THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 14, Number 3, 2008, pp. 315–319 © Mary Ann Liebert, Inc. DOI: 10.1089/acm.2007.7126
Use of Complementary and Alternative Medicine by Physicians in St. Petersburg, Russia SAMUEL BROWN, M.D.
ABSTRACT Background: Interest in complementary and alternative medicine (CAM) is increasing worldwide, although relatively little is known of physician use of CAM, and there are no quantitative reports of CAM use by Russian physicians. Objective: The objective of this study was to determine the prevalence of CAM therapies among practicing physicians and determine predictors of CAM usage. Design: This was a convenience sample prevalence survey. Setting: The study involved 3 urban academic hospitals in St. Petersburg, in Russia. Subjects: Participants included 192 physicians practicing at the three study hospitals. Measurements: The study determined the number (from a list of 32) of CAM therapies that physicians used on themselves, used on their patients, or referred their patients to receive. Results: One hundred and seventy-seven (177; 92%) of the surveyed physicians responded. One hundred percent (100%) of the respondents had practiced CAM or referred patients for at least two CAM therapies. One hundred and seventy-five (175; 99%) had themselves practiced at least two therapies. On average, each physician had practiced or referred patients for 12.7 (95% confidence interval, 11.9–13.6) therapies. On multivariate analysis, knowledge of a foreign language, surgical specialty, and female gender were significantly (p 0.05) associated with increased CAM usage, while critical care specialty and completion of only an internship were associated with lower rates of CAM practice. Conclusions: Physician use of CAM in Russia appears very high. The high prevalence of CAM may complicate adoption of Western evidence-based practices. Predictors and effects of CAM usage in Russian society warrant further study. INTRODUCTION
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omplementary and alternative medicine (CAM) has been defined by Eisenberg as medicine not taught or practiced at conventional U.S. medical schools. Interest in CAM has increased as the majority of patients have been shown to utilize such therapies, and most do not report this use to their physicians.1,2 The relationship of mainstream physicians to CAM has been the object of some international study. A meta-analysis in 19953 and a thorough review in 19984 have summarized that research. Several reports have
documented crosscultural differences, even among the industrialized Western economies.5 One review noted usage rates of 30% in the United States and approximately 50% in France and Germany.6 A survey of 121 Quebecois physicians showed that approximately 75% had referred patients for an alternative therapy and 20% of the physicians had received some training in a CAM therapy.7 Average physician practice of CAM from 19 methodologically acceptable studies ranged from 9% to 19%, with referral rates ranging from 4% to 43%.4 Studies of CAM are often marked by low response rates,
Department of Pulmonary and Critical Care Medicine, University of Utah Health Sciences Center, Salt Lake City, UT (formerly at the Davis Center for Russian Studies, Harvard University, Cambridge, MA).
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potentially exaggerating usage through selection bias. Studies often include only common CAM therapies, potentially underestimating the prevalence of true CAM usage. There has been no published survey of the prevalence of CAM among Russian physicians (based on a search of MEDLINE® with keywords Russia, Russian, Alternative Medicine, and Complementary Therapy) in spite of anecdotal reports of wide CAM use.8,9 A recent report noted that licenses to practice CAM in Russia are given preferentially to physicians. It has been stated that “almost every medical facility practices at least some sort of non-scientific medicine.”10 A licensure official in another report describes nonphysician CAM practitioners as “mentally ill” and views licensure as a means to protect patients from such practitioners.11 More generally, the Russian medical literature has been shown to differ significantly from the Western literature.12,13 A recent prominent paper claimed 90% efficacy for psychotherapy, chiropractic, acupuncture, and reflexotherapy for treatment of chronic illness and called for their broad clinical application.14 Anecdotal reports of the current usage of untested or unusual therapies at scholarly conferences are not uncommon.15,16 To address gaps in the literature, we report a quantitative study of the prevalence of CAM usage at 3 large academic hospitals in St. Petersburg, Russia.
