Complementary medicine. What physicians think of it: a meta-analysis

A Review of Integrative Medicine in Gynaecological Oncology

In recent years complementary and alternative medicine (CAM) has increasingly been the focus of international research. Numerous subsidised trials (7903) and systematic reviews (651) have been published, and the evidence is starting to be integrated into treatment guidelines. However, due to insufficient evidence and/or insufficient good quality evidence, this has mostly not translated to practice recommendations in reviews by the Cochrane collaboration gynaecology group. There is nevertheless a not insignificant number of CAM providers and users. The percentage of oncology patients who use CAM varies between 5 and 90 %. Doctors have been identified as the main providers of CAM. Half of gynaecologists offer CAM because of personal conviction or on suggestion from colleagues. This must be viewed in a critical light, since CAM is mostly practiced without appropriate training, often without sufficient evidence for a given method - and where evidence exists, practice guidelines are lacking - and lack of safety or efficacy testing. The combination of patient demand and lucrativeness for doctors/alternative medicine practitioners, both based on supposed effectiveness CAM, often leads to its indiscriminate use with uncertain outcomes and significant cost for patients. On the other hand there is published, positive level I evidence for a number of CAM treatment forms. The aim of this article is therefore to review the available evidence for CAM in gynaecological oncology practice. The continued need for research is highlighted, as is the need to integrate practices supported by good evidence into conventional gynaecological oncology.

Rheumatologists' opinions towards complementary and alternative medicine: a systematic review

People with chronic musculoskeletal conditions are high users of complementary and alternative medicines (CAM). This systematic review was conducted to evaluate the attitudes of rheumatologists towards CAM and to identify whether these attitudes are affected by the personal or practice characteristics of the rheumatologists. A systematic search of electronic databases identified five eligible studies and one supplementary abstract, published before 1 December 2012. Outcomes measuring rheumatologists' attitudes towards CAM were extracted, as were any analysis of correlations with characteristics of the rheumatologist. Study quality was assessed using the STROBE checklist. Six studies from the USA, Canada and the Netherlands met inclusion criteria, with sample sizes ranging from 101 to 2,000. The studies were of variable methodological quality. Rheumatologists' opinions towards CAM varied according to therapy type. Many held favourable opinions towards bodywork and meditation, believed in their benefits and provided referrals for use. Other therapies, such as energy-based medicine, were regarded with scepticism. There were no demographic characteristics that consistently correlated with CAM attitudes or use. The limited data describing rheumatologist's attitudes to CAM is of varying quality but suggests that attitudes are influenced by the rheumatologist's familiarity with the CAM therapy and the degree to which a therapy has been assessed in a scientific manner. Given the high use of CAM amongst individuals seen in rheumatology clinics, physicians should undertake high-quality research to assess effectiveness of CAM therapy.

Infectious diseases physicians' attitudes and practices related to complementary and integrative medicine: results of a national survey

Background. Complementary and alternative medicine (CAM) and integrative medicine (IM) modalities are widely used by patients, including those with infectious diseases (ID). Methods. One thousand randomly selected ID practitioners were surveyed. The survey was divided into domains related to familiarity and recommendation, beliefs and attitudes, and use of CAM/IM modalities. Results. The response rate was 31%. ID physicians were most familiar with vitamin and mineral supplementation (83%), massage (80%), acupuncture (79%), chiropractic (77%), yoga (74%), and herbal medicine (72%). ID physicians most recommended vitamin and mineral supplementation (80%) and massage (62%). Yoga, meditation, and acupuncture were recommended by 52%, 45%, and 46%, respectively. Drug interactions, clinical research, and knowledge of CAM/IM modalities were factors that were considered a major influence. Almost 80% of respondents indicated an interest in IM versus 11% for CAM. Most respondents (75%) felt that IM modalities are useful, and more than 50% believed that they could directly affect the immune system or disease process. Conclusion. ID physicians expressed a markedly greater interest for IM versus CAM. They appear to be familiar and willing to recommend some CAM/IM modalities and see a role for these in the management of certain infectious diseases. Data regarding clinical efficacy and safety appear to be important factors.

