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

Main Points​

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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.

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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.

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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.