Original Research Article DOI: 10.18231/2348-7682.2016.0011 Panacea Journal of Medical Sciences, September-December,2016;6(3): 159-163 159 Complementary and Alternative Medicine: Hidden presence among doctors and patients, an explorative study RS Solanki Assistant Professor, Dept. of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra Email: drranjansolanki@gmail.com Abstract The term "alternative medicine" is used to describe healing treatments that are not part of conventional medical training. When alternative treatments are used along with conventional therapies then it is known as complementary medicine. This together is known as complementary alternative medicine (CAM). The purpose of our study was to determine the prevalence of complementary and alternative medicine (CAM) and perception about CAM and cultural beliefs among doctors and patients attending primary care at KEM Hospital in Mumbai.A cross-sectional study was carried out in primary care clinics in at GS Seth medical College and KEM Hospital. A random sample of 100 doctors and patients was used. Convenience sampling has been used. Doctors and patients were interviewed by a pretested semi structured questionnaire including CAM use, satisfaction with care, ailment for which CAM used and cultural health beliefs about the same.All the doctors were aware of Ayurveda, homeopathy and yoga. 40% doctors were also aware of Siddha, Unani, Naturopathy, Acupressure and Acupuncture. 82% doctors and 58% patients have tried Complementary and Alternative Medicine at least once in the past. Chronic conditions like skin ailments asthma, arthritis, body aches are most commonly sought after. Amongst different CAM therapies, 52% doctors and 41% patients consulted for Ayurveda which is highest in frequency. This is followed by Homeopathy and Yoga. 63% doctors and 69% patients were relieved of the symptoms for which they had consulted the CAM therapy. Dissatisfaction from conventional treatment, philosophical and spiritual orientation, friendlier approach of CAM therapist and affordability of CAM therapies were chief reasons to seek CAM modalities. Ayurveda is most consulted for. And maximum consultations to CAM therapies were done for skin ailments. 84% patients reported that they had tried some form of home remedies before visiting doctor. And 70% of them found these home remedies to be effective. As seen in this study, use of CAM is much prevalent among health care providers and seekers. The results of this study suggest doctors should be in a better position to make informed choices about CAM modalities. Further research and studies needed to determine the mechanism of action of many of the popular CAM modalities. Keywords: Complementary Alternative Medicine, Prevalence, Tertiary Care Hospital. Introduction The term "alternative medicine" is used to describe healing treatments that are not part of conventional medical training. Many patients and health care providers use alternative treatments together with conventional therapies. This is known as Complementary Medicine. This together is known as Complementary Alternative Medicine(CAM). Current estimates indicate that at least 50% of the population in the United States is using some form of alternative therapy and that, furthermore, very few of these persons will tell their primary care physician of their use of these therapies for fear of criticism and humiliation. Many Americans—more than 30 percent of adults and about 12 percent of children use CAM modalities.(1) In developing countries, where more than one-third of the population lacks access to essential medicines, the provision of safe and effective Complementary and Alternative Medicine therapies could become a critical tool to increase access to health care. With the increase in cost of conventional medical treatment, the incidence of self-medication has increased and many families prefer to try home remedies and alternative therapies before consulting a qualified medical practitioner.(2) Many physicians believe in the usefulness of alternative medicine, especially in cases where conventional medicine cannot provide a cure. Often there seems to be no effective therapy for chronic back or joint pain, depression, gastrointestinal disorders, skin problems or diseases categorized as "allergic" or "autoimmune".(3) As part of its Global Strategy for Health for All in the 21st Century, the World Health Organization (WHO) has supported the integration of conventional and alternative medicine to improve the quality of health care. In India AYUSH department, has been created in ministry of health and family welfare in November 2003. Central council of Industrial Research has prepared guidelines about use of AYUSH, which are being used under National Health Mission. The government of India in association with CSIR has developed Traditional Knowledge Digital Library (TKDL) loaded with ancient medical knowledge. The online database contains translations of manuscripts and textbooks in five languages including English. Patency for traditional medicine has been registered as per international protocol using advanced information technology. On the same ground, this study is an attempt to know the frequency of the use of complementary and RS Solanki Complementary and Alternative Medicine: Hidden presence among doctors…. Panacea Journal of Medical Sciences, September-December,2016;6(3): 159-163 160 alternative medicine by health care providers and health care seekers. The present study also attempts to understand the perception of doctors and patients regarding complementary and alternative therapies at tertiary care hospital in Mumbai. Material and Methods The present study has been conducted at General Out Patient Department at GS Seth Medical College and KEM Hospital, Mumbai in state of Maharashtra. The present study is a cross sectional study done from 1/05/10- 15/05/10. Convenience sampling has been used for this study. The patients attending General outpatient department were chosen by systematic random sampling. Fifty patients who consented to spare time and filling proforma were selected. 