Naturopathic doctors

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From Medscape General MedicineT

Special Article

Naturopathy: A Critical Appraisal

Posted 12/30/2003

Kimball C. Atwood IV, MD

Abstract and Introduction

Abstract

" Naturopathic medicine " is a recent manifestation of the field of

naturopathy, a 19th-century health movement espousing " the healing power of

nature. " " Naturopathic physicians " now claim to be primary care physicians

proficient in the practice of both " conventional " and " natural " medicine.

Their training, however, amounts to a small fraction of that of medical

doctors who practice primary care. An examination of their literature,

moreover, reveals that it is replete with pseudoscientific, ineffective,

unethical, and potentially dangerous practices. Despite this, naturopaths

have achieved legal and political recognition, including licensure in 13

states and appointments to the US Medicare Coverage Advisory Committee. This

dichotomy can be explained in part by erroneous representations of

naturopathy offered by academic medical centers and popular medical Web

sites.

Introduction

Two naturopaths were recently appointed to the US Medicare Coverage Advisory

Committee (MCAC).[1] This contradicts the conclusions of an inquiry made by

the US Department of Health, Education, and Welfare (HEW; now the Department

of Health and Human Services), the department that houses Medicare itself.

In 1968, naturopaths asked HEW to consider Medicare reimbursement for their

practices. The department conducted an investigation and chose not to do so.

Its report concluded:

Naturopathic theory and practice are not based on the body of basic

knowledge related to health, disease, and health care that has been widely

accepted by the scientific community. Moreover, irrespective of its theory,

the scope and quality of naturopathic education do not prepare the

practitioner to make an adequate diagnosis and provide appropriate

treatment.[2]

These conclusions are still valid. Thirty-five years later investigators

from Simon Fraser University in British Columbia reported similar findings:

In our research for this chapter, we provided naturopaths and their

professional associations ample opportunity to refute the conclusions of

several major commissions of inquiry over the years that deemed their

therapeutic rationale lacking in scientific credibility. None of our

informants was able to convince us that the field had taken these earlier

critiques to heart; in fact, precious few seemed to recognize that a problem

still exists. [O]ur own bibliographic searches failed to discover any

properly controlled clinical trials that supported claims of the profession,

except in a few limited areas where naturopaths' advice concurs with that of

orthodox medical science. Where naturopathy and biomedicine disagree, the

evidence is uniformly to the detriment of the former.

We therefore conclude that clients drawn to naturopaths are either unaware

of the well-established scientific deficiencies of naturopathic practice or

choose willfully to disregard them on ideological grounds.[3]

What follows is a summary of the current state of " naturopathic medicine. "

Much of it comes from the position papers and other articles on the Web site

of the American Association of Naturopathic Physicians (AANP); from the

Textbook of Natural Medicine, the only general textbook of the field,

coedited and largely coauthored by one of the Medicare appointees[4,5]; and

from the most visible naturopathic school, Bastyr University in Kenmore,

Washington, where the coeditor of the Textbook was founder and president and

where the other new MCAC appointee is associate dean. Thus, it reflects the

health beliefs of these 2 appointees and of the uppermost levels of

" naturopathic medicine. "

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Section 1 of 8 Next Page: Brief History and Current Status

Kimball C. Atwood IV, MD, Anesthesiologist, Newton-Wellesley Hospital,

Newton, Massachusetts; Assistant Clinical Professor, Tufts University School

of Medicine; Contributing Editor, Scientific Review of Alternative Medicine;

Chairman, Committee on the Quality of Medical Practice, Massachusetts

Medical Society; email: katwood@...

Disclosure: Dr. Atwood has no financial interests to disclose.

Brief History and Current Status

" Naturopathic physicians " are a recent manifestation of the field known as

naturopathy, the origins of which were in the 19th-century German " natural

living " movement. Early naturopaths objected to contemporary medical

advances, such as the germ theory and vaccinations, but espoused the " water

cure, " fasting, herbs, homeopathy, colonic " detoxification, " and other

popular methods of the era.

