Health Communication, 23: 506–515, 2008 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410230802460234
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Practitioner–Client in Acupuncture
Models of Health and Models of Interaction in the Practitioner–Client Relationship in Acupuncture Evelyn Y. Ho
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Department of Communication Studies University of San Francisco, San Francisco, California
Carma L. Bylund Department of Psychiatry and Behavioral Sciences Memorial Sloan-Kettering Cancer Center, New York, New York
The doctor–patient relationship has been widely studied in biomedicine. However, little research has focused on similar provider–client relationships in holistic healthcare forms. Based on ethnographic research with acupuncture clients and practitioners, the authors found that participants used specific models of health to understand and develop subsequent models of interaction, and in doing so, provided a clear critique of biomedicine. This article offers a brief overview of major models of healthcare, including biomedical, biopsychosocial, and holistic. The authors present current models of interaction that have been used to understand the biomedical doctor–patient relationship, and discuss the utility of both sets of models as they relate to the ethnographic observations. Although a particular model of health (biomedical or holistic) does not necessitate a particular model of health interaction (paternalism, consumerism, or collaboration), participants’ attempts to tie these 2 realms together are important to understanding practitioner–patient relationships in all healthcare situations.
The doctor–patient relationship has been widely studied in biomedicine, leading to a better understanding of how doctors and patients affect the communication process (Roter & Hall, 1993) and how communication affects patient and doctor outcomes such as patient satisfaction and compliance (Brown, Stewart, & Ryan, 2003). This body of literature has also provided an evidence base for communication skills training programs (Cegala & Broz, 2002). However, little research has focused on similar relationships in holistic healthcare forms, despite recent findings that 75% of adults have tried holistic medicines (Barnes, Powell-Griner, McFann, & Nahin, 2004) and paid out-of-pocket for these practices comparable to biomedicine (Eisenberg et al., 1998). This gap in the research is particularly troubling considering that one reason patients report using holistic medicine is because of positive practitioner–client communication (Cassidy, 1998b; Vincent & Furnham, 1996).
Research on the doctor–patient relationship has named and compared the different types of health interaction models such as paternalism, mutuality, and consumerism (Beisecker & Beisecker, 1993; Roter & Hall, 1993). However, based on ethnographic fieldwork with acupuncture practitioners and clients, we find that these models provide only limited explanatory value. We argue that in acupuncture settings, the health model, rather than the interaction models, provides the basis for understanding and enacting practitioner–client1 relationships and interactions. Chinese medical theory is translated in the United States into a holistic medical theory that also serves to critique current biomedical models of healthcare and certain models of interaction that are associated with biomedicine. This holistic critique of biomedicine, both in its medical theory and in its health interactions, can be heard in participants’ actual talk about acupuncture. However, the actual health interactions in 1
Correspondence should be addressed to Evelyn Y. Ho, Department of Communication Studies, KA 340, University of San Francisco, 2130 Fulton Street, San Francisco, CA 94117. E-mail:
[email protected]
At the field site where this research was conducted, participants used the term client instead of patient. In this article, we will refer to this relationship as practitioner–client instead of doctor–patient. Although this language is usually used to describe a consumeristic relationship, we did not find that acupuncture relationships were necessarily consumeristic.
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acupuncture treatments do not always follow holistic principles as they have been defined in the United States, and these discrepancies highlight the need to concurrently examine models of health with models of interaction to fully understand the relational dynamics and consequences of communication of a given health encounter. In this article, we begin with a brief overview of major models of healthcare and current models of interaction that have been used to understand the biomedical practitioner–patient relationship. We then discuss the utility of both sets of models as they relate to the ethnographic observations. Although a particular model of health does not necessitate a particular model of interaction (e.g., paternalism does not necessarily coincide with biomedicine), participants’ attempts to tie these two realms together are important to understandings of practitioner–patient relationships in all healthcare situations. Models of health and models of health interaction have been thoroughly researched in the biomedical arena. In the next section, we present these models to establish a background for understanding the ethnographic observations in the acupuncture clinic, in which both practitioners’ and clients’ communications invoke these specific models of health and models of health interaction. It is important to note that two types of models have been studied separately in the biomedical healthcare context, whereas the ethnographic data from the acupuncture clinic provide compelling evidence for studying these two types of models concurrently.
