RESEARCH ARTICLE Open Access

Supportive but “worried”: perceptions ofnaturopaths, homeopaths and Chinesemedicine practitioners through a regulatorytransition in Ontario, CanadaNadine Ijaz1, Heather Boon1*, Sandy Welsh2 and Allison Meads2

Abstract

Background: In line with recent World Health Organization recommendations, many jurisdictions are taking stepsto regulate practitioners of traditional, complementary and alternative medicine (TCAM). Previous studies haveexamined TCAM practitioners’ generally-supportive views about professional regulation; however, little researchhas 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 threeTCAM 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 practitionersfrom these three groups (n = 1047) that could be identified from public registries and professional associations. Thedata presented here are derived from the sub-sample of homeopaths (n = 234), naturopaths (n = 273) and Chinesemedicine practitioners/acupuncturists (n = 181) who provided answers to an open-ended question about theiropinions of the regulatory process at the end of the survey. An inductive, thematic analysis of qualitative surveyresponses 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’ themesemerged: 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’ distinctiveworldviews. Some occupationally-specific concerns appeared related to each group’s particular stage ofprofessionalization. Other ‘worries’ may be related to the relative marginality of TCAM practitioner groupswithin biomedically-dominant national health care systems, and the possibility that inter-professional hierarchies maybe emerging between particular TCAM groups. Specific concerns around overlapping practice scopes between TCAMand other professions raised questions about the implementation of non-monopolistic regulatory models such asOntario’s.

Conclusions: Overall, this study will help inform regulators and TCAM practitioner groups to navigate the uniquechallenge of regulating health care providers long excluded from national health care systems, who frequently workfrom within paradigms distinct from mainstream biomedicine.

Keywords: Traditional complementary and alternative medicine regulation health practitioner professions

* Correspondence: heather.boon@utoronto.ca1Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St. (room 514),Toronto, ON M5S 3M2, CanadaFull list of author information is available at the end of the article

© 2015 Ijaz et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Ijaz et al. BMC Complementary and Alternative Medicine (2015) 15:312 DOI 10.1186/s12906-015-0846-6

BackgroundThe World Health Organization has called for membercountries to increasingly regulate practitioners of trad-itional, complementary and alternative medicine (TCAM),with the aim of increasing safety, quality and effectivenessof TCAM therapies worldwide [1]. Many nations continueto grapple with how to regulate TCAM practitioners andpractices, which have historically fallen outside of thepurview of biomedicine’s globalized dominance ingovernment-sanctioned health care systems, and which,as such, are characterized by relative sociopolitical mar-ginality [2]. TCAM practices are, furthermore, character-ized by paradigmatic features distinct from biomedicine’sunderpinnings; this poses additional regulatory challengesin that many regulatory systems have been designed toaccommodate biomedical-style health care [3, 4]. Regard-less, several nations - including some jurisdictions withinCanada [5] - continue to make significant headway inregulating TCAM practitioner groups. Lessons learnedfrom these jurisdictions may ease the process for others.In some jurisdictions, governments are taking pro-active

steps in support of the WHO’s call for increased integra-tion of TCAM practitioners into their national health caresystems. In 2013, for instance, several southeast Asiancountries co-signed the Delhi Declaration on TraditionalMedicine, agreeing to collaborate towards a ‘harmonizedapproach… [to] regulation of traditional medicine andinvolvement of traditional medicine practitioners in healthservices’ [6]. In many cases, however, the impulse to lobbygovernments to regulate TCAM practitioners has arisenfrom within the occupational groups themselves, as exem-plified in our previous studies involving naturopaths,homeopaths and Chinese medicine practitioners in theCanadian province of Ontario [4, 7–10]. As we and others[3, 11, 12] have noted, some of the principal driversbehind such groups’ professionalization projects include:the pursuit of increased occupational credibility, moreextensive inclusion within third party and/or public healthinsurance programs, and the promotion of higher or moreconsistent training standards.Despite widespread support for professionalization - and

with it, regulation - within many TCAM practitionergroups, some issues continue to prove contentious withinthese communities. Standardization of educational require-ments can - for instance - prove challenging for groupscharacterized by significant inter-occupational diversity interms of both practice style and training background [13].While TCAM practitioner training is increasingly insti-tutionalized worldwide, traditional apprenticeship ormentorship-based training models continue to carry im-portance globally [14]. How much biomedical-style train-ing should be included in TCAM practitioners’ trainingcontinues to be contentious within some groups [10, 15];and some practitioners fear long-term co-optation into a

biomedically-dominant model [3, 16]. In some cases, theseissues have proven so controversial within practitionercommunities that statutory regulation has been largelyabandoned as a common goal [16]. Herbalists in theUnited States, for instance, organize within a professional‘guild’ model which explicitly recognizes multiple practicestyles and diverse training pathways, rather than pursuestate regulation [17]. Regardless, many TCAM practi-tioner groups, as well as an increasing number of nations,remain committed to a regulatory pursuit, in line with theWHO’s call.

The case of naturopaths, homeopaths and Chinesemedicine practitioners in Ontario, CanadaIn 2006 and 2007, the Ontario (Canada) governmentannounced that it would move forward in regulatingpractitioners of naturopathy, homeopathy and traditionalChinese medicine/acupuncture under the RegulatedHealth Professions Act [18]. Two points should be notedabout Ontario’s health professions regulatory structure.First, the province’s health professions are self-regulatedwith government oversight, in contrast with varioustypes of state regulation and co-regulation more typicalin other jurisdictions (such as Europe and Australia).Second, the provincial government does not authorize ex-clusive practice scopes to particular professions (as ismore common in other jurisdictions) [7, 19]. In Ontario’s‘overlapping-scopes’ model, professions are granted spe-cific, protected occupational titles, and in some cases maybe authorized to perform one or more health-related‘controlled acts’ within their scope; controlled acts may beshared across professions [19].In line with new legislation intended to govern each of

the three professions, the Ontario government appointeda regulatory Transitional Council for each group, withthe intention of laying the framework for each profession’sregulation in the public interest. In all cases, members ofTransitional Councils were ‘chosen from individuals whoresponded to a public call for members advertised acrossOntario’; Council members consisted of both practitionersfrom within the profession being regulated, as well as‘general’ members who were not practitioners [20–22].In the case of naturopaths, who had been previouslyregulated under another piece of provincial legislation,all Directors of the previous regulatory Board were in-cluded in the profession’s new Transitional Council [20].We have previously characterized each of the three

occupational groups as being at notably different stagesof professionalization [10], which has contributed to dif-ferent trajectories for each group’s regulatory process.Ontario’s naturopaths were the most tightly organized ofthe three, had achieved standardization in their trainingrequirements many years earlier, and as noted abovehad been previously regulated in the province. Chinese

