|ORIGINAL RESEARCH PAPER
|Year : 2012 | Volume
| Issue : 3 | Page : 172-179
What is a Competent Homeopath and What Do They Need in Their Education? A Qualitative Study of Educators' Views
Petter Viksveen1, Aslak Steinsbekk2, Marit By Rise2
1 Department of Public Health, School of Health and Related Research, University of Sheffield, United Kingdom
2 Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
|Date of Web Publication||29-Mar-2013|
Lindeveien 55, 4314 Sandnes
Source of Support: None, Conflict of Interest: None
Introduction : The rise of complementary and alternative medicine (CAM) professions has taken place alongside an increase in public use of CAM therapies. Some actions have been taken to establish educational standards, often focusing on educating competent professionals to ensure citizens' freedom to make choices for their own healthcare while at the same time ensuring their safety. However, in professions like homeopathy that are unregulated in most European countries, it is not clear what it means to be a competent homeopath. The aim of this study was to investigate educators' views on what a competent homeopath is and what they require in their education. Methods : This was a qualitative study based on grounded theory methodology involving telephone interviews with 17 educators from different schools in 10 European countries. It used constant/simultaneous comparison and analysis to develop categories and properties of educational needs and theoretical constructs and to describe behaviour and social processes. The main questions asked of subjects were "What do you think is necessary in order to educate and train a competent homeopath?" and "How would you define a competent homeopath?" Results : The educators defined a competent homeopath as a professional who, through her knowledge and skills together with an awareness of her bounds of competence, is able to help her patients in the best way possible. This is achieved through the processes of study and self-development, and is supported by a set of basic resources. Becoming and being a competent homeopath is underpinned by a set of basic attitudes. These attitudes include course providers and teachers being student-centred, and students and homeopaths being patient-centred. Openness on the part of students is important to learn and develop themselves, on the part of homeopaths when treating patients, and for teachers when working with students. Practitioners have a responsibility towards their patients and themselves, course providers and teachers have responsibility for providing students with effective and appropriate teaching and learning opportunities, and students have responsibility for their own learning and development. Discussion : According to homeopathy educators' understanding, basic resources and processes contribute to the development of a competent homeopath, who possesses certain knowledge and skills, all underpinned by a set of basic attitudes.
Keywords: Competence-based education, complementary and alternative medicine, grounded theory research, higher education
|How to cite this article:|
Viksveen P, Steinsbekk A, Rise MB. What is a Competent Homeopath and What Do They Need in Their Education? A Qualitative Study of Educators' Views. Educ Health 2012;25:172-9
| Introduction|| |
Complementary and alternative medicine (CAM) professions have developed in recent decades, alongside the public's increasing interest in and use of CAM. ,, Although CAM practice has become regulated in some European countries, it still remains mostly unregulated in most countries worldwide. , Homeopathy is a CAM therapy that was developed by the German physician Samuel Hahnemann (1755-1843). , It is one of the four most established CAM therapies in Europe  with an estimated 6500 non-medical students enrolled and 21,000 graduated from European schools as of 2008.  Homeopathy is based on the principle of 'similiars', where substances known to cause certain symptoms in healthy persons are used in diluted form to treat the same symptoms in diseased individuals.  Homeopathy is used to treat a range of acute and chronic conditions, particularly to enhance the patient's self-healing properties.  It is practised both by unregulated and regulated healthcare practitioners, depending on national regulation and tradition.  Patients of all ages are treated by homeopaths, and adult patients are more often female than male. ,, Health concerns for which patients most commonly consult homeopaths include ear, nose, throat, and respiratory complaints (in particular recurring infections), allergies, mental complaints (anxiety/depression), migraine/headache, musculoskeletal complaints, sleep difficulties, and digestive, female and skin complaints. ,,
In most countries homeopaths are self-regulated and no state recognised national education and training standards exist. , The development of such professions is partially based on their own ability to standardise practitioners' training.  The European Union (EU) works to harmonise healthcare and other higher education standards across member states,  aiming to ensure citizens' freedom to make healthcare choices while ensuring safety.
