Of 537 full-time and part-time physicians with admitting privileges, responses were received from 125 (24%). Response rates were higher among nurse practitioners (NP 23/47, 48%) and physician assistants (PAs 21/45, 46%). Of the 169 respondents, only two were less than 30 years old, and only 12 respondents were over 60 years old (Table 1). Respondents represented the spectrum of clinical departments and programs at the medical center including pediatrics, internal medicine, surgery, psychiatry, obstetrics/gynecology, geriatrics and numerous specialties within these fields.
Among the individual services listed on the survey, clinicians were most interested in having a therapeutic exercise program, followed by consultation services for vitamins/minerals and other dietary supplements; therapeutic massage; environmental therapies; prayer, spiritual healing, ceremony or ritual (pastoral care); and acupuncture; for each of these services, more than 50% of respondents would anticipate making at least one referral in the next 12 months. (Table 2). For example, for therapeutic exercise, 77% of clinicians had made a referral in the past year, nearly half of these to programs in the community (such as the YMCA). If such services were to be offered at the medical center, 80% of clinicians would anticipate referring in the next 12 months, with 58% referring 9 or more times. Less than 40% of clinicians anticipated referring patients for chiropractic, Reiki, or homeopathy, even if they were offered at the medical center.
When asked comprehensive service programs they would likely refer to in the next 12 months if offered at the medical center (Table 3), an overwhelming number would refer at least once a year to a multidisciplinary pain management program (84%), a program offering comprehensive nutritional assessment and advice (84%), a program offering healthy lifestyle promotion for obesity (80%) a fit for life program (exercise and fitness, 76%), a healthy lifestyle promotion program for diabetes (73%), a comprehensive stress management program (73%), and a healthy lifestyle promotion program for cardiovascular health (71%). There was also substantial support for a pharmacy program offering clinicians support for clinical questions about herbs and dietary supplements (68%), a comprehensive back pain program (66%), an integrative headache management program (63%) and a cancer patient support program (62%).
There were numerous comments in the free text fields. Many respondents were very enthusiastic in their responses, often based on their personal experiences:
"Music therapy is fantastic. I spent some time at X in a post op ward, and they had musicians come to the floors and play, and I can guarantee that not only did the visitors appreciate it, so did the patients, which was the important reason."
"I have degenerative arthritis and started taking yoga myself when Vioxx went off the market. I am so thoroughly convinced of its benefits that I think it ought to be offered as a prescribed form of physical and mental therapy. .... It has changed my life."
"We NEED to have a multidisciplinary pain management and back pain clinic. .. My patients would receive much better care if such a clinic were available."
"We need more psychologists here to provide these therapies. Too time consuming for docs to do it."
"Meditation is very important in a person's life, and to teach or lead someone in it is a very valuable asset."
"I really wish massage was readily available for inpatients." "We need it here."
Several clinicians recommended specific acupuncturists, yoga teachers, exercise programs, Tai Chi instructors, and massage therapists in the community with whom they'd had good relationships. Others listed specific dietary supplements they already recommend for their patients (e.g., multivitamins, vitamins C, D, E, folic acid, calcium, zinc, fish oil, glucosamine, melatonin and probiotics).
A few respondents were cautious and expressed concerns about the scientific evidence for effectiveness, the need for additional education about the therapy or the need for the therapy to be provided only under certain circumstances, even for some therapies currently offered at the institution. For example, regarding acupuncture "Need scientific info regarding efficacy," and regarding special diets, "More CME on this topic, please."
Some respondents felt that at least some of the listed therapies are really mainstream because they:
"have ICD9 and CPT codes.... And are covered expenses by insurers."
"The ketogenic and Atkins diets are both used in the treatment of epilepsy."
"We prescribe special diets for patients with swallowing dysfunction."
"Low fat, high fiber diets are a routine part of clinical practice for many dealing with vascular disease."
"I often recommend low glycemic index diets, Mediterranean style or Ornish type intake."
"Talking about diet is pretty mainstream medicine."
Similarly, "Vitamins and minerals are pretty common recommendation." An ophthalmologist stated, "The only proven clinical benefit from vitamin treatment is for macular degeneration." While an endocrinologist averred, "I advise the use of vitamin D, omega three fish oils, calcium and multivitamin every time I am in clinic." Another specialist wrote, "Vitamins such as folate are a routine part of clinical practice for many dealing with vascular disease."
Furthermore, environmental therapies are "routine in the NICU environment to the extent possible, e.g., low lights, light cycling, and noise control." They (phototherapy) were also "routinely used" in dermatology, while "heat and icing are a routine part of clinical practice for clinicians dealing with musculoskeletal diseases." Similarly, "I treat pain and other distressful symptoms, and I fully advocate for non-pharmacologic modalities of therapy." And
Stress management therapies, "I do recommend relaxation, breathing exercises and prayer (meditation) as a way of stress management." "I discuss general stress management in my clinics."
However, respondents from other specialties sometimes stated directly opposing negative or skeptical views, (e.g., regarding environmental therapies), "This is not appropriate medical therapy."
Few respondents had negative or disparaging comments about therapies listed on the survey. For example, in regard to vitamins and minerals, one physician wrote "We are scientists first, artists second." The most consistently negative comments among a larger group of respondents were expressed about chiropractic and homeopathy,
"This (chiropractic) should NEVER be recommended by an allopathic MD. Chiropractic is pseudoscience."
"I don't believe that homeopathy works. I would never recommend it."
Access to and payments for care were cited as concerns by several respondents:
"Would I use these programs, you bet, but working at the __ Clinic, 40% of my patients are self pay. The rest are Medicare and Medicaid. We have only about 5% that are private insurance. So my utilization would to a large extent be based on cost."
"It depends on the cost to the patients as to how much my patients can utilize these therapies."
And most succinctly, "Who pays?"
Several respondents wrote that although a specific therapy or comprehensive service system was not relevant to their particular specialty, they would nonetheless like to see it offered at the medical center. For example, regarding acupuncture,
"It is not applicable to me in my clinical setting (neonatology), but I hope this is a modality that the medical center will take a greater part in, especially for cancer and chronic pain patients."
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