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medicine practitioners (whose practices include traditionalacupuncture) had long lobbied for regulation, but wereconsiderably divided as a community over the issue of pro-fessional standards. Homeopaths were similarly heteroge-neous as a group, but were internally divided in terms ofregulation as a goal, and had lobbied comparatively littlefor regulation.Despite the significant differences in each group’s pro-

fessional evolution, the Ontario government accepted therecommendations of the Health Professions RegulatoryAdvisory Council (http://www.hprac.org/en/index.asp) totake the step of regulating each of these groups aroundthe same time. Regardless, the work of each group’sregulatory Transitional Council has been distinct,informed by the group’s specific needs moving forward.To date, Ontario’s Chinese medicine practitioners arethe only group of the three that has fully implementedits new regulations (in April of 2013); naturopaths andhomeopaths are expected to complete this process sometime in 2015.

The current studyAlthough the literature has extensively detailed TCAMpractitioner groups’ interest in seeking professional legit-imation, including some retrospective studies of suchgroups’ regulatory entry, we are unaware of studiesdetailing the transition of these groups through an activeregulatory process. In an effort to capture the experi-ences and perspectives of Ontario naturopaths, homeo-paths and Chinese medicine practitioners (includingacupuncturists) as they passed through the transition tobeing regulated under the Regulated Health ProfessionsAct, we initiated a cross-sectional survey in 2011, whileall three groups’ regulatory Transitional Councils werepart-way through their work. Our census-style surveyswere mixed in methodological design: alongside numerousquantitative questions, they included one qualitative ques-tion inviting respondents to further expand their views onthe emerging regulatory changes.As will be elaborated elsewhere, and perhaps unsur-

prisingly given the three groups’ previously stated mo-tives for pursuing regulation, the quantitative aspects ofthe survey demonstrated a widespread overall supportfor the proposed new regulations across all three practi-tioner groups; we intend to detail these results else-where. Across the three groups, many respondents alsooffered lengthy and, at times, impassioned written re-sponses to our qualitative survey question, in some caseseven attaching letters and newspaper clippings to theirsurveys in an effort to communicate their perspectives.What was notable across the responses was that, despiteoverwhelming support for the regulatory changes, mem-bers of all three groups felt ‘worried’ in varying degreesabout the proposed regulations. In particular, such

concerns pertained to issues of professional scope, fairregistration standards, and a potential compromise totheir groups’ underlying paradigmatic principles.While some concerns were shared across the three

TCAM practitioners groups, others were occupationally-distinct. This suggests that each group may have beenfacing particular but predictable challenges (e.g. consensusbuilding around common standards) related to its currentstage of professionalization. However, a number of theworries raised across the three groups appeared specific-ally related to the groups’ distinct identities as TCAMoccupations; for example, some concerns appeared rootedin the groups’ relative marginality within the broader sys-tem of biomedical health professions. In addition, someconcerns raised may be related to the implementation ofOntario’s overlapping practice scopes regulatory model, aswill be discussed further on.Regardless, the practitioner ‘worries’ raised in our

study hold perhaps greatest significance in relation tothe palpable challenge of regulating TCAM practitionersand practices hitherto largely excluded from nationalhealth care systems worldwide. As our study respon-dents clearly point out, it is one thing for a governmentto ‘decide’ to regulate, and quite another to unfold thedetails of such regulations in a way that is satisfying tovarious stakeholders. Any professional regulatory projectwill, for instance, invariably exclude some practitionersfrom entry; how to do so fairly and consistently maypose particular challenges in regulating TCAM practi-tioner groups. Cross-jurisdictional differences in regula-tory scope may pose an additional challenge for somegroups. The logistics of ‘grandparenting’ long-standingpractitioners, navigation of cultural alongside clinicalissues present in regulating traditional medicine practi-tioners, and the potential for producing new inter-professional hierarchies are additional issues which studyrespondents raised in Ontario’s context. Many suchissues will likely arise in other jurisdictions as well. Assuch, this work may inform the global conversation onTCAM regulatory initiatives, while raising importantquestions for further scholarly investigation.

MethodsIn 2011 and 2012, we distributed an online survey tonaturopaths (n = 882), homeopaths (n = 784), and bothonline and print surveys to Chinese medicine practitionersor acupuncturists (n = 1286) across Ontario using a censusmodel whereby we aimed to reach as many practitionersas possible. Prior to sending out the surveys, we hadundertaken an extensive process to gather practitionernames and contact information. The naturopath practi-tioner population was contracted through the member-ship lists from the Ontario Association of NaturopathicDoctors (OAND), the largest professional association for

