We have written about naturopathic medicine many times here at Science-Based Medicine, often pointing out the pseudomedical approach to patient care that is so common in the profession. I believe that we have presented ample evidence in support of our conclusion that there is no intervention so implausible, so lacking in quality evidence, or so utterly ridiculous in nature that it is not wholeheartedly accepted by large swaths of the naturopathic community. Whether for prevention, diagnosis, or treatment, naturopaths commonly incorporate homeopathy, acupuncture, energy medicine, detoxification, herbs, supplements, and pretty much any nonsense you can imagine into their practice.
It takes literal seconds to find examples of naturopaths promoting such nonsense. Here is one quick example from the EcoWellness Center:
The energy healer in our clinic has the ability to pick up these influences as energy blocks she can see, translate and connect to a person’s current life, integrating knowledge from several traditions. Often it is these blocks which lead to illness and resist healing. Jennifer has seen cases of disease dissipate when the related blocks shift. She receives help from healing Angels to remove negative entities from individuals, commonly followed by a feeling of increased lightness and relief of symptoms.
At the same time, the naturopathic community has managed to achieve a measure of undeserved recognition as an alternative to the conventional medical system in the United States, particularly on the West Coast. Students at naturopathic training programs even refer to themselves as medical students and they are considered by many to have undergone medical training similar to that of physicians. They have not, but the confusion is understandable considering the propaganda:
In my first year alone I had completely hand dissected a human cadaver, including all muscles, nerves, blood vessels, and organs. I know how to properly palpate, assess and adjust the cervical, thoracic, lumbar spine, and the extremities. I can complete a competent head to toe physical exam including cardiac, pulmonary, fundoscopic, ENT, and neurological complete assessments. The hundreds of hours I have spent with naturopathic doctors, chiropractic doctors, osteopathic doctors, and medical doctors, mastering and understanding the human body through the study of biochemistry, physiology, pathology, and anatomy has only made me a more competent and better prepared doctor for my future patients.
The thought of students who will go on to promote homeopathy or convince a parent to not immunize their baby having access to a donated human cadaver makes me angry. It isn’t right. Nor is the fact that in several states naturopaths have the legal right to order medical labs and imaging or even to prescribe medications.
In addition to their promotion of all manner of implausible treatments, naturopaths often promote anti-vaccine misinformation, overemphasize potential and nonexistent side effects of vaccines while downplaying or ignoring the benefits, or encourage bespoke alternative vaccine schedules that put children at risk of serious disease. And because they are legally recognized as primary care providers in many states, with access to large numbers of pediatric patients, this is particularly problematic. And then there are all those labs. That’s the focus of my post today.
Labs, labs, everywhere…
In a recent issue of The American Journal of Clinical Pathology, there was a study that compared the pediatric lab ordering patterns of naturopathic doctors in the Seattle area to general practitioners. Although, as I’ll explain, the results of the study make it clear that naturopaths order a mess of unnecessary labs with little benefit for their pediatric patients, the introduction unfortunately reads like promotional marketing copy written by a lobbying or practice building firm:
Naturopathic medicine is a health care profession that treats human disease with natural substances. It aims to identify the root cause of diseases and emphasizes the prevention and promotion of health through the self-healing process and the power of nature.
Naturopathy is magic apparently. When I looked into the source listed for the above quote, I found that it was a letter written in to Medscape General Medicine by a satisfied naturopathy patient to rebut a 2004 article by none other than our own Kimball Atwood.
The introduction/marketing section of the study continues:
Naturopathic physicians are trained as primary care providers who diagnose and treat patients with a holistic approach and avoid the use of surgery and synthetic medications…Naturopathy is one of the largest alternative medicine fields and among the fastest growing, with increasing numbers of naturopathic providers.
The authors are not naturopaths, believe it or not. I did half expect a call for the reader to enroll in naturopathic school today though. It’s true that there are a few thousand NDs in the United States, and that they are licensed in 18 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. It’s also likely true that there numbers are increasing. What isn’t clear is that demand is actually increasing.
Later in the paper, the authors point out that globally CAM has a large market of almost 70 billion dollarydoos, which implies that it is widely accepted. This is sadly true. But they employ a bit of misdirection by implying that naturopathic medicine makes up a large part of the market because it is one of the largest fields in CAM. It is, but it pales in comparison to chiropractic and makes up a very small percentage of overall CAM use.
The authors state that 38% of adults and 12% of children use CAM health care services such as naturopathy but this is highly misleading and outdated information from 2008. More recent data has shown that the number of children exposed to CAM every year is actually a bit lower, at around 10%, and the vast majority of CAM does not involve practitioners such as naturopaths. Chiropractic is the most common modality that involves having to go see somebody, but most CAM use by kids comes in the form of OTC herbs, supplements, and mind-body modalities such as meditation.
Now let’s dig in to the meat of the study.
From January to December of 2018, outpatient labs ordered by over 500 providers at Seattle Children’s Hospital, about 80 of which were naturopathic doctors, were analyzed by the study authors. During this period, 35,185 tests were ordered on 6,076 individual patients. On average, the naturopaths ordered twice as many overall tests per patient (10.5 vs 5.5) and twice as many per patient on unique dates of specimen collection (7.4 vs 3.5). Pediatricians and family doctors ordered only one or two tests more than half of the time while naturopaths ordered more than 5 tests on 58% of collection dates.
The general types of tests differed significantly between real doctors and naturopaths. 45% of tests ordered by NDs involved allergens, trace minerals, and toxic metals. NDs were also much more likely to order panels of tests rather than individual tests, which were preferred by medical providers. Not surprising was the finding that tests ordered by NDs were much less likely to be abnormal, because (spoiler alert!) they don’t actually put much thought into what they order.
The conclusion of the paper contains one of the most unintentionally funny interpretations that I’ve ever seen:
These data also suggest that NDs may not use laboratory tests in the same manner as (general practitioners) and may make medical recommendations using different criteria, likely influenced by different laboratory medical training.
The authors, who are non-naturopaths employed at an actual children’s hospital, again provide excellent marketing for naturopaths while appearing to make excuses for the clearly haphazard approach to ordering labs on their patients:
Preventative medicine is a focus of naturopathic practice. Wellness testing commonly refers to single tests or panels of tests that are intended to be performed on well or asymptomatic patients, with the goal of preventing unwanted later complications of disease.
That’s not it. Wellness testing isn’t science-based screening. Wellness testing is a marketing ploy, not good medicine.
The study, which makes naturopaths look like they just order the same tests on every kid they see, is limited. In reality, as anyone with knowledge of the fundamentals of naturopathy would know, their lab ordering problems are much worse than that. The authors hit the nail on the head when they point out that the data in this study likely only represents a fraction of the labs they commonly order because they are known to make use of non-traditional facilities that run a variety of bogus tests that conventional doctors would recognize as a scam.
My final concern/question is this: why is Seattle Children’s Hospital running outpatient labs ordered by naturopaths?