Patients' reasons for choice of physician and expectations
Substantial difference between two groups was found in terms of procedure-related motives. CAM patients stated that a preference for a specific procedure, desire of a comprehensive/mild treatment, and their personal conviction were of great importance to them. At the same time, very few CONV patients mentioned those reasons.
Twice as many CAM patients (compared to CONV) chose their practitioner because of recommendations. Parents' reasons for choices on behalf of their children were similar to those of adult patients.
There are currently three main reasons explaining patients' choice of alternative medicine.
1. Dissatisfaction with orthodox medicine: necessity to treat conditions unresponsive to conventional treatments and/or negative past experiences with conventional medical services. This theory implies that people are choosing alternative health care for expedient reasons: CAM methods are perceived not only as effective, but also as milder and causing less adverse side-effects [1, 17, 21].
2. Determination for more personal involvement in the healing process in order to keep control over own health care decisions. This may result not only in sole preference for CAM, but also in a choosing of combined use of CAM and CONV methods [7, 22].
3. Philosophical compatibility: CAM therapies are attractive because they are perceived as more congruent with patients' spiritual/religious values, beliefs or philosophy regarding the nature and meaning of health and illness [23–25].
The first theory does not account for all patient choices but plays a certain role along with the other two . The latter two are not related to clinical success and are often associated with globalization, and include more sophisticated consumer choice and increased competition among health care providers. Such competition leads, in turn, first to a power shift from provider to consumer, and then to commercialization of values and tradition . This raises a question: should the application of public funds be directed by consumer demand? The population of CAM patients apparently uses health care resources more frequently  and in a more diverse way [12, 17] and it cannot be excluded that this behaviour is related to the fact that these patients have more often a specific procedure in mind when they seek a physician.
The fact that CAM users less often cite pragmatic reasons for seeing a physician may also be related to the observation that CAM physicians care for only a specific subset of patients in primary care ; that is, they provide significantly less emergency care and have fewer accident patients, and less often make home visits – a pattern not fully in line with the general definition of general practice/family medicine . Furthermore, other data within the main project showed considerable differences between physicians for the self declared extent of medical activity in primary care where CONV physicians declared 77.4% (median 90%) of their activity as primary care and CAM physicians only 36.8% (39%). The observed differences in reasons of choosing a particular physician may therefore not only be related to distinct differences in the decision-making process of patients but also to attributes of physicians themselves.
From a health system perspective, however, our results have several implications:
- There may be a downside to boundless shopping around for physicians and procedures. There are inverse relationships between patient empowerment and cost effectiveness in health care . Limiting the choice of patients in managed care practices, for instance, is associated with reduction of health care costs while quality of outcomes are maintained [30, 31]. It may be argued in this context, that CAM provides more efficient care than CONV as patient satisfaction in CAM is higher and cost appear to be equal to CONV[13, 14, 32]. However, this gain of efficiency may by compensated at system level by the fact that CAM patients tend to utilize health related resources more frequently than CONV patients.
- The obvious mismatch of defined and self-concept of practice activity may adversely affect decisions on resource allocation and reimbursement policy for CAM in primary care.
Limitations and strengths
This analysis is only one part of a larger study of alternative medicine in Switzerland, and therefore may suffer from several limitations and caveats common for this type of research. The questionnaires did not allow for an in-depth assessment of absolutely all aspects of the patients motivation, and due to the requirements of statistical analysis the broad variety of motivation was reduced to a few coding categories. Such categories may not reflect the diversity of views and motivations of patients, which may be grounded in different philosophical traditions. CAM was evaluated as an undifferentiated whole; no attempt was made to distinguish between various types of alternative medicine practices (for example, motives of patients attending a traditional Chinese medicine practitioner could differ from those attending a homeopath). A further problem in this context is related to the rationale of using only the first entry in the questionnaire as the motive to consult a specific physician. However, the text field in the questionnaire provided only little room for handwritten entries and multiple motives of consultations were consequently very rarely given by patients. It is therefore unlikely that differences in patient's motives between groups were affected by this restriction. Additional limitations in this context refer to the fact that only CAM procedures provided by certified physicians were included in the study. However, the evaluation of CAM provided by other care providers or self-care CAM or CAM was not in the scope of the main project.
Low response was a problem in this study as physicians perceived the entire project as a government project, which led to some reservations to participate. A formal evaluation of the proportion of participating physicians could not be performed due to the fact the proportion of physicians providing CAM procedures without corresponding certification was not known prior to the study. It is therefore also not possible to calculate the sampling fraction of physicians performing no CAM procedures at all (CONV group). However, it can be assumed that the motivation among participating physicians was different, since CAM physicians were under pressure to demonstrate effective methods – which was not the case for CONV physicians. It can only be speculated that the motivation of CONV physicians is more attributable to a general interest in primary care research. In a strict sense, the generalisability of our results is therefore reduced to physicians with these distinct motivations.
Health insurer data, information of the Swiss medical association and data from other recent studies in Swiss primary care[16, 33, 34] were used to check our data for potential biases. Based on this additional information, we have no reason to consider our sample as well as our results as biased with regard to geographical distribution and gender of physicians and to health status of patients.
Nevertheless, this is the first study of its type in the country, with substantial sample size and sufficient time span. That is why we are reasonably sure that the results accurately describe the motivations CAM patients to consult a primary care physician in Switzerland.