Navigating communication between conventional medicine and traditional Chinese medicine: a case study of cancer patients in Hong Kong

Traditional Chinese medicine (TCM) is a growing phenomenon worldwide. Despite its historical role in Chinese society, however, few studies have explored the nature of communication among patients with cancer who receive TCM care in addition to conventional medicine. If TCM practitioners acquire adequate knowledge to understand the needs and communication issues for their patients with cancer, particularly those who are simultaneously receiving conventional medicine, this will lead to better quality of care and clinical outcomes, such as high patient satisfaction and treatment compliance. To fill this knowledge gap, this study explored the nature of communication among patients with cancer in Hong Kong who receive TCM treatment in addition to conventional medicine. We conducted in-depth interviews with 20 patients, 5 oncologists and 5 TCM practitioners to elicit their views on TCM treatments. We adopted a qualitative approach using an interpretative phenomenological analysis. Based on the themes that emerged from our interview transcripts, we outlined communication priorities when advising patients with cancer who are receiving both TCM and conventional medical care. We developed a framework to train TCM practitioners to better integrate their patients’ conventional medical history when delivering patient care. Our study findings inform communication priorities when caring for patients who opt for TCM care in addition to conventional treatments. In addition, they provide useful information for developing future clinical research studies to explore integrated approaches between TCM and conventional medicine in treating patients with cancer.


