I became interested in pseudo-medicine early in my practice when I was called to see a “leg infection”. What it was a dead leg, wet gangrene, with the horrible smell only rotting human flesh can produce. It was a 24 year old girl who had an osteosarcoma of her leg and rather than be cured with amputation she went to a naturopath who said she could he cured by, among other things, drinking alkaline water and herbs. It didn’t. She refused surgery by us. She had been brought in by her mother when she became unresponsive but perked up with fluids, letting us know her naturopath still assured her that he could cure the tumor, that the rotten leg was her body ‘rejecting’ the tumor. That night the tumor, or the infection, eroded into a major artery and she bled to death. That is my idea of the archetype naturopathic care.

Naturopaths have a small amount of reality based education in a sea of fantasy. The naturopathic education at the Oregon naturpathy school includes hydrotherapy, homeopathy, qui dong, colonics, the nature cure, herbs, and botanicals. Anyone who thinks homeopathy is an appropriate therapy for anything but thirst is in my opinion, unfit to care for others. They are divorced from reality as I understand it.

Once in practice naturopaths expand their practice into other areas that are, in my opinion, useless and divorced from medical reality. Consider these Northwest ND’s:

Kevin Wilson, ND: “spinal manipulation, and prolotherapy. I prescribe many herbal medicines, specific nutrients at therapeutic doses, and homeopathic remedies. Some patients are candidates for intravenous therapies such as vitamin and mineral ‘cocktails’, dilute hydrogen peroxide for infections and soon, chelation therpy for chronic cardiovascular disease.”

Bill Walter, ND: Detoxification coaching. “Nearly everybody, for example, can benefit from nutritional counseling, stress-reduction training, or gentle detoxification.”

Kelly Fitzpatrick, ND: ”Nutritional Supplementation including Intravenous Therapy such as High Dose Vitamin C therapy.”

Liz Dickey, ND: An emphasis on homeopathy.

Hilary Andrews, ND: Treating autism by rebalancing the nervous system with drainage (what ever that is), dietary restrictions and probiotics.

Dawson Farr, ND: prolotherapy, detoxification, and vitamin injection therapy.

Some offer wide ranging testing for “Food Allergy Testing, Hepatic Detoxification Profile, Toxic Heavy Metal Analysis, Pesticide and Solvent Exposure Panel, Hormone Saliva Test, Comprehensive Diagnostic Stool Panel”. I cannot say what these specific testing panels represent and for all I know could be just fine. Color me skeptical.

I see no end of wonky infectious disease testing used by naturopaths for Lyme and the use of live blood analysis. For example, the time an ND diagnosed a patient with a bacterial blood stream infection based on live blood analysis and offered the patient an expensive colonic detox as a cure. After hundreds of dollars of out of pocket testing, the patient saw me for a second opinion before spending several hundred dollars more. The patient had asthma as the cause of this symptoms and he improved with an inhaler. Another great ND diagnosis.

Why choose these NDs? Because they are the authors of “Naturopathic Primary Care. A White Paper to help regulators, lawmakers, and administrators in Oregon address PCP shortages using naturopathic physicians.”

As Jann Bellamy discussed there is an ongoing political debate over whether naturopaths should be credentialed as part of CCOs. They shouldn’t. The white paper suggests we should include people trained in therapies not based on reality and science and offering therapies not based in reality or science as primary care doctors. We suggest that would be a bad idea.

From the introduction:

As both the Affordable Care Act and Oregon’s own healthcare transformation move into full implementation, there has been much discussion about how to address the shortage of primary care providers. Many possible solutions have been proposed in response to this crisis, including the use of non-MD practitioners in helping meet Oregon’s primary care needs.

Oregon is in the excellent position of having a pool of highly trained non-MD primary care providers already licensed by the state and with the scope of practice and formulary needed to practice as primary care providers – Naturopathic Doctors (NDs).

This document offers clarity and insight to decision-makers, medical directors, and insurance administrators on the role that naturopathic medicine could play in serving Oregon’s population. It can act as a roadmap for Oregon’s new Coordinated Care Organizations and Healthcare Exchange insurers on how to effectively integrate naturopathic physicians to help meet the Triple Aim: better health, better care and lower cost.

