Attitude of Conventional and CAM Physicians Toward CAM in India

Introduction

T he complementary and alternative treatments used in India include those that have developed in the subcontinent (such as yoga, Ayurveda, and the less-known Siddha medicine), as well as those derived from other cultures, such as Unani-Tibbs medicine, which is derived from what was then Persian traditional knowledge. ¹

Physicians can moderate patients' beliefs about the use of CAM treatments. ² In a survey carried out in the United States, 61% of physicians did not feel sufficiently knowledgeable about the safety or efficacy of complementary and alternative medicine (CAM), and 81% would have liked to receive more education about CAM. In a survey conducted on 494 physicians in Greece to assess the use and attitudes toward CAM therapies in Greece, ³ the questions were related to the familiarity of the physicians with CAM therapies and the use of CAM therapies by patients with cancer, as perceived by their physicians. Greek physicians were found to be most familiar with homeopathy (58.5%), diets (58.1%), use of vitamin C and other antioxidants (55.9%), and acupuncture (47.9%). On the whole, Greek physicians surveyed showed a low level of interest in CAM. In a survey conducted in the United States, 660 internists at the Mayo Clinic were asked about their attitude toward CAM in general and about their knowledge of specific CAM therapies. ⁴ Of the 233 physicians who responded to the survey, 76% had never referred a patient to a CAM practitioner, though 44% did state that they would refer a patient for CAM treatment if a CAM practitioner was available at their institution. The general outcome was that physicians felt the need for evidence-based information regarding CAM.

A survey was also conducted in the United Kingdom to investigate the views of doctors with a dual clinical and academic (research) role. ⁵ Semistructured interviews were administered to 9 doctors. In this study, like the findings reported above, ⁴ lack of scientific evidence expressed by doctors emerged as the main concern doctors felt when prescribing the use of CAM.

One hundred and ninety two (192) physicians in Russia who were practicing at three study hospitals were given a questionnaire. ⁶ One hundred and seventy-seven (177) physicians responded. All of them had practiced CAM or referred patients for at least two CAM therapies. The factors particularly associated with CAM use were knowledge of a foreign language, having a surgical specialty, and female gender, while those who had completed only their internship or had a specialization in critical care medicine were the least likely to prescribe CAM.

In Israel, 333 primary care physicians and 241 CAM practitioners responded to a questionnaire assessing the attitudes toward integrating CAM in primary care. ⁷ The questionnaire was also given to 1150 patients. Patients supported CAM practitioners regardless of whether the practitioner held a medical degree or not. The overall implication was that primary care physicians would probably be required to have more knowledge and a balanced approach toward CAM use.

The attitude of general practitioners in Turkey was also studied. ⁸ While 521 general practitioners were given the questionnaire, the responses from 49% were analyzed. Among them, 96.5% of physicians did not have any education about CAM, 74.4% wanted to learn more, and 51% believed in the usefulness of CAM, whereas 38% did not. In general, the study indicated that general practitioners have an interest in CAM and want to learn more.

In the studies cited above, medical practitioners from different countries had different levels of interest in CAM. However, all of them expressed an interest in learning more about CAM, and most of them were eager to have evidence regarding whether CAM was useful or not. There have been fewer comparisons of the attitudes of physicians trained in conventional medicine compared to CAM practitioners. One such study was conducted in Switzerland and explored the philosophy of care in 623 general practitioners who provided conventional or complementary primary care. The two groups were found to differ significantly in various aspects of care, such as (1) holistic versus positivistic approach, (2) an intrinsic motivation for CAM versus an extrinsic motivation, and (3) and differences in their priorities in medical activity. Both groups were aware of the limitations of some of the CAM treatments used.

In another study, conducted in Australia, 23 integrative practitioners were interviewed, which included 10 general practitioners (GPs) and 13 naturopaths. ⁹ They were from 16 integrated practices and 1 nonintegrative general medical practice. The interesting finding was that the more training the GPs had in CAM, the greater was the extent to which CAM practitioners were involved as diagnosticians and treatment providers.

