Pennsylvania legislators need to know only one thing about House Bill 612 (licensure of naturopathic “doctors”) to vote against it: As a means of “naturopathic musculoskeletal therapy” the bill would allow naturopaths to “reposition body tissues and organs.”
This is impossible. You cannot “reposition” tissues and organs of the human body by external manipulation.
Why does this tell us everything we need to know about these naturopathic doctors and why they shouldn’t be licensed in Pennsylvania? For one thing, this is no mistake a bill draftsman made in understanding what naturopathic practice includes. House Bill 612 was obviously drafted by naturopaths. That means naturopathic doctors actually believe they can “reposition” your body’s tissues and organs. And that speaks to their poor education and training. They don’t even understand basic anatomy.
For another, it tells us naturopathic doctors reject evidence-based medicine as a standard of practice. There is no evidence that this “repositioning” of organs and tissues is beneficial for any condition or disease, even if they could do it in the first place, which they can’t.
And for yet another, this certainly calls into question their understanding of the disease process and their diagnostic skills. One has to wonder exactly what health problems they think these purportedly out-of-place organs are causing. And how do they go about determining which organs are out of place and where they should go? Or when they have been successfully returned to their proper position? Again, this should raise alarming questions in the legislators’ minds about their education and training.
Yet, if this bill passes, naturopathic doctors will become state-licensed providers of primary care. Yes, primary care providers. It says so right there in the definition of “naturopathic medicine.” (Mark Crislip thoroughly debunked the notion of naturopaths as primary care doctors in a post deconstructing a naturopathic white paper on the subject.) This will allow naturopaths to “reposition” the organs and tissues of unsuspecting Pennsylvania citizens, possibly claiming a right to insurance reimbursement for the privilege, another problem with this bill we’ll get to later.
Of course, this fantasy treatment could be excised from the bill. But that would do nothing to resolve the substantial questions about their education, training, and abilities to perform the most basic tasks of primary care, or any other form of evidence-based healthcare, or even reality-based health care for that matter. And there are plenty more naturopathic fantasy treatments allowed by House Bill 612 even if you get rid of this one. We’ll get to a few more in a minute.
This affinity for fantasy treatments among naturopathic doctors is explained in the first part of the bill, Section 103, which defines “naturopathic medicine” as:
a system of primary health care practiced by doctors of naturopathic medicine for the prevention, diagnosis and treatment of human health conditions, injuries and diseases and that uses education, natural medicines and therapies to support and stimulate the individual’s intrinsic self-healing processes.
This is the central fallacy of naturopathic practice, one that sounds appealing but is at its core meaningless. “Intrinsic self-healing processes” is simply another way of referring to vitalism, a long-discredited, pre-scientific notion that bodily function is controlled by some incorporeal force unknown to science or medicine. As Steve Novella pointed out, vitalism was a placeholder, used to explain bodily functioning until biology, chemistry, physiology and anatomy developed science-based explanations for these functions. Except for naturopaths, who’ve remained stuck in vitalism.
Naturopaths have tried to backfill a scientific explanation into the pre-conceived notion of an “intrinsic self-healing process.” When they can convince a group of respectable physiologists (say, those holding faculty appointments at major research universities or medical schools) that their explanation is credible, I’ll believe it too. Until then, I won’t and no one else should either.
Of course, when you start from the premise that the body is governed by this non-existent life force pretty much anything that you can fit into that paradigm will fly, and naturopaths have used this to their full advantage in devising diagnoses and treatments no responsible medical doctor would agree with. Hence organ repositioning.
Other implausible and unproven treatments either mentioned specifically in the bill or permitted under its broadly defined categories, such as “naturopathic physical medicine,” include all those mentioned in David Gorski’s summary of naturopathic practice:
If I’ve pointed it out once, I’ve pointed it out a thousand times. Naturopathy is a cornucopia of almost every quackery you can think of. Be it homeopathy, traditional Chinese medicine, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine, it’s hard to think of a single form of pseudoscientific medicine and quackery that naturopathy doesn’t embrace or at least tolerate.
