Each year, in a disheartening display of scientific ignorance, state legislators foolishly introduce bills designed to incorporate pseudoscience into the practice of health care, a process I’ve named “Legislative Alchemy.” Nowhere are these efforts more successful than when naturopaths become licensed healthcare professionals via state practice acts, bestowing the imprimatur of government legitimacy on pseudo-scientifically educated and woefully undertrained graduates of naturopathic “medical” schools. Legally permitted to call themselves “doctors” and, in some instances, claim they practice primary care, naturopaths can then go about diagnosing fake diseases and treating real ones with unproven, and sometimes lethal, remedies.
As 2018 draws to a close, we take a look today at how naturopathic “doctors” (or “NDs”, translated as “not-a-doctor” by critics) fared in the state legislative arena during the past year. Fortunately, despite the backing of the multi-billion-dollar dietary supplement industry, their results were decidedly anemic.
With scopes of practice and regulatory schemes varying widely, NDs are currently permitted to practice in 20 states. Naturopathy is illegal or has been abolished in six states. In 2018, eight additional states saw bills introduced to legalize naturopathic practice: Illinois, Indiana, Michigan, Mississippi, New York, North Carolina, Oklahoma, and Wyoming. (Some of these bills were holdovers from 2017 in states with two-year legislative sessions.) So far, their efforts failed in Indiana, Mississippi, Oklahoma, and Wyoming. Given the fact that legislatures are about to adjourn in the four remaining states, it appears highly unlikely that licensing legislation will get to any governor’s desk. In fact, with the exception of Michigan, most bills, as we shall see, came to a halt early in the legislative process. (Although, never say never, as we learned in Massachusetts.)
Michigan, the home of SBM’s own David Gorski, MD, PhD, had a close call indeed. For the second time in as many legislative sessions, a naturopathic licensing bill was introduced giving NDs one of the broadest scopes of practice in the country. Senate Bill 826 passed in the Senate and is now before the House Committee on Health Policy, where it appears it will not be taken up before the legislature adjourns.
Whew! Had the bill passed and been signed by the Governor, naturopaths who graduated from accredited naturopathic “medical” schools (unlike MDs and DOs, residency is not required) would be allowed to diagnose and treat any patient of any age with any disease or condition and call themselves “physicians”. They would be regulated by a naturopathic board consisting of six NDs, one MD or DO, one chiropractor, one pharmacist, and two public members. In addition to bogus remedies like dietary supplements and homeopathy (which they could sell to patients), they could prescribe drugs on a naturopathic formulary devised by the naturopathic board. They would be allowed to perform minor office surgery, including biopsies, and could order and perform lab tests (including the bogus testing favored by naturopaths) as well as order diagnostic testing. They could employ almost all routes of administration, including IV, allowing them to inject patients with worthless and potentially dangerous vitamin, mineral and herbal “cocktails”. The naturopathic board would be given the unfettered authority to add “other naturopathic therapies” to the scope of practice if the board thought naturopathic education and training is sufficient. To head off opposition from traditional naturopaths whose practice might otherwise become illegal if a licensing bill passed, the bill did not prohibit practice of traditional naturopathy.
It is interesting that state legislatures continue to include homeopathy as a staple in naturopathic licensing bills even after the FDA has put everyone on notice that no homeopathic remedy has been approved by the FDA, as required by federal law, thus making all of them “subject to FDA enforcement action at any time.” (Although the FDA, for now, is only selectively enforcing the law.) In other words, state legislatures are attempting to authorize the prescription and sale of illegal drugs.
Similarly broad scopes of practice are, or were, on the table in other states.
In Indiana, House Bill 1427 was assigned to the House Health Committee, where it sat without further consideration until the legislature adjourned. A Senate Resolution full of unsupported claims about the putative benefits of naturopathy also failed.
That’s fortunate for the health of Hoosiers, as HB 1427 would have given NDs a scope of practice similar to that of a primary care physician, limited only in the diagnostic methods and treatments they could employ. Allowed treatments included manipulation, colon hydrotherapy, botanicals, homeopathy, dietary supplements, “nutraceuticals”, and nonprescription drugs, using routes of administration that include vaginal, rectal and intramuscular.
If approved by a Board of Naturopathic Medicine (consisting of five naturopaths and two public members), Indiana NDs would have been allowed to prescribe drugs, including controlled substances, and could administer these prescription drugs via intradermal, subcutaneous or intravenous routes of administration. (It is a testament to the audacity of naturopaths that they continue to push for drug prescription privileges when their own Board of Examiners has admitted that their education and training is insufficient to prescribe drugs.) They could order and perform diagnostic testing, including phlebotomy and electrocardiograms, and order and interpret the reports of diagnostic imaging studies.
