Jan 17 2013
I have some good news and some bad news about a Massachusetts naturopathy practitioner licensing bill.
First the bad news: the bill passed both the Massachusetts House and Senate in December of last year.
Now, I am certainly no expert in the arcane workings of the Massachusetts legislature, but after doing a bit of research I’ve come to wonder if the way the bill passed was entirely above board. I’ll spare you most of the details, but here’s what I found out. See if you don’t agree with me that the whole thing smells a bit fishy.
What’s that smell?
(Please feel free to skip this part and move on to the good news section if you care only about what happened, but not how it happened.)
According to the Massachusetts Bar Association’s explanation of the legislative process, all legislative business of the 2011-2012 session had to be finished by July 31, 2012. The Senate passed a naturopathy licensing bill before the deadline. The Senate bill then went to the House for consideration. (In Massachusetts, they call it “registration,” but I am going to call it “licensing” because it is that is what most states would call it.) As of July 31, the House had amended the Senate’s version of the bill and had proceeded in its deliberations to a point two steps shy of passage. Had the House had enough time to complete this process and the bill had passed, the Senate would have to consider the bill again because of the House’s amendment. Thus, as of July 31, the bill, in its final form, had not been passed in either the House or the Senate. By law, neither legislative branch could meet again in formal session and the bill was dead. Or so we all thought. In fact, the Massachusetts Medical Society reported that the bill did not pass on its website.
Although prohibited from meeting in formal session after July 31, the House and Senate can meet in informal session until December 31. According to the Massachusetts Secretary of State, these informal sessions are designed for consideration of “non-controversial” matters only. Under the Senate’s Rules,
In the case of an informal session, only reports of committees and matters not giving rise to formal motion or debate shall be considered.
(Emphasis in original.) The House has a similar rule.
But a very odd thing happened on December 27. The House, in an informal session, went through the next-to-the-last step required to pass its amended version of the bill. On December 31, the House actually enacted the naturopathy licensing legislation, again in informal session. Also on December 31, the Senate took up and concurred in the House’s amendment to the bill and enacted it, both done in informal session.
I don’t know what the Massachusetts legislature’s definition of “non-controversial” is, but apparently it does not include a matter that has been taken up and defeated in 11 previous legislative sessions, thanks in no small part to the efforts of our own Kimball Atwood. M.D., whose fight against licensing is chronicled on SBM. If this is “non-controversial,” I’d like to see what might fit their definition of “controversial.”
By law, debate on the bill was possible at any of these four events taking place at the end of December. Presumably, had debate actually occurred (which, remember, is forbidden in an informal session) those who opposed the bill could have convinced others not to vote in favor of it and it could have been defeated. And I have to wonder whether a quorum was present at any of these sessions, occurring as they did two days after Christmas and on New Year’s Eve.
Like I said, a bit fishy.
And now for the good news
Fortunately, this ploy didn’t work. Gov. Deval Patrick had the good sense to veto the legislation. But the naturopaths will be back. They always are.
It is worth a look at the failed legislation because it demonstrates a typical naturopathic licensing bill in what many people would likely consider its most benign form because it purports to limit their scope of practice in several ways I describe below. But, as we shall soon see, there is still plenty of room for mischief.
First, by way of background, a little bit about the two types of naturopaths. Traditional naturopaths (those without “N.D.” degrees) usually do not operate under the pretense that they practice medicine or can diagnose or treat disease. Some states allow them to do their thing and some don’t. Whether they should be allowed to practice at all is a subject for another day.
The naturopaths pushing for state licensing are those with “naturopathic doctor” degrees. By falling for the unproven assertion that having a “doctorate” in “naturopathic medicine” affords N.D.s the education and training to operate as real doctors, N.D. licensing bills give N.D.s a broad scope of practice. Some states, such as Oregon, permit N.D.s to practice as primary care physicians. (PCPs) Other states permit them a more limited scope of practice. Practice as PCPs is their goal in all 50 states, but they will take what they can get and later return for more. Requiring an N.D. degree prevents traditional naturopaths from practicing at all, which makes for an interesting turf war between the two groups. A big incentive for licensing in more states is the Affordable Care Act, which prohibits insurer discrimination against any licensed health care provider.
