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Physicians Want Education About Complementary and Alternative Medicine to Enhance Communication With Their Patients
Lisa Corbin Winslow, MD;
Howard Shapiro, PhD
Arch Intern Med. 2002;162:1176-1181.
ABSTRACT
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Background More than one third of patients in the United States use complementary
and alternative medicine (CAM); most also visit conventional physicians. There
is little information about how physicians and patients discuss CAM. We hypothesized
that physicians frequently fielded questions about CAM treatments but felt
uncomfortable discussing them owing to a lack of education.
Objectives To survey physicians to see how they discussed CAM with their patients
and what factors influenced discussions and referrals.
Methods A total of 751 physicians in the Denver, Colo, area were asked about
their experience with CAM and communication about CAM with patients. Analyses
were conducted using the SAS system (version 6, 1989; SAS Institute Inc, Cary,
NC).
Results Of the 705 deliverable surveys, 302 (43%) were returned: 76% of physicians
reported having patients using CAM; 59% had been asked about specific CAM
treatments; 48% had recommended CAM to a patient; and 24% had personally used
CAM. Physician recommendation of CAM was most strongly associated with physician
self-use (odds ratio, 6.98; P<.001). Few physicians
felt comfortable discussing CAM with their patients, and the overwhelming
majority (84%) thought they needed to learn more about CAM to adequately address
patient concerns.
Conclusions Education about CAM modalities is a significant unmet need among Denver
physicians, and education may help alleviate the discomfort physicians have
when answering patients' questions about CAM. Physicians who use CAM treatments
themselves are much more likely to recommend CAM for their patients than physicians
who do not.
INTRODUCTION
COMPLEMENTARY and alternative medicine (CAM) is defined as any medical
practice that is neither widely available nor widely taught in conventional
medical schools in the United States. Surveys reveal that up to 42% of the
US population have used 1 or more CAM modalities, with patients often seeking
CAM care and conventional care for the same problem.1
In addition, insurance companies are beginning to cover some of these treatments
(although some require that conventionally trained physicians make the referrals).
Despite widespread and increasing use of CAM within the United States,
there are limited data on how conventional medical practitioners communicate
with their patients about CAM. We hypothesized that physicians frequently
fielded questions about CAM, but, because of lack of education and experience,
physicians were likely to respond to patient inquiries neutrally or negatively
and feel uncomfortable discussing these treatments with their patients. We
therefore surveyed a metropolitan area group of physicians to ascertain their
patterns of communication with patients regarding CAM and the factors of importance
to these physicians in deciding whether to discuss CAM modalities with their
patients or refer their patients for CAM treatment.
SUBJECTS AND METHODS
Names and addresses of physicians living in the Denver, Colo, metropolitan
area were obtained from the Colorado Medical Society. Based on a review of
previous surveys,2-7
a survey instrument was developed, pilot-tested on 20 physicians, revised,
and then mailed to 751 randomly selected physicians (approximately 14% of
the 5200 on the list). For nonresponders, surveys were remailed twice, for
a total of 3 mailings. Nonresponders were then called by a research assistant
and given the option of receiving another survey or completing the survey
over the telephone. For contacted nonresponders refusing to complete the survey,
we attempted to gather demographic information and answers to the 2 short
questions specifically addressing attitudes toward CAM.
The survey specifically inquired about the same 16 CAM modalities that
patients were asked about in a well-publicized 1993 national survey8: acupuncture, aromatherapy, biofeedback, chiropractic,
energy healing, folk remedies, herbal (botanical) therapy, homeopathy, hypnosis,
massage therapy, megavitamin therapy, relaxation techniques, reflexology,
special diet, spiritual or religious healing, and yoga. With regard to each
of these modalities and CAM in general, physicians were asked if they had
any patients ask about or use that treatment in the last year, if they had
recommended that treatment to patients or used it for themselves, if they
had been educated about that treatment (by book or journal reading, course
work or class attendance, lay press reading, or watching television programs),
and if they believed that treatment was effective or ineffective. Physicians
were also asked whether their typical response was positive or negative when
discussing CAM with patients, whether they were comfortable or uncomfortable
discussing CAM with patients, if they routinely asked patients if they were
using CAM, and if they were interested in learning more about CAM (including
risk-benefit information or cost-effectiveness or learning how to advise patients
who inquire about CAM modalities).
