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Complementary Therapies in Medicine (2004) 12, 1727 Naturopathic and Western herbal medicine practice in Australiaa workforce survey

A. Bensoussana,*, S.P. Myersb, S.M. Wua, K. OConnora a The Centre for Complementary Medicine Research, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia b Australian Centre for Complementary Medicine Education and Research, a Joint Venture of the University of Queensland and Southern Cross University, Australia KEYWORDS Healthcare workforce; Complementary medicine; Herbalism; Naturopathy Summary Background: Despite substantial growth in the use ofcomplementary medicine, no comprehensive national study has been undertaken ofthe naturopathic and Western herbal medicine component ofthe healthcare workforce in Australia. This study aimed to examine the nature ofthese practices and this currently unregulated workforce in Australia. Methods: A comprehensive survey questionnaire was developed in consultation with the profession and distributed nationally to all members ofthe naturopathic and Western herbal medicine workforce. Results: The practices ofherbal medicine and naturopathy make up a sizeable component ofthe Australian healthcare sector, with approximately 1.9 million consultations annually and an estimated turnover of$AUD 85 million in consultations (excluding the cost of medicines). A large proportion ofpatients are referred to practitioners by word of mouth. Up to one third ofpractitioners work in multidisciplinary clinics with other registered sectors ofthe healthcare community. The number ofadverse events associated with herbal medicines, nutritional substances and homoeopathic medicines recorded in Australia is substantial and the types ofevents reported are not trivial. Data suggest that practitioners will experience one adverse event every 11 months of full-time practice, with 2.3 adverse events for every 1000 consultations (excluding mild gastrointestinal effects). Conclusion: These data confirm the considerable degree ofutilisation ofnaturopathic and Western herbal medicine practitioners by the Australian public. However, there is a need to examine whether statutory regulation ofpractitioners ofnaturopathy and Western herbal medicine is required to better protect the public. 2004 Elsevier Ltd. All rights reserved. Introduction A range ofcomplementary and alternative medicine (CAM) practices are being increasingly used by the Australian public.1 Aromatherapy and Tra*Corresponding author. E-mail address: a.bensoussan@uws.edu.au (A. Bensoussan). ditional Chinese Medicine (TCM) have exhibited steady growth, whilst the gros been undertaken 0965-2299/$ see front matter 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2004.01.001 18 A. Bensoussan et al. ofthe naturopathic and Western herbal medicine component ofthe healthcare workforce, which remains unregulated by government. The purpose ofthis study was to commence to map the practice ofnaturopathy and Western herbal medicine, in particular the characteristics of its workforce. Data were collected from practitioners

ofnaturopathy and Western herbal medicine, including basic demographics, consultation fees, patient management and referral processes, private health fund rebate status, level of utilisation ofW estern medical diagnosis, nature and standards ofeducation, compliance with current regulations, including prescribing/dispensing ofdrugs and poisons, adverse events, level ofsupport for a system ofunif orm national accreditation, and extent and type ofmembership ofprof essional associations. Methods In order to undertake a national survey ofpractitioners across various representative professional associations collaboration was sought with a major health insurance provider. Grand United Health Fund (GUHF) was one ofthe first insurers to provide benefits to its members for CAM services, and it holds a comprehensive national database ofpractitioners. This method overcame a number ofdif ficulties, including: extensive overlap in membership lists across the various principal professional associations; anticipated reluctance by some professional associations to the establishment ofa shared central mailing list; absence of incentives for professional associations to encourage participation by their members, due in part to competition between the peak professional associations, and the potential for bias associated with individual professional associations commissioning surveys ofonly their own members. The practitioner provider list held by GUHF was revised and, where possible, updated with membership lists provided by relevant professional associations. Four provider categories were available on GUHF lists: herbalists, naturopaths, homoeopaths and nutritionists. As education in naturopathy generally includes nutritional medicine and homoeopathic medicine the potential to miss naturopaths that had chosen to act as specialists in a single therapeutic modality was possible and a decision was made to survey homoeopaths and nutritionists. The survey was only interested in these practitioners ifthey also practised as naturopaths, or iftheir practices incorporated at least two naturopathic modalities (herbal medicine, nutritional medicine, homoeopathic medicine and tactile therapies). GUHF undertook a direc workforce. The survey instrument was piloted with a sample of13 practitioners in NSW, and modified in response to feedback from this pilot. The survey required no practitioner identifying data, and included an accompanying explanatory letter and a reply-paid envelope. The survey instrument was computer generated into an electronically scannable format to facilitate and increase accuracy ofdata entry. Hence, with the exception ofseveral items that required

