A Literature Review of Health Care Professional Attitudes Toward Complementary and Alternative Medicine

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1 A Literature Review of Health Care Professional Attitudes Toward Complementary and Alternative Medicine Maida J. Sewitch, PhD, Monica Cepoiu, MD, MSc, Nicole Rigillo, MA, and Donald Sproule, MD Complementary Health Practice Review Volume 13 Number 3 October # 2008 SAGE Publications / hosted at Objective. To summarize health care professionals attitudes toward complementary and alternative medicine (CAM). Methods. In October 2006, we searched Allied and Complementary Medicine Database (AMED; ), Excerpta Medica Database (EMBASE; ), and MED- LINE ( ) for Canadian or US studies of health care professionals attitudes toward CAM, published in English or French. Results. A total of 21 surveys of physicians, nurses, public health professionals, dietitians, social workers, medical/nursing school faculty, and pharmacists were included that focused on beliefs about CAM efficacy, personal use, clinical practice use and referrals, communication with patients about CAM, level of knowledge, and the need for information regarding various CAM therapies. Physicians were more negative compared to other health care professionals. Positive attitudes toward CAM did not correlate with CAM referral or prescription patterns. Health care professionals of all disciplines wanted more information about CAM. Conclusions. Heterogeneity in the CAM definition and questionnaire items precluded summarizing health care professionals attitudes toward CAM. Providing CAM education to health care professionals may help to integrate CAM into mainstream medical care. Keywords: complementary and alternative medicine; health care professional; attitudes; perspectives; review From the Department of Medicine (MJS), and Department of Family Medicine (DS), McGill University, Montreal, Quebec, Canada; Department of Clinical Epidemiology and Community Studies (MJS, MC, NR), and Department of Family Medicine (DS), St. Mary s Hospital, Montreal, Quebec, Canada. Address correspondence to: Maida J. Sewitch, PhD, Department of Clinical Epidemiology and Community Studies, St. Mary s Hospital Centre, 3830 Lacombe Avenue, Montreal, Quebec, Canada H3T 1M5; maida.sewitch@mcgill.ca. 139

2 140 Complementary Health Practice Review INTRODUCTION Attitudes of health care professionals toward complementary and alternative medicine (CAM) are important, in part, because CAM use among the general population in North America is widespread. In 1999, it was reported that 73% of Canadians had used at least one alternative therapy at some point in their lives and had spent US$3.8 billion on out-of-pocket costs for visits to CAM providers and treatments (Ramsay, Walker, & Alexander, 1999). Use of CAM in the United States also appears to be common: In 2003, 35% of the adult population was estimated to have used CAM in the preceding 12 months (Tindle, Davis, Phillips, & Eisenberg, 2005). CAM can be defined as a group of diverse medical and health systems, practices, and products that are not presently considered part of conventional medicine (National Center for Complementary and Alternative Medicine, 2007). Its widespread use among patients has raised concerns about safety and efficacy because of the potential for drug interactions and the unknown risks of unproven practices. Patients commonly use CAM products without their physicians knowledge and also frequent unregulated CAM providers (Boon, Verhoef, Vanderheyden, & Westlake, 2006). The growth in CAM use has created interest in CAM from conventional practitioners. In 1999, 13 of Canada s 16 medical schools offered some form of education on CAM in their undergraduate medical curricula, and the remaining 3 schools intended to offer such education in the future (Ruedy, Kaufman, & MacLeod, 1999). Practicing physicians also seem to be increasingly interested in CAM. In 2002 and 2004, 60% and 81%, respectively, of physicians in the United States expressed interest in learning more about CAM (Milden & Stokols, 2004; Winslow & Shapiro, 2002). Recognizing its potential impact on patient care, health care professionals attitudes toward patients use of CAM have been evaluated. However, the reviews conducted show variability in results. In 1 meta-analysis of physician attitudes (Ernst, Resch, & White, 1995), CAM was perceived as only moderately useful and/or effective. A 1998 review of physicians attitudes (Astin, Marie, Pelletier, Hansen, & Haskell, 1998) noted that CAM referrals were influenced by the patient s lack of response to conventional therapy and/or preference for CAM therapies, as well as by the physician s personal belief in the efficacy of a particular CAM modality. Acupuncture was most frequently recommended, followed by chiropractic and massage, with approximately half of the physicians surveyed believing in the efficacy of these modalities (Astin et al., 1998). In an international review, both nurses and physicians were found to hold positive attitudes toward natural therapies (Leach, 2004). A 2005 review of pharmacists attitudes toward dietary supplements (Kwan, Hirschkorn, & Boon, 2006) found that pharmacists were generally unaware of patients use of supplements, possibly because of time constraints and/or a lack of professional practice standards. We undertook a systematic review of the literature on health care professionals attitudes toward CAM to overcome some of the limitations of previous reviews. First, several were limited in scope and focused on the attitudes of specific practitioners such as physicians (Astin et al., 1998; Ernst et al., 1995) or pharmacists (Kwan et al., 2006).