Comparisons of mean results between 2 groups were performed using the
2-tailed, independent samples t test. Correlations
reported consist of Pearson correlation coefficients. Linear regression was
used to provide additional detail beyond correlation coefficients. Categorical
cross-tabulation tables were tested using the  2 test for contingency
tables. Multivariate analyses included logistic regression. Model-building
strategies, assessment of interactions, and evaluation of the appropriate
scales for continuous variables followed those advocated by Hosmer and Lemeshow.9 Statistical significance was assumed at P<.05. All analyses were conducted using the SAS system (version
6, 1989; SAS Institute Inc, Cary, NC).
RESULTS
RESPONSE RATE AND DEMOGRAPHICS
A total of 302 surveys (40%) were returned. Forty-six (6%) of the surveys
were undeliverable and addressee physicians not located. Twenty-six of the
302 returned surveys were disqualified because the physicians indicated that
they were no longer in practice or seeing patients, which left a total of
276 surveys available for analysis. Thus, 41% of deliverable surveys of actively
practicing physicians were analyzed. Demographic characteristics of respondents
compared with the Denver physician population as a whole are detailed in Table 1 (Denver physician data were provided
courtesy of Ed Fryer, PhD, Colorado Health Professionals Panel, Denver).
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Table 1. Demographic Characteristics of Survey Responders Compared
With the Entire Denver, Colo, Physician Population*
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PHYSICIAN-REPORTED PATIENT USE OF CAM
The percentage of physicians reporting patient use of and inquiries
regarding various CAM modalities is shown in Figure 1. Chiropractic, herbal therapy, massage therapy, acupuncture,
and alternative medicine in general were the modalities cited by physicians
as most often used and asked about by their patients. Physicians were asked
about a mean ± SD of 4.1 ± 3.6 of the 16 CAM modalities (range,
0-16). Primary care physicians were more likely to report that their patients
inquired about more CAM modalities than specialists (5.0 ± 3.6 vs 3.3
± 3.5 CAM modalities; P<.001). Physicians
reported that their patients used 4.9 ± 3.7 of the 16 modalities (range,
0-15). Primary care physicians also reported more patients using CAM than
specialists did (5.4 ± 3.8 vs 4.4 ± 3.5, respectively; P = .03). These data indicate substantial physician awareness
of CAM use among their patients and significant patient inquiries directed
to physicians about a wide range of CAM modalities.
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Figure 1. Physician reports of patient use
of and inquiries regarding complementary and alternative medicine (CAM). For
each CAM modality, the top bar shows what percentage of physicians had at
least 1 patient using that modality, and the bottom bar shows the percentage
of physicians who had been asked by patients about that modality. All numbers
indicate percentages of physicians.
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The percentage of physicians who specifically ask their patients about
CAM use is shown in Figure 2. Seventeen
percent never ask, and an additional 52% ask less than half the time, indicating
a pattern of infrequent inquiry about patient CAM use. There were no statistically
significant differences for physician age (P = .61),
sex (P = .11), or degree (MD vs DO; P = .32) in the pattern of physician inquiry regarding patients' CAM
use. These data demonstrate that, despite physician knowledge of the high
rate of patient use of CAM, physicians do not routinely inquire about such
use.
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Figure 2. How often physicians ask their
patients about use of complementary and alternative medicine. Numbers indicate
percentage of physicians.
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DETERMINANTS OF PHYSICIAN DISCUSSION OF CAM WITH THEIR PATIENTS
Physician comfort levels and attitudes toward discussing various modalities
of CAM are shown in Figure 3. More
than 50% of physicians did not have a positive attitude about CAM when discussing
these modalities with patients and were not comfortable during these discussions.
