Making sense of "alternative", "complementary", "unconventional" and "integrative" medicine: exploring the terms and meanings through a textual analysis.

BACKGROUND: Medical pluralism has flourished throughout the Western world in spite of efforts to legitimize Western biomedical healthcare as "conventional medicine" and thereby relegate all non-physician-related forms of healthcare to an "other" category. These "other" practitioners have been referred to as "unconventional", "alternative" and "complementary", among other terms throughout the past half century. METHODS: This study investigates the discourses surrounding the changes in the terms, and their meanings, used to describe unconventional medicine in North America. Terms identified by the literature as synonymous to unconventional medicine were searched using the Scopus database. A textual analysis following the method described by Kripendorff 2013 was subsequently performed on the five most highly-cited unconventional medicine-related peer-reviewed literature published between 1970 and 2013. RESULTS: Five commonly-used, unconventional medicine-related terms were identified. Authors using "complementary and alternative", "complementary", "alternative", or "unconventional" tended to define them by what they are not (e.g., therapies not taught/used in conventional medicine, therapy demands not met by conventional medicine, and therapies that lack research on safety, efficacy and effectiveness). Authors defined "integrated/integrative" medicine by what it is (e.g., a new model of healthcare, the combining of both conventional and unconventional therapies, accounting for the whole person, and preventative maintenance of health). Authors who defined terms by "what is not" stressed that the purpose of conducting research in this area was solely to create knowledge. Comparatively, authors who defined terms by "what is" sought to advocate for the evidence-based combination of unconventional and conventional medicines. Both author groups used scientific rhetoric to define unconventional medical practices. CONCLUSIONS: This emergence of two groups of authors who used two different sets of terms to refer to the concept of "unconventional medicine" may explain why some journals, practitioner associations and research/practice centres may choose to use both "what is not" and "what is" terms in their discourse to attract interest from both groups. Since each of the two groups of terms (and authors who use them) has different meanings and goals, the evolution of this discourse will continue to be an interesting phenomenon to explore in the future.

Melatonin Interaction Resulting in Severe Sedation.

PURPOSE: Natural health products (NHPs), including melatonin, are widely used products. Despite the widespread assumption that all NHPs are safe, they contain pharmacologically active substances and can therefore have adverse effects and/or interact with pharmaceuticals. OBJECTIVE: To investigate the mechanism underlying NHP interactions identified through the Pharmacy SONAR active surveillance study. METHODS: Active surveillance was undertaken in community pharmacies to identify adverse events in patients who had recently taken NHPs together with conventional pharmaceuticals. For suspected NHP-pharmaceutical interactions, the possible mechanism of action was explored by in vitro analysis of samples of different products to identify cytochrome P450 enzyme (CYP) inhibition potential. RESULTS: Active surveillance identified a 19-year-old male taking citalopram, nortriptyline and oxycodone concomitantly and who experienced severe sedation when melatonin was added to this regimen. In vitro analysis involving several melatonin products showed product-dependent inhibition of CYP1A2, CYP2C19 and CYP3A7. CONCLUSION: The adverse event was likely due to a primary pharmacokinetic interaction between melatonin and citalopram; although mechanistically, interactions affecting cytochrome P450-mediated metabolism may have occurred with all of these health products. A pharmacodynamic interaction may also be possible, but beyond the capacity of this study to establish.

Negotiating consent: exploring ethical issues when therapeutic massage bodywork practitioners are trained in multiple therapies.

INTRODUCTION: Obtaining informed consent from competent patients is essential to the ethical delivery of health care, including therapeutic massage and bodywork (TMB). The informed consent process used by TMB practitioners has not been previously studied. Little information is available about the practice of informed consent in a treatment-focused environment that may involve multiple decision points, use of multiple TMB therapies, or both. METHODS: As part of a larger study on the process of providing TMB therapy, 19 practitioners were asked about obtaining informed consent during practice. Qualitative description was used to analyze discussions of the consent process generally, and about its application when practitioners use multiple TMB therapies. RESULTS: Two main consent approaches emerged, one based on a general consent early in the treatment process, and a second ongoing consent process undertaken throughout the course of treatment. Both processes are constrained by how engaged a patient wants to be, and the amount of information and time needed to develop a truly informed consent. CONCLUSIONS: An understanding-based consent process that accommodates an acknowledged information differential between the patient and practitioner, and that is guided by clearly delineated goals within a trust-based relationship, may be the most effective consent process under the conditions of real practice conditions.