The present study was conducted to compare primary care physicians trained in conventional medicine, with CAM practitioners whose training was for a comparable duration. The CAM practitioners included practitioners of Ayurveda, homeopathy, and naturopathy. They also practiced as primary care physicians.

Materials and Methods

Results

Among conventional practitioners, 89% responded that they used CAM, while 11% did not. Among homeopaths it was 99% (yes) and 1% (no), among Ayurveda doctors it was 100% (yes), and among naturopaths it was 94% (yes) and 6% (no). This difference between the percentage responding “yes” to using CAM compared to those who responded “no” was significantly different for all four groups (χ², p<0.001).

The responses to the second question (i.e., “which CAM treatment would you prescribe as a first choice, including the CAM treatment you are trained in?”) had the following responses. Sixty-five percent (65%) of conventional medicine physicians chose yoga, while 46% of homeopaths chose homeopathy, 51% of physicians trained in Ayurveda chose Ayurveda, and 57% of naturopaths chose naturopathy (χ², p<0.001). The remainder under each category chose different options.

The third question assessed the practitioners' views about the usefulness of CAM treatments. Most conventional physicians felt that CAM treatments are useful to some extent (56%), followed by those who believed there was a lot of benefit (42%), with the least percentage believing that CAM treatments were not at all useful (2%). The other 3 CAM practitioners (homeopaths, Ayurveda physicians, and naturopaths) showed a difference. The maximum percentage believed that CAM helped “a lot” (50% for homeopaths, 71% for Ayurveda physicians, and 78% for naturopaths). In this category also, the smallest percentage believed that CAM was not at all useful (6% for homeopaths, 5% for Ayurveda physicians, and 3% for naturopaths). The χ² test showed that the percentages of practitioners in the categories who had different responses were significantly different (p<0.001, comparing the percentage who responded (1) “not” versus “a lot,” (2) “not” versus “some,” and (3) “some” versus “a lot” for the four groups. Hence the comparison was between responses and not between groups, whose responses were comparable.

The fourth question queried the reason why the four categories of physicians chose to prescribe CAM treatments, if they did do so. The percentage values for the four categories of physicians and their reasons to prescribe CAM are given in Table 1. The maximum percentage of conventional physicians (40%) chose CAM treatments because they believed CAM treatments manage a disease by dealing with the cause. This was also true for homeopaths (56%), Ayurveda physicians (42%), and naturopaths (57%). The second most important reason was the same for the four groups and was a strong belief in CAM. However, the magnitude of change as a percent change was different, though not significantly so, for the four groups. This was as follows: for conventional physicians (22%), for homeopaths (15%), Ayurveda physicians (24%), and naturopaths (24%). The percentage of persons who chose “getting to the cause of the disease” as the first reason for selecting CAM was significantly higher for all four groups than those who chose a strong belief in CAM (χ² test, p<0.001), hence also, the comparison was between options rather than groups.

The fifth question assessed the physicians' idea about the usefulness of CAM for specific diseases. The responses were varied. Physicians trained in conventional medicine considered essential hypertension the most likely to respond to treatment, homeopaths considered dermatological conditions the most responsive, Ayurveda physicians considered bronchial asthma the most likely to respond, and naturopaths considered CAM most useful in pain management.

The sixth question gave an indication about which condition was the least likely to be managed with CAM treatment. Conventionally trained physicians mentioned oncological disorders, while Ayurveda physicians considered both oncological disorders as well as persons who were human immunodeficiency virus–positive or had acquired immune deficiency syndrome. In contrast, both homeopaths and naturopaths believed that there were no conditions that could not be managed by CAM treatments.

Discussion

The present study provided interesting insights about the attitudes toward CAM of physicians trained in different disciplines in India. It was interesting to note that most conventional and CAM physicians (homeopaths, Ayurveda physicians, and naturopaths) did prescribe CAM treatments for their patients and that the groups did not differ significantly in this. However, the physicians' average age was 48.2±12.3 years and hence may not have necessarily represented the attitude of younger physicians.

