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Acupuncture in urological practice—A survey of urologists in England
Complementary Therapies in Medicine (2011) 19, 27—31
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
Acupuncture in urological practice—–A survey of urologists in England Heidi Tempest a,∗, John Reynard a, Richard J. Bryant a,b, Freddie C. Hamdy a,b, Stéphane Larré a,b a
Urology Department, Churchill Hospital, Old Rd, Headington, OX3 7LJ Oxford, UK Nuffield Department of Surgery, University of Oxford, Oxford, UK Available online 3 December 2010
b
KEYWORDS Acupuncture; Urology; Questionnaire; Medical practice
Summary Objective: To determine the feasibility of obtaining cooperation from urologists in carrying out large-scale studies on the efficacy of acupuncture for the treatment of urological conditions, based on urologists’ general views and knowledge of acupuncture. Methods: A questionnaire was distributed to 145 urologists within three training deaneries within England. Results: A response rate of 70% (n = 102) was achieved. The majority of urologists rated their knowledge of acupuncture as low (46%, n = 46) and their general attitude towards acupuncture was neutral (54%, n = 55). The majority of responding urologists (95%) thought that acupuncture may be of value in urological conditions, and acupuncture was suggested to patients by 30 urologists (29%). The urologists most likely to suggest acupuncture to their patients were typically over 40 years of age, more experienced, not in a training post, and since starting their urological career had changed their attitude towards acupuncture. In a multivariate analysis, a change of view regarding the efficacy of acupuncture was found to be the only variable significantly associated with a recommendation of acupuncture to patients. Conclusions: Although overall knowledge about acupuncture was poor, most responding urologists thought acupuncture may be useful for urological conditions. Those who had changed their views were most likely to suggest acupuncture to their patients. Acupuncture for urological conditions warrants further investigation and, as this study has shown high interest within the urological community large clinical trials involving multicentres may be feasible. © 2010 Elsevier Ltd. All rights reserved.
There is a growing interest in complementary medicine, especially acupuncture, within both Western society and the Western medical profession. This increased interest may
Abbreviation: OR, odds ratio. Corresponding author. Tel.: +44 01865741841; fax: +44 01865226086. E-mail address: [email protected] (H. Tempest). ∗
reflect increasing frustration with the poor efficacy of many conventional treatments for a range of conditions. Acupuncture is believed to have originated in China during the Stone Age,1 and is typically used to treat symptomatic chronic conditions, especially pain, that are often resistant to conventional therapies. One example of its more widespread use in various clinical conditions is its advocation by the National Institute for Clinical Excellence as a treatment option for back pain.2 Nevertheless, acupuncture remains
0965-2299/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2010.10.001
28 a highly controversial treatment option, particularly as no well-defined conventional pathophysiological mechanism to explain its efficacy has been identified. Numerous urological conditions can be difficult and challenging to treat symptomatically.3 The use of acupuncture for urological conditions was reviewed by Ripoll and Bunn,4 and since then there have only been a limited number of studies investigating its use. These mainly focus on functional disorders such as chronic pelvic pain,5,6 lower urinary tract symptoms,7,8 or, more recently, hot flushes following androgen deprivation therapy for prostate cancer.9,10 Acupuncture treatments have been reported to improve these conditions. Although promising, especially after failure of conventional treatment options, the majority of these studies are observational or contained small numbers of patients, and few of the studies are randomised.4 Larger well-powered studies with multicentre involvement are therefore needed to investigate the efficacy of acupuncture for the treatment of urological conditions. The feasibility of such studies largely depends on the willingness of urologists to participate, and this may be influenced by their interest and beliefs regarding the potential efficacy of acupuncture as a treatment modality for urological conditions. Without a strong and widespread interest within the urological community for acupuncture, such studies may have little chance of success. To date, and to our knowledge, there has been no specific investigation either of the views of urologists in the United Kingdom towards acupuncture or of their attitudes towards this unconventional treatment option for urological conditions. Much of the published literature has concentrated on the use of acupuncture in general practice, where as many as 83% of practitioners believe that acupuncture might be clinically useful and may recommend it to their patients.11 A study of Norwegian doctors showed that they would recommend acupuncture to 38% of their patients suffering from migraine.12 With regard to surgeons, the only study of acupuncture reported to date demonstrated that 63% of surveyed neurosurgeons believed that complementary medicine may have a potential role in patient management but it did not elaborate fully if they recommend it in their clinical practice.13 The principal objective of this study was to investigate the views of urologists in England towards acupuncture and to ascertain their beliefs about its use for urological conditions. We investigated whether sufficient urologists demonstrate an interest in acupuncture as a preliminary step such that future larger studies on acupuncture for urological conditions might be feasible. We also aim to eventually identify a profile of urologists or their clinical centres, which may be more likely to recommend acupuncture to patients, such that these urologists could potentially be requested to become co-investigators and recruiting centres for future large-scale randomised clinical trials.
