The Scope of Yoga Practice-Yoga Alliance Standards Review Survey

Yoga Alliance recently released its “Standards Review Survey” which was conducted in connection with its review of teaching standards. One of the questions in the survey was:

How important is it for yoga teachers to have a clear Scope of Practice and established guidelines for referring yoga student practitioners to complementary licensed professions, or for deferring to the advice of complementary licensed professions (i.e. doctors, physical therapists, nutritionists, etc)?

Guidelines for Scope of Practice were “very or somewhat important” for most respondents (86%) and more than half felt strongly about this topic (59%).

I see several key issues raised by this question. First, (i) if you are a yoga teacher, how do you know when to treat a student or refer a student to a complimentary or alternative practitioner, and (ii) how do you avoid the unauthorized practice of medicine? As a yoga teacher you must have a clear idea of the boundaries that define teaching yoga, complimentary and alternative modalities and the unauthorized practice of medicine.

Second, if you are a complimentary or alternative practitioner, how do you avoid (i) violating the laws of your state that regulate your practice; and (ii) the unlawful practice of medicine?

If you are a yoga teacher, a yoga therapist or practicing contemporary or alternative modalities, you must know whether you are engaged in the unauthorized practice of medicine. If you are, you may be subject to criminal and civil liabilities. You may think that you are not practicing medicine because your practice does not look like that of a conventional medical doctor but you cannot be sure unless you know the laws of your state.

Because the scope of practice guidelines are largely a legal issue, I thought it would be helpful to discuss this topic and provide you with some resources.

What Is CAM?

The National Center for Complementary and Alternative Medicine (“NCCAM”) within the National Institutes of Health, defines complementary and alternative medicine (“CAM”) as healthcare practices that are not currently a part of conventional medical care. The terms “alternative” and “complementary” are often used interchangeably but they refer to different concepts:

1. If a non-mainstream practice is used together with conventional medicine, it is considered “complementary.”
2. If a non-mainstream practice is used in place of conventional medicine, it is considered “alternative.”

According to NCCAM integrative health care often combines conventional and complementary approaches in a coordinated way: “It emphasizes a holistic, patient-focused approach to health care and wellness—often including mental, emotional, functional, spiritual, social, and community aspects—and treating the whole person rather than, for example, one organ system. It aims for well-coordinated care between different providers and institutions.”
CAM health care includes natural products and mind and body practices. They generally cover the following areas:

Mind-Body and Energy Practices

Yoga, chiropractic and osteopathic manipulation, and meditation are among the most popular mind-body practices. Other practices include acupuncture, relaxation techniques (such as breathing exercises, guided imagery, and progressive muscle relaxation), tai chi, qi gong, Reiki, hypnotherapy, Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, and Trager psychophysical integration.

Traditional Health Practices

These include traditional healers, Ayurvedic medicine, Chinese medicine, homeopathy, naturopathy, and functional medicine.

Natural Products

These include products such as herbs (also known as botanicals), vitamins and minerals, and probiotics. They tend to be widely marketed, readily available to consumers, and sold as dietary supplements.

CAM Practitioners and the Unauthorized Practice of Medicine

Based upon a comprehensive report by the National Institute of Medicine and a study published by the New England Journal of Medicine, millions of people are receiving substantial health care services from CAM practitioners.

The wide scope of CAM practice raises the question as to whether they constitute the “practice of medicine.” In some cases, these practices can technically constitute the practice of medicine because they are within the strict letter of the law. The result is that CAM practitioners may be subject to liability for violating medical practice acts.

The fundamental principle is that neither CAM practitioners nor yoga teachers should practice medicine. You must be aware of the many types of activities that are considered the unauthorized practice of medicine within your home state.

