28 H. Tempest et al.a highly controversial treatment option, particularly as no Acupuncture in Urology Questionnairewell-deﬁned conventional pathophysiological mechanism to 1. Sex M/Fexplain its efﬁcacy has been identiﬁed. 2. Age Numerous urological conditions can be difﬁcult and chal- 3. Years of experience in Urologylenging to treat symptomatically.3 The use of acupuncture 4. Gradefor urological conditions was reviewed by Ripoll and Bunn,4and since then there have only been a limited number of 5. How would you rate your knowledge of acupuncturestudies investigating its use. These mainly focus on func- 1 2 3 4 5tional disorders such as chronic pelvic pain,5,6 lower urinary Low hightract symptoms,7,8 or, more recently, hot ﬂushes following 6. What is your general attitude towards acupuncture?androgen deprivation therapy for prostate cancer.9,10 1 2 3 4 5Acupuncture treatments have been reported to improve very negative neutral very positivethese conditions. Although promising, especially after 7. Do you think acupuncture may help in any urological conditions ? Y/Nfailure of conventional treatment options, the majority of 1 2 3 4 5these studies are observational or contained small numbers Very unlikely maybe very likelyof patients, and few of the studies are randomised.4 Largerwell-powered studies with multicentre involvement aretherefore needed to investigate the efﬁcacy of acupuncture If so which ones ?for the treatment of urological conditions. The feasibility ofsuch studies largely depends on the willingness of urologists 8. Have you ever suggested acupuncture to a patient?Y/Nto participate, and this may be inﬂuenced by their interestand beliefs regarding the potential efﬁcacy of acupuncture 9. Have your views towards acupuncture changed since you started your career?as a treatment modality for urological conditions. Withouta strong and widespread interest within the urological Alot more positive/ more positive/ no change/ more neg ative/ Alot more negativecommunity for acupuncture, such studies may have littlechance of success. 10. Has anything changed your views? To date, and to our knowledge, there has been no speciﬁcinvestigation either of the views of urologists in the UnitedKingdom towards acupuncture or of their attitudes towards Thank you for your time in answering these questionsthis unconventional treatment option for urological condi-tions. Much of the published literature has concentrated on Figure 1 Questionnaire used to assess urologists viewsthe use of acupuncture in general practice, where as many regarding acupuncture.as 83% of practitioners believe that acupuncture might be for most of them facilitating identiﬁcation of the urologistsclinically useful and may recommend it to their patients.11 and a high response rate. The three deaneries (and hospi-A study of Norwegian doctors showed that they would rec- tals therein) were Oxford (Churchill (Oxford), Northamptonommend acupuncture to 38% of their patients suffering General, Royal Berkshire (Reading) and Wycombe), Wes-from migraine.12 With regard to surgeons, the only study sex (Royal Bournemouth, Salisbury District, Winchester,of acupuncture reported to date demonstrated that 63% Southampton, Queen Alexandra (Portsmouth), St Richardsof surveyed neurosurgeons believed that complementary (Chichester)) and Eastern (Addenbrookes (Cambridge), Nor-medicine may have a potential role in patient management folk and Norwich, Luton and Dunstable, Bedford, Ipswich,but it did not elaborate fully if they recommend it in their Peterborough and West Suffolk (Bury St Edmunds)). Theclinical practice.13 urologists working at these hospitals were identiﬁed by The principal objective of this study was to investigate contacting the deaneries and hospitals. The urologists asthe views of urologists in England towards acupuncture deﬁned for the purposes of this study were either qualiﬁedand to ascertain their beliefs about its use for urological urologists or urology trainees. There were no exclusion crite-conditions. We investigated whether sufﬁcient urologists ria within this group. All the urologists, who worked in thedemonstrate an interest in acupuncture as a preliminary hospitals within these training deaneries, were contactedstep such that future larger studies on acupuncture for over a 3-month period, either directly or by telephone orurological conditions might be feasible. We also aim to even- e-mail. The urologists included consultants, staff grades,tually identify a proﬁle of urologists or their clinical centres, associate specialists and trainees, and all were asked towhich may be more likely to recommend acupuncture to complete a questionnaire (Fig. 1) evaluating their viewspatients, such that these urologists could potentially be regarding acupuncture and its use in urology. A proﬁle ofrequested to become co-investigators and recruiting centres urologists more likely to have suggested acupuncture to theirfor future large-scale randomised clinical trials. patients was identiﬁed using logistic regression. Statistical analyses were conducted using Stat View 5.0 for WindowsMethods (SAS Institute, Cary, NC, USA).A questionnaire (Fig. 1) was designed to investigate the Resultsopinion of urologists practising in three English trainingdeaneries. These deaneries were chosen as they covered We identiﬁed 145 urologists working within the designatedseveral regions and the authors had professional contacts hospitals. These included 86 consultants, 13 staff grades
