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The metastasis of alternative medicine throughout the health care system comes, in no small part, at the hands of the federal and state governments, mostly the latter and most particularly the state legislatures. Under their jurisdiction rests the decision of who can, and cannot, become a licensed health care practitioner, and what they can, and cannot, do. This is the gateway through which much of pseudo-medicine flows.

I’ve read many CAM practitioner licensing statutes (all of the chiropractic practice acts, in fact) and many legislative proposals to license or to expand the scope of practice. Typical of the boilerplate recited in support of this legislation is the education and training of these practitioners, which is touted as a means of protecting the public from charlatans and quacks out there selling snake oil to the credulous. Naturopathic licensing bills routinely require graduation from a naturopathic “medical” school accredited by the Council on Naturopathic Medical Education. (See, for example, Michigan House Bill 4152, which both David Gorski and I have discussed on SBM .) Unfortunately, what CAM provider legislation often does is simply provide legal cover for selling that very same snake oil.

Naturopaths are licensed in 17 states so far, although what they can and can’t do varies considerably. In some states, they have a scope of practice similar to that of an M.D. or D.O. primary care physician. At the most liberal end of this spectrum, N.D.s can prescribe drugs (as Michigan’s bill would allow), although this, too, varies depending on what’s listed on the state’s naturopathic formulary.

All of this has led me to conclude that the state legislatures do not have internet connections. Because, if they did, it would be pretty easy to Google around and figure out just what this naturopathic “medical” education entails and how practicing naturopaths apply their education and training in actual practice. In fact, I’ve done this myself and reported the results here on SBM . In the last day or so, I found out even more by looking around the websites of the Council on Naturopathic Medical Education, the American Association of Accredited Naturopathic Medical Schools, and its member institutions. We’ll get to the fruits of that research in a minute.

A remedy for naturopathy?

As both Mark Crislip and I have opined, naturopathic education and training is insufficient for primary care scope of practice, and, a fortiori, for prescribing real drugs. I never thought I’d see the day when a state legislator realized that, in order to be a primary care physician one ought to have the education and training of a primary care physician. Because, after all, patients (or, at least, naïve patients) aren’t going to divide themselves neatly into two lines based on the seriousness of their condition, one going into the M.D. PCP’s office and one going into the N.D. PCP’s office. The overweight, hypertensive, hepatitis C positive, uncontrolled diabetic with the flu can walk into either office. The M.D. PCP will have seen many such patients before in training. The N.D.? Probably none.

Hawaii Senate Bill 2577 doesn’t solve all of these problems. But it does address an important one. Hawaii is one of the few states granting N.D.s a broad scope of practice, including prescription privileges in accordance with a naturopathic formulary. Sen. Josh Green, chair of the Senate Health Committee, and himself an M.D. who completed a Family Practice Residency and now practices as an Emergency Room Physician, introduced SB 2577. The bill states, quite simply, that:

To qualify for prescription privileges, a naturopathic physician shall fulfill the same education, examination, and training requirements as physicians or osteopathic physicians . . . prior to the prescription, administration, or dispensing of any prescription medication.

As well, the naturopathic board will not be in control of who makes the cut. The Hawaii Department of Community and Consumer Affairs will make that decision.

Naturally, if you will, this bill has caused all sorts of consternation in the Hawaiian naturopathic community. The Senate Health Committee allows written testimony regarding a bill. (You can access the written testimony here.) Most of the testimony against SB 2577 was simply a regurgitation of what the Hawaii Society of Naturopathic Physicians (which, oddly, took down its suggested testimony from the website) wanted people to say, repeated in N.D. handouts to patients, and went something like this:

It would be both unreasonable and redundant to require that naturopathic physicians have licensure as MDs or osteopaths to qualify for prescription privileges. [Actually, that is not what the bill says.] The training of naturopathic physicians is already so extensive as to more than qualify them in this regard. Naturopathic medicine is a unique form of health care with its own rigorous educational, examination, and training requirements, comparable in many ways to the requirements of other types of physicians such as MDs and osteopaths. Naturopathic physicians receive ample training at nationally accredited naturopathic medical schools, including the same basic sciences taught in conventional medical schools, such as standard methods of physical, clinical, and laboratory diagnosis. They are trained in therapies given by injection, and highly qualified to safely prescribe medications. . . By unreasonably restricting naturopathic physicians from practicing according to their training, SB2577 would have many negative consequences on the overall quality of health care in Hawaii. . .

