Toward a 'green allopathy'? Naturopathic paradigm and practice in Ontario, Canada.

Epistemic tensions have long been evident within naturopathy, a heterodox healthcare occupation licensed across much of North America. Naturopaths less inclined toward bioscientific explanatory and evidentiary norms have long used the trope of the 'green allopath' to critique the practices of their more biomedically- (i.e., 'allopathically') inclined colleagues. Using the 'green allopathy' narrative as a conceptual starting point, this work uses a qualitatively-driven, mixed methods design involving interviews (n = 17) and a census-style survey (n = 366) to characterize the paradigmatic and practice patterns of licensed naturopaths in Ontario, Canada between 2017 and 2019. At odds with many interviewees' accounts, survey results suggest that the occupation's overall epistemic character, aligned with the concept of holism, has not changed much over the last two decades. Nevertheless, findings suggest notable changes in Ontario naturopaths' clinical practice patterns over the same period, including: more frequent use of botanical medicines, nutritional supplements and acupuncture; less frequent use of physical medicine (e.g., massage, hydrotherapy); and, an overall reduction in homeopathic usage. Controlling for other factors, older naturopaths are more likely to rely often on non-biomedical diagnostic modes (p = 0.042), suggesting an emerging shift, in practice, toward a 'green allopathy'. Naturopaths' widespread ongoing engagement with therapeutic modalities whose epistemic premises diverge strongly from conventional biomedicine (e.g., homeopathy, East Asian medicine), appears mediated by the increasing body of related bioscientific evidence, and by gender and age (p-values <0.05). Gender and age also significantly predict naturopaths' alignment with more pharmaceutically-oriented care (p values < 0.05). Though naturopathy's 'green allopathization' appears underway, the demographic predominance of women within the profession may temper this trend in the years ahead.

Safety, Effectiveness, and Professional Judgment: A Survey of Training-Related Perspectives Among Physiotherapists Who Practise Acupuncture in Ontario.

Purpose: Physiotherapists practise various forms of acupuncture worldwide, but no international consensus exists as to the appropriate duration of related training programs. In this cross-sectional study, we aimed to characterize the training-related backgrounds and views of acupuncture-practising physiotherapists. Method: A total of 426 physiotherapists who practised acupuncture in Ontario completed an online survey that included training-related items and an open-ended question (39 provided training-related responses). Statistical analyses included multivariate and multinomial logistical regression models. Thematic analysis was used to interpret respondents' textual responses to the open-ended question. Results: Respondents, who practised predominantly Western medical acupuncture, dry needling, or both, had completed acupuncture-related training programs ranging from < 25 to ≥ 300 hours. Those who had completed programs lasting > 100 hours were significantly more likely to self-report excellent clinical results and an enhanced ability both to recruit and retain patients and to earn a higher income. They were also more likely to endorse longer trainings as necessary for safe and effective patient care. Respondents to the open-ended question expressed a range of views, including the need for more stringent training requirements. Conclusions: PT regulatory requirements for longer (>100 hour) acupuncture trainings may better support clinical effectiveness and safety, patient satisfaction, and professional outcomes.

Objectif : les physiothérapeutes exercent diverses formes d'acupuncture dans le monde, mais il n'y a pas de consensus international sur la durée appropriée des programmes de formation qui s'y rattachent. Dans cette étude transversale, les chercheurs visent à caractériser les expériences de formation et les points de vue des physiothérapeutes qui exercent l'acupuncture. Méthodologie : au total, 426 physiothérapeutes qui exercent l'acupuncture en Ontario ont rempli un sondage en ligne qui incluait des points liés à la formation et une question ouverte (39 ont fourni des réponses liées à la formation). Les analyses statistiques incluaient les modèles de régression logistique multivariées et multinomiales. Les chercheurs ont utilisé l'analyse thématique pour interpréter les réponses textuelles des répondants à la question ouverte. Résultats : les répondants, qui exercent majoritairement l'acupuncture médicale occidentale, les aiguilles sèches ou ces deux techniques, avaient suivi un programme de formation en acupuncture variant entre moins de 25 heures et au moins 300 heures. Ceux qui avaient suivi un programme de plus de 100 heures étaient beaucoup plus susceptibles d'autodéclarer d'excellents résultats cliniques, une meilleure capacité de recruter et de conserver leurs patients ainsi que de gagner un revenu plus élevé. Ils sont également plus susceptibles de prôner une formation plus longue qu'elle est nécessaire pour donner des soins sécuritaires et efficaces aux patients. Les répondants à la question ouverte ont exprimé une variété de points de vue, y compris la nécessité d'exigences de formation plus rigoureuses. Conclusions : les exigences en matière de réglementation de la physiothérapie selon lesquelles une formation plus longue (plus de 100 heures) est exigée, peuvent mieux soutenir l'efficacité et l'innocuité cliniques, la satisfaction des patients et les résultats professionnels.

