Orac is the nom de blog of a (not so) humble pseudonymous surgeon/scientist with an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his miscellaneous verbal meanderings, but just barely small enough to admit to himself that few will. (Continued 
Recently, there's been a movement afoot among purveyors of that special brand of "natural" woo known as naturopathy to convince various legislatures and regulatory bodies that they not only are capable of serving as primary care physicians but that they should be allowed to do so. My first impression was laughter--that is, until I realized that the naturopaths are serious. For example, in New York, naturopaths, spearheaded by the New York Association of Naturopathic Physicians, are lobbying to be given the power to prescribe medications. Never mind that, despite their claims to the contrary, their training is only a fraction of that received by real primary care doctors, whose specialties include internal medicine, family practice, pediatrics, and in some cases OB/GYN. They do not do the three or four years of additional training after they finish school, as real primary care physicians do. Worse, what they do learn in school teaches them that homeopathy, traditional Chinese medicine, herbalism, chiropractic, therapeutic touch, and all manner of woo are effective. As far as I'm concerned, any medical "specialty" that accepts the One Quackery To Rule Them All, One Quackery to Find Them, One Quackery to Bring Them All and in the Darkness Bind Them (homeopathy) as a valid medical treatment, is not capable of applying science and evidence to the care of their patients.
I first started noticing the issue a couple of months ago when I was made aware by Kimball Atwood and I started paying more attention to this issue after blog bud PalMD issued his naturopath challenge. It's a devilishly simply ploy. PalMD, a real primary care physician, presented what should be to any primary care physician a relatively straightforward patient that any doctor might see in his or her practice and challenged naturopaths to tell him what they would do with this patient. Elsewhere, he issued a similar challenge, only with a different case. Thus far, the responses he's received from naturopaths have been--shall we say?--underwhelming. One naturopath ordered a whole bunch of unnecessary laboratory tests and recommended a low carb diet and a whole slew of supplements without an evidence base to support their use. Not impressive. In fact, it made me very afraid of what might happen if naturopaths are ever allowed to function as primary care physicians.
Unfortunately for Canadians, British Columbia is about to find out:
New regulations, announced by Health Services Minister George Abbott on Thursday, also significantly expand the role of other health professionals, including midwives and registered nurses.Expanding the role of midwives, registered nurses and naturopathic physicians allows B.C.'s health system to offer more options for patients, Abbott said in a news release.
British Columbians made it clear during the Conversation on Health that they want increased choice and better access to health services, and today we are meeting our 2008 throne speech commitment to expand the scope of practice for these professions.
Now, I really don't have a problem with expanding the role of registered nurses. For the most part, I don't have a problem with expanding the role of midwives, as long as they have adequate backup for when they get into trouble. However, expanding the role of naturopaths? Oh, woo is me! Of course, naturopaths are practically orgasming over this:
Dr. Christoph Kind, president of the B.C. Naturopathic Association, hailed the government move."Now we have the authority to be able to work with the pharmacy, with the pharmacists," he said. "It will also allow better co-management with other heath-care providers, including medical physicians, so I think all in all it's going to enhance the care that patients get in B.C."
No. It's not. What it is going to do is to give naturopaths virtually carte blanche to "integrate" quackery with scientific medicine, true to the "promise" of "integrative" medicine. It's not enough to treat your hypertension with boring old drugs whether you need them or not, no doubt created by nasty big pharmaceutical companies, the better to separate you from your cash. Oh, no. All manner of pure quackery can now be yours as a patient! Back in the days when naturopaths only prescribed supplements and herbal remedies, the harm they could do was somewhat limited. Now that they can order diagnostic tests and prescribe all non-controlled drugs (essentially anything other than narcotics, certain sedatives, and chemotherapeutic agents), there's no stopping them, at least in British Columbia.
What puzzles me, though, is the question of why. Why on earth would naturopaths want the power to prescribe real drugs, manufactured by big pharma and its minions? It doesn't make sense. It goes against everything they are taught in school; it goes against every bit of philosophy inculcated into them during their "training"; indeed, it goes against naturopathy itself! So why are naturopaths so hot on conning legislators into believing they are qualified as "primary care physicians" and thus should be allowed to function as such? Why aren't they happy with their current scope of practice?
