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Naturopathic Prescribing: The Dark Side Beckons

I am a terrible Oregon chauvinist.  I think there is no better place to live on the planet. Period.  Great natural beauty, not a lot of people, best beer ever and no pro football team. Oregon is both casual and tolerant.  It is safe to say that dressing up in the Pacific NW means tucking your t shirt into your jeans.  And the citizens of the NW, especially in the Portland metro area, are tolerant of  a diverse number of alternative life styles. What more could you want?

No good deed goes unpunished. The downside of toleration is the proliferation of alternative medicine.  Portland has  a school of chiropractic, a college of oriental medicine and  the country’s oldest school of naturopathy, established in 1956.  It is a year older than me. There are about 850 ND’s in Oregon.  To judge from the number of alternative practitioner offices around my hospital,  most of the graduates stay in Portland.

There are five health care systems in Portland.   Three of the five have hired naturopaths as part of their complementary medicine programs.   My system, as of yet, does not have a scam practitioner on staff, a fact of which I am most proud.  Yet,  I suppose it will come some day. However, if you wonder if a hospital practices evidence and science based medicine, see if they have a naturopath, a chiropractor or an acupuncturist on staff.  If they do, they may be interested in issues other than providing quality health care.

Oregon has had a Board of Naturopathic physicians since 1929 to oversee naturopathic practice.  There has been a long tradition of legislative oversight of naturopathy in Oregon, but they have been able, until recently, to only prescribe medications that are naturally derived.  None of that synthetic nonsense for naturopaths. Natural products only.  Until this month.

In Oregon, naturopaths are no longer limited to natural, herbal and homeopathic concoctions, they can also prescribe substances that actually work.  Recently House Bill 327  was passed by the Oregon legislature to expand the prescriptive privileges of naturopaths.  Drugs can now be added to the naturopathic  formulary just by asking.  The bill was passed by the Senate 22-7 and the House unanimously.  Bummer. If you live in Oregon and want to pester your representative on their profound stupidity, a list is at  http://gov.oregonlive.com/bill/SB327/. Send them a link to this post.

As a shill for big pharma and a tool of the medical-industrial complex, I suggest this may not be such a  good idea.  Naturopaths do not have the training, experience  or understanding of medicine to safely prescribe medications. Their understanding of disease and the various therapies taught at naturopathic schools are antithetical to what is required to safely and knowledgeably  prescribe modern medications.

To give prescription medications correctly and safely, one needs to understand anatomy, physiology, pharmacology and the pathophysiology of diseases.  Real medical providers (MD’s, DO’s, NP’s and PA’s)  have to have not only years of education in school, but a residency or other training to be able to appropriately use these medications.

What is a naturopath and what is their education?

First the Philosophy of Naturopathy.  The key components of naturopathy, from the Oregon Board,  sound reasonable in general, but are not so reasonable in their specific application.  Emphasis is added by me of key points to keep in mind as we look to see if granting prescriptive privileges to naturopaths is a good thing.

“The Healing Power of Nature.Vis medicatrix naturae   The body has the inherent ability to establish, maintain, and restore health. The healing process is ordered and intelligent; nature heals through the response of the life force. The physician’s role is to facilitate and augment this process, to act to identify and remove obstacles to health and recovery, and to support the creation of a healthy internal and external environment.”

In naturopathy, you let the body heal itself.  You do not give medications.  There is, by the way, no evidence of a life force.  Magical thinking is major part of the naturopathic philosophy. How prescriptions will fit into this magic is uncertain.

“Identify and Treat the Cause. tolle causam   Illness does not occur without cause.  Underlying causes of disease must be discovered and removed or treated before a person can recover completely from illness. Symptoms are expressions of the body’s attempt to heal, but are not the cause of disease. Symptoms, therefore, should not be suppressed by treatment. Causes may occur on many levels including physical, mental, emotional, and spiritual. The Physician must evaluate fundamental underlying causes on all levels, directing treatment at root causes rather than at symptomatic expression.”

“First, Do No Harm. Primum no nocere    Illness is a purposeful process of the organism.  The process of healing includes the generation of symptoms, which are, in fact, an expression of the life force attempting to heal itself. Therapeutic actions should be complimentary to and synergistic with this healing process.  The Physician’s actions can support or antagonize the actions of the vis medicatrix naturae. Therefore, methods designed to suppress symptoms without removing underlying causes are considered harmful and are avoided or minimized.

Nonsteroidal anti-inflammatories and narcotics are on the list of prescription medications, and are nothing if not symptom suppressors.  Prescription medication seems antithetical to the basic premises of naturopathic theory. Naturopaths always complain that prescriptions medications don’t treat disease, it masks them.  Now they get to join the dark side.

“Treat the Whole Person. The Multifactorial Nature of Health and Disease   Health and disease are conditions of the whole organism, a whole involving a complex interaction of physical, spiritual, mental, emotional, genetic, environmental, social, and other factors. The Physician must treat the whole person by considering all of these factors. The harmonious functioning of all aspects of the individual is essential to recovery from and prevention of disease, and requires a personalized and comprehensive approach to diagnosis and treatment.”

That should lead to creative uses of prescription medications.  The power of modern medicine comes from understanding that many diseases are best treated the same way for everyone.  In the hospital we have guidelines for the prevention and treatment of many diseases.  Multiple studies demonstrate that when patients are treated the same, morbidity and mortality declines.  We have driven hospital acquired infections to almost zero in my hospitals by treating every patient identically based on evidence and science.

And what modalities do Naturopaths use? Few that are based on science and clinical trials.

“Clinical Nutrition.  That food is the best medicine is a cornerstone of naturopathic practice.  Many medical conditions can be treated more effectively with foods and nutritional supplements than they can by other means, with fewer complications and side effects. Naturopathic Physicians use dietetics, natural hygiene, fasting, and nutritional supplementation in practice.”

Botanical Medicine.  Many plant substances are powerful medicines.  Where single chemically derived drugs may only address a single problem, botanical medicines are able to address a variety of problems simultaneously. Their organic nature makes botanicals compatible with the body’s own chemistry; hence, they can be gently effective with few toxic side effects.

Homeopathic Medicine.  Homeopathic medicine is based on the principle of “like cures like.”  It works on a subtle yet powerful electromagnetic level, gently acting to strengthen the body’s healing and immune response.”

I will pause here to point out that if a provider believes that homeopathy is a reasonable therapeutic intervention, they cannot be trusted to understand modern pharmacology.   It is said that the mark of an educated person is the ability to hold two contradictory ideas in the mind at the same time.  That must be true of naturopaths if they can simultaneously think that modern pharmaceuticals and homeopathic nostrums can be used at the same time.

“Physical Medicine.  Naturopathic Medicine has its own methods of therapeutic manipulation of muscles, bones, and spine. ND’s also use ultrasound, diathermy, exercise, massage, water, heat and cold, air, and gentle electrical pulses.”

“Oriental Medicine.  Oriental medicine is a complimentary healing philosophy to naturopathic medicine. Meridian theory offers an important understanding of the unity of the body and mind, and adds to the Western understanding of physiology. Acupuncture theories, without the insertion of acupuncture needles,  provide methods of treatment utilized in naturopathic medicine that can unify and harmonize the imbalances present in disease conditions, which, if untreated, can result in illness.”

Look at the list: nutritional supplements, homeopathy, acupuncture, hydrotherapy and electrical stimulation.  There is no nonsensical therapy that is not in the naturopathic armamentarium. That is part of the problem with describing the practice of naturopathy: any and all medical magic is in their pervue. And all these magical inanities are supported by the board that oversees naturopathic physicians and licenses them. This will be the governing body to decide which medications naturopaths can prescribe. The untrained request from the ignorant the ability to use prescription medications neither understands. Great plan.

If you google naturopathy and hypertension, the first hit I get is at altmd.com.  Take a moment to review http://www.altmd.com/Articles/Naturopathic-Medicine-for-Hypertension.  Healing rocks. Color therapy. Alternating hot and cold foot baths.  All naturopathic treatments of hypertension.

Yet the state of Oregon feels people who treat hypertension with magic rocks will be able to safely give medications with real effects and side effects  and should have access to real medications. It is the equivalent of having people who think planes are kept aloft with fairies wings becoming pilots or having  bridges designed by people who think the central span will be supported by the positive thinking of those traveling across the bridge.

It is scary to let people trained in magic and premodern concepts of disease to give dangerous drugs.

The full list of medications to be allowed is at the end of the post. You will be happy to know, however, that “Board approved certification is required before therapeutic IV chelation is allowed.”  What a relief. I am certainly glad the State board is making sure that useless and potentially fatal chelation therapy requires certification. My tax dollars inaction.

Per the Board, “Naturopathic Physicians (N.D.) are primary care practitioners trained as specialist in natural medicine (1).”

Primarily care practitioners?  OK.  In the world of real medicine, we have two kinds of primary care physicians: internists and family practitioners.  They have four years of medical school and then a three year residency, taking care of patients under the guidance of senior physicians,  to learn the basics of their job before going into practice.  Most naturopaths do not have to have a residency (5) going straight to patient care from school.

The training requirements in pharmacy, per the naturopathic board, is minimal:  “ Naturopathic physicians are required to take 72 hours of pharmaceutical training as a part of  their doctoral degree. Additionally, they must also have 1,500 hours of clinical training. Naturopathic physicians are required to take 25 hours of continuing education course work annually, five of which must be in pharmacology.”

Nine days of pharmacy training in school in school. 1500 hours is 35 forty hour weeks.  A little over half a year of clinical experience. That is the background of naturopaths who will give medications.  For comparison,  in med school we spent 4 hours a day for the three months of the second year in pharmacology and  I had five years of clinical experience just for internal medicine.

At our local natuopathic school they get 72 hours of pharmacology education, and twice (144 hours) as much training in homeopathy (6).  The have the opportunity to do electives to broaden their knowledge: 144 hours in homeopathy,  36 hours in qi gong, 26 hours in Aruyveda, 24 hours in energy work and 12 hours in colonics. But no electives in pharmacology. A good foundation upon which to prescribe medications.

It is also odd finding vaccines on the list, given the long standing opposition of  many naturopaths to vaccines.

The local paper, the Oregonian, did not see giving prescriptive to shamans  with minimal education and experience as a quality issue.  They, as well as the sponsoring Senator, saw it as a “turf battle” between MD’s and ND’s.  I am not surprised as the Oregonian is not noted for its critical think skills to judge from the articles in the weekly medical edition of the “Way We Live” section (4).

It is a quality issue.  If you have people giving drugs they don’t understand for diseases they don’t understand, then problems will occur.  Put a loaded gun in a room of deaf and blind people and someone going to get shot.

If I were Pfizer I would be turning my sales force loose on the 800 plus ND’s in Oregon:  they have no background to understand the truth of what they are told, they have no critical thinking skills, they are used to accepting authority over evidence, they have no issues with being subsidized by industry, and crave respectability.  Perfect fodder for the drug rep.  They don’t have a chance. And neither do their patients.

I like living in a tolerant state.
But there are down sides.

======

1) http://www.oregon.gov/OBNE/Aboutnaturopathy.shtml

2)  http://www.ncnm.edu/naturopathic-medicine-residency-program.php

3) I cannot help but notice that while in our residency program there is zero interaction with any pharmaceutical company, one ND residency is “is receiving the generous support from:, Bezwecken, Biogenesis, Emerita, Integrative Therapeutics Inc., National College of Natural Medicine, Natural Health International, Vital Nutrients, Vitanica, Women’s International Pharmacy”

4) As I write this on 6/17, the Oregonian published a puff piece on Guided Imagry and Cancer therapy, part of which is here (http://www.oregonlive.com/health/index.ssf/2009/06/a_brief_guide_to_guided_imager.html)  and here: http://www.oregonlive.com/health/index.ssf/2009/06/greenlick_combines_standard_an.html

If they print this kind of nonsense, how can I trust their news reporting?  My wife insists on the paper, otherwise I would have given up my subscription years ago.