Efforts have been made to describe curricular properties of homeopathy education and to establish common standards. ,,,
However, opinions differ about standards. ,, Less work has been done to describe qualitative properties of homeopathy education; that is to discern the resources, personal abilities, and learning processes necessary to provide good education. To the best of our knowledge, there are no previous studies in this area. The aim of this study was to investigate educators' views on what a competent homeopath is and what is needed to educate such a practitioner.
| Methods|| |
This qualitative study involved semi-structured individual telephone interviews conducted from June to September 2008. This project was approved by the Faculty of Health Ethics Committee at the University of Central Lancashire (UK).
Informants were recruited from identified schools in 31 countries invited to take part in a cross-sectional survey on undergraduate homeopathy education in Europe. Names of schools were provided by the European Central Council of Homeopaths (www.homeopathy-ecch.eu), which represents the homeopathy profession in 25 countries in Europe. An Internet search only identified another two homeopathy schools. The 16 European countries where no schools were identified either have legislation restricting treatment of patients to medical doctors or were small states where such courses are not likely to be created.
The persons contacted for interviews sometimes recommended others within their school who could participate. Interviewees included mainly teachers, school or organization owners, and rectors; some had more than one role within the education institution. Sixty out of 81 course providers responding to the survey indicated their willingness to participate in the qualitative study. Interviewees were randomly selected from among those willing to participate using a random number generator (http://www.random.org/integers). They were consecutively contacted starting from the top of the list of schools selected using the random number generator until saturation of findings, that is when no new themes were identified with new interviews. If a person could not be contacted after two attempts, the next person on the list was approached. Four persons could not be contacted. The study sample included 17 educators from 17 different schools in 10 European countries.
Interviews were conducted by telephone due to the geographical distance. Sixteen interviews were carried out in English, one in Norwegian (the interviewer's and interviewee's mother tongue). Interviews were semi-structured to ensure that informants talked about the same general topics. The main questions posed to informants were: "What do you think is necessary in order to educate and train a competent homeopath?" and "How would you define a competent homeopath?" Informants were allowed to raise any themes and the follow-up questions were adapted to informants' responses. During the interview process, themes explored were adjusted based on ongoing analyses (see Analysis section). All interviews were conducted by the first author (PV), recorded through verbatim transcripts and lasted 65 minutes, on average (range 35-90).
Grounded theory research methodology ,, was used to analyse data, with simultaneous data collection and analysis, and through establishment of categories with properties. Simultaneous collection and analysis helped generate additional questions to further develop the categories and properties heard. For open analysis, which remained close to the data, initial codes were kept simple and composed by using interviewees' words. Data from different respondents were constantly compared. Validation of interpretation was sought by continually returning to the transcripts. Numbers of categories was gradually reduced from over 60 to 5, a common approach in grounded theory research.  All three authors participated in the discussion of the analysis. Interviews were carried out until saturation.
The study aimed at developing substantive theory, involving a limited field of research. , The approach provides a way to systematically develop theoretical constructs and to describe human behaviour and explain key social processes, grounded in empirical data.  It has been considered an important contribution to medical education development. 
| Results|| |
Seventeen individuals (hereinafter referred to as "educators") were interviewed. Most were rectors (n = 12) or deans (n = 1), teachers (n = 12) and owners (n = 10) and 9 had more than one role within their teaching institution. One course was provided within a University, another by a non-profit organisation, whereas the remaining 15 were offered by privately run schools. Schools were situated in the 10 following countries: Belgium (1), Bulgaria (1), Croatia (1), Finland (1), Germany (5), Israel (1), Netherlands (2), Norway (1), Serbia (1) and the United Kingdom (3).
