Governing therapeutic pluralism: An environmental scan of the statutory regulation and government reimbursement of traditional and complementary medicine practitioners in the United States.

The World Health Organization has called on nation-states to statutorily govern, and integrate into state-funded healthcare systems, practitioners of traditional and complementary medicine (T&CM) (whose therapeutic approaches that fall outside the boundaries of conventional biomedicine). To date, however, there exist few rigorous reports of the degree to which individual nations have responded to this call. This study, an environmental scan, comprehensively documents the statutory governance and government reimbursement of T&CM practitioners in the United States (US). Across the US, where health practitioner governance falls within state and territorial (rather than federal) jurisdiction, over 300 laws have been enacted to statutorily regulate a wide range of T&CM practitioners. Nurse-midwives and chiropractors are universally licensed across all 56 US regulatory jurisdictions (50 states, 5 territories and the District of Columbia); other major T&CM practitioner groups are regulated in fewer jurisdictions (acupuncturists, n = 52; massage therapists, n = 50; direct-entry [non-nurse] midwives, n = 36; naturopaths, n = 24). Additional statutory stipulations exist to govern chiropractic assistants (n = 30), auricular (ear) acupuncture practitioners (n = 24), homeopathic practitioners (n = 3), and psychedelic facilitators (n = 1), as well as biomedical professionals who practice acupuncture and related techniques, e.g., 'dry needling' (n = 44). While professional entry requirements for licensed T&CM practitioners are substantially harmonized across jurisdictions, restricted titles and statutory scopes of practice vary. Ten states have furthermore implemented 'safe harbor' ('negative licensing') exemption laws enabling otherwise-unregulated T&CM practitioners to legally practice. Limited government reimbursement for T&CM care is available across several federal and state programs, including Medicare, Tricare, Veterans Health Authority, and Medicaid. Nurse-midwifery and chiropractic care is most frequently reimbursed; acupuncturists, naturopaths and massage therapists are eligible for much more limited coverage. Medicaid programs for low-income people in ten states furthermore cover the services of (unlicensed but statutorily-recognized) birth doulas. Additional research is needed to assess the impact of these regulations on US health care.

"The Old Ways Are the Old Ways": A Qualitative Study of Chinese Medicine Care in Indigenous Communities in Canada.

Objectives: Owing to colonization's impacts, Indigenous Peoples in Canada face a disproportionate share of health challenges and suffer inequitable access to health care today. In recent years, an increasing number of Indigenous-led health services have emerged, which-informed by decolonial principles, including "culture-as-cure"-holistically center local Indigenous cultural, spiritual, and healing knowledges and practices. Aligned with decolonial principles, this work examines the delivery of Chinese Medicine (CM) care-an East Asian Indigenous therapeutic approach-in Indigenous communities in British Columbia, Canada. Design: Informed by qualitative interviews with three licensed CM practitioners and one biomedical clinician working in such clinics, the work provides a descriptive account of clinical operations, and thematically explores operational successes and challenges. Results: Four CM clinical programs were identified, all operating on First Nations reserves, including settings at multidisciplinary community health centers, a First Nation Band Council office, and a school gymnasium. Most CM care was delivered free of charge, funded variously by nonprofit agency donations and provincial government reimbursement. Three central themes emerged across the study interviews. The first, transculturalism, emphasizes the conceptual overlap between CM and Indigenous belief systems in the Canadian context, which participants described as a source of strength in building trust for CM care as a nonlocal Indigenous therapeutic approach. The second theme, Cultural Humility, characterizes non-Indigenous practitioners' respectful outlook as guests on Indigenous land, taking community members' lead as to how they might best serve. The final theme, Multidimensional Healing, explores the physical, mental, and emotional healing that practitioners witnessed across their work. Conclusions: Despite economic and logistical challenges, study respondents expressed optimism about the potential for similar traditional medicine clinics to provide culturally resonant primary care in other underserved communities. Further research to learn about the experiences of First Nations community members receiving CM care is warranted.