3 Sewitch et al. / A Review of Health Care Professional Attitudes Toward CAM 141 Second, 1 review (Leach, 2004) failed to define natural therapies, using the term interchangeably with alternative therapies and failing to provide a clear reference. Finally, 2 reviews were published approximately 10 years ago (Astin et al., 1998; Ernst et al., 1995) and the relevance of the findings may not be contemporary. Thus, the aim of this literature review was to summarize the results of North American surveys of various categories of health care professionals attitudes toward CAM. Attitudes were defined as beliefs regarding CAM efficacy and/or legitimacy, personal use, clinical practice use and referrals, communication with patients about CAM, level of knowledge, and the need for information regarding CAM therapies. We restricted the review to studies from Canada and the United States because the attitudes of health care professionals in these locales may differ from those in other areas in the world, given cultural, economic, clinical practice, and training differences. Data Sources A systematic literature search on health professionals attitudes toward CAM was undertaken in October The databases searched were Allied and Complementary Medicine Database (AMED; ), Excerpta Medica Database (EMBASE; ), and MEDLINE ( ). Searches were restricted to peer-reviewed studies conducted in Canada or the United States and published in English or French. Study Selection The search words for CAM-reflected categories used by the National Institutes of Health National Center for Complementary and Alternative Medicine (NCCAM): Alternative medicine systems (e.g., homeopathic medicine, naturopathic medicine, Chinese traditional medicine, Ayurveda), mind body interventions (e.g., cognitivebehavioral therapy and support groups), manipulative/body-based methods (e.g., chiropractic or osteopathic medicine, massage), biologically based medicine (e.g., natural health products including megadose vitamins, minerals, herbs), and energy therapies (e.g., Qigong, Reiki, therapeutic touch, electromagnetic fields). A second search strategy combined the key word attitudes with the first search, yielding 564 articles. After abstract reviewing, we excluded articles concerning exclusively patients, CAM practitioners, medical/nursing students, and pharmacologists. We designed a form for data extraction that included the following information: Name of the article, name of the first author and the date of publication, type of health professional, CAM definition, description of survey questionnaire, modes of answering the questionnaire, and results. RESULTS After title and abstract reviewing, we selected 21 articles pertaining to health care professionals attitudes toward CAM. Of the 21 studies, 4 studies were conducted in

4 142 Complementary Health Practice Review Canada and 17 were conducted in the United States. Table 1 summarizes the 21 studies included in this review. Health care professionals surveyed included physicians (16 studies), nurses (3 studies), public health professionals (1 study), dietitians (1 study), social workers (2 studies), medical/nursing school faculty (3 studies), and pharmacists (1 study). Response rates for physicians ranged from 10.6% (Berman et al., 1997) to 87.1% (Ko & Berbrayer, 2000) and for nurses from 46% (Hann et al., 2003) to 88% (Montbriand, 2000). The response rates for the remaining health professional categories ranged from 53% for dietitians (Cashman et al., 2003) to 89% for pharmacists (Montbriand, 2000). The modalities included in CAM definitions varied greatly. Among the articles reviewed, 1 study surveyed physician attitudes toward homeopathy (Berman et al., 1997), 2 focused on herbal therapies (Cashman et al., 2003; Dougherty et al., 1999), and 12 included a variety of modalities from the list produced by NCCAM. These included: Acupuncture/acupressure, aromatherapy, biofeedback, chiropractic, herbs, vitamins, minerals, homeopathy, hypnosis, imagery, diet, massage, osteopathic manipulation, reflexology, prayer, healing, yoga, meditation, and self-help groups (Boutin et al., 2000; Burke et al., 2005; Flannery et al., 2006; Goldszmidt et al., 1995; Jump et al., 1998; Ko & Berbrayer, 2000; Kurtz et al., 2003; Rose et al., 1998; Sikand & Laken, 1998; Verhoef & Sutherland, 1995; Winslow & Shapiro, 2002; Wynia et al., 1999). Six studies did not specify the modalities included in their definition of CAM (Brems et al., 2006; Hann et al., 2003; Kreitzer et al., 2002; Levine et al., 2003; Montbriand, 2000; Richardson, Mâsse, Nanny, & Sanders, 2004). In the articles reviewed, physicians were more negative toward CAM than nurses and other health care professionals (Levine et al., 2003; Montbriand, 2000). Older, more experienced (Jump et al., 1998; Ko & Berbrayer, 2000; Kurtz et al., 2003), male physicians (Goldszmidt et al., 1995; Kurtz et al., 2003; Winslow & Shapiro, 2002) were less likely to recommend CAM therapies to their patients compared to younger, less experienced, female physicians. Older physicians were also less likely to use CAM for themselves and their families compared to younger physicians (Kurtz et al., 2003). Six studies focused on CAM attitudes and behaviors of primary care physicians or general practitioners (Berman, et al., 1997; Flannery et al., 2006; Goldszmidt et al., 1995; Kurtz et al., 2003; Rose et al., 1998). The proportion of primary care physicians referring patients to CAM therapies ranged from 14.1% (Rose et al., 1998) to 80% (Flannery et al., 2006). In the survey of internal medicine and family medicine physicians (Rose et al., 1998), as many as 89% said that they would consider recommending CAM to their patients, but only 14.1% actually made referrals or incorporated CAM into their practices. The same discrepancy between attitudes and behaviors was described by Jump et al. (1998). In their survey of physicians of several specialties, no significant differences were found in CAM referrals or prescribing patterns among recently trained physicians, who were more optimistic about CAM therapies compared to their more experienced colleagues. Yet rural providers, psychiatrists, psychologists, mental health counselors, and social workers suggested CAM to their patients more often than urban general practitioners and nurses (Brems et al., 2006).