Introduction
With its long history of focusing on patients' physical and interpersonal needs, traditional Chinese medicine (TCM) has always given great importance to patient-centred treatments.
While TCM used to dominate medical treatments in China, the importance of conventional medicine has increased over time, especially for cancer treatments. Therefore, it becomes difficult for patients to decide which method they should use to treat their cancer. In China, TCM is widely used to treat Chinese patients with cancer [1][2][3], who generally choose TCM because it is culturally considered an optimal and safe treatment compared with conventional medicine. In this way, TCM is similar to self-help treatments that lead to long-term positive effects [1]. In the Chinese context, many patients and their family members are aware of the limitations of conventional cancer therapies, which provide a strong motivation to opt for TCM. Many patients also use TCM as a complementary therapy integrated with their conventional medical treatments, such as radiotherapy and chemotherapy [4,5]. However, few studies have explored the communication priorities of patients receiving both TCM and conventional medicine. Using data from our interviews with patients with cancer and their oncologists and TCM practitioners, we explored the communication needs of patients with cancer in Hong Kong who receive both TCM and conventional medical treatments.
Cancer is the primary cause of death in Hong Kong. In 2018, cancer claimed 14,446 lives, accounting for about onethird of the total number of deaths in the Hong Kong population [6]. According to Hong Kong government statistics [6], the number of new patients with cancer has increased at a rate of about 2.9% annually over the past decade, with a historical high of 31,468 cases in 2016. By 2030, the average number of new cases is expected to increase by about 35% to more than 42,000 annually. Colorectal, lung, breast, prostate and liver cancers are the five most common cancers in Hong Kong, representing over half (58.1%) of all new cases [6]. In a large-scale study exploring the attitudes of 786 patients with cancer towards TCM treatment, over half (57.1%) used at least one form of TCM before, during or after conventional therapy. Surprisingly, two-thirds of the participants did not inform their oncologists about their TCM use [7]. In addition, over two-thirds of the participants (68.2%) believed that integrating TCM with conventional medicine was effective.
This newly emerging phenomenon naturally leads to questions about whether TCM and conventional medicine are complementary, particularly within the field of cancer treatment. Yang et al. [8] argued that the integrated combination of TCM and conventional medicine could lead to better health effects because this integrated care in the treatment of medium and advanced lung cancer has been shown to improve patients' quality of life (QOL) and survival rate, in addition to the short-term ability to control tumour development. When comparing the long-term effect of using a combination of TCM and conventional medicine with using conventional medicine alone on the prognosis of patients with lung cancer, the combined treatment group had better cumulative survival; however, no significant difference was observed [8]. Moreover, after evaluating the efficacy and side effects of combined Chinese drugs and chemotherapy in treating advanced non-small-cell lung cancer (NSCLC), the combination of TCM drugs and chemotherapy increased short-term therapeutic efficacy in NSCLC treatment and prolong patients' median survival time, but showed no impact on time to progression [2].
Compared with conventional medical treatments, TCM has unique characteristics. For example, each patient's condition is managed individually using patient-tailored TCM treatments from a millennia-old tradition. By identifying patients' imbalance using their pulse, life force and organs during consultation, TCM practitioners focus on their patients' backgrounds (both social and natural). TCM practitioners take a holistic view of the relationship between their patients' physical bodies and their environment in the hope of finding some correlation between their patients' disease and relevant factors within their patients' daily routine. By tracking their patients' daily activities, a TCM practitioner will construct connections between their patients' symptoms and daily activities based on the belief that disease is the result of an unhealthy lifestyle. Chinese herbal medicines are often used in TCM to enhance the physical and emotional well-being of patients. The use of these traditional herbal medicines is very common among patients with cancer, as they reduce cancer therapy-induced toxicity [9,10].
In contrast, conventional medical doctors do not focus as much on their patients' overall habitual behaviour, but concentrate more on identifying the primary clinical concerns and causes of illness. In the adopted diagnostic approaches, TCM practitioners identify issues in the human body using system discrimination and cybernetic approaches, which allow them to understand the patient's illness or zheng [11]. As an outcome of the patient's symptoms and discomfort, such as imbalances in pulse, life force and organs identified by examination, zheng is a vital indicator of the patient's health for TCM practitioners. When divided into its components, zheng consists of inspection, auscultation and olfaction, inquiring and palpation, which in Chinese is called si-zhen, that is, the process that a TCM practitioner uses to evaluate their patients' illness before their final diagnosis. The process of obtaining results from zheng requires an overall and holistic observation of multiple body sensors and organs, in addition to an in-depth analysis of their patients' recent personal experiences [11].
Conventional medicine relies heavily on scientific observations of patient symptoms and the identification of their exact causes. The scientific data generated by physical examinations during conventional treatments are highly valued; however, the level of mutual communication between conventional medical doctors and their patients differs from that between TCM practitioners and their patients. TCM philosophy suggests that cancer results from a lack of balance between yin and yang, which is the balance that maintains health, or the disturbance of the smooth flow of qi (i.e. vital energy), which then manifests as a group of syndromes with a lack of harmony in the body-mind-environment network. TCM focuses on mobilising and activating the body's natural resources to enhance the patients' inner defences against disease and restore their normal, balanced healthy zheng, which is believed to help defeat cancer and promote healing. The goal of TCM cancer therapies is to stimulate and mobilise the patients' natural body resources to counteract the imbalance. By re-establishing the body's normal patterns and enhancing its inner defences, TCM considers that healing can be promoted to defeat cancer [1]. Five TCM modalities have been shown to be effective in cancer treatments: that is, Chinese herbal medicine, acupuncture and moxibustion, therapeutic massage, qigong and Chinese dietary therapy [4,5,7]. In addition, acupuncture studies have shown strong empirical evidence that it largely relieves patients' pain and acute vomiting during conventional cancer treatments [12,13].
Therefore, our study explored the nature of communication between doctors and their patients with cancer in Hong Kong who opt for TCM treatment and conventional medicine. Our findings should support future studies of communication priorities in the care of these patients, in addition to exploring the integration of TCM and conventional medicine in the treatment of patients with cancer.

Methods
In our study, we adopted a qualitative approach, interpretative phenomenological analysis (IPA), to investigate patients' personal experiences from a psychology perspective [9]. According to Smith and Osborn [14], IPA mainly focuses on personal experiences in a detailed exploration of how individuals understand and make sense of their experiences [10]. We must make certain assumptions before performing IPA. First, individuals are constantly actively engaging with the world, and their experiences reflect their relationship with the world [15]. Furthermore, researchers' investigation of participants' experiences involves collaborative allegorical analysis. To make sense of how participants understand their world, both researchers and participants are involved in a dual interpretation or 'double hermeneutic' process. Researchers must play an active role in their attempt to understand how participants make sense of the world [15]. We selected IPA as the analytical method for our study because of its ability to adapt the interpretative approach and capacity to investigate participants' complex lived experiences.
We conducted interviews with five TCM practitioners and five oncologists and patients with cancer currently receiving both TCM and conventional medical treatments for their cancer. These interviews explored the participants' perceptions of the communication practices of their TCM practitioners and conventional medical doctors in navigating their treatments and their attitudes toward TCM care. Specifically, we asked the participants the following questions: (1) What is your view on TCM services in Hong Kong? (2) Based on your experience, what role does TCM play in cancer treatments? (3) What are the key factors in patients' decision to receive TCM care in addition to conventional medical treatments? (4) Are the advantages of TCM greater than those of conventional medicine for patients with cancer? (5) Should TCM and conventional medicine be integrated into cancer treatments?