Regulation of the Practice of Medicine

The right to practice medicine is a privilege granted by the states. Each state has laws that govern the practice of medicine. These laws are embodied in what are usually called medical practice acts. State medical boards are the agencies under these acts that license medical doctors, investigate complaints, and discipline physicians who violate their acts. The mission of the medical boards is to serve the public by protecting it from incompetent, unprofessional, and improperly trained physicians. Medical boards accomplish this by ensuring that only qualified physicians are licensed to practice medicine and that they provide their patients with a high standard of care.

The practice of medicine by unlicensed doctors is known as the unauthorized practice of medicine. How these laws define “the practice of medicine” varies from state to state but most states use a broad definition.

The unauthorized practice of medicine occurs when an unlicensed person does something that is part of the legal definition of “practicing medicine” even though they did not intend to do so. This does not mean offering general advice (as, for example, in a magazine article for the general public) or offering informal advice about a coworker’s cold. However, it does involve holding yourself out as a licensed doctor if you do not have a license to practice medicine and engaging in activities traditionally performed by medical doctors.

The use of home remedies, the self-injection of insulin, tattooing, the sale of healing books, or the sale of vitamins or nutritional substances generally are not considered the unauthorized practice of medicine, provided those activities do not involve making a diagnosis of a patient. However, prescribing vitamins to cure an illness is usually considered practicing medicine. The same is true of taking blood or urine samples for analysis in order to diagnose an illness or prescribe remedies to resolve medical conditions.

Is CAM the Unauthorized Practice of Medicine?

If you are a CAM practitioner you must review the laws of your state to make sure that your practice does not constitute the unauthorized practice of medicine.

Ten states have laws that protect consumer access to CAM practitioners. These are: Oklahoma, Idaho, Minnesota, Rhode Island, California, Louisiana, New Mexico, Arizona (limited exemption for homeopaths only), Colorado, and Nevada. These are known as “Safe Harbor” laws.

There are an additional fifteen states who have introduced similar laws that are working their way through the political process. For example, Iowa has a new bill, the “Iowan’s Access to Complementary and Alternative Health Care” bill, SF 261, and a similar initiative has been introduced in Georgia.

The National Health Freedom Coalition has done an excellent job tracking the legislative activity in the various states and mobilizing supporters of CAM. See the Resources for links.

California and New Mexico are excellent examples of “Safe Harbor” laws that exempt CAM practitioners against liability for the unlawful practice of medicine. These laws protect consumer access to the broad range of CAM modalities, including herbalists, traditional naturopaths, homeopaths, body workers, and culturally specific healing practices.
I am focussing on California and New Mexico laws because they provide excellent examples of Safe Harbor laws. They clearly describe the boundaries of what constitutes the practice of medicine and what constitutes the practice of CAM.

If your state has not adopted Safe Harbor laws, these laws provide good guidelines for you to follow to avoid practicing medicine. They also embody best practices. But, once again, you must know and follow the laws of your home state.

State Safe Harbor Laws: California and New Mexico

California Law

California has passed a law that clarifies the types of activities that constitute the practice of medicine so that providers of CAM modalities will not inadvertently violate the laws prohibiting the unauthorized practice of medicine. This law recognized that over five million Californians receive CAM health services but that these services may be in technical violation of the Medical Practices Act. CAM practitioners could be subject to fines and penalties, even though there is no evidence that their practices harm to the public. Thus, the goal of the law is to provide access to CAM services to California residents.

In California, a person will not be considered practicing medicine unless they do any of the following:

1. Conduct surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
2. Administer or prescribe x-ray radiation to another person.
3. Prescribe or administer drugs or controlled substances to another person.
4. Recommend the discontinuance of drugs or controlled substances prescribed by an appropriately licensed practitioner.
5. Willfully diagnose and treat a physical or mental condition of any person under circumstances that create risk of great bodily harm, serious physical or mental illness, or death.
6. Set fractures.
7. Treat lacerations or abrasions through electrotherapy.
8. Hold out, advertise or imply to a client or prospective client that he or she is a physician or a surgeon.

