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Research
Complementary therapies: have they become accepted in general
practice?
Marie V Pirotta, Marc M Cohen, Vicki Kotsirilos and Stephen J Farish
MJA 2000; 172: 105-109
For related articles see Lewith and Newell
Abstract -
Methods -
Results -
Discussion -
Acknowledgements -
Disclosure -
Authors' details
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More articles on complementary medicine
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Abstract |
Objectives: To describe Victorian general
practitioners' attitudes towards and use of a range of complementary
therapies.
Design: A self-administered postal survey sent to a
random sample of 800 general practitioners (GPs) in Victoria in July
1997.
Participants: 488 GPs (response rate, 64%).
Main outcome measures: GPs' knowledge; opinions
about harmfulness and effectiveness; appropriateness for GPs to
practise; perceived patient demand; need for undergraduate
education; referral rates to complementary practitioners; and
training in and practice of each therapy.
Results: Acupuncture, hypnosis and meditation are
well accepted by the surveyed GPs, as over 80% have referred patients
to practitioners of these therapies and nearly half have considered
using them. General practitioners have trained in various therapies
-- meditation (34%), acupuncture (23%), vitamin and mineral therapy
(23%), hypnosis (20%), herbal medicine (12%), chiropractic (8%),
naturopathy (6%), homoeopathy (5%), spiritual healing (5%),
osteopathy (4%), aromatherapy (4%), and reflexology (2%). A quarter
to a third were interested in training in chiropractic, herbal
medicine, naturopathy and vitamin and mineral therapy. General
practitioners appear to underestimate their patients' use of
complementary therapies.
Conclusions: There is evidence in Australia of
widespread acceptance of acupuncture, meditation, hypnosis and
chiropractic by GPs and lesser acceptance of the other therapies.
These findings generate an urgent need for evidence of these
therapies' effectiveness.
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The past decade has seen a dramatic increase in the reported use of
non-orthodox or complementary therapies by the public.1-4 In one year in
Australia, almost half of a representative sample had used at least
one non-medically prescribed complementary remedy and at least one
in five had attended a non-medically trained complementary
therapist.1 Further, Australians
consume as much non-traditional medicine, vitamin and mineral
supplements as prescription drugs.5 There is evidence that the increasing public use of complementary
medicine is paralleled by acceptance among family doctors. In one
region of the United Kingdom in one week, 25% of general practitioners
(GPs) referred patients for complementary therapies,6 while in Canada
half7
to two-thirds8 of family doctors had at some
time referred patients to alternative practitioners; these studies
did not explore reasons for such referral. However, patient pressure
is an acknowledged factor in medical referrals,9 so willingness
of family doctors to refer their patients for these therapies may not
be a good measure of their acceptance of them.
Interest by GPs in training in and practising complementary
therapies may give a better indication. In New Zealand, 54% of GPs were
interested in further training in non-orthodox
therapies,10 while in Israel 88% wanted
training and 16% had trained.11 Estimates of practice of
complementary therapies by GPs vary from around 16% in
Canada8 and the UK,6,12 to 30% in New
Zealand,10,13 47% in Holland (mainly
homoeopathy)14 and up to 85% in Germany
(mainly herbal medicine).15
Despite this degree of interest in and use of complementary therapies
by family doctors, in the United States it has been estimated that 70%
of people who attend non-medically trained complementary
therapists do not inform their family doctor.3
The corresponding situation in Australia is largely unknown. At
least 15% of Australian GPs practise acupuncture,16 the only
non-orthodox therapy that attracts specific funding from Medicare.
In this study, we describe Victorian GPs' attitudes towards and use of
a range of complementary therapies.
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Methods
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We obtained a random sample of 800 Victorian GPs who had each seen at
least 1500 patients in 1996 from the Health Insurance Commission,
which administers the national health insurance scheme (Medicare).
We designed an 11-page survey to investigate various aspects of GPs'
interactions with the following complementary therapies:
acupuncture, aromatherapy, chiropractic, herbal medicine,
homoeopathy, hypnosis, meditation, naturopathy, osteopathy,
reflexology, spiritual healing (eg, Reiki) and vitamin and mineral
therapy. We developed the survey from the existing
literature17 and by using a focus group
of local GPs. After pilot testing, the survey was mailed to the 800 GPs
with a reply paid envelope in July 1997. Non-responders were sent a
reminder postcard and then a follow-up survey if necessary. Doctors
who had left their clinic leaving no forwarding address, taken
extended leave, were seriously ill, or had moved overseas, retired or
died were excluded.
