Walking down Davie Street to reach St Paul’s Hospital, one encounters a wide variety of businesses and shops. Turning to walk up to the Thurlow Street hospital entrance, one will pass a marijuana dispensary, a naturopathic clinic, and an acupuncture shop, each offering their own unique treatments for chronic pain. Here on the west coast, the depth and breadth of diverse medical services available all on one block is remarkable. As a third–year medical student undergoing rigorous training with endless qualifications and examinations to pass, I start to wonder about the training and legal rules facing healthcare professionals besides physicians. For naturopathic, homeopathic, and traditional Chinese medicine practitioners, what regulations are in place to ensure a high standard of care?
In British Columbia, the Ministry of Health regulates 26 professions, of which 25 have self–regulated bodies and colleges guided by the Health Professions Act. These colleges have the authority to govern their members’ practices, and they must do so with the public interest in mind. Just as the Royal College of Physicians and Surgeons’ mandate is to serve and protect the public, such is also the case for the 26 self–regulated professions. This means that any comment or concern raised by the public against a service provided by a practitioner goes directly to his/her overseeing college, which can choose to investigate the comment, assess the practitioner, and if needed, suspend or remove licenses to practice. In reality, practitioners do not undergo regular inspections. Bodies that are regulated under the Health Professions Act include: Dentistry, Pharmacy, Medicine, Chiropractics, Dietetics, Massage Therapy, Licensed and Registered Nursing, Naturopathic Medicine, and Traditional Chinese Medicine and Acupuncture. Homeopathy, on the other hand, is notable for being currently unregulated by the B.C. government; instead, the profession is guided by a group of invested organizations, such as the Vancouver Homeopathic Academy, the North American Society for Homeopaths (NASH), and the Council for Homeopathic Certification (CNC) in conjunction with European and International Councils for Homeopathy.
Given that each profession has its own regulatory body, what comprises these bodies, and what are their guiding principles beyond what the Health Professions Act authorizes? Regarding governance, provinces and territories are tasked with overseeing the provision of health services in their jurisdictions, while federal regulations are limited to safety and sales of natural health products under the Food and Drug Administration.[3,4] Currently in B.C., homeopaths belong to an unregulated body. Homeopathic practitioners train for four years; each year consists of eleven three–day training sessions that run longitudinally, as per the program offered by the Vancouver Homeopathic Association. In contrast, naturopaths in B.C. are guided by the British Columbia Naturopathic Association. Naturopaths are required to possess a bachelor’s degree in arts or sciences, followed by four years at an accredited naturopathic college. Lastly, those practicing traditional Chinese medicine work under the College of Traditional Chinese Medicine Practitioners and Acupuncturists of B.C. (CTCMA) and have different training requirements for Acupuncturists, Traditional Herbalists, Traditional Medicine Practitioners, and Doctors of Traditional Chinese Medicine.[7,8]
More important than depth and scope of training, however, is the question of how the Health Professions Act regulates the scope of practice of various health disciplines. A glance at the Ministry of Health website quickly links to “regulation” and “scope of practice” as part of each profession’s bylaws. For instance, naturopathic medicine is defined as “the health profession in which a person provides the services of prevention, assessment and treatment … using education and naturopathic techniques, therapies or therapeutics to simulate or support healing processes;”  an accompanying scope of practice statement declares that “a registrant may practice naturopathic medicine.”  This is followed by a list of permitted but restricted activities, including “procedures on the tissues below the dermis or below the surface of a mucous membrane”, “administration of substances by injection, inhalation, irrigation, enteral instillation…”, and so forth. Subsequent to the list, clarifications regarding drug formulary allowances and prescription privileges are detailed.
If there is an issue with the service one receives, a patient can file a comment with the appropriate college, which will investigate further. If a patient is unhappy with the college’s final decision, they can apply to have the matter reviewed by the Health Professions Review Board (HPRB), which is an independent tribunal that reviews the thoroughness of the college’s investigation and the fairness of their decision.
Thus, similar to the medical profession, other health disciplines are given boundaries, scopes of practice, and are largely regulated by their own colleges in most provinces. But how successful is the model of self–regulation? Colleges only disclose the name of the practitioner involved with a complaint once formal disciplinary action is taken. While colleges, such as the College of Naturopathic Physicians of British Columbia, publish lists of practitioners with disciplinary actions, it is hardly a proper account of the efficacy of our regulatory systems, as the total number of complaints is not listed. Furthermore, a list of complaints is not indicative, as some might be biased or not sufficient to warrant disciplinary action.
