Purpose

In assessing how this profession could move forward as a privately-funded system we sought to gain a comprehensive perspective on MT within the province. In another paper[2] we summarized the perspectives of RMTs in regards to their own profession. The purpose of this paper is to examine the perspectives of other stakeholders- MT educational institutions, regulators and funders – soliciting their views on the advancement of this profession.

Recruitment

The research team compiled a list of all stakeholders in MT and contacted them via phone and email. All stakeholders who responded to our requests were keen to be involved. While the research team attempted to contact both elected officials as well as staff within the provincial government we received no response. We were, therefore, unable to include the voice of government in this study. Participants were not financially compensated for their participation.

Protocol

Questions were presented to study participants in written form and are appended here (Additional file1:Appendix). Each participant signed a consent form. Ethical approval was granted by the University of British Columbia Behavioural Research Ethics Board. We employed self-completed questionnaires, focus groups and one-on-one interviews. The first author of this paper conducted all interviews and focus groups. All responses were digitally recorded and partially transcribed in order to capture participants’ exact words. We employed qualitative methods of questionnaire design, interviewing and analysis.

Participants

Ten members of the organization responsible for regulating the practice of MT within the province, the MT regulatory body (MTRB) were interviewed. We distributed questionnaires in advance and collected responses during the focus group. We interviewed twelve administrators representing all MT colleges within the province. All interviews were conducted at the college campuses, except one which was interviewed via email.

We interviewed members of one private and two public insurance companies. Where possible, we held interviews with insurance company representatives in charge of MT claims. We conducted focus groups with four staff members of a private insurance company. We thus interviewed six representatives from public and private insurance companies across the province.

In total, 28 people participated in this study.

Data analysis

Members of our research team partially transcribed all interviews and answers to each question were inserted into appropriate sections. For example, we had section headings of “Do you believe research can advance the profession of massage therapy?”, “Are you satisfied with the current regulation of MT research curricula in schools?” and “In your opinion, what aspects of MT require further research?”. From the categorized sections, we analyzed responses using qualitative techniques of coding, diagramming and thematic analysis. In addition to audio-recording, the principal investigator took notes throughout the interviews. Interviews lasted from 30 to 90 minutes.

Advancing the profession: regulators and educators

Members of the MTRB felt that acceptance from other health professionals, respect from government as well as strong validation of what RMTs do through research would advance the profession.

"“[RMTs would benefit from] strong validation of what we do through research [in addition to] greater acceptance by other health professions, greater referrals [and] no GST.”"

"“If we had national professional recognition we’d be able to move forward.”"

"“[We need to] integrate evidence into practice.”"

"“[We would benefit from respect from] other health professionals, respect from government.”"

The response of MT colleges to “what steps do RMTs need to take in order to elevate the status of the profession” included the following: increasing research in the area of MT and health and educating the public on the qualifications and roles of RMTs.

"“People don’t know how well educated RMTs are. RMTs have excellent training – let’s talk to the public!”"

"“[We need to] establish evidence-based research.”"

One MT college administrator felt that providing leadership to spearhead the needs of RMTs as well as establishing best business practice courses in colleges could help RMTs succeed in their careers.

"“Resistance to business practices in colleges. Chiros realised this and train to be both a good business person and practitioner. The MTA (Massage Therapists’ Association) could look at AMTA (American Massage Therapy Association) and invite them to speak at conferences – they know how to help members.”"

"“Leadership! We need better leadership to raise [the] status of our profession. Let’s bring in the expertise to help us move forward. It would be good to have leaders setting direction for the program [but] we need all the stakeholders working together!”"

Massage colleges and the MTRB recognized the significant role of research in getting greater acceptance for MT from other healthcare professionals and respect from the government. All stakeholders highlighted the importance of research in moving the profession forward. However, although the importance of research was frequently cited, peer-reviewed literature and research education practices are minimal. This topic is discussed in more detail next.

Role of research in moving MT forward

Role of research in the advancement of other professions

Increasing the number and quality of studies examining the efficacy and safety of physiotherapy, nursing and chiropractic practice have helped these professions gain recognition from both other healthcare professionals and governing bodies of healthcare. RMTs and stakeholders of MT feel these issues are of great importance in advancing the profession of MT within British Columbia[2]. Chiropractic, physiotherapy and nursing have advanced partly through research. Each of these professions emphasizes research literacy and other research skills in their curricula. A significant number of their practitioners are actively engaged in evidence-based studies producing a number of robust research articles annually. This has been discussed in detail previously[15].

