Physician use of complementary and alternative medicine (CAM) literature

Physician use of complementary and alternative medicine (CAM) literature H. C. G. Wong,1 J. C. Neill2 1

Division of Allergy and Immunology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada 2 Medical Library Service, College of Physicians and Surgeons of British Columbia, Vancouver, British Columbia, Canada

SUMMARY. Objective: To document the interest of complementary and alternative medicine (CAM) literature use among physicians. Design: A retrospective study. Setting: A medical library service. Main outcome measures: Analysis of photocopy requests from published lists of reference in a two-year period by physicians in the province of British Columbia, Canada. Results: The average number of requests per article was 18.7 among CAM literature and 7.1 among non-CAM literature. Ten of the 15 most frequently requested articles were CAM papers. Review articles on herbal medicine demonstrated the most use. Conclusions: There is a definite interest in CAM literature among a specific group of Canadian physicians. Use of scientifically credible literature in peer-reviewed journals will be helpful for patient care, teaching, and C 2001 Harcourt Publishers Ltd research in this field. °

BACKGROUND

H. C. George Wong Division of Allergy and Immunology , Department of Medicine, Faculty of Medicine, The University of British Columbia, 750 West Broadway , Suite 1200, Vancouver, British Columbia V5Z 1J2 Canada. Text partly presented at UBC Faculty of Medicine Golden Jubilee 2000, November 4, 2000, Vancouver, British Columbia, Canada No grant support

The interest of complementary and alternative medicine (CAM) has been confirmed by national surveys in the United States,1–3 Canada,4 Australia,5 and European countries,6–10 studies on specific groups of patients including arthritis,11 inflammatory bowel disease,12 breast cancer,13 and family practice patients,14–15 and a health science centre faculty.16 All reports are on personal use of CAM. A study of CAM articles published in the mainstream medical literature listed in MEDLINE shows an increase in the number and proportion of reports of clinical trials 1966 thruogh 1996. There is also a trend toward an evidence-based approach to the discipline.17 Literature use is a useful indicator of CAM interest among physicians. A two-year retrospective study of physician use of CAM literature is described.

METHOD We conducted a retrospective study of British Columbia (BC) physicians’ use of CAM liter-

C 2001 Harcourt Publishers Ltd Complementary Therapies in Medicine (2001) 9, 173–177 °

doi:10.1054/ctim.2001.0454, available online http://www.idealibrary.com on

ature during the 2-year period from December, 1996 to November, 1998. The physicians are registrants of the College of Physicians and Surgeons of British Columbia (CPSBC), a provincial licensing authority in Canada. They include active practising physicians in the province of British Columbia (‘BC’), out of province physicians (‘non BC’) consisting of physicians residing in other parts of Canada, United States and elsewhere, ‘non practising’ physicians including mostly retired physicians, and ‘education registrants’ who are residents and fellows in postgraduate training programs with the Faculty of Medicine, the University of British Columbia. The active practising physicians include both medical faculty members and physicians not associated with the University, and family physicians and specialists. The registrants for 1996, 1997 and 1998 with total numbers of 9,355, 9,399 and 9,608 respectively are summarized in Table 1. No attempt was made to break down the requests according to these various groups of physicians. The data on the statistics of photocopy requests for articles listed in Cites & Bytes, the monthly newsletter of the Medical Library Service (MLS),

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CPSBC, were collected and analyzed. Cites & Bytes consists chiefly of citations to new articles, books and other media and is produced by MLS as a current awareness tool to alert physicians to the latest information on topics of interest. All current journals are screened by library staff and articles judged to be of potential interest to members are identified, with the final decision for inclusion remaining with the editor, the second author. Articles are chosen for inclusion based on currency, quality of the journal, topics of interest in the media, and those of seasonal and local interest. Non-CAM and CAM articles were not listed separately. Information which updates recent reference questions is also included. It is distributed to those who request to be on the mailing list and is readily available in the library when visited by physicians in person. The photocopy requests were made by physicians registered with CPSBC. Confidentiality was maintained regarding individual physician literature use. Neither author knew of the specific article requested by a particular physician. The first author did not participate in the request although he subsequently reviewed every CAM article in the study. All articles in Cites & Bytes listed in the 2year period were reviewed. All CAM articles and those in the grey area were read in detail. The data analyzed included: (1) Statistics of photocopy requests (2) Separation of CAM and non-CAM literature (3) Listing of all articles according to frequency of requests (4) Categorization of CAM articles according to the classification of complementary and alternative medical practices based on US National Institutes of Health (NIH) National Center for CAM (5) Identification of review articles according to the criteria of the National Library of Medicine and non-review/research articles among CAM literature.

