The Lebanese public perceives the physician-patient relationship as flawed. The objectives of this study are to assess factors associated with the public’s trust in physicians in the context of the Lebanese healthcare system and to explore potential ways to enhance it.We conducted a qualitative study based on a grounded theory methodology using semi-structured interviews with members of the Lebanese public (not restricted to patients). We selected participants through convenience and maximum variation sampling approaches. The constant comparative analysis resulted in a theoretical framework that describes the factors influencing trust in physicians.Participants trusted an experienced, up-to-date, graduate of a North American or Western European school, working in a reputable hospital, with a high level of diagnostic skills. The personal characteristics that improved trust were physicians who are ‘non-materialistic’, have a good rapport, and have sufficient encounter time with patients. Social factors that enhance trust in the physician include: being a family member, recommended by a family member, featured in mainstream media, and/or having a good reputation. Trust increased compliance, loyalty despite occasional mistakes committed, high consultation fees, and negative attitudes towards the physician’s institution. Conversely, no trust led to severed therapeutic relationship and seeking second opinions.The level of trust of members of the Lebanese public in physicians was affected by the personal characteristics of physicians, their practice or clinical skills, their interactions with the patient, finances, in addition to a number of social factors. Moreover, the level of trust had major implications on patients’ interactions with their physicians.The online version of this article (10.1186/s12913-019-4354-0) contains supplementary material, which is available to authorized users. Trust can be defined “as a state of favourable expectation regarding other people’s actions and intentions” , Simmel Trust is an essential building block in the patient-physician relationship. Pearson and colleagues describe trust in physicians as “a reassuring feeling of confidence or reliance in the physician and the physician’s intent” . MoreoveTrust does not arise from one encounter and is not “blind faith” . It devePatients’ trust in a physician contributes to a long-standing relationship with that same physician for their services and care. In such cases, the physician knows the patient’s medical history, can identify their risk factors more accurately, and can closely monitor their health status. From the patient’s perspective, trust in their physicians increases the patient compliance to treatment . Even wiGlobally, trust in physicians is in decline , which tIn Lebanon, public trust in physicians is also in decline. Arawi and colleagues indicate that the Lebanese public perceives the physician-patient relationship as flawed, “characterized by materialistic gain and a feeling of being treated as a ‘number’ and not as a ‘person’” . HoweverTherefore, the objectives of this study are to assess the factors associated with members of the Lebanese public’s trust in physicians in the context of the Lebanese healthcare system and to explore potential ways to enhance it.In this study we opted for an exploratory qualitative design based on Corbin and Strauss’ grounded theory approach to provide insights on the social processes that were associated with the participants’ trust in physicians . ConsistWe followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) in drafting this manuscript . COREQ gTwo team members (GHA and EAA), with significant experience in conducting and publishing qualitative studies, overlooked the research. The rest of the team  were second-year medical students with no previous experience in qualitative research when the study was conducted. They were trained in interviewing and data analysis techniques. Following the first few interviews, debriefing sessions were held to reflect on the process of data collection and measures for improvement.Our target population consisted of adult (ages 18 and above) Lebanese nationals residing in Lebanon. We did not restrict the population to ‘patients’ as we were seeking perspectives related to the wider general population. We included Arabic and English speakers from this population as the interview and consent form were only available in these two languages. We recruited participants from different governorates, residential areas , and demographic profiles . We also sought participants from public places  and eligible individuals living in the co-investigators’ neighbourhoods to participate in our study.Our sampling was guided by the intention of approaching participants who would count as informant-rich sources. Therefore, we identified and approached eligible members of the Lebanese public through both convenience and maximum variation sampling approaches. To increase heterogeneity, we captured participants that varied by governorate, gender, and age. We made sure that the interviewer and interviewee had no prior relationship. Individuals interested in the study were asked for oral consent and were given at the time of the interview an information sheet that did not require a signature. Abiding by the grounded theory approach, sampling was concurrent with data collection and analysis. We proceeded with recruitment until no further themes emerged (thematic saturation) .We conducted face-to-face in-depth interviews throughout the months of February and March 2017. We chose settings convenient to participants for conducting the interviews. We audiotaped each interview; when participant refused to consent, we resorted to note-taking. We used the interviewee’s language of preference (Arabic or English). Each interview lasted between 15 and 30 min.The interview started with a short questionnaire on the participant’s demographic characteristics  computer. We transcribed audio-recorded interviews conducted in English. Arabic interviews were translated as we were working on the transcription. We proceeded with the processes of transcription, translation, and data analysis immediately following each interview.Consistent with an inductive constant comparative approach, the three pairs of investigators conducting the interviews independently read, categorized, labelled, and coded line by line the first three transcripts (open coding). All the aforementioned co-investigators met with the two senior investigators to share, analyse, compare, and contrast their results (constant comparative technique). We repeated the same process for the second and third set of three interviews and then compared their results with the results of the three previous interviews. This comparison allowed us to identify commonalities and variations when we started eliciting categories from the data.We used these categories to refine the interview guide which was used in the following interviews, as it gave way to more probing and clarified issues which were, otherwise, still uncovered. These subsequent interviews were coded line by line, and their results were compared with each other. The categorization following this process allowed the elicitation of the emerging themes . We continued the data collection until we reached data saturation . Then, we stopped the data collection and met to discuss our final findings and to develop the theoretical framework weaving the thematic categories into an integrated whole. The integrated framework shows the factors associated with the trust of members of the public in physicians in the context of the Lebanese healthcare system (selective coding) . SignifiWe worked hard to refine our findings’ credibility (i.e. referring to confidence in the truth of the data and interpretations of them) and confirmability  . In termAll individuals approached for the study agreed to participate. We recruited a total of 27 individuals from 4 of the 6 governorates in Lebanon. Table Our analysis identified factors associated with individuals’ trust in physicians in the context of the Lebanese healthcare system. Additional file the doctor should use technologically advanced resources like MRI, and scanners. The hospital where the doctor works is an important factor” (P21).Personal and practice characteristics influencing trust in physicians included: country of training, institution of practice, years of experience, having experience versus being up-to-date, gender, and appearance and hygiene. For