5)  There are a few naturopathic residencies where they can hone their skills in using rocks. It would appear that most naturopathic residency programs are supported by pharma.  But they have no conflicts of interest. Oh no. I though MD’s were the tainted ones.

http://www.ncnm.edu/naturopathic-medicine-residency-program/dr.-hudson.php.

http://www.naturopathicresidency.org/support.html

6) http://www.ncnm.edu/academics-at-ncnm/Programs_08-09.htm

Naturopathic Formulary

(1) Abacavir (2) Acarbose (3) Acetic Acid (4) Acetylcysteine (5) Acitretin (6) Acyclovir (7) Adapalene (8) Adenosine Monophosphate (9) Albuterol Sulfate (10) Alendronate (11) Allopurinol (12) Alprostadil (13) Amantadine (14) Amino Acids (15) Amino Aspirins (16) Aminoglycosides (17) Aminolevulinic Acid (18) Aminophylline (19) Aminosalicylic Acid (20) Ammonium Chloride (21) Ammonium lactate lotion 12% (22) Amoxicillin (23) Amoxicillin & Clavulanate (24) Amphotericin B (25) Ampicillin (26) Ampicillin & Sulbactam (27) Anastrozole (28) Anthralin (29) Atorvastatin (30) Atropine (31) Atropine Sulfate (32) Auranofin (33) Azelaic Acid (34) Azithromycin (35) Bacampicillin (36) Bacitracin (37) Baclofen (38) Becaplermin (39) Belladonna (40) Benazepril (41) Benzodiazepines (42) Benzoic Acid (43) Benzonatate (44) Betaine (45) Betamethasone (46) Bethanechol Chloride (47) Bichloracetic Acid* (48) Bimatoprost Solution 0.03% (49) Biologicals (50) Bisphosphonates (51) Bromocriptine (52) Budesonide (53) Buprenorphine (54) Butorphanol (55) Cabergoline (56) Calcipotriene (57) Calcitonin (58) Calcitriol (59) Carbamide Peroxide (60) Carbidopa (61) Carbol-Fuchsin (62) Captopril (63) Cefaclor (64) Cefdinir (65) Cefibuten (66) Cefadroxil (67) Cefditoren (68) Cefixime (69) Cefonicid Sodium (70) Cefpodoxime Proxetil (71) Cefprozil (72) Ceftibuten (73) Cefuroxime (74) Celecoxib (75) Cellulose Sodium Phosphate (76) Cenestin (77) Cephalexin (78) Cephradine (79) Chirocaine* (80) Chloramphenicol (81) Chloroquine (82) Citrate Salts  (83) Clarithromycin (84) Clindamycin (85) Clioquinol (86) Clostridium botulinum toxin (ab) (87) Cloxacillin (88) Codeine (89) Colchicine (90) Colistimethate (91) Collagenase (92) Condylox (93) Cortisone (94) Coumadin (95) Cromolyn Sodium (96) Cyanocobalamin (97) Cycloserine (98) Cytisine (99) Danazol (100) Deferoxamine / Desferroxamine (Board approved certification required before therapeutic IV chelation is allowed) (101) Demeclocycline Hydrochloride (102) Desmopressin (103) Desoxyribonuclease (104) Dexamethasone (105) Dextran (106) Dextromethorphan (107) Dextrose (108) Dextrothyroxine (109) Dicloxacillin (110) Dihydroergotamine Migranal (111) Didanosine (112) Dimethyl Sulfone (DMSO) (113) Digitalis (114) Digitoxin (115) Digoxin (116) Dinoprostone (117) Diphenhydramine 118) Diphylline (119) Dirithromycin (120) DMPS (Board approved certification required before therapeutic IV chelation is allowed) (121) DMSA (122) Doxercalciferol (123) Doxycycline (124) Dronabinol (125) Dyclonine (126) EDTA (Board approved certification required before therapeutic IV chelation is allowed) (127) Electrolyte Solutions (128) Emtricitabine (129) Enalapril (130) Ephedrine (131) Epinephrine* (132) Epinephrine (auto-inject) (133) Ergoloid Mesylates (134) Ergonovine Maleate (135) Ergotamine (136) Erythromycins (137) Erythropoietin (138) Estradiol (139) Estriol (140) Estrogen-Progestin Combinations (141) Estrogens, Conjugated (142) Estrogen, Esterified (143) Estrone (144) Estropipate (145) Eszopiclone (146) Ethyl Chloride (147) Etidronate (148) Exenatide (149) Ezetimibe (150 Famciclovir (151) Fentanyl (152) Fibrinolysin (153) Flavoxate (154) Fluconazole (155) Fludrocortisone Acetate (156) Flunisolide (157) Fluorides (158) Fluoroquinolones (159) Fluoroquinolines (160) Fluorouracil (161) Fluticasone propionate (162) Fluvastatin (163)  Fosinopril (164) Gaba Analogs (165) Gabapentin (166) Galantamine H. Br. (167) Gamma-Hydroxy Butyrate (168) Ganciclovir (169) Gentamicin (170) Gentian Violet (171) Glycerin/Glycerol (172 Griseofulvin (173) Guaifenesin (174) Heparin – subcutaneous, sublingual
and heparin locks (175) Hexachlorophene (176) Homatropine Hydrobromide* (177) Human Growth Hormone  (178) Hyaluronic Acid (179) Hyaluronidase (180) Hydrocodone (181) Hydrocortisone (182) Hydrogen Peroxide (183) Hydromorphone (184) Hydroquinone (185) Hydroxychloroquine (186) Hydroxypolyethoxydodecane* (187) Hyoscyamine (188) Iloprost Inhalation Solution (189) Imiquimod Cream (5%) (190) Immune Globulins* (191) Insulin (192) Interferon Alpha b w/Ribaviron (193) Iodine (194) Iodoquinol (195) Iron Preparations (196) Isosorbide Dinitrate (197) Isotretinoin (198) Itraconazole (199) Kanamycin Sulfate (200) Ketoconazole (201) Lactulose (202) Lamivudine (203) Letrozole (204) Leucovorin Calcium (205) Levalbuteral (206) Levocarnitine (207) Levodopa (208) Levonorgestrel (209) Levorphanol (210) Levothyroxine (211) Lincomycin (212) Lindane (213) Liothyronine (214) Liotrix (215) Lisinopril (216) Lisuride (217) Lithium (218) Lovastatin (219) Mebendazole (220) Meclizine (221) Medroxyprogesterone (222) Medrysone (223) Mefloquine (224) Megestrol Acetate (225) Mercury, Ammoniated (226) Memantine (227) Mesalamine (228) Metformin (229) Methadone (230) Methimazole (231) Methoxsalen (232) Methscopolamine (233) Methylergonovine (234) Methylprednisolone (235) Methylsulfonylmethane (MSM) (236) Methyltestosterone (237) Methysergide (238) Metronidazole (239) Miglitol (240) Minerals (Oral & Injectable) (241) Minocycline (242) Misoprostol (243) Moexipril (244) Monobenzone (245) Morphine (246) Mupirocin (247) Nafarelin acetate (248) Naloxone (249) Naltrexone;  (250)Natamycin (251) Nateglinide (252) Nicotine (253) Nitroglycerin (254) Novobiocin (255) Nystatin (256) Olsalazine (257) Omeprazole (258) Opium (259) Over the Counter (OTC)  (260) Oxacillin (261) Oxamniquine (262) Oxaprozin (263) Oxtriphylline (264) Oxycodone (265) Oxygen (266) Oxymorphone (267) Oxytetracycline (268) Oxytocin* (269) Pancrelipase (270) Papain (271) Papavarine (272) Paramethasone (273) Paregoric (274) Penciclovir (275) Penicillamine (Board approved certification required before therapeutic IV chelation is allowed) (276) Penicillin (277) Pentosan  (278) Pentoxifylline (279) Pergolide (280) Perindopril (281) Permethrin (282) Phenazopyridine (283) Phenylalkylamine (284) Phenylephrine* (285) Physostigmine (286) Pilocarpine (287) Pimecrolimus Cream 1% (288) Piperazine Citrate (289) Podophyllum Resin (290) Polymyxin B Sulfate (291) Polysaccharide-Iron Complex (292) Potassium Iodide (293) Potassium Supplements (294) Pramoxine (295) Pravastatin (296) Praziquantel (297) Prednisolone (298) Prednisone (299) Pregabalin (300) Progesterone (301) Progestins (302) Propionic Acids (303) Propylthiouracil (304) Prostaglandins (305) Proton Pump inhibitor (306) Pseudoephedrine (307) Pyrazinamide (308) Pyrethrins (309) Quinapril (310) Quinidine (311) Quinilones (312) Quinine Sulfate (313) Quinines (314) Quinolines (315) Ramopril (316) Rauwolfia Alkaloids (317) Rho(D) Immune globulins  (318) Rifabutin (319) Rifampin (320) Rimantidine (321) Risendronate (322) Ranolazine (323) Salicylamide (324) Salicylate Salts (325) Salicylic Acid (326) Salsalate (327) Scopolamine (328) Selegiline (329) Selenium Sulfide (330) Sildenafil Citrate (331) Silver Nitrate (332) Simvastatin (333) Sitagliptin (334) Sodium Polystyrene Sulfonate (335) Sodium Tetradecyl Sulfate  (336) Sodium Thiosulfate (337) Spironolactone (338) Stavudine (339) Spectinomycin (340) Sucralfate (341) Sulfasalazine (342) Sulfonamide/Trimethoprim/Sulfones (343) Tacrolimus (344) Tazarotene topical gel (345) Telithromycin (346) Tenofovir (347) Testosterone (348) Tetracycline (349) Theophylline (350) Thiabendazole (351) Thyroid (352) Thyroxine (353) Tiagabine (354) Tibolone (355) Tiludronate (356) Tinidazole (357) Tobramycin (358) Topical steroids (359) Tramadol (360) Trandolapril (361) Trazodone (362) Tretinoin (363) Triamcinolone (364) Triamterene (365) Trichloracetic Acid* (366) Trimetazidine (367) Trioxsalen (368) Triptans (369) Troleandomycin (370) Undecylenic Acid (371) Urea (372) Urised (373) Ursodiol (374) Valacyclovir (375) Valproic Acid (376) Vancomycin (377) Varenicline (378) Verapamil (379) Verdenafil HCL (380) Vidarabine (381) Vitamins (Oral & Injectable) (382) Yohimbine (383) Zalcitabine (384) Zidovudine (385) Zolpidem (386) Local Anesthetics: (a) Benzocaine* (b) Bupivacaine* (c) Chloroprocaine* (d) Dyclonine* (e) Etidocaine* (f) Lidocaine* (g) Lidocaine (non-injectable dosage form) (h) Mepivocaine* (i) Prilocaine* (j) Procaine* (k) Tetracaine*.
(387) Vaccines: (a) BCG* (b) Cholera* (c) Diptheria* (d) DPT* (e) Haemophilus b Conjugate* (f) Hepatitis A Virus* (g) Hepatitis B* (h) Influenza Virus* (i) Japanese Encephalitis Virus* (j) Measles Virus* (k) Mumps Virus* (l) Pertussis* (m) Plague* (n) Pneumococcal* (o) Poliovirus Inactivated* (p) Poliovirus-Live Oral* (q) Rabies* (r) Rubella* (s) Smallpox* (t) Tetanus IG* (u) Tetanus Toxoid* (v) Typhoid* (w) Varicella* (x) Yellow Fever* (388) SkinTests:
(a) Diptheria* (b) Mumps* (c) Tuberculin*.

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99 thoughts on “Naturopathic Prescribing: The Dark Side Beckons

  1. Jules says:

    So it is possible to regulate “CAM” (although, it would seem, not in a way that makes sense). Why can’t they regulate it so that it’s actually sensible?

    Head, meet Desk. I think you’re going to get along great.

  2. Joe says:

    A few years ago, Kim Atwood (www.naturowatch.org) estimated there are around 30 NDs in Massachusetts. I live in the most rural area of the state (Franklin County) and there are 2 (two) within walking distance of my home! I feel blessed. One is a friend of my brother who recently graduated (aged around 50) and gave some seminars to attract business. My brother was compelled by a mutual friend to attend one of the seminars. One attendee, whose daughter has asthma, asked if she should take away her daughter’s inhaler. The ND paused for a moment and then said “I could get in trouble if I said yes.” My brother came home fuming.

    Does anyone else think the ND Creed is strange for having the third item “First do no harm.” I mean, shouldn’t that be the first item on the list?

  3. Scott says:

    In Ontario, the provincial government wisely ignored a recommendation to give naturopaths prescribing privileges:

    http://sciencebasedpharmacy.wordpress.com/2009/05/15/ontario-government-repudiates-advice-on-naturopathy/

    The naturopaths are, as expected, outraged, and have initiated a write-in campaign because they want to be treated like “every other health profession”. See: http://bit.ly/36FBYe

  4. DevoutCatalyst says:

    “Prescription medication seems antithetical to the basic premises of naturopathic theory.”

