Yael Keshet

Complementary medicine in the primary care setting: Results of a survey of gender and cultural patterns in Israel.

OBJECTIVE The purpose of this study was to examine the use of complementary and alternative medicine (CAM) in a primary care practice in Israel to determine prevalence and patterns of use. METHODS Trained research assistants invited all patients attending the administrative, medical, pharmaceutical, or nursing services of 7 clinics in urban and rural areas of northern Israel over a 16-month period, from April 1, 2005, through August 1, 2006, to complete a 13-item written questionnaire about CAM use and beliefs about CAM safety and efficacy. CAM was defined as therapies often referred to as alternative, complementary, natural, or folk/traditional medicine, and which are not usually offered as part of the medical treatment in the clinic, including herbal medicine, Chinese medicine (including acupuncture), homeopathy, folk and traditional remedies, dietary/nutritional therapy (including nutritional supplements), chiropractic, movement/manual healing therapies (including massage, reflexology, yoga, and Alexander and Feldenkrais techniques), mind-body techniques (including meditation, guided imagery, and relaxation), energy and healing therapies, and other naturopathic therapies. The Pearson chi(2) test and multivariate logistic regression were used to assess univariate associations with the odds ratios of CAM use among Arab and Jewish women. A t test was performed to determine whether there were any differences in the continuous variables between the 2 groups. RESULTS Of 3972 consecutive patients who received the questionnaire, 3447 responded; 2139 respondents (62%) were women. Of the female respondents, 2121 reported their religion (1238 respondents [58%] self-identified as being Arab, and 883 [41.6%] as being Jewish). Compared with men, more women used CAM during the previous year (46.4% vs 39.4%; P < 0.001). Women were more likely to use CAM and to be interested in receiving CAM at primary care clinics. Arab women reported less CAM use than Jewish women but were more interested in experiencing CAM, had a higher degree of confidence in CAM efficacy and safety, and more frequently supported the integration of CAM practitioners in primary care clinics. CONCLUSIONS In this study, women visiting primary care clinics in northern Israel used CAM more often than men did. Arab women reported less use of CAM than did Jewish women but also reported greater confidence in CAM efficacy and safety.

The use of boundary objects to enhance interprofessional collaboration: integrating complementary medicine in a hospital setting

Because of the inherent complexity of human health, the provision of good quality patient care requires collaboration in multidisciplinary teams. Integrative healthcare provides a unique setting for the study of interprofessional collaboration in the context of power disparities. The research objective was to examine which means and mechanisms were used to facilitate interprofessional collaboration when integrating complementary medicine (CM) into a hospitals surgical department. Throughout 2010 we conducted a qualitative study in an Israeli public hospitals surgical department, using observations and 30 in-depth interviews with managers, surgeons, physicians, nurses, patients and CM practitioners. The sociological concepts of boundary actor and boundary object and the context of power relations served as a framework for this research. This article contributes to the field of interprofessional collaborative care research by: analysing types of collaboration inhibitors--epistemological and social-structural gaps; pointing to boundary actors who establish interprofessional collaboration in an integrative hospital setting and noting the boundary objects they use; and comparing collaboration levels. The collaboration between CM practitioners and the departments staff is a loosely coupled system. When coordination was achieved, reaching profound agreements seemed of lesser importance to the parties. Closer collaboration and cross-fertilisation were found among CM practitioners.

Attitudes of patients with gynecological and breast cancer toward integration of complementary medicine in cancer care.

Objective The purpose of this study was to explore prospectively the perspectives of patients with breast and gynecological cancers regarding integration of complementary and alternative medicine (CAM) in conventional oncology settings. Methods We developed a 27-item questionnaire that was administered to convenient sample of patients with breast cancer and another with gynecological cancer who were attending a community-based oncology service in northern Israel. Results Of the 275 respondents, 109 (39.6%) had gynecological cancers and 166 (60.4%) had breast cancer. Current and/or previous year CAM use for oncology treatment was significantly higher among the patients with gynecological cancer (73/166 [44%] vs 67/106 [63%], P = 0.03). A logistic regression model indicated that CAM use was associated with gynecological cancer (EXP [B], 2.51; 95% confidence interval for EXP [B], 1.29–4.88; P = 0.007], younger age, Jewish religion, and lesser degree of religiosity. The patients highly expected their gynecologist-oncologist and family doctor to refer them to CAM counseling. Moreover, they expected their gynecologist-oncologist to participate in building a CAM treatment plan if CAM were to be integrated into the oncology service. The patients expected the CAM consultant to inform them of the safety and efficacy of CAM treatments, emphasizing expectations to strengthen their general ability to cope with the disease, reduce chemotherapy side effects, and provide emotional and spiritual support. Conclusion Although patients with gynecological malignancies use CAM significantly more than patients with breast cancer, both groups share similar conceptions regarding the active role of their gynecologist oncologists in the process of CAM integration within supportive care and expect CAM consultation to focus on improving their well-being.

