Key words: complementary and alternative medicine, training, medical schools.

Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine, where alternative medicine is used in place of conventional medicine [1].

In 1992, the National Institute of Health (NIH) of the United States of America convened a meeting to discuss the major areas of alternative medicine and to direct future research activities. The group defined seven fields of alternative therapy; alternative systems of medical practice, bioelectromagnetics, diet and nutrition, herbal remedies, manual healing methods, mind/body interventions, pharmacological and biological treatments [2].

The use of CAM by the community has recently been increasing in many countries. The percentages of people who have used CAM were 42.1% in the USA in 1997 [2]. In Far East countries, there is no nation-wide random sampled or population weighted survey on the prevalent use of CAM. Because of geographical, cultural and historical differences, there might be different characteristics of CAM used in Far East countries, compared to the situation in the West. [3].

There are many other forms of CAM therapies that are not mentioned above [4,5]. CAM methods are being used for different kinds of diseases in different parts of the world such as multiple sclerosis, atopic disorders, menopause, liver disease, epilepsy, cancer, cardiovascular disease, inflammatory disease, and many others [6-16].

Medical practice in Turkey dates back to ancient times. Almost exclusively, people not educated in conventional medicine practice CAM in Turkey. CAM practices cover a wide spectrum regarding herbal prescriptions. Most people are using herbal therapy in Turkey mainly for cancer, constipation, obesity, diabetes mellitus, hypertension, common cold and many other diseases. There is yet no valid data on the referrals of patients to CAM practitioners by orthodox western medicine (OWM) doctors.
The aim of this study was to investigate the knowledge and attitudes of the academic doctors of orthodox western medicine towards complementary and alternative medicine, and opinions on inserting CAM methods in medical curriculum.

Erciyes University Medical Faculty, located in Kayseri Province, Middle Anatolia, has four separate hospital buildings with a capacity of 1395 beds. There are 367 residents and 226 Professors working in the University Hospital.

Questionnaire
A questionnaire of 12 items was prepared and given to the academic doctors of Erciyes University Medical Faculty following the visit of Korean Oriental Medical Service Team Abroad (KOMSTA) in October 2002. The questionnaire was performed by random sampling of the doctors. One of the professors, and two residents did not respond to the questionnaire. The knowledge and the indications of 14 different complementary and alternative medicine therapies were asked. The CAM therapies are selected from a glossary prepared by the National Institute of Health [1].

These CAM therapies were:

1. Acupuncture
   
2. Aromatherapy
   
3. Ayurveda
   
4. Chiropractic
   
5. Diet supplementation
   
6. Electromagnetic field
   
7. Herbal therapy
   
8. Homeopathic
   
9. Massage
   
10. Naturopathic
    
11. Osteopathic
    
12. Qi-gong
    
13. Reiki
    
14. Therapeutic touch

The respondents answered the following questions:

1. The source of knowledge, and whether they are interested in any of these;
   
2. Whether they have had a training course on these, and their patients' level of knowledge about these CAM methods and which one it is;
   
3. Whether they have suggested any of these, and what they think about the usefulness of these methods;
   
4. The presence of knowledge about anyone performing one of these methods;
   
5. Whether they know some subjects who think that the method has been useful;
   
6. The use of herbal medicine by their patients and its name;
   
7. Whether they or their friends and the people they know use any kind of herbal therapy or any CAM methods, which have not been mentioned;
   
8. Whether they have used any of the mentioned CAM methods;
   
9. Whether they would suggest the use of CAM for the treatment of incurable diseases;
   
10. The knowledge of any CAM method, which is licensed in any country, and whether these should be licensed in Turkey;
    
11. Which institution should give the license, and whether they would suggest any if it is licensed;
    
12. Whether there should be some lectures or courses to teach CAM methods in the undergraduate curriculum of the medical faculty.
    
    

Sample
The questionnaire was completed by 195 doctors. One hundred and thirty four (68.7%) were men and 61 (31.3%) were women. The mean age of the doctors was 32.3±7.1 (range, 22-62 years). The questionnaire was given out to almost all branches of medicine, where the most frequent ones were Medicine (14.8%), General Surgery (9.7%) and Paediatrics (7.6%).

Ethics Committee approval
Erciyes University Medical Faculty Ethics Committee does not require consent for surveys.

Statistical analysis
Statistical analysis was performed using SPSS statistical package (Version 11.0, SPSS Inc., Chicago, IL, USA) for Windows. Chi-square tests were used to determine the differences between the groups. The level of statistical significance was set at p < 0.05.

General information
Acupuncture (90.7%), herbal therapy (62.5%), and massage (60.5%) were the most frequently known CAM methods (%95 CI: %86-%94, %55-%69, and %53-%67 respectively). Acupuncture was mainly known to be used for pain, obesity, and giving up smoking. On the other hand, herbal therapy was used for gastrointestinal tract diseases, dermatological diseases, and obesity. The use of massage was stated as for pain, psychiatric disorders, and physical therapy and rehabilitation diseases (Table1). The source of information was mass-media (69.7%), friends (15.8%), patients (6.6%), and seminars (3.0%).

Thirty-seven doctors (18.9%) were interested in CAM. Two doctors (1.0%) had a course on acupuncture and one (0.5%) on Reiki. Eighty-two doctors (42.0%) were asked to give some information on CAM.