The study received ethical approval from both the University of
Melbourne and Monash University.
The statistical analysis was performed using SAS.18 Responses
were analysed to search for groupings of common levels of
use/acceptance. (In all instances, for these data the 95% confidence
intervals for percentages never exceed ± 4.5%.) Qualitative data
from space left for comments were coded and classified by themes.
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| | Results |
Thirty-six GPs were excluded according to the exclusion criteria,
leaving 764 GPs. Questionnaires were returned by 488, giving a
response rate of 64%. The sample was representative of Australian
GPs19,20 in terms of sex, age
distribution, metropolitan or rural practice location and number of
patients seen per week up to 199; doctors seeing more than 200 patients
per week, however, were underrepresented. There was no significant
difference in age or sex between responders and non-responders.
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Knowledge of complementary therapies | |
At least 80% of GPs reported that they knew something of acupuncture,
hypnosis, meditation and chiropractic; about half knew something of
herbal medicine, naturopathy and vitamin and mineral therapy; while
60%-70% had only heard of osteopathy, homoeopathy, spiritual
healing, reflexology and aromatherapy.
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Opinions on the harmfulness and effectiveness of complementary
therapies | |
Most GPs agreed that the well-known therapies (acupuncture,
meditation, hypnosis and chiropractic) were moderately to highly
effective (see Box 1); three-quarters also agreed that chiropractic
was occasionally harmful. When given the opportunity to write
comments, many doctors expressed concern that complementary
therapies could be harmful if a diagnosis is delayed or missed or if a
proven (orthodox) therapy is neglected. Complementary therapies
were considered to have a strong placebo effect. Some respondents
commented that, while some therapies were effective in certain
conditions, one could not generalise and effectiveness may depend
upon the training and competence of the therapist. General
practitioners frequently differentiated between medical and
non-medical practitioners and expressed greater confidence in
medically trained colleagues who practised these therapies.
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Opinions on the appropriateness of GPs to practise complementary
therapies and eligibility for Medicare subsidy | |
Box 2 shows responses to the question of whether it is appropriate for
general practitioners to practise these therapies. Although
chiropractic was considered occasionally harmful by 75% of general
practitioners surveyed, 55% considered it appropriate for trained
GPs to practise.
Doctors who agreed that it was appropriate to practise a therapy were
asked whether GPs should be eligible for Medicare funding when
practising these therapies. Nearly all GPs agreed that acupuncture
should be funded. There was also strong support for specific funding
for GPs practising hypnosis (91%), meditation (77%) and
chiropractic (69%). Even the relatively unknown therapies had
support from approximately a quarter of GPs for specific Medicare
funding.
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Teaching in undergraduate curricula | |
Most respondents (93%) agreed that there should be some education on
complementary therapies in core medical undergraduate curricula.
However, doctors were evenly divided over a five-point scale about
the importance of this education for students.
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Patient demand |
Fifty-nine per cent of GPs reported that patient demand for
complementary therapies was increasing, 29% reported demand was
static, and 10% were unsure. A third of doctors estimated that less
than 10% of their patients used complementary therapies and another
third thought that 11%-30% did. Nearly half of the GPs reported that
less than 5% of their patients had asked them about complementary
therapies in the past month.
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Referrals for complementary therapies | |
Box 3 summarises GPs' responses on referrals to complementary
therapists, from how they would respond if a patient suggested
consulting a complementary therapist to how often they themselves
refer patients to these therapists. The question did not specify
whether the therapists were medically trained.
Most GPs (93%) had referred at least once and 82% had referred at least a
few times a year for a complementary therapy.
Just under half of the sample referred at least a few times per year for
the best-known therapies -- acupuncture, meditation, hypnosis and
chiropractic. While approximately two-thirds of the general
practitioners would encourage a patient who suggested consulting a
practitioner of acupuncture, meditation or hypnosis, only 29% would
do so for chiropractic. In the remaining therapies, GPs were twice as
likely to have actually referred a patient for these therapies than to
endorse a patient's suggestion to consult a practitioner.
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Training and use of complementary therapies | |
Box 4 shows that half of the GPs expressed an interest in training in
acupuncture, meditation and hypnosis and a quarter to a third in
chiropractic, herbal medicine, naturopathy and vitamin and mineral
therapy. Nearly 20% of GPs practised one of the therapies, 8% used two
therapies, 6% three, and 3% of general practitioners practised
between 4 and 11 of these complementary therapies. For most of the
complementary therapies, 80% or more of the GPs who trained in them
practised them to some degree; exceptions were meditation (50%),
hypnosis (56%), herbal medicine (62%) and vitamin and mineral
therapy (64%). The practice of some complementary therapies,
notably homoeopathy, vitamin and mineral therapy, naturopathy and
herbal medicine, represented more than half of the clinical work for a
small number of Victorian GPs.
