WHY DOES QUACKERY FLOURISH UNDER SO MANY NAMES?

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. This family physician in North Vancouver, British Columbia, 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,” Dr. 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 other forms of “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.”

Dr. 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 health care systems. Americans spent $30.2 billion on out-of-pocket “complementary” (another name for alternative) health care, 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. Regarding these issues, I am in total agreement, but, unfortunately, it doesn’t stop there.

Practitioners are critical of Western medicine for what they regard as an over-reliance 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 more likely to become part of health care 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. These schools generally require graduates to complete 4 years of training in nutrition, acupuncture, homeopathic medicine, botanical medicine, physical medicine, and counseling. Students may be required to intern in clinical settings for up to 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 6,000 practicing NDs and an unknown number of unlicensed naturopathic healers.

CAN NATUROPATHS CALL THEMSELVES ‘PHYSICIANS’?

Twenty-two states, the District of Columbia, Puerto Rico, and the U.S. 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 health care 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.

CAN WE EXPLAIN WHY THESE, AND OTHER FORMS OF “ALTERNATIVE” PRACTICES, ARE SUCCESSFUL?

There is no simple answer to this question, but perhaps the most cogent single factor is the so-called “placebo” effect, which is best defined as any treatment that appears successful but exerts no physical effect on a disease. These “treatments” may include virtually any type of intervention—such as simple encounters with medical professionals, physical manipulations, and even surgical procedures.

As I have explained in my book “Snake oil is alive and well,” this effect is believed to be rooted primarily in the emotional effect on symptoms, which may be quite powerful and enhanced by lengthy explanations that usually include expectations of success by the treating caregivers (often possessing a “placebo personality.”) Further enhancement of this effect is achieved through the “laying on of hands,” i.e., physical contact of any type such as acupuncture, massages, spinal manipulations, surgical procedures, etc.

Another factor that drives many patients to seek such practitioners is insufficient time spent on such patients by overburdened conventional physicians, who, after much testing, find no evidence of usual physical illnesses.

ARE NATUROPATHS GAINING GROUND ANYWAY?

Despite the opposition of the medical establishment and many individual health care professionals, a growing number of health care systems are adopting these and other forms of 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 health care 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 health care 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, Edmonton. Dr. 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.”

I would simply add with a question: Aren’t all these so-called “therapeutic” interventions in reality over-hyped forms of expensive placebos? Ironically, however, research has demonstrated that the placebo effect itself is enhanced by excessive monetary charges accompanying the various procedures. Perhaps, in many such cases, the ends—relief of pain and/or suffering—justify the means!

IS THERE ANY HARM?

Some patients clearly want what naturopathy offers. So what’s the harm? “Health care systems that integrate alternative medicine legitimize it and lower the overall standard of care,” Mr. 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,”

Family physician Dr. 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,” Dr. 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 U.S. 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 also be expensive for patients who pay out of pocket.

Ironically, the mainstream health care 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.

In the final analysis, the side-by-side existence of various “alternative” and conventional medical practices probably serves a dual function by providing patients with an “escape valve” that relieves conventional medical practitioners from spending inordinate time catering to imagined or non-threatening maladies, while, at the same time, providing an alternative, relaxed “naturopathic” environment to air out real or imagined complaints. Thus everyone benefits from such a mixture as long as we can separate physical from non-physical disorders, meaning, in effect, “You don’t fix a broken arm by acupuncture.”

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