RESULTS CAM and non-CAM articles listed, and requested, and average number of requests per article between December 1996 and November 1998 are shown in Table 2. The average number of requests per article in these two years was 18.7 among CAM literature and 7.1 among non-CAM literature. The average number of requests per CAM article remained almost constant in both years (18.6 and 18.8), while the average number of requests per non-CAM article decreased from 7.6 in first year of study to 6.7 in the second year. The ratio of the average number of requests per CAM article to the average number of requests per

Table 1 Number of registrants with the College of Physicians and Surgeons of British Columbia, Canada

Year BC

Non Non Education BC Practising Registrants Total

1996 7,937 723 1997 7,976 711 1998 8,169 695

83 74 76

612 638 668

9,355 9,399 9,608

non-CAM article in the first year was 2.4 and that of the second year was 2.8 as shown in Table 3. There was a 2.6 fold difference in 2 years. Table 4 shows that three of the five most frequently requested articles belong to CAM literature. They are: herbal health products,18 glucosamine sulfate in the treatment of osteoarthritis,19 and St. John’s wort.20 Ten of the top 15 are CAM articles. The other topics include clinical trials, interactions, toxicity, adverse effects and safety of herbal remedies, and alternative therapies. The CAM articles are categorized according to the classification of complementary and alternative medical practices based on NIH National Center for CAM.21 As shown in Table 5, the three most frequently listed categories are herbal medicine (22 articles), diet, nutrition, lifestyle changes (17 articles) and alternative systems of medical practice (14 articles). The top three subjects of interest are herbal medicine (average 23 requests/article), pharmacological and biological treatment (22 requests), and alternative systems of medical practice (18 requests). Of the 57 CAM articles listed, 21 are review articles according to the criteria of the National Library of Medicine. The average number of requests for CAM review articles is 22.0 while non-review/research articles average 16.6 requests.

DISCUSSION This paper reports the first study on physician use of CAM literature, rather than on personal use of CAM by specific group of patients, a health science centre faculty or general population. The MLS is part of the CPSBC, providing library service to the physicians registered to practice in BC. It is the only library service associated with a provincial medical licensing body in Canada, with a 40 year history.22 Among various educational services provided by MLS, up to 100 pages of photocopy service which was subsequently changed to 18 articles upon request are provided free to the physicians annually except for the education registrants and additional photocopy services are charged at a nominal fee. This provides a unique setting to study the physicians’

Physician use of CAM literature

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Table 2 CAM and non-CAM articles listed in Cites & Bytes, requested and average number of requests per article in two year period 12/96–11/97

12/97–11/98

Total–2 yrs

23 428 18.6 456 3445 7.6

34 639 18.8 545 3673 6.7

57 1067 18.7 1001 7118 7.1

CAM articles listed CAM articles requested Average no. of requests/CAM article Non-CAM articles listed Non-CAM articles requested Average no. of requests/Non-CAM article

Table 3 Ratio of the average number of requests per CAM article to the average number of requests per non-CAM article First year Second year Two years

(12/96–11/97) (12/97–11/98) (12/96–11/98)

2.4 2.8 2.6

interest in CAM literature, comparing with nonCAM literature. It should be noted that photocopy requests may be made outside of the listing of Cites & Bytes, and physicians may make copies of their own without the MLS service or simply download from Internet on-line services. None of these are included in the study. Besides MLS, there are the bio-medical library of the University of British Columbia and libraries in major university teaching hospitals as well as those in community hospitals throughout the BC province, the latter also with some support from MLS. The first issue of Cites & Bytes was published in May 1996. The two-year study period (December, 1996 and November, 1998) was selected because of paucity of CAM literature listed prior to the December 1996 issue. Each issue of Cites & Bytes is published within the first week of the month. Some of the 80 excellent CAM publications in the November 1998 issue of the Journal of American Medical Association (JAMA) and the Archives journals are listed in the December issue of Cites & Bytes. In addition, the December 1998 issue was included in the general mail out of the CPSBC quarterly publication to all members for the first time. They would dramatically increase the photocopy requests in CAM literature and hence would skew the data. If we expand the study for one more

