How far can complementary and alternative medicine go? The case of chiropractic and homeopathy
Introduction
A number of complementary and alternative medicine (CAM) occupations in Canada are currently seeking to achieve the status of a profession and procure a place for themselves in the formal health care system (Kelner, Wellman, Boon, & Welsh, 2004). Similar trends are occurring in other countries such as Britain (Allsop & Saks, 2002; Clarke, Doel, & Segrott, 2004), Australia (Carlton & Bensoussan, 2002) and the United States (Goldstein, 2002; Ruggie, 2004). It seems that the time is opportune for the study of these professional projects. As Turner (2004) points out, the monopoly over health care that has been enjoyed by the profession of medicine in Western society is being challenged by a complex set of global processes. Among these are broad cultural changes such as the growth of consumerism, transformations in the pattern of disease, rising health care costs, increased access to information through the Internet, and new health-related social movements such as CAM.
There are indications that the current Canadian socio-political environment is sympathetic to the ambitions of the more popular CAM occupations to professionalize. We are seeing increasing consumer utilization and demand for CAM services (Berger, 1999; Ramsay, Walker, & Alexander, 1999; Statistics Canada, 2005). The diverse nature of Canada's population means that its citizens are accustomed to using a variety of treatment modalities for their health care. The increase in chronic health problems has created interest in pursuing alternative solutions for these conditions (Kelner & Wellman, 1997). Expectations for freedom of choice in health care are putting pressure on the state to consider more inclusive policies for the formal system (Coburn, 1999). There also seems to be a growing distrust of authority in general. People are questioning the integrity of government, the motives of politicians, the centrality of religion, the expert knowledge of medicine and the accuracy of testing for pharmaceutical drugs.
In addition, there are signs that the medical profession, while still erecting barriers at an institutional level, is relaxing its original resistance to CAM, at least on an informal basis (Smith-Cunnien, 1998). There appears to be genuine consideration of integrating conventional medicine with CAM (Dalen, 2005). Some physicians are adopting alternative approaches and techniques into their own practices (Tataryn & Verhoef, 2001), and medical schools are increasingly incorporating CAM into their teaching programs (Ruedy, Kaufman, & MacLeod, 1999).
Finally, some provincial governments, such as Ontario and British Columbia, have recently adopted a more open and less monopolistic model for the regulation of health professions (Gilmour, Kelner, & Wellman, 2002). This model makes room for non medical groups to seek state-sanctioned regulation and opens the door to CAM occupations that wish to gain official recognition within the existing health care system (Health Professions Legislation Review, 1989; Welsh, Kelner, Wellman, & Boon, 2004). In Ontario, the Health Practitioners Regulatory Advisory Council (HPRAC) is currently assessing whether non medical groups such as kinesiology and psychotherapy have met the standards required to join the other regulated health care professions.
There are, however, significant structural limitations on what the CAM occupations can accomplish and change. Medical care in Canada is accessible to everyone, regardless of ability to pay, through the public insurance system. In the case of CAM, however, people must pay out of their own pockets. Furthermore, while medical treatments and prescribed drugs are regarded as legitimate tax deductions, the federal government has consistently refused to allow similar deductions for visits to CAM practitioners or use of natural health products.
In the province of Ontario, CAM groups such as traditional Chinese medicine/acupuncture and naturopathy are working to move ahead with the process of professionalizing at the same time as there is concern about rising costs, a growing emphasis on evidence-based medicine, and an ongoing restructuring of the health care system. The government has been taking an increasing role in managing the health care system and the division of labor within it (Beardwood, 1999; Tuohy, 1999).
It is within this institutional and cultural environment that the CAM groups are attempting to professionalize. They are developing strategies and seeking resources in ways that mirror the measures taken earlier by the more established professions such as law and medicine. Yet, this is the twenty-first century, with barriers and opportunities that present new challenges to those seeking professional status.