METHODS A survey instrument was developed, based in part on work by Sikand and Laken.17 It included demographic information and a list of 32 CAM therapies. The list was based on a literature review and a pilot survey of Russian physicians in Boston, MA. For each therapy, physicians were asked whether (a) they used or had used the therapy on themselves; (b) they used or had used the therapy on their patients; or (c) they referred or had referred patients for the therapy. For each use or referral, the participants were also asked to report indications for use or referral. Three (3) hospitals in St. Petersburg were selected, based on their association with the medical academy where the author was based. They included an adult general hospital, a pediatric referral hospital, and an adult infectious disease hospital. The sample did not include, for logistical reasons, physicians working primarily in polyclinics. The survey was performed during the summer holiday period, when approximately half of the staff members are on leave on a given day. The distribution of leave is not associated with any demographic factors. The most numerous departments were chosen to provide a mix of surgical and medical specialties. The convenience sample was all physicians employed by the hospital in each of the departments selected that were not on holiday on the day of the survey. An honorarium (US
$10) was provided for all physicians who completed the survey. Therapies were classified as CAM according to Eisenberg’s definition. Therapies used in the West (e.g., hyperbaric oxygen) were classified as CAM if the indications for therapy differed from U.S. mainstream practice. Therapies were considered locally mainstream if they were included in licensure documents or the fee schedule of at least one facility. Spa therapy was considered mainstream, given its high prevalence and the difficulty of housing a spa inside a hospital. Data entry was validated by random duplicate entry. A multivariate Poisson regression was performed using Stata (version 6.0, Stata Corporation, College Park, TX) with number of therapies as the outcome. Rate ratio (e) was calculated from the coefficient of predictors. The regression was performed in stepwise fashion, excluding predictors with p 0.2. Funding agencies had no control over or influence on data collection, analysis, or manuscript preparation or submission. The author was solely responsible for data collection, analysis, and interpretation.
DATA AND ANALYSIS In the departments surveyed, the total number of physicians employed by the hospital was 302. Of those, 192 (64%) were present for the survey, thus constituting the convenience sample. A total of 177 of the 192 surveys (92%) were completed and returned. Of the physicians completing the survey, 114 (64%) were female and 63 (36%) were male. Physicians represented 14 specialties, including 50 (28%) infectious disease, 50 (28%) intensive care, 24 (14%) pediatrics, and 20 (11%) surgery. Less numerous specialties included internal medicine (7), cardiology (7), neurology (6), allergy (3), nephrology (3), neonatology (2), pulmonology (2), gastroenterology (1), ear, nose, and throat (1). Physician ages ranged from 23 to 75, with a mean of 39 years. Of those specifying an ethnicity (N 136), 117 (86%) were Russian, 7 (5%) were Jewish, and 4 (3%) were Ukrainian, with 8 other ethnicities represented by a single physician each (6%). Sample physicians were primarily trained in St. Petersburg (155/161; 96%).