Exploring the nature of therapeutic massage bodywork practice.

BACKGROUND: Research on therapeutic massage bodywork (TMB) continues to expand, but few studies consider how research or knowledge translation may be affected by the lack of uniformly standardized competencies for most TMB therapies, by practitioner variability from training in different forms of TMB, or from the effects of experience on practice. PURPOSE: This study explores and describes how TMB practitioners practice, for the purpose of improving TMB training, practice, and research. PARTICIPANTS SETTING: 19 TMB practitioners trained in multiple TMB therapies, in Alberta, Canada. RESEARCH DESIGN: Qualitative descriptive sub-analysis of interviews from a comprehensive project on the training and practice of TMB, focused on the delivery of TMB therapies in practice. RESULTS: TWO BROAD THEMES EMERGED FROM THE DATA: (1) every treatment is individualized, and (2) each practitioner's practice of TMB therapies evolves. Individualization involves adapting treatment to the needs of the patient in the moment, based on deliberate and unconscious responses to verbal and nonverbal cues. Individualization starts with initial assessment and continues throughout the treatment encounter. Expertise is depicted as more nuanced and skilful individualization and treatment, evolved through experience, ongoing training, and spontaneous technique exploration. Practitioners consider such individualization and development of experience desirable. Furthermore, ongoing training and experience result in therapy application unique to each practitioner. Most practitioners believed they could not apply a TMB therapy without influence from other TMB therapies they had learned. CONCLUSIONS: There are ramifications for research design, knowledge translation, and education. Few practitioners are likely able to administer treatments in the same way, and most would not like to practice without being able to individualize treatment. TMB clinical studies need to employ research methods that accommodate the complexity of clinical practice. TMB education should facilitate the maturation of practice skills and self-reflection, including the mindful integration of multiple TMB therapies.

Meaning and challenges in the practice of multiple therapeutic massage modalities: a combined methods study.

BACKGROUND: Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice. METHODS: Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada. RESULTS: Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision. CONCLUSIONS: The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.

Becoming old as a 'pharmaceutical person': negotiation of health and medicines among ethnoculturally diverse older adults.

Because medication prescribing and use have become a normative aspect of health care for older adults, we seek to understand how individuals navigate prescribed-medication use within the context of aging. We reasoned that, for those who are ambulatory, medication use is likely influenced by ethnocultural meanings of health and experiences with alternative approaches to health care. Accordingly, we conducted a qualitative study, with in-depth interviews, on a diverse sample of older adults in order to identify elderly persons' perceptions and uses of medicines. Our findings depict older adults as active agents--who draw on a lifetime of experience and knowledge--who take responsibility for adherence (or non-adherence) to medicines and their associated effects on their own bodies. We represent the older person as a "pharmaceutical person" whose experiences of aging are inextricably tied up with the negotiation of medicine-reliant health care.

The difference between integration and collaboration in patient care: results from key informant interviews working in multiprofessional health care teams.

OBJECTIVES: Despite the growing interest in integrative health care, collaborative care, and interdisciplinary health care teams, there appears to be little consistency in terminology and clarity regarding the goal for these teams, other than "working together" for the good of the patients. The purpose of this study was to explore what the terms integration and collaboration mean for practitioners and other key informants working in multiprofessional health care teams, with a specific look at chiropractic and family physician teams in primary care settings. METHODS: Semistructured interviews were conducted with 16 key informants until saturation was obtained in the key emerging themes. All interviews were audiorecorded, and the transcripts were coded using qualitative content analysis. RESULTS: Most participants differentiated collaboration from integration. They generally described a model of professions working closely together (ie, collaborating) in the delivery of care but not subsumed into a single organizational framework (ie, integration). Our results suggest that integration requires collaboration as a precondition but collaboration does not require integration. CONCLUSIONS: Collaboration and integration should not be used interchangeably. A critical starting point for any new interdisciplinary team is to articulate the goals of the model of care.

