Homeopathy and Naturopathy: Practice Characteristics and Pediatric Care

ARTICLE Homeopathy and Naturopathy Practice Characteristics and Pediatric Care

Anne C. C. Lee, BSE; Kathi J. Kemper, MD, MPH

Objective: To describe the practice characteristics and pathic doctors and HPs reported having an average of only pediatric care of homeopathic practitioners (HPs) and 25 to 40 patient visits per week, but children and adoles- naturopathic doctors (NDs). cents accounted for up to one third of these visits. Nearly all reported treating children, but fewer than half of the prac- Design: Cross-sectional, descriptive survey. titioners reported any formal pediatric training. Initial patient visits typically lasted more than 1 hour and cost $140 Setting: Homeopathic and naturopathic practices in to $150. Follow-up visits were scheduled every 4 to 6 weeks Massachusetts. and lasted more than 30 minutes on average. Insurance covered less than one third of the patient visits, and sliding Participants: Homeopathic practitioners (N = 42) and scale payments were offered by less than half of the re- NDs (N = 23) identified from the yellow pages, regional spondents. Most practitioners reported that they did not and national society membership lists, schools, maga- actively recommend immunizations and fewer than half of zine advertisements, and by word-of-mouth. The re- the nonphysician practitioners reported that they would sponse rate was 55% (23/42) for HPs and 65% (15/23) refer a 2-week-old neonate with a fever to a medical doc- for NDs. tor or emergency medical facility.

Main Outcome Measures: Demographics, practice Conclusions: Many patients using homeopathy and na- characteristics, fee structure, and amount of pediatric care. turopathy are children. Visits to these providers are fre- Practitioners were asked for their approach to child- quent and fees are primarily paid out-of-pocket. Failure hood immunizations and to treating a febrile neonate. on the part of these providers to recommend immuni- Data were analyzed using simple descriptive statistics. zations or recognize potentially serious illnesses is cause for concern. Results: Almost all respondents were white. Among the HPs, 13 (57%) were licensed medical doctors. Naturo- Arch Pediatr Adolesc Med. 2000;154:75-80

dilute concoctions are more powerful and Editor’s Note: All of us, even the nay-sayers to complementary therapeutic).1-3 Homeopathic remedies are medicine, should be aware of the information contained in this study. prepared by serial dilutions and vigorous Ignoring it won’t make it go away; we need to understand and use shaking (sucussion) and contain little or no or correct the complementary methods. measurable active ingredients. However, ho- Catherine D. DeAngelis, MD meopaths believe the preparation of the so- lution imparts an energetic imprint, en- abling the patient’s own body and vital energy to fight the original cause of dis- OMEOPATHY, founded by ease.2,3 Two recent meta-analyses of con- 19th-centuryGermanphy- trolled trials of homeopathy demonstrated sicianSamuelHahnemann, positive trends for homeopathy compared is based on 2 major prin- with placebo treatment.4,5 Randomized con- ciples: (1) similia similibus trolled trials have shown that homeo- curentur—“like is cured by like” (ie, an ill- pathic medicine is effective for treating in- H 6,7 From the Center for Holistic ness, such as dermatitis, can be treated by fluenza and acute childhood diarrhea. Pediatric Education and a substance, such as poison ivy extract, The term naturopathy describes a Research, Children’s Hospital, which produces similar symptoms in a wide range of therapies that are consid- Harvard Medical School, healthy person) and (2) doses minimae— ered “natural medicines.” Naturopathic Boston, Mass. “potentiation through dilution” (ie, more doctors (NDs) believe that (1) the body