most, but not all participants, their trust in the physician depended on that physician’s country of training. For example, many participants have more trust in physicians trained in Western Europe or North America as opposed to Eastern Europe. Similarly, many participants indicated that their trust increased when physicians were working at reputable and private hospitals. One participant explained: “Even if a physician had several years of experience and he is not following up on the most recent updates, he wouldn’t be on the same level as a fresh graduate who knows much more of the most recent advancements” (P22). Another participant noted the importance of periodically re-evaluating the physician’s competencies as a governmental measure to improve trust. Furthermore, participants reported that the physician’s gender had no influence on their level of trust. On the issue of appearance and hygiene, the majority of participants reported that trust in physicians was influenced by professional attire as one participant explained: “if I enter a doctor’s clinic and find that it does not reflect a very good hygiene, it would greatly lower my trust in that doctor” (P06).For some, the physician’s years of experience was a very important determinant of trust, and for a few, it was the most important. However, most participants preferred an up-to-date physician with long years of experience. This was illustrated by a participant saying: “the patient has to trust his/her physician and, therefore, must choose a competent one; you can’t trust someone who’s not competent” (P05). Medical competency was defined in terms of answering inquiries, “cur[ing] you” (P03) and “his diagnosis is always correct” (P22). Many participants reported that trust building occurred overtime after several clinical interactions: “trust is built based on experiences with doctors. You can’t trust them from the beginning; you don’t know them. If I have good results with them, this initiates building trust” (P23). While both the ability of the physician to provide accurate diagnosis and to reach the desire cure were important, many considered the physician’s diagnostic skills as crucial. High competency in diagnosis enhanced trust, while low competency gravely decreased it. Repeated misdiagnosis could drive the patient to stop seeking the physician’s care or to pursue a second opinion.Physician’s clinical skills mattered. Those included: being competent, not making mistakes, and educating patients. The physician’s competency was one of the most commonly discussed factors influencing the public’s trust in physicians. One participant explained: “no one is exempt from making mistakes” (P16). However, major mistakes leading to death or disability were certainly a deterrent of trust. For some, the impact of a mistake was tempered whenever the physician admitted committing it and explaining it to the patient.The majority of participants indicated that minor mistakes did not influence their trust, for example one of the participants said: “if they don’t explain to me what is happening then I would trust them less” (P04). Few participants indicated that physicians should take the initiative to educate their patients, not only regarding their medical condition and treatment outcomes but also regarding any medical or surgical procedures.Many participants indicated that patient education, especially for surgical procedures, was suboptimal, thus leading to decrease in trust: “when a doctor just looks at a patient and does a quick examination saying nothing is wrong and doesn’t ask or take into account the simple things, she might miss a serious disease. If she gives him a quick look and dismisses him with a prescription, that means she’s not a [good] doctor” (P16).The interactions with the physician theme included factors such as rapport, encounter time, consultation fees, and being money oriented. A lot of the participants emphasized the importance of a good rapport between the physician and the patient; a relationship built on compassion, honesty and respect of patients. The longer the encounter time, the more they trusted their physicians, as this allowed them to discuss concerns and worries. It also allowed the physician to make the right diagnosis, as shown in the voice of this participant: “doctors want to live. They are not “Caritas” [charity]. They help people but for them, this is a job to support their living. They learn to eventually work” (P02).Participants consistently noted that the consultation fees did not affect their trust in or their choice of the physician: “materialistic” (P24) also described as “businessmen” (P19), in contrast to those with the “more humane” (P20) physicians. However, some participants were in favour of fixed consultation fees, given that some physicians charged exorbitant amounts. Finally, giving free medications by physicians was perceived on a spectrum ranging from positive, to neutral, to negative.The majority consented that trust decreased whenever the physician showed signs of being “everyone who goes on the television is good” (P12). For some, a physician’s good reputation increased trust except for one participant who said that: “some doctors have a good reputation without being good (competent), but some are actually good” (P18).The main social factors mentioned as influencing the individuals’ trust in physicians were: being a family member, recommended by a family member, featured in mainstream media, and/or having a good reputation. All participants said that they trust a physician more who is a family member or who is recommended by a family member. For some, the trust in the physician increased when they made an appearance in the media: “Increased trust in physician led to:  being deI have watched 100s of TV programs where the physician explains to the patient before he treats him, but Lebanese surgeons don’t explain anything” (P06); 2- provide enough encounter time with patients: “The doctor should provide her patient with enough time and specific things related to each patient’s condition” (P09); and 3- close monitoring by the Ministry of Health. They also suggested that the Order of Physicians impose a fixed consultation fee: “Theoretically the check-up for all doctors should be fixed” (P24). In addition, they demand that the government periodically reassess the physicians’ competencies.In order to enhance the public’s trust of physicians, participants expected them to: 1- improve patient education: “One of the objectives of this study was to explore the factors associated with trust of members of the public in physicians in the context of the Lebanese healthcare system. To summarize, we found that members of the public trusted experienced physicians who keep abreast with up-to-date evidence, graduated from North America or Western Europe, and worked at a reputable hospital. As for interpersonal skills, being ‘non-materialistic’, having a good rapport with the patient, and providing sufficient encounter time were also important factors associated with trust. Participants showed high levels of trust for physicians featured in the media and those with a good reputation in their social network, as Mechanic and Meyer suggest “trust initially may be based on reputation” .businessmen” (P19) and “financially oriented” (P20). The physicians’ ethical values were also important traits of trustworthiness. In the Arawi’s study, the physician’s traits most desired by the public were being “honest, humane, ethical, not materialistic, humble/modest, compassionate, respect patient, and God-fearing” [Also, we found that people had higher trust in physicians who are believed to hold the patient’s best interests above everything else. They described the less trustworthy physicians as “fearing” . In a reessmen” P and “finiented” P. The phyWe found that clinical competencies, particularly strong diagnostic skills, were an important factor in increasing trust. This was echoed in several studies that reported physician’s competence including thoroughness and knowledge as factors related to trust , 21–23. In Shanghai, China, authors found that the main cause of distrust in physicians was the asymmetry of information between patients and physicians . In anotIn the context of the health care system, trust can be classified into two categories: the social trust which relates to the system as a whole, and the interpersonal trust which is a function of a relationship between two parties and the interactions between them , 27. In To our