Herbal Product Education in United States Pharmacy Schools: Core or Elective Program?

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1 Articles Herbal Product Education in United States Pharmacy Schools: Core or Elective Program? Elaine D. Mackowiak and Ami Parikh School of Pharmacy, Temple University, 3307 North Broad Street, Philadelph PA Joshua Freely Department of Sociology, College of Liberal Arts, Temple University, Philadelphia PA This study examined the extent of use and knowledge of herbal drugs by pharmacy students. This data was used to revise an existing core course in nonprescription drugs to include basic information about herbal products. A convenience sample of 370, culturally diverse students completed a print survey on the appropriate use of twelve popular herbal products. Pearson Chi-square analysis evaluated students' knowledge. The average score was only 32 percent Individual student scores were affected by ethnicity, work experience, family tradition, and sources of information. This data demonstrates the need for herbal instruction in core curricula of pharmacy colleges if students are expected to provide comprehensive pharmaceutical care in the area of self-care for their patients. Colleges of pharmacy should include formal instruction on herbal products in their curricula; the remaining question to be answered is whether it should be in the core or elective curricula. INTRODUCTION Complementary and alternative medicine (CAM) includes a wide variety of modalities, some of which are more relevant to pharmacy practice than others, such as herbs, megavitamins, and homeopathic products. Other CAM modalities include chiropractic, acupuncture, exercise, massage, biofeedback, aroma therapy, magnetic or energy healing, hypnosis, selfhelp, spiritual healing, lifestyle diets, and relaxation techniques. The use of complementary and alternative medicine (CAM) by the public in the United States increased from 33.8 to 42.1 percent from 1990 to 1997(1), and individual use of herbal products among CAM users was reported as ranging from 12.1 to 26 percent(1-3). Gaedeke et al. reported that 29 percent of a group of college students used herbal products(4). Sales of herbal products were estimated to be as high as $5.1 billion, and many of those sales occurred in community pharmacies(5). Paradoxically, while herbal product use increased, formal instruction in colleges of pharmacy decreased(6). The popularity of CAM has led to a renewed interest among pharmacy colleges and medical schools to include CAM instruction in the curriculum(7-8). However, as recently as 1997, 13 of 60 pharmacy schools responding to a questionnaire reported that herbal products were not discussed in any course(6). (Only 60 of the 77 U.S. pharmacy schools responded to the survey.) CAM instruction, including herbal products, was not available in 13 of 50 pharmacy schools responding to a survey in 1998(7). There was considerable variation in the number of contact hours for both herbal and other CAM instruction ranging from 1.5 to 67 hours per course among 36 out of 50 (72 percent) pharmacy schools(7). A survey of medical schools reported that 75 of 117 schools (64 percent) offered CAM course work(8). Contact hours ranged from two to 10 hours for required courses, and one to 160 hours for elective courses. There was also variation as to whether or not herbal and/or CAM instruction was in a required or elective course in both pharmacy and medical schools. Nursing educators have recommended that CAM therapy becomes a formalized component within the nursing curriculum(9,10). Seven of the 27 schools of veterinary medicine in the U.S. incorporate courses on complementary and alternative veterinary medicine in their programs(11). Pharmacists graduating in this environment of increasing use of CAM therapies should be prepared to answer consumer questions about them because they represent an increasing area of pharmacy sales. All pharmacists require basic knowledge of these products if they intend to offer comprehensive pharmaceutical care to their patients. The question remains as to whether instruction in CAM should be in core or elective courses, and the extent of instruction required. Pharmacy students represent a diverse population including different genders, ages, cultural backgrounds, and educational and work experiences. This study was designed to determine if these differences affected students' use and knowledge of herbal products prior to any formal instruction in a pharmacy school's curriculum. METHODS A written survey instrument was administered to a convenience sample of 370 pharmacy students in a large, eastern, urban, Am. J. Pharm. Educ., 65, 1-6(2001); received 9/30/00, accepted 12/6/00. American Journal of Pharmaceutical Education Vol. 65, Spring

