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clinmed/2002050002v1 (May 16, 2002)
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Medical students’ opinions about complementary and alternative medicine: a questionnaire based survey

 

Shankar PR, Das BD, Partha P, Shenoy N

 

Affiliations:

Dr. P.Ravi Shankar MD                                   Dr.Biswadeep Das

Department of Pharmacology                            Department of Pharmacology                           

Manipal college of medical sciences                  Manipal college of medical sciences

Pokhara, Nepal.                                               Pokhara, Nepal.

 

Dr. Praveen Partha DNB                                 Mr. Nagesh Shenoy MPharm

Department of Internal Medicine                    Department of Community Pharmacy

Manipal teaching hospital                               Manipal teaching hospital

Pokhara, Nepal.                                               Pokhara, Nepal.

 

Address for correspondence:

Dr. P.Ravi Shankar

Department of pharmacology

Manipal college of medical sciences

P.O. Box 155

Deep Heights

Pokhara, Nepal.

Fax: 00977-61-

E-mail: pathiyilravi{at}rediffmail.com

             pathiyilravi{at}hotmail.com


Abstract:

Introduction: Complementary medicine is becoming more popular all over the world. In south Asia indigenous medical systems like ayurveda and herbal remedies continue to be popular. In the west study modules on complementary medicine are included in the MBBS curriculum. In south Asia such study modules are yet to be introduced and information on students’ attitudes towards this introduction are lacking. Hence the present study was carried out at the Manipal college of medical sciences, Pokhara, Nepal. Methods: 180 first and third semester medical students participated in the study. A semi-structured questionnaire was used and demographic details, information on complementary medicine use in the family, attitude towards and opinion on introducing complementary medicine modules in the MBBS curriculum was noted. Results: 128 families had used complementary medicine. 171 students had a favourable attitude towards and 112 students (62.2 %) were in favour of introducing study modules on complementary medicine in the curriculum. Increasing educational levels of the parents were associated with a decline in the use of complementary medicine. A significantly lower proportion of Indian students had used complementary remedies compared to the other nationalities. Discussion: Allopathic doctors must be aware of the different complementary remedies their patients may be taking. Standardization and scientific evaluation of these remedies are required. The fifth semester may be an ideal time for introducing study modules on complementary medicine. More detailed instructions on particular modalities of complementary medicine may be required for the students planning to incorporate complementary medicine in their future practice.

Key words:


Introduction:

Complementary and alternative medicine (CAM) has in recent years grown in popularity worldwide.1 In the United States,  CAM was used by over 42 % of the population in 1997.2 Complementary therapies were used by 20 to 50 % of the population in many European countries.3,4

In Nepal, more than 50 % of the population use CAM due to various reasons.5 Chronologically CAM remedies were the older system of treatment on which modern allopathic medicine was superposed. The use of CAM remedies is cheaper, has fewer side effects and is easily available in the rural areas.6 This situation also holds for the other south Asian countries. A large proportion of the population in south Asia is using CAM.

Most allopathic practitioners will come across patients already using CAM and patients may be using both CAM and allopathic medicines for the same ailments. Consideration should therefore be given to introducing CAM in to the curricula of schools of modern allopathic medicine. Two thirds of the schools in the United States now include instruction on CAM in their curriculum.7,8 In the United Kingdom the university of Southampton9 and the university of Glasgow10 have taken the lead in offering study modules in CAM.

Surveys in the United States show that between 60 and 80 % of medical students would like more instruction on CAM in their medical training.7,8 Between 30 and 50 % of medical students would like to learn how to incorporate selected CAM practices in to their future clinical practice.11 Considering the popularity of CAM remedies in Nepal and the paucity of information in the literature, the present study was carried out. Also at the Manipal college of medical sciences, Pokhara we have students from Nepal, India and Sri Lanka and any nationality differences in the attitudes towards CAM was also sought to be investigated. The attitudes of first and third semester medical students was surveyed using a semi-structured questionnaire in the month of February 2002.