Complementary and Alternative Medicine Use among Physicians in Oriental Medicine Hospitals in Vietnam: A Hospital-Based Survey

Interest in complementary and alternative medicine (CAM) is growing worldwide, even in Vietnam where traditional medicine is considered mainstream. We conducted a survey of the knowledge, attitudes, and practices of CAM therapies among physicians in oriental medicine (OM) hospitals in Vietnam. A two-stage random selection process selected 337 physicians who were interviewed using a face-to-face method with a standardized structured questionnaire. Data from 312 physicians who completed the questionnaire suggested that oriental herbal medicine and acupuncture (Vietnamese OM version) were the more commonly used CAM modalities compared with Vietnamese folk medicine and other forms of CAM. A broad range of CAM modalities, particularly chiropractice, diet supplements, and dietary therapy, and an excessive proportion of western medication were employed in conjunction with OM in the physicians' daily practice. Their daily practice was influenced by the source of knowledge, education level, medical specialty, and working environment. These findings suggest that physicians in OM hospitals in Vietnam have interests in various forms of CAM therapies besides traditional modes.

Prevalence of use of complementary and alternative medicine (CAM) by physicians in the UK: a systematic review of surveys

This systematic review aims to estimate the prevalence of use of complementary and alternative medicine (CAM) by physicians in the UK. Five databases were searched for surveys monitoring the prevalence of use of CAM, which were published between 1 January 1995 and 7 December 2011. In total, 14 papers that reported 13 separate surveys met our inclusion criteria. Most were of poor methodological quality. The average prevalence of use of CAM across all surveys was 20.6% (range 12.1-32%). The average referral rate to CAM was 39% (range 24.6-86%), and CAM was recommended by 46% of physicians (range 38-55%). The average percentage of physicians who had received training in CAM was 10.3% (range 4.8-21%). The three most commonly used methods of CAM were acupuncture, homeopathy and relaxation therapy. A sizable proportion of physicians in the UK seem to employ some type of CAM, yet many have not received any training in CAM. This raises issues related to medical ethics, professional competence and education of physicians.

Acupuncture Use among American Adults: What Acupuncture Practitioners Can Learn from National Health Interview Survey 2007? Evid Based Complement Alternat Med. 2012;2012:710750. [PMID: 22474517 PMCID: PMC3296189 DOI: 10.1155/2012/710750]

This paper examined the National Health Interview Survey (NHIS) 2007 and explored acupuncture users sociodemographics characteristics, reasons and the nature of acupuncture use, and the relationship of such use with conventional medical care. All individuals who completed adults core interviews (N = 23,393) were included. Three subsets of samples (nonuser, former user, and recent user) were used in the analysis performed in Stata. Our findings revealed that ever acupuncture user (including former and recent user) increased from 4.2% to 6.3% of the population, representing 8.19 million and 14.01 million users in 2002 and 2007, respectively. We expected this trend to continue. People not only used acupuncture as a complementary and alternative approach to conventional treatment for a specific health condition, but also used it as a preventive means to promote general health. Effectiveness and safety appeared not to be the main predictors of acupuncture use; rather, awareness, cost, and insurance coverage played a bigger role in decision making.

Referral to and attitude towards traditional Chinese medicine amongst western medical doctors in postcolonial Hong Kong

Recognizing the international trend for patients to choose both allopathic western medicine (WM) and traditional, complementary and alternative medicine (TCAM), the World Health Organization has called for stronger collaboration between WM doctors (WMD) and TCAM practitioners. This resonates with the situation in Hong Kong where the dominant modality of patient care is primarily based on WM practice while traditional Chinese medicine (TCM) is often used as a complement. The roots of this utilization pattern lie in colonial history when TCM was marginalised during the British administration. However since 1997 when China regained sovereignty, policies to regulate and professionalize TCM practices have been formally introduced. Despite both its popularity and this policy shift, progress on implementing collaboration between WM and TCM clinicians has been slow. This study, the first since 1997, explores current attitudes and referral behaviours of WMD towards use of TCM. We hypothesised that WMD would have positive attitudes towards TCM, due to regulation and cultural affinity, but that few actual TCM referrals would be made given the lack of a formal collaboration policy between elements within the healthcare system. Our results support these hypotheses, and this pattern possibly rooted from structural inhibitions originating from the historical dominance of WM and failure of services to respond to espoused policy. These have shaped Hong Kong's TCAM policy process to be closer with situations in the West, and have clearly differentiated it from integration experiences in other East Asian health systems where recent colonial history is absent. In addition, our results revealed that self use and formal education of TCM, rather than use of evidence in decision making, played a stronger role in determining referral. This implies that effective TCAM policies within WM dominated health systems like Hong Kong would require structural and educational solutions that foster both increased understanding and safe referrals.

