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Use and Referral Patterns for 22 Complementary and Alternative Medical Therapies by Members of the American College of Rheumatology
Results of a National Survey
Brian M. Berman, MD;
R. Barker Bausell, PhD;
Wen-Lin Lee, PhD
Arch Intern Med. 2002;162:766-770.
ABSTRACT
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Background This study was designed to determine rheumatologists' self-reported
knowledge, perceptions of legitimacy, referral patterns, and use in practice
of 22 complementary and alternative medicine (CAM) therapies.
Methods A survey was mailed to a random sample of 2000 physician members of
the American College of Rheumatology asking respondents which (if any) CAM
therapies they (1) knew enough about to discuss with patients, (2) considered
part of "legitimate medical practice," and (3) "personally administered" to
patients, or "referred patients to someone else" to administer. The response
rate was 47%.
Results On average, the respondents reported knowing enough to discuss 10 of
the therapies with patients, considered 9 to be part of legitimate medical
practice, and had referred patients to someone else for 8 of the 22 therapies.
Correlates of use and/or referral included sex, age, belief in the legitimacy
of the therapies, and self-reported knowledge.
Conclusions These results provide potentially important preliminary data regarding
rheumatologists' responses to dramatic increases in the use of CAM therapies
among their patients.
INTRODUCTION
IT HAS BEEN ESTIMATED that there are now more office visits made for
complementary and alternative medicine (CAM) therapies in the United States
than for the services of conventional primary care physicians.1
While a number of studies that have also used nationally representative samples2-4 have found considerably
lower estimates of CAM use, there is little doubt that patients' use of therapies
other than those prescribed by their convention physicians is a clinical issue
that must be reckoned with. This is especially true for rheumatologists and
those primary care physicians who treat rheumatological patients, since an
ever-growing number of consumer-based surveys have indicated that visits to
alternative therapists are especially prevalent among patients with chronic
pain–related conditions, such as arthritis5-14
and fibromyalgia.15-18
In general, while some of these surveys (1) were relatively small, (2) did
not use probability sampling methods, (3) used different time intervals on
which to base prevalence estimates, and (4) used varying definitions of what
constitutes a CAM therapy, it appears that estimates of the use of CAM therapies
among rheumatological patients are generally higher than among patients with
a number of other specific conditions. Although this literature is difficult
to summarize, the cumulative weight of the evidence appears to indicate that
the prevalence of the use of CAM therapies among patients with arthritis and
fibromylagia is extremely high and certainly encompasses the majority of rheumatological
patients.
There have been many fewer surveys of rheumatologists with respect to
their clinical response to this movement, although there have been numerous
physician surveys targeting attitudes toward, and use of, CAM therapies among
primary care physicians in general. Two meta-analyses of the survey literature
regarding CAM use19-20 and a number
of individual physician surveys21-44
have shown that there is considerable professional interest in complementary
therapies as well as a general willingness to refer patients to providers
of at least some of the CAM modalities.
Of the 2 published surveys targeting rheumatologists of which we are
aware, one was published in a popular health magazine45
in 1999 and was difficult to evaluate because its methodology was not specified,
while the other involved an exclusively Dutch sample of rheumatologists.8 Both articles identified a number of CAM therapies
that the majority of the respondents viewed positively (capsaicin, relaxation,
biofeedback, meditation, and journal writing in the Arthritis
Today sample; spa treatment, acupuncture, and manipulation in the Dutch
sample), but neither survey was designed to systematically assess the clinical
responses to this growing phenomenon.
Therefore, the primary purpose of the present study was to assess the
extent to which present-day rheumatologists incorporate CAM therapies into
their professional practices, either through direct patient care or through
referral to other providers. A secondary purpose was to assess the extent
to which these behaviors could be explained by the demographic, professional,
and affective characteristics of the clinicians who participated in the survey.
PARTICIPANTS AND METHODS
PROCEDURE
A survey instrument soliciting self-reported knowledge of, attitudes
toward, clinical use of, and referral to providers of 22 separate CAM therapies
was mailed to a random sample of 2000 of the 4879 physician membership of
the American College of Rheumatology residing in the United States. After
2 additional mailings to nonrespondents, 924 usable questionnaires were received
(28 were not delivered), representing an effective response rate of 47%.
SAMPLE
As depicted in Table 1,
the majority of the responding physicians were male (87%) and older than 50
years (78%). In general, the respondents were heavily engaged in direct clinical
practice (75% saw patients at least 24 hours per week) and were qualified,
with 94% reporting possessing board certifications in both rheumatology and
internal medicine.
