eCAM Advance Access published March 17, 2009

eCAM 2009;Page 1 of 8 doi:10.1093/ecam/nep019

Original Article

Integration of Complementary and Alternative into Family Practices in Germany: Results of a National Survey

Stefanie Joos1, Berthold Musselmann1,2 and Joachim Szecsenyi1

1Department of General Practice and Health Services Research, University Hospital Heidelberg, Voßstrasse 2, 69115 Heidelberg and 2Practice of Family Medicine, Academic Teaching Practice, University of Heidelberg, Hauptstrasse 120, 69168 Wiesloch, Germany

More than two-thirds of patients in Germany use complementary and (CAM) provided either by or non-medical practitioners (‘Heilpraktiker’). There is little information about the number of family physicians (FPs) providing CAM. Given the widespread public interest in the use of CAM, this study aimed to ascertain the use of and attitude toward CAM among FPs in Germany. A postal questionnaire developed based on qualitatively derived data was sent to 3000 randomly selected FPs in Germany. A reminder letter including a postcard (containing a single question about CAM use in practice and reasons for non-particpation in the survey) was sent to all FPs who had not returned the questionnaire. Of the 3000 FPs, 1027 (34%) returned the questionnaire and 444 (15%) returned the postcard. Altogether, 886 of the 1471 responding FPs (60%) reported using CAM in their practice. A positive attitude toward CAM was indicated by 503 FPs (55%), a rather negative attitude by 127 FPs (14%). Chirotherapy, relaxation and neural were rated as most beneficial CAM by FPs, whereas neural therapy, phytotherapy and were the most commonly used therapies in German family practices. This survey clearly demonstrates that CAM is highly valued by many FPs and is already making a substantial contribution to first- contact primary care in Germany. Therefore, education and research about CAM should be increased. Furthermore, with the provision of CAM by FPs, the role of non-medical CAM practitioners within the German healthcare system is to be questioned.

Keywords: General Practice – Integrative Medicine – Chirotherapy – Relaxation – Neural Therapy – Phytotherapy – Acupuncture

Background patients believe that there is an increased need for family physicians involvement in providing and supervising The growing popularity of complementary and alter- CAM treatments (13). In the United States, CAM is native medicine (CAM) is associated with an ongoing widely used by the general population (14) and total debate of integrating such therapies into mainstream out-of-pocket expenditures for CAM have been conser- healthcare (1, 2). The extent to which CAM is practiced vatively estimated to be $27 billion. (15). Also, the by physicians and/or non-medical therapists considerably acceptance of CAM among physicians has increased in differs among countries (3–12). Recent data suggest that the last years (16,17). However, most family physicians (FPs) in the United States are not being trained in CAM. For reprints and all correspondence: Stefanie Joos, Department of In a survey of FPs, 76% said their patients use CAM, General Practice and Health, Services Research, University Hospital and the overwhelming majority (84%) thought they Heidelberg, Voßstrasse 2, D-69115 Heidelberg, Germany. Tel: +49- 6221-56-6263; Fax: +49-6221-56-1972; needed to learn more about CAM to adequately address E-mail: [email protected] patient concerns (17). As a first step in this direction,

