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Medical students' attitudes to complementary medical therapies
Complementary Therapiesin Medicine (1995)3, 212-219
© 1995PearsonProfessionalLtd
RESEARCH
Medical students' attitudes to complementary medical therapies A. F u r n h a m , D. H a n n a and C. A. Vincent SUMMARY. One hundred and eighty medical students completed one of five versions of a questionnaire concerning their attitudes to five complementary therapies: acupuncture, herbalism, homoeopathy, hypnosis, and osteopathy. Very few significant statistical differences in students' attitudes to the five therapies were found, suggesting that students had similar attitudes, which were generally positive, despite the fact that they considered they knew little about the therapies. These results are discussed in terms of the growing literature on complementary medicine.
that the reasons for the growth of alternative medicine are attributable in part to the failures of the orthodox medical professional. To what extent these views are shared by trained doctors or medical students is unclear. Various small-scale studies have been carried out in the UK to see how doctors are responding to the new climate of public interest in complementary medicine. Most have examined the attitudes of doctors, particularly general practitioners. Reilly1° examined the attitudes of general practitioner trainees to complementary medicine, and found that a positive attitude emerged from the 86 respondents. The majority considered acupuncture, hypnosis, homoeopathy and manipulation to be fairly useful. In all, 18 of the trainees used at least one complementary method themselves, and 7 wanted to train in one or more methods (especially hypnosis and manipulation). Reilly pointed out, however, that 'it is unlikely that general practitioner trainees are representative of the profession at large. A pilot study has shown much less interest among junior hospital doctors and still less among senior doctors'. Wharton and LewithHfound a high level of interest in complementary medicine among general practitioners in the Avon area. In total, 38% of the 145 respondents had received some training in complementary medicine, and 15% wished to arrange training. In the previous year, 76% had referred patients for alternative treatment to a doctor, 72% had referred patients to non-medically qualified practitioners, and 70% thought that the more acceptable techniques, e.g. hypnosis, acupuncture, spinal manipulation and homoeopathy should be available through the National Health Service (NHS). Anderson and Anderson '2 studied general practitioners in Oxfordshire, and found a high level of interest in, knowledge of, and referral of patients for complementary medicine. Of the 222 respondents, 41% had attended lectures or classes in complementary medicine; 12% had received training, and 42% wanted training in an alternative form of medicine; 16% were practising a form of complementary
INTRODUCTION Complementary medicine (also known as alternative medicine), which is generally excluded from the medical undergraduate curriculum, has expanded rapidly in the past 15 years. Fulder and Monro ~ found that between the years 1978 and 1981 there were substantial increases in numbers of practitioners of all forms of complementary medicine except herbalists. The mean increase in registered complementary therapists was 11.5% per year, which is nearly six times faster than the annual increase in doctors in the United Kingdom. In 1980-81 there were about 12 practitioners of complementary medicine per 100 000 population in the UK (i.e. 27% of the total number of general practitioners), and they estimated that about 1.5 million patients (2.5% of the population) make some 11.7 million consultations with complementary practitioners per year (about 6.5-8.6% of the number of annual consultations with general practitioners). 1 A similar level of demand for complementary medicine has been found throughout Europe and in the USA. 2,3 The growth of, and public interest in, complementary medicine has attracted a limited amount of research, 4~ as well as much comment in both orthodox medical journals 7,8 and national media? In an editorial in the British Medical Journal] it is argued that, due to the growth in the public mind of the concept of consumerism, public sentiment has swung away from its enchantment with science and technology. This general 'flight from science', it argues, means that the public no longer appreciates the achievements of modern orthodox medicine, and seems unwilling to accept its scientific standards of proof or, at least, unwilling to apply these standards to complementary medicine. In 1983, a leader in The Times 9 suggested Professor Adrian Furnham MA, MSc, DPhil, DSc; D. Hanna
BSc(Lond); Charles A. Vincent MPhil, PhD, Department of Psychology, University College London, 26 Bedford Way, London WC1, UK. Correspondence to Professor Furnham. 212
Medicalstudents'attitudesto complementarymedicaltherapies 213 medicine, and 59% had referred one or more patients to complementary practitioners within the previous year. Although the above studies were relatively smallscale, they yielded comparable results, showing a generally high level of interest in complementary medicine among general practitioners. Critics of these studies have stated that many quite orthodox techniques (e.g. manipulation, counselling) were wrongly classified as complementary, so exaggerating the interest in truly complementary techniques. General practitioners may also not be representative of the whole orthodox medical profession. Visser and Peters" suggest that general practitioners have a more pragmatic attitude to medicine than their hospital colleagues, which makes them more willing to accept complementary medicine, although they may remain sceptical of its efficacy. There is a considerable literature on the attitudes, beliefs, expectations, and values of medical students towards various orthodox medical specialties. 14,15 In Furnham's 1986 study of medical students' attitudes to nine orthodox medical specialties, the findings showed that, whereas any one specialty was perceived positively on one dimension (e.g. relationship with patients), it could also be perceived as highly negative on another (e.g., efficacy). 15 However, very few studies have examined medical students' attitudes to complementary medicine. Velimirovic and Raab 16found that alternative medicine was popular with medical students and recent medical graduates of the University of Graz in Austria, despite the fact that the students did not know much about the theory of alternative medicine. More recently, Reilly and Taylor17found 92% of 212 trained Scottish doctors believed alternative medicine useful with 76% saying they had seen patients benefit from treatment. Halliday, Taylor, Jenkins and ReillyTM tested 592 Scottish medical students' attitudes to complementary medicine. In all, 77% thought it useful - increasingly so as they progressed through their training. Of these students, 69% said they would like it in their curriculum and 63% were in favour of its being included in the NHS. The greatest area of doubt among the students is whether they would refer patients to an alternative practitioner outside the NHS; 41% said they would, while 39% were unsure. Furnham 19carried out a study looking at pre-clinical medical students' attitudes to established alternative therapies (acupuncture, herbalism, homoeopathy, and osteopathy) in general, and found a positive attitude among the students. Following on from Furnham's 1986 study, this study examined pre-clinical medical students' attitudes specifically to the following 5 complementary therapies: herbalism, homoeopathy, hypnosis (hypnotherapy), osteopathy and acupuncture, to see if there were any differences in attitudes to these different therapies. These complementary therapies were chosen because they are generally well established, well known, and definable. It
was expected that the students would be a bit cautious about the therapies but, as in other studies, generally positive, less hostile, and less negatively stereotyping than some practising doctors. The vast majority of these students would have been educated at the time when complementary medicine was receiving much public and media attention. The attitudes and beliefs of these students will, no doubt, be strongly shaped by their teachers and their clinical training. Also, these attitudes may play a part in determining whether or not these future doctors eventually decide to learn or use a complementary therapy. METHOD
Subjects One hundred and eighty medical students took part in the study, of whom 98 were male and 82 were female. They ranged in age from 19-30 years, the mean age being 20 years. Most of the medical students were unmarried (99%). They varied in their political affiliations as follows: 34% Conservative; 22% Labour; 20% Liberal Democrat; 6% other (and 18% none). They came from a wide variety of religions, but most (59%) were Christians. One hundred and thirty-eight (77%) of the students were pre-clinical and in their preclinical training, and 42 (23%) were studying for an intercalcated BSc (one academic year) before starting clinical training. The second-year students came from three London University medical schools.
