A bill granting naturopathic doctors one of the broadest scopes of practice in the country passed in the Michigan Senate and is now before the House Committee on Health Policy. Funded by dietary supplement companies, the Michigan Association of Naturopathic Physicians hired a lobbyist this year to push their bill. (Just imagine the outcry if, say, nurse practitioners seeking prescription privileges got money from Big Pharma.) If enacted, Senate Bill 826 will put the imprimatur of state approval on the egregious quackery already being practiced by Michigan naturopathic doctors (or “NDs”, terms I will use in this post to distinguish them from traditional naturopaths) and, by legalizing these practices, will make holding them accountable all but impossible.
This is not the ND’s first attempt to legalize “naturopathic medicine” in Michigan, although the websites of practicing naturopaths in the state indicate they are not dissuaded by current law banning the unlicensed practice of medicine from claiming they can treat a wide range of conditions with their “natural” methods, as myself, Michigan resident David Gorski (also here), and our good friend Orac (also here), have previously discussed. (Orac covered SB 826 yesterday.)
Unfortunately, the Michigan State Medical Society appears to be asleep at the wheel on this one. They are “monitoring” the bill, with no “for” or “against” position taken. This is a shame, if only for their own protection: MDs whose patients see NDs will spend extra time cleaning up the deleterious effects (also here) of their substandard practices and battling the quack notions put into their patients’ heads, not to mention naturopathic anti-vaccination ideology. The good news is that the Michigan Academy of Family Physicians is actively opposing the bill and has some great information on why NDs should not be licensed.
Short on science and 15,000+ hours of training, but no matter
As a demonstration of just how radical this bill is, let’s briefly compare “conventional” medical education to naturopathic “medical” education and training in the context of the scope of practice NDs would attain if SB 826 passes.
As it now stands in Michigan, only medical doctors (MDs) and doctors of osteopathy (DOs) have the legal authority to diagnose and treat, without limitation, the undifferentiated patient, that is, any person with any disease or condition. For this privilege, they go through a highly selective process (mean GPA of 3.56; mean Medical College Admissions Test score of 504; 7% acceptance rate). Four years of medical school, which includes about 9,000 hours of classroom and clinical education, is followed by three or more years of residency, consisting of tens of thousands of hours taking care of patients in a variety of clinical settings, including outpatient and hospital facilities. During medical school and residency, MDs and DOs must also pass the 3-part U.S. Medical Licensing Examination. The entire process of education, training and testing, is part of the traditional university-based educational system and detailed information is available to the public and policy makers.
SB 826 would introduce a new category of practitioner who has the authority to diagnose and treat any patient of any age – neonate to senior citizen – with any disease or condition: naturopathic doctors, who, like MDs and DOs, would be allowed to call themselves “physicians.”
The naturopathic doctor will begin practice at a distinct disadvantage in education and training compared to his supposed peers in conventional medicine. Unlike conventional medical schools, naturopathic medicine is taught in small, independent schools that operate outside the traditional university system and are accredited by an agency run by naturopaths. Although their accrediting agency has been approved by the U.S. Department of Education, the Department focuses on administrative and financial issues and does not vet curricula for their scientific accuracy or rigor. There is no admission test (not even the GRE) for naturopathic medical schools and almost everyone is accepted due to low admission standards.
While the naturopathic curriculum includes conventional scientific subjects, they are entry-level courses, not as rigorous as the advanced courses taught in conventional medical schools. And time that would be devoted to scientific subjects in medical school, like pharmacology, are crowded out by hours spent learning disproven treatments like homeopathy and energy healing, botanical drugs that have never been tested for safety and efficacy in humans, and dangerous modalities like ozone therapy.
Naturopaths have also created their own licensing exam, the NPLEX, which is shrouded in secrecy and has never been independently reviewed to determine whether it adequately vets naturopathic graduates for safe and effective practice. (While SB 826 doesn’t mention the NPLEX, it’s clear the NPLEX is intended.)
But the biggest difference in preparation for practice is in naturopathic clinical training: no residency is required for becoming licensed as a naturopathic doctor in Michigan. (In fact, there are few naturopathic residencies available anyway and even those last only one year.) Their only experience actually diagnosing and treating patients is in the 1,200 hours of clinical training, not all of which involves patient care, required during naturopathic school. This takes place, for the most part, in school clinics, where naturopathic students see patients with a very limited range of diseases and conditions. When no patient with a condition required to complete their training presents himself, naturopathic students simply practice on each other or give a presentation on the condition.
The American Academy of Family Physicians has put a number on that difference in training, and it’s huge: a family practice physician will have a whopping 15,000+ hours more experience diagnosing and treating a broad range of patients than a naturopathic doctor. Yet the state of Michigan will allow naturopathic doctors, 42% of whom typically go into solo practice, to act not only as primary care physicians, but specialists as well, a topic we’ll return to in a moment.