ß 2009 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original workis properly cited. 2of8 Integration of CAM in German family practices the Group on Alternative Medicine of the Society Methods of Teachers of Family Medicine has developed curricu- The presented study was designed as a cross-sectional lum guidelines for programs wishing to include formal survey with a nationwide random sample of FPs training in CAM in residency training (18). Thereupon, (included were ‘Facha¨ rzte fu¨ r Allgemeinmedizin’ and family medicine residency programs incorporating CAM ‘praktische A¨ rzte’). Addresses were obtained from the into their curriculum have been developed with financial databases of the Regional Associations of SHI- support of the National Center for Complementary and Accredited Physicians. Physicians were invited by letter, Alternative Medicine in the United States (19, 20). which was spiced up with a tea bag for relaxation In Germany, the overall percentage of individuals with (provided by the Ostfriesische Tee Gesellschaft/Laurens experience in CAM increased from 52% in 1970 to 73% Spethmann GmbH & Co, Seevetal, Germany). In March in 2002 (21). Specific CAM disciplines (, 2007, questionnaires were sent to 3000 randomly selected , , physical therapy, balneology FPs (Fig. 1). A reminder letter, including the question- & medical climatology, acupuncture) are accredited by naire once more was sent to non-responders 2 weeks the German Federal Medical Chamber. FPs can obtain later. A postcard was attached to the reminder letter, additional CAM qualification after a theoretical and which included the following questions: ‘Do you provide practical training. At the end of 2006, a number of 47 193 CAM in your practice?’ (yes/no) and ‘Why do you refuse CAM qualifications were registered among all 407 000 to complete the questionnaire?’ (no time/do not practice German physicians in Germany (22, 23). In addition, as a FP/in principle not taking part in surveys/ many FPs are providing CAM in their daily practice miscellaneous). FPs were asked either to complete the without having any CAM certification. However, to date questionnaire or at least to send back the postcard. there is little evidence about how many FPs provide CAM in day-to-day practice. In Germany, only a small part of CAM is covered by Questionnaire the statutory health insurance (SHI), namely physiother- The questionnaire was developed based on a preceding apy, chiropractic, classic naturopathy, homeopathy to a focus group study (23). Altogether, the questionnaire very small extent and, newly, acupuncture, in patients comprised 50 questions about the following topics: rating with knee pain and lumbar pain. A must hold of CAM, reality of (CAM) care, philosophy of care, job the corresponding CAM qualification for reimbursement satisfaction and demographics. Within this article, results by SHI. All remaining CAM therapies are not covered of the topics ‘rating of CAM’, ‘reality of (CAM) care’ by SHI but have to be paid by the patients themselves and demographics are presented. For the purpose of this or may be reimbursed by private health insurances. study, CAM was defined as ‘all diagnostic and ther- Moreover, since the beginning of January 2004, all apeutic procedures not ranking among conventional homeopathic and phytotherapeutic drugs (with the excep- medicine (‘‘Schulmedizin’’)’. In this definition, classical tion of mistletoe, St John’s wort, psyllium and ginkgo) naturopathic methods (hydrotherapy, phytotherapy, kine- are non-reimbursable by the SHI (24). siotherapy, dietetics, physical and regulative therapy), Apart from physicians there are non-medical, other traditional healing systems, as well as less well- state-licensed practitioners in Germany, so-called known and used therapies such as bioresonance therapy ‘Heilpraktiker’, providing a great variety of CAM and autohemotherapy were included. For two questions therapies. ‘Heilpraktiker’ is not an occupation requiring regarding use and attitude toward CAM, a predefined list formal training neither for basic medical knowledge nor of CAM disciplines was given. This list included the for CAM. However, a ‘Heilpraktiker’ has to pass following methods: acupuncture, anthroposophic medi- an exam on basic medical knowledge and skills at a cine, autohaematotherapy, relaxation, homeopathy, reg- local public health office to obtain a state license (25). ulative therapy (‘Ordnungstherapie’), / Corresponding to the growing demand for CAM in the chirotherapy/, neural therapy, orthomolecular public, the number of ‘Heilpraktiker’ increased from 9000 therapy and phytotherapy. The term neural therapy is in the year 1993 to nearly 20 000 today. For some used for the therapeutical approach of treating medical patients, the Heilpraktiker already replaces the family problems by injecting local anesthetics symptomatically doctor. in triggerpoints or according to Huneke into so-called This is the first national survey we are aware of ‘interfering field’. to ascertain the use of CAM by FPs and their Most items were measured on 5-point-Likert scale. To attitudes toward specific CAM disciplines in Germany. obtain better overview, responses are summarized within Furthermore, questions with regard to common con- three categories in the result section. Furthermore, within ditions for CAM, attitudes toward Heilpraktiker, educa- the questionnaire, statements about specific aspects of tion and research about CAM were asked during the CAM were given which should be rated by the FPs on survey. 5-point-Likert scales (1 = strongly diasagree, 3 = neutral, eCAM 2009 3of8

5 = strongly agree). The questionnaire was tested among The mean age of respondents was 51 years with ages 20 FPs and revised according to the given notes and ranging from 30 to 71 years. Mean duration of years suggestions of improvement. The original questionnaire in practice was 15 years ranging from 1 to 36 years. (German language) can be requested from the corre- Mean percentage of privately insured patients per sponding author. practice was 12%.

