Wardleetal.Chiropractic&ManualTherapies2013,21:5 http://www.chiromt.com/content/21/1/5 CHIROPRACTIC & MANUAL THERAPIES RESEARCH Open Access Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia Jon L Wardle1,2*, Davi W Sibbritt1,2 and Jon Adams1,2 Abstract Background: Chiropractic and osteopathy form a significant part of the healthcare settingin rural and regional Australia, with national registration of practitioners, public subsidies for services and highutilisation by the Australian public. However, despite their significant role inrural and regionalAustralia, therehas been little exploration of theinterfacebetween chiropractic and osteopathy and conventional primary health care practitioners in this area. The study aim was to examine thereferral practices and factors that underliereferral to chiropractors and osteopaths byrural and regional Australian general practitioners (GPs), by drawing on a sample of GPs inrural and regionalNew South Wales. Methods: A 27-item questionnaire was sent to all 1486 GPs currentlypractisingin rural and regional Divisions of General Practicein NewSouthWales, Australia. Results: A total of 585GPs responded to the questionnaire, with 49 questionnaires returned as“nolonger at this address”(response rate: 40.7%). The majorityof GPs (64.1%) referred to a chiropractor or osteopath at least a few times per year while 21.7% stated that theywould not refer to a chiropractoror osteopath under any circumstances. Patients asking theGP about CAM (OR=3.59; CI: 1.12, 11.55),GP’suse ofCAM practitioners as a major source of information (OR=4.39; 95% CI:2.04,9.41), lackof other treatment options (OR=2.41; 95% CI: 1.18, 5.12), access to a widevariety of medical specialists (OR=12.5; 95% CI:2.4, 50.0), GP’sbelief in theefficacy of chiropractic and osteopathy services (OR=3.39; 95% CI:2.19, 5.25) and experiencingpositive results from patients using these services previously (OR=1.67; CI: 1.02, 2.75) were allindependently predictive ofincreased referral to chiropractic and osteopathy services amongst therural GPs. Conclusions: There is a significant interface between chiropractic and osteopathy and Australian rural and regional general practice inNew South Wales. Althoughthereis generally high support for chiropractic and osteopathy among Australian GPs, this was not absolute and theheterogeneity ofresponses suggests that there remain tensions between theprofessions. The significant interfacebetween chiropractic and osteopathy may be due in part to the inclusion of theseprofessionsin thepubliclysubsidisednational healthcare delivery scheme. The significant impact ofchiropractic and osteopathy and general practice in rural and regional Australian healthcare delivery should serve as an impetus for increased research intochiropracticand osteopathy practice, policy and regulation inthese areas. Keywords: Chiropractic, Osteopathy,General practice, Rural healthcare, Healthservices, Referral, Interdisciplinary care, Primarycare *Correspondence:[email protected] 1FacultyofHealth,UniversityofTechnologySydney,235-253JonesSt, Ultimo,NSW2007,Australia 2NetworkofResearchersinthePublicHealthofComplementaryand AlternativeMedicine(NORPHCAM),www.norphcam.org ©2013Wardleetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited. Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page2of9 http://www.chiromt.com/content/21/1/5 Background significantreferralpatterns,withanationalsurveyindicat- Therisinguseofcomplementaryandalternativemedicine ing 60% of Australian GPs regularly (at least a few times (CAM) - a diverse group of health care practices not peryear)refertochiropractors,and23%regularlyreferto considered part of conventional medicine - has emerged osteopaths [7]. These referrals form a significant part of asasignificantpublichealthissueinAustraliaoverrecent the chiropractic and osteopathic patient load in Australia, decades, with visits to CAM practitioners accounting for with 20% of all chiropractic patients and 16% of osteo- up to half of all health consultations [1]. The professions pathicpatientspresentingviareferralfromaconventional of chiropractic and osteopathy form a significant part of medicalpractitioner[13]. the Australian CAM practitioner sector. Chiropractors Althoughtheredoappeartobehighlevelsofsupportfor