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Table 1. Demographic and Practice Characteristics
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SURVEY INSTRUMENT
The questionnaire that was used in the present study was based on previous
survey research conducted by the University of Maryland Complementary Medicine
Program.43-44 The instrument solicited
information regarding basic demographic and practice variables as well as
self-reported attitudes and clinical behaviors regarding the above-mentioned
list of 22 CAM therapies. The items related to the 22 CAM therapies were contained
in an alphabetical list of the behaviors, with instructions for the respondents
to indicate, for each separate therapy, whether or not they (1) knew enough
about the behavior to discuss it with patients; (2) considered it to be a
part of legitimate medical practice that was designed as a global attitudinal
indicator (and hence possibly related to respondents' perceptions of efficacy);
(3) had personally administered the therapy to patients; and (4) had referred
patients to someone else to administer the therapy. Each of the resulting
88 responses was scored dichotomously (yes or no), with total composite scores
(theoretically ranging from 0-22) computed for the 4 affective/behavioral
dimensions, ie, self-reported knowledge, opinions regarding legitimacy, clinical
use, and referral) by summing across the 22 therapies.
STATISTICAL ANALYSIS
Descriptive statistics were used to present physicians' knowledge, attitudes,
and clinical behavior relevant to the 22 individual therapies, while multiple
linear regression was used to explore the correlates of clinical utilization
of these CAM therapies considered as a whole.
RESULTS
As indicated in Table 2,
the respondents were much more likely to refer patients to other practitioners
for the CAM therapies than to administer them themselves. Trigger point therapy
and nutraceuticals were the 2 therapeutic exceptions, with 51% and 34% of
the respondents, respectively, reporting direct clinical involvement with
these therapies. The other 4 therapies for which the most active direct clinical
use was reported were (1) exercise intervention (41%), (2) dietary prescription
(33%), (3) counseling/psychotherapy (24%), and (4) electromagnetic applications
such as transcutaneous or pericutaneous electrical nerve stimulation (10%).
Totaled across all 22 therapies, the average physician reported having clinically
administered approximately 2.5% of the behaviors, although fewer than 5% of
the sample reported having had direct clinical experience with 11 of the behaviors
(ie, acupuncture, biofeedback, chiropractic, energetic healing, homeopathy,
hypnotherapy, magnets, nonchiropractic manipulation, message, specialized
movement therapies such as qi gong and yoga, and music therapy).
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Table 2. Proportion of 924 Respondents Who Used CAM Therapies in Their
Practice, Referred Their Patients to CAM Providers, Reported Sufficient Knowledge
to Discuss Therapies With Patients, and Considered Therapies a Part of Legitimate
Medical Practice*
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At least 50% of the responding physicians had referred patients to 8
of the therapies (ie, acupuncture, behavioral medicine, biofeedback, counseling/psychotherapy,
dietary prescriptions, electromagnetic applications such as transcutaneous
and percutaneous electrical nerve stimulation, exercise, and massage). When
direct clinical use of the therapies was combined with referral (ie, when
an individual physician either administered the therapy or referred the patient
to someone else to administer it), 9 of the 22 modalities had been used by
more than 50% of the respondents, with counseling/psychotherapy (85%) and
exercise (81%) heading the list.
While there were 9 therapies for which more than 50% of the clinicians
had reported at least some degree of clinical use (ie, either through personal
administration or referral), it is important to note that there were considerably
more of these modalities that were not used in any substantive form by this
group of physicians. There were also 9 therapies, in fact, for which 75% of
the sample had reported no clinical use (in descending order these were meditation
[24%], prayer and spiritual direction [23%], nonchiropractic manipulation
[23%], hypnotherapy [19%], herbal medicine [14%], music therapy [9%], magnets
[5%], energetic healing [5%], and homeopathy [4%]). Interestingly, none of
these modalities were considered part of legitimate medical practice by a
substantial proportion of the sample, nor did as many as 50% of the respondents
report sufficient knowledge to discuss any of them with their patients.
In summary, there appeared to be a major dichotomy among the 22 listed
therapies, with one group having achieved a certain degree of acceptance and
the other group definitely not having achieved anything approaching mainstream
acceptance. In general, physicians' knowledge of a therapy (as defined by
reporting to possess enough knowledge to discuss it with patients) and whether
or not they considered it to be a part of legitimate medical practice were
relatively closely related to one another, as they were to clinical use and
referral patterns.
A multiple regression was then performed to ascertain the extent to
which clinical use of CAM therapies among members of the American Board of
Rheumatology was related to demographic, professional, and attitudinal characteristics
of the sample. The dependent variable in this analysis was the total number
of therapies for which the respondent reported having either personally administered
to patients or referred patients to other clinicians for administration. The
independent variable set included (1) the demographic and professional characteristics
of age, sex, and number of hours per week spent in clinical practice; (2)
the total number of CAM therapies that the respondents thought were a part
of legitimate medicine; and (3) the total number of these therapies that the
physicians considered themselves to be sufficiently knowledgeable about to
discuss with their patients.