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 PARTICIPANTS AND METHODS acupuncture, exercise, and relaxation techniques). Nine questions addressed professional practice characteristics: solo vs group practice, number of patients seen per week, We performed a cross-sectional survey of HPs and NDs in length of initial and follow-up visits, frequency of visits, Massachusetts from July to November 1998. Both HPs and and the source of patients (advertisements or referrals from NDs were identified through the yellow pages, regional and other health professionals). Fee and insurance issues were national society membership, local training schools, ad- addressed in 5 questions that inquired about initial and fol- vertisements in holistic health magazines, and by word- low-up visit fees, the proportion of patient fees covered by of-mouth. From these sources, 42 HPs and 23 NDs were fee-for-service insurance, the use of a sliding scale, and ac- identified in Massachusetts. ceptance of patients receiving Medicaid. The survey instrument was based on the National Hos- Pediatric care was investigated in several questions pital Ambulatory Medical Care Survey from the National about specific training in pediatrics, length of pediatric train- Center for Health Statistics at the Centers for Disease Con- ing, and pediatric patient load. Three subjective questions trol and Prevention, Atlanta, Ga. It was pilot tested in a tele- were included to assess practitioners’ personal beliefs and phone survey of a subset of 5 practitioners listed in the yel- clinical judgment about pediatric care. Practitioners were low pages while we awaited printed lists from the other asked (1) whether they recommend childhood immuniza- sources named earlier. Questions were further refined and tions; (2) how many times they would see a patient before the remaining providers were mailed written surveys in Au- determining that a condition was not responding to ho- gust 1998. meopathy or naturopathy; and (3) what immediate action One month after the initial mailing, nonrespondents re- they would take if presented with a 2-week-old neonate with ceived second surveys and 3 months later were called for fol- a temperature of 38.6°C. For the third question, respon- low-up. One HP and 3 ND addresses were nondeliverable. dents were given the choices of either (1) referring the pa- The response rate was 55% (23/42) for HPs and 65% (15/ tient to a physician, (2) taking more history, (3) treating 23) for NDs. We attempted to reach all nonrespondents to the patient, or (4) a blank option to write in their own re- determine their reasons for nonresponse. Reasons given were sponse. Finally, practitioners were asked about the health that practitioners were too busy to complete the survey, they care professionals (doctor of medicine or doctor of oste- treated only animals (2 veterinary homeopaths), or they did opathy, ND, chiropractor, and others) to whom they com- not see children in their practice. monly refer patients.

SURVEY CONTENT ANALYSIS

The survey contained 4 pages of questions and required ap- All data were entered into a database (Microsoft Access; Mi- proximately 15 minutes to complete. Demographic items crosoft Corporation, Redmond, Wash), exported to a spread- included age, race, and sex. Five questions addressing pro- sheet program (Microsoft Excel; Microsoft Corporation), fessional status were included to determine educational and analyzed using simple descriptive statistics. Normally degrees, attendance at a homeopathic or naturopathic school, distributed data are reported as averages; nonnormally dis- length of training, certifications in homeopathy or natu- tributed data are reported as medians, modes, and ranges. ropathy, and membership in professional societies. Sev- Because no a priori hypotheses were made and because of eral questions addressed therapeutic specialization (nutri- the small sample size, no post hoc statistical analysis was tion, herbal medicine, midwifery, hydrotherapy, massage, performed.

