Legislative Alchemy

Legislative Alchemy

Rhode Island is poised to become the latest state to succumb to the false notion that licensing naturopathic “doctors” will protect the public health, safety and welfare. Via the magic of Legislative Alchemy, and barring a gubernatorial veto, naturopathic doctors will soon be able to diagnose and treat any Rhode Islander with disease or condition, victorious in their sixth attempt at licensing in the state. With the conquest of Rhode Island, naturopathic takeover of New England will be complete, with all six states comprising that area of the United States licensing naturopaths. (Massachusetts passed a licensing law just last year.)

Fortunately, a variety of mechanisms to protect patients are included in the licensing bills. Unfortunately, as we shall see, RI naturopaths stand ready and waiting to foist their fake diagnoses and disproven treatments on unwitting Rhode Islanders without fear of prosecution for practicing without a license.

First, let’s see how RI naturopaths are currently practicing, even without legal authority to do so. Then, we’ll take a brief look at the licensing bills as introduced, which would have been far worse than the bills that passed. After that, we’ll review some of the committee testimony by supporters of the bills, including misrepresentations made to legislators about naturopathy. Finally, we’ll see just what naturopaths will be allowed to do in Rhode Island and, importantly, what they are prohibited from doing in their practices.

As is typical of other states, the lack of a licensing act has not stopped RI naturopaths from diagnosing and treating patients for a wide range of medical issues. Perusing the websites of RI naturopaths, one finds the typical quack diagnostic tests and treatments that fill naturopathic practices in both jurisdictions where they are regulated as well as those where they practice medicine illegally.

The president of the Rhode Island Association of Naturopathic Physicians (RIANP) (note: my web browser gives a security warning for this website) herself, Marcy Feibelman, advises patients how to concoct their own “warming socks” treatment, which essentially consists of wearing wet socks to bed. Indications for the treatment include, she says:

Any inflammation or infection of the throat (including a simple sore throat), neck pain, ear infections, headaches, migraines, nasal congestion, upper respiratory infections, sinus infections. Cold extremities, poor circulation. To prevent a cold.

She claims warming socks:

reflexively increase circulation and decrease congestion in the upper respiratory passages, head, and throat. . . This treatment is also effective for pain relief and increases the healing response during acute infections.

As SBM’s own Scott Gavura pointed out, this sort of nonsense simply demonstrates the limitations of naturopathic understanding of immunity.

The RIANP president also practices “biotherapeutic drainage,” a naturopathic treatment based on a combination of Chinese medicine, homeopathy and anthroposophy. Or, as David Gorski put it:

Biotherapeutic drainage. It’s three, three, three woos in one!

Other RI naturopathic offerings include:

Nationwide, naturopathic organizations and their licensing efforts are being supported by dietary supplement companies. The RIANP, the primary sponsor of the licensing bills, has the financial support of two dietary supplement companies (again note the security warning for the RIANP website), both of which sell their products through health care practitioners’ offices, allowing naturopaths to make a tidy profit on the products they prescribe.

If Designs for Health, one of the corporate sponsors, is typical of these “exclusive” deals, patients are paying a hefty markup for the privilege of buying from their naturopath. For example, Designs for Health aloe vera capsules are six times more expensive than aloe vera capsules available on the internet. Xymogen, the other corporate sponsor, does not make its prices available to the public on its website. Ironically, although dietary supplements available only through practitioners are promoted as superior to their off-the-shelf competitors, Xymogen received a warning letter in 2011 from the FDA, citing it for “significant violations” of the FDA’s good manufacturing practice regulations, as well as illegal therapeutic claims.

Broad scope of practice legislation fails

The licensing bills, House Bill 5474 and Senate Bill 327, as originally introduced in the Rhode Island General Assembly, were typical of the “opening bid” legislation introduced in other states, designed to give naturopaths the broadest possible initial licensing act, but short of the full-primary care scope of practice laws naturopaths really want, a feat achieved so far only in Oregon. (For this, they will pester legislators year after year.)

The original versions of HB 5474 and SB 327 would have allowed naturopaths to call themselves naturopathic “physicians,” prescribe drugs according to a formulary, perform minor office surgery, order diagnostic imaging studies, prescribe and dispense medical devices (including therapeutic devices, barrier contraception, and durable medical equipment) and use all routes of administration for the substances they can prescribe (e.g., minerals, vitamins, homeopathic remedies and prescription drugs on their formulary), including intramuscular and intravenous injections. Fortunately, none of those provisions survived in the final bills.