Methods A questionnaire (Fig. 1) was designed to investigate the opinion of urologists practising in three English training deaneries. These deaneries were chosen as they covered several regions and the authors had professional contacts
H. Tempest et al. Acupuncture in Urology Questionnaire 1.
Sex
2.
Age
3.
Years of experience in Urology
4.
Grade
5.
M/F
How would you rate your knowledge of acupuncture 1
2
3
4
5
Low 6.
high
What is your general attitude towards acupuncture? 1
2
very negative 7.
3
4
neutral
Do you think acupuncture may help in any urological conditions ? 1
2
Very unlikely
3 maybe
5 very positive
4
Y/N 5 very likely
If so which ones ?
8.
Have you ever suggested acupuncture to a patient?Y/N
9.
Have your views towards acupuncture changed since you started your career?
Alot more positive/ more positive/ no change/ more neg ative/ Alot more negative
10. Has anything changed your views?
Thank you for your time in answering these questions
Figure 1 Questionnaire used to assess urologists views regarding acupuncture.
for most of them facilitating identification of the urologists and a high response rate. The three deaneries (and hospitals therein) were Oxford (Churchill (Oxford), Northampton General, Royal Berkshire (Reading) and Wycombe), Wessex (Royal Bournemouth, Salisbury District, Winchester, Southampton, Queen Alexandra (Portsmouth), St Richards (Chichester)) and Eastern (Addenbrookes (Cambridge), Norfolk and Norwich, Luton and Dunstable, Bedford, Ipswich, Peterborough and West Suffolk (Bury St Edmunds)). The urologists working at these hospitals were identified by contacting the deaneries and hospitals. The urologists as defined for the purposes of this study were either qualified urologists or urology trainees. There were no exclusion criteria within this group. All the urologists, who worked in the hospitals within these training deaneries, were contacted over a 3-month period, either directly or by telephone or e-mail. The urologists included consultants, staff grades, associate specialists and trainees, and all were asked to complete a questionnaire (Fig. 1) evaluating their views regarding acupuncture and its use in urology. A profile of urologists more likely to have suggested acupuncture to their patients was identified using logistic regression. Statistical analyses were conducted using Stat View 5.0 for Windows (SAS Institute, Cary, NC, USA).
Results We identified 145 urologists working within the designated hospitals. These included 86 consultants, 13 staff grades
Number of Urologists
Acupuncture in urological practice—–A survey of urologists in England 55
60
50
54
46
40
30
29
27
30
17
20
11
10
0
4
5
1
2 3 4 Atude
9
9
6
2 3 4 Helpfulnes
5
3
0 1
2 3 4 Knowledge
5
5
1
Figure 2 Histograms representing the number of urologists giving each score (1—5) regarding knowledge about acupuncture, attitude towards acupuncture and usefulness of acupuncture.