Suggestion of CAM
Thirty-five doctors (17.9%) suggested a CAM method to their patients. Acupuncture was suggested to 11 patients for obesity, chronic pain, post-herpetic neuralgia, migraine, disc hernia, peripheral facial paralysis, and for giving up smoking. Herbal therapy was suggested for 10 patients. Garlic for hypertension, senna for constipation, fennel for infantile colic were suggested by doctors. Diet supplementation was suggested to 7 patients for diabetes mellitus, hypercholesterolaemia, obesity and polycystic ovary disease. In the evaluation of the usefulness of CAM methods, 40% stated them as useful (Table 2). There were some significant differences when gender was considered, where women stated that CAM was more useful (p< 0.05).

Use of CAM
Thirty-four doctors (17.4%) tried a CAM method for themselves at least once. They tried acupuncture for obesity, disc hernia, migraine and headache, electromagnetic fields for joint pain, Reiki for tinnitus, herbal therapy for flu (peppermint, lemon), hypertension (garlic, hawthorn vinegar), hair loss (nettle), stress (thyme), constipation and dyspepsia (licorice), urolithiasis (corn tassel), and massage for back pain and headache.

There were sixty-five doctors (33.3%) who have patients using herbal therapies. Ninety-nine doctors (50.7%) suggested any CAM method in case of the existence of an incurable disease. In our study group, women stated that they would suggest CAM more in case of incurable diseases (p< 0.05).

Licensing CAM
Fifty-seven doctors (29.2%) knew any kind of CAM, which was licensed. Acupuncture was the most known CAM method that was licensed, and it was thought to be licensed in the United States, China, Korea, Japan, Austria, Germany, and Turkey.
One hundred and sixteen (59.4%) doctors stated that CAM methods must be licensed in Turkey. The most common preferred institution for licensing CAM methods was the Ministry of Health (Table 3). If CAM methods were licensed, 38.9% of doctors stated that they would suggest any one of them (Table 4).

CAM Training
There were 151 doctors (77%) who thought that information about CAM should be given, and 93 (48%) thought that CAM should be taught in medical schools. There were no statistically significant differences in the evaluation of the residents and the Professors' attitudes and opinions on CAM (p>0.05) (Table 5).

Statement of principal findings
Acupuncture, herbal therapy and massage were the most frequently known CAM methods in our study group. Although only 18.9% of doctors were interested in CAM, 77.4% thought that information about CAM should be given, and 47.6% thought that CAM should be taught in medical schools.

Strengths and limitations of the study
The present investigation is the first study evaluating the opinions and attitudes of OWM academic doctors on CAM. This paper provides a basic evaluation of CAM by OWM academic doctors, and there is no previous data on this subject. In addition, the response rate of the study group was very high.

On the other hand, this study has three limitations. First, although the study may represent our medical school, it might not be representative for all of the medical schools in Turkey. Second, the recent performance of an Oriental Medical Team could have a positive influence on the opinions as well. Finally, the questionnaire was not validated.

CAM use in other countries
There are a number of CAM methods, which are being traditionally used in Turkey [17]. Yet, there are no lectures or courses on CAM in medical schools. It has been stated that the CAM is now taught in 60% of medical schools in the United States of America. Indeed, many hospitals have created or are in the process of creating programs that incorporate these disciplines. Whether physicians prescribe CAM or not, they need to have a basic understanding and knowledge regarding its possible benefits and limitations [18]/ In our study group, giving information and training on CAM was accepted with a high percentage.

Strength and weakness in relation to other studies
Witkowski and Parish have stated that referral of patients to practitioners of CAM is often avoided because of fear that a poor outcome might result in legal action [19]. Berman et al. have reported that at least 10% of the physicians receive one or more patient requests for referral for CAM therapies [20]. In our study, 17.9% of doctors have suggested CAM therapies to their patients, upon the requests of the patients. The referrals are not directly made by the physicians. This is probably due to the hesitation of referring patients to some kind of practices that they have very limited information.

Jump et al. have reported that 34.8% of the physicians had personally utilised at least one of the CAM therapies [21]. In our study, there is less utilisation of CAM therapies by OWM doctors (17.4%). This low rate of utilisation could be an indicator of the prejudice against CAM therapies.

Yamashita et al. stated that patients who have used CAM in the last year have evaluated the effectiveness as follows; 'effective' 58.4%, 'not effective' 10%, and 'do not know' 31.6% [3]. In our study, less doctors (39%) stated that CAM was useful.
Implications

The kind of CAM therapies which are licensed vary from country to country. There is much researches being carried out on CAM, where CAM therapies are compared to orthodox western medicine methods. The use of CAM is very common especially when OWM is not very effective. Therefore, the Ministry of Health or any institution that is assigned could prepare guidelines containing the spectrum of use of CAM, and the scientific data that is available about CAM therapies. It might then be easier for OWM doctors to decide whether they could suggest CAM methods or not, and it would be possible to give the most convenient information about indications and contraindications of CAM.

Because of the widespread use of CAM by patients and the growing scientific evidence that certain CAM therapies are more effective than orthodox alternatives, it has been stated that CAM education must be integrated into medical education in allopathic and osteopathic schools in the near future [22]. There is an increase in the use of CAM methods in Turkey as well.

In conclusion, medical doctors should have a basic knowledge on the indications of CAM methods, and be able to consult their patients when they ask about them without prejudice. It seems that inserting lectures on CAM in the medical curriculum could be a necessity in the near future.