The Senate Health and Human Services Committee and the House Health, Education and Welfare Committee both took recorded testimony on the bills. As is too often the case, supporters showed up in far greater numbers than the one opponent who personally testified, although written testimony, which is not available on the General Assembly’s website, apparently augmented both the pro and con positions.

Testifying on the pro side in these hearings were two naturopathic “physicians” (one of whom was Marcy Feibelman), two MDs (one of whom was also an ND), two RNs, and a few patients who had positive experiences with naturopaths. Proponents testified that:

  • Naturopathy is safe. One proponent actually said it is “a lot safer” than traditional medical care.

Actually, there is no reliable evidence that the practice of naturopathy overall is “safe,” while there is plenty of evidence that the treatments they use have an unfavorable risk-benefit profile, like herbs, colon hydrotherapy, dietary supplements, and IV injections.

  • Naturopathy is effective. One proponent even went so far as to say there are “thousands of studies” demonstrating the effectiveness of naturopathic treatments.

Many naturopathic treatments are either unproven or disproven, including homeopathy, “detoxification” and quirky diets, as more expansively detailed in Scott Gavura’s “Naturopathy vs. Science” series here on SBM and former naturopath Britt Hermes blog, Naturopathic Diaries.

  • Naturopathy save on health care costs.

You can reduce health care costs to zero by simply not providing any care. Savings alone don’t mean that good care is being provided.

  • Naturopathy is cost effective.

As Scott Gavura explained, you can’t call CAM cost effective unless it’s actually effective, and what naturopaths typically offer the public simply isn’t science or evidence-based.

  • Naturopaths can help with the opioid crisis.

Again, no evidence.

  • Naturopaths treat the “root cause,” not just the symptoms, like medical doctors do.

This is a bit of alternative medicine nonsense nicely debunked by Harriet Hall.

  • Naturopaths have the same basic training as MDs and DOs, the “only difference” being in clinical training.

Putting aside the fact that the 15,000-hour difference in clinical training creates an enormous experience gap between medical doctors and doctors of naturopathy, former naturopathic doctor Britt Hermes has meticulously dissected naturopathic claims to medical school equivalency and found them wanting.

  • Naturopaths can effectively address chronic disease.

As best I can tell, this claim is based on a single study of naturopathic treatment for cardiovascular disease, or, more accurately, lifestyle and dietary counseling sanitized of the quackery typically included in naturopathic practice, rebranded as “naturopathic medicine,” and added onto usual care provided by a medical doctor.

Unfortunately, the only person who showed up to speak against the bills was a representative from the state’s Physicians Assistants organization, who spoke both for the PAs and the state medical society. While he effectively countered some of the naturopathic claims (like there are “thousands of studies” supporting naturopathic treatments and the lie that medical doctors treat “only the symptoms” and not the cause of disease), the presentations were painfully lopsided. Legislators did not hear about the deleterious health effects (including death) suffered by naturopathic patients (also here and here) or of the conflicts between evidence-based medical advice and pseudoscientific naturopathic advice that complicates patient care (also here).

Naturopathic “doctors” are not primary care physicians

Despite what appeared to be credulous acceptance of the naturopathic talking points by legislators at both hearings, the bills were heavily amended and sharply curtailed the naturopathic scope of practice provided in the original versions, as well as adding important consumer protections.

HB 5474, as amended, passed in both houses of the Rhode Island General Assembly, and is eligible for the governor’s consideration. SB 327, as amended, passed in the Senate and is on the House’s consent calendar.

Assuming the governor doesn’t exercise her veto power, RI naturopaths will be able to “prevent and treat” any disease or condition in any patient of any age (including children, unfortunately) using:

education, natural substances and natural therapies to support and stimulate a patient’s intrinsic self-healing processes . . .

In other words, in a perfect example of Legislative Alchemy, the RI General Assembly has incorporated the long-discredited, pre-scientific notion of vitalism into state law.

While diagnosis is not specifically included in their scope of practice definition, they will be able to:

. . . order and perform physical and laboratory examinations for diagnostic purposes.