A CAM practitioner must, prior to providing services, disclose to the client in a written statement using plain language the following information:

(A) That he or she is not a licensed physician.
(B) That the treatment is alternative or complementary to healing arts services licensed by the state.
(C) That the services are not licensed by the state.
(D) The nature of the services to be provided.
(E) The theory of treatment upon which the services are based.
(F) His or her educational, training, experience, and other qualifications regarding the services to be provided.

If a CAM practitioner advertises his or her services, the ad must disclose that the practitioner is not licensed by California as a “healing arts practitioner.”

The CAM practitioner must obtain a written acknowledgement from the client stating that they have been provided with this information. The client must be given a copy of the acknowledgement. The CAM practitioner must keep the statement for three years.

New Mexico

New Mexico passed the Unlicensed Health Care Practice Act. It is similar in scope to the California Safe Harbor law. The New Mexico Act provides that a CAM practitioner will not violate the Act unless the practitioner:

A. performs surgery;
B. sets fractures;
C. administers x-ray radiation;
D. prescribes or dispenses dangerous drugs or controlled substances;
E. directly manipulates the joints or spine;
F. physically invades the body except for the use of non-prescription topical creams, oils, salves, ointments, tinctures or any other preparations that may penetrate the skin without causing harm;
G. makes a recommendations to discontinue current medical treatment prescribed by a licensed health care practitioner;
H. makes a specific conventional medical diagnosis;
I. has sexual contact with a current patient or former patient within one year of rendering service;
J. falsely advertises or provide false information in documents described in the Act;
K. illegally use dangerous drugs or controlled substances;
L. reveals confidential information of a patient without the patient’s written consent;
M. engages in fee splitting or kickbacks for referrals;
N. refers to the practitioner’s self as a licensed doctor or physician; or
O. performs massage therapy on an individual pursuant to the Massage Therapy Practice Act.


Furthermore, the CAM practitioner must:

A. Provide to a patient prior to rendering services a patient information document containing the following:

(1) the practitioner’s name, title and business address and telephone number;
(2) a statement that the practitioner is not a health care practitioner licensed by the state of New Mexico;
(3) a statement that the treatment to be provided by the practitioner is complementary or alternative to health care services provided by health care practitioners licensed by the State of New Mexico;
(4) the nature and expected results of the complementary and alternative health care services to be provided;
(5) the practitioner’s degrees, education, training, experience or other qualifications regarding the CAM services to be provided;
(6) the practitioner’s fees per unit of service and method of billing for such fees and a statement that the patient has a right to reasonable notice of changes;
(7) a notice that the patient has a right to complete and current information concerning the practitioner’s assessment and recommended services that are to be provided, including the expected duration of the services and the patient’s right to access to its records;
(8) a statement that patient records and transactions with the practitioner are confidential unless their release is authorized in writing by the patient or otherwise provided by law;
(9) a statement that the patient has a right to coordinated transfer when there will be a change in the provider of CAM services; and
(10) the name, address and telephone number of the department and notice that a patient may file complaints with the department; and

B. Obtain a written acknowledgment from a patient stating that the patient has been provided with a copy of the information document. The patient must be provided with a copy of the acknowledgment, and it must be maintained for three years by the practitioner.

Regulation of CAM in the States

There are many CAM modalities that are specifically regulated by most of the states. Some of these modalities are regulated by state boards. Below is a list of the CAM modalities that my research has found are regulated or addressed in some way by the various states. You can see that the list is comprehensive.

Some states have scope of practice committees that consider proposals by practitioners to find that their activities are not considered the practice of medicine. You must check the laws of your state to determine if your CAM or other wellness practice could be construed as the unauthorized practice of medicine or if it is exempt. You must comply strictly with the requirements of the state where you practice.