Questionnaire Subjects completed a questionnaire which was based on a modified version of Furnham's 1986 fifty-item questionnaire, which had been designed to measure medical students' beliefs about the different orthodox medical specialties. The modified version contained 68 statements of attitudes to complementary medicine in general; 40 of the 68 statements were derived from the previous study, and 18 others were added. Five versions of the questionnaire were used. The versions were identical except that each was headed with a particular complementary medical therapy: herbalism, homoeopathy, hypnosis (hypnotherapy), osteopathy or acupuncture. Since the term complementary medical 'specialty' was used in the questionnaires instead of complementary medical 'therapy', these words will be used interchangeably in this report. The attitude statements in each questionnaire covered several aspects of each complementary therapy: its effectiveness at 'curing' patients; the characteristics of its patients; the characteristics of its practitioners; the characteristics of the job; its teaching in medical school; its status in orthodox medicine; its scientific nature; and the growth of the therapy and the characteristics of the patients who use complementary medicine. Many
214
Complementary Therapies in Medicine: Research
patients, of course, use both orthodox and complementary medicine. The subjects were asked to indicate how much they agreed or disagreed with each attitude statement by using a 7-point scale where: 1 = Disagree. The subjects were also asked 5 yes-no questions about their knowledge or experience of complementary medicine.
PROCEDURE Where possible, the subjects were debriefed. The questionnaires were handed out with the aim of ending up with a similar number of questionnaires returned for each specialty and with a similar distribution from each place. The questionnaires were handed out at random. Questionnaires placed in pigeon holes had a much lower return rate than those where students were approached face to face. In total, 325 questionnaires were distributed (65 of each alternative medicine specialty). The overall response rate was 55% (180) completed and usable questionnaires returned. Some students failed to answer all the attitude statements and questions and so, consequently, sample sizes varied slightly. Samples sizes were by questionnaire: herbalism = 37; homoeopathy = 36; hypnosis = 39; osteopathy = 34; acupuncture = 34.
RESULTS
Knowledge and experience of complementary medicine The findings are summarized in Table 1. Questions invited a yes or no answer, although occasionally students responded 'sometimes', and are classified accordingly. Few students had received any form of complementary treatment, although almost a third knew someone who had. They tended to believe that some complementary therapies were useful, and not to believe that complementary patients were necessarily gullible individuals.
Comparability of groups on demographic characteristics If students who had completed a questionnaire on one of the complementary medical specialities differed significantly on any major demographic variable from students who had completed a questionnaire on a different specialty, any attitude differences found between these specialties could be attributed to
demographic differences. Hence, an analysis of variance was computed between the five alternative medicine specialties questionnaire groups to see if there were any significant differences between the specialties in terms of the students' sex, age, marital status, political affiliations, religions, religious natures, and their answers to the five yes-no questions. None of the F-levels obtained approached significance. There was also no significant difference in terms of the year that the students were in (second or BSc), or in terms of the medical schools from which the students came.
Attitudinal items One-way analysis of variance (ANOVA) was computed between the questionnaires referring to the different complementary therapies to see if there was any significant difference between them in mean scores on each of the 58 attitude statements. No significant differences in scores were found (at the p<0.05 level) except on 2 attitude statements: a. 'Repeated treatment in the specialty doesn't cause any harm, but with orthodox medicine it does.' Medical students considered that both herbalism and osteopathy had a potential for harm, but were uncertain about the other therapies. b. 'The training of practitioners of the specialty is woefully inadequate.' Medical students tended towards disagreeing with this statement for acupuncture, but were significantly less certain for herbalism and hypnosis. However, by change alone, one might expect three significant differences and this analysis is capitalizing on Type 1 errors. Because there were so few differences between groups, scores for all 180 students have been grouped together and are shown in Table 2. Some general conclusions are possible about medical students' attitudes to complementary medicine, even though they generally do not distinguish between the different therapies. Students agreed that many patients find complementary medicine to be effective, as well as cheaper, and did not feel that such therapies were a danger to health. Patients were not thought to be gullible, but were thought to need faith in procedures. Students clearly recognized that complementary practitioners might have more time to spend with their patients and that this aspect of the consultation might be important. As regards professional and career issues, the students
Table 1 Experience of alternative medicine Yes (%) 1. Have you ever visited someone who practises alternative (complementary) medicine? 2. Does somebody close to you use an alternative practitioner? 3. Do you believe alternative practitioners have effective treatments? 4. Is it only naive or gullible people who go to alternative practitioners? 5. Do you believe there are m a n y 'quacks' in alternative medicine?
17 31 69 7 76
N o (%) 83 69 17 92 18
Sometimes (%)
12 1 2
Left out (%)
2 4
Medical students' attitudes to complementary medical therapies
215
Table 2 Means (M) and standard deviations (SD) for each attitude statement. Asterisks indicate where significant differences between specialities occur. (1.0-2.2 = strongly disagree; 2.2-3.4 = disagree; 3.4-4.6 = uncertain; 4.6-5.8 = agree; 5.8-7.0 = strongly agree). Attitude statements are numbered according to their numbers on the questionnaire and are placed in order from highest to lowest total mean scores indicated most to least overall agreement. In the actual questionnaire, the word 'specialty' was replaced by 'homeopathy', 'acupuncture', etc.
Statement 58. Medical students in general know little about the specialty. 38. Practitioners of the specialty tend to treat the whole person, not just the physical illness.
Total N = 180 M SD 6.41
0.95
5.41
1.41
5.36
1.55
36. Practitioners of the specialty are held in poor regard by most other doctors.
5.34
1.29
42. A surprising number of patients claim it is effective at curing their illness.
5.31
1.27
51. All patients undergoing treatment from the specialty should be seen by a doctor first.
5.11
1.61
4.88
1.96
50. People choose the specialty simply because they do not receive satisfaction from orthodox practitioners.
4.86
1.57
52. Although the specialty can be effective, it is limited to only specific problems.
4.76
1.43
43. There are too many doubts about the future o f the specialty to choose it as a career.
4.74
1.63
54. The reason for the success of the specialty is mainly due to treating the whole person.
4.72
1.33
26. Practitioners of the specialty are able to offer patients more time and are more prepared to listen than are doctors.
4.72
1.65
57. Concurrent treatment with orthodox medicine and from the specialty is more effective than orthodox medicine alone. 4.69
1.43
34. The specialty is less attractive as a discipline because it is less intellectually comprehensive than medical specialties.
4.64
1.37
8. The specialty has low status within medicine.
5. Practitioners of the specialty should be medically qualified.
35. Doctors should take up the specialty to complement the efficacy of their orthodox medical treatment.
4.62
1.55
41. The specialty is cheaper to carry out than orthodox medicine.
4.61
1.48
55. The specialty works only on patients who believe in it.
4.61
1.54
40. The specialty has fewer side-effects than orthodox medicine.
4.50
1.57
2. On average, practitioners in the specialty make less money than other doctors.
4.49
1.60
16. Practitioners of the specialty are on the whole less dogmatic than other doctors.
4.27
1.27
15. The specialty should be made readily available on the NHS.
4.22
1.73
56. Most practitioners of the specialty receive a thorough training.
4.19
1.35
4.16
1.31
*48. Despite considerable research, there are few replicable results in the specialty. 1. The specialty has advanced considerably in recent years in its understanding of illness and disease.
4.15
1.48
45. The fact that the specialty is rooted in traditional medicine means that we should treat it seriously.
4.14
1.61
30. The specialty is very faddish.
4.14
1.66
10. The specialty is fairly unscientific and imprecise.
4.13
1.64
37. The specialty is more art than science.
4.07
1.47
3.99
1.54
31. In the medical school syllabus, too little time is devoted to the specialty.
7. Problems presented by patients to the specialty are particularly interesting and challenging.
3.99
1.85
39. Patients in the specialty make more emotional demands on doctors than other patients.
3.98
1.41
13. Women tend to enter the specialty more than men.
3.97
1.43
19. Students who express an interest in the specialty are seen by their peers as 'completely mad'.
3.83
1.67
14. Practitioners of orthodox medicine are more threatened by practitioners of the specialty than the other way round.
3.76
1.69
18. The specialty provides more cost-effective treatment compared with orthodox medicine.
3.69
1.47
17. The specialty should be taught in medical school.
3.68
1.78
3.67
1.61
3.59
1.62
3.58
1.65
53. Entering the specialty is a waste of a medical education.
3.51
1.57
27. There is no evidence that the specialty is effective.
3.48
1.49
46. There is really no scientific basis to the specialty.
3.48
1.75
9. The specialty is growing more rapidly than orthodox medicine. 12. The specialty is just a placebo effect. 6. The specialty is only effective in treating minor complaints and ailments.
