In an ideal world, medical practitioners would be well versed in a broad range of modalities and would work hand-in-hand with a range of specialists and allied health practitioners, including practitioners of complementary and alternative medicine (CAM). In this ideal situation individual patients as well as the whole community would be the beneficiaries of integrated, holistic care.
It appears that medical care is slowly gravitating towards this ideal, and a number of social, regulatory, professional, ethical and scientific forces are supporting this shift. Certainly, there is an imperative for collaboration, as most GPs have chronically ill patients who could benefit from the services of CAM practitioners, and virtually all CAM practitioners have patients who require access to mainstream diagnosis and therapy.
The Australian community has embraced CAM,1 and integrated mainstream and CAM services are already available in some multidisciplinary clinics, which seem to be responding to market demands. Further abroad, in countries such as China, mainstream and so-called “complementary” medicine have long been integrated into primary care settings and hospital settings.
Throughout the western world, the healthcare environment is changing rapidly and the past decade has seen a progressive movement of CAM practices into the mainstream. In Australia this is evidenced by:
The increasing biomedical content of natural medicine courses and these courses having achieved university degree status;
The acceptance of some CAM services by private health insurance;
CAM practitioners being given GST exemption status; and
The passing of the Chinese Medicine Registration Act 2000 in Victoria,2 along with recent recommendations for other states to follow Victoria’s lead.3
Alongside the “mainstreaming” of CAM there seems to be a progressive “CAMing” of mainstream medicine. While some doctors may still remember a time when they faced disciplinary action or deregistration for engaging in what were then considered “unorthodox practices”, a 1997 survey found that nearly 20% of Australian general practitioners actively practised at least one form of complementary medicine, and almost 50% had an interest in CAM training.4 These percentages are likely to have increased as university-based courses have emerged that offer GP training in complementary therapies. Further, the Australasian Integrative Medicine Association (AIMA; www.aima.net.au), the peak body for medical practitioners who integrate CAM into their practice, has enjoyed increasing membership and attendance at its annual Holistic Health Conferences.
The integration of complementary medicine into general practice has been further enhanced by the release by the Australian Medical Association (AMA) in 2002 of a formal position statement stating that “the evidence based aspects of complementary medicine are part of the repertoire of patient care and may have a role in mainstream medical practice”, and that “medical practitioners should be sufficiently well informed about complementary medicine to be able to provide advice to patients”.5 More recently, the Royal Australian College of General Practitioners has set up a joint working party in conjunction with AIMA to review the training needs of GPs and provide an outline of how CAM can be incorporated into high quality clinical practice.6
Perhaps the greatest factor supporting the integration of complementary medicine into mainstream medicine is the growing evidence base supporting the efficacy of many CAM interventions. Indeed, there is evidence to suggest that, for some conditions, CAM may offer therapeutic benefits with little risk of adverse events and may therefore be considered as appropriate first-line treatments; an example is the use of glucosamine for osteoarthritis.7 Thus, it has been suggested that “as evidence emerges that some complementary medicines are effective, then it becomes ethically impossible for the medical profession to ignore them”.8 The increasing evidence supporting CAM has led to virtually all mainstream medical journals regularly publishing articles on CAM — and even devoting entire issues to it — as well as the establishment of many new peer-reviewed journals specifically devoted to publishing CAM research. In Australia, GPs and pharmacists are kept abreast of this evidence through the Journal of Complementary Medicine, which is distributed free of charge bimonthly to every general practice surgery and community pharmacy.
While CAM practitioners may feel threatened by doctors invading their turf, and doctors may be hesitant to collaborate with CAM practitioners, educating doctors about CAM is likely to enhance collaboration between these groups, as is the increasing biomedical education of CAM practitioners. Collaboration requires an environment of shared respect and trust, and education is needed on both sides along with time for relationships to become established and strengthened.
