Friday, December 21, 2012

A Critique of the Unfortunate Direction of the Current Time to Talk Campaign: Strategies to Combat Ineffective Methods — Winnie Ng

In 2008, NCCAM launched “Time to Talk”—an educational campaign that targets patients and their providers. This campaign encourages the discussion of Complementary and Alternative Medicine (CAM) practices between the patient and their provider. CAM therapies include but are not limited to acupuncture, herbal supplements, meditation, and chiropractic care. The roots of the campaign originated from a telephone survey conducted by NCCAM and AARP where adults ages 50 and older were surveyed in regards to their communication with their providers about their use of CAM therapies. The results of the survey revealed three things. First, patients and providers do not discuss complementary and alternative therapy use. The primary reason revealed that patients are not aware that they should tell their provider about CAM use. Second, Providers do not ask patient’s about their use of CAM therapies. And third, the reasons adults over 50 years of age are using CAM therapies. The goal of the Time to Talk campaign is to (1) ensure safe and coordinated care, (2) minimize risks of interactions with a patient’s conventional treatments while effectively managing their health and (3) allow providers to be fully informed and help their patients make wise health-related decisions.
The “Tips for Talking” Posters are Impractical
The goal of the posters is to facilitate a discussion between patients and their providers. Posters are hung in hospitals, physician’s offices and waiting rooms. The underlying model with the posters assume that if the patient breaks the ice with their provider regarding their CAM use, then it will automatically lead to coordinate care.  In other words, when health care providers and patients discuss the use of CAM, they ensure coordinate care despite the content of the conversation. In the poster there are two primary speech bubbles which includes “Ask” and “Tell” highlighted with an orange background and white font. The secondary speech bubble says “ASK your patients, TELL your health care providers, TALK about it” and “DISCUSS use of complementary and alternative medicine.” 
            Although NCCAM did not mention a social science theory in the development of the campaign, it can be argued that their poster has many flaws related to the Health Belief Model. The first critique of the Health Belief Model is that individuals make rational choices in which they assess their degree of risk and make a cost benefit calculation about whether or not to engage in the behavior in the campaign. When a patient arrives at their physician’s office, they may notice the poster but will be unlikely to access their risk, given that most are unaware of potential risk factors if they did not disclose information to their physician which results in disregarding the cost-benefit analysis. Another flaw to the poster is that it does not deliberately illustrate what kind of questions should be asked or what kind of answers will be provided. Given the situation with the scenario with a patient in the waiting room, he or she may think of questions that directly affect his or her health, not necessarily related to the use of CAM therapies. For example, the patient noticed significant hair loss. He or she may ask, “What are some reasons for my hair loss?” or “Is there anything I should do to prevent hair loss?” Some patients may come prepared with questions. However, in the scenario, both questions were unrelated to CAM therapy use. Ultimately, in this campaign, it is difficult for any patient to calculate or access their degree of risk and the assumed benefits if he or she does not use CAM therapies.  
Another critique of the Health Belief Model is that it focuses on individual decisions without a regard for social or environmental factors. The purpose of the poster is to promote awareness of the role of patients and providers. By applying the Health Belief Model, it assumes that the patient will want to ask his or her provider questions regarding CAM therapies after looking at the poster. Utami (2009) investigated the types of activities patients did in the waiting room and the activities were recorded for an hour. They observed that the activities included reading, chatting, working, sitting, standing, and walking. Looking at posters or picking up health brochures were not on that list. The study conducted by Utami (2009) indicated that patients already have an activity in mind when they are waiting in the doctor’s office. Additionally, to shed some light on the provider’s side, this campaign failed to acknowledge the busy, fast paced health care setting which contributes to the limited amount of time providers have with their patients. In fact, in the AARP survey and the study conducted by Verhoef et al. (2008), patients and providers have barriers in communications because of the lack of time.
The last critique of the Health Belief Model is that it assumes everyone has an equal access and equivalent level of knowledge to make a rational decision. In some cases, the patient may have more knowledge on CAM therapies than the provider. Those patients would be less likely to ask their physician since they know it is out of their realm of knowledge. “Research has shown that 40% to 77% of patients who use CAM therapies do not disclose their use or intent in CAM, or desire to use CAM, to their physicians because of concerns that their physicians will react negatively or will dismiss their questions” (Verhoef, 2008, pg.88). For those patients who do not have knowledge on CAM therapies, their questions may not be adequately answered.  If the provider cannot answer a patient’s question regarding CAM use, the provider will direct them to a credible website with the assumption that everyone has access to the Internet.
