3-Steps to Building a Successful Ayurvedic Yoga Therapy Practice 

By Jennifer Rioux, Ph.D., AD, AYT, CIAYT, RYT

The International Association of Yoga Therapists (IAYT) paved the way for recognition of yoga therapy in the U.S. Building on that recognition, NAMA has now debuted the new professional category of Ayurvedic Yoga Therapist (AYT-NAMA). Our conception of this emerging profession draws from the IAYT’s statement that “although all yoga is potentially therapeutic and healing, yoga therapy is the specific application of yogic tools—postures/exercises, breathwork, meditation techniques, and more—to address an individual’s physical, mental, and emotional needs.”

The National Ayurvedic Medical Association (NAMA) further defines Ayurvedic Yoga Therapy as the “application of Āyurvedic principles to the practice and principles of Yoga based on the Āyurvedic understanding of the nature of patient, the nature of imbalance, and the nature of the therapies, to promote healing and achieve a harmonious state of body and mind with respect to individual consciousness.”

Step 1: Reach the Appropriate Educational Standards

The education of a yoga therapist must go beyond the usual training of a yoga teacher to include instruction on client assessment and treatment. The individualized nature of yoga therapy separates it from yoga practice in a community studio. IAYT describes this distinction: “A general public yoga class can certainly ease everyday aches, pains, and mood complaints. But a yoga therapy session goes much further because it is tailored to the individual. Yoga therapists have in-depth training to help them assess and keep their clients safe. They work with you to address your specific goals while considering any limitations you might be experiencing.”

The unique nature of an Ayurvedic Yoga Therapist’s role dictates a Scope of Practice that includes services grounded in Ayurvedic theory and applied knowledgesof physiology and cause and effect according to the underlying gunasand the manifesting doshas. The AYT Scope of Practice states that “the Āyurvedic Yoga Therapist shall have the competency to design, implement, demonstrate, instruct, and teach an individual a yoga therapy program to help with their healing process based on the Āyurvedic Prakŗti/Vikŗti paradigm and Āyurvedic definition of health.” 

Currently, IAYT maintains high educational standards for yoga therapists that include the completion of more than 800 hours of training. IAYT now has over 175 schools worldwide that have been accredited to train yoga therapists. Comparatively speaking, our efforts to legitimize the field of Ayurvedic Yoga Therapy as conceived by NAMA are still in their infancy. Schools are in the process of seeking recognition to train individual practitioners. The accomplishment of these goals rests on the assurance that this professional designation requires extensive training t in both Ayurvedic medicine and yoga therapy that enables the practitioner to provide comprehensive whole-person care. To that end, the AYT Standards Committee has increased the required training hours d to between 1,100 and 1,500 hours, with 1.300 as the median.

Step 2: Take Policies into Consideration

An Ayurvedic Yoga Therapist has the ability to help with disease prevention, health promotion, and both acute and chronic health conditions. However, the legal status of such a practitioner will vary from state to state. The National Health Freedom Coalition lists 10 states with Health Freedom Laws. Ayurvedic Yoga Therapists in these states will have more leeway in describing and advertising their practice to the public and in interacting with clients. Consult your local and state statutes for the specific details.

NAMA is not qualified to dispense information or advice on legal issues related to AYT practice; however, we can provide information on what types of guidelines and administrative requirements may influence the nature of your practice. It will be critical that you ensure compliance with any licensing (business or provider related) that is relevant for hands-on healing in your area. It will be necessary to provide a disclaimer on your website and documents indicating that you are not engaged in the practice of medicine. State clearly that your professional objective is to treat Ayurvedic imbalances and request consent for treatment from your clients.

Likewise, it will be helpful to publish a code of conduct on your website that states how you will interact with clients, the parameters for physical contact, and the measures you have in place to protect their confidentiality. Ideally, your clients should feel fully informed before they walk in the door. Always ask if they have questions before beginning assessment or treatment. In addition, make sure that clients understand that you are not equipped to deal with healthcare emergencies. On your voicemail, remind clients to call 911 in the case of any health emergency. Familiarize yourself with NAMA’s Code of Ethics and make sure you can confidently address any client concerns related to ethical practice.

Step 3: Understand Best Practices

Best Practices include behaviors, actions, and approaches that will help you to ensure a high standard of care for your clientele. This may include organizational systems, strategies for keeping yourself accountable to your scope and ethics during sessions, protocols for client documentation, and standards that ensure each client receives equal and appropriate care. You may also want to have an online appointment system or a designated return-call policy of 48 hours. You should have a set of documents you use for recording assessment and treatment information for clients to standardize recordkeeping across your practice. You may want to develop “charting” strategies for tracking patient progress as wellaspprotocols for common conditions that you can use as a foundation for personalized care.

Everyone will set up their practice differently; however, following some of the previously mentioned advice will help the field of Ayurvedic Yoga Therapy gain legitimacy and will helpt AYTs communicate with each other and with other health professionals more effectively. As we recognize more individual members of the AYT professional category and begin to approve training programs, it will benefit all of us to be mindful of the impact of training requirements, the defined Scope of Practice for AYTs, and local and state policy considerations on your approach to providing AYT services. The manner in which we implement best practices will ensure that the public has quality information and will ultimately increase both accessibility and effectiveness of Ayurvedic Yoga Therapy, thereby increasing the clientele for this emerging healing discipline. 


Jennifer Rioux

About the Author
Jennifer Rioux, Ph.D., AD, AYT, CIAYT, RYT
 

Jennifer Rioux specializes in the professionalization of Ayurveda/Yoga and their relationship to Integrative Medicine. Dr. Rioux has been faculty and researcher at the University of New Mexico, Arizona medical schools and the University of North Carolina.

Belonging to a Professional Association

by Marie-Josephine Royall-Schreck

I am a professional nurse and student of Ayurveda transitioning my career into integrative health coaching through education. It’s one of the most exciting times of my professional life, and, as I’ve learned over and over again in my career, I will need support—the support of a professional association. Wanting nothing less than to be valued for my experience, knowledge, ethics, commitment, and to be credible, one day, my education completed, I will venture out into the world and announce that I am ready to serve in a new way. I don’t expect it to be simple—I don’t know what I don’t know. When deciding to add Ayurveda to my professional life, the first thing I looked for was its professional association. NAMA. 

Having resources and professional support available through NAMA will help my self-confidence, and it will help those who choose to work with me, too. This is where belonging to a professional association has always worked for me.

I’ve been a member of associations throughout my career of more than 30 years, so it feels natural to me to seek out the one association that can make a difference for me as I journey into Ayurveda. Associations have been the hub for many areas of my professional life, becoming the one source I can count on for information surrounding policy, best practices, and what are the issues and concerns of other practitioners in my industry. Below are some of the benefits I’ve realized from belonging to professional associations and ones that I know I can count on as a NAMA member. Here’s how I would rank them: 

Industry News and Newsletters
Continued Education
Ethical Standards
Networking/Friendships
Ability to volunteer and serve
Certification/Credentialing
Events/Conferences
Resources
Advocacy
Techniques and Tools
Collaborate with colleagues

How about you? If you have experience as a member of an association, would you agree with my ranking? Write me and let me know. As a member of NAMA’s Membership Committee, Students Subcommittee, I am part of a team striving to help NAMA serves its future professionals, its future volunteers, its future leaders. Also, if you’d like to share some of your insights regarding membership in an association, send those to me as well, and I’ll do my best to share them with our—your—subcommittee.

If you are a NAMA member now, you’ve made a good choice. If you’re not, consider becoming a member of NAMA today and expose yourself to the many resources available, such as ENEWS, Annual Conference, and Professional Ayurvedic Continuing Education (PACE). Also, consider getting involved through volunteering. As you help others, you will see yourself grow in your own practice and enhance your association in the process. The more you know, the more you grow.


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About the Author
Marie-Joséphine Royall-Schreck

Marie-Joséphine Royall-Schreck is a Professional Registered Nurse, Health Coach, Certified Meditation & Mindfulness Teacher, and Registered Yoga Teacher. She is a member of NAMA’s Membership Committee, Students Subcommittee; member, International Association Yoga Therapists; and member, Yoga Alliance. Marie-Joséphine lives in Sedona, Arizona and may be contacted through the NAMA Students subcommittee at students@ayurvedanama.org.

Research and Clinical Practice Highlight

with Clayton Bell M.D.

My name is Clayton Bell, and I am an Integrative Medicine physician and Assistant Clinical Professor in the Department of Family Medicine at the University of Tennessee Medical Center.  My current clinical practice as an Integrative Medicine physician combines cutting-edge, evidence-based Orthomolecular-Functional Medicine with the subtle yet powerful healing insights of Ayurveda. 

Personalized wellness plans are created for each patient based on their prakruti, vikruti, and current medical conditions.  Heavy emphasis is placed upon Lifestyle Medicine treatments and “miracles” often abound in the healing response.  Patients and fellow healthcare providers are often amazed to discover what happens when one brings the various aspects of their life (physical, psychological, emotional, spiritual) into balance.  To help expand this clinical knowledge, I am actively teaching Ayurvedic techniques to rotating medical students, residents, and providing Grand Rounds to various medical departments throughout the hospital as well. Combining the science of Western medicine and the wisdom of Eastern medicine creates the highest level of patient care possible.

Ayurveda began capturing my passion and professional curiosity three years ago during my Integrative Medicine Fellowship at the University of Kansas Medical Center. For my fellowship thesis, I wanted to scientifically validate if the various Ayurvedic prakruti (Vata, Pitta, Kapha) were truly biostatistically correlated with Integrative and Western Medicine diagnosis.  Through researching both national and international peer-reviewed journals, many articles began to emerge linking specific prakruti to various biomarkers and genomic patterns.  However, nowhere could I find where any researchers had ever biostatistically validated these most foundational theorems regarding prakruti and various disease states.  