5 Table 1 Studies Documenting Attitudes Toward CAM of Health Care Professionals in Canada and the United States Author (Year) HCP N CAM Definition Methods RR (%) Findings a Berman, Hartnoll, Singh, and Singh (1997) Boutin, Buchwald, Robinson, and Collier (2000) Brems, Johnson, Warner, and Weiss Roberts (2006) Primary care physician Family/general medicine (29.5%) Internal medicine (32.6%) Pediatric (37.9%) Physicians Medical (73%) Surgical (25%) General practitioners (9.8%) Psychiatrists (6.4%) Physician assistants (14.9%) Nurse practitioners (16.1%) Registered nurses (14.2%) Psychologists (10.5%) Social workers (13.5%) Mental health counselors (14.5%) 783 Homeopathy Mailed questionnaire þ 2 additional mailings þ closure card Knowledge ¼ training in homeopathy Attitudes ¼ the extent to which physicians consider homeopathy as a legitimate medical practice Use ¼ actual use and would use in practice Referrals ¼ referral of patients for homeopathic treatment 250 NIH therapeutic categories: Mind body interventions Bioelectromagnetics applications Alternative systems of medical practice Manual healing methods Herbal medicine Diet and nutrition Anonymous self-administered survey Questions (Yes/No): Use of CAM by their patients Provided CAM Recommended CAM Support availability of CAM in the hospital Level of concern over incorporating CAM in their care: 0 ¼ no concern to 6 ¼ very serious concern 1555 NS Mailed survey, US$50 compensation for returning the survey: A 21-page survey b (project funded by the National institute of Drug Abuse) Three questions about CAM (11-point rating scale, from 0 ¼ not at all/never to 10 ¼ very much/ always): 1. How often was clients/patients desire to use nonstandard or alternative treatment approaches a barrier to your providing optimal care? 2. How often did your clients/patients ask you about complementary or alternative treatment? 3. How often did you suggest alternative or complementary approaches to care to help overcome barriers in providing care? Efficacy/legitimacy: Only 17% of physicians thought that homeopathy is a legitimate medical practice; 38% were unsure; 22.7% of family physicians and 14.9% of internists saw homeopathy as a legitimate practice ( p <.05); 39.4% of DOs and 16.5% of MDs saw homeopathy as a legitimate practice ( p <.05). Clinical practice use: 6% used homeopathy in their practice, 28% would consider using it, and 66.2% would not use it. Family physicians were more likely to use homeopathy than internists and DOs more likely to use homeopathy than MDs Referrals: 13.8% of physicians made referrals for homeopathy. Training: 15.8% of physicians have training in homeopathy 34 Efficacy/legitimacy: Most of the physicians had moderate concern about integrating CAM in their care Communication: 86% indicated that their patients used CAM (similar with the 85% of patients reporting using CAM) Training: Most of the physicians indicated that they are not adequately informed about CAM 43 Communication: Overall, providers: Suggested CAM more often than their clients/patients requested Suggested CAM more often than they perceived requests as a barrier Perceived requests as a barrier less often than they received requests for such treatments from their clients Referrals: Behavioral health care providers suggested CAM more often than physical health care providers Clinical practice use: Small rural providers offered CAM most commonly and urban providers least often Female providers offered CAM more often than male providers

6 Table 1. (continued) Author (Year) HCP N CAM Definition Methods Burke, Ginzburg, Collie, Trachtenberg, and Muhammad (2005) PHP (MPH degree) Other (46% MPH degree, 16% others CAM degree) 153 Massage, meditation, yoga, relaxation, herbal remedies, prayer, acupuncture, spiritual practices, chiropractic, aromatherapy, energy work, acupressure, visualization, homeopathy, hypnosis, biofeedback, Ayurveda, tai chi/ Qigong, osteopathy, and others Anonymous self-administered survey: A 19-item survey c offered at the 2003 APHA annual meeting personal use of CAM (all sample); professional use of CAM (PHP sample ¼ 92) Cashman, Burns, Otieno, and Fung (2003) Dietitians 158 Herbal supplements Mailed questionnaire þ advance notice postcards Sections: Herbal knowledge Health philosophy Personal use Recommendations to clients/patients Sources of herb knowledge Attitude/opinions Dougherty, Touger- Decker, and O Sullivan Maillet (1999) Full-time faculty of the medicine and dentistry university 451 Herbal therapies Mailed questionnaire: Personal beliefs and practices, Professional practices regarding herbal therapies Flannery, Love, Pearce, Luan, and Elder (2006) Primary care physicians 65 Massage, yoga, herbal/botanical remedies, spiritual healing (by others), acupuncture, chiropractic, aromatherapy, homeopathy, hypnosis, biofeedback, folk remedies, megavitamin therapy, reflexology, relaxation techniques, special diets Mailed survey þ 3 reminders (by /fax, second mailing, telephone message): A 4-page survey d (patients asked about CAM, patients reported CAM use, clinicians used CAM for their own care, and clinicians recommended CAM to patients) RR (%) Findings a 34 Personal use: 97% reported personal use of CAM; the most frequently