And so forth. Note the many conclusory statements about the quality of naturopathic education and training and the unsupported allegation of negative consequences to health care, consequences that seem not to have materialized in states that don’t allow N.D.s to practice or which don’t allow N.D.s to prescribe drugs. In other words, the vast majority of states.

The anti-bill testimony from naturopathic patients is much more revealing about naturopathic practice than the cut-and-pasted rhetoric. Indeed, one wonders which side might have submitted this testimony, given the alarming anecdotes of naturopathic care. From the patients, we hear of homeopathy prescribed for sick twin infants, a thyroid problem (“adrenal insufficiency”?) undiscovered by an M.D. but found by an N.D. and being treated with compounded drugs (glandulars?), a homeopathic remedy prescribed for a “trigger thumb,” and testimony such as this, from the parent of an autistic child,

It was only the naturopath physician, who advised us to obtain the lab work to discover how truly toxic his blood work was. Following their chelation protocol to remove the mercury, lead, aluminum, etc has lifted the “cloud of heavy metals” that separated Dale from the rest of the world.

And this:

I am a parent of a child with autism, epilepsy and other serious digestive disorders. While I have turned to MDs in the past for his general health and neurological health, no improvements were observed. About a year and half ago, I turned to an ND, referred to her by other parents of autistic children, who introduced me to biomedical treatments for Autism and Epilepsy. Our son just turned 12 years old this past weekend. Thanks to the biomedical treatments and his ND’s guidance and her ability to prescribe pharmaceutical medicine,including folinic acid, amino acid carnitine, and others, our son has been making great strides, improvements which we had not seen in years.

Yes, extensive, rigorous, ample, highly qualified, and all that.

This is not to say there weren’t supporters of the bill. In fact, a large group of other medical care providers, besides physicians, offered support, in the form of favorable testimony from the Healthcare Association of Hawaii, which describes itself as “a 116 member organization that includes all of the acute care hospitals in Hawaii, the majority of long term care facilities, all the Medicare-certified home health agencies, all hospice programs, as well as other healthcare organizations including durable medical equipment, air and ground ambulance, blood bank and respiratory therapy.”

“Rigorous” education and training requirements?

Let’s take a closer look.

The Association of Accredited Naturopathic Medical Colleges perpetuates the party line that naturopathic doctors receive education and training comparable to that of medical doctors. (I could not find a comparison between medical and naturopathic education on the website of the Association of American Medical Colleges, but it is something I’m sure we’d all like to see.) A handy chart purports to support this view by claiming that, during the first two years, N.D.s earn equivalent credits in the biomedical sciences as M.D.s. Indeed, according to the chart, N.D.s earn even more credits in anatomy, embryology, biochemistry, physiology, pathology, and clinical and “modality” training, twice as many in this latter category. (These “modalities” include homeopathy.) Medical students, on the other hand, have about three times more credits in a category called “other.”

Of course, it hardly bears mentioning that a course name and assigned credit hours say little about the content, quality or rigor of the course. Nevertheless, the Association soldiers on with its comparison, to the point of creatively turning the lack of N.D. residencies into a plus:

[A]lthough MD students see plenty of patients during these clerkships [in the third and fourth year], their roles are primarily observational: they are not primarily responsible for patient care [like naturopathic students]. As a result, naturopathic medical students graduate prepared to begin practice and to diagnose and treat patients, whereas MD students are required to complete residencies after graduation in order to gain clinical experience.