The content of the field has changed little since then, but the trappings

have become modern. A subset of naturopaths now seeks to distinguish itself

from " traditional naturopaths " : it professes to practice " a distinct form of

primary health care, " according to the official definition on the Web site

of its national organization, the AANP.[6] At the National College of

Naturopathic Medicine in Portland, Oregon, " naturopathic physicians " are

described as

....primary care physicians, most of whom are in general private practice

[and] trained to be the doctor first seen by the patient for general

healthcare, for advice on keeping healthy, and for the diagnosis and

treatment of acute and chronic conditions.[7]

" Naturopathic doctors " (NDs), as they also call themselves, state that they

have received training appropriate to the practice of medicine, including a

basic science curriculum equivalent to that taught in medical schools. This

training occurs at 1 of 4 schools in the United States or 1 in Canada, each

of which offers a 4-year, on-campus curriculum but no significant hospital

or residency experience. Four of the schools are not attached to larger

universities; the fifth, the University of Bridgeport College of

Naturopathic Medicine in Connecticut, is owned by Reverend Sun Myung Moon's

Unification Church.

These naturopaths are now licensed in 13 states (Alaska, Arizona,

California, Connecticut, Hawaii, Kansas, Maine, Montana, New Hampshire,

Oregon, Utah, Vermont, and Washington) and the District of Columbia. Their

scope of practice is typically limited only by prohibitions against

performing major surgery and prescribing controlled substances.[8] In all of

these states they are free to make broad claims of medical expertise. In

Washington, an " every category of provider " law forces private insurers to

reimburse naturopaths.[9]

The Naturopathic Belief System

Naturopathic beliefs -- including those of " naturopathic physicians " -- are

rooted in vitalism, the pre-20th-century assertion that biological processes

do not conform to universal physical and chemical principles. Naturopaths

describe a " healing power of nature, " which is compromised by modern

medicine.[10] They state that they " treat the cause of a problem, rather

than to merely eliminate or suppress the symptoms. " [6] They state that they

treat " the whole person. " They state that they can " boost the immune system "

with herbs and homeopathic preparations. They profess knowledge about

preventive medicine that is, implicitly, unknown to medical doctors, public

health experts, nurses, nutritionists, and others. They profess special

expertise in nutrition and in the use of " natural remedies " made from

animal, vegetable, and mineral sources.

Naturopaths invoke a few simplistic theories to explain the causes of

disease. These include the actions of ubiquitous " toxins " (including most

pharmaceuticals); widespread food allergies; dietary sugar, fat, and gluten;

inadequate vitamin and mineral intake; epidemic candidiasis; vertebral

misalignments; intestinal " dysbiosis " ; imbalances of Qi; and a few others.

To diagnose these entities, naturopaths use an assortment of nonstandard

methods, among which are iridology or iris diagnosis, which holds that the

entire body is represented on the iris of the eye[11]; applied kinesiology,

by which an allergy to a food is detected by placing the food particle in

one hand of a patient and observing a resulting weakness in the other; hair

analysis for alleged toxins and vitamin and mineral deficiencies;

electrodiagnosis, which can purportedly detect parasites and other problems

by measuring the skin's resistance to a tiny electric current; " live cell

analysis " ; " pulse " and " tongue " diagnosis; and others.[12,13]

Naturopathic Treatments

Naturopathic treatments include colonic irrigation (enemas) and fasting for

" detoxification, " hydrotherapy (wrapping part or all of the body in wet

towels), homeopathy, acupuncture, chiropractic manipulation, aromatherapy,

arduous dietary regimens, intravenous vitamin C, hydrogen peroxide and

ozone, whole enzyme pills, herbs, desiccated animal organs, and other

" natural remedies. " Naturopaths sell these preparations to their clients at

a profit, a practice that is both formally approved and joined by the

AANP.[14-16]

How does this translate into the practice of naturopathic medicine? The

following recommendations and practices are representative:

The repudiation of standard treatments of streptococcal pharyngitis,[17]

acute otitis media,[18] and other childhood infectious diseases, offering

instead homeopathy, hydrotherapy, and " natural antibiotics " (eg, herbs such

as Goldenseal).