Competent homeopaths were characterised as possessing certain knowledge, skills, attitudes and an awareness of bounds of their competence. Educating competent homeopaths was described as requiring certain resources, processes and attitudes on the part of the teacher and student. A theoretical model is presented to illustrate findings. Results are divided into two sections in line with the two main research questions, and the key elements for each area are presented and illustrated by educators' statements.
| What is a Competent Homeopath?|| |
The main purpose of being a homeopath
The main purpose of becoming a competent homeopath was said to be to help patients through clinical practice. "[A] competent homeopath is someone who is able to heal people." (Educator 7) It involves becoming "[…] [a] clinically skilled homeopath […]". (Edu 13) The homeopath was said to obtain competence with awareness of and acting within her bounds of competence.
[Table 1] lists the knowledge, skills and attitudes that the educators saw as necessary in order for someone to be a competent homeopath.
|Table 1: What educators considered necessary in order to be a competent homeopath|
Click here to view
Competent homeopaths were said by the educators to have subject knowledge in several areas, in particular in homeopathy, medicine and psychology, and in ethics. Educators also mentioned areas such as nutrition, other CAM fields, and integrated healthcare.
[There] is the huge range of homeopathy skills […] homeopathic philosophy, materia medica, case taking, case analysis and case management […] medical skills, which ranges from anatomy, physiology, pathophysiology, disease progression, differential diagnosis, and perhaps simple biomedical skills […] (Edu 17)
Although educators emphasised the importance of research, there were differing opinions on the degree to which this is important.
[Students should be] doing some sort of dissertation. […] ranging from a long essay based on literature review, to doing qualitative or quantitative research. It is important if we are to become a research based profession […] (Edu 17)
We encourage students to keep up with current homeopathy research. […] but it's not [an] essential element of our course. It has to be of benefit to patients. (Edu 16)
Educators stated that interpersonal skills include communication skills such as interviewing, listening, informing, providing advice, showing empathy, cooperating and drawing boundaries. The homeopathic interview was said to be key in order to obtain information needed to be able to successfully prescribe homeopathic remedies.
[When] the interview is not good, you never find the right remedy. (Edu 12)
A good homeopathic interview was, according to the educators, firstly based on listening to the patient so that the practitioner's interest in and attempt to understand the patient is conveyed.
In his personal qualities I would expect him to be able to listen, to give the patient the opportunity to open up […] to create an atmosphere so the patient can do it. (Edu 10)
Communication was thought not to rest on listening skills alone, but also informing patients and providing advice and preparing them for what may happen during a healing process.
[…] to be able to give the patient advice if needed, in personal development, in lifestyle, things that contribute to health, diet, physical exercise and things like that. (Edu 10)
It is important for patients to understand what real healing is, not just to take away a part of symptoms. (Edu 14)
The process was considered to be one in which practitioner and patient become equal partners in the therapeutic relationship. Effective communication included other contexts, in particular communication with other healthcare professionals. Educators thought that this contributes to enabling practitioners to work with practitioners of other therapeutic disciplines.
Observational and analytical skills
Educators pointed out the importance of observational and analytical skills, which included observing, extracting, analysing, individualising and understanding what comes out of the consultation. The practitioner needs to extract what is essential and understand the meanings of what is said and what she observes in patients.
Hearing and understanding, rather than just listening. To listen is one thing, you can listen, but you may or may not hear what people are saying. […] it's understanding, not just hearing words, but the meaning of the words. (Edu 9)
Ability to extract what is essential was thought to help practitioners to extract the most essential features in understanding homeopathic medicines.
[…] to become a competent homeopath [you must have] the ability to read materia medica, to extract the essential. If you do this, then you will be able to use the same skill when you extract the essential in cases. (Edu 13)
Educators pointed out the importance of competent homeopaths being able to consider and analyse patients individually. Approaches used to understand patients would therefore vary.
[You have to] find what is important in the case, individuality […] [You] must think logically, on reasonable principles, to have scientific knowledge […] [be] good observers […] extrapolate, synthesise and analyse […] Meta-cognition is more important than knowledge itself. (Edu 2)
Developmental skills should, according to the educators, contribute to practitioners' increasing degrees of self-awareness. Each practitioner brings her own issues into the consulting room, and these issues may influence the practitioner's understanding of patients and thereby the outcome of treatment. These skills are developed over long periods of time.