50 residents doctors who consented to participate were also selected for the study. Critically ill patients and patients below 18 years of age were excluded from the study. A socio demographic profile that included age, name sex, educational status, residence and socioeconomic status were administered. In addition to above stated questions the self-administered questionnaire semi structured questionnaire administered to doctors also included questions regarding CAM use the most common reasons for using CAM and patient perceptions of CAM therapy ailments for which patients are referred to CAM and their opinion regarding safety of use of CAM. These were derived from the current literature and listed as choices referral of patients to CAM. The questionnaire for patients consists of 15 direct questions on the use and attitudes towards alternative medicine. The questionnaire for doctors consists of 20 direct questions on perception and their view about incorporating alternative medicine into the health care system. The questions also dealt with awareness about possible harmful effects of alternative medicine. Results 50 patients and 50 doctors approached for the study completed the questionnaire. The study participants’ demographics are outlined in Table1.The mean age of doctors who participated in the study was 26 yrs whereas for patients it was 34years. 66% (n=33) patients and 56% (n=29) doctors were males.44% (n=21) doctors and 34% (n=17) patients were females. 51% (n=26) doctors were from Department of Community Medicine. None of the patient is illiterate. 62% (n=31) of the patients have completed their secondary schooling. 18% (n=9) patients have completed higher secondary education. Only 12% (n=6) patients are graduates. Table 1: Socio demographic profile of study participants Doctors n=50 Patients n=50 17-22yrs - 9(18%) 22-40yrs 50(100%) 25(50%) >40yrs - 16(32%) Male 29(56%) 33(66%) Female 21(44%) 17(34%) PSM 26(51%) - Medicine 15(30%) - Pediatrics 9(18%) - Illiterate nil Primary Pursuing M.D. 4(8%) Secondary 31(62%) Higher secondary 9(18%) Graduation 6(12%) Table 2: Attitude and Perception of Doctors and Patients about Complementary and Alternative Medicine The frequency of therapies known by patients (multiple responses) P value Complementary and alternative Medicine % of patents aware of it 1 Ayurveda 44(88%) 2 Homeopathy 40(80%) 3 Yoga 42(84%) 4 Unani 5(10%) 5 Others 4(8%) 6 Nil 6(12%) Frequency of doctors and patients who have tried Complementary and alternative therapies P=0.0088 CAM tried (n=50) 1 Doctors 41(82%) 2 Patients 29(58%) Ailments for which CAM were tried by doctors and patients Doctors(n=41) Patients(n=29) 1 Skin 8(19%) 5(17%) 2 URTI 9(21%) 3(10%) RS Solanki Complementary and Alternative Medicine: Hidden presence among doctors…. Panacea Journal of Medical Sciences, September-December,2016;6(3): 159-163 161 3 Arthritis 3(7%) 7(24%) 4 Hepatitis 3(7%) 2(6%) 5 Bodyache - 7(24%) 6 Others 18(43%) 5(17%) Frequency of CAM tried by doctors for themselves and tried by patients P=0.0869 Therapy Doctors(n=41) Patients(n=29) 1 Ayurveda 21(52%) 12(41%) 2 Homeopathy 12(29%) 8(27%) 3 Yoga 8(19%) 9(32%) Frequency of doctors and patients who reported relief from symptom after use of CAM Doctors(n=41) Patients(n=29) P = 0.8209 Symptoms got relieved 26(63%) 20(69%) Reasons for going for CAM by Doctors and Patients Doctors(n=41) Patients(n=29) 1 Dissatisfied with conventional treatment 11(26%) 13(44%) 2 CAM more effective 9(22%) 8(27%) 3 Due to philosophical and spiritual orientation 7(17%) 1(3%) 4 Therapist is more friendly 6(14%) 6(20%) 5 CAM is cheaper 2(4%) 6(20%) Frequency of CAM therapies referred for by doctors n=22 1 Ayurveda 12(54%) 2 Homeopathy 5(22%) 3 Yoga 4(18%) 4 Unani 1(4%) Frequency of ailments for which the patients are being referred Frequency of reference (n=22) 1 Skin ailments 8(36%) 2 Arthritis 4(18%) 3 Anxiety and depression 3(15%) 4 Backache 2(12%) 5 Others 2(10%) All the doctors were aware of Ayurveda, homeopathy and yoga. 40% doctors were also aware of Siddha, Unani, Naturopathy, Acupressure and Acupuncture. Only 6% doctors were aware of chiropractic, aromatherapy, gem therapy and Tibetan medicine. 88% patients are aware of Aurveda, 84% patients are aware of yoga 80% patients are aware of homeopathy. 10% patients are also aware of Unani. Out of 84% patients who are aware about yoga, 14% patients are also practicing it regularly.82% (n=41) doctors and 58% (n=29) patients have tried Complementary and Alternative Medicine at least once in the past. Significantly higher number of doctors have sought complementary and alternative therapies than patients (p=0.0088). For skin ailments 19% (n=8) doctors and 17%(n=5) patients sought CAM therapies. 