One obvious answer is legitimacy. They crave legitimacy, and they know they don't have it. They also recognize that science- and evidence-based medicine does have legitimacy. Moreover, they also know that, if they are licensed by the state, they immediately gain the patina of respectability. After all, the state wouldn't license them if they weren't a legitimate specialty, would it? That's what appears to be happening in Minnesota, which recently jumped on the bandwagon of licensing naturopaths. Most importantly, legitimacy allows them to be paid by insurance companies. After all, if naturopaths are licensed, it is harder for insurance companies to resist calls to pay for naturopathic treatments. Worse, it's a snowball effect. The more states and provinces that license naturopathy, the harder it is for other states to resist the ever-widening snowball rolling downhill.
One thing that I find rather amusing about this whole issue is how naturopaths have utterly betrayed their beliefs and their profession. After all, to them big pharma is bad; "natural" medicines are always better. To them, pharmaceuticals are harmful because they aren't "natural" and vaccines are highly suspect because they don't entail getting the diseases against which the protect "naturally." How often do naturopaths rail against the "drugging" of patients by "allopathic" doctors with mood altering drugs or with blood pressure medicines, claiming that "natural" remedies, diet, or homeopathy works better? Or against how we treat diabetes, preferring instead to recommend various supplements?
In the end, as much as I realize we must battle against the legitimization of quackery. However I take some comfort in how desperate naturopaths seem to be to be given the power to do exactly what we "allopathic" physicians do and prescribe all those nasty, toxic , big pharma profit center drugs to patients. I find vindication in the fact that many herbal medicines and supplements favored by naturopaths are so frequently intentionally adulterated with "real" drugs. To me, it's the ultimate admission that naturopaths at some level must know that their nostrums are ineffective quackery. They need real medicine to give the illusion that they do anything for patients other than provide them with placebo medicine and an ear to listen. Certainly, there's nothing wrong with lending an ear to listen, but you don't need to prescribe placebo medicine in order to accomplish that.
Medicine & Health
Comments
Well, now it becomes legal to prescribe a tablespoon of parsley flakes, a dash of tarragon and a crushed viagra pill as natural remedy for ED; and it's effect is clearly the natural power of the herbs, never mind that bit of pink powder, that's just for presentation.
Posted by: Mu | April 14, 2009 10:33 AM
Maybe they just want their cut of the pharmaceutical lobby giving kickbacks to doctors for prescribing specific drugs.
Ironically enough, in today's Web 2.0 culture people can research their condition and the medication and see for themselves what is good. Doctors exists because they are the experts and the burden is placed on them to not make a mistake. The catch-22 is self-diagnosis and refusal to believe a conflicting opinion from a medical professional.
Unfortunately, if this comes to fruition, I can see every death, harmful side effect, and serious problems traced back to the drug companies rather then improper drug prescriptions.
Posted by: peter syms | April 14, 2009 10:35 AM
I wonder if the woomeisters have thought about it fully - you become a licensed practioner you fully open youself to a malpractice suit. And when they dont have a clue what they are dispensing, the effects of mix-n-matching various compounds, or even what problem the person has in the first place, it is inevitable that somone is going to have a bad reaction (or die) and go running for the lawyers.
Still in the very short term though, it will have the effect that Abbot is desiring. All the hypocondriacs, nutters, and doctor shoppers will flock to the Woo Doctor who will probably be free and happy handing out anything they want or have self diagnosed from Google-U. This will free up real GP's workloads by removing the 'time wasters' from their appointment lists. Abbot can then prance around and score political points about how wonderful his scheme is.
At least until the bodies begin to pile up...
Posted by: LC | April 14, 2009 10:55 AM
So, people want more choice, even if those extra choices are harmful and useless. Power to the people. Yay.
Personally I don't want choice...I want the best.
Actually wasn't there a set of studies done which showed that too much choice was actually counterproductive because the human brain doesn't like choosing between large amounts of similar things?
Posted by: Richard Eis | April 14, 2009 10:56 AM
Naturopaths can also use Web 2.0 to perform a differential diagnosis and provide treatment, which is what troubles me. It's clear that these woo-pushers don't have the education, training and experience to make complicated diagnoses, so they might order the wrong drug or combine it with some useless vitamin, giving credit to the vitamin for success of the treatment.