They have to be aware of their own weaknesses and strengths […] to develop themselves. […] If you want to help other people, you first have to help yourself. […] If you know yourself very well, then you can realise what is you and what is not a part of you. (Edu 14)
Educators emphasised the importance of organisational skills, which involve skills to organise their practice, to work independently and possess specific practice/business skills.
It is no good going out there and knowing everything they know about homeopathy and not know how to set up their business. (Edu 17)
Competent homeopaths were thought to possess essential basic attitudes, which coupled with their knowledge and skills, influence how competently they treat patients. These basic attitudes included patient-centeredness, openness and responsibility.
Educators thought that an attitude of respect involved respect for patients and for the practitioner herself. This contributes to facilitating good conversation between patients and practitioners, communicating intent to hear and help the patient, and at the same time respecting herself by setting her own boundaries.
Respect, for yourself and the patients, secure environment for […] both […] so they can freely discuss things. To be authentic and establish clear boundaries, clear messages to the patients […] (Edu 9)
An attitude of empathy and unconditional positive regard was considered by educators to be key in patients' treatment.
You have to be compassionate, so you really feel what is happening. […] I think empathy is a better word." (Edu 11) And: "You need […] an enormous respect […] [and] […] unconditional positive regard for people. (Edu 16)
Educators thought openness or a non-judgemental attitude is important and involves being open to different ways of thinking. It concerned openness to understanding science, healthcare and treatment overall.
There's got to be a level of openness […] You don't have to accept everything, but to be open to the possibilities. […] You need openness and willingness to learn […] [It is] being like a child, open-minded, curious, surprised […] always with an open heart. (Edu 16)
Educators said practitioners should take an attitude of shared responsibility, support patients and assume responsibility for their homeopathic treatment, whereas patients assume responsibility for their own health.
I feel we share responsibility, the patient decides he wants to be treated this way […] The homeopath's responsibility is to do [her] best […] to be fully, maximally attentive, give [the] best of [her] experience and knowledge. […] The patient's responsibility is to decide [what] treatment [she wants]. (Edu 14)
Educators said competent homeopaths need an ethically appropriate attitude. This involves respecting issues of confidentiality, taking responsibility, acting honestly, in a clinical practice and business sense. One informant brought it beyond the patient-practitioner context:
I'm imagining about being an ethical practitioner, not ripping people off, having a contract and working to it. That could apply from homeopath to patient, from homeopath to homeopath, homeopath to professional organisation, from homeopath to state system. (Edu 17)
Bounds of competence
A central element of being competent homeopaths involved practitioners possessing awareness of their competence, and hereunder awareness of the bounds of their competence. This includes knowing when to refer a patient for medical diagnosis and/or treatment. Practitioners should act according to existing laws and regulations.
Medical knowledge, know what in pathology is calling for immediate action or emergency, where a different approach than homeopathy is needed. Not everything can be treated with homeopathy, you need to know what to do, to whom to refer. (Edu 1)
Bounds of competence became apparent through attitudes such as shared responsibility and ethically appropriate attitude.
[The] homeopath needs to be aware of [what] is her responsibility and what is the responsibility of the patient." (Edu 2) And: "[How] I behave […] as a homeopath, should be underpinned by […] how I behave ethically as a person in every aspect of my life. (Edu 17)
What is needed to educate a competent homeopath?
[Table 2] lists the resources, processes and attitudes that the educators saw as necessary to educate competent homeopaths.
|Table 2: What educators considered necessary for someone to be educated and trained as a competent homeopath|
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Educators described several resources as necessary to educate competent homeopaths; people, which involved students, teachers and staff; and physical resources, including premises and financial resources.
[You need a] lecturing room, physical stuff, to have the place where you can teach. (Edu 9) And: Most important are teachers and a good plan. (Edu 1)
Information such as course information/curriculum/guidelines; support systems, teachers' own learning programmes, accreditation/recognition systems were considered to be important.