Dual embedded agency: Physicians implement integrative medicine in health-care organizations

The paradox of embedded agency addresses the question of how embedded agents are able to conceive of new ideas and practices and then implement them in institutionalized organizations if social structures exert so powerful an influence on behavior, and agents operate within a framework of institutional constraints. This article proposes that dual embedded agency may provide an explanation of the paradox. The article draws from an ethnographic study that examined the ways in which dual-trained physicians, namely medical doctors trained also in some modality of complementary and alternative medicine, integrate complementary and alternative medicine into the biomedical fortress of mainstream health-care organizations. Participant observations were conducted during the years 2006–2011. The observed physicians were found to be embedded in two diverse medical cultures and to have a hybrid professional identity that comprised two sets of health-care values. Seeking to introduce new ideas and practices associated with complementary and alternative medicine to medical institutions, they maneuvered among the constraints of institutional structures while using these very structures, in an isomorphic mode of action, as a platform for launching complementary and alternative medicine practices and values. They drew on the complementary and alternative medicine philosophical principle of interconnectedness and interdependency of seemingly polar opposites or contrary forces and acted to achieve change by means of nonadversarial strategies. By addressing the structure–agency dichotomy, this study contributes to the literature on change in institutionalized health-care organizations. It likewise contributes both theoretically and empirically to the study of integrative medicine and to the further development of this relatively new area of inquiry within the sociology of medicine.

Giving voice to cancer patients: assessing non‐specific effects of an integrative oncology therapeutic program via short patient narratives

The aim of this study was to assess patient perspectives regarding non‐specific effects of a complementary medicine (CM) consultation and intervention within an integrative oncology setting.

Integration of Herbal Medicine in Primary Care in Israel: A Jewish-Arab Cross-Cultural Perspective

Herbal medicine is a prominent complementary and alternative medicine (CAM) modality in Israel based on the countrys natural diversity and impressive cultural mosaic. In this study, we compared cross-cultural perspectives of patients attending primary care clinics in northern Israel on herbal medicine specifically and CAM generally, and the possibility of integrating them within primary care. Research assistants administered a questionnaire to consecutive patients attending seven primary care clinics. About 2184 of 3713 respondents (59%) defined themselves as Muslims, Christians or Druze (henceforth Arabs) and 1529 (41%) as Jews. Arab respondents reported more use of herbs during the previous year (35 versus 27.8% P = .004) and of more consultations with herbal practitioners (P < .0001). Druze reported the highest rate of herbal consultations (67.9%) and Ashkenazi Jews the lowest rate (45.2%). About 27.5% of respondents supported adding a herbal practitioner to their clinics medical team if CAM were to be integrated within primary care. Both Arabs and Jews report considerable usage of herbal medicine, with Arabs using it significantly more. Cross-cultural perspectives are warranted in the study of herbal medicine use in the Arab and Jewish societies.

Can holism be practiced in a biomedical setting? A qualitative study of the integration of complementary medicine to a surgical department

In recent decades, complementary medicine (CM) has been increasingly integrated to conventional healthcare organizations, in which the biomedical profession clearly maintains dominance. Our objective was to investigate empirically what integration and ‘holism’ mean to the diverse professional groups involved and whether treatment becomes more holistic when CM is integrated. A qualitative study was conducted in a general surgery department at a public hospital in Israel. Data were collected by means of observations of medical encounters and daily work, and 30 in-depth interviews with medical directors, surgeons, senior nurses, CM practitioners and hospitalized patients. We found that most of the interviewed nurses, surgeons and directors and some patients believed that CM treatments were of value in addressing the psychological needs of patients within this predominantly somatic-oriented department. To CM practitioners and some of the patients, integration means introducing and practicing a holistic outlook in this biomedical context, which involves elements such as Qi, energy, soul and spirit. Such practices were directed to a suitable audience, namely, patients as well as conventional medical staff who were willing to explore a holistic approach. We concluded that patient care tends to become more comprehensive when CM is integrated. Despite the overall dominance of biomedicine, holistic CM practices were introduced to the biomedical setting of the hospital. Yet, the question whether holistic CM practices and perceptions will eventually lead nurses and physicians toward paradigmatic integration, has still to be examined.

