J Am Board Fam Pract 2002; 15 (6):463-480
Characteristics of Visits to Licensed Acupuncturists,
Chiropractors, Massage Therapists, and Naturopathic Physicians
Daniel C. Cherkin, PhD; Richard A. Deyo, MD,
MPH; Karen J. Sherman, PhD, MPH; L. Gary Hart,
PhD; Janet H. Street, RN, MN, PNP; Andrea
Hrbek; Roger B. Davis, ScD; Elaine Cramer, MD,
MPH; Bruce Milliman, ND; Jennifer Booker, ND;
Robert Mootz, DC, DABCO; James Barassi, DC;
Janet R. Kahn, PhD, LMT; Ted J. Kaptchuk, OMD; and
David M. Eisenberg, MD,
Center for Health Studies (DCC, KJS, JHS), Group Health
Cooperative, Seattle; the Departments of Medicine and Health Services
(RAD) University of Washington, WWAMI Center for Health Workforce
Studies (LGH) and Department of Family Medicine (LGH), University of
Washington, Seattle; the Beth Israel-Deaconess Center for Alternative
Medicine Research and Education (AH, RBD, JB, TJK, DME), and the
Department of Medicine (RHB, TJK, DME), Harvard Medical School, Boston;
the Vessel Sanitation Program (EC), Centers for Disease Control,
Atlanta; Bastyr University (BM), Kenmore, a private practice (JB), and
Department of Labor and Industries (RDM), Olympia, Washington;
and the American Massage Therapy Association Foundation (JRK), Silver
[J Am Board Fam Pract 15(6):463-480, 2002. ©2002 American Board of Family Practice]). Data were collected on more than 1,800 visits to each profession by 99 to 133 practitioners.
Despite growing popularity of
complementary and alternative medical (CAM) therapies, little is known
about the patients seen by CAM practitioners. Our objective was to
describe the patients and problems seen by CAM practitioners.
We collected data on 20 consecutive visits
to randomly sampled licensed acupuncturists, chiropractors, massage
therapists, and naturopathic physicians practicing in Arizona,
Connecticut, Massachusetts, and Washington. Data were collected on
patient demographics, smoking status, referral source, reasons for
visit, concurrent medical care, payment source, and visit duration.
Comparative data for conventional physicians were drawn from the
National Ambulatory Medical Care Survey.
In each profession, at least 99
practitioners collected data on more than 1,800 visits. More than 80%
of visits to CAM providers were by young and middle-aged adults, and
roughly two thirds were by women. Children comprised 10% of visits to
naturopathic physicians but only 1% to 4% of all visits to other CAM
providers. At least two thirds of visits resulted from self-referrals,
and only 4% to 12% of visits were from conventional physician
referrals. Chiropractors and massage therapists primarily saw
musculoskeletal problems, while acupuncturists and naturopathic
physicians saw a broader range of conditions. Visits to
acupuncturists and massage therapists lasted about 60 minutes compared
with 40 minutes for naturopathic physicians and less than 20
minutes for chiropractors. Most visits to chiropractors and
naturopathic physicians, but less than one third of visits to
acupuncturists and massage therapists, were covered by insurance.
This information will help inform
discussions of the roles CAM practitioners will play in the health care
system of the future.
In spite of rapid growth in numbers of CAM
providers and use of CAM services,[2,3] little
is known about the practices of the various types of CAM providers in
the United States. This lack of fundamental information about CAM
providers and their practices has limited the ability of patients,
health care providers, and insurers to make informed decisions about
the appropriate role of CAM providers in the health care system. This
basic information would also be useful "to guide future research and
to identify areas of greatest public health concern."
To begin to remedy this deficiency of information, we surveyed random
samples of licensed acupuncturists, chiropractors, massage therapists,
and naturopathic physicians and collected data on patients who visited
A study was undertaken to describe the personal and practice
characteristics of representative samples of licensed providers in each
of the four largest CAM professions: acupuncture, chiropractic, massage
therapy, and naturopathy. An initial article described
the characteristics of CAM practitioners and presented details of the
study design. This article summarizes practice characteristics based on
Sampling and Eligibility of Licensed Providers
Each of the four types of CAM providers was surveyed in one
northeastern and one western state: acupuncturists in Massachusetts and
Washington, chiropractors in Arizona and Massachusetts, and massage
therapists and naturopathic physicians in Connecticut and Washington.