knowledge, this is the first study to qualitatively explore the factors which are associated with the trust of the public in physicians in the Middle East region. One strength of this study was the use of quality control approaches such as thorough training of investigators in data collection and data analysis. We also conducted the analysis in a duplicate and independent manner followed by consensus building. Additionally, the sample of participants captured both genders equally, and varied by region and age. One limitation of this study was that participants could not be sampled from all the governorates of Lebanon, but we assume that most findings would likely be shared by other Lebanese. Another limitation is that certain characteristics of participants, such as level of education, may have had an impact on trust and was not captured in this study.Trust is one of the central pillars of the physician-patient relationship and has major implications on the patients’ interactions with their physicians. The results of this study revealed five main themes that impacted trust and comprise: the personal and practice characteristics of physicians, clinical skills, interactions with the patient, finances, and several social factors. This is an important step in capturing the unique determinants of trust in Lebanon, especially as the healthcare system continues to change and develop. Reinforcing the physician-patient trust depends on the ability to measure these factors and consequently promote all positive determinants and abolish all threats to the trust relationship. We hope that this study will help promote future research that develops validated tools to measure trust and develop specific interventions and policies to enhance it. Knowing these factors will enable physicians to reflect on their own practice and hopefully help them increase the patients’ trust.Additional file 1:Questionnaire on the participants’ demographic characteristics entitled “Data collection sheet”. (PDF 36 kb)Additional file 2:Interview guide that we used to guide the discussion during the semi-structured interviews. It is entitled “Interview guide”. (PDF 39 kb)Additional file 3:Contains an example of themes, subthemes and codes. (XLSX 14 kb)


Complementary and alternative medicine (CAM) is very popular with patients frequently combining it with orthodox health care. The high prevalence of CAM use and satisfaction with CAM reported by patients directly challenges an orthodox system that can only approve such use if it results from the application of biomedical concepts and science. Studies highlighting this as a cultural, sociological and historical phenomenon emphasise the value of choice for consumers of health care. Musculoskeletal conditions typify common problems for which the effectiveness of orthodox care is often unclear. We postulated that the reasons people give for using or not using CAM for musculoskeletal conditions, would therefore indicate the full range of expectations that people have of health care. Furthermore, these reasons would indicate how much people feel orthodox health care is or is not meeting their expectations. Therefore, this study aims to investigate people’s reasons for choosing or avoiding CAM for non-traumatic musculoskeletal conditions.A systematic search and narrative synthesis was conducted of published qualitative and quantitative studies related to CAM and non-traumatic musculoskeletal conditions.We identified 169 relevant papers detailing 152 separate studies, from which 1486 justifications were extracted concerning CAM use. Content analysis resulted in 11 distinct categories across four themes: practical aspects of care, clinical effectiveness, non-clinical outcomes of care, and a person’s philosophy of illness and care. People provided similar rationales for both using and avoiding CAM, emphasising that, whilst CAM is perceived by many patients with musculoskeletal conditions to fill gaps in care , orthodox care also seeks to deliver these aspects of care. However, people who used CAM also highlighted its alignment with their general philosophy and ideas about illness and health care, and often emphasised CAM’s capacity to give them control over their condition and its treatment.Currently, CAM appears to have a significant role for patients with common painful long-term conditions in providing choices to enable individual needs to be met. The model of modern orthodox scientific Western medical practice can be summarised as ‘find the pathological disease underlying a patient’s illness and treat it; identify causal mechanisms underlying the disease and prevent it occurring in the first place’. The sick patient gets better; the incidence of disease declines. Musculoskeletal conditions, in total estimated to be the commonest reason for disability globally , containThere is no single model of complementary and alternative medicine (CAM). Some therapies, such as herbal remedies, may be developed, tested and applied entirely within the orthodox biomedical framework. Others, such as traditional acupuncture, have a philosophy and principles of action which do not originate and may not fit with orthodox Western medical science. For many people, this makes much CAM implausible and beyond justification as a rational approach to ill-health.However, there is now widespread acceptance that Western medicine, for all its successes in diagnosing and treating disease, needs a wider view of the sick person than biology and pathology alone provide and must set care in the wider context of a patient’s personal, emotional, social and cultural life, especially for long-term illness such as common musculoskeletal conditions  for which ‘scientific cures’ are often lacking. This reflects the importance of patient autonomy, self-care, choice and expectations, and growing evidence that wider components of care beyond biomedical treatments can improve response to those treatments . Belief Attention to this wider context of care has been a feature of the traditional healer in societies across the world, and researchers and CAM proponents have argued that this, and placing support for self-care at the heart of the consultation in many types of CAM, is what CAM can deliver ,5. OtherMusculoskeletal conditions typify common problems for which the effectiveness of orthodox care is often unclear. We hypothesised that the reasons people give for using or not using CAM for musculoskeletal conditions would highlight the full range of expectations that people have of health care. Furthermore, these reasons would indicate how much people feel orthodox health care is or is not meeting their expectations.We therefore set out to identify and categorise the body of reasons that people give for seeking out and using CAM for musculoskeletal conditions and the reasons others avoid it, by conducting a systematic search and narrative synthesis of literature related to CAM and musculoskeletal medicine.In people with non-traumatic musculoskeletal conditions, what are the justifications given for choosing, continuing, avoiding or discontinuing CAM?Quantitative and qualitative studies of any design were included. Intervention studies were only included if participants were able to choose whether they were allocated to CAM therapy or not and their reasons for choice reported. We did not restrict searches by country or date. However, for practical reasons, all non-English language articles were excluded, as were conference abstracts and studies where the full text could not be retrieved.e.g. primary care and disease/condition specific population. Studies of post-operative pain, trauma-related conditions e.g. acute sprains and fractures, and conditions that were primarily neurological e.g. multiple sclerosis, were excluded if no other non-traumatic musculoskeletal condition was included.Individuals of any age, sex or ethnicity with non-traumatic musculoskeletal conditions were included, whether from a general or specific population health care approaches developed outside of mainstream Western, or conventional, medicine for specific conditions or overall well-being.” , “prescription drugs too expensive” [ID49] and “affordable alternative to expensive prescription drugs” [ID480] were all coded as A36.Step 2: Conceptually identical/similar: justifications which were considered identical/very similar conceptually were identified and coded (with a ‘B’ group code) and provided with a code descriptor by NC and reviewed by JJ and PC. For example, those coded A36 (see above) along