Methods:

One hundred and eighty students participated in the study. A semi-structured questionnaire was used to collect the information. Student details like sex, nationality, urban or rural residence, medium of instruction at school and socioeconomic status of the family were collected. The level of education of the father and mother and the family structure were also noted. Information was sought on the student attitudes towards complementary medicine and on the use of CAM and faith healing practices by the family. Reasons for using CAM, attitude towards CAM and whether the family of the respondents use CAM and modern medicines concurrently was noted. In their future practice whether they will allow their patients to use CAM along with their medications was noted. Information was collected on the students’ opinion on the introduction of study modules on CAM in the MBBS curriculum and also on whether the students would like to practice CAM along with the allopathic system of medicine.

The proportion of students using CAM remedies and faith healing practices was compared according to the level of education of the parents, nationality and the place of residence. The attitude towards CAM and towards the introduction of CAM in the MBBS curriculum was compared according to sex, nationality and place of residence. The z test of proportions was used and a p value of <0.05 was taken as statistically significant.


Results:

One hundred and eighty undergraduate medical students participated in the study. One hundred and five respondents (58.3 %) were males and 75 were female. Eighty four students (46.7 %) were Indians, 64 (35.5 %) were Nepalese, 30 (16.7 %) were Sri Lankans and 2 were non-resident Indians. One hundred and fifty two respondents were from an urban area while 28 were from rural areas. One hundred and thirty two students had done their schooling in English medium schools while the rest had studied in vernacular medium schools. The majority of the students belonged to the middle and upper middle socioeconomic strata.

Regarding the educational level of the fathers, 24 were matriculate, 68 were graduates, 62 were postgraduates, 18 were doctors and 8 were PhDs. Regarding the education of the mothers, 59 were matriculate, 62 were graduates, 38 were postgraduates, 9 were illiterate, 7 were doctors and 5 were PhDs. The family structure was extended in 42 students and nuclear in 138 students.

One hundred and twenty eight families (71.7 %) had used complementary medicines. Ayurveda and homeopathy were the most popular systems of CAM. The respondents had used more than one system of CAM.  Out of the 128 families using CAM, the majority (114 families) had used modern medicines also. The commonest reasons cited for the use of CAM were less side effects, low cost of treatment and increased efficacy especially for chronic diseases. Only 45 of the 128 families who had used CAM used them concurrently with modern allopathic medicines.    

One hundred and seventy one students had a favourable attitude towards CAM and only 9 students had an unfavourable attitude. Majority of the students [136(75 %)] agreed with the commonly held belief that CAM had less side effects. Only 57 respondents said that they will allow their future patients to use CAM remedies along with the allopathic medicines prescribed by them. Increased side effects, drug interactions and the principle that one should use only one system of medicine at a time were the commonly cited reasons against concurrent use.

One hundred and twelve students (62.2%) were in favour of introducing study modules on CAM in the MBBS curriculum. Majority of the respondents wanted the courses to be started from the fifth semester along with the start of the clinical postings. A general overview of CAM was preferred. Eighty respondents were in favour of prescribing CAM remedies in their future practice if proper training was given.

Table 1 shows the use of CAM in the family according to the level of education of the father. Increasing education was associated with a significant decline in the use of CAM remedies. The use of CAM remedies was the lowest if the father was an allopathic doctor. Similar trends were noted with increasing levels of education of the mother.

The use of CAM according to the nationality of the students is shown in table 2. A significantly lower proportion of Indian students had used CAM compared to the Nepalese and the Sri Lankans. There were no significant urban rural differences in the proportion of students using CAM.

A significantly higher proportion of the families residing in rural areas had used faith healing practices (Table 3). There were no significant differences with regard to sex, nationality and place of residence in the attitude to complementary medicine. A greater proportion of the female students were in favour of introduction of study modules on CAM in the MBBS curriculum but it was not statistically significant. A lesser proportion of the Indian students favoured introducing a course on CAM in the MBBS curriculum(Table 4). 


Discussion:

In Nepal and the Indian subcontinent, CAM  remedies continue to be popular especially among the rural population. However, none of the allopathic medical colleges have any study module on CAM. In Nepal there is a course of five years duration at the Institute of Medicine, Kathmandu awarding the degree of Bachelor of Ayurvedic medicine. Similar courses are there in India and Sri Lanka.