What follows is an impressive spin for what it doesn’t mention: that naturopaths have severely inadequate training in reality based medicine and it makes them unfit to be primary care medicine providers. They forget to mention that the basis of their practice is nonsense.

The initial description of naturopaths and their qualifications looks good on paper. Upon close inspection it resembles the Melanesian cargo cult. From a distance it looks like soldiers and planes and radios and all the accoutrement of modern industrial society, but upon closer inspection everything is made of twigs and vines, the form without the function. So too with the white paper. The overview looks good, examined in detail naturopathy’s

They start with a description of naturopathy:

  • emphasize prevention and self-care as a cornerstone of health;

  • focus on patient-centered care, addressing the determinants of health in treatment plans;

  • prioritize a “therapeutic order” that begins with minimal intervention and proceeds to higher intervention; and

  • address the underlying cause of the condition rather than focus solely on symptomatic treatment.

It sounds good until you consider the tools used to apply that philosophy. Homeopathy. Acupuncture. Hydrotherapy. Chelation. Live Blood Analysis. Craniosacral Therapy. Flower Essences. The nonsense that is often the subject of this blog. The twigs and vine equivalent of medicine. I entered “Portland Naturopathic Physician” into Google and went to site after site. I could not find one that offered at least one non-reality based therapy. The focus of naturopathy is to attempt to apply fantasy to reality.

The same reasonable sounding overview of naturopathic education:

Didactic education in biomedical, diagnostic, and clinical sciences

  • Biomedical and Diagnostic Sciences: physiology, anatomy, biochemistry, microbiology, pathology, immunology, etc.

  • Clinical Sciences: clinical, laboratory and physical diagnosis, gastroenterology, pharmacology, rheumatology, endocrinology, neurology, gynecology, cardiology, etc.

  • Therapeutics: botanical medicine, nutrition, homeopathy, physical medicine, counseling, pharmacology, minor surgery.

At the Portland naturopathic school they receive 72 hours of pharmacology education, and twice (144 hours) as much training in homeopathy. 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.

If there is a litmus test by which you could judge magic vrs reality, it is homeopathy, perhaps the most popular and, arguably, the rankest of rank nonsense. If a practitioner thinks homeopathy is reasonable, avoid them.

Here, as an example of the treatments found in ND schoool, is a common treatment for nasal stuffiness in the naturopathic armamentarium:

Directions

Take a pair of cotton socks and soak them completely with cold water. Be sure to wring the socks out thoroughly so they do not drip.

Warm your feet first. This is very important as the treatment will not be as effective and could be harmful if your feet are not warmed first. Soaking your feet in warm water for at least 5-10 minutes or taking a warm bath for 5-10 minutes can accomplish warming.

Dry off feet and body with a dry towel.

Place cold wet socks on feet. Cover with thick wool socks. Go directly to bed. Avoid getting chilled.

Keep the socks on overnight. You will find that the wet cotton socks will be dry in the morning.

Effects of the Wet Sock Treatment

This treatment acts to reflexively increase the circulation and decrease congestion in the upper respiratory passages, head, and throat. It has a sedating action and many patients report that they sleep much better during the treatment. This treatment is also effective for pain relief and increases the healing response during acute infections.

It is inexpensive, patient centered, self care, minimalist, and inexpensive. It is also divorced from physiology and reality and is, for lack of a better word, stupid.

It is not hard to find weird naturopathic approaches for any disease. All you need is Google and search terms. My first hit for naturopathy and asthma:

Some doctors recommend taking baths with a cup or so of 3% hydrogen peroxide in the water to bring extra oxygen to the entire surface of the skin, thus making the lungs somewhat less oxygen hungry.

Nonsense. I remember riding the bus to medical school and a naturopathic student noted what I was reading and struck up a conversation with me. Warts, he informed me, are not due to a virus but the body walling off toxin and expelling them. I thought he was either misinformed. Turns out the root cause of warts is toxins, at least in the fantastical world of some naturopaths. So much for the root of diseases.

They then note that naturopaths are required to have 45 hours a year in continuing medical education. Sounds good, they are kept educated. But in what? The local naturopathic school is offering CME in Integrative Oncology.

