Mark Crislip, MD, SBM’s own infectious diseases expert, recently observed that he was increasingly seeing patients whose very real diseases are being managed with bogus naturopathic therapies, as opposed to his experience earlier in his career, where naturopathic treatment was more commonly in addition to medical management.
What to do when the patient has the ND not as a supplement to the real doctor, but the ND IS their doctor? I do not want to be complicit in approving ND care, but I may be the only ID doctor the patient can see and I want the patient to see a real doctor (me) so I can’t say no. But it is an awkward ethical position, participating in care that I know is bogus yet legal. I tend to feel a little weaselly with these cases, mostly ignoring the steaming pile of ND care in the room and focus on making sure the patient gets the best medical diagnosis and treatment I can provide. If asked about the ND care, I give an honest answer, but I do not go out of my way to discuss it. It is, I think, the lesser the two evils, but it leaves me feeling dirty.
He is not the first physician frustrated by dubious naturopathic diagnoses and treatments foisted on his patients. (See here, here and here.) As he observed, the problem is likely to get worse “as pseudo-medical providers increase their presence in health care.”
His observation has proved tragically prescient. Aided by the Oregon Legislature, and barring a veto by the Governor, the “steaming pile of ND care” is about to get a lot bigger and he and his fellow physicians (the real ones: MDs and DOs) are going to be wading in it big time.
Oregon already grants naturopathic doctors the same scope of practice as MD and DO primary care physicians, the most liberal among the 19 states that give naturopathy some form of legal recognition. But NDs weren’t satisfied with merely being able to practice primary care while at the same time skipping the rigorous requirements of medical school (entrance exams, high undergrad GPAs, tough science-based courses, meaningful clinical experience), validated testing of their knowledge, and thousands of hours of post-grad residency.
What was the source of this dissatisfaction? As in every state, Oregon’s laws have requirements that, when certain medico-legal issues arise, competent medical judgments must be made by those appropriately educated and trained to make them. For example, many states permit people to make what are often called “living wills,” directing their end-of-life care in case they are not able to communicate their wishes. Typically, living wills describe the circumstances under which a person no longer wants to receive further medical treatment, nutrition and hydration, even if it hastens death. To protect the patient, state law will require a physician to make the medical judgments necessary to determine key issues, such as whether the patient lacks the capacity to make decisions on his own, whether he has a terminal illness from which he is unlikely to recover and whether further treatment would be of any benefit. Other medico-legal issues include mental capacity in guardianship proceedings, eligibility for government services (such as special education) based on disability, and determinations of whether crimes such as sexual assault and child abuse have occurred.
Oregon NDs were miffed that they were being cut out of the decision-making and other benefits (such as eligibility for state employment as “physicians” and fees for some services) because state laws referred only to “physicians” or to physicians licensed as MDs and DOs, but not “naturopathic physicians,” making it unclear whether they were included. So, as they often do, the NDs went running to their friends in the state legislature. Having combed through the entire Oregon Revised Statutes and picked out the offending sections, they managed to get introduced a 79-page bill (Senate Bill 856) inserting “naturopathic physician” in all the relevant state laws. That bill just passed in the Oregon House and Senate and is on its way to the Governor for consideration. Having won primary care physician status via Legislative Alchemy, they are now bootstrapping themselves into every nook and cranny of the Oregon health care system. (SB 856 is but one of several naturopath-friendly bills pending in Oregon.)
The Oregon Association of Naturopathic Physicians (OANP) argued that this was not a scope of practice expansion, although both the (woefully inadequate) House and the Senate staff analyses appear to disagree. According to the OANP, even though NDs are “now recognized as primary care physicians,” the statutes “have not evolved to reflect the procedures and services that naturopathic physicians now provide.”
Before turning to these “procedures and services” NDs will now be able to legally provide (again, barring veto by the Governor), it is important to keep in mind a few points about naturopathic doctors:
- No independent professional evaluation of the adequacy of ND education and training to practice as primary care physicians (or as anything, for that matter) has ever been carried out. There is, however, considerable evidence that it is wholly inadequate to the task.
- There is not a shred of evidence that NDs can safely and effectively deliver primary healthcare services. There is, however, evidence that their care is substandard. (Also, here.)
- NDs have no discernible standard of care, reject evidence-based medicine, and, by all accounts, offer the public a plethora of dubious diagnoses and pseudoscientific treatments.
- Each of the privileges SB 856 grants to naturopathic physicians can be carried out by a graduate of a four-year naturopathic “medical” education program, one of which is conducted in a building located in an office park, a graduate who is highly unlikely to have ever seen a patient with many of the diseases and conditions she will face in making the momentous medico-legal decisions Oregon law would allow. She may have had zero training in any mainstream health care facility, such as a hospital, specialty care clinic or nursing home.