The relationship between physicians asking patients about CAM use and physicians'
comfort level discussing CAM use was further explored by calculating the Pearson
correlation, which was statistically significant (r
= 0.33; P<.001). We conclude that there is a linear
association between an increasing comfort level in discussing CAM use with
an increasing propensity to ask patients about their use of CAM modalities.
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Figure 3. Physicians' overall feelings (A)
and comfort levels (B) when discussing complementary and alternative medicine
with patients. Numbers indicate percentages of physicians.
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Physician recommendations to patients about use of CAM and physician
personal use of CAM modalities are illustrated in Figure 4. Massage therapy, relaxation techniques, acupuncture, and
biofeedback are the CAM modalities most often recommended by physicians to
their patients. Female physicians were more likely to recommend CAM modalities
than male physicians. Female physicians recommended a mean ± SD of
3.3 ± 2.9 therapies, while their male counterparts recommended 2.4
± 2.7 (P = .005). There was no statistical
difference in the number of treatments recommended by osteopathic physicians
(3.9 ± 3.7) vs allopathic physicians (2.6 ± 2.8) (P = .16), likely because of the small number of osteopathic physicians
in the sample. Physician age was not associated with the number of therapies
recommended to patients (Pearson r = -0.16; P = .34).
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Figure 4. Physician reports of personal
use of complementary and alternative medicine (CAM) modalities and likelihood
of recommending them to patients. For each CAM therapy, the top bar represents
the percentage of physicians who have used this therapy for themselves, and
the bottom bar represents the percentage of physicians who have recommended
this therapy to a patient. Numbers indicate percentages of physicians.
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Physicians used 1.1 ± 1.8 of the 16 CAM treatment modalities
themselves (range, 0-9). Figure 4
shows the percentage of physicians who have used each therapy. Physicians
who used a CAM therapeutic modality for themselves were more likely to recommend
a CAM therapy to their patients (Pearson r = 0.55; P<.001). From extrapolation of linear regression, we
found that physicians who do not use any CAM treatment still recommend such
treatments to their patients (average of 1.8 treatments recommended). Belief
in efficacy of selected CAM modalities and self-reported education about specific
modalities were clearly associated with high frequency of physician recommendation
of the modality to patients (Table 2
and Table 3). Belief in efficacy
of CAM in turn was related to specific education about the CAM modality (Table 4).
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Table 2. Association Between Belief in Efficacy and Recommendation
of a Particular CAM Modality*
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Table 3. Association Between Education About CAM Modalities and Recommendation
of Those Modalities to Patients*
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Table 4. Association Between Education About a Particular CAM Modality
and Belief That It Works*
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To identify predictors of likelihood of a physician recommending CAM
therapy, logistic regression analysis was used. The number of CAM modalities
recommended was dichotomized into 0 and 1 or more. Traditional univariate
analysis was used to identify potential predictor variables of interest, with
univariate logistic regression agreeing with the selection of variables for
the multivariate model testing. Stepwise logistic regression selected self-use
and interest in learning as independently significant variables (P = .001 and P<.001, respectively). Self-use
has an estimated odds ratio of 6.98, which is interpreted as showing that
compared with physicians who do not use CAM modalities, physicians who use
1 or more modalities are almost 7 times more likely to recommend CAM to their
patients. Interest in learning has an estimated odds ratio of 4.38, so that
physicians who are interested in learning are 4.4 times more likely to recommend
CAM than physicians not interested in learning.
PHYSICIAN ATTITUDES TOWARD CAM EDUCATION
In view of the impact of education on physician belief in efficacy,
we analyzed further physician interest in CAM education (Figure 5). Most physicians (60%) wanted to learn more about CAM.
Female physicians were more interested than male physicians (91.0% vs 80.1%; P = 0.02). There was no statistically significant difference
in mean ± SD age for physicians who were and were not interested in
CAM education (44.0 ± 10.2 years vs 45.8 ± 11.1 years; P = .30).