216 ComplementaryTherapies in Medicine: Research 25. Teaching the specialtyto medical students is not feasible.
3.47
1.75
*47. Repeated treatment in the specialtydoesn't cause any harm, but with orthodox medicine it does.
3.43
1.52
24. Patients of the specialtytend to be better educated than patients of orthodox medicine.
3.23
1.69
32. Treating a condition using the specialtyis safer than using orthodox medicine.
3.13
1.45
44. Doctors who haven't studied the specialtyat medical school will find it difficult to acquire in future years.
2.98
1.60
22. Much of the specialtyis actually dangerous to the health of patients.
2.95
1.30
28. On the whole, people taking up training in the specialtyare running away from participation in real medicine.
2.94
1.43
11. Patients in the specialtyhardly ever get better.
2.94
1.14
23. The specialtyis unrewarding because the treatment is so lengthy.
2.91
1.32
49. The least intelligent doctors tend to practise the specialty.
2.89
1.49
29. Practitioners of the specialty get more satisfactionfrom their work than other doctors.
2.73
1.46
2.66
1.45
2.35
1.44
4. These days, the specialtyis becoming a more important part of the curriculum in medical schools. 21. You need to be 'gifted' to carry out the specialty.
considered that complementary medicine had low status within medicine, although they did not dismiss doctors who practised complementary medicine as unintelligent or unstable. However, the doubts about complementary medicine therapies made this an unsafe career choice. The prevailing view was that it was acceptable for a doctor to practise a form of complementary therapy alongside more orthodox techniques, as this was not seen to be an abandonment of orthodox medicine. Students did not, as a group, express a clear opinion about whether complementary therapies should be taught in medical school, though they were clear that there was no sign of this happening in their respective institutions.
correlated with demographic characteristics of the students. Unsurprisingly, a belief in the efficacy of complementary medicine was associated with positive attitudes towards its scientific credibility and a belief that complementary therapies should be included in the medical school curriculum. Conversely, a belief that there are many quacks in complementary medicine was inversely correlated with these attitudes. Interestingly, however, females students had more positive attitudes to the scientific status of complementary medicine (r=0.23, p<0.001), to teaching complementary medicine in medical school (r=0.16, p<0.01) and to the use of complementary medicine in the N H S (r=0.18, p<0.001) (Point bi-serial correlations).
Content analysis Clearly the attitude statements are related. Factor analysis, cluster analysis and content analysis were completed to study the structure of the 58 items. Of the three analyses, the most meaningful results were obtained by the content analysis which was done independently by the first and second author. Most of the statements were content analysed into the following 8 scales: 1. Characteristics of complementary practitioners 2. Characteristics of complementary medicine job 3. Characteristics of complementary medicine patients 4. Status with unorthodox medicine 5. Effectiveness of the therapy 6. Scientific nature of complementary medicine 7. Teaching of complementary medicine 8. Expansion of complementary medicine The attitude statements used to obtain the 8 scales are shown in Table 3. The alpha coefficients (indicating the reliability of the scales), are also shown in Table 3. These factor scores were then used to compute differences between the 5 groups using ANOVA. N o t surprisingly, there were no significant differences across. An analysis was computed to see if the various scales
DISCUSSION This study examined the different attitudes of pre-clinical medical students to various complementary therapies. The findings of this study show that there were no significant differences between the students' attitudes to herbalism, homoeopathy, hypnosis (hypnotherapy), osteopathy and acupuncture, on the majority of items. There are various possible explanations for this. The students all strongly agreed that they knew little about the five complementary therapies and were also uncertain about many of the attitude statements. Thus, it could be that, because the students knew little or believed they knew little about the individual complementary therapies, they simply (knowingly or unknowingly) expressed their attitudes to complementary medicine in general, rather than to the particular complementary therapy they were asked about. A second possibility is that, due to their lack of knowledge, the students were cautious in expressing strong beliefs about the specialties. This would have led to the many uncertain (mid-points) beliefs obtained for all the specialities. Perhaps if students were given information about the complementary specialities during
Medical students' attitudes to complementary medical therapies 217
Table 3 Attitude statements making up the 8 alternative medicine scales (X=alpha coefficient) CHARACTERISTICS OF ALTERNATIVE PRACTITIONERS (X=0.82) 3. 5. 13. 20. 21. 48. 56.
All practitioners of the specialty should be medically qualified. Practitioners in the specialty are as emotionally stable as other orthodox medicine doctors. Women tend to enter the specialty more than men. Only doctors should be allowed to practise the specialty. You need to be 'gifted' to carry out the specialty. The training of practitioners of the specialty is woefully inadequate. Most practitioners of the specialty receive a thorough training.
CHARACTERISTICS OF THE ALTERNATIVE M E D I C I N E JOB (X=0.60) 2. On average, practitioners in the specialty make less money than other doctors. 26. Practitioners of the specialty are able to offer patients more time and are more prepared to listen than are doctors. 38. Practitioners of the specialty are held in poor regard by most other doctors.
CHARACTERISTICS O F T H E ALTERNATIVE M E D I C I N E PATIENT (X=0.50) 7. Problems presented by patients to the specialty are particularly interesting and challenging. 24. Patients of the specialty tend to be better educated than patients of orthodox medicine. 39. Patients in the specialty make more emotional demands on doctors than other patients.
STATUS W I T H I N ORTHODOX M E D I C I N E (X=0.67) 8. 14. 19. 36.
The specialty has low status within medicine. Practitioners of orthodox medicine are more threatened by practitioners of the specialty than the other way round. Students who express an interest in the specialty are seen by their peers as 'completely mad'. Practitioners of the specialty are held in poor regard by most other doctors
EFFECTIVENESS (X=0.58) 6. 11. 12. 18. 22. 23. 27. 32. 35. 40. 41. 42. 47. 52. 54. 55. 57.
The specialty is only effective in treating minor complaints and ailments. Patients in the specialty hardly ever get better. The specialty is just a placebo effect. The specialty provides more cost-effective treatment than orthodox medicine. Much of the specialty is actually dangerous to the health of patients. The specialty is unrewarding because the treatment is so lengthy. There is no evidence that the specialty is effective. Treating a condition using the specialty is safer than using orthodox treatments. Doctors should take up the specialty to complement the efficacy of their orthodox medical treatments. The specialty has fewer side-effects than orthodox medical treatments. The specialty is cheaper to carry out than orthodox medicine. A surprising number of patients claim it is effective at curing their ills. Repeated treatment in the specialty doesn't cause any harm, but with orthodox medicine it does. Although the specialty can be effective, it is limited to only specific problems. The reason for the success of the specialty is mainly due to treating the whole person. The specialty works only on patients who believe in it. Concurrent treatment with orthodox medicine and from the specialty is more effective than orthodox medicine alone.
SCIENTIFIC N A T U R E OF ALTERNATIVE M E D I C I N E (X=0.70) 10. 33. 34. 37. 46.
The specialty is fairly unscientific and imprecise. Despite considerable research, there are few replicable results in the specialty. The specialty is less attractive as a discipline because it is less intellectually comprehensive than medical specialities. The specialty is more art than science. There is really no scientific basis to the specialty.
T E A C H I N G O F ALTERNATIVE M E D I C I N E (X=0.52) 4. 17. 31. 58.
These days, the speciality is becoming a more important part of the curriculum in medical schools. The specialty should be taught in medical school. In the medical school syllabus, too little time is devoted to the specialty. Medical students in general know little about the specialty.