Under the Massachusetts bill, N.D.s can’t refer to themselves as “physicians” or claim to provide “primary care,” although I imagine those distinctions are lost on a majority of the public. It also includes the usual requirements of a degree from an accredited naturopathic school, passing a licensing exam, continuing education, and a board to oversee the practice of naturopathy, all false assurances of public protection. As Edzard Ernst, M.D., says, “the most meticulous regulation of nonsense must still result in nonsense.”
In an apparent attempt to address naturopathic opposition to vaccination, the Massachusetts bill requires:
mandatory tracking and documentation of the immunization status of a patient under 18 . . . and the required referral of such patients to a primary care or collaborative care physician where evidence exists that the individual has not been immunized.
You would think the necessity of this sort of language would raise a big red flag in the minds of legislators. After all, wouldn’t a thinking person wonder why a group wanting to be licensed as “doctors” would oppose one of the most successful public health measures of all time? Wouldn’t opposition to vaccination of children and the avoidance of vaccine-preventable disease imply a certain deficiency in the education and training of a health care provider? And wouldn’t that raise the further thought: “I wonder what else about the prevention and treatment of disease does this person not understand”?
The bill prohibits naturopaths from prescribing, dispensing or administering drugs, which prevents their using some of their favorite treatments, such as IV vitamins and minerals and chelation therapy. While we’re on this subject let’s take a brief look at the unfortunate results of allowing naturopaths the privilege of giving IV infusions.
IV nutrient bags: a brief digression
In Arizona, licensed naturopathic doctors, who must have a degree from a naturopathic college, can administer intravenous nutrients, vitamins and minerals. (They can also prescribe and administer some drugs.) Last week, the Phoenix CBS affiliate ran a story about a naturopathic doctor, Carol Spooner, who is offering IV “nutrient bags” of vitamins and minerals for flu prevention. Because these nutrients go straight to the bloodstream the benefits are almost immediate, according to the story. Spooner explains that
These vitamins and minerals are the hammers and nails the body understands to put back, put itself back together again. . . For anybody, regardless of whether they’ve had flu shots or not, these IV nutrients work very well.
At a hefty price too. The nutrient bags are $100 to $200 a pop and take up to an hour to administer. Spooner says that one bag carries a healthy person through the flu season while “others may need a few more.”
Remember, folks, these are the people who want to be licensed as primary care physicians in all 50 states, according to the National Association of Naturopathic Physicians.
Back to Massachusetts
Despite attempts to limit naturopathic practice and make them toe the line on vaccinations, this bill nevertheless buys into pseudoscientific concepts and unproven treatments typical of naturopaths. Unfortunately, the bill also gives naturopaths plenty of opportunity to employ them even though the pretense that they are PCPs has been taken away.
The purpose of “naturopathic health care” is, according to the bill,
to support, stimulate or supplement the human body’s own natural self-healing processes.
Having accepted the pleasant-sounding but essentially meaningless concept that the body has a “natural self-healing process” which requires support, stimulation or supplementation, the bill fastens onto the equally nonsensical corollary that there are means available to accomplish this very task and that naturopaths are just the persons to provide them. How? Through “the use of education, nutrition, natural medicines and therapies and other modalities.”
I don’t know about you, but “other modalities” seems disconcertingly unlimited to me. This unbridled discretion is reinforced by a definition of “naturopathic health care” that “include[s]” but is not “limited to:”
dispensing, administering, ordering and prescribing natural medicines of mineral, animal or botanical origin, including food products or extracts, vitamins, minerals, enzymes, digestive aids, natural hormones, plant substances, homeopathic preparations, natural antibiotics and topical medicines and nonprescription drugs, therapeutic devices and barrier contraceptives to prevent or treat illnesses, injuries and conditions of the human body [and] the use of manual mechanical manipulation of body structures or tissues [and] the use of naturopathic physical medicine to restore normal physiological functioning the human body.
So, if it comes from a plant, an animal or a mineral and it’s not a prescription drug, with manipulation and physical medicine thrown in for good measure, it’s o.k. Effectiveness and safety be damned.
The bill defines “naturopathic health care” as:
a system of health care practices for the prevention, evaluation and treatment of illnesses, injuries and conditions of the human body . . . .