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| | Discussion
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Our survey provides the first comprehensive description of the use of
complementary therapies by GPs in Victoria. As the large sample is, in
nearly all characteristics, similar to Australian GPs as a whole, our
findings about GP attitudes and use of complementary therapies are
likely to reflect the situation across the country. Nearly 20% of GPs
had used acupuncture, meditation or hypnosis, and almost half had
considered practising these therapies. Over 80% of GPs had referred
patients to practitioners of these therapies. A quarter to a third
were interested in training in chiropractic, herbal medicine,
naturopathy and vitamin and mineral therapy. Further, around 5% of
doctors use therapies, such as osteopathy, homoeopathy,
aromatherapy and spiritual healing, which are relatively unknown to
most of their colleagues.
It is interesting to speculate on the discrepancy between the number
of GPs who trained in meditation, hypnosis, herbal medicine and
vitamin and mineral therapy and the number who actually practise
these therapies (Box 4). Possible reasons may include GP or patient
dissatisfaction with outcomes, poor acceptance by patients, lack of
financial reward, or difficulty accommodating more time-consuming
therapies in a busy clinic.
The GPs we surveyed estimated a lower use of complementary therapies
by their patients than indicated by population-based research. This
may be because the portion of the population who do not attend GPs for
their primary health care may attend complementary therapists, and
because those who do attend GPs may be less likely to use complementary
therapies.
The interpretation of our findings is limited by several possible
sources of bias. We have no information on non-responders, and the 64%
who did respond may have been more likely to participate because they
had particularly strong positive or negative views. The effects of
self-report and recall bias are also unknown. Further, we did not
define the therapies listed in the questionnaire and GPs may have
different interpretations of the terms used, particularly vitamin
and mineral therapy.
Reviewing studies of various designs shows that Victorian doctors
have similar levels of interest in training in, and of referral of
patients for, complementary therapies as their colleagues in other
Western countries, with the exceptions of Holland and
Germany.6-8,10,12-15 However, the
popularity of therapies varies. For example, the most popular
therapy practised in Victoria was acupuncture, with 23% of
respondents having trained, whereas only 8% of GPs in
Canada8 and 4% in the UK12 had had
acupuncture training. By contrast, homoeopathy, which has an
established role in Europe,4 was the most popular
complementary therapy practised by British GPs,6,12 but one of the
least popular therapies in Victoria.
Complementary therapies may well have something to offer, but it is of
concern that therapies of unproven effectiveness are apparently
being accepted in mainstream general practice. Many editorials,
while acknowledging that randomised controlled trial evidence is
lacking for many aspects of orthodox Western medical practice, have
called for quality trials in complementary therapies.21,22 The
Cochrane Library is coordinating a search for randomised controlled
trials of complementary therapies and is undertaking systematic
reviews of therapies for specific conditions.23 Meanwhile,
other reviews have found some evidence of efficacy, for example St
John's wort in treating mild to moderate depression,24 acupuncture
for antiemesis,25 and also an overall
greater than placebo effect for homoeopathy in a meta-analysis of
trials for various conditions.26
There are diverse reasons for the lack of evidence for complementary
therapies. Many therapies have not been challenged before because of
their long history, "natural" origins or patients' or doctors'
anecdotal reports of success. In this era of evidence-based
medicine, there are difficulties applying the gold standard of
randomised controlled trials to therapies which are based on
different and varied paradigms of health and illness. Funding for
trials in "natural" therapies is also lacking. Freely available
herbs cannot be patented, so there is little incentive for research,
particularly if the public is buying them regardless of evidence.
Lewith et al suggest that lack of structure to enhance research in
complementary therapies is a barrier in Britain.27 Our
experience would suggest a similar situation in Victoria.
Our findings show that general practitioners are actively using
complementary therapies. Therefore, whatever the profession's
attitude towards these therapies, well-designed trials,
disseminated and accessible results and education are urgently
needed to inform GPs' decision-making.
Further research is also required into why GPs decide to practise
these therapies and why they are less likely to endorse a patient's
suggestion to consult a complementary therapist than to refer
themselves. The problems of compliance with and interactions
between orthodox and complementary therapies are also areas where
much research is needed. As our findings support those of Eisenberg et
al3
that GPs may not communicate sufficiently with their patients and are
not aware of their widespread use of complementary therapies, the
issues of communication between doctors and complementary
therapists, as well as between doctors and their patients, also need
to be addressed.