21% (n=9) doctors and 10% (n=3)patients Consulted CAM practitioners for URTI. 7% (n=3) doctors and 24% (n=7) patients sought CAM practitioners for arthritis. For hepatitis 24% (n=7) patients and none of the doctors went for CAM consultation. For body ache 43% (n=18) doctors and 17% (n=5) took consultation from CAM practitioners. Amongst different CAM therapies, 52% (n=21) doctors and 41% (n=12) patients consulted for Ayurveda which is highest in frequency. This is followed by Homeopathy for which 29% (n=12) doctors and 27% (n=8) patients took consultation from.19% (n=8) doctors and 32% (n=9) patients consulted for Yoga. As table suggest, 63% (n=26) doctors and 69% (n=20) patients were relieved of the symptoms for which they had consulted the CAM therapy. So, 26% (n=11) doctors 44% (n=13) patients consulted CAM therapies because they were dissatisfied by conventional treatment. 22% (n=9) doctors and 27% (n=8) patients thought that CAM was RS Solanki Complementary and Alternative Medicine: Hidden presence among doctors…. Panacea Journal of Medical Sciences, September-December,2016;6(3): 159-163 162 more effective for certain ailments like skin ailments, arthritis, myalgia, anxiety and depression than conventional therapy. 17% (n=7) doctors and 3% (n=1) patients had tried CAM due to philosophical and spiritual orientation whereas 14% (n=6) doctors and 20% (n=6) patients have found CAM therapist more friendly.4% (n=2) doctors and 20% (n=6) patients found CAM therapies cheaper than conventional therapies. Maximum referrals to CAM therapies by doctors are done for Ayurveda(54%) this is followed by homeopathy referral that amounts to 22% followed by yoga upto 18%. Least referrals are done towards Unani that measured upto 4%. The ailments for which maximum referrals were done by doctors to CAM therapies were Skin ailments (36%) that was followed by arthritis (18%) followed by anxiety and depression (15%). During history taking from patients, 78% doctors reported that they usually took history regarding use of CAM therapies by patients. 78% Doctors opined that Complementary and Alternative therapies should be incorporated in mainstream medicine whereas 92% doctors felt that sanitization about CAM therapies should be introduced in MBBS curriculum. 64% doctors thought that Complementary and alternative therapies could be harmful, if used without supervision and at unskilled hands. 24% doctors expressed their concern regarding presence of heavy metals and steroids in some CAM drugs which come in market without clinical trial. 12% doctors think that the CAM medicines should be standardized and should undergo clinical trial for safety measures. As per 14% of doctors, CAM therapist also should be brought under supervision and monitoring by respective councils. They also expressed need of evaluation of affectivity of CAM and need of standardization of CAM drugs. Whereas only 6% patients viewed CAM therapies as harmful. 32% (n=16) doctors had attended some conference or read some article about CAM. Out of 16(32%) doctors who have attended conference or read some article about CAM, 52% (n=9) said that they got positive about CAM after attending the conference. 84% (n=42) patients reported that they had tried some form of home remedies before visiting doctor. And 70% (n=59) of them found these home remedies to be effective (Table 2). Discussion The results of the study indicate that alternative medicine has an significant hidden presence and influence within the health care system. The results showed considerable use of alternative medicine among doctors and patients. This is surprising finding that more doctors (82%) than patients(58%) have indicated personal use of CAM for different ailments. Amongst different CAM therapies, majority of doctors and patients took consultation for Ayurveda which is highest in frequency. This is followed by Homeopathy and Yoga. Most of the doctors and patients were relieved of the symptoms for which they had consulted the CAM therapy. The various reasons cited by doctors and patients for which they sought CAM therapies were dissatisfied by conventional treatment, perceived more effectiveness of CAM modalities for chronic ailments, due to philosophical and spiritual orientation, friendlier approach of CAM therapist and affordability of CAM therapies. Maximum referrals to CAM therapies by doctors were done for Ayurveda. (54%) which was followed by homeopathy and yoga. Maximum patients were referred for chronic ailments like by doctors to CAM therapies. Less than half (32%)doctors had attended some conference or read some article about CAM. Majority of patients had used some form of home remedies before visiting doctor and most of them found these home remedies to be effective. A considerable number of patients are also reportedly satisfied by using home remedies. This necessitates research in the effectiveness of home remedies. The conditions for which patients were referred were chronic ailments, such as asthma, arthritis, backache and skin disorders, and a variety of non- specific disorders, including headache, backache, joint pain, and depression. It is found that for the similar ailments CAM is consulted for in many other studies.