The use of complementary and alternative medicine (CAM) has emerged as an important public health issue in Australia [1, 2], with patient visits to CAM practitioners accounting for half of all health consultations, and CAM accounting for half of all out-of-pocket healthcare costs . Australian Chinese medicine practitioners (CMPs) provide approximately 15 million consultations annually, with 7.4% of Australians visiting a practitioner for acupuncture, 3.2% for Chinese manipulative therapy (Tui Na), 2.9% for Tai Chi or Qi Gong therapy, 2.3% for Chinese herbal medicine and 0.6% for Chinese dietetic therapy .
In Australia, acupuncture services are not necessarily provided by Chinese medicine (CM) practitioners practising CM principles [4, 5]. However, CM does have a long history in Australia compared to other Western countries. The arrival of Chinese immigrants during the Victorian gold rushes helped establish the CM system, which was used extensively beyond the Chinese immigrant community by 1911 . At the height of herbal medicine in Australia in the 1920s, one-fifth of all herbalists were practising CM . Acupuncture was popularised by chiropractors and naturopaths in the late 1960s, and later by conventional medical professionals [4, 8]. However, despite the long history and popularity of CM in Australia, few studies have investigated the relationship between CAM and the Australian health system [9–12].
The Australian Bureau of Statistics ranked CMPs the fifth largest groups of CAM primary care professions in Australia, after naturopaths, chiropractors, acupuncturists and osteopaths . The Chinese Medicine Board of Australia allows traditional practitioners to register as comprehensive CMPs or practice-specific practitioners (such as acupuncturists or herbalists). Among traditionally trained practitioners, comprehensive CMPs form a larger professional group than do acupuncturists: 59.5% of registrants were qualified as comprehensive CMPs, with 37.9% qualified as acupuncturists only, 1.9% solely as Chinese herbalists, and the remainder as Chinese herbal dispensers . The CM profession in Australia is growing significantly, with over one-quarter (27.3%) of practitioners entering the profession within the last 5 years . The CM profession was recently included in the Australian national registration scheme for health practitioners, with most CMP training now being offered in the public university sector .
A few Australian studies have indicated significant levels of referral to CAM practitioners by general practitioners (GPs) [9–11], suggesting the existence of working relationships between CAM practitioners and GPs. GPs tend to prefer to refer to biomedical practitioners for CAMs more than to non-medically trained CAM practitioners . Integration of CAM is an evolving and often controversial practice within the primary health care community in Australia [17, 18], and as such, there is uneven integration, with different CAM therapies attracting different levels of support from and integration by GPs  (e.g., some GPs may support some types of CAM, such as chiropractic, more than others, such as homeopathy).
Few studies have been conducted to investigate medical practitioners’ attitudes and behaviours with respect to specifc referrals to CMPs. Although acupuncture as a form of CAM appears to have good acceptance by the Australian GP community [9, 11], GPs’ attitudes to other elements of CM practice remain mixed. This may be because biomedical practitioners regard CM as being pseudoscientific and incompatible with conventional medical principles .
A national GP survey  of the use of Chinese herbal medicine and Western herbal medicine found lower levels of use in practice and referrals by Australian GPs for Chinese herbal medicine than for Western herbal medicine. However, the survey also found that GPs perceived Chinese herbal medicine as being more effective than Western herbal medicine. However, to date there has been no comprehensive or focused investigation of GP attitudes (e.g., whether GPs accept CM more than they do Western CAM) and practices in working with CMPs.
Geographical differences in CAM consumption were noticeable both in Australia and other countries , with increased use by rural populations over their urban counterparts , although a longitudinal investigation found no significant difference in acupuncture use between rural and urban Australian populations . The prevalence and use of other forms of CM in rural and regional Australia have yet to be determined. In one study, acupuncturists and CMPs represented only 11% of the ‘primary care capable’ CAM practitioner workforce in rural and regional New South Wales , which is a lower proportion than these practitioners represent in national data . CMPs may be consulted for very specific conditions; an exploratory study showed that nearly half of patients (47.1%) attending a private CM practice in rural Victoria saw the CM practitioner to treat pain, with a further 20.5% attending for fertility treatment and pregnancy management . The results of a previous national workforce investigation suggested that treatment of musculoskeletal conditions is the primary reason Australians visit a CM practitioner .
This study aimed to investigate the patterns of referrals by GPs to CMPs in rural and regional New South Wales, Australia to fill this gap in the knowledge.