used modalities were massage, meditation, yoga, and relaxation Clinical practice use: Used/endorsed CAM with clients 34% often/very often; 35% sometimes, 31% rarely/never Integration of CAM into the work setting: 52% through education, 36% making referrals to CAM resources, and 32% direct demonstrations The most frequently reported CAM modalities used: Herbal preparations, massage, yoga, relaxation, meditation, and acupuncture Significant relationship between the amount of CAM resources used personally and the tendency to use CAM in work settings 53 Personal use: 37% used herbal supplements for the past year Clinical practice use: 23% recommended to clients herbal supplements for the past year Communication: 35% reported that their clients inquire often/very often about herbal supplements Need for information: 89% believed that education on herbal supplements should be incorporated into the route of dietetic registration 51.2 Personal use: 29.6% personally used herbal medicine. Among them, the main reasons for use were for disease prevention, improved feeling of well-being, symptom relief, immune system benefits, increased energy, and disease treatment Clinical practice use: Among the 190 respondents involved in patient care, 22.1% recommend herbal medicine to their patients 64 Personal use: 49% (95% CI: 37% 61%) reported personal use of CAM in the past year Clinical practice use: 80% (95% CI: 70% 90%) recommended CAM to at least one of their patients Communication: 86% (95% CI: 78% 94%) reported that at least 1 patient asked about CAM and 94% (95% CI: 88% 100%) reported that at least 1 patient reported CAM use in the past year

7 Goldszmidt, Levitt, Duarte- Franco, and Kaczorowski (1995) Hann, Baker, and Denniston (2003) Jump, Yarbrough, Kilpatrick, and Cable (1998) General practitioners 121 Acupuncture, chiropractic, hypnosis, and others Oncology health professionals: Physicians Nurses Social workers Therapies used in conjunction with or as an adjunct to conventional therapies Primary care: Family medicine Internal medicine General pediatrics Specialty care: All other specialties 138 Massage, relaxation techniques, herbal remedies, prayer, acupuncture, spiritual healing, chiropractic, energy healing, homeopathy, hypnosis, biofeedback, imagery, lifestyle diets, self-help groups, folk remedies, and lifestyle exercises Mailed questionnaire e Referral practices Opinion on usefulness Knowledge Past training and desire for more training Mailed survey f þ 1 reminder (letter) Professional-initiated discussion of CAM Comfort level discussing CAM Perceived impact of discussing CAM on the patient professional relationship The percentage of patients who use CAM Referral to other sources of information about CAM; indicate the source Which health professional cancer patients most often discuss their use of CAM Availability of CAM in the office/clinic Questionnaire distributed to the physicians in the hospital: Opinions about the legitimacy of alternative therapies as medical treatments, patterns of prescribing alternative therapies for their patients, levels of personal use, and training in alternative medicine 73 Efficacy/legitimacy: 83% believed that at least 1 of the 3 CAM practices has some degree of usefulness; female GPs were more likely than male GPs to perceive the 3 CAM practices as useful. Referrals: 59% referred patients to MDs who practice CAM and 68% to nonmedical practitioners; GPs born outside Canada were less likely to refer patients to a chiropractor; GPs graduates of McGill University were more likely to refer patients to nonmedical practitioners of hypnosis Training: Self-reported knowledge of the 3 CAM practices was poor; knowledge increased with age, and GPs trained at French universities reported lower scores than those trained elsewhere 20% reported prior training in at least 1 of the 3 CAM practices Need for information: 48% indicated that they wanted training in at least 1 CAM practice Communication: Only 21% of physicians, 22% of nurses, and 37% of social workers initiated discussion of CAM often and very often; 63% of physicians, 44% of nurses, and 68% of social workers felt comfortable and very comfortable discussing CAM; 55% of physicians, 77% of nurses, and 35% of social workers thought that patients most often discuss CAM with nurses; women were significantly more likely than men to initiate discussion about CAM and to report that discussions of CAM enhance the patient professional relationship; 55% of health professionals in a university hospital or cancer center, compared to 74% in a nonuniversity hospital or cancer center, and 68% of those in other work settings felt that always or sometimes discussions of CAM enhance patient professional relationship 38 Efficacy/legitimacy: More than 50% of physicians viewed prayer, lifestyle exercise, self-help groups, and relaxation techniques as legitimate medical practice. More than 45% viewed massage, lifestyle diets, and biofeedback as legitimate medical practice. A significantly greater acceptance of CAM therapies was noted among physicians in practice for less than 10 years. Personal use: 34.8% of physicians tried themselves at least 1 alternative therapy. Clinical practice use: 65% of the physicians used at least 1 CAM therapy in their practice