Data analysis
We adopted IPA as an idiographic approach in this study to analyse a tightly defined participant group to provide a specific perspective in this particular area. Twenty patients, five oncologists and five TCM practitioners were recruited for this study. They were experienced TCM practitioners and oncologists with several years of practice in treating intestinal cancer or patients with a diagnosis of intestinal cancer. We used the analytical stages suggested by Smith et al. [15] to analyse the interview transcripts. Initially, we attached great importance to an individual focus and descriptive level before moving to a mutual understanding of interpretations of the clinical context. Each interview transcript was read line by line with additional emphasis on what was being said about cancer treatments and the integration of TCM and conventional medicine, information that was also extracted as initial comments. As a second priority, exploratory comments based on the researchers' interpretations of the participants' use of language and communication issues related to the topic were also noted from the transcripts. Based on these exploratory comments without comparison with other interview transcripts, we developed concise themes that followed the participants' comments. Finally, we used the subsumption and abstraction techniques of Smith et al. [15] to identify similar patterns among the themes, which led to a series of superordinate themes for the participants.

Results
The interviewees expressed a series of opinions about TCM, which facilitated our thorough examination of their perceptions of communication practices during cancer treatments with TCM and conventional medicine. We identified four common themes in the interviews with the patients with cancer: that is, (1) their confidence in TCM in cancer treatments, (2) TCM communication mode, (3) advantages of TCM over conventional medicine and (4) the integration of TCM with conventional medicine in cancer treatments.

Confidence in TCM in cancer treatments
Patients with cancer living in Hong Kong are increasingly integrating TCM into their conventional cancer treatments. When discussing the trend of using TCM to treat intestinal cancer, Patient (L) explained that the assurance factor is what made him stick with TCM for a long time. People largely turn to TCM for mental reassurance and confirmation due to their preferences for the TCM consultation style that involves the overall lifestyle and health condition of a patient before making a diagnosis. Patients are often in favour of such detailed and tailored treatment, resulting in greater confidence in involving TCM in their cancer treatment [16,17].
If the practitioner could make you confident about what he is doing and give you plenty of information about your health condition, it will settle your heart … In my case, as I have only visited TCM practitioners twice, the experience has been quite positive overall because I got clear answers to whatever I asked. So far, I am quite satisfied with TCM. (Patient L, interview 39) One quality of TCM is that it does not exclude simultaneous treatments and even encourages patients to seek other forms of help when necessary. This openness is crucially important in clarifying patients' doubts during their experiences of health difficulties, as a patient with cancer observed. Because TCM also recommends conventional treatments when necessary, patients feel that TCM practitioners consider their health care to be the utmost priority. Therefore, patients are more receptive to TCM practitioners' information and suggestions in their belief that it is correct.
I have consulted a TCM practitioner simultaneously with my conventional medical doctors since 2013. I consulted a TCM practitioner even before I received chemo. My sister recommended Dr C to me and I kept visiting him until he retired … I do not consult TCM practitioners as often as a conventional medical doctor. However, after listening to a TCM practitioner explain my treatment needs, I feel more confident even when my conventional medical doctor gives me conflicting information. That is also the reason why I have not stopped visiting TCM practitioners. (Patient Z, interview 37)