written responses, all data entry were undertaken electronically. In all cases data entry was supervised and checked by two authors (A.B., S.W.). The Human Ethics Committee, University ofW estern Sydney, granted ethics approval for the study. Results Response rate In total, 3540 survey forms were mailed out to practitioners. Ofthese, 423 surveys were returned to sender and the practitioners could not be contacted to resend the survey. This left an effective mailing list of3117 practitioners. Verbal reports suggested that a number ofpractitioners, despite being on professional association mailing lists, were not currently in practice. In order to check the accuracy ofthe mailing list, 100 names were randomly selected (after returns to sender had been excluded), and efforts were made to make direct telephone contact with these practitioners. Phone numbers were checked with professional association listings, and telephone directories. Over a 2-week period ofcontinuous attempted contact (including at least five attempted calls during day, night and weekends), 76 were contacted: 73 (96%) were currently practising, and 3 (4%) were no longer practising. Ofthe remaining practitioners who could not be contacted (24), it was assumed that halfwere not practising. Therefore, out of 3117 practitioners on the mailing list it has been assumed that a total of16% are not currently in practice. This generates an active mailing list of Naturopathic and Western herbal medicine practice in Australiaa workforce survey 19 2618 practitioners. The survey responses totalled 859providing an initial response rate of33%. This initial response rate is considered to be artificially low as a product ofthe inclusive enrolment strategy undertaken, where surveys were sent to homoeopaths and nutritional practitioners who may not be naturopaths or Western herbalists. Accordingly, an adjusted response rate was calculated which compensates for the over inclusive enrolment. During analysis ofthe data, practitioners who indicated they practised only as homoeopaths, nutritionists or massage therapists were removed from the final database (64 cases). An adjusted response rate was calculated for comparison, with these cases removed from the final database (numerator), and with the remaining number ofhomoeopaths and nutritionists who were sent a survey form removed from the initial mailout count (denominator). An effective mailing list of 1778 herbalists and naturopaths was generated, which allowed for 16% not in practice. Calculated on 795 responses, the adjusted response rate was 45%. This response rate is similar to the response rate obtained for the workforce survey of TCM

practitioners.2 The overall response rate was deemed adequate for analysis, and the database which has been established is regarded by the researchers as accurate for the purposes of drawing conclusions about the Australian naturopathic and Western herbal medicine workforce. Nature of practice Practitioners were asked which ofa series oftitles best describes their practice: 489 practitioners (62%) identified herbalism as one oftheir practice descriptors. 604 practitioners (76%) identified naturopathy as one oftheir practice descriptors. 54 respondents were also members ofconventional and registered health professions: 3 were qualified medical specialists, 12 were general Table 2 Mean percentage (with standard deviation) ofpractice time estimated by practitioners to be devoted to herbal medicine, homoeopathy, nutritional medicine, massage and tactile therapies, and others (including include iridology and aromatherapy) by herbalists, naturopaths and all practitioners. Practice devoted to Herbalists (489) Naturopaths (604) Total (795) Herbal medicine 53.1 27.1 43.7 25.6 46.7 27.3 Homoeopathy 22.4 23.7 24.6 23.8 26.2 26.4 Nutritional medicine 41.7 26.0 42.5 25.7 41.6 25.9 Massage and tactile therapies 28.9 24.5 31.0 24.1 31.6 25.4 Other 37.5 27.9 36.0 27.0 38.6 28.2 Table 1 Titles selected by respondents to describe their practices. Nature ofpractice Number (N = 795) (%) Herbalist 489 (61.5) Naturopath 604 (76.0) Homoeopath 208 (26.2) Nutritionist 315 (39.6) Massage therapist 277 (34.8) Aromatherapist 32 (4.0) Bach flowers practitioner 175 (22.0) Meditation/relaxation (including yoga, qi gong) 50 (6.3) Medical specialist 3 (0.4) General medical practitioner 12 (1.5) Pharmacist 10 (1.3) Chiropractor 6 (0.8) Osteopath 9 (1.1) Physiotherapist 1 (0.1) Nurse 28 (3.5) Counsellor 59 (7.4) Psychologist 5 (0.6) Traditional Chinese Medicine practitioner 20 (2.5) Acupuncturist 41 (5.2) Other 141 (17.7) Missing 11 (1.4)

