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As regular readers know, I live in the great Pacific Northwest, specifically Portland, Oregon. I am at home in the organic/hippy/environmental mind-set. It is what I grew up with. It is a relaxed, informal place to live. It is not much of an exaggeration to say that formal attire is tucking your tee shirt into your jeans. At least the metro area, and perhaps much of the state, is relatively tolerant of the actions of others. A real what’s the harm/shruggie approach to life, the universe and everything.

I will admit that the irrational/shruggie/emotional/Oregonian/goateed part of my brain is often at odds with my more rational brain, which wants me to give a rat’s ass about issues I think are just wrong. It showed up strongly with fluoridation in Portland, where my rational brain knew adding fluoride to the water was a great idea and my Oregonian nature said water should be pure, man, like nature intended. I keep my inner Oregonian under tight control as his approach often sounds good until you carefully examine how his ideas are implemented. Except at the pub of course. Bring on the hops, man, like nature intended beer to be.

Naturopathy is well tolerated in Oregon, with two schools in the NW producing NDs. We have a Board of Naturopathic Medicine, whose vision is to:

To protect the health, safety and welfare of the public in the matters of care provided by Naturopathic physicians in Oregon.

One would think, as we will see, that the vision could best be served by ridding the state of both the Board and Naturopaths, but that seems unlikely.

They do have a definition that would appeal to the Oregonian in me if I knew nothing about Naturopathy;

Naturopathic Medicine is a unique and distinct system of health care that emphasizes the use of prevention and natural therapeutics. The doctors who practice naturopathic medicine, called naturopathic physicians (NDs), are trained to serve as primary care general practitioners who are experts in the prevention, diagnosis, management, and treatment of both acute and chronic health conditions.

I would think, in passing, that a naturopathic physician would be an NP, not an ND, a small point, but emblematic of the ND approach. Having a great deal of respect for nurse practitioners, I will not sully their abbreviation by calling NDs NPs.

The key phrase: “…trained to serve as primary care general practitioners who are experts…”

Well, not so much, as we have discussed at length on this blog and over at the Naturopathic Diaries, which is a must read if you really want to know about NDs from an insider, a former ND. Start with this essay and wonder at the fantastical practice that is naturopathy.

Dissecting a sausage

Several years ago ND were given prescriptive privileges for a wide variety of medications, which I discussed here.

The State of Oregon has gone so far as to define NDs as primary care providers in the statues. House bill 3301 A, which was passed and signed by the Governor this year and will take effect in 2016, states that it:

Requires insurer to permit naturopathic physician to determine whether naturopathic physician is apply to be primary care provider or specialty care provider for purposes of insurer credentials. Adds primary care to definition of “naturopathic medicine. Permits naturopathic physician to represent that naturopathic physician is medical specialist or practices medical specialty.

This year I became interested in the hows and whys of legislating of pseudo-medicines, and it has been a slow learning curve. It is quite remarkable how much occurs in the legislature with minimal reporting unless you specifically go looking for it. There were no objections to the bill on the part of the Oregon Medical Society, which was not a surprise. I have been puzzled by the lack of engagement of medical societies in issues relating to pseudo-medicine. The Infectious Disease Society of America (IDSA), as best as I can tell, has had little to do with countering the anti-vaccine movement. Perhaps the spanking of the AMA by chiropractors and the hassles of the chronic Lyme proponents with the IDSA has made them gun shy. Or more likely they don’t care, having bigger fish to fry.

So in Oregon, NDs have all the legislative support to practice as primary care providers: a state board to proselytize ND pseudo-medicine with nonsense like:

Homeopathic Medicine. Homeopathic medicine is based on the principle of “like cures like.” It works on a subtle yet powerful electromagnetic level, gently acting to strengthen the body’s healing and immune response.

Not to mention prescriptive privileges, a ‘find an ND’ function, and legal designation as primary care provider.

You can’t always get what you want, unless you have a good lawyer

Health insurance plans often do not pay for all physicians. They often have restricted panels and will pay less, or not at all, if a patient sees a provider off panel. Many will not pay for naturopathic care. The result? A class action suit.

The lawsuit was filed on behalf of naturopathic physicians and their patients who allege that Health Net discriminates against Oregon licensed naturopathic physicians by denying claims for services provided by Naturopathic Doctors (NDs) that are otherwise covered when delivered by a different medical provider.

Because:

In Oregon, NDs practice as primary care providers including providing all preventative services, prescribing pharmaceuticals, and are able to order laboratory and diagnostic imaging tests needed to diagnose and treat illness.

Since:

The discriminatory Health Net/ASH practices cited in the lawsuit allege that unlawful limitations are imposed on naturopathic physicians as compared to other medical practitioners who provide commensurate medical services.

I will let Jann Bellamy comment on the legal aspects of the case and whether the plaintiffs have a legal leg to stand on. The law, like statistics, turns me into Mr. Gumby. Legally I suspect they have lined up all their ducks. But commensurate services? Really? NDs provide care that is equal to the practice of an MD/DO/NP/RN/PA? I think not.

As one ND noted:

Much of the alleged discrimination stems from ignorance about naturopaths’ training and licensure.

Sure, but trained in what?

It is always worth a recap of the ND qualifications as understanding ND training and licensure makes it very clear they have no business acting as PCPs. The state might declare an NP a PCP, but like legislating the value of pi, legislating reality doesn’t make it so.