The list of modalities includes the following:
1. Acupuncture;
2. Homeopathy;
3. Massage;
4. Naturopathy;
5. Alexander Technique;
6. Aromatherapy;
7. Art therapy;
8. Bioenergetics;
9. Biofeedback;
10. Chelation;
11. Dance Therapy;
12. Feldenkrais Method;
13. Hellerwork;
14. Herbology;
15. Holistic Healing;
16. Hydrotherapy;
17. Hypnotherapy;
18. Music Therapy;
19. Naprapathy;
20. Oriental Medicine;
21. Polarity Therapy;
22. Reflexology;
23. Reiki;
24. Rolfing;
25. Shiatsu;
26. Spiritual Healing;
27. Touch Therapy; and
28. The Trager Approach.

What About National Credentialing for CAM Practitioners?

“Credentials” are a broad term that can refer to a practitioner’s license, certification or education. There is no standardized national system for credentialing CAM practitioners.

State agencies are responsible for deciding what credentials CAM practitioners must have to be properly licensed and not violate their medical practice act. Trade associations and professional organizations may also certify practitioners and offer certification examinations to graduates of accredited education and training programs.

The credentials required for complementary health practitioners vary widely from state to state and from discipline to discipline so you must check the laws of your state as well as any professional organizations that may regulate or certify your practice.

Yoga Therapy and Yoga Alliance

Yoga Alliance has adopted a policy on the use of “yoga therapy” or “yoga therapists” by registered yoga teachers. Yoga Alliance determined that the International Association of Yoga Therapists (“IAYT”) did not clearly distinguish between yoga practice and yoga therapy. Moreover, it felt that the IAYT Scope of Practice was too broad and vague, and that it may create the risk that yoga therapists may be engaged in the unauthorized practice of medicine. Yoga Alliance felt this could create confusion between yoga and yoga therapy, and increase the risk that yoga may become regulated. Yoga Alliance decided to separate yoga and yoga therapy and adopted the following policy:

Therefore, no Yoga Alliance Registered Yoga School or Registered Yoga Teacher may rely on or use their RYS, RYT, or YACEP Designations to hold themselves out as qualified to work as a “yoga therapist” or to train others in “yoga therapy” methods. Yoga Alliance considers “yoga therapy” references to include the terms “yoga therapy,” “yoga therapist,” or any claim to provide yoga-related training or instruction designed to diagnose or treat mental or physical health conditions, injuries, or illnesses. As a matter of policy, Yoga Alliance will not allow Registry directory listings to include “yoga therapy” references… In marketing or advertising materials that are independent of the Registry directory, a teacher or school that references “yoga therapy” services or training must identify the source (other than Yoga Alliance) of certification, accreditation, licensure, or other credential on which they base their “yoga therapy” offerings. For example, a teacher who is a licensed physical therapist may have a website or use advertising materials identifying themself as an RYT and as a “PT licensed in {states},” offering “yoga therapy as a component of my physical therapy practice.” Failure to identify a credential or qualification related to the teacher or school’s “yoga therapy” work or training activities would create the incorrect impression that the Yoga Alliance registration provides the foundation for the claimed “yoga therapy” expertise.

See Resources for links to more further information.

Yoga Therapy and the IAYT Scope of Practice

The IAYT adopted a Scope of Practice for yoga therapists on September 1, 2016. The document is lengthy but I have set forth below the actions that a yoga therapist may not take:

1. Work with clients presenting with issues outside the therapist’s areas of competence/professional expertise;
2. Advertise himself or herself as a licensed healthcare practitioner, unless he/she is also a licensed healthcare practitioner;
3. Perform physical adjustments, manipulations, or massage, unless appropriately qualified to do so;
4. Undertake individual or group psychological counseling, unless appropriately qualified to do so;
5. Recommend specific lifestyle or nutrition changes outside of a yoga therapy framework, unless appropriately qualified to do so;
6. Diagnose a medical or psychological condition, unless qualified to do so as a licensed healthcare practitioner;
7. Advise about other health treatment modalities, other than referring clients to appropriate personnel or services, unless appropriately qualified to do so;
8. Request diagnostic tests or procedures outside their professional areas of expertise or qualifications;
9. Interpret raw medical or psychological diagnostic test results, unless qualified to do so as a licensed healthcare practitioner;
10. Prescribe medication, unless qualified to do so as a licensed healthcare practitioner;
11. Prescribe nutritional supplements or herbs from Western or traditional medical methods such as Chinese Medicine or Ayurveda, unless appropriately qualified to do so;
12. Advise clients about ceasing medication prescribed by another healthcare practitioner, unless qualified to do so as a licensed healthcare practitioner;
13. Perform any invasive procedures, unless qualified to do so as a licensed healthcare practitioner; or
14. Make recommendations regarding the advice or treatment provided by another healthcare professional, unless appropriately qualified to do so.