Affiliation with the antivaccination movement.[10]

The repudiation of standard treatments of asthma, offering instead, for

example, a hydrogen peroxide bath to " bring extra oxygen to the entire

surface of the skin, thus making the lungs somewhat less oxygen hungry " or

" gems and minerals ... worn as jewelry, or placed around the home in special

places. " [19] This quotation is from " Articles written by Naturopathic

Physicians for the general public " (on the AANP Web site). The author is

listed as a " senior editor of the Journal of Naturopathic Medicine, the

official publication of the AANP. "

Recommendations, by the Bastyr University AIDS Research Center, for

treatment of HIV-positive patients with St. 's wort and garlic (both of

which have been shown to reduce blood levels of highly active antiretroviral

therapy agents), " acupuncture detoxification auricular program, " whole-body

hyperthermia, " adrenal glandular, " homeopathy, " cranioelectrical

stimulation, " digestive enzymes, colloidal silver, and nearly 100 other

dubious methods.[20,21]

Warnings against proven medical and surgical treatments for hypertension,

hyperlipidemia, and atherosclerosis, while instead recommending herbs and

EDTA chelation.[22]

The insertion of endonasal balloons, followed by their inflation in the

nasopharynx, to " release tensions stored in the connective tissue and return

the body to its original design, " thus curing learning disorders and a host

of other problems.[23,24]

Treatment of the acute stroke patient for at least 20 minutes with an

" ice-cold compress ... over the carotid arteries under the jaw bone on the

neck " (which " may even abort the stroke " ) and subtle energy medicine.[25]

The author of these recommendations is listed as a " senior editor of the

Journal of Naturopathic Medicine, the official publication of the American

Association of Naturopathic Physicians. "

The early detection of multiple sclerosis by " pulse " and " tongue " diagnosis,

such as to effect a cure by hydrotherapy, homeopathy, acupuncture, diet, and

other methods.[26] The author of these claims is Chief Medical Officer of

the Southwest College of Naturopathic Medicine.

The prevention and cure of breast cancer by an assortment of nonstandard

tests and " supplements. " [27] The author of these claims " has lectured

regularly at the Canadian College of Naturopathic Medicine on breast health

and stress management. "

The treatment of cancer of the prostate with " electrical current in the form

of positive galvanism, applied transrectally. " [28] This recommendation is

from " Articles written by Naturopathic Physicians for the general public "

(on the AANP Web site). The author is Chief Medical Officer of the Southwest

College of Naturopathic Medicine.

Ubiquitous " toxin " claims, including antifluoridation statements, warnings

against most proven pharmaceuticals, and the assertion that " 25% of

Americans suffer from heavy metal toxicity. " [29]

" Natural childbirth care in an out-of-hospital setting " using a

" naturopathic approach [that] strengthens healthy body functions so that

complications associated with pregnancy may be prevented. " [7]

Nearly 100 nonstandard uses for vitamin C recommended by the Textbook of

Natural Medicine.[4]

The promotion and sale of " dietary supplements " for virtually all

complaints.

Naturopaths have not subjected their basic tenets to critical scrutiny,

apparently because they are already convinced that they are correct. For

example, the AANP position paper on treatment of streptococcal pharyngitis,

offering no supporting evidence, makes this claim: " naturopathic physicians

.... have been successfully treating Strep pharyngitis with very low

incidence of poststreptococcal sequelae, using various natural antibiotics,

and natural immune enhancing therapies, for close to one hundred years

.... " [17]

A 1999 survey of the small number of NDs in Massachusetts, performed by 2

investigators from Children's Hospital in Boston, is consistent with these

findings. They reported that only 20% of those surveyed would recommend that

parents have their children vaccinated and that only 40% would refer a

2-week-old infant with a temperature of 101° F for definitive medical

care.[30]

Implications for Medicare

In an interview for the Seattle Times, one of the new MCAC appointees

offered examples of how he might affect the process of selecting therapies

for Medicare coverage:

[The new appointee] said he plans to push for more emphasis on prevention

and health promotion. He also wants well-proven and cost-effective

alternative techniques to be covered by Medicare.

Examples could include natural ear-infection treatments for infants and

acupuncture treatments for those suffering sports injuries or drug

addiction, he said.[1]

Naturopathic literature suggests that by prevention and health promotion

this Medicare adviser is referring to " detoxification, " " cleansing programs "

for " food allergies " and " candidiasis, " enemas, " constitutional " homeopathic

preparations, and so forth. " Natural ear-infection treatments for infants "

are not only unproved but are implausible and dangerous. Acupuncture

treatments for sports injuries are unlikely and unproven, and acupuncture

for drug addiction has been convincingly disproved.[31]