Despite repeated efforts, naturopathic licensing has not made much headway in the southern U.S. This year was no exception. Bills allowing NDs to call themselves “physicians,” describing naturopathy as “primary health care”, and allowing NDs to treat any patient with any disease or condition, were introduced in Mississippi and Oklahoma. Bills in both states would have allowed NDs to prescribe drugs, perform minor office surgery, and order diagnostic testing, in addition to their usual menu of dietary supplements, colonics, and homeopathic remedies. Mississippi would have allowed NDs to use virtually all routes of administration, including IVs, and practice “naturopathic childbirth attendance“. Fortunately, neither the Oklahoma nor the Mississippi bills ever made it out of committee.
For the eighth consecutive legislative session, bills regulating the practice of naturopathy were introduced in North Carolina, where the session is scheduled to end today. [Update: Statescape now shows the session ending on December 31st. Unlike most states, there is no N.C. constitutional or statutory provision in mandating when a legislative session must end.] Instead of licensing, Senate Bill 258 and House Bill 692 create a “certification” (not licensing) for NDs, but otherwise give them a starter scope of practice (treat any patient with any problem, prescribe and sell dietary supplements and other unproven remedies, diagnostic testing) they could live with until they can come back to the legislature asking for more, as they inevitably do. A Naturopathic Doctors Certification Board, with a naturopathic majority, would regulate their practice. Interestingly, while “gross negligence” is sanctionable, mere malpractice (that is, falling below the standard of care, or ordinary negligence) is not mentioned, further reinforcing the conclusion that there is simply no standard of care in naturopathy.
As of this writing, both the House and Senate bills are sitting in the committee to which they were initially assigned, virtually assuring they won’t pass. Unfortunately, what did pass with lightning speed, rushing through the House and Senate in a couple of days, was House Bill 277, which was signed into law by the Governor. While purporting to establish a work group to study “the appropriate oversight and regulation” of naturopathic practice in North Carolina, the game seems rigged in favor of licensing. The work group is tasked with identifying “an approved study of naturopathy medicine” for licensing purposes, but defines that “approved study” so that only one outcome is possible: the current system of self-regulated naturopathic “medical” schools, which produces NDs whose brief clinical training, for the most part, concerns itself with the care of the worried well. The work group consists of two naturopaths appointed by the North Carolina Association of Naturopathic “Physicians,” two MDs, one of whom must have experience working with naturopaths (in my view, designed to insure a naturopathy-friendly MD), and one designee of the state Secretary of Health.
North Carolina is surpassed by New York in naturopathic licensing bids, this being the ninth session in which a bill legalizing naturopathic practice has been introduced in that state. Both bills are still sitting in the committee to which they were originally assigned. The New York State Legislature adjourns on January 2, 2019, and is in recess until December 31st. Keep your fingers crossed.
Senate Bill 4297 and Assembly Bill 5913 give naturopaths the typical broad scope of practice “to address the shortage of primary care physicians,” based on the fiction that naturopaths can stimulate the “inherent property in a living organism to heal itself,” i.e., vitalism. In addition to homeopathic remedies, dietary supplements, and herbs, they could prescribe thyroid hormones, estrogen, progesterone, and DHEA, all of which they would be able to administer by the usual routes (vaginal, rectal, oral) and, if registered with the state, by injection, including IV administration. This would permit them to concoct dubious remedies like Myers cocktails, high dose vitamin C, and other substances and administer them intravenously. They could order diagnostic imaging, including MRIs and thermography, and perform cryotherapy, ligation, fulguration, other minor office procedures and colonics. They would be regulated by a naturopathic board consisting of six naturopaths, two public members and one MD or DO. After two years naturopaths would have to have completed a one-year “residency” to become licensed.
Finally, in Wyoming, yet another broad-scope-of-practice, naturopathy-as-“primary care” bill didn’t make it. That bill got as far as being assigned a number (House Bill 151), but no further, ignominiously failing to warrant even a committee assignment. Wyoming naturopaths itching for the authority to inject patients with bogus vitamin and mineral “cocktails” and practice obstetrics, both granted by the bill, will have to wait. And in Illinois, similar to legislation introduced in prior years, bills licensing NDs (House Bill 2530 and Senate Bill 708) but otherwise not defining their scope of practice failed to meet legislative deadlines for further consideration.
NDs are not fit to practice primary care
As noted, many licensing bills are based on the notion that naturopathic “doctors” are capable of practicing “primary care”. Before we move on to practice expansion bills, let’s pause briefly to consider the meaning of that term. Here are excerpts from definitions from the American Academy of Family Physicians, focusing on the nature of the services primary care doctors provide to patients:
Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.
Primary care practices are organized to meet the needs of patients with undifferentiated problems, with the vast majority of patient concerns and needs being cared for in the primary care practice itself.
The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient’s medical and health care needs – not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.