Flawed Promotional Photos
            The Time to Talk campaign produced five promotional photos to distribute to hospitals and health care providers. The first photo has a woman who is reading material on patient-provider communication; there is an underlying assumption that after she reads the material, she will automatically start a conversation with her provider regarding CAM therapies. The second photo has a man filling out a patient wallet card. A patient wallet card keeps track of all the medication, supplements and commentary health products. The assumption for the patient wallet card is that patients will be willing to fill these out as soon as they see them in the waiting room and that they will be willing to fill these out during their waiting time instead of doing something else. The third photo is a doctor examining a little boy with the Time to Talk poster in the background. This photo is the most problematic of all because the target audience for CAM therapy is not usually a child and it is very unlikely for a young boy to ask his provider about CAM use; to make the photo more convincing, they should at least include the parent. The fourth photo shows two doctors reviewing a folder with Time to Talk material; the assumption here is that doctor’s will make an effort to ask their patient about the types of CAM therapies they are using. The fifth photo has a patient and provider sitting together to review campaign materials, with the assumption that the patient will find the information to be beneficial to them.
            All of these promotional photos are flawed in different ways. One may argue that the person who designed these photos for the campaign did not put much thought and effort into the photo and also lacked knowledge in effective social and behavioral theories, especially the alternative health models. But most importantly, the campaign failed to identify its target audience. If the campaign had a better understanding of its target audience, those who are leading the campaign will be able to reach out to the patient’s deepest aspirations in order for them to have a better engagement. The promotional photos failed to identify the target audience(s) especially the fourth photo with the young boy who is unlikely to be a CAM user. In order for these promotional photos to be slightly more effective, the investigators of this campaign should conduct more research regarding their target population to have some background knowledge and characteristics of CAM users.
Who is the Target Audience?
            One striking attribute about this campaign is that a target population was not identified, which was also apparent based on the promotional photos. In the AARP survey that lead to the Time to Talk campaign, the results show that their participants were all over 50 years of age (AARP, NCCAM). Although participants over 50 years of age are not representative of all CAM users in the United States, they are a good example of a target audience for the purposes of this campaign. In a study conducted by Sparber et al. (2000), they revealed that most patients undergoing cancer treatment also choose to use selected forms CAM therapies, including natural health products. The campaign would be strengthened if they identified their target audience as oncology patients who were also over 50 years of age. This would also be easier for the provider to ask questions regarding the types of treatments they are interested in. In addition, it is also the physician’s duty to provide alternatives to the patient, including both the risks and benefits of a certain treatment.
            Another problem is that this campaign failed to target diverse populations since all of the campaign resources are in English. As the United States is increasingly more multicultural, it is best if the campaign material were also available in different languages such as Spanish, Chinese, Korean and Russian. If the patients are diverse, health outcomes will most likely be positive if the provider is culturally competent. Crandall et al. (2003) conducted a study to evaluate the importance of cultural competence among medical students. The have sufficient evidence that providing culturally competent care promotes positive health outcomes since practitioners will have a better understanding of the patients’ beliefs.
What is the Physician’s Role?
            The role of the physician is unclear and may also lead to controversial consequences. Physicians are trained in biomedical knowledge, not on CAM therapies.
“Patients also think that physicians do not need to know that they are using CAM, because the patient may believe that CAM therapies are natural, completely safe and not within the scope of providers” (Voehoef, 88) However, patient-provider relationships may be different as it is easier for some providers to start the discussion regarding CAM use to their patients. An example of this would be Oncology patient-provider relationships because they are different from a simple checkup with a pediatrician. As studies have shown, oncology patients are more likely to use CAM therapies than younger populations.
Physicians also have the obligation to respect the patient’s autonomy. Physicians have the duty to inform patients about all alternative therapeutic options, including CAM. This means they must be prepared to provide advice about: (1) the benefits and likely outcomes of the treatment, (2) risks involved in the treatment, (3) possibility and probability of complications and (4) side effects and alternative treatment options (Verhoef, 2008 pg. 89). Although the physician has the duty to inform, this does not mean the physician has adequate knowledge to tell patient’s about alternatives such as CAM therapies. Tosaki identified major barriers in CAM discussion with the patient. These barriers include: perceived indifference or opposition toward CAM by the physician, emphasis on scientific evidence, and anticipating a negative response from the physician (Verhoef, 2008 pg. 89). Physicians have limited time to learn CAM and discuss CAM related issues during their appointment with the patient that are already short to address the patient’s main health concerns.
