- Email: [email protected]
Naturopathic and Western herbal medicine practice in Australia—a workforce survey
Complementary Therapies in Medicine (2004) 12, 17—27
Naturopathic and Western herbal medicine practice in Australia—a workforce survey A. Bensoussan a,*, S.P. Myers b , S.M. Wu a , K. O’Connor a 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 of complementary medicine, no comprehensive national study has been undertaken of the naturopathic and Western herbal medicine component of the healthcare workforce in Australia. This study aimed to examine the nature of these 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 of the naturopathic and Western herbal medicine workforce. Results: The practices of herbal medicine and naturopathy make up a sizeable component of the Australian healthcare sector, with approximately 1.9 million consultations annually and an estimated turnover of $AUD 85 million in consultations (excluding the cost of medicines). A large proportion of patients are referred to practitioners by word of mouth. Up to one third of practitioners work in multidisciplinary clinics with other registered sectors of the healthcare community. The number of adverse events associated with herbal medicines, nutritional substances and homoeopathic medicines recorded in Australia is substantial and the types of events reported are not trivial. Data suggest that practitioners will experience one adverse event every 11 months of full-time practice, with 2.3 adverse events for every 1000 consultations (excluding mild gastrointestinal effects). Conclusion: These data confirm the considerable degree of utilisation of naturopathic and Western herbal medicine practitioners by the Australian public. However, there is a need to examine whether statutory regulation of practitioners of naturopathy and Western herbal medicine is required to better protect the public. © 2004 Elsevier Ltd. All rights reserved.
Introduction A range of complementary and alternative medicine (CAM) practices are being increasingly used by the Australian public.1 Aromatherapy and Tra-
* Corresponding
author. E-mail address: [email protected] (A. Bensoussan).
ditional Chinese Medicine (TCM) have exhibited steady growth, whilst the growth of naturopathic practices, including Western herbal medicine, homoeopathy, touch (tactile) therapies (including massage), nutrition and lifestyle advice, because of their eclectic nature has been more difficult to monitor.1 Our group has previously surveyed the Australian TCM workforce in 1996.2—4 However, no comprehensive national study has been undertaken
0965-2299/$ – see front matter © 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2004.01.001
18 of the naturopathic and Western herbal medicine component of the healthcare workforce, which remains unregulated by government. The purpose of this study was to commence to map the practice of naturopathy and Western herbal medicine, in particular the characteristics of its workforce. Data were collected from practitioners of naturopathy and Western herbal medicine, including basic demographics, consultation fees, patient management and referral processes, private health fund rebate status, level of utilisation of Western medical diagnosis, nature and standards of education, compliance with current regulations, including prescribing/dispensing of drugs and poisons, adverse events, level of support for a system of uniform national accreditation, and extent and type of membership of professional associations.
Methods In order to undertake a national survey of practitioners across various representative professional associations collaboration was sought with a major health insurance provider. Grand United Health Fund (GUHF) was one of the first insurers to provide benefits to its members for CAM services, and it holds a comprehensive national database of practitioners. This method overcame a number of difficulties, including: extensive overlap in membership lists across the various principal professional associations; anticipated reluctance by some professional associations to the establishment of a 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 of only 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 if they also practised as naturopaths, or if their practices incorporated at least two naturopathic modalities (herbal medicine, nutritional medicine, homoeopathic medicine and tactile therapies).
A. Bensoussan et al. GUHF undertook a direct mailout. Approximately 3 weeks later practitioners were sent a reminder postcard encouraging them to complete the survey instrument. A comprehensive questionnaire was developed in consultation with the National Herbalists Association of Australia and the Federation of Natural and Traditional Therapists. It contained 84 items over eight pages and was designed to address the lack of available data on the characteristics of the naturopathic and Western herbal medicine workforce. The survey instrument was piloted with a sample of 13 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 of data entry. Hence, with the exception of several 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 of Western Sydney, granted ethics approval for the study.
Results Response rate In total, 3540 survey forms were mailed out to practitioners. Of these, 423 surveys were returned to sender and the practitioners could not be contacted to resend the survey. This left an effective mailing list of 3117 practitioners. Verbal reports suggested that a number of practitioners, despite being on professional association mailing lists, were not currently in practice. In order to check the accuracy of the 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 of continuous 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. Of the remaining practitioners who could not be contacted (24), it was assumed that half were not practising. Therefore, out of 3117 practitioners on the mailing list it has been assumed that a total of 16% are not currently in practice. This generates an active mailing list of
Naturopathic and Western herbal medicine practice in Australia—a workforce survey 2618 practitioners. The survey responses totalled 859–—providing an initial response rate of 33%. This initial response rate is considered to be artificially low as a product of the 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 of the 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 of homoeopaths 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 of a series of titles best describes their practice: • 489 practitioners (62%) identified herbalism as one of their practice descriptors. • 604 practitioners (76%) identified naturopathy as one of their practice descriptors. • 54 respondents were also members of conventional and registered health professions: 3 were qualified medical specialists, 12 were general
19
Table 1 Titles selected by respondents to describe their practices. Nature of practice
Number (N = 795) (%)
Herbalist Naturopath Homoeopath Nutritionist Massage therapist Aromatherapist Bach flowers practitioner Meditation/relaxation (including yoga, qi gong) Medical specialist General medical practitioner Pharmacist Chiropractor Osteopath Physiotherapist Nurse Counsellor Psychologist Traditional Chinese Medicine practitioner Acupuncturist Other Missing
489 604 208 315 277 32 175 50
(61.5) (76.0) (26.2) (39.6) (34.8) (4.0) (22.0) (6.3)
3 12 10 6 9 1 28 59 5 20
(0.4) (1.5) (1.3) (0.8) (1.1) (0.1) (3.5) (7.4) (0.6) (2.5)
41 (5.2) 141 (17.7) 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 of allied health practitioners using one or a number of modalities 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% of the time,
Table 2 Mean percentage (with standard deviation) of practice 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 Homoeopathy Nutritional medicine Massage and tactile therapies Other