or associate specialists and 46 trainees. A completed questionnaire was obtained in 102/145 cases, giving a response rate of 70%. These were 41 from the Eastern deanery, 39 from the Oxford deanery and 22 from the Wessex deanery. Of the 43 non-responders, 10 were due to incorrect e-mail address or phone number, leading to an adjusted response rate of 76%, if this group is not included. The response rate was higher from trainees (93%) compared with non-trainees (60%) (p < 0.001). The male to female ratio was 10:1 (4:1 for trainees and 58:1 for non-trainees). The overall mean age (range) was 40 years (29—66) whilst the mean (range) age was 33 years (29—41) for trainees and 46 years (36—66) for non-trainees. Results concerning knowledge, attitude and usefulness of acupuncture are outlined in Fig. 2. The majority of urologists rated their knowledge of acupuncture as low (n = 46, 46%) and their general attitude towards acupuncture as neutral (n = 55, 54%). Nevertheless, 95 (95%) urologists thought that acupuncture may be a useful treatment modality for urological conditions, including chronic pain, overactive bladder, prostatitis and hot flushes. At least one urological condition was mentioned as being treatable through acupuncture by 78 urologists (76%), with pain being the most frequently quoted of these (n = 76, 75%). Acupuncture was suggested as a therapeutic option for patients by 30 urologists (29%). This was significantly more frequent among non-trainees (42%) than trainees (12%) (p < 0.001). Univariate analysis demonstrated that the chance of acupuncture being suggested as a treatment option for patients was significantly higher if the urologist was of a higher age (>40 years), had more years of uro-
29
logical experience, was of non-trainee status, had greater knowledge of acupuncture, had a greater positive attitude towards acupuncture, had a greater belief in its possible helpfulness, and if the urologist had changed their opinion regarding acupuncture during their career (Table 1). In the multivariate analysis, the only variable associated with a higher probability of suggesting acupuncture to a patient was when the urologist had changed their opinion regarding acupuncture during their career (odds ratio (OR): 10.4 (2.5—42.4), p = 0.001). This group of urologists represents almost half (n = 48, 48%) of the responders in this study. Trainees (n = 15, 35%) were less likely to have changed their views regarding acupuncture compared with non-trainees (n = 33, 57%) (p = 0.03). Of those who had changed their view, the change was always either ‘‘more positive’’ (n = 45, 93%) or ‘‘a lot more positive’’ (n = 15, 7%), and was never ‘‘negative’’ or ‘‘a lot more negative.’’ Within the group of urologists, who had changed their views regarding the possible efficacy of acupuncture, 27 (56%) suggested acupuncture as a treatment to their patients, although 3 out of 53 respondents (6%), who had not changed their views had also suggested acupuncture. Reasons identified as factors causing a change of view included feedback from patients (n = 16), reading literature/media (n = 4) and personal experience (n = 1). There was no significant difference among the three deaneries for all data analysed except for the number of urologists, who had their view changed about acupuncture, which was higher (p = 0.025) in the Eastern group (n = 25, 63%) compared with the others (n = 23, 38%).
Discussion This study demonstrates that despite most urologists having poor knowledge about acupuncture, many believe that it may play a role in the urological management of some patients. Half of the urologists in this study had changed their views regarding the effectiveness of acupuncture and, in general, this was in a positive manner. Generally, poor knowledge about acupuncture is unsurprising given that acupuncture is not routinely taught to medical students in universities in the UK. Specialised training is available from institutions such as the British Medical Acupuncture Society (a registered charity); however, this is only within fee-paying courses. Interestingly, it has been shown that when a medical course includes some tuition on
Table 1 Univariate analysis indicating the odds ratio (OR) of having suggested acupuncture to a patient with a 95% confidence interval.
Sex: male Age: >40 Experience: >10 years Status: non-training Knowledge: score >3 Attitude: score >3 Helpful: score >3 Views changed: yes OR: odds ratio.
OR
95% inf.
95% sup.
p-Value
0.818 4.126 3.417 5.59 5.098 4.818 5.588 21.429
0.191 1.604 1.327 1.92 1.366 1.941 2.226 5.856
3.511 10.617 8.796 16.13 19.021 11.958 14.03 78.411
0.7871 0.0033 0.0109 0.0016 0.0153 0.0007 0.0002 <0.0001
30 complementary therapies, doctor’s views become more positive towards such treatments.14 It has also been shown that the majority of doctors and medical students believe that alternative therapies should be taught during their undergraduate medical degree course.15 Whilst the overall interest in acupuncture by respondents in this study was neutral, 95% of urologists believed in a useful potential role of acupuncture in the management of some urological conditions, suggesting that most urologists would be keen on referring patients to acupuncture clinics. In practice, however, only around one-third of urologists have suggested it to their patients. The exact reasons for the discrepancy between urologists’ beliefs regarding acupuncture, and the frequency with which they recommend this treatment, are unknown but may potentially be explained by the fact that the majority of patients may be successfully treated by conventional medicine. It is also possible that urologists may have reservations about suggesting a treatment with minimal high-quality research and little scientific evidence. The study results presented herein apply only to the three English deaneries investigated, and may not represent the views of other urologists in the United Kingdom or elsewhere. That said, we did not observe significant differences between