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Figure 5. Physician interest in learning
more about complementary and alternative medicine. Numbers indicate percentages
of physicians.
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Five reasons for physician desire to learn more about CAM are illustrated
in Figure 6. The most cited reasons
were "want to dissuade patient if alternative method is unsafe and/or ineffective"
(94% said this reason was somewhat or very important) and "want to recommend
method to patient if safe and effective" (90% said this reason was somewhat
or very important). Interestingly, the physicians who felt very positive or
somewhat positive about CAM therapies were more interested in education and
learning how to advise patients (P = .001; 2 test for contingency tables), yet there was no correlation between
interest in education and comfort level discussing CAM with patients.
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Figure 6. Importance of various reasons
that physicians were interested in further education about complementary and
alternative medicine (CAM). Numbers indicate percentages of physicians.
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COMMENT
Given the widespread public interest in and use of CAM, we were interested
in ascertaining how conventional physicians communicate with their patients
regarding CAM treatments. We found that physicians commonly do not explicitly
inquire about CAM use by their patients. However, when specific inquires were
made, it was statistically related to a higher level of comfort in discussing
such modalities with patients. Although physicians often do not specifically
inquire about CAM use, they are often aware of such use, presumably because
of patient self-disclosure.
Our study also provides new information about physician recommendations
of CAM to their patients. Physicians most commonly recommended massage therapy,
relaxation techniques, acupuncture, and biofeedback. We found several factors
significantly associated with physicians recommending use of CAM: female sex
of physician, physician self-use of CAM, physician self-reported education
in CAM, and physician self-reported belief in CAM efficacy. Together, these
data provide information on characteristics of physicians who advise patients
to seek CAM and the specific modalities recommended.
Our study also demonstrates a desire by most physicians to learn more
about CAM. Physicians who had positive attitudes toward CAM were those most
interested in learning more about CAM. We found several reasons for physicians'
desire for CAM education. By far the most powerful reason was the desire to
dissuade patients from undergoing an unsafe or ineffective modality. Other
frequently cited reasons were the desire to recommend a safe and effective
CAM modality, the desire to receive factual information about CAM modalities,
and the desire to be able to respond to patient queries.
We should note some of the shortcomings of our analysis. Our survey
was conducted in a single geographic area, and thus the results may not be
generalizable. Also, despite many contacts, our overall response rate of 41%
is suboptimal, and we thus cannot be sure that our results are applicable
to the entire population of physicians surveyed. However, the demographic
characteristics of responders did not differ substantially from the survey
area's physician population in general. Finally, our questions were global
rather than specific. For example, a physician may feel very comfortable discussing
acupuncture but not homeopathy. Other studies have looked at the responses
by treatment.4
Our study is the first that we are aware of to investigate communication
between physicians and patients about CAM. We conclude that physicians often
do not explicitly ask their patients about CAM use and feel uncomfortable
discussing risks and benefits of CAM modalities. These findings likely drive
the overwhelming desire of physicians to learn more about CAM, a point underscored
by comments made on returned surveys such as this: "let's study these things
and find out if they work; if so, we can recommend them wholeheartedly and
they will no longer be ‘complementary or alternative' but conventional."
AUTHOR INFORMATION
Accepted for publication November 19, 2001.
This study was funded by HealthONE Alliance, Denver, Colo.
Corresponding author and reprints: Lisa Corbin Winslow, MD, Center
for Integrative Medicine, University of Colorado Hospital, PO Box 6510, Mail
Stop F730, Aurora, CO 80045 (e-mail: lisa.winslow{at}uchsc.edu).
From the Departments of Rehabilitation Medicine and Medicine, University
of Colorado Health Sciences Center (Dr Winslow) and HealthONE Alliance (Dr
Shapiro), Denver Colo. Dr Winslow is now with the Center for Integrative Medicine,
University of Colorado Hospital, Aurora.
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