Unfortunately, for complicated diagnoses, like the one that PalMD described, the Web will fail you. The best answer he received from a naturopath read like they used Web 2.0 for their answer, because it appeared that she was attacking each symptom individually, rather than looking at the total presentation. And dietary changes will not have enough effect to do anything.
Have these regulatory bodies thought through the consequences? If a naturopath treats a patient with Type II diabetes with magical treatments that don't work, and the patient does not reduce their blood glucose, then the prognosis for the patient is poor. And the expense will be huge, because a real physician with real tools is going to have to treat them for everything from loss of eyesight to CVD.
And who's going to take the moral responsibility for mistreating patients?
I swear, I'm going to switch to sports blogs for my reading pleasure. Articles like this one make me cranky.
Posted by: Michael Simpson | April 14, 2009 11:01 AM
Now, I really don't have a problem with expanding the role of registered nurses. For the most part, I don't have a problem with expanding the role of midwives, as long as they have adequate backup for when they get into trouble.
How about PAs? Where do you put them and their rapidly expanding role in medicine? After all, they have 2-3 year programs and
Actually now that I think about it I'd like to hear all y'all MD bloggers on these topics of expanding responsibility, prescribing rights, etc of nonMDs in the other legitimate medical professions.
Posted by: DrugMonkey | April 14, 2009 11:22 AM
Naturopaths in regular medical practice is a hot-button for me. 29 years ago, a naturopath "doctor" misdiagnosed my father for almost a year and led directly to his death. We couldn't sue, because he was an Air Force "doctor". These people make me sick.
Posted by: invisible dragon | April 14, 2009 11:27 AM
"What puzzles me, though, is the question of why. Why on earth would naturopaths want the power to prescribe real drugs, manufactured by big pharma and its minions?"
Money. If a "Dr" can prescribe Rx medicines and order lab tests, then it is almost impossible for an insurance company to deny payment of the "Dr" 's fees.
Posted by: wfjag | April 14, 2009 12:23 PM
This is troubling, and I didn't realize it was happening in Minnesota. I guess I'm going to have to start actually reading those certificates on the wall when I go to the doctor.
By the way, will naturopaths have to take a hippocratic oath?
Posted by: Shae | April 14, 2009 12:45 PM
"It will also allow better co-management with other heath-care providers, including medical physicians, so I think all in all it's going to enhance the care that patients get in B.C."
I don't think so; it will only force medical physicians to waste a lot of time "conferring" with naturopaths. Valuable time, that they could have spent on their patients.
Posted by: JennyJo | April 14, 2009 12:55 PM
What's giving the woomeisters an opening to exploit in America is the sad fact that our health care system is the costliest in the world, and most woo treatments, particularly the herbal ones, start out being much cheaper than the conventional treatments for the same maladies. When people are faced with having to file for bankruptcy as a result of a battle with cancer, it's easy to see why they might be tempted to try Laetrile or Vitamin C or whatever comparatively-cheap woo mirage is waved in front of them.
Posted by: Phoenix Woman | April 14, 2009 1:00 PM
sooooooooooooo....
Do the wanna-be doctors know that by having insurance companies recognize them means prior authorizations before many things are payed for and abysmal reimbursements? The naturopaths will have to inflate their costs to the patient in order to get any funds.
Not to mention the malpractice protection, that ups the cost.
And the lawsuits. Even a sniff of lawsuit means money out before money in.
Has homeopathy always been this "special snowflake-y" or is this just recently with the rise of the healthy middle to upper middle class who have absolutely nothing else to worry about?
Posted by: e.d. | April 14, 2009 1:49 PM
Shae, what makes you think that any doctor has to take the Hippocratic oath? Are you under the impression that that is required on entry or upon graduation from medical school? Or by the various licensing or certification boards?
Besides, most physicians these days would object to swearing by "Apollo, Asclepius, Hygieia, and Panacea." And how could a surgeon forswear surgery?
Posted by: Russell | April 14, 2009 2:16 PM
Good grief, they can prescribe antibiotics, too? That's worse than what I first heard, which was that they were pretty much limited to vitamins, herbs, and similar stuff, ie: mostly ineffective, but also mostly harmless. The scarey question is: will they eschew antibiotics as Evil Drugs, or prescribe them incompetently and totally screw up the drug-resistance problem?