SURVEY RESULTS One hundred and seventy-seven (177) of 177 (100%) respondents had practiced or referred patients for at least two therapies. On average, each physician had used personally, treated patients with, or referred patients to a practitioner of 12.7 (95% confidence interval, 11.9–13.6) therapies not widely recognized in U.S. biomedicine, or 6.4 therapies not
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TABLE 1. PERCENT Therapy Massage Phytotherapy Cupping Vitamin therapy Herbal therapy Electrical physiotherapy Spa therapy Homeopathy Mineral water Acupuncture IV Radiation Acupressure IV Laser Hyperbaric oxygena Chiropractic Faith healing Mud baths Hirudotherapyb Folk medicinec Boteiko Breathingd Phagotherapye Salt therapyf Low-intensity laserg Osteopathy Reflexology Hypnosis Biofield manipulation Urine therapy Extrasensory perception Aromatherapy Sound therapy Iridology Znakharstvoh
OF
PHYSICIANS REPORTING USE
Licensed* Y
Y Y Y Y Y Y Y Y
Y Y Y
OF
SPECIFIC ALTERNATIVE THERAPIES (N 177)
Any use or referral (%)
Use on self (%)
Use on patients (%)
Referral (%)
90 83 81 80 79 78 64 58 57 54 52 50 47 45 37 37 33 31 27 23 23 23 21 17 17 16 12 8 8 7 6 5 3
58 71 55 72 67 58 37 31 32 21 7 28 6 9 20 11 15 5 23 5 5 10 5 6 6 2 5 4 3 3 4 1 1
71 76 67 77 71 55 44 29 45 22 39 26 32 28 17 24 12 22 19 9 20 9 10 6 8 4 6 3 1 3 2 1 2
55 34 14 19 23 55 39 38 26 38 32 28 32 29 26 22 24 15 9 19 5 12 13 15 15 14 7 3 6 7 3 4 1
*Having official licensure or billing status in at least one of the hospitals surveyed; Y, yes. for a wide variety of indications beyond wound healing and carbon monoxide intoxication. bUse of leeches to treat infections, detoxify the human body, et cetera. cIncludes teas, herbs, poultices, et cetera. dIntentional hypoventilation to suppress the hypercapneic ventilatory drive; believed to cure respiratory and systemic disease. eUse of bacteriophages clinically to treat infections. fPlacement of patient in salty, wet room; for treatment of respiratory conditions, usually asthma. gFlashlight is shone on skin of patient; for hepatitis and other “toxic” diseases of the blood. hRussian shamanism, involving herbs, teas, incantations, and religious symbols. aUsed
licensed in Russia. For the 32 therapies surveyed, the prevalence of practice ranged from a high of 90% for massage to a low of 3% for znakharstvo, Russian shamanism. Table 1 presents the proportion of the physician sample who had treated themselves or their patients or referred their patients for care for a given therapy. Several therapies were commonly used by physicians but were rarely cause for referrals, such as phytotherapy (use 76%, referral 34%), herbal therapy (use 71%, referral 23%), vitamin therapy (use 77%, referral 19%), and cupping (use 67%, referral 14%). Certain therapies were applied with similar frequency to self and patients, for example, massage (self 58%, patients 71%), herbal therapy (self 67%, patients
71%), and vitamin therapy (self 72%, patients 77%). Physicians used certain therapies frequently on their patients but not on themselves, for example, intravenous laser (patients 32%, self 6%) and intravenous ultraviolet radiation (patients 39%, self 7%). Specialty appeared to influence rates of CAM usage. On multivariate analysis, as shown in Table 2, surgeons were much more likely to use CAM than other specialists, while intensivists were much less likely to practice CAM. No other specialties differed in a statistically significant way. As shown in Table 2, several predictors were significantly associated with increased CAM usage on multivariate Poisson regression, including female gender, mastery of foreign
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BROWN TABLE 2. MULTIVARIATE POISSON REGRESSION OF PREDICTORS OF TOTAL NUMBER OF ALTERNATIVE THERAPIES USED Predictor Female gender Foreign language Russian nationality Childhood in St. Petersburg Studied alternative medicine Completed internship only Completed residency Surgeon Intensivist Religious affiliation
Rate ratio
95% Confidence interval
p-Value
1.16 1.17 1.14 1.10 1.15 0.81 0.88 1.42 0.70 1.09
1.00–1.34 1.07–1.28 0.94–1.37 0.96–1.26 0.98–1.34 0.70–0.95 0.76–1.00 1.17–1.72 0.58–0.84 0.97–1.23
0.05 0.001 0.18 0.17 0.09 0.01 0.06 0.001 0.001 0.15
languages, formal training in alternative therapies, and selfreported religious affiliation. Other predictors were associated with lower rates of CAM usage, including postgraduate clinical training limited to internship. Prior formal study of CAM therapies was associated with a trend toward higher rates of CAM (p 0.09).