Intersectionality and underrepresentation among health care workforce: the case of Arab physicians in Israel

BackgroundAn intersectionality approach that addresses the non-additive influences of social categories and power structures, such as gender and ethnicity, is used as a research paradigm to further understanding the complexity of health inequities. While most researchers adopt an intersectionality approach to study patients’ health status, in this article we exemplify its usefulness and importance for studying underrepresentation in the health care workforce. Our research objectives were to examine gender patterns of underrepresentation in the medical profession among the Arab minority in Israel.MethodsWe used both quantitative and qualitative methodologies. The quantitative data were obtained from the 2011 Labor Force Survey conducted by the Israeli Central Bureau of Statistics, which encompassed some 24,000 households. The qualitative data were obtained through ten semi-structured, in-depth interviews conducted during 2013 with Arab physicians and with six nurses working in Israeli hospitals.ResultsThe findings indicate that with respect to physicians, the Arab minority in Israel is underrepresented in the medical field, and that this is due to Arab women’s underrepresentation. Arab women’s employment and educational patterns impact their underrepresentation in medicine. Women are expected to enter traditional gender roles and conform to patriarchal and collectivist values, which makes it difficult for them to study medicine.ConclusionsUsing an intersectionality approach to study underrepresentation in medicine provides a foundation for action aimed at improving public health and reducing health disparities.

Workforce ethnic diversity and culturally competent health care: the case of Arab physicians in Israel

Objectives. In recent years, a growing body of literature has been calling for ethnic diversity in health systems, especially in multicultural contexts. Ethnic diversity within the health care workforce is considered to play an important role in reducing health disparities among different ethnic groups. Methods. The present study explores the topic using quantitative data on participation of Arab employees in the Israeli health system and qualitative data collected through semi-structured interviews with Arab physicians working in the predominantly Jewish Israeli health system. Results. We show that despite the underrepresentation of Arabs in the Israeli health system, Arab physicians who hold positions in Israeli hospitals do not perceive themselves as representatives of the Arab sector; moreover, they consider themselves as having broken through the ‘glass ceiling’ and reject stereotyping as Arab ‘niche doctors.’ Conclusions. We conclude that minority physicians may prefer to promote culturally competent health care through integration and advocacy of interaction with the different cultures represented in the population, rather than serving as representatives of their own ethnic minority population. These findings may concern various medical contexts in which issues of ethnic underrepresentation in the health system are relevant, as well as sociological contexts, especially those regarding minority populations and professions.

Attitudes of Arab-Muslims toward integration of complementary medicine in primary-care clinics in Israel: the Bedouin mystery.

Introduction. In this study, we have compared attitudes of two social groups within the Israeli-Muslim population in order to examine the influence of modernization on the use of traditional and Complementary/Alternative Medicine (CAM). Research design and methods. We developed a 13-item questionnaire that addresses issues of CAM use, expectations from the primary-care physicians concerning CAM and attitudes toward CAM integration within the patients primary-care clinic. Data for statistical analysis were obtained from 472 respondents who defined themselves as Bedouins and 869 non-Bedouins attending five primary-care clinics. Results. Respondents in the two groups were equally distributed by demographic characteristics. Bedouin respondents reported less CAM use during the previous year (26.3% vs. 50.2%, P<0.0001), and less use of traditional medicine and herbs. Compared to non-Bedouins, Bedouin respondents who were considering CAM use expressed more drug reluctance. Respondents in both groups greatly supported a theoretical scenario of CAM integration in primary-medical care, and expected their family practitioner to initiate the referral to CAM. Bedouin respondents held higher expectations for their physician to refer them to CAM and to offer CAM treatment in the clinic. Moreover, Bedouins expected to receive CAM in a primary-care setting, and supported the option that their family physician would provide CAM in such a setting more than the non-Bedouin Muslims did. Conclusions. We hypothesize that the two communities differ due to later modernization in the Bedouin society that may highly regard and pursue medical science while forsaking traditional and herbal medicine.