EXPANSION O F ALTERNATIVE M E D I C I N E (X=0.47) 1. The specialty has advanced considerably in recent years in its understanding of illness and disease. 15. The specialty should be made readily available on the NHS.
218 ComplementaryTherapiesin Medicine:Research their training, or if they had experience of the specialties, differences in attitudes towards them might emerge. A minority (17%) of the students had visited someone who practised complementary medicine, but almost a third knew someone close who uses or who had used a complementary practitioner. However, this could not guarantee knowledge of the particular complementary therapy about which these students were questioned. A third possibility is that, because the five complementary therapies considered in this study are the more established and well-known ones, students saw them as similarly effective and beneficial. If less well-established, more controversial specialties such as faith healing, reflexology, or aromatherapy were included in the study, students' beliefs about them may have differed significantly from those about the more established complementary therapies. It was interesting that male medical students were more likely than females to believe that complementary medicine is unscientific, not advancing, and that it should not be taught in medical school. Thus, male medical students seem more sceptical about complementary medicine than do females. However, it is important to remember that the correlations between sex and the attitude scales were relatively low. Also, it could just be that females were more likely to be uncertain about statements where males were more ready to give an agree or disagree answer. Despite their uncertainly about factors that one would expect students of orthodox medicine to take into account, such as whether or not complementary medicine has a scientific basis, and whether there is evidence for its efficacy, the students had a generally positive attitude to complementary medicine. They nevertheless believed that complementary medicine has low status in orthodox medicine, and that complementary practitioners are held in low regard by most other doctors. In all, 75% of the students believed that complementary practitioners had effective treatments, and 92% did not believe that complementary practitioners were less intelligent and less emotionally stable than other doctors. The students also recognised the holistic approach of complementary medicine, and felt that complementary practitioners spend more time than doctors listening to their patients. However, despite this, they did not believe that complementary practitioners get more satisfaction from their work than doctors. The students also agreed that a surprising number of patients claim complementary medicine is effective at curing their ills. The students' positive attitudes to complementary medicine were, however, accompanied by caution, since 76% of the students believed there are many 'quacks' in complementary medicine. It is not, however, clear whether students believed these quacks were predominantly in the established complementary therapies, in the less well-established therapies, or both. The students tended to believe that all patients
undergoing complementary treatment should be seen first by a doctor, and that complementary practitioners should preferably be medically qualified. They were, however, unsure about whether only doctors should practise complementary medicine. Possibly, the students would prefer complementary practitioners to have some knowledge of, or training in, orthodox medicine to ensure against 'quacks' and to ensure patient safety. Interestingly, Conservative medical students were more likely than Labour students to be cautious, to believe that complementary practitioners should be medically qualified, and that doctors should see patients before they undergo complementary treatment. The studies looking at attitudes of general practitioners to complementary medicine~°,t2 concluded that the interest in complementary medicine shown by general practitioners should be met in undergraduate curriculum or post-graduate training programmes. This view was supported by Wharton and Lewith," who argued that teaching about complementary medicine needs to be given to general practitioners in order to provide them with an overall and informed view about these treatments. Velimirovic and Raab 16 argued that Austrian medical students needed the opportunity to discuss complementary medicine critically and objectively. Hansen2° suggested a medical curriculum for learning about complementary medicine in this objective manner. In this study, however, although the students had positive attitudes to complementary medicine, they were unsure about whether or not the complementary specialties should be taught in medical school, and whether or not it was feasible. This could be because the students already have a busy orthodox medical curriculum, and so were unsure whether it would be possible also to include complementary medicine. Ideally, rather than using an attitude statement, a question could have been asked about whether medical students should be taught complementary medicine, and to what extent this should occur. It could be that students have definite views on the extent to which complementary medicine should be covered. Students may not mind being given a short overview. Students did not believe that you need to be 'gifted' to practise complementary medicine, or that doctors who have not studied alternative medicine at medical school would find it difficult to acquire in future years. Thus, it seems that these students would be willing to have post-graduate training in complementary medicine. The students recognised these therapies as complementary, rather than as alternative to orthodox medicine. In Wharton and Lewith's 1986 study, H 70% of the 145 respondents thought that the more acceptable alternative therapies should be made available on the NHS. However, the medical students in this study were unsure about this. The minority of students who had visited a complementary practitioner, or who knew someone close who uses or had used one, were
Medical students' attitudes to complementary medical therapies
more likely than other students to have positive attitudes to the complementary therapies. This suggests that exposure to complementary medicine may generate positive attitudes towards it. However, it is not clear whether these students had positive attitudes towards complementary medicine before they or someone close visited the practitioner, or whether the positive attitudes developed as a result of these events. The vast majority of students in this study will complete their clinical training and will become practising doctors. Although attitudes and beliefs may not be the only factors influencing whether these medical students eventually choose to take up complementary medicine, these findings should be taken into account when considering future medical curricula and post-graduate training. The BMA~smost recent report on complementary medicine21 is markedly more willing to accept the role of complementary practitioners than its predecessor. It calls for more research on all aspects of complementary medicine, particularly efficacy, and for registration and regulation of the main complementary professional groups - all of which would be endorsed by the complementary professional associations. Given medical students' positive attitudes to complementary medicine and this changing climate, it would seem time to consider an introduction to complementary medicine within the medical curriculum, though training in complementary techniques should be left until after graduation. ACKNOWLEDGEMENT We are grateful to the Research Council for Complementary Medicine for their support.
REFERENCES
Fulder S, Monro RE. Complementary medicine in the United Kingdom: patients, practitioners and consultations. Lancet 1985; 2: 542-545.
2 19
2. Lewith GT, Aldridge D, eds. Complementary medicine and the European Community. Saffron Walden, Essex: CW Daniel, 1991. 3. Eisenberg DM, Kessler RC, Foster C et al. Unconventional medicine in the United States: prevalence, costs and patterns of use. New Engl J Med 1993; 328: 246-253. 4. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a general practitioner and a homoeopath. Soc Sci Med 1988; 26: 685-689. 5. Murray J, Shepherd S. Alternative or additional medicine? A new dilemma for the doctor. J Roy Coll Gen Pract 1988; 38: 511-514. 6. Sharma U. Complementary medicine today: practitioners and patients. Rev edn. London: Routledge, 1995. 7. The flight from science (Editorial). BMJ 1980; 280: 1-2. 8. Smith T. Alternative medicine (Editorial). BMJ 1983; 287: 307. 9. Physician, heal thyself. The Times 1983; 10 August. 10. Reilly D. Young doctors' views on alternative medicine. BMJ 1983; 287: 337-339. 11. Wharton R, Lewith G. Complementary medicine and the general practitioner. Lancet 1986; 292: 1498-1500. 12. Anderson E, Anderson R General practitioners and alternative medicine. J Roy Coll Gen Pract 1987; 37: 52-55. 13. Visser G J, Peters L. Alternative medicine and general practitioners in the Netherlands: towards acceptance and integration. Fam Pract 1990; 7(3): 227-232. 14. Bruhn J, Parsons O. Medical students' attitudes toward four medical specialties. J Med Educ 1964: 39: 40-49. 15. Furnham A. Medical students' beliefs about nine different specialties. BMJ 1986; 293: 1607-1610. 16. Velimirovic B, Raab S. Attitudes of medical students towards alternative medicine. Offentliche Gesundheitswesen 1990; 52(3): 136-1141. 17. Reilly D, Taylor M. Developing integrated medicine. Compl Therap Med 1993; 1(4): supplement. 18. Halliday J, Taylor M, Jenkins A, Reilly D. Medical students and complementary medicine. Compl Therap Med 1993: 1(4): supplement, 3~33. 19. Furnham A. Attitudes towards alternative medicine: a study on the perception of those studying orthodox medicine. Compl Therap Med 1993; 1(3): 120 126. 20. Hansen E A suggested medical curriculum for learning about complementary medicine. J Roy Soc Med 1991; 84: 702-703. 21. British Medical Association. Complementary medicine: new approaches to good practice. Oxford: OUR 1993.