with similar justifications coded in Step 1 including “conventional treatment too expensive” [ID961], “cost” [ID372], “low cost compared to medical services” [ID710] and “"stopped going to physical therapy because couldn’t afford it any more"” [ID981] were all given the same code (B30 –which can be summarised here as ‘Motive: CAM cheaper than orthodox care’).Step 3: Categorisation: justifications from steps 1 and 2 were sorted and grouped to identify broader categories by NC which were coherent and could be designated with a unifying label. During this process there was a point at which no new categories emerged i.e. saturation of categories was attained. Preliminary labels were then assigned to each category. For example, those coded B30 (see above) along with similar justifications including those coded as B139 ‘Barrier: CAM perceived/considered too expensive to try’, B6 ‘Discontinued: too expensive, could not afford’, B191 ‘Continue: cost-effectiveness’ and B273 ‘Motive: CAM covered by insurance’ were labelled ‘COST’.Step 4: Categories identified and labelled in step 3 were presented to the two ‘second’ reviewers. Discussion between all three reviewers led to minor amendments in the contents and labels of some categories e.g. ‘COST’ was merged into the category ‘ACCESS’. Then, using these amended categories, two reviewers (JJ and PC) independently allocated a randomly selected subset of all justifications to the available categories . This provided a check on the appropriateness and robustness of the categorisations. Disagreements were documented and resolved through discussion between all three reviewers.Step 5: Finally, all justifications were arranged according to their assigned category and then were checked again independently by all three reviewers to ensure accuracy and consistency of categorisation.Justifications could be assigned to more than one category: this was particularly pertinent for qualitative studies where multiple reasons were often given in one statement.The search was rerun at the beginning of February 2017 and new papers fitting the inclusion criteria were identified. Full texts were retrieved and justifications were identified to check if any additional reasons were given beyond those already described. In this way, the robustness of the categorisation was checked, using the criterion that no new justifications would be identified with the publication of new studies.We followed the PRISMA statement guidelines for reporting systematic review of studies that evaluate health care interventions , as far n = 67) and Europe ; however, Asia (n = 16), Australia and New Zealand (n = 12), the Middle East (n = 9) and Africa (n = 2) were also represented.One hundred and fifty-two studies, reported in 169 papers see . Almost n = 65, 43%), although population- and community-based settings were also popular . In comparison few studies focused on recruiting participants from CAM settings , with a minority recruiting from more than one setting : the setting was not clear for one study.Orthodox health care was the most frequent setting for studies (i.e. <18 years old) and one on older people (> = 65 years) but most studies included adults (age = 18–64 years) with children and/or older adults (n = 137): five studies did not include the age of their participants.There were approximately twice as many quantitative as qualitative studies in population- and community-based or CAM settings, and studies set in orthodox health care were predominantly quantitative .e.g. GP, but also advice, suggestions and recommendations of trusted others, the provision of CAM by family or friends and on occasion doctor, information provided via the media, curiosity and experimentation, and finally awareness.Referral, both formally and informally, to CAM therapy was frequently identified in the data. This broad category encompasses not only formal referral to, or prescription of, CAM by healthcare professionals Three major sources of referral were prominent: general (family) practitioners and other healthcare professionals; family and friends; and the media including TV, radio, magazines, books and the internet. But also, to a lesser extent testimonials from trusted others including patients with a similar condition, co-workers and famous individuals.e.g. “…GP who told me first that Harpagophytum was relevant for arthritis.” ”  and the pain came back, so I tried moxa cautery” ” , “I’ve shatever”  and “I rty good”  and “Chitrength” ; and thoworking” , “failurymptoms”  and “I wcautery” .e.g. “both Western and Eastern forms of medical care can complement each other nicely, one supplying the patient with treatments the other may be lacking. This can only help all patients stay as well as possible.” , like. Because those things are long term anyway, and I didn’t feel any benefits from it to be quite honest” ” [e.g. “treatment is long and results are slow to appear” [i.e. “pharmacologic therapy already working” [The barriers to CAM use associated with this category were: the view that CAM was not effective fective”  or was licines]” , or had  appear” . In contworking” .Key terms associated with this category: improve, alleviate, relieve, enhance, increase, cure and control of condition or symptoms.i.e. a specific beneficial outcome, often in relation to a particular symptom or condition as the following examples highlight: “long-term relief of symptoms”   .Key terms associated with this category: Confidence, credibility, legitimacy, trust, faith, expectation/belief, evidence, proof, training and expertise.e.g. “I believe in it”  [“most patients were concerned they might be laughed at” [Barriers to using CAM therapies reflected the antithesis of the reasons for use: lack of belief in CAM nd yang”  or lack fession"  or reputAccess’] . One stughed at”  if they Key terms associated with this category: satisfaction, happy, disappointment, disillusioned and frustration.doctors are hopeless”  on the basis of the perceived type of pain e.g. chiropractic for nerve pain or massage therapy for muscular pain” . I wanted to do something” [I believe that complementary therapy enables me to take a more active part in maintaining my health” [psychologically, I feel as though I am actually doing something. I feel in control” [being able to select their own practitioner” [personal preference” [Often there was mention of individuals taking control and being proactive with regard to their own healthcare, as shown in the following comments “mething” , “I beli health”  and “psycontrol” . But thiitioner”  and “perference” .to avoid long term drug taking” [desire for symptomatic relief without the use of allopathic medication” [fear or avoidance of surgery” [I want to stay with my own knee, no matter what” [Reactions to orthodox medicine as a driver for CAM use were also identified in this category, and were primarily associated with limiting or avoiding orthodox interventions, for example, “ taking” , the “deication” , “fear osurgery”  and “I wer what” .became users because of coincidence” [no interest” [e.g. “not having a reason to try” [not wanting to be seen as a complainer” [Only four reasons fell into the miscellaneous category. One regarding CAM use “cidence” ; the remnterest” , lack of to try” , and “noplainer” .A total of 87 new studies, reported in 101 articles, published between July 2011 and the beginning of February 2017 were pertinent to this review (see S5 for full list of papers included in robustness testing). The full texts were scrutinised and justifications for CAM use/non-use were cross-referenced against the reasons identified in the original search. No additional reasons were identified, thus supporting the robustness of the categorisation presented above.We have identified quantitative and qualitative empirical work that describes and reports on the reasons why people use or do not use CAM for the treatment of common musculoskeletal pain syndromes. This reflects a substantial literature, and does not rely only on samples drawn from people surveyed or interviewed in CAM settings.a group of diverse medical and health care interventions, practices, products or disciplines that are generally not considered part of conventional medicine” [grey and mobile and culturally bound” [CAM is not one single entity or monolithic practice; it embraces many different settings and types of care, with a highly variable ‘fit’ with Western notions of mechanism and evidence of effectiveness. This heterogeneity, however, is also true of orthodox medicine. We