    Nah, Big Nature pulls this kind of crap all the time. The natural industrial complex denounced the addition of BHT to food packaging, then turned around and sold BHT in capsule form as a supplement without the slightest crisis of conscience. Big Cereal was shamed for selling sugar coated breakfast products, and now Big Organic peddles crunchy flakes of their own, supplemented with evaporated organic cane juice as part of their outreach to children.

    The “complementary” in CAM means hitching a ride on legitimate coattails, hoping the customer won’t notice what’s what. The addition of prescription drugs ought to benefit naturopaths in a way that will allow their patients to make a clean break from allopathy altogether. Crislip, it doesn’t matter if people suffer as a result of naturopathic incompetence, because CAM has a bullshit answer for that as well — “Even when we can’t cure, we can still heal.”

  5. daedalus2u says:

    I notice that their Naturopathic Formulary includes (225) Mercury, Ammoniated. What is the safe and effective dose of that and for what indication?

  6. Scott says:

    “I notice that their Naturopathic Formulary includes (225) Mercury, Ammoniated. What is the safe and effective dose of that and for what indication?”

    30C for autism, maybe? (I wish I were joking, but it makes an unfortunate amount of sense.)

  7. “Their organic nature makes botanicals compatible with the body’s own chemistry; hence, they can be gently effective with few toxic side effects.”

    Botulinum toxin is organic, as is the small pox virus…

    ——————————————————————–
    Has any Naturopath actually explained how their desire to prescribe drugs fits in with (and does not contradict with) the philosophy of Naturopathy?
    ———————————————————————
    I imagine this will eventually lead to an increase in lawsuits against naturopaths regarding harm suffered due to prescription error.

  8. daedalus2u says:

    Homeopathic thimerosal is actually used by some DAN! practitioners (I can’t call them doctors).

  9. Fredeliot2 says:

    Setting aside the cognitive dissonance involved, there may be some benefit in allowing ND’s to prescribe a limited number of medications with proper training. The list proposed seems to be too broad compared to the training involved. Limited privileges could force them to learn more about the science of medicine and when to refer patients to real doctors. I am curious about how doctors reading this blog feel about psychologists with special training being allowed to prescribe medication.

  10. DoctorLaw says:

    This is the U.S. osteopathic story all over again. Just 45 years ago, organized medicine was rabidly against presecriptive authority for DOs in jurisdictions which didn’t already grant same (~24/48 states in 1927, 39/50 by 1963, when DOs gained plenary licensure nationwide). Nonetheless, despite AMA’s labeling of osteopathy as a cult, despite their derision of osteopathic education, derision of osteopathic residency training and the lack of uniformity of osteopathic training (some had pharmacology, some didn’t) the sky didn’t fall when osteopaths broke in their prescription pads.

    Mark Crislip sounds like the AMA of 1962. I don’t know Mark’s age, but if history is any guide, 45 years from now, an ND might be his PCP.

  11. Calli Arcale says:

    DoctorLaw — osteopaths in 1963 weren’t being trained uniformly, but they were being much better trained that naturopaths are now. A modern osteopath ought to know what he’s doing. Given that the basic philosophy of naturopathy directly contradicts the use of prescription medicines, I fail to see how this move makes any sense at all. If the naturopaths are serious about their beliefs, and don’t just want to get into medicine without all that pesky education, then they should be appalled at this idea. After all, why would they want to prescribe manufactured compounds that mask symptoms?

  12. DoctorLaw,
    “but if history is any guide, 45 years from now, an ND might be his PCP”

    If Naturopathy grows up like Osteopathy did and abandons or mostly ignores it’s wooey parts and “integrates” conventional, scientific medicine and conventional, science based medical training and education into itself like Osteopathy did, that might indeed be the case.

    Perhaps, just as Osteopaths now have mostly the same education and training as MDs, with an Osteopathic focus thrown in, maybe some Naturopaths will get nearly the same education and training as MDs, with some added focus involving the few scientifically valid aspects of Naturopathy.

    Until then, if it walks like a duck and quacks like a duck…don’t let it prescribe drugs.

  13. Seriously, can we get any actual Naturopaths to explain why they want the right to prescribe drugs, and how that fits in with the philosophy of Naturopathy?

  14. Versus says:

    Did the Oregon Legislature, in its wisdom, also raise the amount of malpractice insurance NDs are required to carry?
    Will the ND’s educational limitations require “Big Pharma” to include special ND-friendly information with drugs sold in Oregon? If they don’t, will they be sued when the NDs improperly prescribe drugs? (Deep pockets are always welcome in any malpractice action.)

    I posted a comment to Val Jones’s post, Barriers to the Adoption of Science-Based Medicine, that I am proposing legislation here in Florida requiring a basic scientific standard for all health care. However, they are all busy arguing with Fred Dagg about what science is and isn’t, so I’ll mention it again here. http://www.sciencebasedhealthcare.org.

  15. shadowmouse says:

    “A modern osteopath ought to know what he’s doing.”

    I found out the hard way that the DO I had been sent to for a basic orthopedic surgical procedure sure proved that wrong.

    I returned to his office days later for a post-surgical follow-up because of increasing pain, cellulitis, and erythema around the surgical site. I was concerned about infection, and requested WBC/ESR/CRP – he refused, insisting the symptoms were normal for just having surgery, and sent me home.

    I was admitted to the hospital 4 days later, with MRSA septicemia and joint necrosis. Multiple extensive surgical salvage procedures, months of IV antibiotics, and extensive rehab saved my life and my leg, but permanently lost knee function.

    Too bad the asshole is still practicing.

  16. Mark,

    NDs prescribing real drugs in Oregon is not new, although it may have been recently expanded. Look here for the 2005 version of the Oregon naturopathic formulary. In the past few years NDs in Oregon have killed a few patients with Na2EDTA and colchine, drugs that are hardly ‘natural’ but that were legal for NDs to use.

    KA

  17. Psyche78 says:

    Fredeliot,

    Based on what I am reading, I don’t think a parallel can be drawn between presciption privileges for doctoral-level psychologists and naturopathic doctors. Prior to New Mexico passing prescriptive authority for psychologists, the Dept. of Defense did a pilot study (a small one, mind you) in which 10 psychologists were trained and followed to see whether they could prescribe safely; New Mexico requires post-doctoral training (at least 450 hours of coursework; a 400 hour/100 patient practicum under physician supervision; and pass a national certification examination. The academic component includes psychopharmacology, neuroanatomy, neurophysiology, clinical pharmacology, pharmacology, pathophysiology, pharmacotherapeutics, pharmacoepidemiology, as well as physical and lab assessments.) and supervision for two years by a physician before the psychologist can prescribe independently. Louisiana requires doctoral psychologists to earn a master’s degree in clinical psychopharmacology and they are not allowed to prescribe independently and are limited in what they can prescribe. I don’t see this level of caution being exercised with the prescriptive privileges for NDs. And that is frightening, as looking at the list of what NDs will be allowed to prescribe, benzodiazepines, morphine, and methadone pop out at me. Without proper training and supervision, I think this is a prescription for disaster.

  18. Fred Dagg says:

    Let the consumer decide. As long as there is informed consent and informed choice, with a disclaimer on the fact the the Naturopaths do not have the same qualifications as the PCP, then there should be no problems.
    This is a democracy.
    Educate first, regulate second. You treat the population of the U.S.A. like a bunch of uneducated morons.
    Give the education system and the U.S. population some credit for being able to make a decision based upon correct information.
    This should apply to all Health Care Professionals.

  19. weing says:

    Fred,
    This is a public health and safety issue. I suppose it’s OK with you to have dope dealers plying their trade as long as people know drugs are addicting.

  20. Fred Dagg says:

    Weing

    you have misunderstood what I said. As far as I am aware, we are not talking about illegal drugs, nor am I advocating what you suggested. However, you cannot play “god”.
    Educate, not regulate.
    Do not treat the public like uneducated morons, this is a democracy, people should be able to decide for themselves.

  21. shadowmouse says:

    “A modern osteopath ought to know what he’s doing.”

    Except for the DO that operated on my knee. He refused to consider that I had a post-op infection – resulting in extended hospitalizations for MRSA septicemia that required multiple orthopedic salvage operations to save my life and my and leg, long-term IV antibiotic therapy, and eventually ending in permanent disability.

    Too bad the asshole still practices.

    What, me, bitter??

  22. Geekoid says:

    Fred,
    nice idea, but practitioners of SCAMs lie ot have no idea how to read a study.
    They go on and on about unprovable nonsense, and use FUD to push the crap.
    If soeoen is going claim they are practicing medicine, then they need to practice medicine. People will take information from these snake oil salesmen as factual.
    People die, and worse, people who aren’t making the decsion die.

    see Whatstheharm.net for examples

    Regulation has its place, and regulating pharmaceuticals is one of those places.

  23. Calli Arcale says:

    Fred Dagg,

    You’ll have to forgive me if I’m not eager to trust the scientific expertise of a general public which can rarely find China on a map, can’t tell you what %25 off of $100 would be without a calculator, and thinks that “nuclear magnetic resonance” means it involves fission or fusion and frankly isn’t clear on the difference between fission and fusion anyway.

    The American public are not morons, but they *are* undereducated.

  24. DVMKurmes says:

    Fred Dagg’s Libertarian utopia is like any utopia, it will never exist quite the way he thinks it will. I am sure he benefits from some type of regulation, even if he will never admit it. No one is an expert in everything, and that is what licensing is meant to help us with-making sure that some basic level of competence exists in the professionals we rely on. Are you really so smart that you will never be tricked or taken advantage of Fred?

  25. whamo says:

    “Mark Crislip sounds like the AMA of 1962. I don’t know Mark’s age, but if history is any guide, 45 years from now, an ND might be his PCP.”

    Baw-ha-ha-ha-ha! You don’t listen to the quackcast often, eh?

    Whamo

  26. Fred Dagg says:

    Hello DVMKurmes

    “No one is an expert in everything, and that is what licensing is meant to help us with-making sure that some basic level of competence exists in the professionals we rely on.”

    I absolutely share you sentiment in this quote. So what is needed is to make sure that the Health Care Provider (HCP) has a level of competence to make them safe. This is seen within the “Scope of Practice” (SOP) of the HCP. Make it robust and accountable. Educate the provider so they practice within the SOP, and educate the public so that they make an informed choice, with informed consent.

    If there is a problem with the U.S. education system, then maybe this site should spend some time figuring out how to sort it out.

  27. DVMKurmes says:

    Fred Dagg,

    Have you been reading this blog for long? If you have, you would know that the standard of practice for naturopaths is exactly the problem with licensing them. When their practice is based on nonsense and lacks any evidence for safety and efficacy, a state license gives them a form of approval and legitimacy they do not deserve.

    It is also very rare for state boards of naturopathy to discipline their members for anything. For example, a naturopath might recommend a cold water bath and homeopathic remedies for a child suffering an asthma attack. If I treated an animal that way, I would justifiably be at risk of loosing my license. If the child dies, the naturopath was only following the standard of naturopathic care.

    What do you think the scope of practice is for a naturopath?

  28. Fred Dagg says:

    That is a problem with the system. I agree with your sentiment as far as responsibility is concerned.

    “When their practice is based on nonsense and lacks any evidence for safety and efficacy”

    This is a very dangerous statement, as iatrogenic (MD, DO, DC, PT, NP etc) causes of death rates as in the top 6.

  29. ... says:

    In the advent of personalized genome sequencing, wouldn’t patient treatment require “a personalized and comprehensive approach to diagnosis and treatment.”?

  30. DVMKurmes says:

    “That is a problem with the system. I agree with your sentiment as far as responsibility is concerned.

    “When their practice is based on nonsense and lacks any evidence for safety and efficacy”

    This is a very dangerous statement, as iatrogenic (MD, DO, DC, PT, NP etc) causes of death rates as in the top 6.”

    You did not answer my question; what is an appropriate scope of practice for a naturopath?

    We don’t know how many people die because they receive ineffective treatments from homeopaths, naturopaths, etc. At least the other health care providers you mention try to keep track of mistakes, complications and adverse side effects and reduce or eliminate them. That problem has been discussed on this blog and elsewhere as well and is not really a part of this discussion.

  31. JasonB says:

    Gee,

    its awfully tempting to move to Oregon, go back to school for a bit, and then start raking in big bucks with little to no effort!

    Part of me knows its dishonest, but on the other hand, its beautiful country, and there seems to be a public that’s all too willing to part with their money for these silly services.

