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Complementary therapies: have they become accepted in general practice?

Marie V Pirotta, Marc M Cohen, Vicki Kotsirilos and Stephen J Farish
Med J Aust 2000; 172 (3): 105-109.

Complementary therapies: have they become accepted in general practice?

Marie V Pirotta, Marc M Cohen, Vicki Kotsirilos and Stephen J Farish

MJA 2000; 172: 105-109
For related articles see Lewith and Newell

Abstract - Methods - Results - Discussion - Acknowledgements - Disclosure - Authors' details
- - More articles on complementary medicine

Abstract Objectives: To describe Victorian general practitioners' attitudes towards and use of a range of complementary therapies.
Design: A self-administered postal survey sent to a random sample of 800 general practitioners (GPs) in Victoria in July 1997.
Participants: 488 GPs (response rate, 64%).
Main outcome measures: GPs' knowledge; opinions about harmfulness and effectiveness; appropriateness for GPs to practise; perceived patient demand; need for undergraduate education; referral rates to complementary practitioners; and training in and practice of each therapy.
Results: Acupuncture, hypnosis and meditation are well accepted by the surveyed GPs, as over 80% have referred patients to practitioners of these therapies and nearly half have considered using them. General practitioners have trained in various therapies -- meditation (34%), acupuncture (23%), vitamin and mineral therapy (23%), hypnosis (20%), herbal medicine (12%), chiropractic (8%), naturopathy (6%), homoeopathy (5%), spiritual healing (5%), osteopathy (4%), aromatherapy (4%), and reflexology (2%). A quarter to a third were interested in training in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. General practitioners appear to underestimate their patients' use of complementary therapies.
Conclusions: There is evidence in Australia of widespread acceptance of acupuncture, meditation, hypnosis and chiropractic by GPs and lesser acceptance of the other therapies. These findings generate an urgent need for evidence of these therapies' effectiveness.

The past decade has seen a dramatic increase in the reported use of non-orthodox or complementary therapies by the public.1-4 In one year in Australia, almost half of a representative sample had used at least one non-medically prescribed complementary remedy and at least one in five had attended a non-medically trained complementary therapist.1 Further, Australians consume as much non-traditional medicine, vitamin and mineral supplements as prescription drugs.5

There is evidence that the increasing public use of complementary medicine is paralleled by acceptance among family doctors. In one region of the United Kingdom in one week, 25% of general practitioners (GPs) referred patients for complementary therapies,6 while in Canada half7 to two-thirds8 of family doctors had at some time referred patients to alternative practitioners; these studies did not explore reasons for such referral. However, patient pressure is an acknowledged factor in medical referrals,9 so willingness of family doctors to refer their patients for these therapies may not be a good measure of their acceptance of them.

Interest by GPs in training in and practising complementary therapies may give a better indication. In New Zealand, 54% of GPs were interested in further training in non-orthodox therapies,10 while in Israel 88% wanted training and 16% had trained.11 Estimates of practice of complementary therapies by GPs vary from around 16% in Canada8 and the UK,6,12 to 30% in New Zealand,10,13 47% in Holland (mainly homoeopathy)14 and up to 85% in Germany (mainly herbal medicine).15

Despite this degree of interest in and use of complementary therapies by family doctors, in the United States it has been estimated that 70% of people who attend non-medically trained complementary therapists do not inform their family doctor.3

The corresponding situation in Australia is largely unknown. At least 15% of Australian GPs practise acupuncture,16 the only non-orthodox therapy that attracts specific funding from Medicare. In this study, we describe Victorian GPs' attitudes towards and use of a range of complementary therapies.

Methods We obtained a random sample of 800 Victorian GPs who had each seen at least 1500 patients in 1996 from the Health Insurance Commission, which administers the national health insurance scheme (Medicare).