Interviews for each profession were conducted in the western and
northeastern states at the same time of year. The Northeast and West
were selected because these regions are where licensed CAM providers
are concentrated. Licensure listings of providers with
in-state addresses were obtained from Washington (1998), Arizona
(1999), Connecticut (1999), and Massachusetts (1999). Providers without
valid telephone numbers or not in practice were ineligible. More detail
on the survey process is reported elsewhere. Enough
eligible providers in each profession in each state were interviewed to
yield at least 50 participants willing to collect data on 20
consecutive patient visits.
Practitioners in each profession with extremely low patient volumes
were not asked to collect visit data. Extremely low patient volumes
were defined as fewer than 10 visits per week for acupuncturists and
naturopathic physicians, fewer than 30 visits per week for
chiropractors, and fewer than 5 visits per week for massage therapists.
This criterion resulted in the exclusion of about 15% of the lowest
volume practitioners in each profession who collectively accounted for
about 2% of all visits to the profession.
To maximize the accuracy of statewide estimates, data collection
efforts were concentrated on high-volume practitioners from each
profession: acupuncturists and naturopathic physicians with at least 20
patient visits per week, massage therapists with at least 10 visits,
and chiropractors with at least 60 visits. About 60% to 70% of
practitioners in each profession had a high-volume practice and
accounted for roughly 85% to 90% of all visits to the profession. The
remaining practitioners were categorized as low-volume providers. All
high- volume practitioners, but only the first 10 low-volume
practitioners (the first 20 for massage therapy), were asked to collect
data on 20 consecutive visits. The rationale was to collect only enough
data from low-volume providers to ascertain whether their practices
differed markedly from those of high-volume providers. It was
ultimately decided, however, to weight data for high- and low-volume
providers in a manner that produced annual estimates of visits to each
profession in each state.
Visit data were collected in 1998 (Washington) and 1999 (Arizona,
Connecticut, Massachusetts). Data for each profession were collected in
both states at the same time of year. No financial incentives to
participate were offered. Practitioners were provided with blank visit
forms coded with unique identification codes and began data collection
on randomly assigned weekdays to minimize reporting bias. They were
asked to collect data on 20 consecutive visits even if the same patient
was seen more than once.
Visit data were collected using one-page forms modeled after the one
used by the National Ambulatory Medical Care Survey
(NAMCS). To permit comparison with the NAMCS data,
identical questions were used (eg, patient's demographic
characteristics, smoking status, reason for visit, referral source,
source of payment, visit duration, and visit disposition). New
questions were added about whether the patient was receiving care from
a conventional physician for their primary problem and whether the CAM
practitioner had discussed care of the patient with a conventional
physician. Data on diagnoses (for chiropractors and naturopathic
physicians), tests, treatments, and self-care recommendations, tailored
to each profession, were also collected and will be reported elsewhere.
Practitioners were asked to record up to five "complaints, symptoms,
or other reasons for this visit," using the patient's own words,
listing the most important reason first. The NAMCS Reason for Visit
Classification System (RVCS), which distinguishes among
symptoms; diseases; diagnostic, screening, or preventive interventions;
treatments; and injuries was used. Clinically similar reasons for visit
(eg, back sprain, back pain, back stiffness) were combined. A copy of
this categorization scheme is available from the authors.
Comparative Data for Conventional Medical Physicians
Comparative data on visits to conventional medical and osteopathic
physicians (collectively referred to as conventional physicians) were
obtained from the 1995 to 1998 National Ambulatory Medical Care
The study used a two-stage sampling design. We selected a random
sample of practitioners, stratified by weekly visit volume (described
above), and obtained data on consecutive patient visits. Each visit in
the sample was weighted by the inverse of the sampling probability,
reflecting both the chance that the particular provider was selected
and the proportion of that provider's annual visits sampled. As a
result, the statistics we report reflect estimates for all visits
within a state except for the roughly 2% of visits made to the lowest
volume practitioners. To account for the complex sampling design,
we used SAS-callable SUDAAN software (version 7.5, Research Triangle
Institute, Research Triangle, NC) to estimate standard errors using
Taylor series linearization.