has a strong, vital, and innate power to heal itself; common medical knowledge, many others, such as hy- (2) symptoms of disease reveal the body’s attempt to reach drotherapy, colonic irrigation, fasting, physical medi- a natural balance, and (3) practitioners must consider the cines (therapeutic use of touch, heat, cold, electricity, and entire person (including mental, emotional, and social sound), and herbal and nutritional supplements have not health) in treatment.8 Curing disease requires natural been adequately tested in controlled clinical trials. methods to restore the proper balance and health to the Homeopathy and naturopathy are experiencing a re- body. Naturopathic therapies focus on eliminating bad naissance in the United States. Almost 2 million visits to habits and on detoxification (eliminating or reducing the homeopathic practitioners (HPs) were estimated in 1997.10 use of tobacco, alcohol, and coffee and detoxification of Retail sales of homeopathic remedies were estimated at the liver and bowel); eating clean, organic food (a pes- $100 million in 1988, $165 million in 1994, and $250 ticide-free, high-fiber, low-protein diet and taking nu- million in 1996.3,11 Worldwide sales were estimated at tritional and herbal supplements); corrective habits and $1.15 billion in 1997.3 Naturopathic therapies, which in- lifestyle modification (exercise, meditation, imagery, coun- clude vitamins, dietary supplements, and herbal rem- seling, biofeedback, and breathing techniques); and hy- edies, have enjoyed even greater popularity. In 1990, di- drotherapy (steam, sitz, and Turkish baths; hot tub use, etary supplements and megavitamin sales were projected colonic irrigation, and poultices).9 Acupuncture, chiro- at $2 billion dollars. In 1997, this number increased to practic medicine, and particularly homeopathy are thera- $10.1 billion.10,12 pies that rely on vitalistic energy and are often used by Homeopathy and naturopathy are common prac- naturopaths to stimulate the body’s natural healing pro- tices in the pediatric population. According to a survey cesses. While the efficacy of certain naturopathic thera- by Spigelblatt et al13 of the use of complementary and al- pies, such as a balanced diet and regular exercise, are ternative medicine (CAM) in pediatrics, HPs and NDs

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 were the second and third most frequently consulted CAM practitioners. Furthermore, this workforce of CAM pro- Table 1. Practice Characteristics of Homeopathic viders is growing rapidly. In 1997, there were an esti- Practitioners and Naturopathic Doctors* mated 1900 NDs in the United States,14 and that num- Homeopathic Naturopathic ber is expected to triple in the next 15 years. An estimated Practitioners Doctors 2500 to 4000 professionals practice homeopathy in the Characteristic (n = 23) (n = 15) United States, a few hundred of whom are physi- 15,16 Group practice, % 48 53 cians. The National Center for Homeopathy (Alex- Total No. of patients seen per week 37 (20) 26 (16) andria, Va) grew 50% between 1991 and 1994 and re- Pediatric patients seen per week 12 (10) 5 (3) ported 7000 members in 1998, with almost half of those Visit length, min being interested laypeople.15, These estimates might even Initial visit 72 (22) 70 (19) underestimate the number of HPs. According to a state17 Follow-up visit 33 (12) 36 (14) and a national18 survey of chiropractors, 10% to 37% of Visit fees, $ Initial visit 157 (53) 139 (61) chiropractors practice some form of homeopathy (5200 Follow-up visit 66 (17) 72 (17) to 18 500 chiropractors). Percentage of patients covered by 32 (22/0) 16 (1/0) Given the increasing use of CAM, media publicity, insurance (median/mode) and the number of providers, it is likely that primary care Percentage of practitioners offering 39 33 physicians will increasingly be asked to refer patients to sliding scale fee Percentage of practitioners accepting 26 13 CAM providers and to coordinate their services. Yet, little Medicaid is known about the practice patterns, fee structures, and pediatric care provided by CAM practitioners such as HPs *Data are given as mean (SD) unless otherwise indicated. and NDs. We decided to undertake an exploratory descriptive study to answer the following questions: What is the best way to locate HPs and NDs? What are the de- ing in homeopathy as of August 1998 was 3 years and mographics and training of the identified providers? What ongoing, ranging from 3 weeks to 20 years. Most HPs are their practice patterns, including visit length, fre- trained at several schools or with several mentors; 9 (39%) quency, fees, and insurance reimbursement? How many trained at the New England School of Homeopathy (Am- have special pediatric training and regularly treat chil- herst, Mass); 9 (39%) at the National Center for Home- dren? And finally, considering many alternative practi- opathy ; and 4 (17%) at the International Foundation for tioners’ opposition to conventional medicine, how do HPs Homeopathy (Edmonds, Wash). Of those who attended and NDs view childhood immunizations and approach a formal program, the average year of graduation was potentially serious pediatric conditions? 