What a bunch of dummies! Medical school graduates need three more years of training to become primary care practitioners, while naturopathic school graduates can waltz out into the world ready to practice from the get-go because they’ve been given primary responsibility for patients even though they haven’t even graduated yet.

Does this education and clinical training — training so wonderful it can substitute for a full three years of a medical residency — qualify N.D.s to prescribe medications?

Well, the chart shows N.D.s have 5 credits in pharmacology versus 8 for M.D.s, that is, a little over 60% of what M.D.s have. The N.D. schools websites, unlike many medical school websites, do not contain much in the way of course descriptions. For example, here is a description of the two pharmacology courses at the National College of Natural Medicine:

presents the principles of pharmacodynamics, including drug absorption, metabolism, distribution, excretion and mechanism of action. Students are expected to classify and describe the pharmacodynamics, side effects and therapeutics of drug prototypes from the contemporary drug classes. Special emphasis is given to drugs contained in Oregon [which includes most drugs used in primary care] and other naturopathic formularies.

That’s it. The website does not say who teaches these courses, although I do not see a single Pharm.D. on the faculty. I also looked at the faculty of Bayster, another naturopathic school. Its faculty has one Pharm.D.

A fair comparison of this curriculum would be that of Florida State University’s College of Medicine, since its mission is to graduate more medical doctors who go into primary care. You can find a syllabus of the first pharmacology course here and the second course here. The listed instructors for these courses are three Ph.D.s, two M.D.s and three Pharm.D.s. I invite your comparison.

Let’s move on to clinical training. The Council on Naturopathic Medical Education (CNME, the accrediting agency for N.D. schools) establishes the number of clinical hours a student must have to graduate. In order to compare this to medical residency training, the approximate equivalent in weeks of residency, at 80 hours per week, is listed in parentheses each requirement. Much of the clinical education of N.D.s takes place in clinics associated with the naturopathic schools. Only training in these clinics counts toward required patient contact hours. The balance of clinical training occurs in preceptor-type relationships with practitioners in the field, in botanical medicines labs, giving talks to the public on the value of naturopathy, and other activities.

CNME requires a total of 1200 clock hours (15 weeks) of clinical training. Of these, only 850 hours (less than 11 weeks) must involve primary or secondary responsibility for patient care. The student must have at least 450 “separately scheduled patient interactions” during this training (including those in preceptorship). In 225 of these patient interactions, the student must be working in “primary capacity in assessment and/or treatment” under faculty supervision. No further definition of “patient interaction” is given, but, by way of comparison, a family practice M.D. will typically see 20-25 patients per day. Making the (likely safe) assumption that each of these constitutes the M.D. acting in a “primary capacity in assessment and/or treatment,” and using an average of 22.5 patients per day, the entirely of N.D. clinical education involving primary responsibility for assessing and treating patients is the equivalent of as little as 10 days of real-world family practice. Even being extremely generous, and counting all 450 “patient interactions,” that’s 20 days in a family practitioner’s office.

But, of course, according to the AANMC, “naturopathic medical students graduate prepared to begin practice and to diagnose and treat patients.”

I looked at these naturopathic school clinics on the websites of AANMC members, which consists of all accredited naturopathic schools in the U.S. and Canada. And here I discovered that there is virtually no mention of treatment with prescription drugs. (Some clinic websites don’t mention prescription drugs at all.) Typically, the clinics offer “natural” therapies, dietary supplements, lifestyle and nutritional modification, acupuncture, hydrotherapy (including colonic irrigation), herbs, homeopathy, physical medicine, “mind/body” treatments, and minor surgery. As an example, from the website of the Canadian College of Naturopathic Medicine (CCNM):

Homeopathic remedies are particularly effective for depression, anxiety, allergies, infections, gynecological concerns, skin conditions, digestive problems , chronic and acute conditions including colds and flu.