53.1 22.4 41.7 28.9 37.5
43.7 24.6 42.5 31.0 36.0
46.7 26.2 41.6 31.6 38.6
± ± ± ± ±
27.1 23.7 26.0 24.5 27.9
± ± ± ± ±
25.6 23.8 25.7 24.1 27.0
± ± ± ± ±
27.3 26.4 25.9 25.4 28.2
20
A. Bensoussan et al.
Figure 1
Number of practitioners by State, country or metropolitan location.
and herbalists regularly practising both homoeopathy and nutritional medicines. The average (mean) age of the naturopathic and Western herbal workforce was 44 years (S.D. 10.4 years). Females made up 76% of the workforce. Distribution of practitioners by State is summarised in Fig. 1. Approximately twice the number of practitioners 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) of initial and follow-up consultations (standard deviations in brackets). Total Hours spent in clinical practice per week Face-to-face contact–—initial consultation (min) Face-to-face contact–—follow-up consultation (min)
23.8 ± 13.3 23.0 ± 5.8 13.4 ± 6.3
The mean number of consultations 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 of practitioners). 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 of Western 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% of all practitioners to guide their clinical practice 50% or more of the time. A further 48% of them claimed to use diagnostic tests occasionally. Forty-seven percent of practitioners reported that they used Western medical diagnoses to guide their naturopathic or herbal medicine treatments in 50% or more of patient 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 Australia—a workforce survey
homoeopathic medicines. Approximately one half of practitioners indicated they mixed or combined 90% or more of their herbal medicines in their own clinics using standardised source material provided by suppliers.
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) Hair testing
172 (21.6)
Traditional testing Iris diagnosis Tongue diagnosis Oriental diagnosis Face diagnosis
641 454 68 130
21
Referrals between naturopathic, herbal and other practices
177 (22.3)
The use of traditional naturopathic diagnostic techniques was high with 81% of practitioners indicating they used iris diagnosis in their practices. The use of these diagnostic tools or methods in clinical practice is reported in Table 4.
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 of practitioners (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 of practitioners indicated they occasionally receive referrals from general practitioners, and a further 14% stated they occasionally receive referrals from medical specialists. Approximately one third of practitioners (30%) worked in a multidisciplinary clinical environment, and 7% of respondents indicated their multidisciplinary team included a general practitioner or medical specialist. Forward referral to another health practitioner is not as common: 7% of practitioners stated they refer on to a general practitioner in about half or more of cases, whilst 73% of practitioners stated that they occasionally refer their patients on to GPs.
Form and labelling of preparations
Clinical experience
Whilst nutritional medicines are generally prepared and provided as over-the-counter commercial formulations, there is variation in the methods of preparation and dispensing of herbal medicines and
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
Alternative testing Electro-dermal screening (e.g. LISTEN, Vega) Muscle testing Haemaview/live blood analysis Physical examination (BP, auscultation, palpation, etc.)
(80.6) (57.1) (8.6) (16.4)
94 (11.8) 160 (20.1) 95 (11.9) 493 (62.0)
Other
172 (21.6)
Missing
14 (1.8)
Self referred Advertising Professional asso. Another CM TCM Practitioner Chiropractor Osteopath GP Medical specialist Physiotherapist Pharmacist Counse. /psycho. HFS worker Nurse
0
Figure 2
5
10
15 percentage
45
60
75
Percentage of referral sources frequently, always or almost always used.
