Approximately one in four practicing clinicians appear to be aware of two major federally funded clinical trials of alternative therapies, and many do not express confidence in their ability to interpret research results, according to a report in the April 13 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Complementary and alternative (CAM) therapies are widely used, but until recently few rigorous studies of their safety and effectiveness have been conducted, according to background information in the article. The National Institutes of Health (NIH) has invested more than $2 billion into this type of scientific research in the past decade. "For this investment to achieve its anticipated social value, clinical research must be translated into improvements in clinical and public health practice—a process fraught with obstacles," the authors write.
"For evidence from clinical research to have an impact on medical practice, health care professionals must first be aware of the research. Once aware, health care professionals must be able to interpret these findings, judging both their validity and their implications. Finally, they must apply the scientific evidence to their own practices," they continue. To assess this translation process surrounding CAM research, Jon C. Tilburt, M.D., M.P.H., of the NIH, Bethesda, Md., and Mayo Clinic, Rochester, Minn., and colleagues surveyed 2,400 practicing acupuncturists, naturopaths, internists and rheumatologists about their awareness of and attitudes toward CAM research.
A total of 1,561 clinicians (65 percent) completed the survey. Of those, 59 percent were aware of at least one of two major clinical trials recently published on CAM therapies for osteoarthritis of the knee (on assessing acupuncture and the other about the supplement glucosamine); only 23 percent were aware of both trials. Acupuncturists (46 percent) and rheumatologists (49 percent) were more likely to be aware of the acupuncture study than naturopaths (30 percent) and general internists (22 percent), whereas for the glucosamine trial, internists (59 percent) and rheumatologists (88 percent) were more aware than acupuncturists (20 percent) and naturopaths (39 percent).
A minority of clinicians in all groups said they were "very confident" in their ability to critically interpret research literature (20 percent of acupuncturists, 25 percent of naturopaths, 17 percent of internists and 33 percent of rheumatologists); more described themselves as "moderately confident" (59 percent of acupuncturists, 64 percent of naturopaths, 67 percent of internists and 59 percent of rheumatologists)
"Compared with those who were not aware of CAM trials, clinicians who were aware of CAM trials were much more likely to be rheumatologists, to be practicing in an institutional or academic setting, to have some research experience, to express greater ability to interpret evidence and to report greater acceptance of evidence," the authors write.
The results suggest that the translation of CAM trial results into clinical practice may vary widely based on the training, attitudes and experiences of the clinicians who might apply them, they continue. "For clinical research in CAM (and conventional medicine) to achieve its potential social value, concerted efforts must be undertaken that more deliberately train clinicians in critical appraisal, biostatistics and use of evidence-based resources, as well as expanded research opportunities, dedicated training experiences and improved dissemination of research results," the authors conclude.
Funding for this research was provided by the National Center for Complementary and Alternative Medicine and the Department of Bioethics, National Institutes of Health. Co-author Dr. Curlin is supported by a grant from the National Center for Complementary and Alternative Medicine.
Editorial: Evidence-Based Medicine Goes Beyond Research Results
"If we are to teach more evidence-based medicine to physicians, we need to broaden and deepen our understanding of what counts as 'evidence' and which types of evidence are best used to inform differing aspects of clinical decision making," writes Wayne B. Jonas, M.D., of the Samueli Institute, Alexandria, Va., in an accompanying editorial.
"Rather than imposing an academic, hierarchical structure on medical decision making, evidence-based medicine should seek to inform the processes practitioners actually use in making clinical decisions to more effectively incorporate science into practice," Dr. Jonas writes. "That is, physicians need to know how to use a complete 'evidence house' and not just the 'evidence hierarchy' currently dominating evidence-based medicine in both conventional and complementary medicine."
"As with any skill, sufficient time and supervised application is needed before evidence-based medicine can become a habit in daily practice. Thus, both CAM and conventional practitioners should each seek to fill their respective gaps in knowledge and skills to make practices both more patient relevant and scientifically rigorous."
- Tilburt et al. Alternative Medicine Research in Clinical Practice: A US National Survey. Archives of Internal Medicine, 2009; 169 (7): 670 DOI: 10.1001/archinternmed.2009.49
- Wayne B. Jonas. Scientific Evidence and Medical Practice: The "Drunkard's Walk". Archives of Internal Medicine, 2009; 169 (7): 649 DOI: 10.1001/archinternmed.2009.4
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