Sisyphus
The Maryland Naturopathic Doctors Association is not pleased with the Society for Science-Based Medicine. Not at all.

That is a good thing, for several reasons. It demonstrates the importance of stopping naturopathic licensing (and practice expansion) legislation in the state legislatures. It shows how they handle legitimate criticism of their practices. And it is a lesson in their modus operandi of obfuscating the facts with platitudinous- but-vague pronouncements about their education, training and practice, pronouncements that wither under criticism.

Why is the MNDA so upset with the SFSBM?

We’ll answer that question soon, but some background first. The Maryland Legislature passed a naturopathic licensing bill this year. Fortunately, as I’ve written, the Legislature didn’t give naturopaths everything they wanted, such as the right to prescribe real drugs. That’s not stopping them from coming back to the Legislature to revisit the issue. According to naturopathic school Bastyr’s website:

The [Maryland] law limits some parts of the naturopathic scope of practice — such as intravenous (IV) therapies and prescription drugs — that the state association will work to secure in the future.

Instead of giving naturopaths their own regulatory board, like they wanted, the Legislature put them under the authority of the Maryland Board of Physicians. The Legislature created a Naturopathic Advisory Committee to recommend regulations governing naturopathic practice to the Board. The Maryland Naturopathic Doctors Association (MNDA) states, incorrectly, on its website that the Committee will actually be promulgating the regulations and implementing the law. The statute is quite clear that this is not the case. Those duties are entirely within the jurisdiction of the Board.

The Committee consists of two medical physicians, two naturopaths and one public member. It has met several times, with the next meeting scheduled for December 19th.

The Society for Science-Based Medicine took this as an opportunity to insert a much-needed dose of reality into the regulatory process. In October, we presented a Report to the Naturopathic Advisory Committee documenting how Maryland naturopaths are currently practicing, even before a licensing law goes into effect, which won’t be until March, 2016. We also recommended specific regulations. We’ll get to the substance of the report in a minute. (You can access the report on the SFSBM’s website.)

The naturopaths and their lobbyist had been meeting with legislators for several years. From what I can tell, their plan was to present themselves as benign souls who were simply interested in health promotion and disease prevention and were all about collaboration with other health care professions. This is in accordance with the public persona created by such groups as the American Association of Naturopathic Physicians (AANP) and the MNDA, as well as their schools.

The naturopaths also took legislators on a field trip to the Casey Health Institute, an “integrative” practice in Maryland which employs a naturopath, Carrie Runde, whom you’ll see again later in this post. One can’t help but notice the tight reins Casey keeps on its staff naturopath compared to the scope of practice allowed in the new law. According to the website:

Dr. Runde works with people to achieve success in the foundations of health and wellness, working on diet, stress management, sleep habits, and movement.

It will be interesting to see whether Casey allows her practice to expand to the full extent permitted, such as seeing patients without MD supervision and ordering sophisticated diagnostic tests, in 2016.

Not so pretty

The reality, of course, is much different. Or, as my grandmother used to tell me, “pretty is as pretty does.” As we’ve documented time and again at SBM, naturopaths regularly employ quack treatments and diagnose patients with fake diseases. Even though they are few in number and have few patients, we at SBM have considered naturopaths and their expanding attempts to gain full primary care practitioner status a sufficient concern to warrant numerous posts. No one could come away from Scott Gavura’s excellent series, Naturopathy v. Science, and think naturopaths (including those with a four-year naturopathic “medical” education) are competent to diagnose and treat patients. Or David Gorksi’s chilling post revealing what naturopaths say to each other when they think no one is listening. (And Orac’s as well. Also here.) Finally, because Maryland naturopaths want the right to perform Pap smears, I’ll mention one more: Harriet Hall’s post on the naturopath who thought she’d cured cervical dysplasia. (She didn’t.)

A few simple internet searches will reveal what they are actually up to. So, that is what we at SFSBM did. We looked on the MNDA’s website and got the names of their members. Then we looked at the members’ websites (links for which are provided by the MNDA). And there it was. Many of the same unproven and disproven diagnoses and remedies we’ve discussed here at SBM were hiding in plain sight.

