Communication in Integrated Medicine: A Study of Communication

Evidence Based Practice 2

Sarah Louise Dickson 97023146

Communication in Integrated Medicine: A Study of Communication between CAM(Complementary and Alternative Medicine)practitioners and General Practitioners.

Abstract Objectives: To Investigate the views and attitudes of CAM practitioners towards communication with GP.'s. To investigate the views and attitudes of GP.'s towards communication with CAM practitioners.

Then to investigate the ideas of both GP.'s and CAM practitioners towards improving their communication.

Design: Questionnaires for both GP's and CAM practitioners made up of Demographic questions and open ended questions regarding views and attitudes.

Results: A total lack of data from GP's. Only a small sample size of CAM therapist showing some significant differences in opinion between CAM practitioners regarding communication with GP's.

Respondents had received both positive and negative responses from GP's when trying to communicate and there were differing beliefs held regarding the reasons for this. However due to the small sample size it is hard to see make any conclusions.

Conclusion: The differing opinions and attitudes of CAM practitioners show there is need for more research in the area of communication as this will enable better education. Although there is no conclusive evidence found there are some recommendations for further research.

Contents:

Introduction---------------------------------------------------------------------------------

Page 2

Literature Review-------------------------------------------------------------------------Research Methodology------------------------------------------------------------------Results---------------------------------------------------------------------------------------Discussion-----------------------------------------------------------------------------------Recommendations for further research.--------------------------------------------References----------------------------------------------------------------------------------Appendices --------------------------------------------------------------------------------GP Questionnaire--------------------------------------------------------------------------CAM practitioner Questionnaire-------------------------------------------------------Cover Letter for the questionnaires---------------------------------------------------Table of Results ---------------------------------------------------------------------------

Page 2-4 Page 4-6 Page 6-7 Page 7-8 Page 9 Page 9-10 Page 11-26 Page 11-16 Page 17-21 Page 22 Page 23-26

Introduction 21

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As CAM grows in popularity throughout Europe including the UK (Perry & Dowrick 2000)there seems the need for integration into mainstream medicine so as to meet the needs of patients.

Integrated Medicine can only work if there is collaboration between orthodox medicine practitioners and CAM practitioners. For collaboration to happen there needs to be communication. Interest in CAM in the UK is increasing so for the benefit of patients/ clients this type of collaboration may be beneficial. Doctors are reacting to there patients CAM use in different ways ranging from being enthusiastic to critical of its use according to (Owen, Lewith and Stephens 2001). The aims of this research is to investigate communication between CAM Practitioners and GP's(General Practitioners).

With the objectives of investigating the views and attitudes of CAM practitioners towards communication with GP's, along with the views and attitudes of GP's towards communication with CAM practitioners. Furthermore to investigate the ideas of both GP's and CAM practitioners towards improving their communication if they feel the need for improvement. As referrals from Orthodox medicine practitioners to CAM therapists take place it seems important to investigate how this takes place and the types of communication used(Ben-Arye, Scharf & Frenkel 2007).

Literature review Many studies mention the growing interest in and popularity of CAM(Perry & Dowrick 2000).

There have been numerous qualitative studies looking at the perceptions and attitudes towards CAM. The majority of these qualitative studies are from the perspective of orthodox medicine practitioners including GP's, hospital doctors and medical students. There were a few studies looking at the perspective of the patient noting the importance of clients views and autonomy. I also found one study by (Ben-Arye, Scharf & Frenkel 2007) comparing CAM practitioners and GP's attitudes towards their collaboration. There was a low response rate from GP's compared with a 50% response rate from CAM practitioners. study shows that primary care physicians and CAM practitioners hold positive views of communication between the "other practitioner" themselves in regards to mutual patients. It was stated that receiving a medical or referral from a patient's "other practitioner" would 21

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increase willingness to respond in kind. The report implies that a referral letter from a physician to a CAM practitioner not only communicates clinical information but that it may also affect the development of collaboration between physicians and CAM practitioners. Both physicians and CAM practitioners reported low rates of inter-profession communication in daily practice, however they suggest their patients may support this form of communication. The study also indicated that both CAM practitioners and physicians expect collaboration regarding mutual patients rather than communication alone. The study also shows that physicians would prefer a physician – directed model of collaboration and CAM practitioners would prefer a co directed model. The researchers believe that physicians and CAM practitioner see collaboration differently. It is indicated that there is language gap between conventional medicine and CAM schools of thought. It is suggested that this communication barrier may be overcome by implementing educational initiatives for physicians and CAM practitioners alike. The study also suggests that these educational initiatives should focus on aspects of communication and methods for writing referral or medical letters within the scope of CAM. Some of the studies show there are distinct geographical differences in attitudes towards and use of CAM(Perry and Dowrick 2000).