MODELS OF HEALTH Biomedical Models of health focus on how health and illness are conceptualized. Rooted in the Cartesian division between mind and body (Alonso, 2004), biomedicine focuses on the causal explanation for an abnormal pathophysiological state (Tyreman, 2006). To adopt a biomedical model means to think of health and disease as something grounded solely in biochemistry and remedied solely by technology (Kleinman, 1980; Roter & Hall, 1993). According to Schreiber (2005), the biomedical model is based in Western science, characterized by reductionism, often critiqued for being pathology-oriented instead of prevention-oriented, and deemed efficacious through doubleblind experiments of its treatments. Schreiber also recognizes that although the biomedical model does not necessitate a specific relational model, it is often the case that biomedicine includes authoritarian or doctor-powerful relationships. Similarly, biomedicine is critiqued as an inadequate tool for understanding patients’ experiences (Kolb, 1979). Biopsychosocial Although the biomedical model has been a contributing factor in improving health, it has failed to meet changing
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healthcare needs (Hewa & Hetherington, 1995). Thus, the biopsychosocial model was proposed as an alternative. The biopsychosocial model holds that health and illness are more than just something physical, and instead, have emotional, cognitive, and situational influences (Engel, 1977). As George Engel, pioneer of the biopsychosocial model, said, “Scientific medicine requires a paradigm capable of encompassing the human domain” (Engel, 1992, p. 15). The biopsychosocial model does not just widen the biomedical model, but instead changes the focus of explanation for the illness experience. Health is not evaluated as an isolated phenomenon but, rather, health is understood by a person’s effective relations to his or her environment (Tyreman, 2006). The biopsychosocial model, serving as an ideal approach to health and illness, is confirmed by evidence that emotions and thoughts influence overall health and that people tend to describe their medical conditions as they affect their everyday lives (du Pre, 2000).
Holistic The holistic model focuses on a whole that is made up of interdependent parts, is aimed at prevention, and understands health as a matter of balance or homeostasis that is achieved through the active participation of patients in equal cooperative relationships (Schreiber, 2005). The American Holistic Medical Association (AHMA; 2004a) further describes holistic medicine as, “the art and science of healing that addresses care of the whole person – body, mind, and spirit” (¶1) in an integrative way to promote health and prevent disease. As models, these do not imply that all allopathic medicine in the United States is biomedical and all alternatives2 are holistic. In fact, organizations like the AHMA and the American Holistic Health Association work with medical doctors and osteopaths to develop practices that adhere to holistic principles. In addition, patients are supposed to take an active role, working on changing “lifestyel [sic], beliefs and old habits in order to facilitate healing” (AHMA, 2004a, ¶2). The popularity of this model of holistic health makes sense, given the current healthcare situation in the United States in which biomedical practice has been heavily critiqued for many reasons, including not being patient-centered (see special issue of Health Communication, “The Patient as,” 1997) or taking into account the patient’s lifeworld (Mishler, 1984), for not paying enough attention to the larger bio-psycho-social aspects of health (Engel, 1977), for the side effects of medications (Farquhar, 1994; Pawluch, Cain, & Gillett, 2000; Vincent & 2 Ordinarily, we would use the terms biomedical and holistic, but because these are also the terms used for the models of health, we used the closest synonyms of allopathic and alternative. We recognize that both of these terms are not exactly accurate, as alternative implies that the therapies are alternative to some preferred or dominant form, and allopathy can imply only a comparison to homeopathy.
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Furnham, 1996), and for inefficacious treatment (Cassidy, 1998a; Vincent & Furnham, 1996). A focus on holism stands in stark contrast to the biomedical model of health and illness, in part because of the way the model of health is tied to models of interaction. According to the AHMA (2004b), holistic healthcare includes such practices as patient personal responsibility and education, patient–practitioner partnership, preventative care, and physician modeling of healthy lifestyles as part of a larger holistic philosophy. Although not explicitly stated, these definitions of holism imply that other health models do not emphasize patient responsibility or practitioner–client partnership. A holistic model of health and illness can be used in all forms of healthcare, both in biomedicine and in Chinese or other holistic medicines. However, holism as a term has been found to be so definitive of certain forms of healthcare (see Ho, 2007) that it has been recommended that holistic medicine is a more appropriate cover term than either complementary or alternative medicine, which are more widely used (Schreiber, 2005). Whether, and to what extent, “holistic” medicine actually coincides with the holistic model of health can be another question altogether (Ho, 2007). For purposes of this discussion, what is important is that holistic medicine is often seen as a different and competing model to both the biomedical and biopsychosocial models.
Somewhere in the middle of these two ends are the collaborative (du Pre, 2000), mutual (Roter & Hall, 1993), and partnership (Beck, 2001) models of health interaction. These collaborative models focus on the fact that both parties bring expertise to any given health interaction, and thus the goals and agenda for the interaction are mutually negotiated (Roter, 2000). Although some have associated biomedicine with paternalism (Schreiber, 2005), theoretically these are distinct. Many physicians and patients have collaborative encounters that are grounded in biomedicine. Alternatively, although adopting a biopsychosocial model of health, a physician– patient interaction may also be paternalistic. However, as discussed, some descriptions of the holistic model of health imply a particular type of collaborative healthcare interaction, whereas others do not include these models of interaction. As such, it was our goal in this study to describe and explore the applicability of models of health and models of interaction, as used in an acupuncture clinic. The research questions that guided this project were: RQ1: What models of health were promoted in this acupuncture community? RQ2: What models of interaction did practitioners and clients demonstrate?