Why is evidence-based MT lagging behind?

Both RMTs[2] and other stakeholders of MT recognize the importance of high quality research in advancing MT’s professional recognition with other healthcare professionals, governmental healthcare organizations as well as the general public. Lack of research capacity is a substantial obstacle to moving MT forward. There is a lack of research training in MT colleges and consequently, a lack of research personnel. Ideally, academic researchers and RMTs ought to be working in teams in order to conduct studies on the effects of MT. Part of this problem stems from the fact that research skills and literacy are not emphasized in MT colleges. The focus of these colleges is to have their graduates become accredited RMTs by the MTRB which means passing the MTRB board examinations. As this is the final goal for most MT colleges and as the examination process is focused on clinical knowledge and skills and less on research, there is little motivation to pursue research literacy and development.

Another reason has to do with the limited funding opportunities available to RMTs who wish to involve themselves in MT research. Only two organizations across Canada have directly provided funding for MT research: the Holistic Health Research Foundation of Canada and the Massage Therapy Foundation. The limited funding opportunities, coupled with the fact that clinical MT practice is more lucrative and MT college gradudates are often saddled with large debts means the incentive to pursue MT research is low.

Degree status for MT education could help advance the profession

Some MTRB participants liked the idea of RMTs earning a degree from a public university and others did not. Half of respondents were supportive of the idea, 3 respondents opposed the idea and 2 were undecided. Of those that were supportive, maintaining standards on par with other health professionals, increasing opportunities to transfer course credits and recognition for the amount of course work completed in the MT program were frequently cited reasons.

"“University degree status is unavoidable. We could create a working agreement between colleges and universities to make [the] TRU (Thompson Rivers University) agreement mandatory. Education may be better delivered at a public university than a private college [as we] don’t need to raise the bar to get into university.”"

"“Yes – to remain viable as profession.”"

"“Yes … in order to remain competitive with other health professions.”"

"“Last time we had a stakeholders’ meeting people were not keen to mandate a degree, to allow laddering is good. I’d be quite upset if this happened. In Ontario there is public education and it has created chaos.”"

In meeting with colleges of MT they too noted that they would like to see RMTs gaining a university degree but they would like to be granted the authority to grant degrees themselves. One of the college’s faculty members suggested that 3,000 hours of education was more than an undergraduate degree so it was only fair that RMTs should earn a degree and not a diploma.

"“What will it take [for us] to become a degree-granting institution? [Our graduates require] 3000 hours of training, [that is] more than university degree.”"

"“[We would like a] degree program [but] universities may not because private colleges [would be] offering it.”"

"“A local university/college was willing to partner with us [to obtain degree granting status for RMTs] but it didn’t work after 3.5 years of trying. We spent approximately $100,000 trying to obtain such a status.”"

Baccalaureate status has helped advance the professions of physiotherapy and chiropractic, professions with similar “hands-on” approaches to healthcare[16]. To become a chiropractor in Canada, for example, one must complete undergraduate credits and then enrol in a postgraduate chiropractic college for 3–4 years[17]. Physiotherapists undergo a similar process with most students completing an undergraduate degree and then enrolling in a Masters of Physical Therapy program now available in many public universities across the country[18]. Increased educational requirements for both chiropractors and physiotherapists have meant, 1) graduates of these programs are more knowledgeable regarding clinical and research practice in their professions and, 2) exclusivity related to requiring a post-baccalaureate degree allows colleges to be highly selective in selecting their students for these programs, accepting only the most qualified and/or accomplished[16]. It is likely expected that a push for obtaining degree status for RMTs could facilitate their advancement in a similar way.

Insurance company participants express requirements for evidence-based practice

The top health issues that our insurance company participants address are mental health issues, as well as soft tissue injuries – neck, back, shoulders and knees. All company representatives noted that RMTs effectively address these health issues and that MT provides positive health benefits. They also believed that MT successfully prevents disease and treats injury although some wanted more research-backed evidence regarding the effect on disease prevention. In terms of helping people get back to work, one insurer felt that RMT outcomes were good but not great, as the return to work (RTW) outcomes during 2000–2006 was, on average, 44.6%. The goal was to improve the RTW within 5 weeks of first visit to 50%.