8 Table 1. (continued) Author (Year) HCP N CAM Definition Methods Ko and Berbrayer (2000) Kreitzer, Mitten, Harris, and Shandeling (2002) Psychiatrists 101 Acupuncture, biofeedback, chelation, chiropractic, craniosacral therapy, faith healing, herbology, homeopathy, hypnosis, naturopathy, neural therapy, osteopathy, prolotherapy, and reflexology Medical, nursing, and pharmacy Faculty Medical, nursing, and pharmacy Students Mailed surveys þ second mailing þ donation made on behalf of the respondent to a recognized charity or research foundation Attitudes toward alternative medicine Perceived knowledge and usefulness of 14 CAM therapies Whether each therapy should be made available in the local hospital, be taught in medical school, and be covered by private or provincial insurance plans Clinical approach to CAM: Referral rate, training, and practice NS Self-report survey Overall attitudes toward CAM Attitudes and information about training Personal use Perceived barriers Intent to integrate CAM into clinical practice Kurtz, Nolan, and Rittinger (2003) Primary care physicians 423 Massage, relaxation techniques, herbal remedies, prayer, acupuncture, chiropractic, magnetic healing, homeopathy, hypnosis, biofeedback, imagery, lifestyle diets, self-help groups, folk remedies, chelation therapy, aromatherapy, high-dose antioxidants, mineral therapy, vitamin therapy, touch therapy Mailed questionnaire g Used any CAM modalities with their patients Referred their patients to CAM practitioners Had personal or family use of CAM Formal training in CAM Their patients discussed the use of CAM with their physicians Physicians attitudes toward 20 CAM modalities RR (%) Findings a 87.1 Efficacy/legitimacy 38.8% believed that CAM worked by placebo effect 9.2% believed that CAM is a threat to public health Personal use 19.8% practiced some form of CAM Referrals 71.9% referred their patients to CAM practitioners Younger and more recently graduated psychiatrists were more likely to refer patients to CAM practitioners ( p ¼.02 and p ¼.008, respectively). Training 20% had some previous training in some form of CAM 55 Efficacy/legitimacy: More than 90% of the faculty in medicine, nursing, and pharmacy said that clinical care should integrate best of conventional and CAM practices. Nursing faculty reported the most positive attitude toward CAM. More pharmacy students than nursing and medical students said that CAM treatments have no true effect and CAM is a treat to public health. Faculty and students viewed lack of evidence as the most significant barrier to use CAM 38.4 Personal use: Physicians aged 35 years and younger were 5 times as likely as those aged 60þ to use CAM for themselves ( p ¼.010) and 6 times as likely to use CAM for their families ( p ¼.009) Referrals: Female physicians were 2.7 times as likely as male physicians to refer patients to CAM ( p ¼.007) Communication: Female physicians were 4.4 times as likely as male physicians to talk to their patients about CAM ( p ¼.022)

9 Levine, Weber- Levine, and Mayberry (2003) Milden and Stockols (2004) Montbriand (2000) Primary care medical school faculty Licensed California physicians (all specialties, undifferentiated) Physicians Pharmacists Nurses 143 Any substance, activity, or practice not usually taught in detail or recommended to medical students (list of 30 CAM therapies) modalities falling into the 5 NCCAM categories (alternative medical systems, mind body interventions, biologically based treatments, manipulative and body-based methods, and energy therapies) 153 Chiropractors and alternative therapies in general Mailed questionnaire h þ 2 additional mailings þ 3 telephone calls Questions about CAM: Legitimate medical practice Training Personal experience with General attitude Placebo effects Use Mailed questionnaire with letter of introduction, consent letter, survey, self-addressed stamped return envelope. A 6-page survey Beliefs/attitudes ¼ extent to which physicians consider the modality legitimate/effective Knowledge ¼ of specific modalities Behavior ¼ advice/prescribing for patients Technology ¼ extent to which computer and so on are used to gather CAM information CAM education ¼ courses, CME, other education Face-to-face,computer-assisted interviews; validity and reliability checked; Likert attitude scale (from 1 ¼ positive to 5 ¼ negative) 72 Personal use: 83% reported personal experience with at least 1 CAM therapy. The MD and PhD respondents reported personal experience with significantly fewer therapies; 87% of the personal experiences were rated as effective. Efficacy/legitimacy: More than 70% considered nutrition and diet, counseling and psychotherapy, fitness and exercise, emotional support groups, and biofeedback as legitimate medical practices. More than 50% considered acupuncture, herbal medicine, massage therapy, chiropractic, hypnotherapy, and meditation as legitimate medical practices. Less than 25% considered colon therapy, naturopathy, bioelectromagnetics, tai chi, ayurvedic medicine, aromatherapy, and Reiki as legitimate medical practices. The general attitude toward CAM was positive, MDs being the least favorable. Respondents disagreed with statements