are the second largest CAM profession in Australia, after chiropractic and osteopathy amongst Australian GPs, such naturopaths [2,3]. Although smaller than chiropractic, support is not uniform and significant heterogeneity in GP osteopaths were the fastest growing CAM profession in attitudes towards these professions exists. Although a na- Australia inthe ten years between 1996 and 2006[3]. Be- tional survey of Australian GPs uncovered high levels of tween them, chiropractors and osteopaths represent 45% supportamongstGPsforreferraltochiropracticandosteo- ofthe ‘primary-care capable’CAM practitionerworkforce pathic services, it also showed that a significant number of inrural andregional New SouthWales[2]. Inadditionto GPs would actively discourage patient use of chiropractic theirsignificantpresenceintermsofpractitionernumbers, (16%) and osteopathy (21%) [7]. Medical practitioner sup- both chiropractic and osteopathy professions are being in- port for chiropractic and osteopathic services may also be creasingly integrated into healthcare delivery in Australia limited to their use in specific circumstances only; such [4], with practitioners in both professions recently being distinctions were observed in a postal survey of Canadian included in the Australian national registration scheme for GPs, which uncovered high levels of GPsupport for CAM health practitioners [5], as well as consultations with incertaincircumstances(suchaschiropracticformusculo- practitionersinbothprofessionsbeingandeligibleforpub- skeletal problems) but did not infer general support (such licsubsidies(Medicare)fortheirservices[6]. aschiropracticforgeneralcare,whichwasratedthelowest GeneralpracticeisonebranchofmedicinewhereCAM ofallCAMforgeneralhealthcaretreatment)[17]. is making its presence felt, with data from Australian Research is also uncovering geographical differences in surveys indicating significant levels of referral from gen- CAM consumption both in Australian and internation- eral practitioners (GPs) to CAM practitioners [7-9]. ally, with increased use by rural populations when WhilstthesestudiesindicatethatGPreferraltootherGPs compared to their urban counterparts [18]. Previous practising CAM therapies is more common than referral studies have shown high utilisation of chiropractic and to those trained specifically in CAM modalities [9], there osteopathy services in rural and regional Australia isalsoevidenceofthedevelopmentofacloserworkingre- [12,14,19]. Additionally, in the Australian setting, the lationship between CAM practitioners and GPs [7,8]. distribution of CAM practitioners in some regional and However, CAM integration is still an evolving and highly rural areas may be as great as conventional primary contestedpracticeissuewithinprimaryhealthcare[10,11] health care providers; with chiropractor and osteopath and the trend has been towards uneven integration with numbers being 40% of the numbers of GPs in rural and different therapies attracting different levels of support regional New South Wales [2]. However, rather than re- fromGPs[7]. placing conventional providers in underserved areas, Morespecifically,chiropracticandosteopathyaremajor CAM practitioner density appears to follow conven- forms of CAM that are highly utilised by the Australian tional provider density [2,20], and patients in rural public, with surveys indicating utilisation rates estimated areas may express dissatisfaction in the level of CAM tobebetween16%and26% [12-15].Therealsoappearto services in their community as well as the level of con- be relatively high levels of support for chiropractic treat- ventional providers [21,22]. Research has also indicated ment amongst the Australian general practitioner (GP) that some CAM practitioners, such as chiropractors community (compared to other CAM therapies), with a [23] appear to have a broader scope of practice and national survey indicating 72% of GPs rate chiropractic treat a wider variety of conditions in rural areas than as moderately or highly effective while only 44% of they do in urban areas. respondents report the same of osteopathy [7]. However, Thehighlevelofintegrationofchiropracticandosteop- issues such as the medico-legal implications of referral to athy in the Australian healthcare sector, relative to