Science is the Concept by which
we measure our reality
I don’t believe in magic
I don’t believe in I-ching…
I just believe in science…and that reality.
As regular readers of the blog are aware, I am science/reality based. I think the physical and basic sciences provide an excellent understanding of reality at the level of human experience. Physics, chemistry, biology, anatomy, biochemistry, physiology, evolution etc. provide a reliable and reproducible framework within which to understand health and disease. My pesky science may not know everything about reality, but day to day it works well.
Pictured: Reality, with it’s well-known liberal bias.
“There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy. – Hamlet (1.5.166-7).”
Perhaps, but all the medical advances in my lifetime have been not yielded new science, just (amazing) variations and extensions of known processes. I sometimes think the blog should have been called reality-based medicine, but science is the tool by which we understand reality, and while the tool is constant, our understanding of reality is prone to changing. An understanding of the rules of the universe combined with an awareness of the innumerable ways whereby we can fool ourselves into believing that those rules do not apply to us is part of what makes a science and reality based doctor.
We are often told of the need to keep an open mind, but I like to keep it open to reality. Not that I do not like fantasy and magic, it is a common category for my reading. I just finished Red Country by Joe Abercrombie, and while I love the world he has created, I would not want to apply the rules of that imaginary world to my patients. Well, one exception. As Logen Ninefingers would say, “You have to realistic about these things.” Fictional worlds should be limited to the practice of art, not the practice of medicine.
Part of having a scientific bent is the urge to classify. Supplements, Complementary, and Alternative Medicine (SCAM) is such a hodgepodge of ideas and practices it is difficult to categorize. Carolus Linnaeus I am not, but in my mind I have come to classify SCAM into four broad types.
A typology of nonsense
Type 1: Total nonsense with zero prior plausibility. These are SCAMs based on ideas divorced from reality as I understand it, cannot have efficacy and do not have efficacy. It includes, but is not limited to, homeopathy, acupuncture, chiropractic, Ayurvedic, reiki and other energy therapies, iridology, applied kinesiology, craniosacral therapy, water therapy, and on and on and on. Whenever I makes this kind of list I am amazed at how
age cannot wither SCAM,
nor custom stale
It’s infinite variety.
People who inflict these modalities on others may be well intentioned, but as we all know “the road to Hell is paved with frozen type 1 providers. On weekends, many of the younger demons go ice skating down it.”
All type 1 SCAMs are useless, non-reality based magic.* I would think anyone who proposes any type I SCAM for diagnosis and treatment should be kept as far from providing medical care as is feasible.*
Type 2: Those SCAMs that may or may not have efficacy. These are mostly various herbs, whose reasons for use are often historical or related to aggressive marketing. The prior plausibility that a given herb will actually have efficacy for a given disease is small, but not zero, and occasionally an herb or supplement, like red rice, is discovered to have actual active ingredients and effect. Unlike pharmaceuticals, the actual contents of most herbs may be unknown and efficacy is based on experience. I stand by my opinion that, when it comes to therapeutic interventions, that the most dangerous words a health care provider can utter are ‘in my experience’.
Type 3: Those SCAMs where a little efficacy in the test tube or in a small poorly done study is blown out of all proportion to its real effect. The effects are perhaps real, often small, and usually not clinically relevant. Green coffee beans are a recent example, thank you very much Dr. Oz.
Type 4: SCAMs that are not SCAMs at all. For example diet and exercise. Diet and exercise are often part of the marketing of SCAM, and there is nothing alternative about diet and exercise as such.
Reality based doctors generally avoid the first type 1 SCAMs and may have a nodding acquaintance with types 2 and 3. We all recognize the importance of diet and exercise although implementation will vary.
And now, alternative-reality-based medicine
Naturopaths, in contrast, have a gobbet of reality based education in a sea of fantasy. I have written about naturopathic education before. The result was that one of the faculty of the local ND school, I forget which one, wrote a letter to my boss obliquely complaining about me. Figures. Didn’t write to me, oh no, went straight to my boss.
I became interested in SCAMs early in my practice when I was called to see a “leg infection”. What it 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 refused surgery by us. 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. That night the tumor, or the infection, eroded into a major artery and she bled to death. That is my idea of the archetype naturopathic care.
