The costs of medical care continue to spiral in developed countries. The situation is unlikely to get better in the future, with further technological developments such as gene therapies, new drug classes, immunodiagnostic and therapeutic devices in the midst of an ageing population that will consume an ever-greater proportion of health care resources. Yet, according to integrative doctors such as Professor Avni Sali, there appear to be justifiable concerns about whether these burgeoning health care costs are actually delivering better health outcomes for our community. In addition, evidence is mounting that a more wholistic approach to primary care, integrating complementary medicine with conventional practice has great potential to reduce both these problems.

Complementary medicine may be defined as 'diagnosis, treatment and/or prevention that complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy and by diversifying the conceptual frameworks of medicine.' [1] The term 'alternative medicine' tends to indicate that it is not integrated with mainstream medicine and that the patient must choose one or the other. The term 'complementary medicine' is preferable, as it promotes a cooperative relationship leading to improved health care for an individual patient.

General practice can learn from complementary medicine. A survey in the UK [2] found that patients chose complementary medicine for four main reasons:

• Dissatisfaction with conventional medicine
  
• Lack of holism in conventional medicine
  
• A greater sense of self-control
  
• Support in chronic illness.

While GPs are trained and encouraged to provide this approach to all their patients, the statistics would indicate that many GPs can improve in these areas by undertaking further education and training and by accessing appropriate resources to improve their understanding of appropriate applications of complementary medicine as well as limitations and potential dangerous interactions.

The trend towards integrating evidence-based complementary medicines into conventional medicine is growing in the western world.

In 2001, the Royal Australian College of General Practitioners (RACGP) survey showed that, 43% of urban and 43% of rural patients reported attending complementary medicine practitioners. [3] While some forms of complementary medicine have been around for centuries, there have been substantial changes in its scientific base and organisational structure. Such changes have led to increasing integration with conventional medicine. A potential result of this change is that similar clinical, scientific and regulatory standards could be applied to all forms of primary health care.

It is now recognised that public spending on complementary medicines within developed nations far exceeds the patient contribution for all pharmaceutical medications. [5] These trends are consistent in the United States, which suggests that use of complementary medicines is increasing. Between 1990 and 1997 expenditure on these therapies in the US increased by 45.2%, with the total of over US$21 billion exceeding out-of-pocket expenditures for all US hospitalisations. Furthermore, visits to practitioners of complementary medicine exceeded the total of visits to all US primary care physicians. [6]

Similarly, use of complementary medicines by Australian General Practitioners (GPs) is increasing. Surveys have estimated that between 30-40% of GPs practice a complementary medicine and over 75% formally refer their patients for such medicines. [7,8] It is also estimated that over 80% of Australian GPs think it appropriate for GPs to practice therapies such as hypnosis, meditation and acupuncture and that most GPs desire further training in various complementary medicines. [8] This interest is supported by the forming of links between the Australasian Integrative Medicine Association, the Royal Australian College of General Practitioners and the Australian Medical Association's Advisory Committee on Complementary Medicine as well as the introduction of teachings in complementary medicine in undergraduate medical courses and the development of new postgraduate courses to train doctors in various modalities.

The increased interest in complementary therapies by both doctors and patients is paralleled by an increasing support for these therapies by government. In Australia, the government has provided these therapies with formal recognition by establishing an Office of Complementary Medicine as part of the Therapeutic Goods Administration, and the Victorian Government is the first outside of China to regulate the practice of traditional Chinese medicine.

Australian Institute of Health and Welfare statistics show that Australians spend around $1 billion annually on complementary medicines which include vitamin supplements, homeopathic medicines and traditional Asian and indigenous medicines.

In November 2006, the Australian Commonwealth Government announced a $5 million funding program through the National Health and Medical Research Council (NHMRC) to investigate the use and effectiveness of complementary medicines. [11]
This new funding is in addition to the Commonwealth Government's recent $529 million investment in NHMRC grants for health and medical research.

In the USA, individuals spend more than US$35 billion on complementary medicines. This includes herbal, vitamin and diet products, relaxation therapy, massage, spiritual healing, self-help groups, folk remedies, homeopathy, hypnosis, biofeedback, acupuncture and books and classes.

About 58% of Americans who used complementary medicines treatments paid for these services themselves, since they were not covered by health insurance or health maintenance organisations. [12]

Nearly 60% of people using complementary medicines were seeking to prevent illness or maintain health; only 42% were using complementary medicines to treat an illness. Chronic conditions such as back and neck problems, anxiety, arthritis and headaches were the most common reasons given for using these medicines. As in Australia, those who used complementary medicines in the USA were mainly female with a university education, aged 35-49 and of higher socioeconomic status.
The total spends on complementary medicines and therapies in Australia are in excess of $2.3 billion per annum.