What rheumatologists in the United States think of complementary and alternative medicine: results of a national survey

Background

We aimed to describe prevailing attitudes and practices of rheumatologists in the United States toward complementary and alternative medicine (CAM) treatments. We wanted to determine whether rheumatologists' perceptions of the efficacy of CAM therapies and their willingness to recommend them relate to their demographic characteristics, geographic location, or clinical practices.

Methods

A National Institutes of Health-sponsored cross-sectional survey of internists and rheumatologists was conducted regarding CAM for treatment of chronic back pain or joint pain. In this study we analyzed responses only from rheumatologists. Response items included participant characteristics and experience with 6 common CAM categories, as defined by the National Institutes of Health. Descriptive statistics were used to describe attitudes to CAM overall and to each CAM category. Composite responses were devised for respondents designating 4 or more of the 6 CAM therapies as "very" or "moderately" beneficial or "very likely" or "somewhat likely" to recommend.

Results

Of 600 rheumatologists who were sent the questionnaire, 345 responded (58%); 80 (23%) were women. Body work had the highest perceived benefit, with 70% of respondents indicating benefit. Acupuncture was perceived as beneficial by 54%. Most were willing to recommend most forms of CAM. Women had significantly higher composite benefit and recommend responses than men. Rheumatologists not born in North America were more likely to perceive benefit of select CAM therapies.

Conclusions

In this national survey of rheumatologists practicing in the United States, we found widespread favorable opinion toward many, but not all, types of CAM. Further research is required to determine to what extent CAM can or should be integrated into the practice of rheumatology in the United States.

Designing a 'NHS friendly' complementary therapy service: a qualitative case study

BACKGROUND

Provision of complementary therapy services within the NHS is scarce and contested. However, their adoption may be more likely in a service model that is designed to the specifications of clinicians and Primary Care Trust (PCT) managers. Our objective was to identify the features of a 'NHS friendly' service to inform service designers who wish to develop NHS complementary therapy services.

METHODS

Using a case study approach, two sites offering complementary therapies on NHS premises were studied using interview and documentary data. We conducted interviews with 20 NHS professionals, including PCT managers and clinicians. We used descriptive content analysis to analyse interview data. We collected and analysed documentation, such as referral data, funding bids and evaluations, to compare reported and documented behaviour.

RESULTS

Ideally, a 'NHS friendly' complementary therapy service should offer a limited number of therapies for a specific condition for high priority patient populations (e.g. acupuncture for addictions). In this service model, the therapies should be perceived to have 'good' evidence for conditions where there are 'effectiveness gaps' (i.e. current treatments are limited). The service should be evaluated and regularly promoted. Inter-professional relationships would flourish through opportunities for informal contact and formal interactions, such as observations of consultations. However, the service should include gatekeeper mechanisms to control demand and avoid picking up 'unmet need' (i.e. individuals currently not accessing NHS services). The complementary therapy service should pay for itself and reduce NHS costs elsewhere, such as hospital admissions.

CONCLUSION

The service design model identified in this study is problematic. For example, it is contradictory to provide specific interventions for specific conditions within a holistic healthcare framework. It is difficult to avoid providing for 'unmet need' while concurrently filling 'effectiveness gaps'. In addition, demonstrating the impact of a community service on reducing hospital admissions is challenging. Those seeking to establish a NHS complementary therapy service might be well-advised to meet as many of the criteria of a 'NHS friendly' model as possible, recognising that its full realisation may be impossible. However, during periods of innovation and financial security, some relaxation of expectations may occur.

Use of complementary and alternative medicine by physicians in St. Petersburg, Russia

BACKGROUND

Interest in complementary and alternative medicine (CAM) is increasing worldwide, although relatively little is known of physician use of CAM, and there are no quantitative reports of CAM use by Russian physicians.

OBJECTIVE

The objective of this study was to determine the prevalence of CAM therapies among practicing physicians and determine predictors of CAM usage.

