UPDATE: Unfortunately, Gov. Baker signed the bill on January 11th. We’ll be watching, and reporting, as naturopathic quackery spreads throughout Massachusetts.
The Massachusetts Legislature (formally known as the “General Court”) passed a licensing bill for naturopaths on January 3, 2017. (Orac covered the bill’s passing as well.) The bill is now on the Governor’s desk for consideration. We’ll get to the legislative machinations behind the bill in a minute, but first let’s look at some key provisions of the bill and what they mean in actual practice.
Definition of naturopathy
Naturopathy is defined in the bill as
a system of health care practices for the prevention, evaluation and treatment of illnesses, injuries and conditions of the human body through the use of education, nutrition, natural medicines and therapies and other modalities which are designed to support, stimulate or supplement the human body’s own natural self-healing processes.
What this means
Stimulating the body’s “natural self-healing processes” is vitalism, a long discredited, pre-scientific notion that there is some incorporeal force operating outside the realm of scientific knowledge controlling human bodily function. Massachusetts naturopaths will be free to discard evidence-based medicine and even the most basic principles of chemistry, biology and physiology, as long as they believe that this mythical force, which they call “vis,” is at work via their treatments.
While they are prevented by this bill from claiming they are physicians or practice primary care, this definition essentially obliterates any patient protection offered by those restrictions by giving naturopaths the right to diagnose and treat any disease or condition in any patient of any age. Comments like that of a physician quoted in the Boston Globe‘s story on the bill ignore this reality:
Dr. Michelle Dossett, a Massachusetts General Hospital internist who specializes in mind-body medicine, said that naturopaths often do a better job than physicians at ‘using lifestyle-based approaches to prevent and help to manage chronic disease.’
Even if that were true (which it isn’t, a point we’ll return to shortly), the Massachusetts Legislature isn’t limiting naturopaths to “life-style approaches to prevent and help manage chronic disease.” Instead, without limitation, naturopaths will be able to diagnose and treat what is known as the “undifferentiated patient” – anyone who walks in the door with a collection of symptoms, challenging the health care practitioner to figure out what those symptoms mean. The patient could have, for example, undiagnosed cancer, diabetes, hypertension, epilepsy, AIDS or a host of other infectious diseases, COPD, asthma, allergies, MS or other challenging-to-diagnose neurological disease. MDs and DOs spend thousands of hours in residency learning to evaluate and treat these diseases and, importantly, learning when to refer and to whom. Naturopaths do not do residencies. Their education and training is woefully inadequate to diagnose, manage or know when to refer these patients, a topic we’ll return to later.
The bill allows naturopaths to use
non-invasive physical examinations and the ordering clinical and laboratory procedures from licensed clinics or laboratories to evaluate injuries, illnesses and conditions in the human body.
What this means
The use of unproven tests to diagnose fake diseases and conditions is the bread and butter of naturopathic practice, and this bill allows it. The mere fact that a clinic or lab is “licensed” does not mean that the testing it offers is legitimate.
It is well-documented that naturopaths employ an array of bogus tests to “diagnose” patients with fabricated diseases and conditions. These include:
- IgG food allergy/intolerance testing
- Hair analysis
- Salivary hormone testing
- Bioidentical hormones
- Blood nutrition analysis
- Electrodermal screening
- MELISA testing
- Autonomic response testing
- MTHFR genetic testing
- Various tests for “toxins”
- Live blood analysis
The bill says naturopathic practice includes
the prevention and treatment of human illness, injury or disease through education, dietary or nutritional advice and the promotion of health ways of living.
Natural medicines of mineral, animal or botanical origin, including food products or extracts, vitamins, minerals, enzymes, digestive aids, natural hormones, plant substances, homeopathic preparations [and] natural antibiotics. . . to prevent or treat illnesses, injuries and conditions of the human body.