2 Table I. Use and Knowledge of herbal products by Pharmacy students Percent Characteristic Sample Use Knowledge Score a Ethnicity: White (n=142) ±22.7 Black (n=68) ±18.7 Asian (n=136) ±19.5 Other (n=24) ±21.4 Total (n=370) Chi-square Biyariate analysis P= P< Gender: Male(n=151) ±25.1 Female (n=219) ±21.3 Chi-square Biyariate analysis P= P = 0.72 Age: yr(n=309) ± yr(n=56) ± yr(n=2) ±32.6 Refuse identity (n-3) ±32.0 Chisquare Biyariate analysis P =0.683 P=0.98 Work experience: Community (n=150) ±22.8 Hospital (n=75) ±22.0 Other pharmacy ±21.1 related (n= 15) Not working (n=129) ±21.0 Chisquare Biyariate analysis P= P = < a Percent correct responses of therapeutic use of common herbal products Culturally Diverse Pharmacy School (Temple University) Before The Students Were Scheduled To Take A Required Course In Over-The-Counter Products Which Discusses Popular Herbal Products. The Survey Was Pre-Tested By Students Enrolled In An Elective Course. The Survey Included Multiple Choice Objective Questions About The Therapeutic Use Of 12 Popular Herbal Drugs, Ginkgo Biloba, St. John's Wort, Garlic, Echinacea, Ginseng, Saw Palmetto, Valerian, Feverfew, Cranberry Extract, Kava-Kava, Hawthorn Extract, And Ephedra. The Choice Of Herbs For Inclusion In The Survey Was Based On Published Lists Of Popular Use And Sales Volume(12,13). The Last Choice For Each Question Was, Don't Know, To Eliminate Guessing. Students' Knowledge Was Calculated As The Percent Correct Of The Multiple Choice Questions. In addition to demographic questions, the survey also asked students about their personal use of herbal products and their sources of information. The results were analyzed using SPSS (Statistical Package for Social Sciences). Pearson chisquare anaylsis was used to evaluate students' use and knowledge of herbal products. Bivariate analysis (Comparison of Means) revealed that ethnicity, work experience, and personal experience were statistically significant factors (P < 0.05) affecting knowledge scores. The large difference in knowledge scores based on ethnicity, working experience, and sources of information were used to design the models for regression Table II. Percent knowledge scores based on employment site a Site Community Hospital Other b Not working White n=76 n=20 n=4 n=42 Black n=20 n=10 n=5 n=33 Asian n=42 n=39 n=6 n=49 Other n=12 n=6 n=l n=5 a Bivariate anaylsis P < (Students could list more than one work site.) b Other pharmacy sites include nursing homes, long term care facilities, industry. c Other includes four Hispanic students and 20 students refusing ethnic identification. equations. The regression models were determined a priori. Multiple linear regression analysis determined the influence that each of these factors had on the knowledge score. RESULTS The sample was composed of 219 (59.2 percent) women and 151 (40.8 percent) men. Students identified themselves as white (n = 142, 38.4 percent), black (n = 68, 18.4 percent), Asian (n = 136, 36.8 percent), and Hispanic (n = 4, 1.1 percent). Twenty students (5.4 percent) students did not indicate any ethnic group. The latter two groups were combined and classified as other for all subsequent analyses. Students were primarily of typical college age, between the ages 18 to 30 (84.3 percent, n = 309); 15.1 percent (n = 56) were between 31 to 50, and 0.5 percent (n = 2) were between 51 to 65; three students did not indicate their ages. The majority of the students, 40.5 percent (150) worked in community pharmacy settings; 20.3 percent (75) worked in hospitals, 3.1 percent (15) worked in other pharmacy settings such as long term care facilities, nursing homes, or pharmaceutical industry, and 34.9 percent (129) did not work in any pharmacy related setting. Most students learned about herbal products from the lay press (39.1 percent), personal research (13.6 percent), family tradition (11.7 percent), employer training (3.5 percent), friends or co-workers (3.3 percent), special classes (1.2 percent), product labels (0.5 percent), or some other means (14.1 percent). The survey form allowed students to choose more than one source of information if applicable. There was no statistically significant difference in personal use of herbal products based on ethnicity (culture), gender, age, or working experiences, nor was there any difference in knowledge scores based on gender or age (Table I). Bivariate analyses revealed that ethnicity, working experience, and sources of information, which included personal experience, had a statistically significant effect (P < 0.05) on knowledge scores of herbal products. The mean score for white students was 43.5 percent correct; Asian students scored 24.6 percent, and black students scored 24.6 percent. Students classified as other, 6 percent of the sample, scored 39.2 percent. All students who worked in a pharmacy practice area scored higher than those with no pharmacy related experience. Students working in community settings had higher scores than those working in hospitals or other pharmacy settings. Table II 2 American Journal of Pharmaceutical Education Vol. 65, Spring 2001

