J Am Board Fam Pract: first published as 10.3122/jabfm.11.4.272 on 1 July 1998. Downloaded from Primary Care Physicians and Complementary-Alternative Medicine: Training, Attitudes, and Practice Patterns Brian M. Berman, MD, Betsy B. Singh, PhD, Susan M. Hartnoll, B. Krishna Singh, MB, PhD, and D, Reilly, MB, FRCp, MRCGP Background: Physician interest in complementary medicine is widely documented in many Western countries. The extent of level of training, attitudes toward legitimacy, and use of complementary therapies by US primary care physicians has not been extensively surveyed. We conducted a national mail survey of primary care physicians to explore these issues. Methods: Primary care specialties represented were family and general practice, internal medicine, and pediatrics. A total of 783 physicians responded to the survey. For the multivariate analysis, sample weights were assigned based on specialty. Assessments were done for training, attitudes, and usage for complementary medicine. Additional data collected included years in practice, specialty, and type of medical degree. Results: Biofeedback and relaxation, counseling and psychotherapy, behavioral medicine, and diet and exercise were the therapies in which physicians most frequently indicated training, regarded as legitimate medical practice, and have used or would use in practice. Traditional Oriental medicine, Native American medicine, and electromagnetic applications were least accepted and used by physicians. Conclusions: Many psychobehavioral and lifestyle therapies appear to have become accepted as part of mainstream medicine, with physicians in this study having training in and using them. Such therapies as chiropractic and acupuncture appear to be gaining in acceptance despite low training levels among physicians. Those in practice more than 22 years had the least positive attitudes toward and use of complementary therapies. Osteopathic physicians were more open than medical physicians to therapies that required administering medication or a procedural technique. In the multivariate analysis, attitude and training were the best predictors of use. (J Am Board Fam Pract 1998;11:272-81.) http://www.jabfm.org/ Therapies currently not taught or used in West­ Alternative Medicine, in a recent report to the ern or US medical schools or institutions are National Institutes of Health (NIH), grouped grouped within the general classification of com­ these practices into seven broad categories.4 plementary and alternative medicine.l,z A widely Physicians' attitudes toward alternative treat­ divergent group of more than 150 different prac­ ments vary among countries, suggesting that the tices representing a "hodgepodge of beliefs and distinction between alternative and conventional on 24 September 2021 by guest. Protected copyright. treatments"3 falls within this heading. In one of medicine is not always clear-cut and that many the most extensive efforts to map the field of com­ therapies previously considered fringe have be­ plementary or alternative medicine, the Office of come more accepted and used. Studies in many Western countries5-17 indicate that physician inter­ Submitted, revised, 7 October 1997. est in the use of complementary or alternative From the Division of Complementary Medicine, Depart­ ment of Family Medicine, University of Maryland at Balti­ therapies appears substantial, but scientific evi­ more (BMB, BBS); the Behavioral Research Group (SMH) dence does not appear to be the basis for their in­ and the Research and Statistical Consultant Group (BKS), terest.ll In the United States, a survey of primary Baltimore; and the Glasgow Homeopathic Hospital (DR), Scotland. Address reprint requests to Brian M. Berman, MD, care physicians in the Chesapeake Bay area found Division of Complementary Medicine, Department of F am­ physicians to be not only open to using or referring ily Medicine, University of Maryland at Baltimore, Kernan Hospital Mansion, 2200 Kernan Ave, Baltimore, MD 21207. patients for certain complementary therapies but This study was supported by a grant from the Boiron also interested in receiving training in many com­ Homeopathic Foundation, The American Academy of Family 16 Physicians, and the Laing Foundation, Thera Trust, and the plementary therapies. Other studies have found National Institutes ofIIealth Office of Alternative Medicine. between 55 and 94 percent of physicians to be will- 272 JABFP July-August 1998 Vol. 11 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.11.4.272 on 1 July 1998. Downloaded from ing to refer their patients for a complementary Samplillg therapy, although fewer (11 to 36 percent) were Poor physician response rates to surveys have been practicing some form of complementary medicine repeatedly documented.1H-21 Although recommen­ themselves. 