    Hell, even the government is endorsing it! I wouldn’t even have to worry about getting prosecuted for fraud!

    OREGON, HERE I COME!

    nah just kidding I have too much integrity.

  32. tmac57 says:

    Fred Dagg- “This is a very dangerous statement, as iatrogenic (MD, DO, DC, PT, NP etc) causes of death rates as in the top 6.”
    Now, Fred, you should know by now you can’t just throw out such a statement on this blog without being asked for a reference.
    Reference please.

  33. LionDancer says:

    What kinda pharm shill are you if you don’t just let everybody dispense all those wonderful pharmaceuticals. Is not a shills job to… well… shill? Of course I’m just a lion dancer what do I know?

    Patient: Doctor I think I’ve been shot.
    Doctor: Think. Aren’t you sure?
    Patient: Of course I’m sure. Can’t you see the wound; the bleeding?
    Doctor: Of course, of course. This is only a manifestation of deeper problems.
    Patient: I’m bleeding….
    Doctor: I’m a naturopath and it’s important that the body is allowed to heal itself.
    Patient: Bleeding. Faint. Body. Bullet.
    Doctor: Ah, there now you understand.
    Patient is unresponsive. The naturopathic doctor pokes and prods to no avail.
    Doctor: Nurse. Call this patients family.
    Nurse: Does he need to be admitted.
    Doctor: No. He’s dead. We need to bill someone.
    Next!

  34. lonelystudent says:

    “If Naturopathy grows up like Osteopathy did and abandons or mostly ignores it’s wooey parts and “integrates” conventional, scientific medicine and conventional, science based medical training and education into itself like Osteopathy did, that might indeed be the case.”

    DoctorLaw, thanks for bringing up Osteopathy. I’ve always wondered why the bloggers here never talk about osteopathic medicine. Could someone give me a link of a past article (if there is one)?

    This statement by Karl Withakay is simply not true. My sister goes to Western University in California (an osteopathic school) and she spent a great deal of time in her first two years learning and performing craniosacral therapy. She also learned some homeopathy. One of her instructors even performs touch therapy (yes, he thinks he can CURE people simply by touching them). So where’s the criticism of osteopathic medicine?

  35. Psyche78 says:

    With regards to the statement Fred Daggs made about iatrogenic mistakes and fatality, he may be referring to the 2000 article in JAMA by Starfield in which she posits that iatrogenic mistakes is the 3rd leading cause of death in the US. I don’t have access to said article, but would be interested to hear what it says. The only summaries I can find are on anti-Western medicine sites.

    Here is the full cite: Barbara Starfield, “Is US Health Really the Best in the World?,” JAMA 284 (2000):483-485

  36. lonelystudent says:

    What you guys don’t understand is that there is conflict within the naturopathic community. One side does NOT want prescriptive rights (the nature cure NDs who rarely ever prescribe drugs) and shun “green allopathy” (a term that annoys me to no end, which refers to using supplements/herbs the way MDs use drugs). The other group of NDs want to act as primary care providers and tend to use more “evidence based” natural products and want more science-based education and training as PCPs. These two groups are clashing.

  37. @lonelystudent
    They understand. Naturopaths have been extensively discussed on this website, and on the blogs of multiple people associated with this website.

    @Fredd

    “When their practice is based on nonsense and lacks any evidence for safety and efficacy”

    This is a very dangerous statement, as iatrogenic (MD, DO, DC, PT, NP etc) causes of death rates as in the top 6.

    Firstly, DC? You’re including DC? DC is not medicine.

    Secondly, this straw man has been addressed on this blog already: http://www.sciencebasedmedicine.org/?p=364

    Thirdly, when you say “Iatrogenic … causes of death rates as in the top 6.” you don’t know what you’re talking about.
    What’s the alternative? What would have happened to people without the treatment that eventually lead to iatrogenic problems?

    For example, imagine a disease without conventional medical treatment kills 90 of every 100 people. Let’s imagine with conventional treatment that figure falls to 30 people dieing. But now the people aren’t dieing of the disease, they die of an iatrogenic event. Now, your naturopathic (non evidence based treatment) kills zero people by Iatrogenic causes. But people on the naturopathic treatment still die – 90 out of 100 of them. In that case, is the iatrogenic death number a bad thing?

    Sure we don’t want anyone to die. But dropping the number of deaths by that much is pretty good. The fact that the deaths switch into the iatrogenic column is just your ammunition, without considering the actual number of deaths with the alternate treatment you suggest.

    We always want to reduce the iatrogenic damages we cause. We can’t do that by just “going without” treatments. The whole point of science based medicine is to figure out when a treatments benefits outweigh the risks of using the treatment.
    When we have such numbers, the number who die of “iatrogenic” causes are meangingless in isolation. When comparing to other treatments, one must compare the overall deaths, the overall complications. Not just a buzz word you picked up at the libertarian party.

    What’s really dangerous is you talking about these things without having done your homework.

  38. lonelystudent says:

    @whitecoat
    If they understand, then why are they saying, “I don’t get it. I thought NDs don’t want to prescribe drugs.” I’m just saying that some NDs do NOT want prescriptive rights.

  39. gretemike says:

    This is a travesty! How can you print such drivel?

    “Oregon . . . best beer ever . . .”

    You have clearly never been to Belgium.

    Seriously though, thanks so much for all the work you put into these blogs, I really appreciate the info.

  40. Fred Dagg says:

    Whitecoattales,

    in regard to Iatrogenic causes of death. You can start with Vioxx, then Ipubrufen. The absolute tragedy of Thalidomide springs to mind and I am sure there are others you are able to name better than I.

    Look at the research into the use of Prozac type meds in comparison to Omega 3 and St. Johns Wort, will give you another example of how “natural medicine”is safer than “pharmaceutical”, what is more, science has proven that.

    I included DC’s, as they are licensed and regulated Health Care Providers, whether you want to believe it or not.
    “Iatrogenic” is “physician” caused, not “medicine”.

  41. nwtk2007 says:

    tmac57 – “Now, Fred, you should know by now you can’t just throw out such a statement on this blog without being asked for a reference.
    Reference please.”

    http://www.ahrq.gov/qual/errback.htm

    There you go tmac57.

  42. You ignored my point entirely.
    Thalidomide is a tragedy, but the system today is not the system in the day of thalidomide.

    You’re actually cherry picking stupid examples that don’t support your point. You said the number of iatrogenic deaths was very high. Yet very few people died from Vioxx before it was pulled from the market. That is infact, the system (put into place AFTER thalidomide) that keeps america safe from medications that have such risks.

    Ibuprofen (and aspirin for that matter), on the other hand, is exactly what I was talking about. It’s a VERY safe drug, where the benefits FAR outweigh the risks, but there are risks – especially to chronic use.

    If you’re going to look at the large causes of iatrogenic death, you’d have to break it down into different categories. While I don’t have the numbers in front of me, I would think that complications of common treatments in very sick people and complications caused by systemic medical problems, for example, hand washing.

    You still haven’t addressed the fact that you haven’t gathered even the smallest amount of actual medical knowledge before claiming we’re all wrong and you know better.

    You mention that DC’s are licensed and regulated. Yet on this blog generally people generally object to DC’s, claiming their treatments are never science based. So including them is stupid because they are exactly what we are saying shouldn’t be used.

    You appear to not understand what you’re saying. First you use thalidomide as an example, then you say Iatrogenic means physician caused not medicine caused. You’ve just contradicted yourself.

    Most common definitions of Iatrogenic injury include adverse drug reactions, polypharmacy, medical error/negligence, nosocomial infection, and other complications of procedures.

    I’m very familiar of the research on St Johns, Omega 3′s, SSRI’s and TCA’s.

    From what I’ve seen, the balance of evidence says that St John’s is more effective than placebo, and in some cases, as effective as SSRI’s in mild to moderate (but basically useless in severe) depression, but that they interact with sooooo many drugs that it’s difficult to use them. For example, they interact with the metabolism of birth control pills, antiretrovirals, benzos, immune suppressives used in transplant, warfarin, even grapefruits.

    The evidence Omega 3′s do anything at all is much weaker. I see some preliminary data with small numbers saying it might be better than placebo, certainly nothing saying as good as standardized care. Notably more than half the trials I saw showed no benefit at all.

    On the flip side, you’re right to point out that a recent study shows that maybe SSRI’s aren’t as effective as we thought they were. Firstly, that’s still 1 study. We’ll practice as more studies are performed and see if that’s a persistent trend. Secondly, none of the alternate treatments you suggested performed any better!

  43. daijiyobu says:

    Great post.

    -r.c.

  44. Joe says:

    @whitecoattales, I appreciate your post vide supra (especially inre St. Johns wort); but thalidomide was a success for the FDA. That tragedy was mostly confined to Europe (and to Americans who imported it illegally) because the US FDA did not approve it.

  45. Psyche78 says:

    Whitecoattales,

    I understand what you’re saying, but I would caution you to be careful in making the following statement: “What’s the alternative? What would have happened to people without the treatment that eventually lead to iatrogenic problems?” You are assuming that the treatment that leads to iatrogenic problems is necessary, and this is not always the case. Obstetrics as practiced in the US is a good example of this. Induction of labor for no medical reason has been implicated as one of the primary reasons for the decreasing average length gestation in the US and increasing prematurity rate (http://www.news-medical.net/news/2006/03/23/16824.aspx). The already high and increasing rate of c-sections in the US is another issue, as the chance of iatrogenic complication is higher for this major abdominal surgery over vaginal birth.

    Just being a little nit-picky :).

  46. @Joe

    I wasn’t being specific to the FDA, but in defense of science and regulation generally, my apologies if my comment was unclear on that point. It is correct that Thalidomide was a tragedy specifically in Europe, of course.

    @Psyche78

    You are assuming that the treatment that leads to iatrogenic problems is necessary, and this is not always the case.

    My apologies. I’m not assuming that. The assumption I am making, that I should have clarified, is that I’m referring to those iatrogenic injuries caused by science and evidence based therapies. Either that, or I was taking the entirety of iatrogenic injuries into account, and making the assumption that those injuries for medically unjustifiable reasons were a small portion of the total that we will be working to reduce further.

    Presumably, thats the standard by which we decide which treatments are necessary. Admittedly, my mistake for not clarifying this point. But this blog is generally about promoting science and evidence based practices, implicit in that mission is the admission that many doctors do not currently practice science and evidence based medicine.

    Obstetrics as practiced in the US is a good example of this. Induction of labor for no medical reason has been implicated as one of the primary reasons for the decreasing average length gestation in the US and increasing prematurity rate (http://www.news-medical.net/news/2006/03/23/16824.aspx). The already high and increasing rate of c-sections in the US is another issue, as the chance of iatrogenic complication is higher for this major abdominal surgery over vaginal birth.

    I’m not in disagreement with what I think your overall point is here -that iatrogenic injury caused by overzealous surgery or induction may not be justified. Certainly I won’t disagree with you on induction of labor for no medical reason.

    However I just came off of almost 2 months of obstetrics and gynecology just now so I have a slightly different perspective. The rate of C sections in the US IS too high. Yet how do we decide who gets that C section? Now don’t get me wrong, I’m not at all in favor of elective C sections without any good reason.

    The obstetrics ward I rotated on was primarily high risk (>70% high risk patients) so our C section rate was even higher – closer to 50%. The question is, how do we decide who gets those C sections? It’s one thing to identify that the statistic is “we do too many C sections.” It’s quite a bit more difficult to identify WHY we do too many C sections, and how should we identify those patients who DON’T need C sections.

    For example, I scrubbed around 50 sections in 18 days on a large obstetrics ward. Around 20 of them were repeat C sections, after a trial of labor (without induction), around 20 were for “nonreassuring fetal well being”, 5 were stat sections for severe pre-eclampsia (that is, 5 for maternal well being related to pre-eclampsia instead of fetal well being), and a few for other (for the sake of discussion, lets just call them other, medically justifiable) reasons.

    So who out of that group should we not have operated on?
    Well, evidence says that routine fetal monitoring leads to too many C sections (at least at this time) so some of the “nonreassuring fetal well being” patients probably didn’t have to be operated on.

    Yet routine fetal monitoring is pretty widespread. Perhaps this practice will change as the evidence continues to mount. Perhaps studies will identify different criteria to determine nonreassuring fetal well being using fetal monitoring, to better identify which patients really should be sections using this technology.