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NDs in Ontario. The OAND sent an email with alink to the survey to their members (n = 882). TheTransitional Council of the College of Homeopaths ofOntario (TC-CHO) provided a list of homeopathicpractitioners interested in receiving information aboutregulation and we supplemented this with furthercontacts generated through personal connections andinternet searches (n = 784). Finally, Chinese medicine prac-titioners were identified from practitioner organizations’publicly-accessible member lists, internet searches usingGoogle and online indexes, such as the Yellow Pages,Chinese newspapers, and personal visits to Chinesebusiness centres in the greater Toronto area. Based onpre-test information, we determined that the surveyshould be offered in both English and traditional Chineselanguage, as well as accessible in both online and paperversions. The questionnaire, introductory letters, andreminders were translated into traditional Chinese by aprofessional translator and then back translated to checkfor accuracy. Respondents were then contacted by emailto fill out the online survey (n = 659) and by post mail forthe paper survey (n = 627). Initial response rates acrossthe three groups were 50 % (naturopaths), 56 % (homeo-paths), and 37.5 % (Chinese medicine practitioners).Because both Chinese medicine practitioners and ho-

meopaths were not regulated at the time of our study,any individual self-identifying as a practicing Chinesemedicine practitioner or homeopath was included in theoriginal sampling frame, regardless of their current edu-cation or work status. However, once our sample wascompiled, the data were limited to include only thosepracticing in Ontario on a full or part-time basis (this alsoexcluded some naturopaths). Furthermore, for Chinesemedicine practitioners, respondents already registered inOntario under another regulated health profession(physiotherapists, nurses, MDs, etc.) where acupunc-ture is included as part of their scope of practice wereexcluded from our study (n = 111), given our focus onthose who must register as a Chinese medicine practi-tioner to practice acupuncture. These exclusions left uswith a final sample of 1047, broken down as 427 natu-ropaths, 329 homeopaths and 291 Chinese medicinepracititoners. Of these respondents, a sub-sample of273 naturopaths (64 %), 234 homeopaths (71 %) and181 Chinese medicine practitioners (63 %) providedresponses to the qualitative question in our study, whichis the focus of this paper. The study received ethicalapproval from the Research Ethics Board at the Universityof Toronto.The key demographics describing the groups are pre-

sented in Table 1.1 From these results, we can see thatwomen are most predominant among naturopaths (79 %)and least so among Chinese medicine practitioners (57 %).Additionally, naturopaths report an average age of

approximately 38 years, while homeopaths and Chinesemedicine practitioners have mean ages of 47 and 49 years,respectively. With respect to years in practice, Chinesemedicine practitioners have been practicing the longest atapproximately 17 years, while naturopaths report an aver-age of 8 years of experience and homeopaths nine. Finally,a little over half of naturopaths report working part-timecompared to 65 % of homeopaths and 34 % of Chinesemedicine practitioners.2

The surveys contained a range of questions focusedon the demographic, practice and educational character-istics of practitioners, with some questions commonacross surveys and some reflecting particular aspects ofeach group. After a series of closed-ended questions re-lated to regulation, respondents were asked a broadquestion to solicit their views on the regulatory changesfacing their occupational group. Homeopaths, for in-stance, were asked: Finally, what are your thoughtsabout the decision to regulate homeopaths under theRegulated Health Practitioners Act in Ontario? Ques-tions posed to the other groups were very similar, withthe practitioner group name appropriate replaced.Qualitative responses from across the three surveyswere inductively coded by two independent coders foremergent themes. The two coders compared and cor-roborated coded findings for consistency and reliability.Themes emerging across the three groups were thencompared to find areas of overlap and uniqueness.

ResultsOverall, written responses from across the three sur-veyed groups affirmed quantitative findings showingsignificant support for regulation from about three-quarters of all respondents across the three groups. Amore extensive analysis of quantitative findings willbe reported elsewhere. Written survey responses sug-gested that this support reflected respondents’ percep-tions that the regulatory changes would enhance theiroccupations’ credibility, increase availability of thirdparty insurance coverage for their services, and helpprotect the public from untrained practitioners. How-ever, despite this widespread support for the regula-tory changes in principle, quantitative findings acrossthe naturopathic, homeopathic and Chinese medicinepractitioner groups also showed that a considerableproportion of respondents (48, 44 and 33 % respect-ively) agreed or strongly agreed when asked torespond to the following statement: “I am worriedabout regulation”.The substance of such ‘worries’ is difficult to evalu-

ate from the quantitative findings alone, results ofwhich are limited by the specific questions asked.However, thematic analysis of written survey re-sponses from naturopathic [N], homeopathic [H] and

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Chinese medicine [CM] practitioners proved useful indrawing out a number of key regulation-related con-cerns, some of which were common across the threegroups, and others being occupation-specific.Some respondents who expressed concerns about the

regulatory changes were in fact opposed to these changes,characterizing it, for instance, as “not a good idea” [CM].A small number of practitioners argued that a discourseemphasizing public safety was being disingenuously ban-died about as a political pretext for increased regulatorycontrol over low-risk clinical activities, for instance:

One regulates activities that are dangerous.Homeopathy is not dangerous. [H]

Others felt poorly informed about the regulatory changes,and had difficulty understanding how it would affect them:

I feel that I am uninformed about the change inregulation and find the information that is provided tobe confusing. [N]

However, the majority of those expressing ‘worries’ didin fact support the new regulations, but had concerns orfelt unsure about the way in which these were beingimplemented:

I do support it but don’t know what will be the realoutcome. Hopefully it will be a positive one to bothpublic and practitioners. [CM]

I feel this regulation has been long overdue. Now thatthe opportunity has come about I am disappointed inthe quality of the regulations proposed. [N]

More specifically, respondents from all three groupsexpressed concerns with the actions of the TransitionalCouncils responsible for drafting their respective newregulations:

After reviewing the Draft regulation put out by theTransitional council, my support for regulationdiminished almost immediately. [H]

I am not confident that all of those who are representingmy profession are acting appropriately on my behalf. [N]

Within the Chinese medicine group, respondentsraised concerns about the composition of their particularTransitional Council:

My only wish is to have authentic TCM andacupuncture professionals involved in the regulations toensure fairness, equitableness [sic], and openness. [CM]

Overall, respondents’ ‘worries’ cut across four pri-mary themes, most of which were broadly sharedacross the three groups, though with occupationally-specific components. These four themes involvedconcerns that the new regulations might: a) producean unwanted financial and administrative burden onpractitioners; b) detrimentally affect groups’ practicescopes; and c) implement inappropriate or unfair regis-tration standards; and d) compromise occupationalgroups’ paradigmatic foundations.