1990. Five (22%) were certified by a board in homeopathy (American Board of Homeotherapeutics, Charlottes- RESULTS ville, Va, or the Council for Homeopathic Certification, San Francisco, Calif). Forty-two HPs and 23 NDs were identified in Massachu- Naturopathic doctors held the following degrees: BA setts. Because Massachusetts does not regulate the cre- or BS, 12 (80%); license in acupuncture, 2 (13%); or DC, dentialing or licensing of HPs or NDs, no central gov- 2 (13%). Most naturopaths attended 4-year programs, ernment agency was available to provide a comprehensive graduating on average in 1990. Eight (53%) attended Bas- list of practitioners. We identified practitioners from the tyr University (Kenmore, Wash) and 6 (40%) attended following sources: the yellow pages (5 HPs and 7 NDs), the National College of Naturopathic Medicine (Port- the North American Society of Homeopaths (Seattle, land, Ore). Eleven (73%) of naturopaths were certified Wash) (6 HPs), the National Center for Homeopathy (27 by a state board (such as those of Washington, Oregon, HPs), the Massachusetts Association of Naturopathic Phy- Arizona, or Connecticut) or a national certification board sicians (Boston, Mass) (18 NDs), the American Associa- (Naturopathic Physicians Licensing Examinations, Phoe- tion of Naturopathic Physicians (Seattle) (12 NDs), the nix, Ariz). Homeopathic Academy of Naturopathic Physicians (Am- herst, Mass) (2 NDs), the New School of Homeopathy PRACTICE CHARACTERISTICS (15 HPs), advertisements in holistic health magazines (3 HPs), and word-of-mouth (1 ND). Some practitioners Homeopaths saw an average of 37 patients per week, while were identified in more than 1 source. naturopaths saw 26 (Table 1). Visit frequency was typically 1 visit every 4 to 6 weeks for both groups. DEMOGRAPHICS AND TRAINING SCOPE OF PRACTICE Almost all respondents were white (97%) and male (53%). The average (SD) ages of HPs and NDs were 46 (± 4) years Aside from prescribing homeopathic remedies, 18 HPs and 37 (± 5) years, respectively. (78%) prescribed nutritional supplements, 9 (39%) coun- The HPs held the following degrees: BA or BS, 21 seled on nutrition, 9 (39%) recommended herbal thera- (91%); MD, 13 (52%); license in acupuncture, 3 (13%); pies and phytotherapies, and 7 (30%) recommended re- DC, 2 (9%); and MN, 2 (9%). Homeopathic education laxation techniques. All NDs prescribed nutritional varies considerably and formal training is not required supplements, herbal therapies, and phytotherapies, and for practice in Massachusetts; the median reported train- performed nutritional counseling, and 14 (60%) recom-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 nate with a fever, 5 (67%) of 10 of nonphysician HPs Table 2. Practice Characteristics of Physician would immediately refer the patient directly to a physi- vs Nonphysician Homeopathic Practitioners* cian, 3 (33%) would treat the child, 1 (10%) would take more history, and 1 (10%) omitted the question. Among Physician Nonphysician Homeopathic Homeopathic NDs, 8 (53%) of 15 would take additional history, 6 (40%) Practitioners Practitioners would refer the patient directly to a physician, and 1 (7%) Characteristic (n = 13) (n = 10) would treat the child. Group practice, % 46 (n = 6) 50 (n = 5) Pediatric patients treated, % 100 (n = 13) 90 (n = 9) PHYSICIAN VS NONPHYSICIAN HOMEOPATHS Total No. of patients seen per week 40 (23) 29 (6) No. of pediatric patients seen per week 16 (11) 8 (7) Compared with nonphysician HPs, physician HPs in Visit length, min our sample saw more patients weekly, with a higher pro- Initial visit 75 (19) 77 (9) portion of pediatric patients (Table 2). Initial and Follow-up visit 32 (10) 40 (8) Visit fees, $ follow-up visit fees were slightly higher for physician Initial visit 165 (50) 144 (57) HPs. However, physician HP visits were more often Follow-up visit 69 (16) 60 (17) covered by insurance than nonphysician HP visits. More Percentage of fees covered by 51† 6‡ physician HPs accepted Medicaid patients (46% vs 0%) insurance and participated in a health maintenance organization Percentage of practitioners offering 31(n=4) 50(n=5) sliding scale fee plan (62% vs 20%). There were no other major differ- Percentage of practitioners accepting 46(n=6) 0(n=0) ences in practice characteristics of physician and non- Medicaid physician HPs.