I won’t go into all the naturopathic websites, but here are some highlights from state naturopathic leaders. (The websites were accessed in September. They may have been changed, especially in light of the Report.)

Kevin Passero, ND, Advisory Committee chair:

“Natural treatment of hypothyroidism” includes “herbal therapy, vitamin/nutrient therapy, homeopathy and prescriptive thyroid hormones including natural glandular extracts and compounded thyroid hormone.” Criticizes standard medical diagnosis and treatment of thyroid disease.

Prescribes “bio-identical hormones”, claims that they do not have the same risks as prescription-only HRT [Editor’s note – they have the same risks because they are still hormones] and that their use can “reduce risk related to certain conditions including bone loss and even certain forms of cancer.”

Emily Telfair, ND, former president, MNDA:

Advertises “Fall Detox . . . adapted from Thorne’s MediClear Detox Plan.” According to the Thorne MediClear Detox website, “The MediClear Plus program is designed to do two things: first, to decrease your exposure to toxins and allergens, and second, to help your body cleanse.” [Editor’s note – “detox” is a marketing strategy pretending to be medicine] It is a “formula that blends a combination of rice and pea protein with a full complement of vitamins, minerals, amino acids, botanicals, probiotics, and other nutrients for the enhancement of detoxification.”

“Detox add-on kits” are also offered on Telfair’s website, which are “additional supplements to further enhance your detox experience.” These include “Belly Boost: To help aide digestion for those with sensitive stomachs.” “Liver Love: To help clear toxins while protecting the liver.”

Kristaps Paddock, ND, current president, MNDA:

“Homeopathy is a system of natural medicine [that] is used to treat a range of illnesses, from simple coughs to chronic conditions. It is known for . . . being able to alleviate symptoms where other treatments have been ineffective.” [Editor’s note – homeopathy doesn’t work]

In addition to exposing these practices, the Report provided an explanation, with citations, of what these treatments are and why naturopathic claims for them are unfounded. The Report does the same thing for each and every diagnosis and treatment quoted from Maryland naturopathic websites. Not surprisingly, in addition to these examples, we found naturopaths using biotherapeutic drainage, cranial-sacral therapy, alkaline diets, electrodermal screening, autonomic response testing, far-infrared saunas and chelation for improper purposes, use of DMSA challenge protocol, salivary hormone testing and blood nutrition analysis.

Our Report provided the Committee with recommendations for specific regulations to ensure that Maryland patients are not subjected to these fake diagnoses and treatments, some of which are dangerous. For example, we suggested that all continuing education courses be vetted by the Board. The MNDA’s CE offerings reinforced our point: “The Top Five Homeopathic Remedies in the Treatment of Depression” and “Naturopathic Treatment of Chronic Kidney Disease.” (More on the latter here).

The Report also urged the Committee to adopt a regulation recognizing a patient’s right to informed consent, which in Maryland means the health care provider must disclose:

the nature of the ailment, the nature of the proposed treatment, the probability of success of the contemplated therapy and its alternatives, and the risk of unfortunate consequences associated with such treatment.

Of course, many standard naturopathic treatments would be rejected if this information were given.

As one final example, because of naturopathic opposition to vaccination and other public health measures, the Report recommended that naturopaths be required to refer all questions regarding vaccination to the patient’s physician and that they not be allowed to give advice contrary to evidence-based based health care practices.

All in all, we at SFSBM are quite happy with our report. 25 pages (not including attachments) and 62 citations. And not a single challenge from naturopaths to our facts or citations of authority. Not bad for our first foray into the regulatory area.

Naturopaths take umbrage

And what was the naturopaths’ reaction to this? Professed shame at their dubious practices and a pledge to clean up their acts? No. Enthusiastic adoption of our perfectly reasonable suggestions for regulation? No. Even a teensy-weensy hint that SFSBM might have something worthwhile to say? No.

The MNDA’s reaction was to fire off a letter to the Board and Advisory Committee attacking the integrity of SFSBM and one of the Committee’s physicians, Gregory S. Pokrywka, MD, a private practitioner and an Assistant Professor of General Internal Medicine at Johns Hopkins, who supported our Report during Committee meetings.