We designed an 11-page survey to investigate various aspects of GPs' interactions with the following complementary therapies: acupuncture, aromatherapy, chiropractic, herbal medicine, homoeopathy, hypnosis, meditation, naturopathy, osteopathy, reflexology, spiritual healing (eg, Reiki) and vitamin and mineral therapy. We developed the survey from the existing literature17 and by using a focus group of local GPs. After pilot testing, the survey was mailed to the 800 GPs with a reply paid envelope in July 1997. Non-responders were sent a reminder postcard and then a follow-up survey if necessary. Doctors who had left their clinic leaving no forwarding address, taken extended leave, were seriously ill, or had moved overseas, retired or died were excluded.

The study received ethical approval from both the University of Melbourne and Monash University.

The statistical analysis was performed using SAS.18 Responses were analysed to search for groupings of common levels of use/acceptance. (In all instances, for these data the 95% confidence intervals for percentages never exceed ± 4.5%.) Qualitative data from space left for comments were coded and classified by themes.

Results Thirty-six GPs were excluded according to the exclusion criteria, leaving 764 GPs. Questionnaires were returned by 488, giving a response rate of 64%. The sample was representative of Australian GPs19,20 in terms of sex, age distribution, metropolitan or rural practice location and number of patients seen per week up to 199; doctors seeing more than 200 patients per week, however, were underrepresented. There was no significant difference in age or sex between responders and non-responders.

Knowledge of complementary therapies
At least 80% of GPs reported that they knew something of acupuncture, hypnosis, meditation and chiropractic; about half knew something of herbal medicine, naturopathy and vitamin and mineral therapy; while 60%-70% had only heard of osteopathy, homoeopathy, spiritual healing, reflexology and aromatherapy.

Opinions on the harmfulness and effectiveness of complementary therapies
Most GPs agreed that the well-known therapies (acupuncture, meditation, hypnosis and chiropractic) were moderately to highly effective (see Box 1); three-quarters also agreed that chiropractic was occasionally harmful. When given the opportunity to write comments, many doctors expressed concern that complementary therapies could be harmful if a diagnosis is delayed or missed or if a proven (orthodox) therapy is neglected. Complementary therapies were considered to have a strong placebo effect. Some respondents commented that, while some therapies were effective in certain conditions, one could not generalise and effectiveness may depend upon the training and competence of the therapist. General practitioners frequently differentiated between medical and non-medical practitioners and expressed greater confidence in medically trained colleagues who practised these therapies.

Opinions on the appropriateness of GPs to practise complementary therapies and eligibility for Medicare subsidy
Box 2 shows responses to the question of whether it is appropriate for general practitioners to practise these therapies. Although chiropractic was considered occasionally harmful by 75% of general practitioners surveyed, 55% considered it appropriate for trained GPs to practise.

Doctors who agreed that it was appropriate to practise a therapy were asked whether GPs should be eligible for Medicare funding when practising these therapies. Nearly all GPs agreed that acupuncture should be funded. There was also strong support for specific funding for GPs practising hypnosis (91%), meditation (77%) and chiropractic (69%). Even the relatively unknown therapies had support from approximately a quarter of GPs for specific Medicare funding.

Teaching in undergraduate curricula
Most respondents (93%) agreed that there should be some education on complementary therapies in core medical undergraduate curricula. However, doctors were evenly divided over a five-point scale about the importance of this education for students.

Patient demand Fifty-nine per cent of GPs reported that patient demand for complementary therapies was increasing, 29% reported demand was static, and 10% were unsure. A third of doctors estimated that less than 10% of their patients used complementary therapies and another third thought that 11%-30% did. Nearly half of the GPs reported that less than 5% of their patients had asked them about complementary therapies in the past month.

Referrals for complementary therapies
Box 3 summarises GPs' responses on referrals to complementary therapists, from how they would respond if a patient suggested consulting a complementary therapist to how often they themselves refer patients to these therapists. The question did not specify whether the therapists were medically trained.

Most GPs (93%) had referred at least once and 82% had referred at least a few times a year for a complementary therapy.

Just under half of the sample referred at least a few times per year for the best-known therapies -- acupuncture, meditation, hypnosis and chiropractic. While approximately two-thirds of the general practitioners would encourage a patient who suggested consulting a practitioner of acupuncture, meditation or hypnosis, only 29% would do so for chiropractic. In the remaining therapies, GPs were twice as likely to have actually referred a patient for these therapies than to endorse a patient's suggestion to consult a practitioner.