other CAMprovidersmayconstitutebarrierstoreferralsarising CAM professions, has significant implications for general fromsuchhighlevelsofsupportforchiropracticandoste- practice and healthcare delivery in rural and regional opathy amongst Australian GPs [16]. Support for chiro- Australia, especially whenviewedinthe context of higher practic and osteopathy amongst Australian GPs still use of these therapies in non-urban areas. However, des- appears, in part, to have translated into practice through pitetheextensivepresenceofchiropracticandosteopathic Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page3of9 http://www.chiromt.com/content/21/1/5 practitioners, and the significant interactions that appear osteopaths, relative to other professions, in rural and re- to occur between these practitioners and conventional gional NSW specifically [2]. To minimise the effects of medical providers, there has been little research to date local variation, every rural and regional GP in Australia’s exploring the level of integration at the grass-roots or largest state(New South Wales)wassurveyed. the factors that underlie any integration of chiropractic Questionnaire data was analysed using descriptive and osteopathy in general practice in rural and regional statisticsviafrequencydistributionsandcross-tabulations. Australia. This paper provides a first step in addressing Demographic and practice characteristics of GPs who re- thisresearchgapbyexploringthereferralpatternsofGPs ferred to chiropractors and osteopaths often (at least inrelation to chiropractic and osteopathy inrural and re- monthly) and seldom or never were compared using chi- gionalNewSouthWales,Australia. square tests. Logistic regression modelling, that included all practitioner and practice characteristics variables, was Methods conducted using a backwards stepwise method of elimin- A 27-item questionnaire (Additional file 1) was mailed ation using a likelihood ratio test, to parsimoniously pre- by post to all 1486 GPs registered as practising in rural dict referral to chiropractors and osteopaths. Statistical and regional General Practice Divisions of NSW, with a significance was set at the α=0.05 level. Data were reminder card sent after two months. The questionnaire analysedusingthesoftwareprogramSTATA11. was adapted for rural and regional use from previous Australian surveys of GP attitudes, use and practices of Results CAM[7,8].Thesurvey waspiloted at the Departmentof A total of 585 questionnaires were returned completed, General Practice, School of Medicine and Public Health, with 49 questionnaires returned uncompleted as ‘no University of Newcastle, with modifications made based longer at this address’; giving a response rate of 40.7%. on feedback to ensure the instrument was clinically rele- Respondents had anaverage age between 45and 54years vant. GPs were asked about their knowledge, attitudes, and were53.5% male. Over three-quarters of respondents and practice and referral patterns to chiropractors and (77.8%,n=456)hadcompletedtheirmedicaltrainingatan osteopaths and about CAM use in their areas more Australian university. Aside from a slight over- generally. representation of women, the respondent profile was The final survey questionnaire contained 27 items broadly representative of the GP community in the study which included multiple choice and multiple response areainrelationtoaverageageandtraininglocation[25]. close endedquestions. Thesurvey had five general areas: Referral rates of rural GPs to chiropractors and the GPs’ assumptions on chiropractic and osteopathy osteopaths are shown in theTable 1. One quarter (23.1%, use by patients in their area; the GPs’ personal use and n=135) of GPs referred to a chiropractor or osteopath at knowledge of chiropractic and osteopathy; the GPs’ pro- least once per month, witha further 41.0% (n=240) refer- fessional relationship with chiropractic and osteopathy ring a few times per year. Most GPs were either actively practice and practitioners; the GPs’ information seeking referring to chiropractors and osteopaths, or would con- behavioursonchiropractic andosteopathy, and;theGPs’ sider referring in the right circumstances, however ap- specific opinions on chiropractic and osteopathy. GPs proximately one-fifth (21.7%, n=127) of