Complementary and Alternative Medicine

Approved by Council: November 1997
Reviewed and Updated: February 2004, November 2011, September 2021

Companion Resource: Advice to the Profession

Definitions

Conventional Medicine: refers to therapeutic concepts, diagnoses, treatments, practices, and products that are considered mainstream medicine. This type of medicine is commonly provided in hospitals and specialty or primary care practices and taught in medical schools.

Complementary and Alternative Medicine: refers to a broad and diverse range of therapeutic concepts, diagnoses, treatments, practices, and products that are not commonly accepted as part of conventional medicine.¹

For the purposes of this policy, it also includes:

• conventional treatments, practices, and products being used in non-conventional ways, and
• new or emerging treatments, practices, and products that are based on conventional medical understanding and scientific reasoning.²

Integrative medicine: a commonly used term within the complementary and alternative medicine environment, referring to an approach to patient care that integrates conventional and complementary medicine.

Professional affiliation: For the purposes of this policy a professional affiliation is where a physician associates themselves with a clinic, treatment, product, or device. For example, where a physician invests in or owns a clinic, sells a product in their practice, or speaks publicly in support of a treatment or device.

Policy

The aim of this policy is to support and regulate the safe and appropriate provision of complementary and alternative medicine, not to prohibit or prevent its use.

The Medicine Act, 1991 provides that physicians shall not be found guilty of professional misconduct or incompetence solely on the basis that they practice “a therapy that is non-traditional or that departs from the prevailing medical practice unless there is evidence that proves that the therapy poses a greater risk to a patient’s health than the traditional or prevailing practice”.

1. As in all other areas of clinical practice, physicians who provide complementary or alternative medicine must practice:
   1. in their patient’s best interests;
   2. in a manner that is in keeping with their professional, ethical, and legal obligations;
   3. in a manner that is informed by evidence³ and scientific reasoning; and
   4. within their conventional scope of practice and the limits of their knowledge, skill, and judgment.⁴
2. Physicians must comply with the expectations of this policy whenever providing complementary or alternative medicine, regardless of whether they are doing so:
   1. in addition to a conventional treatment,
   2. as an alternative to a conventional treatment, or
   3. in the absence of an available conventional treatment.
3. Physicians must practice in a manner that is respectful of patient’s treatment decisions and their ability to set health care goals in accordance with their own wishes, values and beliefs. This includes the decision to pursue or refuse treatment, whether that treatment is conventional, complementary or alternative.

Before Providing Complementary or Alternative Medicine

Conducting an Assessment

4. Physicians must conduct a conventional clinical assessment in accordance with the standard of practice, including:
   1. conducting a comprehensive patient history;
   2. obtaining information regarding any relevant treatments the patient may already be receiving;
   3. conducting any necessary assessments, examinations, tests, or investigations and considering those already undertaken by other health care professionals, to understand the patient’s symptoms, complaints, or condition, or to reach a diagnosis; and
   4. taking any other reasonable steps that may be necessary to obtain relevant and comprehensive information about the patient’s symptoms, complaints, or condition.

Reaching and Communicating a Diagnosis

5. Prior to offering complementary or alternative medicine, physicians must make a conventional diagnosis or differential diagnosis⁵ on the basis of the conventional assessment, communicate it to the patient, and inform the patient of any conventional treatment options that are available to treat their symptoms, complaints or condition.
6. Physicians must only offer an additional diagnosis that is not generally accepted as part of conventional medicine, what is sometimes referred to as a ‘complementary or alternative diagnosis’, where:
   1. the diagnosis is informed by the conventional assessment and conventional diagnosis or differential diagnosis;
   2. any additional assessments conducted to reach the complementary or alternative diagnosis are informed by evidence and scientific reasoning; and
   3. the complementary or alternative diagnosis itself is informed by evidence and scientific reasoning.

Providing Complementary or Alternative Medicine

7. Physicians must not provide complementary or alternative treatments that have been demonstrated to be ineffective.
8. Physicians must only provide complementary or alternative treatments:
   1. to diagnose or treat symptoms, complaints or conditions that are within their scope of practice to treat using conventional medicine;
   2. that they have the knowledge, skill, and judgment to provide;
   3. that are supported by sound clinical judgment; and
   4. that are informed by evidence and scientific reasoning to a degree that is proportionate to the risks to the patient associated with the treatment.⁶
9. In addition to the requirements in provision 8, physicians must only provide a complementary or alternative treatment to a patient where the potential benefits outweigh the risks taking into account:
   1. The health status and needs of the patient;
   2. The strength of evidence and scientific reasoning regarding the efficacy of the complementary or alternative treatment for the patient’s symptoms, complaints, or condition; and
   3. The potential for harm to the patient due to factors including:
      1. the nature of the proposed complementary or alternative treatment itself,
      2. the potential interaction between the proposed option and any other treatments the patient is undergoing,
      3. the conventional options available to treat that patient and their respective efficacy, and
      4. whether the treatment will be provided alongside conventional treatment or as an alternative to it.
10. Physicians must be aware of, consider, and take reasonable steps to address the patient’s potential vulnerability.⁷ A patient’s potential vulnerability will depend on a number of factors including:
    • any potential financial hardship the patient may be experiencing;
    • the probability of the treatment producing a meaningful benefit; and
    • the patient’s individual circumstances (for example, the patient suffers from a serious, life-threatening, or terminal illness).