3 Table III. Percent knowledge scores based on sources of information a Source of information Lay Personal Family Friends/ press research tradition co-workers Employee White 47.1% 57.4% 28.7% 38.5% 30.1% n=62 n=28 n=11 n=3 n=5 Black 26.7% 53.8% 18.5% 28.2% 0.0 Asian n=30 n=3 n=5 n=3 38.3% 25.0% 19.8% 0.8% 25.0 n=41 n=12 n=26 n=6 n=8 Other n=7 n=5 a Bivariate analysis P< (Students could list more than 1 source of information.) b Other includes 4 Hispanic students and 20 students refusing ethnic identification. n number of respondents. Table IV. Unstandardized regression coefficients of students' knowledge of herbal products on various independent variables a Ethnicity Model 1 Model 2 Model 3 Black (-0.386)*** (-0.217)*** (-0.171)*** Asian (-0.363)*** (-0.321)*** (-0.253)*** % answered Don't Know (-0.551)*** (-0.495)*** Information Sources Lay press (0.335)*** Personal research (0.244)*** Friends (0.128)*** Family tradition (0.081)* Employed (0.135)*** Constant R *P < 0.05; **P < 0.01; ***P < Standardized coefficients in parentheses. and Table III show the differences in the mean knowledge scores among the various ethnic groups based on work experiences and sources on information, respectively. There was also a statistically significant difference in knowledge scores among the students who chose the response of don't know based on ethnicity. Multiple linear regression coefficients were determined for three different models to examine the effects of these variables on the knowledge score (Table IV) for three groups of students, white, black and Asian. The category of other was omitted in the regression analyses because of the small number of students. Students identified as white scored 21.5 points higher than blacks and 18 points higher than Asians. Model 1 shows that these two variables only account for 18 percent of the variance in the herbal test scores. As might be expected, this variable is negatively correlated with the percent correct score, but the correlation is not extraordinarily strong (-0.606), indicating that some students who wouldn't guess scored lower and other students guessed and answered incorrectly. Black students were more likely to answer don't know as a response in the herbal test than the other groups. Model 2 Table V. Comparison of ethnicity and gender of students between AACP data and study data Percent AACP enrollment Study enrollment 1998 a b Gender: Male Female Ethnicity: White Black Asian Hispanic Foreign 2.4 na a U.S. citizens. b U.S. na = not appliable introduces this variable which significantly reduces the effect of ethnicity on the test scores. The strength of main effect is reduced from a score that is 21.5 points lower to a score that's 12 points lower. Its relative strength (as indicated by the beta weight in Table IV) is significantly reduced as well. The introduction of the don't know variable slightly reduces the effect of Asian ethnicity, and is itself the strongest predictor of knowledge with a beta weight of Model 3 incorporates the sources of information used by students as a variable. All were significant predictors of students' knowledge scores (Table IV). Students who read about herbal products in the lay press, who did personal research, or who received training at work scored between 16.5 and 17 points higher on the test. (These categories were not mutually exclusive and students could have indicated all three sources.) Students whose families had traditions of using herbal products scored about five points higher on the knowledge test. While these four variables greatly reduced the effects of ethnicity, they failed to completely eliminate them. Black and Asian students still scored 11 and 12 points lower respectively in the knowledge test. Beta weights for the source of information variables indicate that they are significantly weaker predictors of test scores, but their effects still remain. This model accounts for 57 percent of the variance in students' knowledge of herbal products. The survey did not distinguish the country of origin for any of the students, thus limiting the ability to cite specific cul American Journal of Pharmaceutical Education Vol. 65, Spring