METHOD MODELS OF INTERACTION Models of doctor–patient interaction have typically been conceptualized in terms of power (balance or imbalance) in the biomedical doctor–patient relationship. These models primarily focus on the distribution of power as it affects, or is practiced in, healthcare interactions. Although much has been written about models of health interaction,3 no research has yet examined power relationships as they influence health interactions in holistic healthcare settings. However, as we will argue later in this article, these models prove useful for understanding relational roles in holistic health interactions as well. The most recognizable, and perhaps currently most criticized, model is the paternalistic model (Beisecker & Beisecker, 1993; Emmanuel & Emmanuel, 1992; Roter & Hall, 1993) or activity–passivity (Szasz & Hollender, 1956). In the paternalistic model, doctors are experts who issue orders and patients are supposed to comply with those orders. On the other hand, the consumerist model is one in which patients are viewed as clients shopping for a doctor’s services in an equal relationship of exchange (Beck, 2001).
Data presented here were collected by the first author as part of a larger ethnographic project studying acupuncture discourse and the valued ways of speaking about acupuncture.4 Using participant observation and informal interviewing over a 9-month period of field work, from October 2002 to June 2003, data were collected at three locations in Seattle, Washington. The primary site for participant observation was the Good Fortune Acupuncture Clinic5 (GFAC), a small and fairly informal acupuncture clinic that was part of a larger Asian social services agency (the Seattle Asian Agency). Established as a teaching clinic for a local acupuncture school, one licensed acupuncturist and up to six interns per half-day shift served a clientele consisting mostly of Seattle Asian Agency clients, staff, and employees. This site was chosen because this was the clinic in which the first author was granted the most open access to both practitioners and clients. The GFAC clinic space was a multipurpose room that was converted once a week into an acupuncture clinic by adding three folding massage tables and paper screens to create two treatment areas and one large reception area. In the reception area stood a 6-foot-long folding table that
3 For writing on models of interaction in biomedical health settings, see Beck (2001), Beisecker and Beisecker (1993), Emmanuel and Emmanuel (1992), Roter (2000), Roter and Hall (1993), or Szasz and Hollender (1956).
4 This research project was approved in 2002 by the Institutional Review Board of the University of Iowa. 5 All names of people and institutions have been changed to maintain privacy.
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served as a check-in and student conference area. The first author, sat at this table and was able to listen to conversations between Yuri, the licensed acupuncturist, and the interns about treatment, assist in greeting and checking in clients,6 and conduct informal interviews with clinic staff. On two occasions when interns did not have time to fully answer questions posed by the first author, the interns sent answers via e-mail so they could take time to explain their answers in more detail. All interns were informally interviewed throughout the field work process. GFAC staff treated anywhere from 15 to 20 clients a day. When the clinic ran smoothly, three sets of student intern pairs treated three clients per three-hour shift. Treatments were scheduled for 60 min with the first 5 to 15 min devoted to an intake interview, 5 to 10 min for students to discuss treatment options with Yuri, 5 to 10 min for needle insertion, up to 30 min for clients to rest with the needles in, and a few minutes for needle removal. Yuri was the supervisor of the 16 interns who used GFAC to accumulate clinical hours necessary for state licensing. Acupuncturists are licensed state by state, and Washington requirements included 2 years of academic training in basic and acupuncture sciences, 500 hr of supervised clinical training, and successful performance on the National Certification Commission for Acupuncture and Oriental Medicine exam (Washington State Department of Health, 2006). The interns worked at GFAC for their clinical experience and ranged in age from the mid-20s to mid-50s, with slightly more women than men. They were white, Asian, or Asian American and some had previous health careers working as nurses, massage therapists, and counselors. Ethnically and nationally Japanese, Yuri was bilingual and had lived and worked in the United States for the past 10 years in a variety of public health settings providing free and low-cost acupuncture. Between October 2002 and June 2003, the first author visited GFAC 25 times, with each visit lasting between 4 and 8 hr. During this time, the first author took field notes and left an audio-recorder at the conference table, capturing most of the formal and informal conversations taking place at the main table. Twelve patient intake interviews were also recorded and transcribed. The clients ranged in age from early 30s to late 70s or early 80s and were mostly Asian and Asian American. In addition to the data from GFAC, the first author was also a participant observer in both an Introduction to Chinese Medicine course and an Introduction to Alternative Medicine course. Field work was also conducted at a variety of one-time events related to acupuncture and holistic medicine. All field notes and transcribed audio were uploaded into Atlas.ti (Muhr, 1997) qualitative data analysis software. Audio data were transcribed and together with field notes were analyzed inductively in Atlas.ti using open-coding and 6 Clients began to treat the first author as a clinic staff member and would often ask her to collect their payments or schedule future appointments.