It seems that CAM is more widely used and endorsed throughout Europe than it is in the UK(Fisher & Ward 1994). According to (Fisher & Ward 1994)public demand for CAM is strong and growing however the regulation of practitioners varies widely throughout Europe with the UK being the least regulated. According to (Perry & Dowrick 2000) 13% of the GP's they surveyed had treated patients with Complementary medicine themselves. 31 % had referred to CAM practitioners and 38% had endorsed Complementary therapies. They suggest that acupuncture was the most popular therapy followed by chiropractic and osteopathy. Reflexology, aromatherapy and medical herbalism were considered with more scepticism. 62 % of the GP's surveyed reported successful outcomes of CAM and 21% reported adverse effects of Complementary therapies. They discovered that there was uncertainty about the theoretical validity of CAM therapies. The therapies that the GP's wanted to learn about were acupuncture and homeopathy. They found that support for CAM in the socioeconomically deprived area of Liverpool was similar to that in the rest of the UK. According to (Brien & Howells etal 2008)Access to CAM seems to be common in primary care but little is known about GP referrals to CAM through an NHS contract. They found that referrals are based on patient motivation and openness toward CAM. Referrals to CAM often occur when there is no other therapeutic option. GP's that refer to CAM usually hold a positive attitude towards CAM as well as a trusting relationship with a CAM practitioner. In depth knowledge of CAM was not a vital factor for GP's when making decisions regarding referral to CAM. They also state that Increasing knowledge and research base for CAM will assist GP's in making referrals.

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Sarah Louise Dickson 97023146 (Ernst & Resch etal. 1995) State that on average that physicians view CAM as moderately effective with younger doctors having a more positive attitude toward CAM than older doctors. They found there is no trend to show that CAM is increasingly seen as effective. They also state that from the data they reviewed they cannot ascertain whether physicians view CAM as a non specific powerful placebo or as specifically effective. They conclude that CAM seem useful but there is a need for further research in the form of randomised controlled trials to prove its effectiveness.

Research Methodology This pilot study research is going to be made up of mixed methods. Although interviews or focus groups would be the preferred research methods to collect qualitative data, due to time constraints questionnaires will be used to gather information from both CAM practitioners and GP.'s.

They will be made up of questions about demographics, multiple choice questions about knowledge followed by open questions to investigate attitudes and experiences of communication between practitioners and their ideas and recommendations for improving this communication. The open questions about attitudes and views will aim to gain an emic perspective with subjective accounts of participants experiences. Where the demographic questions and the multiple choice questions may lead to the formation of an etic perspective by looking objectively at patterns which may or may not arise.

The questionnaires will be piloted before sending them to research participants. To pilot questionnaires will help to ensure the questions are understandable and have the same meaning to those reading them. It will also help to make sure the questions are unbiased. Questionnaires are included as appendix at the end of this document.

There are 7 GP surgeries within 2 miles of Blackburn with Darwen and 41 GP surgeries within 5 miles of Blackburn with Darwen. The first seven will be contacted in person although if this is not possible due to time constraints then by telephone will suffice. To ask if they are willing to fill out the questionnaire after speaking to practice managers or the GP.'s themselves to explain research project.

A stamped addressed envelope will be given with each questionnaire. The other 34 surgeries will be contacted by telephone to ask if they are willing to participate and those willing will be sent the questionnaires by post with stamped addressed envelope to return completed questionnaire.

The questionnaires for the CAM practitioners will be sent via FHT(Federation of Holistic Therapists) support group organiser who will forward it to all the group members by email also giving them a choice to receive by post. There are 18 members of the FHT in Blackburn and 4 in Darwen.

