Are More Non-MDs Trying to Compete With Docs?

James F. Sweeney

May 12, 2021

Jon Hislop, MD, PhD, hadn't been in practice very long before patients began coming to him with requests to order tests that their naturopaths had recommended.

The family physician in North Vancouver, British Columbia, Canada, knew little about naturopathy but began researching it.

"I was finding that some of what the naturopaths were telling them was a little odd. Some of the tests they were asking for were unnecessary," Hislop said.

The more he learned about naturopathy, the more appalled he became. He eventually took to Twitter, where he wages a campaign against naturopathy and alternative medicine.

"There is no alternative medicine," he said. "There's medicine and there's other stuff. We need to stick to medicine and stay away from the other stuff."

Hislop is not alone in his criticism of naturopathic medicine. Professional medical societies almost universally oppose naturopathy, but that has not stopped its spread or prevented it from becoming part of some healthcare systems.

Americans spent $30.2 billion on out-of-pocket complementary healthcare, according to a 2016 report from the National Institutes of Health. That includes everything from herbal supplements and massage therapy to chiropractic care.

What Is Naturopathic Medicine?

Naturopathy came to the United States from Germany in the 1800s, but some of its practices are thousands of years old. Naturopathic treatments include homeopathy, IV vitamin infusions, acupuncture, Reiki, and herbal supplements.

Naturopathy is based on the belief that the body has an innate ability to heal itself. It discourages drugs and surgery in favor of supplements, herbs, and other so-called natural treatments. Much of it centers around addressing lifestyle issues and counseling patients to improve their diets, quit smoking, exercise more, lose weight, etc, in order to address the root causes of some health problems.

Practitioners are critical of Western medicine for what they regard as an overreliance on drugs and technology and for treating symptoms rather than the causes of disease.

"We get a lot of people who are at the end of their ropes, people with hard-to-diagnose diseases who know they are sick but whose labs are normal," said Jaquel Patterson, ND, former president of the American Association of Naturopathic Physicians (AANP) and medical director of a naturopathic practice in Connecticut.

Separate Training and Licensing

There are major differences among naturopaths.

At one extreme are unlicensed, self-taught "healers," who can embrace everything from homeopathy to aromatherapy.

At the other end are naturopathic doctors (NDs), who are are more likely to become part of healthcare systems. These caregivers are trained and licensed, though not by the same institutions as traditional physicians.

To be licensed, NDs must graduate from one of seven accredited naturopathic medical schools in the United States and Canada. In addition to a standard medical curriculum, schools require graduates to complete four years of training in clinical nutrition, acupuncture, homeopathic medicine, botanical medicine, physical medicine, and counseling. Medical students intern in clinical settings for 2 years.

NDs are eager to distinguish themselves from their uncredentialed counterparts.

"Some people go to a weekend class and call themselves naturopaths. That's very concerning. I don't want those people to be licensed either," said Hallie Armstrong, ND, who practices in Michigan.

In the United States, there are 6000 practicing NDs and an unknown number of unlicensed naturopathic healers.

Can Naturopaths Call Themselves "Physician"?

Twenty-two states, the District of Columbia, Puerto Rico, and the US Virgin Islands have licensing or registration laws for naturopathic doctors. Three states ― South Carolina, Tennessee, and Florida — prohibit practicing naturopathic medicine without a license, according to the AANP.

States that license NDs differ in what they permit them to do.

Nine states allow licensed NDs to use the term "physician," although this is prohibited in seven states. Most licensed states allow naturopathic practitioners some prescribing authority, including the prescribing of many controlled substances, although only a few states permit full prescribing rights. Most states that license NDs allow them to prescribe and administer nonprescription therapeutic substances, drugs, and therapies.

Twelve states and the District of Columbia allow licensed naturopathic doctors to perform some minor procedures, such as stitching up wounds. Additionally, 13 states allow NDs to order diagnostic tests.

Although the AANP lobbies to get licensure in more states and to expand the activities that NDs can perform, the medical establishment in those states nearly always opposes the legislation, as do national organizations, such as the American Academy of Family Physicians and the American College of Physicians.

"They absolutely will not stop until they get licenses. They've done a really good job of selling themselves as legitimate healthcare professionals to state legislatures," said David Gorski, MD, PhD, FACS, a surgical oncologist and managing editor of Science-Based Medicine, a blog that attacks unproven medical claims and defends traditional medicine. Naturopathy is a favorite target.

Are Naturopaths Gaining Ground Anyway?

Despite the opposition of the medical establishment and many individual healthcare professionals, a growing number of healthcare systems are adopting alternative medicine.

In 2018, the AANP stated that 28 prominent health systems, hospitals, and cancer treatment centers had one or more licensed NDs on staff. Among them were Cancer Treatment Centers of America, Cedars-Sinai, Columbia University's Herbert Irving Comprehensive Cancer Center, and the Fred Hutchinson Cancer Research Center.