TCM communication mode
During the process of cancer treatment, patients are inevitably scared and full of doubts about their future. Thus, the TCM practitioner's communication mode, which focuses on learning about the patient's general health conditions, naturally builds a connection between the practitioner and the patient [5]. Following this solid foundation for communication, their consultations could become much deeper than consultations in a conventional medical context. This depth of communication often calms patients, such as patient M: I visited TCM practitioners before I visited a conventional medical doctor … When the hospital informed me that I needed to receive chemo, I turned to my TCM practitioner for advice. He told me that I must go through the chemo process and I listened. He told me that he understood how hard it is to go through chemo and explained to me that it does not have any side effects … When I visit a TCM practitioner, the complete process of consultation is much more detailed. I was asked for a report about my situation and the practitioner took careful notes and gave me suggestions about the whole situation, which made me feel more confident. (Patient M, interview 34) However, because of the lack of general understanding among patients of TCM practices, this communication mode also has drawbacks. As Patient N mentioned, it would be difficult to understand what is fundamentally going on if one has not learnt the basics of TCM treatments, in contrast with the conventional medical context where people tend to have some understanding of the basics of health care. However, this issue does not seem to affect patients' understanding during a TCM consultation. As Patient G explained, the TCM practitioner's explanations are clear and straightforward. Therefore, this TCM communication mode still works to give patients confidence in their health care.
During the whole treatment process, the TCM practitioner's explanations were quite clear. Although we were not informed about the functions of the traditional herbal medicines, we did not need to know this information. All we know is that TCM helped me after my operations. (Patient G, interview 35) Whenever I visit a TCM practitioner, the consultation is always much more personal and well communicated because I always see the same doctor, unlike in conventional medical consultations, where I may need to see different doctors who tend to quickly finish our conversations. It gives me confidence to know that my TCM practitioner is tracking my health care and helping to control my illness. However, if you do not know anything about TCM, what a TCM practitioner says may not make much sense. In that case, a conventional medical doctor would offer a clearer explanation. (Patient N, interview 33) Advantages of TCM over conventional medicine TCM practitioner K mentioned TCM's 'suitability' for patients, which is missing from conventional medicine. By suitability, he explained that regardless of the type of illness, whether cold or hot, physical or emotional, TCM always finds a way to explain the overall issues, while conventional medicine separates the issues into different illnesses, which are then treated individually. In addition, TCM practitioner K noted that TCM considers the weather and the patients' environmental conditions while healing and gives greater attention to the patients themselves instead of their symptoms. In contrast, conventional medicine treats patients more like a problem to be solved. TCM practitioner K also hoped that this situation could be improved.
The change in seasons leads to different causes for the cold, such as wind, cold, heat, wetness, dryness and fire. Different methods can be used to treat colds with different causes. We must also consider the seven emotions caused by the cold before prescribing TCM to our patients. These emotions are happiness, anger, worry, thoughtful, scared, horrified and sadness. (TCM practitioner K, interview 5) TCM practitioner K claimed that the result of conventional treatments could sometimes be ineffective. For example, he met a patient who fainted after taking the prescribed conventional medicine.
Sometimes conventional medical doctors randomly give patients medicine without considering their bodies thoroughly. One of my patients fainted after taking conventional medicine and came to find me at once. (TCM practitioner K, interview 5) However, TCM practitioner K observed that he could not blame conventional medical doctors because they have their own method for treating patients, just like TCM practitioners, and both TCM practitioners and conventional medical doctors are health care practitioners who consider their patients' health to be the highest priority. A patient diagnosed with intestinal cancer confirmed this sentiment: I cannot promise that TCM will cure you, but you should visit a TCM practitioner after visiting a conventional medical doctor because the consultation will help you gain a healthier body. The TCM treatments tend to cause fundamental changes in your body, while conventional medicine does not work to this extent. (Patient L, interview 36)

Integration of TCM and conventional medicine in cancer treatments
However, TCM should not be used in isolation when dealing with cancer, especially during the first stage of diagnosis. Furthermore, because of their different focuses during the treatment process, both TCM and conventional medicine could provide patients with various benefits that cannot be compensated for by conventional or alternative medicine alone [18].
When talking about TCM in cancer treatment, the cancer must be diagnosed using conventional medicine and can then be analysed further using TCM in combination. This is because we can only rely on conventional medicine to make sure that the illness is cancer, in the same way that the differentiation theory in TCM can only be used for proper medication use. (TCM practitioner C, interview 1) When discussing the attitudes held by many doctors and the general public, Doctor M observed a constant rivalry between TCM practitioners and conventional medical doctors, who quarrelled about which modality should dominate their patients' cancer treatment. However, he also thought that both sides should treat each other with greater respect and understanding based on more in-depth communication: I think TCM practitioners could have a much deeper dialogue with conventional medical doctors, with everybody becoming less prejudiced against each other. I consider myself to be pretty neutral when talking about the relationship between TCM and conventional medicine because my family is made up of TCM practitioners and I am a conventional medical doctor. Whenever I see conflicts between the two sides, I always think that they should coexist in harmony. (Doctor M, interview 12)