4 tural differences. The survey did not have any ability to determine the level of students' proficiency in the English language, which could have had an effect on choice of work sites and sources of information. DISCUSSION Pharmacy students at a large, urban, multicultural, eastern university (Temple University) completed a print survey to determine their use and knowledge of herbal products. These students entered the pharmacy program between 1997 and Table V compares this sample with national enrollment data for 1998 for all pharmacy schools, the most recent published data(14). The American Association of Colleges of Pharmacy (AACP) enrollment figures for white, black, Asian, and Hispanic students included only students who were U.S. citizens. This survey did not distinguish between U.S. citizens and foreign students. Students who have immigrated to the U.S. since the dissolution of the U.S.S.R. and several other European countries are included in the white category; citizens of African and Caribbean countries are included in the black category. The Asian group included U.S. citizens and students primarily from Vietnam and India, with some students from Korea and China. There was no attempt to enumerate the number of students in these subgroups because the small numbers would not have provided a statistically significant sample. There are notable differences between AACP's distribution of students and those in this study. Although women represented the majority of students in this study (59.2 percent), their percentage was somewhat less than the nation average (64.4 percent). The AACP enrollment data was for the year 1998, but the study sample also included students admitted to the University in 1999, and this may account for some of the difference between the sample and AACP data. Although the sample had five percent fewer female students than the AACP data, it is a reasonable approximation of the national data. This study had a larger proportion of minority students than the national average, 56.3 vs 32.2 percent, respectively. Reasons for this difference include the overall multicultural composition of the student body at Temple University due primarily to its programs for recruitment of minority students and its location in a large metropolitan city. The pharmacy school itself has a Health Careers Opportunity Program, whose goal is to increase underrepresented minority and other socially disadvantaged student enrollments. Additionally, this study included all students within each ethnic group, not just U.S. citizens. Table V compared study participants with AACP's data and revealed that the sample had fewer white and Hispanic students but a greater number of black and Asian students. How these differences would affect use and overall knowledge of herbal products in the entire pharmacy student population is unknown. This study also has essentially no data on Hispanic students because only four students (1.1 percent) study in the sample identified themselves in this manner. These four students were classified in a group designated other in this study, along with 20 students who did not indicate any ethnic group. AACP data reported that Hispanic students made-up 3.5 percent of the pharmacy student population in 1998(14). One could speculate that the national student average score could be higher than the students in this sample because of the higher percentage of white students in the national population. This study showed than ethnicity had an affect on scores, and white student scores were significantly higher than any other ethnic group. However, site of pharmacy practice, personal use, and family traditions also affected the knowledge score. No national information was available so there is no exact way in which to predict how a national average score would compare with the study's average score. The majority of students, 84.3 percent, were between the ages of 18 and 30, which was not unusual; 15.1 percent of the group were between the ages of 31 and 50, and 0.5 percent were between 51 and 65. Three students did not reveal their ages, but they had to be within the ages cited because no student was over the age of 65. Because the average age of students in the University is usually higher than that of many other colleges and universities, the study examined use and knowledge of herbal products based on age. There were no statistically significant differences based on age in either use or knowledge. AACP