I have long been of the opinion that you can judge a person by the company they keep. The naturopathic education at my local school includes hydrotherapy, homeopathy, qui dong, colonics, the nature cure, herbs, and botanicals. Anyone who thinks homeopathy is an appropriate therapy for anything but thirst is in my opinion, unfit to care for others. They are divorced from reality as I understand it.*
Once in practice naturopaths expand their practice into other areas that are, in my opinion, useless. Consider these Northwest NDs:
Kevin Wilson, ND: “spinal manipulation, and prolotherapy. I prescribe many herbal medicines, specific nutrients at therapeutic doses, and homeopathic remedies. Some patients are candidates for intravenous therapies such as vitamin and mineral ‘cocktails’, dilute hydrogen peroxide for infections and soon, chelation therapy for chronic cardiovascular disease.”
Bill Walter, ND: Detoxification coaching. “Nearly everybody, for example, can benefit from nutritional counseling, stress-reduction training, or gentle detoxification.”
Kelly Fitzpatrick, ND: “Nutritional Supplementation including Intravenous Therapy such as High Dose Vitamin C therapy.”
Liz Dickey, ND: An emphasis on homeopathy.
Hilary Andrews:, ND: Treating autism by rebalancing the nervous system with drainage (whatever that is), dietary restrictions and probiotics.
Dawson Farr, ND: prolotherapy, detoxification, and vitamin injection therapy.
Some offer wide ranging testing for “Food Allergy Testing, Hepatic Detoxification Profile, Toxic Heavy Metal Analysis, Pesticide and Solvent Exposure Panel, Hormone Saliva Test, Comprehensive Diagnostic Stool Panel”. I cannot say what these specific testing panels represent and for all I know could be just fine. Color me skeptical.
I see no end of wonky infectious disease testing used by naturopaths for Lyme and the use of live blood analysis. For example, the time an ND diagnosed a patient with a bacterial blood stream infection based on live blood analysis and offered the patient an expensive colonic detox as a cure. After hundreds of dollars of out of pocket testing, the patient saw me for a second opinion before spending several hundred dollars more. The patient had asthma as the cause of this symptoms and he improved with an inhaler. Another great ND diagnosis.
Why choose these NDs? Because they are the authors of “Naturopathic Primary Care. A White Paper to help regulators, lawmakers, and administrators in Oregon address PCP shortages using naturopathic physicians.”
As Jann Bellamy discussed last week, there is an ongoing political debate over whether naturopaths should be credentialed as part of CCOs. They shouldn’t. The white paper suggests we should include people trained in therapies not based on reality and science and offering therapies not based in reality or science as primary care doctors. I suggest that would be a bad idea.
The White Paper: A black mark on the profession
From the introduction:
As both the Affordable Care Act and Oregon’s own healthcare transformation move into full implementation, there has been much discussion about how to address the shortage of primary care providers. Many possible solutions have been proposed in response to this crisis, including the use of non-MD practitioners in helping meet Oregon’s primary care needs.
Oregon is in the excellent position of having a pool of highly trained non-MD primary care providers already licensed by the state and with the scope of practice and formulary needed to practice as primary care providers – Naturopathic Doctors (NDs).
This document offers clarity and insight to decision-makers, medical directors, and insurance administrators on the role that naturopathic medicine could play in serving Oregon’s population. It can act as a roadmap for Oregon’s new Coordinated Care Organizations and Healthcare Exchange insurers on how to effectively integrate naturopathic physicians to help meet the Triple Aim: better health, better care and lower cost.
What follows is an impressive spin for what it doesn’t mention: that naturopaths have severely inadequate training in reality based medicine and it makes them unfit to be primary care medicine providers. They forget to mention that the basis of their practice is nonsense.*
The initial description of naturopaths and their qualifications looks good on paper. Upon close inspection it resembles the Melanesian cargo cult. From a distance it looks like soldiers and planes and radios and all the accoutrement of modern industrial society, but upon closer inspection everything is made of twigs and vines, the form without the function. So too with the White Paper. The overview looks good, examined in detail naturopathy’s:
“but a walking shadow, a poor player that struts and frets his hour upon the stage and then is heard no more: it is a tale told by an integrative practitioner, full of sound and fury, signifying nothing.”*
They start with a description of naturopathy:
• emphasize prevention and self-care as a cornerstone of health;
• focus on patient-centered care, addressing the determinants of health in treatment plans;
• prioritize a “therapeutic order” that begins with minimal intervention and proceeds to higher intervention; and
• address the underlying cause of the condition rather than focus solely on symptomatic treatment.
It sounds good until you consider the tools used to apply that philosophy. Homeopathy. Acupuncture. Hydrotherapy. Chelation. Live Blood Analysis. Craniosacral Therapy. Flower Essences. The nonsense that is often the subject of this blog. The twigs and vine equivalent of medicine. I entered “Portland Naturopathic Physician” into Google and went to site after site. I could not find one that offered at least one non-reality based therapy. The raison d etre of the field is to attempt to apply fantasy to reality.* I will admit that I could not find an office where all the equipment was made of vines and twigs, but then I was speaking metaphorically, not literally.