Statistics Use of CAM in Practice For statistical calculations we used SPSS 15.0 software. In cases of less than 3% missing values, percentages are Of the 1027 FPs, 737 (72%) responded to the question given as valid percentages, which means that they are ‘Do you use CAM in your every-day practice?’ with ‘yes’, summed up to 100%. Otherwise, the numbers of missing 141 (14%) responded ‘no’ and 149 (14%) did not answer values are stated explicitly. the question. Of the 444 FPs returning only the postcard, To check for representativeness, demographic data of 149 (34%) indicated that they use CAM in their our sample are compared with data of the German practices, whereas 198 (45%) negated this question and Physician sample 2006 produced by the National 97 (22%) FPs did not answer it at all. Thus, altogether Association of SHI-Accredited Physicians (22) and the 886 FPs of 1471 FPs (60%) indicated to use CAM in sample of the Commonwealth Fund Survey 2006 (26). their practice. Figure 2 displays the frequency to which the different CAM disciplines had been used by the FPs in the previous 12 months. Neural therapy was the CAM Results therapy most frequently used with 565 out of 872 FPs Of the 3000 FPs, 1027 returned the questionnaire and 444 indicating a (very) frequent use in practice. It was FPs returned the postcard. Thus, for the key question followed by phytotherapy (n = 459/873) and acupuncture ‘Do you provide CAM in your practice’ the combined (n = 316/858). On average, FPs applicate CAM in 25.5% response rate (questionnaire + postcard) was 49%. For the remaining questions, the response rate was 34% Table 1. Basic characteristics of responding FPs (Fig. 1). The 444 FPs returning only postcards indicated the following reasons for not completing the whole Our sample Other samples questionnaire: 215 FPs indicated ‘no time’, 141 indicated Gender (n) ‘in principle not taking part in surveys’, 38 did not like F 40% 39.5%a the questionnaire, and 13 did not practice (anymore) as M 59% 60.5%a FP. Age (years) 51.3 (min. 30, max. 71) 51.2 a In Table 1, demographic data of our sample is displayed. FPs in our sample had various CAM Years of work in practice 15.2 (min. 1, max. 36) Data not available certifications headed by acupuncture certification. Structure of practice (n) Solo practice 525 (51%) 68%b Location of practice (n) 3000 questionnaires were sent to randomly selected GPs City 562 (55%) 50%b Privately insured patients 12% Data not available per practice (%) 592 completed questionnaires were sent back Qualifications of FPs (n) Acupuncture 318 (31%) Data not availablec 2408 reminder letters including the questionnaire and a postcard with Naturopathy 221 (21%) 8–18%d the question “Do you provide CAM in your practice?” were sent to non- d responders 2 weeks later Chiropractic 158 (15%) 8–20% Homeopathy 88 (9%) 3–8%d Balneology 33 (3%) 1–3%d Physical therapy 19 (2%) 2–4%d 435 completed questionnaires were sent back 444 postcards were sent back aGerman Physician sample 2006; Source: National Association of SHI-Accredited Physicians (22). bSample of the Commonwealth-Fund-Survey 2006 (26, 49). Combined response rate (questionnaire/postcard): 49% (1471/3000) cSince acupuncture was newly accredited by the German federal medical Response rate for the questionnaire: 34% (1027/3000) current data are not available. It is estimated that around 30–40% of FPs had a training course in acupuncture. dExact data not available; numbers calculated from data of the German Figure 1. Flow chart. Physician sample 2006. 4of8 Integration of CAM in German family practices

bioresonance therapy bioresonance therapy anthroposophic medicine relaxation orthomolecular therapy autologous blood autologous blod therapy homeopathy homeopathy phytotherapy chirotherapy acupuncture acupuncture neural therapy phytotherapy relaxation neural therapy chirotherapy 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

(very) frequent use occasional use seldom/no use (high) benefit moderate benefit no benefit unknown

Figure 2. Use of specific CAM therapies in practice in the last 12 Figure 4. Benefit rating of specific CAM therapies. months.

Conditions Treated with CAM Figure 5 displays type and number of mentioned conditions treated with CAM. The most frequent 35 conditions for CAM indicated by FPs as free-text item 30 were cold symptoms (indicated by 358 FPs) followed by 25 pain (including musculoskeletal pain conditions) indi- 20 cated by 251 FPs and mental illness indicated by 247 FPs 15 (Fig. 5). 10 5 0 Discussion very positive positive neutral negative very negative Given the widespread public interest in CAM, the aim of Figure 3. Overall attitude toward CAM (given as percentages of FPs). this study was to ascertain the use of and attitude toward CAM among FPs. To our knowledge, this is the first nationwide study supplying quantitative data regarding of their patients (SD 25.1; 15% missing items). Only 64 attitudes toward and use of CAM among FPs in out of 737 FPs stated problems for a combination of Germany. CAM with conventional therapy. Use of CAM in Practice

