The most interesting results of the present study are the striking difference in patient satisfaction and perception of side effects in conventional and homeopathic treatment. Our results confirm previous studies that show that patients of HP are more likely to be female, younger, to have a higher educational status, to suffer more often of chronic diseases, musculoskeletal problems, and mental disorders than patients of CP [4, 10, 11, 23]
To the best of our knowledge this study is the first using the Europep questionnaire to investigate patient satisfaction comparing homeopathy and conventional care. The most significant differences concern doctor-patient relationship and communication. This is the first time, differences in communication patterns between CP and HP were reported. However, some limitations are to be taken into account:
1. The questionnaire used in the present study was not designed specifically for the assessment of homeopathy. Although it allowed determination of the frequency and severity of patients' side effects, it could not give further detailed information. For example, no distinctions were made between side effects related to the pharmacological properties of drugs, adverse events not necessarily caused by drugs, complications arising from adverse events following invasive interventions, homeopathic aggravations, and adverse drug reactions, which were all grouped as one entity: side effects. Due to these limitations, the influence of side effects and homeopathic aggravations on patient's satisfaction rate could not be determined precisely.
2. A single assessment one month after consultation does not sufficiently distinguish long-term from short-term effects. This was due to the overall limitations of the PEK study protocols and to the follow-up questionnaire after one month.
3. Different demographic attributes and higher educational level of the CAM patient population, and a potential overrepresentation of patients and physicians who were interested and motivated in the study may have positively biased the results towards homeopathy .
4. It may be argued that patients who were treated by HP physicians who used in specific cases exclusively CP procedures are misclassified with reference to the study groups. The rationale of maintaining this classification is given by the design of the overall project aimed at physicians and not at specific treatment procedures. Furthermore, specific properties of homoeopathic consultations may have been maintained by physicians even if only conventional procedures were applied.
5. Compliance in completing questionnaires may differ between CP and HP depending on their different commitment to this field of research and between satisfied and not satisfied patients.
6. Low participation of physicians was a problem in this study as physicians perceived the entire project as a government initated, which led to reservations to be involved. Furthermore, it must be assumed that the motivation among participating physicians was different, since HP physicians were under pressure to demonstrate effective methods–which was not the case for CP physicians. It can only be speculated that the motivation of CP physicians is more attributable to a general interest in primary care research. The generalisability of our results is therefore reduced to physicians with these distinct motivations. Nevertheless, a comparison of the sample population with the general population of all Swiss primary care providers indicated no difference with reference to geographic location of practices and gender of physicians; clinical data of the project including patient perceived health status with regard to other recent research in Swiss primary care showed also no difference[25, 26]. Based on this additional information, we have no reason to consider our sample as well as our results as biased with regard to geographical distribution and gender of physicians or to health status of patients.
These findings reflect the fundamental differences between conventional and homeopathic medicine: in conventional care, a diagnosis is needed and specific problems are treated with specific procedures and medication. In homeopathy it is believed that the cause of all diseases is the disturbance of the person's life force, and all complaints are individual expressions of this. Accordingly, homeopathic treatment is based on all reported or observed symptoms of the patient's body and personality. Indeed, the physician can be lost without the patient's co-operation, because collection of characteristic symptoms is the central issue of choosing the optimal homeopathic remedy . This active role of the patient in both remedy-seeking process and healing process (taking responsibility for their health) may contribute to the positive assessment of the quality of communication and thoroughness by patients of HP [19, 28]. These patient- and physician-related factors may also be the reason for greater thoroughness reported by patients of HP.
Two factors may be related to the high degree of satisfaction with homeopathic treatment despite of lower degree of symptom relief compared to the CP group: 1) physician's empathy manifested in detailed and holistic approach of homeopathic case-taking and consultation [15, 29, 30] and 2) existence of so-called "effectiveness gaps", chronic conditions where conventional therapies are either not available or not effective and which are then overrepresented among patients of HP .
The high percentage of complete fulfilment of treatment expectation among HP patients seems to be a contradiction to the low percentage of symptoms resolution in the same patient group (Table 5). A possible explanation is that both patients and physicians in homeopathy may give priority to a holistic and person-centered treatment approach aimed to increase self-healing capacities of patients [32, 33]. These shared beliefs may also contribute to a better physician-patient communication and better patient satisfaction .
The other results of the Europep questionnaire showed less consistent answer patterns. However, with reference to emergency situations the question concerning "getting through to the practice on the telephone" was answered significantly more positively by patients of CP . We suggest therefore that homeopaths should improve their accessibility by telephone. Building networks of homeopathic practices is one possibility .
In order to better understand 1) reasons for differences in the patient satisfaction between CP and HP and 2) the association between side effects and the overall satisfaction, we would need a further in-depth analysis of more detailed and different set of questionnaires than used in the present study.