Naturopathic physicians are asking for licensure as independent practitioners of primary health care. They think their education adequately prepares them to act as physicians for ambulatory patients, who may have a broad range of medical complaints and concerns, of known and unknown cause and of all degrees of potential severity. They say they are different from primary care medical doctors, but claim they are just as qualified to provide good medical care for most of the patients who might otherwise initially consult an off ice-based primary care medical doctor (such as a family physician, a general internist or a general pediatrician). They say they also provide special kinds of "natural" treatment that primary care medical practitioners do not. They assert that these "natural" treatments not only enhance the effectiveness of standard medical care, but offer unique health care benefits not available from mainstream medical practitioners.
However, the Board of Registration in Medicine of the Commonwealth of Massachusetts is skeptical about these claims. The Board believes that the granting of a license to naturopathic physicians for the independent practice of primary care medicine would in effect put Massachusetts citizens at extra and unnecessary risk for receiving substandard medical care and would add nothing of commensurate value to the health care already available in the Commonwealth.
Here are the Board's reasons:
1. The safe practice of primary health care requires much more clinical education and experience than NDs have received when they begin independent practice. Naturopathic students who successfully complete four years of education in an approved college of naturopathy, and pass examinations after their second and fourth years of schooling, are deemed by the American Association of Naturopathic Physicians to be ready for independent practice as primary care physicians. However, the total time assigned to the clinical teaching of standard (or "allopathic") medicine in the last two years of naturopathy school is less than two-thirds of that provided in medical schools. (The remainder of the clinical instruction in the naturopathic curriculum is concerned with the special philosophy and therapeutic methods of naturopathy.) Furthermore, all clinical teaching in naturopathy schools is in the outpatient clinics and private offices associated with those schools. No teaching is in hospitals, and therefore naturopathic students are not likely to become familiar with the clinical manifestations of diseases serious enough to require hospital care. Lacking hospital experience, naturopathic students are inadequately prepared to recognize and treat the early manifestations of the serious illnesses that will occasionally occur among the ambulatory patients they see in their practice. They are also inadequately educated to deal with the acute problems sometimes unexpectedly encountered in the practice of primary care medicine.
In contrast, medical students receive both outpatient and inpatient training in teaching hospitals during their four years of medical school. In addition, before they can be certified as fully trained primary care physicians they are required to have at least three more years of intensive clinical experience in an approved teaching hospital residency program, where they observe and learn to treat a wide variety of ambulatory and hospitalized patients with acute and chronic, mild and severe illnesses. Medical educators are universally agreed that students newly graduated from medical school would not be qualified to practice medicine independently. Yet naturopathy educators apparently believe the opposite about their graduates, because they ask states to license them straight out of naturopathy school. In Massachusetts, medical graduates can apply for a license after they have completed only one year of approved hospital training and have passed an approved licensing examination, but they would not be certified or given hospital privileges as a primary care physician unless they had completed a total of three years of postgraduate training in family practice, general internal medicine or general pediatrics. Currently, almost all MDs who practice primary care in this state have taken at least 3 years of residency training, and this additional clinical education makes them far better qualified professionally than naturopathic physicians.
The competent care of patients who consult primary care practitioners requires physicians who can recognize illnesses in their early as well as late stages. Such physicians must have the judgment to know when a seemingly mild complaint is really the sign of a serious underlying illness that may need intensive medical treatment. It is not enough for naturopaths simply to say they will refer all serious problems to hospitals or to appropriate medical specialists. They need to be adequately trained to know when a patient ought to be referred, and that requires much more medical knowledge and clinical experience than naturopathic graduates have when they complete their required education and enter practice. They also need to know how to deal with the medical emergencies that can occur unexpectedly even in outpatient practice. Naturopathic physicians claim they can do these things, but their limited training raises serious doubts about whether the public can rely on that assurance.
Of course, no physician is infallible, no matter how well trained. Mistakes in clinical judgment are inevitable and occur among all health professionals. But everything else being equal, better trained practitioners are less likely to make major mistakes. There is no current shortage of fully-trained primary care MDs in Massachusetts. Why, then, should we give independent responsibility for primary care to NDs, who have had much less clinical training than the MDs who are already licensed and certified as primary care specialists? In effect, we are being asked to lower the educational standards for the independent practice of ambulatory medicine, at a time when the need is for more, rather than less, training in this important area of health care.