attributing the effectiveness of CAM therapies to placebo only; 27% of PhDs and 4% of MDs strongly agreed with the statement that patients with untreatable conditions be encouraged to seek CAM therapies Training: 85% reported at least some training in one or more CAM therapies Need for information: 62% wanted training in at least one of the listed CAM therapies 26 Beliefs/attitudes: Positive beliefs concerning CAM were better than midrange; 80% would prefer to rely solely on biomedical treatments Knowledge: 61% do not feel sufficiently knowledgeable about CAM safety/efficacy Behavior: Intention to use CAM in own practice in future was lower than midrange; 76% asked patients about their CAM use Technology: 42% willing to use online databases to find CAM information Education: 81% want more CAM education Efficacy/legitimacy: Physicians were significantly more negative toward CAM than other professionals; 69% of professionals wanted regulations for CAM therapies Communication: Professionals estimates of percentage of patients who use CAM: 30% physicians, 28% nurses, 29% pharmacists; the patients survey revealed that 71% of patients used CAM

10 Table 1. (continued) Author (Year) HCP N CAM Definition Methods Rose, O Toole, Skeist, Pfeiffer, and Carlsen (1998) Sikand and Laken (1998) Primary care physicians Internal medicine Family medicine CAM therapies, excluding Ayurveda, Native American healing, traditional Chinese medicine, and homeopathy Pediatricians 348 Acupuncture/acupressure, biofeedback, chiropractic manipulation, herbs, high-dose antioxidant vitamins/minerals, homeopathy, hypnosis, imagery, lifestyle diet, massage therapy, osteopathic manipulation, prayer healing, relaxation (yoga, meditation), self-help groups Mailed questionnaire Own or family use of CAM Estimate the percentage of their young old (60 74) and old (75þ) patients who use CAM The reasons their patients use CAM Knowledge about CAM Comfort in communicating with their patients about CAM Referrals to CAM practitioners Integration of CAM in their practice Mailed questionnaire i þ second mailing Pediatricians perceptions of their patients use of CAM Patients/parents of their patients discussed use of CAM Personal and family use of CAM Referral practices Formal training in CAM Whether they practiced any CAM therapies Attitudes regarding the safety/harmfulness and the effectiveness of 14 CAM therapies Verhoef and Sutherland (1995) General practitioners Alberta Ontario 200 Chiropractic, herbal medicine, naturopathy, homeopathy, osteopathy, faith healing, hypnosis, reflexology, and acupuncture Mailed questionnaire i þ 2 reminders Involvement in alternative medicine Perceived demand for alternative therapies The estimated percentage of patients who saw an alternative practitioner the previous year The most popular alternative medicine practice The type of condition alternative medicine is needed Belief in the efficacy of alternative medicine RR (%) Findings a 60 Clinical practice use: 14.1% of physicians incorporate CAM in their practice. Referrals: 14.1% make referrals to CAM practices Communication: 21.9% were comfortable communicating with their patients about CAM and 86% to 89% of physicians would consider suggesting CAM for anxiety, pain, insomnia and depression Need for information: 48% of physicians wanted to know more about CAM 40.5 Efficacy/legitimacy: The CAM therapies viewed as the most effective were: Relaxation, self-help groups, acupuncture/acupressure, biofeedback, and massage therapy Personal use: 55.2% would consider using CAM for them or their family and 37% used CAM personally Communication: 88.5% believe some of their patients are using CAM; 53.5% talk with their patients/patients parents about CAM; and 84.7% reported that the discussion is initiated by the patients Referrals: 50.3% would refer their patients to CAM practitioners Need for information: 54.1% were interested in learning about CAM therapies Efficacy/legitimacy: 91% thought that chiropractic was the most popular alternative approach. The conditions for which alternative therapies were perceived as needed were musculoskeletal problems and chronic pain or illness Communication: Two thirds of physicians perceived a demand from their patients for alternative therapies. Need for information: 73% indicated that they believed a GP should have some knowledge about the most important alternative therapies

11 Winslow and Shapiro (2002) Wynia, Eisenberg, and Wilson (1999) Physicians (all specialties) 276 Massage, relaxation techniques, herbal remedies, acupuncture, spiritual healing, chiropractic, energy healing, homeopathy, hypnosis, biofeedback, special diets, folk remedies, yoga, aromatherapy, reflexology, megavitamin therapy Physicians caring for HIV-infected patients 89 Massage, relaxation techniques (yoga, meditation), herbal remedies, acupuncture, highdose vitamins, homeopathy Mailed survey þ 2 additional mailings þ telephone call Had patients ask about or use CAM the previous year Recommended CAM treatment to patients Used CAM themselves Were educated about CAM therapies Their belief about effectiveness of CAM therapies Positive or negative attitude when discussing CAM with patients Comfortable discussing CAM with patients Asking