In this paper, we compare two CAM occupations, chiropractors and homeopaths, that are currently seeking to establish themselves as institutionalized health care professions in the province of Ontario. We chose to focus on these two groups of practitioners because they illustrate different stages of the professionalization process. Among the various CAM groups in Canada, the chiropractors are the farthest along in the process. They are regulated and have been able to develop consistent strategies and solid resources to advance their interests. The homeopaths, on the other hand, are still struggling to develop appropriate strategies and assemble the resources they would require to realize their potential as a profession. In tracking the development of these two CAM occupations, we attempt to answer the following research questions: (1) To what extent are they implementing strategies and mobilizing the required resources to professionalize? and (2) To what extent does the larger socio-political context influence the process?
In framing this work, we found that we needed to use several different perspectives to describe and understand the process: (1) the trait functionalist approach which assesses a group in terms of how many professional traits (such as standards of education) they possess, (2) the concept of social closure which points to the efforts of a group to limit access to a selected few and exclude outsiders through credentialing, certification and developing a group identity, (3) the system of professions perspective which sees each group jockeying with other groups in the system for power and jurisdiction., and (4) the notion of countervailing powers which points to the ways in which groups in the larger society pursue their own interests and try to constrain each other as they struggle for prestige, power, markets and money.
The trait functionalist framework of Hughes (1963), Larson (1977), and Freidson (1986) regards a profession as a socially negotiated status and focuses on the actions people take to become and remain professional. This framework draws attention to strategies for professionalizing such as improving standards of education, upgrading and enforcing standards of clinical practice and establishing uniform ethical codes. It also highlights the need to develop a distinctive scope of practice that can delineate a jurisdictional boundary around the work of an occupation.
The neo-Weberian concept of social closure used by scholars such as Collins (1990), Witz (1992), and Saks (2000) points to the political aspects and power struggles involved in the process of professionalizing. It refers to the strategies employed by a group to limit access to those who have been certified and have gone through the process of credentialing, thus reducing competition by excluding outsiders and monopolizing available opportunities. Another strategy; building a body of peer-reviewed research, helps to justify and solidify their particular identity. The profession of medicine has used all of these methods to great advantage to gain a legally underwritten monopoly and establish its professional sovereignty at the top of the health care hierarchy. In this paper, we use both these long-standing theoretical frameworks to analyze the extent to which chiropractors and homeopaths are proceeding on the road to professionalizing.
The process of professionalization, however, does not take place in a vacuum. The system of professions used by Abbott (1988), conceptualizes professions as organized into an interacting system in which each competes for power. This perspective draws attention to both internal occupational divisions, and conflicts with other occupations over jurisdiction. It emphasizes that a group cannot occupy a jurisdiction without either finding it vacant or fighting for it (White, 1970). The treatment of chronic illness has been left as a vacancy by conventional medicine, with its concentration on acute conditions (Anderson, 2003). But while the growth in chronic illness provides an opportunity for CAM groups, they have only been partially successful in occupying this vacancy. The profession of medicine has been unwilling to cede this boundary without a fight, and CAM occupations have not been able to act in concert to make their claims. Developing a cohesive membership and identity is a key strategy for mobilizing a group to overcome internal divisions as well as overtaking other groups that are competing for jurisdiction
According to Macdonald (1995), the study of the professions must take into account “the other protagonists in the arena in which the professions are pursuing their goals”(p. 19). Light (2000) conceives of the various protagonists as countervailing powers, each of which has different interests, cultures and goals that are at odds with the others. This concept of countervailing powers places the study of professions within a larger framework of institutional and cultural forces. It posits that one group may achieve dominance by subordinating other groups who, in time, may mobilize to redress the resulting imbalances. The focus is on “the interactions of powerful actors in a field where they are inherently interdependent yet distinct” (Light, 1995, p. 26). Halpern (1992) and others have argued that analysis also needs to take into account how the different segments within a group contend for dominance and thereby influence the boundaries between it and other occupations and professions.