Exploring consumer and pharmacist views on the professional role of the pharmacist with respect to natural health products: a study of focus groups.

BACKGROUND: Natural health products (NHPs) such as herbs, vitamins and homeopathic medicines, are currently available for sale in most Canadian pharmacies. However, most pharmacists report that they have limited knowledge about these products which have been regulated in Canada as a specific sub-category of drugs. In this paper, consumers' and practicing pharmacists' perceptions of pharmacists' professional responsibilities with respect to NHPs are examined. METHODS: A total of 16 focus groups were conducted with consumers (n = 50) and pharmacists (n = 47) from four different cities across Canada (Vancouver, Edmonton, Toronto, and Halifax). RESULTS: In this paper, we illustrate the ways in which pharmacists' professional responsibilities are impacted by changing consumer needs. Many consumers in the study utilized a wide range of information resources that may or may not have included pharmacists. Nevertheless, the majority of consumers and pharmacists agreed that pharmacists should be knowledgeable about NHPs and felt that pharmacists should be able to manage drug-NHPs interactions as well as identify and evaluate the variety of information available to help consumers make informed decisions. CONCLUSION: This paper demonstrates that consumers' expectations and behaviour significantly impact pharmacists' perceptions of their professional responsibilities with respect to NHPs.

Integrative medicine: a tale of two clinics.

BACKGROUND: Integrative medicine (blending the best of complementary and alternative medicine (CAM) with conventional medicine) is becoming increasingly popular. OBJECTIVES: The objectives of this paper are to compare and contrast the development of two teams that set out to establish integrative medical clinics, highlighting key issues found to be common to both settings, and to identify factors that appear to be necessary for integration to occur. METHODS: At St Michael's Hospital (an inner-city teaching hospital in Toronto, Canada), a total of 42 interviews were conducted between February 2004 and August 2006 wi18 key participants (4 administrators, 2 chiropractors, 2 physiotherapists and 10 family physicians). At the CARE (Complementary and Alternative Research and Education) Program at Stollery Children's Hospital, Edmonton, Canada, 44 interviews were conducted with 24 people on four occasions: June 2004, March 2005, November 2006, and June 2007. Basic content analysis was used to identify the key themes from the transcribed interviews. RESULTS: Despite the contextual differences between the two programs, a striking number of similar themes emerged from the data. The five most important shared themes were: 1) the necessity of "champions" and institutional facilitators to conceive of, advocate for, and bring the programs to fruition; 2) the credibility of these champions and facilitators (and the credibility of the program being established) was key to the acceptance and growth of the program in each setting; 3) the ability to find the "right" practitioners and staff to establish the integrative team was crucial to each program's ultimate success; 4) the importance of trust (both the trustworthiness of the developing program as well as the trust that developed between the practitioners in the integrative team); and 5) the challenge of finding physical space to house the programs. CONCLUSION: The programs were ultimately successful because of the credibility of the champions, institutional facilitators and the staff members. Selection of excellent clinicians who were able to work well as a team facilitated the establishment of trust both within the team itself as well as between the team and the host institution.

A systematic review of natural health product treatment for vitiligo.