their patients routinely about the use of CAM Interest in learning more about CAM Mailed survey þ 2 additional mailings þ a postcard reminder þ telephone reminder How often they discussed CAM with their patients How often they would recommend CAM to their patients How helpful they think CAM therapies are 40 Efficacy/legitimacy: 40% of physicians had a neutral attitude toward CAM use, 35% somewhat positive, and 9% very positive Communication: Chiropractic, herbal therapy, and massage therapy were the most used and asked about by patients; primary care physicians reported more use of CAM by their patients and more inquires about CAM than specialists; 8% of physicians always ask their patients about CAM use, 52% of physicians ask less than half the time and 17% never ask; 30% of physicians were somewhat uncomfortable and very uncomfortable talking to their patients about CAM; and female physicians were more likely to recommend CAM modalities than male physicians 68 Efficacy/legitimacy: 63% reported that CAM therapies were often/usually helpful for their patients Clinical practice use: 51% would usually/always recommend a CAM therapy to a patient interested in pursuing CAM therapy, 38% for a patient with symptoms not relieved by conventional medicine, and 65% to a patient with a specific condition for which a CAM therapy may be useful NOTES: APHA ¼ American Public Health Association; CAM ¼ complementary and alternative medicine; CI ¼ confidence interval; CME ¼ continuing medical education; DOs ¼ doctors in osteopathy; GPs ¼ general practitioners; HCP ¼ health care provider; HIV ¼ human immunodeficiency virus; MDs ¼ medical doctors; NCCAM ¼ National Center for Complementary and Alternative Medicine; NIH ¼ National Institutes of Health; NS ¼ nonsignificant; PHP ¼ public health professional; MPH ¼ Master of Public Health; RR ¼ relative risk. a Aspects of HCP attitudes toward CAM: Efficacy/legitimacy ¼ the perceived efficacy or legitimacy of specified CAM therapies. Personal use ¼ use of CAM therapies by HCP for themselves and their families. Clinical practice use ¼ use of CAM therapies by HCP in their practice. Referral ¼ HCP referred patients to CAM practitioners. Communication ¼ communication of HCP with their patients about CAM. Training ¼ reported training of HCP in CAM. Need for information ¼ HCP expressed the need for more information and/or training in CAM. b The survey was based on key informant interviews and focus groups and was pilot tested. c Similar items with the Alternative Health/CAM supplement to the 2002 Health Interview Survey. d Survey used in previous studies. e Survey used in a previous study. Questionnaire reviewed by psycho-oncology researchers, an expert in survey development and medical oncologists. g Modified version of a questionnaire used in a previous study. h Questionnaire used in previous studies. Pretested questionnaire. Pretested questionnaire, internal consistency of the 4-item scale for desired involvement was checked. f i j

12 150 Complementary Health Practice Review Two surveys examined medical conditions that primary care physicians would consider treating with CAM therapies. In the United States, the majority would consider prescribing CAM therapies for anxiety, pain, insomnia, and depression (Rose et al., 1998), whereas in Canada they would recommend CAM for musculoskeletal problems, chronic pain, and chronic illnesses in general (Verhoef & Sutherland, 1995). Most Canadian primary physicians viewed chiropractic as the most popular alternative practice (Verhoef & Sutherland, 1995), whereas Canadian psychiatrists indicated that acupuncture, biofeedback, and chiropractic were the most useful (Ko & Berbrayer, 2000). Interest in CAM among health care professionals is high. Up to 81% of primary care physicians wish to increase their knowledge about CAM modalities (Goldszmidt et al., 1995; Milden & Stokols, 2004). Moreover, medical and surgical physicians (Boutin et al., 2000), dietitians (Cashman et al., 2003), pediatricians (Sikand & Laken, 1998), and primary care medical school faculty (Levine et al., 2003) report they need more information about CAM modalities. Oncology health care professionals (e.g., physicians, nurses, and social workers) views on CAM therapies were the focus of 2 articles (Hann et al., 2003; Richardson et al., 2004). Approximately two thirds of those surveyed felt comfortable discussing CAM with their patients, although only 21% initiated the discussion, (Hann et al., 2003; Richardson et al., 2004), even though patient nondisclosure of CAM use is common. Attribution of the responsibility for nondisclosure is inconsistent: Physicians attribute nondisclosure to patient fear of being discouraged, while patients attribute nondisclosure to their own uncertainty of benefits and to the observation that their physicians rarely ask them about CAM use (Richardson et al., 2004). DISCUSSION Summarizing the attitudes of health care professionals toward CAM is difficult owing to the variability in the questionnaire items used. Four studies used questionnaires that were used in previous studies (Flannery et al., 2006; Goldszmidt et al., 1995; Kurtz et al., 2003; Levine et al., 2003), 1 study used items from a national survey (Burke