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.

The reluctant and the envious: Therapeutic subalternity and the practice of homeopathy in North America.

This work presents a neo-Gramscian theorization of therapeutic hegemony and subalternity, deployed with reference to the practice of homeopathy in North America by two increasingly-professionalized but unorthodox health occupational groups: Homeopaths and Naturopaths. Despite both occupations' contemporary sociopolitical subordination to dominant biomedicine, the continent's Homeopaths have been less successful in their professionalization efforts, owing partly to homeopathy-their primary therapeutic modality-being widely considered incommensurable with biomedical science. For Naturopaths, who increasingly align themselves with biomedical evidentiary norms, homeopathy represents but one among several central therapeutic modalities. Using survey (n = 588) and interview (n = 31) data from an empirical case involving Homeopaths and Naturopaths in Ontario, Canada-a jurisdictional outlier in which both groups are regulated by the state-the author employs the theory of therapeutic subalternity to illuminate the internal struggles faced by homeopathy-practising occupations in a biomedically-dominant context. Despite their regulated standing, Homeopaths' negative media characterization and ongoing lack of access to third-party insurance reimbursement contribute to ongoing frustration among practitioners, expressed as displaced envy toward the province's more elite, homeopathy-practising Naturopaths. However, while most Naturopaths express appreciation for homeopathy's clinical merits, many appear increasingly reluctant to use or discuss the practice to prevent compromise to their profession's therapeutic legitimation.

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.

Beyond Professional Licensure: A Statement of Principle on Culturally-Responsive Healthcare.

This work calls on healthcare institutions and organizations to move toward inclusive recognition and representation of healthcare practitioners whose credibility is established both inside and outside of professional licensure mechanisms. Despite professional licensure's advantages, this credentialing mechanism has in many cases served to reinforce unjust sociocultural power relations in relation to ethnicity and race, class and gender. To foster health equity and the delivery of culturally-responsive care, it is essential that mechanisms other than licensure be recognized as legitimate pathways for community accountability, safety and quality assurance. Such mechanisms include certification with non-statutory occupational bodies, as well as community-based recognition pathways such as those engaged for Community Health Workers (including Promotores de Salud) and Indigenous healing practitioners. Implementation of this vision will require interdisciplinary dialogue and reconciliation, constructive collaboration, and shared decision making between healthcare institutions and organizations, practitioners and the communities they serve.

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.

Evaluating the international standards gap for the use of acupuncture needles by physiotherapists and chiropractors: A policy analysis.

BACKGROUND: Acupuncture needles have become an increasingly-popular treatment tool used by multiple health professions. However, the World Health Organization (WHO)'s 1999 training guidelines for acupuncture address only medical doctors and licensed acupuncturists, leaving a gap as to appropriate training standards for other professions. AIMS AND METHODS: With reference to an extensive document analysis, and interviews with seventeen acupuncture educators from across several professions in Ontario, Canada, this work uses a critical qualitative policy analytic approach to: a) present a comprehensive account of statutory training requirements for acupuncture-needling physiotherapists and chiropractors in the United States, Canada, and Australia; and b) evaluate competing stakeholder discourses pertaining to recent related controversies. RESULTS: A wide range of educational requirements are evident across the jurisdictions under study (most below the 200-hour WHO guideline for physicians); and there is considerable disagreement among stakeholders as to what constitutes sufficient training in various forms of acupuncture, including 'dry needling'. Organizations defending brief post-graduate training for needling physiotherapists and chiropractors are generally associated with these two professions, and contend that their 'dry needling' practices differ substantially from traditional acupuncture. Characterizing such brief training as insufficient, opportunistic and unsafe, and 'dry needling' as a subset of acupuncture practice, are the voices of all acupuncture educators interviewed, as well as professional organizations representing physicians, licensed acupuncturists, and some physiotherapists and chiropractors. DISCUSSION AND CONCLUSION: Critiquing claims on both sides of the debate, this work calls for the development of independent, international safety-geared training guidelines that explicitly address the recent, evidence-informed trend towards biomedicalized acupuncture needling. Findings also suggest a need for additional research regarding the current shift towards overlapping-rather than exclusive-health professional practice scopes in industrialized countries.

