Positive Health Online

This question is perhaps not always asked out loud by patients but is certainly present when they first consult a practitioner of complementary therapies.

It is also of concern to doctors and other practitioners who might wish to refer their patient for complementary therapies. A reasonable question to ask – everyone wants to feel as though they are in safe hands – but not necessarily an straightforward question to answer.

Probably most practitioners in the UK using complementary therapies could show certificates of courses completed or membership of a professional organisation but what does that qualification mean? Qualified to practise what? Just what scope of practice does this qualification relate to? A qualification in reflexology does not mean the practitioner is qualified to prescribe homoeopathic medicines or offer psychotherapy. An orthodox medical education would not make a doctor qualified to practise osteopathy or acupuncture. It is perhaps unlikely that a reflexologist would venture into these other forms of therapy without appropriate training and equally unlikely that medical doctors would claim to be osteopaths or acupuncturists without some formal training. But how much training is enough? What does a practitioner need to know to be safe and competent?

This depends very much upon the kinds of cases they take on and the claims made by the practitioner and what kind of competence is reasonable to expect from a practitioner of that modality. This question is relatively straightforward for a discipline such as osteopathy where the competencies expected of an osteopath have been published (CROP) by the professional body and the scope of practice for the majority of osteopaths is concentrated on musculoskeletal problems. It becomes much more problematic with disciplines such as homoeopathy that treat patients with a wide range of health related problems. It is not uncommon to hear from practitioners that they 'treat patients rather than the diseases' but this rhetoric is a fob. If practitioners are taking on patients who have serious diseases like cancer then it is reasonable to expect they have training to manage patients with such conditions and to recognise their limits. But how would a practitioner recognise the limits of their competence. What would be the yard stick. Because some of the new professions are still forming, they have not yet clearly articulated what they see as their sphere of activity and therefore what skills might be required for competent practice that is safe and effective – especially given the limited evidence base. To claim that 'we would not treat cancer but we would treat a patient with cancer' skirts around the issue of clinical responsibility. If practitioners are managing patients with serious medical conditions it is important they can demonstrate adequate training and experience to be competent and safe in these areas. If they are not taking such responsibilities it is important to define where the boundaries of competence and clinical responsibility lie, just as it is important that doctors using non-conventional techniques recognise that training in the use of a technique does not confer competence in the system of therapeutics from which that technique derives.

There is the question of competence to practise a particular discipline and it is up to the professional bodies to determine this level. But who scrutinises the professional bodies? It seems that anyone who wants to run a course can set up a school and form an association which effectively becomes the 'professional body' for graduates from those schools. But for these institutions to be credible they need to be open to public and peer scrutiny. University courses are validated by a panel of academics from other disciplines and other institutions to ensure that courses are taught at an appropriate academic standard.

Professional bodies like the British Acupuncture Council have non acupuncturist members to represent the interests of patients and who are consulted on legal, educational and medical matters. This lead could be followed by some of the newly emerging disciplines.

When a practitioner confines their work to a discrete discipline, establishing their qualification is relatively straightforward, but it is not uncommon for practitioners to extend the scope of their practice by giving dietary advice, nutritional supplements and lifestyle recommendations or prescribing of herbal or homeopathic remedies.

On what basis can you judge whether they are qualified to give such advice? A reasonable approach would be to get in touch with the professional body of the practitioner. They should be able to indicate the level of training and scope of practice of its members. Whilst it may be laudable for a practitioner with a holistic orientation to consider the wider aspects of their patients' health and illness, it is bad practice and potentially dangerous for them to exceed their sphere of competence.

This issue of competence is clouded by the fact that different professions have unique ways of understanding and describing what is going on when a patient is ill. This will in some way shape their beliefs about what the safe competent professional needs to know; e.g. if the Shiatsu practitioner sees patients in terms of energy balance it might be argued that biological and psychological knowledge are not particularly important in their training. On the other hand if as part of their assessment a practitioner considers the psychological or social dimension of their patients' health then an appropriate level of education and training in these areas is probably mandatory. How practitioners describe what is encountered in the patient-practitioner interaction and the meaning they attribute to those events will radically alter what is considered appropriate knowledge and competence.

If the problems that patients present to their practitioners are seen as biopsychosocial and spiritual events then the educational process needs to prepare aspiring professionals to deal with these realms. I am not suggesting that practitioners need to be an expert in all domains but that education and training needs to reflect the claims and aspirations of the profession.