What this means
Again, the bill gives naturopaths an extremely broad scope of practice: the treatment of any disease or condition in any patient of any age, essentially the same as an MD or DO. Treatment of fake diseases and substandard treatment of real diseases and conditions are endemic to naturopathic practice, and this bill does nothing to prevent it. Thus, far from “using lifestyle-based approaches to prevent and help to manage chronic disease,” naturopaths actually convince patients they are ill when, in fact, they may be perfectly healthy. Some examples of fabricated diseases and substandard treatment of real diseases:
- “Wilson’s temperature syndrome“
- “Chronic candidiasis“
- “Adrenal fatigue“
- Hypothyroidism (pseudoscientific version)
- Bipolar disease
The difference between physician scope of practice and naturopathic scope of practice is in the limitation on the methods of treatment they can use. Here lies another central fallacy of naturopathic licensing: that somehow preventing or treating disease with “natural” remedies is as effective as, but less dangerous than, using prescription drugs, so we should give naturopaths carte blanche to use “natural” remedies to treat real diseases.
Neither is true. In fact, among the substances listed in the bill, with limited exceptions for real vitamin deficiency (rarely seen in the U.S.) and a handful of other situations (like folate supplementation in pregnancy), the majority do not have an adequate body of evidence supporting their use and some are downright worthless, but are used by naturopaths in practice anyway (also here). One of those in the “worthless” category is homeopathy, a staple of naturopathic practice. Another is “ozone therapy.” Other problematic remedies include “natural hormones” and glandulars (desiccated animal glands), used to treat endocrine conditions. Both are considered substandard in medical practice. Dietary supplements, a category that encompasses vitamins, minerals, botanicals and enzymes, are not required to be tested for safety or efficacy prior to sale and contamination is an issue (also here).
Naturopaths will be able to sell these “remedies” to patients, at a tidy profit.
Dr. Dossett and others who think naturopaths simply offer “lifestyle recommendations” to manage chronic disease should read the accounts of three patients (here, here and here) whose chronic conditions were grossly mismanaged using naturopathic regimens typical of their grab-bag approach to patient care. (For even more dubious naturopathic practices, see here.)
The bill also allows “naturopathic physical medicine.” Significantly, physical medicine includes “hydrotherapy,” which means naturopaths will be able to employ “colonic irrigation;” essentially, a big enema. The purpose of colonics, in the naturopathic mind, is to remove ubiquitous “toxins” (never specified and never identified upon their supposed removal) that naturopaths believe are lurking in our digestive systems and elsewhere. This is not only useless, it carries the risk of bowel perforation, infection and depletion of electrolytes. Other naturopathic means of “detox” include ingestion of unproven herbs and sitting in saunas.
Restrictions on practice
In addition to preventing them from calling themselves “physicians” or claiming they practice primary care, naturopaths must track and document their patient’s immunization status and refer patients to a primary care practitioner when the patient has not been fully immunized. They may not prescribe drugs or practice surgery.
What this means
It is well documented that naturopaths are anti-vaccination (also here, here, here, and here) and the Massachusetts Legislature tacitly acknowledges this fact in the bill. It is disturbing that the legislators were well aware of naturopathic anti-vaccination ideology, yet chose to allow them a broad scope of practice and self-regulation.
The American Association of Naturopathic Physicians desires full primary care scope of practice in all 50 states, including full prescription privileges. Their strategy has been to accept more limited scope initially, then come back to the legislature for prescription privileges, or expanded prescription privileges, year after year. We can rest assured that they will do the same in Massachusetts.
Requirements for licensure
Naturopaths must have graduated from a four-year naturopathic school and must take an exam for licensure. While the bill allows regulators to create their own exam, it also permits them to use the NPLEX, which is created by naturopaths. (This is the option I imagine regulators will choose.) Licensure by reciprocity is also allowed. No malpractice insurance is required.
What this means
No one outside of naturopathy has ever seen a copy of the NPLEX exam nor has it ever been evaluated by outside experts for its scientific quality, or lack thereof. Given the combined factors of poor employment prospects elsewhere, the lack of licensure in other states, and the extremely generous scope of practice granted by this bill (other states have a more restricted practice), Massachusetts can expect more naturopaths to move to the state.