DESIGN

This was a convenience sample prevalence survey.

SETTING

The study involved 3 urban academic hospitals in St. Petersburg, in Russia.

SUBJECTS

Participants included 192 physicians practicing at the three study hospitals.

MEASUREMENTS

The study determined the number (from a list of 32) of CAM therapies that physicians used on themselves, used on their patients, or referred their patients to receive.

RESULTS

One hundred and seventy-seven (177; 92%) of the surveyed physicians responded. One hundred percent (100%) of the respondents had practiced CAM or referred patients for at least two CAM therapies. One hundred and seventy-five (175; 99%) had themselves practiced at least two therapies. On average, each physician had practiced or referred patients for 12.7 (95% confidence interval, 11.9-13.6) therapies. On multivariate analysis, knowledge of a foreign language, surgical specialty, and female gender were significantly (p < 0.05) associated with increased CAM usage, while critical care specialty and completion of only an internship were associated with lower rates of CAM practice.

CONCLUSIONS

Physician use of CAM in Russia appears very high. The high prevalence of CAM may complicate adoption of Western evidence-based practices. Predictors and effects of CAM usage in Russian society warrant further study.

Turkish general practitioners and complementary/alternative medicine

BACKGROUND

Complementary and alternative medicine (CAM) is in the spotlight of society. However, what is the position of physicians at this point?

OBJECTIVES

To determine general practitioners' (GP) knowledge, attitudes, and approaches to CAM.

METHODS

All GPs (n=521) practicing in Bursa Province, Turkey were surveyed by a questionnaire.

RESULTS

Responses from 49% of GPs were analyzed. Altogether, most of our physicians (96.5%) had not received any education about CAM, wanted to learn more (74.4%), and their knowledge levels were low (60.8%). About half of them (51%) believed in the efficiency of CAM, whereas 38.0% did not. GPs desire more information about herbal medicine and acupuncture. Only 29% of GPs were using some type of CAM for themselves.

CONCLUSIONS

GPs are aware of the subject's importance and want to learn more about CAM and improve their knowledge. It would be reasonable to provide training possibilities for GPs, primarily for the CAM types highly used by the population and most requested by the physicians.

Pediatricians' attitudes, experience and referral patterns regarding Complementary/Alternative Medicine: a national survey

BACKGROUND

To assess pediatricians' attitudes toward & practice of Complementary/Alternative Medicine (CAM) including their knowledge, experience, & referral patterns for CAM therapies.

METHODS

An anonymous, self-report, 27-item questionnaire was mailed nationally to fellows of the American Academy of Pediatrics in July 2004.648 of 3500 pediatricians' surveyed responded (18%).

RESULTS

The median age ranged from 46-59 yrs; 52% female, 81% Caucasian, 71% generalists, & 85% trained in the US. Over 96% of pediatricians' responding believed their patients were using CAM. Discussions of CAM use were initiated by the family (70%) & only 37% of pediatricians asked about CAM use as part of routine medical history. Majority (84%) said more CME courses should be offered on CAM and 71% said they would consider referring patients to CAM practitioners. Medical conditions referred for CAM included; chronic problems (headaches, pain management, asthma, backaches) (86%), diseases with no known cure (55.5%) or failure of conventional therapies (56%), behavioral problems (49%), & psychiatric disorders (47%). American born, US medical school graduates, general pediatricians, & pediatricians who ask/talk about CAM were most likely to believe their patients used CAM (P < 0.01).

CONCLUSION

Pediatricians' have a positive attitude towards CAM. Majority believe that their patients are using CAM, that asking about CAM should be part of routine medical history, would consider referring to a CAM practitioner and want more education on CAM.

Content Validity of the Integrative Medicine Attitude Questionnaire: Perspectives of a Hong Kong Chinese Expert Panel

BACKGROUND

Although the Integrative Medicine Attitude Questionnaire (IMAQ) is a validated instrument developed in the United States for measuring allopathic physicians' attitudes toward complementary and alternative medicine, little is known about attitudes among western-trained doctors in other societies, particularly in the Far East. In Hong Kong, cultural and historical forces have created a unique environment for integration. Thus, consideration of such forces suggests that direct use of the original IMAQ for assessing attitudes of allopathic physicians' views on Traditional Chinese Medicine (TCM) in Hong Kong would be inappropriate. This hypothesis was tested using content validity judgment and local experts' opinions, to assess the three domains of IMAQ: "holism," "introspection and doctor-patient relationship," and "effectiveness of integrative treatment."