Attitudes Toward CAM and Rated Benefit of Specific In our study, 60% of the responding FPs indicated to CAM Therapies provide CAM in practice, which is the highest percentage of CAM provision in comparison with other countries The question concerning the overall attitude toward with percentages ranging between 13% and around 38% CAM was responded by 910 of the 1027 FPs (87%). Of (4–10). This high percentage is in accordance with a small these, 503 FPs indicated a ‘positive’ or ‘very positive’ non-representative survey of Himmel in 1993 (11) and a attitude toward CAM, whereas 127 indicated a ‘negative’ subgroup analysis by Haltenhof et al. in 1995, revealing or ‘very negative’ attitude (Fig. 3). Chirotherapy was rates of 85% and 56%, respectively, for the provision of assessed as the most beneficial CAM discipline (with 818 CAM by German FPs (12). However, both studies are out of 1016 FPs indicating a [high] benefit), followed by older than 10 years and hampered by methodological relaxation (n = 810/1013) and neural therapy (n = 790/ problems such as small sample sizes and convenience 1017) (Fig. 4). sampling. Of the statements, which were given in the question- Our study provides information about the most naire to be rated by FPs, most agreed was the statement commonly used CAM disciplines in family practice, that FPs should have a basal education about the most which are neural therapy and phytotherapy provided by important CAM disciplines (73%), followed by the 50–70% of FPs. Both therapies have a long tradition in statement that research in CAM should be increased German-speaking countries. Therefore, it is not surpris- (68%). Most disagreed was the statement to refer a ing to find similar results in a Swiss survey (27), but patient to a Heilpraktiker (Table 2). More than half of lower rates in other countries (7, 8, 10, 28). (Most surveys the FPs claimed for more control regarding patient care did not even ask for the use of ‘neural therapy’.) There is by Heilpraktiker. a robust evidence-base for several herbal drugs such as eCAM 2009 5of8

Table 2. Attitudes of FPs to statements about education, research and the provision of CAM

Disagree Neutral Agree (%) (%) (%) FPs should have a basic education for the most important CAM disciplines 9 18 73 CAM should be provided solely by physicians 37 24 39 In specific cases I would suggest a patient to go to a Heilpraktiker 49 18 33 For the protection of patients there should be a quality control of Heilpraktiker 20 21 59 Research in CAM should be increased 15 17 68