The same reasonable sounding overview of naturopathic education:
Didactic education in biomedical, diagnostic, and clinical sciences
• Biomedical and Diagnostic Sciences: physiology, anatomy, biochemistry, microbiology, pathology, immunology, etc.
• Clinical Sciences: clinical, laboratory and physical diagnosis, gastroenterology, pharmacology, rheumatology, endocrinology, neurology, gynecology, cardiology, etc.
• Therapeutics: botanical medicine, nutrition, homeopathy, physical medicine, counseling, pharmacology, minor surgery.
“At our local naturopathic school they get 72 hours of pharmacology education, and twice (144 hours) as much training in homeopathy. The have the opportunity to do electives to broaden their knowledge: 144 hours in homeopathy, 36 hours in qi gong, 26 hours in Aruyveda, 24 hours in energy work and 12 hours in colonics.”
A litmus test of a highly dilute acid
If there is a litmus test by which you could judge magic vs. reality, it is homeopathy, perhaps the most popular and, arguably, the rankest of rank nonsense. If a practitioner thinks homeopathy is reasonable, run. the Here, as an example of the learnin’ in ND school, is a common treatment for nasal stuffiness in the naturopathic armamentarium:
Directions
Take a pair of cotton socks and soak them completely with cold water. Be sure to wring the socks out thoroughly so
they do not drip.
Warm your feet first. This is very important as the treatment will not be as effective and could be harmful if your feet are not warmed first. Soaking your feet in warm water for at least 5-10 minutes or taking a warm bath for 5-10 minutes can accomplish warming.
Dry off feet and body with a dry towel.
Place cold wet socks on feet. Cover with thick wool socks. Go directly to bed. Avoid getting chilled.
Keep the socks on overnight. You will find that the wet cotton socks will be dry in the morning.Effects of the Wet Sock Treatment
This treatment acts to reflexively increase the circulation and decrease congestion in the upper respiratory passages, head, and throat. It has a sedating action and many patients report that they sleep much better during the treatment. This treatment is also effective for pain relief and increases the healing response during acute infections.
It is inexpensive, patient centered, self-care, minimalist, and inexpensive. It is also divorced from physiology and reality and is, for lack of a better word, stupid.*
It is not hard to find weird* naturopathic approaches for any disease. All you need is Google and search terms. My first hit for naturopathy and asthma:
Some doctors recommend taking baths with a cup or so of 3% hydrogen peroxide in the water to bring extra oxygen to the entire surface of the skin, thus making the lungs somewhat less oxygen hungry.
Say what? I remember riding the bus to medical school and a naturopathic student noted what I was reading and struck up a conversation with me. Warts, he informed me, are not due to a virus but the body walling off toxin and expelling them. I thought he was either misinformed or a lunatic. Turns out the root cause of warts is toxins, at least in the fantastical world of some naturopaths. So much for the root of diseases.
It is almost like the old joke. How do you tell if a naturopath is speaking unscientific nonsense? If his mouth is open.
Continuing (mis)education
They then note that naturopaths are required to have 45 hours a year in continuing medical education. Sounds good, they are kept educated. But in what? The local naturopathic school is offering CME in Integrative Oncology. As I have mentioned before, if you integrate cow pie with apple pie, the cow pie is not improved, the apple pie is made worse.
Included in the days education is:
“Dr. Joseph Pizzorno, ND, describes diet-induced cellular acidosis, and how this phenomenon is documented to contribute to chronic diseases, including cancer, osteoporosis, diabetes and more.”
and the summary states
Diet-induced cellular acidosis is real and clinically significant. Cellular acidosis induces mitochondrial dysfunction, calcium loss from bones, increased risk of kidney stones, increased risk of cancer—the list is long and substantiates the long held belief that an alkaline diet is health promoting. Of particular significance in cancer, lower pH levels in the extracellular fluid increases intracellular calcium, which induces carcinogenic pathways, and promotes invasiveness and metastases.
Maybe I will get to see another death from wet gangrene from progressive cancer treated with alkaline water instead of effective therapies. I hope not. The CME includes Ayurvedic medicine and acupuncture. Maybe it should be CNE, (the ‘N’ for nonsense*) since it certainly does not appear to include education in the science based biomedical sciences my job requires. Collecting more vines and twigs into a simulacra of medicine is unlikely to improve medical care.