See resources for links to the IAYT Scope of Practice.

When Should I Refer Students to CAM Practitioners or Doctors?

As a yoga teacher how do you know when to refer a student with a wellness or medical problem to a CAM practitioner or to a traditional doctor? How do you know where you should refer the student? How do you know if you should treat the problem yourself?
In thinking about referrals, your guiding light is that your actions must always be in the best interest of your student and you must follow any laws that may apply to your actions.

In considering whether to treat or refer the student, ask yourself the following questions:

1. Have I received any special training with regard to the problem that the student seems to be having?
2. If I do feel that I have special training in the area relevant to the student’s problem, am I certain that I am qualified? Am I certain that my treatment will not be considered the unauthorized practice of medicine?
3. Is the student’s problem something that should be handled by a different CAM practitioner with appropriate expertise?
4. Is the student’s problem something that should be handled by a medical doctor?
5. Do I have the expertise to evaluate the student’s problem and make an effective referral?
6. If I make a referral, can I give the student several options both with regard to different CAM modalities that may be helpful and qualified practitioners within those modalities?
7. Am I comfortable that the practitioner to whom I want to make a referral has the expertise to treat the student’s problem? Have I worked with the practitioner before? What was the feedback I have received from other patients that I have referred to the specialist?
8. Do I feel that the patient will respond positively to the specialist that I refer the patient to? Will they “click”? Am I prepared to advise the patient about what they should expect when they work with the specialist?
9. What is the urgency of the student’s problem and their need for a referral? Should I contact the specialist before I refer the student to discuss the situation? Am I confident that these discussions will be held strictly confidential?
10. Am I prepared to follow up with the student to see if they saw a specialist and whether their problem was resolved?

If you are in doubt about what to do, your “safe harbor” is always to refer a student to a medical doctor. You should never attempt to treat a student unless their problem is squarely within your area of expertise, your treatment is within the scope of practice of your area of expertise, and you are not engaged in the unauthorized practice of medicine.

Resources

The Website of the NCCAM has many resources about CAM and information about what may constitute the unauthorized practice of medicine. This site provides guidance for practitioners of yoga and other wellness modalities. Here is the link:

http://nccam.nih.gov/

The American Medical Association has resources on efforts by CAM practitioners who wish to expand the scope of their practice legally.

https://www.ama-assn.org/practice-management/payment-delivery-models/scope-practice

National Center for Complimentary and Alternative Health

https://nccih.nih.gov/

AMA Journal of Ethics: Licensure of Complementary and Alternative Practitioners

https://journalofethics.ama-assn.org/article/licensure-complementary-and-alternative-practitioners/2011-06

International Association of Yoga Therapists and Scope of Practice

https://www.iayt.org/
https://www.iayt.org/page/IntroScope

Yoga Alliance Policy on Yoga Therapy

https://www.yogaalliance.org/yoga_therapy_usage
https://www.yogaalliance.org/YogaTherapyPolicy

Yoga Alliance Standards Review Project Survey

THE THREE LIMBED STRATEGY FOR PROTECTING YOURSELF FROM LIABILITY-CAREFUL TEACHING STRATEGIES (Part 3)

The third limb of our strategy to reduce the risk of liability involves preventing the harm in the first place by using careful teaching strategies. Yoga studios and teachers should work together to determine these strategies and make sure that they are followed within the studio.