This bill will also allow naturopathic doctors to pump patients full of unnecessary vitamins and minerals intravenously, and use other favorite and potentially dangerous treatments such as peat baths, colonic irrigation (which the Journal of Family Practice warned against in this 2011 article), fasting and severely restricted diets, and recommendation of dietary supplements of unknown safety and effectiveness, to name a few. Naturopaths will be able to diagnose diseases they’ve invented, such as chronic yeast overgrowth, ubiquitous toxins (that no one else seems to be able to find), and food “sensitivities” (again, that no one else seems to be able to detect).
In addition to what we might politely refer to as their “unique” diagnoses and therapies, N.D.s will also be able to use some conventional diagnostic means such as mammography, X-rays, and lab tests. They will be able to perform physical exams, including well baby checkups and vaginal and proctologic exams. But permitting naturopaths to do these things and their knowing what they are doing are two entirely different things.
Naturopathic education, such as it is
I trust no one could get to this point in reading and think that naturopathic doctors have sufficient education and training to diagnose and treat patients. Unfortunately, all naturopathic licensing bills make the mistake of assuming their education and training is somehow the equivalent of, or at least close to, that of a medical doctor.
House Bill 612 makes this same unfounded assumption. An applicant to practice as a naturopathic doctor must have “completed a doctorate-level naturopathic medical program” accredited by an accreditation agency recognized by the U.S. Department of Education and must pass an examination administered by the North American Board of Naturopathic Examiners (The “NPLEX”). Let’s see what this education, accreditation and examination are really like. This is ground we have covered before at SBM, but it bears repeating because I have never seen a shred of evidence that the sponsors of this bill, or any state naturopathic licensing bill, have ever set foot on the campus of a naturopathic school and critically evaluated its programs, or looked at one of these licensing exams or researched the requirements for becoming an accrediting agency. All the bills I’ve read simply parrot language obviously supplied by naturopaths.
So here’s what’s actually going on: These naturopathic “medical” schools have simply appropriated the word “medical” and pasted into the school’s name. There are five of these schools in the U.S. and two in Canada. Unlike medical schools, where students must score well on the grueling MCAT to be accepted, there is no entrance exam. All are private and none are part of a mainstream public or private university or college. Unlike real medical schools and science departments at other colleges and universities, their faculty members have published little and do virtually no research.
The Council on Naturopathic Medical Education has been approved by the U.S. Department of Education to accredit naturopathy schools. While naturopaths pushing licensing seem to want to use this as a sort of federal government seal of approval, it is nothing of the sort. The goal of the Department is to ensure that accredited schools meet certain financial, disclosure and similar requirements in order to protect prospective and current students from such problems as financially unsound institutions or schools that are dishonest about post-graduation job opportunities. It is also designed to determine which schools can take advantage of student loan programs. The accreditation program is not designed to protect the public health by ensuring these schools instruct their students in the use of safe and evidence based healthcare. It does not mean that graduates are capable of practicing primary care, nor of providing health care at all. The Department does not vet course content. That is simply not the function of the accreditation programs.
Nor does passing the NPLEX exam guarantee the delivery of quality healthcare by naturopaths. This somewhat mysterious document seems to be carefully protected by naturopaths. No one outside of naturopathy appears to have seen a copy or reviewed its contents. In fact, even when Kimball Atwood asked for a copy as part of a state-appointed commission reviewing naturopathy licensure for Massachusetts in 2002 he couldn’t get one. (Naturopaths are still not licensed in Massachusetts, even after trying numerous times. I think they are up to a dozen attempts, maybe more.) No person voting on House Bill 612 should miss reading Dr. Atwood’s series on naturopathy, which you can find referenced here. It would be unconscionable to vote without this information.
Let’s also look at a huge gap in their training, which we’ll discuss in the context of their claims to being “primary care” providers.
Primary Care Practice?