There is no common definition of CAM worldwide. The definition by the Cochrane complementary medicine field is useful and essential.12 CAM is defined as ‘a broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period.’ 12 In the south Asian countries increasing political patronage and financial commitment is given to western allopathic medicine. For the purpose of our study CAM has been defined as ‘all practices and ideas preventing or treating illness or promoting health and well-being other than modern allopathic medicine.’

In south Asia the allopathic doctors should be aware of the different CAM remedies their patients may be using and the possibility of interactions between the CAM remedies and allopathic drugs. The high status of CAM practitioners in rural society, especially in Nepal, can be used to increase the acceptance of modern practices like immunization among the rural population.

In our study ayurvedic and herbal remedies were the most popular CAM remedies used. These are medical systems indigenous to the subcontinent and continue to be popular. In a previous study in Japan13 Kampo which is the Japanese variant of traditional Chinese herbal medicine was found to be very popular in Japan. Maybe as suggested in a previous study, knowledge of the indigenous medical system precedes knowledge of western medicine and provides the framework with in which these are reinterpreted and used.14

The significantly lower use of CAM remedies by the families of Indian students could be explained by the increased educational level of the parents and the higher proportion of allopathic medical practitioners among the parents. In England though doctors had an positive attitude towards CAM overall they raised doubts about the competence of CAM practitioners and lack of recognized qualifications.15 The same attitude seems to be prevalent in south Asia also.

The students in their future medical career were reluctant to allow the concurrent use of complementary and allopathic remedies. They agreed with the commonly held belief that CAM remedies had fewer side effects. This may not always be the case as seen from reports in the literature.16,17 The lack of standardization of CAM remedies and lack of evidence based practice are major problems. One of the goals of teaching CAM in the MBBS curriculum should be to prepare the doctors to scientifically evaluate CAM remedies.13

Female students were more in favour of introducing CAM into the medical curriculum but the result was not statistically significant. This is in accordance with the results of a previous study.18 In the west the use of CAM remedies is more frequent among women.19

We agree with the majority of our respondents that the fifth semester will be an appropriate time for introducing CAM in to the medical curriculum. That is the time of clinical orientation and the introduction of CAM will help in giving a holistic view of the healing process. Including topics on CAM would better prepare the practicing physician for soliciting information from the patient about current use of CAM, for responding to patients’ inquiries about CAM and for assessing the merit of introducing or removing a CAM modality in the overall treatment plan. In Southampton, England the introduction of an optional CAM module was well received by the students and also offered a reflective insight into conventional medicine.20

As the population in south Asia ages the incidence of chronic diseases and diseases associated with aging will increase. The health care needs of the chronically ill will be a major stimulus for increasing use of CAM. The increasing westernization of south Asian socities may decrease the use of CAM remedies by the population. There may be a shift of focus from indigenous forms of CAM to modalities, which are more internationally accepted. The relationship between CAM and allopathic medicine must be taught so that the doctors may be fully aware of the benefits offered by the different systems.

Eighty respondents wanted to prescribe CAM in their future practice. So along with a familiarization module in CAM, a more detailed instruction in a CAM system of the students’ choice may be required.

We therefore support others who have encouraged medical trainees and doctors to pursue learning about this aspect of patient care.21 Kathmandu University and other universities in the subcontinent should seriously consider introducing CAM study modules in the MBBS curriculum.


References:

1)      Golbeck-Wood S. Complementary medicine is booming worldwide. BMJ                                               1996;313:131.

2)      Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, van Rompay MV et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998;280:1569-1575.

3)      Tisher P, Ward M. Complementary medicine in Europe. BMJ 1994;309:107-111.

4)      Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001;9:2-11.

5)      Gartoulla RP. Ethnomedicine and other alternative medication practices, a study in medical anthropology in Nepal. PhD thesis, North Bengal University, Darjeeling, 1992.

6)      Dhungel B. Accessibility to social services in rural Nepal: a case study of Kavre district. MA thesis, Asian Institute of Technology, Bangkok, 1983.