© 1995PearsonProfessionalLtd
RESEARCH
Medical students' attitudes to complementary medical therapies A. F u r n h a m , D. H a n n a and C. A. Vincent SUMMARY. One hundred and eighty medical students completed one of five versions of a questionnaire concerning their attitudes to five complementary therapies: acupuncture, herbalism, homoeopathy, hypnosis, and osteopathy. Very few significant statistical differences in students' attitudes to the five therapies were found, suggesting that students had similar attitudes, which were generally positive, despite the fact that they considered they knew little about the therapies. These results are discussed in terms of the growing literature on complementary medicine.
that the reasons for the growth of alternative medicine are attributable in part to the failures of the orthodox medical professional. To what extent these views are shared by trained doctors or medical students is unclear. Various small-scale studies have been carried out in the UK to see how doctors are responding to the new climate of public interest in complementary medicine. Most have examined the attitudes of doctors, particularly general practitioners. Reilly1° examined the attitudes of general practitioner trainees to complementary medicine, and found that a positive attitude emerged from the 86 respondents. The majority considered acupuncture, hypnosis, homoeopathy and manipulation to be fairly useful. In all, 18 of the trainees used at least one complementary method themselves, and 7 wanted to train in one or more methods (especially hypnosis and manipulation). Reilly pointed out, however, that 'it is unlikely that general practitioner trainees are representative of the profession at large. A pilot study has shown much less interest among junior hospital doctors and still less among senior doctors'. Wharton and LewithHfound a high level of interest in complementary medicine among general practitioners in the Avon area. In total, 38% of the 145 respondents had received some training in complementary medicine, and 15% wished to arrange training. In the previous year, 76% had referred patients for alternative treatment to a doctor, 72% had referred patients to non-medically qualified practitioners, and 70% thought that the more acceptable techniques, e.g. hypnosis, acupuncture, spinal manipulation and homoeopathy should be available through the National Health Service (NHS). Anderson and Anderson '2 studied general practitioners in Oxfordshire, and found a high level of interest in, knowledge of, and referral of patients for complementary medicine. Of the 222 respondents, 41% had attended lectures or classes in complementary medicine; 12% had received training, and 42% wanted training in an alternative form of medicine; 16% were practising a form of complementary
INTRODUCTION Complementary medicine (also known as alternative medicine), which is generally excluded from the medical undergraduate curriculum, has expanded rapidly in the past 15 years. Fulder and Monro ~ found that between the years 1978 and 1981 there were substantial increases in numbers of practitioners of all forms of complementary medicine except herbalists. The mean increase in registered complementary therapists was 11.5% per year, which is nearly six times faster than the annual increase in doctors in the United Kingdom. In 1980-81 there were about 12 practitioners of complementary medicine per 100 000 population in the UK (i.e. 27% of the total number of general practitioners), and they estimated that about 1.5 million patients (2.5% of the population) make some 11.7 million consultations with complementary practitioners per year (about 6.5-8.6% of the number of annual consultations with general practitioners). 1 A similar level of demand for complementary medicine has been found throughout Europe and in the USA. 2,3 The growth of, and public interest in, complementary medicine has attracted a limited amount of research, 4~ as well as much comment in both orthodox medical journals 7,8 and national media? In an editorial in the British Medical Journal] it is argued that, due to the growth in the public mind of the concept of consumerism, public sentiment has swung away from its enchantment with science and technology. This general 'flight from science', it argues, means that the public no longer appreciates the achievements of modern orthodox medicine, and seems unwilling to accept its scientific standards of proof or, at least, unwilling to apply these standards to complementary medicine. In 1983, a leader in The Times 9 suggested Professor Adrian Furnham MA, MSc, DPhil, DSc; D. Hanna
BSc(Lond); Charles A. Vincent MPhil, PhD, Department of Psychology, University College London, 26 Bedford Way, London WC1, UK. Correspondence to Professor Furnham. 212
Medicalstudents'attitudesto complementarymedicaltherapies 213 medicine, and 59% had referred one or more patients to complementary practitioners within the previous year. Although the above studies were relatively smallscale, they yielded comparable results, showing a generally high level of interest in complementary medicine among general practitioners. Critics of these studies have stated that many quite orthodox techniques (e.g. manipulation, counselling) were wrongly classified as complementary, so exaggerating the interest in truly complementary techniques. General practitioners may also not be representative of the whole orthodox medical profession. Visser and Peters" suggest that general practitioners have a more pragmatic attitude to medicine than their hospital colleagues, which makes them more willing to accept complementary medicine, although they may remain sceptical of its efficacy. There is a considerable literature on the attitudes, beliefs, expectations, and values of medical students towards various orthodox medical specialties. 14,15 In Furnham's 1986 study of medical students' attitudes to nine orthodox medical specialties, the findings showed that, whereas any one specialty was perceived positively on one dimension (e.g. relationship with patients), it could also be perceived as highly negative on another (e.g., efficacy). 15 However, very few studies have examined medical students' attitudes to complementary medicine. Velimirovic and Raab 16found that alternative medicine was popular with medical students and recent medical graduates of the University of Graz in Austria, despite the fact that the students did not know much about the theory of alternative medicine. More recently, Reilly and Taylor17found 92% of 212 trained Scottish doctors believed alternative medicine useful with 76% saying they had seen patients benefit from treatment. Halliday, Taylor, Jenkins and ReillyTM tested 592 Scottish medical students' attitudes to complementary medicine. In all, 77% thought it useful - increasingly so as they progressed through their training. Of these students, 69% said they would like it in their curriculum and 63% were in favour of its being included in the NHS. The greatest area of doubt among the students is whether they would refer patients to an alternative practitioner outside the NHS; 41% said they would, while 39% were unsure. Furnham 19carried out a study looking at pre-clinical medical students' attitudes to established alternative therapies (acupuncture, herbalism, homoeopathy, and osteopathy) in general, and found a positive attitude among the students. Following on from Furnham's 1986 study, this study examined pre-clinical medical students' attitudes specifically to the following 5 complementary therapies: herbalism, homoeopathy, hypnosis (hypnotherapy), osteopathy and acupuncture, to see if there were any differences in attitudes to these different therapies. These complementary therapies were chosen because they are generally well established, well known, and definable. It
was expected that the students would be a bit cautious about the therapies but, as in other studies, generally positive, less hostile, and less negatively stereotyping than some practising doctors. The vast majority of these students would have been educated at the time when complementary medicine was receiving much public and media attention. The attitudes and beliefs of these students will, no doubt, be strongly shaped by their teachers and their clinical training. Also, these attitudes may play a part in determining whether or not these future doctors eventually decide to learn or use a complementary therapy. METHOD
Subjects One hundred and eighty medical students took part in the study, of whom 98 were male and 82 were female. They ranged in age from 19-30 years, the mean age being 20 years. Most of the medical students were unmarried (99%). They varied in their political affiliations as follows: 34% Conservative; 22% Labour; 20% Liberal Democrat; 6% other (and 18% none). They came from a wide variety of religions, but most (59%) were Christians. One hundred and thirty-eight (77%) of the students were pre-clinical and in their preclinical training, and 42 (23%) were studying for an intercalcated BSc (one academic year) before starting clinical training. The second-year students came from three London University medical schools.