The best and brightest do not apply to ND schools. With a GPA around 3.2 and a 66% acceptance rate, it is safe to say the sharpest knives are not in the ND drawer. Compare that to medical school, with a 3.7 GPA and a 3% acceptance rate.This verges on the ad hominem, I know. Being the smartest does not the best doctor make, and I have known some smart premeds who have not made good doctors. Medicine is hard. Really hard. But do you want your health care from mediocre students edumacated in institutions with low standards? Then an ND is for you. On the other hand, given the ND curriculum, a ‘B’ average is probably more than sufficient to allow them to master kt. The thin gruel of an ND education is not rocket science. Or even science for that matter. Their education is based in imaginary pseudo-medicine. While NDs try to suggest their education is on par with MDs, puh-lease. Homeopathy, water therapy, acupuncture and energy therapy are not part of a standard medical education because they are fictions, divorced from reality. The practical foundation of naturopathy is the application of any and all pseudo-medicines. And all the time spent on nonsense detracts from learning real medicine. There is, after all, limited time and a vast amount of information. If you are going to stuff your head with nonsense, there will be no time to learn real medicine. They have little or no post graduate training. We get new house staff every June, fresh from medical school, ready to start their three year medicine residency. I have yet to meet a medical school student who is even barely able to manage or understand a patient. We really learn our craft in residency, three or more very intense years where patient care is under the watchful eye of senior physicians.Naturopaths usually do not have a residency. Fresh from school, with next to no practical training, they start practice. Those who do get a residency as a rule are under the tutelage of a naturopath, the untrained leading the untrained. The ND gets around 1,200 hours of clinical training in school (much of it in nonsense) compared to the around 4,000 hours of a medical student followed by about 10,000 hours from an internal medicine training program. It takes time to master a field like medicine; NDs do not have it. Once in practice, anything goes. They are proud of the fact that:

There is no naturopathic-specific standard of care. And if you look at naturopathic websites you will find a huge hodgepodge of pseudo-medical diagnoses and treatments. If it is goofy, it will be offered by a naturopath. Condition-specific treatment guidelines present more of a challenge with naturopathic physicians than conventional providers. Each person’s treatment is individualized taking into consideration conventional treatment guidelines, but combined with a complex array of natural and conventional modalities that may vary among providers. Which I would call “making shit up as you go along”, the slogan for ND care. NDs are generally anti-vaccine and in Oregon opposed the mandatory vaccination law that failed in the Oregon legislature last session. When compared to real doctors (my preferred term instead of allopathic doctors), NDs do a poor job at health maintenance, not following guidelines for cancer screening and vaccination. The result? More vaccine-preventable illness.

Children aged 1–17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care. And perhaps delays in cancer diagnosis. NDs are often unethical. While they say that:

Naturopathic doctors are taught and held to the same standards of care as conventional providers. Really? Do you see an ND as a provider? Do they just so happen to sell the supplements and treatments you need to treat your often imaginary diagnosis? How convenient. It is a fundamental conflict of interest to sell product in your office. As the American College of Physicians position paper notes: When deciding whether to sell products out of the office and, if so, which ones, physicians should carefully consider such criteria as the urgency of the patient’s need, the clinical relevance to the patient’s condition, the adequacy of evidence to support use of the product, and geographic and time constraints for the patient in otherwise obtaining the product. Physicians should make full disclosure about their financial interests in selling the product and inform patients about alternatives for purchasing the product. Charges for products sold through the office should be limited to the reasonable costs incurred in making them available. Are you a ND patient? Are they doing that? I suspect not.

The summit of Mount Turdpile

To sum it up: mediocre applicants, inadequate education consisting mostly of pseudo medicine, no post graduate training, no standards, no ethics, and poor performance compared to real doctors. This is why it has been suggested that ND means Not a Doctor. Non Doctors who treat Non Diseases with Non Drugs. ND.

It hardly seems like a group who should get scarce health care dollars. It would fry my bacon if my insurance payments went to ND care.

Is there a plus to having NDs on your panel? Well, some patients like the philosophy of the ND, despite getting care from mediocre applicants, with inadequate education consisting mostly of pseudo medicine, no post graduate training, no standards, no ethics, and poor performance compared to real doctors. If I were unaware to the truth about naturopathy, it would appeal to my inner Oregonian.

I always remember by first experience with naturopathy.

Early in my practice I was called in to see a “leg infection.” What it was, was a dead leg. Wet gangrene, with the horrible smell only rotting human flesh can produce. It was a 24-year-old girl who had an osteosarcoma of her leg and rather than be cured with amputation she went to a naturopath who said she could be cured by, among other things, drinking alkaline water and herbs. It didn’t. She had been brought in by her mother when she became unresponsive but perked up with fluids, letting us know her naturopath still assured her that he could cure the tumor, that the rotten leg was her body ‘rejecting’ the tumor. She refused surgery. That night the tumor, or the infection, eroded into a major artery and she bled to death in her sleep.

Although the outcome was extreme, that is not unusual for ND treatment: totally divorced from reality,

So I can see why insurance companies would not want to pay for ND care. This class action suit is like worrying about the discrimination against astrologers by astronomy departments. Unfortunately, the Oregon legislature has metaphorically made astrology readings the legal equivalent of Astronomia nova and magical medicine looks to have the same legal standing as reality based medical practice.

Medicine is changing, and as an old school dinosaur I sometimes think some aspects are not for the better. I have no love of insurance companies, having spent enough time jumping through hoops to get needed care paid for or sometimes denied. As has been noted, just because there are issues with the airlines does not mean we should rely on flying carpets. Or in the case of naturopathy, flying doormats pulled by rainbow unicorns.

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