Between 78% and 94% of eligible practitioners in 7 of the 8
samples agreed to be interviewed and between 62% and
82% of the interviewed practitioners who did not have very low patient
volumes agreed to collect visit data (Table 1
The great majority of visits to all four professions were made by
young and middle-aged adults (Table 2).
Children made more than 10% of the visits to naturopathic physicians
but only 1% to 4% of visits to the other professions. Adults older
than 65 years of age comprised 7% to 10% of visits to massage
therapists and naturopathic physicians and 12% to 20% of visits to
acupuncturists and chiropractors. Conventional physicians were much
more likely than the CAM practitioners to see both children (18% of
visits) and older adults (24% of visits). The percentage of visits
made by women ranged from about 60% for chiropractors and conventional
physicians to 75% for naturopathic physicians.
Only 3% to 9% of visits to CAM practitioners were by nonwhites (Table 2). Hispanics were also relatively infrequent consumers of CAM care except in Arizona, where 11% of visits to chiropractors were by
Hispanics. The percentage of visits made by known cigarette smokers
ranged between 8% and 15% for acupuncturists, chiropractors, and
massage therapists, compared with only about 5% for naturopathic
physicians. The percentage of visits to conventional physicians by
current smokers was also relatively low (9%), although they were much
more likely to fail to report their patients' smoking status than were
the CAM providers (28% missing vs 1%-9%, respectively). The
percentage of visits with missing data on smoking status was high even
for conventional physicians in family and general practice (26%).
Role of CAM Practitioners in Care of Patients
Most patients seeking care from CAM practitioners were
self-referred (Table 3). Chiropractors
and naturopathic physicians were particularly dependent on
self-referrals, which represented more than 80% of their visits.
Between 4% and 12% of visits resulted from referrals by conventional
physicians, with acupuncturists most likely to receive referrals
(10%-12% of visits). Massage therapists were most likely to receive
referrals from other CAM practitioners (about 18% of visits),
As is the case for visits to conventional physicians, roughly 80% of
visits to CAM practitioners were by patients who had been seen by the
practitioner before, usually for the same reason (Table 3). About one half of visits to acupuncturists and one third to one half of visits to
naturopathic physicians were for problems that the CAM practitioner
believed were concurrently being cared for by a conventional physician.
Acupuncturists and naturopathic physicians, however, indicated that
they had discussed the care of their patient with a conventional
physician for only 10% to 15% of visits. Finally, massage therapists
were most likely to discuss the care of their patients with other CAM
providers (primarily chiropractors), doing so for about one in five
Major Reasons for Visit
About 75% of visits to acupuncturists and naturopathic physicians
were for chronic conditions, 20% for acute problems, and 5% for care
not related to illness (including preventive and wellness care).
Massage therapists provided care for chronic problems at about one half
of their visits and wellness care at about 30% of visits.
Chiropractors provided almost equal proportions of chronic and acute
care (about 45% and 40%, respectively) and provided care not related
to illness during 12% of visits. Visits to conventional physicians
were also evenly split between acute and chronic problems (37% of
each), and they provided care not related to illness (preventive) for
18% of visits. A small percentage of visits (1%-8%) to each
profession were presurgical or postsurgical or for injury follow-up.
The most frequent primary reasons for visits to CAM practitioners are
listed in Table 4. The five most frequent
reasons patients were seen by chiropractors made up 85% of total
visits. Although the great majority of these visits related to
musculoskeletal conditions, visits for wellness care, primarily for
maintenance for musculoskeletal problems, were also common. Massage
therapists also saw a relatively limited range of problems, with their
top five primary reasons for visit comprising about 70% of all visits.
In addition to musculoskeletal conditions, substantial fractions of
visits to massage therapists were for wellness (primarily relaxation)
care (about 20%) and anxiety or depression (5%-9%).
Of the four CAM professions, acupuncturists and naturopathic physicians
saw the broadest range of conditions. Musculoskeletal problems were
common in the practices of acupuncturists, as were anxiety-depression
and fatigue (Table 4). The top five reasons for visit to acupuncturists represented only about 35% of all visits, indicating that
acupuncturists saw most patients for a wide variety of reasons, most
commonly allergies, infectious diseases, abdominal pain, and knee pain.
