The natural medicine workforce in Australia: a national survey part 2.
The Australian Traditional Medicine Society Research Committee sought collaboration with all Australian professional associations to undertake a survey of the natural medicine workforce. Natural medicine professional associations were identified using information from previous surveys, online telephone directories (www.whitepages.com.au and www.yellowpages.com.au), and through the associations listed on the webpage www.naturaltherapies.com.au. Sixteen associations elected to participate in the survey (see JATMS 19(1): 13-18).
An email was sent by participating professional associations inviting members to take an online Qualtrics survey. A total of 14174 natural medicine practitioners were invited to participate. The ATMS Research Committee offered all participants the chance to be in a draw for an iPad. The winner was selected using an electronic random number generator. Data analysis was conducted using Excel and SPSS.
A total of 3784 responses were received between 7 September 2012 and 8 January 2013. After blanks, duplicates, incomplete surveys, and surveys from participants not residing in Australia had been discounted 3177 (22.4%) responses remained for analysis. Due to missing data points, the total sample size for some questions may be different.
Primary disciplines were clustered into five main categories:
* Registered professions including medicine, osteopathy, chiropractic, acupuncture and Chinese medicine, podiatry and psychology
* Physical medicine including massage and bodywork therapies in all their forms (e.g. Swedish massage, remedial massage, aromatherapy massage, reflexology, kinesiology, Shiatsu, traditional Chinese massage, deep tissue massage therapy)
* Ingestive medicine including Western herbal medicine, vitamins and minerals, nutritional supplements, aromatherapy products, and Ayurvedic and other traditional medicines
* Energetic or vibrational medicine including Bach flower remedies, Australian bush flower remedies and homoeopathy
* Mind-body medicine including cognitive behaviour therapy, counselling, hypnotherapy, meditation, guided imagery, hypnosis, biofeedback and spiritual healing
The results are presented in two parts:
Part 1--practitioner and consultation profile (see JATMS 19(1): 13-18)
Part 2--ABN and GST status, professional association membership, professional indemnity insurance, adverse reactions, practitioner education, and referral patterns (presented in this paper).
AUSTRALIAN BUSINESS NUMBER (ABN), GOODS AND SERVICES TAX (GST) STATUS, PROFESSIONAL INDEMNITY INSURANCE AND PROFESSIONAL ASSOCIATION MEMBERSHIP
Most respondents (75%) reported having an ABN, 5% reported not having an ABN and 20% did not answer the question. Only 23% reported being registered for GST; 57% were not registered and 20% did not answer the question. Most respondents (87%) reported having professional indemnity insurance, 1% reported not having it and 12% did not answer the question. Of the 2886 respondents who answered the question, 65% (n=1874) reported being a member of one association only, 26% (n=752) were members of two associations, 6% (n=186) were members of three associations and 2% (n=64) were members of four or more associations.
In the last 12 months 8% of respondents reported suspecting that an adverse reaction may have occurred while they treated a client. Ingestive medicine practitioners (19%) and registered professionals (13%) reported the highest incidence of suspected adverse reactions in their clients; mind-body medicine practitioners (5%) and physical medicine therapists (4%) suspected the least incidence.
Of the 215 cases of suspected adverse reactions reported, 21 (9.8%) needed to see a medical practitioner about their adverse reaction. Only six (2.8%) of those cases were reported to the Therapeutic Goods Administration (see Tables 1 and 2). Types of suspected reactions included skin reactions, bruising, digestive dysfunction, panic attacks and a broken wrist.
EDUCATION OF NATURAL MEDICINE PRACTITIONERS
Participants were asked about their main qualifications in natural medicine. Of the 2775 who answered the question, 41% (1147) had a Diploma level qualification in natural medicine, 10% (276) had a Certificate and 11% (9316) had an Advanced Diploma. Fourteen percent (399) had completed a Bachelor's degree in natural medicine and 1% (28) held a post-graduate qualification (see Figure 1).
The main education providers of natural medicine were private colleges (81%). Eleven percent of respondents reported receiving their natural medicine qualification from a university, 4% from a TAFE and 4% from a private teacher. Participants were asked how well their main qualification in natural medicine had prepared them for clinical practice. Most (95%) respondents were satisfied with the preparation for practice provided by their natural medicine education: 22% said they were adequately prepared, 42% said they were quite well and 31% said they were extremely well prepared for clinical practice. These results were relatively consistent when analysed by discipline cluster.
