This is the first focused examination of conventional medical practitioner referral to chiropractors and osteopaths in rural and regional Australia. Our study findings show that a significant level of interaction exists between GPs and chiropractors and osteopaths in this area. The high prevalence of personal professional relationships and referral between GPs and chiropractors and osteopaths may be indicative of high presence of practitioners in the study area, as previous research has identified chiropractor and osteopath numbers around 40% of GP numbers in rural and regional New South Wales .
However, the high level of professional relationships and referral amongst GPs with chiropractors and osteopaths may also be related to formal referral arrangements that exist for chiropractic and osteopathic services in the Australian public health care system. Chiropractic and osteopathic patients are eligible to receive a subsidy of $51.95 from the Australian government when referred by a medical practitioner under the Medicare Extended Care Plan (MBS Item Numbers 10964, 10966, 81345 and 81350; figures correct as at August 2012) . This interpretation is supported by the findings of this study, which show that the numbers of patients enquiring with their GP about CAM is a significant predictive factor for GP referral to chiropractors and osteopaths.
Chiropractors and osteopaths are currently the only CAM practitioners eligible for such subsidies in Australia. Formalised arrangements and subsidies for chiropractic and osteopathic services may therefore provide a cost-effective avenue (from the patient’s perspective) for GPs to explore CAM approaches to healthcare when such referrals are requested by patients, rather than being solely indicative of support for chiropractic and osteopathic treatments. Previous research on naturopaths in rural Australia, for example, indicates that although patients have a high level of support for CAM services, rural patients are often unable or unwilling to pay fully out-of-pocket costs associated with these services, and actively seek more cost-effective ways to access the advice of CAM practitioners . With the introduction of other CAM professions into Australia’s national regulation scheme (Chinese medicine has already been included from July 2012, and naturopaths have been recommended for later inclusion ), there may be pressure to publicly subsidise these services as well, removing the current monopoly chiropractors and osteopaths regarding publicly-subsidised CAM services in Australia.
However, the issue of how government reimbursements or formalized arrangements affect referral patterns between conventional and specific CAM providers has not been explored in depth. Such exploration may be warranted, particularly as chiropractic more than any other profession appears to be driving high CAM practitioner use in rural areas in Australia [12, 14]. Whether patient requests to GPs (and subsequent referrals by GPs) are specifically for chiropractic and osteopathy services, or whether the formalised arrangements mean that chiropractors and osteopaths simply provide a convenient avenue for GPs to refer to a CAM provider, will have a significant impact on which services GPs choose to refer to as more practitioner options become available. The finding from this study that GPs who rely on CAM providers as major sources of CAM information may not only indicate higher levels of interaction with CAM providers amongst referrers than non-referrers, but also that GPs are willing to communicate and refer to a broad variety of CAM practitioners beyond chiropractors and osteopaths. With medical referrals comprising nearly one-fifth the patient load for Australian chiropractors and osteopaths , increasing subsidised access to other CAM professions could have significant impacts on the professions of chiropractic and osteopathy, with reductions in referrals one possible scenario as GPs share their formal CAM referrals amongst a broader range of practitioners. Whilst this may benefit patients in terms of improved access to a broader range of therapeutic options, it could also pose professional challenges to the chiropractic and osteopathy communities.
Although our study results suggest that chiropractors and osteopaths may be largely accepted by the majority of the Australian rural and regional GP community, our findings also help identify remaining tensions between conventional medicine and the two CAM modalities, with one-fifth of GPs maintaining that they would never refer to a chiropractor or osteopath under any circumstances. This finding mirrors those of a previous national survey of Australian GPs which indicated both significant levels of support for, and opposition to, chiropractic and osteopathy referrals amongst the Australian GP community . Such tensions have achieved recent attention in Australia, with calls from within the conventional medical sector for chiropractic and osteopathic practice to receive no further mainstream medical attention . Findings from this study suggest that such ideologically opposed views to chiropractic and osteopathy do not seem representative of the majority of medical practitioners in our study area. However, significant tensions between the professions do highlight the need for further detailed research into factors that influence conventional practitioner opinion on CAM professions such as chiropractic and osteopathy.
However, other factors beyond ideological or professional opposition may also result in GPs being unwilling to refer to chiropractors and osteopaths, even if they exhibit positive attitudes towards the professions. Medico-legal concerns relating to GP referral to chiropractors have been disseminated to the practice community via a number of high profile court cases [16, 30, 31] and such concerns may be exacerbated by the focus of medical professional literature to the risks associated with CAM, rather than broader discussions of efficacy . Indeed, previous Australian surveys of GPs have highlighted patient risk as a major determinant of GP opinion on CAM, often more than efficacy [7, 8, 33, 34]. Further exploration of factors that make GPs less willing to refer to CAM practitioners (including osteopaths and chiropractors), as well as those factors that predict referral, would assist in providing further insights into the interface between CAM and general practice, the impact of CAM on primary health care, and the role that chiropractic and osteopathy can play in the broader health care system.
Rural and regional issues associated with patient CAM use and practice may also affect chiropractic referral, as some commentators have suggested that higher CAM use in rural and regional areas may be related to lower levels of conventional healthcare providers (e.g. specialists, allied health) in these areas . Although a lack of other treatment options for patients was predictive of increased referral rates to chiropractors and osteopaths by rural and regional Australian GPs in our study, limited access to medical specialists was in contrast predictive of lower levels of referral. As such, increased referral to chiropractors and osteopaths may be related more to GPs referring to CAM after exhausting their own treatment options for patients, rather than serving as alternative referral recipients when specialist treatment is sought. This may be partly related to previous study findings that have suggested that rather than replacing conventional practitioners in areas of high need, CAM practitioner density often follows that of conventional practitioners, with areas of high service need experiencing shortages in both conventional and CAM practitioners [2, 20]. Additionally, although previous large-scale surveys have highlighted a lack of access to or dissatisfaction with conventional medical services as associated with higher CAM use, such studies have also uncovered dissatisfaction in CAM service provider provision in rural areas [21, 22]. Rather, other historical and cultural drivers (such as positive community connections, rural patient’s increased independence and stoicness, underlying community affinity for holistic principles and increased value of rural patients on experiential over empirical forms of evidence) may be push factors for CAM use by rural populations , which in turn may increase patient requests for CAM services and referrals for GPs in rural areas.
The high prevalence of professional relationships with individual practitioners may also be partly related to the rural and regional nature of the sample in this study, as smaller communities may facilitate increased interaction between CAM and conventional providers [18, 19, 36]. This may facilitate an increased level of referrals by rural and regional GPs as compared to their urban counterparts. Further investigation of referral patterns in the broader GP population, or comparative work with urban GPs, will assist in further ascertaining what role, if any, geographic factors such as the level of rurality have on the interface between CAM and general practice.
Though limited to one state (New South Wales), the large and varied study area was chosen to be broadly representative of Australian rural and regional general practice demographics . Nevertheless, the demographics of the GPs in this study compared to national statistics (being as they are drawn from rural and regional areas and exhibiting a higher proportion of females) should be considered in generalising the study’s results to the broader Australian general practice population.
Other limitations of the study, in common amongst other questionnaire studies, include the use of self-reported data and possible recall bias inherent in retrospective collection of data over a 12 month period, as well as self-selection may also have resulted in some form of response bias. The response rate is typical for large-scale GP surveys on CAM conducted in Australia over the past decade, which have reported response rates of between 29.4-58.0% [7, 33, 37]. The response rate also compares well to general surveys of Australian GPs, which routinely have difficulty receiving response rates of over 30% .