400 Attitudes Toward CAM and Perceived Benefit of Specific 358 350 CAM Therapies

300 251 247 Only a few studies have included an ‘overall-CAM- 250 attitude question’. Schmidt et al. investigated whether 200 152 there is a difference in FPs’ attitudes toward CAM in the 150 116 106 United Kingdom and in Germany and found a (non- 100 significant) more positive attitude in German FPs (39). In 51 42 50 26 24 a recently published Turkish survey, 51% of the 0 requested FPs indicated to believe in the efficiency of e pain ders CAM, whereas 38% did not (40). In our study, the majority of FPs had a positive mental illness cold symptoms stress / fatigue skin problems attitude toward CAM. One aim of this study was to allergic conditions malignant diseassleeping problems headache / migraine gastroint. disor assess generalized statements concerning CAM. This was Figure 5. Type and number of mentioned conditions treated with CAM to obtain an idea of the current general attitude in the indicated by FPs. ‘family medicine community’ toward CAM. This, although having in mind that this atitude is not exclusively influenced by scientific evidence but also by St. Johns wort for depression or Echinacea for common political, social and economic factors. cold (29, 30). For some commonly used herbal drugs In our study, chirotherapy and relaxation techniques such as milk thistle or Passiflora, the evidence is contra- were the most highly valued CAM therapies with more dictory or insufficient to draw conclusions (31, 32). than 80% of FPs indicating a (high) benefit. Regarding neural therapy, there are data proving the Chirotherapy is supported by a robust evidence-base at efficacy of the injection of local anaesthetics into trigger least for acute low back pain and pain disorders of the points, for example, in neck disorders (33). However, skeletal system (41, 42). Also for relaxation techniques there is no proper randomized controlled study about such as yoga, there is evidence from several randomized neural therapy according to Huneke that is injecting local controlled studies about potentially beneficial effects anaesthetics into so-called ‘interfering fields’ (34). (43, 44). However, only a minority of FPs provides Our study also demonstrates that more than one-third these two CAM disciplines in practice. This might be due of FPs use acupuncture. The prevalent use of acupunc- to the fact that many FPs have no formal training ture, on the one side, may reflect the strong evidence-base in these disciplines and, therefore, may refer their of acupuncture particularly in pain disorders (35, 36) and patients. Concerning relaxation it is supposed that the inclusion of acupuncture in guidelines (37, 38). On patients use courses offered by gyms, sports clubs or the other side, prevalent acupuncture use in Germany can other communal institutions. be explained by reimbursement of acupuncture for back More than 50% of the responding FPs in our survey pain and osteoarthritis by the SHI. thought that patients would (highly) benefit from Therapies underpinned by little or no evidence, such as acupuncture. This is in accordance with survey from autologous blood therapy, or orthomolecular therapy, other countries where acupuncture takes a ‘top position’ were provided by a lesser number of FPs. Sustained use among CAM disciplines (5, 8, 9, 11). Between 30 and of such CAM therapies may be explained by positive 50% of the FPs have a positive attitude toward experiences of the individual FP and/or may just reflect homeopathy and autologous blood therapy, respectively, a ‘pragmatic’ therapeutic approach of the doctors. which is intriguing, considering the fact that both These therapies warrant further research to discover therapies lack a substantial evidence base. potential therapeutic effects but also to look for side Opinions whether CAM should be provided by non- effects. medical practitioners or solely by physicians are not 6of8 Integration of CAM in German family practices consistent among FPs. About 30% of the FPs would There was a response rate of nearly 50% for the key suggest a patient to go to a Heilpraktiker, but nearly question and 34% for the remaining questions, which is 50% disagreed. About 60% of the FPs want more acceptable compared to international studies surveying control concerning patient-care with CAM provided by the provision of CAM among FPs (16, 17, 40). The Heilpraktiker. From our preceding qualitative study motivation of German doctors to participate in surveys we know that FPs feel pressurized by more and of this type is generally low with rates between 15% and more quality control in their day-to-day practice (23). 