22
A. Bensoussan et al.
Table 5 Income earnings (in Australian dollars) and
percentage of gross income from practice. Income–—herbal and naturopathic practices
Total
Income ($) Less than 20,000 20,001—40,000 40,001—60,000 60,001—80,000 80,001—100,000 More than 100,000
172 137 218 72 55 30
(21.6) (17.2) (27.4) (9.1) (6.9) (3.8)
Percentage of gross income Less than 20 21—40 41—60 61—80 81—100
129 99 114 106 323
(16.2) (12.5) (14.3) (13.3) (40.6)
of clinical experience of respondents 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 of 1,900,980 consultations) in consultation fees. This does not include cost of herbal 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 of gross practitioner income. Twenty-two percent of the workforce stated they earned less than $AUD 20,000 and 45% between $AUD 20,000 and $AUD 60,000. Approximately 4% of practitioners stated they earned more than $AUD 100,000 from their herbal medicine or naturopathic practices. When asked what percentage of gross total income is derived from this practice, 16% stated their income represented 20% or less of their gross earnings, with 41% indicating it represented more than 80% of their gross earnings. Approximately half (48%) of responding practitioners felt they
were fully employed in their practice. At the time of the survey 68% of practitioners 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 of times 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 of a 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 of adverse events are extrapolated for the whole workforce, based on response rates to the survey. Therefore, an estimate of the 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 Australia—a workforce survey
23
Table 6 Adverse events identified by practitioners, which have occurred during their practice lifetimes through the use of herbal, nutritional and homeopathic medicines. Adverse events
Number of occasions reported Herbal medicine
Nutritional medicine
Homoeopathy
Mild gastrointestinal symptoms (nausea, discomfort) Severe gastrointestinal symptoms (vomiting, diarrhoea or pain) Significant skin reaction Severe fatigue Jaundice Fainting or dizziness Headache Menstrual irregularities Palpitations High blood pressure Psychiatric disturbance Hepatotoxicity (as identified by blood tests) Renal toxicity (as identified by blood tests) Significant respiratory disturbance CNS effects (e.g. numbness, palsy) Referral to medical practitioner/hospital Death Missing to all
1952
1023
178
3053
296
150
23
469
307 144 4 110 870 322 128 42 12 9
127 74 4 53 434 56 52 14 6 1
244 73 0 31 171 72 27 7 27 0
678 291 8 194 1475 450 207 63 45 10
2
1
0
3
9 17 82 0 75
8 11 14 1 97
16 5 17 0 123
33 33 113 1 295
Total adverse events
4306
2029
891
7226
Adverse events extrapolated to the total workforce*
9633
4539
1993
16165
*
Total
Based on the adjusted response rate of 44.7%.
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 of the healing process and therefore not necessarily viewed as ‘adverse’.] Approximately one third of practitioners (33%) indicated that they usually report adverse events. However, slightly less (27%) were aware of the 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 of adverse events recorded is substantial. This workforce survey suggests that practitioners will experience a significant number and wide range of adverse 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 of adverse 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 of patient 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) Adverse events per year of full-time practice Adverse events per consultation Consultations per adverse events
3760
3237
4073
1.1 (2.0) 0.0020 (0.0060) 500
1.2 (2.9) 0.0025 (0.0087) 400
1.1 (2.7) 0.0023 (0.0078) 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 of full-time practice are calculated for each practitioner responding to the workforce survey. Total adverse events reported by a practitioner are divided by the practitioner’s equivalent full-time years of practice. The mean rate of adverse events per year of full-time practice was then calculated for each respondent. The adverse events per number of patient consultations has been derived for each practitioner by dividing the total adverse events reported by that practitioner by an estimation of total 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 of practice. This calculation is less robust and assumes that the number of patients practitioners are currently seeing has remained static throughout their practice lifetime. The mean rate of adverse events per number of patient consultations was then calculated. This figure can only be used as a crude measure of the frequency of adverse events. Table 7 gives figures for these two variables for the whole of the workforce. The number of adverse events per year of full-time practice is 4073, excluding mild gastrointestinal effects. These data suggest that a full-time practitioner will experience one adverse event each 11 months of full-time practice. This figure includes adverse events related to herbs, nutritional medicines and homoeopathic medicines.
Education The reported length of undergraduate or first herbal or naturopathic qualification for practitioners ranged from 6 months to 6 years, with an average of 3.1 years. Approximately 31% of herbal and naturopathic practitioners additionally
hold non-naturopathic qualifications, with approximately one third (11%) of these 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 of practitioners are educated in and practice other traditions of herbal 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 of practitioners reported that they had been adequately or well prepared for practice in all aspects of theoretical and clinical training, except for inter-professional communications where 44% felt they were poorly prepared. In addition, 22% of practitioners felt they were poorly prepared in the area of clinical training. Participation in continuing education in naturopathy or herbal medicine was reported by 89% of the workforce. This included seminar attendance (81% of the workforce) and 24 Masters degree and PhD students. More than 80% of practitioners viewed participation in continuing education as very important. Current first-aid certification was held by 85% of the workforce.
Regulation Practitioners were invited to identify what they perceive as positives or negatives of potential government regulation of herbal medicine or naturopathic practice. Their views are summarised in Table 8. Overall practitioners perceived a more positive than negative change in professional status, standards of practice, standards of education, access to research infrastructure, practitioner income, postgraduate education, access to scheduled herbs
Naturopathic and Western herbal medicine practice in Australia—a workforce survey
25
Table 8 Practitioner perception of potential government regulation of practice (percentage of responses in
brackets).
Professional status Standards of practice Standards of education Access to research infrastructure Practitioner income Litigation Postgraduate education Patient costs Quality of herbal medicines, nutritional supplements and homoeopathics Access to scheduled herbs, homoeopathics, nutritional substances Definition of occupational boundaries Freedom of practice Medical influence on practice
Positive change
Negative change
Unsure
625 580 578 464 212 99 474 158 370
37 53 55 34 80 212 43 170 76
100 123 127 254 446 429 222 407 301
(78.6) (73.0) (72.7) (58.4) (26.7) (12.5) (59.6) (19.9) (46.5)
(4.7) (6.7) (6.9) (4.3) (10.1) (26.7) (5.4) (21.4) (9.6)
(12.6) (15.5) (16.0) (31.9) (56.1) (54.0) (27.9) (51.2) (37.9)
439 (55.2)
121 (15.2)
191 (24.0)
328 (41.3) 172 (21.6) 100 (12.6)
157 (19.7) 273 (34.3) 352 (44.3)
252 (31.7) 299 (37.6) 292 (36.7)
and products, quality of herbs and products, and definition of occupational boundaries. Practitioners were unsure of the likely effect of government regulation of practice 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. Half of the respondents reported belonging to two or more professional associations, with an extraordinarily large number of small associations (115) identified. Most practitioners (73%) estimated they are registered with six or more health insurance providers for patient rebates. Seventy percent of all practitioners hold professional indemnity insurance arranged through their professional association, with the remaining 19% arranging insurance independently. Two percent of practitioners held no indemnity insurance.
