States license “complementary and alternative” (CAM) practitioners (chiropractors, naturopaths, acupuncturists/TCM practitioners and homeopaths) via the magic of “legislative alchemy.” Ironically, licensing statutes are enacted based on the states’ constitutional power to protect the health, safety and welfare of the public. Yet these CAM practice acts actually increase public vulnerability to unsafe and ineffective health care practices. It is, in short, a bad idea. (A point we’ve discussed many times on SBM.) Here are six reasons why. Feel free to add to the list.
1. Practice acts grant CAM practitioners a broad scope of practice, including legalization of scientifically implausible and unproven (or disproven) diagnostic methods, diagnoses and treatments.
Like medical doctors, dentists and nurses, CAM practitioners must practice under licensing legislation, also referred to as a practice act. Otherwise, they risk prosecution for the unlicensed practice of medicine or other licensed profession unless they are exempted by one of the so-called “health freedom” laws, which basically give everyone the right to practice medicine.
Chiropractic practice acts incorporate the absurd notion that patients are suffering from “subluxations” that adversely affect their (or their children’s) health. Acupuncture practice acts are based on the equally absurd notion that the body contains “meridians” which, when blocked, cause ill health, but can be relieved by sticking people with needles. Naturopaths can diagnose and treat conditions they invented out of whole cloth, such as chronic yeast overgrowth, ubiquitous “food sensitivities,” and adrenal fatigue. Homeopaths can treat patients with expensive little bottles of water. (You can find out much more about these CAM practices in the pull-down menu accessed via the “Categories” tab to the right of this post.)
Although there are exceptions, most practice acts grant CAM providers the right to diagnose and treat any patient, no matter what age or physical condition, suffering from any disease or condition, as long as the disease or condition is described in the terms of the practice act and the treatment is within the scope of practice. This is perhaps best illustrated by examples. Suppose a patient sees a chiropractor for vertigo. The chiropractor is legally allowed to diagnose the cause of vertigo as one or more subluxations of the spine and to treat the patient with adjustments. What if the patient sees an acupuncturist? If the acupuncturist diagnoses blockage of “qi” as the cause of vertigo and performs acupuncture to unblock the “qi,” the acupuncturist has done nothing outside his scope of practice. And if the patient sees a naturopath? The naturopath is free to diagnose, for example, “toxins” as the cause of the vertigo and proceed to treat these toxins with colonic irrigation. How about a homeopath? Same result: the patient is treated with what is essentially water. None of this will address the patient’s vertigo but it is all perfectly legal.
There is no better way to demonstrate the legalization of quackery accomplished by licensing legislation than to quote from the law itself. A few examples:
Nevada: Defines “homeopathic medicine” or “homeopathy” as
employing substances . . . [p]repared according to homeopathic pharmacology by which the formulation of homeopathic preparations is accomplished by the methods of Hanemannian dilution and succession or magnetically energized geometric patterns applicable in potencies above 30X, as defined in the official Homeopathic Pharmacopoeia . . . and . . . prescribed . . . in accordance with the principle that a substance which produces symptoms in a healthy person can eliminate those symptoms in an ill person.
Nevada’s homeopathy practice act also permits “cell therapy, neural therapy, . . . neuromuscular integration, [and] orthomolecular therapy. . .” [As is the case with other terms in CAM practitioner statutes, I do wonder what “magnetically energized geometric patterns” are and how they are “applicable in potencies above 30X.”]
North Carolina: Defines the practice of chiropractic as
[T]he science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.
Colorado: It is distressing to report that the Colorado’s naturopathic licensing bill was passed by the legislature and signed by the governor. It defines the practice of “naturopathic medicine” in a broad fashion typical of naturopathic licensing statutes:
A system of health care for the prevention, diagnosis, evaluation, and treatment of injuries, diseases and conditions of the human body through the use of education, nutrition, naturopathic preparations, natural medicines and other therapies, and other modalities that are designed to support or supplement the human body’s own natural self-healing processes.