deaneries, making geographical location unlikely to result in differences of opinion between regions. We also did not investigate any ethnical or economic backgrounds of respondents that may have had an effect on views. More experienced urologists, who had completed their training, were more likely to suggest acupuncture to their patients. This was, however, not statistically significant in a multivariate analysis, suggesting that years of experience may be a confounding factor. More experienced urologists are more likely to have seen the same patients on many occasions, especially in the outpatient setting, and they may realise the limits that conventional medicine can offer their patients. Curative treatment of chronic prostatitis, for example, may not be realistic in some patients, leaving symptom management to be the only route to an improvement in quality of life. The current treatment strategies for chronic prostatitis including antibiotics, ␣-blockers, antiinflammatory agents and other medical agents are not effective for many patients3 ; therefore, they may be offered alternative treatments, such as acupuncture, after poor results of standard treatments or to avoid more invasive treatments. Intriguingly, the use of acupuncture has resulted in good results for patients with this condition.5,6 Our results showed that good feedback from patients was the reason for 16 urologists to have changed their views concerning acupuncture. This highlights the fact that patient satisfaction with acupuncture has a significant impact on a doctor’s views and prescribing practice. These results suggest that younger urologists are less interested and more sceptical about acupuncture than older urologists. This may be for reasons similar to those described above, but may also be explained by the rising development of evidence-based practice in current medical teaching,16 underpinned by the need for large randomised trials to establish the role of acupuncture in urological practice. Acupuncture clinics are sometimes available as part of a chronic pain management service offered by anaesthetic departments in hospitals; however, this is an unusual feature
H. Tempest et al. within the National Health Service. This may explain why only a third of the urologists in this study suggest acupuncture to their patients, and why trainees are less likely to discuss this treatment modality during patient consultations. Most urologists believe acupuncture may play a role in the management of urological conditions, some having already suggested it to their patients. Urologists declaring the most knowledge and positive attitudes regarding acupuncture were also most likely to find this treatment helpful for their patients. Urologists, who changed their views about acupuncture, were unsurprisingly more likely to have suggested the treatment to their patients. The most powerful predictor for an urologist to recommend acupuncture was them ‘‘having changed their views,’’ and this increased the chance of this treatment being offered 21-fold. Many urologists tend to develop more favourable views towards acupuncture later in their career, which may reflect the existing limited efficacy of conventional treatment options for some chronic conditions, in particular. Although the questionnaire in this study did not directly question whether urologists would be willing to participate in acupuncture research, it has supplied the preliminary knowledge to future researchers that there is considerable interest within the urological community about the possible positive effects of acupuncture in the management of urological conditions. In conclusion, this survey indicates that studies on acupuncture may be largely accepted among the urological community and that cooperation from urologists may be expected, such as mentioning the existence of a trial and the possibility of referring patients to an investigator for more details and inclusion. This study has also defined the profile of urologists more likely to have suggested acupuncture to their patients. This group of urologists may be suggested as being the most appropriate for researchers to initially approach with regarding recruitment of patients for largescale high-quality future clinical studies of acupuncture in urology.
Competing interest None.
Acknowledgements The authors are grateful to all the urologists who answered the questionnaire in this study.
References 1. Ernst E. Acupuncture—–a critical analysis. J Intern Med 2006;259:125—37. 2. National Collaborating Centre for Primary Care. Low back pain: early management of persistent non-specific low back pain. NICE Clin Guideline 2009:10. 3. Capodice JL, Bemis DL, Buttyan R, Kaplan SA, Katz AE. Complementary and alternative medicine for chronic prostatitis/chronic pelvic pain syndrome. Evid Based Complement Altern Med 2005;2:495—501.
Acupuncture in urological practice—–A survey of urologists in England 4. Ripoll E, Bunn T. The role of acupuncture in the treatment of urologic conditions. World J Urol 2002;20:315—8. 5. Tugcu V, Tas S, Eren G, Bedirhan B, Karadag S, Tasci A. Effectiveness of acupuncture in patients with category IIIB chronic pelvic pain syndrome: a report of 97 patients. Pain Med 2010;11:518—23. 6. Lee SH, Lee BC. Electroacupuncture relieves pain in men with chronic prostatitis/chronic pelvic pain syndrome: three-arm randomized trial. Urology 2009;73:1036—41. 7. Li J, Han CH, Cheng XH, Zhu GX, Gong XH, Hou WG, et al. Observation on therapeutic effects of elongated needle therapy on dysuria induced by benign prostatic hyperplasia. Zhongguo Zhen Jiu 2008;28:707—9. 8. Kelleher C, Filshie J, Burton G, Khullar V, Cardozo L. Acupuncture and the treatment of irritative bladder symptoms. Acupunct Med 1994;12:9—10. 9. Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, et al. Acupuncture for hot flashes in patients with prostate cancer. Urology 2010. 10. Harding C, Harris A, Chadwick D. Auricular acupuncture: a novel treatment for vasomotor symptoms associated with
11.