Thus, while the means N.D.s can use may be curtailed in this bill, the ability to diagnose and treat any condition or disease is not. The danger here is that their education and training is nothing like that of an M.D. primary care physician and does not prepare them for the wide range of undifferentiated symptoms they will encounter in the population of patients they will see. For one thing, M.D. primary care physicians spend at least three years after graduation caring for patients with a variety of illnesses, some of them gravely ill, supervised and in a hospital setting. N.D.s do not. They may very well be prevented from claiming they practice primary care medicine or calling themselves a physician. This does nothing to prevent patients with conditions N.D.s have no business diagnosing and treating from coming to see them.
This illusion of diagnostic ability is furthered by a provision in the bill including in “the practice of naturopathic health care”:
the use of physical examinations and the ordering of clinical, laboratory and radiological diagnostic procedures from licensed clinics or laboratories to evaluate injuries, illnesses and conditions in the human body.
I will leave it to others to evaluate naturopaths’ level of understanding of conventional lab tests and x-rays. But it is worth noting that the Textbook of Natural Medicine (2013), the foundational text of naturopathic education and practice, has an entire section (Section 2) titled “Supplementary Diagnostic Procedures.” I take “supplementary” to mean “not used in convential medicine, at least not in this way.” The twenty-two chapters include several tests for detection of the ubiquitous “toxins” naturopaths believe are causing ill health in us all. Other tests address “functional nutritional analysis,” a standard of “functional medicine,” and “immune function assessment,” because, as we know, naturopathy is all about “boosting the immune system,” another fuzzy and essentially meaningless term they use. In addition to being unnecessary themselves, the results of these tests can lead to all sorts of unnecessary treatments, such as vitamins, minerals and “detoxification.”
I’ve already mentioned nutrient bags for flu prevention. While the Massachusetts bill would not allow IV administration of vitamins, minerals and such, there is, as I said, plenty of opportunity for mischief. Let’s look at just a couple of the nonsensical and potentially dangerous treatments currently being used by naturopaths, both of which would have been within their scope of practice had this legislation not been vetoed by Gov. Patrick.
Fresh from the website of the American Association of Naturopathic Physicians, in honor of Cervical Health Awareness Month, is this advice on “Management of Cervical Dysplasia and Human Papillomavirus.” The article starts innocently enough with standard advice on the subject from the American College of Obstetricians and Gynecologists and another medical group. It then goes off the rails with advice on “natural” treatment of HPV and cervical dysplasia. Interestingly, while it discusses prevention, the article wholly fails to mention the HPV vaccine.
Here I’ll focus on just two of the treatments promoted in this article. In addition to recommendations citing evidence for other treatments which no responsible physician would regard as sufficient, “green tea suppositories” are touted as “effective for cervical dysplasia and HPV.” And the evidence? One study. As the article itself admits, this study used two chemical components of green tea, not green tea suppositories, and looked at its effect on cells. Not humans, cells in a laboratory. Nevertheless green tea suppositories are “effective for cervical dysplasia and HPV.”
Another recommended treatment: vaginal depletion packs. These packs are made up of vitamins, minerals and several oils derived from plants. The evidence of their effectiveness for “mild dysplasia and/or high risk HPV,” their intended use? None cited. However, they “have been used since the 1800s,” which is, of course, an excellent reason to continue their use despite not having any evidence of safety or effectiveness. Another reason is that some of the ingredients are “effective against many microbial pathogens.” Not necessarily these microbial pathogens, but “many.”
The article ends with this observation:
Critics of natural medicine say there is no published evidence that these options work or are backed in [sic] science. There are several recent published articles explaining the science and patient outcomes. One can be found at http://www.ncbi.nlm.nih.gov/pubmed/19679625.
One? Where are the others? In any event, if you click on the reference you find a single case study. As all regular SBM readers know, a case study is an anecdote, a single report about a single patient. It is not evidence of anything and it certainly doesn’t support the notion that “these options work or are backed in science.”
“Backed in science”?
As I have mentioned before, I have absolutely no training in science. I took one biology and one general science course in high school. I took geology in college. That’s it. Yet I can figure out that the naturopathic treatment recommendations in this article don’t have sufficient evidence of safety and effectiveness. Why can’t they?
Whether naturopaths are already licensed in your state or it’s just a possibility, your state legislators need to know the facts about naturopathic practice. They won’t unless you take the time to tell them.
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