Our research study participants were patients of the KU Integrative Medicine Clinic. Eligibility criteria included adult patients ages 21 and older with no language barriers and the ability to give consent. Approximately 150 participants were screened, 129 were enrolled with 119 successfully completing both the Mind-Body Survey and the Medical History Form. The Mind-Body Survey consisted of 10 self-assessment questions pertaining to specific physical and psychological characteristics. This survey was adapted from The Chopra Center’s Prakruti Patient Intake Form and provided quantitative subscores for each Ayurvedic dosha (Vata, Pitta, Kapha). Participants were also given a Medical History Form to determine active, past, or lack of history for 47 common integrative medicine diagnoses. Biostatistical analysis was analyzed to determine positive and inverse correlations between prakruti and specific disease diagnosis.

Based on our findings, we have discovered multiple statistically significant positive and inverse correlations between prakruti and self-reported medical diagnosis. Vata was associated with anxiety (r = .22, p = .02) and sleep disorders (r = .25, p = .01), whereas Kapha appeared to be protective from anxiety (r = –.31, p = .001) and sleep disorders (r = –.19, p = .04) as well as osteoporosis (r = –.22, p = .02), hyperthyroidism (r = –.24, p = .01) and environmental allergies (r = –.19, p = .04). However, Kapha was statistically associated with obesity (r = .32, p = .001) and overweight (r = .32, p = .001), whereas Vata was protective from obesity (r = –.19, p = .05) and overweight (r = –.39, p < .001). Vata was also statistically correlated with constipation (r = .19, p = .04), depression (r = .22, p = .02), irritable bowel syndrome (r = .26, p = .01), and panic attacks (r = .29, p = .002). Vata was inversely correlated with hypertension (r = –.22, p = .02) and solid organ cancers (r = –.25, p = .01). No statistical associations were found for Pitta.

We were very excited to discover the positive and inverse correlations, which verified the ancient Ayurvedic teachings and our research was published in the Ayurveda Journal of Health—an incredible experience! I learned so much through the entire research and publication process and highly recommend others to do the same.  Our research and many other current publications are validating Ayurveda as an incredibly useful and pragmatic medical system.  To learn more, see the Ayurveda Journal of Health 2017 Summer edition and read our article: Ancient Wisdom: Can Ayurvedic Prakruti Provide Invaluable Insights into Integrative Medicine?

Remember, as a NAMA member you have a subscription discount to the Journal. Check your Member Discounts from the NAMA Member Center.


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About the Author
Clayton Bell, M.D.

Dr. Clayton Bell is an Integrative Medicine physician and Assistant Clinical at the University of Tennessee Medical Center.  He utilizes evidence-based Orthomolecular Functional Medicine and the ancient wisdom of Ayurveda to create personalized wellness plans for each patient.  

How to Build a Successful Ayurvedic Practice with Education, Legalities and Business Practices

By Felicia Tomasko, RN, C-IAYT, AP


If you’ve embarked on a course of study of Ayurveda, you’ve likely done so out of passion. You may have found some purpose in the teachings or even some measure of healing in your own life. Then, perhaps you decide to put the teachings into practice in a practical way and build a profession from your passion. When it comes to building a successful Ayurvedic business, there are a number of factors to address, from understanding the scope of practice in relation to your education, to knowing the laws you are practicing within, to fully understanding yourself. In addition, even if you didn’t set out with this goal in mind, it’s time to embrace the art of being an entrepreneur. Here are some suggestions for transitioning from Ayurveda as passion to Ayurveda as practice.
 

Know Yourself

While this may seem like a bit of a cliche, taking some time for an inventory of self-awareness is a key component to building any successful career. This is distinct from understanding the scope of your education. Knowing yourself includes understanding something about the ways in which you want to engage with your practice and your business. Where and how do you want to work? For example, do you thrive as part of a team and want to join an integrative medical clinic or group? Do you prefer to set up a solo practice? If so, is there a space at home where you can create a professional office space? Are you looking to make or sell products? Are there specialties within Ayurveda that you feel you want to focus on? Do you visualize a full-time practice or part-time work to accommodate family or other commitments? Try journaling or finding a friend, mentor, or colleague who is willing to brainstorm or heartstorm (as one of my friends says) with you. Know that some of your ideas might change, but it’s helpful to start the process of self-inquiry at the beginning, as it may inform some of your direction and subsequent decisions. As with any business, you’ll be starting where you are in the moment yet making plans to grow a practice and hold an expanded vision.


Embrace Your Education and Scope of Practice

Ayurveda is a vast science and practice. In order to promote clarity in the different educational paths, the National Ayurvedic Medical Association (NAMA) offers separate categories of practitioner types, each with their own course of study, requirements and scope of practice. Of course, Ayurveda is a life-long pursuit, and no matter where you begin there are options available to earn new certifications. In the meantime, understand where you are now and organize your business so that you are operating within the scope of practice appropriate to your educational competencies and certification. Continuing your education is important from the perspective of adhering to ethical guidelines as well as setting yourself up for success.


Commit to Continuing Your Education

Wherever you land in terms of a certification and title, completing continuing education on an annual basis is an important part of staying fresh and current. Even if you are seeing clients daily, nothing substitutes for an ongoing infusion of knowledge and insight from master teachers, clinicians with different experience than your own, and the ongoing wisdom that comes from being a perpetual student. This will continue to expand your skill as a practitioner, clinician, and businessperson, promoting your personal success. Through conferences, classes, and even conference calls and webinars, NAMA offers and refers numerous opportunities for continuing education. Personally, every event or class I attend provides at least one (if not many) a-ha moments that fine-tune or expand my ability to practice successfully.

Know the Laws and Choose a Business Structure

Once you understand the scope of your Ayurvedic specialty, relate that to the laws where you are. This includes understanding the state or regional regulations that apply to the practice of complementary and alternative medicine or therapies. If you have an active medical license, make sure that you are operating within the scope of practice of your Ayurvedic certification as well as your medical license.

Follow the legalities of operating a business in your local area including maintaining a business license and sales tax reporting (if applicable). Look into liability and other insurance policies that relate to both your place of business as well as your practice. Also, create a business structure and accounting system to provide the greatest ease and set yourself up for a long-term successful practice. You may decide to operate as a sole proprietor or to create an LLC or other business corporate structure for liability reasons, for greater clarity, or to facilitate long-term growth if you plan to hire employees or sell products.

Even though you may start small, keep in mind your extended vision. Set up the structures that support your growth. This projected growth may be from one client to five clients or one client to five thousand. The size of the expansion doesn’t matter but having systems in place that create a container for your practice allows you to be the best practitioner you can be. Along the way, utilize the support available for small business owners and budding entrepreneurs. In the US, resources like the Small Business Administration offer free- and low-cost classes as well as opportunities to access mentors.


Ethics Including Confidentiality

Taking an online ethics course is part of maintaining your ongoing professional status with NAMA. Implementing appropriate ethics is essential to maintaining a long-term successful practice. Make sure to implement the appropriate levels of confidentiality surrounding record-keeping and working with clients. Apply this to the systems you set up as well as how you conduct yourself in public. Your clients will notice the care with which you handle sensitive information; it helps to build trust and empowers them to confide in you more freely. This allows you to make appropriate recommendations that set your client up for greater success.
 

Build Your Networks

When it comes to building your networks, think about this from a variety of perspectives. On one level, it relates to building out-bound as well as in-bound referral networks in your community. Who will you call upon when faced with something that is outside your scope of practice? Who will you turn to for advice? Continue to maintain referral relationships with the teachers and mentors from your Ayurvedic programs when you need to discuss (confidentially, of course) a specific case. In addition, develop relationships with people in your community, including providers from other disciplines, for when you are looking for advice or when one of your clients needs services from another system. Get to know acupuncturists, chiropractors, OB/GYNs, massage therapists, energy workers, primary care providers, and more. Find people that you feel sympatico with and would feel comfortable making referrals to. At the same time, develop relationships with people who would be willing to refer clients to you. There may be other providers in your community who are looking for an Ayurvedic specialist whom they can trust. Considering providing some of them a free introductory session so they can get to know you, or offer to give a talk at their office. You may want to host an Ayurvedic tea and chat and invite them for a meet and greet. Developing these relationships in your community is an important aspect of solidifying the success of your own practice.

The other part of building your network is related to growing your group of clients. Start out by connecting to your spheres of influence and being open and communicative about your practice and what you do. You could volunteer at health fairs, donate gift certificates when the opportunity presents itself, encourage (and reward?) referrals from your regular clients. Come back to knowing yourself and your areas of specialty and/or competency. Connect to relevant communities through your areas of expertise. This may include working with kids, women, men, special populations or conditions, areas of interest, and more. As you know yourself, share yourself. As you grow, expand and nurture your networks. Take every opportunity daily to connect your passion to your practice.


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About the Author
Felicia Tomasko, RN, E-RYT-500

Felicia combines decades of Ayurvedic study with her background as a registered nurse. Her experience includes working in hospice care, in drug and alcohol recovery, and in biochemical and cognitive neuropsychology research and is the editor in chief of LA YOGA Ayurveda and Health Magazine.

Being an Ayurvedic Doctor in the United States

For over a decade, NAMA has tirelessly worked to create and implement internal regulatory standards for the practice of Ayurveda.  These standards were designed to improve and promote the safety, efficacy, recognition and legitimacy of the practice.  They were also intended to serve as a framework for state licensing and regulation of Ayurveda in the United States.

NAMA’s regulatory standards recognize three professional practice categories: Health Counselor, Ayurveda Practitioner; and Ayurvedic Doctor.  A scope of practice has been defined for each category, as indicated below:

Ayurvedic Health Counselor: Ayurvedic professionals trained to focus on preventive healthcare as well as health promotion, with a specific focus on diet and lifestyle.

Ayurvedic Practitioner: Ayurvedic professionals with additional training in pathology and disease management beyond that of the AHC. These professionals also practice preventive healthcare and health promotion, using diet and lifestyle.