(2,4)A study by Jump et al. demonstrated that the majority of physicians in the United States viewed many of CAM therapies as not part of legitimate medical practice.(5-7)In addition, Milden et.al found that while a random sample of California physicians demonstrated an overall positive attitude toward CAM, 61% still found themselves discouraging CAM therapies because they are not knowledgeable enough about the safety or efficacy of CAM treatments. A less than quarter patients even practice yoga regularly which shows receptivity of the patients for CAM. The fact that a fairly large number of the doctors even suggested patients to approach practitioners of alternative medicine shows that doctors not only acknowledge the existence of unconventional therapies, but also support them, even if they are viewed as a last resort. In this study, Most of the doctors have made referral to indigenous medicine Ayurveda and Yoga. Ayurveda is the most consulted CAM by both doctors and patients followed by yoga and homeopathy. In this study, most of the residents suggested that CAM were effective and should be incorporated in mainstream of medicine and further added that M.B.B.S. students should be sensitized regarding CAM. Doctors and patients both have tried CAM for Skin ailment, arthritis and bodyache, hepatitis and asthma have experienced a considerable degree of contentment. Majority of Doctors and patients have not experienced any side effect of CAM. Majority of Doctors and patients said that they would recommend it to others. Majority of doctors and patients had tried allopathic before going for CAM. Most of the doctors have indicated that they RS Solanki Complementary and Alternative Medicine: Hidden presence among doctors…. Panacea Journal of Medical Sciences, September-December,2016;6(3): 159-163 163 always take history of use of CAM from their patients. Furlow ML et al(8) also suggest that, 83% of physicians surveyed routinely query their patients about CAM use. Marian F et al 2008(9) suggests that in a primary care setting, patient satisfaction seems to be higher with homeopathic treatment compared to conventional treatment. And also indicated that homeopathic treatment is perceived as a low-risk therapy with less side effects than conventional treatment. These findings are consistent with our study. Present study indicates than a less than quarter number of doctors never asks their patients about use of CAM therapies. This could also be harmful, as many herbal medicines have been found to have strong drug interaction with conventional medicines.(10-11) Considering the high prevalence of use of home remedies, evidence base needs to be generated for them. Qualified practitioners of alternative medicine should be integrated in health team so that they can share their knowledge and skills with and develop their understanding of holistic approach towards health. CAM panels need to be introduced in health system, to take integrated decision about management of many chronic conditions. The involvement of qualified practitioners of alternative medicine will also help the participants to assess each other's strengths, limitations and practice patterns and provide an opportunity to discuss solutions for individual and community health. This will also reduce misunderstandings and resistance between so-called conventional and unconventional therapists. Communication between students, doctors and practitioners of alternative medicine will promote research in neglected areas and further develop health care providers' ability to deal with uncertainties. Our studies primary limitation was its small sample size. With larger sample size more useful perspectives could be sought on part of doctors and patients as well. Conclusion As seen in this study, use of CAM is much prevalent among health care providers and seekers. The results of this study suggest doctors should be in a better position to make informed choices about CAM modalities. Further research and studies needed to determine the mechanism of action of many of the popular CAM modalities. Acknowledgements The author would like to thank Department of Community Medicine, Seth GS Medical College and KEM Hospital, Mumbai for support provided to conduct this study. Author is also grateful to all study participants who spared their valuable time to fill the self-administered questionnaire required for the study. References 1. Eisenberg DM, Kessler RC, Forster C, Norlock FE, Calkins DR, Deldano TL. Unconventional medicine in the United States; prevalence, costs and patterns of use. N Engl J Med 1993;328:246-252. 2. Lam CL. Self-medication among Hong Kong Chinese. Social Science and Medicine 1994;39(12):1641-7. 3. Eisenberg DM. Unconventional medicine in the United States. Prevalence, costs and patterns of use. New England Journal of Medicine 1993;328(4):246-52. 4. Regulatory situation of herbal medicines: a worldwide review. Geneva, World Health Organization, 1998. 5. Wharton R, Lewith G. Complementary medicine and the general practitioner. British Medical Journal 1986;292:1498-500 6. Jump J, Yarbrough L, Kilpatrick S, Cable T. Physicians' Attitudes toward Complementary and Alternative Medicine. Integrative Medicine 1998;1:149–153. 7. 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