Using the GCC(General Chiropractic council) find a Chiropractor web service, 2 practising chiropractors were found within 5 miles of Blackburn. After searching The GOC(general osteopathic council) website one clinic was found in Darwen with 3 practitioners. The chiropractors and osteopaths will be contacted by telephone to ask if they are willing to participate before sending 21

Evidence Based Practice 2

Sarah Louise Dickson 97023146 questionnaires. This use of purposive and convenience sampling is the most relevant and cost effective methods available for the situation. The participants of both groups will have anonymity however there will be a slip at the end of the questionnaire giving them the opportunity to give their name and contact details if they are willing to participate in further research, which may include further questionnaires, interviews or focus groups. The data collected using the questionnaires is to be compiled and coded looking for similar themes and views in answers.

Results There were no responses from the questionnaire for GP's.

All of the respondents to the CAM practitioners questionnaire were female. Ranging from 0-5 years to 20+ years of practice. All of the respondents practice Aromatherapy and Reflexology, 5 of them practice body work therapies including massage and one Bach flower remedies. All of the respondents take part in Continuing Professional Development (CPD) and all of the respondents except the ones that had been in practice over 20 years, agreed they would find CPD seminars regarding communication with GP's useful.

Half of the respondents had contacted GP's regarding clients to ask permission to treat. Of the therapists that had contacted GP's, two of them had received some positive response from some GP's however all 3 of the therapists that contacted GP's gave details of lack of response, one detailed a negative response where the GP had said the client should not be treated.

Half of the respondents had not contacted GP's. Only one respondent gave reasons for not contacting GP's, they felt they had not had any need to, they also stated other CAM practitioners receive no reply. All of the respondents had referred their clients to GP regarding suspected conditions. One states that they suspected a fungal infection and suggested client see GP. The client was diagnosed by the GP and received appropriate treatment.

One respondent states that they have had clients who had come for reflexology treatment after a suggestion from their GP, although none had had an actual referral from a GP. There were no other reasons that therapists had tried to communicate with GP's.

In regards to views and attitudes towards communication with GP's one third of the respondents believe GP's are to busy to communicate with CAM therapists. One states that they would only communicate with with a GP if they had any concerns. One third of the respondents mention GP's lack of knowledge about complementary therapies. One states that they have found GP's unwilling to communicate at all, they believe this is due to GP's lack of knowledge about complementary therapies and their benefits, causing barriers in communication.

One third of respondents talk about the importance of communication between CAM therapists and GP's. One states that this communication is important to help build integration and believes it should be mandatory for both CAM therapists and GP's. Whilst the other states that communication between CAM therapists and GP's is important as GP's are now managing the monies 21

Evidence Based Practice 2

Sarah Louise Dickson 97023146 in their clinics. One of the respondents believes GP's are not allowed to refer to CAM therapists, they state that even if GP's were allowed to refer to CAM practitioners they would discouraged to do so, due the variations in qualifications in areas like reflexology and aromatherapy. The need for GP education regarding complementary therapies and their benefits is also mentioned. One respondent explains that Cancer patients and their carers are often referred to complementary therapy services.

Half of the respondents gave recommendations for improving communication between CAM therapists and GP's. One states it may be beneficial if CAM practitioners informed G P’s when they are treating their patients to increase awareness, leading to interest when patients benefit from treatment, they also state that some kind of referral system between GP's and CAM practitioners may also be useful. Two respondents believe that arranging open events for GP's and inviting them to talks and training may help communication. One of these also states that approaching practice nurses and counsellors at GP surgeries may also be a good way to develop communication.

Discussion The lack of response from GP's may have been due to the the length of the questionnaire and the time it would therefore take to fill out, it may also have been due to a lack of interest. However we are not able to make such assumptions. Although in the literature review there is information regarding GP's views toward CAM and communication with CAM practitioners.