Participants made suggestions as to how their education in natural medicine could be improved. Twenty four percent of those who responded thought that no improvements were necessary. Suggestions for improving natural medicine education included more business management skills (30%), more theoretical training (19%) and more clinical experience (11%).
Participants were asked to rate how well their natural medicine education had prepared them for working with health practitioners other than natural medicine practitioners: 31% said they were adequately prepared, 34% said they were quite well prepared and 15% said they were extremely well prepared.
According to participants, their main sources of clinical information were professional association newsletters, magazines or journals (66%), professional association conferences (63%), academic textbooks (52%) and internet sources (52%). Only 25% of respondents reported using peer-reviewed journals as a source of clinical information (see Table 3). Analysis by discipline group revealed that ingestive medicine practitioners and physical medicine practitioners reported higher use of all sources of clinical information than other practitioner groups (see Table 4).
Most natural medicine practitioners (86%) reported having completed 20 or more hours of continuing professional education in the past 12 months. Thirteen percent reported having completed in excess of 80 hours of continuing professional education in the past year.
Forty-eight percent of practitioners reported occasionally referring clients to general medical practitioners for medical diagnostic tests (e.g. blood tests, X-rays), 21% reported referring frequently and 3% reported referring very frequently/ always. Seventeen percent said they rarely referred clients to general medical practitioners and 11% said they never referred patients to them. When cross-tabulations were performed, differences between discipline groups were apparent: 55% of mind-body medicine practitioners, for example, reported rarely, very rarely or never referring clients to general practitioners for medical diagnostic tests. Ingestive medicine practitioners reported the highest rates of referral to general medical practitioners (43% frequently, and 8% very frequently/always).
Respondents were also asked about referring clients for functional pathology tests like live blood analysis and hair analysis. Forty eight percent reported occasionally referring, 21% reported frequently referring, and 3% reported that they very frequently/always referred clients for functional tests. When analysed by discipline groups, registered professionals and ingestive medicine practitioners were the highest referrers for functional pathology tests.
Seventy-two percent of respondents (n=2513) reported using mainstream medical diagnostic tests (e.g. reading blood test or X-ray reports) to inform their assessment of clients: 48% said they used medical diagnostic tests occasionally, 21% said frequently and 3% reported very frequently/always. As Figure 2 illustrates, overall practitioners use medical diagnostic tests to inform their clinical practice at the same rate as they refer clients for diagnostic tests. The referral rates to medical diagnostic tests occur at about the same as referral to functional pathology tests.
Forty-eight percent of respondents reported occasionally seeing clients who were referred to them by other health practitioners; 21% reported that they received these referrals frequently, and 3% reported very frequently/always. Referral rates were high across all disciplines: highest for ingestive medicine practitioners (90%) and registered professionals (87%) and lowest for mind-body medicine practitioners (48%) (see Table 5).
Respondents were asked about how frequently they collaborated with another health practitioner to discuss treatment options for a client: 28% reported never/very rarely or rarely; 48% reported occasionally, 21% reported frequently and 3% reported very frequently/always collaborating with another health practitioner. Ingestive medicine practitioners (90%) and registered professionals (85%) reported the highest rates of collaboration (see Table 6).
Respondents were asked to identify they type of health practitioner with whom they had collaborated. A limitation of the study was observed when analysing the open responses to this question. It was apparent from many of the responses that collaborate was interpreted as have professional contact with. Figure 3 represents the type of health practitioners that natural medicine practitioners reported referring to, receiving referrals from, treating clients simultaneously with, and collaborating with regarding clinical decisions. Collaborations were reported at about the same rate for other natural medicine practitioners and allied health practitioners (38% and 37%), and at 25% for medical practitioners.
When analysed by discipline cluster, practitioners of energetic and mind-body medicine reported the highest rates of collaboratin with other natural medicine practitioners (45% and 50% respectively); ingestive medicine practitioners and registered professionals reported the highest rate of collaborations with medical practitioners (32% and 30% respectively).