Discussion The findings of this study indicate that the practices of herbal 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 of usage reported by a recent Australian population survey of consumers of complementary medicine.1
The herbal and naturopathic workforce is predominantly female (76%), but otherwise a diverse cohort of practitioners, particularly in terms of length and nature of education 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 of equivalent full-time experience, although this varied from recent graduates to 47 years in practice. Practitioners use a wide and eclectic range of conventional and non-conventional diagnostic tests. In some cases the clinical value of these tests has not been proven. There appears to be some degree of integration with other registered sectors of the healthcare team. Approximately 8% of herbalists and naturopaths receive referrals from general practitioners or medical specialists for half or more of their patients. Eleven percent of members of the herbal and naturopathic workforce are qualified in another healthcare discipline, including general practice, medical specialty, physiotherapy, pharmacy or nursing. Importantly, 30% of practitioners reported they worked in a multidisciplinary healthcare facility. However, many practitioners (44%) felt they were poorly prepared for inter-professional communications, emphasising the importance of continuing professional education. A large proportion of patients are referred to practitioners by word of mouth. The overall number of consultations provides evidence of the high degree of utilisation of Western herbal and naturopathic practice in Australia. The wide recognition of these practices by health
26 insurers for the purposes of patient rebates (three quarters of practitioners 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 of practitioners 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 of the workforce provided by this survey may assist in the assessment of these professions’ ability to provide GST-free services after 30 June 2003. Section 195-1 of the 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 of a professional association that has uniform national registration requirements relating to the supply of the 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 of bodies that are not representative of their professions. The Committee considered that such recognition may mitigate against the development of strong, cohesive and representative professional bodies.5 The data provided in this study report the characteristics of these professions irrespective of their affiliations with specific professional associations. The number of adverse 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 of full-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 of herbal medicines than with nutritional and homoeopathic medicines. This finding is significant in terms of the current NSW-based review of the public health risks presented by the practice of various forms of complementary medicine6 and the commissioning by the Victorian Department of Human Services of a study of the risks, benefits and regulatory requirements associ-
A. Bensoussan et al. ated with the practice of naturopathy and Western herbal medicine. The risks and the adequacy of the regulatory arrangements to protect public health and safety warrant review in terms of the needs for statutory occupational regulation. The minimisation of risks should be a priority of the 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 of adverse events is required to provide a more accurate assessment of the risks involved in the practice of these disciplines. Overall, one third of practitioners reported that they notify adverse events to a variety of agencies, although it is of concern that these reports were largely provided back to the manufacturer or supplier of product rather than the Commonwealth’s Adverse Drug Reactions Advisory Committee. Adverse event reporting by the herbal medicine and naturopathy professions needs to be strengthened through appropriate centralisation of data using established processes of the Australian adverse drug reaction reporting procedures. The professions need to work with the Adverse Drug Reactions Units of the TGA to increase awareness of the reporting mechanisms amongst their members. It is interesting that practitioners reported membership of an extraordinarily large number of small associations (115). While the majority of practitioners reported membership of one of the four principal associations, the findings confirm the fragmented and underdeveloped nature of professional 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 of any potential government regulation of Western herbal or naturopathic practice. It is important to acknowledge the potential limitations of this study. All surveys are vulnerable to biased or incorrect responses. Practitioners may, for example, have over-reported the number of treatments they perform. As a retrospective survey there is also the potential for recall bias, which may have resulted in under-reporting of adverse 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 of the 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 Australia—a workforce survey sector and are being incorporated into the referral patterns and included in the practices of other registered health practitioners. In the light of the current government reviews of the CAM professions, policy decisions on naturopathy and Western herbal medicine can be better informed through a clearer understanding of the nature of these workforces.
Acknowledgements This study was funded by the National Herbalists Association of Australia and the Federation of Natural and Traditional Therapists with the financial support of the Commonwealth Department of Health and Ageing and with the collaboration of Grand United Health Fund.
27
References 1. MacLennan AH, Wilson DH, Taylor AW. The escalating cost and prevalence of alternative medicine. Prev Med 2002;35(2):166—73. 2. Bensoussan A, Myers SP. Towards a safer choice: The practice of Traditional Chinese Medicine in Australia. Sydney: University of Western Sydney, 1996. 3. Bensoussan A, Myers SP, Carlton AL. Risks associated with the practice of Traditional Chinese Medicine. Arch Fam Med 2000;9:1071—8. 4. Carlton AL, Bensoussan A. Regulation of complementary medicine practitioners in Australia: Chinese medicine as a case example. Complement Ther Med 2002;10:20—6. 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 of Health. Regulation of complementary medicine practitioners–—a discussion paper. October 2002.