Although the sample of CAM practitioners is small there is still quite a variety of opinions regarding communication with GP's. With some CAM practitioners believing there is no need to contact GP's unless they have concerns regarding their client. Whilst others believe it should be mandatory to have communication between GP's and CAM practitioners particularly as GP's are now in charge of the monies in their clinics which had previously been the responsibility of the PCT's(Primary Care Trust). (Brien & Howells etal 2008)state that access to CAM is common through primary care. So as the NHS is changing and GP's are taking responsibility for the money they may also become more responsible for referring to CAM. As such it seems CAM practitioner and GP collaboration is going to be more important in the future. The practitioners that had been in practice over 20 years seemed to be the least likely to communicate with GP's and did not feel the need for CPD regarding communication with GP's. This seems to correlate with the attitude of doctors that have been in practice for longer. Whilst the practitioners that had been practising for a shorter period 21

Evidence Based Practice 2

Sarah Louise Dickson 97023146 of time seem to be more willing to communicate and had more positive views toward communication and collaboration. This also seems to correlate with the views of younger doctors and medical students as shown in a study by (Perkin, Pearcy & Fraser 1994). It may be the case that this is due to the practitioners education as complementary medicine education has improved over the years and the ideas of integration between mainstream medicine and complementary medicine has been promoted more recently. Particularly since the publication of the house of lords sixth report in 2001.

In a study by (Greenfell, Patel & Robinson 1998) it is stated that of the the users of CAM they surveyed, over half stated that they did not tell their GP they were using CAM therapies, they also state they would use a CAM therapy before seeing there GP. As adverse reactions to CAM are often reported as stated by (Fisher & Ward 1994) it seems that as patients often do not tell their GP's about CAM use, the responsibility may then lie with the CAM therapist to do so. However the patients autonomy should also be taken into account and if a patient chooses not to inform their GP it would be unethical for the CAM therapist to then inform the GP. It could be assumed that patients do not tell their GP's about CAM use as they expect a negative response.

Perceived negative response was given as a reason for CAM practitioners not communicating with GP's regarding mutual patients and barriers in communication were believed to be due to GP's lack of knowledge. However all of the respondents practised aromatherapy and reflexology and all but one practice massage, according to (Perry & Dowrick 2000) reflexology and aromatherapy are seen more sceptically by GP's than CAM therapies such as acupuncture chiropractic and osteopathy.

This may explain the negative responses the respondents had received. This scepticism is most likely due to the lack of regulation of therapies such as reflexology and aromatherapy and the fact that acupuncture, osteopathy and chiropractic are chartered therapies and have more of an evidence base.

Recommendations for further research This study shows no conclusive evidence regarding communication between GP's and CAM therapists due to the small size it is not generalisable data. However it does raise some questions which may inform further research regarding communication. Barriers in communication need to be 21

Evidence Based Practice 2

Sarah Louise Dickson 97023146 looked at on both sides and collaboration between GP's and CAM practitioners would help to deal with these barriers. The study also shows there is a need for better regulation of therapies such as aromatherapy and Reflexology. This will help to build trusting relationships between CAM practitioners and GP's, which may further collaboration. There seems to be a real need for some sort of educational initiative or CPD for CAM practitioners regarding when and how to communicate with GP's.

There also seems to be a need for more research into patient perspectives regarding communication between GP's and CAM practitioners as patient autonomy is very important. The terms Alternative and complementary are used as a catch all definition for anything not taught in medical school according to (Pietroni 1994) as such maybe future research regarding attitudes towards CAM therapies should be more specific concentrating on particular therapies or groups of therapies as set out in the house of lords sixth report 2001.

References Ben-Arye E, Scharf M, Frenkel M(2007)Family Medicine –World Perspective: How Should Complementary Practitioners and Physicians Communicate? A Cross-Sectional Study from Israel. The Journal of the American Board of Family Medicine 20 (6): 565-571 Brien S, Howells E, Leydon GM, & Lewith G (2008). Why GPs refer patients to complementary medicine via the NHS: a qualitative exploration. Primary health care research & development,Cambridge university. 9:203-215: Ernst E, Resch KL, White AR,(1995)Complementary Medicine:What Physicians Think of It: A Metaanalysis, Arch Intern Med. ;155:2405-2408 Fisher P, Ward, A (1994) Medicine in Europe: Complementary medicine in Europe. British Medical Journal; 309:107-11 Greenfell A, Patel N, Robinson N (1998) Complementary therapy: General Practitioners' referral and patients' use in an urban multi ethnic area. Complementary Therapies in Medicine;vol. 6:3 pp 127 -132 Owen DK, Lewith G & Stephens CR (2001) Can doctors respond to patients' increasing interest in complementary and alternative medicine?. British Medical Journal;322:154-8 21

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Perkin MR, Pearcy RM & Fraser(1994). A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine. Journal of the Royal society of Medicine;vol. 87:pp 523-525.