Increased administrative and financial burdenA number of respondents who otherwise supported theregulatory changes raised concerns that these changesmight increase administrative work for practitioners, andpotentially cause negative financial impacts:

Worried about added costs, bureaucracy and paperwork headaches but am generally supportive of thismeasure to further professionalize our profession. [CM]

Several respondents raised financial concerns withinthe broader context of monetary struggles within theiroccupational group:

It will…likely raise my registration dues, which will makepracticing unaffordable to myself who is a newerpractitioner. [N]

Others concurrently connected such concerns with theissue of providing financially accessible services to patients:

Table 1 Demographic characteristics by group for qualitative respondents

Naturopaths(n = 273)

S.D. Response Rate Homeopaths(n = 234)

S.D. Response Rate CMPc

(n = 181)S.D. Response Rate

Gendera 0.793 - 99 % 0.740 - 99 % 0.572 - 99 %

Age 38.3 9.79 97 % 47.1 10.6 99 % 48.7 11.6 96 %

Years in practice 8.06 7.49 100 % 9.29 8.89 99 % 17.3 12.01 99 %

Part-timeb 0.520 0.501 100 % 0.645 0.479 100 % 0.337 0.474 100 %a0 = Men, 1 =WomenbReference category is full-timecChinese medicine practitioners

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Regulation will cause more expenses for the Homeopath,thus making it more and more difficult for aHomeopath to make a viable living. Regulation willcause rate increases thus reducing affordability to theaverage family/public. [H]

Some respondents even predicted that “regulationcosts” (amongst other factors) could “cause a lot of prac-ticing homeopaths to go underground/practice withoutlicensing” [H].

Negative impact on practice scopesRespondents from all three groups worried that the newregulations might have detrimental impacts related totheir specific practice scopes. Where concerns aboutreduced scope predominated naturopaths’ comments, itwas a concern around overlapping scopes that repeatedlyappeared in homeopaths’ and Chinese medicine practi-tioners’ responses. Common across all three groups’scope-related concerns were allusions to both inter- andintra-occupational turf battles.As noted above, naturopathic respondents repeatedly

expressed concern that their existing practice scopewould be reduced under the new regulations:

If the intent of the regulations is to evolve into a betterregulated profession it cannot be at the cost ofdecreasing our scope of practice. [N]

Furthermore, several naturopaths expressed a concernthat the new regulations might not expand their scopeadequately. Specifically, such respondents hoped thatnaturopaths’ diagnostic rights would be broadened toinclude particular biomedical tests (such as “Xray, MRI,CT scans” [N]), and the ability to deliver “intravenoustherapies” and “prescribe base-line pharmaceuticals” aswell as specialized supplements such as “hesperidin” [N]and “L-carnitine” [N].Some naturopaths connected their scope-related con-

cerns to a goal of practising as independent, primarycare practitioners, on par with biomedical physicians:

My inability to directly order lab tests [sic] or prescribebase-line pharmaceuticals inhibits me from being a onestop shop for primary care. I have to rely on walk-inclinic MDs to offer complete care to my patients. [N]

Others felt that the practice scope proposed in Ontario’semerging naturopathic regulatory structure would disad-vantage the province’s naturopaths in relation to otherNorth American jurisdictions:

I feel the change will make us the laughing stock ofmedical providers in Ontario and we are already being

scoffed at by other ND’s across the country. It’s time fora national Naturopathic Regulation at the level ofBritish Columbia and with the scope of Arizona. [N]

However, not all respondents favoured all aspects of aregulatory scope of practice, particularly with respect topharmaceutical drugs:

I have no desire to prescribe drugs and giving us thisright invalidates the meaning behind our profession andprinciples. [N]

Like naturopaths, some Chinese medicine practitioners -who otherwise supported the regulatory changes - alsoexpressed concern that their scope would be limited underthe new regulations:

[Regulation] is necessary. I am looking forward to myservices being covered under supplementary healthinsurance. I am very concerned about restrictions in mypractice. [CM]

More specifically, such concerns related to particularcomponents of Chinese massage practice (Tuina), whichinvolve techniques similar to spinal manipulations usedby chiropractors, which are restricted under Ontario’s‘controlled acts’ model.Amongst homeopaths and Chinese medicine practi-

tioners, qualitative scope-related responses largelyreflected a concern that the regulations would continueto permit other occupational groups to perform theirrespective core practices. Homeopaths specifically raisedconcerns about naturopaths’ continued authority topractice homeopathy:

I do not understand how homeopaths with extensivetraining in homeopathic remedies are not able toprescribe “restricted” remedies, yet naturopaths that onlystudy 28 h[ours] of homeopathics have license toprescribe these restricted remedies when they have littleunderstanding of how these remedies work. [H]

Several homeopaths furthermore deplored that unlikenaturopaths, they were not expecting to be granted a‘doctor’ title in their professional legislation, presumablyfurther undermining their relative credibility:

I am upset that we will be deemed as secondary healthcare practitioners underneath naturopaths, with ourdesignation of Doctor of Homeopathy being withdrawnto Homeopath. [H]

Similarly, numerous Chinese medicine practitionersraised concerns that non-Chinese medicine based health

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care professionals (such as physiotherapists, chiroprac-tors and naturopaths) would retain the right to practiseacupuncture within their professional scope. Manyexpressed a perception that such professionals were lessqualified to practise acupuncture so than traditional acu-puncture practitioners:

I am in favor of regulation for the profession, I wish thatit was also more restricted to fully qualified/future fullyregistered with the college practitioners instead of beingallowed to be practiced in other fields as Chirop[ractic]… who do not receive or are required to have propereducation and yet will be able to practice acupuncturewithin their scope of practice and profession. [CM]

Evidently such concerns around overlapping practicescopes relate to the issue of training standards, whichwill be discussed in greater detail further on. However,the question of regulatory turf repeatedly emerged aswell, with several homeopaths and Chinese medicine prac-titioners expressing a wish - as described above - to seetheir core practice scopes more exclusively restricted.Some Chinese medicine practitioners accepted that

they would continue, within Ontario’s regulatory con-text, to share some core practices such as acupuncturewith other professions. However, they wished to seethe term ‘acupuncture’ protected for Chinese medicinepractitioners under the regulations, thus differentiat-ing traditional acupuncture from more biomedically-informed needling techniques, which one Chinesemedicine respondent proposed be termed “intramus-cular stimulation or dry needling” [CM] instead of‘acupuncture’.

