TVM is composed of two parts: the Vietnamese version of OM and Vietnamese folk medicine. TVM has been widely used in Vietnam as an integral part of the national mainstream health care system. Because of globalization, various other forms of CAM have been adopted and have spread among Vietnamese CAM practitioners. This study is the first attempt to investigate the current trends in CAM practice, including TVM in OM hospitals, which provide the most CAM services in Vietnam, by assessing the knowledge, practice, and attitude toward CAM among physicians in the OM hospitals.
This study showed that oriental herbal medicine and acupuncture, the main components of OM, were most well known and practiced by the physicians in OM hospitals and were more commonly used than Vietnamese folk medicine, the other component of TVM. In addition to TVM, many physicians have employed other CAM modalities in their daily practice, including chiropractice (77.6%), dietary therapy (44.6%), dietary supplements (42.3%), Qigong (34.3%), aromatherapy (29.8%), yoga (22.8%), and reflexology (19.6%), whereas the physicians rarely practiced Ayurveda and homeopathy. Another characteristic of CAM practice among the physicians in OM hospitals was a high proportion of western medication use that was integrated with OM (42,4%), even among OMDs (41.8%).
In accord with findings from Japan and Korea, OM has been the most commonly used CAM modality by OMDs and physicians [7
]. The main reason of this trend may be that OM originated from ancient Chinese medicine that was introduced to Japan, Korea, and Vietnam a thousand years ago and is considered part of the oriental culture [3
]. The other reasons may be that OM courses have been provided in medical school, even for GPs in Japan and Vietnam [2
], and that many OM services are covered by the national health insurance systems in these countries [2
]. However, acupuncture has not been widely used by Japanese physicians (8%), although it is the most popular CAM therapy in Korea and Vietnam [8
]. Vietnamese OMDs are officially authorized to prescribe western medication, whereas the OMDs in Korea and Japan can only refer patients to western medical doctors for conventional interventions. The intense combination of western medication with CAM practice may encourage the practice of integrative medicine by OMDs, but western medication that has been abused by OMDs is unknown. Further investigation should be conducted on how, when and where the integration of western medication in CAM practice is performed. Other forms of CAM such as chiropractice, dietary supplement, and aromatherapy are also known to and practiced by a large number of GPs and OMDs in these Asian countries, but Ayurveda and homeopathy were rarely used [8
]. The trend in which OM contributes as the mainstream modality of CAM use, in addition to the increasing interest regarding other CAM modalities, is in contrast with the trend in American and European countries, where no particular CAM modality dominates in popularity [4
]. Burg et al. found that the most commonly used CAM therapies among health professionals in Florida were massage (32%), dietary supplements (28%), and relaxation techniques (24%) [13
], whereas Kurtz et al. reported a heterogeneity in the CAM therapies used by primary care physicians in Michigan, which included vitamin therapy (32.4%), herbal therapy (20.8%), mineral therapy (19.6%), and dietary therapy (19.6%) [11
Although the physicians in OM hospitals in Vietnam have a strong favorable attitude toward CAM, a large proportion of them also desired to practice CAM based on scientific evidence. Solid evidence and reliable information are influential factors for the attitude and practice of CAM therapies among medical doctors [14
]. Further study in the future should be conducted on the evidence-based CAM practice in Vietnam.
Various factors may influence CAM use. The dominance of OM and disregard for folk medicine in the medical school curriculum may be attributed to the higher use rate of oriental herbal medicine (95.5%) and acupuncture (99.7%) rather than Vietnamese folk medicine (66.0%). Another reason for this difference may be that few physicians (less than 30%) reported having inherited their CAM knowledge from practitioners in the community or in their family who practiced folk medicine rather than OM. On the other hand, the out-of-school knowledge, particularly from the internet (73.7%), may be implicated in the heterogeneity of the CAM modalities used by the physicians, including chiropractice, dietary therapy, and dietary supplements.