It is crucial that the curriculum holds together and has a thread that runs through a course." (Edu 17) And: "[It must be] a solid and meaningful accreditation system [which] involves visits to schools, talking to students, to see if people deliver what they say they deliver, what promises they make to people paying them a fee. It [should be] tied to national occupational standards and a proper code of practice and ethics. (Edu 16)
Processes needed to become competent homeopaths involved various forms of studying mentioned by educators. Studying methods involved cognitive and interpersonal processes. Moreover, self-development, involving self-reflective processes over time, to develop self-awareness, sort out one's own issues, and develop self-confidence, were believed to be of significant importance.
Study processes involved various teaching and learning activities and were characterised by being active and interactive, at appropriate and increasing levels of difficulty and carried out with enthusiasm and persistence.
All educators stressed the importance of students' active involvement in their studies, whether through giving and receiving feedback, peer supervision, learning by doing (including clinical experience), giving presentations, or carrying out problem-based projects or other assignments.
Students learn more from doing. […] I don't think this is peculiar to homeopathic education, but for any education. If you want to be a carpenter, you have to learn by doing it. (Edu 7)
Active involvement might include experiencing homeopathic treatment themselves or participating in so-called homeopathy drug provings.
Every homeopath should also be a homeopathic patient, because when they didn't go through that process, they are not able to understand what the patient is going through. (Edu 14)
The educational programme should according to the educators be carried out at appropriate and increasing levels of difficulty, with a certain level of persistence.
[The] curriculum must [be] spiralling. Every time it is a little more difficult, complex, complicated to solve […] (Edu 4) And: If it is just a hasty course where you try to put in tons of information, it is not going to be a personal growth process as well as a profession. Four years is really a minimum. (Edu 8)
Enthusiasm conveyed by teachers was thought to encourage students to persist in their studies.
Enthusiastic teachers […] who love what they are doing […] [can] create a situation where students are interested, […] [and] want more. (Edu 6)
According to the educators, becoming a competent homeopath involves processes of self-development, including self-reflective processes, to develop self-awareness, sort out personal issues, and develop self-confidence. These processes were considered to be spiralling, in the sense that the person will return to the same issues repeatedly during their education, each time with an opportunity to develop further. All processes take place over time.
Personal development so students become aware of their limitations, prejudices, life-experiences, and how this colours the way they look at the world. It helps them not to project their feelings onto patients. (Edu 16)
Educators also pointed out that self-development is important for teachers, course providers and for courses.
Re-assess everything you do […] improve it […] A teaching institution should be a moveable force and progressing […] (Edu 15)Attitudes
Several basic attitudes were considered by educators to be important in producing a competent homeopath. The same attitudes were considered important throughout the educational process. Student-centeredness was one of the central perceived attitudes in educating competent homeopaths, whereas patient-centeredness was considered important to be competent homeopaths. The education is based upon students developing into competent practitioners, and educational programmes should support students throughout their education in a wide range of ways:
They've got to have a really good support network (Edu 16) And: Beginners listen, […] when they have a bit [of] experience they could start doing their own cases under supervision. Then supervision could be less and less, but there would be someone next door that could help, who could sit in […] a closely related cooperation. (Edu 7)
A model describing the characteristics of a competent homeopath and the process to become one
Educators' views on characteristics of a competent homeopath and what they believe is necessary in order to be educated/trained to become one have been integrated into a model presented in [Figure 1].
|Figure 1: Model of educators' views on what a competent homeopath is and what they require in their education|
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Basic resources (people, systems, physical and informational resources) and processes (studying and self-development) were considered necessary by educators to become competent homeopaths. Resulting knowledge and skills were thought to be characteristics of competent homeopaths. Competent homeopaths, as well as the process that takes someone to become a competent homeopath, are underpinned by a range of basic attitudes. These attitudes involve patient/student-centeredness, openness and responsibility. The ultimate result was thought to be competent homeopaths whose main purpose was, through their clinical practice, to help patients. Moreover, competent homeopaths should be aware of their bounds of competence.
| Discussion|| |
Competent homeopaths were described by homeopathic educators in European countries to have knowledge in a range of areas; to possess certain interpersonal, observational, analytical, developmental and organisational skills; and to act according to their bounds of competence. Such practitioners should in their clinical practice be able to help patients in the best ways possible.