accept that lumping together many different practices under the heading of ‘CAM’ and ‘orthodox medicine’, and treating them as separate entities, is artificial. However, there is a general public perception of CAM that reflects its definition as “edicine” ; and in y bound” .Our review has not addressed the evidence base for effectiveness of either CAM or orthodox medicine in the treatment and care of patients with musculoskeletal conditions, nor entered the debate about the status and appropriateness of different forms of evidence in judging usefulness or importance to health care and health policy . Our stath Century London, choice has always been rated highly by patients seeking symptom relief [st Century medicine now embraces this in tackling issues like travel distance and waiting times. Lay and professional recommendation or referral provide practical authority to choose treatments when there is no obvious and immediate cure, reflecting the importance of public culture in driving CAM use and the frustration of orthodox practitioners treating musculoskeletal conditions.We identified eleven distinct justification categories, grouped into four themes. The first theme was practicalities of care. As Porter observed of 17m relief ; 21st CePerceived effectiveness was a second theme, regardless whether this was backed by orthodox scientific evidence or not. People experiment for themselves. This is discomforting and problematic for Western scientific thought, because the individual’s rationale is based on a belief that CAM helps; but that belief may rest on claims that ignore Western notions of science and evidence. CAM also meets more general expectations of effectiveness and provides confidence, but so also does orthodox medicine. Most patients with musculoskeletal conditions in Western countries use both forms of health care , workingThe third theme identified outcomes other than clinical effectiveness. Satisfaction with care and safety of care are now considered important outcomes for orthodox health care also . Dissatithe logic that they (the patients) follow in deciding to seek help may not resonate with clinicians, since it will be shaped by a wider range of factors than the straightforwardly biomedical” [The fourth theme finds CAM meeting a need among patients confronted by the medicine of high technology and scientific interventions—namely for care that coheres with broader aspects of life and motivates self-help. As Braunack-Mayer and Avery observed about why people go to the doctor “medical” . CAM of medical” . Our revGeneral reviews of perspectives on CAM and general population surveys have highlighted comparable categories to those identified here. Bishop et al.’s review of beliefs predicting CAM use identified a sense of control and participation, beliefs about holism and natural treatments, and general philosophies of life . One US There have been studies in other disease groups, such as patients with cancer, and groups expected to be more ‘resistant’ to the attractions of CAM, which confirm the generalisability of the justifications emerging here. Shumay et al. found that patients with cancer who used CAM wished to avoid damage or harm to the body, and some reported an unsatisfactory relationship with health care providers . The autthere is more to life than medicine may diagnose, and family medicine should strive to move closer to the lives of our patients than the medical model alone could allow” [The traditional medical model, according to Soler and Okkes, provides an incomplete framework for primary care generally: “d allow” . Paskinsd allow” .Our aim in this review was to summarise empirical evidence about the reasons given by patients with musculoskeletal conditions for using or avoiding CAM.The choice of a broad inclusion category of all musculoskeletal conditions was based on important features of these conditions. They are by far the commonest group of conditions globally that cause continuing disability but low mortality over time  and poseWe chose to exclude psychotherapy treatments and practitioners from our search . In our analysis and discussion of a number of the justification categories, it is clear that one of the attractions of CAM for many people is the perceived promotion of mental well-being achieved through both the therapeutic relationship, and the time, context and style provided by a number of CAM therapies. Orthodox health care also aims to provide this in routine health care, but more specifically through counselling and psychotherapies. Therefore, this was one area where the overlap between orthodox and CAM practice is likely to be difficult to disentangle and so for the particular purposes of this study, these were excluded.Strengths include the comprehensiveness and inclusiveness of the literature search, and the blinded independent assessment of categories that emerged for classifying the wealth of reasons which appear in the literature. On the other hand, the inclusion of quantitative as well as qualitative studies was a potential limitation, given that ‘closed’ options may restrict or influence respondents’ choice as compared with qualitative material, and the quotes we have used to illustrate categories are more likely to reflect qualitative sources.Another potential limitation of our study is that its methods are not those of a conventional systematic review and lie in the middle of the spectrum of review ‘types’. However, we would argue that this is a strength in relation to the aim and task of the work described in this paper. We wanted to undertake a systematic search of all relevant peer-reviewed English language literature in order to supply the fullest possible range of sources of published ‘justifications’ for CAM use and non-use, and hence provide an extensive and comprehensive pool (or ‘denominator’) of justifications for our analysis. This was not a search only for studies whose principal aim was to investigate justifications, so quality assessment or selection by study method was inappropriate. Whilst we recognise the potential that justifications in some papers might be selective, we are reassured by the fact that many justifications came from studies in non-CAM settings and that our updated 2017 search indicated that saturation of commonly expressed justifications for both use and non-use of CAM is likely to have been reached.The second limitation that arises from the particular choice of methods is that a structured narrative was adopted to follow the systematic search for all published justifications. However, this is a likely strength in relation to the aim of the analysis—namely, to use robust methods  to classify justifications as the basis for discussion without any selective assumptions of what are ‘valid’ justifications. The whole point of the paper is to present an accessible summary and account of all justifications for use and non-use as the basis for debate about the needs of patients that are or are not being met by both CAM and orthodox medicine.Lastly, a further limitation was that non-English language literature was excluded for practical reasons of scale; it may be that further categories or a different balance of justifications for CAM use would emerge if other languages had been included. However, our systematic search identified studies from many countries across the globe, making it less likely that culture-specific justifications were missed.Whether rational evidence-based clinicians focused on the biomedical model of disease like it or not, many people like CAM, and their justifications align with criticisms of the shortfall of Western medicine in providing a fully effective and satisfying system of health care. In the current climate of evidence-based medicine underpinning national recommendations for care, it is unlikely that the commissioning of CAM by health services will reflect its popularity. A fruitful way forward for health care systems may be to use the justifications that people have for using CAM as a framework to address the shortfalls and problems of their own systems. The extent to which CAM itself should be included in national policy and clinical practice to address those gaps in health care remains a topic for debate, including about the nature of evidence that should underpin choice of care for long-term conditions such as chronic musculoskeletal pain .S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOC)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.S5 Appendix(DOCX)Click here for additional data file.