2. The second reason the Board of Medicine opposes the licensure of naturopaths as primary care physicians is that most of the so-called "natural" methods of treatment they claim as their special province are at best of little or no proven value, and sometimes even dangerous. The distinctive philosophy of naturopathic medicine and many of its methods of diagnosis and treatment are for the most part unscientific in concept, biologically improbable, and clinically unproven. As they are used in naturopathic practice they may delay the use of needed and more effective medical treatment and thus may be harmful.
(a) A basic tenet of naturopathy is that so-called "natural" treatments are preferable to drugs or surgery and should usually be tried first. Naturopathic practitioners have no experience with, and do not use, most of the tested and accepted pharmaceutical agents that are of proven value in the treatment of a wide variety of common but serious illnesses. They rely instead on unstandardized herbal preparations that have not been evaluated by the FDA for purity, safety or effectiveness, and whose use is not supported by rigorous clinical trials in the medical literature. Nevertheless, naturopaths claim that their education and their personal clinical experience with over-the-counter herbals enable them to use these preparations effectively and safely as an alternative to prescription pharmaceuticals. My previously submitted critique of The Textbook of Natural Medicine and Dr. Atwood's forthcoming report to the Commission explain why the medical profession and most medical scientists are skeptical about these claims and are concerned about the dangers of using untested and unstandardized herbals as if they were safe and established therapeutic agents.
There is no reason to doubt that some herbal products now in use, and others that may be introduced in the future will be found to contain substances that will be of real therapeutic value, but the active agents will have to be identified, purified and tested in the same scientific manner as have the other naturally derived pharmaceuticals now in medical use. It ignores the advance of medical science, and it jeopardizes the health and safety of patients, when naturopathic practitioners rely on untested crude botanical preparations of unknown composition and purity, instead of tested and FDA-approved pharmaceuticals. By licensing naturopathic physicians, Massachusetts would in effect be endorsing this dangerous practice. Naturopaths claim they only prescribe the herbal preparations they believe to be safe and effective on the basis of their own clinical experience, but such personal opinions are not supported by published scientific evidence, and the herbal preparations are marketed without FDA regulation or any other public control. Independent scientific tests have shown such alarming variations in the purity and content of over-the-counter herbals that the public cannot be expected to trust the assurances of NDs any more than the advertising claims of the manufacturers themselves.
(b) Other treatments routinely taught at the colleges of naturopathy and used in naturopathic practice include health counseling, therapeutic nutrition, homeopathy, Oriental medicine, hydrotherapy, Ayurvedic medicine and naturopathic manipulative therapy. Counseling and therapeutic nutrition are also taught in medical schools, because they generally have a sound basis in biological science. They were a part of regular medical teaching long before the current naturopathic colleges were even founded, although it is true that much responsibility for therapeutic nutrition has recently tended to be shifted to professional dietitians and nutritionists, who work in collaboration with physicians. The other modalities used by naturopaths are not taught in medical schools, because they are for the most part unscientific and unsupported by any credible body of clinical knowledge. Their use, along with other irrational and unsupported treatments such as chelation, magnetotherapy and colonic irrigation, is sometimes cited by naturopaths as evidence of the unique contributions of their profession. However, it is hard to understand why the Commonwealth would want to put its imprimatur on health care practices that defy well established scientific principles, and have no credible support in the medical literature.
(c) Naturopaths counter these criticisms with claims that their unorthodox methods are in fact validated by a large "scientific" literature. Their Textbook of Natural Medicine and the material they have submitted to the Commission cite numerous published articles (over 10,000 in the Textbook) to buttress these claims. But as Dr. Atwood and I have pointed out elsewhere, these citations actually provide little or no scientific support for the clinical methods of naturopathy. Careful reading of the references suggests that they have been listed more for their impressive number than for their actual content or relevance. Most of the references have nothing to do with clinical practice, and virtually none describe clinical trials or case studies in the peer-reviewed literature. In short, despite naturopathy's claims to the contrary, and all its posturing about "science", almost none of its special therapeutic practices are "evidence-based", or even biologically plausible.