The MNDA challenged the qualifications of Dr. Pokrywka to serve on the Committee and charged him with being “biased.” It said SFSBM was “comprised of unknown individuals in disparate parts of the country.” [Now, there’s a crime if I’ve ever seen one.] And they accused us of being founded recently “for unclear purposes.” [Suggestion: check out our website.] Accordingly, SFSBM should be “the subject of scrutiny.” [Fine with us.] We lack, per the MNDA, “an understanding of naturopathic training and practice” thus we “should not be consulted as a resource in the drafting of regulations.” [Actually, we understand these all too well, and we provided plenty of documentation regarding both.]

This is not the first time naturopaths have taken umbrage at criticism from the science-based community. Of course, what else can they do? I mean, the Report’s discussion of their practices came from their own words. We didn’t make anything up. We can’t help it if the authors of the journal articles and other sources we cited looked at the evidence and decided against the naturopaths. It’s not our fault. We didn’t come up with Avogadro’s number. Blame him.

We fired right back with our own letter:

we are not surprised that the MNDA has chosen to avoid a discussion of the extensive documentation concerning unproven, disproven and, in some cases, dangerous practices by Maryland license-eligible naturopaths. The MNDA’s recommendations wholly fail to address how the Board might ensure that these practices do not continue. Indeed, the MNDA’s recommendations would permit these very practices to continue unabated.

The MNDA has instead attempted to divert the attention of the Advisory Committee and the Board by attacking the integrity of both the Society and Gregory Pokrywka, M.D. We do not speak for Dr. Pokrywka, nor is he our representative at Board meetings, as the MNDA implies. We have no doubt he is perfectly capable of defending himself against the spurious charge that he is somehow unqualified to serve on the Advisory Committee or that he is “biased.” His concern for Maryland citizens who seek naturopathic treatment and his respect for the scientific method and evidence-based medicine are not “bias.”

You won’t be surprised to learn that the MNDA has come up with some regulatory suggestions of its own. They want to default to naturopathic organizations and naturopaths the authority that the Legislature has clearly placed with the Board of Physicians. Such as, they want all continuing education courses approved by the MNDA and the American Association of Naturopathic Physicians automatically accepted. They want a disciplinary committee made up of two naturopaths and one Board representative, even though the Maryland statutes clearly provide otherwise.

The new law says that their practices must be “consistent with naturopathic education and training” and gives the Board the authority to require additional testing and completion of more education and training before qualification for licensure. The MDNA wants none of it. They say it is “not necessary.” They want no restrictions placed on their diagnoses and treatment, except those clearly required by the statute, even though the Legislature has given the Board authority to do so.

The MNDA wants the AANP Code of Ethics, which consists of barely over 2 pages, adopted in their regulations as their ethical rules. And they want the State of Maryland (i.e., taxpayers) to finance, at no interest, their licensing fee ($5,140 initially; $4,000 renewal) over a 2 year period, a privilege not granted other licensed health care professionals nor one which finds any support in the law.

According to a another document submitted by one of the Advisory committee members (Runde, the naturopath), naturopaths want the authority to order:

Laboratory testing of all bodily fluids, blood, secretions, excretions, and human tissue . . . [and] obtain specimens for laboratory examination . . . [including but not limited to] phlebotomy, urinalysis, samples for bacterial culture, endothelial cells for pap test, and others [including] all CLIA-waive tests, which can be performed in-office.

And to the authority to perform:

All tests . . . to assess and diagnose physiological processes in all bodily systems.

Diagnostic imaging should, according to the naturopaths, include, but not be limited to:

X-ray, ultrasound, mammogram, bone densiometry [sic], CT scan, MRI scan, endoscopic exam, and all other forms of nuclear imaging.

They are not allowed to interpret these tests, but can interpret the reports. They also want access to the images themselves.

The definition of “electromagnetic energy” (which they are allowed to employ) should include (but not be limited to), they say:

Transcutaneous electrical nerve stimulation, microcurrent electrical muscle stimulation, diathermy, infrared, UV treatments, and other devices which utilize electrical or magnetic force for therapeutic effect.