Overall, the strength of regulation depends on community reporting to bring about change. As it stands today, there are simply not enough financial resources to support routine inspection of all healthcare practitioners, and many feel this is unnecessary. Of those colleges that do perform office visits, it is worthwhile to note that the purpose of the review is for “education and practice improvement, not to discipline,” as stated on page 39 of the Ministry of Health’s Quality Assurance program document. Indeed, the review itself is usually “limited to a visual inspection” with “no observation of clinical service delivery to patients, in part because of privacy issues.”  The Quality Assurance Program Review notes that identifying “bad apples” is a more traditional stance on quality improvement, an assessment that engenders distrust, defense tactics, and frustration. We now strive to function on a model governed by a “Theory of Continuous Improvement”, which is more sensitive to the cost and ineffectiveness of relying on inspection to improve quality. These are measures that must continue but that do not actively improve care to the same extent as initiatives such as continuing education.
Now as I walk by the shops on Thurlow Street advertising their cures for Crohn’s disease, back pain, and weight loss, I am reminded that health care practitioners of many schools of thought are governed by a set of rulings that are strictly regulated and enforced. However, the responsibility for bringing substandard practices to light lies with the clients who seek out these health services; in essence, the efficacy of the regulations is directly proportional to the public’s willingness to engage with the process. Ultimately, it appears that our laws are only as strong as the people who support them.
- Government of British Columbia. Professional Regulation, Ministry of Health [Internet]. 2015 [cited 2015 Mar 8]. Available from:http://www.health.gov.bc.ca/professional-regulation/
- Vancouver Homeopathic Academy. Regulation of Homeopathy [Internet]. 2011 [cited 2015 Mar 9]. Available from: http://www.v-ha.com/index.php?option=com_content&view=article&id=59&Itemid=65
- Health Canada. Provincial/Territorial Role in Health, Health Care System Delivery [Internet]. 2014 May 16 [cited 2015 May 10]. Available from: http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/ptrole/index-eng.php
- Health Canada. Complimentary and Alternative Health Care: the other mainstream? [Internet]. 2005 Aug 9 [cited 2015 May 10]. Available from: http://www.hc-sc.gc.ca/sr-sr/pubs/hpr-rpms/bull/2003-7-complement/index-eng.php
- Vancouver Homeopathic Academy. Practitioner Course [Internet]. 2011 [cited 2015 Mar 9]. Available from: http://www.v-h-a.com/index.php?option=com_content&view=article&id=47&Itemid=53
- British Columbia Naturopathic Association. Becoming a Naturopathic Doctor: yours questions answered [Internet]. 2015 [cited 2015 Mar 8]. Available from: http://www.bcna.ca/about-bcna/becoming-naturopathic-doctor/
- Ministry of Health, Government of British Columbia. Traditional Chinese Medicine and Acupuncture [Internet]. 2015 [cited 2015 Mar 8]. Available from: http://www.health.gov.bc.ca/professional-regulation/notice/tcm_and_acupuncture.html
- College of Traditional Chinese Medicine Practitioners and Acupuncturists of British Columbia. Registration Examinations Requirements [Internet]. 2015 [cited 2015 Mar 9]. Available from: http://www.ctcma.bc.ca/index.php?id=6
- Health Professions Act of 1996, Naturopathic physicians regulation, BC Reg 282/2008 [Internet]. 2008 [cited 2015 Mar 9]. Available from: http://www.bclaws.ca/EPLibraries/bclaws_new/document/ID/freeside/282_2008#section5
- Royal College of Physicians and Surgeons of British Columbia. Complaints Process [Internet]. 2015 [cited 2015 Mar 5]. Available from: https://www.cpsbc.ca/for-public/faqs
- College of Naturopathic physicians of British Columbia. Public Notifications, Notices of Consents Orders and/or Disciplinary Action [Internet]. 2014 [cited 2015 Mar 8]. Available from: http://www.cnpbc.bc.ca/public/public-notifications/
- Ministry of Health of British Columbia. Review of British Columbia Health Profession’s’ Quality Assurance Programs [Internet]. 2003 Mar [cited 2015 Mar 8]. Available from: http://www.health.gov.bc.ca/professional-regulation/pdfs/Quality_Assurance_Program_Review.pdf
Verma P. Regulating Health Professions in British Columbia. UBCMJ. 2015: 7.1 (42-43).