Issues of safety and efficacy have dominated the natural medicine literature. Safety indicators include adverse drug reactions, medication allergies, and patient safety incident investigations. (Australian Commission on Safety and Quality in Health Care, 2012). A survey of Australian naturopaths and Western herbal medicine practitioners in 2002 reported a substantial number of adverse events associated with herbal medicines, nutritional substances and homoeopathic medicines in Australia. According to this survey practitioners were likely to experience one adverse event every 11 months of full-time practice, with 2.3 adverse events for every 1000 consultations (excluding mild gastrointestinal effects) (A. Bensoussan, S. Myers, S. Wu, & K. O'Connor, 2004). However, a survey by Hale (2002) at the same time found that the reported adverse reactions were of a minor nature, and that recent graduates may be more inclined to medicalise client reactions, suggesting changing perceptions about what constitutes an adverse reaction. In the present study 8% of respondents reported suspecting that an adverse reaction may have occurred while treating a client. It appears that many reactions may have been minor as only 10% of the suspected cases needed to see a medical practitioner. Safety concerns for interactions between natural medicines and prescription medication also exist and are not reported here. Information about natural medicine interactions with prescribed medications has become increasingly available through an increasing number of case reports, independent research and web-based resources, making interactions largely predictable and therefore preventable (Moses, 2010).
Forty-three percent of respondents of Hale's (2002) survey of acupuncturists, naturopaths and Western herbal medicine practitioners had four years of educational training and 10.5% of respondents had completed a Bachelor degree in complementary medicine. In the current survey, more than 10 years later, the number of respondents with a Bachelor degree was 14%; another 1% had a post-graduate qualification. In recent years, a number of courses have been removed from university settings (e.g. naturopathy and osteopathy at the University of Western Sydney and herbal medicine at the University of Sydney). Concern has been raised that removing these programs may 'decrease the educational rigour of these courses, to the detriment of patients' (Myers, Xue, & Cohen, 2012).
Naturopaths and Western herbal medicine practitioners who participated in the survey conducted by Bensoussan et al. (2004) reported that the duration of undergraduate or first herbal or naturopathic qualifications for practitioners ranged from six months to six years, with an average of 3.1 years. The majority of practitioners reported being adequately or well prepared for practice, although 22% felt that they were poorly prepared in clinical training. Participation in continuing education in naturopathy or herbal medicine was reported by 89% of the workforce. Similar satisfaction with natural medicine education and high participation rates in continuing professional education were reported in the present survey, which also included registered professionals, mind-body medicine practitioners and physical therapists.
A Singaporean study of doctors, registered nurses, physiotherapists and occupational therapists found that participants did not refer patients for complementary and alternative medicine (CAM) because of lack of personal knowledge on the subject (53.4%); not knowing a suitable complementary practitioner (29.0%); and not thinking it was necessary (14.6%) (Wong, Toh, & Kong, 2010). The main reasons for referring were patients' preferences (58.0%); efficacy of complementary medicine for specific conditions (39.1%); and other treatment modalities proving unsuccessful (21.9%). Other researchers found that positive attitudes toward CAM did not correlate with CAM referral or prescription patterns (Sewitch, Cepoiu, Rigillo, & Sproule, 2008). The researchers concluded that further education about CAM to health care professionals may help to integrate CAM into mainstream medical care. Greater communication, respect and co-operation among all health practitioners working in maternity care was needed to understand the dynamics that shape providers' decision to use or refer to complementary and alternative medicine in maternity care (Adams, Lui, Sibbritt, Broom, & Wardle, 2011). The present study found that more than a third of practitioners reported collaborating with allied health practitioners (37%) and also with natural medicine practitioners (37%); 25% reported collaborating with medical practitioners.
SUMMARY OF PART 2
The business profile of the natural medicine practitioners in this survey shows most (75%) having an ABN, 87% having professional indemnity insurance, but only 23% registered for GST. The sampling method meant that all respondents were members of professional associations; however 34% belonged to more than one association.
Suspected adverse reactions were reportedly 8% in the past 12 months. Of the 215 cases of suspected adverse reactions reported, 9% needed to see a medical practitioner about their adverse reaction. Fewer than 3% were reported to the Therapeutic Goods Administration.