Naturopathic and Western herbal medicine practice in Australia—a workforce survey A. Bensoussan a,*, S.P. Myers b , S.M. Wu a , K. O’Connor a 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 of complementary medicine, no comprehensive national study has been undertaken of the naturopathic and Western herbal medicine component of the healthcare workforce in Australia. This study aimed to examine the nature of these 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 of the naturopathic and Western herbal medicine workforce. Results: The practices of herbal medicine and naturopathy make up a sizeable component of the Australian healthcare sector, with approximately 1.9 million consultations annually and an estimated turnover of $AUD 85 million in consultations (excluding the cost of medicines). A large proportion of patients are referred to practitioners by word of mouth. Up to one third of practitioners work in multidisciplinary clinics with other registered sectors of the healthcare community. The number of adverse events associated with herbal medicines, nutritional substances and homoeopathic medicines recorded in Australia is substantial and the types of events reported are not trivial. Data suggest that practitioners will experience one adverse event every 11 months of full-time practice, with 2.3 adverse events for every 1000 consultations (excluding mild gastrointestinal effects). Conclusion: These data confirm the considerable degree of utilisation of naturopathic and Western herbal medicine practitioners by the Australian public. However, there is a need to examine whether statutory regulation of practitioners of naturopathy and Western herbal medicine is required to better protect the public. © 2004 Elsevier Ltd. All rights reserved.
Introduction A range of complementary and alternative medicine (CAM) practices are being increasingly used by the Australian public.1 Aromatherapy and Tra-
* Corresponding
author. E-mail address: [email protected] (A. Bensoussan).
ditional Chinese Medicine (TCM) have exhibited steady growth, whilst the growth of naturopathic practices, including Western herbal medicine, homoeopathy, touch (tactile) therapies (including massage), nutrition and lifestyle advice, because of their eclectic nature has been more difficult to monitor.1 Our group has previously surveyed the Australian TCM workforce in 1996.2—4 However, no comprehensive national study has been undertaken
0965-2299/$ – see front matter © 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2004.01.001
18 of the naturopathic and Western herbal medicine component of the healthcare workforce, which remains unregulated by government. The purpose of this study was to commence to map the practice of naturopathy and Western herbal medicine, in particular the characteristics of its workforce. Data were collected from practitioners of naturopathy and Western herbal medicine, including basic demographics, consultation fees, patient management and referral processes, private health fund rebate status, level of utilisation of Western medical diagnosis, nature and standards of education, compliance with current regulations, including prescribing/dispensing of drugs and poisons, adverse events, level of support for a system of uniform national accreditation, and extent and type of membership of professional associations.
Methods In order to undertake a national survey of practitioners across various representative professional associations collaboration was sought with a major health insurance provider. Grand United Health Fund (GUHF) was one of the first insurers to provide benefits to its members for CAM services, and it holds a comprehensive national database of practitioners. This method overcame a number of difficulties, including: extensive overlap in membership lists across the various principal professional associations; anticipated reluctance by some professional associations to the establishment of a 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 of only 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 if they also practised as naturopaths, or if their practices incorporated at least two naturopathic modalities (herbal medicine, nutritional medicine, homoeopathic medicine and tactile therapies).
A. Bensoussan et al. GUHF undertook a direct mailout. Approximately 3 weeks later practitioners were sent a reminder postcard encouraging them to complete the survey instrument. A comprehensive questionnaire was developed in consultation with the National Herbalists Association of Australia and the Federation of Natural and Traditional Therapists. It contained 84 items over eight pages and was designed to address the lack of available data on the characteristics of the naturopathic and Western herbal medicine workforce. The survey instrument was piloted with a sample of 13 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 of data entry. Hence, with the exception of several 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 of Western Sydney, granted ethics approval for the study.
Results Response rate In total, 3540 survey forms were mailed out to practitioners. Of these, 423 surveys were returned to sender and the practitioners could not be contacted to resend the survey. This left an effective mailing list of 3117 practitioners. Verbal reports suggested that a number of practitioners, despite being on professional association mailing lists, were not currently in practice. In order to check the accuracy of the 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 of continuous 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. Of the remaining practitioners who could not be contacted (24), it was assumed that half were not practising. Therefore, out of 3117 practitioners on the mailing list it has been assumed that a total of 16% are not currently in practice. This generates an active mailing list of
Naturopathic and Western herbal medicine practice in Australia—a workforce survey 2618 practitioners. The survey responses totalled 859–—providing an initial response rate of 33%. This initial response rate is considered to be artificially low as a product of the 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 of the 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 of homoeopaths 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 of a series of titles best describes their practice: • 489 practitioners (62%) identified herbalism as one of their practice descriptors. • 604 practitioners (76%) identified naturopathy as one of their practice descriptors. • 54 respondents were also members of conventional and registered health professions: 3 were qualified medical specialists, 12 were general
19
Table 1 Titles selected by respondents to describe their practices. Nature of practice
Number (N = 795) (%)
Herbalist Naturopath Homoeopath Nutritionist Massage therapist Aromatherapist Bach flowers practitioner Meditation/relaxation (including yoga, qi gong) Medical specialist General medical practitioner Pharmacist Chiropractor Osteopath Physiotherapist Nurse Counsellor Psychologist Traditional Chinese Medicine practitioner Acupuncturist Other Missing
489 604 208 315 277 32 175 50
(61.5) (76.0) (26.2) (39.6) (34.8) (4.0) (22.0) (6.3)
3 12 10 6 9 1 28 59 5 20
(0.4) (1.5) (1.3) (0.8) (1.1) (0.1) (3.5) (7.4) (0.6) (2.5)
41 (5.2) 141 (17.7) 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 of allied health practitioners using one or a number of modalities 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% of the time,
Table 2 Mean percentage (with standard deviation) of practice 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 Homoeopathy Nutritional medicine Massage and tactile therapies Other
