The Council issued its Naturopathic Physicians Scope of Practice (Preliminary Report) in December 1998. The public hearing was held on 23 November 1999. The following are changes to the Preliminary Report which arose from the submissions made either at the public hearing or in subsequent written submissions.

I.    SCOPE OF PRACTICE

In its Preliminary Report the Council recommended the following scope of practice for naturopathic physicians:

The practice of naturopathy is the prevention, diagnosis and treatment of diseases, disorders or conditions of an individual through the use of educational and natural therapies or therapeutics to support and stimulate inherent self-healing processes.

In recommending this statement, the Council agreed that the current scope of practice provided in the Naturopaths Act did not reflect the current practice of the profession. However, the Council was not prepared to expand the scope to allow naturopathic physicians to perform surgery or use or administer anaesthetics.

At the hearing, the differences between the training and education of naturopathic physicians and medical practitioners was discussed at length. The Association of Naturopathic Physicians of British Columbia, now the College of Naturopaths of British Columbia (the College) maintained its position that medical practitioners and naturopathic physicians receive the same undergraduate pre-medical training, and both attend medical school for four years, except that medical students complete rounds after college while naturopathic students do so during college. The Council also received submissions on this issue from the College of Physicians and Surgeons of British Columbia, and reviewed and examined the training and education of each of these professions.

In the Council’s view, the training of naturopathic physicians is considerably less than medical practitioners, particularly in respect of clinical hours. The clinical training that naturopathic physicians receive in the four-year curriculum is insufficient for anyone to become competent in the great number of areas which the College wishes to have included in the scope of practice.

In order to perform the reserved acts safely, sufficient supervised clinical experience is necessary. The amount of time spent in supervised clinical activity at the end of four years at Bastyr College is less than the amount experienced by students graduating from North American medical schools. There is no post-graduate training required in order to obtain a license to practice naturopathy in B.C. Most clinical activity in naturopathy is confined to "natural" therapies: botanical medicine, homeopathy, clinical nutrition, naturopathic hygienic principles and lifestyle modifications.

Naturopathic students have less clinical experience than medical students who are still required, at the end of four years of schooling, to complete a minimum of another 5000 hours of supervised clinical experience before being eligible for licensure as a medical practitioner. The insufficient time assigned for both the academic and clinical aspects, plus the fact that the majority of clinical time for naturopathic students is spent on natural therapies, means that graduates of naturopathy schools are not competent to practise in the areas into which the profession wishes to expand, such as midwifery, invasive surgery, and use and application of anaesthesia.

The Council has also determined, as a general matter, that scope of practice statements should not contain or attempt to list the reserved acts granted to a profession. Accordingly, the Council has removed the term "diagnosis" from the scope of practice statement.

There is no doubt, however, that naturopathic physicians may perform diagnosis as that reserved act has been granted to them.

The Health Professions Council recommends the following scope of practice for naturopathic physicians: The practice of naturopathy is the prevention and treatment of disease, disorder or condition of an individual through the use of education and natural therapies or therapeutics to support and stimulate inherent self-healing processes.

II.     RESERVED ACTS

In its Preliminary Report, the Council recommended the following reserved acts for naturopathic physicians:

1. Making a diagnosis using naturopathic methods.

2. Performing procedures below the dermis but only for the purposes of venipuncture and skin pricking for the collection of blood samples; needle insertion acupuncture; removal of foreign bodies from superficial structures; and first aid treatment of minor cuts, abrasions and contusions. Procedures on tissue below the surface of mucous membrane, the cornea or the surface of teeth, including the scaling of teeth, or any other surgical procedures are not included within this reserved act.

3. Performing the following physically invasive or physically manipulative acts:

   1. Moving the joints of the spine beyond the limits the body can voluntarily achieve but within the anatomical range of motion using a high velocity, low amplitude thrust;

   2. Administering a substance by injection or inhalation but not including anaesthetic;

   3. Putting an instrument, hand or finger(s)
      1. beyond the point in the nasal passages where they normally narrow,
      2. beyond the opening of the urethra,
      3. beyond the labia majora,
      4. beyond the anal verge.

