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Policy Report on SB 1366: Regarding Naturopaths and the Definition of Physician

Digital Exclusive - November 2022
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Executive Summary

Background

SB 1366, introduced in Arizona's Fifty-fifth Legislature – Second Regular Session, did not pass into law. The bill would have expanded the definition of physicians that provide covered services for members through the Arizona Health Care Cost Containment System (AHCCCS) to include naturopathic doctors. I advised this bill should have be opposed and naturopathic doctors not be granted legal recognition as physicians. Naturopathic doctors lack the same qualifications as medical doctors (MDs and DOs), the reasons for which include the following:

  • Naturopathic medicine, as a whole, lacks a scientific basis

  • Education and training of naturopathic doctors is of questionable quality

  • Certain therapies employed by naturopathic doctors are unproven or disproven and may cause harm, either through adverse side effects or indirectly through delayed diagnosis and treatment.

 

Policies that allow AHCCCS coverage for specific therapies to be used in a complementary fashion with conventional medical treatments may be worthwhile, but granting naturopathic doctors legal recognition as physicians would open up patients to being misled regarding naturopathic therapies. To improve access to quality primary care for Arizonans, policies should instead be pursued that promote the training and recruitment of physicians in Arizona and that incentivize physicians to practice in rural and underserved areas.

 

Introduction

SB 1366 was a bill that would expand the definition of physicians that provide covered services for members through the Arizona Health Care Cost Containment System (AHCCCS) to include naturopathic doctors.(1) (It should be noted that this bill has been amended such that this provision would only take effect upon approval by the Centers for Medicare and Medicaid Services.) AHCCCS statute currently defines a physician as a person licensed as a medical doctor (MD) or as an osteopathic surgeon or physician (DO).(2)

 

The practice of naturopathy, as defined in Arizona law, is the “diagnosing and treating [of] disease, injuries, ailments, infirmities and other conditions of the human mind and body, including by natural means, drugless methods, drugs, nonsurgical methods, devices, physical, electrical, hygienic and sanitary measures and all forms of physical agents and modalities.”(3) To qualify for a naturopathic license in Arizona, one must graduate from an approved school of naturopathic medicine and complete an approved internship, preceptorship, or clinical training program in naturopathic medicine.(4)

 

There has been a development of increasingly murky language surrounding this topic. Where the words doctor and physician used to be used interchangeably in the clinical or hospital setting, there is now confusion regarding what these terms actually mean. Naturopaths have been using the title of doctor for years, but they have not been regarded as physicians, like allopathic and osteopathic doctors (MDs and DOs). This is primarily because, unlike MDs and DOs, naturopaths do not practice conventional medicine. Naturopathic medicine, a form of alternative medicine, has been criticized for its use of a wide variety of pseudoscientific practices, which are widely considered ineffective and, in some cases, harmful.(5) Ethical concerns have been raised by the medical community due to its use of unproven or disproven alternative treatments, even in cases where conventional medicine offers an evidence-based treatment.(5) When used in a complementary fashion to conventional medical treatment, some therapies employed by naturopathic practitioners may benefit some patients, but naturopathic doctors should not be given the same legal recognition as MDs and DOs. Naturopathic medicine is largely lacking in evidence and naturopathic doctors do not possess the same qualifications or competency as medical doctors. Expanding the definition of physician to include naturopathic doctors would further muddy the waters for patients and may lead to some being misled about the qualifications of the provider they are seeing, and thus raises concerns regarding patient safety and public health.

Main Points​

Naturopathy's Poor Evidence Basis

Naturopathy has long been criticized for lacking a substantial evidence basis.(5,6) Among its core principles is vitalism, a belief in a vital force often referred to in naturopathic medicine as “the healing power of nature” and described as the “inherent, self-organizing and healing process” of living organisms.(7) This vital force is a metaphysical concept that cannot be explained by physical or chemical factors; thus, its existence cannot be proven. However, it serves as the philosophical basis for many naturopathic therapies.

 

Some within the field of naturopathy have gone so far as to outright reject the paradigm of evidence-based medicine as “incongruent with” or “antithetical to” naturopathy due to what they see as a reductionist approach that fails to recognize the impact of holistic, multi-modal approaches that typify naturopathic medicine.(8) However, even recent studies examining such “whole-system, multi-modality” approaches fail to demonstrate convincing evidence of long-term effectiveness or are subject to significant bias.(9) Therefore, even with the increased amount of studies in recent years, naturopathic medicine continues to stand on shaky evidentiary ground.