Acupuncture in urological practice—–A survey of urologists in England 29 60 55 54 logical experience, was of non-trainee status, had greaterNumber of Urologists 50 46 knowledge of acupuncture, had a greater positive attitude 40 towards acupuncture, had a greater belief in its possible 27 29 30 30 helpfulness, and if the urologist had changed their opinion 17 regarding acupuncture during their career (Table 1). In the 20 11 9 9 10 4 5 3 6 multivariate analysis, the only variable associated with a 0 0 higher probability of suggesting acupuncture to a patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 was when the urologist had changed their opinion regard- Knowledge A tude Helpfulnes ing acupuncture during their career (odds ratio (OR): 10.4 (2.5—42.4), p = 0.001). This group of urologists representsFigure 2 Histograms representing the number of urolo- almost half (n = 48, 48%) of the responders in this study.gists giving each score (1—5) regarding knowledge about Trainees (n = 15, 35%) were less likely to have changed theiracupuncture, attitude towards acupuncture and usefulness of views regarding acupuncture compared with non-traineesacupuncture. (n = 33, 57%) (p = 0.03). Of those who had changed their view, the change was always either ‘‘more positive’’ (n = 45, 93%) or ‘‘a lot more positive’’ (n = 15, 7%), and was neveror associate specialists and 46 trainees. A completed ques- ‘‘negative’’ or ‘‘a lot more negative.’’ Within the group oftionnaire was obtained in 102/145 cases, giving a response urologists, who had changed their views regarding the possi-rate of 70%. These were 41 from the Eastern deanery, 39 ble efﬁcacy of acupuncture, 27 (56%) suggested acupuncturefrom the Oxford deanery and 22 from the Wessex deanery. as a treatment to their patients, although 3 out of 53Of the 43 non-responders, 10 were due to incorrect e-mail respondents (6%), who had not changed their views hadaddress or phone number, leading to an adjusted response also suggested acupuncture. Reasons identiﬁed as factorsrate of 76%, if this group is not included. The response rate causing a change of view included feedback from patientswas higher from trainees (93%) compared with non-trainees (n = 16), reading literature/media (n = 4) and personal expe-(60%) (p < 0.001). The male to female ratio was 10:1 (4:1 for rience (n = 1).trainees and 58:1 for non-trainees). The overall mean age There was no signiﬁcant difference among the three(range) was 40 years (29—66) whilst the mean (range) age deaneries for all data analysed except for the number ofwas 33 years (29—41) for trainees and 46 years (36—66) for urologists, who had their view changed about acupuncture,non-trainees. which was higher (p = 0.025) in the Eastern group (n = 25, Results concerning knowledge, attitude and usefulness of 63%) compared with the others (n = 23, 38%).acupuncture are outlined in Fig. 2. The majority of urologistsrated their knowledge of acupuncture as low (n = 46, 46%)and their general attitude towards acupuncture as neutral Discussion(n = 55, 54%). Nevertheless, 95 (95%) urologists thought thatacupuncture may be a useful treatment modality for urolog- This study demonstrates that despite most urologists hav-ical conditions, including chronic pain, overactive bladder, ing poor knowledge about acupuncture, many believe thatprostatitis and hot ﬂushes. At least one urological condi- it may play a role in the urological management of sometion was mentioned as being treatable through acupuncture patients. Half of the urologists in this study had changedby 78 urologists (76%), with pain being the most frequently their views regarding the effectiveness of acupuncture and,quoted of these (n = 76, 75%). in general, this was in a positive manner. Acupuncture was suggested as a therapeutic option Generally, poor knowledge about acupuncture is unsur-for patients by 30 urologists (29%). This was signiﬁcantly prising given that acupuncture is not routinely taught tomore frequent among non-trainees (42%) than trainees medical students in universities in the UK. Specialised train-(12%) (p < 0.001). Univariate analysis demonstrated that the ing is available from institutions such as the British Medicalchance of acupuncture being suggested as a treatment Acupuncture Society (a registered charity); however, thisoption for patients was signiﬁcantly higher if the urologist is only within fee-paying courses. Interestingly, it has beenwas of a higher age (>40 years), had more years of uro- shown that when a medical course includes some tuition on Table 1 Univariate analysis indicating the odds ratio (OR) of having suggested acupuncture to a patient with a 95% conﬁdence interval. OR 95% inf. 95% sup. p-Value Sex: male 0.818 0.191 3.511 0.7871 Age: >40 4.126 1.604 10.617 0.0033 Experience: >10 years 3.417 1.327 8.796 0.0109 Status: non-training 5.59 1.92 16.13 0.0016 Knowledge: score >3 5.098 1.366 19.021 0.0153 Attitude: score >3 4.818 1.941 11.958 0.0007 Helpful: score >3 5.588 2.226 14.03 0.0002 Views changed: yes 21.429 5.856 78.411 <0.0001 OR: odds ratio.