These educators believed that practitioners' competences are underpinned by a range of attitudes including patient-centeredness, openness and responsibility. These attitudes, together with an element of student-centeredness, are central parts of the process in which someone develops into a competent homeopath. The process involves studying and self-development, and is supported by basic resources.
Strengths and limitations
We do not claim that the presented model is the only plausible one, but it has been developed inductively. The theory emerged from data obtained through qualitative interviews and is, therefore, grounded in the data.
Participants were randomly selected from a total sample including most homeopathy education institutions in Europe. 
However, other interviewees might have provided different responses. It is also possible that interviewees might have given different responses had they been asked to base them on course curricula or to discuss the interview's questions with their colleagues prior to the interview. Moreover, using theoretical sampling might have increased diversity and thereby influenced development of the emerging theory.  This could be done in future studies.
Competence-based education and learning, study topics and length of courses
Considerable research has been carried out in the field of competence-based education and learning. Areas most relevant to the study described in this paper involve education of healthcare practitioners such as medical doctors. Carraccio et al. found through extensive literature reviews that medical education has undergone a paradigm shift from structure- and process-based to competency-based education over the past decades. This involves components of active learning, which to a large extent have been described by categories and properties found in our study. Competency-based education has also become common in other healthcare professions, such as nursing, physiotherapy and occupational therapy. 
The US Accreditation Council for Graduate Medical Education (ACGME) Outcomes Project identified six abilities students need to develop:  "Patient care", "medical knowledge", "practice-based learning and improvement", "interpersonal/communication skills", "professionalism" and "systems-based practice". These can also be identified in the properties of the categories described in our study.
Many curricula areas, such as clinical training, anatomy, physiology and pathology, have been stressed as important in homeopathy education in recently published international guidelines.  The importance of practitioners acting within their bounds of competence was outlined in guidelines developed by the homeopathy profession. 
Education of homeopaths should, according to the educators in our study, take place over a longer period of time. It was recommended by the Norwegian Ministry of Health and Care Services  that homeopathy courses should last for four years, full time, as practitioners have independent responsibility for their patients.
How the results contribute to existing knowledge
Findings from the present study add to current knowledge about development of competence in arising and partially unregulated professions such as homeopathy. This might serve regulatory and educational purposes and may be of use to professional associations, accreditation bodies, regulatory bodies and educators. Educational purposes may involve establishing new and developing existing programmes aimed at educating and training competent homeopaths. Assessment of existing homeopathy education programmes could be used in independent accreditation processes, whether carried out by professional bodies registering practitioners, independent external accreditation bodies or government established bodies responsible for regulation of arising professions. However, these results should first be tested through further research, to confirm or further develop the proposed model. Moreover, occupational standards should preferably form the basis for description of competencies acquired by professionals. Research could also test transferability of the results of this study to other fields of education of either unregulated or regulated healthcare professions.
Grounded theory research in other areas of education might contribute to develop formal theory explaining development of competence through education or development of competence in CAM professions as well as in other areas of life.
| Conclusions|| |
This study proposes a substantive theory to answer what homeopathy educators believe a competent homeopath is and what it takes to be educated and trained to become one. The model suggests that certain basic resources and educational and self-developmental processes contribute to developing knowledge and skills necessary to be competent homeopaths. It also pinpoints underlying attitudes needed in the education as well as the clinical practice of competent homeopaths.
| Acknowledgements|| |
First and foremost, thank you to all study participants. Many thanks to Jean Duckworth at the University of Central Lancashire for supervision and support during the process of planning and carrying out the study.
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[Table 1], [Table 2]