12. 13.
14.
15.
16.
31
luteinizing-hormone releasing hormone agonist treatment for prostate cancer. BJU Int 2009;103:186—90. Lipman L, Dale J, MacPherson H. Attitudes of GPs towards the provision of acupuncture on the NHS. Complement Ther Med 2003;11:110—4. Norheim AJ, Fonnebo V. Doctors’ attitudes to acupuncture—–a Norwegian study. Soc Sci Med 1998;47:519—23. Wu C, Weber W, Kozak L, Standish LJ, Ojemann JG, Ellenbogen RG, et al. A survey of complementary and alternative medicine (CAM) awareness among neurosurgeons in Washington State. J Altern Complement Med 2009;15:551—5. Hopper I, Cohen M. Complementary therapies and the medical profession: a study of medical students’ attitudes. Altern Ther Health Med 1998;4:68—73. Perkin MR, Pearcy RM, Fraser JS. A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine. J R Soc Med 1994;87:523—5. Walker PD, Dorsey SM. Creating an evidence-based culture within the schools of public health and medicine. Med Ref Serv Q 2009;28:385—93.
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
Acupuncture in urological practice—–A survey of urologists in England Heidi Tempest a,∗, John Reynard a, Richard J. Bryant a,b, Freddie C. Hamdy a,b, Stéphane Larré a,b a
Urology Department, Churchill Hospital, Old Rd, Headington, OX3 7LJ Oxford, UK Nuffield Department of Surgery, University of Oxford, Oxford, UK Available online 3 December 2010
b
KEYWORDS Acupuncture; Urology; Questionnaire; Medical practice
Summary Objective: To determine the feasibility of obtaining cooperation from urologists in carrying out large-scale studies on the efficacy of acupuncture for the treatment of urological conditions, based on urologists’ general views and knowledge of acupuncture. Methods: A questionnaire was distributed to 145 urologists within three training deaneries within England. Results: A response rate of 70% (n = 102) was achieved. The majority of urologists rated their knowledge of acupuncture as low (46%, n = 46) and their general attitude towards acupuncture was neutral (54%, n = 55). The majority of responding urologists (95%) thought that acupuncture may be of value in urological conditions, and acupuncture was suggested to patients by 30 urologists (29%). The urologists most likely to suggest acupuncture to their patients were typically over 40 years of age, more experienced, not in a training post, and since starting their urological career had changed their attitude towards acupuncture. In a multivariate analysis, a change of view regarding the efficacy of acupuncture was found to be the only variable significantly associated with a recommendation of acupuncture to patients. Conclusions: Although overall knowledge about acupuncture was poor, most responding urologists thought acupuncture may be useful for urological conditions. Those who had changed their views were most likely to suggest acupuncture to their patients. Acupuncture for urological conditions warrants further investigation and, as this study has shown high interest within the urological community large clinical trials involving multicentres may be feasible. © 2010 Elsevier Ltd. All rights reserved.