METHOD

Standard content validity establishment methodologies were followed. An 8-member panel (4 with TCM and 4 with allopathic medicine backgrounds) was convened to assess the content validity of a modified Hong Kong TCM specific IMAQ. Experts were provided with explicit instructions on how to evaluate the content validity of individual items, and the instrument as a whole, both quantitatively and qualitatively.

RESULT

Of 28 items, 12 items of the modified IMAQ were content validity adequate (Content Validity Index (CVI) > 0.70 and kappa > 0.4). Seven items were considered content invalid and removed. The overall CVI and kappa of the instrument were 0.71 and 0.09, respectively, indicating the need to modify 9 marginally valid items that remained in the questionnaire. Qualitative expert comments were used for the revision.

CONCLUSION

The process of validation showed that it would be inappropriate for the U.S.-derived IMAQ to be used without modification in Hong Kong. Most of the content valid items were in the "effectiveness of integrative treatment" domain, which reflected the influence of the evidence-based TCM movement on the experts' judgment.

General practitioners' knowledge and practice of complementary/alternative medicine and its relationship with life-styles: a population-based survey in Italy

Background

The growing popularity of CAM among the public is coupled with an ongoing debate on its effectiveness, safety, and its implications on the reimbursement system. This issue is critically important for GPs, who have a "gatekeeping" role with respect to health care expenditure. GPs must be aware of medications' uses, limitations and possible adverse effects. Our objective was to explore GPs' knowledge of CAM and patterns of recommendation and practice, as well as the relationship between such patterns and GPs' life-styles.

Methods

A cross-sectional study was conducted in Tuscany, a region of central Italy. One hundred percent female GPs (498) and a 60% random sample of male GPs (1310) practising in the region were contacted through a self-administered postal questionnaire followed by a postal reminder and telephone interview.

Results

Overall response rate was 82.1%. Most respondents (58%) recommended CAM but a far smaller fraction (13%) practised it; yet 36% of CAM practitioners had no certificated training. Being female, younger age, practising in larger communities, having had some training in CAM as well as following a vegetarian or macrobiotic diet and doing physical activity were independent predictors of CAM recommendation and practice. However, 42% of GPs did not recommend CAM to patients mostly because of the insufficient evidence of its effectiveness.

Conclusion

CAM knowledge among GPs is not as widespread as the public demand seems to require, and the scarce evidence of CAM effectiveness hinders its professional use among a considerable number of GPs. Sound research on CAM effectiveness is needed to guide physicians' behaviour, to safeguard patients' safety, and to assist policy-makers in planning regulations for CAM usage.

Chiropractic and CAM utilization: a descriptive review

OBJECTIVE

To conduct a descriptive review of the scientific literature examining use rates of modalities and procedures used by CAM clinicians to manage chronic LBP and other conditions

DATA SOURCES

A literature of PubMed and MANTIS was performed using the key terms Chiropractic; Low Back Pain; Utilization Rate; Use Rate; Complementary and Alternative Medicine; and Health Services in various combinations.

DATA SELECTION

A total of 137 papers were selected, based upon including information about chiropractic utilization, CAM utilization and low back pain and other conditions.

DATA SYNTHESIS

Information was extracted from each paper addressing use of chiropractic and CAM, and is summarized in tabular form.

RESULTS

Thematic analysis of the paper topics indicated that there were 5 functional areas covered by the literature: back pain papers, general chiropractic papers, insurance-related papers, general CAM-related papers; and worker's compensation papers.

CONCLUSION

Studies looking at chiropractic utilization demonstrate that the rates vary, but generally fall into a range from around 6% to 12% of the population, most of whom seek chiropractic care for low back pain and not for organic disease or visceral dysfunction. CAM is itself used by people suffering from a variety of conditions, though it is often used not as a primary intervention, but rather as an additional form of care. CAM and chiropractic often offer lower costs for comparable results compared to conventional medicine.