A mixed-methods survey of physiotherapists who practice acupuncture and dry needling in Ontario, Canada: practice characteristics, motivations, and professional outcomes.

BACKGROUND: Physiotherapists (PTs) across the globe are increasingly incorporating filiform needling techniques (e.g., acupuncture, dry needling) into their clinical toolkits; and, the evidence base for these complementary therapies is becoming progressively more robust. However, to date, little is known about needling PTs themselves. METHODS: Using a cross-sectional survey design, PTs authorized to perform needling therapies in Ontario, Canada were recruited for anonymous participation (n = 2061) in an online survey. The survey asked providers about their demographics and practice characteristics, rationale for and views about therapeutic needling, and their related clinical and professional outcomes. The response rate was 20.7% (n = 426), and 22.3% (n = 95) of respondents provided textual responses to an open-ended qualitative question. RESULTS: While study respondents' demographic features appear similar to their broader professional population, Ontario's needling PTs are less likely to work in public sector settings. Most completed training in medical acupuncture rather than dry needling, and typically used needling in over one-third of patient visits. Almost all endorsed needling as an effective musculoskeletal treatment, the primary factor informing their adoption of the practice. While many viewed traditional Chinese medical theories as a useful explanatory framework, most relied on biomedical epistemology to drive their needling work. A majority of respondents reported that the inclusion of needling within their clinical toolkits had improved their likelihood of achieving excellent clinical results, helped support patient recruitment and retention, and heightened their professional satisfaction. While a few reported earning a higher income as a result, most reported that their clinical use of needling in addition to other PT modalities reduced their physical fatigue after a day's work. CONCLUSIONS: This study represents a first scholarly investigation into the motivations, training backgrounds and practice patterns of PTs who use acupuncture or dry needling. Additional research from other jurisdictions is needed to evaluate the transferability of study findings.

A cross-sectional workforce survey of three traditional and complementary medicine professions in Ontario, Canada.

BACKGROUND: Workforce studies about traditional and complementary medicine (T&CM) occupations in industrialized countries are scant; and, these occupations' position within the broader occupational workforce remains unclear. This study aims to address these gaps using a comparative approach. METHODS: Naturopaths, traditional Chinese medicine (TCM) / acupuncture practitioners, and homeopaths in Ontario, Canada were surveyed regarding their demographics, practice characteristics and self-reported income. Results were compared with parallel data from within and outside of Ontario. RESULTS: Study response rate: 23.3% (n = 1205). While predominantly female (57.9%), Ontario's TCM/acupuncture profession was less feminized than the naturopathic (77.1%) and homeopathic (78.3%) groups. Naturopaths were significantly younger than, and reported fewer years of clinical experience than, the other two groups. About half of TCM/acupuncture practitioners, and almost one-third of homeopaths had trained outside of Canada, predominantly in East and South Asia, respectively. More TCM/acupuncture practitioners (58.9%) and homeopaths (57.6%) had multilingual clinical practices than naturopaths (19.1%). Homeopaths worked fewer hours and saw fewer patients per week than the other occupations. Self-reported mean incomes varied across groups, with naturopaths earning more on average ($63,834, SD $57,101) than did TCM/acupuncture practitioners ($45,624, SD $44,081) or homeopaths ($29,230, SD $41,645). Holding other variables constant, internationally-trained practitioners reported earning one-third less than their Canadian-trained counterparts. DISCUSSION & CONCLUSIONS: Study findings echo occupationally-specific data from other industrialized jurisdictions; and, affirm that different T&CM occupations have distinctive demographic and practice characteristics. The demographic makeup of Ontario's TCM/acupuncture and homeopathy occupations suggests a role for these groups in delivering culturally-responsive care within Asian ethnic communities. T&CM practitioner incomes, in particular for internationally-trained practitioners, fell below the provincial population income median, and in many cases below the poverty line. T&CM occupations' relative socio-political marginality may be impacting clinicians' ability to earn a viable living.