medical practitioners, 10 were pharmacists, 28 were nurses and 1 was a physiotherapist. Table 1 summarises the descriptors selected by respondents to describe their practices and the range ofallied health practitioners using one or a number ofmodalities included in naturopathic practice. Most practitioners (76%) identified more than one title to describe their practice. Additional titles selected by herbalists and naturopaths are also summarised in Table 2. This indicates the extent to which these professions overlap in the modalities practised, with naturopaths, including herbal medicine, in their practice up to 44% ofthe time, 20 A. Bensoussan et al. Figure 1 Number ofpractitioners by State, country or metropolitan location. and herbalists regularly practising both homoeopathy and nutritional medicines. The average (mean) age ofthe naturopathic and Western herbal workforce was 44 years (S.D. 10.4 years). Females made up 76% ofthe workforce. Distribution ofpractitioners by State is summarised in Fig. 1. Approximately twice the number ofpractitioners surveyed practise in metropolitan compared with country regions in Australia. However, almost one third of practitioners have two or more different practice locations. Practitioners on average undertake 22 naturopathic or herbal medicine consultations per week, although this figure varied enormously from only one consultation per week to 250 consultations. Hours spent in clinical practice, and duration of initial and follow-up consultations are reported in Table 3. Table 3 Average (mean) hours in practice per week, with duration (in minutes) ofinitial and follow-up consultations (standard deviations in brackets). Total Hours spent in clinical practice per week 23.8 13.3 Face-to-face contactinitial consultation (min) 23.0 5.8 Face-to-face contactfollow-up consultation (min) 13.4 6.3 The mean number ofconsultations per year for naturopathic and Western herbal medicine practitioners has been calculated by multiplying consultations per week for these groups by 48 weeks. This figure has been used to estimate the total consultations per year provided by the naturopathic and Western herbal medicine workforce (mean total yearly consultations multiplied by estimated number ofpractitioners). The workforce as a whole is expected to undertake approximately 1,900,980

consultations in 2003. This figure is consistent with recent estimates made through population surveys.1 Diagnostic tests used by practitioners Practitioners were asked to respond to two questions regarding their use ofW estern medical tests to guide clinical practice. Western diagnostic tests, such as pathology, radiology, etc. (either self-initiated or provided by patients or colleagues), were used by 38% ofall practitioners to guide their clinical practice 50% or more ofthe time. A further 48% of them claimed to use diagnostic tests occasionally. Forty-seven percent ofpractitioners reported that they used Western medical diagnoses to guide their naturopathic or herbal medicine treatments in 50% or more ofpatient cases. A further 45% claimed to use Western medical diagnoses occasionally. Sixty-two percent perform physical examination assessments. Naturopathic and Western herbal medicine practice in Australiaa workforce survey 21 Table 4 Numbers and percentages (in brackets) of practitioners using various diagnostic tools or methods in their practices. Diagnostic tools or methods Total (N = 795) Pathological testing Functional pathology (e.g. salivary tests, stool analysis) 177 (22.3) Hair testing 172 (21.6) Traditional testing Iris diagnosis 641 (80.6) Tongue diagnosis 454 (57.1) Oriental diagnosis 68 (8.6) Face diagnosis 130 (16.4) Alternative testing Electro-dermal screening (e.g. LISTEN, Vega) 94 (11.8) Muscle testing 160 (20.1) Haemaview/live blood analysis 95 (11.9) Physical examination (BP, auscultation, palpation, etc.) 493 (62.0) Other 172 (21.6) Missing 14 (1.8) The use oftraditional naturopathic diagnostic techniques was high with 81% ofpractitioners indicating they used iris diagnosis in their practices. The use ofthese diagnostic tools or methods in clinical practice is reported in Table 4. Form and labelling of preparations Whilst nutritional medicines are generally prepared and provided as over-the-counter commercial formulations, there is variation in the methods of preparation and dispensing ofherbal medicines and Self referred