Recently, collaboration between doctors and CAM practitioners has been given a boost with the Australian government’s newly released MedicarePlus package. This package proposes an unprecedented rebate for allied health and CAM services when delivered to patients managed through the Enhanced Primary Care program. The government has based this initiative on evidence that “using professionals who complement GPs in care — such as with assessment, treatment management, self-management support, and follow-up — improves patient satisfaction, clinical and health status, and use of health services”.9
While there are many indicators suggesting that integrated care is both desirable and achievable, there are still obstacles. Questions remain around the credentials and regulation of practitioners, the differences in nomenclature between disciplines, equity of access in different healthcare settings, the requirements for evidence-based practice, appropriate funding models and medicolegal issues. However, these questions are not insurmountable and will be addressed in this series. Further, the very real dangers of not having integrated care (including orthodox practitioners depriving patients of safe, effective and efficient CAM therapies, CAM practitioners causing delays in their patients receiving effective mainstream diagnosis or treatment, and the possibility of harmful interactions between CAM and mainstream therapies) provide an incentive to overcome these obstacles.
Ultimately, medicine has a single aim: to relieve human suffering. When measured against this benchmark, different therapies can be seen as either effective or ineffective rather than “orthodox” or “unorthodox”. No single professional group has ownership of health, and the best healthcare requires a multidisciplinary approach. Thus, there is an imperative for all healthcare professionals to work together for the benefit of their patients and the wider community.
- Marc M Cohen
- School of Health Sciences, RMIT University, Melbourne, VIC.
Marc Cohen is the current President of the Australasian Integrative Medicine Association and receives an honorarium as a member of the Editorial Board of the Journal of Complementary Medicine.
- 1. MacLennan A, Wilson D, Taylor A. The escalating cost and prevalence of alternative medicine. Prev Med 2002; 35: 166-173.
- 2. Chinese Medicine Registration Act 2000. Available at: www.dms.dpc.vic.gov.au/Domino/Web_Notes/LDMS/PubLawToday.nsf/2184e627479f8392ca256da 50082bf3e/2782e6bc767c3b93ca256e760015ad9f/$FILE/00-18a008.pdf (accessed May 2004).
- 3. Expert Committee report: complementary medicines in the Australian Health System. Report to the Parliamentary Secretary to the Minister for Health and Ageing, 2003. Available at: www.tga.gov.au/docs/html/cmreport1.htm (accessed May 2004).
- 4. Pirotta MV, Cohen MM, Kotsirilos K, Farrish SJ. Complementary therapies: have they become mainstream in general practice? Med J Aust 2000; 172: 105-109. <MJA full text>
- 5. AMA position statement: complementary medicine (released 04/11/2002). Available at: www.ama.com.au/web.nsf/doc/SHED-5FK4U9 (accessed May 2004).
- 6. Royal Australian College of General Practitioners Online. College Fax 26 March, 2004. First meeting of the joint RACGP/AIMA (Australian Integrative Medicine Association). Available at: www.racgp.org.au/document.asp?id=12491 (accessed May 2004).
- 7. Segal L, Day SE, Chapman AB, Osborne RH. Can we reduce disease burden from osteoarthritis? An evidence-based priority-setting model. Med J Aust 2004; 180 (5 Suppl): S11-S17. <MJA full text>
- 8. AMA Complementary Medicine: policy discussion paper — AMA National Conference 2001. Available at: www.ama.com.au/web.nsf/doc/WEEN-5LN478 (accessed May 2004).
- 9. Australian Government Department of Health and Ageing, MedicarePlus Update March 2004 [cited 2004 March 15]. Available at: www.health.gov.au/medicareplus/ (accessed May 2004).
Abstract
Integrated clinics have already been established in response to community demand.
The growing evidence base for complementary and alternative medicine (CAM) and its widespread community use compels doctors to understand complementary therapies and to refer patients to CAM practitioners where appropriate.
Most general practitioners have patients with chronic illness who could benefit from the services of CAM practitioners, and virtually all CAM practitioners have patients who require access to mainstream diagnosis and therapy.
Collaboration requires shared respect and trust, and education.
Dangers of not integrating care include delaying or depriving patients of safe and effective management, and the potential for harmful interactions.
Integration is currently being supported by government initiatives such as the new MedicarePlus package, as well as by initiatives from organisations such as the Australian Medical Association, the Royal Australian College of General Practitioners and the Australasian Integrative Medicine Association.