Naturopaths often respond to this last criticism with their own charge that most clinical practices used in conventional medicine aren't "evidence-based" either. However, medical practice is far more strongly supported by science and empirical evidence than naturopathy. It is true that the validity of much of medical practice has not yet been established beyond reasonable doubt by randomized, controlled clinical trials, but most current practice has at least some empirical support in the peer-reviewed literature and almost all has biologically-based plausibility. The pharmaceutical agents used by medical physicians have been clinically tested and are approved by the FDA. As new knowledge accumulates, medical therapeutics constantly improves and evolves.
Unfortunately the same cannot be said of naturopathic clinical practices, many of which are based on ancient theories about the nature of health and disease, which have not changed over the years, and almost none of which have been critically tested or even documented in the medical literature.
3. The third and final reason the Board of Medicine opposes the licensure of naturopathic physicians as independent primary care practitioners is that licensure probably will do little or nothing to protect the public from the risks stemming from the inadequate clinical education and unscientific practices of NDs or of other "natural healers."
Judging from the laws and regulations governing their licensure in some other states, naturopathic physicians would, if licensed as independent primary care practitioners, regulate themselves and set their own standards of professional performance. That would not remedy the problems already discussed. Instead, it would in effect place the Commonwealth's approval on naturopathy as a legitimate alternative to primary medical care. It would imply that patients could safely consult naturopathic physicians, instead of medical doctors, as a source of ambulatory medical care. And yet most would agree, even the naturopaths themselves, that naturopathic practitioners are not qualified to handle the full range of medical care problems, a primary care physician is likely to see. In recognizing that certain types of medical problems, even in ambulatory patients, need the care of medical doctors, the naturopathic practitioners are virtually acknowledging that they are not sufficiently educated to practice primary care medicine totally independently. Their assertion that they would refer all medical problems that are beyond their expertise to regular physicians is not reassuring, because naturopaths lacking experience may not always know when they are dealing with such problems, or may only realize it too late.
In theory, licensure of naturopaths, with appropriate limitations on the scope and independence of their practice, might answer some of these concerns. For example, nurse practitioners and physicians' assistants who, like naturopathic physicians, have substantially less than the full clinical training of a certified primary care physician, are required in Massachusetts to practice primary care under the supervision of a physician. A similar restriction on naturopathic practice might in principle address the problems related to the limited clinical training of NDs. It would not, however, deal with the fundamental incompatibility between many of the to special" methods of naturopathy and the standards of scientific, evidence-based medicine. In any case, it is not likely that the naturopathic physicians would accept such a limitation on their independence. Thus, we believe the legislature will have to decide whether to license NDs as independent primary care practitioners (albeit with certain restrictions on scope of practice, such as limited prescribing authority and no major surgery) or not to license them at all. For all the reasons already advanced, we believe the latter choice is the only one consistent with public welfare and safety.
Finally, the Board wishes to mention an argument often advanced by the American Association of Naturopathic Physicians, i.e., that licensure of naturopathic practitioners who have earned the ND degree after graduation from a four-year college of naturopathic medicine would enable the public to distinguish such graduates from all the other "natural healers" who do not have similar educational qualifications and -- according to the NDs -- are therefore less qualified to provide "natural medicine". The other practitioners include a wide variety of healers who employ many of the same therapeutic modalities as the NDs, but usually limit their practice to one or more of these modalities and do not hold themselves out as primary care general physicians. Their education is highly variable in length and quality. A national organization known as the Coalition for Natural Health claims to represent about 2,500 of these "natural healers" nationwide. They oppose licensure of NDs because they believe the terms of such licensure usually restrict their freedom to practice.
The Board takes no position in this debate between the Coalition for Natural Health and the American Association of Naturopathic Physicians, but it would simply observe that licensure of NDs would not per se eliminate less educated "healers". They could be prevented from holding themselves out as "naturopaths" or "naturopathic physicians", but not from offering their services to anyone willing to pay for them. The problem of unlicensed "healers" has been with us for a long time and is not likely to disappear soon.
Dr. Relman is Emeritus Professor of Medicine and of Social Medicine, Harvard Medical School; Editor-in-Chief Emeritus of The New England Journal of Medicine; and a member of the Massachusetts Board of Registration in Medicine (BORM). He prepared this report while serving as BORM's representative to the Special Legislative Commission on Complementary and Alternative Medical Practitioners, an ad hoc group formed to advise the Massachusetts legislature.