Advertising Professional asso. Another CM TCM Practitioner Chiropractor Osteopath GP Medical specialist Physiotherapist Pharmacist Counse. /psycho. HFS worker Nurse percentage 0 5 10 15 45 60 75 Figure 2 Percentage of referral sources frequently, always or almost always used. homoeopathic medicines. Approximately one half ofpractitioners indicated they mixed or combined 90% or more oftheir herbal medicines in their own clinics using standardised source material provided by suppliers. Referrals between naturopathic, herbal and other practices Practitioners were asked to identify the sources of patient referral and how frequently their patients were referred from each source. These referral patterns to naturopathic and Western herbal medicine practitioners are summarised in Fig. 2. The majority ofpractitioners (74%) indicated that their patients were frequently or almost always referred by word of mouth, which includes referral from other patients and friends. Forty-four percent ofpractitioners indicated they occasionally receive referrals from general practitioners, and a further 14% stated they occasionally receive referrals from medical specialists. Approximately one third ofpractitioners (30%) worked in a multidisciplinary clinical environment, and 7% ofrespondents indicated their multidisciplinary team included a general practitioner or medical specialist. Forward referral to another health practitioner is not as common: 7% ofpractitioners stated they refer on to a general practitioner in about half or more ofcases, whilst 73% ofpractitioners stated that they occasionally refer their patients on to GPs. Clinical experience Clinical experience in naturopathy and Western herbal medicine varies significantly, ranging from recent graduates with little experience to 47 years clinical experience. The average (mean) amount 22 A. Bensoussan et al. Table 5 Income earnings (in Australian dollars) and percentage ofgross income from practice. Incomeherbal and naturopathic practices Total

Income ($) Less than 20,000 172 (21.6) 20,00140,000 137 (17.2) 40,00160,000 218 (27.4) 60,00180,000 72 (9.1) 80,001100,000 55 (6.9) More than 100,000 30 (3.8) Percentage ofgross income Less than 20 129 (16.2) 2140 99 (12.5) 4160 114 (14.3) 6180 106 (13.3) 81100 323 (40.6) ofclinical experience ofrespondents is 9.1 years (S.D. 7.3) (full-time and part-time years) or 6.7 years (S.D. 6.1) (full-time equivalent years). Cost of treatment and practitioner income The average fee charged for an initial consultation was $AUD 61.70 (S.D. $26.50) with little variation between naturopaths and herbalists. The average fee charged for follow-up consultations was $AUD 42.10 (S.D. $15.20). Using the average fee of $AUD 45.00 per consultation (allowing for initial consultation fees), the naturopathic and herbal workforce will turnover approximately $AUD 85 million in 2003 (based on above estimate of1,900,980 consultations) in consultation fees. This does not include cost ofherbal products, nutritional supplements or homoeopathic medicines that may be prescribed by the practitioner during the consultation and dispensed directly to the patient. The overall income generated from naturopathic or herbal medicine practice is summarised in income distribution brackets in Table 5, along with the percentage this represents ofgross practitioner income. Twenty-two percent ofthe workforce stated they earned less than $AUD 20,000 and 45% between $AUD 20,000 and $AUD 60,000. Approximately 4% ofpractitioners stated they earned more than $AUD 100,000 from their herbal medicine or naturopathic practices. When asked what percentage ofgross total income is derived from this practice, 16% stated their income represented 20% or less oftheir gross earnings, with 41% indicating it represented more than 80% oftheir gross earnings. Approximately half(48%) ofresponding practitioners felt they were fully employed in their practice. At the time ofthe survey 68% ofpractitioners were registered with the Tax Office for the purposes of collecting the Australian Goods and Services Tax (GST) (consumption tax businesses are required to collect if business income exceeds $AUD 50,000 per annum). Adverse events in herbal medicine and naturopathy Five questions in the workforce survey requested