Overall, 41% of the variation in the overall self-reported clinical
use of the 22 CAM therapies was shared with the set of 5 predictors (Table 3). Only the number of board certifications
was not an individually significant correlate of clinical use. The strongest
predictor was, not surprisingly, beliefs in the legitimacy of the CAM therapies.
Even after this variable was statistically controlled for, however, knowledge
and hours spent in clinical practice were positively related to use. Female
physicians were also marginally more likely to engage in the clinical use
of CAM therapies (P = .052), while there was a negative
relationship (P = .008) between physician age and
referral or administration of the CAM therapies. Interestingly, however, a
secondary analysis (not shown) indicated that this latter relationship was
mitigated by the fact that physicians 55 years of age or older were actually
significantly more likely to personally administer certain therapies (most
notably counseling and behavioral medicine techniques), while being less likely
than their younger colleagues to refer patients to other practitioners.
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Table 3. Demographic and Practice Correlates of Referral or Clinical
Administration of CAM Therapies*
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COMMENT
This survey suffered from a number of limitations. The response rate,
while respectable for a physician survey, could have been higher. Its interpretation
also depends upon self-reported data, and there is always a question regarding
exactly what does and does not constitute a CAM therapy. Many types of psychologically
based therapies (a number of which, such as counseling, psychotherapy, relaxation
techniques, and behavioral medicine, are difficult to separate into distinct,
mutually exclusive modalities), for example, have almost certainly crossed
the boundary into conventional medical practice, while exercise therapy is
actually a component of the American College of Rheumatology's clinical guidelines
for osteoarthritis of the knee and hip.46 Other
therapies, such as biofeedback and transcutaneous electrical nerve stimulation,
may well be in the process of making this transition from complementary to
conventional medicine. Finally, the responses generated by this survey cannot
be assumed to be representative of rheumatological practice, since the present
sample of clinicians are obviously better trained and probably more knowledgeable
than clinicians in general.
With these caveats in mind, however, the present results do appear to
reflect an openness among rheumatologists toward a number of CAM treatment
modalities that they consider to be a part of legitimate medical practice
and, to a lesser extent, about which they report possessing enough knowledge.
These results, along with the weaker age and sex relationships, are generally
consonant with those reported previously (our surveys), although the latter
variables are not always correlated with physicians' use of CAM therapies.19 Finally, although the clinical administration of
CAM therapies by conventional physicians has not been well studied, some researchers
have found a relationship between a tendency to accept CAM or to refer patients
to CAM providers and experience/knowledge of the therapies involved,21, 28, 30, 36 while
others have not.24, 26
These results are also remarkably consistent with those of a smaller
survey (Table 4) conducted recently
using a random sample of the membership of the International Association for
the Study of Pain,44 especially given the fact
that the 2 sets of respondents were probably treating different types of patients
for different conditions. This survey also comprised a large proportion of
board-certified physicians (86%) and achieved a similar response rate (53%).
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Table 4. Rheumatologists' vs Pain Specialists' CAM Clinical Use/Referral*
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Among the 14 CAM therapies that were common to the 2 surveys, the rank
ordering of the use (as defined by referral or personal administration) for
these therapies was quite similar ( = 0.88, P<.001),
and the 2 samples had, on average, administered or referred patients to approximately
half of these nonpharmacological (nutraceuticals were not included in the
pain specialists' survey) therapies (6.6 of the 14 among the rheumatologists;
7.4 among the pain specialists).
What neither survey addresses, of course, is whether patients actually
benefit from exposure to these therapies. More investigations targeted at
rigorously assessing their efficacy is therefore urgently needed, both by
practitioners who must make referral decisions and by patients who need to
know what viable treatment options are available to them.
In the meantime, while this evidence is accumulating, opinions understandably
differ regarding the appropriateness of using some of these individual therapies.
The present results can thus be interpreted as reflecting a very real and
appropriate commitment among this highly qualified group of clinicians toward
the treatment of a variety of patient conditions for which completely viable
pharmacological options do not yet exist. It will be interesting to see whether
the use of CAM therapies among mainstream rheumatologists will increase over
time, the way that public acceptance and use of alternative therapists have.
AUTHOR INFORMATION
Accepted for publication August 7, 2001.
This study was supported in part by grant 1P50AT0008401 from the National
Center for Complementary and Alternative Medicine, National Institutes of
Health, Bethesda, Md.
Corresponding author and reprints: R. Barker Bausell, PhD, Complementary
Medicine Program, University of Maryland School of Medicine, Kernan Hospital
Mansion, 2200 Kernan Dr, Baltimore, MD 21207 (e-mail: bbausell{at}compmed.ummc.umaryland.edu).
From the Complementary Medicine Program, University of Maryland School
of Medicine, Baltimore.
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