30% (49, 50). Therefore, the response rate in the This is in contrast with lacking standards for of presented study has exceeded expectations of the authors Heilpraktiker. Therefore, the claim for more quality and may be seen as a result of a well-developed control concerning the care provided by Heilpraktiker is questionnaire. Nevertheless, the response rate leaves understandable. room for bias and may limit the extent to which these ‘Stiftung Warentest’, a foundation established by the findings are representative for all German FPs. It may be German Bundestag with the aim of providing indepen- possible that the proportions of CAM providing FPs may dent and objective support for consumers, recently be overestimated. Since it was an pseudonymous survey, assessed the quality of consultations in 40 Heilpraktiker there is no information about non-responding FPs. by means of test-patients. The authors concluded that However, based on the reasons for non-participation in Heilpraktiker might have their strengths, for example, in the survey, which FPs had indicated on the postcards, it service, structure of practice, and providing enough time can be concluded that the reasons were mostly CAM- and a pleasant practice atmosphere for patients. independent. However, the authors raised serious concerns in partic- Moreover, comparisons with available data aiming at ular regarding the quality of medical-history-taking (e.g. validating work parameters and demographic parameters medication, conventional treatment), patient information at least confirm that respondents were representative (e.g. about the intended treatment including costs), in basic respects such as gender, age, and location of documentation of the consultation, and education stan- practice (22, 26, 50). Also, the number of FPs holding dards (45). Indeed, Heilpraktiker are allowed to applicate a CAM qualification was only slightly higher in our injections, for instance, of homeopathic remedies, and sample compared with the German Physician Sample of other invasive procedures, without proving a formal 2006 (22). Moreover, the indicated statements for education. Heilpraktiker still seem to have an exceptional not participating in the survey (48% ‘no time’ and 32% role among healthcare provider in Germany. This may ‘in principle not taking part in surveys’) do not argue complicate progress concerning quality and research for substantial bias. Supposing the case that all non- issues in CAM. responders would not provide CAM would still result in a substantial rate of 30% (886/3000) CAM-providing FPs in Germany. Condition for CAM Use The most frequent conditions for CAM use were cold Implications for the Future symptoms, pain (including musculoskeletal), and mental According to preceding qualitative research, patients illnesses. Other surveys among FPs rarely asked for the believe a combined approach of CAM and conventional conditions treated with CAM. However, studies investi- medicine is better than either alone. Patients wish to gating reasons for healthcare utilization underpin the discuss CAM use with well informed FPs (51). Hence, the significance of those three conditions in general practice high rate of CAM-providing FPs in Germany compared (46, 47). with other Western countries can be regarded as a For the therapeutical management of cold symptoms beneficial situation for patients. and mental illnesses in primary care, herbal drugs such as However, there is some homework Germany has to do: Echinacea, Pelargonium sidoides or St. Johns wort play all CAM therapies with a proper evidence base should be an important role in Germany (29, 30, 48). For pain reimbursed by the SHI. First steps in this direction are conditions of the musculoskeletal system, acupuncture taken by SHIs offering the choice of specific CAM rates. and neural therapy may be the most commonly applied Furthermore, the role of Heilpraktiker within the CAM disciplines. German healthcare system urgently has to be reconsid- ered. Crucial points are the intransparency of education and of provided care and, alongside, the reimbursement Strengths and Limitations of the Study of their services by private insurances or even SHI A main strength of this study is the nationwide random (within specific CAM rates). Standards about education sample. A further strength is the use of a questionnaire and quality control should be introduced by healthcare developed based on qualitative data (23) assuring that policy. Furthermore, beliefs and existing practices of included questions refer to issues with practical relevance. Heilpraktiker should be assessed e.g. by focus groups or eCAM 2009 7of8 in-depth interviews (52) to explore the chances for References collaboration between FPs and Heilpraktiker. 1. Thomas KJ, Coleman P, Weatherley-Jones E, Luff D. Developing Our study revealed a clear vote among FPs for more integrated CAM services in primary care organisations. Complement research and education in CAM, which is in accordance Ther Med 2003;11:261–7. 2. Pelletier KR, Astin JA. Integration and reimbursement of com- with the international literature (16, 17, 53). Considering plementary and alternative medicine by managed care and insurance the relevance CAM has in the public, it must be claimed providers: 2000 update and cohort analysis. Altern Ther Health Med for state-funded research and education programmes 2002;8:38–9, 42, 44. 