Background In Sweden there has been limited work investigating the integration and nature of collaborative relationships between pharmacists and other healthcare practitioners. Objective To explore the working relationships of physicians, nurses and ward-based pharmacists in a rural hospital after the introduction of a clinical pharmacy service. Setting General medical ward in a rural hospital in northern Sweden. Method Mixed methods involving face-to-face semi-structured interviews with nurses, physicians and pharmacists, and a physician survey using the Physician-Pharmacist Collaboration Index to measure the extent of physician-reported collaborative working relationships. Main outcome measure Perceptions about collaborative working relationships between physician, nurses and pharmacists. Results All physicians (n = 9) who interacted with the clinical pharmacists completed the survey. The mean total score was 78.6 ± 4.7, total 92 (higher scores represent a more advanced relationship). Mean domain scores were highest for relationship initiation , and trustworthiness , followed by role specification . The interviews (with nurses and physicians), showed how communication, collaboration and joint knowledge-exchange in the intervention changed and developed over time. Conclusion This study provides new insights into collaborative working relationships from the perspectives of physicians and nurses. The Physician-Pharmacist Collaboration Index scores suggest that physicians felt that clinical pharmacists were active in providing patient care; could be trusted to follow up on recommendations; and were credible. The interviews suggest that the team-based intervention provided good conditions for creating new ways to work to achieve commitment to professional working relationships. For pharmacists, training with other professions such as physicians and nurses may provide possibilities to improve interprofessional collaborative care.For physicians, nurses and pharmacists improved interprofessional collaborative care may lead to job satisfaction as well as an understanding of the responsibilities of other professionals in their professional roles.Improved interprofessional collaborative care may also lead to improved patient safety.Today, many pharmacists are involved in clinical pharmacy services in hospital wards, and in many places, pharmacists have become integral members of the ward teams , 2. The To assist researchers and practitioners interested in pharmacist collaboration, a theoretical framework for physician/pharmacist collaborative working relationships (CWR) has been proposed . In thisRelatively little work has been done in Sweden to investigate the integration and nature of CWRs between pharmacists and other healthcare practitioners such as physicians and nurses , 8. In SThe aim of this study was to explore the working relationships of physicians, nurses and ward-based pharmacists in a rural hospital after the introduction of a clinical pharmacy service.The study was approved by the Regional Ethical Review Board in Umeå (Registration Number 2014/322-31Ö).This study was performed at a medical ward in a hospital located in northern rural Sweden. At the time of the study, the general medical ward had 18 beds. The hospital is one of three hospitals situated in Västerbotten County and is the only one located inland, providing medical services for around 40,000 people Due to its geographic location it is also the base of the ambulance helicopter , 12.The intervention  was implemented in September 2015. Three clinical pharmacists provided clinical services including medication reconciliation, medication reviews and participation in ward rounds. The intervention is described in detail in Peterson et al. . The serAll physicians and nurses in the ward in which the pharmacists’ intervention was implemented were invited to participate. Email invitations to participate in a face-to-face, semi-structured interview, were sent by the clinical nurse manager. Days and times were chosen to best suit the workload and staffing of the ward. All pharmacists involved in the intervention were interviewed. All interviewees were given information about the study and were informed that participation was voluntary. An interview schedule was developed with a list of topics to be discussed during the interviews, including practice environment, barriers and enablers and interactions/relationships with the pharmacists. Physicians and nurses were asked about the pharmacist’s role and contribution, and challenges of having a ward-based pharmacist.This study employed mixed methods including individual semi-structured interviews and a physician survey. The Physician-Pharmacist Collaboration Index (PPCI)  was usedA thematic analysis was conducted of the interview transcripts, which followed several steps . TranscrIn total, 19 physicians and nurses were invited, and 14 agreed to participate. Non-participation in the study was referred to lack of time, busy schedules and transfers to other hospitals. Nine medical physicians, five nurses and three pharmacists were interviewed. Interviews typically lasted between 20 and 40 min for the physicians and nurses, and between 45 and 60 min for the pharmacists. Five of the eight physicians were male; all nurses and pharmacists were females. Four of the physicians were consultants.All physicians (n = 9) who interacted with the clinical pharmacists during the introduction of a clinical pharmacy service completed the Physician-Pharmacist Collaboration Index (PPCI) survey. The mean total PPCI score was 78.6 ± 4.7, total 92 (higher scores represent a more advanced relationship). Mean domain scores were highest for relationship initiation , and trustworthiness , followed by role specification . A summary of PPCI domain and total scores is provided in Table Initiating relationships, two subthemes emerged: (1) Initial expectations and apprehensions, and (2) Learning to collaborate. Within the second theme, Role specification, three subthemes were identified: (1) Value added, (2) Accessibility and, (3) Patient care and safety. The third theme comprised Barriers and enablers. To allow the reader to judge the veracity of the interpretation, quotations have been used to illustrate the themes presented.The interviews were used to further explore the relationships between physicians, nurses and pharmacists. The CWR domains were used to initially describe the interactions. Three broad themes were identified. Within the first theme, initiated the relationship with both the physicians and nurses through this presentation.In this study, the pharmacists first visited the hospital to introduce themselves and the intervention. Hence, they drug knowledge. Physicians had concerns about being told what to do. However, these concerns dissipated, being instead described as “a very humble … discussion” (Physician 3).Pharmacists described the apprehensiveness of physicians and nurses before the intervention: “A little curiosity mixed with a little skepticism” (Pharmacist 1). It was difficult to explain their role: “We noticed that they looked confused. They wondered, what exactly we were going to do?” (Pharmacist 1). Both physicians and nurses commented on an expected focus on Relationships were built over time and developed through understanding the pharmacists’ contributions to the team. One physician reflected on “bringing in knowledge from different roles into the work on the rounds … so that you can have good teamwork” (Physician 7). Physicians, nurses and pharmacists built collaborative relations consistent with the CRW model; the more providers worked and communicated with each other, the more providers relied on the pharmacists’ knowledge and greater collaboration. The pharmacists reported the climate as “open-minded” (Pharmacist 2). However, relationship initiation takes time: “It takes a while before you get to know each other” (Pharmacist 1). Some physicians commented on the importance of the pharmacists’ personal traits for team collaboration as “having the right people in the