A previous study suggested that younger physicians used more CAM therapies in their daily practice [10
]. In this study, the abundance of knowledge of and the favorable attitude toward CAM were not related to age, but the length of TM practice. Interestingly, the respondents with fewer years of TM practice had more knowledge and a more favorable attitude. A possible explanation may be that younger physicians are familiar with a broader range of CAM modalities rather than focusing only on TVM, which is the tendency of those who have a large amount of experience in TM practice. Those who practice TM for a long period of time may have a reasonable belief in the effectiveness of CAM and TM, whereas beginners tend to overestimate the effectiveness of CAM therapies. However, we found no difference in the heterogeneity of CAM use by age and length of TM practice.
Education level in TM, hospital level, and specialty of doctor (GP or OMD) appeared to be crucial influential factors for the trend of CAM use among physicians in OM hospitals in Vietnam. We found that physicians who had graduate education degrees and who worked in national OM hospitals possessed a broader knowledge of CAM therapies along with the application of various CAM modalities, regardless of other demographic factors. Although OM has been the main content included in graduate courses in OM medical schools, graduate students may have a chance to expand their knowledge of various CAM modalities during the course, and then they may integrate different CAM therapies in their practice. This finding suggests that further education in TM brings about more benefits for physicians and should be encouraged. The working environment may also influence the CAM use of physicians. The physicians in the national OM hospitals may have a better chance of learning from outstanding CAM or OM experts, and they have access to a large resource of academic references (e.g., journals, conference, and training). We also found that the knowledge sources of CAM therapies were different by working environment. The physicians in the national OM hospitals had more opportunities to gain out-of-school knowledge on CAM (e.g., from academic journals, the internet, conference/training, and magazines) than those in lower level hospitals ().
This study also underlined the excessive use of western medication by physicians in OM hospitals and a higher rate of western medication use in the national hospitals (54.5%) compared with that in the lower level hospitals (42.3%). Although the physicians in the national OM hospitals possessed more knowledge and tended to use more CAM therapies, their prescriptions may be further influenced by various marketing strategies of pharmaceutical companies, which do not reach their colleagues in lower level hospitals. The physicians who were trained as GPs in medical school tended to use more western medication than those who were trained as OMD, although the attitudes toward CAM therapies between these two groups were comparable. This finding suggests the need to enhance the knowledge of CAM and TM therapies of the GPs working in OM hospitals to better encourage more appropriately used integrative medicine.
The present findings must be interpreted in the context of the study's strengths and potential limitations. The strengths of this study were that participants were selected randomly after taking into account their geographic and hospital level factors, and the interviews were performed by a face-to-face method that resulted in a high response rate and less data collection bias. However, the participants who were physicians in the OM hospitals may not have represented the CAM practitioners in all of Vietnam because they provided the highest level of CAM services. In Vietnam, CAM can be practiced by both licensed physicians and practitioners. Because the knowledge of CAM practitioners did not originate from medical school, but was inherited from their parents, a high rate of Vietnamese folk medicine may be used among this population. Another limitation of this study is that the self-administered questionnaire may generate biases due to the respondents' overestimation of their capacity and perception of the questions. Although a concrete definition was provided for each CAM modality, the respondents may have been inclined to perceive chiropractice as a technique of massage and dietary therapy as a part of OM. The Cronbach's α coefficient of attitudinal scale was relatively low that may be partly due to a small number of items included, whereas knowledge and practice scales exhibited acceptable internal consistency. However, these scales should be validated for further application.
In conclusion, this study indicated that OM rather than Vietnamese folk medicine and other forms of CAM is the most commonly used CAM modality by physicians in OM hospitals in Vietnam. A broad range of CAM modalities and an excessive proportion of western medication were employed in conjunction with OM in the physicians' daily practice. This trend was influenced by the source of the CAM knowledge obtained, the education level, the specialty of the physicians, and the work environment. These findings suggest the marked interest in other CAM therapies in addition to traditional modes among physicians in the OM hospitals in Vietnam.