Training and use of complementary therapies
Box 4 shows that half of the GPs expressed an interest in training in acupuncture, meditation and hypnosis and a quarter to a third in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. Nearly 20% of GPs practised one of the therapies, 8% used two therapies, 6% three, and 3% of general practitioners practised between 4 and 11 of these complementary therapies. For most of the complementary therapies, 80% or more of the GPs who trained in them practised them to some degree; exceptions were meditation (50%), hypnosis (56%), herbal medicine (62%) and vitamin and mineral therapy (64%). The practice of some complementary therapies, notably homoeopathy, vitamin and mineral therapy, naturopathy and herbal medicine, represented more than half of the clinical work for a small number of Victorian GPs.

Discussion Our survey provides the first comprehensive description of the use of complementary therapies by GPs in Victoria. As the large sample is, in nearly all characteristics, similar to Australian GPs as a whole, our findings about GP attitudes and use of complementary therapies are likely to reflect the situation across the country. Nearly 20% of GPs had used acupuncture, meditation or hypnosis, and almost half had considered practising these therapies. Over 80% of GPs had referred patients to practitioners of these therapies. A quarter to a third were interested in training in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. Further, around 5% of doctors use therapies, such as osteopathy, homoeopathy, aromatherapy and spiritual healing, which are relatively unknown to most of their colleagues.

It is interesting to speculate on the discrepancy between the number of GPs who trained in meditation, hypnosis, herbal medicine and vitamin and mineral therapy and the number who actually practise these therapies (Box 4). Possible reasons may include GP or patient dissatisfaction with outcomes, poor acceptance by patients, lack of financial reward, or difficulty accommodating more time-consuming therapies in a busy clinic.

The GPs we surveyed estimated a lower use of complementary therapies by their patients than indicated by population-based research. This may be because the portion of the population who do not attend GPs for their primary health care may attend complementary therapists, and because those who do attend GPs may be less likely to use complementary therapies.

The interpretation of our findings is limited by several possible sources of bias. We have no information on non-responders, and the 64% who did respond may have been more likely to participate because they had particularly strong positive or negative views. The effects of self-report and recall bias are also unknown. Further, we did not define the therapies listed in the questionnaire and GPs may have different interpretations of the terms used, particularly vitamin and mineral therapy.

Reviewing studies of various designs shows that Victorian doctors have similar levels of interest in training in, and of referral of patients for, complementary therapies as their colleagues in other Western countries, with the exceptions of Holland and Germany.6-8,10,12-15 However, the popularity of therapies varies. For example, the most popular therapy practised in Victoria was acupuncture, with 23% of respondents having trained, whereas only 8% of GPs in Canada8 and 4% in the UK12 had had acupuncture training. By contrast, homoeopathy, which has an established role in Europe,4 was the most popular complementary therapy practised by British GPs,6,12 but one of the least popular therapies in Victoria.

Complementary therapies may well have something to offer, but it is of concern that therapies of unproven effectiveness are apparently being accepted in mainstream general practice. Many editorials, while acknowledging that randomised controlled trial evidence is lacking for many aspects of orthodox Western medical practice, have called for quality trials in complementary therapies.21,22 The Cochrane Library is coordinating a search for randomised controlled trials of complementary therapies and is undertaking systematic reviews of therapies for specific conditions.23 Meanwhile, other reviews have found some evidence of efficacy, for example St John's wort in treating mild to moderate depression,24 acupuncture for antiemesis,25 and also an overall greater than placebo effect for homoeopathy in a meta-analysis of trials for various conditions.26

There are diverse reasons for the lack of evidence for complementary therapies. Many therapies have not been challenged before because of their long history, "natural" origins or patients' or doctors' anecdotal reports of success. In this era of evidence-based medicine, there are difficulties applying the gold standard of randomised controlled trials to therapies which are based on different and varied paradigms of health and illness. Funding for trials in "natural" therapies is also lacking. Freely available herbs cannot be patented, so there is little incentive for research, particularly if the public is buying them regardless of evidence. Lewith et al suggest that lack of structure to enhance research in complementary therapies is a barrier in Britain.27 Our experience would suggest a similar situation in Victoria.

