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On January 1, 2018, the California Naturopathic Doctors Act will be automatically repealed unless the California Legislature deletes or extends that date during the 2017 legislative session, which convenes on December 5, 2016. In addition, according to California law, the Naturopathic Medicine Committee of the Osteopathic Medical Board of California, which regulates naturopathic doctors (NDs), is subject to review by “appropriate policy committees of the Legislature” in the upcoming session.

The California Legislature should not extend the date of the Naturopathic Practice Act. Currently licensed naturopathic doctors could be allowed to continue their practices under a substantially revised practice act but no new licenses should be issued. Frankly, I do not think naturopaths, whether they claim they are “doctors” or not, should be allowed to practice at all. However, the political realities of getting a bill passed completely doing away with the practice of naturopathy may require some accommodation to currently licensed NDs.

The Naturopathic Doctor Act (Senate Bill 907) was passed in 2003. At the time, naturopaths with degrees from naturopathic “medical schools” could practice under California’s “health freedom” law, enacted in 2002, and still in effect. This law exempted “alternative” health care practitioners from prosecution for the unlicensed practice of medicine as long as they didn’t engage in certain acts, such as prescribing drugs or performing surgery. They could diagnose and treat any ailment as long as it was not

under circumstances or conditions that cause or create a risk of great bodily harm, serious physical or mental illness, or death.

Regular bodily harm, not-all-that-serious physical or mental illness, or near-death are apparently permitted.

Naturopathic doctors and other practitioners could tell patients about their education and training, but had to disclose that “natural and alternative medicines” are not licensed in California and that the practitioner is not a licensed physician. NDs, however, craved the legitimacy bestowed by having their own practice act and a greatly increased scope of practice.

The Naturopathic Doctors Act was supported by several groups, who told legislators how, in their view, the Act would benefit California patients.

The California Association of Naturopathic Physicians (now the California Naturopathic Doctors Association, because NDs are not allowed to call themselves “physicians.”):

improve consumer access to safe and effective complimentary [sic] and alternative medicine therapies in addition to allopathic ones, and because it will provide for licensure consistent with the naturopathic physician’s education and training, and their scope of practice in other jurisdictions.

American Specialty Health Plans, an insurer offering coverage of CAM treatments:

ensure public safety and accountability to appropriately trained and examined applicants for licensure, and that consumers deserve comparable regulatory standards and oversight mechanisms for all health care providers including naturopathic physicians.

California Citizens for Health Freedom:

help enhance the health/medical services in California, reduce the rising cost of health care, assist in meeting the crisis of a decline in primary care physicians, increase the professional resources of experts to the growing nutritional industry in California . . .

The Council on Naturopathic Medical Education:

licensing will help ensure that patients know the doctor they are seeing has been thoroughly trained at a four-year naturopathic medical school which is all important to making correct diagnoses and prescribing effective treatments.

National College of Naturopathic Medicine:

will ensure accountability that physician-level doctors be licensed and regulated . . . [T]he public deserves comparable (to allopathic medicine) regulatory standards for naturopathic physicians who are primary care providers . . . [T]he bill will improve public safety since, at present California has no standards to inform consumers whether their naturopathic physician has completed a four-year, graduate-level naturopathic medical school, passed standard board exams, and meets federally recognized standards of education and professional accountability.

That last sentence is not true, as NDs could tell patients those very things under the “health freedom” law.

The bill was opposed by the California Chiropractic Association, the California Medical Association, the California Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and traditional naturopaths, who do not have degrees from naturopathic “medical schools.” Opponents questioned the reliance on naturopathic education and training to support the scope of practice authorized by the Act, including the naturopathic claim that they could act as primary care providers.

As best I can tell, the legislature relied completely on the NDs’ and supporters’ claims that their education and training was sufficient to support the scope of practice they wanted, including their claims of proficiency in primary care, and no independent investigation of their education and training was ever done. Nor can I find that the legislature did any independent investigation of actual naturopathic practices, including whether they were supported by sufficient evidence of safety and efficacy, or whether the NDs were giving patients accurate information about those practices – in other words, ensuring informed consent.

ND “boutiques”

California’s Naturopathic Practice Act defines “naturopathic medicine” as

a distinct and comprehensive system of primary health care practiced by a naturopathic doctor for the diagnosis, treatment, and prevention of human health conditions, injuries, and disease.