Naturopathic physicians most often saw fatigue, back symptoms,
anxiety-depression, headache, skin rashes, and menopausal symptoms,
although their five most common problems represented only about 25% of
their practices. Other conditions seen relatively frequently by
naturopathic physicians were bowel and abdominal problems, allergies,
and neck symptoms. The top reasons for visit to conventional physicians
were routine and special examinations (21.8%), screening and
diagnostic tests (4.1%), cough (3.5%), upper respiratory tract
infections (2.6%), and back symptoms (2.4%).
Visit Duration and Disposition and Insurance Coverage
The median reported duration of visit to acupuncturists and
massage therapists was 60 minutes. Naturopathic physicians reported
visits averaging about 40 minutes, and chiropractors and conventional
physicians reported the shortest visits (medians between 15 and 17
Between 57% (Washington) and 68% (Connecticut) of visits to
chiropractors and 50% (Washington) to 61% (Connecticut) of visits to
naturopathic physicians were covered by insurance compared with 8%
(Connecticut) to 26% (Washington) of visits to acupuncturists and 10%
(Massachusetts) to 33% (Washington) of visits to massage therapists.
Thus, the percentages of insured visits to acupuncturists and massage
therapists in Washington were markedly higher than in the northeastern
states. The percentage of visits to conventional physicians covered by
insurance, 86%, is much higher than for any of the CAM professions.
Between 75% and 85% of visits to acupuncturists, chiropractors, and
naturopathic physicians and about 60% of visits to massage therapists
and conventional physicians concluded with a plan for the patient to
return at a specific time. Naturopathic physicians were about twice as
likely as other CAM practitioners to refer patients to conventional
physicians (almost 4% of visits). Massage therapists were about twice
as likely as acupuncturists, chiropractors, and naturopathic physicians
to refer patients to other CAM practitioners (about 4% of visits).
Regional Variation in CAM Practice
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Revised Code of Washington 48.43.045, 2001.
This study provides unique data on the practices of representative
samples of providers in the four largest licensed CAM professions in
the United States. For each profession, data are presented from one
state in each of the two regions where CAM services are most popular,
the West and the Northeast.[1,3] Despite the large distance
between these regions, differences between states within a profession
were generally much smaller than differences between professions. The
largest differences appear to be related to differences in the
sociodemographic characteristics of the states. For example, compared
with patients of Massachusetts chiropractors, patients of Arizona
chiropractors were more likely to be Hispanic, reflecting the high
percentage of Hispanics in that state. The extensive similarities
between states in the practice characteristics of each CAM profession
suggest that the results of this study might generalize to other states
that license CAM practitioners. The only certain way of knowing whether
these findings are nationally representative, however, is to survey a
national sample of CAM practitioners. The absence of a comprehensive
national listing of licensed CAM practitioners would make a
representative national survey difficult.
Patient Populations Served by CAM Practitioners and Conventional
Consistent with national surveys,[3,11] this study
found that patients of CAM practitioners are mostly young to
middle-aged, female, and white. Except for naturopathic physicians, CAM
practitioners provided very little care for children, at levels
substantially below those for conventional physicians. Adults older
than 65 years were also less frequently seen by CAM practitioners
than by conventional physicians in the United States. The
percentages of visits by nonwhites to CAM practitioners (ranging from
3%-9%) were substantially lower than the percentages of nonwhites
living in these states, which ranged between 16% and
24%.* The age, sex, and race-ethnicity of
the patients of CAM practitioners generally resemble those of the
This study suggests that patients of naturopathic physicians might have
healthier habits than do those of the other CAM practitioners, ie,
their patients are one half as likely to smoke. Whether naturopathic
physicians are more attractive to nonsmokers or better at convincing
patients to stop smoking is unclear. The percentage of visits to
conventional physicians by smokers falls within the range reported by
the four CAM professions. Even primary care conventional physicians,
however, were much more often unaware of their patients' smoking
status than were CAM providers. Whether this apparently greater
attentiveness to medically relevant lifestyle issues by CAM providers
generalizes to other behaviors (eg, diet, exercise, stress reduction)
is worthy of further investigation.