information on adverse events. Three main questions listed common and adverse events related to herbal medicines, nutritional medicines and homoeopathic medicines, respectively. Practitioners were asked to indicate the number oftimes each adverse event had occurred during their practice lifetimes. The total responses to these questions are given in Table 6. Where practitioners indicated that more than five adverse events ofa particular kind had occurred, unless specified, this was taken conservatively to represent seven adverse events. In the final row of Table 6, the raw numbers ofadverse events are extrapolated for the whole workforce, based on response rates to the survey. Therefore, an estimate ofthe total adverse events extrapolated to all Australian practitioners who prescribe herbal, nutritional and/or homoeopathic medicines is 16,165 events during their practice lifetimes. The most common adverse events reported in herbal medicine are mild gastrointestinal symptoms (n = 1952), headaches (n = 870), menstrual irregularities (n = 322), significant skin reactions (n = 307) and severe gastrointestinal symptoms (n = 296). Serious adverse events reported include CNS effects (n = 17), hepatotoxicity (n = 9) and significant respiratory disturbance (n = 9). Eighty-two adverse event cases were significant enough to refer on to medical practitioners or hospital, although no deaths were reported. The most common adverse events reported associated with nutritional medicines are mild gastrointestinal symptoms (n = 1023), headache (n = 434) and severe gastrointestinal symptoms (n = 150). Serious adverse events reported include CNS effects (n = 11), significant respiratory disturbance (n = 8), renal toxicity (n = 1) and one death. Fourteen adverse events cases were significant enough to refer on to medical practitioners or hospital. The most common adverse events reported in homoeopathic medicine are significant skin reactions (n = 244), mild gastrointestinal symptoms (n = 178) and headache (n = 171). Serious adverse events reported include CNS effects (n = 5) and significant respiratory disturbance (n = 16). Naturopathic and Western herbal medicine practice in Australiaa workforce survey 23 Table 6 Adverse events identified by practitioners, which have occurred during their practice lifetimes through the use ofherbal, nutritional and homeopathic medicines. Adverse events Number ofoccasions reported Herbal medicine Nutritional medicine Homoeopathy Total Mild gastrointestinal symptoms (nausea, discomfort) 1952 1023 178 3053 Severe gastrointestinal symptoms (vomiting, diarrhoea or pain) 296 150 23 469

Significant skin reaction 307 127 244 678 Severe fatigue 144 74 73 291 Jaundice 4 4 0 8 Fainting or dizziness 110 53 31 194 Headache 870 434 171 1475 Menstrual irregularities 322 56 72 450 Palpitations 128 52 27 207 High blood pressure 42 14 7 63 Psychiatric disturbance 12 6 27 45 Hepatotoxicity (as identified by blood tests) 9 1 0 10 Renal toxicity (as identified by blood tests) 2103 Significant respiratory disturbance 9 8 16 33 CNS effects (e.g. numbness, palsy) 17 11 5 33 Referral to medical practitioner/hospital 82 14 17 113 Death 0 1 0 1 Missing to all 75 97 123 295 Total adverse events 4306 2029 891 7226 Adverse events extrapolated to the total workforce* 9633 4539 1993 16165 * Based on the adjusted response rate of44.7%. Seventeen adverse events cases were significant enough to refer on to medical practitioners or hospital, although no deaths were reported. Reporting adverse events to homoeopathic medicines was more problematic for practitioners, as evidenced by the considerable increase in missing responses (123) for this item. [Some physiological responses are considered by homoeopaths as part ofthe healing process and therefore not necessarily viewed as adverse.] Approximately one third ofpractitioners (33%) indicated that they usually report adverse events. However, slightly less (27%) were aware ofthe Australian adverse drug reaction reporting procedures. Practitioners indicated that adverse events related to products are usually reported to the manufacturer (22%), the supplier (14%), the professional association (13%), the Australian Drug Advisory Committee (4%), the Therapeutic Goods Administration (1%) or other groups (3%), including mentors, professional supervisors and other healthcare providers. The overall number ofadverse events recorded is substantial. This workforce survey suggests that practitioners will experience a significant number and wide range ofadverse events during their practice lifetimes. Adverse event rates associated with the practice of herbal medicine and naturopathy The adverse event data reported by practitioners and associated with herbal, nutritional and homoeopathic