*Data are given as mean (SD) unless otherwise indicated. †Range, 0% to 100%; median, 50%; mode, 50%. COMMENT ‡Range, 0% to 25%; median, 0%; mode, 0%. In our study of HPs and NDs, we focused on questions that pediatricians might ask about CAM practitioners in mended hydrotherapy, 5 (33%) recommended exercise, their communities. We identified practitioners in our re- and 5 (33%) recommended relaxation techniques. gion and characterized their practice characteristics and pediatric care. REFERRAL PATTERNS Identifying HPs and NDs in Massachusetts was dif- ficult given the lack of state regulations for practice or a Respondents reported that most of their patients (57% of central licensing agency. The National Center for Ho- HP patients and 72% of ND patients) were self-referred meopathy and the local homeopathic school, the New (ie, via the yellow pages, friends, and advertisements). Thir- School of Homeopathy, served as our primary sources teen percent of HP patients and 9% of ND patients were for HPs. Similarly, the Massachusetts Association of Na- referred by physicians. The remaining were referred by turopathic Physicians and the American Association of other health care professionals. Most HPs and NDs re- Naturopathic Physicians were the primary sources for ferred patients to physicians (16 and 12, respectively), mas- NDs. Few practitioners (Ͻ12% of HPs and Ͻ30% of NDs) sage therapists (12 and 9, respectively), psychologists (12 were listed in the yellow pages. We identified 42 HPs and and 11, respectively), and acupuncturists (11 and 9, 23 NDs in Massachusetts. However, the number of people respectively). prescribing these therapies could be much higher; interested laypeople account for almost half of the members PEDIATRIC CARE of the National Center for Homeopathy.15 Many of them provide these services as a small part of their practice Seven (30%) of HPs and 5 (33%) of NDs reported train- and/or could be identified only by word-of-mouth refer- ing in pediatrics. Almost all HPs (22 [96%]) and all NDs rals within communities. Currently, there is a move- (15 [100%]) saw pediatric and adolescent patients regu- ment within both communities to establish formal li- larly. Pediatric and adolescent patients comprised 32% censing and certification procedures to ensure certain of the total number of patients for HPs (12 of 37 visits qualifications and training requirements. In the United per week) and 19% for NDs (5 of 26 visits per week). States, homeopathy is presently licensed in only 3 states to physicians and in 1 state under the supervision of a CLINICAL JUDGMENT doctor of medicine or doctor of osteopathy; naturopathy is licensed in 11. When questioned about the number of treatments nec- At the height of their popularity in the early 1900s, essary to determine that homeopathy or naturopathy was there were 12 naturopathic colleges and 20 homeo- not helping a patient’s condition, both groups reported pathic medical colleges in the United States.19,20 Cur- an average of 3 sessions. Eight (35%) of 23 of HPs and 3 rently, there are 4 full-time schools of naturopathy and (20%) of 15 of NDs actively recommended immuniza- no full-time homeopathy schools, although 20 schools tions, while 2 HPs (9%) and 1 ND (7%) openly opposed offer courses and continuing education in homeopa- childhood immunizations. The remainder reported that thy.21 While there is a formal university program for na- they did not make any recommendations regarding im- turopathy, homeopathy currently lacks uniform educa- munization or omitted the question. Faced with a neo- tional and training standards. Naturopathic doctors who

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 responded to the survey reported an average of 4 years bursement rates (Table 2). These data suggest that ho- of training, whereas HPs reported anywhere from 180 meopathic care performed by physicians might be more hours to 20 years of training. Within the homeopathic affordable and increase access to low-income groups seek- community, there is a push to form formal 4-year ho- ing CAM services. meopathic medical schools to “establish consistent A substantial proportion of patients of HPs and NDs standards for homeopathic medical education.”22 How- are children—approximately one third in our study. The ever, this process will be tedious and costly, and in the use of CAM in pediatrics is of concern for 3 major rea- meantime, how do physicians considering patient refer- sons: (1) the possible toxicity of therapy; (2) attitudes held rals determine practitioner qualifications? Several na- by some CAM providers against immunization; and (3) tional