Inappropriate or unfair registration standardsAmongst homeopaths and Chinese medicine practi-tioners, groups for whom there were (at the time) nonational educational or regulatory standards, consider-able concerns were raised as to how the new regulationsmight assess practitioners’ qualifications for profes-sional entry. Respondents across the two groups tendedto agree in principle that some practitioners’ currenttraining within their occupational groups were “not highenough” [H]; and that the enforcement of standardswould likely “improve the quality of care to patients”by increasing “the practitioners’ level of treatment”[CM]. However, a concern around how such stan-dards might be set - particularly in light of signifi-cant intra-occupational diversity - permeated manyrespondents’ comments:

I am hoping that there will be a fair way of assessingeach of our training as there are many ways to practicethat benefit the patient. [H]

In particular, respondents across both homeopathicand Chinese medicine groups raised concern that vari-ous practitioner subgroups might be inappropriatelyexcluded from registration, depending on how the stan-dards were set. However, each group’s individual con-cerns in this regard were more occupationally-specific.

HomeopathsAmongst homeopathic respondents, standards-relatedcomments were dominated by the question of howmuch biomedical scientific training should be requiredof practitioners in the forthcoming registration stan-dards. Those advocating for more extensive biomedicaltraining argued it would produce higher competencywithin, and greater credibility for, the homeopathiccommunity:

[U]ntil we come together as a scientific communitywhere those who wish to practice homeopathy arerequired to attain a significant and competentknowledge of the hard sciences and even the soft sciences(biology, nutrition, physiology, etc..), credibility will sufferwhether we regulate or not. [H]

Others de-emphasized the importance of biomedicalscientific training in the professional development ofcompetent homeopaths:

I think regulation is good in that, only those homeopathswho have been properly trained will be permitted topractice. I don’t think, however, that rigoroustraining in the health sciences is necessary to be agood homeopath. [H]

Overall, such comments illustrated a clear lack of con-sensus on this issue, and worry within disparate homeo-pathic ‘camps’ as to how the standards would eventuallyemerge to determine what - or who - would be included.Several respondents feared that those representing amore “classical, Hahnemannian homeopathy” [H] wouldnot get their voices heard in this regard, perceiving thatthe regulatory process had thus far been dominated by“a minority of homeopaths” [H].A number of homeopaths also raised concern that the

standards proposed for ‘grandparenting' long-standingpractitioners under the new regulations might inappropri-ately exclude those practising part-time and in rural areas,new graduates, and practitioners with overseas training:

[T]he number of hours proposed as a minimum toqualify for registration are unrealistically high and notreflective of the difficulties of introducing this unknownform of medicine to the public - particularly in semi-rural and rural areas. [H]

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…the drafts as prepared to date… will likely precludethe possibility of the majority of recent homeopathicgraduates from becoming registered. [H]I am concerned if I will be accepted by the Act because Istudied in South Africa. [H]

Chinese medicine practitionersSome Chinese medicine practitioners, by contrast,worried that the standards had been too-narrowly set,excluding those practising East Asian varieties of trad-itional acupuncture falling outside of the Chinesetradition:

My understanding is that [the regulation] focuses onlyon the Chinese tradition which is a mistake. It shouldinclude all Qi-based medicine and specialties likeKorean and Japanese acupuncture. [CM]

Others worried that those who had been trained viaapprenticeship or family lineage, which one respond-ent termed “the special path of studying TCM andacupuncture” [CM] might not be eligible for registration.Also raised were the potential challenges long-standingpractitioners might face in collecting documentation oftheir training for the grandparented registration process:

Asking for transcripts or study reports may [create]great difficulties for those old practitioners, for theseschools, or professors may not exist anymore [sic]. [CM]

A small number of respondents opposed the grand-parented registration process outright, arguing that allregistrants should be required to

[W]rite an exam in order to have a legal license!…noGrandfather law. [CM]

However, Chinese medicine practitioners’ most pro-nounced concern around grandparented registrationpertained to the issue of language. Numerous practi-tioners asserted that the regulations should permit prac-titioners not only to permitted to conduct their clinicalpractices in a Chinese language, but also to completeregistration examinations and keep patient recordsexclusively in Chinese. Several respondents raised sig-nificant alarm that they might be excluded from registra-tion if the regulations enforced English (or French) asthe profession’s primary language. For some individuals,such concerns had entirely dissuaded them for support-ing the regulations as currently proposed:

Current legislation is biased towards eliminating TCMdoctors, ousting TCM doctors. I oppose. Was taughtTCM by grandfather. I don’t know English. Grand-

fathered regulation requires English testing. I am on theverge of being eliminated. [CM]

The potential compromise that the new regulationsposed in terms of occupationally-specific values -whether cultural or otherwise - was an issue raised bypractitioners across the three surveyed groups.