In allowing naturopathic doctors to see, without supervision, the undifferentiated patient, Michigan legislators seriously underestimate the importance of diagnostic skills. A basic fallacy underlying all naturopathic licensing is that, because they are supposedly using “natural” treatments to boost the “body’s self-healing ability,” diagnostic skill doesn’t matter. This ignores the fact that effective treatment depends on accurate diagnosis. There are thousands of diseases and conditions. As noted by the National Academies of Science et al. in Improving Diagnostics in Health Care (2015):
At the outset, it can be very difficult to determine which particular diagnosis is indicated by a particular combination of symptoms, especially if symptoms are nonspecific, such as fatigue. Diseases may also present atypically, with an unusual and unexpected constellation of symptoms.
The most frequently cited diagnostic errors are cancers, heart disease, cardiovascular disease, infections and stroke. Obviously, naturopathic doctors who have seen only a handful of these cases (if any) in clinical training are going to be woefully unequipped to appropriately diagnose them. The adequacy of current medical education in teaching diagnostic skills is itself under review; receiving a small fraction of clinical training that current medical education requires does not improve the situation. NDs often say they will collaborate with MDs and refer when necessary, but that misses the point. You can’t collaborate on a disease you don’t have the skills to diagnose or refer to a specialist when you don’t recognize the condition requiring specialty care. These are the “unknown unknowns,” as Donald Rumsfeld put it.
Adding to the dangers of naturopathic diagnosis is the tendency of NDs to fabricate conditions that don’t exist. Constellations of vague symptoms like fatigue, dizziness, headaches and nausea are turned into Wilson’s Temperature Syndrome, adrenal fatigue, “chronic” Lyme, “chronic” candidiasis, and the alternative medicine version of thyroid disease. Any of these could be a misdiagnosis of a very real disease or, alternatively, putting a label on benign symptoms and treating them unnecessarily.
Unfortunately, these diagnostic misadventures are aided, in SB 826, by the authority to order and perform laboratory testing and order diagnostic imaging. This presents two problems. The first is lack of training in ordering an appropriate test, a task that can stump even MDs and DOs:
The task of selecting the appropriate diagnostic testing is challenging for clinicians, in part because of the sheer volume of choices. For example, Hickner and colleagues (2014) found that primary care clinicians report uncertainty in ordering laboratory medicine tests in approximately 15 percent of diagnostic encounters.
SB 826 limits NDs to diagnostic testing “consistent with his or her naturopathic education and training” (the bill doesn’t say who gets to make that call), implicitly recognizing the problem this bill creates: NDs will have far less “education and training” in diagnostic testing, necessarily limiting their testing choices, but aren’t limited in the diseases they can diagnose and treat. How is that going to work?
Under the category of “minor office surgery,” NDs would also be allowed to obtain “specimens to diagnose, assess, and treat disease.” Presumably, this would include needle, aspiration, and skin biopsies.
And that’s only the valid tests. The second problem is that naturopathy is steeped in the use of clinically unvalidated tests (unfortunately, because of lack of FDA oversight these are widely available) which they use to justify all manner of unwarranted treatments. These include dubious MTHFR genetic testing, IgG food intolerance testing, “provoked” testing for heavy metals, hair mineral analysis (“a cardinal sign of quackery”), live blood analysis, and applied kinesiology, to name a few.
In sum, NDs, with their inadequate command of valid diagnostic tools, aren’t up to the task of diagnosing the unlimited range of patients this Michigan bill would allow them to see, although they do have an impressive grasp of bogus testing modalities.
Dubious naturopathic treatments
Having diagnosed that problem, let’s turn to the treatments SB 826 would allow. Here again we find a combination of conventional medicine (without the conventional training) and pseudoscience.
Their scope of practice would include prescription of dietary supplements and botanical medicine (the vast majority of which are untested in humans for safety and efficacy) and homeopathic medicines (all of which, the FDA recently admitted, are on the market illegally because they’re not FDA-approved). In addition to colonics (see below), massive doses of dietary supplements are a key ingredient in naturopathic “detox” scams. NDs, oblivious to ethical concerns about conflicts of interest, make a good bit of their income selling dietary supplements, homeopathic remedies, and the other nostrums they prescribe to patients.
They would also be able to prescribe drugs (except controlled substances) and medical devices and non-prescription drugs listed on a formulary approved by the Board of Naturopathic Medicine, a body we’ll return to shortly. Routes of administration include oral, nasal, auricular, ocular, rectal, vaginal, transdermal, intradermal, subcutaneous, intravenous, or intramuscular. As you will soon see, we have every reason to believe the formulary will include the makings of discredited and potentially dangerous naturopathic favorites like Myers cocktails, turmeric infusions, escharotic treatment of cervical dysplasia (also here), compounded chelators (administered IV), high-dose Vitamin C, and intravenous peroxide for chronic infections.