Patient Care Roles Played by CAM Practitioners and Conventional
Most visits to CAM practitioners resulted from self-referrals. The
highest rates of self-referral were found for the professions whose
care is most likely to be covered by insurance: chiropractors and
naturopathic physicians. CAM practitioners are not dependent on
conventional physicians for referrals, receiving only about 5% to 10%
of patients from this source. Concurrent care, however, appears to be
common, representing between one quarter and one half of visits to
acupuncturists, massage therapists, and naturopathic physicians.
Nevertheless, these CAM providers typically do not discuss care for
concurrent patients with conventional physicians, which might not be
surprising, given the small percentage of concurrent visits resulting
from referrals by conventional physicians. Even so, this finding, in
conjunction with the fact that patients rarely discuss their CAM care
with conventional physicians,[2,3] raises concerns about the
coordination and safety of concurrent care. Lack of coordination and
safety issues are a particular concern for care by acupuncturists and
naturopathic physicians, who might prescribe herbs that interact with
medications prescribed by conventional physicians.[12-16]
Although the overlap in the types of problems addressed by the four CAM
professions is considerable, each profession has unique aspects.
Chiropractors and massage therapists have the narrowest clinical focus,
treating mostly musculoskeletal problems. Previous studies have also
found that chiropractors' practices consist almost entirely of
patients who have musculoskeletal complaints and
conditions.[17,18] Chiropractors and massage therapists are
also the most likely to provide care not related to illness. For
chiropractic patients, most such care is for maintenance, typically
directed at maintaining spinal function or addressing activities
and lifestyle.[19,20] Care for other than illness in massage
patients, representing almost one in five visits, is focused on
relaxation and stress reduction. Massage therapists also see a
substantial number of patients for self-reported anxiety or depression,
some of whom might also want help relaxing and coping with stress.
Another distinctive aspect of chiropractic is its relatively large role
in caring for acute conditions (about 40% of visits compared with
roughly 20% of visits for the other CAM professions).
Acupuncturists and naturopathic physicians see a broader range of
conditions than do chiropractors and massage therapists, often
providing care for such problems as anxiety, depression, fatigue, and
allergies (acupuncturists), and for fatigue, skin rashes, and
menopausal symptoms (naturopathic physicians). Compared with the other
CAM practitioners, naturopathic physicians provide relatively
little care for musculoskeletal conditions. The most notable
differences between the practices of conventional physicians and CAM
providers was the relatively large fraction of visits to the former for
examinations, screening, and diagnostic tests and for symptoms
associated with respiratory tract infections.
Although this study documented substantial differences among the
professions in visit duration, reported visit duration might not
accurately reflect amount of time actually spent with patients.
Although it is likely that massage therapists spend most of their
1-hour visits with the patient, such might not be true for
acupuncturists, who often leave the room after inserting needles or who
might treat 2 or more patients simultaneously, using different rooms.
The fraction of the total visit length that chiropractors, naturopathic
physicians, and conventional physicians spend with patients is less
clear. Furthermore, because of the different circumstances under which
each type of practitioner sees patients and differences in the types of
patients they see, it is difficult to know whether the observed
differences in visit duration are likely to have implications for
patient satisfaction or specific clinical outcomes. Nevertheless, even
though spinal manipulation is a brief procedure, it is noteworthy that
chiropractors appear to spend as much time with patients as do
Insurance, Licensure, and Future Demand for CAM Services
Visits to conventional physicians were much more likely to be
covered by insurance than visits to CAM practitioners, and coverage for
visits to acupuncturists and massage therapists in the states included
in this study remains limited. Acupuncture and massage visits were
three times as likely to be covered in Washington as in the
northeastern states, possibly reflecting an effect of an enhanced
access law enacted in Washington several years ago.
Naturopathic care, however, was less likely to be covered in Washington
than in Connecticut, where naturopathic services have been covered for
At present, chiropractic is licensed or regulated in all 50 states,
acupuncture in 39 states, massage therapy in 30 states, and naturopathy
in 11 states. Thus, there is substantial room for growth in the number
of states in which CAM professions are licensed. As this occurs, it is
likely that demand for their services and for insurance coverage will
also increase. Furthermore, the large increases in the numbers of CAM
practitioners projected for the future will likely
provide further impetus to increase access to their services
throughout the country.