    Vaginal birth after C section is often recommended so that is another area we could influence, and at my institution we try very hard to do that. Yet we still need to offer the option to patients to have a C section if they’ve had one before. It’s just standard practice. Given the option, alot of women just don’t want to try a vaginal birth if they’ve had a C section before.

    I’m sure there are other areas, and this is by no means comprehensive.
    The institution I’m at is probably by no means representative, we have a large number of MFM (maternal fetal medicine – OB superspecialists), we’re at a significant academic hospital and so I can’t speak with any experiential confidence on what happens anywhere else. I’m sure there are things we can do right now to reduce that number, and improve care.

    I’m just trying to point out that looking at the population data, it’s alot easier to see the problem. But looking at the patient in front of you, it’s alot harder to identify the goldilocks point “the correct amount of C sections.”

  47. (put into place AFTER thalidomide)

    I’m an idiot, on another read through I see the clear mistake and I’m not sure where it came from Joe

  48. Joe says:

    @ whitecoattaleson 20 Jun 2009 at 12:49 pm “(put into place AFTER thalidomide) {snip} on another read through I see the clear mistake and I’m not sure where it came from Joe”

    The thalidomide episode did forever change the way we approach drug use in pregnancy.

  49. daedalus2u says:

    The goal of interventions is to minimize the sum of the harm caused by intervening and the harm caused by not intervening.

    In the case of C-sections, the “harm” from doing an unnecessary C-section is pretty minor. More inconvenience and pain for the mother, longer time to recover, perhaps side effects from surgery, higher expense. What is the harm from not doing a necessary C-section? Dead babies, injured babies, injured mothers, etc. How many unnecessary C-sections does it take to “balance” the harm from a necessary C-section not performed?

    What constitutes “harm” is subjective. The harm of a C-section should include (with proper weighting), the narcissistic injury that happens to mothers who treat childbirth as an extreme sport, where the higher the degree of difficulty the larger the score, where the epitome of performance is “free birth” that is birth alone, with no support following a pregnancy with no prenatal care.

    I think a lot of the “harm” of SBM is similar, the narcissistic injury to those who want only “natural” remedies delivered by Naturopaths.

  50. @daedalus2u

    Well i mean, C sections can have some pretty major complications down the line. Adhesions can make future surgeries more difficult, you have more complications later. The argument Psyche is making is that in this country we absolutely do too many C sections – we don’t know which sections are “extra”, but (as far as we can tell so far) the relatively comparable populations have lower overall complications to babies+mother and a lower C section rate.

    So there is a valid point in there, its just not a refutation of SBM. It’s the challenge of SBM to evolve those practices over time. The only reason we know that there is such a problem is SBM documenting it.

    I agree completely with

    The goal of interventions is to minimize the sum of the harm caused by intervening and the harm caused by not intervening.

  51. Psyche78 says:

    @Daedalus2u: C-sections have been associated with a higher incidence or a variety of complications to both mother and infant. These include:

    - risks to child: future higher risk of asthma, increased rate of admissions to NICU, iatrogenic prematurity (which carries with it higher risk of breathing problems, feeding difficulties, temperature instability (hypothermia), jaundice, delayed brain development and death than babies born at term), and increased risk of neonatal death (N Engl J Med 2009;360:111-120,183-184.; http://www.marchofdimes.com/printableArticles/22684_30185.asp)
    - Immediate/short-term maternal complications: infection, injury to other abdominal organs, difficulties in establishing breastfeeding, difficulties in being able to care for the infant, hemorrhage, blood clots, pain, 2.3 times higher risk of rehospitalization
    - Long-term complications of c-section: repeated c-section, higher risk of placental abnormalities in future pregnancies (which carry higher risk of maternal and fetal/neonatal mortality), higher risk of uterine rupture, higher risk of fertility problems, higher risk of hysterectomy, miscarriage, uterine scarring, abdominal adhesions, higher risk of ectopic pregnancy, pain, increased risk of stroke ((Lin, et al., Am J Obstet Gynecol. 198(4):391.e1-7, 14 Feb 08; Rosen, Clin Perinatol. 35(3):519-29, September 2008; http://www.guardian.co.uk/society/2008/jan/01/health.medicalresearch)

    These are not “minor inconveniences.” The fact that c-sections are the most common surgical procedure performed in the US does not negate the fact that a c-section is major abdominal surgery. If the circumstances warrant such surgery, then the risks of intervention outweigh the risks of not intervening, but it does not nullify the risks of intervention. Put another way (and I wish I could claim credit for this analogy), jumping out of a 4th floor window is dangerous and risky and most people would not consider doing it unless the building was on fire and there was no other way down; so it is with c-sections. There is harm from doing unnecessary cesareans, period. To try and justify said harm by suggesting that they are necessary in order for there to be adequate intervention in those cases that truly do warrant it not only shows a lack of empathy for those who have experienced the harm, it suggests that what these women and their infants experience is merely collateral damage and there is no need to alter methods or procedures to decrease said damage. You ask, “How many unnecessary C-sections does it take to ‘balance’ the harm from a necessary C-section not performed?” Science does not have the answer to that; only those who have suffered the harm have the answer to that, and I daresay that many of them would not readily place themselves or their infants in harm’s way solely for the benefit of someone else. It is one thing to cause harm on accident or when it is unavoidable; it is quite another to cause harm and then take none to few steps to avoid causing the same harm in the future and, instead, engage in practices that lead to an increase in the number of situations when such harm is likely to occur.

    Your statement about “narcissistic injury” betrays a great deal of disdain for the psychological well-being and needs of women and suggests little understanding of the reasons women birth outside of the mainstream medical establishment. I challenge you to talk to the women who have been bullied into unnecessary and unwanted intervention during childbirth or read their stories, and see if you would be so cavalier in describing their psychological distress afterwards.

    @whitecoattales: I will try to address your concerns about ways to decrease the c-section rate tomorrow – it’s getting late right now!

  52. I challenge you to talk to the women who have been bullied into unnecessary and unwanted intervention during childbirth or read their stories, and see if you would be so cavalier in describing their psychological distress afterwards.

    Noone should ever be “bullied” into unnecessary and unwanted intervention of any sort. I don’t think daedalus was trying to say that either, I suspect there is just some misunderstanding going on both ways.

    Daedalus, if I’m reading him correctly, is saying that our goal is to keep the overall rate of iatrogenic injury + injury from disease to a minimum, and that it’s deceptive to look MERELY at the iatrogenic injury rate. I suspect that he was not aware that C-sections are an area where the evidence says we overtreat. That’s not widely known outside of the medical/healthcare community. Am I way off Daedalus?

    You ask, “How many unnecessary C-sections does it take to ‘balance’ the harm from a necessary C-section not performed?” Science does not have the answer to that; only those who have suffered the harm have the answer to that, and I daresay that many of them would not readily place themselves or their infants in harm’s way solely for the benefit of someone else.

    At the same time, while science can’t make value judgements, physicians are asked to make that decision all the time. I mean when we say that the C section rate is “too high”, we’re saying that based on exactly the kind of decision we’re making. We’ve implicitly said “well we might be catching a few more C-sections that SHOULD happen, but we’re doing so at the cost of sectioning too many people getting sectioned who DIDN’T need too.”

    I’m not sure if this one is as widespread, but another example is appendectomy. If someone comes in with a good story for appendicitis, and supportive imaging (if there’s time) you take them right to the OR, because we’ve decided the possible damage done by doing an unnecessary appendectomy is small than the damage done by missing an appendictis. Infact on my rotation, they often said (I doubt this is evidence based) that if you aren’t ever getting a normal appendix, you likely aren’t doing enough appendectomies – because if you’re never getting a normal appendix, your threshold for cutting somone is too high.

  53. jumping out of a 4th floor window is dangerous and risky and most people would not consider doing it unless the building was on fire and there was no other way down; so it is with c-sections.

    I appreciate the power of analogies as a way to get across the gist of a point. This analogy though, seems overly dramatic. There is a difference of degree – jumping out of a window is MUCH more dangerous than a C-section. There is a difference of quality – we aren’t talking about “jumping out of a window when there is a stairway around the corner” we’re talking about how we decide exactly who to C-section, not just cutting people open willy-nilly.

    A much less eloquent, butchered analogy, that I think appropriately describes the difficulty involved:

    “jumping out of a 4th floor window is dangerous, one time you’d consider it is if the building is on fire. If you know the stairwell is on fire, jump out the damn window. If you know the building is on fire, but it’s on the 10th floor, run down the stairs. The question is, how do you tell where the fire is when you just hear the alarms going off.”

  54. gretemike says:

    It may be true that “natural medicine” has no tragedy comparable to thalidomide. Maybe. But why is that considered a slur against pharmacology? Pharmacology is dealing with substances that are inherently more dangerous, in general, than the substances being dealt with in “natural medicine,” isn’t that true? It would therefore be odd if there weren’t some serious tragedies with the generally more dangerous pharmacological substances.

    It’s like an avid walker pointing at the recent Air France crash and saying, “see, we don’t have disasters like that, walking is superior to aviation.” But try walking to from Brazil to France. The point is that you can go much farther with aviation, even though it is inherently more dangerous than walking.

    Likewise, it strikes me that for most serious medical conditions, “natural medicine” just won’t get you very far. So when my wife recently had a meningioma removed and subsequently developed a blood clot in her head (the tumor was growing into a sinus), pharmacology seemed to deal quite well with the clot. Come to think of it, there were likely a lot of other medicines involved prior to the clot. I suspect that “natural medicine” could not have gone very far at all for my wife. What would it have had to offer her?

    The issue isn’t whether or not pharmacology has sad stories or not. EVERY field has sad stories (even “natural medicine”). The issue is, what works. Occasional tragedies are a red herring that distract from the real issue.

  55. Fred Dagg says:

    Mike, I agree with your last sentiment. What works is very important.

  56. gretemike says:

    Fred,

    Then what “natural medicine” would have worked for my wife’s brain tumor?

  57. Sam says:

    Whitecoattales states: “The evidence Omega 3’s do anything at all is much weaker. I see some preliminary data with small numbers saying it might be better than placebo, certainly nothing saying as good as standardized care. Notably more than half the trials I saw showed no benefit at all.”

    The evidence for Omega 3′s is actually quite strong:

    http://www.nutraingredients-usa.com/Research/Omega-3-science-review-supports-DRI-for-heart-benefits?nocount#more-5

    “The scientists reviewed over 15 prospective cohort studies in generally healthy populations, a retrospective case-control study of sudden cardiac death, four large randomized controlled trials with fish or fish oil in patients with and without known heart disease, and several in vivo and animal experimental studies.

    This evidence indicates that modest EPA and DHA consumption “markedly” reduces the risk of cardiac death, they said.

    “The quality, strength, and concordance of this evidence are remarkable, meeting and indeed generally exceeding those for any other dietary factor for which a DRI has been set based on reducing risk for chronic disease, including saturated fat, dietary cholesterol, salt, and dietary fiber,” they wrote.”

  58. Sam: We were talking about Omega 3′s for depression

    Omega 3′s are part of PCP’s armament for cardiac disease already. Please read the context before criticizing.

  59. daedalus2u says:

    Omega-3 fatty acids are essential fatty acids. Humans are incapable of making them and they are an absolute requirement of the human diet. They are essential components of structural lipids in the brain. They are also components of signaling pathways. What levels are necessary is not well established. There are many dietary sources, and levels in excess of needs for structural and signaling pathways are oxidized as fatty acids for energy.

    There is some evidence that omega-3 fatty acids do act as antidepressants to some extent.

    http://www.ncbi.nlm.nih.gov/pubmed/19499625

    There is somewhat anecdotal evidence that they normalize brain function (as in preventing psychosis during pregnancy). Since requirements for omega-3 fatty acids are tied to brain growth, pregnant and lactating women have increased requirements for them. What those precise requirements are is difficult to say because depriving pregnant women of omega-3 fatty acids until symptoms of deficiency are observed is criminally unethical and no IRB would allow it.

    I notice a slight elevation in mood when using them, so I do. There is essentially no downside to them other than perhaps expense (they are cheap but not free), or heavy metal and PCB contamination when fish oil is used as the source, or a slight increase in bleeding time (but maybe that is protective against forming clots?)

    To people trying to live with depression, life is not a “science experiment”. Effective treatment for depression is still very hard to get. As I pointed out earlier, ineffective treatment for depression is the 11th leading cause of death. There are many reasons why people are unable to get effective treatment for depression. If they can modify their diet and achieve some mood improvement without resorting to the stigma of being treated or labeled as “mentally ill”, that is a good thing.

