This survey of clinicians at a North Carolina academic medical center supports findings from previous surveys of clinicians and informs the planning of future services. Most physicians, such as those in our study and others, are interested in and refer to diverse services and would like to see integration of a variety of evidence-based services at their institution [25,30,41]; the greatest interest is in therapies with which they have had personal experience or professional training such as lifestyle therapies (nutrition and exercise) and mind-body therapies [11,13,19,45,46].
In this study, the highest level of support was for an integrated, comprehensive pain treatment program available for referrals from across the institution. This is similar to other surveys which have ranked pain as the most common reason for physician referral for CAM services [15,26,47]. Pain is also a common reason that patients seek CAM services [4,48-50]. This survey also showed a very strong interest in comprehensive programs for obesity and diabetes, which have not been noted in previous surveys. It is possible that future studies may reveal this interest elsewhere as the obesity epidemic continues to grow. It is also possible that numbers were higher in this survey than previous surveys because questions were asked about specific therapies and comprehensive programs for specific conditions rather than labeling them as CAM.
Most physicians view at least some therapies previously referred to as CAM as mainstream rather than alternative [22,30,51]. Our results are similar to others in that lifestyle therapies such as advice about exercise, fitness, nutrition, and stress management/relaxation are now considered mainstream [11,12,31,41]. In our sample, nutrition services were viewed by respondents as mainstream whereas in Crock's 1999 survey, food and special diets were rarely used or recommended by physicians [18]. In other recent surveys, more than half of physicians referred patients for massage, chiropractic and acupuncture [13,14]. Similarly, in our sample, 50% or more clinicians had referred patients to massage or stress management programs, but only slightly more than 25% had referred patients for acupuncture or chiropractic. These data support suggestions that as the field rapidly evolves, changes in terminology are needed to more accurately reflect specific services, rather than lumping groups of therapies under heterogeneous terms such as CAM.
Unlike most other surveys about physician attitudes, this one included a question about the desirability of having expert consultation about herbs and other dietary supplements. Two thirds of our respondents reported having recommended dietary supplements in the past year. A consult service providing expert information about dietary supplements was viewed as desirable by the majority of respondents, perhaps reflecting clinicians' growing awareness of their patients' use of dietary supplements and the potential for side effects and supplement-medication interactions [52-56].
Integrative care is supplanting the dichotomy between mainstream and CAM for some clinicians as well as patients [21,57-62]. Most clinicians have been asked about CAM therapies by patients and are aware that patients are using these therapies [24,34,63]. Physicians are most comfortable in referring patients for therapies they have used personally [16,23,36] and those for which they've received professional training and are most knowledgeable [11,42,59,64]. For example, therapies that are not commonly taught and which appear to be inconsistent with current scientific understanding, such as homeopathy and biofield therapies (e.g., magnets and therapeutic touch) appear to have the least support among medical staff [45,51].
Researchers and policy makers should be aware that not all clinicians view therapeutic options similarly. For example in our survey, pediatricians (including neonatologists) reported providing environmental therapies (cycling light, reducing noise, using phototherapy) and recommending massage therapy whereas other specialists did not often recommend environmental changes or they restricted them to one modality, e.g., light therapy for certain dermatologic conditions. Other specialists were frankly skeptical about therapies viewed as routine by others. For example, most specialists routinely recommended dietary supplements, whereas others did not and questioned the need for ever using them.
The different attitudes and practices of different specialists in this survey are consistent with previous surveys, and suggest important gaps in communication and the need for additional education. Many physicians in our survey appeared to be unaware of the availability of nutrition services and massage services throughout the institution or the Cancer Patient Support Program available through the Comprehensive Cancer Center or fitness advice and programs available through physical therapy. We suspect these kinds of gaps are not unique to our institution, and that they demonstrate the need for better intra-institutional communication.
As interest grows in integrating diverse therapies into mainstream practice, there is a tremendous need for professional education about them. Our results are consistent with earlier studies reporting strong interest among physicians in receiving additional training about therapies previously known as CAM [19,20,24], e.g., more than 70% of practicing physicians want additional training in CAM [11,24,29,34,40]. Although most medical schools and a growing number of residency programs now provide some training in CAM [25,62,65,66], physicians who trained more than ten years ago may not have received formal training about these topics during medical school or residency training. This presents a large market for institutions offering Continuing Medical Education.
In addition, medical centers that are planning new or augmented clinical services need to consider access to care and payment strategies to ensure that these services are financially sustainable and equitably available to those who need them. Several respondents in this survey indicated their interest in providing integrated services, but concern about their patients' ability to pay for them. Reimbursement by insurance is changing, but in North Carolina, it does not provide universal coverage for services such as nutrition and fitness counseling, stress management, therapeutic massage or acupuncture, particularly when these services are provided by non-physician clinicians. Most insurance does cover chiropractic services, but few physicians appear eager to provide these services within an academic medical center.
Most research on CAM has assessed patient use of therapies, and there appears to be some incongruence between what patients want, what insurers cover, what physicians recommend, and what hospitals provide. Among patients, the most commonly used so-called CAM therapies include prayer, dietary supplements such as herbs and vitamins, mind-body therapies (such as relaxation techniques, meditation and breathing techniques), chiropractic, and massage [1]. Insurers, on the other hand, cover chiropractic, acupuncture, and biofeedback more often than home remedies, dietary supplements, or prayer [67]. More than 25% of hospitals offer CAM therapies, most often to outpatients. Among the hospitals that offer complementary services, the services most often provided on an outpatient basis include massage (71%); tai chi, yoga or chi gong (48%); relaxation training (43%); acupuncture (39%); guided imagery (32%); and therapeutic touch (30%). Among the hospitals providing complementary services to inpatients, the most common services are: massage (37%); music/art therapy (26%); therapeutic touch (25%); guided imagery (22%); relaxation training (20%) and acupuncture (12%) [68].
Typical of physician surveys, this study had a low response rate, which may lead to over-representation of responses among those with the strongest feelings about an issue. Furthermore, the survey included only one medical center at one point in time, further limiting generalizability. However, it is reassuring that the major findings of this survey are consistent with similar surveys at other medical centers over the past five years. Although the study included a broad range of specialties reflective of the institution, we did not analyze data by specialty, age or gender of respondents because the purpose was to aid strategic planning rather than test hypotheses and because the number of physicians responding in each specialty was too small for meaningful comparisons. Future research may target particular groups of clinicians as services are developed for individual departments and programs. Finally, the types of therapies and service lines listed in this survey may not have been exhaustive, and researchers in areas in which other services are used may need to ask additional questions. Similarly, some questions may have covered overlapping topics, and future planners may wish to distinguish therapies more precisely before implementing new service lines.
Answers to all your Biology Questions