A Survey of Acupuncture-Providing Registered Massage Therapists in Ontario, Canada: Motivation, Training, and Practice Characteristics.

BACKGROUND: An increasing number of licensed massage therapists in several countries are providing acupuncture to their clients, but little is known about this practice. PURPOSE: To characterize the motivations, training backgrounds, practice patterns, and clinical experiences of licensed massage therapists who perform acupuncture. RESEARCH DESIGN: The study used a cross-sectional, online survey design involving acupuncture-providing registered massage therapists (RMTs) in the province of Ontario, Canada, where acupuncture is explicitly permitted within the massage therapy profession's scope. Analysis involved descriptive statistics and thematic content analysis of qualitative findings. RESULTS: The survey response rate was 33.7% (n=212), representing 25.5% of all Ontario RMTs rostered to practice acupuncture. Participant demographics mirrored the RMT profession as a whole, except that providers were, on average, several years older than other RMTs. Most respondents (72.7%) had completed over 200 hours of training in acupuncture; most training included clean needle technique (96.8%), clinical supervision (93.5%), traditional Chinese medicine content (83.4%), and a final examination (96.8%). Respondents typically used acupuncture in about one-third of their sessions (mean 32.3%, SD 5.0) with an average of 10.5 weekly clients (SD 14.3). Acupuncture-providing RMTs had been initially motivated by acupuncture's potential effectiveness for musculoskel-etal conditions (97.2%), a wish to attract more clients (61.3%), and physical fatigue from delivering manual therapies (48.3%). Most reported being more likely to achieve excellent clinical results (84.9%), experience greater professional satisfaction (79.9%), and attract or retain clients (64.8%) since using acupuncture. A minority also reported earning a higher income (34.6%) and experiencing more adverse events in practice (21.5%). Qualitative responses added explanatory nuance to numeric results. CONCLUSIONS: This study of the use of acupuncture by Ontario's licensed massage therapists represents a first scholarly account of an emerging global trend that holds promise in enhancing clinical care, professional stability, and provider longevity. Additional research is needed to investigate the practice's use in other jurisdictions, and to establish international standards for safe and effective practice.

State risk discourse and the regulatory preservation of traditional medicine knowledge: The case of acupuncture in Ontario, Canada.

Several United Nations bodies have advised countries to actively preserve Traditional Medicine (TM) knowledge and prevent its misappropriation in regulatory structures. To help advance decision-making around this complex regulatory issue, we examine the relationship between risk discourse, epistemology and policy. This study presents a critical, postcolonial analysis of divergent risk discourses elaborated in two contrasting Ontario (Canada) government reports preceding that jurisdiction's regulation of acupuncture, the world's most widely practised TM therapy. The earlier (1996) report, produced when Ontario's regulatory lobby was largely comprised of Chinese medicine practitioners, presents a risk discourse inclusive of biomedical and TM knowledge claims, emphasizing the principle of regulatory 'equity' as well as historical and sociocultural considerations. Reflecting the interests of an increasingly biomedical practitioner lobby, the later (2001) report uses implicit discursive means to exclusively privilege Western scientific perspectives on risk. This report's policy recommendations, we argue, suggest misappropriation of TM knowledge. We advise regulators to consider equitable adaptations to existing policy structures, and to explicitly include TM evidentiary perspectives in their pre-regulatory assessments.

Supportive but "worried": perceptions of naturopaths, homeopaths and Chinese medicine practitioners through a regulatory transition in Ontario, Canada.