The Questionable Quality of Naturopathic Education and Training

Naturopathic education and training are wholly inadequate, especially when compared with that of medical doctors (MDs and DOs). Naturopathic programs are accredited by the Council on Naturopathic Medical Education (CNME).(10) The CNME requires programs to have a minimum of 4,100 educational hours, including a minimum of 1,200 hours devoted to clinical training.(11) Naturopathic doctors are not required to undergo post-graduate training, like the residency required of medical school graduates (MDs and DOs).(12) In comparison, the American Academy of Family Physicians estimates that becoming a family physician requires approximately 20,700 to 21,700 hours, including 6,000 clinical hours during medical school and 9,000 to 10,000 hours of post-graduate residency training.(13) Therefore, family physicians receive roughly 15,000 more hours of education and clinical training than a naturopathic doctor by the time they begin independent practice.

 

Furthermore, MD and DO physicians are required to pass three licensing exams, the first two being taken during medical school and the third typically taken in the first post-graduate year of training. The United States Medical Licensing Examination (USMLE), administered to MD students and physicians, is governed by multiple committees made up of qualified medical professionals that ensure the validity of the exam in assessing’s a physician’s ability to practice medicine safely.(14) The Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX), administered to DO students and physicians, is similarly reviewed to ensure quality.(15)

 

There are concerns that the Naturopathic Physicians Licensing Exam (NPLEX), administered by the North American Board of Naturopathic Examiners (NABNE) in two parts, is a poor test of examinees’ clinical competence and ability to safely practice medicine.(16) As has been noted by others, NPLEX has not been investigated by any authority independent of naturopaths to determine its validity or scientific accuracy.(16) Both the Federation of Naturopathic Medicine Regulatory Authorities (FNMRA) and the NABNE websites merely state that exam questions are reviewed by other naturopathic doctors.(17,18) A 2005 report by the Colorado Department of Regularly Agencies concluded that there was “little generalizable evidence that the NPLEX Part II clinical licensing examinations actually measure clinical competence.”(19) While organizations like the FNMRA like to claim that NPLEX is similar to the USMLE and COMLEX,(17) there is simply no evidence that this is the case.

Specific Naturopathic Therapies: Absent Benefits and Potential Harms

Some alternative therapies may benefit patients when used in combination with conventional medical treatments. Furthermore, naturopathic doctors commonly employ nutritional and lifestyle counseling similar to what medical doctors and nutritionists provide.(11) Unfortunately, much of what is unique to naturopathy is ineffective and potentially harmful. During the course of their training, naturopaths are educated and tested on therapies such as homeopathy and botanical supplements.(11,20) Homeopathy refers to the administration of very low concentrations of substances which, when undiluted, would cause symptoms similar to those of the disease to be treated.(21) These substances may be derived from plants, minerals, or animal products. According to the National Center for Complementary and Integrative Health (NCCIH), little evidence exists to support homeopathy as an effective treatment for any specific disease.(21) A 2010 review of systematic reviews in the Cochrane Database of Systematic Reviews (generally considered to be a highly reliable source of evidence) found no convincing evidence in favor of homeopathic treatment compared to placebo for a variety of conditions, including cancer, asthma, and influenza.(22) Additionally, in 2015, the Australian government conducted a comprehensive review on 57 systematic reviews containing 176 individual studies, which concluded that there is no reliable evidence that homeopathy is effective for any health condition.(23)

 

The amount of evidence for botanical medicines, another type of therapy employed by naturopathic doctors, varies widely.(24) Some herbal or botanical supplements may produce benefits, but determining the quality of any individual botanical supplement is difficult. This is because no U.S. law currently requires standardization of botanical supplements to identify and measure specific chemicals or assure consistent amounts of active ingredients.(24) To date, multiple high quality systematic reviews have failed to find sufficient evidence to support the use of botanicals for common conditions such as diabetes,(25,26,27,28,29) high cholesterol,(30) hypertension,(31) and influenza (32). Those studies that do find benefits are often discovered to have design flaws and biases. Furthermore, some botanicals are known to interact with certain medications, leading to an increased risk of adverse reactions.(33) The harms of naturopathic therapies like these are not always direct, however. In some cases, naturopathic treatment leads to indirect harm, as patients delay seeking care from conventional medical professionals.(34) Delayed diagnosis and treatment can cause severe, even life-threatening, harm.(34)

 

Homeopathy and botanical medicine do not constitute a comprehensive list of unproven or disproven naturopathic therapies but serve to illustrate the difference in clinical competency and practices between naturopathic and medical doctors.