Section snippets
Methods
In 2004, we conducted personal semi-structured interviews with the leaders of four of the most commonly used CAM occupations in the province of Ontario: chiropractic, traditional Chinese medicine/acupuncture, naturopathy and homeopathy. These leaders, 34 in total, were identified through their schools and associations. Here, we focus on the data obtained from the leaders of two of these groups: chiropractors (10) and homeopaths(6). The imbalance in numbers reflects the difference in size of the
Background description: Chiropractors and homeopaths
Chiropractors are the largest group of CAM practitioners (around 3500 in Ontario) and the closest to being considered ‘mainstream’. A recent survey of health services indicates that an estimated 11% of Canadians use chiropractic services; much more that any of the other CAM services available (Statistics Canada, 2005). They are one of the few CAM groups to have been granted official self-regulatory status by the government of Ontario and have had their own associations on a provincial and
Findings
We found that the chiropractic and homeopathic leaders were striving to follow similar strategies for professionalizing. While these strategies resemble the ones used by other professions such as the clergy, law and medicine in the past, our findings show that the strategies and resources need to be considered within the larger framework of current cultural and institutional forces.
The nature of professions
The choice to professionalize has been important for a number of CAM groups in Canada such as the chiropractors and homeopaths. It is useful to note, however, that other CAM occupations like Reiki have not yet made this choice. Those groups who have decided to pursue a professional project have come to understand the defining core characteristics of a profession. These have been identified as “A prolonged specialized training in a body of abstract knowledge, and a collectivity or service
Acknowledgments
This research was conducted with the financial support of the Social Science and Humanities Research Council of Canada. We wish to acknowledge the cooperation of the leaders of the chiropractors and homeopaths in Ontario as well as the assistance of sociology graduate students, Erin Demaiter and Krista Whitehead.
References (61)
The role of evidence in alternative medicine: Contrasting biomedical and anthropological approaches
Social Science & Medicine
(2006)- et al.
Regulation of complementary medicine practitioners in Australia: Chinese medicine as a case example
Complementary Therapies in Medicine
(2002) - et al.
Demarcation and transformation within homeopathic knowledge: A strategy of professionalization
Social Science & Medicine
(1996) - et al.
No alternative? The regulation and professionalization of complementary and alternative medicine in the United Kingdom
Health & Place
(2004) - et al.
Limits to medical dominance: The case of chiropractic
Social Science & Medicine
(1986) Homeopath and patient—A dyad of harmony? Patterns of communication, sources of conflict and expectations in homeopathic physician–patient relationship
Social Science & Medicine
(2002)- et al.
Health care and consumer choice: Medical and alternative therapies
Social Science & Medicine
(1997) - et al.
Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario
Social Science & Medicine
(2004) The system of professions: An essay on the division of expert labor
(1988)- et al.
Introduction: The regulation of health professions
Physician, public, and policymaker perspectives on chronic conditions
Archives of Internal Medicine
The loosening of professional boundaries and restructuring: The implications for nursing and medicine in ontario, Canada
Law & Policy
Social overview report
Social research methods: Qualitative and quantitative approaches
Doctors in Canada: The changing world of medical practice
Shifting sands: Government-group relationships in the health care sector
The chiropractic profession: Its education, practice, research and future directions
Professional powers in decline: Medicine in a changing Canada
Professional autonomy and the problematic nature of self-regulation: Medicine, nursing and the state
Market closure and the conflict theory of the professions
The chiropractic curriculum: A problem of integration
Journal of Manipulative and Physiologic Therapeutics
How can a conventionally trained physician support integrative medicine?
Alternative Therapies in Health & Medicine
Professional powers
Profession of medicine: A study of the sociology of applied knowledge
Opening the door to complementary and alternative medicine: Self-regulation in Ontario
Law & Policy
The emerging socioeconomic and political support for alternative medicine in the United States
The Annals of The American Academy of Political and Social Science
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