Ayurvedic Doctor: Ayurvedic professionals with additional training and knowledge beyond the AP.  Although an AD is not permitted to diagnose a Western disease entity, they are taught to refer out appropriately. They interface with Western medicine, are well versed in all branches of Ayurveda, and possess substantial research skills. The AD has significantly more clinical experience based on a more extensive internship.

These categories and scopes of practice not only represent the current state of Ayurveda in this County; they also represent NAMA’s vision for future growth of the profession.  This article addresses legal and practical issues related to the “Ayurvedic Doctor” designation. 

The Ayurvedic Doctor designation represents the highest level of professional practice recognized by NAMA.  It requires education and training well beyond that required of Ayurvedic Health Counselors and Ayurvedic Practitioners.  Ayurvedic Doctors must have extensive, in-depth education, and relevant clinical experience in all eight branches of Ayurvedic medicine.  They must also have substantial experience in teaching, demonstrations, panchakarma, and research methods.

In addition to their academic studies, Ayurvedic Doctors must possess clinical experience equal to one-year of supervised clinical practice, and including a minimum of 250 documented patient encounters. Ayurvedic Doctors must understand disease from an Ayurvedic perspective, and have a working knowledge of Western medical pathology, pharmacology, diagnoses, and treatment, sufficient to correlate with the practice of Ayurveda.   Ayurvedic Doctors are not required to order western diagnostic tests or prescribe western medicines. Further information regarding the Ayurvedic Doctor category and scope of practice can be found here.

 Under the current legal paradigm in the United States, Ayurvedic professionals are not always able to legally practice Ayurveda to the full extent it is practiced in other countries.   Each state has laws prohibiting the unlicensed practice of medicine.  These laws often restrict the services that Ayurvedic professionals can offer their clients.  Violation of these laws can result in both civil and criminal penalties.  Some states have laws referred to as health freedom laws, which provide methods, which if followed, help to insulate a professional from liability for violation of the medical licensing laws.  For more information regarding these laws and tips for the legal practice of Ayurveda, visit this link here.

 Additionally, some states restrict the use of the Doctor title to those that have a medical license in that state or a PhD.  Therefore, even if you have graduated from an Ayurvedic Doctor program in the United States or elsewhere, or been approved as an Ayurvedic Doctor member of NAMA, you should not use the Doctor title or Dr. prefix until you confirm the laws of your state allow you to do so.

Furthermore, there are laws that restrict false and deceptive commercial practices.  Therefore, if you make any representation that you are a doctor, via use of the suffix A.D., a diploma or certificate hanging on a wall, an advertisement or otherwise, you should be sure to provide a written explanation regarding your certification and disclose the fact that you are not a licensed medical doctor.  It is considered best practice to be clear, direct and honest regarding your credentials, scope of practice, and the services you provide.  NAMA recommends the use of a written client disclosure form that includes this and other information.  You should make sure each client signs the form prior to receiving any of your services. 

NAMA considered our country’s current legal paradigm when developing its three professional practice categories.  As mentioned previously, these categories were developed with an awareness of the current status of the law, and an eye toward the future.  NAMA’s vision is that the future will evolve to allow the full and legal practice of Ayurveda in each state of our country.  NAMA is working toward this vision through the development and implementation of its regulatory standards, and by supporting efforts to further health freedom laws and state licensing. 

Until NAMA’s vision becomes a reality, it will be more difficult to receive the clinical training and experience required for NAMA’s Ayurvedic Doctor designation.  In the United States, there are only a few Ayurveda clinics where students can receive the clinical training and experience required to qualify for the Ayurvedic Doctor designation.  Moreover, these clinics have fewer clients than would otherwise be optimal to complete the requirements in a timely manner.  As a result, many U.S. Ayurveda schools are offering training in India, where students are able to experience all aspects of Ayurveda and have access to a vast number of clients. 

While the available training in India is a positive, there are some hurdles to overcome such as additional administrative demands, increased costs to the schools and students, and all involved having to spend large amounts of time away from home, family and friends.  Additionally, as previously mentioned, the Ayurveda practiced in India does not always translate to the Ayurveda that can be legally practiced in the United States.   As a result of these hurdles, some schools have chosen not to add an Ayurvedic Doctor program to its current curriculum.  Others are choosing to open new schools and clinics in health freedom states.  NAMA foresees that in the near future, there will be an expansion of training programs and facilities for Ayurvedic Doctors.  In the meanwhile, Ayurvedic professionals will gain additional knowledge and experience as they grow their practices and take part in continuing education to enhance their knowledge base.

The legal and educational issues currently faced by NAMA are not exclusive to Ayurveda.  In its early stages, western medicine faced some of the same issues.   Even today, in relation to the practice of acupuncture, some state limit the practice to Medical Doctors, Osteopaths and Chiropractors.  Other states have not yet enacted laws that license, regulate or prohibit acupuncture. 

NAMA seeks your patience and support as it moves forward to expand the role of Ayurveda as an integral part of the United States healthcare system.  The need to practice legally and with clarity, honesty and integrity is important not only to you; your actions can affect your fellow practitioners, and the profession of Ayurveda.  If even one Ayurvedic professional is prosecuted for practicing medicine without a license or acting in a deceptive manner, it becomes a stain on the entire profession and sets back our efforts to legitimize Ayurveda in the United States.  To ensure that Ayurveda maintains a solid and respected reputation within the healthcare field, members are encouraged to be thoughtful and careful in their actions, and to work within the laws of the states in which they practice.

 

About the Author:

Susan Etheridge is an attorney, Ayurvedic Practitioner and yoga teacher.  She is a graduate of Boston University School of Law (J.D.), Florida State University (B.A.), the Ayurvedic Center for Well Being (Guru Kula Program), and Sadhana Healing Arts (Ayur-Yoga 200 Hour Teacher Training Program).  Susan is the founder of the Alternative Health Law Firm, which provides legal services that support the expansion, integration and acceptance of alternative healthcare throughout the world.

 

Legal Disclaimer:

The information provided in this article is for informational purposes only and should not be considered to be legal advice. The information does not necessarily reflect the opinions of the National Ayurvedic Medical Association or the principal author and is not guaranteed to be correct, complete, or up-to-date.  This article may contain links to other resources on the Internet.  These links are provided as citations and aids to help you identify and locate other Internet resources that may be of interest, and are not intended to state or imply that the National Ayurvedic Medical Association or the principal author recommends, supports, sponsors, or is in any way affiliated or associated with any person or entity associated with those links, or is legally authorized to use any trade name, registered trademark, logo, legal or official seal, or copyrighted symbol that may be reflected in the links.

The Legal, Unlicensed Practice of Ayurveda

Ayurveda is at an exciting stage in its development as a healthcare system in the U.S. We have a growing number of schools producing an exponential number of new graduates. Awareness of our profession is growing among the general public. With this growing awareness, we must all be cognizant of the importance of appropriate professional behavior. This can be a bit tricky as there is currently no licensure for the practice of Ayurveda. Our profession is at that awkward teenage-stage of development when it’s sometimes unclear about what to say and how to behave.

All states have medical practice laws that prohibit the practice of medicine without a medical license. Fortunately, complementary alternative medicine (CAM) practitioners have worked diligently with their state legislators to pass health freedom acts in 10 states. These Acts exempt non-licensed practitioners from the violation of any licensing law related to health care services provided the practitioners comply with a list of things they can and cannot do. These requirements are relatively straightforward and compliance is not onerous. The specifics vary somewhat state-to-state, but they are all similar.

For example, an unlicensed practitioner cannot perform surgery, administer x-rays, prescribe pharmaceuticals or represent himself or herself as a doctor or physician. Regarding the must-dos, the unlicensed practitioner must advise their clients prior to providing services that they are not a licensed doctor, that their services are alternative or complementary to healing arts services, that their services are not licensed by the state, they also need to explain the theory upon which their services are based, and describe their education and training. Compliance is really quite simple.

Ayurvedic practitioners have a reasonable amount of latitude practicing in these states provided they structure their language in Ayurvedic terms. They can diagnose and treat Ayurvedically. There are some cautionary aspects, so practitioners must be familiar with the specifics of their state’s health freedom act. Organizations formed to help pass these health freedom acts have helpful information interpreting the acts along with practitioner’s compliance information and client document templates. Make use of these resources.

We must all be knowledgeable of the medical practice law in our respective states to practice Ayurveda legally. Simply do an online search for “[your state] medical practice act”. Most of these laws are written in simple, common sense language.

Now… about those other 40 states. Ayurvedic practitioners in these remaining states have a more complicated task providing services. Some of these states’ statutes provide a little leeway, but some are completely restrictive. The following excerpt is a good example of how restrictive statues can be, “any person who practices or attempts to practice… any system or mode of treating the sick or afflicted … or who diagnoses, treats, operates for, or prescribes for any ailment, blemish, deformity, disease, disfigurement, disorder, injury, or other physical or mental condition … without having a valid certificate… is guilty of a public offense”. This statute clearly prohibits all forms of treatment by any system for any ailment. Operating outside the statute leaves the practitioner open to both civil and criminal charges up to and including felony charges. This reflects poorly on both the individual practitioner and our entire profession. Again, it is very important that you have read and understood your state’s statutes.

All is not lost! You can practice Ayurveda in a non-health freedom state, but everything you do must be in terms of providing education. Your verbal and written communication and your actions must consistently demonstrate that you are acting as an educator, and as such, you are not practicing medicine without a license.

A service agreement is a good first step in establishing the educational nature of your services. All of the health freedom acts require a similar document. The service agreement demonstrates your intent to act as an educator. This is a document that defines the terms and conditions of your relationship with your client. It lists the parties involved – you and your client. It should specifically state that you are not a doctor, that you cannot legally diagnose or treat, and that you are only providing educational services. The payment terms and duration of the services you provide should be specified. Both you and the client sign this document.

Once you have stated your intent and signed the service agreement, you have to operate within the terms of the agreement. Do not diagnose or treat, not even using Ayurvedic terminology. Remember, as the above example illustrates, some state’s statutes are globally prohibitive.