did not publish any information on enrollments based on age. Herbal products use by pharmacy students (44 percent) in this study was higher than that of the general population (12 to 26 percent) and a group of college students (29 percent)(2-4). There was no statistically significant difference in use of herbal products based on ethnicity, gender, age, or work experience (Table I). Knowledge scores ranged from 0 to 92 percent with 9.2 percent of the sample receiving a zero score because they answered don t know to all of the questions rather than trying to guess. The average score including all 370 respondents was 32.2 percent ± Also, there was no difference in the average knowledge scores based on gender (32.8 percent ± 25.1 for males and 31.9 percent ±21.3 for females, P = 0.72) or age (32.2 percent ± 22.6 for yr old, 32.0 percent ± 24.4 for yr old, and 38.5 percent ± 32.6 for yr groups, p = 0.98). All data appear in Table I. Correct answers for individual herbs based on gender showed no significant differences except for kava kava, garlic, and saw palmetto. Females' knowledge of the therapeutic use of kava kava and garlic was greater than that of males and reached statistical significance (P < 0.05, while males were more knowledgeable about the adverse effects of garlic and the use of saw palmetto (P < 0.05). Males may have had more knowledge about saw palmetto because it is used to treat a gender specific condition, benign prostatic hyperplasia. Only one herb, kava kava, had a statistical significant difference in knowledge scores based on age, and that was in the yr age group, who were more likely to answer correctly. Evaluation of the survey forms did not provide a possible explanation for the gender and age differences in the knowledge scores. Students working in a community setting had statistical significant higher scores for all herbs except ginkgo biloba, ginseng, garlic, and valerian. This finding is not unexpected because pharmacies are among the major retail establishments selling herbal products. Students working in community settings were more likely to receive employee training and were more likely to learn about herbal products from co-workers and friends (Table III). They were also more likely to use personal research and lay press articles to increase their knowledge, and this may be related to their contact with consumers who frequently seek advice from pharmacists. Hospital pharmacists do not usually dispense herbal products because physicians don't usually prescribe these products, especially in hospitalized patients. Students working in industry or not working at all had the lowest knowledge scores (Table II). These students also had the lowest reported rate of 4 American Journal of Pharmaceutical Education Vol. 65, Spring 2001

5 use of herbal products, 38.8 percent, compared with students working in community, 48.0 percent, or hospital, 45.3 percent, settings, but it was not statistically significant. Ethnicity had a statistically significant effect on all individual herbal scores except for ginkgo biloba, garlic, and Hawthorn extract. White students were nearly twice as likely to work in community and hospital settings than black students, about 47 percent compared to 24 percent (Table II). White students were also more likely to work in community and hospital settings than Asian students at almost the same rates, 47 and 28 percent respectively. Whether or not communication and language skills played a role in the choice of work setting was not addressed in this study. However, it would be reasonable to expect that students who had difficulty with the English language would seek jobs in areas where frequent communication with consumers is minimal, such as a hospital or pharmaceutical industry. Black students were more likely to choose the option of don't know as an answer rather than guess in the multiple choice section of the survey. Since knowledge scores were calculated by dividing the percent correct by the total number of questions, these students would be expected to have lower scores than students who chose to guess. If another distracter had been substituted for the don't know option, students would have had a 20 percent chance of guessing the correct response and improving their total score. The study authors were interested in actual knowledge and decided to include the don't know option. Students who identified family tradition as a source of herbal information also had higher knowledge scores (Table III). The fact that more white students listed herbal product use as a family tradition than black or Asian students was quite unexpected. Because