BACKGROUND: In line with recent World Health Organization recommendations, many jurisdictions are taking steps to regulate practitioners of traditional, complementary and alternative medicine (TCAM). Previous studies have examined TCAM practitioners' generally-supportive views about professional regulation; however, little research has been conducted on TCAM practitioners' experiences and perspectives amidst an active regulatory process. In 2006 and 2007, the province of Ontario, Canada announced it would grant self-regulatory status to three TCAM practitioner groups--homeopaths, naturopaths and Chinese medicine practitioners/acupuncturists. METHODS: In 2011 and 2012, part-way through each group's regulatory process, we surveyed all practitioners from these three groups (n=1047) that could be identified from public registries and professional associations. The data presented here are derived from the sub-sample of homeopaths (n=234), naturopaths (n=273) and Chinese medicine practitioners/acupuncturists (n=181) who provided answers to an open-ended question about their opinions of the regulatory process at the end of the survey. An inductive, thematic analysis of qualitative survey responses was conducted. RESULTS: Survey responses affirmed a pro-regulatory stance across all groups, but revealed considerable 'worry' amongst practitioners as to how the regulations might be implemented. Four primary 'worry-related' themes emerged: a) regulation's potential administrative and financial burden on practitioners; b) scope-related concerns; c) implementation of fair registration standards; and d) whether regulation might erode the groups' distinctive worldviews. Some occupationally-specific concerns appeared related to each group's particular stage of professionalization. Other 'worries' may be related to the relative marginality of TCAM practitioner groups within biomedically-dominant national health care systems, and the possibility that inter-professional hierarchies may be emerging between particular TCAM groups. Specific concerns around overlapping practice scopes between TCAM and other professions raised questions about the implementation of non-monopolistic regulatory models such as Ontario's. CONCLUSIONS: Overall, this study will help inform regulators and TCAM practitioner groups to navigate the unique challenge of regulating health care providers long excluded from national health care systems, who frequently work from within paradigms distinct from mainstream biomedicine.

Reporting natural health product related adverse drug reactions: is it the pharmacist's responsibility?

OBJECTIVES: Herbal medicines and other natural health products (NHPs) are sold in Canadian pharmacies as over-the-counter products, yet there is limited information on their safety and adverse effect profile. Signals of safety concerns associated with medicines can arise through analysis of reports of suspected adverse drug reactions (ADRs) submitted to national pharmacovigilance centres by health professionals, including pharmacists and the public. However, typically such systems experience substantial under-reporting for NHPs. The objective of this paper is to explore pharmacists' experiences with and responses to receiving or identifying reports of suspected ADRs associated with NHPs from pharmacy customers. METHODS: A qualitative study in which in-depth, semi-structured interviews were conducted with 12 community pharmacists in Toronto, Canada. KEY FINDINGS: Pharmacists generally did not submit reports of adverse events associated with NHPs to the national ADR reporting system and cited several barriers, including lack of time, complexity of the reporting process and lack of knowledge about NHPs. Pharmacists who accepted responsibility for adverse event reporting appeared to have different perceptions of their professional role: they saw themselves as 'knowledge generators', contributing to overall healthcare knowledge. CONCLUSIONS: Reporting behaviour for suspected ADRs associated with NHPs may be explained by a pharmacist's perception of his/her professional role and perceptions of the relative importance of generating knowledge to share in the wider system of health care.

Roles and responsibilities of pharmacists with respect to natural health products: key informant interviews.

BACKGROUND: Although many pharmacies sell natural health products (NHPs), there is no clear definition as to the roles and responsibilities (if any) of pharmacists with respect to these products. OBJECTIVE: The purpose of this study was to explore pharmacy and stakeholder leaders' perceptions of pharmacists' professional NHP roles and responsibilities. METHODS: Semi-structured key informant interviews were conducted with pharmacy leaders (n=17) and stakeholder (n=18) leaders representing consumers, complementary and alternative medicine practitioners, conventional health care practitioners, and industry across Canada. RESULTS: All participants believed a main NHP responsibility for pharmacists was in safety monitoring, although a one challenge identified in the interviews was pharmacists' general lack of NHP knowledge; however, stakeholder leaders did not expect pharmacists to be experts, but should have a basic level of knowledge about NHPs. CONCLUSION: Participants described pharmacists' professional roles and responsibilities for NHPs as similar to those for over-the-counter drugs; more awareness of existing NHP-related pharmacy policies is needed, and pharmacy owners/managers should provide additional training to ensure front-line pharmacists have appropriate knowledge of NHPs sold in the pharmacy.