Other healthcare systems may not have NDs on staff but provide naturopathic treatments, usually under the heading of "complementary medicine" or "integrative medicine." For example, the Cleveland Clinic's Center for Integrative and Lifestyle Medicine offers acupuncture, Chinese herbal medicine, Reiki, yoga, and culinary medicine.

Critics find this appalling.

"I think it's a mistake to integrate that kind of practice into a science-based healthcare setting. If we learned anything over the past year it's that medicine based on magical thinking is dangerous," said Timothy Caulfield, LLM, FCAHS, research director at the Health Law Institute of the University of Alberta, in Edmonton, Alberta, Canada.

Gorski added: "I'm not exactly sure why doctors who should know better have become more accepting of practices that aren't science-based or are outright quackery."

Becoming Part of the System

Beaumont Health, Michigan's largest healthcare system, added integrative medicine in 2006 and hired its first naturopathic practitioners a year later.

The integrative practitioners began in oncology, offering such things as massage therapy, acupuncture, guided imagery, and Reiki. "Very quickly, people outside oncology began saying, 'I've got a cardiology patient who would really benefit from this.... I've got a GI patient who could benefit from this....,' " said Maureen Anderson, MD, medical director of Beaumont Integrative Medicine.

Beaumont now offers integrative medicine at three locations. They average 20,000 visits a year and work with 50 to 60 practitioners, many of whom work part-time.

Because Michigan does not license NDs, their scope of practice at Beaumont is limited. They take patient histories, provide advice on nutrition, diet, and exercise, and prescribe herbs and supplements. Beaumont operates its own herbal and supplement pharmacy.

NDs work under the medical supervision of Anderson, an emergency medicine physician who became interested in naturopathy because she thought traditional medicine doesn't do a good job of providing care for chronic conditions.

Any initial skepticism on the part of the medical staff has been overcome by seeing the benefits naturopathy provides, Anderson said. The claim is echoed by Armstrong, an ND who works in the system part-time: "As soon as [doctors] understand our schooling and where we're coming from and understand that we want to do the same things, then they're very accepting."

The University of California, Irvine, healthcare system has one of the largest naturopathic medicine programs in the country, the result of a $200 million donation in 2017 from a couple who champion alternative medicine. The Susan Samueli Integrative Health Institute includes 28 healthcare professionals, including MDs, NDs, RNs, acupuncturists, dietitians, yoga instructors, and others. It includes a research arm, which is focused primarily on acupuncture.

The alternative medicine offerings benefit the system, said Kim Hecht, DO, medical director of inpatient and ambulatory services at the Samueli Institute.

"I'm not against traditional medicine, because I think everything has a time and a place," Hecht said. However, she rejects the idea that MDs can offer the same holistic approach as NDs.

"Medical science likes to say we're interested in treating the whole person, but if you look at medical school courses, that's not what's being taught," she said.

The chance to work within a traditional healthcare system was attractive to Arvin Jenab, ND, medical director of naturopathic medicine at the institute.

"It offers the opportunity to refine our medicine and trim the things that aren't necessary or are controversial and concentrate on the things at the core of what we do," he said.

UCI Health practices a conservative model of naturopathy that supports traditional practitioners, Jenab said.

Is There Any Harm?

Some patients clearly want what naturopathy offers. So what's the harm?

Healthcare systems that integrate alternative medicine legitimize it and lower the overall standard of care, Caulfield said. Most naturopathy claims are not backed by evidence, and making it available to patients amounts to deceiving them, he said.

"If there's good science behind it, it's not going to be alternative medicine; it's going to be medicine," Caulfield said.

Family physician Hislop said that refusing to order naturopath-recommended tests interferes with his relationships with patients and often requires lengthy conversations to explain the problems with naturopathy.

Naturopathic medicine can deter patients from seeking proven conventional treatments, which can put their health at risk, Gorski said.

Some naturopaths could potentially be harmful.

In 2017, a California woman died after receiving an IV preparation of curcumin, a chemical constituent in the Indian spice turmeric featured in alternative medicine. The US Food and Drug Administration found that the treating ND mixed the curcumin emulsion product with ungraded castor oil that had a warning label stating, "CAUTION: For manufacturing or laboratory use only."

Because naturopathic care is generally not covered by insurance, it can be expensive for patients who pay out of pocket.

Ironically, the mainstream healthcare system helps create the environment in which naturopathic medicine thrives.

It offers patients a more relaxed and personal alternative to rushed visits with harried doctors scrambling to see the required number of patients in a day. By contrast, an initial visit with an ND might last a leisurely 60 minutes, with 30-minute follow-up appointments.

Caulfield acknowledged that the relaxed naturopathic approach can be more attractive to patients but said the answer is to reform the current system: "You don't fix a broken arm by acupuncture."

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