of the large number of African, Carribean, Vietnamese, and Indian students in the sample, a higher rate of traditional use was expected by the authors in the black and Asian groups. These countries tend to use natural products to a greater degree than the United States. The herbal products in this survey were primarily of western and not eastern cultures and that may have had an effect on total knowledge scores. Only ginkgo biloba, ginseng, and ephedra products are common to both cultures which may be a partial explanation for the lower than expected use and scores among the Asian group. Three regression modules were developed a priori to examine the effect that ethnicity, working experience, personal experience, and selection of the don't know choice showed on the average knowledge scores. Model 1 considered only ethnicity and accounted for 18 percent of the difference between the groups. Since black students chose the don't know choice at a statistically significant higher rate than either white or Asian students, it was included as a variable in Model 2. This model accounted for 46 percent of the difference in knowledge scores. Model 3 added sources of information (lay press, personal research, co-workers and friends, and family tradition) as variables. This model accounted for 57 percent of the variance in students knowledge of herbal products. While these factors account for the majority of the difference in knowledge scores, there remain other factors that this survey was not able to elucidate. Perhaps further information on students' backgrounds, exact nations of origin, and length of time in the U.S. for foreign students could have accounted for more of the variance in the models. CONCLUSIONS This study showed that less than half of the pharmacy students were able to identify the appropriate use and adverse effects of twelve commonly used herbal products in the United States. The ethnic diversity of pharmacy students, their personal use of herbal products, and their choice of pharmacy working sites were identified as factors that accounted for 57 percent of the variance in students knowledge of herbal products. Although this sample of pharmacy students contained fewer women students and more minority students than the U.S. pharmacy student population based a data published by AACP on student enrollment figures for 1998, the finding of this study are probably a reflection of knowledge most pharmacy students possess about herbal products. Two reasons for this assumption are: (i) gender had no statistically significant effect on either the use or knowledge of herbal products (see Table I); and, (ii) ethnicity accounted for only 18 percent of the variance in knowledge scores as determined by linear regression analysis (see Model 1, Table IV). The major questions facing pharmacy faculty are: (i) Should CAM course be in the core or elective curriculum? (ii) How much time should be devoted to CAM instruction? (iii) How much time should be allocated specifically to traditional pharmacy topics like herbal products, megavitamins, and homeopathy? The majority of medical and pharmacy schools have addressed these questions and included CAM in their curricula(7,8,17). Recent surveys revealed a wide range of contact hours assigned to CAM instruction and a lack of consensus about whether or not it should be in the required or elective curriculum in pharmacy schools. Results of this survey clearly demonstrated that pharmacy students have a wide range of knowledge scores (0 to 92 percent) about the therapeutic use of most common herbal products prior to any formal instruction. Except for students who did personal research on herbal remedies, all students mean scores were less than 50 percent. This fact makes a strong argument for inclusion of CAM instruction in the core curriculum. It could be included in an existing course or a separate course, but it should not remain an elective option. All the herbal products in this survey are included in a core course at Temple University. A three credit elective course in CAM was introduced into the pharmacy program during the Spring 2000 semester. Rickert et al. reported that 73.8 percent of 18 practicing pharmacists correctly identified the use of some popular herbal products (echinacea, ginkgo, garlic, St. John's wort, valerian, Ma Huang, feverfew, ginseng, hawthorn, saw palmetto, ginger, grape seed, chamomile, and milk thistle)(16). Less than half of the pharmacists were able to correctly answer questions about mechanism of action, adverse effects, drug interactions, active ingredient, or dose. Pharmacy students in this study score a mean