In other words, an ND can diagnose and treat any patient of any age with any disease or condition.

NDs can order and perform physical and lab exams and order (but not perform or interpret) diagnostic imaging. They can prescribe, administer and sell dietary supplements, homeopathic remedies, “nutraceuticals,” and natural and synthetic hormones. They can use oral, nasal, auricular, ocular, rectal, vaginal, transdermal, intradermal, subcutaneous and intramuscular routes of administration. They can also administer substances IV and practice “natural childbirth attendance” with additional education and training. Under physician supervision, they can prescribe certain drugs.

Originally, NDs were regulated by the Bureau of Naturopathic Medicine, which operated within the Department of Consumer Affairs. However, jurisdiction was later transferred to the Naturopathic Medicine Committee of the Osteopathic Medical Board. During the 2015-2016 legislative session, NDs fought to remove physician supervision over their prescribing and otherwise expand their practice act, a subject I covered extensively over on SfSBM. Fortunately, those efforts failed.

In the 13 years since California passed the Naturopathic Medicine Act, we’ve learned a great deal more about naturopathic doctors, their practices, and their education and training. That knowledge should be judiciously applied by the California Legislature when considering the future of the Act.

While I was not able to perform a comprehensive search of all naturopathic websites, my review of about a dozen sites representing the practices of some 25 NDs revealed a common theme: while they may say they practice “primary care,” what they’ve actually done is establish boutique practices offering numerous unproven, or disproven, treatments and unorthodox lab tests for both recognized conditions and diseases and those they have fabricated. Here’s a list of what I found offered by California NDs, as well those located by Britt Hermes in a post written earlier this year:

In addition, Britt Hermes found these practices advertised by California NDs. See her post on Naturopathic Diaries for more information:

ultraviolet blood irradiation

ABM Bioenergy Patches

prozolone therapy

IV vitamin infusions

homeopathy

biotherapeutic drainage

clinical “detoxification”

These observations are consistent with other surveys of naturopathic websites finding numerous unsupported claims.

In over a decade since California licensed NDs, there is still virtually no research supporting the safety and effectiveness of naturopathic care. On the other hand, we do know that naturopaths and their institutions subscribe to anti-vaccination ideology, a fact that has been confirmed in several studies. We also know that naturopathy is associated with substandard care in other areas, such as STD screening. Analysis of naturopathic diagnostic methods and treatment of other conditions has shown them wanting in safety and efficacy: diabetes, MTHFR testing (also here), autism, cancer, infertility, allergies, thyroid conditions, and prenatal vitamins. And we know that there is increasing evidence that dietary supplements, the stock-in-trade of naturopaths, are not useful in preventing or treating disease.

Education, training, and licensing

Thanks to the revelations of Britt Hermes, the California legislature now has far more information about naturopathic education and training than it did in 2003. A thorough review of all she’s written on the subject is beyond the scope of this post, but listed below are must-reads for anyone who wants to understand the naturopathic educational system. At the very least, the California legislature no longer has any excuse for accepting at face value naturopathic representations about the quality of their education or its ability to produce health care practitioners competent to diagnose and treat all comers, especially children. In fact, I have Britt to thank for originally proposing the idea of using the upcoming repeal to advocate for changes to the licensing law. I hope she’ll write on the subject herself, with her insider’s vast knowledge of naturopathic education and practice.

One of the rationales for passing the licensing act put forth by the California Naturopathic Doctors Association was that it would be “consistent with . . . their scope of practice in other jurisdictions.” To be “consistent” with the scope of practice in other jurisdictions in 2016 means it is unlikely there would be a scope of practice and, if there were, it would be more limited than in California. Since California licensed naturopaths, only three small states have followed suit: North Dakota, Colorado, and Maryland. In each instance, the scope of practice is more restrictive than in California.

In North Dakota, licensed NDs do not have prescription privileges, cannot practice naturopathic childbirth attendance, or perform minor office procedures. A bill granting those additional privileges was defeated last year.

Colorado passed a registration, not licensing, act for naturopaths. Colorado naturopaths must advise patients they are not medical doctors and naturopathy is not described in the law as “primary care.” They are forbidden from telling patients to discontinue their medications. NDs are severely restricted in their treatment of pediatric patients, with provisions ensuring that children are also seeing a pediatrician and getting recommended vaccinations. NDs must advise patients to see a medical doctor and attempt to coordinate care with that doctor. They are prohibited from practicing obstetrics.