year, the requests in the third year will definitely be much higher than the first two. The retrospective nature of the study will not provide selection bias as well. The articles, both CAM and non-CAM, were from a wide selection of journals and publications, ranging from highly cited ones including New England Journal of Medicine, Lancet, JAMA, Annals of Internal Medicine, British Medical Journal, to other general and subspecialty journals as well as others including Medical letter, and Drug Information Prospectives. The Cites & Bytes serves as a monthly newsletter, primarily bibliographic in nature and is not intended to be a critical/scientific review journal. Although some mainstream journals were available in electronic format, many provided only abstracts and full articles were available only to the subscribers or through a paid intermediary, in contrast to the free delivery of photocopy from MLS. Many of the requests were checked off from Cites & Bytes and sent to MLS. Our study indicates a definite interest by BC physicians who made the photocopy requests in CAM literature over non-CAM literature over 2-year study period according to average number of requests per article, with a 2.6 fold difference, and most frequently requested articles with three of the top five, and 10 of the top 15 belonging to CAM literature. There appears more interest in the second year comparing with the first year according to the ratio of the average number of requests per CAM article to that per non-CAM article. Review articles demonstrate the most use. With respect to the CAM articles categorized according to the classification of NIH National Center for CAM, Table 5 shows the total number of articles listed to be 66. This is different from the

Table 4 The five most frequently requested articles

Topic Herbal health products Glucosamine sulfate in the treatment of osteoarthritis Medical management of vertigo St. John’s wort Treating low back pain

CAM/Non-CAM

No. of requests

CAM CAM Non-CAM CAM Non-CAM

56 51 46 44 43

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Complementary Therapies in Medicine Table 5 CAM articles categorized according to the classification of NIH National Center for CAM21

Classification of complementary and alternative medical practices

No. of articles listed

Total no. of request

Average no. requested/article

Herbal Medicine Diet, Nutrition, Lifestyle changes Alternative Systems of Medical Practice Pharmacological and Biological Treatments Mind/Body Control Manual Healing Bioelectromagnetic Applications

22 17 14 5 5 1 0

510 259 253 110 67 7 –

23.2 15.2 18.1 22.0 13.4 7.0 –

2

27

13.5

General

total number in Table 2, because some articles are included in more than one category.23,24,25 There was no article listed in Cites & Bytes belonging to the bioelectromagnetic applications category. Two articles14,26 were classified as ‘general’, as they were not specific to any category. Articles on herbal medicine were most frequently listed (22 articles) and requested, the latter according to the number of requests per article (23 requests). Although there were only five articles listed in the category of pharmacological and biological treatment, this category was the second most frequently requested per article (22 requests). There is a possibility of increased number of requests per article simply indicating that there are fewer good articles in this particular category. The tremendous interest of herbal medicine literature among physicians is similar to the personal use of herbal medicine of the general population which increased the most between 1990 and 1997.2 It was second only to relaxation techniques and was followed by massage and chiropractic as the most commonly used therapies. There could be a number of reasons for the apparent interest in CAM literature. They include prominent coverage in the media, patient requests and physician interest for personal use,16 advancement in knowledge, teaching and research. With 42% of US population in the 1997 national survey using CAM,2 it is not surprising physicians in North America and elsewhere are now paying more attention to CAM, including the study of CAM literature. Evidence-based approach in CAM in medical education and clinical practice should be emphasized.27 Articles indexed as alternative medicine formed a small proportion (0.4%) of the total number of MEDLINE—listed articles throughout the period of 1966 through 1996.17 For this period, the proportion of clinical trial—type alternative medicine articles was low (mean, 2.1% per annum) but increased significantly from 1987 through 1996, reaching arround 10% of the total in 1996. There is obvious paucity of CAM literature, and only a few randomized controlled studies have been reported. In addition, only a limited number of citations of randomized controlled tri-

als is suitable for systematic review.28,29 They may be related to poor methodology, deficiencies related to sample size, blinding, completion rates and description of randomization, and absence of intent-to-treat analysis. There may be insufficient information about study design and conduct to allow definitive evaluation. In addition to good quality randomized control trials, surveys,1,2 editorials,30 reviews,31,32 individual reports of allergic33 and other adverse reactions,34,35 and even letters to the editor16,36,37 are useful among CAM literature. Systematic research is needed in CAM.37 The evidence from randomized controlled trials and systematic reviews among scientifically credible CAM literature is particularly important. In summary, there is a definite interest in CAM literature by Canadian physicians, who made the photocopy requests, demonstrated in this study. Additional research is required in this area. The use of scientifically credible CAM literature in peerreview journals will be helpful for patient care, teaching & research in this field.

ACKNOWLEDGMENTS The authors would like to thank Mr Jim Henderson, Director, Medical Library Service, College of Physicians and Surgeons of British Columbia for his advice and support on this study.

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