of 32 percent when questioned on the therapeutic use and adverse effects of many of the same herbal remedies before any formal instruction. Physicians today are more likely to recommend CAM therapy for their patients. Recommendations for herbal products were reported to range between 7 to 13 percent in the few studies that examined the use of CAM therapies(17-19). The range of patients using CAM therapy includes college students, low-income consumers, and patients with serious illnesses like cancer and AIDS(20-22). Many patients combine CAM with prescription drugs and the documentation of drug interactions occurring will increase as more controlled clinical studies are American Journal of Pharmaceutical Education Vol. 65, Spring

6 performed. Potentially dangerous interactions between the use of ginkgo biloba and digoxin and St. John's wort and serotonin reuptake inhibitors have appeared in the literature(23). In order to provide comprehensive pharmaceutical care, pharmacists today must possess basic knowledge about CAM therapy, especially herbal products. CAM should be included in every pharmacy school's curriculum, and it should be part of the core curriculum. References (1) Eisenberg, D.M., Davis, R.B., Ettner, Susan et at., Trends in alternative medicine use in the United States, , JAMA, 280, (1998). (2) Gulla, J. and Singer. A.J., Use of alternative therapies among emergency department patients, Ann. Emerg. Med., 35, (2000). (3) Druss, B.G. and Rosencheck, R.A., Association between use of unconventional therapies and conventional medical services, JAMA, 282, (1999). (4) Gaedeke, R.M., Tootelian, D.H. and Holst, C., Alternative medicine among college students, J. Hosp. Mark., 13, (1999). (5) Pal, S., Herbal sales reach mainstream market, U.S. Pharmacist., 24, 12(1999). (6) Miller, G. and Murray, W.J., Herbal instruction in United States pharmacy schools, Am. J. Pharm. Educ., 61, (1997). (7) Rowell, D.M. and Kroll, D.J., Complementary and alternative medicine education in United States pharmacy schools, Am. J. Pharm. Educ., 62, (1998). (8) Wetzel, M.S., Eisenberg, D.M. and Kaptchuk, T.J., Courses involving complementary and alternative medicine at U.S. medical schools, JAMA, 280, (1998). (9) Breda, K.L. and Schulze, M.W., Teaching complementary healing therapies to nurses, J. Nurs. Educ., 37, (1998). (10) Reed, F.C., Pettigrew, A.C. and King, M.O., Alternative and complementary therapies in nursing curricula. J. Nurs. Educ., 39, (2000). (11) Schoen, A.M., Results of a survey on educational and research programs in complementary and alternative veterinary medicine at veterinary medical schools in the United States, J. Am. Vet. Med. Assoc., 216, (2000). (12) Grauds, C., Top ten herbs, Pharm. Times, 62 (No. 12), 84(1996). (13) Anon., Top 20 herbal/supplement ingredient categories, The Tan Sheet, 7(Special Dietary Suppl August), 11(1999). (14) Meyer, S.M. and Marmorino, M.P., The pharmacy student population: Applications received , degrees conferred , fall 1998 enrollments,,4m. J. Pharm. Educ., 63, 57S-68S(1999). (15) Kligler, B., Gorgon, A., Stuart, M. and Sierpina, V., Suggested curriculum guidelines on complementary and alternative medicine: Recommendations of the Society of Teachers of Family Medicine Group on Alternative Medicine, Fam. Med., 31, 30-33(2000). (16) Rickert, K., Martinez, R.R. and Martinez, T.T., Pharmacist knowledge of common herbal preparations, Proc West. Pharmacol. Soc., 42, 1-2(1999). (17) Berman, B.M., Singh, B.B., Ferentz, K.S., et at., Physicians' attitudes toward complementary alternative medicine, J. Am. Board Fam. Pract., 8, (1995). (18) Goldstein, M.S., Sutherland, C, Jaffee, D.T. and Wilson, J., Holistic physicians and family practitioners: Similarities, differences and implications for health policy, Soc. Sci. Med., 26, (1988). (19) Astin, J.A., Pelletier, K.R., Hansen, E. and Haskell, W.L., A review of the incorporation of complementary and alternative medicine by main stream physicians, Arch. Int. Med., 158, (1998). (20) Planta, M., Gunderson, B. and Petitt, J.C., Prevalence of the use of herbal products in a low-income population, Fam. Med., 32, (2000). (21) Lee, M.M., Wrensch, M.R., Adler, S.R. and Eisenberg, D., Alternative therapies used by women with breast cancer in four ethnic populations, J. Natl. Cancer Inst., 92, 42-47(2000). (22) Burack, J.H., Cohen, M.R. and Hahn, J.A., et al, Pilot randomized controlled trial of Chinese herbal treatment for AIDS-associated symptoms, J. AIDS Hum. Retro., 12, (1996). (23) Fugh-Berman, A. Herb-drug interactions, Lancet, 355, (2000). 6 American Journal of Pharmaceutical Education Vol. 65, Spring 2001