There is a growing interest in complementary medicine, especially acupuncture, within both Western society and the Western medical profession. This increased interest may
Abbreviation: OR, odds ratio. Corresponding author. Tel.: +44 01865741841; fax: +44 01865226086. E-mail address: [email protected] (H. Tempest). ∗
reflect increasing frustration with the poor efficacy of many conventional treatments for a range of conditions. Acupuncture is believed to have originated in China during the Stone Age,1 and is typically used to treat symptomatic chronic conditions, especially pain, that are often resistant to conventional therapies. One example of its more widespread use in various clinical conditions is its advocation by the National Institute for Clinical Excellence as a treatment option for back pain.2 Nevertheless, acupuncture remains
0965-2299/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2010.10.001
28 a highly controversial treatment option, particularly as no well-defined conventional pathophysiological mechanism to explain its efficacy has been identified. Numerous urological conditions can be difficult and challenging to treat symptomatically.3 The use of acupuncture for urological conditions was reviewed by Ripoll and Bunn,4 and since then there have only been a limited number of studies investigating its use. These mainly focus on functional disorders such as chronic pelvic pain,5,6 lower urinary tract symptoms,7,8 or, more recently, hot flushes following androgen deprivation therapy for prostate cancer.9,10 Acupuncture treatments have been reported to improve these conditions. Although promising, especially after failure of conventional treatment options, the majority of these studies are observational or contained small numbers of patients, and few of the studies are randomised.4 Larger well-powered studies with multicentre involvement are therefore needed to investigate the efficacy of acupuncture for the treatment of urological conditions. The feasibility of such studies largely depends on the willingness of urologists to participate, and this may be influenced by their interest and beliefs regarding the potential efficacy of acupuncture as a treatment modality for urological conditions. Without a strong and widespread interest within the urological community for acupuncture, such studies may have little chance of success. To date, and to our knowledge, there has been no specific investigation either of the views of urologists in the United Kingdom towards acupuncture or of their attitudes towards this unconventional treatment option for urological conditions. Much of the published literature has concentrated on the use of acupuncture in general practice, where as many as 83% of practitioners believe that acupuncture might be clinically useful and may recommend it to their patients.11 A study of Norwegian doctors showed that they would recommend acupuncture to 38% of their patients suffering from migraine.12 With regard to surgeons, the only study of acupuncture reported to date demonstrated that 63% of surveyed neurosurgeons believed that complementary medicine may have a potential role in patient management but it did not elaborate fully if they recommend it in their clinical practice.13 The principal objective of this study was to investigate the views of urologists in England towards acupuncture and to ascertain their beliefs about its use for urological conditions. We investigated whether sufficient urologists demonstrate an interest in acupuncture as a preliminary step such that future larger studies on acupuncture for urological conditions might be feasible. We also aim to eventually identify a profile of urologists or their clinical centres, which may be more likely to recommend acupuncture to patients, such that these urologists could potentially be requested to become co-investigators and recruiting centres for future large-scale randomised clinical trials.
Methods A questionnaire (Fig. 1) was designed to investigate the opinion of urologists practising in three English training deaneries. These deaneries were chosen as they covered several regions and the authors had professional contacts
H. Tempest et al. Acupuncture in Urology Questionnaire 1.
Sex
2.
Age
3.
Years of experience in Urology
4.
Grade
5.
M/F
How would you rate your knowledge of acupuncture 1
2
3
4
5
Low 6.
high
What is your general attitude towards acupuncture? 1
2
very negative 7.
3
4
neutral
Do you think acupuncture may help in any urological conditions ? 1
2
Very unlikely
3 maybe
5 very positive
4
Y/N 5 very likely
If so which ones ?
8.
Have you ever suggested acupuncture to a patient?Y/N
9.
Have your views towards acupuncture changed since you started your career?
Alot more positive/ more positive/ no change/ more neg ative/ Alot more negative
10. Has anything changed your views?
Thank you for your time in answering these questions
Figure 1 Questionnaire used to assess urologists views regarding acupuncture.
for most of them facilitating identification of the urologists and a high response rate. The three deaneries (and hospitals therein) were Oxford (Churchill (Oxford), Northampton General, Royal Berkshire (Reading) and Wycombe), Wessex (Royal Bournemouth, Salisbury District, Winchester, Southampton, Queen Alexandra (Portsmouth), St Richards (Chichester)) and Eastern (Addenbrookes (Cambridge), Norfolk and Norwich, Luton and Dunstable, Bedford, Ipswich, Peterborough and West Suffolk (Bury St Edmunds)). The urologists working at these hospitals were identified by contacting the deaneries and hospitals. The urologists as defined for the purposes of this study were either qualified urologists or urology trainees. There were no exclusion criteria within this group. All the urologists, who worked in the hospitals within these training deaneries, were contacted over a 3-month period, either directly or by telephone or e-mail. The urologists included consultants, staff grades, associate specialists and trainees, and all were asked to complete a questionnaire (Fig. 1) evaluating their views regarding acupuncture and its use in urology. A profile of urologists more likely to have suggested acupuncture to their patients was identified using logistic regression. Statistical analyses were conducted using Stat View 5.0 for Windows (SAS Institute, Cary, NC, USA).