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constant-comparison techniques (Strauss & Corbin, 1998) and Spradley’s (1980) domain analysis. For this article, all discourse coded with themes related to the practitioner– client relationship was extracted for further examination. From this smaller set of data, we then coded these excerpts for models of health and models of interaction. What became readily apparent in attempting to define and conceptualize practitioner–client interaction in acupuncture was the importance of participants’ use of a holistic model of health as a justification for particular valued ways of interacting. In other words, we found that the participants’ holistic health model included a desire for more collaborative interactions. Serving as a critique of biomedicine, some participants expressed a desire and expectation for acupuncture’s alternative model of health to also provide an alternative model of health interaction. Despite the fact that literature on biomedicine treats these two models as separate, some acupuncture participants in this community combined the two models, connecting the biomedical model with paternalism and the holistic model with collaboration.
CONSTRUCTING THE PRACTITIONER–CLIENT RELATIONSHIP IN AN ACUPUNCTURE CLINIC In the next three sections, we describe the practitioner–client relationship as enacted in the acupuncture related field sites. First, we begin by presenting holism as the primary model of health. Second, we show how clients invoke the holistic model of health to express their expectations for certain models of interaction. Finally, we provide some examples in which practitioners attempt to separate the holistic model of healthcare from collaborative or mutualistic models of interaction. Holistic Model of Health Both the biomedical and biopsychosocial models of health and illness are virtually impossible to apply to acupuncture and Chinese medicine. The core assumptions and beliefs of the biomedical view of health and Chinese medicine are extremely different, most notably because the biomedical model does not recognize the essential Chinese medical theories of Qi, energetic organs, and yin and yang, which are difficult to translate into English or scientific understandings of the body.7 In Chinese medicine, health is maintained through a balance of Qi and other fluids/energies that are regulated by energetic organs along meridian pathways. This balance is best understood in the dialectical relationship of yin and yang in which excesses in one area lead to deficiencies in others that ultimately lead to illness. Similarly, the biopsychosocial model, although recognizing that 7 For a much more comprehensive explanation of Chinese medical theory, see Kaptchuk (2000).
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health and illness involves more than just the physical body, still lacks the complete perspective of health and illness utilized by Chinese medicine. Echoing holistic critiques of the biopsychosocial model, Chinese medicine is similarly a whole greater than the sum of its parts. Not only does the holistic model fit Chinese medical theory better, but perhaps more importantly, participants invoked the holistic model by using a holistic vocabulary in talk and explanations about Chinese medicine. As described by participants, Chinese medicine focuses on the person as a whole and unique person. Clients are not merely important because of their symptoms. Rather, there is an effort on the part of practitioners to understand the whole picture of what is going on with clients (using a system of meaning consisting of components like Qi and energy) and some of the larger environmental and relational issues affecting each client’s specific situation. Both practitioners and clients articulated these aspects of holism as providing something different from and often better than biomedicine. Using holism to translate or explain acupuncture. Practitioners were very explicit about articulating their commitment to holism, especially when talking to new clients. In a first office call when the two interns discovered that a client had never had acupuncture before, Susan, an intern, provided an introduction: June 9, 2003: First office visit, Intern Susan and Client Bekka 1 Susan: I’ll just tell you sorta what we’re gonna do (.) we’re gonna ask you questions 2 about why you’re here and then we’ll ask you questions pretty much head to toe 3 about how your body’s functioning (.) ’Cause it helps us treat you (.) ’Cause we 4 wanna treat the whole you and not just the symptoms that you’re coming in (.) So 5 we’ll ask you a lot of questions that may or may not seem relevant to why you’re 6 coming in (.) Um then we take your pulses and we feel your wrists on both sides 7 (.) and that tells us a little bit about your energy and your body and the fluids in 8 your body and how (.) how things are functioning and then look at your tongue (.) 9 and then we talk to Yuri and come up with a treatment plan.