Despite moves to support complementary medicines, it often seems that there are two healthcare systems- conventional and complementary that operates in parallel without much interaction. It is estimated that out of the patients who go to complementary practitioners, over 70% do not inform their doctor they are doing so.[9] This lack of communication about complementary medicines is potentially hazardous as it raises the possibility of treatment interactions and indicates a deficiency in the doctor-patient relationship. This is even more significant when it is considered that 83% of people seeking complementary treatment for "serious medical conditions" were found to be receiving treatment from a medical doctor for the same condition. [9]

The term "integrative medicine" can be seen to describe medical practice that aims for a balance between its complementary aspects. Thus, integrative medicine balances art and science, supportive and curative therapies and aims for a true partnership model whereby the practitioner avoids a paternalistic attitude and fully involves the patient in decision making and the implementation of their therapy. As well as describing medical practice that is balanced, the practice of integrative medicine can also be seen to involve principles for choosing between different interventions. Thus, "complementary medicines" may be integrated into medical practice by considering principles that include the Hippocratic ethic of "first do no harm", respect for patient autonomy and informed consent as well as the treatments practicality, cost effectiveness, evidence of efficacy and applicability. When medicine is practiced by applying a consideration of these principles in the full context of a person's life, it may be said to be "wholistic".

With integrative medicine becoming widely supported, the achievement of a truly integrated practice requires collaboration across all medical disciplines as well as support from government and professional organisations. This is slowly happening and recently organisations such as the Australian Medical Council have stated that a "wholistic, integrative approach is a prerequisite for best orthodox practice" [10] and the RACGP have advocated a "whole-person, integrated approach". Certainly, the practice of integrative medicine is fully compatible with current best practice and it is likely that in the future this type of practice will be simply considered "good medicine".

It is therefore obvious that health professionals can no longer ignore the rising interest in complementary medicine by their patients.

The growth of complementary medicine poses a range of dilemmas for the medical profession.

GPs are mainly involved in doing short consultations, where they write prescriptions, order investigations and refer to specialists. There is an enormous opportunity for doctors to expand their services by offering scientifically validated complementary medicine modalities in their treatment armamentarium.

It is essential that doctors, especially GPs but also specialists, have some understanding of what, on average one-half of their patients are doing. Doctors who are familiar with complementary medicine modalities can be regarded a more completely educated in general medicine and are more likely to discuss complementary medicine options with their patients in a non-judgemental way.
Doctors will be better able to serve their patients by integrating the science of conventional medicine with the science of complementary medicine. It is becoming increasingly more necessary for doctors to be educated in integrative medicine; otherwise their patients will go elsewhere. In fact, not only in the USA but in Australia, it is reported that more members of the public visit a complementary medicine health professional than a doctor.

There are, however, clear pointers about the way in which the profession may start to come to terms with the area.

It is important to recognize that complementary medicines and some therapies are well established and increasingly being used by the public. It is expected that such use will continue to increase.

Evaluation of a range of complementary medicines and therapies is currently being carried out by researchers using scientific methodology. In the near future, evidence based use of such medicines and therapies will be supported by high quality research. At the same time, training in certain complementary therapies will be increasingly undertaken by universities and integrated into medical education.

This was emphasised by the Australian Medical Association (AMA), past Federal President, Dr Kerryn Phelps at the AMA National Conference 2001.

"..as evidence emerges that some complementary medicines are effective, then it becomes ethically impossible for the medical profession to ignore them.

The basis of judgement must be on the basis of evidence concerning safety, quality and efficacy. If such products are being widely used then it becomes dangerous to ignore the potential beneficial or adverse effects when used in conjunction with mainstream (conventional) medicines or in conjunction with other herbs. On the other hand, if the evidence does not support the use of particular complementary medicines to therapies, it is crucial that consumers and practitioners - both mainstream and complementary - are informed." [13]

Practitioners must be aware of both situations in which complementary medicines provide potential benefits to patients as well as those where there may potentially be adverse reactions or interactions with prescription drugs. Complementary medicines must be judged on an evidence basis and medical practitioners can no longer make judgments based on prejudice either for or against complementary medicine.

Throughout Europe, complementary medicine has been very popular in the community and also the medical profession. Several of these medicines, especially herbal medicine and homeopathy, are a significant part of medical practice in Europe and have been established for many years.
There has been a gradual introduction of complementary medicine teachings in various medical schools in Australia, Europe and the United States. The British Medical Association has encouraged the incorporation of complementary therapies into the medical undergraduate curriculum and postgraduate training. [14] Furthermore, the British Medical Association is in favour of doctors working with accredited complementary medicine practitioners. The European Parliament is working towards guaranteeing the status of various forms of complementary medicine in the 15 European Union member countries. The Health Ministries of Singapore and Malaysia have established national policy to integrate traditional Chinese medicine within mainstream medical practice for a complete approach to community health care.

It is crucial that governments around the world fund research in complementary medicine. We need to find out exactly how much the practice of integrative medicine can save the community. We also need to find out what percentage of patients who see their family doctors do so because they want to prevent illness, and also what percentage of the public consults complementary medicine practitioners compared with consultations with GPs.