position” (Physician 1).joint knowledge and collegiality were used. Mutual respect developed through understanding the role and capabilities of the pharmacists as “a professional relationship in which I have great respect for their knowledge” (Physician 2).Relationships were built over time; proximity and visibility allowed both physicians and nurses to interact and understand the pharmacists’ professional ability. Words such as something to add for physicians and nurses as well as patients. One physician noted: “You continually receive education through their comments on the rounds” (Physician 6). These issues were discussed collaboratively in the team as “a joint exchange of knowledge” (Nurse 1) in which nurses and physicians could “ask questions and discuss things” (Pharmacist 1). One physician explained: “The work with drugs is a big piece in some way, and it is missing in the teamwork” (Physician 4).Most participants mentioned that pharmacists had The pharmacists, nurses, and physicians exchanged information directly on the rounds “about drugs which don’t work together” (Nurse 1), which “saved us time” (Physician 4). One physician noted the pharmacists’ expertise: “We physicians have relatively little drug knowledge” (Physician 4). The professional relationships initially built during the ward rounds, continued with individual contacts with the pharmacists. These results are consistent with the relatively high score in the PCCI relationship initiation trustworthiness.The pharmacists reported being based in the ward as positive. One pharmacist mentioned a physician who often came by to ask questions: “It takes a while before you understand what we [pharmacists] know” (Pharmacist 2). Nurses also took advantage of the pharmacists being nearby: “Nurses could come occasionally and ask something” (Pharmacist 1). One physician noted: “You could always knock on the door and ask. I have thought about this [drug]. Is this [drug] good or is there another alternative?” (Physician 4).The pharmacists’ expert knowledge on side effects, speaking to patients and reviewing patients’ medication lists were seen as important. According to one physician: “They know more about drugs and we can actually help out together, this helps the patient mainly” (Physician 5). Physicians and nurses were positive about the pharmacists speaking to patients, being as “especially good if you can explain an interaction” (Physician 8). For the pharmacists, patients provided reliable information as they were “a little more open” (Pharmacist 2).Regarding patient safety, one pharmacist reported a patient on an unsuitable drug: “With her state of illness, she really shouldn’t have been taking this” (Pharmacist 2). Another pharmacist discovered an error when a patient switched wards: “They had taken drug levels of a drug that was very neurotoxic … and the patient had already been discharged” (Pharmacist 3).Overall pharmacists, physicians and nurses only identified a few barriers to the implementation of the intervention. Funding was noted: “If it is taken from the nurses’ budget, then it’s a direct no” (Nurse 5). Another barrier was time, as the rounds took longer: “Surely you can find good forms for how to do this” (Physician 6). Disagreement in decision-making was noted as a potential barrier: “In these cases I have the mandate to decide” (Physician 1). Another barrier was medication review documentation, for seeing that “the medication review has been reviewed relatively recently” (Physician 2). For the pharmacists, being based and employed at another hospital, 127 km from this rural hospital, distance was a barrier. One pharmacist reflected: “You could have been on site [at the hospital in TOWN] even more if you lived in TOWN” (Pharmacist 2).Enablers were also reported, such as a climate at the ward which was “accepting” (Nurse 3). Another enabler was the size of the hospital: “It is smaller in [name of the place], and it is easier for you to get hold of a physician” (Pharmacist 1).This study explored the working relationships of physicians, nurses and ward-based pharmacists in a rural hospital after the introduction of a clinical pharmacy service. The study found that CWR are multifaceted and involve a consideration of the professionals’ understanding of the pharmacist’s role and capabilities. As described by McDonough et al. , this stStudies exploring CWR have been community-based  , 17. RatThe PPCI scores suggest that physicians felt that clinical pharmacists were active in providing patient care; could be trusted to follow up on recommendations; and were credible, but that within the domain of role specification there is room for growth of CWRs. Our PCCI scores were also similar to those found in other research studies , 20. BotOther factors which may affect CWR are individual, context and exchange characteristics. As noted by the participants in the study, individual characteristics do make a difference. This was mentioned by one physician with the idea of the right person in the right place for the pharmacists. From the pharmacists’ point of view this was also noted as physicians’ and nurses’ willingness to discuss, and their open-mindedness. The participants linked these conditions to patient safety and care. Communication was described as open, discussion-based and collaborative, and therefore knowledge-building, according to the participants. As previously described, the apprehension regarding knowledge experts joining the rounds was not of relevance in this study. Specifically, in this case, issues of power related to the expert role were not seen to be a problem. In this study, only female pharmacists were interviewed. A male perspective had been interesting, however, the sample reflects the gender demographics in ward-based practice in Sweden.One of the main findings in this study related to role specification. According to this study, if pharmacists train with other professions such as physicians and nurses there may be possibilities to improve interprofessional collaborative care as well as understanding the responsibilities of other professional roles , 22. In There are several limitations that need to be considered. First, our study took place in a rural hospital where no clinical pharmacy services are provided; this provides a unique setting, where staff shortages and long distances are common. The clinical pharmacists were highly trained and experienced. Another limitation is data collection and analysis. While interviews were in Swedish, the data analysis was done in English. It is possible that certain information was lost in translation. However, most studies to date have focused on CWR between community-based pharmacists and physicians. There is less information about ward-based clinical pharmacists, physicians and nurses. To our knowledge this is the first study exploring these relationships in Sweden. The study was also longitudinal, documenting perceptions before and after implementation of the intervention, and over a long period of time (6 months). The results of the study may also be relevant in countries were ward-based pharmacists are infrequent, such as in Latin America, the Middle East, Africa and some parts of Asia and Europe.This study was able to provide new insights into CWR from the perspectives of physicians and nurses. The PPCI scores suggest that physicians felt that clinical pharmacists were active in providing patient care, could be trusted to follow up on recommendations and were credible, and that within the domain of role specification there is room for growth of collaborative relationships. The interviews with the pharmacists, physicians and nurses, in line with CWR, show how communication, collaboration and joint knowledge exchange in the team-based intervention developed over time, with a focus on patient care and safety. As the team moved from professional awareness and recognition, through exploration and trial, professional relationships expanded, providing conditions for finding and creating new ways to work to achieve commitment to professional working relationships.