By explaining to the client that she was going to ask many seemingly irrelevant questions for the sake of treating the “whole you” (line 4), Susan was able to immediately establish the importance of holism as a way of understanding illness. By explicating this holistic process of questioning, Susan also reinforced the idea that this is a different way of understanding health. In addition, Susan used this explanation as a way of walking the client through what was going to happen to the client: first they will ask questions; second, they will feel her pulse; third, they will look at her tongue; and finally, they will determine a treatment plan. Other interns used this level of explanation in their first office visits as well. In some ways, at first glance, it may appear strange that Susan spent so much time explaining why they were going to ask so many questions (see repetition in lines 1, 2, 5) and spent relatively little time explaining why feeling the pulses and looking at the tongue are necessary. In addition, Susan never explicitly justified (in this or any other instance) why a holistic model of health is beneficial. Instead, “the whole you” (line 4) was unproblematically stated as the way
acupuncture functions. By framing this introduction to acupuncture around the idea of holism, the subsequent mention of the Chinese medical concepts of energy and fluids (line 7) did not require justification because, presumably, they are also part of the same holistic plan of treatment. In these introductory remarks, Susan established with the client that, unlike other health interviews that only focus on certain symptoms, a holistic way of asking questions is a necessary and meaningful way of performing acupuncture. Having to account for the wide variety of questions asked in intake interviews was a recurrent pattern in practitioner–client interactions. In another first intake interview, a client presented with a cold and sore throat. The intern, Ryan, began by asking her questions about the cold and sore throat and then continued with questions about energy level, sleep, digestion, appetite, bowel movements, water intake, temperature, vision, hearing, stress, anxiety, sweating. February 3, 2003: First office visit, Interns Ryan & Susan and Client Erica 1 Ryan: Is there anything that I ha:ven’t asked you that anything else that’s on your 2 mind that you’d like to add to 3 Erica: No I think that’s all 4 R: OK 5 E: You are very thorough 6 R: I know (.) well it’s your first time in here too so we tend to ask you even more 7 questions your first time in
This exchange occurred near the end of the intake interview and it is reasonable to read Ryan’s question in line 1 as asking Erica to add anything to the holistic picture that Ryan and Susan have elicited from their client. After Erica’s “no” in line 3 and Ryan’s affirmation in line 4, Erica then added “you are very thorough” in line 5. Erica’s comment on line 5 prompted Ryan in lines 6 and 7 to give an account of why he has asked so many questions. Both Erica’s comment and Ryan’s response point to the fact that holistic questioning is not an expected practice for health intake interviews. However, following Ryan’s explanation, the conversation continued smoothly just as it did in the previous example with Susan. In both of these conversations, once the intern provided an explanation that holistic questioning is a part of acupuncture practice, the clients did not ask any additional questions nor did they provide any other commentary regarding this practice. Holism as biomedical critique. Holism is also used as a way of both subtly and explicitly critiquing biomedicine. The following conversation occurred in reference to a special issue of Newsweek (“Health for Life,” 2002) that explored alternative therapies. A couple weeks after it was published, the first author brought the magazine to the GFAC clinic to share with the practitioners. Some had already read the magazine and others were reading it for the first time. After flipping through the magazine, Yuri and intern Kate discussed the use of scientific studies to prove that acupuncture works. Their conversation turned to the results of such scientific studies in biomedicine:
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December 23, 2002: GFAC Clinic, Yuri, Intern Kate 1 Yuri: It’s just so funny every time I see those things oh this medication is gre:at 2 indication is great for nausea or whatever (.) It helps nausea great but 3 contraindication is like ((laughs)) this big ((makes hand gesture signifying a long 4 list)) (.) but FDA approves it because it works! It can work because it helps 5 nausea great but you gotta be careful because you may have constipation and 6 diarrhea and low back pain and headache and high blood pressure 7 Kate: You could have a stroke 8 Y: Seriously, you know? 9 K: And you could just put a few points
Using the understanding that biomedically based pharmaceuticals rely solely on a one-symptom, one-drug system, Yuri and Kate critiqued drugs as being unhealthy even though they may be scientifically effective. Although U.S. FDA drug approval is based on this one-to-one effectiveness, Yuri’s laughter in line 3 can be read as another way of stating that the wide array of side effects should make these drugs undesirable. Clearly, a drug that is great for nausea, but has a long list of contraindications, would not be a very healthy choice holistically speaking. Instead of dealing with the additional complications, such as constipation, diarrhea, low back pain or even a stroke, Kate’s comment in line 9 seems to argue that even very simple acupuncture (“a few points”) is as powerful and effective but has little or no side effects. Holism, or a picture of the whole you, was never explicitly mentioned in this conversation. However, a clear critique of these pharmaceuticals emerges from a holistic model in which all aspects of one’s life—including side effects—need to be considered when choosing healthcare. In another conversation, Intern Jean was telling the first author that many clients are not aware of how their lifestyles contribute to their health. Jean began by explaining the specific ways in which lifestyle practices like vegetarian eating or overworking can affect one’s (Chinese medical) body. Jean’s conversation can be read as holistic in that she argued that a client’s whole way of living leads to imbalances that lead to illness. The excerpt below ended with Jean’s critique of “Western medicine” for not being able to deal with illnesses in their early stages (when they are still imbalances) like “Oriental medicine” can. February 3, 2003: GFAC, Intern Jean and the first author 1 Jean: Somebody is just overworking 2 First author: mm hmm 3 J: They drain their kidney [jing because overworking (.5) So ?it’s just (.) 4 FA: [mm hmm 5 J: everybody’s lifestyle (.) you know? (.2) eventually gets sick (.2) beauty part of the 6 Oriental medicine I’m always being so happy? (.) that I’m in? (.2) is (1.0) you can 7 detect those imbalance earlier than Western medicine 8 FA: mm hm 9 J: It’s so sensitive (.3) you already kno:w something is imba?lanced (.) [before your 10 FA: [before 11 J: body get fall apart 12 FA: °Ri:ght ri:ght° 13 J: So (.) so good (.9) I’m so happy= 14 FA: =Yeah you don’t have to wait (.) until (.) you’re really sick