The peak body organizations seek with interest the increasing level of scientific research being undertaken in the areas of complementary medicine. Scientific evidence provided by such studies has the potential to lead to further integration of primary health care to the point where patients do not have to make a choice. Patients can then openly discuss any and all potential modes of diagnosis, treatment and prevention with their GP and complementary medicine practitioner.

As indicated in this article, the implementation of integrative medicine in professional practice presents a number of issues for the health professional so that the best advice and treatment can be provided to the patient.

Below is some valuable resources and associations which specialise in integrative medicine that is recommend for all health professionals, educators and students to review for their further reference.

IMgateway.net ( www.imgateway.net )

IMgateway is currently accessed by over 6,000 General Practitioners, Allied Health Professionals and students, including the following leading organisations, Australasian Integrative Medicine Association (AIMA), Medical accredited medical education providers, the Western Australian General Practice Education and Training organisation (WAGPET), the Victorian Metropolitan Alliance (VMA), Victoria Felix (VicFelix), Epworth Hospital and The Prince Charles Hospital Health Service District.

IMgateway provides members with access to a wide range of flexible and easy-to-use services including-

• Over 3,000 detailed scientific monographs that uniquely present both conventional and
  
• complementary treatment strategies
  
• Evidence based information collected from over 3,000 industry-standard sources, including over
  
• 700 medical and complementary journals
  
• Regularly updated monographs, which include 350 conditions, 300 herbs, 250 supplements
  
• drug-nutrient depletions, herb-drug and supplement-drug interactions
  
• Peer-reviewed information by 90 medical and complementary medicine practitioners
  
• 3,000 Patient information sheets

In addition, IMgateway is supported by leaders in the field of complementary medicine including-
Prof Marc Cohen, Department of Complementary Medicine, RMIT University, Lesley Braun, Leading consultant/Lecturer & Naturopath/Pharmacist and Prof Avni Sali, Director, National Institute of Integrative Medicine.

The Australasian Integrative Medicine Association (AIMA) Inc. ( www.aima.net.au )
The Australasian Integrative Medicine Association (AIMA) Inc. is a national, voluntary non-profit organisation. Our members consist of medical practitioners who provide holistic health care for their patients - integrating Western medicine with complementary medicine. Associate members include allied health professionals including physiotherapists, nurses, dieticians, pharmacists and other health professionals. AIMA is officially affiliated with the Victorian AMA (Australian Medical Association) and the Graduate School of Integrative Medicine at Swinburne University and is recognised as a special interest group by the RACGP (Royal Australian College of General Practitioners). AIMA is widely recognised as a responsible authority in holistic, complementary and integrative medicine and as an organisation that has been in existence for over ten years, AIMA has made steady progress in establishing credibility in the field of Integrative Medicine.
AIMA seeks to provide:

• A support network and forum for practitioners interested in integrative medicine.
  
• Provision of a website including a public referral service.
  
• A regular international conference.
  
• Publication of a regular Journal (JAIMA)
  
• Representation for members to medical institutions (AMA, RACGP, HIC, etc.)
  
• Promotion of high standards of professional ethics, competence and conduct.
  
• Networking with medical and government organisations to promote the practice of integrative medicine.
  
• Facilitation of education through seminars, CME meetings, workshops etc.
  
• Support for research in integrative medicine.
  
• Member's benefits such as discounts on annual conference, products, insurance, finance etc
  
• The National Institute of Integrative Medicine (NIIM) ( www.niim.com.au )

The National Institute of Integrative Medicine (NIIM) aims to bring together teaching, research and the practice of Integrative Medicine and its allied activities with the objectives of facilitating improved understanding of the utilisation, safety and limitations, evaluation and development of complementary and alternative medicine (CAM) to mainstream medicine. The Institute is the outcome of many years of expertise gathered from the management of the Graduate School of Integrative Medicine (GSIM) originally located at Swinburne University . This Institute has achieved significant support from researchers and practitioners in a collaborative effort to promote research and education in Victoria and Australia generally on numerous facets associated with Integrative Medicine.

NIIM seeks to expand the original mission of GSIM and achieve the following aims:

• To establish quality assurance teaching programs for medical professionals and other allied health personnel
  
• To contribute to and support the development of an education and a research culture in CAM which observes the highest ethical standards,
  
• To facilitate collaborative research into Integrative Medicine, drawing on expertise in CAM and in research methodology,
  
• To source funding for CAM research and disseminate research findings and to assure students and prospective research industry partners of the highest possible standards, in particular in herbal and other natural medicines,
  
• To disseminate information about Integrative medicine to those involved with healthcare delivery in all disciplines, researchers, regulatory authorities and the public,
  
• To establish a wellness clinic that will provide integrative medical care for the best possible health.
  
• To continue building on our existing education and research activities - to further enhance our innovative reputation.

The NIIM belongs to a network of partners from around the world including Asia, Europe, the Middle East and the United States of America. This network provides the backbone structure of NIIM teaching and research capabilities.