The most commonly reported qualification in natural medicine was a diploma (41%), followed by a Bachelor degree (14%) and an Advanced Diploma (11%). Private colleges dominated the educational providers (81%) and almost all respondents (95%) were satisfied with the preparation for practice provided by their natural medicine education.
The extent to which natural medicine is integrated with mainstream health care may be indicated by referral patterns and collaborations among practitioners. Seventy-one percent of respondents were referring patients to general medical practitioners occasionally, frequently or very frequently. The same percentage of respondents also referred clients for functional pathology tests. Ingestive medicine practitioners and registered practitioners were the highest referrers. Overall, practitioners used medical diagnostic tests to inform their clinical practice at the same rate as they referred clients for diagnostic tests. Referrals to natural medicine practitioners were also reported at high rates (71% reporting occasionally, frequently or very frequently seeing clients who had been referred by other health practitioners). Highest rates were again reported by ingestive medical practitioners and registered practitioners.
Adams, J, Lui, Cw, Sibbritt, D, Broom, A, & Wardle, J. (2011). Attitudes and referral practices of maternity care professionals with regard to complementary and alternative medicine: An integrative review. Journal of Advanced Nursing, 67(3), 472-483.
Australian Commission on Safety and Quality in Health Care. (2012). Draft national set of practice-level indicators of safety and quality for primary health care. http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/Draft-national- practice-level-indicators-of-safety- andquality-for-primary-health-care.pdf
Bensoussan, A, Myers, Sp, Wu, Sm, & O'Connor, K. (2004). Naturopathic and Western herbal medicine practice in Australia-a workforce survey. Complementary Therapies in Medicine, 12(1), 17-27.
Hale, A. (2002). 2002 Survey of ATMS: acupuncturists, herbalists and naturopaths. Journal of the Australian Traditional Medicine Society, 8(4), 143-149.
Moses, G. (2010). Drug interactions with complementary medicines (Vol. 33, pp. 177-180): Australian Prescriber.
Myers, SP, Xue, CC, & Cohen, MM. (2012). The legitimacy of academic complementary medicine. Standing up for common sense. Medical Journal of Australia, 197(2), 69-70.
Sewitch, Mj, Cepoiu, M, Rigillo, N, & Sproule, D. (2008). A literature review of health care professional attitudes toward complementary and alternative medicine. Complementary Health Practice Review, 13(3), 139-154.
Wong, Ly, Toh, Mp, & Kong, Kh. (2010). Barriers to patient referral for Complementary and Alternative Medicines and its implications on interventions. Complementary Therapies in Medicine, 18(3-4), 135-142.
Grace S, Senior Lecturer, Southern Cross University; Rogers S, CEO, National College of Traditional Medicine; Eddey S, Principal, Health Schools Australia
TABLE 1: NEED TO SEE A MEDICAL PRACTITIONER ABOUT ADVERSE REACTION YES NO Energetic Medicine 4 (1,9%) 8 (3.7%) Ingestive Medicine 8 (3.7%) 102 (47.4%) Mind-Body Medicine 0 (0%) 2 (0.9%) Physical Medicine 8 (37%) 51 (23.7%) Registered 1 (0.5%) 20 (9.3%) Professional Total 21 (9.8%) 183 (85.1%) NOT ANSWERED TOTAL Energetic Medicine 1 (0.5%) 13 (6%) Ingestive Medicine 5 (2.3%) 115 (53.3%) Mind-Body Medicine 0 (0%) 2 (0.9%) Physical Medicine 4 (1.9%) 63 (29.3%) Registered 1 (0.5%) 22 (10.3%) Professional Total 11 (5.1%) 215 (100%) TABLE 2: REPORTING SUSPECTED ADVERSE REACTION TO THE THERAPEUTIC GOODS ADMINISTRATION