Consumers of natural health products: natural-born pharmacovigilantes?

BACKGROUND: Natural health products (NHPs), such as herbal medicines and vitamins, are widely available over-the-counter and are often purchased by consumers without advice from a healthcare provider. This study examined how consumers respond when they believe they have experienced NHP-related adverse drug reactions (ADRs) in order to determine how to improve current safety monitoring strategies. METHODS: Qualitative semi-structured interviews were conducted with twelve consumers who had experienced a self-identified NHP-related ADR. Key emergent themes were identified and coded using content analysis techniques. RESULTS: Consumers were generally not comfortable enough with their conventional health care providers to discuss their NHP-related ADRs. Consumers reported being more comfortable discussing NHP-related ADRs with personnel from health food stores, friends or family with whom they had developed trusted relationships. No one reported their suspected ADR to Health Canada and most did not know this was possible. CONCLUSION: Consumers generally did not report their suspected NHP-related ADRs to healthcare providers or to Health Canada. Passive reporting systems for collecting information on NHP-related ADRs cannot be effective if consumers who experience NHP-related ADRs do not report their experiences. Healthcare providers, health food store personnel, manufacturers and other stakeholders also need to take responsibility for reporting ADRs in order to improve current pharmacovigilance of NHPs.

Adverse event reporting for herbal medicines: a result of market forces.

Herbal products are readily available over the counter in health food stores and are often perceived to be without risk. The current Canadian adverse event reporting system suffers from severe underreporting, resulting in a scarcity of safety data on herbal products. Twelve health food store personnel in the Greater Toronto Area were interviewed about their responses to herbal product-related adverse reactions. They generally fostered customer loyalty by offering generous return policies, which included collecting contact information to be sent to the manufacturers with the returned product. Thus, despite the public's lack of knowledge about the formal reporting system, adverse reaction information was directed to manufacturers whenever it resulted in a product return. The relationship between health food stores, industry and Health Canada provides a new opportunity to facilitate adverse event reporting. Additional information could be collected during the return process, and educational initiatives could be implemented to augment current post-market surveillance procedures for herbal products.

Exploring consumer and pharmacist views on the professional role of the pharmacist with respect to natural health products: a study of focus groups.

BACKGROUND: Natural health products (NHPs) such as herbs, vitamins and homeopathic medicines, are currently available for sale in most Canadian pharmacies. However, most pharmacists report that they have limited knowledge about these products which have been regulated in Canada as a specific sub-category of drugs. In this paper, consumers' and practicing pharmacists' perceptions of pharmacists' professional responsibilities with respect to NHPs are examined. METHODS: A total of 16 focus groups were conducted with consumers (n = 50) and pharmacists (n = 47) from four different cities across Canada (Vancouver, Edmonton, Toronto, and Halifax). RESULTS: In this paper, we illustrate the ways in which pharmacists' professional responsibilities are impacted by changing consumer needs. Many consumers in the study utilized a wide range of information resources that may or may not have included pharmacists. Nevertheless, the majority of consumers and pharmacists agreed that pharmacists should be knowledgeable about NHPs and felt that pharmacists should be able to manage drug-NHPs interactions as well as identify and evaluate the variety of information available to help consumers make informed decisions. CONCLUSION: This paper demonstrates that consumers' expectations and behaviour significantly impact pharmacists' perceptions of their professional responsibilities with respect to NHPs.

How far can complementary and alternative medicine go? The case of chiropractic and homeopathy.

This paper examines the efforts of two complementary and alternative occupations, chiropractors and homeopaths, to move from the margins to the mainstream in health care in the province of Ontario. We use a variety of theoretical perspectives to understand how health occupations professionalize: the trait functionalist framework, social closure, the system of professions, and the concept of countervailing powers. The research traces the strategies that the leaders of the two groups are employing, as well as the resources they are able to marshal. These are analyzed within the context of the larger institutional and cultural environment. The data are derived from in-person interviews with 16 leaders (10 chiropractic and 6 homeopathic) identified through professional associations, teaching institutions and informants from the groups. The responses were analyzed with qualitative content analysis. We also used archival materials to document what the leaders were telling us. The data revealed four main strategies: (1) improving the quality of educational programs, (2) elevating standards of practice, (3) developing more peer reviewed research, and (4) increasing group cohesion. Although both groups identified similar strategies, the chiropractors were bolstered by more resources as well as state sanctioned regulation. The efforts of the homeopaths were constrained by scarce resources and the absence of self-regulation. In both cases the lack of strong structural support from government and the established health professions played an important role in limiting what was possible. In the future, it may be to the state's advantage to modify the overall shape of health care to include alternative paradigms of healing along with conventional medical care. Such a shift would put complementary and alternative medicine occupations in a better position to advance professionally and become formal elements of the established health care system.