The White Paper then notes that, like MD’s, there is residency training for naturopaths:
Accredited residencies are available for one, two or three-year terms. Currently, all residencies are privately funded. Consequently, residency opportunities are not available for all graduates.
I count 55 residencies on the AANMC web site and there were 507 first year students enrolled in 2007-2008. So at best 11% of have training beyond naturopathic school, and one or two years at that. I practice in a teaching hospital with medical students and residents and no one is ready to take care of patients on their own after medical school. And they have had to learn reality-based medicine.
After 4 years of reality based medical school, MD’s have residency and fellowships where we have years of supervised training. For me it was three years of internal medicine, two years of ID fellowship and two years of post-fellowship training, all under the watchful eyes of senior physicians. Naturopaths often go from school to practice. Next time you see a naturopath, remember it is the same as seeing an unsupervised medical student. And a medical student extensively schooled in type 1 SCAM. Not that a residency under the watchful eye of another magician could improve their practice.
Sometimes men change for the better. Sometimes men change for the worse. And often, very often, given time and opportunity . . .’ He waved his flask around for a moment, then shrugged. ‘They change back.
― Joe Abercrombie, Best Served Cold
Inadequate training and experience even in their own area, much less real medicine, and then thrown into the world under the mistaken impression that they are competent to care for people*. It makes the next part of the white paper scary*:
Naturopathic Scope of Practice
Naturopathic doctors are licensed to work as independent providers in Oregon. They do not require supervision or oversight by other providers, and are licensed to:
• Diagnose, prevent, and treat disease;
• Perform physical exams including orificial exams (oral, vaginal, anal);
• Order x-rays, electrocardiograms, ultrasound, CT, MRIs, and laboratory tests;
• Draw blood and perform CLIA-waived lab tests in-office;
• Perform minor surgery;
• Provide prenatal, intrapartum, and postpartum care (with additional certification);
• Provide injections including vaccinations and IV medications;
• Prescribe all natural & pharmaceutical medications needed in a primary care setting;
• Are eligible for Drug Enforcement Agency (DEA) numbers for Schedules II- V (authority to prescribe controlled medications).
Just what I want poorly-trained, unsupervised medical students to do. As we have seen, it is not the broad concepts that make the scope of naturopathic practice problematic, it is the inadequate training, experience and fanciful modalities used that make the ND unfit to care for humans in health and disease.* The White Paper makes it sound like real medicine, but men change back.
Standard of whatnow?
Standard of Care & Competencies
There is no naturopathic-specific standard of care. Naturopathic doctors are taught and held to the same standards of care as conventional providers.
No kidding. Wander the web looking at naturopathic practices. There is a complete lack of standards since any and all non-reality based practices are fair game.*
Treatment Guidelines
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.
It is always harder to follow guidelines when you have no standard of care and their inadequate training would make them hard to understand and much of the tools of their trade are in direct opposition to science based reality.*
There is now
The Naturopathic Academy of Primary Care Physicians is newly created and is establishing a board certification program for primary care naturopathic doctors. However, it is still years away from a formalized program.
Oregon naturopathic primary care doctors are able to do all of the following:
• Examine, diagnose, prescribe and treat patients as family physicians;
• Manage all pharmaceuticals needed in a primary care setting;
• Manage patients’ routine preventive screenings, vaccinations and blood work;
• Order diagnostic tests, images, blood-work and labs;
• Perform well-child visits, women’s health visits, sports physicals, sign birth/death certificates, assist with advance directives, handicap permit and driver impairment, etc.;
• Perform minor surgery, including excisional biopsies and laceration repair;
• Coordinate care with a referral network of labs, specialists, physical therapy, behavioral health, social services, hospitals, and out-patient facilities;
• Educate patients about lifestyle, diet, stress management and chronic disease management;
• Write orders for residential facilities, hospice, in-home nursing care, etc.
I can’t see how a ND, with inadequate training in biomedicine, immersed in type 1 SCAM, little, or more likely no, post graduate training in biomedicine can “Examine, diagnose, prescribe and treat patients as family physicians.” FP’s, besides 4 years of real medical school and three years of supervised residency, have continued and ongoing real biomedical education. It is why the joke is ND stands for Not a Doctor.
Proof is boring. Proof is tiresome. Proof is an irrelevance. People would far rather be handed an easy lie than search for a difficult truth, especially if it suits their own purposes.