Questionnaire Subjects completed a questionnaire which was based on a modified version of Furnham's 1986 fifty-item questionnaire, which had been designed to measure medical students' beliefs about the different orthodox medical specialties. The modified version contained 68 statements of attitudes to complementary medicine in general; 40 of the 68 statements were derived from the previous study, and 18 others were added. Five versions of the questionnaire were used. The versions were identical except that each was headed with a particular complementary medical therapy: herbalism, homoeopathy, hypnosis (hypnotherapy), osteopathy or acupuncture. Since the term complementary medical 'specialty' was used in the questionnaires instead of complementary medical 'therapy', these words will be used interchangeably in this report. The attitude statements in each questionnaire covered several aspects of each complementary therapy: its effectiveness at 'curing' patients; the characteristics of its patients; the characteristics of its practitioners; the characteristics of the job; its teaching in medical school; its status in orthodox medicine; its scientific nature; and the growth of the therapy and the characteristics of the patients who use complementary medicine. Many
214
Complementary Therapies in Medicine: Research
patients, of course, use both orthodox and complementary medicine. The subjects were asked to indicate how much they agreed or disagreed with each attitude statement by using a 7-point scale where: 1 = Disagree. The subjects were also asked 5 yes-no questions about their knowledge or experience of complementary medicine.
PROCEDURE Where possible, the subjects were debriefed. The questionnaires were handed out with the aim of ending up with a similar number of questionnaires returned for each specialty and with a similar distribution from each place. The questionnaires were handed out at random. Questionnaires placed in pigeon holes had a much lower return rate than those where students were approached face to face. In total, 325 questionnaires were distributed (65 of each alternative medicine specialty). The overall response rate was 55% (180) completed and usable questionnaires returned. Some students failed to answer all the attitude statements and questions and so, consequently, sample sizes varied slightly. Samples sizes were by questionnaire: herbalism = 37; homoeopathy = 36; hypnosis = 39; osteopathy = 34; acupuncture = 34.
RESULTS
Knowledge and experience of complementary medicine The findings are summarized in Table 1. Questions invited a yes or no answer, although occasionally students responded 'sometimes', and are classified accordingly. Few students had received any form of complementary treatment, although almost a third knew someone who had. They tended to believe that some complementary therapies were useful, and not to believe that complementary patients were necessarily gullible individuals.
Comparability of groups on demographic characteristics If students who had completed a questionnaire on one of the complementary medical specialities differed significantly on any major demographic variable from students who had completed a questionnaire on a different specialty, any attitude differences found between these specialties could be attributed to
demographic differences. Hence, an analysis of variance was computed between the five alternative medicine specialties questionnaire groups to see if there were any significant differences between the specialties in terms of the students' sex, age, marital status, political affiliations, religions, religious natures, and their answers to the five yes-no questions. None of the F-levels obtained approached significance. There was also no significant difference in terms of the year that the students were in (second or BSc), or in terms of the medical schools from which the students came.
Attitudinal items One-way analysis of variance (ANOVA) was computed between the questionnaires referring to the different complementary therapies to see if there was any significant difference between them in mean scores on each of the 58 attitude statements. No significant differences in scores were found (at the p<0.05 level) except on 2 attitude statements: a. 'Repeated treatment in the specialty doesn't cause any harm, but with orthodox medicine it does.' Medical students considered that both herbalism and osteopathy had a potential for harm, but were uncertain about the other therapies. b. 'The training of practitioners of the specialty is woefully inadequate.' Medical students tended towards disagreeing with this statement for acupuncture, but were significantly less certain for herbalism and hypnosis. However, by change alone, one might expect three significant differences and this analysis is capitalizing on Type 1 errors. Because there were so few differences between groups, scores for all 180 students have been grouped together and are shown in Table 2. Some general conclusions are possible about medical students' attitudes to complementary medicine, even though they generally do not distinguish between the different therapies. Students agreed that many patients find complementary medicine to be effective, as well as cheaper, and did not feel that such therapies were a danger to health. Patients were not thought to be gullible, but were thought to need faith in procedures. Students clearly recognized that complementary practitioners might have more time to spend with their patients and that this aspect of the consultation might be important. As regards professional and career issues, the students
Table 1 Experience of alternative medicine Yes (%) 1. Have you ever visited someone who practises alternative (complementary) medicine? 2. Does somebody close to you use an alternative practitioner? 3. Do you believe alternative practitioners have effective treatments? 4. Is it only naive or gullible people who go to alternative practitioners? 5. Do you believe there are m a n y 'quacks' in alternative medicine?
17 31 69 7 76
N o (%) 83 69 17 92 18
Sometimes (%)
12 1 2
Left out (%)
2 4
Medical students' attitudes to complementary medical therapies
215
Table 2 Means (M) and standard deviations (SD) for each attitude statement. Asterisks indicate where significant differences between specialities occur. (1.0-2.2 = strongly disagree; 2.2-3.4 = disagree; 3.4-4.6 = uncertain; 4.6-5.8 = agree; 5.8-7.0 = strongly agree). Attitude statements are numbered according to their numbers on the questionnaire and are placed in order from highest to lowest total mean scores indicated most to least overall agreement. In the actual questionnaire, the word 'specialty' was replaced by 'homeopathy', 'acupuncture', etc.
Statement 58. Medical students in general know little about the specialty. 38. Practitioners of the specialty tend to treat the whole person, not just the physical illness.
Total N = 180 M SD 6.41
0.95
5.41
1.41
5.36
1.55
36. Practitioners of the specialty are held in poor regard by most other doctors.
5.34
1.29
42. A surprising number of patients claim it is effective at curing their illness.
5.31
1.27
51. All patients undergoing treatment from the specialty should be seen by a doctor first.
5.11
1.61
4.88
1.96
50. People choose the specialty simply because they do not receive satisfaction from orthodox practitioners.
4.86
1.57
52. Although the specialty can be effective, it is limited to only specific problems.
4.76
1.43
43. There are too many doubts about the future o f the specialty to choose it as a career.
4.74
1.63
54. The reason for the success of the specialty is mainly due to treating the whole person.
4.72
1.33
26. Practitioners of the specialty are able to offer patients more time and are more prepared to listen than are doctors.
4.72
1.65
57. Concurrent treatment with orthodox medicine and from the specialty is more effective than orthodox medicine alone. 4.69
1.43
34. The specialty is less attractive as a discipline because it is less intellectually comprehensive than medical specialties.
4.64
1.37
8. The specialty has low status within medicine.
5. Practitioners of the specialty should be medically qualified.
35. Doctors should take up the specialty to complement the efficacy of their orthodox medical treatment.
4.62
1.55
41. The specialty is cheaper to carry out than orthodox medicine.
4.61
1.48
55. The specialty works only on patients who believe in it.
4.61
1.54
40. The specialty has fewer side-effects than orthodox medicine.
4.50
1.57
2. On average, practitioners in the specialty make less money than other doctors.
4.49
1.60
16. Practitioners of the specialty are on the whole less dogmatic than other doctors.
4.27
1.27
15. The specialty should be made readily available on the NHS.
4.22
1.73
56. Most practitioners of the specialty receive a thorough training.
4.19
1.35
4.16
1.31
*48. Despite considerable research, there are few replicable results in the specialty. 1. The specialty has advanced considerably in recent years in its understanding of illness and disease.
4.15
1.48
45. The fact that the specialty is rooted in traditional medicine means that we should treat it seriously.
4.14
1.61
30. The specialty is very faddish.
4.14
1.66
10. The specialty is fairly unscientific and imprecise.
4.13
1.64
37. The specialty is more art than science.
4.07
1.47
3.99
1.54
31. In the medical school syllabus, too little time is devoted to the specialty.
7. Problems presented by patients to the specialty are particularly interesting and challenging.
3.99
1.85
39. Patients in the specialty make more emotional demands on doctors than other patients.
3.98
1.41
13. Women tend to enter the specialty more than men.
3.97
1.43
19. Students who express an interest in the specialty are seen by their peers as 'completely mad'.
3.83
1.67
14. Practitioners of orthodox medicine are more threatened by practitioners of the specialty than the other way round.
3.76
1.69
18. The specialty provides more cost-effective treatment compared with orthodox medicine.
3.69
1.47
17. The specialty should be taught in medical school.
3.68
1.78
3.67
1.61
3.59
1.62
3.58
1.65
53. Entering the specialty is a waste of a medical education.
3.51
1.57
27. There is no evidence that the specialty is effective.
3.48
1.49
46. There is really no scientific basis to the specialty.
3.48
1.75
9. The specialty is growing more rapidly than orthodox medicine. 12. The specialty is just a placebo effect. 6. The specialty is only effective in treating minor complaints and ailments.