Convergent Points for Conventional Medicine and Whole Systems Research: A User's Guide.

CONTEXT: Value-based health care has emerged as a manifestation of the conventional medicine community's awareness of the overlapping needs to both better incorporate patient centeredness into practice and research paradigms and further develop a systemic approach to cost reduction. BACKGROUND: The origins of the whole systems research (WSR) movement date to the late 1990s, when the U.S. Congress legislated appropriation of funds to stimulate the U.S. National Institutes of Health to evaluate popular traditional, complementary, and integrative medicine (TCIM) practices. Questions immediately arose over how well these forms of practice could be measured through standard randomized controlled trials, and the WSR community began to articulate and adapt innovative methodologies for evaluating TCIM interventions. DISCUSSION: This column explores the potential impact of WSR methods and exemplars on the clinical practice and research communities seeking to successfully implement and measure the complexities of value-based health care. Four potentially cross-talking themes are specifically discussed: complex behaviorally focused interventions, patient-centered outcomes, team-based care, and resilience and well-being. CONCLUSION: The time is ripe for clinicians and investigators to capitalize on methodologies, exemplars, and learnings from the WSR literature toward improving care, developing more robust research strategies, and furthering the dialogue between the TCIM and conventional medicine communities.

Whole Systems Research Methods in Health Care: A Scoping Review.

OBJECTIVES: This scoping review evaluates two decades of methodological advances made by "whole systems research" (WSR) pioneers in the fields of traditional, complementary, and integrative medicine (TCIM). Rooted in critiques of the classical randomized controlled trial (RCT)'s suitability for evaluating holistic, complex TCIM interventions, WSR centralizes the principle of "model validity," representing a "fit" between research design and therapeutic paradigm. DESIGN: In consultation with field experts, 41 clinical research exemplars were selected for review from across 13 TCIM disciplines, with the aim of mapping the range and methodological characteristics of WSR studies. Using an analytic charting approach, these studies' primary and secondary features are characterized with reference to three focal areas: research method, intervention design, and outcome assessment. RESULTS: The reviewed WSR exemplars investigate a wide range of multimodal and multicomponent TCIM interventions, typified by wellness-geared, multitarget, and multimorbid therapeutic aims. Most studies include a behavioral focus, at times in multidisciplinary or team-based contexts. Treatments are variously individualized, often with reference to "dual" (biomedical and paradigm-specific) diagnoses. Prospective and retrospective study designs substantially reflect established biomedical research methods. Pragmatic, randomized, open label comparative effectiveness designs with "usual care" comparators are most widely used, at times with factorial treatment arms. Only two studies adopt a double-blind, placebo-controlled RCT format. Some cohort-based controlled trials engage nonrandomized allocation strategies (e.g., matched controls, preference-based assignment, and minimization); other key designs include single-cohort pre-post studies, modified n-of-1 series, case series, case report, and ethnography. Mixed methods designs (i.e., qualitative research and economic evaluations) are evident in about one-third of exemplars. Primary and secondary outcomes are predominantly assessed, at multiple intervals, through patient-reported measures for symptom severity, quality of life/wellness, and/or treatment satisfaction; some studies concurrently evaluate objective outcomes. CONCLUSIONS: Aligned with trends emphasizing "fit-for-purpose" research designs to study the "real-world" effectiveness of complex, personalized clinical interventions, WSR has emerged as a maturing scholarly discipline. The field is distinguished by its patient-centered salutogenic focus and engagement with nonbiomedical diagnostic and treatment frameworks. The rigorous pursuit of model validity may be further advanced by emphasizing complex analytic models, paradigm-specific outcome assessment, inter-rater reliability, and ethnographically informed designs. Policy makers and funders seeking to support best practices in TCIM research may refer to this review as a key resource.