    If someone is actually depressed what they need more than anything is effective medical treatment by a knowledgeable mental health practitioner. Modifying one’s diet to include more omega-3 fatty acids may help, but is no substitute for effective medical treatment.

  60. Fred Dagg says:

    Mike

    the best thing you could have done for your wife is what has been done. I hope all goes well. I am not a “Naturopath”, however, I am very interested in fairness, so my comments I hope, reflect this.

  61. Pthib says:

    I happened upon this site by chance and after reading the comments I felt the need to respond. Medical Science failed me. I suffered for years and a simple change in diet (prescribed by a “quack”) and an over the counter homeopathic remedy made my life bearable. I still see my “regular” Dr. and value her opinion as well.

  62. daedalus2u says:

    Fred, what do you mean by “fair”? Is it “fair” to subject people to ineffective methods while charging them? To me, there is no concept of “fair” that fits with that behavior.

  63. Fred Dagg says:

    There are numerous axamples of health care that would not be considered “fair”. No matter what discipline.
    We see this every day. Please tell me that this never happens in medicine.

  64. Fred you’ve failed to address any of the other comments responding to your consistent inaccurate commenting. You’ve also completely failed to address what daedalus2u asked.

    Is it “fair” to charge people for inneffective treatments? and What do you mean by fair?

  65. Joe says:

    @whitecoattales on 21 Jun 2009 at 5:39 pm “… What do you mean by fair?”

    Perhaps Fred wants a statement like “Chiro is based in ignorance; but, to be fair, most of them are blissfully unaware of it and are nice people.”

    Someone I know likes to say “If you can’t understand; maybe it’s you: http://www.apa.org/journals/features/psp7761121.pdf
    The article is titled Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments

  66. Joe says:

    Maybe I slipped a track from naturopaths to chiropaths; but the bottom line is the same.

  67. Psyche78 says:

    Whitecoattales,

    I appreciate your response. I agree that in your situation, seeing patients who are higher risk than the general population, the c-section rate is going to be higher. I think we can all agree that there are conditions that necessitate c-section. My experiences are quite different from yours and come from what I encountered during my first pregnancy and my current one (in two different metro areas) and from my experiences with pregnant and postpartum women (as well as their labor support) as a clinical psychologist who has a special interest in treating women who have experienced negative birth experiences. I’ll be upfront – there is little scientific research about the psychological impact of negative birth experiences (though Cheryl Beck of UConn has been doing some great prelim studies), so much of my preparation for treating women dealing with depression and anxiety related to their births comes from correspondence/talking with these women and midwives/childbirth educators/doulas in the community (for obvious reasons, obstetricians generally don’t want to talk to me about negative birth experiences). I understand that there is a difference between looking at studies and dealing with a real live patient. But I think one that thing that is missed is that the patient is not a passive individual to be treated – many of the women I am in contact with or work with do not feel as if they were offered informed consent to the procedures that were done. Hearing their stories, I’ll be honest, it is hard for me not to biased and upset about the level of intervention that currently occurs; one can only compartmentalize so much.

    You have asked several times what we need to do to reduce the c-section rate. I don’t think anyone knows the answer to that – WHO suggests a c-section rate of no higher than 15%, as negative outcomes start increasing after that point to where they offset the positives. It is unfortunate that while there is much discussion about the rising c-section and some agreement that it needs to decrease, the rate continues to increase. I was disturbed to learn that in Miami-Dade County last year, the number of babies born by c-section was higher than those born vaginally; at one hospital in that area, the overall c-section rate is 70%. At the hospital closest to me, the c-section rate is 40% and rising. These are alarming numbers.

    What are ways to reduce the c-section rate? Well, I believe the studies can point the way on that. One way to reduce the c-section rate is to reduce the number on non-medically indicated inductions, as studies have shown that a first-time mother who is undergoing induction for non-medically reason can have as much as a 1 in 2 chance of a failed induction ending in c-section (Macer JA et al. Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol 1992;166(6 Pt 1):1690-1697.) Induction/c-section for suspected macrosomia continues in spite of even ACOG stating that this is not a valid reason for either intervention. Another way to reduce the c-section rate is to decrease the number of amniotomies, as studies show that AROM does not speed up labor to a clinically significant degree (www.ncbi.nlm.nih.gov/pubmed/3627629) and the rupturing of membranes generally leads to women being “put on the clock” to deliver; not only that, but if the fetus is not engaged in the pelvis, rupturing the membranes could lead to cord prolapse, necessitating a c-section. VBACs need to supported and encouraged; at present, there are at least 1400 hospitals in the US that have on the books VBAC bans; more hospitals than this have de facto bans because no obs/practices who deliver at the hospital support VBAC. The routine administration of pitocin during labor needs to be looked at more critically, as studies have shown that pitocin is correlated to increases in fetal distress and maternal exhaustion, which, in turn, can lead to c-section. We need to take a second look at whether breech presentation means an automatic c-section; there has been tremendous criticism of the Term Breech Trials study, and just last week, the Canadian obstetrics society, SCOG, changed the recommendation to encourage a trial of labor for breech. And finally, if mom and baby are doing fine, they should be allowed to labor off the clock. You’ve already mentioned that the use of continuous fetal monitoring does not correlate with better outcomes but does correlate with higher c-section rates, yet CFM is still policy in many hospitals and practices.

  68. daedalus2u says:

    Psyche, when I wrote my comment on C-sections and birth as an extreme sport, I was thinking of this blog post about the practice.

    http://skepticalob.blogspot.com/2009/06/stuntbirth.html

    The author of that site did look at the study quoted in the March of Dimes that you linked to and noted that the increase in late preterm C-section rate was accompanied by a decrease in late preterm stillbirths.

    http://homebirthdebate.blogspot.com/2008/05/late-prematurity-rising-as-result-of-c.html

    The degree of “medical necessity” was determined from the birth certificate, which doesn’t always completely record the medical indications. There are a lot of reasons why C-section rates may be higher in the US compared to other places other than bad care during delivery. Virtually every other industrialized nation has much better access to prenatal care. I think that better prenatal care, better access to health care for all, reduced need by hospitals to wring out every penny of reimbursement, and reduced legal jeopardy would help reduce the C-section rates.

    The term “narcissistic injury” as applied to childbirth is from her.

    http://homebirthdebate.blogspot.com/search/label/C-section

    She also discusses reasons for change in VBAC practices.

    My mother was an RN CNM who delivered babies in the back woods of Kentucky for Frontier Nursing. She had all of her children in a hospital. She did mention that during the birth of her first child, the anesthesiologist did try to give her gas during it and she slugged him. I don’t think she would ever have considered giving birth at home if a hospital was available. My mother completely embraced science based medicine. I think that was the reason that Frontier Nursing had such a low rate of birth complications; they used the best science that they knew because they wanted to have the best birth outcomes, not because they wanted to massage their egos.

    I was present at the birth of both of my children and tried to help their mother as much as I was able to. The most important thing was the health of my children and their mother, and everything else was so far down the list that it didn’t register. For our first child she was extremely anxious. I was there when she misinterpreted what the staff was trying to do to help her. She misinterpreted what I was trying to do. I don’t fault her at all. None of the difficulties she had were about narcissism; mostly they were about anxiety and misinterpretation.

    I think that a lot of the “pull” that Natural Medicine has is about the narcissism of the patients. The natural practitioner knows how to push those narcissism buttons and the patients love it.

  69. The Blind Watchmaker says:

    To quote Richard Saunders, “What does N.D. stand for?….Not a Doctor!”

    My question are these:

    Will the N.D.s have to pay the same malpractice insurance that I (an internist and pediatrician) have to pay?

    If they are going to be able to prescribe just about any med, are they going to have laboratory privileges at real labs to do proper monitoring? Are they going to do proper monitoring?
    Do they know what to monitor?

    Are insurance companies going to cover such tests? They can be rather expensive.

    Are the Jeffrey Fiegers of the world (trial lawyers) starting to salivate at the prospects?

  70. Fred Dagg says:

    So, how “fair” is the prescribing of Ritalin, or Prozac for disorders that they were nefver designed for?
    Tell me how fair it is that the rates of surgery in the U.S.A. for low back problems is five times the rate than the U.K.
    Tell me how fair it is that the U.S. office of Technology said “Only 10 to 20 % of all proceedures in medical practice have been shown to be efficacious by controlled trials”.
    Tell me how fair it is that the rates of major surgery in the U.K. is 50% less than that of the U.S.A. and that the people in the U.K. live longer. (Lynn Parker, Medicine and Culture: Varieties of Treatments in the U.S.A. England, West Germany and France).

  71. gretemike says:

    Fred,

    First of all, I searched for the word “efficacious” on the website of the Office of Science and Technology (www.ostp.gov) but was not able to find support for your quote, which in my opinion fails the “smell test.”

    But the real point I want to make is that none of your statements really require a reply. This is a website devoted to the idea that mainstream medicine is based on science, and is superior in all respects to alternative modalities, which is not based on science.

    So regarding the other statements in your post – perhaps it is true about the U.K. / U.S. difference, I don’t know, but if true it does not detract from the idea that mainstream is better than alternative. Your post would perhaps be an interesting point for consideration if the purpose of this website was a discussion of how the litigious nature of U.S. society impacts the practice of medicine (I have a suspicion that lawsuits and/or the threat of lawsuits result in many unnecessary medical treatments in the U.S.), but it is neither here nor there regarding mainstream v. alternative.

  72. Fred Dagg says:

    You miss the point!! I am not arguing that alternative is better. What I am suggesting is that none of you should hold the sanctimonious attitude that you do have without looking at the flaws in your own professions (MD, DO, DC. NP, PT).
    Again, you hide behind the word “science”as if it is a shield, not realizing that your shield is full off holes, as I am pointing out.

  73. albion tourgee says:

    So, my wife has severe allergies. She went to a generally good MD and recommended allergists for about 10 years, and we spent several thousand dollars getting her the “tested” desensitizing shots. Her allergies only got worse.

    We’ve always been skeptical of naturopathy but she was persuaded to try. The ND looked at my wife’s conditions from a systematic perspective. A few dietary changes, and in 2 weeks, allergies improved dramatically (not gone, but maybe 80% better to put a number on it.)

    Hmm. Why’s nobody testing dietary changes as treatment for hay fever? Well, no money in it for the drug companies, for one. Otherwise, you have to ask the scientific community I guess.

    ND’s by the way, are not Homeopathic doctors by and large. Lumping them together shows misunderstanding of the subject.

    During my lifetime, medicine has become more and more a matter of match the symptoms to a menu of treatments. A limited approach. The main difference between the ND and our MDs is, the ND was looking at physiological systems, not just symptoms. If you limit treatment to experimentally based stuff, well, you exclude treatment that can’t be subjected to this approach. I think experimentally based medicine is indispensable and has led to great advances in health care, but when I read defensive, overbearing stuff like this blog, I feel sorry for people who have such closed minds about things we actually know so little about.

  74. Joe says:

    No, Fred, all your points have been addressed, repeatedly. Health care professionals (MD, DO, NP, PT) do look for the flaws in their professions. That is why you can read about them.

    DCs, on the other hand, are not really professionals, certainly not in health care. They deny the numerous errors of fact in their magical thinking and the harm they cause.

  75. What I am suggesting is that none of you should hold the sanctimonious attitude that you do have without looking at the flaws in your own professions (MD, DO, DC. NP, PT).
    Again, you hide behind the word “science”as if it is a shield, not realizing that your shield is full off holes, as I am pointing out.

    We do look at the flaws in our own professions. Lots of the articles on this blog are about practices within our own professions that SHOULD be more evidence based. <

    ND’s by the way, are not Homeopathic doctors by and large. Lumping them together shows misunderstanding of the subject.

    Look at the ND curriculum, their board exams explicitly cover homeopathic medications. It may not be their only practice, but it is a significant part of their practice, education, and certification. It’s therefore, fair game. Not having checked on that fact before pronouncing us wrong shows a misunderstanding of the subject.

  76. albion tourgee says:

    Whitecoattales — I actually said nothing at all about ND education or boards, so your comment is off base. You’d have to show that NDs by and large are homeopathic doctors to address my point. Not my experience, but I don’t think anyone has done a formal study! It’s a minor point, but your comment actually reinforces my point — people in the medical community have become so defensive and intent on dissing all other forms of health care treatment, that rational discussion of these issues has become very difficult, what with all the straw men and twisting words. Oh well. As a friend reminded me yesterday, you can’t reason someone out of an opinion they arrived at irrationally.