4. Allergy challenge testing in which a positive result of the test is a significant allergic response or allergy desensitizing treatment in which there is a risk of significant allergic response.

A.     Procedures Below the Dermis [Reserved Act 2(a)]

In its Preliminary Report, the Council recommended reserved act 2(a) for naturopathic physicians as follows:

Performing procedures below the dermis but only for the purposes of venipuncture and skin pricking for the collection of blood samples; needle insertion acupuncture; removal of foreign bodies from superficial structures; and first aid treatment of minor cuts, abrasions and contusions. Procedures on tissue below the surface of mucous membrane, the cornea or the surface of teeth, including the scaling of teeth, or any other surgical procedures are not included within this reserved act.

The Council has changed the wording of this reserved act to make it easier to read.

B.     Manipulation [Reserved Act 2(c)]

In its Preliminary Report, the Council recommended the following reserved act for naturopathic physicians:

Performing the following physically invasive or physically manipulative acts of moving the joints of the spine beyond the limits the body can voluntarily achieve but within the anatomical range of motion using a high velocity, low amplitude thrust.

At the public hearing, the British Columbia College of Chiropractors (BCCC) opposed this recommendation. BCCC argued that information by naturopathic physicians given to the Council about their competence to perform this reserved act is inaccurate and may be misleading. Specifically, the BCCC contended that the last part of the reserved act, "using a high velocity, low amplitude thrust", has not been adequately addressed by naturopathic physicians, and that the alleged 200 hours of training to understand manipulation is actually spent on other courses aside from manipulation. The BCCC also suggested that cervical manipulation is the most dangerous aspect of this act.

After reviewing this issue, the Council is satisfied that naturopathic physicians have the training and education and do perform some manipulation. However, the Council is concerned that naturopathic physicians are not adequately trained in the area of cervical manipulation which, the evidence indicates, is the most dangerous aspect of spinal manipulation.

C.    Administering a Substance [Reserved Act 2(d)]

This reserved act was modified after the Preliminary Report to add the words substance "other than a drug" and this necessitates a modification to this reserved act as granted to naturopathic physicians. Also, as this reserved act deals with the means of administration, not the substances administered, the reference to anaesthetics need not be included.

The Health Professions Council recommends the following reserved acts for naturopathic physicians: 2. Performing the following physically invasive or physically manipulative acts: procedures below the dermis but only for the following purposes: venipuncture and skin pricking for the collection of blood samples; needle insertion acupuncture; removal of foreign bodies from superficial structures; and first aid treatment of minor cuts, abrasions and contusions; moving the joints of the thoracic or lumbar spine beyond the limits the body can voluntarily achieve but within the anatomical range of motion using a high velocity, low amplitude thrust; administering a substance, other than a drug, by injection or inhalation.

D.     Forms of Energy (Reserved Act 4)

In the Preliminary Report, the Council set out the submissions of the B.C. Naturopathic Association and the College which essentially indicated that "energy is used in all aspects" of naturopathic medicine, without including a comprehensive list of hazardous energies employed in the practice of the profession.

In October 1999, the Council asked the College and the B.C. Naturopathic Association to list the energies they use, the indications and contraindications for use of the listed energies, and the training and education of naturopathic physicians in the use of energies. Neither group responded. This reserved act cannot be considered without information about the indications, contraindications and known hazards to the forms of energy as applied by naturopathic physicians. Therefore, the Council cannot recommend the granting of the reserved act 4, "applying or ordering the application of a hazardous form of energy."

E.     Prescribing Drugs [Reserved Act 5(a)]

The purpose of reserved act 5(a) is to reserve only substances which require a prescription (Schedule I) and substances which are non-prescription but must be sold from a restricted area of pharmacy (Schedule II). The use of substances not falling within this act is not restricted by reserved act 5(a). Therefore, it is not necessary to develop a list of all substances naturopathic physicians propose to use in their practice. Rather, all that is required is a listing of substances which naturopathic physicians use and which fall within the reserved act.

At the hearing, the College and B.C. Naturopathic Association provided a list of 28 Schedule I substances for use by naturopathic physicians that was approved by the College of Pharmacists of British Columbia (CPBC). The pharmacists supported some drug use by naturopathic physicians but conceded they had not considered whether such drugs were related to the scope of practice. The CPBC also stated that a certification process, perhaps including procedures to deal with emergencies, should be instituted.