Compromise to occupational paradigmA subgroup of respondents from across all threegroups expressed concern that the regulatory changesthreatened to compromise their respective occupa-tions’ underlying paradigmatic foundations, despitethe changes being perceived as positive in otherrespects. Within the Chinese medicine and homeop-athy groups, practitioners expressed concern thattheir paradigmatically-distinct practices were beingforced into a regulatory structure designed to accom-modate professions more fundamentally rooted inbiomedicine:

We should not try to ‘fit homeopathy’ into a set ofregulations designed for other professions. [H]Regulation of TCM/acupuncture should be based onTCM/acupuncture’s unique Chinese medical nuances. Itshould not blindly follow the regulatory methods ofWestern medicine. [CM]

Several homeopathic respondents expressed concernthat under the new regulations, their profession wouldbecome “more medical and less homeopathic” [H],thereby compromising the “spirit of homeopathy” [H].Similarly, a number of naturopaths characterized theregulatory changes as part of a trend “moving away fromour true purpose as nature doctors” [N], and “treatingmore like Green MDs” [N]. They described a shift withinnaturopathy away from a “drugless therapy” [N] scope ofpractice to “more of an allopathic medical scope ofpractice” [N], which emphasized “treating the disease,instead of the individual” [N]. According to some prac-titioners, such shifts in naturopathy’s focus were aris-ing from a regrettable “need for approval from theconventional medical world” [N].Within the Chinese medicine group, several respon-

dents expressed concern that regulators were notadequately taking into account factors related to “cul-ture and tradition” [CM], ultimately threatening toerode the occupation’s paradigmatic foundations, andwith it the quality of Chinese medicine care. These det-rimental effects would, they argued, detrimentally im-pact patients, especially people of East Asian originusing Chinese medicine as their predominant form ofhealth care. For example:

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[Decision makers] don’t know this professional field sotheir decisions cannot reflect real TCM [traditionalChinese medicine] practitioners’ thought and practice.If this regulation is passed it will definitely kill TCM’slong-term practice in Ontario. The public who heavilydepend on Chinese medicine will suffer. [CM]

It is clear that respondents from across all three occu-pational groups - naturopaths, homeopaths and Chinesemedicine practitioners - expressed multiple ‘worries’about the way in which Ontario’s new regulations gov-erning their work would be implemented. Some con-cerns reflected fundamental issues relating to eachgroup’s underlying worldview and core practices; otherspertained to more immediate financial or administrativeconcerns. It is important to note that for the majority ofpractitioners surveyed, such ‘worries’ appeared notablysecondary to an overarching spirit of support for Ontario’snew regulations governing each of them. Nevertheless, theexpressed ‘worries’ do warrant careful considerationin relation to the broader global issues surroundingregulation of traditional, complementary and alterna-tive medicine (TCAM) practitioner groups.

DiscussionIn several ways, practitioners’ accounts of moving towardsregulatory inclusion in this study appear to describe a lessidealized experience than many might have hoped, echo-ing previous studies pointing to the tradeoffs inherent inTCAM groups’ professionalization projects [2–4]. Somerespondents’ concerns that regulation might comprom-ise their occupations’ paradigmatic foundations are notnew: the threats of occupational co-optation within abiomedically-dominant health care system (in whichinstitutionalized training is highly valued) have beenextensively discussed [2, 3, 23, 24]. Whereas somerecent studies suggest that institutionalization of someTCAM practitioner trainings may permit considerableinclusion of holistic philosophical content at odds withbiomedical epistemologies [25, 26], other work hasnoted that institutionalization tends to promote in-creased biomedicalization of TCAM trainings [27, 28].Regardless, another potential challenge for TCAMpractitioners to face is that any regulatory processdesigned to implement stringent registration standardswill necessarily exclude some applicants. However, thevaried ‘worries’ raised in our study appear in severalways to move beyond such previously reported issues.Of particular relevance in our findings are practitioner

fears about unjust exclusion of specific practitioner sub-groups, whether part-time or foreign-trained practi-tioners, immigrants, those lacking English fluency, orthose trained through traditional apprenticeship. Theprofessions literature does indeed document inequities

inherent in many regulatory bodies’ registration practices[29, 30], and it remains to be seen how effectively Ontario’sTCAM professional regulatory bodies are able to firstdefine, and subsequently implement, fair registration prac-tices. As Ontario’s provincial Fairness Commissioner - agovernment body responsible for ensuring equitable regis-tration requirements across the health professions - hasnoted, regulation of professions like homeopathy andChinese medicine, ‘that have their roots in traditional waysof knowing,’ raises unique challenges from a regulatoryequity perspective [31]. In particular, the issue of regula-tory grandparenting strategies - a commonly engagedshort-term strategy for bringing long-standing practi-tioners under the auspices of a new professional regulatorystructure [32] - may warrant significant additional researchin relation to TCAM practitioners groups. Indeed, whilesome studies have described the details of grandparentingstrategies for TCAM practitioner groups [32–34], littlesociological analysis has been applied to such approaches.In addition to such equity-related points, our findings

highlight the significant internal diversity characterizingparticular TCAM occupational groups, in which distinctsubgroups may hold notably different views about regu-lation and its implementation, as well – in particular –as appropriate educational standards. Although such in-ternal diversity has been previously pointed out [3, 10, 15],its dimensions and implications within and across variousTCAM practitioner groups may warrant further scholarlyexploration.Moving to the distinct ways in which each occupational

group framed its particular ‘worries’ about regulation, it ispossible that such distinctions may have been influencedby each group’s stage of professionalization at the timewhen they were granted regulatory status. As wenoted in our earlier study of the same occupations,naturopaths represented the most advanced stage ofprofessionalization of the three groups, having previ-ously established clear, cross-jurisdictional standardsand a distinct professional identity. That naturopathssurveyed in the current study articulated few standards-re-lated concerns but focused instead on achieving a broadregulatory practice scope on par with other NorthAmerican jurisdictions is thus not surprising.Chinese medicine practitioners, whom we character-

ized in our 2004 study as internally fragmented over thedegree of biomedical sciences that should be included inoccupational standards, appeared to have since movedbeyond this concern as a community, instead focusingon a more nuanced set of tensions between acupunctureas a clinical practice, and the importance of Chinesemedicine’s cultural/historical dimensions. This focus isreflected in practitioner concerns around languageproficiency requirements, recognition of practitionerstrained by apprenticeship, and the question of ‘which’