et al., 2005), and 4 used questions developed with expert help (Brems et al., 2006; Hann et al., 2003; Sikand & Laken, 1998; Verhoef & Sutherland, 1995). In general, physicians were less positive toward CAM compared to other health care professionals. Moreover, even when they held positive attitudes, it was not reflected in CAM referral or prescription patterns. This may be because of the lack of consistent regulation concerning CAM therapies and practitioners in both Canada and the United States. Only 3 provinces in Canada, namely Alberta, Ontario, and British Columbia, have legislation that protects physicians from disciplinary actions resulting from recommending or practicing CAM therapies (Silversides, 2002), and with the exception of chiropractic, the modalities that are regulated differ widely between the provinces (Boon, 2002). Widespread licensure and credentialing of CAM practitioners

13 Sewitch et al. / A Review of Health Care Professional Attitudes Toward CAM 151 is likewise challenging given that these practices fall within the jurisdiction of the provinces in Canada and the states in the United States (Boon, 2002). Barriers and facilitators to recommending CAM were identified. The most significant barriers were the lack of evidence for effectiveness, potential side effects, and interactions with allopathic treatments (Kurtz et al., 2003). Despite this, the majority of health care professionals felt that clinical care should integrate the best conventional and CAM treatments. Including CAM practitioners in the evaluation of research protocols may facilitate the creation of a body of evidence for frequently used CAM practices and therapies (Cohen, Hrbek, Davis, Schachter, & Eisenberg, 2005). Younger and more recently trained physicians were more likely to recommend CAM compared to their older and more experienced colleagues. This may be because of the increased exposure of younger physicians to CAM in the past decade (Jump et al., 1998) or to the higher likelihood that younger physicians use CAM themselves (Kurtz et al., 2003). More positive attitudes among female health professionals may be explained by their lower average age or by the higher probability that they use CAM themselves (Kurtz et al., 2003). The difficulty in patient physician communication about CAM may be because of patients nondisclosure of CAM use and to physicians reluctance to ask about patient use of CAM therapies (Hann et al., 2003; Richardson et al., 2004). The difference between patient and physician views on CAM therapies is notable and deserves further attention. Several limitations of this literature review are acknowledged. First, it was difficult to summarize and compare attitudes of various health care professionals because of the variability in the topics assessed in the articles included in our review. Second, generalizability of the findings is limited because of the low response rates (<50%) that were reported in half of the studies reviewed. Thus, it is not possible to know whether the reported findings are representative of the underlying target populations; the health care professionals who were included may have been either very favorable or very unfavorable toward the use of CAM therapies in medical practice. CONCLUSION A vast literature exists on health professionals attitudes toward CAM therapies and the diversity of survey items and definitions make it challenging to summarize the findings. Not only could few comparisons be made across categories of health care professionals, but also the low response rates reported by most studies precludes generalizability of the findings. Despite the inconclusive findings, there is a growing interest in and a desire for more information about CAM by health care professionals of all disciplines and by physicians of varying specialties. Discrepancies were found between attitudes and clinical practice behaviors such that holding positive attitudes toward CAM was not reflected in physicians referral or prescription patterns. Given that the ultimate goal of health care is to improve patient health, increasing health care professionals knowledge of CAM therapies and their availability in the community may help to integrate CAM into mainstream medical care.

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16 154 Complementary Health Practice Review Maida J. Sewitch, PhD, is an epidemiologist and assistant professor in the Department of Medicine at McGill University. She is an associate member of the Department of Clinical Epidemiology and Community Studies at St. Mary s Hospital Center in Montreal, Canada where she leads the research program in Integrative Medicine. Monica Cepoiu, MD, from Carol Davila University holds an MSc in Epidemiology form McGill University and is presently a research associate in the Department of Community Health Studies, University of Calgary. Nicole Rigillo, MA, is pursuing her PhD in medical anthropology at McGill University. She presently holds the position of research coordinator at the Department of Clinical Epidemiology and Community Studies at St. Mary s Hospital Centre in Montreal, Quebec. Donald Sproule, MD, is a family physician who teaches at St. Mary s Hospital Centre in Montreal, Quebec.