Results We identified 145 urologists working within the designated hospitals. These included 86 consultants, 13 staff grades
Number of Urologists
Acupuncture in urological practice—–A survey of urologists in England 55
60
50
54
46
40
30
29
27
30
17
20
11
10
0
4
5
1
2 3 4 Atude
9
9
6
2 3 4 Helpfulnes
5
3
0 1
2 3 4 Knowledge
5
5
1
Figure 2 Histograms representing the number of urologists giving each score (1—5) regarding knowledge about acupuncture, attitude towards acupuncture and usefulness of acupuncture.
or associate specialists and 46 trainees. A completed questionnaire was obtained in 102/145 cases, giving a response rate of 70%. These were 41 from the Eastern deanery, 39 from the Oxford deanery and 22 from the Wessex deanery. Of the 43 non-responders, 10 were due to incorrect e-mail address or phone number, leading to an adjusted response rate of 76%, if this group is not included. The response rate was higher from trainees (93%) compared with non-trainees (60%) (p < 0.001). The male to female ratio was 10:1 (4:1 for trainees and 58:1 for non-trainees). The overall mean age (range) was 40 years (29—66) whilst the mean (range) age was 33 years (29—41) for trainees and 46 years (36—66) for non-trainees. Results concerning knowledge, attitude and usefulness of acupuncture are outlined in Fig. 2. The majority of urologists rated their knowledge of acupuncture as low (n = 46, 46%) and their general attitude towards acupuncture as neutral (n = 55, 54%). Nevertheless, 95 (95%) urologists thought that acupuncture may be a useful treatment modality for urological conditions, including chronic pain, overactive bladder, prostatitis and hot flushes. At least one urological condition was mentioned as being treatable through acupuncture by 78 urologists (76%), with pain being the most frequently quoted of these (n = 76, 75%). Acupuncture was suggested as a therapeutic option for patients by 30 urologists (29%). This was significantly more frequent among non-trainees (42%) than trainees (12%) (p < 0.001). Univariate analysis demonstrated that the chance of acupuncture being suggested as a treatment option for patients was significantly higher if the urologist was of a higher age (>40 years), had more years of uro-
29
logical experience, was of non-trainee status, had greater knowledge of acupuncture, had a greater positive attitude towards acupuncture, had a greater belief in its possible helpfulness, and if the urologist had changed their opinion regarding acupuncture during their career (Table 1). In the multivariate analysis, the only variable associated with a higher probability of suggesting acupuncture to a patient was when the urologist had changed their opinion regarding acupuncture during their career (odds ratio (OR): 10.4 (2.5—42.4), p = 0.001). This group of urologists represents almost half (n = 48, 48%) of the responders in this study. Trainees (n = 15, 35%) were less likely to have changed their views regarding acupuncture compared with non-trainees (n = 33, 57%) (p = 0.03). Of those who had changed their view, the change was always either ‘‘more positive’’ (n = 45, 93%) or ‘‘a lot more positive’’ (n = 15, 7%), and was never ‘‘negative’’ or ‘‘a lot more negative.’’ Within the group of urologists, who had changed their views regarding the possible efficacy of acupuncture, 27 (56%) suggested acupuncture as a treatment to their patients, although 3 out of 53 respondents (6%), who had not changed their views had also suggested acupuncture. Reasons identified as factors causing a change of view included feedback from patients (n = 16), reading literature/media (n = 4) and personal experience (n = 1). There was no significant difference among the three deaneries for all data analysed except for the number of urologists, who had their view changed about acupuncture, which was higher (p = 0.025) in the Eastern group (n = 25, 63%) compared with the others (n = 23, 38%).
Discussion This study demonstrates that despite most urologists having poor knowledge about acupuncture, many believe that it may play a role in the urological management of some patients. Half of the urologists in this study had changed their views regarding the effectiveness of acupuncture and, in general, this was in a positive manner. Generally, poor knowledge about acupuncture is unsurprising given that acupuncture is not routinely taught to medical students in universities in the UK. Specialised training is available from institutions such as the British Medical Acupuncture Society (a registered charity); however, this is only within fee-paying courses. Interestingly, it has been shown that when a medical course includes some tuition on
Table 1 Univariate analysis indicating the odds ratio (OR) of having suggested acupuncture to a patient with a 95% confidence interval.
Sex: male Age: >40 Experience: >10 years Status: non-training Knowledge: score >3 Attitude: score >3 Helpful: score >3 Views changed: yes OR: odds ratio.
OR
95% inf.