Prevalence of complementary and alternative medicine and use among children in South Australia

AIM

To determine the use of complementary and alternative medicines and therapies (CAM) and common treatment modalities in children.

METHODS

This is a cross-sectional, population-based survey of 2985 adult and 911 children aged 15 years or less, conducted in South Australia in Spring 2004. The outcome measures are CAM use in children in the previous 12 months.

RESULTS

Overall, the 12-month prevalence of CAM use in children was 18.4% (95% confidence interval 15.9-21.0). A wide variety of CAM modalities were used by children including ingestible therapies (33%), chiropractic (34%) and massage (20%). Common reasons for use of CAM were to prevent illness or to maintain health (39%) and for musculoskeletal conditions (22%), respiratory problems (20%) and skin complaints (18%). There was little difference in the use of CAM treatment modality across child ages.

CONCLUSION

Approximately one in five children used CAM in the past 12 months in South Australia. Our findings further highlight the importance of increasing public awareness about the need to inform doctors and primary health-care providers of CAM use in children. Health professionals working with children should ask parents about their children's use of CAM. There is a need for further research examining the safe and judicious use of CAM in children.

Use of complementary and alternative medicine by Brazilian oncologists

Complementary and alternative medicine (CAM) is frequently employed by patients with cancer. An extensive survey was conducted among Brazilian cancer physicians to understand their attitude towards CAM. A questionnaire was sent to all 655 members of the Brazilian Cancer Society asking what is their opinion regarding CAM and if they would prescribe any CAM modality for their patients. They were also questioned regarding their degree of awareness of CAM self-administration by their patients. Overall, 119 questionnaires were returned to us (18%). Most oncologists knew at least one type of CAM (96.6%) and 76.7% had previously made use of at least one type of CAM for themselves. We observed that 76 (63.8%) of the oncologists used to ask their patients about CAM utilization and 37.8% described at least one reason to stimulate its use (68.8% as complementary treatment). Only 10% of the oncologists would prescribe at least one type of CAM and this attitude correlated significantly with previous physicians' use of CAM and with being a clinical oncologist as well as with having questioned patients about CAM use. Most oncologists (80.7%) would not indicate the use of CAM, mainly for lack of scientific proof of its efficacy (56.2%). Physicians knew many kinds of CAM and had frequently used some of them themselves, but only a minority of Brazilian oncologists would indicate them. As CAM use is very prevalent in our population, we believe that most of its utilization depends, probably, on patient's own and independent initiatives. However, these results should be viewed with caution because of the low response rate we observed in this study.

Conceptualizing mainstream health care providers' behaviours in relation to complementary and alternative medicine

There has been an explosion of literature on the attitudes of a variety of health care providers, particularly physicians, to the growing utilization of complementary and alternative medicines and modalities (CAM). What is most seriously lacking is a conceptual framework that helps to distill this mountain of literature into a manageable and more understandable amount. In this paper, we address these important issues by examining the literature that surveys the attitudes and behaviour of providers regarding CAM comparatively across the professions of medicine and nursing and across settings. We do so by drawing upon existing, more general theoretical contributions to the area of CAM in order to propose a comparative conceptual framework with which to interpret the diverse and at times discrepant results of this body of research.

Herbal medicines: predictors of recommendation by physicians

BACKGROUND

We hypothesized that as the use of herbal medicines increases in the general population, so do patients' requests to physicians for recommendations. However, why some physicians recommend herbal medicines while others do not is not well understood.

OBJECTIVE

To identify factors, which predict recommendation of herbal medicines by physicians. DESIGN, LOCATION, SUBJECTS: Face-to-face interview using a structured questionnaire of 206 physicians working at the University of Malaya Medical Centre, Malaysia.

RESULTS

About a third (206 of 626) of the physicians in the Centre participated. Only nine of the 215 approached refused to participate. Forty physicians (19%) recommended herbal medicines to patients. Logistic regression modelling identified personal use, general interest, interest in receiving training, race and higher level of medical training as significant predictors of physicians recommending herbal medicines.

CONCLUSIONS

Physicians' personal attributes and training influence their likelihood of recommending herbal medicines.