  77. Joe says:

    albion tourgee on 22 Jun 2009 at 4:21 am “… The main difference between the ND and our MDs is, the ND was looking at physiological systems, not just symptoms.”

    You are parroting standard quack dis-information. Naturopathy is the universal quackery since they incorporate every type of quackery they can, they even have their own type of chiropractic. You should read about it: http://www.naturobase.org

  78. weing says:

    “The main difference between the ND and our MDs is, the ND was looking at physiological systems, not just symptoms.”

    What the hell does that even mean?

    “If you limit treatment to experimentally based stuff, well, you exclude treatment that can’t be subjected to this approach.”

    Do you mean that all medical practice is science based? Not yet, it isn’t. We’ve come far, but not that far.

  79. Scott says:

    “If you limit treatment to experimentally based stuff, well, you exclude treatment that can’t be subjected to this approach.”

    Not a problem. Treatment that actually has an effect can in principle be subjected to empirical testing. Only if it has no detectable effects (which would include making the patient feel better) is it not subject to scientific testing.

    Put another way, “if I do X, Y will happen” is testable if X can be done or not done in a controlled manner and Y can be detected. Any purported remedy can obviously either be used or not, so the former is satisfied. And any effect which cannot be detected is by definition useless (it accomplished nothing to benefit the patient if the patient can’t tell the difference), so the latter is satisfied too.

    And don’t even try quantum arguments to get around this; anyone with any real knowledge of quantum physics can instantly identify those as complete BS.

  80. I actually said nothing at all about ND education or boards, so your comment is off base. You’d have to show that NDs by and large are homeopathic doctors to address my point

    No.
    I don’t.
    If you’re education and certification require you to learn homeopathy, and you accept that without saying “This is wrong, homeopathy is baseless” and you treat patients with homeopathy, how are you not a homeopathic doctor? I don’t need to prove that ND’s as a whole are “by and large homeopathic doctors” because that’s an incoherant statement.

    At any rate, “lumping together” of homeopaths and ND’s is a side issue.
    The comment is “ND education is inadequate for them to be prescribing physicians.” The ND education in homeopathy is significant because it shows a fundamental misunderstanding of pharmacokinetics and pharmacodynamics, without which you can’t possibly understand how to prescribe medication in a rational way.

    Not my experience, but I don’t think anyone has done a formal study!

    … becuase ND’s refuse to participate in any formal study of it.

    Look, the accupuncturists try. They have trial after trial. They’re basically all negative, but they’re looking for evidence. They’re intellectually honest about it.
    ND’s as whole, refuse to practice evidence based medicine, and refuse any attempt to rationalize their practices.

    Addressing the rest of your earlier comments:

    Hmm. Why’s nobody testing dietary changes as treatment for hay fever? Well, no money in it for the drug companies, for one. Otherwise, you have to ask the scientific community I guess.

    The scientific community will test anything. ND practioners refuse to test their practices.

    During my lifetime, medicine has become more and more a matter of match the symptoms to a menu of treatments. A limited approach.

    All this proves is that during your lifetime you’ve been increasingly disconnected with the practice of medicine. My education has had nothing to do with “matching symptoms to a menu of treatments”, it’s all about treating base causes, and when base causes can’t be treated, increasing quality of life and empirically improving outcomes.

    The main difference between the ND and our MDs is, the ND was looking at physiological systems, not just symptoms.

    That’s crap. We all look at systems. We all look at pathophys. There was a thread here, and over at PalMD’s joint, where naturopaths were welcomed to discuss how they would treat a patient. It revealed a profound misunderstanding of physiology, or the assumption that textbook physiology that I learned in college was exactly how things happened in vivo.
    We learn from the real world that the real world doesn’t work like a textbook, so the base presuppositions on which many naturopathic treatments are completely wrong.

    I encourage you to read Tim Kreider’s pieces on CAM on capmus, there is a discussion about his encounter with a naturopath in a campus discussion that also reveals a similar basic misunderstanding of biology on multiple levels.

    If you limit treatment to experimentally based stuff, well, you exclude treatment that can’t be subjected to this approach.

    What naturopathic treatment can’t be subjected to experimental based treatment? What alt med treatment, in general, can’t be tested?

    I think experimentally based medicine is indispensable and has led to great advances in health care, but when I read defensive, overbearing stuff like this blog, I feel sorry for people who have such closed minds about things we actually know so little about.

    Ah, so we’re close minded because we ask people to prove they aren’t wrong before we try dangerous and or silly treatments on our patients?

  81. Scott says:

    “Look, the accupuncturists try. They have trial after trial. They’re basically all negative, but they’re looking for evidence. They’re intellectually honest about it.”

    Unfortunately, “intellectually honest” is quite far from the truth. Taking the strongest possible result that acupuncture doesn’t work, and presenting it as evidence that it DOES, is about as intellectually dishonest as it gets short of outright manufacturing data.

    http://www.sciencebasedmedicine.org/?p=492

  82. I stand corrected. I’ve read that article and I came away thinking that they just think they lack even the most basic understanding of science, I’ll agree that a better reading is that they are intellectually dishonest as well.
    My point was they try to produce evidence. The pile of evidence that shows no effect of accupuncture is getting too large to ignore… because they keep testing it.

    There is no evidence piling up for or against ND because they don’t try to do any research.

  83. Scott says:

    I’ll certainly agree with that – data is better than no data, without a doubt.

  84. Psyche78 says:

    daedalus2u,

    I think you are operating under the assumption that all medical doctors are practicing SBM and so to reject the doctor and the care they offer is to reject SBM. I’m not trying to start yet another debate on homebirthing, but I will say this: women who choose to birth outside of the hospital setting are often doing it because they cannot find a SBM care provider to be present for an in-hospital birth. I know this is the case for myself. I had a great birth in a hospital with a CNM attending with my first son; she was my second care provider – I “fired” the ob/gyn who was my initial provider at towards the end of my second trimester when it became obvious that she was not practicing SBM and had no intention of letting the evidence alter her practice. If I was still living in the same city, I would be under the care of the same CNM and preparing to deliver at the same hospital with my current pregnancy. I thought I would have no problem finding another SBM care provider for this pregnancy, having moved to a larger metro area – I was wrong. After interviewing area obstetric care providers, it became painfully obvious to both my husband and I that we weren’t going to find a SBM care provider within a reasonable distance to attend a hospital birth; this was a difficult realization for my husband, as he was and is in no way what you could classify as “crunchy” or “hippy.” I’m not going into the gory details, but suffice it to say, I was not impressed by practices that a) told me during the 1st trimester that they would induce me at 38/39 weeks in order to “manage” my labor; b) refuse to provide any statistics about their outcomes (ex: c-sec rate, epidural rate, episiotomy rate, etc); c) made it standard policy to send anesthesiologists to the rooms of laboring women who had expressly stated they did not want epidurals; or d) prescribe medications that were expressly contraindicated based on medical history (probably due to the care provider not bothering to read the chart prior to the 5 minutes she spent with me). You can call me crazy if you want, but being a low-risk patient, I’m not going to choose sub-optimal care providers just so I can give birth in a hospital.

    And for the record, the CPM that my husband and I chose to provide care during this pregnancy started our very first meeting (before even taking my history) by going over the risks of homebirthing, who was an appropriate candidate and who wasn’t, what circumstances would lead to a transfer of care, and the stats for all the births she has attended in her 20+ years of midwifery.

  85. daedalus2u says:

    To my knowledge I have only had SBM based care, so it is hard for me to imagine otherwise. It is hard for me to imagine how difficult and upsetting it must be to not be able to find a SBM based practice for delivery. I wish you good luck.

  86. albion tourgee says:

    Whitecoat, again I think you miss the point. My wife had severe allergies. She has a very good md and went to some very well regarded allergists. Ten years, we put our trust in that system, and condition only got worse. We like you refused to accept that “non-medical” approaches such as dietary restrictions might be better. But, finally we got to an ND who advanced the theory that food intolerance may excite the body’s defenses exacerbating allergies. Okay, pretty loosey goosey, perhaps. But, it just happens to be true. Now, don’t tell me that medical science can’t test dietary restrictions for allergies because NDs say no. It’s because, well, the drug companies simply are not going to test anything that can’t be patented, and I don’t think it will advance your career in science or medicine if you start working on these “natural” approaches rather than biochem or something more acceptable. Remember that guy who did the work on homocisteins at Harvard some years back? He was very right and it took his career several decades to recover.

    Let me give another example, this one from an MD, Dr. Samuel Mann, from Cornell. His book, Healing Hypertension, suggests that the condition is often caused by suppressed emotions, and that psychotherapy (ie talk therapy, the kind that “scientific” testing always shown to be ineffective) often is helpful. Now, as Dr. Mann recognizes, his theories would be very hard to rigorously test — how do you separate the control group of those who have suppressed emotions, which they are generally unaware of, from the group that does not have suppressed emotions. And then how do you test the effectiveness of talk therapy in this context? Even if you set up some large population study of the effects of talk therapy on blood pressure, something none of the studies I know of has ever done, how do you know what other variables are involved or which patients have actually benefited? So, most doctors continue to simply say, 80% or more of hypertension is ideopathic, and they prescribe medications that do help hypertension, but without too very much attention to the side effects.

    I’m glad you don’t see your medical practice as match symptoms to a treatment, and I hope you treat hypertension, allergies, and other poorly understood conditions with more insight than most doctors I’ve seen do. We need more doctors who get deeper than giving their patients pills. But the ones who can affod to see patients more than say 20 minutes for a checkup, well, mostly you can afford them if you can pay for a concierge service.

  87. Calli Arcale says:

    It’s because, well, the drug companies simply are not going to test anything that can’t be patented, and I don’t think it will advance your career in science or medicine if you start working on these “natural” approaches rather than biochem or something more acceptable.

    What makes you think that a) drug companies are the only ones willing to fund research and that b) “natural” approaches are “not acceptable” (I assume you mean socially unacceptable in a university setting)? Quite a lot of research goes on into non-patentable things, and quite a lot of that is in stuff that one might consider “natural” (though I’m rather fuzzy on what the difference is between “natural” and “biochem”, since nature is basically all about biochemistry).

    There’s research going on all the time about dietary interventions, the role of different nutrients in disease processes, the fundmental workings of the immune system, and so on. Far from being less “acceptable” than whatever you mean by “biochem”, these are actually rather fashionable at the moment, and there’s even a big government agency directing funds *specifically* into that sort of research.

    NDs are full of excuses for why they don’t do any of the research, but these excuses don’t hold up to examination.

  88. We like you refused to accept that “non-medical” approaches such as dietary restrictions might be better.

    In no way did I say that. I said test it, prove it. I’m an equal opportunity physician, I’ll use whatever works.

    But, finally we got to an ND who advanced the theory that food intolerance may excite the body’s defenses exacerbating allergies.

    Again, I highly recommend Tim Krieder’s posts, and Dr Atwoods posts on naturopathic medicine, for any thoughts on a naturopath’s theories of allergies.

    Now, don’t tell me that medical science can’t test dietary restrictions for allergies because NDs say no.

    How many MDs do you know that have dietary restriciton algorithims? If we don’t use it, we don’t know how to use it. The ND’s are the ones claiming it’s effective, they’re the one who have a way to determine who gets what restrictions.

    it’s because, well, the drug companies simply are not going to test anything that can’t be patented

    That’s just crap. One of the great therapies for lipid disorders is niacin. firstly, it’s available without a patent. Secondly, the drug companies found a way to patent a version of it for those who can’t tolerate the dirt cheap version (different delivery system), and have found quite a large market. So you’re wrong on both counts, the research happens, and they can patent anything somehow, some way.

    , and I don’t think it will advance your career in science or medicine if you start working on these “natural” approaches rather than biochem or something more acceptable.

    Completely crap. There is a whole branch of pharmacology based on “natural” therapies, it’s called pharmacognosy. Lots of people make their careers this way.

    Remember that guy who did the work on homocisteins at Harvard some years back? He was very right and it took his career several decades to recover.

    I’m not at all sure what you’re talking about. Whose career was ruined by being correct about homocysteine research?