Life, liberty and property
With that, let’s turn to SB 856 and just what NDs will be allowed to do if the Governor signs on:
- Withdraw medical treatment, hydration and nutrition from a patient when the ND has determined that the patient has a terminal condition and would not likely benefit from further medical care or is at an advanced stage of illness and unlikely to improve, even in the absence of a patient’s having previously expressed his wishes on these issues. OANP’s summary of SB 856’s provisions for legislators and the public completely misrepresents the sweeping nature of this change by describing it as “Adds NDs to providers who can sign Advanced Directives.”
- Order physical or chemical restraint, or psychotropic medication, for elderly and disabled persons.
- Sign Physicians Orders for Life Sustaining Treatment (POLST). A POLST is a standing medical order directing or withholding specific medical treatment (for example, an order not to resuscitate the patient) designed for seriously ill or frail patients whose health care professional believes may die within a year. POLSTs should be executed by the health care professional only after a discussion with the patient concerning his wishes for end-of-life care.
- Determine that a patient is not competent to give informed consent to mental health treatment, as well as consent to that treatment for the patient, including convulsive treatment, psychoactive medication, psychosurgery, and retention in a mental health care facility.
- Conduct medical examinations of sexual assault and child abuse victims; allows courts to order treatment of child abuse victim by an ND.
- Review state correctional facility medical plans, provide medical care to prisoners and juvenile detainees, train non-medical facility personnel in administering medications and order special diets for prisoners. (Considering the whacko diets favored by naturopaths, this one could prove a real challenge to Oregon’s budget.)
- Give disability ratings to veterans.
- Authorize administration of medication at school to students.
- Perform the medical exam necessary for a child to receive special education services.
- Receive fees for providing care to cystic fibrosis patients.
- Treat those convicted of sex crimes enrolled in a medical treatment program.
- Make diagnostic evaluations of persons alleged to have mental illness or developmental disability who are candidates for court-ordered commitment to a care facility, and provide medical care, including prescription medications, for mentally and developmentally disabled patients committed to care facilities.
- Participate in Oregon Health Authority (OHA) drug treatment programs, including treatment with synthetic opiates.
- Recommend voluntary sterilization or abortion.
- Give orders for patients of home health agencies, nursing home facilities and hospice and determine eligibility for hospice care.
- (Dr. Crislip will love this one.) Perform exams of food handlers suspected of having infectious or contagious disease and issue health certificates to food handlers suspected of having communicable diseases.
- Give orders for respiratory therapy.
- Enter into clinical pharmacy agreements with pharmacists, meaning clinical pharmacists can provide direct patient care to the ND’s patients under the ND’s supervision.
- Provide health care services at Oregon Health and Science University with protection from liability for malpractice.
- Allows the OHA to refer patients to NDs for “consultation, examination, medical treatment and prescription” for contraception.
- Expands the use of NDs in state-funded medical care programs.
- Forces insurers to cover the services of “naturopathic physicians specializing in women’s health” if a female insured wants to designate same as her PCP. (Escharotic treatment of cervical dysplasia, anyone?)
I could not find that the Oregon Medical Association took a position on SB 856, although two MDs did show up at a committee hearing and testified against it, pointing out the inadequacy of naturopathic education and training, naturopathic belief in homeopathy, naturopathic opposition to vaccination, their rejection of evidence-based medicine, and criticism of the NPLEX for failure to meet national licensing standards. As one said:
Graduate MDs are held to a standard of residency training and so should naturopaths if they want to hold the title “physician” with these same privileges. To ensure fairness, graduate MDs should be allowed to take the NPLEX exam to practice in the state of Oregon without a residency; or vice versa, naturopaths should take the USMLE and obtain a standardized medical residency.
In sum, the Oregon Legislature has made it clear that naturopathic “physicians” will be able to make life and death decisions for seriously ill patients and provide medical care for vulnerable populations like the mentally ill, developmentally disabled, prisoners, addicts, juvenile detainees, the poor, crime victims and hospice patients. NDs will be able to weigh in on whether people should be deprived of their liberty through involuntary commitment and of the right to control their own property through determinations of competency. They will make the call on whether the public is at risk for the spread of communicable diseases. Those are weighty matters to put into the hands of folks who think water has magical properties. Life, liberty and property are in jeopardy when outcomes are based on incompetent medical judgments.
Naturopaths want to have it both ways. They like to portray themselves as purveyors of “natural” treatments that “stimulate the body’s self-healing ability” and as experts at prevention and management of chronic diseases. But what they really want is exactly the same broad-scope privileges as MDs and DOs, from pre-natal care right down to pulling the plug on the terminally ill, and this bill proves it. State legislators should be reminded of this as naturopaths seek licensing and practice expansion: naturopaths will return to the statehouse again and again until they reach full equivalency with MDs and DOs.
There may be a silver lining of sorts here: as their inclusion in the mainstream healthcare system expands, their incompetency will be increasingly exposed. Perhaps their greedy grab for power will prove their undoing.
If you would like to contact Oregon Gov. Kate Brown and ask her to veto Senate Bill 856, click here.