YES NO Energetic Medicine 1 (0.5%) 7 (3.3%) Ingestive Medicine 5 (2.3%) 38 (17.7%) Mind-Body Medicine 0 (0%) 0 (0%) Physical Medicine 0 (0%) 5 (2.3%) Registered Professional 0 (0%) 3 (1.4%) Total 6 (2.8%) 53 (24.7%) NOT ANSWERED TOTAL Energetic Medicine 5 (2.3%) 13 (6%) Ingestive Medicine 72 (33.5%) 115 (53.3%) Mind-Body Medicine 2 (0.9%) 2 (0.9%) Physical Medicine 58 (27%) 63 (29.3%) Registered Professional 19 (8.8%) 22 (10.2%) Total 156 (72.6%) 215 (100%) TABLE 3: MAIN SOURCE OF CLINICAL INFORMATION (N=2506) Professional association newsletter/magazine/journal 1651 66% Professional association or conferences 1582 63% Academic textbooks 1298 52% Internet (World Wide Web, email) 1294 52% Professional Peers 898 36% Industry Conferences (Mediherb, Blackmores, etc) 728 29% Peer reviewed journals (e.g., Complementary 624 25% Therapies in Medicine, Lancet) Industry newsletters 536 21% Health magazines (e.g., Wellbeing, Nature and 371 15% Health, Diversit-e) General medical information (e.g., Australian 305 12% Doctor, Medscape, Health CDs/DVDs (e.g., Hyperhealth) Library database 169 7% Webinars/Seminars/CPD 130 5% General magazine or newspaper articles 99 4% Television or radio 69 3% TABLE 4: MAIN SOURCES OF CLINICAL INFORMATION BY DISCIPLINE GROUP Energetic Ingestive Mind-Body Medicine Medicine Medicine Professional association 10% 23% 2% newsletter/magazine/journal Industry conferences 6% 62% 1% Professional association 9% 21% 1% newsletter/magazine/journal Industry newsletters 6% 34% 1% Peer review journals 11% 40% 1% General Medical Information 7% 41% 2% Internet 9% 21% 1% Academic textbooks 9% 26% 1% General books from the 9% 17% 3% popular press Health magazines 7% 14% 1% General magazines or 8% 22% 3% newspaper articles Television or radio 13% 20% 3% Professional Peers 11% 19% 3% Library databases 11% 41% 2% Health CDs/DVDs 6% 26% 2% Webinars/Seminars/CPD 8% 3% 2% Physical Registered Medicine Profession Professional association 58% 7% newsletter/magazine/journal Industry conferences 24% 7% Professional association 63% 6% newsletter/magazine/journal Industry newsletters 55% 5% Peer review journals 35% 13% General Medical Information 40% 11% Internet 61% 7% Academic textbooks 55% 8% General books from the 66% 4% popular press Health magazines 75% 3% General magazines or 60% 7% newspaper articles Television or radio 55% 9% Professional Peers 61% 6% Library databases 36% 10% Health CDs/DVDs 63% 3% Webinars/Seminars/CPD 78 9% TABLE 5: REFERRAL RATES FROM OTHER HEALTH PRACTITIONERS NEVER/VERY RARELY RARELY OCCASIONALLY Energetic Medicine 14% 17% 45% Ingestive Medicine 3% 7% 39% Mind-Body Medicine 30% 23% 41% Physical Medicine 14% 22% 52% Registered Professional 14% 22% 52% Total 3% 11% 57% VERY FREQUENTLY/ FREQUENTLY ALWAYS Energetic Medicine 22% 2% Ingestive Medicine 43% 8% Mind-Body Medicine 7% 0% Physical Medicine 12% 1% Registered Professional 12% 1% Total 26% 4% TABLE 6: COLLABORATION WITH ANOTHER HEALTH PRACTITIONER TO DISCUSS TREATMENT OPTIONS FOR A CLIENT NEVER/VERY RARELY RARELY OCCASIONALLY Energetic Medicine 13% 17% 45% Ingestive Medicine 3% 7% 39% Mind-Body Medicine 30% 23% 41% Physical Medicine 14% 22% 52% Registered Professional 4% 11% 57% Total 11% 17% 48% VERY FREQUENTLY/ FREQUENTLY ALWAYS Energetic Medicine 22% 2% Ingestive Medicine 43% 8% Mind-Body Medicine 7% 0% Physical Medicine 12% 1% Registered Professional 25% 4% Total 21% 3%
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|Author:||Grace, S.; Roger, S.; Eddey, S.|
|Publication:||Journal of the Australian Traditional-Medicine Society|
|Date:||Jun 1, 2013|
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