Naturopathic Doctors: Primary Care?

I understand I will take flack for the picture depicting a fake doctor with the title of the blog/article referencing Naturopathic doctors (1)?  I write this blog because I care what is happening in health care today, and I’m proud to be an MD. I understand those earning a doctorate can use the title in academic settings, but this article references Naturopathic doctors (1) “will be granted a license by the New Mexico Medical Board to practice as a PCPs when they have:”

1. Completed an approved naturopathic medical education from an accredited four-year graduate level medical program similar to that of medical doctors, offering full-time didactic and supervised clinical training.
2. Passed a national professional examination.
3. Passed state jurisprudence and pharmacy exams.
4. Demonstrated good moral and professional character.

According to the article, New Mexico is experiencing a dangerous shortage of primary care healthcare providers. The premise is that NDs can fill that gap. To me, this is another discipline trying to solve a physician problem. Why can’t everyone just stay in his or her lanes? According to the article, 

“Naturopathic doctors bridge the worlds of Western, allopathic medicine, and holistic, time-honored natural medicine. They are trained in scientific diagnostics (labs, diagnostic imaging, and physical examination); pharmaceutical therapies and minor surgery as well as evidence-based integrative medicine including nutrition, herbal medicine, hydrotherapy (think warm compresses or applying an ice pack to sprained ankle), homeopathy and naturopathic manipulation.”

According to The American Association of Naturopathic Physicians (AANP) (2):

“Naturopathic doctors are educated and trained in accredited naturopathic medical colleges. They diagnose, prevent, and treat acute and chronic illness to restore and establish optimal health by supporting the person’s inherent self-healing process. Rather than just suppressing symptoms, naturopathic doctors work to identify underlying causes of illness, and develop personalized treatment plans to address them. Their Therapeutic Order™, identifies the natural order in which all therapies should be applied to provide the greatest benefit with the least potential for damage (2).

So that being said, how can they function as PCP’s? In New Mexico, PCP’s include internal medicine and family practice doctors, doctors of osteopathy, physician assistants, nurse practitioners, and beginning in July 2020, naturopathic doctors (1). The focus is the persons’ inherent self-healing process with evidence-based integrative medicine including nutrition, herbal medicine, hydrotherapy (think warm compresses or applying an ice pack to sprained ankle), homeopathy and naturopathic manipulation (1). Therapeutic diet and lifestyle recommendations are usually offered, since health is significantly affected by behaviors such as smoking, diet, stress, physical activity and sleep habits (1). The AANP says NDs use therapies to stimulate and strengthen the body’s innate self-healing and curative abilities. These therapies include modalities such as clinical nutrition, botanical medicines, constitutional hydrotherapy, homeopathy, and acupuncture (2). They also say however that:

When life, limb, or function must be preserved, NDs refer patients to MDs who are expertly trained in these arenas. At the same time, NDs use complementary or supportive therapies to decrease side effects and increase the effectiveness of these invasive procedures (2).

The operative question becomes can this be a method of primary care? The American Academy of Family Physicians (AAFP) (3) defines primary care as:

“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.”

The position of the AAFP on “Non-physician primary care providers (3)” is that:

There are providers of health care other than physicians who render some primary care services. Such providers may include nurse practitioners, physician assistants and some other health care providers. These providers of primary care may meet the needs of specific patients. They should provide these services in collaborative teams in which the ultimate responsibility for the patient resides with the primary care physician. (1975) (2006) In this document, the term physician refers only to doctors of medicine (M.D.) and osteopathy (D.O.) (3).

Thus the AAFP stance on NDs could be one of providing service on collaborative teams, but the doctors of medicine (M.D.) and osteopathy (D.O.) bear the “ultimate responsibility.” It make you wonder how it came to pass that legislation to allow NDs in New Mexico to function as PCPs came to fruition. A little digging, the bill (4) was sponsored by Senator Gerald Ortiz y Pino – (D) (5) himself a social worker which may explain some of the ease with which NDs could convince a non-physician provider for expanded scope of practice. Everyone these days seem to want to expand his or her scope of practice into the physician lane. It seems every non-physician health care discipline wants to encroach and hijack physician roles, so I suspect it wasn’t difficult to get this senator on board with the NDs.

So I guess if you live in New Mexico and you want clinical nutrition, botanical medicines, constitutional hydrotherapy, homeopathy, and acupuncture, then NDs are your choice. Does this pose a threat to doctors of medicine (M.D.) and osteopathy (D.O.) practice of actual medicine? I suppose, as people by and large won’t know the difference. Is this dangerous? I think so. They’ll be told homeopathy will cure their strep-throat and prevent their rheumatic heart disease rather than good ole penicillin. I’ll admit that I am mostly ignorant to the ND world, and am in no way trying to cause friction. However, I think the friction started now that NDs have now steered into the physician lanes. Next they’ll want prescriptive privileges, admitting privileges, and hospital credentialing. When/where does this stop? We see it with other mid-level providers (NPs, PAs, CRNAs etc), and now we have to contend with NDs hijacking predominantly physician roles. This needs to stop. A recent Authentic Medicine called A Disaster in Waiting (6) recently wrote about ignoring the warning by those possessing the expertise to tell them that what they are about to do will lead to a disaster (6). I care, which is why I write here that giving the NDs the PCP role is dangerous. Another organization also wrote about it, the www.physiciansforpatientprotection.org – can’t solve physician shortage by substituting non-physicians (7). Lastly, an article has been floating around social media that discusses the parallels between the airline industry and the medical industry regarding training. One quote: “A type rating refers to the levels of certification required by a pilot to fly certain aircrafts (think: like a special license). As such, no additional training of pilots was required, despite the numerous changes to the aircraft…. (8)” There’s many more references, but that’s all for now. Have a great day. 

REFERENCES

1. https://www.lcsun-news.com/story/life/wellness/2019/09/07/naturopathic-doctors-can-now-primary-care-physicians/2246346001/?fbclid=IwAR06Erd4wb1om3ah5jpZxuo-zd2NzpfEdgb3l_3lTRparJEjdjFZ1TNTjCI
2. https://www.naturopathic.org/content.asp?contentid=60
3. https://www.aafp.org/about/policies/all/primary-care.html
4. https://www.nmlegis.gov/Legislation/Legislation?chamber=S&legType=B&legNo=135&year=19
5. https://www.nmlegis.gov/Members/Legislator?SponCode=SORTI
6. https://authenticmedicine.com/a-disaster-in-waiting/
7. https://www.physiciansforpatientprotection.org/cant-solve-physician-shortage-by-substituting-non-physicians/?
8. https://www.medicaldesignandoutsourcing.com/boeings-737-max-crisis-why-the-medical-device-industry-should-care/?fbclid=IwAR2N_GGJ6djSGMlGPAiE1szqkVFu6cgiqOkydzAZW06hA9pyBOgO7OhrI-o