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East Asian acupuncture styles should be explicitly vali-dated in Ontario's regulations. These issues – whichour research team is currently investigating further –raise a number of complex regulatory questions whichmay be unique to traditional medicine occupationalgroups, for whom both clinical and cultural concernsmay hold parallel importance. As several survey re-spondents suggest, the question of regulatory Englishproficiency requirements may not, for instance, be ad-equately addressed as a public safety issue alone, butappears to raise a range of complex historical and cul-tural dimensions related to preserving the traditionalEast Asian medicine system’s roots within a westernliberal democratic regulatory structure.Homeopaths, who in our previous study were the

smallest and least organized of the three group, andarguably the least ‘ready’ for regulation, continued tostruggle internally over the issue of biomedical scientifictraining even as Ontario granted them self-regulatorystatus: a concern which had similarly dominated ourearlier discussions with community leaders. It is perhapsself-evident that biomedicine is currently the ‘linguafranca’ in widespread usage between regulated healthprofessions, and that TCAM professions’ adoption ofbiomedical language and perspectives may indeed facili-tate their participation in mainstream health care sys-tems. However, as Hollenberg and Muzzin have pointedout [24], the increased biomedicalization of TCAM pro-fessions is neither socially nor politically neutral, butmay better be understood within the related historicalcontexts of increased biomedical dominance in healthcare worldwide. As such, the process of TCAM profes-sions ‘integrating’ into mainstream health care necessarilyraises complex questions of power; and TCAM groups’concerns that they may be losing their core identities in aprocess of ‘enforced assimilation’ should be further inves-tigated in this light. Furthermore, it is worth noting thatsome TCAM occupations (e.g. naturopathy, chiropractic)appear to have more enthusiastically adopted biomedicaltheory and terminology as essential to implementation oftheir therapeutic systems than have others (e.g. Chinesemedicine, homeopathy, Ayurveda), which may have con-siderable sociological and political consequences.Homeopaths’ and Chinese medicine practitioners’

concerns around having to ‘share’ some of their keyclinical practices with other professions had not ap-peared in our earlier studies. These concerns may havesimply reflected some practitioners’ poor understandingof Ontario’s health professions regulatory structure,which governs ‘controlled acts’ but does not authorizeexclusive practice scopes. This in itself is an importantissue, emphasizing a potential challenge regulators mayface in effectively communicating with TCAM practi-tioners through a regulatory process. It is unclear

whether such communication challenges are similar tothose otherwise faced by government bodies in otherpursuits, or if there are more TCAM-specific issues atplay in this regard. However, more broadly contextual-ized, the concerns raised by members of both of theseoccupational groups about overlapping practice scopesmay also speak to larger trends at play in the field ofTCAM professional regulation.For example, some Ontario Chinese medicine practi-

tioners’ concern that under the new regulations theywould continue to ‘share acupuncture’ with other profes-sions significantly echoes ongoing professional turf bat-tles over acupuncture across the non-East Asian world[35]. In the United States, for example, two recent courtcases launched by traditional East Asian medicine prac-titioners in the states of Oregon [36] and Washington[37], have ruled that chiropractors and physiotherapists,respectively, may no longer engage in acupuncture-like‘needling’ practices within their scopes. Although thesestates’ regulatory structures are certainly different fromOntario’s in that they employ licensure models withexclusive practice scopes, it remains noteworthy thatsuch inter-occupational turf battles over acupunctureare increasingly common. Elsewhere, in Australia, whereChinese medicine practitioners have recently beengranted the protected title of ‘acupuncturist’ and exclu-sive professional authority to describe their work as‘acupuncture’, the act of inserting thin needles for thera-peutic purposes remains in the public domain, that is,not exclusive to this occupational group. As such, mem-bers of several other professions have ‘rebranded’ theirneedling activities using such nomenclature as ‘dry need-ling’ and ‘intramuscular stimulation’ [38], raising the ire ofEast Asian acupuncturists. Although an Australian regu-latory impact analysis had previously determined thatlimiting acupuncture practice to East Asian medicinepractitioners was unlikely to produce public benefit [39],an early Ontario government analysis of similar issues(which was later abandoned) had reached considerablydifferent conclusions [40]. Aside from the vital question ofpublic safety in this regard, there are several additional di-mensions warranting consideration in this regard. For in-stance, various occupations will not only occupy distinctpositions within an interprofessional hierarchy/ecology[41, 42], but will also approach a particular practice (suchas acupuncture) from distinct epistemological foundations.Of similar interest is the concern raised by several

homeopaths that they would be sharing the practicescope of homeopathy with Ontario’s naturopaths. To beclear, the practice of recommending homeopathic remed-ies has not been designated as a ‘controlled act’ underOntario’s Regulated Health Professions Act. As such, thepractice remains in public domain; and no limitationsexist in Canada on the sale of homeopathic remedies

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themselves, as long as they meet the country’s federalrequirements governing natural health products. Regard-less, what is poignant in some homeopaths’ accounts is aperception that the new regulations may secure for thehomeopathic group a subordinate sociopolitical positionin relation to the naturopathic profession. Indeed, theregulations will at once permit both naturopaths andhomeopaths to ‘practice homeopathy’ within their profes-sional scopes, while requiring less homeopathy-specifictraining for naturopaths, and granting the coveted ‘doctortitle’ to naturopaths and not homeopaths, the apparent‘homeopathy experts’. Two points are significant in thisregard.First, in terms of regulatory structures, these claims