When advocating against legalizing naturopathic practice, it is important to emphasize the obvious quackery, the ethical impropriety of their self-dealing, in the form of routinely selling remedies they prescribe to patients, and their lack of standards for care. Equally important, in my view, although perhaps under-appreciated, is calling out the insanity of allowing naturopathic “doctors” to practice primary care. The idea that someone with four years of education and training, a large portion of which is taken up by learning herbs and homeopathy and tending to the worried well, can competently serve as the “first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern . . . not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis” with “the vast majority of patient concerns and needs being cared for” is dangerously naïve. Equally absurd is the belief that NDs can be effective “advocates for the patient in coordinating the use of the entire health care system to benefit the patient,” when their appallingly inadequate training occurs almost exclusively outside of this health care system. Either legislators have no idea what the term “primary care” means or they are credulously swallowing naturopathic talking points without any independent investigation of their claims.
Practice expansion shutout
Even when a licensing bill passes, naturopaths often do not get the scope of practice they desire. However, having successfully stuck their noses under the tent, they will return to the statehouse door year after year, seeking practice expansion. Eight states saw practice expansion bills this year (again, some were holdovers from 2017). All failed.
Pennsylvania is an excellent example of this strategy. Last legislative session (2015-16), Pennsylvania passed a naturopathic registration act, allowing NDs to register with the state but without defining a scope of practice and leaving the details of regulation to the state medical board, under whose jurisdiction they will practice. Before the medical board could even begin its task of writing the rules, a licensing bill was introduced in the 2017-18 session allowing NDs to see, diagnose (with the authority to perform testing and order diagnostic imaging) and treat the undifferentiated patient with dietary supplements, herbs, homeopathy and like nostrums. The bill failed.
(The Society for Science-Based Medicine submitted comments [SFSBM Comment on Naturopathic Registration in Pennsylvania PDF] to the Pennsylvania State Board of Medicine discussing appropriate regulations. The Board appears to have listened. Proposed regulations require informed consent, including “notification to the client that the naturopathic doctor is not a physician and is not authorized to practice medicine”. Financial exploitation of patients is prohibited. Also included are restraints on misrepresentation, deception and untruthfulness in advertising that make one wonder whether they will be able to successfully advertise their practices at all.)
But wait, that’s not all! These bills also failed:
- Alaska Senate Bill 120 and House Bill 326: Would have enlarged the fairly narrow scope of practice to include drug prescriptions, minor office surgery, and performing and ordering diagnostic testing.
- Arizona Senate Bill 1085: Defined NDs as primary care practitioners under the state’s Medicaid system.
- California Senate Bill 746: As originally drafted, would have allowed NDs (and chiropractors) to perform school athletics physicals, but bill provisions were changed to a totally different subject.
- Connecticut House Bill 5294: In 2017, the Connecticut Department of Public Health issued an unfavorable report on giving NDs prescription privileges, including a discussion of their lack of education and training in pharmacology. Despite this, a bill was introduced giving NDs the right to prescribe drugs, leaving it to the Public Health Department, in consultation with the State Board of Naturopathic Examiners (but without input from medical or pharmacological groups) to establish additional requirements and a formulary.
- Hawaii House Bill 1949 and Senate Bill 2299: A perennial attempt to get the authority to prescribe testosterone, describing naturopaths as “experts” in bio-identical hormones, which are not recommended by responsible medical authorities.
- Minnesota Senate Bill 1514 and House Bill 1138: Another try at adding prescription privileges, as well as authority to perform minor office surgery and biopsies, do speculum exams, phlebotomy, and call themselves “naturopathic physicians.” Neither bill was considered in committee.
- Washington Senate Bill 5369: Would have expanded existing prescription privileges to include controlled substances as well as perform minor office surgery per naturopathic board rules. Would also allow NDs to sign “guardianships, powers of attorney, disability determinations, and similar legal documents.” (As an attorney, I am aghast at the thought.) The bill was never considered in committee.
The only, and minor, legislative success was in Colorado, and that wasn’t a practice expansion. NDs there were required to identify themselves as “registered naturopathic doctor” (RND). The NDs don’t like this, so they got House Bill 1433 passed eliminating that requirement. They still cannot call themselves “physicians” (a prohibition that was being honored in the breach until someone started filing complaints with the state) but can advertise that they are members of naturopathic organizations that refer to naturopaths as “physicians,” unless it is misleading or deceptive to do so.
Because all of the state legislatures covered in this post were in one-year sessions, or two-year sessions ending in 2018, none of the bills will carry over to 2019. Assuming the current situation holds, naturopaths suffered a shutout in 2018 in licensing and practice expansion. But naturopaths will be back – they always are. According to the American Association of Naturopathic Physicians, naturopaths have their sights set on licensing in 2019 in New Mexico, Texas, Mississippi, Georgia, Wisconsin, Ohio, New Jersey, and my state, Florida, as well as the Canadian Northwest Territories. Wherever they pop up, we’ll be following them on Legislative Updates.
Thanks to all of you SBM fans who contacted your state legislators to oppose naturopathic licensing and practice expansion. A special shout-out to the Center for Inquiry Michigan for its work in educating legislators about why naturopaths should not be licensed as health care professionals. Keep up the good work, everyone!