The next step is ensuring that your language does not slip into the realm of practicing medicine. To avoid this do not make any personally prescriptive recommendations or instructions to your client. Also, do not make any recommendations to treat a specific condition or issue, even if you are using Ayurvedic terminology. All communication and actions must be educational in nature and in no way be personally applicable to the client.

Clients seek healthcare services when they have a health issue. They come to the health practitioner with the expectation that they will be told what to do to resolve their issue. You cannot move into this personally prescriptive role, you must maintain the educational boundary between you and the client. It is appropriate to explain the legal issues and limitations and why you must communicate in this particular manner. Clients are obviously open to alternative healthcare, they have sought your services and they will be understanding and appreciative.

Special care should be given to any documents you provide to your clients. All documents should contain an educational disclaimer that states that the information is for educational purposes only and the information is not to be used as, used as a substitute for, or considered as a medical diagnosis, treatment or prescription. The disclaimer should also encourage your clients to consult a licensed health care professional before using any herbs or herbal products, before beginning any new exercise or health regime, and for any persistent problem or complaint.

What does this mean in day-to-day practice? How do you conduct a consultation? You can certainly assess a client. (Another nuance, do not use the word patient. You must not use any language or perform any actions that could imply the practice of medicine – so, client, not patient.) You can ask questions, prashna. You can ask your client to complete a health questionnaire that you provide and review it with the client. You can discuss the client’s specific health concerns and goals. You can perform an exam. You can review all the information you have collected and then provide a factual report of findings of their prakruti and vikruti.

Now for the important part: You cannot make any recommendations that are personally applicable to the client. You would not want to say, for example, “ Take Triphala to reduce Vata in your colon”. This is a prescriptive recommendation personally applicable to the client. Your state’s statues likely prohibit even this type of diagnosis and treatment.

What you can say in your report of findings is: “According to Ayurvedic theory, the symptoms you describe are typical of a person with elevated vata in the colon area. I also detect elevated vata in your colon pulse. The Ayurvedic formula, Triphala, has been classically used to support normal colon function”.

What’s the difference in these two statements? In the second statement, you have educated your client as to the Ayurvedic perspective of their symptoms. You have advised them that their vata is elevated. This is not diagnostic, only a descriptive fact. This is similar to reviewing a patient’s laboratory test results and confirming to them that their cholesterol is 265, but you are not interpreting and evaluating this information by saying they have hyperlipidemia. The difference is factual statement vs. diagnosis. You have provided education about Ayurvedic herbology in a very specific manner. What you did not do is make a medical claim. A medical claim is stating “take this to fix that”. Continuing with our cholesterol example above, saying “take guggulu to lower cholesterol” is a medical claim. Saying “classically Ayurveda has used guggulu to support normal liver function” is not a medical claim. Additionally, you did not make a personally prescriptive recommendation, only a correct factual statement.

You could even make the additional cautionary disclaimer, “I am not a doctor or a physician. I am not saying that you should personally take Triphala or guggulu, but should you decide they are appropriate for you, you may want to discuss this with your doctor before starting”.

You do not instruct the client to do or change anything. You provide education that is relevant to their health concerns and goals. You make it clear that you are not making personal recommendations. Communicate to the client that it is their responsibility to decide if the education you have provided is applicable to them and that it is also their responsibility to decide if they take action based on that information. The essential aspect of practicing in this way is that you always act as an educator. You must be consistent in your verbal and written communications and your actions, and they must be educational in nature. Our first amendment right provides for the freedom of speech, which includes education. That said, you are providing services for payment, you are still liable for providing correct and accurate information.

While adapting one’s language to be legally correct can be a bit tedious until it becomes a habit, it is straightforward. There are a number of phrases that you can incorporate to keep you in the educational realm. Phrases such as, “according to the classical teachings of Ayurveda” or “Ayurveda believes or recognizes” keeps the conversation educational and not personally instructive. You can also say, “what I would do for myself in similar circumstances is….”. This is your personal opinion about yourself, you are not telling the client to take specific action.

Even if you do everything correctly, this does not mean that you are 100% insulated from investigation and potential legal action. This will only occur if someone files a complaint. If a complaint is filed, the appropriate agency is required to investigate. That does not mean the action has merit. If you have taken the proper precautions, you will be able to demonstrate consistent good intent of your role as an educator. Common sense goes a long way in avoiding conflict. If you have an unhappy client, immediately give them a complete refund and ask that they return the herbs, supplements and documents you supplied them. It is rare, but other practitioners sometimes file complaints. This is often due to jealously or the fear of losing revenue. There is nothing that can be done to avoid this besides maintaining good relationships with fellow practitioners.

One last issue that often arises is the question of providing hands-on therapies such as abhyanga. Ayurveda certainly recognizes abhyanga as distinct and unique from massage. But to the non-Ayurvedic observer, abhyanga and massage appear to be the same thing. While one could attempt to argue that the client is being educated about abhyanga by the demonstration of receiving abhyanga, the counter argument is that the practitioner should be affiliated with a licensed massage school. To practice Ayuvedic bodywork safely, one should either have a license that allows for touch, or work legally under the supervision of a licensed healthcare practitioner. It is certainly acceptable for the practitioner to demonstrate self-abhyanga to their client.

Our profession is growing. This is the result of the actions of practitioners who came before us. We all have the responsibility to continue this tradition by practicing both legally and ethically. The intent of this article is to raise awareness of the importance of practicing legally. This article is much too brief to cover all legal aspects as each practice is unique with its different types of services offered and areas of specialty. Take the time to become knowledgeable about your state’s statues and how they apply to you. If you have any questions or concerns, retain a knowledgeable attorney for an hour’s consult. This will allow you to confidently operate your practice within your area of expertise compliant with all legal requirements.

 

About the Author

Jeff Turner operates Living Ayurveda, an integrated health clinic in Monterey, CA specializing in advanced chronic diseases and panchakarma. He is an author and an Ayurvedic educator teaching at various Ayurvedic schools in the U.S. and the California State University system. He has been actively involved with Ayurvedic legal and licensing issues since NAMA’s inception.

Legal Disclaimer: The information provided in this article is for informational purposes only and should not be considered to be legal advice. This article may contain links to other resources on the Internet.  These links are provided as citations and aids to help you identify and locate other Internet resources that may be of interest, and are not intended to state or imply that the National Ayurvedic Medical Association or the principal author recommends, supports, sponsors, or is in any way affiliated or associated with any person or entity associated with those links, or is legally authorized to use any trade name, registered trademark, logo, legal or official seal, or copyrighted symbol that may be reflected in the links.

Credentialing the Ayurvedic Profession

NAMA has been systematically building a credentialing program based on the belief that credentialing is one of the most important ingredients to the advancement of the Ayurvedic profession and a key component to the goal of licensing. There are many steps toward credentialing and NAMA has been hard at work over the past twelve years laying the groundwork. We are now ready to establish viable and fair National Exams for the Ayurvedic Health Counselor and the Ayurvedic Practitioner and will eventually create one for the Ayurvedic Doctor level.

Here we answer some questions you may have about the certification process, its impact on you and why NAMA’s certification program will be recognized nationally as the gold standard for competency in the field of Ayurveda.

Why Credentialing?

Credentialing facilitates standardized practice across a wide variety of treatment settings. Most importantly it assures ethical professionals are available to clients, families and their communities. Certification serves the following purposes:

  • It gives the general public a basis for evaluating a service provider
  • It helps employers judge the skills of existing or potential employees
  • It allows those who are certified to differentiate themselves from others in the profession and to advance their career

What is NAMA doing in the certification process?

First, NAMA had to identify the competencies an individual must possess to perform his/her job functions competently at various levels. NAMA identified Scopes of Practice required for these various levels of professionals. Additionally, we looked at educational guidelines required to meet the scopes of practice and took into consideration the value of experience needed to successfully complete a competency-based exam. These steps have been completed.

The next step was to find an experienced and appropriate partner to assist in creating the exams. After evaluating a number of proposals, we have teamed up with an outside consulting firm to provide expertise in psychometrics to ensure a valid and rigorous competency exam. A well-designed examination avoids the pitfalls of developing test questions that are not legally defensible or valid, thus resulting in poor data, and potential legal challenges.

Why develop a certification process?

According to the Center for Association Leadership, certification programs have become increasingly popular during the last few years. There have been many cases of organizations setting up certification programs and credentialing examinations without the proper rigor, judgment and stakeholder buy-in. For some organizations, it is seen simply as a quick revenue stream.

NAMA has chosen this rigorous path of certification in order to foster increased recognition of the profession nationally. However, creating and then maintaining a certification program requires planning and close attention to several important steps. NAMA is committed to a thorough and comprehensive process that includes the use of an experienced organization skilled in the creation and implementation of fair and legal examinations. The costs and time are significant in developing, marketing and administering a certification program and must be thoughtfully planned and implemented.

What are the biggest mistakes that some organizations make?

Underestimating the support needed in creating a defensible rigorous certification program. The support of the Ayurvedic community from the practitioners to the schools is paramount to its success.

>>NAMA has long worked with representatives of Ayurvedic schools, practitioners, and other key members of our community. In the cases where this is not done there tends to be many issues that arise around fairness and even legality of the exam itself. Thus creating a weak and indefensible component to the future licensing ingredients.

Underestimating the time needed. The variables included in the exam process include identifying the job tasks (competencies), identifying the exam objectives, the subject matter expert availability, and obtaining a good sample of beta candidates. If shortcuts are taken here, they usually come back to haunt the program in poor test items, unsatisfied test takers, and unreliable data.

>>NAMA has thoughtfully been working on the entire process over the past 10 years and is now entering the phase of the actual exam creation with a target date of December 2016 for implementation.

Failure to account for recertification. Few organizations certify for life without at least requiring some sort of skills maintenance. You should be skeptical of any organization that does not have a recertification process.