Discussion
By exploring the communication modes between patients with cancer and their TCM practitioners and conventional medical doctors, this study contributes to the literature on doctor-patient communication and ways to improve Hong Kong patients' confidence and satisfaction with their health care. By comparing the different approaches adopted in conventional medicine and TCM consultations, we found that TCM practitioners exchange medical information with their patients in ways that allow them to construct an interpersonal relationship, which leads to better clinical outcomes and higher patient satisfaction. The results of this study are consistent with the results of the literature exploring the nature of doctor-patient interactions in Hong Kong [19][20][21]. For example, health care providers' use of effective, interpersonal linguistic communication strategies leads to more positive patient outcomes. When treating patients with cancer who consult oncologists and TCM practitioners simultaneously, health care providers in the TCM context tend to effectively target their communication to balance their interpersonal communication by communicating medical expertise, which is essential for their patients' active involvement, comprehension and satisfaction with their health care. Most of the TCM practitioners interviewed adopted these linguistic strategies, which are necessary to achieve effective patient-centred care. Thus, they should be promoted in the training of future conventional medical doctors to equip them with effective communication strategies to deal with Cantonese patients, integrate conventional medicine and TCM and assist patients with cancer in navigating their communication issues and treatment decisions in their journey between TCM and conventional medical care in their cancer treatment. Our study findings can also extend our understanding of the medical communication needs of patients with cancer who should be confident that their primary needs are supported, as the results suggest. Furthermore, our study provides an evidence-based foundation for the development of communication strategies and interventions to improve health care practices, with multiple benefits for conventional medical doctors and caregivers to communicate with their patients using TCM terms. A limitation of this study, however, is the number of participants, considering the small group of people who visit TCM practitioners. This study also offers insights into the development of effective medical communication techniques for the interactions of TCM practitioners and conventional medical doctors with their patients with cancer to guide their decision-making process and deliver holistic patient care. TCM practitioners and conventional medical doctors can then learn to effectively use these communication strategies to help their patients navigate between TCM and conventional medical care in their cancer treatment journey. The results of our study show TCM practitioners how to use an integrated model of health care by considering their patients' conventional medical care while delivering holistic patient-centred supportive care. The study findings should inform the future training of both TCM practitioners and conventional medical doctors by fostering better communication when implementing an integrated health care model for their patients with cancer. In particular, conventional medical doctors and caregivers can learn more effective ways to manage communication issues in relation to TCM terminology. This finding should be more popular with family physicians trained in evidence-based complementary medicine, who could then integrate holistic patient-centred care practices optimally.

Conclusion
The role of the TCM practitioner is not only to investigate the causes of their patients' concerns and treat them but also to explore the overall conditions to obtain a mutual understanding of their patients' problems. Differences between the frames of concern of patients and practitioners may lead to inappropriate diagnoses and treatment noncompliance, resulting in medical failure. Therefore, it is vitally important to understand the communication methods that TCM practitioners and conventional medical doctors adopt during their consultations. In comparing the different communication modes between TCM and conventional medicine, which are rather different in terms of their philosophy (e.g. conventional medicine is based on scientific data, while TCM is based on experience, medical and disease terminology and consultation procedures), we identified the advantage of combining TCM and conventional medicine in treating patients with cancer. When treating patients who are consulting TCM practitioners and conventional medical doctors simultaneously, TCM practitioners are more skilled at giving their patients confidence in their health care and explaining the patients' overall health conditions. This communication significantly improves health care quality, despite the increasing number of patient presentations, greater cultural and linguistic diversity and patients with comorbidities and a wide variety of health conditions. In particular, using natural communication skills during TCM consultations can improve patients' active participation in their health care, which could also be an example of a better way to integrate TCM and conventional medicine in treating cancer.