    Let me give another example, this one from an MD, Dr. Samuel Mann, from Cornell. His book, Healing Hypertension, suggests that the condition is often caused by suppressed emotions, and that psychotherapy (ie talk therapy, the kind that “scientific” testing always shown to be ineffective) often is helpful. Now, as Dr. Mann recognizes, his theories would be very hard to rigorously test — how do you separate the control group of those who have suppressed emotions, which they are generally unaware of, from the group that does not have suppressed emotions.
    And then how do you test the effectiveness of talk therapy in this context? Even if you set up some large population study of the effects of talk therapy on blood pressure, something none of the studies I know of has ever done, how do you know what other variables are involved or which patients have actually benefited?

    Let’s pretend Mann was correct. In a world were Mann is correct, how was he planning on diagnosing patients with “suppressed emotional hypertension”, and differentiating them from those with say, renal artery stenosis. Or those who are legitimately idiopathic?

    If he has a method of diagnosis, then thats the method by which you would separate out patients with “suppressed emotional hypertension,” and then test them with whatever the heck he thinks works.

    If he has no method of diagnosis, how was he ever planning on gauging effectiveness? By response? Because then you can test it. If some patients respond, some patients don’t, than you should get a bimodal distribution of response – some response, or no response. All you have to do is use populations matched for whatever other variables are relevant.

    So, most doctors continue to simply say, 80% or more of hypertension is ideopathic, and they prescribe medications that do help hypertension, but without too very much attention to the side effects.

    Are you kidding? On family medicine, most of my job was balancing side effects, while helping patients hypertension.

    Look, you’re opinions are clearly colored by an anecodotal experience. I’m glad your wife’s allergies improved. Really. If the ND’s can do that good a job, they should publish how they’re doing it. We can’t just magically figure out what’s going on in their heads to diagnose and treat their way.

  89. JGL says:

    @psyche78
    re: unwelcome anesthesiologist visits

    So I’m an anesthesiologist. In fact, as I’m typing this, I’m about halfway through a 24-hour in-house OB shift.

    Anyway, there are good reasons for anesthesiologists to visit all laboring women on the ward, regardless of stated epidural preference. A big part of my job is to be prepared for the worst-case scenario. In OB, that means an emergent c-section. I do not want to be meeting a patient for the first time while wheeling into the OR with a mom or baby that is in distress. It’s much better that I know a little about about the patient’s medical conditions, surgical history, and airway anatomy well in advance, so that I can anticipate possible problems and come up with a reasonable anesthetic plan. It is also a little less stressful for the patient to have met me ahead of time — at least I’m a familiar face amidst the confusion and chaos of an emergent section.

    I have also taken care of many, many women who came in to the hospital stating that they weren’t interested in an epidural, only to change their minds once their pain was out of control. I have difficulty getting a good history from a woman who is writhing in pain, and I also feel that proper informed consent is difficult to obtain under these circumstances. So I think it’s a good idea to visit all women in labor, get a decent history, and talk briefly about the risks, benefits, and alternatives to epidural analgesia — not to be coercive, but to lay the groundwork for proper informed consent.

    Believe me, I have no wish to be intrusive. I would be happy to sleep all night during my OB shifts. I’m just trying to do the right thing medically, ethically, and medicolegally.

    Anyway, best of luck with your planned home birth.

  90. albion tourgee says:

    Whitecoattales, the homocysteine researcher is named Kilmer McCully. (Thanks for overlooking my wobbly spelling.) See New York Times Magazine, 8/10/97

    If you are unaware of Dr. Mann’s work, I highly recommend his book. He isn’t a naturopath but an MD and associated with a leading medical school. If you do treat people with hypertension, the thing about Dr. Mann’s book is, it’s based on extensive observation of patients and standard medical training in the way of physiology, biochemistry, etc. He does have some insight into differential between renal artery stenosis (and other identifiable causes) and suppressed emotion based hypertension. (However, this argument is something of a straw dog, since so much hypertension is considered idiopathic that most doctors don’t even do a work up to identify a cause unless there is already some evidence of a condition that would cause hypertension.) You can reject Dr. Mann’s work because the hypothesis is difficult or impossible to prove by a controlled experiment, but you’d be depriving your patients of the benefit of some very careful study. To be sure, this is exactly what most physicians do. You can say that treatment of hypertension is done well, but my friends who have run medical facilities and are on august scientific boards say, actually, poor treatment of hypertension by gps who prescribe drugs on flimsy grounds is a big problem today in the profession. I do hope you’re the exception, and you do have a good matrix for deciding whether to use beta blockers or ace inhibitors or calcium channel blockers with or without diuretics, and so forth. But it’s complicated and mostly poorly understood, by practitioners, as I understand it. Especially in this era of the 20 minute visit, enforced by insurance companies and Medicare.

    Yes my opinions in this area are to some degree based upon anecdotal experience — something doctors have traditionally pad alot of attention to, and I certainly hope they continue to. But there is a deeper problem here. Not every condition and treatment can be put through an experimental matrix meaningfully. And, according to people I know who are involved directly in medical research, there are several very serious problems in the area. With regard to academic researchers, there’s a huge bias toward finding some way to have a “successful” outcome of an experiment. If you spend several years working on an experiment that fails to prove what you set out to (and doesn’t serendipitously prove something else meaningful) your career is not going to thrive in most environments. Yes, there are some studies in academia about nutrition, but it’s really hard to do a rigorous controlled experiment on people’s diets for obvious reasons, and populations studies are vulnerable to misreporting by participants as well as undetected extraneous influences, so as proof they are usually quite weak. When you say drug companies are willing to invest in non-patentable therapies, I think you must be living in a different reality than I. Well, there are generic drug producers, but they don’t do a lot of research, except in the legal area defending against lawsuits.

    Many MDs seem very defensive about “alternative” therapies. Instead of talking about what’s reasonable and sensible, the attack is generally that “alternative” therapies aren’t based on a certain kind of experimental science. (Of course, lots of MDs do things every day that aren’t very scientific, either, but we can regard these as aberrations, I suppose) Yes, experimental science has led to lots of effective treatments and you’d have to be an idiot not to recognize its value. But, there are other ways of identifying and developing treatments which I think of as being based much more on observation and careful evaluation of patients. Yeah you raise good questions about how we decide which of these is worth using and how, and which ones should be rejected. (Much, I suppose, as we have to make these decisions about drugs like Vioxx and antidpressants, after we’ve done the very expensive experiments to assure that the drugs are safe and efficacious, at least sort of.) Just because it’s difficult to answer these questions doesn’t mean that we have to reject all therapies that aren’t experimentally proven. By claiming that a certain kind of experimental method is necessary for a treatment to be valid, you close the door to a more open, skeptical view that admits sometimes experimental medicine goes wrong and sometimes alternative approaches can be effective. But that makes it sound more like the healing arts, I guess.

  91. Joe says:

    @albion tourgee 24 Jun 2009 at 2:25 am

    I call BS- you are not an innocent bystander with an anecdote. You are an ND who thinks your faulty thinking will impress health professionals and scientists.

    albion tourgee “… there are other ways of identifying and developing treatments which I think of as being based much more on observation and careful evaluation of patients.”

    That sort of approach brings us bleeding, purging, chiropractic, acupuncture, etc. My brother recently suffered through a seminar by an ND who offered “It isn’t scientific, it just works.” The same can be said for trepanning (and it doesn’t “work”).

    albion tourgee “By claiming that a certain kind of experimental method is necessary for a treatment to be valid, you close the door to a more open, skeptical view that admits sometimes experimental medicine goes wrong and sometimes alternative approaches can be effective.”

    All you have to do is prove, experimentally, that your “alternative methods” work, then they become medicine. It’s that simple.

  92. You can reject Dr. Mann’s work because the hypothesis is difficult or impossible to prove by a controlled experiment, but you’d be depriving your patients of the benefit of some very careful study.

    Thats not what I did. I systematically gave you a simple way to test Dr Mann’s hypothesis, using science. Oddly enough, psychiatrists find ways to fund talk therapy basd research all the time. So do psychologists.

    Kilmer McCully became obsessed with an idea before proving it, and didn’t get tenure because he stopped attempting to bring in any funding. It actually says that in the article. Despite the idea in the article that “It’s all about the money”, the most prescribed class of drug for cholesterol after statins (the money maker in question) is niacin… without a patent.
    In my medical school education we’ve discussed homocysteine levels and their relation to heart disease. It’s of significance

    Yes my opinions in this area are to some degree based upon anecdotal experience — something doctors have traditionally pad alot of attention to,

    Traditionally we treat every problem possible with leechs too. Traditions aren’t necessarily a good thing.

    I know who are involved directly in medical research, there are several very serious problems in the area. With regard to academic researchers, there’s a huge bias toward finding some way to have a “successful” outcome of an experiment.

    noones claiming science is a perfect system. There are ways of detecting bias, and we decide how much to trust a study ourselves based on reading the evidence. Even when people falisfy data and cheat, over relatively short periods of time the cheating is revealed, and information is adjusted. That’s the self correcting nature of science – bias or not.

    When you say drug companies are willing to invest in non-patentable therapies,

    I did not say that. I said that anything is patentable. For example, niaspan and niacor – 2 niacin patented drugs for lipid disorders. Niacin is clearly not patentable. Niacin extended delivery system however, is patentable.

    Secondly. I said nonpatentable things get researched all the time. I did not say by drug companies. Among other organizations, NIH funds such research.

    Instead of talking about what’s reasonable and sensible, the attack is generally that “alternative” therapies aren’t based on a certain kind of experimental science.

    Completely wrong.
    The attack on alternative therapies is usually that the theories they are based upon are meaningless, and already have been proved wrong. Because they have no pyramid of basic science research to stand on, the options left to them are to build such a supportive pyramid, or to attempt to prove their results empirically. Generally they see empirical proof as the only option because they know their theory is baseless.

    For example, homeopaths claims break the laws of physics. They don’t fit with basic pharmacology. They treat entirely based on symptom. The entire basis of “like treats like” is based on a story Hahneman told, that sounds like Hahneman having a hypersensitivity reaction to a NOT diluted chemical he injected into himself.

    Naturopaths (And here for the third time I recomend you read Krieder’s post about naturopathy on campus) have a bunch of clearly-contradictory-to-known-physiology claims about allergies and bacterial and yeast infections, which are crap. Not to mention, they buy into every other unscientific claim possible, lie accupuncture, homeopathy, et al.

    Just because it’s difficult to answer these questions doesn’t mean that we have to reject all therapies that aren’t experimentally proven.

    It’s NOT diffcult to answer these questions. The people who need to answer them just won’t try.

    But that makes it sound more like the healing arts, I guess.

    *cough* naturopath*cough*
    You may not be one, but you’re spouting their propaganda.

    A doctors job is an art.

    Despite this, any given intervention (drug, procedure, therapy) we prescribe, and the method by which we research those interventions is a science.

    The art is using that fund of knowledge to treat your patient. Medicine is, in essence, a human art, not a science. But the art isn’t about making up crap therapies. The art is about connecting with a person, establishing a relationship, and improving their life with the tools at your disposal. The tools don’t make the art. The doctor does.

  93. Having done a little more homework on Mann (without buying his book) all the discussion relating to him appears to only be concerning episodic hypertension. This is not the 80% “idiopathic” hypertension you discussed earlier.

  94. albion tourgee says:

    Well, interesting argument, whitecoattales. No, Mann is not just writing about episodic hypertension, although he of course mentions it. But, I don’t expect you to buy the book based on my recommendation, actually. You seem more interested in arguing the points than figuring things out. Anyway, though you make some good points, it’s gotten to the point where the argument seems more important than what we’re talking about. I’d just comment, that I do think experimental science of the type you describe is in my view absolutely essential to medicine, but it’s quite imperfect for several reasons I mention (er, Vioxx, etc.). I also happen to believe there are other sources of effective treatments that experimentally proven and aren’t “crap” as you so eloquently put it. Let’s just say, for me, many years ago, desensitization treatment by an allergist helped lots. For my wife, years of the experimentally developed desensitization treatment (hopefully improved since I was a kid) was totally ineffective, while a naturopathic approach helped enormously. The particular naturopathic approach was rational and based upon good science — at least my friend who’s on the National Academy of Sciences seemed to think so in dinner-party conversation. I’d be surprised if you actually disagreed with what I’m saying outside the context of this comment-argument, which by the way, I’ve enjoyed immensely.

    Oh, and Joe, no I’m certainly not a naturopath! If your a doctor, I hope you don’t diagnose the way you comment!

  95. Joe says:

    @albion tourgee on 25 Jun 2009 at 1:13 pm “Oh, and Joe, no I’m certainly not a naturopath!”

    Nevertheless, you are a fool to shill for them. http://www.naturowatch.org

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