Perry R, Dowrick CF (2000) Complementary medicine and general practice: an urban perspective.

Complementary therapies in medicine vol. 8: pp 71-75.

Pietroni PC(1992). Beyond the boundaries: relationship between general practice and complementary medicine. British Medical Journal;305:564-6.

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Communication in Integrated Medicine: A Study of Communication between CAM(Complementary and Alternative Medicine)practitioners and GP.'s Please answer as many questions as you feel you can and return using the Stamped addressed envelope provided.

1. Gender Male [ ]

Female [ ]

2. How many years have you been practising as a GP. 0-5 [ ]

6-10 [ ]

11-15 [ ]

16-20 [ ]

20+ [ ]

3. Do you have an interest in CAM ?

Yes [ ]

No [ ]

4. If Yes do you read current, up to date research about any CAM therapies? Please explain here: ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _______________________________________________ 5. If no please could you explain your reasons for this: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________

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Sarah Louise Dickson 97023146 6. In the house of Lords sixth report published in 2001 Complementary and Alternative medicine therapies are split into 3 groups.

Group 1: Professional Organised Alternative Therapies Acupuncture [] Chiropractic [] Herbalism [] Homeopathy [] Osteopathy [] Group 2 : Complementary Therapies Alexander Technique [] Aromatherapy [] Bach Flower Remedies [] Bodywork Therapies including Massage [] Counselling [] Hypnotherapy [] Reflexology [] Shiatsu [] Maharishi Ayurvedic Medicine [] Nutritional medicine [] Yoga [] Group 3 : Alternative Disciplines 3A: Long established and traditional systems of health care Anthroposophical medicine [] Ayurvedic Medicine [] Chinese Herbal Medicine Eastern Medicine(Tibb) Naturopathy Traditional Chinese Medicine

[] [] [] []

3B : Other alternative Disciplines Crystal Therapy Dowsing Iridology Kinesiology

[] [] [] []

Please could you tick any disciplines whose practitioners you have communicated with regarding patients in your care.

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7. Are you trained in any of the CAM therapies listed above?

Yes [ ] No [ ] If yes please list the therapies you are trained in and give details regarding how long you have been practising : __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 8. In your opinion do think some of these CAM therapies are more useful to patients than other ones?

Please include explanation as to why you believe this to be the case? ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ 9. In your opinion do you find there is a difference in the quality of communication with practitioners of different CAM therapies? Please give a detailed answer including which therapies you find better or worse and the reasons for this in your opinion. ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _______________________ 10. Do you refer any of your patients to CAM practitioners?

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Sarah Louise Dickson 97023146

No [ ]

If yes which disciplines do you refer to and how do you find communication with the CAM practitioners. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________ 11. Do you have a preferred method of communication if you refer patients to CAM practitioners? If so please give details: ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _________________________________________ 12. Do you receive letters from CAM practitioners asking permission to treat your clients? If so what are your views of this form of communication? ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _________________________________________ 13. Have you had patients coming to you after recommendation from CAM practitioners? If so how do you find communication with CAM practitioners in these cases? ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 21

Evidence Based Practice 2

Sarah Louise Dickson 97023146 ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________

14. Do you have any suggestions or ideas regarding improvement of communication between GP.'s and CAM practitioners? Please give details: ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ 15. Please include any other issues you feel are relevant regarding communication with CAM practitioners: ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ If you are willing to participate in further research next year in the form of questionnaires, interviews or focus groups please include your name and contact details here: Name:_______________________________________________ Address:___________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ________________________________________________________________________ Telephone number:______________________________________ Email Address:_________________________________________ 21

Evidence Based Practice 2

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Sarah Louise Dickson 97023146

Evidence Based Practice 2

Sarah Louise Dickson 97023146

Communication in Integrated Medicine: A Study of Communication between CAM(Complementary and Alternative Medicine)practitioners and GP.'s Please answer as many questions as you feel you can and return using the stamped addressed envelope provided or via Email.