Other modalities in their scope of practice include:
- Hydrotherapy, the umbrella under which “colon cleanses” reside, used by naturopaths for bogus “detoxification.”
- Health education and health counseling and use of food in treatment. This will allow NDs to legally prescribe their kooky diets and fasting, which can be dangerous.
- Repair and care incidental to superficial lacerations or abrasions, therapeutic devices, electromagnetic energy and barrier contraceptives.
NDs would be regulated by a Board of Naturopathic Medicine, consisting of six “naturopathic physicians,” one MD or DO physician, one pharmacist, one chiropractor and two public members. The Board will regulate all aspects of naturopathic practice, including enacting rules, approving continuing education courses, discipline and, as mentioned, crafting the naturopathic formulary. Given the fact that there is no standard of care in naturopathy, it will be virtually impossible to discipline NDs for malpractice, no matter how egregious the harm or outlandish the quackery, especially with naturopaths holding a majority on the Board. This will also guarantee that the formulary’s list of drugs they prescribe will be long. The well-documented fact that NDs do not have (once again) adequate education and training to prescribe drugs will undoubtedly fall on deaf ears. (For Connecticut’s analysis of why NDs shouldn’t be allowed to prescribe, see here, and click on “Special Act 16-3 Committee on the Practice of Naturopathy.)
It will be interesting to see if the formulary includes vaccines. Naturopathy is notoriously anti-vaccination, and seeing a naturopathic is associated with both not being up-to-date on vaccinations and acquisition of vaccine-preventable diseases. In fact, the longer they are in school, the more anti-vaccination they become.
And no telling what will come of this provision, rounding out their scope of practice:
Other naturopathic therapies approved by the Board.
In a fascinating deviation from other licensing bills, SB 826 does not define naturopathic medicine as “primary care.” Rather, it says:
“Naturopathic medicine” means a system of practice that is based on the natural healing capacity of individuals for the diagnoses, treatment, and prevention of disease.
“Natural healing capacity of individuals” is, of course, vitalism, a long-discredited notion of how the human body functions. That aside, I suspect the omission of “primary care” is intentional and meant to expand their scope of practice beyond primary care. According to the American Association of Naturopathic Physicians (AANP) NDs also practice as specialists, and nothing in this bill would prevent them from doing so:
Like MDs, a growing number of naturopathic doctors choose to specialize or focus their practices. Specialty associations currently exist for Endocrinology, Environmental Medicine, Gastroenterology, Parenteral Therapies, Pediatrics, Primary Care Physicians, Psychiatry, and Oncology. In addition, while practicing Family Medicine, many naturopathic doctors choose an area of focus based on a therapeutic, condition, or population subset.
Like the pseudo-medicine practiced by NDs, these are pseudo-specialties. With one exception, all you need to do to become a “specialist” in these fields is to pay a membership fee. (There was no publicly available information on the Parenteral Therapies “specialty.”) To become a “Fellow to [sic] the American Board of Naturopathic Oncology,” you must meet these low-bar requirements: paid membership dues, devote at least 65% of your practice to oncology patients, fill out an application form, and “present case studies and pass an exam.” By way of comparison, to become a board-certified oncologist in “conventional” medicine, you must be Board-certified in Internal Medicine (3-year residency), complete a fellowship in oncology, and pass an examination. That the AANP would call these “specialties” with a straight face says a lot about the organization’s commitment to providing truthful information to the public about naturopathy.
Once again, credulous legislators have fallen for the myth that naturopaths can successfully treat and prevent chronic disease, all at a lower cost than conventional medical care. There is simply no good evidence to support these claims but plenty of evidence that naturopaths can cause real harm. If SB 826 passes, it will be one of the few bright spots in the naturopathic legislative agenda for 2018. Naturopathic licensing and practice expansion have been rejected this year (so far) in Alaska, Connecticut, Hawaii, Indiana, Mississippi, Oklahoma, Washington and Wyoming. (Looks like their bill in Minnesota is not going anywhere either.) In fact, the majority of states do not license naturopathic doctors and have repeatedly rejected licensing efforts (also here and here). Michigan should follow suit.
Resources for opposing naturopathic licensing
- 2018 Fact Sheet on Naturopathic Medicine
- Naturopathic Diaries
- American Academy of Family Physicians, Education and Training: Family Physicians versus Naturopaths
To follow Michigan Senate Bill 826 and CAM legislation nationwide, see the Society for Science-Based Medicine website.