This voracious appetite for sophisticated diagnostic tests belies the MNDA’s claim that naturopaths offer “clinical nutrition, herbal medicine, lifestyle counseling, homeopathy, naturopathic physical medicine and pharmaceuticals” (which the MNDA admits they “currently” can’t prescribe.) Why on earth do they need to order CT scans, mammograms and endoscopic exams for those tasks? (I do hope that, if these regulations stand, the health care professionals who actually perform these tests will refuse to do so without an adequate clinical rationale.)

So what is going on with the Advisory Committee? (I have not attended but I am relying on staff documents and the accounts of Dr. Pokrywka.) One of the 2 naturopathic members nominated the other (Passero) for Committee chair and that was seconded by the public member, Eldon Miller, Ph.D, who apparently is a mathematician. According to the minutes of the last meeting (Nov. 21), the vote was unanimous for Dr. Passero, although the accuracy of that report will be questioned at the next meeting, December 19th. The Society for Science-Based Medicine’s Report has been ignored, despite protestations from Dr. Pokrywka. On the other hand, the recommendations of the MNDA and naturopaths have been embraced.

The naturopaths were livid at the charge that they are anti-vaccination, vigorously denying it even though SFSBM provided copious evidence to the contrary. Dr. Pokrywka, quite sensibly, wanted a limitation on testing for fake diseases we discussed in the Report. The naturopaths didn’t.

They defended homeopathy, saying that “obviously” interventions like homeopathy are deemed safe because they are allowed in the statute regardless of SFSBM’s questioning their efficacy. And just because there is no evidence of efficacy, it doesn’t mean it’s not safe. In other words, whether it’s effective or not, you can prescribe it anyway. If that is the case, why bother with all the dilutions and succussions, and the bottling and labeling? Why not just give patients a glass of water? (Perhaps that would be an overdose?)

In meetings, Dr. Passero has run through the regulations proposed by the Board staff quite rapidly, with little discussion. The naturopaths and the public member have voted in lockstep. Dr. Pokrywka and Dr. Suresh Gupta, the other physician on the Committee, wanted regulations that would protect the public from naturopathic practices but were regularly overruled.

Unfortunately, while the staffs’ recommendations are not quite as liberal as the naturopaths’, it appears the naturopaths are getting most of what they wanted. That is, in part, due to the statute itself, which never should have been passed in the first place. In giving the naturopaths a broad scope of practice, the Board’s hands are someone tied, although not nearly to the extent the naturopaths would have the Committee think. But that is a legal argument best left to be made before the Board.

The Committee’s recommended regulations default to the AANP and MNDA to approve continuing education courses, as the naturopaths wanted. There are no further education and training requirements or limitations on their practice, other than those set by the statute. (Again, despite the fact that the Legislature gives the Board the authority to impose such requirements.)

Here is what is unclear to me at this point. The staff has provided a packet of documents for the December 19th meeting. One document is labeled “Revised Scope of Practice Definitions” but its source is not clear. It appears to me to be the work of the staff. If this is true, then it means that the Committee has approved regulations adopting the naturopaths’ recommendations regarding use of diagnostic imaging (including nuclear imaging) and physiological function testing, and its definition of electromagnetic energy. Who knows what quack diagnostic methods and treatments that might engender?

For the next meeting, the naturopaths have also submitted information “FYI” listing the courses they are required to take and the textbooks for that course from Bastyr, a list of course requirements from another naturopathic school, and the CNME’s accreditation standards. All of these are already available on the internet and tell us little of substance about naturopathic education and training. It’s simply what the naturopathic organizations are willing for the public to see. It does not include, for example, a copy of any past NPLEX exam or other sufficient detail for their education and training to be fully analyzed.

Fortunately, what really matters is what the Board does. It has ultimate authority to accept or reject any or all of the Committee’s proposed regulations. One hopes that the Board won’t abandon evidenced-base medicine and science for 19th century philosophy. We’d hoped that debate was settled in the last century.

 

 

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.