In reviewing all of the clinic websites, mention of prescription drugs was limited to (1) the fact that N.D.s at some clinics have prescription privileges (Boucher); (2) IV vitamin “cocktails” (CCNM oncology clinic); (3) mistletoe injections (ditto); (4) hormone prescriptions (National College of Natural Medicine); (5) antibiotics for parasites or infections as part of “detoxification” therapy (Southwest College of Naturopathic Medicine); and (6) injection therapy for pain (neural, trigger point and prolotherapy, also SCNM).

One can’t help but noticing the narrow range of diseases and conditions seen. Typically mentioned are mild, self-limiting conditions, such as colds and back pain, a handful of chronic diseases, and conditions for which there may be few effective options (and are therefore ripe for exploitation), such as autism, chronic fatigue and fibromyalgia. This is in addition to those conditions simply fabricated by naturopaths, like chronic yeast overgrowth, adrenal fatigue, food “sensitivities,” and “toxins.”

As Mark Crislip (or maybe it was Kimball Atwood) said, “Your results may differ.” Feel free to search on your own. If you wish, you can compare N.D. clinical training to an M.D. primary care (in this case, family practice) residency program. (Click on “Family Medicine Curriculum”)

The fate of Hawaii Senate Bill 2577

After a hearing before the Senate Health Committee on January 27. Voting on the bill was deferred until February 3, then February 5. As this post “goes to press,” the bill passed the Health Committee unanimously, but with amendments (one vote was “with reservations,” and two members were not present). I do not have the text of the amendments yet, but will update the post when it is available.

Whatever happens, we all owe a debt of gratitude to Sen. Josh Green, who had the fortitude to swim against the formidable CAM tide. I don’t know how many people will read this post and agree with it, but if you’re among them, I hope you write Sen. Green an e-mail of gratitude. Flood his inbox with praise! CC: the Senate Health Committee.

Thank you, Senator Green, thank you. And keep up the good work.

Update:

The Health Care Committee voted in favor of Senate Bill 2577, as amended by the committee. Unfortunately, the amendments substantially changed the original bill’s requirements. As the bill stands now, a naturopath with prescribing privileges must have a “collegial relationship” with a licensed medical doctor or doctor of osteopathy, who will review the naturopath’s prescriptions quarterly and report any concerns to the naturopath and to the naturopathic board. In addition, naturopaths have to maintain a list of all prescriptions and report to the Board monthly what was prescribed. The Board will report this information to the Legislature annually.

The bill also limits the type of drugs that may be prescribed to 7 categories, thus curbing the naturopathic board’s authority to expand the formulary in the future. Unfortunately, the list includes non-prescription and prescription vitamins, minerals, nutritional supplements, dietary supplements, botanical medicines, homeopathic “medicines,” and “all biological substances including extracts or their products and residues.” This means naturopaths will be able to administer these substances IV, as injection of dietary supplements, vitamins, and the like, transforms them from off-the-shelf products into drugs under federal law. The list also includes all hormones except those that are controlled substances. This leaves open the possibility of such nonsensical diagnostics as saliva testing for alleged hormone deficiencies and prescription of hormones to relieve these purported deficiencies.

We can all hope that physician oversight will curb some of the pseudo-science behind naturopathic prescribing practices. However, “collegial relationship” is defined as “a professional relationship intended to foster cooperation and collaboration in integrative care.” The physicians who would be willing to oversee naturopaths on these terms might well be the very ones willing to tolerate the incorporation of “alternative medicine” into medicine, thereby simply enabling the naturopaths to employ their evidence-free treatments. Finally, each naturopath who wants prescribing privileges will have to complete 15 hours of continuing medical education in pharmacology annually. Of course, the quality of these courses is key to their success in moving naturopaths toward evidence-based prescribing, if that is indeed possible. Fifteen hours in, for example, IV vitamin cocktails will not serve the bests interests of patients.

The bill has now moved to the Senate Committee on Commerce and Consumer Protection. If the bill passes, it could either serve as a much-needed curb on some of the outlandish prescribing practices of naturopaths, or it could simply turn out to be window-dressing, giving the appearance of patient protection without making any real difference in how naturopaths practice.