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Conclusions |
Acupuncture, meditation, hypnosis and, possibly, chiropractic may
be considered to be well-accepted therapies in Victorian general
practice, while herbal medicine, naturopathy, vitamin and mineral
therapy, osteopathy and homoeopathy are accepted by a sizable
minority of doctors. Doctors underestimate their patients' use of
these therapies, which may contribute to compliance and medication
interaction problems. There is an urgent need for well-designed
trials to search for evidence of the effectiveness of these
non-orthodox therapies, to inform doctors' and patients' use of
them.
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Acknowledgements
| |
We thank Dr Jane Gunn and Dr Ngaire Kerse for advice, and Eleni Sita and
Sue Vallance for assistance with data collection. Dr I Brighthope,
Blackmores Ltd, Aveda, Nutrition Care Pharmaceuticals and the
Australian Integrative Medicine Association contributed funding
for this research.
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| |
Disclosure |
Those who funded this trial had no input into its design, analysis,
conclusions, writing of the manuscript or the decision to submit it
for publication.
|
| | References
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(Received 13 May, accepted 5 Oct,1999)
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Authors' details | |
Department of General Practice and Public Health, University of
Melbourne, Carlton, VIC.
Marie V Pirotta, MMed, FRACGP, Senior Lecturer.
Stephen J
Farish, BSc(Hons), MEd, Biostatistician and Senior Lecturer.
Complementary Medicine Research Unit, Monash University,
Melbourne, VIC.
Marc M Cohen, PhD, MB BS(Hons), Senior Lecturer.
Clayton, VIC.
Vicki Kotsirilos, MB BS, General Practitioner.
Reprints will not be available from the authors.
Correspondence: Dr M
V Pirotta, Department of General Practice and Public Health,
University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053.
m.pirottaATgpph.unimelb.edu.au
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1: Attitudes among the 488 general practitioners on the harmfulness and effectiveness of complementary therapies* | | Harmful
| Effective
| | Frequently | Occasionally | Seldom | Highly | Moderately | Seldom | |
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| | Acupuncture | 1 (0) | 76 (16%) | 395 (82%) | 93 (21%) | 294 (67%) | 41 (9%) | | Chiropractic | 32 (7%) | 362 (75%) | 82 (17%) | 48 (11%) | 306 (70%) | 61 (14%) | | Hypnosis | 1 (0) | 141 (29%) | 305 (63%) | 77 (18%) | 260 (60%) | 61 (14%) | | Meditation | 0 | 10 (2%) | 436 (90%) | 124 (29%) | 230 (53%) | 41 (10%) | | Osteopathy | 12 (3%) | 180 (37%) | 141 (29%) | 31 (7%) | 138 (32%) | 114 (26%) | | Herbal medicine | 20 (4%) | 262 (54%) | 144 (30%) | 14 (3%) | 128 (30%) | 199 (46%) | | Naturopathy | 16 (3%) | 200 (42%) | 165 (34%) | 19 (4%) | 125 (29%) | 191 (44%) | | Vitamin and mineral therapy | 11 (2%) | 214 (45%) | 182 (38%) | 22 (5%) | 94 (22%) | 224 (52%) | | Spiritual healing (Reiki) | 8 (2%) | 57 (12%) | 199 (41%) | 12 (3%) | 83 (19%) | 123 (28%) | | Homoeopathy | 13 (3%) | 143 (30%) | 188 (39%) | 10 (2%) | 72 (17%) | 217 (50%) | | Aromatherapy | 3 (1%) | 22 (5%) | 313 (65%) | 5 (1%) | 67 (16%) | 215 (50%) | | Reflexology | 12 (3%) | 47 (10%) | 198 (41%) | 4 (1%) | 31 (7%) | 207 (48%) |
| | *Many GPs offered no opinion, resulting in some missing values.