Insurers also told us that their company would cover RMTs more widely for visits and larger maximum annual pay outs if there was proof of effectiveness, research and more endorsement from MDs. One said that they always gave approval to MT if doctors had recommended it. A review of massage therapy by a BC physician recommended that the physician who has referred a patient should ask the therapist to provide a progress note describing measured outcomes of the therapy[19].

One insurer felt that the perception of MT as a ‘touchy/feely therapy’ had to change and that MT needs to be seen as an active therapy that shouldn’t create dependency. The concept of active therapy came up in all interviews with insurance companies as they continuously compared exercises taught by physiotherapists to time on the table with RMTs. They encouraged the MTRB to make MT as ‘active’ as possible.

Empirical evidence linking MT to benefit and outcomes would make RMT more appealing to all insurance company respondents we interviewed. All the insurance companies stated that they utilized research literature in determining the approval of claims and one even had an evidence-based practice group which did reviews of findings. All wanted to receive research literature on MT including information on return to work outcomes, new studies, emerging techniques and other focused information.

Concurring with the views expressed by the insurance companies, one member of an MT college stated:

"“The results speak for themselves. RMTs that do not keep up with best practice techniques may not get the results in their practice. Insurance companies see the poor results (and poor reporting of outcomes) by some therapists and generalize to all massage therapists. Published studies in peer-reviewed journals are what the insurance providers want to see. Even case reports and case series can be of benefit to the profession.”"

The MT-related organizations are keen to improve relations between RMTs and insurance providers. They hold information sessions for RMTs to learn about interacting with insurance companies effectively.

Abuse of claims

Another important issue insurance company participant’s noted is the perceived abuse of claims, although they noted that these were not necessarily done deliberately. One private insurance company was concerned that some RMTs are billing for medically unnecessary MT. We repeatedly heard one example during an interview: a $300 receipt from a spa from an RMT. When the insurance company asked for an itemized receipt they saw that $300 included wine, chocolate covered strawberries and other items that were not legitimate. This company urged RMTs to be better informed about billing only for medically necessary MT. Currently, most RMTs use generic, non-specific receipts. They suggested that if RMTs had more official receipts they would be better able to judge the legitimacy of the claims. The other concern this private insurer had was that MT claims had substantially increased over the past 2 years. Participants were disturbed by this trend as they suspected part of the increase was due to illegitimate expenses.

Insurer respondents felt that there needed to be a clear distinction between medical massage and wellness massage. Within the MT profession there is a parallel discussion where some RMTs would like the profession to devote itself to rehabilitation and purely therapeutic practices whereas others believe MT better serves population health by being more comprehensive as a form of health promotion, disease prevention, rehabilitation and palliation. The latter group incorporate wellness massage into their practice. A third group, the spa practitioners, only practice relaxation massage. Insurers made it clear that they were interested in funding medical massage.

However, it was interesting to ask each participant about their own personal experience with MT. Those who had received regular MT stated that they were willing to pay out of pocket for relaxation massage and be covered for injuries only. The one participant who had never received the services of an RMT held the most negative views on MT. This suggests that personal experience with MT can have a significant influence on individuals’ professional views of it. Literature on holistic practices in general echo this idea. For example, physicians who have received MT treatment for their own healthcare services or have more knowledge regarding MT feel more comfortable discussing MT treatments with their patients[20].

Stakeholder dynamics

Each of these stakeholders has an agenda. The regulatory agency’s agenda is related to their mandate of protecting the public. The agenda of the insurance companies is to protect their profits while assisting patients to improve their health. The agenda of the educational institutions is educating RMTs while maintaining profitability. Profit margins are important to at least two out of our three stakeholder groups and this is where conflict within the profession may exist. Furthermore, within each of these groups also lie many conflicts, partly based on personalities, egos and politics. The profession of MT in BC is fraught with internal struggles that impede its progress. It will not move forward until the agenda of all stakeholder groups are aligned and unity amongst groups and individuals is achieved.