Conventional physicians were most likely to prescribe yoga. Though this was not asked in the questionnaire, some of them (4%) did mention that this was because they had been exposed to evidence that yoga is an effective add-on therapy. However, yoga is not part of the curriculum for the degree course for conventional physicians in India. ¹⁰ Forty-six percent (46%) of homeopaths prescribed homeopathy, 51% of Ayurveda physicians prescribed Ayurveda, while 57% of naturopaths prescribed naturopathy. The remaining CAM physicians prescribed CAM treatments other than those for which they had received primary training. This may be taken as a sign of openness of the physicians. However, since some of the courses for these disciplines are of short duration (as short as 1 month), it is probably essential for the guidelines for prescribing CAM therapies to be streamlined, so that physicians interested in using these treatments are able to do so with maximum benefit and no risk to the patient. The reason for mentioning this is that to obtain a degree to practice as a naturopath, a homeopath or an Ayurveda physician takes a minimum of 5 years, but there are various short-duration courses that a physician may take and practice a CAM treatment other than the treatment for which they were primarily trained. This emphasizes the importance of strict regulations for the prescription of CAM treatments to ensure that the physician is adequately qualified.

The largest percentage of both conventionally trained and CAM physicians believed that CAM treatments helped a lot. The lowest percent (41%) was among conventionally trained physicians and the highest percent (78%) was among naturopaths. It would have been interesting to know why those conventionally trained physicians who were conservative in their estimate about the usefulness of CAM treatments did have reservations. Not finding this out is one of the inadequacies of this study.

It was interesting to note that all four categories of physicians studied chose CAM treatments because they believed these treatments helped to manage a disease by modifying the factors causing it. This may be related to the fact that in yoga and Ayurveda, like many CAM treatments, this is an important part of the treatment. ¹¹ It was also interesting that the second most common reason was a strong belief that CAM treatments work. Earlier it was mentioned that 4% of conventionally trained physicians studied here mentioned (without being specifically questioned about it) that having evidence that a CAM treatment worked influenced their choosing that treatment. The present questionnaire did not determine whether the strong belief was based on their own clinical experience, published research, or was “blind faith.” Not having this information is a serious limitation of the present study, which suggests the line of questioning further studies may take.

All four categories of physicians selected diseases (as their choice of what can be managed with CAM), which are well managed by CAM treatments. Physicians trained in conventional medicine considered that essential hypertension was the most likely to respond to treatment. This may be considered interesting, because despite the fact that a variety of CAM approaches have been used in the treatment of hypertension, the potential benefit of these interventions is not yet conclusive. ¹² A review of the evidence supporting CAM approaches used in treating hypertension, based on references in MEDLINE^® and EMBASE between January 1966 and May 2008, showed that while many CAM therapies can be considered part of an evidence-based approach to the treatment of hypertension, the potential benefit of these interventions warrants further research. The conditions mentioned by the conventionally trained and CAM physicians were essential hypertension, dermatological conditions, bronchial asthma, and pain management. For hypertension, bronchial asthma, and also possibly pain managements, it is essential that the physicians be well informed, so that the patients also could understand all aspects of their condition so as to avoid untoward emergencies. ¹³ Maximum numbers of conventionally trained and Ayurveda physicians were convinced that oncological conditions did not respond to CAM. Another limitation of the study is that the sample was selected by convenience sampling and was a self-selected group who had chosen to join the program of Indian culture. In Indian culture, yoga and Ayurveda are considered ways of living and as therapies secondarily. Hence, this group may already have been interested in CAM treatments.

The study showed that in India, conventionally trained physicians and those trained in CAM had a comparable approach to CAM treatments. Given the physicians' interest in CAM treatments, using CAM treatments for certain conditions such as bronchial asthma and essential hypertension requires both physicians and patients to be well informed about the disease and the treatment. Providing evidence-based education about CAM treatments seems to be important, given the interest physicians expressed in CAM treatments.

Conclusions

Eighty-two (82) conventionally trained and 213 CAM physicians were equally likely to prescribe CAM treatments for their patients. Their reasons for prescribing CAM treatments were (1) the idea that the CAM treatments manage the cause of the disease, and (2) a belief in the treatment. A limiting factor of the survey is that it did not determine whether the belief was based on evidence or on faith alone.