As Jean mentioned in line 9, it is Oriental medicine’s sensitivity that allows it to function as preventative medicine. Rather than having to wait until “you’re really sick” (line 14) as in Western medicine, Jean stated that she likes Oriental medicine better
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because the imbalances can be fixed before the onset of illness or the moment when your body begins to fall apart (line 11). By emphasizing holism as a model of ideal healthcare, the participants’ discourse frames conversations about acupuncture as focusing on clients as whole systems and taking into account the wide variety of environmental and other factors that affect one’s health. These holistic principles are not only necessary to the practice of Chinese medicine, but through explicit comparison, they also provide a critique of the current dominant systems of healthcare. Conflating Models of Health with Models of Interaction One day at GFAC, the acupuncture interns and the first author got into a conversation specifically dealing with the practitioner–client relationship. The conversation was not finished because the students had to go back to work treating the clients, so the first author followed up with the interns over e-mail. One intern, Julie, wrote: I think it’s a mutual relationship. That’s mainly what we were taught. That you can’t help someone unless they are an active participant in their health. . . . So you can’t position yourself as a God or a father-figure because you are just a piece of that person’s puzzle, and recognition of that fact helps to empower that person and releases you of any burn-out/failure. . . . So I’d basically say that you draw it as concentric circles. The patient– practitioner are in one circle and that is contained within another larger circle of all the factors that influence a person’s well-being (diet/emotions/exercise) and that’s within the circle of the universe—the energy of the seasons/place/people etc. That’s what I love about this medicine: it’s about connecting yourself and your patients to the greater whole (the Tao, the yin–yang circle), and by doing so you both can rise to your highest potential.
As Julie described, holism focuses on the whole relationship of practitioner and client as a series of “concentric circles” where both “are in one circle” taking into account “all the factors that influence a person’s well-being (diet/emotions/exercise),” drawn inside a larger circle of “the universe—the energy of the seasons/place/people etc.” This focus on holism, according to Julie, is essential for the both practitioner and client to “rise to your highest potential.” As evidence of the holistic model of healthcare, what is important in Julie’s quote is the way that this holistic model works to affect how healthcare is delivered. In other words, it is precisely this holistic model of health that leads to a more mutual relational model that is made manifest in health interactions. As argued in a previous article based on this ethnographic data (Ho, 2006), a focus on the whole individual was not just a way for practitioners to view clients. Instead, clients articulated a holistic view of medicine as a way of relating with and assessing their relationships with practitioners. In many situations clients were encouraged and taught to participate in their own health through avoiding some foods or ingesting other foods to achieve balance. In the
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excerpt that follows, Jean (intern) encouraged Carol (client) to use the hot/cool categorization of food to achieve a healthy balance. The following excerpt happened after Carol inquired about her recent unusual hunger.
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January 27, 2003: Intake interview, Intern Jean, Client Carol. 36 Jean: I want you to be aware when you’re unusually hungry (.) Like I eat but it feels 37 like there’s no bottom on that part (.) Kinda go in and still hungry (.) You eat and 38 still feel achy even (.) That’s stomach (.) fire (.) I mean yin (.) yin deficient (.) So 39 (.5) To soothing that (.) look for like ahh cold in nature food (.) Instead of ah (.) 40 spicy? Or (.) little ginger garlic those kinda things is not good when that happens 41 (.) It it creates more heat (.) So there is ah (.) three different food group (.) One is 42 really cold in nature (.) And mediocre (.) neutral (.) There’s really hot in nature (.) 43 And warmer so between but (.) the most thing that we know hot in nature you 44 should avoid that time is (.) Hot pepper (.) cinnamon (.) ginger garlic (.) Those 45 kind of things all hot in nature (.) Cold in nature is like sushi (.) Raw sushi (.) Or 46 tofu? And there’s a cucumber and watermelon (.) And Asian pear (.) These kinda 47 thing’s very good to ah moisturing the internal (fire)