Conclusions and Recommendations

 

SB 1366, by expanding the AHCCCS definition of physician to include naturopathic doctors, suggests equivalency between naturopathic and medical doctors. However, there is no such equivalency. Overall, the field of naturopathy lacks scientific evidence supporting its efficacy and safety, and certain naturopathic practices, such as homeopathy, have been widely criticized for demonstrating no proven value. Furthermore, naturopathic doctors do not receive education and training that even approaches that of MDs or DOs in terms of quality, duration, or rigor. Patients, most of whom are laypeople with respect to the medical field, are less likely to be familiar with these points and may not understand the vast distinction between medical doctors and naturopaths, especially if naturopaths are granted the legal title of physician. Therefore, granting naturopathic doctors the legal title of physician under AHCCCS would open the door to patients being misled about unproven naturopathic therapies.

 

To ensure patient safety and promote public health in Arizona, the recommendation of this report was to oppose SB 1366 and future bills like it. If our goal is to address Arizona’s supply of qualified physicians and improve access to primary care, SB 1366 was not the way to accomplish it. As an alternative, AHCCCS coverage can be provided to specific complementary therapies that have been demonstrated through high quality studies to provide benefits that outweigh potential harms. This should not require expanding the definition of physician to include naturopathic doctors. Additionally, policies should be pursued that promote the training and recruitment of medical doctors in Arizona and provide incentives for medical doctors to practice in rural and other underserved areas. Every Arizonan deserves access to quality primary care physicians, and naturopaths should not be allowed to mislead patients by claiming the legal title of physician.

References:

1. Senate Bill 1366: An Act Amending Section 36-2901, Arizona Revised Statutes; Relating to the Arizona Health Care Cost Containment System. Arizona State Senate; 2022.

2. Section 36-2901. Arizona Revised Statutes: https://www.azleg.gov/viewdocument/?docName=https://www.azleg.gov/ars/36/02901.html

3. Section 32-1501. Arizona Revised Statutes. https://www.azleg.gov/viewdocument/?docName=https://www.azleg.gov/ars/32/01501.html

4. Section 32-1522. Arizona Revised Statutes. https://www.azleg.gov/viewdocument/?docName=https://www.azleg.gov/ars/32/01522.html

5. Society for Science-Based Medicine. Report to the Maryland Board of Physicians Naturopathic Advisory Committee: Recommendations for Naturopathic Regulation. October 2014. http://sfsbm.org/index.php?option=com_content&view=article&id=486:naturopathic-board&catid=52:legislative&Itemid=435

6. Ooi SL, Rae J, Pak SC. Implementation of evidence-based practice: A naturopath perspective. Complementary Therapies in Clinical Practice. 2016;22:24-28. doi:10.1016/j.ctcp.2015.11.004

7. Coulter I, Snider P, Neil A. Vitalism-A Worldview Revisited: A Critique of Vitalism and Its Implications For Integrative Medicine. Integrative medicine (Encinitas, Calif). 2019;18(3):60-73. PMID: 32549817. 

8. Jagtenberg T, Evans S, Grant A, Howden I, Lewis M, Singer J. Evidence-Based Medicine and Naturopathy. The Journal of Alternative and Complementary Medicine. 2006;12(3):323-328. doi:10.1089/acm.2006.12.323

9. Myers SP, Vigar V. The State of the Evidence for Whole-System, Multi-Modality Naturopathic Medicine: A Systematic Scoping Review. Journal of alternative and complementary medicine. 2019;25(2):141-168. doi:10.1089/acm.2018.0340

10. U.S. Department of Education. Accreditation in the United States. February 24, 2022. https://www2.ed.gov/admins/finaid/accred/accreditation_pg4.html

11. Council on Naturopathic Medical Education. Handbook of Accreditation for Naturopathic Medicine Programs. 2022. https://cnme.org/wp-content/uploads/2022/03/CNME-Handbook-of-Accreditation-2022.01-edition-final.pdf

12. Association of Accredited Naturopathic Medical Colleges. Post-Graduate Naturopathic Residencies. https://aanmc.org/naturopathic-residencies/