>>NAMA is making a long-term commitment by assuring a process for recertification through a continuing education program that will require those certified through the grandfathering process, or ultimately through the examination process to maintain and/or improve their skills on a regular basis. Developing side-by-side with the examinations, the Professional Ayurvedic Continuing Education (PACE) requirements provide evidence that our organization is continuing to invest in the credential that will maintain its value in the health field.

Failure to have a certification revocation process. This involves two steps: developing and distributing a “Code of Ethics” and confirming that all Professional Members have agreed to adhere to this standard, and creation of a “States of Professional Conduct” plan to establish a process by which complaints can be lodged and investigations conducted.

>>NAMA has a “Code of Ethics & Professional Conduct” in place and all professional members agree to follow the code when they submit their membership application. All professional members are also required to take a short Ethics Exam every two years as a part of their Professional Ayurvedic Continuing Education requirements. NAMA’s Ethics Committee reviews any complaints or breach of the code of ethics by professional members. The next step in the development of a certification revocation process is to take great care to ensure a disciplinary process is applied consistently and fairly. This process must also allow for a mechanism by which disciplinary actions can be appealed.

Failure to design a rigorous and fair exam that has both internal and external validity. When looking at a certification exam ask if it’s an exam that’s criterion based. That means it provides an objective reference standard. In a nutshell, this means that the candidates taking the exam are evaluated on how they perform relative to a fixed set of criterion, and not judged relative to their peer group’s performance.

>>NAMA is engaging experts in the field to work with us to assure this validity.

Failure to use experts in the exam development. Creating a fast and easy quiz or test without attention to the details of the exam process can result in invalidating any credential offered for everyone who has taken the exam.

>>NAMA has recognized few people are trained in rigorous test development. We’ve acknowledged that to provide a rigorous exam it needs guidance and expertise in exam development. We have teamed up with a psychometrical team of experts who are working closely with us to provide the necessary tools and guidance to help ensure our certification exam is:

Useful: Achieves our professional goals

Credible: Has perceived value and holds up under the scrutiny of others in the healthcare field

Reliable: Consistently measures whatever the test is measuring

Valid: The scores provide meaningful information based on the purpose of the test(s)

Legally Defensible: Has followed best practices to help ensure the test scores are fair, reliable, and valid

A lot boils down to the integrity of the exam. If the certification exam is too easy, too hard, or does not measure what it’s supposed to, then everything else will fade over time.

It is not enough to just offer a certification program for its own sake. We must raise the bar for the profession and follow through with a certification process that identifies and supports the best practitioners in our profession - those that practice to a well-defined and excellent standard of practice. NAMA is committed to offering a rigorous, valid and fair certification exam and has spent the last 12 years creating the groundwork to put it all in place.

NAMA has taken on this challenge for its members and ultimately for the viable future of Ayurveda in the United States. State organizations that adopt NAMA’s credentialing process, including the certification examinations, will have a strong and fully developed program to present to their legislatures in the efforts toward licensure. With a strong, thoughtful, and well-designed process, everyone wins.

 

References

Institute for Credentialing Excellence (2010). Defining features of quality certification and assessment-based certification programs. Retrieved from: http://www.credentialingexcellence.org/

Kryterion. Test development Analysis: retrieved from: http://www.kryteriononline.com/services/test_development/job_task_analysis/

Lenora G. Knapp, Ph.D., Joan E. Knapp, Ph.D. (2014). Business of Certification: A Comprehensive Guide to Developing a Successful Program. Center for Association Leadership. Retrieved from: http://www.asaecenter.org/

Institute for Credentialing Excellence (2010). Defining features of quality certification and assessment-based certification programs. Retrieved from: http://www.credentialingexcellence.org/

Reed A. Castle, PhD. (2002) Developing a Certification or Licensure Exam. Schroeder Measurement Technologies, Inc. Retrieved from: http://home.smttest.com

Health Freedom: What Is It and Why Is It Important?

Health freedom is a concept based on the belief that medicine, as it is practiced in the United States, is a narrowly defined modality and that individuals have the right to seek other forms of health care that may not fall within the definitions and scope of conventional medicine. 

Brief History of the Medical Profession in the United States

In 1847, the American Medical Association was formed and signaled the beginning of a more regulated and formal oversight of the practice of medicine. The article, "Doctor of medicine profession (MD)", from the National Institutes of Health website, states that: 

Medicine was the first of the professions to require licensing. State laws on medical licensing outlined the "diagnosis" and "treatment" of human conditions in medicine. Any individual who wanted to diagnose or treat as part of the profession could be charged with practicing medicine without a license.

As state laws were established, other healing professions such as naturopathy, homeopathy, and herbalism came under increased scrutiny, and, in some cases, were shut down for practicing medicine without a license, which had become the common purview of those licensed as medical doctors. 

Most alternative health care practitioners are unaware of the legal ramifications of practicing their chosen profession. Practicing medicine without a license is a misdemeanor; in some states, it is a felony. An article written by Paul Bergner of the Rocky Mountain Herbal Institute explains this further: 

…one of the common methods of prosecuting an alternative practitioner is to document the manner in which the practitioner describes her practice to clients, both verbally and in certain terminology to describe their profession and its purposes: “consult with patients”, “treatment of disease or illness”, “prescribe remedies”, “diagnose illness”, “cure illness”, provide therapy”, “administer medicine”, “relieve symptoms of illness” as well as other. The routine use of these words and phrases when describing or explaining one’s profession and purpose to clients constitutes prima facie evidence of practicing medicine, then one may be prosecuted for practicing medicine without a license.

This still holds true in the 40 states that do not currently have health freedom legislation.

Why Health Freedom Legislation?

Health freedom legislation was created to open the doors for more healing professionals to practice openly without the threat of being prosecuted for practicing medicine without a license.  

Current health freedom laws provide the following limitation and requirement to practice:

1. Ensure that the practitioner does not perform any actions that pose an imminent risk of harm to a consumer by clearly stating what the practitioner cannot do.

Example from the current health freedom bill in Massachusetts:

……perform surgery or any other procedure that punctures the skin of a person; (ii) use radiation, radioactive substances or local, general or spinal anesthesia; (iii) prescribe or administer any form of fluoroscopy on any person; (iv) prescribe or administer a legend drug or controlled substance or a legend medical device not otherwise licensed to prescribe; (v) provide a medical diagnosis; (vi) perform a chiropractic adjustment of the articulations of joints or the spine; (vii) represent that they practice massage therapy; (viii) fail to comply with any local licensing or regulatory requirements; (ix) hold out, state, indicate, advertise, or imply to any person that he or she is a health care provider licensed, certified, or registered, by the Commonwealth.

2. Require the practitioner to disclose certain information about him/herself.

Example from the current health freedom bill in Massachusetts:

Prior to providing complementary and alternative health services to a client for the first time, the practitioner shall disclose the following information to the client in a plainly worded written document: (i) the practitioner’s name, title, and business address and telephone number; (ii) a description of the complementary and alternative health services to be provided; (iii) the practitioner’s degrees, training, experience, credentials, or other qualifications relative to the complementary and alternative health services being provided; (iv) a statement recommending to the client that they notify his or her other health care providers of complementary and alternative health services he or she receives; and (v) that any violation of this section of law constitutes a violation of chapter 93A, the Commonwealth’s consumer protection law. Before providing complementary and alternative therapeutic services to a client, a practitioner must obtain an acknowledgment from the client stating that he or she has been provided with the information described in this subsection. The client shall be provided with a copy of this acknowledgment. The signed acknowledgment must be maintained for seven years by the person providing the services.

Successful health freedom legislation accomplishes several important things:

  • Provides parameters of practice for professionals and allows unlicensed professionals an opportunity to share their services with the health care consumer more openly and freely.
  • Increases awareness of the healthcare consumer about alternative health professionals, who can openly advertise and educate the public about their services.
  • Creates more open and inclusive dialogue around health care.
  • Establishes the potential for collaborations among professions in providing more options and opportunities for the public.

Although initial health freedom legislation began in Idaho in 1976, it did not take root until 1999, after which several states enacted legislation every few years. Until now, state-by-state licensing of health care professions was the only legal and respected process. Fortunately, the healthcare climate is changing and health freedom laws are providing additional opportunities to practice legally.

NAMA’s Position on Health Freedom Legislation

It is currently the goal of NAMA to help pursue licensure for the Ayurvedic profession while simultaneously supporting health freedom as an important option.

If you live in a health freedom state, you have much more latitude and can practice without the threat of a criminal charge looming over your head. Ayurvedic professionals who live in a state without health freedom must continue to practice with great caution and follow the current laws in your state.

For more information on health freedom legislation in the United States, visit the National Health Freedom Coalition: www.nationalhealthfreedom.org. If you reside in a state without health freedom, consider getting involved with passing a health freedom law in your state.

Legal Disclaimer: The information provided in this article is for informational purposes only and should not be considered to be legal advice. This article may contain links to other resources on the Internet.  These links are provided as citations and aids to help you identify and locate other Internet resources that may be of interest, and are not intended to state or imply that the National Ayurvedic Medical Association or the principal author recommends, supports, sponsors, or is in any way affiliated or associated with any person or entity associated with those links, or is legally authorized to use any trade name, registered trademark, logo, legal or official seal, or copyrighted symbol that may be reflected in the links.

BAMS In the U.S.A

Over the past 40 years, many graduates with a Bachelor of Ayurvedic Medicine and Surgery (BAMS) degree, as well as BAMS MD, have come to the U.S. We owe a great deal to these individuals and are very fortunate for the risks they have taken and challenges they have overcome in bringing Ayurveda to the west.

We can consider these generous souls to be our Ayurvedic godmothers and godfathers as many were our first teachers, offering short courses and introductions to Ayurveda. As their students increased in number and dedication, many began to teach more formally. Historically, this is how many of our current Ayurveda schools were founded. It is because of the dedication of these early leaders and teachers that Americans leapt into the sacred waters of Ayurveda and began to study in earnest.