Posted by: Eamon Knight | April 14, 2009 3:51 PM
As I understand US medical history, a hundred years ago osteopaths were more like chiropractors, but since they embraced the rise of science-based medicine they are now mostly no different from MD physicians. Could we maybe do the same with naturopaths? Of course they would want to regulate and accredit themselves without "allopath" input, but insurance and malpractice could hopefully force them to meet the same standards as physicians. Tell them we love their bedside manner, but now that they are licensed PCPs they just can't sell placebos anymore. If they are willing to compromise their ideological aversion to pharma for the sake of legitimacy, then maybe they will abandon homeopathy to avoid lawsuits.
It sounds like a dangerous idea, but I'm wondering what the endgame is otherwise. Resist their licensure forever as they pump out more grads from more schools? It's a good fight, but I imagine it will only get harder given the looming shortage of PCPs I hear about. Could naturopaths possibly be assimilated into medicine, or is the risk to scientific integrity too great?
Posted by: TimK | April 14, 2009 5:09 PM
"By the way, will naturopaths have to take a hippocratic oath?"
If they are prescribing Teh Drugz they'll be taking the hypocratic oath.
Posted by: danai | April 14, 2009 5:39 PM
oops, that would be "hypocritic" oath.
Here in Quebec we are very short on MD's, especially family practice/PCPs. The plan to help fill the gap in the hospitals was the training of Nurse Practitioners, but the training programs are now poorly populated because the backward hospital admins aren't hiring the new grads, simply because they don't like the higher NP pricetag and frankly don't have a good understanding of what exactly they can do for the system. The admins adore the cheaper costing nurses' aides, but don't see the NP's as potentially cheaper first line MD's. Of course they aren't MD's but imagine how many things they could which would free up the MD's for the trickier stuff: order an xray, prescribe some antiinflammatories, do routine exams, diagnose an ear infection, this would greatly relieve the backups in the ER's here. Obviously if there's any complication or question, an MD doublechecks. Given the fact that so many Quebecers don't have a PCP, and eventually all wind up in the ER for minor issues, wouldn't it be ridiculous to not have NP's on hand to stem the tide?
There has also been some flak from MD's here about NP's "encroaching on" their turf. Mind you, this is the same province that only has First Responders in their ambulances- not paramedics/EMT's, because the MD's fought to keep "lifesaving procedures" under their aegis. No emergency trach's in the ambulance, no drugs beyond aspirin, no defibrillation, no IV's. Nope, they'd rather have you arrive dead than alive, than allow some trained personnel dare to do something "medical". If this isn't shooting yourself in the foot, I don't know what is.
Posted by: danai | April 14, 2009 5:59 PM
Disclaimer up front: I'm an MD student blogger, rather than an MD blogger
I think its a question of what the practioner in question considers their role.
I've spent most of my schooling on inpatient services/outpatient clinics directly associated with a fairly large research medical school. Within that contet, all of the Nurse Practioners I know have a specific, well defined role, with well defined duties.
They're exceedingly good at their role. The NP's who work a given field know the range of complaints they are going to see backwards and forwards. They also know when they're out of their depth, and need some help. When that happens, they call an MD. The same can generally be said for the PAs I've seen.
Additionally, the NPs and PAs I've seen have done significant portions of their training in a hospital! They are also educated primarily in evidence based medicine. The same cannot be said of the ND's, who do 4 years of coursework, and as far as I can tell don't have an obligation to do postgraduate clinic/hospital training
before hanging up a shingle and practicing.
I think what really scares the MDs about NDs and other Woo power players is their lack of appropriate training, rather than their 'threat' to MD's hegemony on medical care. One of the most important jobs I have as a medical student is to know when I need help. When I'm in the ER and I walk in a room and see that a patient can't protect his airway, or is otherwise in pretty significant danger my job is to go get a doctor. Quickly. The same cannot be said for NDs despite the fact that they have only slightly more training than I do right now.
PAs, NPs, (most) DOs, agree to the same basic model of care as MDs, and agree on basic basic things like the germ theory of disease, or that vitalism is wrong.
Incidentally, med schools in the US don't generally administer the hippocratic oath. Generally students colloborate and create an oath that embodies most of the values of the hippocratic oath, updated for this century.