Paradigm-Specific Risk Conceptions, Patient Safety, and the Regulation of Traditional and Complementary Medicine Practitioners: The Case of Homeopathy in Ontario, Canada.

While the principle of risk reduction increasingly underpins health professional regulatory models across the globe, concepts of risk are neither static nor epistemically neutral. Conventional biomedicine's risk conceptions are substantially rooted in principles of scientific materialism, while many traditional and complementary medicine systems have vitalistic epistemic underpinnings that give rise to distinctive safety considerations. The statutory regulation of traditional and complementary medicine providers has been identified by the World Health Organization as a strategy for enhancing public safety. However, complex risk-related questions arise at the intersection of medical epistemologies whose concepts are at best overlapping, and at worst incommensurable. Elaborating a theoretical concept of "paradigm-specific risk conceptions," this work employs Bacchi's poststructural mode of policy analysis ("What's the Problem Represented to Be?") to critically analyze risk discourse in government documents pertaining to the 2015 statutory regulation of homeopathic practitioners in Ontario, Canada. The Ontario government's pre-regulatory risk assessments of the homeopathic occupation discursively emphasized cultural safety principles alongside homeopathy-specific risk conceptions. These paradigm-specific concepts, rooted in homeopathy's epistemic vitalism, extend beyond materialist constructions of adverse events and clinical omission to address potential harms from homeopathic "proving symptoms", "aggravation," and "disruption," all considered implausible from a biomedical standpoint. Although the province's new homeopathy regulator subsequently articulated safety competencies addressing such vitalistic concepts, the tangible risk management strategies ultimately mandated for practitioners exclusively addressed risks consistent with the scientific materialist paradigm. This policy approach substantially echoes the implicit biomedical underpinnings evident in Ontario's broader legislative context, but leaves a significant policy gap regarding the primary safety considerations originally articulated as substantiation for homeopathy's statutory regulation. To optimally preserve patient safety and full informed consent, regulators of traditional and complementary medicine professionals should favor a pragmatic, epistemically-inclusive approach that actively negotiates paradigm-specific risk conceptions from both biomedicine and the occupation under governance.

Statutory Regulation of Traditional Medicine Practitioners and Practices: The Need for Distinct Policy Making Guidelines.

The World Health Organization (WHO) has called for the increased statutory regulation of traditional and complementary medicine practitioners and practices, currently implemented in about half of nations surveyed. According to recent WHO data, however, the absence of policy guidelines in this area represents a significant barrier to implementation of such professional regulations. This commentary reviews several key challenges that distinguish the statutory regulation of traditional medicine practitioners and practices from biomedical professional regulation, providing a foundation for the development of policy making parameters in this area. Foremost in this regard are the ongoing impacts of the European colonial encounter, which reinforce biomedicine's disproportionate political dominance across the globe despite traditional medicine's ongoing widespread use (particularly in the global South). In this light, the authors discuss the conceptual and historical underpinnings of contemporary professional regulatory structures, the tensions between institutional and informal traditional medicine training pathways, and the policy challenges presented by the prospect of standardizing internally diverse indigenous healing approaches. Epistemic and evidentiary tensions, as well as the policy complexities surrounding the intersection of cultural and clinical considerations, present additional challenges to regulators. Conceptualizing professional regulation as an intellectual property claim under the law, the authors further consider what it means to protect traditional knowledge and prevent misappropriation in this context. Overall, the authors propose that innovative professional regulatory approaches are needed in this area to address safety, quality of care, and accessibility as key public interest concerns, while prioritizing the redress of historical inequities, protection of diverse indigenous knowledges, and delivery of care to underserved populations.

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.