Patterns and perceptions of complementary/alternative medicine among paediatricians and patients' mothers: a review of the literature

For many families and their children, the use of complementary/alternative medicine (CAM) is an accepted adjunct or alternative to conventional therapy, even if data available in the literature regarding risks and adverse drug reactions (ADRs) pertaining to childhood populations are scarce. Moreover, despite widespread and increasing use of CAM, there are limited data on how paediatricians communicate with mothers and/or patients about CAM. Therefore, we report the studies available in the literature in the paediatric field and summarise what is known about ADRs and risks of CAM, taking into account in particular problems related to interactions between phytotherapy and conventional medicines and to counselling.

CONCLUSION

from the analysis of the literature, some interesting aspects emerge: (1) the extent of CAM use in the paediatric field is increasingly sought by parents of children with chronic illnesses; (2) most parents who choose CAM medicine for their children believe that these therapies are "natural" and thus "safe" and (3) physicians often feel to know too little about CAM and wish to learn more for different reasons including "to dissuade whether the alternative method is unsafe and/or ineffective". Therefore, paediatricians should be prepared to discuss alternative therapies with parents, since talking about CAM may help to minimise the risks and to restrain parental misconceptions and doubts. Educational interventions for parents should also be performed to bring about a more aware use of traditional and alternative medicines.

Alternative, complementary, and conventional medicine: is integration upon us?

In attempts to improve their health and/or combat illness, approximately 4 in 10 Americans will use a complementary and alternative medicine (CAM) therapy this year. CAM therapies vary widely, with acupuncture, chiropractic, herbal medicine, and homeopathy among the more prominent modalities. CAM therapies are used in addition to and/or instead of the more conventional forms of medical care available in U.S. hospitals or licensed physicians' offices. A rapidly increasing interest in CAM has led to a nascent movement aimed at integrating various CAM therapies with the conventional health care system. In Washington State, for example, health insurance coverage for CAM therapies has been mandated, and a number of "integrated" delivery systems have been born. Although the political and economic forces leading to adoption and integration of CAM therapies vary widely by geographic locale, it is likely that some degree of integration will occur throughout much of the United States. Similar processes are occurring in Canada, Europe, and Australia, and indeed within middle and upper level socioeconomic strata worldwide. This paper identifies potential barriers and facilitators to potential integration, of medical disciplines and argues for an accessible, multidisciplinary and evidence-based, yet humanistic and patient-oriented approach.

Complementary therapy involvement of physicians: implications for practice and learning

OBJECTIVE

We studied physicians' current and desired clinical role functions within the complementary health paradigm and their perceptions of the necessary educational programs to support them.

DESIGN AND SETTING

A questionnaire to determine clinical activities within different complementary therapies was developed and mailed-out to 837 eligible physicians in Hamilton, Ontario, Canada, using a modified Dillman approach.

RESULTS

The overall response rate to the mailed survey was 49.8% (417/837), with response rates of 50.2% (115/229) for family physicians and 49.7% (302/608) for specialists. The amount of interactions around complementary therapies between physicians, their patients and complementary therapists appears to be low. At the same time, there is a growing interest among physicians about complementary therapies, particularly with respect to developing their knowledge about efficacy and enhancing their skills in assessment and counselling.

CONCLUSIONS

The differential levels of acceptance of different therapies by physicians will influence integration of complementary therapies in mainstream medicine.

Unconventional medicine teaching at the Universities of the European Union

CONTEXT

The recent rapid increase in demand for and use of unconventional medicine requires an adequate medical education. In the United States, 64% of medical schools offer undergraduate courses. No information is available about similar courses at European universities.

OBJECTIVES

To document the incidence of educational courses on unconventional medicine offered by the European universities and their topic content.

DESIGN

Mail survey, which consisted of two questionnaires and was conducted in 1999 (January-June). The first questionnaire was sent to the universities' Rectorats, the second one to the faculties or lecturers indicated by the replies to the first questionnaire.

PARTICIPANTS

The Universities listed by the Confederation of European Union Rectors' Conference.

MAIN OUTCOME MEASURES

Courses offered at European Universities, both at medical faculties and at other faculties.

RESULTS

Five hundred and fifty (550) universities were contacted. Replies were received from 326 (59%); 141 have a faculty of medicine and 107 (76%) of them replied. We also received answers from 29 faculties of health sciences. In addition we received 190 (50%) answers from 380 other miscellaneous universities. Courses on unconventional medicine were offered by 43 (40%) medical schools, 21 (72%) health sciences faculties, and by 15 (8%) other faculties. Topics covered encompassed a wide range of techniques (33), from homeopathy to shamanism.