raise questions about what constitutes competency inrelation to Ontario’s ‘overlapping-scopes’ regulatorystructure. This question, which arose both in relation to‘homeopathic scope’ and with regards ‘acupuncture scope’across various professions in our study, is important froma policy perspective. Indeed, an overlapping-scopes regula-tory model has been increasingly adopted across Canadianjurisdictions, but little research has explored the nuancesof its implementation or impacts since O’Reilly’s pioneer-ing study describing the model’s emergence in Ontario[19]. Furthermore, interest in adopting overlapping-scopesregulatory models has been growing in the UnitedStates since the publication of the 1995 Pew Report onReforming Health Care Regulation [43]. The PewReport recommended phasing out regulatory structuresbased on exclusive practice scopes which promote pro-fessional monopolies that ‘unnecessarily restrict otherprofessions from providing competent, effective andaccessible care’ [44].If overlapping-scopes regulatory models are to become

more normative in North America, it may becomeimportant for regulators to engage more directly withclear criteria for what constitutes competent or effectivecare for specific practices. Such engagement may presentseveral challenges. Within a self-regulatory context suchas Ontario’s, it is typically professions themselves –rather than the state – which establish training stan-dards. Moreover, even outside of a self-regulatorycontext, any state engagement with standards wouldlikely require considerable input from those with ex-pertise in the relevant fields – namely members of thescope-overlapping professions themselves. The chal-lenge of balancing each profession’s self-interest withthe public interest through this process may requireconsiderable negotiation. This may be particularly chal-lenging in regulating TCAM professions and practiceswithin biomedically-dominant regulatory frameworks,as high quality scientific evidence for TCAM therapiesis in some cases just emerging; and because some prac-titioner groups may draw in varying degrees on non-

biomedical evidentiary paradigms. Governments mayconsider adopting the World Health Organization’seducational standards guidelines for various TCAMpractices to assist in this type of groundbreaking regu-latory work.The second point of interest around the homeopathy/

naturopathy tension suggested in some respondents’comments in our study is the issue of inter-professionalstratification under a regulatory model that was origin-ally intended to ‘level the playing field’ between profes-sions, rather than fortify additional hierarchies betweenthem [19]. The sociological professions literature hasdetailed the subordination of TCAM practitioner groupsin relation to biomedical physicians [3, 7, 12], but to datelittle work has addressed the unequal power relationsthat may be emerging between TCAM groups as theymove to professionalize.

ConclusionsIn conclusion, the current study raises several key theoret-ical and practical points while providing a unique snap-shot of practitioner perspectives across three distinctTCAM professions as they pass through a long-awaitedtransition into state-regulated status. The advantage ofour study’s census survey model is that it offered a broadcross-section of respondents with an opportunity to con-tribute their perspectives. Having undertaken an extensiveprocess to gather practitioner names and contact informa-tion across multiple media, our search was quite compre-hensive. Nevertheless, some practitioners may havebeen inadvertently missed. That said, the broad rangeof perspectives exposed through inductive analysis ofparticipants’ responses to an open-ended question ina predominantly quantitative survey (quantitative findingsdiscussed elsewhere) represent an important series ofinsights, which may not have otherwise been exposed[45], thus highlighting the potential scholarly value of arigorous, mixed-methods approach.Regardless, this work does have limitations. Some re-

spondents’ opinions, for instance, may have been basedon incorrect information either about Ontario’s regula-tory structure, about the details of their occupation’sregulatory process, or both. We furthermore recognizethe limitations of collecting robust qualitative data usinga survey format as compared, for example, to conductingin-depth interviews, which invariably provide more de-tailed information with greater nuance. Regardless, thatso many survey respondents gave lengthy and detailedwritten comments in response to a single qualitativequestion posed in a predominantly quantitative survey,suggested a high level of practitioner engagement in theregulatory project, which we considered significant.It remains to be seen to what degree the diverse ‘wor-

ries’ described by Ontario homeopaths, naturopaths and

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Chinese medicine practitioners experiencing an importantmilestone in their professional projects shall endure as theregulations take effect; or whether such concerns moresimply reflect the inevitable transitional discomforts thatmay be expected to accompany the impacts of a signifi-cant regulatory change. We will continue to follow theseissues as these groups evolve into established regulatedprofessionals in the province of Ontario. In the interim, itis our hope that the perspectives explored in this workmay help to illuminate the internal struggles faced globallyby TCAM practitioner groups passing through regulatorytransitions, and to inform further investigation aroundhow such regulations may be more effectively and seam-lessly implemented, in the public interest, across nations.

Endnotes1Not all qualitative respondents provided demographic

data for all key variables, so within group response ratesare listed for each demographic variable in Table 1.

2Post-hoc tests were conducted within each group todetermine whether those who responded to the qualitativequestion differed significantly on these key demographiccharacteristics as compared to those who did notanswer the qualitative question. For naturopaths, theseresults showed that qualitative respondents are olderand less likely to be women than non-respondents. Forboth homeopaths and Chinese medicine practitioners,the only difference is with respect to age: qualitativerespondents are older than non-qualitative respondents.There are no differences in any group with respect toyears in practice or part-time versus full-time status.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsNI carried out analysis of qualitative data and drafted the manuscript. HBconceived of the study, participated in its design and coordination, participatedin qualitative analysis, and helped to draft the manuscript. SW conceived of thestudy, participated in its design and coordination, participated in statisticalanalysis, and helped to draft the manuscript. AM performed the statisticalanalysis and helped to draft the manuscript. All authors read and approvedthe final manuscript.

AcknowledgmentsThe authors would like to thank the Lotte and John Hecht MemorialFoundation, which provided valuable funding for this study; the OntarioAssociation of Naturopathic Doctors, and the Transitional Council of theCollege of Homeopaths of Ontario for their assistance and collaboration inreaching practitioners; and all survey participants, who were so forthcomingwith their views at a time of great change in their professions. Special thanksalso to Ida-Maisie Famiyeh, Rayesha Bhatt, Aalia Parker and Teresa Tsui fortheir contribution to data entry and analysis, and to Teresa Tsui and Eric Siufor their assistance with Chinese language survey translation.

Author details1Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St. (room 514),Toronto, ON M5S 3M2, Canada. 2Department of Sociology, University of Toronto,Toronto, Canada.

Received: 31 March 2015 Accepted: 2 September 2015

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