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2: Opinions among general practitioners about the appropriateness of GPs to practise and charge Medicare for complementary therapies | | Appropriate for trained GPs to practise | Should be eligible for Medicare rebates* |
| | Acupuncture | 97% (419/434) | 91% (384/422) | | Hypnosis | 92% (396/430) | 91% (364/399) | | Meditation | 80% (342/428) | 77% (282/367) | | Chiropractic | 55% (238/432) | 69% (207/301) | | Vitamin and mineral therapy | 44% (184/423) | 54% (137/254) | | Herbal medicine | 43% (183/427) | 53% (138/263) | | Naturopathy | 28% (117/424) | 42% (93/224) | | Osteopathy | 27% (113/423) | 44% (94/216) | | Homoeopathy | 23% (98/424) | 36% (77/213) | | Spiritual healing (Reiki) | 18% (74/422) | 27% (50/189) | | Aromatherapy | 17% (73/428) | 24% (47/197) | | Reflexology | 11% (48/426) | 22% (38/174) |
| | *Follow-on question answered only if the therapy was considered appropriate to practise.
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3: Referral of patients for complementary therapies among general practitioners | | | Those who ever referred patients
| | | | Frequency of referrals
| | Encourage a patient's suggestion to attend | % (No.) | Rarely | Few times a year | At least monthly | At least weekly |
| | Meditation | 74% (374/470) | 80% (379/476) | 31% (118) | 40% (153) | 20% (76) | 9% (32) | | Acupuncture | 71% (332/470) | 90% (424/473) | 24% (100) | 47% (199) | 19% (82) | 10% (43) | | Hypnosis | 62% (292/470) | 82% (386/473) | 44% (168) | 46% (179) | 10% (37) | 1% (2) | | Chiropractic | 29% (137/470) | 69% (326/476) | 37% (122) | 41% (135) | 17% (54) | 5% (15) | | Vitamin and mineral therapy | 17% (79/469) | 33% (157/472) | 57% (90) | 30% (47) | 8% (12) | 5% (8) | | Osteopathy | 16% (75/467) | 30% (141/476) | 55% (78) | 30% (42) | 11% (15) | 4% (6) | | Spiritual healing (Reiki) | 14% (66/469) | 20% (93/476) | 74% (69) | 20% (19) | 4% (4) | 1% (1) | | Naturopathy | 13% (62/470) | 30% (141/474) | 56% (79) | 26% (37) | 13% (18) | 5% (7) | | Herbal medicine | 12% (56/469) | 29% (138/474) | 63% (87) | 24% (33) | 9% (13) | 4% (5) | | Homoeopathy | 9% (43/470) | 20% (91/473) | 73% (66) | 18% (16) | 8% (7) | 2% (2) | | Aromatherapy | 9% (42/471) | 18% (83/475) | 70% (58) | 23% (19) | 6% (5) | 1% (1) | | Reflexology | 7% (22/470) | 10% (48/476) | 77% (37) | 17% (8) | 6% (3) | 0
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4: Training in and practice of complementary therapies among general practitioners | | Those who practise the therapy
| | % Who practise
| | Interest in training | Have trained* | No. | 5% | 6%-24% | 25%-50% | >50% |
| | Meditation | 59% (283/477) | 34% (151/441) | 75 | 67% (50) | 27% (20) | 5% (4) | 1% (1) | | Hypnosis | 52% (246/478) | 20% (89/442) | 50 | 78% (39) | 20% (10) | 0 | 2% (1) | | Acupuncture | 49% (235/477) | 23% (102/441) | 99 | 58% (59) | 34% (33) | 4% (4) | 3% (3) | | Herbal medicine | 36% (169/474) | 12% (53/438) | 33 | 61% (20) | 27% (9) | 3% (1) | 9% (3) | | Vitamin and mineral therapy | 34% (160/470) | 23% (98/434) | 63 | 46% (29) | 38% (24) | 3% (2) | 13% (8) | | Naturopathy | 25% (117/476) | 6% (26/439) | 25 | 56% (14) | 24% (6) | 8% (2) | 12% (3) | | Chiropractic | 24% (112/475) | 8% (34/437) | 29 | 76% (22) | 21% (6) | 3% (1) | 0 | | Aromatherapy | 17% (83/477) | 4% (19/438) | 18 | 83% (15) | 16% (3) | 0 | 0 | | Homoeopathy | 16% (75/477) | 5% (23/440) | 21 | 67% (14) | 19% (4) | 0 | 14% (3) | | Osteopathy | 13% (61/475) | 4% (17/437) | 22 | 68% (15) | 18% (4) | 9% (2) | 5% (1) | | Spiritual healing (Reiki) | 12% (57/473) | 5% (21/439) | 17 | 71% (12) | 24% (4) | 0 | 6% (1) | | Reflexology | 7% (33/475) | 2% (9/438) | 12 | 100% (12) | 0 | 0 | 0 |
| *Includes self-taught.
These figures, which show that more doctors use osteopathy and reflexology than have actually trained in it, reflect inconsistencies in individual responses.
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