It is not an easy task to introduce a new system of medicine into a completely different culture. It has taken these pioneers of Ayurveda several years in order to be comfortable enough to talk about and share their wisdom. They have had to acclimate themselves by examining our western culture, the environments in which we live, the foods we eat, and our ways of being in order to appropriately apply the principles of Ayurveda to our western world. Through their own personal studies of the American culture, they have succeeded in translating Ayurveda into not only the English language, but also the western culture as a whole.

Unfortunately, it is not possible to presume that all immigrants with a B.A.M.S. have had this kind of exposure to and education about the U.S. To practice or teach Ayurveda here, it is essential to understand the laws pertinent to practicing as a health care professional – licensed or otherwise. Currently, it is not legal to practice the full scope of Ayurveda here in the United States as it is in India. Considering that 40 out of 50 states do not have health freedom legislation, anyone residing in those states and practicing Ayurveda must understand their legal limitations and take the appropriate steps to protect themselves and their practice.

Much of what Ayurvedic doctors and B.A.M.S. professionals practice in India is not legal here. There are many herbs, treatments and procedures that simply cannot be offered. In many states, Ayurvedic professionals can only work as Ayurvedic educators within the realm of diet and lifestyle. This, of course, limits the scope of practice that many B.A.M.S. graduates have been taught.

Equally important for those relocating to the United States is taking the time to learn the language, the types of foods people eat, and the American lifestyle. It is difficult for Americans to understand recommendations that do not apply to their environment and lifestyle. Often these interactions end up being ineffective and clients walk away discouraged and confused.

In conventional medicine, doctors emigrating from other countries are required to meet U.S. medical school standards, which often requires returning to school and passing a series of tests before they are allowed to practice as an M.D. Although this is not expected for B.A.M.S. immigrants, it is encouraged that a period of education and acclimation be considered before entering into an American practice.

Recommendations for Recent BAMS Immigrants 

1. Join NAMA as a professional member. This will provide many levels of support and education that you may need as well as connect you with a community of Ayurvedic professionals including members with B.A.M.S. degrees that have experience practicing in the United States.

2. Take time to polish your English conversational skills.

3. Find a local NAMA member to mentor you. Shadow them for a while to get comfortable with American customs and attitudes.

4. Take Professional Ayurvedic Continuing Education (PACE) courses for topics in which you may need additional training or study.

An Overview of Regulatory Issues for Yoga, Yoga Therapy, and Ayurveda

Abstract: In order to gain greater credibility, emerging healthcare and health-related fields usually establish a variety of self regulatory structures and organizations. These structures serve to promote safe and effective practice, strengthen the field’s legal status, expand professional opportunities, increase the profession’s political influence, and legitimize a field in the eyes of potential patients, potential students, governmental entities, and the healthcare industry. Self-regulatory structures can also set the groundwork for professional licensure and other types of external recognition. Developing self-regulatory structures, however, can pose significant challenges and invariably involves trade-offs. Therefore, practitioners and educators within emerging fields should engage in inclusive, representational, and transparent decision-making processes to build support for any self-regulatory measures being considered.

Correspondence: Daniel Seitz at P.O. Box 178, Great Barrington, MA 01230; danseitz@verizon.net; 413-528-8877.

Introduction

The purpose of this article is twofold: (1) to explore several of the key professional/regulatory issues associated with the acceptance and recognition of Yoga, Yoga therapy, and Ayurveda in the United States, and (2) to outline and analyze the options available to these professions to engage in a process of self-regulation.

In the United States, emerging medical fields and fields that are healthcare-related or health enhancing—such as traditional Chinese medicine, naturopathic medicine, Ayurveda, Yoga, and Yoga therapy—often follow a similar trajectory in their development as a formal profession. This developmental process helps move the field from the fringes of society to a place of greater visibility, credibility, and impact. Movement along this trajectory typically involves creating over time a variety of professional organizations and regulatory structures to better define the range of practices associated with a field and provide a basis for identifying qualified practitioners. Among other things, these organizations and structures serve to:

  • Promote safe and effective practice;
  • Legitimize a field in the eyes of potential patients, the general public, governmental entities, and the healthcare industry;
  • Legally safeguard the right to practice;
  • Increase the political influence of the practitioner community; and
  • Expand the range and attractiveness of professional opportunities for practitioners.

Once in place, these organizations and regulatory structures serve another key function: they provide a starting place or basis for the ongoing development of the field through upgrading educational standards and related requirements for practice. This, in turn, leads to enhanced knowledge and skills on the part of practitioners.

The formal development of a profession is usually accompanied by strong reactions from practitioners within the emerging field who may disagree on the fundamental goals to pursue or the pragmatic directions to take. There may also be strong reactions from conventional physicians and others who may perceive their professional interests as being threatened or who are opposed to the paradigm represented by the emerging field. There are often rhetorical battles as an emerging field grows in prominence. Proponents characterize their practices in neutral or positive terms such as “complementary and alternative medicine” (CAM), “integrative,” “health and wellness,” “natural,” “holistic,” “traditional,” or “mind-body-spirit,” while opponents—in an attempt to discredit the field—may use terms like “unconventional,” “non-evidence-based,” “unscientific,” or, at an extreme, “quackery.”

Political and legal battles also routinely occur as practitioners of CAM and health-related and health-enhancing fields seek greater legal recognition and expanded professional opportunities. Conventional practitioners may seek to co-opt, limit, or outlaw the practice of certain therapies and even to legally own the use of certain words like “physician” and “diagnose.” At an extreme, a state board of medicine may seek the prosecution of unregulated practitioners for practicing medicine without a license. Conversely, conventional physicians who integrate alternative therapies may be targeted by their licensing board for practicing outside of the scope of practice.

In addition to conflicts with conventional healthcare professions, there are often rivalries among emerging professions due to overlapping practices. Sometimes, newer professions are forced by more established professions to impose limitations on what they consider their rightful scope of practice. For example, naturopathic doctors study acupuncture in school, but their use of this modality may be prohibited in states where acupuncture is a licensed profession. The examples above demonstrate that there is an unavoidable messiness associated with professional recognition and regulation due to the many competing interests and stakeholders. Nonetheless, a variety of pragmatic options and strategies are open to practitioners, educators, and professional organizations within an emerging field to develop a stronger, more coherent professional identity. Gaining greater public recognition and credibility, improving the overall quality of practice, opening up new professional opportunities, and strengthening the legal status of a field are, for most practitioners and educators, compelling motives to create some sort of regulatory structure, whether or not the structure is used at a later time as a basis for seeking a state-sanctioned or mandated role in the healthcare system. Despite the challenges in gaining respect and recognition, leaders within an emerging field should take heart in the well-known quote of Mahatma Gandhi: “First they ignore you, then they ridicule you, then they fight you, then you win.”

Internal versus External Regulation

To better understand the options for professional and regulatory structures, it’s useful to distinguish between internal (or self-regulatory) and external structures. These can be defined as follows:

Internal structures are developed by a profession on its own without the involvement of governmental entities or organizations unrelated to the profession; examples of this are an accrediting agency for schools and a professional association’s registry of practitioners.

External structures are developed through political action and negotiation with outside entities; an example of this is state licensure of a healthcare field.

Of course, virtually no organization is totally free of the need to interact with external entities. For example, state boards or departments of education have regulatory requirements and processes that would likely apply to formal training programs in an emerging field; establishing a nonprofit organization requires state incorporation; and gaining tax-exempt status or some other special classification requires IRS approval. Also, as a field develops, the distinction between internal and external regulation may shift in regard to an organization. For example, a private, nonprofit accrediting agency might, after having been in existence for a number of years, seek recognition by the U.S. Department of Education (DOE) in order to gain greater credibility in the eyes of regulators and/or provide students with access to federal loans. Whatever organizational structures an emerging profession may choose to establish, it’s safe to say that the profession will initially need to focus its efforts more inwardly to develop educational and practice standards and to define its identity. External recognition is impractical—if not impossible—to achieve until reasonably solid structures are in place.

Even before a profession can develop internal and external regulatory structures, it must first develop organizations that can provide a vehicle for pursuing collective goals and interests. Two of the most basic types of organizations are practitioner associations and school associations. Such organizations provide a forum for the open discussion and the foundational visioning that eventually leads to the creation of a more formal regulatory process. It is beyond the scope of this article to analyze in depth how emerging professions coalesce into formal organizations and how these organizations, in turn, embark on the task of creating internal regulatory structures and processes. However, it should be noted that—as touched upon earlier—efforts toward formalizing a profession are likely to cause apprehension and even conflict within the practitioner and school communities. Thus, as regulatory structures are being developed, it is important to design reasonably inclusive, representational, and transparent decision-making processes and to allow ample opportunity for comment on any proposed standards or requirements.

With the distinction between internal and external regulation in mind, we can now turn to the main subject of this article: (1) a review of the primary options for internal/self-regulation of an emerging medical or health-related profession, and (2) a discussion of the benefits and challenges associated with these options. Internal efforts at self-regulation—if carefully carried out—can lay the necessary groundwork for future efforts to establish external regulatory structures that enhance the recognition and legal status of a field, should the profession choose to pursue these goals.

 

Primary Types of Internal Regulatory Structures

Registration of Practitioners and Schools

Perhaps the most basic approach to self-regulation within a profession is for a professional membership organization to establish a registry of practitioners. Eligibility for registration may initially be as simple as being a dues-paying member of the organization or may involve demonstrating completion of certain educational requirements. Usually, registration is based on the submission of required documentation that is reviewed for compliance with requirements, accuracy, and authenticity. There are, of course, limitations inherent in any regulatory process based solely on a paper review, since there may be no independent way of verifying the applicant’s education.