The Alternative to the Poster and Promotional Photos
            The campaign should discard the posters and the promotional photos and replace them with a compilation of promotional videos that utilizes effective social science theories such as communication theory. The posters and promotional photos are a hit or miss since most patients do not pay attention to the things on the wall; patients usually have an idea of an activity of what they will do while they are in the waiting room such as reading a book. With a video, patients in a waiting room are more likely to watch if they can relate to the content that is being delivered.
            The video should have a clear and effective message such as “control over one’s life through one quick and easy discussion with a provider.” The individuals delivering this message also play an important role in the effectiveness of the campaign. This is why the individuals delivering the message should be people who have a positive image and are likable, preferably celebrities and athletes who use CAM therapies. The audience will be more receptive of the message in the campaign if they like the person who is delivering the message. In addition, the campaign should include different celebrities and athletes in different age groups in order to effectively target different audiences. For example, an oncologists’ waiting room should display  a video on a large television monitor of a 50 year old ex-Olympian delivering a message regarding her control of her life by asking a couple of questions related to CAM use. She will give some examples of questions to ask her provider and will claim she has control of her life and at the end, she will ask the audience if they have control of their lives. The 50 year old ex-Olympian will not be delivering the message in an obstetrics and gynecology (OB/GYN) office because she does not relate to audience of prospective mothers. In an OB/GYN setting, a 35 year old celebrity will deliver the message by telling the audience that she has control over her life because she asked her provider questions regarding safe CAM use during pregnancy. With different videos with celebrities or athletes that relate to patients in a specific health care setting, patients from varying age groups and health concerns will be aware of the issue and will be likely to address the issue.
            The content of the video should emphasize the goals of the campaign and should also provide a message with a degree of uncertainty regarding CAM therapies. If people do not know an aspect about CAM therapy use, they will probably be stimulated to formulate some questions to ask their providers. On the providers’ end, he or she could ask their patients what they thought of the video and if they have any questions related to CAM therapies. Since the video was displayed in the waiting room, physicians can use that as a conversation starter with their patients. If by any chance, the provider cannot answer their patients’ question(s), he or she should refer their patients to a CAM practitioner or expert. If the questions are related to associated risk and benefits of CAM therapies, the campaign should provide a brochure or pamphlet with all of the CAM therapies that are scientifically proven, including but not limited to the side effects if it is concurrently used with biomedicine. Additionally, these brochures or pamphlets should have colored visuals of the herb or drug so that patients can distinguish between them.
            All of these alternatives are definitely more effective than the Time to Talk campaign posters and promotional photos. The videos provide the audience with something patients can relate to in a health care setting, whereas the promotional photos lacked a target audience. The Time to Talk posters has the two speech bubbles with “Ask” and “Tell,” which does not tell the audience what the message is about. Are they supposed to ask just any question pertaining to their health or should they ask about CAM therapies? The “Tell” speech bubble is also problematic because it assumes that providers will be able to answer every question. The videos are also conversational starters for the provider since it is easier for them to ask about CAM because of the video than out of the blue.
Outreach to Diverse Populations
            The Time to Talk campaign did not indicate a target audience but it also failed to outreach to diverse populations since all of the campaign materials are in English. In order for this campaign to be more successful, campaign strategists must have a better outreach to diverse populations. Especially in large metropolitan areas, certain ethnic populations lack English proficiency. The best way to introduce the campaign to ethnic populations is through ethnic media such as the radio and newspaper. The newspaper should have an ad or a press release-like article regarding the importance of the campaign. The press release should include a real tragic story related to a patient who used a drug and had an adverse health effect that resulted in death. The purpose of the press release is to emphasize the importance of sharing the types of medications and CAM therapies with their providers. The sharing of this information will not necessarily prevent unintentional deaths but it will definitely reduce the risks if they had a conversation with their provider.