53.1 22.4 41.7 28.9 37.5
43.7 24.6 42.5 31.0 36.0
46.7 26.2 41.6 31.6 38.6
± ± ± ± ±
27.1 23.7 26.0 24.5 27.9
± ± ± ± ±
25.6 23.8 25.7 24.1 27.0
± ± ± ± ±
27.3 26.4 25.9 25.4 28.2
20
A. Bensoussan et al.
Figure 1
Number of practitioners by State, country or metropolitan location.
and herbalists regularly practising both homoeopathy and nutritional medicines. The average (mean) age of the naturopathic and Western herbal workforce was 44 years (S.D. 10.4 years). Females made up 76% of the workforce. Distribution of practitioners by State is summarised in Fig. 1. Approximately twice the number of practitioners 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) of initial and follow-up consultations (standard deviations in brackets). Total Hours spent in clinical practice per week Face-to-face contact–—initial consultation (min) Face-to-face contact–—follow-up consultation (min)
23.8 ± 13.3 23.0 ± 5.8 13.4 ± 6.3
The mean number of consultations 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 of practitioners). 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 of Western 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% of all practitioners to guide their clinical practice 50% or more of the time. A further 48% of them claimed to use diagnostic tests occasionally. Forty-seven percent of practitioners reported that they used Western medical diagnoses to guide their naturopathic or herbal medicine treatments in 50% or more of patient 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 Australia—a workforce survey
homoeopathic medicines. Approximately one half of practitioners indicated they mixed or combined 90% or more of their herbal medicines in their own clinics using standardised source material provided by suppliers.
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) Hair testing
172 (21.6)
Traditional testing Iris diagnosis Tongue diagnosis Oriental diagnosis Face diagnosis
641 454 68 130
21
Referrals between naturopathic, herbal and other practices
177 (22.3)
The use of traditional naturopathic diagnostic techniques was high with 81% of practitioners indicating they used iris diagnosis in their practices. The use of these diagnostic tools or methods in clinical practice is reported in Table 4.
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 of practitioners (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 of practitioners indicated they occasionally receive referrals from general practitioners, and a further 14% stated they occasionally receive referrals from medical specialists. Approximately one third of practitioners (30%) worked in a multidisciplinary clinical environment, and 7% of respondents indicated their multidisciplinary team included a general practitioner or medical specialist. Forward referral to another health practitioner is not as common: 7% of practitioners stated they refer on to a general practitioner in about half or more of cases, whilst 73% of practitioners stated that they occasionally refer their patients on to GPs.
Form and labelling of preparations
Clinical experience
Whilst nutritional medicines are generally prepared and provided as over-the-counter commercial formulations, there is variation in the methods of preparation and dispensing of herbal medicines and
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
Alternative testing Electro-dermal screening (e.g. LISTEN, Vega) Muscle testing Haemaview/live blood analysis Physical examination (BP, auscultation, palpation, etc.)
(80.6) (57.1) (8.6) (16.4)
94 (11.8) 160 (20.1) 95 (11.9) 493 (62.0)
Other
172 (21.6)
Missing
14 (1.8)
Self referred Advertising Professional asso. Another CM TCM Practitioner Chiropractor Osteopath GP Medical specialist Physiotherapist Pharmacist Counse. /psycho. HFS worker Nurse
0
Figure 2
5
10
15 percentage
45
60
75
Percentage of referral sources frequently, always or almost always used.