The Council is not satisfied that naturopathic physicians are trained and educated to use the proposed Schedule I substances, nor is it satisfied that the use of these substances is related to the practice of naturopathic medicine. The limited amount of supervised clinical experience with drugs is of concern, particularly in light of the very serious side effects related to many of the substances. Therefore, the Council does not recommend the use of Schedule I substances by naturopathic physicians.

While the Council’s review of scope of practice proceeded, the federal government undertook a project aimed at addressing the need for regulation of natural health products. The Office of Natural Health Products was created, and a consultation and investigation process was commenced. The Council is not aware of any final recommendations that have been made but understands that the thrust of the process was to create a new federally created category of "natural health products" in addition to food and drugs. It is important that the provincial government keep apprised of that process in order to ensure that provincially regulated health care practitioners, like naturopathic physicians, maintain access to natural health products which are essential to their practice.

F.     Allergy Testing (Reserved Act 7)

In its Preliminary Report, the Council recommended the following reserved act for naturopathic physicians:

Allergy challenge testing in which a positive result of the test is a significant allergic response or allergy desensitizing treatment in which there is a risk of significant allergic response.

Subsequently, the wording of reserved act 7 was modified so that the current reserved act states:

Allergy challenge testing or allergy desensitizing treatment involving injection, scratch tests or inhalation, and allergy challenge testing by any means with respect to a patient who has had a previous anaphylactic reaction.

At the public hearing the B.C. Dietitians’ and Nutritionists’ Association (BCDNA) opposed this recommendation. In its February 1999 submission to the Council, BCDNA stated:

Based on the reasons detailed here, we submit that Naturopathic training does not provide the practitioner with skills to safely:
• Administer skin tests
• Accurately interpret skin tests
• Accurately interpret RAST, ELISA and other immunological tests
• Administer challenge tests
• Administer invasive desensitization (e.g. injection) therapy
• Develop and supervise complex elimination diets
• Adequately provide for replacement of nutrients restricted in an elimination diet
• Supervise a reintroduction program to determine a client’s limit of tolerance to foods
• Treat an anaphylactic reaction
.

In its November 1999 submission to the Council, BCDNA reiterated its arguments and stated that naturopathic physicians lack the medical training to safely administer allergy testing and manage either food or drug allergies.

Several submissions were made at the public hearing which questioned the ability of naturopathic physicians to perform this reserved act. The concerns focussed mainly on naturopathic physicians’ ability to deal with anaphylactic reactions. The Council has similar concerns, mainly because this reserved act requires the ability to deal with anaphylactic reactions which in turn involves other reserved acts which have not been granted to naturopathic physicians. These reserved acts are administering a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act [reserved act 5(a)], and performing prescribed procedures below the dermis [reserved act 2(a)]. These reserved acts are fundamental to the process of dealing with anaphylactic reactions.

The Council is not satisfied that naturopathic physicians have the necessary training and qualifications to administer these procedures.

It is important to note however that the reserved act does not restrict the performance of allergy challenges testing or allergy desensitizing treatment through oral means. This is because the Council concluded from its investigations that the immediate risk of anaphylactic reactions generally arises from injections rather than oral injuries. Therefore, naturopathic physicians may still perform activities in this area involving oral ingestion.

Accordingly, the Council has determined that it is not in the public interest to grant reserved act 7 to naturopathic physicians.

III.     OTHER ISSUES

Hospital privileges

In its preliminary report, the Council recommended that naturopathic physicians be granted hospital treating privileges. The Council has decided to change its recommendation on this issue. At the public hearing, the Dean of Bastyr College said that primary area of care is out patient, not hospital based. The B.C. Dietitians’ and Nutritionists’ Association opposed hospital treating privileges because of the possibility for harm from food diets prescribed by naturopathic physicians. In the Council’s view, hospital treating privileges are not necessary for the practice of naturopathic medicine and also have the potential to create confusion and conflict within the context of hospital based practice. Therefore, the Council does not recommend that naturopathic physicians be granted hospital treating privileges.