GPs stated that were also asked for demographic and practice informa- theywouldnotrefertoachiropractororosteopathunder tion such as gender, age, number of years in practice, lo- any circumstances. Most GPs were aware of local cation of practice, number of patients seen per week and chiropractorsand osteopathsin their area, withonly 2.2% country ofgraduation. Ethical approvalfor the study was ofrespondentsunabletoidentifypractitionerstoreferto. obtained from the School of Population Health Research Some GPs also perform chiropractic or osteopathic Ethics Committee of the University of Queensland techniques themselves, with 10.4% (n=61) identifying (JW130508) and the Human Research Ethics Committee that they had performed manipulative therapies on a oftheUniversity ofNewcastle(H-2008-0344). Table1ReferralratesofruralGPstochiropractorsand Rural and regional areas were defined by their classifi- osteopathsinthepast12months(n=585) cation in the Rural, Remote and Metropolitan Area Atleastweekly 45(7.7%) (RRMA) classifications [24]. The RRMA classification categorises areas based on population and remoteness as Atleastmonthly 90(15.4%) large or small metropolitan (1–2), large, small and other Afewtimesperyear 240(41.0%) rural centres (3–5); and remote or other remote (6–7). Ihavenotreferredbutwouldconsider 70(12.0%) Rural and regional NSW was chosen as the study area Iwouldneverrefer 127(21.7%) due to research indicating high use of chiropractic and Idonotknowofanypractitioners 13(2.2%) osteopathy in rural Australia [12,14,18,19], and further Noresponse 0(0%) research indicating high prevalence of chiropractors and Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page4of9 http://www.chiromt.com/content/21/1/5 patient during the past 12 months (data not shown). patients askingabout CAM (p<0.001), personal CAM use One-fifth (21.2%; n=124) of GPs had a personal profes- bytheGP(p<0.001),patientrequestforreferral(p<0.001), sional relationship with a specific individual chiropractor not having other options available (p=0.005), having had or osteopath. More GPs had professional relationships positive results with chiropractors or osteopaths previ- with individual chiropractors (18.4%, n=108) than with ously (p<0.001), using CAM practitioners as a major individualosteopaths (5.6%, n=33). sourceforCAMinformation(p<0.001),usingpatientsasa Table 2 shows a comparison between GPs who referred major source for CAM information (p=0.001), belief in to a chiropractor often (at least weekly or at least theefficacyofchiropracticorosteopathy(p<0.001),having monthly) and seldom (less than a few times per year or prescribed CAM previously to patients (p<0.001) and never) by demographic characteristics. GPs were signifi- beingcomfortablewithreferraltoachiropractororosteo- cantlymorelikelytorefertoachiropractororosteopathif path(p<0.001). they had a high (over 151 patients per week) patient load (p<0.001). There was no significant association between Predictivefactors referral to a chiropractor or osteopath and sex, age, level The result of multiple logistic regression modelling to of rurality, nation of graduation from medical school and determine independent predictive factors for referring to whethertheyhadinitiallycomefromaruralarea. chiropractors and osteopaths is shown in Table 4. GPs Table 3 shows a comparison between GPs who referred who believed in the efficacy of chiropractic or osteop- toachiropractoroften(atleastweeklyoratleastmonthly) athy were 3.39 (95% CI: 2.19, 5.25) times more likely to and seldom (less than a few times per year or never) by refer to a chiropractic or osteopath at least once per other factors. Referral to a chiropractor or osteopath was month than those who did not. GPs who had seen posi- significantly associated with level of knowledge about tive results from chiropractic or osteopathy previously chiropractic or osteopathy (p<0.001), the number of were 1.67 (95% CI: 1.02, 2.75) times more likely to refer Table2Demographicandpracticecharacteristicsassociatedwithreferraltochiropracticorosteopathybyruraland regionalGPsinNewSouthWales,Australia(n=585*) Referraltochiropracticorosteopathy Demographiccharacteristics Weeklyormonthly Seldomornever p-value % % Sex Male 50.9 58.1 0.096 Female 49.1 41.9 Age 25-34 8.3 10.0 0.539 35-44 21.3 21.9 45-54 37.6 38.1 55-64 26.7 21.4 >65 6.1 8.6 RRMA 3 27.5 30.0 0.067 4 45.6 34.8 5 23.5 28.1 6 3.5 1.4 7 0.0 5.7 Australiangraduate? Yes 77.6 78.6 0.786 No 22.4 21.4 Initiallyfromaruralarea? Yes 36.3 25.2 0.066 No 63.7 74.8 Patientload(perweek) <50 17.3 13.8 0.001 51-100 35.5 37.1 101-150 24.8 38.6 151-200 16.5 5.7 >200 5.9 4.8 *exceptforRRMA,wheren=579. Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page5of9 http://www.chiromt.com/content/21/1/5 Table3OtherfactorsassociatedwithreferraltochiropracticorosteopathybyruralandregionalGPsinNewSouth Wales,Australia(n=585) Referraltochiropracticorosteopathy Factors Weeklyormonthly Seldomornever p-value % % GPslevelofknowledgeofchiropracticandosteopathy Excellent 3.5 7.1 <0.001 VeryGood 15.5 11.9 Satisfactory 54.3 37.6 Poor 26.1 34.3 VeryPoor 0.8 9.1 PercentageofpatientswhohaveaskedaboutCAM <10% 28.5 47.6 <0.001 11-25% 4.1 44.8 26-50% 9.9 5.2 >50% 20.5 2.4 GP’spersonaluseofCAM Regularly 17.6 4.3 <0.001 Often 15.7 21.4 Once/Rarely 35.2 22.9 Never,butwouldconsider 15.2 9.1 Never,andwouldnotconsider 15.2 41.0 Accesstomedicalspecialistsisaproblem Yes 2.4 3.3 0.509 No 97.6 96.7 Patientrequestforreferral Yes 51.2 30.0 <0.001 No 48.8 70.0 Lackofotheroptions Yes 13.9 6.7 0.005 No 86.1 93.3 Positiveresultspreviously Yes 58.7 30.5 <0.001 No 41.3 69.5 CAMpractitionersareamajorsourceofinformationonCAM Yes 26.9 6.2 <0.001 No 73.1 93.8 PatientsareamajorsourceofinformationonCAM Yes 52.3 38.1 0.001 No 47.7 61.9 Beliefinefficacy Yes 69.3 31.4 <0.001 No 30.7 68.6 GPinterestedinincreasingCAMknowledge? Yes 57.1 51.9 0.173 No 42.9 48.1 GPhasprescribedCAMtopatientspreviously Yes 79.5 58.6 <0.001 No 20.5 41.4 CGP’scomfortlevelwithchiropracticandosteopathy Comfortableingeneral 30.9 4.8 <0.001 Onlyinspecificcircumstances 52.4 22.9 OnlyifIknewtheminperson 14.0 14.3 Iwouldnotrefer 1.9 58.1 to a chiropractor or osteopath at least once per month for CAM use were 12.5 (95% CI: 2.4, 50.0) times more than those who had not and were 2.41 (95% CI: 1.18, likely to refer to a chiropractor or osteopath more than 5.12) times more likely to often refer if they perceived once per month than those who did. No demographic there were no other options available. GPs who factors were predictive for referral to chiropractors or perceived access to medical specialists not being a driver osteopaths. Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page6of9 http://www.chiromt.com/content/21/1/5 Table4PredictivefactorsforreferralbyGPstochiropracticandosteopathyatleastoncepermonthbyruraland regionalGPsinNewSouthWales,Australia(n=573) Factor Oddsratio 95%CI PercentageofpatientswhohaveaskedaboutCAM <10% 1.00 ─ 11-25% 2.48 1.41,4.37 26-50% 7.64 3.54,16.47 >50% 3.59 1.12,11.55 Accesstomedicalspecialistsisaproblem No 1.00 ─ Yes 0.08 0.02,0.41 Lackofotheroptions No 1.00 ─ Yes 2.41 1.18,5.12 Positiveresultspreviously No 1.00 ─ Yes 1.67 1.02,2.75 BeliefinEfficacy No 1.00 ─ Yes 3.39 2.19,5.25 CAMpractitionersamajorsourceofinformationonCAM No 1.00 ─ Yes 4.39 2.04,9.41 Discussion indicative of support for chiropractic and osteopathic Thisisthefirstfocusedexaminationofconventionalmed- treatments. Previous research on naturopaths in rural ical practitioner referral to chiropractors and osteopaths Australia, for example, indicates that although patients in rural and regional Australia. Our study findings show have a high level of support for CAM services, rural that a significant level of interaction exists between GPs patients are often unable or unwilling to pay fully out-of- and chiropractors and osteopaths in this area. The high pocket costs associated with these services, and actively prevalence of personal professional relationships and re- seek more cost-effective ways to access the advice of ferralbetweenGPsandchiropractorsandosteopathsmay CAM practitioners [27]. With the introduction of other beindicativeofhighpresenceofpractitionersinthestudy CAM professions into Australia’s national regulation area, as previous research has identified chiropractor and scheme(Chinesemedicinehasalreadybeenincludedfrom osteopath numbers around 40% of GP numbers in rural July 2012, and naturopaths have been recommended for andregionalNewSouthWales[2]. later inclusion [28]), there may be pressure to publicly