This will leave patients vulnerable to the sort of unvalidated testing naturopaths favor, like the already-mentioned salivary hormone testing and hair analysis for “heavy metals.” (One naturopath actually mentioned the widely-debunked heavy metal testing in her committee testimony as a reason naturopaths need the authority to do diagnostic testing.) They can then use these bogus results to prescribe dietary supplements, homeopathic remedies, botanicals, “neutriceuticals,” and other “natural” substances, as well as nonprescription drugs, all of which are allowed by the amended bills. These can be dispensed or ordered using oral, nasal, auricular, ocular, rectal, vaginal and transdermal routes of administration, but can be administered only using transdermal routes of administration. Naturopaths will also be able to use hydrotherapy (which includes colon hydrotherapy aka enemas) and naturopathic musculoskeletal mobilization.

Fortunately, RI naturopaths will not be able to prescribe drugs. They are also prohibited from:

. . . advis[ing] patients regarding prescription drugs beyond possible dietary supplement/herb-drug interactions.

Importantly, this will prohibit them from advising against immunization, because vaccines are prescription drugs. Given naturopathic anti-vaccination ideology, this is vital for consumer protection. Nor will they be able to advise patients to forego prescription hormone therapy in favor of desiccated animal glands, which are sold as dietary supplements and promoted by naturopaths as a “natural” treatment for thyroid disease.

Thankfully, the bills also make it absolutely clear that naturopaths are not primary care physicians. They cannot:

. . . practice or claim to practice as a medical doctor or physician, . . . a primary care doctor, a primary care practitioner, a primary care provider [or] a primary care naturopath . . .

Because of this, RIANP may be required to change its name, as has happened in Maryland and California, other states where naturopaths are not allowed to call themselves “physicians.”

In addition, naturopaths must have a written collaboration and consultation agreement with a licensed physician. Patients must read and sign a consent form that includes this information:

Rhode Island does not recognize doctors of naturopathy as primary care providers and a doctor of naturopathy is not responsible for the overall medical care of any patient.

Naturopathic care is intended only as an adjunct to, and not a substitute for, medical care . . . and doctors of naturopathy shall coordinate patient care with physicians and other health care providers.

Patients are urged to have a primary care provider and to have all specialty care provided by a properly credentialed physician specialist.

All questions regarding prescription medications should be directed to the prescriber or the patient’s primary care provider or licensed registered pharmacist.

They are also prohibited from making “willful misrepresentations in treatments,” raising the possibility that telling patients obvious falsehoods, such as a diagnosis of “adrenal fatigue” or “chronic candidiasis” would be subject to disciplinary action. On the other hand, one would be hard pressed to concoct a more scientifically dubious misrepresentation than homeopathy, which is specifically permitted.

A major weakness in the bills is that they create a Board of Licensure for Naturopathy consisting of two naturopaths, two physicians and one public member, appointed by the Director of the state department of health and approved by the Governor. The effectiveness of this board will hinge on appointing physicians who are not naturopathic sympathizers and who are familiar with their pseudoscience, as well as a public member who is not so enamored of naturopathy and so unschooled in science that he or she will automatically side with the naturopaths.

The Board will have the authority to adopt rules and regulations for the practice of naturopathy, investigate possible disciplinary violations and recommend the commencement of disciplinary proceedings to the Director, and approve continuing education courses. They also have the power to approve a licensing exam. I imagine the naturopaths will try to get the Board to sign off on using the NPLEX, which was created by and for naturopaths without outside expert analysis, but I hope the physicians and public member will demand to see and evaluate the NPLEX before agreeing to an exam. If they do so, they will become, to my knowledge, the first people outside of naturopathy ever to lay eyes on the exam.

Another weakness is that naturopaths are held to a naturopathic standard of care, which doesn’t seem to exist. The bills would subject naturopaths to discipline if they fail to practice naturopathy:

. . . with the level of care, skill, and treatment that is recognized by a reasonably prudent similar doctor of naturopathy as being acceptable under similar conditions and circumstances.

Given the wide range of quackery they regularly practice, it is difficult to imagine what might not be “acceptable” to a naturopath or how one might go about defining what a “reasonably prudent” naturopath is.

It is not difficult to imagine what happens next: RI naturopaths will be back year after year pestering legislators to expand their scope of practice. They always do.

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.