Results of this national survey showed that most rheumatologists express favorable attitudes toward most categories of CAM practices relevant to the care of patients with chronic back pain or joint pain. More than half of the respondents consider common individual CAM therapies to be beneficial and are at least moderately likely to recommend them. However, rheumatologists' opinions regarding perceived benefit of common CAM therapies and their likelihood of recommending them varied widely across different CAM modalities; percentage of favorable responses ranged from as high as 70% for body work to as low as 11% for energy medicine. After controlling for other factors, female sex and being born outside the United States were independently associated with rheumatologists' favorable ratings of perceived benefit and willingness to recommend CAM.
Because chronic musculoskeletal conditions are a leading indication for the use of CAM, rheumatologists have been urged to discuss CAM with their patients [15
]. Provider attitudes seem to be becoming more favorable; a recent study suggests that if rheumatologists use more participatory styles of decision making with patients, patients are more likely to tell them about their CAM use [16
]. The main result of our study contributes to the literature from the providers' perspective in that the historical antagonism between CAM practitioners and mainstream rheumatology physicians seems weakened.
We found that female rheumatologists were twice as likely to perceive benefit of common CAM therapies as their male counterparts, a result that is consistent with some but not all previous surveys of other physician groups [17
]. Sex has been of no clear significance in other studies [21
]. Although we had no particular a priori hypothesis about a sex difference, it is possible that women, who are more favorably disposed to CAM in general, may carry over that attitude into their professional attitudes [24
]. Furthermore, these data showing a sex difference at least suggest that core physician characteristics are integral to their attitudes and clinical reasoning about CAM that cannot be ignored.
Other factors associated with favorable attitudes toward CAM are not well explained from this exploratory study. Although their numbers were small, rheumatologists practicing in an institutional practice were more likely to perceive benefit from spinal manipulation and body work compared with their colleagues in group and academic settings. The reasons for this are not clear from our data. Large institutional practices may incorporate certain CAM treatments into their programs based on the availability of certified practitioners in their area or may have arrangements for reimbursement for particular CAM therapies, thus making it easier for physicians to access and gain a level of familiarity with these practices. It is quite likely that consumer demand for CAM is motivating more insurers and hospitals to incorporate CAM [25
], which may differentially affect institutional practices.
Results from this national survey did not show regional variations in attitudes toward CAM treatments according to geographic region of the United States. This is consistent with a study by Borkan et al [21
], which did not identify a significant difference in belief of effectiveness of CAM among practice locations in the United States. Further corroboration is provided by another study showing that a physician's country of origin did not have a significant effect on his or her belief in CAM [23
]. We did, however, find that rheumatologists born outside the United States had more favorable attitudes toward CAM overall. This may reflect ethnic familiarity with some CAM therapies such as meditation.
We found a gradient of acceptance of CAM. Only 11% of respondents considered energy medicine beneficial, and physicians were less likely to recommend treatments such as Reiki. This may reflect to some extent the availability of, or experience with, energy medicine. Also, research in the area of energy medicine is lacking compared with other CAM therapies such as chiropractic, acupuncture, and body work, which may equally influence the lack of legitimacy ascribed to this category of CAM treatment. It is also possible that physicians have difficulty believing in a therapy that they view as scientifically implausible. It is worth noting that the CAM modalities that were most favored are those that appear most regularly in the popular media, which, to some extent, may influence physician choices [28
This study raises larger questions that remain unanswered. For instance, should CAM be "integrated" into the routine treatment options of rheumatologists? If an integrated approach is to be developed that allows a combination of the best of conventional medicine and CAM to provide an informed choice for patients with osteoarthritis, then it must be research led and evidence based. Signs show that CAM is becoming increasingly integrated. The number of randomized trials of CAM treatments is increasing, and the Cochrane Library now includes more than 200 reviews of complementary medicine interventions.
One consequence of the increase in the availability of high-quality data is that guidelines and consensus statements published by conventional medical bodies have supported the value of CAM. For example, current Osteoarthritis Research Society International guidelines list acupuncture and glucosamine with or without chondroitin as nonpharmacologic treatment for hip and knee osteoarthritis [9
]. Therefore, it appears that one stimulus for increasing integration has been the increase in research evidence. Nevertheless, many unanswered questions remain before a truly integrated practice of rheumatology would be practically possible, including potential attitudinal trends among rheumatologists themselves.
Notable strengths of this study include a random (representative) sampling of rheumatology providers from defined areas of the United States. This provides a comprehensive view of rheumatology specialist attitudes, whereas previous surveys have mostly focused on primary care providers [6
]. The reliability of the questions in this survey has been rigorously tested. Aspects not previously studied that can influence physician perceptions of CAM, such as ethnic background, practice setting, and geographical region, were examined. Previous physician surveys have tended to define CAM in various ways, from as few as 3 modalities to as many as 25. The definition of CAM in this survey was based on well-described categories by the National Institutes of Health, thus enhancing interpretation of data.
Some limitations of this survey include the quantitative nature of data gathering. A close-ended survey style does not allow for description of the "art of medicine" and decision making. A qualitative study would allow rheumatologists the opportunity to describe and discuss the manner in which they manage common musculoskeletal conditions on a day-to-day basis [30
]. This study was cross-sectional, and as CAM therapies evolve and more studies are published, the trend of physician attitudes will likely change. It is important to note that our results may not be generalizable to physicians on the West Coast because the sample of respondents was small compared with that from the Northeast. Additionally, we do not know how physician attitudes may shift and change when treating particular rheumatologic conditions other than osteoarthritis. The response rate of 58% could potentially exaggerate response bias, but responders and nonresponders did not differ significantly. We included only common CAM therapies, potentially underestimating the prevalence of true CAM usage. The incorporation of questions on placebo prescribing could potentially affect the attitudes of the physician toward CAM. Other important considerations that potentially affect rheumatologists' attitudes toward CAM in formulating a treatment recommendation, including patient preferences, clinical experience, and published research, will be addressed in a subsequent analysis.