22
A. Bensoussan et al.
Table 5 Income earnings (in Australian dollars) and
percentage of gross income from practice. Income–—herbal and naturopathic practices
Total
Income ($) Less than 20,000 20,001—40,000 40,001—60,000 60,001—80,000 80,001—100,000 More than 100,000
172 137 218 72 55 30
(21.6) (17.2) (27.4) (9.1) (6.9) (3.8)
Percentage of gross income Less than 20 21—40 41—60 61—80 81—100
129 99 114 106 323
(16.2) (12.5) (14.3) (13.3) (40.6)
of clinical experience of respondents 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 of 1,900,980 consultations) in consultation fees. This does not include cost of herbal 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 of gross practitioner income. Twenty-two percent of the workforce stated they earned less than $AUD 20,000 and 45% between $AUD 20,000 and $AUD 60,000. Approximately 4% of practitioners stated they earned more than $AUD 100,000 from their herbal medicine or naturopathic practices. When asked what percentage of gross total income is derived from this practice, 16% stated their income represented 20% or less of their gross earnings, with 41% indicating it represented more than 80% of their gross earnings. Approximately half (48%) of responding practitioners felt they
were fully employed in their practice. At the time of the survey 68% of practitioners 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 of times 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 of a 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 of adverse events are extrapolated for the whole workforce, based on response rates to the survey. Therefore, an estimate of the 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 Australia—a workforce survey
23
Table 6 Adverse events identified by practitioners, which have occurred during their practice lifetimes through the use of herbal, nutritional and homeopathic medicines. Adverse events
Number of occasions reported Herbal medicine
Nutritional medicine
Homoeopathy
Mild gastrointestinal symptoms (nausea, discomfort) Severe gastrointestinal symptoms (vomiting, diarrhoea or pain) Significant skin reaction Severe fatigue Jaundice Fainting or dizziness Headache Menstrual irregularities Palpitations High blood pressure Psychiatric disturbance Hepatotoxicity (as identified by blood tests) Renal toxicity (as identified by blood tests) Significant respiratory disturbance CNS effects (e.g. numbness, palsy) Referral to medical practitioner/hospital Death Missing to all
1952
1023
178
3053
296
150
23
469
307 144 4 110 870 322 128 42 12 9
127 74 4 53 434 56 52 14 6 1
244 73 0 31 171 72 27 7 27 0
678 291 8 194 1475 450 207 63 45 10
2
1
0
3
9 17 82 0 75
8 11 14 1 97
16 5 17 0 123
33 33 113 1 295
Total adverse events
4306
2029
891
7226
Adverse events extrapolated to the total workforce*
9633
4539
1993
16165
*
Total
Based on the adjusted response rate of 44.7%.
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 of the healing process and therefore not necessarily viewed as ‘adverse’.] Approximately one third of practitioners (33%) indicated that they usually report adverse events. However, slightly less (27%) were aware of the 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 of adverse events recorded is substantial. This workforce survey suggests that practitioners will experience a significant number and wide range of adverse 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 of adverse 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 of patient 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) Adverse events per year of full-time practice Adverse events per consultation Consultations per adverse events
3760
3237
4073
1.1 (2.0) 0.0020 (0.0060) 500
1.2 (2.9) 0.0025 (0.0087) 400
1.1 (2.7) 0.0023 (0.0078) 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 of full-time practice are calculated for each practitioner responding to the workforce survey. Total adverse events reported by a practitioner are divided by the practitioner’s equivalent full-time years of practice. The mean rate of adverse events per year of full-time practice was then calculated for each respondent. The adverse events per number of patient consultations has been derived for each practitioner by dividing the total adverse events reported by that practitioner by an estimation of total 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 of practice. This calculation is less robust and assumes that the number of patients practitioners are currently seeing has remained static throughout their practice lifetime. The mean rate of adverse events per number of patient consultations was then calculated. This figure can only be used as a crude measure of the frequency of adverse events. Table 7 gives figures for these two variables for the whole of the workforce. The number of adverse events per year of full-time practice is 4073, excluding mild gastrointestinal effects. These data suggest that a full-time practitioner will experience one adverse event each 11 months of full-time practice. This figure includes adverse events related to herbs, nutritional medicines and homoeopathic medicines.
Education The reported length of undergraduate or first herbal or naturopathic qualification for practitioners ranged from 6 months to 6 years, with an average of 3.1 years. Approximately 31% of herbal and naturopathic practitioners additionally
hold non-naturopathic qualifications, with approximately one third (11%) of these 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 of practitioners are educated in and practice other traditions of herbal 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 of practitioners reported that they had been adequately or well prepared for practice in all aspects of theoretical and clinical training, except for inter-professional communications where 44% felt they were poorly prepared. In addition, 22% of practitioners felt they were poorly prepared in the area of clinical training. Participation in continuing education in naturopathy or herbal medicine was reported by 89% of the workforce. This included seminar attendance (81% of the workforce) and 24 Masters degree and PhD students. More than 80% of practitioners viewed participation in continuing education as very important. Current first-aid certification was held by 85% of the workforce.
Regulation Practitioners were invited to identify what they perceive as positives or negatives of potential government regulation of herbal medicine or naturopathic practice. Their views are summarised in Table 8. Overall practitioners perceived a more positive than negative change in professional status, standards of practice, standards of education, access to research infrastructure, practitioner income, postgraduate education, access to scheduled herbs
Naturopathic and Western herbal medicine practice in Australia—a workforce survey
25
Table 8 Practitioner perception of potential government regulation of practice (percentage of responses in
brackets).
Professional status Standards of practice Standards of education Access to research infrastructure Practitioner income Litigation Postgraduate education Patient costs Quality of herbal medicines, nutritional supplements and homoeopathics Access to scheduled herbs, homoeopathics, nutritional substances Definition of occupational boundaries Freedom of practice Medical influence on practice
Positive change
Negative change
Unsure
625 580 578 464 212 99 474 158 370
37 53 55 34 80 212 43 170 76
100 123 127 254 446 429 222 407 301
(78.6) (73.0) (72.7) (58.4) (26.7) (12.5) (59.6) (19.9) (46.5)
(4.7) (6.7) (6.9) (4.3) (10.1) (26.7) (5.4) (21.4) (9.6)
(12.6) (15.5) (16.0) (31.9) (56.1) (54.0) (27.9) (51.2) (37.9)
439 (55.2)
121 (15.2)
191 (24.0)
328 (41.3) 172 (21.6) 100 (12.6)
157 (19.7) 273 (34.3) 352 (44.3)
252 (31.7) 299 (37.6) 292 (36.7)
and products, quality of herbs and products, and definition of occupational boundaries. Practitioners were unsure of the likely effect of government regulation of practice 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. Half of the respondents reported belonging to two or more professional associations, with an extraordinarily large number of small associations (115) identified. Most practitioners (73%) estimated they are registered with six or more health insurance providers for patient rebates. Seventy percent of all practitioners hold professional indemnity insurance arranged through their professional association, with the remaining 19% arranging insurance independently. Two percent of practitioners held no indemnity insurance.