Posted by: Whitecoat Tales | April 14, 2009 6:57 PM
So they are willing to sell out their firmly held beliefs and betray their philosophy of care for a few shekels?
Have they no shame!
Posted by: Tsu Dho Nimh | April 14, 2009 8:27 PM
Danai - "this is the same province that only has First Responders in their ambulances- not paramedics/EMT's, because the MD's fought to keep "lifesaving procedures" under their aegis. No emergency trach's in the ambulance, no drugs beyond aspirin, no defibrillation, no IV's."
WHAT!!! Can you point me to a law or other reliable cite for that?
Posted by: Tsu Dho Nimh | April 14, 2009 8:33 PM
Slightly off topic, but something implicit in the recent post about the best anti-homeopathy poster ever has only just truly sunk in to me. If water has a memory for whatever has been in it, then surely you don't need a homeopath to "create" a cure for what ails thee, because the water he uses will already have had contact with the active ingredient sometime in the past.
Posted by: grasshopper | April 14, 2009 8:47 PM
Tsu Dho Nimh:
I'll try to find some QC sites outlining this. One of my classmates rides with the Cote St. Luc ambulance, and truly- this is all they are allowed to do. It is shameful but true.
It is not that different than "old tyme" medicine, unfortunately, here in QC. They still don't get the latest heart transplant or assist technologies, the French still try to railroad clients into seeing "physiatrists" before seeing a PT, etc. The French system in particular seems to have a chip on its shoulder about entering North American med standards openly. There are many examples of this sort of close-minded "I am the Dr." ways of thinking.
Several professions are not expected to pass national Canadian exams- as long as you pass the French language test. You can be the worst student in your nursing/PT/OT class, but as long as you know the joual, that's ok...
We need help up here...
Posted by: danai | April 14, 2009 11:18 PM
I won't pretend to understand legal matters, will this open them to the possibility of a malpractice suit? Because, if so, this sounds like great news in terms of accountability.
Posted by: Tess | April 15, 2009 2:51 AM
You know that in the former USSR, doctors received alternative medicine training as part of their medical training. It was completely integrated. So there was never that duality of "modern" medical practitioners and traditional ones, they were one and the same.
It was not uncommon, for your doctor (GP) to prescribe accupuncture or any number of herbal remedies depending on your condition.
The point is, traditional medical practitioners should be trained as real doctors and/or the other way around. Up until that happens I would rather self-medicate then let the prescribe medicine for me.
Posted by: Alan | April 15, 2009 4:51 AM
Alan,
That is my point as well. The N's can take 4 years of science in undergrad. Then, a couple of years in graduate school. Then, a couple of years interning learning the basics of providing care in a hospital. Then, a possible fellowship. AFTER the N's take all of that education and pass the board to become a licenses Doctor (MD) they can practice whatever woo they like - as long as they subscribe to the standard of care for a licensed Doctor when prescribing drugs. Accountability, ho....
Posted by: DPSisler | April 15, 2009 4:51 PM
I live in British Columbia and have had both an MD and a ND for years. My Medical Doctor sometimes suggests herbs and my Naturopath sometimes suggests I see my MD for a needed prescription.
I research my own health issues and discuss it with both my doctors. I work with them in tandem and it's a great combination.
Several times Naturopathy has improved my health a great deal when a medical doctor could not... sometimes a medical doctor has been the only one who could help.
I suggest less polarization for or against naturopathy and other alternative practices, and a clear look at the best way to provide true integration.
Posted by: Dean | April 17, 2009 12:07 PM
Hm, I've been working in the pharmaceutical industry for the past four years... and end up researching about different drugs constantly, can I get privileges to write scripts? Surely I must know more than NDs do about meds, the medical/legal departments at the pharma companies are always ok with patient/doctor education written material I create!
Gah! In a couple of years, everyone will be saying "Yeah, but the major pharma drugs ARE natural, it's just natural chemicals produced in a controlled setting!!! And all the naysayers who used to huff at me when I said the exact same phrase will be gaga over their bottle of major pharma pills.
Posted by: outre | April 19, 2009 2:57 AM
I think ND's should not prescribe drugs. It goes against our philosphy. I do refer clients to their primary MD and collaborate with their MD in their care. The two disciplines can and do work well together. BTW
Posted by: naturodoc | November 3, 2009 11:53 PM