BACKGROUND: Vitiligo is a hypopigmentation disorder affecting 1 to 4% of the world population. Fifty percent of cases appear before the age of 20 years old, and the disfigurement results in psychiatric morbidity in 16 to 35% of those affected. METHODS: Our objective was to complete a comprehensive, systematic review of the published scientific literature to identify natural health products (NHP) such as vitamins, herbs and other supplements that may have efficacy in the treatment of vitiligo. We searched eight databases including MEDLINE and EMBASE for vitiligo, leucoderma, and various NHP terms. Prospective controlled clinical human trials were identified and assessed for quality. RESULTS: Fifteen clinical trials were identified, and organized into four categories based on the NHP used for treatment. 1) L-phenylalanine monotherapy was assessed in one trial, and as an adjuvant to phototherapy in three trials. All reported beneficial effects. 2) Three clinical trials utilized different traditional Chinese medicine products. Although each traditional Chinese medicine trial reported benefit in the active groups, the quality of the trials was poor. 3) Six trials investigated the use of plants in the treatment of vitiligo, four using plants as photosensitizing agents. The studies provide weak evidence that photosensitizing plants can be effective in conjunction with phototherapy, and moderate evidence that Ginkgo biloba monotherapy can be useful for vitiligo. 4) Two clinical trials investigated the use of vitamins in the therapy of vitiligo. One tested oral cobalamin with folic acid, and found no significant improvement over control. Another trial combined vitamin E with phototherapy and reported significantly better repigmentation over phototherapy only. It was not possible to pool the data from any studies for meta-analytic purposes due to the wide difference in outcome measures and poor quality ofreporting. CONCLUSION: Reports investigating the efficacy of NHPs for vitiligo exist, but are of poor methodological quality and contain significant reporting flaws. L-phenylalanine used with phototherapy, and oral Ginkgo biloba as monotherapy show promise and warrant further investigation.

Becoming the best mom that I can: women's experiences of managing depression during pregnancy--a qualitative study.

BACKGROUND: The purpose of this constructivist grounded theory study was to develop a theoretical model that explains women's processes of managing diagnosed depression when pregnant. METHODS: We explored the experiences of 19 women in Ontario who were diagnosed with depression during their pregnancy. RESULTS: The model that emerged from the analysis was becoming the best mom that I can. Becoming the best mom that I can explains the complex process of the women's journey as they travel from the depths of despair, where the depression is perceived to threaten their pregnancy and their ability to care for the coming baby, to arrive at knowing the self and being in a better place. In order to reground the self and regain control of their lives, the women had to recognize the problem, overcome shame and embarrassment, identify an understanding healthcare provider, and consider the consequences of the depression and its management. When confronting and confining the threat of depression, the women employed strategies of overcoming barriers, gaining knowledge, and taking control. As a result of counseling, medication, or a combination of both, women felt that they had arrived at a better place. CONCLUSION: For many women, the idea that depression could occur during pregnancy was antithetical to their vision of the pregnant self. The challenge for a pregnant woman who is diagnosed with depression, is that effective care for her may jeopardize her baby's future health. This provides a dilemma for about-to-be parents and their healthcare providers. Improved awareness of depression during pregnancy on the part of healthcare professionals is needed to improve the women's understanding of this disorder and their ability to recognize and seek help with depression should it occur during the prenatal period. Further qualitative research is needed to determine the specific aspects that need to be addressed in such classes.

Natural health product labels: is more information always better?

OBJECTIVE: To explore how the information provided on labels as mandated by the new Canadian natural health product (NHP) regulations impacts consumers' perceptions of risks associated with using NHPs. METHODS: Six focus groups were conducted in three locations across Ontario. Consumers were asked to react to two labels for a fictitious product called Saturnflower that represented the "old" standards (label 1) and the new standards (label 2). Groups were audio-taped and transcribed verbatim. Qualitative content analysis was used to identify key themes. RESULTS: The 38 participants criticized label 1 for lacking information about the uses of the product and discussed their frustration at trying to obtain good quality information about NHPs. The lack of risk information on label 1 reinforced their perceptions of NHPs as natural, mild and safe. The majority of participants found label 2 much more informative, but a few were unsettled by the extent of the risk information, questioning if it was necessary. CONCLUSION: The label requirements of the new NHP regulations were generally viewed positively by the consumers who participated in this study. PRACTICE IMPLICATIONS: The additional risk information may generate more NHP-related questions for health care practitioners especially with respect to possible interactions between NHPs and conventional medicines.

Community identification of natural health product-drug interactions.