2. CAM practitioner education is inadequate preparation for the scope of practice permitted.
Almost without exception, state statutes simply require that a CAM practitioner have graduated from a school accredited by an accrediting agency approved by the U.S. Department of Education. These accrediting agencies are run by the schools and practitioners themselves. And while the Department gives lip service to the goal of assuring educational “quality,” it does not address the scientific validity of what these schools teach. Nor does it have jurisdiction to determine whether further clinical education is necessary for practice after graduation. While medical doctors and osteopaths must complete an additional three years to practice as primary care providers in a grueling residency program, no such residency requirement exists for CAM providers. In addition, these CAM schools have low admission requirements compared to medical schools. For example, unlike medical and other professional educational institutions, there is no admissions test.
CAM providers also create their own licensing exams – exams which are not vetted by, or have even been seen by, outside sources. And, because there is no residency requirement, unlike medical doctors there is no further testing for licensing eligibility during residency training.
Yet, as noted elsewhere in this post, some states specifically allow practitioners to practice “primary care” – like M.D.s and D.O.s – without nearly the quality, or quantity, of education and training medical doctors must have. As discussed in a previous post, chiropractors are now promoting themselves as primary care physicians, in the form of “advanced practice chiropractors.” This includes the right to prescribe certain drugs, including drugs no respectable physician would use, based on a flimsy prescription drug education course.
The only fact-based, well-reasoned analysis of CAM practitioner education I’ve ever seen was done by SBM’s own Kimball Atwood, M.D. In 2001, he authored a scathing analysis of the practice of naturopathy and the insufficiency of naturopathic “medical” education. Unfortunately, he and Arthur Relman, M.D., members of a 2001 committee created to vet the possibility of licensing naturopaths in Massachusetts, ended up issuing a minority report opposing naturopathic licensing due to the bias in favor of licensing apparent in other members of the committee. Dr. Atwood chronicled his experience for SBM readers, as well as the many foibles of naturopathic practice, in posts collected here. (Fortunately, naturopaths still aren’t licensed in Massachusetts, although they came awfully close last year. This year brings a fresh attempt.)
3. The fox is allowed to guard the henhouse (self-regulation).
CAM practitioner licensing acts typically allow self-regulation via boards empowered to enact rules governing practice and to discipline practitioners, in the same fashion as medicine, nursing, optometry and similar boards regulate the practice of other professions. These boards are usually made up of practitioners and a couple of public members. In turn, the boards, in some cases, simply default to the CAM schools and trade associations to set standards for education and practice. In addition, via their authority to enact rules, the boards are able to approve even more quack practices not specifically mentioned in the practice acts. Boards can administer, without answering to anyone, a light hand in disciplining practitioners even in the most egregious of cases. In other words, the fox guards the henhouse.
Some examples:
Nevada: In case you have not heard of some of the homeopathic practices permitted by Nevada law (see above), these Nevada Administrative Code regulations enacted by the Board of Homeopathic Medical Examiners fill in the gaps.
“Neuromuscular integration” is “the progressive harmonization of the endocrine system, immune system, autonomic nervous system, skeletal system and smooth muscle system of a patient with the cognitive and noncognitive faculties of a patient.”
“Orthomolecular therapy” is “the treatment and prevention of disease, including, without limitation, infection, malignancy and degenerative illness, by adjusting the natural chemical constituents of the body on the molecular level.”
Other permitted homeopathic treatments are defined as well, including the use of “bio-oxidative substances” which are “used to promote healing at the cellular level by the use of oxygen in its various forms” and “thought field therapy,” defined as “a technique that uses the energy meridians of the body which are used in acupuncture . . . to treat abnormal patterns of thought that cause emotional and psychophysiological distress.”
Alaska: Chiropractic-board-approved “specialty programs” include the “Chiropractic Diagnosis and Management of Internal Disorders (DABCI) program administered by the American Chiropractic Association Council on Family Practice” and the “Certificate in Chiropractic Pediatrics program administered by the International Chiropractors Association (ICA) Council on Chiropractic Pediatrics.” (The “D” in “DABCI” stands for “Diplomate.”)
California: Regulations enacted by the chiropractic board state that a “duly licensed chiropractor may treat any condition, disease, or injury in any patient, including a pregnant woman, and may diagnose, so long as such treatment or diagnosis is done in a manner consistent with chiropractic methods and techniques and so long as such methods and treatment do not constitute the practice of medicine by exceeding the legal scope of chiropractic practice . . .”