Included in the days education is

“Dr. Joseph Pizzorno, ND, describes diet-induced cellular acidosis, and how this phenomenon is documented to contribute to chronic diseases, including cancer, osteoporosis, diabetes and more.”

and the summary states

Diet-induced cellular acidosis is real and clinically significant. Cellular acidosis induces mitochondrial dysfunction, calcium loss from bones, increased risk of kidney stones, increased risk of cancer—the list is long and substantiates the long held belief that an alkaline diet is health promoting. Of particular significance in cancer, lower pH levels in the extracellular fluid increases intracellular calcium, which induces carcinogenic pathways, and promotes invasiveness and metastases.

Maybe I will get to see another death from wet gangrene from progressive cancer treated with alkaline water instead of effective therapies. I hope not. The CME includes Ayurvedic medicine and acupuncture.

The white paper then notes that, like MD’s, there are residency training for naturopaths:

Accredited residencies are available for one, two or three-year terms. Currently, all residencies are privately funded. Consequently, residency opportunities are not available for all graduates.

I count 55 residencies on the AANMC web site and there were 507 first year students enrolled in 2007-2008. So at best 11% of have training beyond naturopathic school, and one or two years at that. I practice in a teaching hospital with medical students and residents and no one is ready to take care of patients on their own after medical school. And they have had to learn reality based medicine.

After 4 years of reality based medical school, MD’s have residency and fellowships where we have years of supervised training. For me it was three years of internal medicine, two years of ID fellowship and two years of post fellowship training, all under the watchful eyes of senior physicians. Naturopaths often go from school to practice. Next time you see a naturopath, remember it is the same as seeing an unsupervised medical student. And a medical student extensively schooled in type 1 SCAM. Not that a residency under the watchful eye of another magician could improve their practice.

Inadequate training and experience even in their own area, much less real medicine, and then thrown into the world under the mistaken impression that they are competent to care for people. It makes the next part of the white paper concerning:

Naturopathic Scope of Practice

  • Naturopathic doctors are licensed to work as independent providers in Oregon. They do not require supervision or oversight by other providers, and are licensed to:

  • Diagnose, prevent, and treat disease;

  • Perform physical exams including orificial exams (oral, vaginal, anal);

  • Order x-rays, electrocardiograms, ultrasound, CT, MRIs, and laboratory tests;

  • Draw blood and perform CLIA-waived lab tests in-office;

  • Perform minor surgery;

  • Provide prenatal, intrapartum, and postpartum care (with additional certification);

  • Provide injections including vaccinations and IV medications;

  • Prescribe all natural & pharmaceutical medications needed in a primary care setting;

  • Are eligible for Drug Enforcement Agency (DEA) numbers for Schedules II- V (authority to prescribe controlled medications).

Just what I want poorly trained unsupervised medical students to do. As we have seen, it is not the broad concepts that make the scope of naturopathic practice problematic, it is the inadequate training, experience and fanciful modalities used that make the ND unfit to care for humans in health and disease. The white paper sounds like real medicine. It is not.

Standard of Care & Competencies

There is no naturopathic-specific standard of care. Naturopathic doctors are taught and held to the same standards of care as conventional providers.

Search the web looking a naturopathic practices. There is a complete lack of standards since any and all non-reality based practices are fair game.

Treatment Guidelines

Condition-specific treatment guidelines present more of a challenge with naturopathic physicians than conventional providers. Each person’s treatment is individualized taking into consideration conventional treatment guidelines, but combined with a complex array of natural and conventional modalities that may vary among providers.

It is always harder to follow guidelines when you have no standard of care and their inadequate training would make them hard to understand and much of the tools of their trade are in direct opposition to science based reality.

There is now

The Naturopathic Academy of Primary Care Physicians is newly created and is establishing a board certification program for primary care naturopathic doctors. However, it is still years away from a formalized program.

Oregon naturopathic primary care doctors are able to do all of the following:

  • Examine, diagnose, prescribe and treat patients as family physicians;

  • Manage all pharmaceuticals needed in a primary care setting;

  • Manage patients’ routine preventive screenings, vaccinations and blood work;

  • Order diagnostic tests, images, blood-work and labs;

  • Perform well-child visits, women’s health visits, sports physicals, sign birth/death certificates, assist with advance directives, handicap permit and driver impairment, etc.;

  • Perform minor surgery, including excisional biopsies and laceration repair;

  • Coordinate care with a referral network of labs, specialists, physical therapy, behavioral health, social services, hospitals, and out-patient facilities;

  • Educate patients about lifestyle, diet, stress management and chronic disease management;

  • Write orders for residential facilities, hospice, in-home nursing care, etc.