Elsewhere, the same appointee recommends a flower pollen extract for benign

prostatic hypertrophy,[32] an " intranasal douche with hydrastis tea " for

bacterial sinusitis,[33] a " general bowel detoxification diet " for

autism,[34] and oral bromelain (a protein extracted from pineapples) for the

" lumpy skin around varicose veins. " [35] For cervical dysplasia and pelvic

inflammatory disease, he recommends " vaginal depletion packs, " 1 by 3-inch

cotton tampons containing a tar-like mixture of botanical oils, left in

place for 24 hours at a time and repeated weekly.[36]

Formal criteria require that appointees to the MCAC be " from among

authorities in clinical and administrative medicine, biologic and physical

sciences, public health administration, health care data and information

management and analysis, the economics of health care, medical ethics, and

other related professions. " [37] How were the 2 naturopaths selected? On

February 18, 2003, I sent a letter to A. Scully, the Administrator of

the Centers for Medicare & Medicaid Services, making points similar to those

in this article and implicitly asking that question. There were 30

cosignatories.* Mr. Scully had not replied as of December.

*Lee S. , Marcia Angell, Seth Asser, Baratz, R.

Barden, Barrett, Brock, Carl E. Bartecchi, Henry N. Claman,

E. Curry, E. Dodes, Bruce L. Flamm, J. Fochtmann,

Gorski, Saul Green, Arthur P. Grollman, J. Kenney, M. Lohr,

Janice Lyons, Madras, Frederick L. Merian, Novella, Arnold

Relman, A. , Barbara Rockett, Francis X. Rockett, ,

Wallace Sampson, Sally Satel, Gerald Weissmann

Dissent From the White House Commission on Complementary and Alternative

Medicine Policy

Two dissenting members of the recently adjourned White House Commission on

Complementary and Alternative Medicine Policy warned, in a letter to

Department of Health and Human Services Secretary Tommy , of the

problems introduced by official endorsements of naturopaths and other

" complementary and alternative medicine " (CAM) practitioners:

Vulnerable Populations

Patients will often resort to " CAM " practices, modalities and practitioners

upon the diagnosis of a debilitating, chronic or terminal condition. Recent

Senate hearings have documented the special vulnerability of the elderly

[emphasis added] on fixed-incomes to these phenomena.

[CAM practitioners] are not positioned for equivalency with conventional

primary care providers. Efforts to equate their degree of training, or the

scientific basis of their practice, with that of the designated primary care

specialties puts the public at risk of receiving unvalidated and

non-evidence based primary care.

.... " CAM " " health promotion " and " prevention practices " also include

preventing disease by " balancing qi, " " eliminating parasites and toxins, "

" cleansing the liver " and/or by " cleansing the blood " via a multitude of

supplements and questionable practices. Our uncritical acceptance of " CAM "

wellness and health promotion can be interpreted as an endorsement of these

claims. It is absolutely unclear what role, if any, " CAM " practices play in

preventing disease and to what extent patients are burdened with useless

treatments and products in their pursuit of " wellness. "

In sum, generic pronouncements about " CAM " neither serve the public interest

nor protect the public health. It is essential to separate the effective

from the ineffective, the safe from the unsafe and to contextualize these

practices against conventional modalities before [emphasis added] any of

them can be recommended for incorporation into the Nation's healthcare

system.[38]

Even if Medicare itself successfully resists the efforts of its new

advisers, their appointments are already being trumpeted to the public as

evidence that the federal government considers naturopathic practices to be

valid.[39,40] This will likely help naturopaths in their pursuit of

universal state licensure and reimbursement by health insurers. Because

licensed health care providers determine their own standards of care,[41] it

would be detrimental to the public if naturopaths were successful in this

pursuit.[42]

Comment

" Naturopathic medicine " is an eclectic assortment of pseudoscientific,

fanciful, and unethical practices. Implausible naturopathic claims are still

prevalent and are no more valid now than they were in 1968. The current wave

of unexamined CAM fascination, however, appears to have helped naturopaths

convince some that they have special abilities and that they are trained to

be primary care physicians.

Most treatises on naturopathy that physicians and the public are likely to

read are uncritical promotions that simply restate what naturopaths claim.