Jean’s description of the three types of food—hot, cold, and warmer—was used as a way to educate Carol so that she could become an active participant in her own treatment, matching well with the holistic principles and the mutual model of Roter and Hall (1993) or the deliberative model of Emmanuel and Emmanuel (1992). Because Carol had “stomach fire” or is “yin deficient” (line 38), it was important that she not add heat to the fire with more hot foods. Although Jean also treated Carol’s yin deficiency with acupuncture, ultimately, it was not Jean’s sole responsibility to heal Carol, and her explanation of hot and cold foods serves to construct acupuncture as a participant-oriented, everyday health practice that should happen outside, as well as inside, the practitioner’s office. Jean’s educational component of acupuncture interaction was explicitly acknowledged by Carol. Later in this same visit, Carol tried to explain to Jean why she was her favorite practitioner. In the following excerpt, Jean had just explained to Carol that all of her various health complaints (from sweet cravings to hunger to toe pain to a sore in the mouth to anger) were interconnected and related to an “overactive liver attacking the spleen.” Carol’s presenting complaint was pain in her toes, but such an assessment could only be done because Jean asked questions holistically about everything going on in Carol’s life and then explained the diagnosis in ways that Carol could understand. However, it is this same holistic model that also leads to a more mutual relationship, as Carol articulated. January 27, 2003: Intake interview, Intern Jean, Client Carol. 166 Carol: I really enjoy you to be my person that’s why I say you’re my favorite (.) cause 167 you you have more insight than anyone else that I’ve met (.) on what’s going on 168 with my body 169 Jean: I think I talk too much I think 170 C: No (.) I mean you can poke me and it’s just right there (.) oh you hit em (.) I mean 171 I’ve been coming here since they’ve been doing this (.) and I’ve had a lot of 172 people work on me (.) and I’m telling you, you always hit the points (.) and you 173 know! You help me understand! 174 J: I think that other people (.) that’s everybody’s goal (.) I hope everybody found 175 that spot (.) but that’s that’s 176 C: But I can have my favorite
In this exchange Carol cited three specific reasons for saying that Jean is her favorite. In line 167, she said that Jean has more insight than anyone else. In lines 170 to 172,
she said that Jean “always hit the points” accurately. And finally in line 173, she said to Jean that “you help me understand!” The basis for choosing Jean as her favorite practitioner relied on a holistic insight into her body, a certain level of practitioner competence (in being able to hit the points), and on Jean’s ability to explain to Carol what is happening in terms of diagnosis and treatment (a “holistic” model of interaction). The conflation of all three of these abilities in Carol’s explanation reveals how she views acupuncture as holistic, both as a way of understanding the health practice and as a model for interaction. According to Carol, good healthcare consists of more than just hitting the points (a matter of technical competence); it also includes things like knowing a person well and being able to explain what is happening. Notably, in this exchange, Jean attempted (in lines 169 and 174) to downplay the fact that she is anything other than a competent practitioner for Carol by pointing to the fact that “everybody’s goal” is to find the right spots. She worked to separate acupuncture from the relational or communicative aspects of interaction (line 169). However, Carol’s response that she can have (her) favorite (line 176) further reinforces her view that Jean, as a good acupuncturist, does more than just hit the points accurately. Based on her responses, good healthcare is, in part, a good practitioner– client relationship. Separating Models of Health and Models of Interaction Although models of health do not necessarily correlate with specific models of interaction for understanding the practitioner–client relationship, the data collected here work to blur the lines between these two seemingly independent types of models, as the exchange between Jean and Carol demonstrates. The practitioner–client interactions at GFAC were never solely paternalistic, nor were they only consumeristic or completely mutualistic. Instead, interactions moved in and out of these various models of interaction and worked in conjunction with the holistic model of health described previously. As described in the last section, Jean (practitioner) and Carol (client) shared a holistic conceptualization of health that established certain expectations for the health interaction. For Jean, her holistic interaction was demonstrated by asking a wide constellation of questions that went beyond Carol’s presenting symptoms. For Carol, her expectation was to be known holistically, treated accurately, and given an explanation of what and why certain treatments are used. Later in this same conversation, Carol and Jean spoke explicitly about the practitioner–client relationship: January 27, 2003: Intake interview, Intern Jean, Client Carol. 178 Carol: I mean it’s easier on me when I feel like 179 Jean: Some connection 180 C: yeah. The other people are good and some people are you know more in harmony 181 with others. Some of them have been really good 182 J: Don’t want to cut down our treatment time so. Headache?
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This interchange is especially noteworthy because from lines 178 to 179, both Carol and Jean established that good practitioner–client relationships consist of some kind of connection that presumably involves both practitioner and client. However, when (in lines 180–181) Carol described this as a matter of harmony, Jean brought the conversation back to a more business-like one when she stated “don’t want to cut down on our treatment time.” This abrupt change directs the focus away from Carol’s praise about their harmonic relationship and back to Jean’s work of eliciting symptoms and ailments. In doing so, Jean’s talk is able to maintain the holistic medical principles as described earlier while simultaneously moving toward a more paternalistic approach in which Jean is able to control the amount and scope of talk happening in the visit. Practitioners used a variety of conversational moves that worked to separate the holistic model from a presumed collaborative model of interaction. Yuri often complained about how much time interns spent talking to patients because she did not need as much patient participation to successfully treat patients. She often told stories of her time working in the county jail and treating up to 70 clients in 2 hours. Most of these were quick ear treatments done for substance de-tox. However, Yuri still wrote up chart notes for every client. Reconstructed from field notes, Yuri explained, I treat people while I’m talking. When you come in you lie down and I start feeling your pulse. I have a few key questions to ask but otherwise I’m doing the treatment right then. I can do it in half an hour. I don’t need all the talking.