Because educational approaches in emerging fields often vary widely in terms of content, duration, philosophy, and delivery, the type of education that qualifies a practitioner for registration is often defined broadly and inclusively at the outset. This is generally a good thing. The pioneers of a field in the U.S. are often engaged in a grand experiment of transplanting traditional arts to a new cultural and legal environment, and diversity allows for creative space to find what works effectively. There are many crosscurrents inherent in this initial experimental phase: traditionalists may question the adaptations that educators make to run programs in the U.S. (e.g., offering shorter programs than exist in the country of origin, eliminating certain practices that may raise issues in a Western culture); the creation of diploma mills and abbreviated training programs—often widespread in the early years of an emerging profession—may compromise the field’s reputation by producing substandard practitioners; new theories and techniques may be developed under the rubric of traditional practices; and a welter of professional titles may dilute the professional identity of a field, causing confusion to the consumer.

These sorts of issues point to the ultimate tension in professional regulation: the need to seek a balance between the freedom for individuals to innovate, teach, and practice as they wish, and the collective desire among educators and practitioners to create a reasonably unified set of professional standards that support safe and effective practice and that promote public awareness and confidence.

Registration of schools often develops hand-in-hand with a registration of practitioners. Graduates of registered schools are eligible to be registered practitioners, and registered practitioners are seen as qualified to teach at registered schools. While the main goal for registering practitioners is to provide the public with contact information on practitioners, the main goal of school registration is to provide potential students information on training opportunities for the profession.

Once an emerging field starts to attain some measure of stature and public attention, it is natural for the field to reexamine the basic regulatory structures that characterized the initial phase of development. There are typically a number of individuals involved with the field who are knowledgeable about professional education and regulation in the U.S., and some or many members of the practitioner community have aspirations for further growth and recognition of the field. Also, some organizations will start to develop discretionary financial resources beyond what is needed simply to survive and can invest them in building the profession.

Almost inevitably, during this stage of evolution a group of people within the profession starts questioning the adequacy of the initial registration requirements: the very breadth and inclusivity that helped get the field off the ground are now seen as a limiting factor to its success. This, in turn, often leads to a push to upgrade the registration requirements and/or to develop other approaches to self regulation. The push to upgrade educational and practice requirements can cause considerable conflict within a profession unless there is extensive open discussion and careful consideration of how to equitably include practitioners trained under the old requirements who are interested in being recognized at a higher level. Even when decisions are arrived at through a genuinely inclusive process, a field may still experience a difficult and perhaps divisive transition to increased standards.

Certification of Practitioners

Certification is a process, often voluntary, by which individuals who have demonstrated the level of knowledge and skill required in a given profession, occupation, role, or skill are identified to the public and other stakeholders. Typically, a single private entity grants recognition—a certificate—to an individual who has met a set of qualifications established by that agency. These qualifications often consist of meeting certain educational standards and passing an examination. The examination may be entirely written or may have both written and practical components.

It should be noted that the word “certification,” as it relates to professional education and practice, causes confusion. In an emerging profession, before schools gain authorization to grant degrees, they generally issue a certificate or diploma signifying completion of the training. This may lead schools to state that they are certifying practitioners. However, certification within a profession is meant to be a uniform, objective credential, not one that varies from training program to training program. In fact, until an agreed upon certification process is established, the “certification” of practitioners by individual schools and other organizations can, paradoxically, create a “race to the bottom,” as it is likely that some schools will issue a certificate for completion of relatively cursory training programs.

The very creation of a certification examination has a de facto defining and constraining effect on the educational programs in the field and on the profession’s scope of practice. This is because the certification agency must articulate with reasonable specificity the subject matter that the exam will cover. While individual programs may continue to teach a wide variety of approaches and philosophies, their need to equip students with the knowledge and skills to pass the exam will naturally lead to a greater conformity among programs over time. Moreover, the outliers—those programs whose philosophies and practices are furthest from the mainstream—will face the challenge of ensuring that students gain sufficient knowledge of the material that will be tested in the exam, while staying true to their vision. Any emerging profession developing a certification exam will have to work painstakingly and inclusively to ensure buying among a critical mass of stakeholders. The process will benefit from seeking an acceptable balance between being prescriptive in terms of subject matter and providing latitude for some non-mainstream approaches in the field.

Creating a reliable certification exam is no small task, and the legitimacy of any certification process—especially at the outset—can be contested, both as to the level or type of education that qualifies someone for certification and the soundness of the exam itself. The challenges of creating a satisfactory certification process include defining the content of the exam, developing a pool of carefully formulated questions, establishing exam policies and secure testing sites and procedures, developing statistically reliable and defensible means to set passing scores, and ensuring sufficient funding to cover start-up expenses and ongoing operations. For a profession that wishes to establish a certification agency and exam, there is a substantial body of technical knowledge available as well as experts in the area of professional testing who can provide advice. However, accessing such resources can be expensive.

Given the complexity of developing a reliable certification process, the credibility of the process can always be questioned. One way that an agency may seek to gain greater credibility is through external “accreditation” of the certification process. Such an accreditation service is offered by the National Commission for Certifying Agencies (NCCA), the accrediting division of the National Organization for Competency Assurance (NOCA). This agency sets quality standards and accredits certification programs covering hundreds of professions and occupations. In seeking external recognition such as NCCA accreditation, there is a natural trade-off for an agency. The costs and time involved—which are not insubstantial—must be weighed against the perceived need to demonstrate the credibility of the certification process to important stakeholders. There is also an international standard, ISO/IEC 17024 (ISO is the International Organization for Standardization), that sets forth criteria for certification agencies that offer “certification of persons.” The purpose of such a standard is to foster worldwide consistency in how certification agencies conduct their work. Such a standard may pave the way for recognition of professional training across national boundaries—a goal that some governmental entities and other organizations are actively promoting.

Within a medical or healthcare-related field there is sometimes pressure to develop a practical exam component in addition to the written component. This is especially true if minimally trained individuals—or individuals whose training is not easily verified—may be allowed to take the exam. Since a written exam only tests theoretical knowledge at one point in time, there is always a concern that a person could pass the exam regardless of his or her practical skills and abilities; such skills and abilities are, of course, at the heart of being a competent practitioner in any healthcare- related field. Developing a reliable practical exam is, however, even more challenging than developing a reliable written exam, and administering such an exam is costly for applicants. Such exams are also more likely to be challenged by examinees on the basis of inconsistency or bias. For these reasons, some certification agencies choose to use a written format exclusively.

Regardless of whether an agency uses a written exam format or a combination of written and practical components, the agency must address the issue of what educational credentials will qualify someone to sit for the exam. In more well-established fields in the U.S., such as naturopathic medicine and acupuncture, graduation from—or current attendance in—an accredited U.S. program is the primary qualification. The stronger the educational requirements for taking a certification exam, the less pressure there is to ensure that a certification test covers the full range of theoretical knowledge and practical skills, since there is an assumption that the examinees’ formal education ensures basic competence in a wide range of areas. In an emerging field, educational requirements for taking a certification exam tend to be looser—especially if accreditation or some other more rigorous school approval process does not yet exist.

As with a registration process, there is typically some sort of “grandfathering” (also referred to as “grandparenting”) provision at the time when a certification process is implemented that applies to more senior practitioners trained at an earlier time when educational levels and programs were different. The grandfathering process can be applied in two ways: (1) a person who is grandfathered is deemed qualified to take the exam based on educational requirements and/or professional experience that is appropriate to the era in which he or she was trained, or (2) a person who is grandfathered is not required to take the exam at all based on satisfying era-appropriate educational requirements and/or professional experience. Generally speaking, designing a grandfathering process to be reasonably inclusive will help promote buy-in by a larger proportion of the profession. However, there is almost inevitably a trade-off, since some grandfathered practitioners may be deficient in the knowledge and skills considered necessary for safe and effective practice.

 

Accreditation of Educational Programs and Institutions

The primary purpose of registration and certification is to identify and qualify individual practitioners of a profession. As noted above, schools, training programs, and instructors can be registered as well. If this process involves making a determination that the school or program is legitimate and offers an acceptable level of training, then school registration is also a de facto approval process aimed at ensuring the quality and rigor of the education.

Accreditation is a widely used approval process for higher education in the U.S. Accreditation can be defined as the granting of national public recognition to an institution or program of study that meets or exceeds an established set of standards. (Note that “accreditation” in this context is different from the accreditation of certification agencies discussed in the previous section, and use of the same word in a different but related context often causes confusion in the regulatory arena.) The determination of whether the institution or program meets or exceeds the accreditation standards is based on a review of detailed reports and documentation submitted by the institution and a subsequent on-site evaluation conducted by a team of qualified experts, which includes educators and practitioners. Accreditation is primarily a quality control mechanism: a credible, objective third party gives its public stamp of approval to an educational program and/or institution. Additionally, accreditation is a peer-review process that supports the ongoing improvement of institutions and programs.

Accreditation for a healthcare or health-related field in the U.S. is generally carried out by a nongovernmental agency that is initially established by a professional association or a group of schools. The agency’s board of directors is responsible for developing a set of standards that includes educational requirements specifying the necessary baseline or entry-level knowledge and skills for the field. To ensure their acceptance, accreditation standards are generally developed through an open process involving representatives of the key stakeholders in the field, including educators and practitioners. An opportunity to comment is given to those not engaged directly in the standards development process.

Accreditors are often divided into two categories: institutional and programmatic. Institutional accreditors grant accreditation to an entire institution, such as the University of Massachusetts, while programmatic accreditors deal with specific academic programs, such as a medical or chiropractic degree. In some cases, an accrediting agency will combine these functions when dealing with what are called “single purpose institutions”—schools that offer programs in only one field of study. In this case, the accrediting agency grants both an umbrella accreditation for the entire institution and also accredits one or more specific programs.

Programmatic accrediting agencies that focus on a specific profession are also often referred to as “specialized” or “professional” accreditors. The primary focus of the accreditation standards of such agencies is on the content of educational and training programs. However, the accreditation standards of these agencies typically cover a wide range of other areas, including faculty, administrative and governance structures, finances, facilities, and other facets of educational institutions. For example, in the area of faculty, an accreditation agency might have requirements pertaining to educational degrees/credentials of the faculty, the proportion of full-time/core faculty hired by an institution, and the involvement of faculty in academic matters.