Yet these views are found on the Web sites of academic medical centers and

the large commercial sites for the general public. For several years, the

Caregroup/Harvard Medical School Web site urged readers, without further

comment, to " please consult your local telephone yellow pages " for

" naturopathic physicians " and other CAM practitioners.[43] The Web site of

the University of Washington School of Medicine portrays " naturopathic

physicians " as well trained to practice " primary care integrative natural

medicine, " with a " scope of practice [that] includes all aspects of family

and primary care, from pediatrics to geriatrics, and all natural medicine

modalities. " It further asserts that " naturopathic diagnosis and

therapeutics are supported by scientific research drawn from peer-reviewed

journals from many disciplines. " [44] None of these statements can withstand

rigorous scrutiny.

InteliHealth, a joint venture between Harvard Medical School and Aetna,

promises to " [provide] credible information from the most trusted

sources. " [45] As recently as the spring of 2002 InteliHealth stated, " NDs

are trained as family physicians " ; they " treat the whole patient, not just

the disease symptoms " ; they " successfully combine so many therapies " ;

" Naturopathic doctors throughout the country are becoming increasingly

recognized as primary care providers. " The article suggested that if the

reader were already consulting an ND, she might reasonably choose not to see

an MD.[46] When InteliHealth replaced this article with a new one, it did so

without explanation, failing to warn readers of the dangers of having

trusted the previous information. The replacement article, moreover,

approvingly describes naturopaths as " [concentrating] on principles of

holistic health (pertaining to body, mind and soul), prevention and

self-care. " It does not address the serious shortcomings of the field.[47]

WebMD, the parent corporation of Medscape, offers this:

A naturopathic doctor often combines many different complementary therapies

to enhance the body's natural vital force.

A licensed naturopathic physician (ND) attends a 4-year, graduate-level

naturopathic medical school and is educated in the same basic sciences as a

medical doctor (MD).[48]

Naturopathic medicine is used for health promotion, the prevention of

disease, and treatment of illness. Most naturopaths can treat earaches,

allergies, and other common medical problems. Naturopathic medicine tries to

find the underlying cause of the person's condition rather than focusing

solely on symptomatic treatment.[49]

The WebMD treatise also advises, " Naturopathy should not replace

conventional methods of treatment for certain conditions, " [49] but how is

the patient to know? The assumption is that naturopaths will act

responsibly, but they have neither the medical training nor the requisite

scientific skepticism to do so. On the contrary, they portray themselves as

primary care physicians. The unwary reader might conclude that naturopaths

are trained to provide " conventional methods " when appropriate, but NDs have

had only a small fraction of the training of primary care MDs. Instead they

have been steeped in homeopathy and other highly implausible, ineffective

practices. It is unlikely that readers of WebMD and the other sources

mentioned here will appreciate this dichotomy.

The National Center for Complementary and Alternative Medicine (NCCAM) has

had 3 naturopaths on its advisory council in the past 3 years.[50] It

proposes to conduct research into CAM methods advocated by

" licensed/certified CAM practitioners (Doctors of chiropractic, naturopathy,

[etc.]). " [51] The NCCAM advises citizens who consult CAM practitioners to

ask about licensure or certification early in the process.[52]

Like the NCCAM, WebMD also admonishes readers to seek only licensed

naturopaths: " without licensing standards, individuals with little or no

formal education may proclaim themselves naturopathic physicians without

medical school education or board testing. " [48] The clear message is that

such licensing implies competence. There is, however, no evidence that

" educated " naturopaths -- the most prominent of whom provided the clinical

examples for this article -- are more competent than others.[9] If anything,

" traditional naturopaths " (ie, those who did not attend the " approved "

schools) may be less of a threat to public health because they do not

pretend to be primary care physicians.

Graduates of campus-based, 4-year naturopathic programs who have passed a

standardized examination may demonstrate consistency from one practitioner

to the next. But that says nothing about the validity of what they do --

which can be determined only by reference to the facts of nature and by

rigorous testing of biologically plausible claims. At least one leading CAM

researcher has acknowledged this fact:

Those who believe that regulation is a substitute for evidence will find

that even the most meticulous regulation of nonsense must still result in

nonsense.[53]

Conclusion

This is the first article in a mainstream medical journal that critically

summarizes the field of " naturopathic medicine. " If physicians continue to

consider naturopaths and other " alternative " practitioners as

inconsequential -- or, if the only articles on CAM that most physicians read

are uncritical -- pseudoscience will continue to make inroads into patient

care and health policy. The information presented herein illustrates why

official sanctioning of naturopaths as health care providers, including

their appointments to the MCAC, should be considered unwise.

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