            The radio show should invite one CAM practitioner and an expert on contemporary biomedicine. The show should give a brief background on the importance of interacting and raising questions regarding CAM therapy use with providers. Both health care experts will accept calls and will answer any questions anyone may have. This method not only answers a question(s) for an individual, but it also allows hundreds or even thousands of listeners to be aware of the issue. In addition, radio shows outreach to many people at the same time. The housewife will be able to listen to the show while she is preparing dinner, the truck driver will be able to listen to the show while he or she is delivering furniture, a group of elderly will be able to listen to the show at a local YMCA, and all of the office workers who turn on the radio at work will be able to listen to the show.
CAM Therapy Workshop Series for Interested Physicians
            To address the role of physicians, workshops should be given to educate them about CAM therapies and the characteristics of CAM users. At the beginning of the workshop series, physicians need to acknowledge medical pluralism, which is increasingly being acknowledged by many scholars as an integrated health care perspective that incorporates the diverse health care needs and practices of the changing U.S. population (Meade et al., 2005).  Medical pluralism is defined as the use of multiple-forms of health care therapies where consumers practice and utilize multiple healing systems including contemporary biomedicine, Chinese medicine and religious healing (Bodeker et al. 2002). Physicians will need to be aware of the fact that as the U.S. is becoming increasingly diverse, medical pluralism will likely become an integral part of the health system as patients explore multiple options to meet their health care needs such as CAM therapies.
            After physicians have a better of medical pluralism, they will probably understand the rationale behind the CAM workshops. Physicians should learn as much as they can in the workshop, including a list of appropriate questions to ask their patients. Examples of good questions are: (1) “What else are you doing to take care of your cancer?” (2) “Have you seen other practitioners?” (3) “Many of my patients are interested in CAM therapies, have you used any type of therapy for this problem?” (Verhoef 2008). The other segment of the workshop should explore the reasons why patients are using CAM therapies including their beliefs and values because a great deal more than evidence goes into a patients’ decision to use CAM (Verhoef 2008).
            Bylund et al. (2010) recently used the Time to Talk campaign as part of their intervention to increase patient-provider communication in a clinical setting. They used a concordance framework for understanding communication skills. CAM users were recruited to complete a facilitator led 60 minute patient communications course called “How to talk to your biomedical practitioner about CAM.” Concordance is a negotiated agreement that makes an effort to respect the wishes and beliefs of the patient, based on the experiences with his or her life. Concordance also promotes the shared understanding between patients and providers regarding when and how CAM therapies should be used.
            The patient-provider setting would improve drastically if both parties had an understanding of the underlying goals of the campaign. Since CAM therapies are not taught in medical school, these workshops are necessary to ensure that physicians have adequate knowledge to help their patients. Through these workshops, providers will have a better understanding of CAM therapies and their users and therefore their role in the patients’ life is increasingly more important. After this workshop, the physician is not expected to know everything about CAM therapies. If for any reason, they cannot answer their patients’ question regarding CAM use, the physician should provide the patient with a contact number of someone who can answer that question.

(1) AARP, NCCAM. Complementary and Alternative Medicine: What People 50 and Older Discuss With Their Health Care Providers. Consumer Survey Report.  (2011, April 13).
(2) Backgrounder. (2012, March 12). In Time to Talk. Retrieved December 4, 2012, from
(3) Bodeker, G., & Kronengberg, F. (2002, October). A Public Health Agenda for Traditional, Complementary, and Alternative Medicine. American Journal of Public Health, 92(10), 1581-1592.
(4) Bylund, C. L., D'Agostino, T. A., Ho, E. Y., & Chewning, B. A. (2010, July). Improving Clinical Communication and Promoting Health through Concordance-Based Patient Education. Communication Education, 59(3), 294-311.
(5) Crandall, S. J., George, G., Marion, G. S., & Davis, S. (2003, June). Applying Theory to the Design of Cultural Competency Training for Medical Students: A Case Study. Academic Medicine, 78(6), 588-594.
(6) Meade, M., & Earickson, R. (2005). Medical Geography (2nd ed.). New York, NY: The Guilford Press.
(7) Sparber A, Bauer L, Curt G (2000). Use of complementary medicine by Adult Patients Participating in Cancer Clinical Trials.
Oncol Nurs Forum, 27, 623–630.
(8) Utami, D. (n.d.). What do People do in the Waiting Room?. Retrieved December 10, 2012, from
(9) Verhoef, M. J., Boon, H. S., & Page, S. A. (2008). Talking to Cancer Patients about Complementary Therapies: Is it the Physician's Responsibility? Current Oncology, 15(S2), S88-S93.

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