12.17 These studies have been limited dations for overcoming this problem include mul­ either geographically or in size, and more compre­ tiple mailings22 with a Total Design Method pro­ hensive surveys are needed regarding US primary posed by DilIman,23 researchers have found that care physicians' attitudes toward the use of com­ physician response rates can remain poor (approxi­ plementary or alternative medicine practices. mately 16 percent) even with the multiple-wave To gauge such attitudes toward complementary data-collection method described by Dillman and medicine, we conducted a nationwide survey of others.24•25 Even though data from general public primary care physicians during late 1994 through surveys are mixed in terms of the differences in 1995. Survey questions addressed (1) which com­ early and late responders,26.27 Leslie28 found that plementary therapies physicians considered to be surveys of homogeneous groups did not require legitimate medical practices, (2) in which therapies high response rates for generalizability. physicians had been trained, and (3) whether Because physicians are a relatively homoge­ physicians personally practiced various comple­ neous group compared with the general public, mentary therapies. Based on the results of an ear­ they might not require large samples to ensure ex­ lier regional study,16 we hypothesized that the ternal validity of the data.29 Many researchers greater the knowledge of complementary medical have found no differences in early and late respon­ practices (as measured through training), the more ders on demographic characteristics.30.31 \Vhen positive the attitudes toward such practices, and Sobal and Ferentz32 tested Leslie's contention that the more likely physicians would utilize such prac­ physicians are a homogeneous group and that tices for their patients. It was also hypothesized high response rates are not necessarily required that knowledge of, attitudes toward, and practice for generalizability, they found that the additional of complementary medicine would vary based on responses received in the second wave of their test physician specialty, type of medical degree, and mailing did not alter the representativeness of the number of years in practice. sample or change the results markedly. In a second study Sobal et al 33 found that physician samples, Methods particularly within specialty groups, might not re­ population quire extensive follow-up efforts, nor did data lack The survey sample was drawn from the 1994 external validity with low response rates. http://www.jabfm.org/ American Medical Association (MIA) member­ Realizing that response rates from physicians ship list of family practice, general practice, inter­ might be poor in spite of a full-field effort, that nal medicine, and pediatric physicians. Re­ each specialty sample would be homogeneous, searchers requested name, address, degree, and and that the larger the population from which the . specialty information for members describing sample is drawn, the fewer respondents are neces­ themselves as direct patient care providers in the sary for representativeness if the sample is chosen on 24 September 2021 by guest. Protected copyright. areas mentioned above. Of the 150,012 physicians randomly,34 the researchers determined to calcu­ meeting the criteria, 65,177 (43.5 percent) were late a ± 4 percent error rate for sample size by general or family practitioners,S 5,537 (37 per­ oversampling based on an estimated response rate cent) were specialists in internal medicine, and of approximately 20 percent.35 30,264 (20.2 percent) were pediatricians. The sampling frame was a random, hierarchical, strati­ Response Rate fied sample selected proportionally by specialty A ± 4 percent margin of error rate required the re­ and then by state or territory turn of approximately 602 questionnaires; 783 It should be noted that MIA membership does were returned. Sample weights were assigned for not include all primary care physicians practicing multivariate analyses based on proportions of each in the United States, and thus any generalizations specialty in the sample and subsequent question­ are limited to those who are members of the naire returns. Among the three different specialty MIA. Nevertheless, the MIA listing is the largest groups, the response rates were family physicians available data source. and general practitioners, 10.6 percent; internal Complementary-Alternative Medicine 273 -- J Am Board Fam Pract: first published as 10.3122/jabfm.11.4.272 on 1 July 1998. Downloaded from medicine, 13.7 percent; and pediatricians, 31.7 across the 19 complementary and alternative prac­ percent. Each specialty sample was weighted in tices.