However,thehighlevelofprofessionalrelationshipsand subsidise these services as well, removing the current referral amongst GPs with chiropractors and osteopaths monopoly chiropractors and osteopaths regarding may also be related to formal referral arrangements that publicly-subsidisedCAMservicesinAustralia. exist for chiropractic and osteopathic services in the However, the issue of how government reimbursements Australian public health care system. Chiropractic and orformalizedarrangementsaffectreferralpatternsbetween osteopathic patients are eligible to receive a subsidy of conventional and specific CAM providers has not been $51.95 from the Australian government when referred by exploredindepth.Suchexplorationmaybewarranted,par- a medical practitioner under the MedicareExtendedCare ticularly as chiropractic more than any other profession Plan (MBS Item Numbers 10964, 10966, 81345 and appears to be driving high CAM practitioner use in rural 81350;figures correct as at August2012) [26]. This inter- areasinAustralia[12,14].WhetherpatientrequeststoGPs pretationissupported bythefindingsofthisstudy,which (andsubsequentreferralsbyGPs)arespecificallyforchiro- show that the numbers of patients enquiring with their practic and osteopathy services, or whether the formalised GPaboutCAMisasignificantpredictivefactorforGPre- arrangementsmeanthatchiropractorsandosteopathssim- ferraltochiropractorsandosteopaths. plyprovideaconvenientavenueforGPstorefertoaCAM Chiropractors and osteopaths are currently the only provider, will have a significant impact on which services CAMpractitionerseligibleforsuchsubsidiesinAustralia. GPschoosetorefertoasmorepractitioneroptionsbecome Formalised arrangements and subsidies for chiropractic available.ThefindingfromthisstudythatGPswhorelyon and osteopathic services may therefore provide a cost- CAMprovidersasmajorsourcesofCAMinformationmay effectiveavenue(fromthepatient’sperspective)forGPsto not only indicate higher levels of interaction with CAM explore CAM approaches to healthcare when such providers amongst referrers than non-referrers, but also referralsarerequestedbypatients,ratherthanbeingsolely that GPs are willing to communicate and refer to a broad Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page7of9 http://www.chiromt.com/content/21/1/5 variety of CAM practitioners beyond chiropractors and Rural and regional issues associated with patient CAM osteopaths.Withmedicalreferralscomprisingnearlyone- use and practice may also affect chiropractic referral, as fifth the patient load for Australian chiropractors and somecommentatorshavesuggestedthathigherCAMuse osteopaths [13], increasing subsidised access to other in rural and regional areas may be related to lower levels CAM professions could have significant impacts on ofconventionalhealthcareproviders(e.g.specialists,allied the professions of chiropractic and osteopathy, with health) in theseareas[35].Althougha lack of othertreat- reductions in referrals one possible scenario as GPs share ment options for patients was predictive of increased their formal CAM referrals amongst a broader range of referral rates to chiropractors and osteopaths by rural practitioners. Whilst this may benefit patients in terms of and regional Australian GPs in our study, limited access improvedaccesstoabroaderrangeoftherapeuticoptions, to medical specialists was in contrast predictive of itcouldalsoposeprofessionalchallengestothechiroprac- lower levels of referral. As such, increased referral to ticandosteopathycommunities. chiropractorsand osteopathsmayberelated more toGPs Although our study results suggest that chiropractors referring to CAM after exhausting their own treatment andosteopathsmaybelargelyacceptedbythemajorityof options for patients, rather than serving as alternative re- the Australian rural and regional GP community, our ferral recipients when specialist treatment is sought. This findings also help identify remaining tensions between may be partly related to previous study findings that conventionalmedicineandthetwoCAMmodalities,with have suggested that rather than replacing conventional one-fifth of GPs maintaining that they would never refer practitioners in areas of high need, CAM practitioner to a chiropractor or osteopath under any circumstances. density often follows