216 ComplementaryTherapies in Medicine: Research 25. Teaching the specialtyto medical students is not feasible.
3.47
1.75
*47. Repeated treatment in the specialtydoesn't cause any harm, but with orthodox medicine it does.
3.43
1.52
24. Patients of the specialtytend to be better educated than patients of orthodox medicine.
3.23
1.69
32. Treating a condition using the specialtyis safer than using orthodox medicine.
3.13
1.45
44. Doctors who haven't studied the specialtyat medical school will find it difficult to acquire in future years.
2.98
1.60
22. Much of the specialtyis actually dangerous to the health of patients.
2.95
1.30
28. On the whole, people taking up training in the specialtyare running away from participation in real medicine.
2.94
1.43
11. Patients in the specialtyhardly ever get better.
2.94
1.14
23. The specialtyis unrewarding because the treatment is so lengthy.
2.91
1.32
49. The least intelligent doctors tend to practise the specialty.
2.89
1.49
29. Practitioners of the specialty get more satisfactionfrom their work than other doctors.
2.73
1.46
2.66
1.45
2.35
1.44
4. These days, the specialtyis becoming a more important part of the curriculum in medical schools. 21. You need to be 'gifted' to carry out the specialty.
considered that complementary medicine had low status within medicine, although they did not dismiss doctors who practised complementary medicine as unintelligent or unstable. However, the doubts about complementary medicine therapies made this an unsafe career choice. The prevailing view was that it was acceptable for a doctor to practise a form of complementary therapy alongside more orthodox techniques, as this was not seen to be an abandonment of orthodox medicine. Students did not, as a group, express a clear opinion about whether complementary therapies should be taught in medical school, though they were clear that there was no sign of this happening in their respective institutions.
correlated with demographic characteristics of the students. Unsurprisingly, a belief in the efficacy of complementary medicine was associated with positive attitudes towards its scientific credibility and a belief that complementary therapies should be included in the medical school curriculum. Conversely, a belief that there are many quacks in complementary medicine was inversely correlated with these attitudes. Interestingly, however, females students had more positive attitudes to the scientific status of complementary medicine (r=0.23, p<0.001), to teaching complementary medicine in medical school (r=0.16, p<0.01) and to the use of complementary medicine in the N H S (r=0.18, p<0.001) (Point bi-serial correlations).
Content analysis Clearly the attitude statements are related. Factor analysis, cluster analysis and content analysis were completed to study the structure of the 58 items. Of the three analyses, the most meaningful results were obtained by the content analysis which was done independently by the first and second author. Most of the statements were content analysed into the following 8 scales: 1. Characteristics of complementary practitioners 2. Characteristics of complementary medicine job 3. Characteristics of complementary medicine patients 4. Status with unorthodox medicine 5. Effectiveness of the therapy 6. Scientific nature of complementary medicine 7. Teaching of complementary medicine 8. Expansion of complementary medicine The attitude statements used to obtain the 8 scales are shown in Table 3. The alpha coefficients (indicating the reliability of the scales), are also shown in Table 3. These factor scores were then used to compute differences between the 5 groups using ANOVA. N o t surprisingly, there were no significant differences across. An analysis was computed to see if the various scales
DISCUSSION This study examined the different attitudes of pre-clinical medical students to various complementary therapies. The findings of this study show that there were no significant differences between the students' attitudes to herbalism, homoeopathy, hypnosis (hypnotherapy), osteopathy and acupuncture, on the majority of items. There are various possible explanations for this. The students all strongly agreed that they knew little about the five complementary therapies and were also uncertain about many of the attitude statements. Thus, it could be that, because the students knew little or believed they knew little about the individual complementary therapies, they simply (knowingly or unknowingly) expressed their attitudes to complementary medicine in general, rather than to the particular complementary therapy they were asked about. A second possibility is that, due to their lack of knowledge, the students were cautious in expressing strong beliefs about the specialties. This would have led to the many uncertain (mid-points) beliefs obtained for all the specialities. Perhaps if students were given information about the complementary specialities during
Medical students' attitudes to complementary medical therapies 217
Table 3 Attitude statements making up the 8 alternative medicine scales (X=alpha coefficient) CHARACTERISTICS OF ALTERNATIVE PRACTITIONERS (X=0.82) 3. 5. 13. 20. 21. 48. 56.
All practitioners of the specialty should be medically qualified. Practitioners in the specialty are as emotionally stable as other orthodox medicine doctors. Women tend to enter the specialty more than men. Only doctors should be allowed to practise the specialty. You need to be 'gifted' to carry out the specialty. The training of practitioners of the specialty is woefully inadequate. Most practitioners of the specialty receive a thorough training.
CHARACTERISTICS OF THE ALTERNATIVE M E D I C I N E JOB (X=0.60) 2. On average, practitioners in the specialty make less money than other doctors. 26. Practitioners of the specialty are able to offer patients more time and are more prepared to listen than are doctors. 38. Practitioners of the specialty are held in poor regard by most other doctors.
CHARACTERISTICS O F T H E ALTERNATIVE M E D I C I N E PATIENT (X=0.50) 7. Problems presented by patients to the specialty are particularly interesting and challenging. 24. Patients of the specialty tend to be better educated than patients of orthodox medicine. 39. Patients in the specialty make more emotional demands on doctors than other patients.
STATUS W I T H I N ORTHODOX M E D I C I N E (X=0.67) 8. 14. 19. 36.
The specialty has low status within medicine. Practitioners of orthodox medicine are more threatened by practitioners of the specialty than the other way round. Students who express an interest in the specialty are seen by their peers as 'completely mad'. Practitioners of the specialty are held in poor regard by most other doctors
EFFECTIVENESS (X=0.58) 6. 11. 12. 18. 22. 23. 27. 32. 35. 40. 41. 42. 47. 52. 54. 55. 57.
The specialty is only effective in treating minor complaints and ailments. Patients in the specialty hardly ever get better. The specialty is just a placebo effect. The specialty provides more cost-effective treatment than orthodox medicine. Much of the specialty is actually dangerous to the health of patients. The specialty is unrewarding because the treatment is so lengthy. There is no evidence that the specialty is effective. Treating a condition using the specialty is safer than using orthodox treatments. Doctors should take up the specialty to complement the efficacy of their orthodox medical treatments. The specialty has fewer side-effects than orthodox medical treatments. The specialty is cheaper to carry out than orthodox medicine. A surprising number of patients claim it is effective at curing their ills. Repeated treatment in the specialty doesn't cause any harm, but with orthodox medicine it does. Although the specialty can be effective, it is limited to only specific problems. The reason for the success of the specialty is mainly due to treating the whole person. The specialty works only on patients who believe in it. Concurrent treatment with orthodox medicine and from the specialty is more effective than orthodox medicine alone.
SCIENTIFIC N A T U R E OF ALTERNATIVE M E D I C I N E (X=0.70) 10. 33. 34. 37. 46.
The specialty is fairly unscientific and imprecise. Despite considerable research, there are few replicable results in the specialty. The specialty is less attractive as a discipline because it is less intellectually comprehensive than medical specialities. The specialty is more art than science. There is really no scientific basis to the specialty.
T E A C H I N G O F ALTERNATIVE M E D I C I N E (X=0.52) 4. 17. 31. 58.
These days, the speciality is becoming a more important part of the curriculum in medical schools. The specialty should be taught in medical school. In the medical school syllabus, too little time is devoted to the specialty. Medical students in general know little about the specialty.
EXPANSION O F ALTERNATIVE M E D I C I N E (X=0.47) 1. The specialty has advanced considerably in recent years in its understanding of illness and disease. 15. The specialty should be made readily available on the NHS.