Unlike Carol’s assertion that successful acupuncture should be based on a kind of relational harmony, Yuri’s explanation is that successful acupuncture is based on successful (and often quick) treatment. Acupuncture can still be holistic if the client does not talk or talks only a little. Because Yuri uses the pulse and other nonverbal ways of examining a person, she can still take into account a holistic picture of the client. Yuri’s explanation of her preferred way of performing acupuncture describes a paternalistic practice in which the practitioners take into account only information that they deem relevant for successful treatment. As these data demonstrate, acupuncture talk reveals a variety of understandings for preferred aspects of care. Practitioners and client interactions both combine and separate the holistic model of health with different models of health interaction. It seems that although all practitioners recognize the holistic nature of acupuncture as a health model, they also perform acupuncture in ways that can range from paternalistic to collaborative and places in between.
DISCUSSION In this article, we have presented models of health and models of interaction, discussing them in light of data collected
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from ethnographic observations of a particular acupuncture site. This research works to illuminate how a group of acupuncture practitioners and clients worked to negotiate the practitioner–client relationship by drawing on a specific holistic model of health that bled into expectations for health interaction. Because the very nature of acupuncture differs substantially from biomedicine, we found the biomedical model and biopsychosocial models difficult, if not impossible to apply. Instead, the holistic model serves as a useful translational model of health, and participants used a holistic vocabulary to describe acupuncture. The reason holism works so well as a translational bridge is because of the larger health context in which holism serves as a readily acceptable critique of biomedicine (see, e.g., Ho, 2007). The result of using this holistic model is that acupuncture is not necessarily valued through its own model of health but, rather, is understood as an alternative form of healthcare. Holism is certainly a basic assumption of the theory of acupuncture, but it is important to remember that acupuncture’s holistic theory existed thousands of years before there was biomedicine, the need for a biomedical critique, or the current trend of holistic healthcare. Given this situation, in which the term and concept of holism is often used as a discursive critique of biomedicine, some acupuncture users incorrectly expected that acupuncture serves as an alternative both in the holistic sense of the whole-self and also in a holistic sense of health interaction, which included practitioner–client collaboration and mutuality. This conflation of model of health and model of interaction happened in part because of the assumption that the biomedical model of health requires paternalistic practitioner– client interactions. Therefore, critiques aimed at Western biomedicine can be aimed at either the biomedical model of health or at paternalism, and sometimes both. Theoretically, models of health and models of interaction are not connected (e.g., one can find a paternalistic, biopsychosocial approach), but one finding of this research is that seekers of healthcare may, in fact, be treating them as interdependent. For example, a Chinese medical model of health does not necessarily require a collaborative model of interaction. As we have shown, the paternalistic model of interaction is often used at GFAC. Through this research we also came to see how models of interaction are not static but, rather, are quite dynamic in that a provider’s and client’s behavior may reflect more than one interaction model within a single consultation. It is certainly possible that the dynamic flow of interactional models is also a phenomenon in the practice of biomedicine, and future research should pay attention to how this occurs in other health settings. Future research in both the biomedical and holistic medical arenas should pay closer attention to the ways participants in healthcare understand the practitioner–client relationship in light of models of health and models of interaction. Because these data are so specific to one particular
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community, it is important to see if, and to what extent, other holistic and nonholistic healthcare settings also reveal that models of health influence expected models of interaction. If this is the case, it makes more sense for scholars to discuss these two aspects of healthcare—health models and interaction models—together rather than separately. In Seattle, Washington, where this field work took place, it was and is not unusual to have conversations about acupuncture or other nonpharmaceutically based health options. However, the participants themselves often commented on how this was “not normal” for the rest of the United States. In addition, field work for this project was spent either with English speaking, middle- and upper-class whites or with Asians and Asian Americans of varied economic classes, so these findings may be even more specific to this very particular acupuncture community. Additional investigation should explore the practitioner–client relationship in a larger variety of U.S. acupuncture clinics and communities, paying attention to how different clients and practitioners do health communication in those settings. Research in these wider acupuncture and other health settings will help to uncover whether the interaction of health models and interaction models is specific to this community, to acupuncture, to holistic medicine, or is found in medicine in general. This article raises important issues about the ways health communication scholars understand practitioner–client relationships. Studying this relationship with only models of interaction ignores the many ways participants use models of healthcare to understand this relationship. One implication of this research into acupuncture relationships is the recognition that all healthcare practices are at once influenced both by models of interaction and by related models of health. Recognizing the connection between models of health and interaction will help to broaden our scope of understanding holistic medicine and the patients who adopt it as a model of health.
ACKNOWLEDGMENTS Funding for this research was provided by the University of Iowa’s Graduate Merit Fellowship. An earlier version of this article was presented at the Annual Convention of the National Communication Association, Miami, FL, November 2003. We would like to thank Mark Goold and two anonymous reviewers for all of their insightful comments and suggestions on earlier drafts as well as all of the practitioners and clients at GFAC for sharing their lives and their work.
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