As mentioned, this bill will allow naturopaths to practice primary care. N.D.s would have the same scope of practice as an M.D. or D.O. primary care physician but be limited in some of the therapies they could offer. (For example, they could not prescribe controlled substances.) They will be able to see, and treat, any patient of any age with any disease or condition, no matter how serious.
Full scope of practice as a primary care physician, including all prescription drugs, is actually the goal of the American Association of Naturopaths. Naturopaths are willing to accept a more narrow scope, as is apparently the case in Pennsylvania, and then return for increased scope once entrenched. They have achieved this in Washington state, including mandatory insurance coverage, with interesting results. Two reviews of insurance claims for naturopathic care revealed that less than 2% of the insured adult and pediatric population made such claims, indicating an extremely low use of licensed naturopathic doctors for health care even where they are fully licensed and covered by insurance.
In defining what a primary care physician does, I turn again to an American Association of Family Physicians definition:
Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.
Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.
Note specifically that this bill would allow the N.D. to see and treat the “undifferentiated patient” straight out of N.D. school, with 1200 hours of clinical training. This training is usually done in naturopathy school clinics where the students typically see patients who have a variety of mild, self-limiting conditions, such as colds and musculoskeletal pain. Compare this to the clinical training medical students must have before they can become board certified in family practice, general internal medicine or pediatrics (the three primary care specialties in medicine). During med school, in the third and fourth year, students see patients in a variety of settings (hospital, office, emergency room) in clinical rotations among a variety of specialists (pediatrics, surgery, oncology, obstetrics etc.). After graduation they also spend an additional three years, at about 80 hours per week, in clinical training. For an idea of what they do during that residency, you can find a broad outline of the curriculum for a three-year family practice residency at Penn Medicine on its website. Again, naturopathic doctors do not have this training.
Naturopathic treatment of pediatric patients is especially troubling because of naturopathic opposition to vaccination. Studies have found:
- A negative influence of naturopaths on mothers’ decision to vaccinate children.
- Consultation with a naturopath significantly decreased the likelihood of receiving a flu shot among women in contact with young children.
- Children in Washington state were significantly less likely to receive recommended vaccinations if they saw a naturopathic doctor, and significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care.
Forced insurance reimbursement? And other problems.
To add insult to injury, the Affordable Care Act’s non-discrimination provision may require reimbursement of naturopathic health care if naturopathic doctors are licensed. That is certainly what they are aiming for. And they aren’t shy about making a huge fuss when they aren’t included in physician practice groups because they don’t practice evidence-based medicine.
House bill 612 will require naturopathic doctors to refer a patient to a physician “when the patient is presenting a contraindication to the practice of naturopathic medicine.” I am not even sure what that means. (Based on what we know about naturopathic practice one might argue that pretty much all patients present with a “contraindication to the practice of naturopathic medicine.”) In any case, note that it will be the N.D. who makes the call here. That presents two problems. First, N.D.s already think they are capable of practicing as primary care physicians. Given this overblown view of their abilities, abilities I feel fairly sure I’ve just demonstrated they do not possess, might one not be concerned that they will fail to realize their shortcomings when a patient needs a referral? Second, given their lack of training in diagnosing patients, who could be confident that they will be able to recognize a disease or condition requiring referral in the first place?
Nor should Pennsylvania legislators take comfort in the fact that naturopaths would be regulated by the state medical board. The board can only regulate within the confines of the scope of naturopathic practice granted by this bill. It will have no authority to prevent naturopaths from doing anything the legislature says they can do. In fact, regulation by the medical board will create quite a quandary. How will the board determine, for example, whether a naturopath’s repositioning of an organ fell below the standard of care? How about an injection of vitamins and minerals for “flu prevention”? Or a prescription for homeopathy?
If I were Rep. Mark Mustio, the bill’s main sponsor, or any of the other legislators who signed on as sponsors, I would be furious with the naturopaths for putting me in this position, subject to ridicule for sponsoring such bill. Rep. Mustio can redeem himself, and save his colleagues a lot of embarrassment, by quietly withdrawing House Bill 612 from consideration before it even comes up for a vote before the House Professional Licensure Committee on June 5th.