medicines were combined to provide overall figures for adverse events. Two variables have been calculated to generate two measures ofadverse event rates, using years in full-time practice and total consultations from the workforce data. These are adverse events per year of full-time practice, and adverse events per number ofpatient consultations. Mild gastrointestinal reactions have been excluded from both calculations in order to focus 24 A. Bensoussan et al. Table 7 Total adverse events extrapolated to the whole workforce, adverse events per year of full-time practice, adverse events per consultation and consultations per adverse event for practitioners (mild gastrointestinal effects excluded). Adverse event figures and rates Herbalists Naturopaths Total Total adverse events (excluding mild gastrointestinal effects) 3760 3237 4073 Adverse events per year off ull-time practice 1.1 (2.0) 1.2 (2.9) 1.1 (2.7) Adverse events per consultation 0.0020 (0.0060) 0.0025 (0.0087) 0.0023 (0.0078) Consultations per adverse events 500 400 357 Standard deviations are given in brackets. in particular on potentially more serious adverse reactions that may be distinctly associated with naturopathic or herbal medicine practice. The adverse events per year off ull-time practice are calculated for each practitioner responding to the workforce survey. Total adverse events reported by a practitioner are divided by the practitioners equivalent full-time years of practice. The mean rate ofadverse events per year off ull-time practice was then calculated for each respondent. The adverse events per number ofpatient consultations has been derived for each practitioner by dividing the total adverse events reported by that practitioner by an estimation oftotal consultations for that same practitioner. Total consultations are calculated by multiplying average consultations per week by 48 weeks per year by equivalent full-time years ofpractice. This calculation is less robust and assumes that the number ofpatients practitioners are currently seeing has remained static throughout their practice lifetime. The mean rate of adverse events per number ofpatient consultations was then calculated. This figure can only be used as a crude measure ofthe frequency ofadverse events. Table 7 gives figures for these two variables for the whole ofthe workforce. The number ofadverse events per year off ull-time practice is 4073, excluding mild gastrointestinal effects. These data suggest that a full-time practitioner will experience one adverse event each 11 months off ull-time practice. This figure includes adverse events related

to herbs, nutritional medicines and homoeopathic medicines. Education The reported length ofundergraduate or first herbal or naturopathic qualification for practitioners ranged from 6 months to 6 years, with an average of3.1 years. Approximately 31% of herbal and naturopathic practitioners additionally hold non-naturopathic qualifications, with approximately one third (11%) ofthese qualifications in other healthcare disciplines. Practitioners were asked which tradition of herbal medicine they were educated in and which they practise most regularly. Responses indicate that whilst there is an emphasis on Western herbal medicine training, a significant proportion ofpractitioners are educated in and practice other traditions ofherbal medicine, particularly Ayurvedic (18%) and Chinese herbal medicine (19%). Practitioners were asked whether their primary naturopathic and herbal courses adequately prepared them for professional practice. The majority ofpractitioners reported that they had been adequately or well prepared for practice in all aspects oftheoretical and clinical training, except for inter-professional communications where 44% felt they were poorly prepared. In addition, 22% ofpractitioners felt they were poorly prepared in the area ofclinical training. Participation in continuing education in naturopathy or herbal medicine was reported by 89% ofthe workforce. This included seminar attendance (81% ofthe workforce) and 24 Masters degree and PhD students. More than 80% ofpractitioners viewed participation in continuing education as very important. Current first-aid certification was held by 85% ofthe workforce. Regulation Practitioners were invited to identify what they perceive as positives or negatives ofpotential government regulation ofherbal medicine or naturopathic practice. Their views are summarised in Table 8. Overall practitioners perceived a more positive than negative change in professional status, standards ofpractice, standards ofeducation, access to research infrastructure, practitioner income, postgraduate education, access to scheduled herbs Naturopathic and Western herbal medicine practice in Australiaa workforce survey 25 Table 8 Practitioner perception ofpotential government regulation ofpractice (percentage ofresponses in brackets). Positive change Negative change Unsure Professional status 625 (78.6) 37 (4.7) 100 (12.6) Standards ofpractice 580 (73.0) 53 (6.7) 123 (15.5) Standards ofeducation 578 (72.7) 55 (6.9) 127 (16.0)