Pre-existing Medical Conditions and Injuries

Yoga studios and teachers are often faced with the question of how they should teach students who have pre-existing medical conditions or injuries yet avoid subjecting themselves to an increased risk of liability for personal injuries sustained by students. (I will use “condition” to refer to both medical conditions such as diseases and pain as well as physical injuries.)

Should a teacher inquire before class if any students have a condition or should a teacher not make any inquiry at all? If a teacher makes an inquiry, how should the teacher use that information to guide the student in class? How should a teacher respond if he or she does not inquire but a student volunteers information about a condition? What if the student has an open and obvious condition such as pregnancy?

The answers to these questions may vary for different practices such as hot yoga, power, pre-natal, therapeutic yoga and private lessons.
A related issue is whether yoga studios and teachers should request medical information in new student sign-up forms or private lesson intake forms. If so, what risks and obligations does the collection of this information create?

These questions are further complicated because they may involve conflicts between our yogic and legal responsibilities. How do we balance our duties of ahimsa (non-violence), compassion and caring against our interest in avoiding legal liability for aggravating a pre-existing condition?

Summary of Best Practices

Below is a summary of the best practices that I recommend to address these issues. My book “Light on Law-Essential Information for Yoga Studios, Teachers and Wellness Businesses” has comprehensive information on these best practices.

1. Teachers should not ask students about pre-existing conditions at the beginning of class. Rather, teachers should make a general announcement that students should “keep themselves safe”, “honor their bodies” or similar language. Teachers should emphasize that students with injuries must exercise special care to protect themselves. When teachers offer modifications for poses, they should offer specific modifications rather than simply advising students to “modify.” Specific modifications should always be offered for those poses which tend to produce injuries. If a student has disclosed a specific condition, specific modifications should be provided.

2. Teachers who choose to ask students about pre-existing conditions may be subject to a higher duty of care. This may subject a teacher to a higher risk of liability if the teacher does not meet this higher duty of care. The higher duty of care may require a teacher to closely monitor a student with a condition and offer specific modifications to poses that could aggravate the student’s condition. If the teacher is not able to carry this higher duty of care, the best practice is that the teacher should not ask about pre-existing conditions.

3. Yoga therapists, specialty teachers and teachers providing private lessons have a duty to inquire as to any pre-existing conditions of their students.

4. If a teacher has actual knowledge of a student’s condition because it is open and obvious, the teacher has a duty to inquire about the condition. The teacher must then meet the higher duty of care with respect to caring for that student in class.

5. If a student volunteers information about a condition, the teacher has a duty to inquire about the condition. The teacher must then meet the higher duty of care with respect to caring for that student in class.

6. In most cases, studios and teachers should not obtain specific medical information about their students on new student questionnaires. However, this may be appropriate for yoga therapists and other teachers with specialty practices. If this information is collected, all of the privacy regulations, both state and federal, must be followed.

Confidential Treatment of Private Information

Yoga schools and teachers have an important obligation to maintain the confidentiality of all private information disclosed by students and clients.

Private information means any non-public information that a student or client designates as private or that, under the circumstances, should be treated as private. Private information includes a student or client’s personal contact and account information (i.e., name, address, credit card information, passwords, and email) medical and health information, and attendance records.

One common way that private information is disclosed is though gossip or third parties accidentally hearing private information being discussed. Yoga studios and teachers should be very mindful about discussing private information belonging to a student with anyone. These can be embarrassing to a student and in some cases personally or professionally damaging.

All yoga studios should maintain commercially reasonable policies and procedures to protect the confidentiality of all private information provided by its students and clients.

A school or teacher who receives any private information from a student or client should not disclose such information unless it obtains the written consent of the student or client. Generally, a school or teacher may disclose private information about a student or client without obtaining consent in the following situations:
(a) to comply with the law or the order of a court;
(b) to prevent bodily harm or danger to the student or client or to others; or (c) where the information has already been disclosed to the public.