It is important to note that in recent years, accreditors have shifted the emphasis from simply listing the required subject areas and hours of study for programs to identifying the range of competencies that students must attain during the course of study in order to be adequately or comprehensively trained. The main idea behind a competencies oriented approach is that, at the end of the day, the graduate of a training program should be able to demonstrate that he or she has actually learned the knowledge base and skills associated with the field and has not merely spent a prescribed number of hours in a classroom or a clinical setting.

Despite the greater emphasis on competencies, accreditors still normally specify certain broad requirements in terms of classroom hours and/or credits, such as the total minimum length of the program and the time that must be devoted to clinical instruction and internship. This is to guard against a program’s claim that its students are able to master a complex set of competencies within what experts in the field would consider an unreasonably short period of time.

State higher education departments have the responsibility for authorizing schools to grant academic degrees (e.g., bachelor’s, master’s, and doctoral degrees). However, programmatic accreditors specify the degree level of the programs they accredit. Therefore, one of the key questions that the educational and practitioner communities within a field must address is what degree level is an appropriate starting point for the field. For example, the accrediting agency for acupuncture and Oriental medicine started out by developing educational standards for a single type of program: a master’s degree-level training in acupuncture. The same agency subsequently developed educational standards for a master’s degree-level program in Oriental medicine and, more recently, for a doctoral degree program. The accrediting agency for naturopathic medicine, by contrast, started out accrediting programs at the doctoral degree level (ND programs), and has not markedly changed or extended this mission in three decades—though it has periodically revised its educational requirements.

An agency has the option to create one or more sets of educational standards for a given field that correspond to different scopes of practice, different sets of competencies, and different degree levels. An emerging field needs to consider very strategically what educational program requirements and degree levels are realistically achievable for a critical mass of the programs that it hopes to attract into the accreditation process.

Accreditation is considered a voluntary process. However, once the accreditation process within a field is widely accepted by consumers and practitioners in the field—as well as by practitioners in other healthcare-related fields—schools that forgo accreditation will lose their competitive edge. If a field becomes licensed, gaining accreditation is even more important to a school’s competitiveness, as graduation from an accredited program is typically a requirement for licensure within most jurisdictions.

Many accrediting agencies, though not all, choose to seek recognition from the U.S. Department of Education (DOE) once they are solidly up and running. DOE recognition of an institution’s accrediting body is the basis upon which an institution may be authorized to provide federal financial aid to students. Since federal financial aid greatly increases the marketability of educational programs, many fields are committed to seeking DOE recognition for their accrediting body.

DOE recognition also greatly enhances the credibility and legitimacy of an accrediting agency in the eyes of potential students, external regulators, and the general public. This is because DOE recognition is a demanding regulatory process that requires accreditors to demonstrate conformance to a stringent set of criteria as well as a high degree of professionalism. Generally, if a profession is seeking state licensure, establishing a DOE-recognized accrediting agency is almost a mandatory prerequisite. Otherwise, a state legislature or administrative agency has no independent way of determining whether the accrediting process is legitimate and effective. In fields where there are numerous diploma mill operations, the owners of these operations often establish sham accrediting bodies (referred to as “accreditation mills”) that endorse their programs. The existence of multiple accrediting bodies within a field can cause confusion to state officials.

Establishing an accreditation agency—like establishing a certification agency—requires solid financial resources as well as sufficient expertise regarding higher education practices. Typically, an accreditation agency has a board of directors consisting of representatives of schools, practitioners, and members of the public that is responsible for developing educational standards and agency policies and for making accreditation decisions. Additionally, an agency needs to assemble and train a pool of individuals who will have the knowledge and skills needed to assess the quality of programs during an onsite visit. Finally, an agency needs administrative staff, which at the outset often consists of a single part-time employee. The costs of running an agency are typically borne by the accredited schools through annual fees. In some cases, professional associations and individuals may also provide financial support, and supporting organizations may also allocate some staffing, space, and other resources.

Unlike registration and certification of practitioners, accreditors do not grandfather schools/programs. This is partly because accreditation is an ongoing process that includes periodic reevaluation and re-accreditation of schools, and partly because the DOE requires recognized accrediting agencies to enforce their standards with equal consistency. However, the initial accreditation standards may be set at a level that is within reach of most of the institutions in existence at the time. Setting the standards at a realistically achievable level encourages buy-in to the process.

Conclusion

The fact that the emerging professions of Yoga, Yoga therapy, and Ayurveda have established—or are in the process of establishing—their own registration, credentialing, and/or school-approval processes is an implicit acknowledgement that the forward movement of a profession, at least in the U.S., requires creating a professional regulatory structure and identity. Typically, taking these steps will synergistically raise the quality of practice, increase public awareness and trust of these fields, extend the political influence of the practitioner community, and expand professional opportunities.

For these emerging professions, there is no right answer regarding whether and how to self-regulate or, for that matter, whether it might be advantageous to seek external recognition via professional licensure at some point in the future. Any self-regulatory structure involves a variety of trade-offs and financial costs that can be substantial. Additionally, establishing a self-regulatory structure demands extensive internal discussion—discussion that is open, respectful, and inclusive—to ensure a reasonable degree of acceptance by practitioners and educators and to minimize the risk of creating schisms within the field.

 

While there are tried-and-true approaches to self-regulation that emerging professions can use as models, no emerging profession should be a slave to convention. New paradigms of health and wellness may well require the creation of new regulatory paradigms. At a minimum, efforts to create a conventional self-regulatory structure may benefit from a healthy degree of skepticism and experimentation so that the soul of the field is honored and nurtured as the profession becomes increasingly established and recognized.

The work of self-regulation is never complete. Almost as soon as any regulatory structure is created by an emerging profession, the weaknesses and omissions of the structure will start to become apparent. Also, the growing experience and expertise of practitioners and educators will bring about new aspirations for the development of the field. The sheer growth and success of a profession will, over time, necessitate the reformulation of structures and standards. This ongoing work, painstaking as it usually is, should be welcomed, as it often results in continued improvement in education and in quality of services offered by practitioners.

Patient Encounter Guidelines

Definition of Patient Encounter (PE)

A patient encounter is defined as a combination of the following, a substantial percentage of which should involve direct, hands-on contact. A patient encounter refers to each encounter: initial or follows up. Schools are encouraged to provide the opportunity for long-term follow up by which students can experience outcomes.

a) Experience history and/or outcomes of patients in order to build an internal database of clinical knowledge and experience. This internal database can be built by a variety of experiences whether it is observation, internship, externship, small group work or apprenticeship (working under and alongside the practitioner in a graduated responsibility model).

b) Carry out procedures such as history taking; prakṛti and vikṛti assessment; pulse, tongue and nail diagnosis; as well as other appropriate methods in order to gain assessment fluency. This cannot be accomplished by passive observation but can be attained in a variety of settings including intern, small group work or apprenticeship (working under and alongside the practitioner in a graduated responsibility model). 

c) Carry out the clinical application of Ayurveda as per category designation. *Refer to the Scope of Practice for the Ayurvedic Profession, Ayurvedic Health Counselor: Educational Outline for Competency, Ayurvedic Practitioner: Educational Outline for Competency and Ayurvedic Doctor: Educational Outline for Competency documents for specific details.

Three Settings for Patient Encounters

1) Observation: Observing the teacher/clinician working with a client in a classroom setting.

2) Student/client encounter with direct supervision of a teacher. This includes working one-on-one or in small groups of two or three.

3) Student/client one-on-one, in a more intimate setting with the student doing complete intake, recommendations, and follow-up; to be supervised directly or via externship.

Patient Encounter Requirements by Category

Ayurvedic Health Counselor

Requires a minimum of 50 patient encounters with at least 25 in the first two settings as indicated above and 25 one-on-one*.

Ayurvedic Practitioner

Requires a minimum of 100 patient encounters over and above the 50 of the AHC category. Twenty-five observation, 25 under direct supervision onsite and 50 completely one-on-one* with direct or indirect supervision.

Ayurvedic Doctor

Requires 250 client encounters that will include the 100 client encounters from the AP category with the additional 150 as mainly one-on-one sessions reviewed by senior faculty or senior Doctor of Ayurveda.

*One-on-one typically means one client, per one student/intern. However, some schools have found that students learn better when working with a client in groups of two or three students, all of whom are fully engaged in all aspects of diagnosis and chikitsa. This is an acceptable substitution for one-on-one encounters, provided students also gain experience working with patients one-on-one before graduating.

Definition of Supervised/Supervision

Each and every patient encounter a student has is supervised by one or more of the methods outlined below. Schools offer a variety of valid methods of supervision, including but not limited to:

a) Supervisor present during consultation

b) Onsite supervisor checks students’ work after student has seen patient

c) Live Internet supervision via a HIPPA-compliant telemedicine platform, e.g. VSee (www.vsee.com)

d) Roundtable discussions

e) Use of approved local mentors

“Six months of supervised clinical practice” should read “Equivalent to six months of supervised clinical practice.” While some school formats would deliver this in a six-month block, others might be interspersing it throughout the training. A student might see only a few patients in six months. Hence, the number of clinical patient encounters is of more importance than the time taken to accrue them.

Recording Patient Encounters

For schools with onsite clinics, students can fill out a form or worksheet that is signed by the clinic for verification. For schools where the students are being mentored from a distance, an online recording system could be used. Some schools may choose to retain the patient encounter forms, while others might record the patient encounters on spreadsheets and return them to the students for their portfolio.

When the student applies for NAMA professional membership, the school informs NAMA that they have completed the required patient encounters, just as the school informs NAMA that they have completed the other educational requirements.

Recommended Roll-out of Increased Patient Encounter Criteria by 2016

Ayurvedic Health Counselor 50 PE

Ayurvedic Practitioner 100 PE