218 ComplementaryTherapiesin Medicine:Research their training, or if they had experience of the specialties, differences in attitudes towards them might emerge. A minority (17%) of the students had visited someone who practised complementary medicine, but almost a third knew someone close who uses or who had used a complementary practitioner. However, this could not guarantee knowledge of the particular complementary therapy about which these students were questioned. A third possibility is that, because the five complementary therapies considered in this study are the more established and well-known ones, students saw them as similarly effective and beneficial. If less well-established, more controversial specialties such as faith healing, reflexology, or aromatherapy were included in the study, students' beliefs about them may have differed significantly from those about the more established complementary therapies. It was interesting that male medical students were more likely than females to believe that complementary medicine is unscientific, not advancing, and that it should not be taught in medical school. Thus, male medical students seem more sceptical about complementary medicine than do females. However, it is important to remember that the correlations between sex and the attitude scales were relatively low. Also, it could just be that females were more likely to be uncertain about statements where males were more ready to give an agree or disagree answer. Despite their uncertainly about factors that one would expect students of orthodox medicine to take into account, such as whether or not complementary medicine has a scientific basis, and whether there is evidence for its efficacy, the students had a generally positive attitude to complementary medicine. They nevertheless believed that complementary medicine has low status in orthodox medicine, and that complementary practitioners are held in low regard by most other doctors. In all, 75% of the students believed that complementary practitioners had effective treatments, and 92% did not believe that complementary practitioners were less intelligent and less emotionally stable than other doctors. The students also recognised the holistic approach of complementary medicine, and felt that complementary practitioners spend more time than doctors listening to their patients. However, despite this, they did not believe that complementary practitioners get more satisfaction from their work than doctors. The students also agreed that a surprising number of patients claim complementary medicine is effective at curing their ills. The students' positive attitudes to complementary medicine were, however, accompanied by caution, since 76% of the students believed there are many 'quacks' in complementary medicine. It is not, however, clear whether students believed these quacks were predominantly in the established complementary therapies, in the less well-established therapies, or both. The students tended to believe that all patients
undergoing complementary treatment should be seen first by a doctor, and that complementary practitioners should preferably be medically qualified. They were, however, unsure about whether only doctors should practise complementary medicine. Possibly, the students would prefer complementary practitioners to have some knowledge of, or training in, orthodox medicine to ensure against 'quacks' and to ensure patient safety. Interestingly, Conservative medical students were more likely than Labour students to be cautious, to believe that complementary practitioners should be medically qualified, and that doctors should see patients before they undergo complementary treatment. The studies looking at attitudes of general practitioners to complementary medicine~°,t2 concluded that the interest in complementary medicine shown by general practitioners should be met in undergraduate curriculum or post-graduate training programmes. This view was supported by Wharton and Lewith," who argued that teaching about complementary medicine needs to be given to general practitioners in order to provide them with an overall and informed view about these treatments. Velimirovic and Raab 16 argued that Austrian medical students needed the opportunity to discuss complementary medicine critically and objectively. Hansen2° suggested a medical curriculum for learning about complementary medicine in this objective manner. In this study, however, although the students had positive attitudes to complementary medicine, they were unsure about whether or not the complementary specialties should be taught in medical school, and whether or not it was feasible. This could be because the students already have a busy orthodox medical curriculum, and so were unsure whether it would be possible also to include complementary medicine. Ideally, rather than using an attitude statement, a question could have been asked about whether medical students should be taught complementary medicine, and to what extent this should occur. It could be that students have definite views on the extent to which complementary medicine should be covered. Students may not mind being given a short overview. Students did not believe that you need to be 'gifted' to practise complementary medicine, or that doctors who have not studied alternative medicine at medical school would find it difficult to acquire in future years. Thus, it seems that these students would be willing to have post-graduate training in complementary medicine. The students recognised these therapies as complementary, rather than as alternative to orthodox medicine. In Wharton and Lewith's 1986 study, H 70% of the 145 respondents thought that the more acceptable alternative therapies should be made available on the NHS. However, the medical students in this study were unsure about this. The minority of students who had visited a complementary practitioner, or who knew someone close who uses or had used one, were
Medical students' attitudes to complementary medical therapies
more likely than other students to have positive attitudes to the complementary therapies. This suggests that exposure to complementary medicine may generate positive attitudes towards it. However, it is not clear whether these students had positive attitudes towards complementary medicine before they or someone close visited the practitioner, or whether the positive attitudes developed as a result of these events. The vast majority of students in this study will complete their clinical training and will become practising doctors. Although attitudes and beliefs may not be the only factors influencing whether these medical students eventually choose to take up complementary medicine, these findings should be taken into account when considering future medical curricula and post-graduate training. The BMA~smost recent report on complementary medicine21 is markedly more willing to accept the role of complementary practitioners than its predecessor. It calls for more research on all aspects of complementary medicine, particularly efficacy, and for registration and regulation of the main complementary professional groups - all of which would be endorsed by the complementary professional associations. Given medical students' positive attitudes to complementary medicine and this changing climate, it would seem time to consider an introduction to complementary medicine within the medical curriculum, though training in complementary techniques should be left until after graduation. ACKNOWLEDGEMENT We are grateful to the Research Council for Complementary Medicine for their support.
REFERENCES
Fulder S, Monro RE. Complementary medicine in the United Kingdom: patients, practitioners and consultations. Lancet 1985; 2: 542-545.
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2. Lewith GT, Aldridge D, eds. Complementary medicine and the European Community. Saffron Walden, Essex: CW Daniel, 1991. 3. Eisenberg DM, Kessler RC, Foster C et al. Unconventional medicine in the United States: prevalence, costs and patterns of use. New Engl J Med 1993; 328: 246-253. 4. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a general practitioner and a homoeopath. Soc Sci Med 1988; 26: 685-689. 5. Murray J, Shepherd S. Alternative or additional medicine? A new dilemma for the doctor. J Roy Coll Gen Pract 1988; 38: 511-514. 6. Sharma U. Complementary medicine today: practitioners and patients. Rev edn. London: Routledge, 1995. 7. The flight from science (Editorial). BMJ 1980; 280: 1-2. 8. Smith T. Alternative medicine (Editorial). BMJ 1983; 287: 307. 9. Physician, heal thyself. The Times 1983; 10 August. 10. Reilly D. Young doctors' views on alternative medicine. BMJ 1983; 287: 337-339. 11. Wharton R, Lewith G. Complementary medicine and the general practitioner. Lancet 1986; 292: 1498-1500. 12. Anderson E, Anderson R General practitioners and alternative medicine. J Roy Coll Gen Pract 1987; 37: 52-55. 13. Visser G J, Peters L. Alternative medicine and general practitioners in the Netherlands: towards acceptance and integration. Fam Pract 1990; 7(3): 227-232. 14. Bruhn J, Parsons O. Medical students' attitudes toward four medical specialties. J Med Educ 1964: 39: 40-49. 15. Furnham A. Medical students' beliefs about nine different specialties. BMJ 1986; 293: 1607-1610. 16. Velimirovic B, Raab S. Attitudes of medical students towards alternative medicine. Offentliche Gesundheitswesen 1990; 52(3): 136-1141. 17. Reilly D, Taylor M. Developing integrated medicine. Compl Therap Med 1993; 1(4): supplement. 18. Halliday J, Taylor M, Jenkins A, Reilly D. Medical students and complementary medicine. Compl Therap Med 1993: 1(4): supplement, 3~33. 19. Furnham A. Attitudes towards alternative medicine: a study on the perception of those studying orthodox medicine. Compl Therap Med 1993; 1(3): 120 126. 20. Hansen E A suggested medical curriculum for learning about complementary medicine. J Roy Soc Med 1991; 84: 702-703. 21. British Medical Association. Complementary medicine: new approaches to good practice. Oxford: OUR 1993.