7)      Wetzel MS, Eisenberg DM, Katchuk TJ. Courses involving complementary and alternative medicine at US medical schools. JAMA 1998;280:784-787.

8)      Moore NG. A review of alternative medicine courses taught at US medical schools. Alter Therap 1998;4:90-101.

9)      Owen DK, Lewith G, Stephens CR. Can doctors respond to patients’ increasing interest in complementary and alternative medicine. BMJ 2001;322:154-157.

10)  Bryden H. Commentary: Special study modules and complementary and alternative medicine-the Glasgow experience. BMJ 2001;322:157-158.

11)  Furnham AD, Hanna D, Vincent CA. Medical students’ attitudes to complementary medical therapies. Complement Ther Med       1995;3:212-219.

12)  Zolleran C, Vickers A. ABC of complementary medicine. What is complementary medicine? BMJ 1999;319:693-696.

13)  Tsuruoka K, Tsuruoka Y, Kajii E. Complementary medicine education in Japanese medical schools: a survey. Complement Ther Med 2001;9:28-33.

14)  Geissler PW. ‘Worms are our life’ Part 2: Luo children’s thoughts about worms and illness. Anthropology and Medicine 1998;5:133-144.

15)  White AR, Mitchell A, Ernst E. Familiarization with complementary medicine: a report of a new course for primary care physicians. J Altern Complement Med 1996;2(2):307-314.

16)  Ernst E. Harmless herbs? A review of the recent literature. Am J Med 1998;104(2):170-178.

17)  Ernst E. The risks of complementary therapy methods. Fortschr Med 1998;116:28-30.

18)  Chez RA, Jonas WB, Crawford C. A survey of medical students’ opinions about complementary and alternative medicine. Am J Obstet Gynecol 2001;185:754-757. 

19)  Nilsson M, Trehn G, Asplund K. Use of complementary and alternative remedies in Sweden. A population-based longitudinal study within the northern Sweden MONICA project. J Int Med 2001;250(3):225-233.

20)  Owen D, Lewith GT. Complementary and alternative medicine (CAM) in the undergraduate medical curriculum: the Southampton experience. Med Educ 2001;35:73-77.

21)  Panel of Medical and Nursing education in complementary medicine. Recommendations for incorporating complementary practices into medical/nursing education. Alt Therap Health Med 1996;2:25.


     Table 1: Use of complementary and alternative medicines according to the level of education of the father

 

Level of education of father

Use of complementary medicine

Proportion using complementary medicine

 

Yes

 

No

Matriculate

21

3

0.87*

Graduate

51

17

0.75**

Postgraduate

42

20

0.68

Doctor

8

10

0.44

PhD

4

4

0.56

Total

126

54

 

 

 * z= 2.96, p<0.05 compared to the group where the father was a doctor

 ** z= 2.58, p<0.05 compared to the group where the father was a doctor


Table 2: Use of complementary and alternative remedies according to the nationality of the respondents

 

Nationality of respondents

Use of complementary remedies

Proportion using complementary remedies

Yes

No

Nepalese

50

14

0.78

Indian

53

31

0.63*

Sri Lankan

24

6

0.8

Others

1

1

0.5

Total

128

52

 

  

* Z= - 2.3, P<0.05 compared to the Nepalese respondents


Table 3: Rural-urban differences in the use of faith healing practices

 

Place of residence

Use of faith healing practices

Proportion using faith healing practices

Yes

No

Rural

15

13

0.53*

Urban

28

124

0.18

Total

43

137

 

 

* z= 3.88, p<0.05 compared to the urban residents


 

          

 Table 4: Attitude towards the introduction of complementary medicine in the MBBS curriculum according to the nationality of the respondents

 

Nationality

Attitude towards introduction of CAM in the MBBS curriculum

 

Proportion in favour

Favourable

Unfavourable

Nepalese

45

19

0.7

Indians

48

36

0.57

Sri Lankans

22

8

0.73

Others

1

1

0.5

Total

116

64

 

 

 




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ClinMed NetPrints, 27 Jan 2003 [Full text]

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