1. Gender Male [ ]

Female [ ]

2. In the house of Lords sixth report published in 2001 Complementary and Alternative medicine therapies are split into 3 groups. Please tick the therapies you practice: Group 1: Professional Organised Alternative Therapies Acupuncture [] Chiropractic [] Herbalism [] Homeopathy [] Osteopathy [] Group 2 : Complementary Therapies Alexander Technique [] Aromatherapy [] Bach Flower Remedies [] Bodywork Therapies including Massage [] Counselling [] Hypnotherapy [] Reflexology [] Shiatsu [] Maharishi Ayurvedic Medicine [] Nutritional medicine [] Yoga [] Group 3 : Alternative Disciplines 3A: Long established and traditional systems of health care 21

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Sarah Louise Dickson 97023146

Anthroposophical medicine Ayurvedic Medicine

[] []

Chinese Herbal Medicine Eastern Medicine(Tibb) Naturopathy Traditional Chinese Medicine

[] [] [] []

3B : Other alternative Disciplines Crystal Therapy Dowsing Iridology Kinesiology

[] [] [] []

3. How many years have you been practising as a CAM practitioner?

0-5 [ ]

6-10 [ ]

11-15 [ ]

16-20 [ ]

20+ [ ]

4. What setting do you work in? ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ 5. Do you take part in CPD(continuing professional development)?

Yes [ ]

No [ ]

6. Do you think CPD courses about communication with GP.'s would be useful to you?

Yes [ ]

No [ ]

7. Have you ever contacted GP.'s to ask if it is OK to treat their patients?

Yes [ ]

No [ ]

If yes how did you find this communication? Please include any details you feel are appropriate: 21

Evidence Based Practice 2

Sarah Louise Dickson 97023146 ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________ If no are there any particular reasons for this? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________ 8.

Have you ever recommended clients see their GP. regarding a condition you suspect or for any other reason?

Yes [ ]

No [ ]

If yes did you have any further communication with the GP.? How did you find this communication if it existed? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________ 9. Have you ever had clients referred to you by their GP. ? If so how do you find the communication with GP.'s in these cases? ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ 21

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10. Have you ever communicated with your clients GP.'s for any other reasons? If so please explain and include details of how you found this communication. ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ 11. Please explain your views and attitudes in general towards communication with GP.'s? ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ 12. Do you have any suggestions or ideas regarding improvement of communication between GP.'s and CAM practitioners? Please give details: ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ 13. Please include any other issues you feel are relevant regarding communication with GP.'s

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Sarah Louise Dickson 97023146 ___________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________ If you are willing to participate in further research next year in the form of questionnaires, interviews or focus groups please include your name and contact details here: Name:_______________________________________________ Address:___________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ________________________________________________________________________ Telephone number:______________________________________ Email Address:_________________________________________

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Sarah Louise Dickson 97023146 Miss Sarah Dickson 17 Beaumaris Avenue,

Blackburn, BB2 4TW Email: heartfeltholistics@hotmail.co.uk Dear Participant My name is Sarah Dickson and I am a second year student on an FdSc in Complementary Medicine at the University centre at Blackburn College. I am carrying out a research project for the evidence based practice module of my course. I will have a supervisor for this module . I am researching communication between complementary therapists and GP.s . I have enclosed a copy of a questionnaire for you to complete. The final

return date for this questionnaire is the 23

rd

of April 2012. You can either reply by email or

by post; prompt return will be much appreciated as there is a deadline for completion of the project. This is voluntary however I believe it is an important piece of research and would really appreciate your input. The questionnaire is anonymous. However there is a tear off slip at the end of the questionnaire, for you to include your personal contact details if you feel you would like to be involved in further research next year; this may include focus groups and interviews. Your personal information will be kept under lock and key in line with the Data Protection act and will only be used for the reasons mentioned above.

Yours Faithfully

Sarah Dickson

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