Access to research infrastructure 464 (58.4) 34 (4.3) 254 (31.9) Practitioner income 212 (26.7) 80 (10.1) 446 (56.1) Litigation 99 (12.5) 212 (26.7) 429 (54.0) Postgraduate education 474 (59.6) 43 (5.4) 222 (27.9) Patient costs 158 (19.9) 170 (21.4) 407 (51.2) Quality ofherbal medicines, nutritional supplements and homoeopathics 370 (46.5) 76 (9.6) 301 (37.9) Access to scheduled herbs, homoeopathics, nutritional substances 439 (55.2) 121 (15.2) 191 (24.0) Definition ofoccupational boundaries 328 (41.3) 157 (19.7) 252 (31.7) Freedom ofpractice 172 (21.6) 273 (34.3) 299 (37.6) Medical influence on practice 100 (12.6) 352 (44.3) 292 (36.7) and products, quality ofherbs and products, and definition ofoccupational boundaries. Practitioners were unsure of the likely effect of government regulation ofpractice on patient costs, and perceived regulation would have an overall negative effect on litigation (legal cases brought against practitioners), freedom of practice and medical influence on practice. Practitioners were asked to list the professional associations they were members of, in order of importance to themselves. Halfofthe respondents reported belonging to two or more professional associations, with an extraordinarily large number ofsmall associations (115) identified. Most practitioners (73%) estimated they are registered with six or more health insurance providers for patient rebates. Seventy percent ofall practitioners hold professional indemnity insurance arranged through their professional association, with the remaining 19% arranging insurance independently. Two percent ofpractitioners held no indemnity insurance. Discussion The findings ofthis study indicate that the practices ofherbal medicine and naturopathy make a substantial contribution to the Australian healthcare sector, with approximately 1.9 million consultations annually and an estimated turnover of$AUD 85 million in consultations, excluding the costs of medicines. This is consistent with the high levels ofusage reported by a recent Australian population survey ofconsumers ofcomplementary medicine.1 The herbal and naturopathic workforce is predominantly female (76%), but otherwise a diverse cohort ofpractitioners, particularly in terms of length and nature ofeducation and clinical experience. Primary professional qualifications varied from 6 months to 6 years in length. Practitioners on average work approximately 24 h per week in clinical practice and hold 6.7 years ofequivalent full-time experience, although this varied from recent graduates to 47 years in practice. Practitioners

use a wide and eclectic range ofconventional and non-conventional diagnostic tests. In some cases the clinical value ofthese tests has not been proven. There appears to be some degree ofintegration with other registered sectors ofthe healthcare team. Approximately 8% ofherbalists and naturopaths receive referrals from general practitioners or medical specialists for halfor more oftheir patients. Eleven percent ofmembers ofthe herbal and naturopathic workforce are qualified in another healthcare discipline, including general practice, medical specialty, physiotherapy, pharmacy or nursing. Importantly, 30% ofpractitioners reported they worked in a multidisciplinary healthcare facility. However, many practitioners (44%) felt they were poorly prepared for inter-professional communications, emphasising the importance ofcontinuing professional education. A large proportion ofpatients are referred to practitioners by word of mouth. The overall number ofconsultations provides evidence ofthe high degree ofutilisation ofW estern herbal and naturopathic practice in Australia. The wide recognition ofthese practices by health 26 A. Bensoussan et al. insurers for the purposes of patient rebates (three quarters ofpractitioners have provider status with six or more funds), may reflect the pressure on insurers generated by a public wishing to exercise choice. However, the annual earnings associated with herbal and naturopathic practice appear modest. The significant proportion ofpractitioners who identify as a priority and participate in continuing professional education, the widespread participation in first-aid training and the almost universal professional indemnity insurance coverage are indicators that naturopaths and herbalists take their responsibilities to consumers seriously. The understanding ofthe workforce provided by this survey may assist in the assessment ofthese professions ability to provide GST-free services after 30 June 2003. Section 195-1 ofthe GST Act [A New Tax System (Goods and Services Tax) Act 1999] states that GST-free services may be provided only by a recognised professional. In the absence of statutory regulation, a recognised professional is a member ofa professional association that has uniform national registration requirements relating to the supply ofthe services. The Expert Committee on Complementary Medicine in the Health System established by the Commonwealth Government noted concern regarding the possibility that the GST provisions might be interpreted as de facto recognition ofbodies that are not representative oftheir professions. The Committee considered that such