95% sup.
p-Value
0.818 4.126 3.417 5.59 5.098 4.818 5.588 21.429
0.191 1.604 1.327 1.92 1.366 1.941 2.226 5.856
3.511 10.617 8.796 16.13 19.021 11.958 14.03 78.411
0.7871 0.0033 0.0109 0.0016 0.0153 0.0007 0.0002 <0.0001
30 complementary therapies, doctor’s views become more positive towards such treatments.14 It has also been shown that the majority of doctors and medical students believe that alternative therapies should be taught during their undergraduate medical degree course.15 Whilst the overall interest in acupuncture by respondents in this study was neutral, 95% of urologists believed in a useful potential role of acupuncture in the management of some urological conditions, suggesting that most urologists would be keen on referring patients to acupuncture clinics. In practice, however, only around one-third of urologists have suggested it to their patients. The exact reasons for the discrepancy between urologists’ beliefs regarding acupuncture, and the frequency with which they recommend this treatment, are unknown but may potentially be explained by the fact that the majority of patients may be successfully treated by conventional medicine. It is also possible that urologists may have reservations about suggesting a treatment with minimal high-quality research and little scientific evidence. The study results presented herein apply only to the three English deaneries investigated, and may not represent the views of other urologists in the United Kingdom or elsewhere. That said, we did not observe significant differences between deaneries, making geographical location unlikely to result in differences of opinion between regions. We also did not investigate any ethnical or economic backgrounds of respondents that may have had an effect on views. More experienced urologists, who had completed their training, were more likely to suggest acupuncture to their patients. This was, however, not statistically significant in a multivariate analysis, suggesting that years of experience may be a confounding factor. More experienced urologists are more likely to have seen the same patients on many occasions, especially in the outpatient setting, and they may realise the limits that conventional medicine can offer their patients. Curative treatment of chronic prostatitis, for example, may not be realistic in some patients, leaving symptom management to be the only route to an improvement in quality of life. The current treatment strategies for chronic prostatitis including antibiotics, ␣-blockers, antiinflammatory agents and other medical agents are not effective for many patients3 ; therefore, they may be offered alternative treatments, such as acupuncture, after poor results of standard treatments or to avoid more invasive treatments. Intriguingly, the use of acupuncture has resulted in good results for patients with this condition.5,6 Our results showed that good feedback from patients was the reason for 16 urologists to have changed their views concerning acupuncture. This highlights the fact that patient satisfaction with acupuncture has a significant impact on a doctor’s views and prescribing practice. These results suggest that younger urologists are less interested and more sceptical about acupuncture than older urologists. This may be for reasons similar to those described above, but may also be explained by the rising development of evidence-based practice in current medical teaching,16 underpinned by the need for large randomised trials to establish the role of acupuncture in urological practice. Acupuncture clinics are sometimes available as part of a chronic pain management service offered by anaesthetic departments in hospitals; however, this is an unusual feature
H. Tempest et al. within the National Health Service. This may explain why only a third of the urologists in this study suggest acupuncture to their patients, and why trainees are less likely to discuss this treatment modality during patient consultations. Most urologists believe acupuncture may play a role in the management of urological conditions, some having already suggested it to their patients. Urologists declaring the most knowledge and positive attitudes regarding acupuncture were also most likely to find this treatment helpful for their patients. Urologists, who changed their views about acupuncture, were unsurprisingly more likely to have suggested the treatment to their patients. The most powerful predictor for an urologist to recommend acupuncture was them ‘‘having changed their views,’’ and this increased the chance of this treatment being offered 21-fold. Many urologists tend to develop more favourable views towards acupuncture later in their career, which may reflect the existing limited efficacy of conventional treatment options for some chronic conditions, in particular. Although the questionnaire in this study did not directly question whether urologists would be willing to participate in acupuncture research, it has supplied the preliminary knowledge to future researchers that there is considerable interest within the urological community about the possible positive effects of acupuncture in the management of urological conditions. In conclusion, this survey indicates that studies on acupuncture may be largely accepted among the urological community and that cooperation from urologists may be expected, such as mentioning the existence of a trial and the possibility of referring patients to an investigator for more details and inclusion. This study has also defined the profile of urologists more likely to have suggested acupuncture to their patients. This group of urologists may be suggested as being the most appropriate for researchers to initially approach with regarding recruitment of patients for largescale high-quality future clinical studies of acupuncture in urology.
Competing interest None.
Acknowledgements The authors are grateful to all the urologists who answered the questionnaire in this study.
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