Wow a ND, with inadequate training in biomedicine, immersed in pseudo-medicine, little, or more likely no, post graduate training in biomedicine can “Examine, diagnose, prescribe and treat patients as family physicians.” FP’s, besides 4 years of real medical school and three years of supervised residency, have continued and ongoing real biomedical education. It is why the joke is ND stands for Not a Doctor.

What little data there is suggests that utilizing a naturopath for primary care is associated with worse care: less cancer screening, mammography and Chlamydia screening But considering they are trained in magic instead of modern bioscience, why would I expect otherwise?

Immunizations

Naturopathic doctors are educated according to the public health laws of the state, and understand the role that vaccinations play in preventing communicable disease. But because naturopathic care is by definition patient- centered, many NDs will customize the vaccination schedule to address the patient’s risk factors, environment, and personal beliefs. See Appendix A: How NDs can help Oregon increase immunization rates.

and the white paper appendix says

How NDs can help Oregon increase immunization rates

Oregon naturopathic physicians can help CCOs provide care for more patients and may in fact assist in increasing rates of immunizations in populations who otherwise completely opt out.

The Oregon Association of Naturopathic Physicians (OANP) is a strong proponent of preventive medicine and of the protection of children and adults from the serious consequences of infectious disease. Naturopathic physicians, as primary care providers, are morally obliged and legally required to uphold and carry out the public health mandates of the state. All physicians are also ethically obliged to give patients, parents and legal guardians accurate and current information on both the benefits and risks of all medical interventions.

It is no surprise that the reality does not match the spin given the long standing antipathy towards vaccines in large sections of the naturopathic community. Naturopathic care leads to fewer vaccinations and an increase in vaccine preventable diseases:

Outcomes included receipt by children aged 1-2 years of four vaccine combinations (or their component vaccines) covering seven diseases, and acquisition of vaccine-preventable diseases by enrollees aged 1-17 years. Children were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children who saw chiropractors were significantly less likely to receive each of three of the recommended vaccinations. Children aged 1-17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care.

As naturopathic students move though their education, the support of vaccination declines:

We found that only 12.8% (40 of 312) of the respondents would advise full vaccination; however, 74.4% (232 of 312) of the respondents would advise partial vaccination. Importantly, both willingness to advise full vaccination and trust in public health and conventional medicine decreased in students in the later years of the programme.

The hesitancy of patients to get the recommended vaccines may be fed in part by the anti-vaccine nonsense perpetuated by many NDs. Like Hilary Andrews, one of the authors of the white paper, on vaccines and autism:

While the measles-mumps-rubella or MMR vaccine has been strongly linked to the onset of autism, I believe that prior vaccinations also play a cumulative role in this disease. Current vaccination schedules overload very young, fragile immune systems with a huge number of viruses.

We are not so sanguine that naturopathy represents a way to increase vaccinations in Oregon, much less improvements in primary care.

The paper gives the distinct impression the white paper is presenting information they think people what they would like to hear, rather than mentioning the unsavory and imaginary details that make up much of naturopathic practice. But when it comes to money it is better to look good than be good*.

It is imperative to note that naturopathic physicians are independent practitioners. Patients increasingly also turn to naturopathic physicians as first point of contact providers and would refrain from care with a conventional doctor if they cannot access their naturopathic physician.

If you have a problem in astronomy, you do not call an astrologer. Sure, he knows the names of the planets and the stars and has a good patter about how his system works. But astrology is nonsense. If you have a shortage of pilots, you don’t hire a transcendental mediation practitioner to levitate the plane. And if you have a shortage of primary care providers, including those with inadequate training in real medicine, extensive knowledge of fanciful fields who treat cancer with alkaline water and misdiagnose asthma as a blood stream bacterial infection, might not be the best choice to improve the health of the population.

As Simon Singh noted, if there are problems with the airlines, you do not turn to magic carpets for transportation.

The whole white paper is a disingenuous “argument by assertion… the logical fallacy where someone tries to argue a point by merely asserting that it is true, regardless of contradiction”.

Naturopaths lack the knowledge and training to do primary care despite their assertions otherwise.