Three are the main postulates of our article under discussion: First, both human intelligence and personality are hierarchically organized, with a general factor at the apex of each hierarchy, i.e., g for intelligence and GFP for personality. Second, these two general factors interact at various levels, with a common core coordinating this interaction: this is a super-g, i.e., gP (P for the whole Person), connecting g and GFP. Third, everything changes in development; thus, gP changes too. Three studies are presented mapping these changes. Individuals from 7 to 20 years of age were examined, across studies, by a wide range of cognitive and personality measures. To capture these relations, confirmatory factor analysis and structural equation modeling were used, but also other powerful methods currently available. The reader may consult our article for more information about each postulate. This rejoinder focuses on points raised by two commentators, which are crucial for the further development of research and theory in a field that is as old as the inquiry about human nature but rather new as a field of systematic empirical research.We concur with Ackerman  that theTherefore, a next wave of research may start from here that would ad hoc measure the constructs of interest and predictively model their relations. Future research would have to devise measures of cognitive and personality processes at equivalent levels of precision and construct validity to minimize the concerns of the commentators, which we do share. The main difference between cognitive and personality measures lies in what they stand for: cognitive measures stand for measures of actual performance as specified by the researcher; personality measures stand for self-characterizations given by the research participant. Each set of measures may be internally highly reliable, as observed here; however, they may still reflect different levels of precision and objectivity in the measurement of the constructs they represent. This is especially true if children and adolescents are involved, because one’s own performance is differentially transparent to self-observation and evaluation during growth. Bäckström’s  objectioBefore this target article was written, we were neither in favor nor against the GFP. The findings came in support of it. In fact, motivated by the reviewing process, we systematically tested models to disconfirm both the GFP and the gP. This has not been possible: Both constructs persisted to emerge across studies; these models are described in the paper. In fact, these findings align with several other papers published in this Special Issue, which showed that cognition–personality relations emerge at different levels of the organization of each realm and engage several components in each ,10,11. HEvaluation factor dominates [Physics progresses by first assuming and then searching for and experimentally demonstrating “entities of nature” to account for phenomena unaccounted for by the current models. The notorious Higgs particle is an example of a big recent discovery in the search of general forces of nature. We suggest that g, GFP, and gP may be such “entities of nature”. They seem needed to account for patterns in our experimental data but also for consistent patterns of behavior of real people, be they infants, children, or adults, especially as they change over age. For instance, gP may explain the distinct profile of individuals reflected in general characterizations addressed to them, such as strong, determined, persistent, flexible, resilient, etc. Obviously, both cognitive and personality properties converge and merge into these characterizations. We suggested that cognizance is a core process in gP, the junction bridging g with GFP. This process changes drastically in development, causing changes in g–GFP relations. The three studies presented in the article provide a glimpse of these relations. For instance, they show that likeability, a phenomenon Bäckström invokes to back his argument, is actually a derivative of changes in this construct. Notably, evidence suggests that in one-factor models of personality an ominates . This isBäckström raised several points about some technical issues in our modeling approach. First, he notes that Exploratory Graph Analysis (EGA) is not confirmatory. Precisely: EGA was used to map the terrain of a not-so-well-known territory and capture relationships between a theory-based structure and the empirical structure that is estimated from the data. Then, the exploratory model was verified via confirmatory and structural equation modeling. In this sense, the use of EGA in the paper adds value to the main goal of the paper, since it enables the comparison of a theory-based model with a data-driven model. Second, Bäckström takes some pains to show that the direct Gf–GFP relation in the third study is negative (−0.16), while the indirect relation estimated from the Gf–cognizance (0.22) and the cognizance–GFP relation (0.58) is positive and lower (0.13). This is not a problem. On the one hand, some personality dimensions, such as neuroticism and conscientiousness, are negatively related to g . Thus, Finally, Bäckström is concerned that very high relations between cognitive and personality dimensions, such as those reported across studies, may reflect model mis-specification. Model mis-specification is always a risk in structural equation modeling, especially in research lying in the “context of discovery”, where theory for generating specification predictions is not fully precise. However, our models were technically acceptable, as indicated by the technical information provided by the model outputs (see Supplementary Tables). The values obtained reflect the fact that we used very refined developmental measures of cognitive processes, obtaining the variation that is necessary to map their relations with personality measures. Finally, it is stressed that we residualize predictor factors in the various models (see models shown in the Supplementary). This ensures that collinearities are controlled. To our knowledge, few programs, such as EQS, can do this with precision. Thus, if a precise residualization of factors was not done by Bäckström, his models are not comparable to our models. In short, technical and other problems may always linger in this kind of modeling blurring boundaries between actual psychological constructs and technical constructs or distorting their relative importance ,17. Howe