13. American Academy of Family Physicians. Education and Training: Family Physicians versus Naturopaths. https://www.aafp.org/dam/AAFP/documents/advocacy/workforce/gme/ES-FPvsNaturopaths-110810.pdf

14. About the USMLE. USMLE.org. https://www.usmle.org/about-usmle

15. National Board of Osteopathic Medical Examiners. Standards for Quality Assurance. June 22, 2018. https://www.nbome.org/wp-content/uploads/2020/01/Standards-for-Quality-Assurance-2018.pdf

16. Society for Science-Based Medicine. Report to the Maryland Board of Physicians Naturopathic Advisory Committee: Recommendations for Naturopathic Regulation. October 2014. http://sfsbm.org/index.php?option=com_content&view=article&id=486:naturopathic-board&catid=52:legislative&Itemid=435

17. The Federation of Naturopathic Medicine Regulatory Authorities. NPLEX. https://www.fnmra.org/affiliates/nplex

18. North American Board of Naturopathic Examiners. Frequently Asked Questions. https://www.nabne.org/f-a-q/

19. Colorado Department of Regulatory Agencies Office of Policy, Research and Regulatory Reform. Naturopathic Physicians. October 14, 2005. https://centerforinquiry.org/wp-content/uploads/sites/33/quackwatch/naturowatch/licensure/coloradosunrise05.pdf

20. North American Board of Naturopathic Examiners. NPLEX Examination Overview. https://www.nabne.org/exam-overview/

21. National Center for Complementary and Integrative Health. Homeopathy: What You Need to Know. https://www.nccih.nih.gov/health/homeopathy

22. Ernst E. Homeopathy: what does the “best” evidence tell us? Medical Journal of Australia. 2010;192(8):458-460. doi:10.5694/j.1326-5377.2010.tb03585.x

23. National Health and Medical Research Council (Australian Government). NHMRC Information Paper: Evidence on the Effectiveness of Homeopathy for Treating Health Conditions. March 2015. https://www.nccih.nih.gov/health/homeopathy

24. National Institutes of Health Office of Dietary Supplements. Botanical Dietary Supplements - Background Information. December 11, 2020. https://www.ods.od.nih.gov/factsheets/BotanicalBackground-Consumer/

25. Chen W, Zhang Y, Li X, Yang G, Liu JP. Chinese herbal medicine for diabetic peripheral neuropathy. Cochrane Database of Systematic Reviews. 2013;doi:10.1002/14651858.CD007796.pub3

26. Ooi CP, Yassin Z, Hamid T-A. Momordica charantia for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews. 2012;doi:10.1002/14651858.CD007845.pub3

27. Grant SJ, Bensoussan A, Chang D, et al. Chinese herbal medicines for people with impaired glucose tolerance or impaired fasting blood glucose. Cochrane Database of Systematic Reviews. 2009;doi:10.1002/14651858.CD006690.pub2

28. Sridharan K, Mohan R, Ramaratnam S, Panneerselvam D. Ayurvedic treatments for diabetes mellitus. Cochrane Database of Systematic Reviews. 2011;doi:10.1002/14651858.CD008288.pub2

29. Zhang HW, Zhang H, Grant SJ, Wan X, Li G. Single herbal medicine for diabetic retinopathy. Cochrane Database of Systematic Reviews. 2018;doi:10.1002/14651858.CD007939.pub2

30. Liu ZL, Liu JP, Zhang AL, et al. Chinese herbal medicines for hypercholesterolemia. Cochrane Database of Systematic Reviews. 2011;doi:10.1002/14651858.CD008305.pub2

31. Zhang HW, Tong J, Zhou G, Jia H, Jiang JY. Tianma Gouteng Yin Formula for treating primary hypertension. Cochrane Database of Systematic Reviews. 2012;doi:10.1002/14651858.CD008166.pub2

32. Jiang L, Deng L, Wu T. Chinese medicinal herbs for influenza. Cochrane Database of Systematic Reviews. 2013;doi:10.1002/14651858.CD004559.pub4

33. Henderson L, Yue QY, Bergquist C, Gerden B, Arlett P. St John's wort (Hypericum perforatum): drug interactions and clinical outcomes. British journal of clinical pharmacology. 2002;54(4):349-56. doi:10.1046/j.1365-2125.2002.01683.x

34. Wardle JL, Adams J. Indirect and non-health risks associated with complementary and alternative medicine use: An integrative review. European Journal of Integrative Medicine. 2014;6(4):409-422. doi:10.1016/j.eujim.2014.01.001