Obtaining Informed Consent

11. Physicians must obtain informed consent as required by applicable legislation⁸, the College’s Consent to Treatment policy, and as set out in this policy.
12. As part of obtaining informed consent physicians must communicate the following information to the patient or their substitute decision-maker before providing complementary or alternative medicine:
    1. the extent to which the complementary or alternative diagnosis reached (if applicable) is supported by the conventional medical community;
    2. the rationale for recommending the treatment;
    3. any benefit, financial or otherwise, that the physician will receive for providing the treatment⁹;
    4. an accurate representation of the strength of evidence (e.g., quality and quantity) and scientific reasoning that supports the decision to offer the treatment;
    5. reasonable expectations for the efficacy of the treatment; and
    6. a clear and impartial description of how the treatment compares to:
       1. any conventional treatment that could be offered to treat the patient (including a comparison of risks, side effects, expectations for therapeutic efficacy, cost to the patient, and any other relevant considerations); and
       2. the option of receiving no treatment.

Documentation

13. Physicians providing complementary or alternative treatment must comply with the College's Medical Records Documentation policy which, among other expectations, includes the expectation that the medical record contain documentation that supports the treatment or procedure provided (i.e., the rationale for the treatment or procedure is evident in the record).¹⁰
14. Physicians providing complementary or alternative treatment must document that consent to the treatment was obtained and that information was communicated to the patient in accordance with Provision 12 of this policy.

Conflicts of interest and professional affiliations 

15. As in all areas of clinical practice, physicians must:
    1. avoid or recognize and appropriately manage conflicts of interest,¹¹ and
    2. not charge an excessive fee for the services provided.¹²
16. Physicians who wish to form professional affiliations with complementary or alternative clinics, therapies, products, or devices must:
    1. critically assess the efficacy and safety of the treatments offered by the clinic and/or the therapeutic benefit to be obtained from the therapy or device and only form a professional affiliation if they are satisfied that they comply with the expectations in this policy;
    2. comply with the Advertising provisions in the General Regulation under the Medicine Act, 1991 including that they:
       1. not associate themselves with any advertising for a commercial product or service other than their own medical services, or for any facility where medical services are not provided by the physician¹³; and
       2. ensure any published materials¹⁴ relating to that professional affiliation are accurate, factual, and based on evidence and scientific reasoning.¹⁵

Endnotes

^1. For additional information and clarification on what is considered to be complementary and alternative medicine, please see the College’s Advice to the Profession: Complementary and Alternative Medicine document.

^2. This policy applies to new medical treatments, including devices, that are not otherwise subject to regulation by other bodies such as Health Canada. Health Canada requires that some treatments or therapies be registered with them as part of a clinical trial. For example, currently stem cell therapies must be authorized by Health Canada to ensure that they are safe and effective before they can be offered to patients. For more information please see Health Canada's website.

^3. For more information on use of evidence, please see the Advice to the Profession document.

^4. In compliance with Sections 2(1)(c), 2(5), O.Reg. 865/93, Registration, enacted under the Medicine Act, 1991, S.O. 1991, c.30, the College’s Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy, and the Essentials of Medical Professionalism. Please see the Advice to the Profession: Complementary and Alternative Medicine document for more information about scope of practice.

^5. This could include determining that there is no conventional diagnosis that can be made or that the patient is "not yet diagnosed".

^6. Treatments that are low risk will require less evidence to support their provision to a patient, while treatments that may be high risk will require stronger evidence to support their use. For more information on appropriate evidence please see the Advice to the Profession: Complementary and Alternative Medicine document.

^7. For more information see the  Advice to the Profession: Complementary and Alternative Medicine document.

^8. Applicable legislation includes the Health Care Consent Act, 1996 (HCCA).

^9. Physicians are expected to comply with the O. Reg. 114/94: GENERAL under Medicine Act, 1991, S.O. 1991, c. 30 (the Conflicts of Interest Regulation) which states that it is a conflict of interest for a member where “they or a member of their family, or a corporation wholly, substantially, or actually owned or controlled by them or their family… sells or otherwise supplies any drug, medical appliance, medical product or biological preparation to a patient at a profit, except, a drug sold or supplied by a member to his or her patient that is necessary, (A) for an immediate treatment of the patient, (B) in an emergency, or (C) where the services of a pharmacist are not reasonably readily available…”.

^10. The greater the potential risks to the patient are, or the further outside of conventional medicine a treatment is, the greater the need may be to document the full analysis undertaken to determine the appropriateness of providing the treatment.

^11. See O.Reg. 114/94 General, Part IV, Conflicts of Interest, and O.Reg. 856/93 Professional Misconduct, enacted under the Medicine Act, 1991, S.O. 1991, c.30. For example, the Conflict of Interest Regulation requires a physician who or whose family has a proprietary interest in a facility where diagnostic or therapeutic services are performed to inform the College of the details of the interest. The College’s Conflict of Interest Declaration Form is available online.

^12. Section 1(1), paragraph 21, O.Reg. 856/93 Professional Misconduct, enacted under the Medicine Act, 1991 S.O. 1991, c.30. See also the Uninsured Services: Billing and Block Fees policy.

^13. As prohibited by the College’s Advertising policy and O. Reg. 114/94: GENERAL under Medicine Act, 1991, S.O. 1991, c. 30.

^14. For example, presentation materials for conferences, published research or patient materials.

^15. O. Reg. 114/94: GENERAL under Medicine Act, 1991, S.O. 1991, c. 30.