boards certify homeopathic practitioners: the Coun- the questionable ability of CAM providers to recognize po- cil on Homeopathic Certification; North American Society tentially serious, medically treatable conditions. Homeo- of Homeopaths (certification test similar to the United pathic remedies are generally considered very safe, be- Kingdom’s Society of Homeopaths); American Board of cause they contain little, if any, measurable or active Homeotherapeutics, Charlottesville, Va (which offers the ingredients. Many naturopathic techniques or products are diplomate in homeotherapeutics certification for physi- well-known constituents of general health, such as a high- cians), and the Homeopathic Academy of Naturopathic fiber, low-protein diet rich in fruits and vegetables; exer- Physicians (which offers the diplomate of the Homeo- cise; relaxation; and avoidance of tobacco, alcohol, and caf- pathic Academy of Naturopathic Physicians). feine. However, NDs commonly prescribe herbal remedies and dietary supplements whose contents and drug inter- actions in children are unknown. Pediatricians reported RACTICE PATTERNS of physician HPs have been a case of partial thickness burns from a garlic petroleum described by Jacobs et al.16 Our study builds jelly plaster, which was placed on the feet of a febrile in- on this data by including nonphysician HPs fant under the direction of an ND.25 Others have reported and NDs. The average ages of physician and 2 deaths thought to be related to coffee enemas, a com- nonphysician HPs in our study were 45 and mon naturopathic treatment.26 Other procedures that may 46P years, respectively, similar to the study by Jacobs et al.16 be dangerous for children include colonic irrigation and The NDs were younger, with an average age of 37 years. fasting. In our study, both HPs and NDs reported visit costs simi- The attitudes against immunization held by HPs and lar to those given in the study by Jacobs et al16: for initial NDs are documented by several investigators. In sur- visits, $150 and $139 for HPs and NDs, respectively, com- veys of homeopaths in Australia and the United King- pared with $137; and for follow-up visits, $60 and $72 for dom, most (83% and 70%, respectively) practitioners did HPs and NDs, respectively, compared with $55. The typi- not recommend immunization.27,28 In fact, a study in En- cal cost for a pediatric office visit ranges from $90 to $110 gland found that homeopathy was the most common rea- for new patients and approximately $50 for established pa- son for noncompliance with immunization regimens.29 tients.23 Our respondents reported slightly longer visits than Similar sentiments against immunization are shared by the survey by Jacobs et al16: 72 and 70 minutes for HPs NDs, who often view immunization programs as “un- and NDs compared with 59 minutes; and 33 and 36 min- natural, unnecessary, and elitist.”30 Less than one third utes for HPs and NDs compared with 25.4 minutes. The of our respondents recommended immunization, less than shorter visit length of physician HPs might reflect the 10% opposed immunization, and the remainder did not greater time constraints on physicians. However, visits for actively make recommendations. Several reasons have homeopathy and naturopathy, even when performed by been postulated for these views: a general antipathy with physicians, are substantially longer (33 minutes on aver- conventional medicine, apprehension of detrimental side age24) than visits to conventional physicians (14 minutes). effects of immunization, and the opinion that their own This greater contact time and the nature of the homeo- practices provide better, natural protection that “obvi- pathic history-taking process might contribute to patient ates the need for vaccination.”31 satisfaction. Physicians may also fear the consequences of de- Fees for homeopathy and naturopathy are primar- layed treatment for serious medical conditions. Of the ily paid by patients and families out-of-pocket. The me- respondents, both HPs and NDs saw patients an average dian percentage of fees covered by insurance and other of 3 times, or for 3 to 4.5 months, before determining third parties was 22% for homeopathy and 1% for natu- that a condition was not responding to therapy. When ropathy. Visits (1 every 4-6 weeks) are more frequent than presented with a infant with a fever, 60% of NDs and 50% those to mainstream physicians and, coupled with low of nonphysician HPs would not immediately refer the pa- insurance reimbursement, indicate substantial ex- tient to a physician or an emergency facility. Thirty- penses for these services. Only about one