3. Astin JA, Marie A, Pelletier KR, Hansen E, Haskell WL. A review such as the National Center for Complementary and of the incorporation of complementary and alternative medicine by Alternative Medicine in the United States and other mainstream physicians. Arch Intern Med 1998;158:2303–10. initiatives (19). In Germany, CAM has been integrated in 4. Giannelli M, Cuttini M, Da Fre` M, Buiatti E. Family physicians’ knowledge and practice of complementary/alternative medicine and undergraduate education in 2003 with the aim that its relationship with life-style: a population-based survey in Italy. students obtain a basic theoretical knowledge about BMC Fam Pract 2007;15:8–30. frequently used, evidence-based CAM methods. 5. Verhoef MJ, Sutherland LR. Alternative medicine and family physicians. Opinions and behaviour. Can Fam Physician Concerning post-graduate education, it may be ques- 1995;41:1005–11. tioned whether the breakdown of CAM into several 6. Thomas KJ, Nicholl JP, Fall M. Access to complementary medicine additional qualifications, as it is in Germany, is a good via general practice. Br J Gen Pract 2001;51:25–30. 7. Thomas KJ, Coleman P, Nicholl JP. Trends in access to way for CAM. Concerns have been raised that this is complementary or alternative via primary care in contrary to the comprehensive approach of CAM. England: 1995-2001 results from a follow-up national survey. Fam Probably, a better way would be to integrate (practical) Pract 2003;20:575–7. 8. Poynton L, Dowell A, Dew K, Egan T. Family physicians’ CAM training into residency programmes. However, attitudes toward (and use of) complementary and alternative although more research and education will be needed, medicine: a New Zealand nationwide survey. NZMedJ there no longer is a need to wait to use CAM: Cochrane 2006;119:U2361. 9. Hall K, Giles-Corti B. Complementary therapies and the family database already includes over 5000 randomized, con- physician. A survey of Perth FPs. Aust Fam Physician 2000;29: trolled trials on CAM. 602–6. 10. Cohen MM, Penman S, Pirotta M, Da Costa C. The integration of complementary therapies in Australian general practice: results of a national survey. J Altern Complement Med 2005;11:995–1004. Conclusion 11. Himmel W, Schulte M, Kochen MM. Complementary medicine: are patients’ expectations being met by their family physicians? Br J Our study clearly demonstrates that CAM is highly Gen Pract 1993;43:232–5. valued by many FPs and is already making a substantial 12. Haltenhof H, Hesse B, Bu¨ hler KE. Evaluation and utilization of complementary medical procedures – a survey of 793 physi- contribution to first-contact primary care in Germany. cians in general practice and the clinic]. Gesundheitswesen 1995;57: Considering the popularity CAM has in the public, 192–5. integration of CAM is a chance for family medicine. 13. Frenkel M, Ben Arye E, Carlson C, Sierpina V. Integrating complementary and alternative medicine into conventional primary However, FPs should be aware that patients expect not care: the patient perspective. Explore 2008;4:178–86. only to combine CAM and conventional medicine but to 14. Goldstein MS, Brown ER, Ballard-Barbash R, Morgenstern H, integrate CAM within a whole-system approach as Bastani R, Lee J, et al. The use of complementary and alternative medicine among california adults with and without cancer. Evid ‘integrative medicine’ (50). ‘Integrative medicine’ stands Based Complement Alternat Med 2005;2:557–65. for a healing approach, allowing for the bio-psycho- 15. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of socio-spiritual context of the individual patient, drawing complementary and alternative medicine by US adults: 1997–2002. Altern Ther Health Med 2005;11:42–9. on both, conventional medicine and CAM, on the basis 16. Wahner-Roedler DL, Vincent A, Elkin PL, Loehrer LL, Cha SS, of a trustful physician–patient relationship (54). Bauer BA. Physicians’ attitudes toward complementary and alter- native medicine and their knowledge of specific therapies: a survey at an academic medical center. Evid Based Complement Alternat Med 2006;3:495–501. Acknowledgements 17. Corbin Winslow L, Shapiro H. Physicians want education about complementary and alternative medicine to enhance communication We thank ‘The Ostfriesische Tee Gesellschaft/Laurens with their patients. Arch Intern Med 2002;162:1176–81. Spethmann GmbH & Co, Seevetal, Germany’ for 18. Kligler B, Gordon A, Stuart M, Sierpina V. Suggested curriculum guidelines on complementary and alternative medicine: recommen- providing tea bags free of charge. Thanks to Jost dations of the Society of Teachers of Family Medicine Group on Steinhaeuser for his advice on the manuscript. Alternative Medicine. Fam Med 2000;32:30–3. Furthermore, we would like to sincerely thank all FPs 19. Pearson NJ, Chesney MA. The CAM Education Program of the National Center for Complementary and Alternative Medicine: an for their participation in the survey. overview. Acad Med 2007;82:921–6. 20. Maizes V, Silverman H, Lebensohn P, Koithan M, Kligler B, Rakel D, et al. The integrative family medicine program: an innovation in residency education. Acad Med 2006;81:583–9. Funding 21. Hartel U, Volger E. Use and acceptance of classical natural and alternative medicine in Germany-findings of a representa- BMBF (Federal Ministry of Education and Research) tive population-based survey. Forsch Komplementarmed Klass. (FKZ: 01GK0514). Naturheilkd 2004;11:327–34 [German]. 8of8 Integration of CAM in German family practices