Oklahoma: The chiropractic board defines “scope of practice” to include all diagnostic methods and treatments “taught by an accredited chiropractic college and approved by the Board of Chiropractic Examiners.” As well, chiropractors are authorized to use naturopathic and homeopathic remedies.
4. Mandatory public and private insurance coverage
Once licensed, CAM providers inevitably lobby for mandatory public and private insurance coverage. (This sharing of CAM costs via insurance premiums and tax dollars is in addition to the billions Americans spend each year on “alternative medicine.”) For example, Florida law mandates that whenever an insurance policy “provides for the payment of medical expense benefits or procedures” the policy “shall be construed to include payment to a chiropractic physician who provides the medical service benefits or procedures which are within the scope of a chiropractic physician’ license.” Coverage of such services under Florida’s no-fault insurance law saw chiropractors, acupuncturists and massage therapists become the top-paid providers under the program, an unsustainable situation recently addressed by the state legislature.
As another example, in Oregon naturopaths and acupuncturists are covered providers under a publicly funded medical assistance program for Native American patients. As we have seen, naturopaths are now demanding that they be permitted to practice in coordinated care practice groups serving Medicaid patients, even though they reject evidence-based medicine, a quality and cost-saving requirement of all practitioners per Oregon law.
The Affordable Care Act (ACA) may exacerbate this problem via its non-discrimination provision (Section 2607), which prohibits discrimination against any health care provider who is acting within the scope of his or her license. Inclusion of CAM in essential health benefits and as providers in practice groups per the ACA may offer additional means of accessing insurance dollars. California already includes acupuncture as an essential health benefit under the ACA and other states include chiropractic.
5. Licensing confers undeserved legitimacy causing public confusion.
Once licensed, CAM practitioners enjoy an imprimatur of legitimacy as “doctors.” This causes public confusion about who is a medical doctor and who is another type of practitioner. This is no doubt exacerbated by the fact that many statutes defined CAM practitioners as providers of “primary care.” And some statues permit practitioners to call themselves “physicians.”
This status as “doctors” and “physicians” allows practitioners to insinuate themselves into other situations formerly denied them. For example, some states allow chiropractors to perform sports and school physicals. Arizona’s regulations governing child care group homes includes in its definition of “physician” persons licensed to practice “naturopathic medicine” and “homeopathic medicine.”
6. Licensing decreases important health care consumer protections.
Incorporating pseudoscience into practice acts and permitting self-regulation decreases consumer protection. Obviously, if the state chiropractic practice act permits the detection and correction of subluxations, a chiropractor is not going to be disciplined by the state chiropractic board for detecting and correcting subluxations, even though there is no such thing as subluxations and they cannot be detected. If the patient attempts to sue a chiropractor for fraud in a civil action, the chiropractor can raise the affirmative defense that he is permitted to detect and correct subluxations under state law.
Once CAM practitioners are licensed and governed by their own boards, the medical boards have little authority to prosecute these practitioners for the unlicensed practice of medicine. Even in the rare case where the medical board might attempt it, the CAM practitioner will raise the defense that his practice is exclusively under the jurisdiction of their state board.
And there is that most egregious assault on the health care consumer in the form of “health freedom” statutes. Unfortunately, another state’s citizens are now subject to the imaginative treatments of charlatans: the “Colorado Natural Health Consumer Protection Act, or, as I prefer, the Quack Full Employment Act, recently passed the Colorado legislature and was signed by the governor. This statute (as do others) almost completely removes the despicable snake oil salesmen who prey on the sick from the jurisdiction of the medical board.
A couple of cases highlight how consumer protection has been sacrificed by the legalization of quackery.
In Yow v. Dept. of Health, the Washington Court of Appeals upheld a state medical board finding that Yow, a practitioner of colonic irrigation who did not hold any sort of health care practitioner license, was engaged in the unlicensed practice of medicine. The court also upheld a fine of $444,000.
Testimony before the medical board revealed that Yow claimed colonic irrigation would purge accumulated “toxins” and referred to irrigation as a “detoxification process.” He sometimes added herbs to the water used for irrigation.
Yow admitted that the benefits of colonic irrigation were “anecdotal.” A gastroenterologist testified that the procedure carries the potential for colonic perforation and that introduction of herbs into patients’ colons could cause side effects, such as difficulty breathing, and may result in allergic reactions. This expert also testified that irrigation creates a risk of electrolyte shifts and subsequent cardiac arrhythmias.