― Joe Abercrombie, Last Argument of Kings
What little data there is suggests that utilizing a naturopath for primary care is associated with worse care: less cancer screening, mammography and Chlamydia screening. But considering they are trained in magic instead of modern bioscience, why would I expect otherwise?*
Pttttttthhhhhbbbtttt (drip, drip)
There is a pause while I had to go buy a new computer. I was drinking milk when I read the next section and did an impressive spit take into my keyboard when I read:
Immunizations
Naturopathic doctors are educated according to the public health laws of the state, and understand the role that vaccinations play in preventing communicable disease. But because naturopathic care is by definition patient- centered, many NDs will customize the vaccination schedule to address the patient’s risk factors, environment, and personal beliefs. See Appendix A: How NDs can help Oregon increase immunization rates.
And the white paper appendix says:
How NDs can help Oregon increase immunization rates
Oregon naturopathic physicians can help CCOs provide care for more patients and may in fact assist in increasing rates of immunizations in populations who otherwise completely opt out.
The Oregon Association of Naturopathic Physicians (OANP) is a strong proponent of preventive medicine and of the protection of children and adults from the serious consequences of infectious disease. Naturopathic physicians, as primary care providers, are morally obliged and legally required to uphold and carry out the public health mandates of the state. All physicians are also ethically obliged to give patients, parents and legal guardians accurate and current information on both the benefits and risks of all medical interventions.
It is no surprise that the reality does not match the spin given the long standing antipathy towards vaccines in large sections of the naturopathic community. Naturopathic care leads to fewer vaccinations and an increase in vaccine preventable diseases:
Outcomes included receipt by children aged 1-2 years of four vaccine combinations (or their component vaccines) covering seven diseases, and acquisition of vaccine-preventable diseases by enrollees aged 1-17 years. Children were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children who saw chiropractors were significantly less likely to receive each of three of the recommended vaccinations. Children aged 1-17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care.
As naturopathic students move though their education, the support of vaccination declines:
We found that only 12.8% (40 of 312) of the respondents would advise full vaccination; however, 74.4% (232 of 312) of the respondents would advise partial vaccination. Importantly, both willingness to advise full vaccination and trust in public health and conventional medicine decreased in students in the later years of the programme.
The hesitancy of patients to get the recommended vaccines may be fed in part by the anti-vaccine nonsense perpetuated by many NDs*. Like Hilary Andrews, one of the authors of the white paper, on vaccines and autism:
While the measles-mumps-rubella or MMR vaccine has been strongly linked to the onset of autism, I believe that prior vaccinations also play a cumulative role in this disease. Current vaccination schedules overload very young, fragile immune systems with a huge number of viruses.
Regular readers of this blog recognize the above paragraph as das ist nicht nur nicht richtig, es ist nicht einmal falsch! Let’s say that I am not so sanguine that naturopathy represents a way to increase vaccinations in Oregon, much less improvements in primary care.
Naturopaths are three monkeys with six arms*, **
I get the distinct impression the white paper is presenting information they think people what they would like to hear, rather than mentioning the unsavory and imaginary details that make up much of naturopathic practice. But when it comes to money it is better to look good than be good.*
It is imperative to note that naturopathic physicians are independent practitioners. Patients increasingly also turn to naturopathic physicians as first point of contact providers and would refrain from care with a conventional doctor if they cannot access their naturopathic physician.
Health care in the US is a mess. I have no clue what the solution is. I hope for a single payer system. I came to the conclusion long ago that sometimes there are sometimes no good solutions to some problems, just the least bad solution. Right now health care is a mess in innumerable ways; a single payer system will make it a mess in one way.
If you have a problem in astronomy, you do not call an astrologer. Sure, he knows the names of the planets and the stars and has a good patter about how his system works. But astrology is nonsense. If you have a shortage of pilots, you don’t hire a transcendental meditation practitioner to levitate the plane. At least not a plane I would get on. And if you have a shortage of primary care providers, perhaps including those with inadequate training in real medicine, extensive knowledge of fanciful fields who treat cancer with alkaline water and misdiagnose asthma as a blood stream bacterial infection, might not be the best choice to improve the health of the population.
The whole white paper is a disingenuous “argument by assertion… the logical fallacy where someone tries to argue a point by merely asserting that it is true, regardless of contradiction.”
Naturopaths have the knowledge and training to do primary care.
Not.
*Opinion. I hate saying in my opinion out of paranoia, it is repetitive and ruins the flow of the prose. So if you see an asterisk, it refers to this footnote that points out, yes, that was my opinion. This is all my opinion. Opinion. Opinion. Opinion. So I am writing an opinion piece filled with humor. Everything not referenced is my opinion. OK?
** See, there’s these monkeys, and normally they only see, hear, and speak no evil one at a time, but these monkeys have six arms, so they can…look, it’s a metaphor, OK?