that of conventional practitioners, Thisfindingmirrorsthoseofapreviousnationalsurveyof with areas of high service need experiencing shortages in Australian GPs which indicated both significant levels of both conventional and CAM practitioners [2,20]. Add- support for, and opposition to, chiropractic and osteop- itionally, although previous large-scale surveys have athy referrals amongst the Australian GP community [7]. highlighted a lack ofaccesstoordissatisfactionwithcon- SuchtensionshaveachievedrecentattentioninAustralia, ventionalmedicalservicesasassociatedwithhigherCAM withcallsfromwithintheconventionalmedicalsectorfor use, such studies have also uncovered dissatisfaction in chiropracticandosteopathicpracticetoreceivenofurther CAMserviceproviderprovisioninruralareas[21,22].Ra- mainstream medical attention [29]. Findings from this ther, other historical and cultural drivers (such as positive study suggest that such ideologically opposed views to community connections, rural patient’s increased inde- chiropracticandosteopathydonotseemrepresentativeof pendence and stoicness, underlying community affinity the majority of medical practitioners in our study area. forholisticprinciplesandincreasedvalueofruralpatients However, significant tensions between the professions do on experiential over empirical forms of evidence) may be highlighttheneedforfurtherdetailedresearchintofactors pushfactorsforCAMusebyruralpopulations[18],which that influence conventional practitioner opinion on CAM in turn may increase patient requests for CAM services professionssuchaschiropracticandosteopathy. andreferralsforGPsinruralareas. However, other factors beyond ideological or profes- The high prevalence of professional relationships with sional opposition may also result in GPs being unwilling individual practitioners may also be partly related to the to refer to chiropractors and osteopaths, even if they ex- rural and regional nature of the sample in this study, as hibit positive attitudes towards the professions. Medico- smaller communities may facilitate increased interaction legalconcernsrelatingtoGPreferraltochiropractorshave betweenCAMandconventionalproviders[18,19,36].This been disseminated to the practice community via a num- may facilitate an increased level of referrals by rural and ber of high profile court cases [16,30,31] and such regional GPs as compared to their urban counterparts. concernsmaybeexacerbatedbythefocusofmedicalpro- Further investigation of referral patterns in the broader fessional literature to the risks associated with CAM, ra- GPpopulation,orcomparativeworkwithurbanGPs,will ther than broader discussions of efficacy [32]. Indeed, assist in further ascertaining what role, if any, geographic previous Australian surveys of GPs have highlighted pa- factors such as the level of rurality have on the interface tientriskasamajordeterminantofGPopiniononCAM, betweenCAMandgeneralpractice. often more than efficacy [7,8,33,34]. Further exploration Though limited to one state (New South Wales), the of factors that make GPs less willing to refer to CAM large and varied study area was chosen to be broadly practitioners (including osteopaths and chiropractors), as representative of Australian rural and regional general well as those factors that predict referral, would assist in practice demographics [25]. Nevertheless, the demo- providing further insights into the interface between graphics of the GPs in this study compared to national CAM and general practice, the impact of CAM on pri- statistics (being as they are drawn from rural and re- mary health care, and the role that chiropractic and oste- gional areas and exhibiting a higher proportion of opathycanplayinthebroaderhealthcaresystem. females) should be considered in generalising the Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page8of9 http://www.chiromt.com/content/21/1/5 study’s results to the broader Australian general prac- References tice population. 1. XueC,ZhangA,LinV,DaCostaC,StoryD:Complementaryand AlternativeMedicineUseinAustralia:ANationalPopulation-Based Other limitations of the study, in common amongst Survey.JAlternComplementMed2007,13:643–650. other questionnaire studies, include the use of self- 2. 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