Our findings show that general practitioners are actively using complementary therapies. Therefore, whatever the profession's attitude towards these therapies, well-designed trials, disseminated and accessible results and education are urgently needed to inform GPs' decision-making.

Further research is also required into why GPs decide to practise these therapies and why they are less likely to endorse a patient's suggestion to consult a complementary therapist than to refer themselves. The problems of compliance with and interactions between orthodox and complementary therapies are also areas where much research is needed. As our findings support those of Eisenberg et al3 that GPs may not communicate sufficiently with their patients and are not aware of their widespread use of complementary therapies, the issues of communication between doctors and complementary therapists, as well as between doctors and their patients, also need to be addressed.

Conclusions Acupuncture, meditation, hypnosis and, possibly, chiropractic may be considered to be well-accepted therapies in Victorian general practice, while herbal medicine, naturopathy, vitamin and mineral therapy, osteopathy and homoeopathy are accepted by a sizable minority of doctors. Doctors underestimate their patients' use of these therapies, which may contribute to compliance and medication interaction problems. There is an urgent need for well-designed trials to search for evidence of the effectiveness of these non-orthodox therapies, to inform doctors' and patients' use of them.

We thank Dr Jane Gunn and Dr Ngaire Kerse for advice, and Eleni Sita and Sue Vallance for assistance with data collection. Dr I Brighthope, Blackmores Ltd, Aveda, Nutrition Care Pharmaceuticals and the Australian Integrative Medicine Association contributed funding for this research.

Disclosure Those who funded this trial had no input into its design, analysis, conclusions, writing of the manuscript or the decision to submit it for publication.

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(Received 13 May, accepted 5 Oct,1999)

Authors' details
Department of General Practice and Public Health, University of Melbourne, Carlton, VIC.
Marie V Pirotta, MMed, FRACGP, Senior Lecturer.
Stephen J Farish, BSc(Hons), MEd, Biostatistician and Senior Lecturer.

Complementary Medicine Research Unit, Monash University, Melbourne, VIC.
Marc M Cohen, PhD, MB BS(Hons), Senior Lecturer.

Clayton, VIC.
Vicki Kotsirilos, MB BS, General Practitioner.

Reprints will not be available from the authors.
Correspondence: Dr M V Pirotta, Department of General Practice and Public Health, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053.

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1: Attitudes among the 488 general practitioners on the harmfulness and effectiveness of complementary therapies*





Acupuncture1 (0)76 (16%)395 (82%)93 (21%)294 (67%)41 (9%)
Chiropractic32 (7%)362 (75%)82 (17%)48 (11%)306 (70%)61 (14%)
Hypnosis1 (0) 141 (29%)305 (63%) 77 (18%)260 (60%)61 (14%)
Meditation0 10 (2%)436 (90%)124 (29%)230 (53%)41 (10%)
Osteopathy12 (3%)180 (37%)141 (29%)31 (7%)138 (32%)114 (26%)
Herbal medicine20 (4%)262 (54%)144 (30%)14 (3%)128 (30%)199 (46%)
Naturopathy16 (3%)200 (42%)165 (34%)19 (4%)125 (29%)191 (44%)
Vitamin and mineral therapy11 (2%)214 (45%)182 (38%)22 (5%)94 (22%)224 (52%)
Spiritual healing (Reiki)8 (2%)57 (12%)199 (41%)12 (3%)83 (19%)123 (28%)
Homoeopathy13 (3%)143 (30%)188 (39%)10 (2%)72 (17%)217 (50%)
Aromatherapy3 (1%)22 (5%)313 (65%)5 (1%)67 (16%)215 (50%)
Reflexology12 (3%)47 (10%)198 (41%)4 (1%)31 (7%)207 (48%)