third of HPs three percent of nonphysician HPs would rather treat the and NDs offered a sliding scale for patients and few ac- child themselves with homeopathic remedies. It is wor- cepted Medicaid patients. An interesting finding was the risome that a substantial proportion of these providers difference in fee structure between the physician and non- of pediatric care are not equipped with the clinical skills physician homeopaths. Although physician HPs charged to recognize emergent conditions for which homeopa- slightly more ($21 and $9 more for initial and fol- thy or naturopathy might not be effective or expedient, low-up visits, respectively), many more physician HPs and that could result in detrimental outcomes. accepted Medicaid patients, belonged to a health main- This study has several limitations. First, it was con- tenance organization, and had higher insurance reim- fined to Massachusetts and needs to be replicated in vari-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 ous geographic areas, particularly locations outside of plemetary and Alternative Medicine. New York, NY: Churchill Livingstone Inc; New England, with a larger sample population. Selec- 1996:67-78. 4. Knipschild P, Kleijnen J, Riet GT. Belief in the efficacy of alternative medicine tion bias also limits this study. Because the surveys re- among general practitioners in the Netherlands. Soc Sci Med. 1990;31:625- quired 10 to 20 minutes to complete, busier practices and 626. those practices with less pediatric experience were less 5. Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy pla- likely to respond. Other limitations included the self- cebo effects? a meta-analysis of placebo-controlled trials. Lancet. 1997;350: reporting of data as opposed to direct observation. This 834-843. 6. Ferley J. A controlled evaluation of a homeopathic preparation in the treatment general survey of practitioners also does not address pa- of influenza like syndromes. Br J Clin Pharmacol. 1989;27:329-335. tient satisfaction, efficacy, or adverse effects of home- 7. Jacobs J, Jimenez J, Gloyd S, Gale J, Crothers D. Treatment of acute childhood opathy or naturopathy. diarrhea with homeopathic medicine: a randomized clinical trial in Nicaragua. Pe- In summary, a substantial number of children are diatrics. 1994;93:719-725. treated by HPs and NDs who are not licensed in most 8. Shealy N. Complete Family Guide to Alternative Medicine. Versailles, Kentucky: Rand McNally; 1996. states and may not be adequately trained in pediatric care. 9. Pizzorno J. Naturopathic medicine. In: Micozzi M, ed. Fundamentals of Comple- Visits to these alternative medicine providers are more mentary and Alternative Medicine. New York, NY: Churchill Livingstone Inc; 1996: frequent and substantially longer than visits to primary 163-182. care physicians. Fees for these services are rarely cov- 10. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in ered by insurance. Of concern to pediatricians, most re- the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998; 280:1569-1575. spondents said that they did not recommend childhood 11. Homeopathy. Harvard Women’s Health Watch. 1997;4:2-3. immunizations and most NDs would not immediately re- 12. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Un- fer a neonate with a fever to a physician or an emer- conventional medicine in the United States: prevalence, costs, and patterns of gency facility. These results indicate a clear need to in- use. N Engl J Med. 1993;328:246-252. crease communication with the alternative medicine 13. Spigelblatt L, Laine-Ammara G, Pless B, Guyver A. The use of alternative medicine by children. Pediatrics. 1994;94:811-814. community and perhaps initiate education about the risks 14. Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysi- and benefits of immunization and the ability to recog- cian clinicians. JAMA. 1998;280:788-794. nize emergent medical conditions. Additional studies are 15. Homeopathy: much ado about nothing? Consumer Reports. 1994:201-206. needed to address the safety and effectiveness of homeo- 16. Jacobs J, Chapman EH, Crothers D. Patient characteristics and practice pat- pathic and naturopathic therapies for children, as well terns of physicians using homeopathy. Arch Fam Med. 1998;7:537-540. 17. Kelly R. Homeopathy and chiropractic. Resonance. 1993;15:7-8, 11-13. as the elements of that care that contribute most strongly 18. National Board of Chiropractic Examiners. Job Analysis of Chiropractic. Greely, to patient satisfaction. Colo: National Board of Chiropractic Examiners; 1993. 19. 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