In Maryland, NDs cannot administer treatments IV, use colonic irrigation, or perform minor office procedures. They must have a collaboration and consultation agreement with an MD or DO physician, must attest that they will refer patients to and consult with physicians and other health care providers, and are regulated by the state medical board. They cannot claim they are primary care doctors. Patients must sign a consent form stating they understand that the ND’s scope of practice is limited. The law specifically states they cannot deviate from “safe care of patients” and they can be disciplined even without evidence of patient harm.

During the same period, the vast majority of state naturopathic licensing bills were voted down, in some cases multiple times: in Florida, Massachusetts, Pennsylvania, New York, North Carolina, Rhode Island, New Jersey, Mississippi, Michigan, Nevada, Iowa, Indiana and Illinois. In 2015, Idaho actually delicensed naturopathic doctors, as did Florida in the 1950s. In the last few years, most practice expansion bills failed as well.

In sum, we now know that naturopathic medical education and training isn’t as naturopathic doctors represented it to the legislature in 2003. We know that California NDs are setting up “boutique” practices claiming to specialize in only a few diseases and conditions and offering a range of unproven remedies and diagnostic methods. We know that consumers aren’t being protected; quite the contrary, we know they are being defrauded by licensed naturopathic doctors. We know that most of what naturopaths do is lacking in evidence of safety and effectiveness. We know that NDs are anti-vaccination because it is well-documented. We know that most states have rejected naturopathic licensing and practice expansion since 2003, and that the three states passing some sort of regulatory act granted practice privileges more restrictive than California.

Given these facts, what to do?

Since naturopathic doctors cannot point to any meaningful contribution to the health and welfare of Californians, there is no good reason to continue licensing them. As of 2013 (I could not find a more current number) there were only 437 active NDs licensed in California. By way of comparison, according to figures compiled by the Kaiser Family Foundation, there are almost 50,000 licensed primary care physicians in the state, over 52,000 specialist physicians and 8,000 physician assistants. There are almost 13,000 Nurse Practitioners, almost 300,000 RNs and over 80,000 LPNs. (All of these are professionally active.) It is time to get rid of these fringe practitioners while the numbers are still small and few NDs are affected. State expenditure of money and effort can then be focused on increasing the number of health care practitioners with proven contributions to the welfare of Californians, like physicians, nurses, and physician assistants. If patients insist on “alternative” care providers, California has the “health freedom” law I just mentioned, plus about 14,000 chiropractors and (as of 2004, the latest figure I could find) 9,000 acupuncturists.

So, what to do with the 450 or so licensed NDs, once licensing is discontinued? (Again, I don’t think they should be allowed to practice at all.) A much-narrowed practice act could be passed with the following provisions:

Require a collaboration or consultation agreement with an MD or DO on all patients;

Require disclosure to patients of the limitations of their practice and urge patients to have a primary care physician;

Require informed consent;

Don’t allow the use of unproven remedies (like homeopathy and dietary supplements) to treat disease;

Prohibit the use of unvalidated diagnostic tests like salivary hormone testing;

Don’t allow them to treat children;

Prohibit them from diagnosing and treating fake diseases like adrenal fatigue and chronic yeast overgrowth;

Require the referral to a physician specialist for diseases and conditions like thyroid and endocrine disorders, cancer, diabetes, cardiovascular disease, or any other disease or condition that a family practice physician would refer to a specialist.

Prohibit them from giving advice on vaccination;

Don’t allow them to sell dietary supplements and other remedies they prescribe to patients, it’s an inherent conflict of interest; and

Require the Naturopathic Medicine Committee to give accurate information to the public about naturopathic practice and its limitations. For example, right now the NMC tells consumers that NDs are “trained as primary care practitioners,” that “naturopathic medicine can benefit all Californians,” and that some NDs “may focus on particular areas of health such as detoxification.” It also provides links to the California Naturopathic Doctors Association (which recently offered a continuing education course on “ozone therapy”) and the American Association of Naturopathic Doctors, which is filled with naturopathic boosterism and pseudoscientific health advice.

If you are a Californian, please contact your legislators and tell them it’s time to get rid of naturopathic licensing.