But note that colonic irrigation is perfectly legal in Washington if performed by a licensed naturopathic doctor, as is true in any state that licenses naturopaths. In Florida, massage therapists are licensed to perform colonic irrigation. The facts have not changed: there is no evidence of effectiveness (anecdotes are not evidence), “toxins” are not removed by the procedure (not that toxins are present in the first place), and there are recognized risks. The only difference is the legality of the procedure.
In Ames v. Dept. of Health, the Washington Supreme Court upheld the state’s imposition of sanctions against Ames, an M.D., for falling below the standard of care for medical doctors and use of an ineffective device. Ames used a galvanic skin response device to diagnose and treat patients. The inventor of the device himself testified at the hearing that the machine – called “LISTEN” – was a biofeedback device and not approved by the FDA for the diagnosis and treatment of disease. According to testimony at the administrative hearing:
Ames instructed P1 [Patient 1] to lie on his back while holding a small brass probe in his hand. The probe connected to LISTEN. While P1 lay prone, Ames performed a basic muscle resistance test by asking P1 to resist downward pressure on his upraised forearm, which P1 ably achieved. Next, Ames typed the word “eggs” into LISTEN’s computer interface and performed the resistance test again. Apparently, Ames was able to force P1’s arm down.
Based on this absurd test, Ames diagnosed the patient with egg allergies.
The LISTEN machine, as employed by Ames, is a type of electrodermal diagnostic device. According to Quackwatch:
Thousands of practitioners use “electrodiagnostic” devices to help select their recommended treatment. Many claim to determine the cause of any disease by detecting the “energy imbalance” causing the problem. Some also claim that the devices can detect whether someone is allergic or sensitive to foods, deficient in vitamins, or has defective teeth.
Yet the Arizona Board of Homeopathic and Integrated Medicine Examiners not only approves the use of electrodermal testing, it also permits “homeopathic physicians” to train persons not registered by the Board in this testing by providing “180 hours of homeoptherapeutic instruction and 100 hours of supervised clinical experience.” Likewise, the Florida Board of Acupuncture rules provide that “traditional Chinese medical concepts and modern oriental medical techniques shall include . . . electrodermal screening.”
There is also the problem posed by an amorphous standard of care when a patient sues the CAM practitioner for malpractice. As Bob Baratz, M.D., D.D.S., pointed out in a recent discussion of CAM practitioner licensing acts:
One only has to go as far as the basic textbooks of naturopathy to see that these are not centered on a theme of method, so much as they are a collection of a hodge-podge of “treatments” without following the basics of medical care. At a minimum these should be: defining the condition with a set of criteria which any practitioner could see and evaluate, defining the condition being treated with knowledge of the natural history of this condition/disease/malady when untreated, and then confirming a diagnosis with physical examination and confirmatory tests, followed by a treatment plan which could then be objectively assessed with objective criteria of success or failure of the treatment.
This is equally true of subluxation-based chiropractic, acupuncture and homeopathy. And this lack of a systematic approach presents a problem: an incoherent system necessarily creates an incoherent standard of care. If each naturopathic treatment is “individualized,” how can there be a standard of care applicable to all patients? How could a chiropractor possibly fall below the standard of care for detection of subluxations when there are no reliable parameters for diagnosing a subluxation? And how would one ever determine whether “qi” is successfully unblocked when there is no “qi” in the first place?
Conclusion: A single standard of care excludes unscientific practitioners
An Institute for Science in Medicine policy statement, “State Licensing and Regulation of CAM Practitioners,” succinctly summarizes many of the points I’ve made in this post and correctly concludes:
The world’s health care systems need to be rooted in a single, science-based standard of care for all practitioners. Effective, reliable care can only be delivered by qualified professionals who practice within a consistent framework of scientific knowledge and standards. Practitioners whose diagnoses, diagnostic methods, and therapies have no plausible basis in the scientific model of medicine should not be licensed by any government, nor should they be allowed to practice under any other regulatory scheme. Any statute permitting such practices should be amended or repealed as necessary to achieve this policy. Unscientific practices in health care should further be targets of aggressive prosecution by regulatory authorities.