*Many GPs offered no opinion, resulting in some missing values.
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2: Opinions among general practitioners about the appropriateness of GPs to practise and charge Medicare for complementary therapies


Appropriate for trained GPs to practise Should be eligible for Medicare rebates*

Acupuncture97% (419/434)91% (384/422)
Hypnosis92% (396/430)91% (364/399)
Meditation80% (342/428)77% (282/367)
Chiropractic55% (238/432)69% (207/301)
Vitamin and mineral therapy44% (184/423)54% (137/254)
Herbal medicine43% (183/427)53% (138/263)
Naturopathy28% (117/424)42% (93/224)
Osteopathy27% (113/423)44% (94/216)
Homoeopathy23% (98/424)36% (77/213)
Spiritual healing (Reiki)18% (74/422)27% (50/189)
Aromatherapy17% (73/428)24% (47/197)
Reflexology11% (48/426)22% (38/174)

*Follow-on question answered only if the therapy was considered appropriate to practise.
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3: Referral of patients for complementary therapies among general practitioners


Those who ever referred patients

Frequency of referrals

Encourage a patient's suggestion to attend% (No.)RarelyFew times a yearAt least monthlyAt least weekly

Meditation74% (374/470)80% (379/476)31% (118)40% (153)20% (76)9% (32)
Acupuncture71% (332/470)90% (424/473)24% (100)47% (199)19% (82)10% (43)
Hypnosis62% (292/470)82% (386/473)44% (168)46% (179)10% (37)1% (2)
Chiropractic29% (137/470)69% (326/476)37% (122)41% (135)17% (54)5% (15)
Vitamin and mineral therapy17% (79/469)33% (157/472)57% (90)30% (47)8% (12)5% (8)
Osteopathy16% (75/467)30% (141/476)55% (78)30% (42)11% (15)4% (6)
Spiritual healing (Reiki)14% (66/469)20% (93/476)74% (69)20% (19)4% (4)1% (1)
Naturopathy13% (62/470)30% (141/474)56% (79)26% (37)13% (18)5% (7)
Herbal medicine12% (56/469)29% (138/474)63% (87)24% (33)9% (13)4% (5)
Homoeopathy9% (43/470)20% (91/473)73% (66)18% (16)8% (7)2% (2)
Aromatherapy9% (42/471)18% (83/475)70% (58)23% (19)6% (5)1% (1)
Reflexology7% (22/470)10% (48/476)77% (37)17% (8)6% (3)0
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4: Training in and practice of complementary therapies among general practitioners


Those who practise the therapy

% Who practise

Interest in trainingHave trained*No.5%6%-24%25%-50%>50%

Meditation59% (283/477)34% (151/441)7567% (50)27% (20)5% (4)1% (1)
Hypnosis52% (246/478)20% (89/442)5078% (39)20% (10)02% (1)
Acupuncture49% (235/477)23% (102/441)9958% (59)34% (33)4% (4)3% (3)
Herbal medicine36% (169/474)12% (53/438)3361% (20)27% (9)3% (1)9% (3)
Vitamin and mineral therapy34% (160/470)23% (98/434)6346% (29)38% (24)3% (2)13% (8)
Naturopathy25% (117/476)6% (26/439)2556% (14)24% (6)8% (2)12% (3)
Chiropractic24% (112/475)8% (34/437)2976% (22)21% (6)3% (1)0
Aromatherapy17% (83/477)4% (19/438)1883% (15)16% (3)00
Homoeopathy16% (75/477)5% (23/440)2167% (14)19% (4)014% (3)
Osteopathy13% (61/475)4% (17/437)†22†68% (15)18% (4)9% (2)5% (1)
Spiritual healing (Reiki)12% (57/473)5% (21/439)1771% (12)24% (4)06% (1)
Reflexology7% (33/475)2% (9/438)†12†100% (12)000

*Includes self-taught.
†These figures, which show that more doctors use osteopathy and reflexology than have actually trained in it, reflect inconsistencies in individual responses.
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Marie V Pirotta
Marc M Cohen
Vicki Kotsirilos
Stephen J Farish