22. National Association of SHI-Accredited Physicians; http:// 40. Ozcakir A, Sadikoglu G, Bayram N, Mazicioglu MM, Bilgel N, www.kbv.de/publikationen/125.html (last accessed March 19, 2008). Beyhan I. Turkish family physicians and complementary/alternative 23. Joos S, Musselmann B, Miksch A, Rosemann T, Szecsenyi J. The medicine. J Altern Complement Med 2007;13:1007–10. role of complementary and alternative medicine (CAM) in 41. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Germany - a focus group study. BMC Health Serv Res 2008;12: Spinal manipulative therapy for low back pain. Cochrane Database 8–127. Syst Rev 2004;1:CD000447. 24. Allin S, Busse R, Dixon A, Figueras J, Mcdaid D, Mossialos E, et al. 42. Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative Healthcare systems in transition template 2006; http://www.mig. treatment for low back pain: a systematic review and meta-analysis tu-berlin.de/menue/publications/thematisch/intgesundheitssystem/ of randomized controlled trials. BMC Musculoskelet Disord parameter/(last accessed March 19, 2008). 2005;4:6–43. 25. Ernst E. Healing practitioner – a German phenomenon. What are 43. Pilkington K, Kirkwood G, Rampes H, Richardson J. the rights and responsibilities of healing practitioners? Fortschr Med Yoga for depression: the research evidence. J Affect Disord 1997;115:38–41. 2005;89:13–24. 26. Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On 44. Culos-Reed SN, Carlson LE, Daroux LM, Hately-Aldous S. A pilot the front lines of care: primary care doctors’ office systems, study of yoga for breast cancer survivors: physical and psycholo- experiences, and views in seven countries. Health Aff (Millwood) gical benefits. Psychooncology 2006;15:891–7. 2006;25:w555–71. 45. Stiftung Warentest-2008-03-Heilpraktiker. http://www.scribd.com/ 27. Schlussbericht Programm Evaluation Komplementa¨ rmedizin. http:// doc/2251282/Stiftung-Warentest-2008-03-Heilpraktiker (last www.bag.admin.ch/themen/krankenversicherung/00263/00264/ accessed December 3, 2008). 04102/index.html. 46. Palinkas LA, Kabongo ML. San Diego Unified Practice Research 28. White AR, Resch KL, Ernst E, Complementary medicine: use and in Family Medicine Network. The use of complementary and attitudes among FPs. Fam Pract 1997;14:302–6. alternative medicine by primary care patients – a SURF*NET 29. Linde K, Mulrow CD, Berner M, Egger M. St John’s wort for study. J Fam Pract 2000;49:1121–30. Cochrane Database Syst Rev depression. 2005;2:CD000448. 47. Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, 30. Linde K, Barrett B, Wo¨ lkart K, Bauer R, Melchart D. Echinacea Baum E, et al. Use of complementary alternative medicine for low for preventing and treating the common cold. Cochrane Database back pain consulting in general practice: a cohort study. BMC Syst Rev 2006;1:CD000530. Complement Altern Med 2007;18:7–42. 31. Rambaldi A, Jacobs BP, Gluud C. Milk thistle for alcoholic and/or 48. Lizogub VG, Riley DS, Heger M. Efficacy of a pelargonium hepatitis B or C virus liver diseases. Cochrane Database Syst Rev sidoides preparation in patients with the common cold: a 2007;4:CD003620. 32. Miyasaka LS, Atallah AN, Soares BG. Passiflora for anxiety randomized, double blind, placebo-controlled clinical trial. Explore disorder. Cochrane Database Syst Rev 2007;1:CD004518. 2007;3:573–84. 33. Peloso PM, Gross AR, Haines TA, Trinh K, Goldsmith CH, 49. Glaab T, Banik N, Singer C, Wencker M. Guideline conformance Aker P. Medicinal and injection therapies for mechanical neck for outpatient management of COPD in Germany. Dtsch Med disorders. Cochrane Database Syst Rev 2007;18:CD000319. Wochenschr 2006;131:1203–8 [German]. 34. Fischer L. Pathophysiology of pain and neural therapy. Schweiz 50. Koch K, Gehrmann U, Sawicki PT. Primary Care in Germany – an Rundsch Med Prax 2003;26;92:2051–9. International Comparison. Dtsch Arztebl Int 2007;104:A-2584 35. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, http://www.aerzteblatt.de/int/article.asp?id = 58153 (last accessed Koes BW, et al. Acupuncture and dry-needling for low back pain. March 19, 2008) [German]. Cochrane Database Syst Rev 2005;25:CD001351. 51. McCaffrey AM, Pugh GF, O’Connor BB. Understanding patient 36. Manheimer E, Linde K, Lao L, Bouter LM, Berman BM. Meta- preference for integrative medical care: results from patient focus analysis: acupuncture for osteoarthritis of the knee. Ann Intern Med groups. J Gen Intern Med 2007;22:1500–5. 2007;146:868–77. 52. Barrett B, Marchand L, Scheder J, Appelbaum D, Plane MB, 37. Chou R, Huffman LH. American Pain Society; American College of Blustein J, et al. What complementary and alternative medicine Physicians. Nonpharmacologic therapies for acute and chronic low practitioners say about health and healthcare. Ann Fam Med back pain: a review of the evidence for an American Pain Society/ 2004;2:253–9. American College of Physicians clinical practice guideline. Ann 53. Wayne PM, Pensack LM, Connors EM, Buring JE, Davis RB, Intern Med 2007;147:492–504. Schachter SC, et al. Increasing research capacity at the New 38. Becker A, Niebling W, Chenot JF, Kochen MM. DEGAM-Leitlinie England School of Acupuncture: building grants management Nr. 3: Kreuzschmerzen http://www.degam.de/typo/index.php?id=71 infrastructure. Altern Ther Health Med 2008;14:56–64. (last accessed March 19, 2008). 54. Bell IR, Caspi O, Schwartz GE, et al. Integrative medicine and 39. Schmidt K, Jacobs PA, Barton A, Cross-cultural differences in FPs’ systemic outcomes research: issues in the emergence of a new model attitudes towards complementary and alternative medicine: a survey for primary healthcare. Arch Intern Med 2002;162:133–40. comparing regions of the UK and Germany. Complement Ther Med 2002;10:141–7. Received August 4, 2008; accepted February 12, 2009