BACKGROUND: The majority of Canadians use natural health products (NHPs), most of which are purchased in pharmacies. Community pharmacists regularly field inquiries regarding NHPs. As such, pharmacists are ideally placed to answer questions about NHP use and interactions with other medications. OBJECTIVE: To identify community pharmacists' familiarity with NHPs and NHP-related adverse events (AEs) and their knowledge and ability to counsel on potential and known NHP-drug interactions. METHODS: Survey questions were derived from a literature review of previous surveys, data collected from Health Canada, and in consultation with clinicians, pharmacists, policy-makers, and researchers. A convenience sample of 321 community pharmacists in Alberta and British Columbia were asked to participate. RESULTS: We received responses from 132 pharmacists, resulting in a response rate of 41% (132/321). A total of 19% of the sample had previously reported an adverse event to Health Canada. When asked specifically about NHP-drug interactions/AEs, 47% of pharmacists stated that they had identified a potential interaction; however, only 2 of these reported it to Health Canada. Pharmacists were most familiar (76% of respondents) with the interaction between sertraline and St. John's wort and were least familiar with interactions between NHPs and anti-retrovirals. CONCLUSIONS: This survey provides evidence to suggest that pharmacists encounter reportable NHP-drug interactions, yet rarely choose to report these events. The current lack of available data on NHP AEs makes it difficult to provide patients and healthcare providers with useful strategies for managing AEs and drug interactions. Changes to the current system of monitoring AEs due to NHPs and further education of healthcare professionals regarding NHP-drug interactions is required.

Trends in complementary/alternative medicine use by breast cancer survivors: comparing survey data from 1998 and 2005.

BACKGROUND: Use of complementary and alternative medicine (CAM) by women with breast cancer is often said to be increasing, yet few data exist to confirm this commonly held belief. The purpose of this paper is to compare overall patterns of CAM use, as well as use of specific products and therapies at two different points in time (1998 vs 2005) by women diagnosed with breast cancer. METHODS: Surveys were mailed to women randomly selected from the Ontario Cancer Registry (Canada) in the spring of 1998 (n = 557) and again in the spring of 2005(n = 877). RESULTS: The response rates were 76.3% in 1998 and 63% in 2005. In 1998, 66.7% of women reported using either a CAM product/therapy or seeing a CAM therapist at some time in their lives as compared with 81.9% in 2005 (p = 0.0002). Increases were seen in both use of CAM products/therapies (62% in 1998 vs. 70.6% in 2005) and visits to CAM practitioners (39.4% of respondents in 1998 vs 57.4% of respondents in 2005). Women in 2005 reported that 41% used CAM for treating their breast cancer. The most commonly used products and practitioners for treating breast cancer as reported in 2005 were green tea, vitamin E, flaxseed, vitamin C, massage therapists and dietitians/nutritionists. CONCLUSION: CAM use (both self-medication with products and visits to CAM practitioners) increased significantly from 1998 to 2005. Now that more than 80% of all women with breast cancer report using CAM (41% in a specific attempt to management their breast cancer), CAM use can no longer be regarded as an "alternative" or unusual approach to managing breast cancer.

The scope of naturopathic medicine in Canada: an emerging profession.

In Canada, naturopathic medicine is an emerging profession that is gaining formal recognition, including provincial/territorial regulation. While naturopathic medicine has undergone significant growth and legitimization, it still faces substantial challenges to acceptance as a full-fledged health care profession within the Canadian health care system. For example, professionalization theories indicate the importance of clear professional boundaries as well as the need for 'new' groups to find a place in the system of professions. This has been problematic for naturopathic practitioners who continue to practice within a broad scope of practice that encompasses many different therapeutic modalities. Development of statutory regulation also requires delineation of a specific, well-defined scope of practice. The purpose of this study was to describe naturopathic practitioners' perception of their training and their current scope of practice. Two thirds (n = 315) of all licensed Canadian naturopathic practitioners responded to the survey. The results showed that naturopathic practitioners are trained in, and practice, a wide range of therapeutic modalities and diagnostic procedures. Practitioners disagreed about their scope of practice, as 57% thought it was too restrictive, 31% felt it was about right and 13% thought it was too broad. A large majority felt there was some or a great deal of overlap with other practitioners' scope of practice. We conclude that multiple challenges are facing naturopathic medicine, including scope of practice, overlap with other professions, social closure, scarcity of vacancies and lack of cohesion. The future of naturopathic medicine will depend on how effectively the profession will use available strategies to overcome barriers to statutory self-regulation.