The role of the state in the social inclusion of complementary and alternative medical occupations.

OBJECTIVE: To examine the views of government spokespersons regarding the efforts of five complementary and alternative medicine (CAM) groups (chiropractic, traditional Chinese medicine/acupuncture, naturopathy, homeopathy and Reiki) to take their place in the formal health care system. DESIGN: In this small scale, exploratory study, we conducted in-depth interviews with 10 key government officials at the federal (5), provincial (4) and municipal (1) levels. We used qualitative techniques such as constant comparison to describe and explain their responses to three main questions: (1) What should be the role of the state in the professionalization of CAM? (2) Is there a legitimate place for CAM groups in the formal health care system? and (3) Should CAM services be integrated with conventional medical care? SETTING: Ontario, Canada. RESULTS: The findings identify a fundamental tension between the various levels of government. Their mandate to protect the public comes into conflict with the obligation to respond to consumer pressure for CAM. Safety, efficacy and cost-containment were the chief explanations given for the government's slowness to catch up to consumers. They also mentioned fears of rising health care costs and the lack of cohesion among and between CAM groups as barriers to legitimacy and integration. CONCLUSION: Realizing the professional aspirations of CAM practitioners will depend on the outcome of a political contest between the public, the state and the established health care professions.

Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario.

This paper examines the reactions of leaders of established health professions in Ontario, Canada to the efforts of selected complementary and alternative (CAM) occupational groups (chiropractors, naturopaths, acupuncture/traditional Chinese doctors, homeopaths and Reiki practitioners) to professionalize. Stakeholder theory provides the framework for analysis of competing interests among the various groups in the healthcare system. The data are derived from personal interviews with 10 formal leaders from medicine, nursing, physiotherapy, clinical nutrition and public health. We conceived of these leaders as one group of stakeholders, with both common and conflicting interests. The findings demonstrate that these stakeholders are reluctant to endorse the professionalization of CAM. They propose a series of strategies to contain the acceptance of CAM groups, such as insisting on scientific evidence of safety and efficacy, resisting integration of CAM with conventional medicine and opposing government support for research and education. These strategies serve to protect the dominant position of medicine and its allied professions, and to maintain existing jurisdictional boundaries within the healthcare system. The popular support for CAM will require that health professional stakeholders continue to address the challenges this poses, and at the same time protect their position at the apex of the healthcare pyramid.

Moving forward? Complementary and alternative practitioners seeking self-regulation.

Complementary and alternative medicine (CAM) occupations continue to struggle towards achieving professional status, especially in the form of statutory regulation. Many consider professional status a worthwhile goal for CAM occupations, yet it is a process fraught with tensions. In this paper we present in-depth interview data from the leaders of three CAM groups (naturopaths, traditional Chinese medicine practitioners acupuncturists, and homeopaths) in Ontario, Canada that demonstrate four main strategies used by these groups to professionalize. The strategies discussed are related to how the knowledge base of each group is organised and transmitted. These strategies include: improving educational standards, improving practice standards, engaging in peer-reviewed research and increasing group cohesion. At the core of these strategies is the demarcation of who is qualified to practice, and a signalling to 'outsiders', such as medicine and the government, that practitioners are qualified and legitimate. Across the three groups, the leaders referred to the inclusion of medical science as a basis for distinguishing between 'science' and 'non-science' as well as who should practice and who should not. We highlight how internal battles over the infusion of medical science into the knowledge base are part of the process for establishing legitimacy for the three CAM groups in our study. We end with a brief discussion of the implications of these internal battles over medical science knowledge for the future of CAM groups.