While naturopaths tout their education and training as equal to that of a primary care physician, this is a gross misrepresentation. The best source of accurate information on the subject is Britt Hermes, a former licensed naturopath who quit after becoming disgusted and disillusioned with her chosen profession. She has spoken out forcefully, and effectively, against licensing naturopaths and practice expansion. I can do no better than to refer you to her posts on naturopathic education and training on her own blog, Naturopathic Diaries.
The bill creates a five-member naturopathic regulatory board, which will write regulations governing naturopathic practice, including “requirements for a specialty practice.” The Board will also approve continuing education courses, establish a code of ethics and oversee disciplinary proceedings. The Board will consist of two naturopaths, one physician who has experience working with naturopaths, one clinical pharmacologist and one public member.
What this means
Having a physician on the Board experienced in working with naturopaths is likely designed to ensure that a sympathetic “integrative physician” who also incorporates pseudoscience into his or her practice will apply and be appointed. That means the clinical pharmacologist may be the sole voice of science and evidence on the board. It is also possible that naturopaths will urge patients sympathetic to naturopathy to apply for the public member seat. Based on personal knowledge of the situation, this is what happened in Maryland, where the public member voted with the two naturopathic members and against the two physician members of a naturopathic advisory committee time and again.
Because naturopathy has no discernible standard of care and naturopaths do not practice evidence-based medicine, the board will have little to guide it when deciding complaints against naturopaths for substandard care. One wonders whether, except in the case of some sort of gross incompetence, a naturopath would ever be disciplined for malpractice, because malpractice doesn’t seem to exist in the naturopathic mindset. If there isn’t a standard of care, how does one fall below it? For example, an Arizona naturopath was caught illegally importing and giving patients a cancer drug that had not been approved by the FDA, but was only lightly disciplined.
Some naturopaths claim they are “specialists” in cancer and pediatrics, although they do not do real medical residencies or fellowships in these specialties. This provision means that the board will have the power to determine what “specialties” naturopaths can claim in advertising and what requirements (if any) these “specialists” must fulfill.
Based on the Multistate website’s calendar of legislative sessions, I was under the impression that the Massachusetts legislature adjourned December 31, 2016, and therefore the bill was dead. This is incorrect, and I apologize to any readers who were misled by that information. In the future, I will use a more reliable calendar.
Even so, the bill’s transformation from languishing in committee to a lightning-speed trip through the Legislature does raise suspicions that the legislators were less than well-informed about what the bill actually said and what it will do.
The Senate passed a naturopathic licensing bill in early June, 2016. The bill then went to the House, where it was referred to the House Ways and Means Committee on June 15. There it sat until January 3, 2017. Here’s what happened on that single day:
- Bill amended and reported out of the House Ways and Means Committee
- Bill referred to the House Steering, Policy and Scheduling Committee
- Bill went from that Committee through the three required readings before the House (Because the House was in informal session, no attendance was taken and no votes recorded.)
- House adopted an amendment to the bill
- House passed the bill and sent back to Senate
- Senate concurred in the House amendment (Because the Senate was in informal session, no attendance was taken and no votes recorded.)
- House enacted the bill
- Senate enacted the bill and sent to the Governor
The Governor could either sign the bill or veto it. Or, he could do nothing. If he chooses that option, according to the Massachusetts Bar Association, it either becomes law, after 10 days in which the Legislature is in session, or, if the Legislature has adjourned, it is “pocketed vetoed” after 10 days. The Legislature has adjourned the session in which this bill passed, although the effect of this is unclear. This is not the first time the Massachusetts legislature has engaged in last-minute legislative shenanigans in passing a naturopathic licensing bills. The last time this happened, then-Governor Deval Patrick vetoed it. A Boston Globe editorial urges the Governor to veto this bill as well. I agree. (You can reach Gov. Charlie Baker at 617-725-4005.)