30 H. Tempest et al.complementary therapies, doctor’s views become more pos- within the National Health Service. This may explain whyitive towards such treatments.14 It has also been shown that only a third of the urologists in this study suggest acupunc-the majority of doctors and medical students believe that ture to their patients, and why trainees are less likely toalternative therapies should be taught during their under- discuss this treatment modality during patient consulta-graduate medical degree course.15 tions. Whilst the overall interest in acupuncture by respondents Most urologists believe acupuncture may play a role in thein this study was neutral, 95% of urologists believed in a management of urological conditions, some having alreadyuseful potential role of acupuncture in the management of suggested it to their patients. Urologists declaring the mostsome urological conditions, suggesting that most urologists knowledge and positive attitudes regarding acupuncturewould be keen on referring patients to acupuncture clin- were also most likely to ﬁnd this treatment helpful forics. In practice, however, only around one-third of urologists their patients. Urologists, who changed their views abouthave suggested it to their patients. The exact reasons for the acupuncture, were unsurprisingly more likely to have sug-discrepancy between urologists’ beliefs regarding acupunc- gested the treatment to their patients. The most powerfulture, and the frequency with which they recommend this predictor for an urologist to recommend acupuncture wastreatment, are unknown but may potentially be explained them ‘‘having changed their views,’’ and this increasedby the fact that the majority of patients may be successfully the chance of this treatment being offered 21-fold. Manytreated by conventional medicine. It is also possible that urologists tend to develop more favourable views towardsurologists may have reservations about suggesting a treat- acupuncture later in their career, which may reﬂect thement with minimal high-quality research and little scientiﬁc existing limited efﬁcacy of conventional treatment optionsevidence. for some chronic conditions, in particular. The study results presented herein apply only to the three Although the questionnaire in this study did not directlyEnglish deaneries investigated, and may not represent the question whether urologists would be willing to participateviews of other urologists in the United Kingdom or else- in acupuncture research, it has supplied the preliminarywhere. That said, we did not observe signiﬁcant differences knowledge to future researchers that there is considerablebetween deaneries, making geographical location unlikely interest within the urological community about the possi-to result in differences of opinion between regions. We also ble positive effects of acupuncture in the management ofdid not investigate any ethnical or economic backgrounds of urological conditions.respondents that may have had an effect on views. In conclusion, this survey indicates that studies on More experienced urologists, who had completed their acupuncture may be largely accepted among the urologi-training, were more likely to suggest acupuncture to their cal community and that cooperation from urologists may bepatients. This was, however, not statistically signiﬁcant in expected, such as mentioning the existence of a trial and thea multivariate analysis, suggesting that years of experience possibility of referring patients to an investigator for moremay be a confounding factor. More experienced urologists details and inclusion. This study has also deﬁned the pro-are more likely to have seen the same patients on many ﬁle of urologists more likely to have suggested acupunctureoccasions, especially in the outpatient setting, and they to their patients. This group of urologists may be suggestedmay realise the limits that conventional medicine can offer as being the most appropriate for researchers to initiallytheir patients. Curative treatment of chronic prostatitis, approach with regarding recruitment of patients for large-for example, may not be realistic in some patients, leaving scale high-quality future clinical studies of acupuncture insymptom management to be the only route to an improve- urology.ment in quality of life. The current treatment strategies forchronic prostatitis including antibiotics, -blockers, anti-inﬂammatory agents and other medical agents are not Competing interesteffective for many patients3 ; therefore, they may be offeredalternative treatments, such as acupuncture, after poor None.results of standard treatments or to avoid more invasivetreatments. Intriguingly, the use of acupuncture has resultedin good results for patients with this condition.5,6 Our results Acknowledgementsshowed that good feedback from patients was the reasonfor 16 urologists to have changed their views concerning The authors are grateful to all the urologists who answeredacupuncture. This highlights the fact that patient satisfac- the questionnaire in this study.tion with acupuncture has a signiﬁcant impact on a doctor’sviews and prescribing practice. These results suggest that younger urologists are less Referencesinterested and more sceptical about acupuncture than olderurologists. 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