DISCUSSION In a convenience sample of 192 physicians with a 92% response rate (177 respondents), physicians at 3 hospitals in the second-largest city in Russia made extensive use of therapies not widely accepted in Western biomedicine. Usage among these physicians was at least twice as high as rates reported for European and North American physicians.4,6 Approximately half of the CAM usage involved practices considered mainstream in Russia. Many CAM therapies are licensed for use in St. Petersburg hospitals. These results clarify certain conclusions of another study. Only 11%–20% of a random sample of 1500 St. Petersburg residents reported visiting CAM providers.18 However, as CAM is often provided by conventional physicians, visits to CAM practitioners may not adequately reflect actual use of CAM, which is likely to be much higher than previously estimated. On multivariate analysis, age was not associated with CAM usage, a result that is consistent with mixed findings from other studies.4,7,19–22 Female physicians were somewhat more likely to use CAM than males, whereas gender has been of no clear significance in other studies.7,19–23 A physician’s personal experience with disease, either prior illness or surgery, was not associated with increased CAM usage. The association of religious affiliation with CAM usage did not reach statistical significance (p 0.15). Knowledge of foreign languages, a possible surrogate for overall education and exposure to foreign literature and lifestyles was significantly associated with increased CAM usage. This may suggest that general education or increased
knowledge of English will not necessarily lead to decreased CAM usage, a hypothesis that should be evaluated by further investigation. There appear to be at least two types of CAM therapies: traditional therapies widely used on patients and doctors and more technological therapies, such as intravenous laser, reserved for treatment of patients. This possible distinction should be characterized better in further study. Methodologically, a disadvantage is the possibility that the locally significant honorarium may have induced higher rates of endorsement of therapies, thus inflating estimates of CAM prevalence. This effect, if present, may have been sufficient to counterbalance the effect of the honorarium in limiting participation bias, which affects many studies based on uncompensated survey instruments. The fact that many CAM therapies are formally licensed for use in St. Petersburg hospitals and actively recommended in Russian medical literature argues against a reporting bias related to the honorarium, though such a bias is difficult to exlude. An advantage of this study is the clear lack of participation bias. However, other selection bias could exist in this convenience sample, as department selection was not random. It is possible that physicians from less-common and less-numerous departments use CAM at different rates from their surveyed colleagues. The prominent representation of intensivists (a result of much higher staffing rates in those departments) would tend to underestimate overall usage rates, as they tended to use fewer therapies than their colleagues. Other limitations of this study include lack of distinction between primary and adjunctive use of CAM, lack of data about current use, and lack of data on belief in efficacy. The first two factors should be addressed in further studies, while the latter is subsumed by high rates of use on self and patients. In addition, this survey may have failed to capture the full diversity of Russian CAM, as it was based on a pilot survey in Boston and a literature review. Informally, many respondents described therapies for common diseases using wine, vodka, and sauna therapy. Other respondents described therapeutic hemopurification by passage of blood
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through a freshly excised pig spleen with immediate return to the patient, so-called xenotransfusion. The exclusion of these therapies—and others reported in the popular press— probably underestimates the true extent and diversity of CAM in Russia.
CONCLUSIONS These data may be relevant to international clinical and scientific collaborations and the treatment of Russian émigrés, as they demonstrate distinction from U.S. norms.24,25 The results of this study further suggest that clinical quality improvement efforts, including evidence-based medicine, may be difficult to implement, given their explicit reliance on validated, mainstream therapies. Such efforts will require special awareness of the complex repertoire of biomedical and CAM therapies in active use in Russia.
ACKNOWLEDGMENTS This work was supported by a Paul Dudley White Traveling Research Grant from Harvard Medical School, Boston, MA, and a Russian Research Traveling Grant from the Davis Center for Russian Studies, Harvard University, Cambridge, MA.
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Address reprint requests to: Samuel Brown, M.D. Department of Pulmonary and Critical Care Medicine University of Utah Health Sciences Center Wintrobe 701 26 N 1900 E Salt Lake City, UT 84132 E-mail:
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