Strengths and Limitations of Study
The major strengths of this study are the selection of random
samples of the four largest groups of licensed CAM practitioners
practicing in two geographically diverse states, the large sample
sizes, and the relatively high participation rates. The main limitation
is that, despite the similarities between the states studied, it is not
known whether the results are nationally representative.
This study adds important information to the sparse literature
describing the practices of CAM practitioners in the United States. In
addition to providing descriptive data for each CAM profession, this
study identified which questions will be important for future policy
makers and researchers to address. These data will help inform
discussions underway that will determine the future role of CAM
practitioners in the health care system.
Submitted, revised, 11 February 2002.
Address reprint requests to Daniel C. Cherkin, PhD,
Center for Health Studies, Group Health Cooperative, 1730 Minor Ave,
Suite 1600, Seattle, WA 98101.
This project was supported by grants from the Group Health Foundation,
grants #HS09565 and #HS08194 from the Agency for Healthcare Research
and Quality (formerly the Agency for Health Care Policy and Research),
and grant #AR43441-04S1 from the National Institutes of Health. In-kind
support was provided by the Centers for Disease Control and
We would like to express our thanks and appreciation to the
following people for their assistance with this project:
Washington State acupuncturists: Daniel
Bensky, DO; Carol Conlon, LAc; Terry Courtney, LAc; O. Rachel Diaz,
MSW, LAc; John Fenoli, LAc; Pat Flood MS, LAc; Tom Glynn, LAc; Chris
Huson, MAc, LAc; Hai Lan, LAc; Brenda Loew, LAc; Shou-Chun Ma, OMD,
LAc; Barbara Mitchell, JD, LAc; Haifeng Wu, LAc, OMD; Hoy Ping Yee
Chan, LAc, OMD; Amy Zhuan Ying Chen, LAc, OMD. Washington State massage therapists: Kathleen
Appleyard, LMP, RN; Lucy Baker, LMP; Lori Bielinski, LMP; Greg Bolton,
LMP; Nancy Emory, LMP; Jeri Hudson, LMP; John T. Jackson, LMP, CST;
Lucy Krakowiak, LMP; Susan Rosen, LMP; Cheri Schell, LMP; Dawn Schmidt,
LMP; Sari Spieler, LMP; Ann Marie Taylor Thomas, LMP. Washington naturopathic physicians: Thomas Ballard,
ND; Michelle Gartley; Jane Guiltinan, ND; Mark Nolting, ND, LAc; Sheila
Quinn; Leanna Standish, ND, PhD. Arizona chiropractors: Jim Badge, DC; Nathan Conlee,
DC; Stephen Doholis, DC; Arlan Fuhr, DC; Allen Gentry, DC; Kevin
Gilbertson, DC; Sally Quick, DC; Barry Rahn, DC; Ed Weathersby, DC;
Susan Wenberg, DC. Center for Health Studies staff: Kristin Delaney,
MPH; Virginia Dorgan; Sarah Greene, MPH; Kari-Mae Hickman; Heidi Jantz;
Laura Patton, MD; Jessica Smith; Rene Talenti-Perry; Stephanie Wahab,
PhD. Massachusetts acupuncturists: Martin Feldman, LAc;
Ellen Highfield, LAc; Michael Hussin, LAc, Dipl Ac; Joseph Kay, LAc;
Weidong Lu, LAc; James McCormick, LAc; William Mueller; Peter
Valaskatgis, MAc, LAc. Connecticut massage therapists: Shirley Cooper, LMT;
Linda Derick; Margo Gross, MS, OTR, LMT; Steve Kitts; Cliff Korn, LMT;
Synthia Ramsby-Andrews, LMT; Maureen Stott, LMT; Susan Taff, MPH,
LMT. Connecticut naturopathic physicians: Enrico Liva,
ND. Massachusetts chiropractors: Joseph Boyle, DC; Barry
Freedman, DC; Peter Hill, DC; Peter Hyatt, DC; Albert Kalter, DC;
Thomas S. Perrault, Sr, DC; Tony Rosner, DC, PhD. University of Washington team and others: Pat
Brunzell; Donna Kalauokalani, MD; Deborah Senn.
- Cooper RA, Stoflet S. Trends in the education and practice of alternative medicine clinicians. Health Affairs (Millwood)
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