recognition may mitigate against the development ofstrong, cohesive and representative professional bodies.5 The data provided in this study report the characteristics ofthese professions irrespective of their affiliations with specific professional associations. The number ofadverse events associated with herbal, nutritional and homoeopathic medicines recorded in Australia is significant and the types of events reported are not trivial, for example, severe gastrointestinal symptoms, palpitations and hepatotoxicity. The workforce survey data suggest that practitioners will experience one serious adverse event every 11 months off ull-time practice, with 2.3 adverse events for every 1000 consultations (excluding mild gastrointestinal effects). There were noticeably more adverse events reported with the use ofherbal medicines than with nutritional and homoeopathic medicines. This finding is significant in terms ofthe current NSW-based review ofthe public health risks presented by the practice ofvarious forms ofcomplementary medicine6 and the commissioning by the Victorian Department ofHuman Services ofa study ofthe risks, benefits and regulatory requirements associated with the practice ofnaturopathy and Western herbal medicine. The risks and the adequacy ofthe regulatory arrangements to protect public health and safety warrant review in terms of the needs for statutory occupational regulation. The minimisation ofrisks should be a priority ofthe herbal and naturopathic professions working with government policy makers. This may involve more formalised statutory or self-regulatory arrangements to provide enforceable minimum education and clinical practice standards. A prospective study ofadverse events is required to provide a more accurate assessment ofthe risks involved in the practice of these disciplines. Overall, one third ofpractitioners reported that they notify adverse events to a variety of agencies, although it is ofconcern that these reports were largely provided back to the manufacturer or supplier ofproduct rather than the Commonwealths Adverse Drug Reactions Advisory Committee. Adverse event reporting by the herbal medicine and naturopathy professions needs to be strengthened through appropriate centralisation ofdata using established processes ofthe Australian adverse drug reaction reporting procedures. The professions need to work with the Adverse Drug Reactions Units ofthe TGA to increase awareness ofthe reporting mechanisms amongst their members. It is interesting that practitioners reported membership ofan extraordinarily large number ofsmall associations (115). While the majority ofpractitioners reported membership ofone ofthe four principal

associations, the findings confirm the fragmented and underdeveloped nature ofprof essional representation in the field, and the need for government intervention to promote more uniform educational and practice standards and other mechanisms to ensure public protection. Overall practitioners perceived a more positive than negative influence ofany potential government regulation of Western herbal or naturopathic practice. It is important to acknowledge the potential limitations ofthis study. All surveys are vulnerable to biased or incorrect responses. Practitioners may, for example, have over-reported the number oftreatments they perform. As a retrospective survey there is also the potential for recall bias, which may have resulted in under-reporting ofadverse events. Furthermore, indirect adverse events, such as missed conventional diagnosis or delayed treatment, are not likely to be picked up in this survey. This study provides the first comprehensive mapping ofthe naturopathy and Western herbal medicine professions in Australia. It is clear from the data provided that these professions are engaging in substantial activity within the healthcare Naturopathic and Western herbal medicine practice in Australiaa workforce survey 27 sector and are being incorporated into the referral patterns and included in the practices ofother registered health practitioners. In the light ofthe current government reviews ofthe CAM professions, policy decisions on naturopathy and Western herbal medicine can be better informed through a clearer understanding ofthe nature ofthese workforces. Acknowledgements This study was funded by the National Herbalists Association ofAustralia and the Federation ofNatural and Traditional Therapists with the financial support ofthe Commonwealth Department ofHealth and Ageing and with the collaboration ofGrand United Health Fund. References 1. MacLennan AH, Wilson DH, Taylor AW. The escalating cost and prevalence ofalternative medicine. Prev Med 2002;35(2):16673. 2. Bensoussan A, Myers SP. Towards a safer choice: The practice ofT raditional Chinese Medicine in Australia. Sydney: University ofW estern Sydney, 1996. 3. Bensoussan A, Myers SP, Carlton AL. Risks associated with the practice ofT raditional Chinese Medicine. Arch Fam Med 2000;9:10718. 4. Carlton AL, Bensoussan A. Regulation ofcomplementary medicine practitioners in Australia: Chinese medicine as a case example. Complement Ther Med 2002;10:206. 5. Expert Committee on Complementary Medicines in the Health System. Complementary medicines in the Australian Health System. Report to the Parliamentary Secretary to the

Minister for Health and Ageing, Canberra, September 2003. http://www.health.gov.au/tga/docs/html/cmreport.htm. 6. NSW Department ofHealth. Regulation ofcomplementary medicine practitionersa discussion paper. October 2002.

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