patients and nine of their carers conducted at the time of transplant and three months later. Transcripts were read for instances of mention of alternative advice, and for instances of contested understanding of information relevant to the transplant. Patients and carer pairs expressed closely concordant views about alternative advice. Five pairs were consulting alternative practitioners. Contested understanding was expressed in four domains--understandings of the transplant itself and its underlying theory, of the relationship between the components of the 'transplant', of the nature and role of stem cells, and of beliefs about bodily function and life-style. Contested understandings of the transplant treatment were expressed as predominantly personal interpretations of orthodox information. Patients and carers seemed to recognise that alternative and conventional systems were discordant, yet they were able to separate the two, and adhere to each practice without prejudicing their medical treatment. A single case of late, post-transplant repudiation of Western medicine is discussed to emphasise some of the possible determinants of dissonance when it does occur.

The influence of significant others in complementary and alternative medicine decisions by cancer patients

Individuals living with cancer are faced with numerous treatment decisions that encompass both conventional therapies and complementary and alternative medicine (CAM). Although a beginning body of research has explored the CAM decision-making process by cancer patients, the social context of these treatment decisions has been largely ignored. As a part of a larger grounded theory research project exploring CAM decision-making processes of cancer patients living in British Columbia, Canada, the purpose of this secondary inquiry was to explore how significant others were involved in patients' decisions related to CAM. In total, 61 patients with early and advanced-stage breast and prostate cancer and 31 significant others participated in semi-structured interviews. Using constant comparative analysis, four main types of decisional involvement by significant others were identified: creating a safe place for the patient to make a decision, "becoming a team": collaborative decision-making, moving the patient towards a decision, and making the decision for the patient. Significant others were often found to engage in more than one type of decision involvement as a consequence of several key factors. Within the types of decisional involvement, nine distinct roles in the CAM decision-making process were described by the significant others. The findings of this inquiry extend previous research by highlighting the importance of significant others in cancer patients' CAM decisions and challenge past conceptualizations of autonomy in treatment decision making.

Naturopathy/herbalism consultations by mid-aged Australian women who have cancer

Complementary and alternative medicine (CAM) is now a significant practice issue for those delivering cancer care with a range of CAM being utilized by a significant number of patients with cancer. While various studies have explored the prevalence of CAM use among cancer patients, little is currently known about naturopathy/herbalism use by patients with cancer in Australia. This paper reports the prevalence of naturopath/herbalist consultations among mid-aged Australian women with cancer. The research was conducted as part of the Australian Longitudinal Study on Women's Health, with the data for this analysis coming from the third survey of 11,202 women aged 50-55, conducted in 2001. For all cancers combined, 15.7% of women with cancer were found to consult a naturopath/herbalist. Mid-aged women with cancer were found to be more likely to consult a naturopath/herbalist than mid-aged women without cancer. Naturopathy/herbalism consultations appear to be utilized by the women with cancer alongside and as a supplement to conventional health services. Given the prevalence of consultations with herbal therapists/naturopaths among mid-aged women with cancer in Australia, it is important that physicians and others involved in cancer patient care and management are informed and educated about naturopathy/herbalism and its use among their patients.

Core assumptions and research opportunities in clinical communication

OBJECTIVE

Contemporary clinical communication teaching and research reflect the axiomatic importance of building a clinical relationship and of empowering patients as partners. The apparent moral unassailability of these principles has inhibited their scientific scrutiny. By questioning this current hegemony in communication teaching and research, our objective is to identify research opportunities that remain to be fully exploited.

METHOD

We identify assumptions in current communication literature and evaluate them from the perspective of relevant empirical and theoretical literature.

FINDINGS

The view that the clinical relationship is an objective thing which needs to be 'built' can lead researchers to neglect factors within patients that influence their subjective sense of the relationship. The model of partnership is hard to reconcile with patients' vulnerability and associated dependency needs. The widespread use of the term 'communication skills' emphasises processes at a skill level at the expense of those at levels of cognition, emotion, and value.

CONCLUSION

Research is needed into: the extent to which patients' sense of relationship arises from factors outside the relationship; the implications of their vulnerability and dependency for clinical relationships; and the processes at the level of cognition, emotion and value, as well as skill, that are entailed in clinical communication and in communication teaching. RESEARCH AND PRACTICE IMPLICATIONS: Pursuing the research opportunities that we have identified will enhance the theoretical validity and practical relevance of clinical communication research and teaching.