CONCLUSIONS

Unconventional medicine courses are widely represented at European universities. They cover a wide range of therapies. Many of them are used clinically. Research work is underway at several faculties.

Alternative and Complementary Therapies in Nursing Curricula

The growing interest in and use of alternative and complementary therapies by health care professionals and laypersons, the incorporation of these therapies in medical curricula and practice, and the greater acceptance of the legitimacy of such treatment methods require that nurse educators consider how this content may be incorporated into curricula. The authors propose that prelicensure students learn the premises that support such healing practices and develop skill in eliciting and evaluating patients' use of alternative therapies. In-depth study of one or more complementary therapies may be the focus of continuing education or elective courses. Students in graduate programs may investigate the safety and efficacy of nonorthodox therapies.

Physician-patient communication about complementary and alternative medical therapies: a survey of physicians caring for patients with human immunodeficiency virus infection

OBJECTIVE

To examine frequency and correlates of physicians' reports of discussions with patients with human immunodeficiency virus (HIV) about complementary and alternative medical (CAM) therapies.

DESIGN

Mailed physician survey.

SETTING

The setting was Eastern Massachusetts.

PARTICIPANTS

Participants included 89 physicians caring for patients with HIV.

MEASUREMENTS AND MAIN RESULTS

Physicians were asked how common the use of CAM therapies was among their patients, how useful these therapies were, how often they discussed the use of CAM therapies with new and follow-up patients, and whether they had used a CAM therapy themselves in the last year. We also collected information on physicians' sociodemographic and practice characteristics. Sixty-eight percent (89/130) of physicians responded, and 26% and 5% reported discussing CAM therapies with HIV-infected patients at most new and follow-up visits, respectively. Respondents' attitudes toward the use of CAM therapies were generally positive, and they believed their HIV-infected patients used CAM therapies more than their non-HIV infected patients. The majority (63%) believed that CAM therapies may be helpful for HIV-infected patients. Thirty-six percent (36%) had used a CAM therapy themselves in the last year. In multivariate analyses, only the belief that CAM therapies are helpful was correlated with discussion of CAM therapies (p = 0.006). Respondents' demographic characteristics, training, personal use of CAM therapies, reported visit length, and satisfaction with visit length were not associated with discussion of CAM therapies.

CONCLUSIONS

Despite awareness that their HIV-infected patients commonly use CAM therapies and positive attitudes towards such therapies, most of these physicians did not routinely discuss CAM therapies with them. Barriers to physician-patient communication about CAM therapies merit further investigation.

Use of complementary therapies by patients attending musculoskeletal clinics

Patients with musculoskeletal disorders commonly seek treatment outside orthodox medicine (complementary therapy). In patients attending hospital clinics we investigated the prevalence of such behaviour and the reasons for it. Patients attending rheumatology and orthopaedic clinics who agreed to participate were interviewed on the same day by means of a structured questionnaire in three sections: the first section about demographic characteristics; the second about the nature and duration of the complaint, the length of any treatment and whether the patient was satisfied with conventional treatment; and the third about the use of complementary medicine, the types of therapy that had been considered and the reasoning behind these decisions. The data were examined by univariate and bivariate analysis as well as logistic regression multivariate analysis. 166 patients were interviewed (99% response rate) and the predominant diagnosis was rheumatoid arthritis (22.3%). 109 patients (63%) were satisfied with conventional medical treatment; 63 (38%) had considered the use of complementary therapies, and 47 (28%) had tried such a therapy. 26 of the 47 who had used complementary therapy said they had gained some benefit. Acupuncture, homoeopathy, osteopathy and herbal medicine were the most popular types of treatment to be considered. Patients of female gender (P = 0.009) and patients who had expressed dissatisfaction with current therapies (P = 0.01) were most likely to have considered complementary medicine. These results indicate substantial use of complementary therapy in patients attending musculoskeletal disease clinics. The reasons for dissatisfaction with orthodox treatment deserve further investigation, as does the effectiveness of complementary treatments, which must be demonstrated before they are integrated with orthodox medical practice.