Discussion The findings of this study indicate that the practices of herbal 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 of usage reported by a recent Australian population survey of consumers of complementary medicine.1
The herbal and naturopathic workforce is predominantly female (76%), but otherwise a diverse cohort of practitioners, particularly in terms of length and nature of education 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 of equivalent full-time experience, although this varied from recent graduates to 47 years in practice. Practitioners use a wide and eclectic range of conventional and non-conventional diagnostic tests. In some cases the clinical value of these tests has not been proven. There appears to be some degree of integration with other registered sectors of the healthcare team. Approximately 8% of herbalists and naturopaths receive referrals from general practitioners or medical specialists for half or more of their patients. Eleven percent of members of the herbal and naturopathic workforce are qualified in another healthcare discipline, including general practice, medical specialty, physiotherapy, pharmacy or nursing. Importantly, 30% of practitioners reported they worked in a multidisciplinary healthcare facility. However, many practitioners (44%) felt they were poorly prepared for inter-professional communications, emphasising the importance of continuing professional education. A large proportion of patients are referred to practitioners by word of mouth. The overall number of consultations provides evidence of the high degree of utilisation of Western herbal and naturopathic practice in Australia. The wide recognition of these practices by health
26 insurers for the purposes of patient rebates (three quarters of practitioners 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 of practitioners 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 of the workforce provided by this survey may assist in the assessment of these professions’ ability to provide GST-free services after 30 June 2003. Section 195-1 of the 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 of a professional association that has uniform national registration requirements relating to the supply of the 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 of bodies that are not representative of their professions. The Committee considered that such recognition may mitigate against the development of strong, cohesive and representative professional bodies.5 The data provided in this study report the characteristics of these professions irrespective of their affiliations with specific professional associations. The number of adverse 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 of full-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 of herbal medicines than with nutritional and homoeopathic medicines. This finding is significant in terms of the current NSW-based review of the public health risks presented by the practice of various forms of complementary medicine6 and the commissioning by the Victorian Department of Human Services of a study of the risks, benefits and regulatory requirements associ-
A. Bensoussan et al. ated with the practice of naturopathy and Western herbal medicine. The risks and the adequacy of the regulatory arrangements to protect public health and safety warrant review in terms of the needs for statutory occupational regulation. The minimisation of risks should be a priority of the 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 of adverse events is required to provide a more accurate assessment of the risks involved in the practice of these disciplines. Overall, one third of practitioners reported that they notify adverse events to a variety of agencies, although it is of concern that these reports were largely provided back to the manufacturer or supplier of product rather than the Commonwealth’s Adverse Drug Reactions Advisory Committee. Adverse event reporting by the herbal medicine and naturopathy professions needs to be strengthened through appropriate centralisation of data using established processes of the Australian adverse drug reaction reporting procedures. The professions need to work with the Adverse Drug Reactions Units of the TGA to increase awareness of the reporting mechanisms amongst their members. It is interesting that practitioners reported membership of an extraordinarily large number of small associations (115). While the majority of practitioners reported membership of one of the four principal associations, the findings confirm the fragmented and underdeveloped nature of professional 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 of any potential government regulation of Western herbal or naturopathic practice. It is important to acknowledge the potential limitations of this study. All surveys are vulnerable to biased or incorrect responses. Practitioners may, for example, have over-reported the number of treatments they perform. As a retrospective survey there is also the potential for recall bias, which may have resulted in under-reporting of adverse 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 of the 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 Australia—a workforce survey sector and are being incorporated into the referral patterns and included in the practices of other registered health practitioners. In the light of the current government reviews of the CAM professions, policy decisions on naturopathy and Western herbal medicine can be better informed through a clearer understanding of the nature of these workforces.
Acknowledgements This study was funded by the National Herbalists Association of Australia and the Federation of Natural and Traditional Therapists with the financial support of the Commonwealth Department of Health and Ageing and with the collaboration of Grand United Health Fund.
27
References 1. MacLennan AH, Wilson DH, Taylor AW. The escalating cost and prevalence of alternative medicine. Prev Med 2002;35(2):166—73. 2. Bensoussan A, Myers SP. Towards a safer choice: The practice of Traditional Chinese Medicine in Australia. Sydney: University of Western Sydney, 1996. 3. Bensoussan A, Myers SP, Carlton AL. Risks associated with the practice of Traditional Chinese Medicine. Arch Fam Med 2000;9:1071—8. 4. Carlton AL, Bensoussan A. Regulation of complementary medicine practitioners in Australia: Chinese medicine as a case example. Complement Ther Med 2002;10:20—6. 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 of Health. Regulation of complementary medicine practitioners–—a discussion paper. October 2002.