Complementary and alternative medicine: a rising healthcare issue.

More than half of all Canadians use some form of complementary and alternative medicine (CAM) every year. The way CAM is being used, the magnitude of its use and the lack of clarity on standards of evidence make CAM a rising healthcare issue. A recent research priority-setting exercise by the Canadian Interdisciplinary Network for CAM Research (IN-CAM) identified three research priority areas: (1) healthcare delivery and policy research, including (a) exploring if and how CAM should be regulated, (b) defining what constitutes acceptable evidence of safety and efficacy, (c) investigating the organization and delivery of integrative healthcare; (2) methodological research, including exploring how best to assess whole systems of care and how to choose patient-, practitioner- and policy-relevant outcome measures; and (3) knowledge transfer, including formal education strategies, the provision of information and dialogue with those who use information in decision-making. The high use of CAM products and therapies leads to many questions from patients, practitioners and policy makers. The research agenda presented here provides a guide to begin programs of research that will answer these questions.

Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: a systematic review.

PURPOSE: To conduct a systematic review of reasons for and sociodemographic and disease characteristics associated with complementary and alternative medicine (CAM) use in cancer patients. METHODS: Eligible studies were identified by searching the following databases: Alt Health Watch, AMED, CINAHL, CancerLit, PremMEDLINE, MEDLINE, Pub-Med, Ingenta, EMBASE, and Health Star, as well as reference lists in review articles. Only English-language articles published between 1994 and 2004 were included. Search terms included CAM and oncology/cancer, decision making and CAM and oncology/cancer, treatment decision making and CAM and oncology/cancer, and health care choices and CAM and oncology/cancer. RESULTS: Fifty-two eligible studies were identified and summarized. These studies were conducted in 14 different countries, with the largest number of studies being completed in the United States (34.6%). A therapeutic response, wanting control, a strong belief in CAM, CAM as a last resort, and finding hope were the most commonly cited reasons for using CAM. Age, socioeconomic status, and gender were the dominant characteristics associated with CAM use. CONCLUSION: Reasons for and characteristics associated with CAM use among cancer patients have been studied extensively. Future CAM research among cancer patients should focus on identifying decision-making processes and building theoretical decision-making models. These can be used in the development of decisional aids for patients when confronted with the choice to use CAM as part of their cancer treatment.

Practice patterns of naturopathic physicians: results from a random survey of licensed practitioners in two US States.

BACKGROUND: Despite the growing use of complementary and alternative medicine (CAM) by consumers in the U.S., little is known about the practice of CAM providers. The objective of this study was to describe and compare the practice patterns of naturopathic physicians in Washington State and Connecticut. METHODS: Telephone interviews were conducted with state-wide random samples of licensed naturopathic physicians and data were collected on consecutive patient visits in 1998 and 1999. The main outcome measures were: Sociodemographic, training and practice characteristics of naturopathic physicians; and demographics, reasons for visit, types of treatments, payment source and visit duration for patients. RESULT: One hundred and seventy practitioners were interviewed and 99 recorded data on a total of 1817 patient visits. Naturopathic physicians in Washington and Connecticut had similar demographic and practice characteristics. Both the practitioners and their patients were primarily White and female. Almost 75% of all naturopathic visits were for chronic complaints, most frequently fatigue, headache, and back symptoms. Complete blood counts, serum chemistries, lipids panels and stool analyses were ordered for 4% to 10% of visits. All other diagnostic tests were ordered less frequently. The most commonly prescribed naturopathic therapeutics were: botanical medicines (51% of visits in Connecticut, 43% in Washington), vitamins (41% and 43%), minerals (35% and 39%), homeopathy (29% and 19%) and allergy treatments (11% and 13%). The mean visit length was about 40 minutes. Approximately half the visits were paid directly by the patient. CONCLUSION: This study provides information that will help other health care providers, patients and policy makers better understand the nature of naturopathic care.