Monday, March 16, 2015

Naturopathic Doctors vs. MDs

When I moved to New Hampshire 11 years ago, I was in for a bit of a medical culture shock. One of the biggest surprises was my first realization that there are "Doctors of Naturopathy," or "NDs" in New Hampshire who are licensed to practice medicine.  In New York, I had had no experience with this.  This is not to say that people there didn't see people who practiced "alternative medicine."  What I'm talking about are practitioners who had attended a school of naturopathy and held themselves out to be primary care physicians with equivalent education and training to mine.


My first encounter with this was a patient who came to me because she had been diagnosed by her ND with "heavy metal poisoning."  She actually was my partner's patient, but had been squeezed onto my schedule as an emergency appointment because she wanted to be admitted to the hospital immediately to begin treatment.  My curiosity was piqued when I saw the chief complaint on my schedule.  How does an adult in Portsmouth, NH end up with heavy metal poisoning?  Had she had some kind of toxic exposure at work?  What kind of neurological problems was she manifesting?  Imagine my surprise when I walked into the room and saw a well-dressed, healthy looking woman in her late 40s.  She told me that she had seen a local ND for fatigue and difficulty losing weight (her weight was perfectly normal, by the way).  The ND had tested her for heavy metal poisoning.  She told me she was given some sort of pill, and then had her urine tested for heavy metals.  She handed me a lab report that looked something like this:


I'd never seen anything like this.  I asked her about her history and possible exposures...there was nothing significant.  I asked her very specific questions about neurological symptoms- there were none.  I performed a neurological exam, and it was normal.  I did a quick test of cognitive status, and it was normal.  I then excused myself from the room and went to my office to make a quick call to a doctor I knew who specialized in occupational medicine and toxic exposures.  He gave a sigh after I outlined the case, saying "I'm seeing more and more of this crap.  The test is worthless.  The pill was a chelating agent (a medication that binds to metals in the body).  This makes them pee out metals, but the reference ranges for the results are based on what you should pee out when not given a chelator.  It's a way to make patients think there's a problem and then they can be convinced to do all sorts of useless, expensive therapies to cure their 'toxicity.'"  I thanked him and hung up.  I went back to the patient and explained, trying to be diplomatic, what I had found out.  She didn't exactly believe me.  I offered to repeat the testing, by checking both her blood and urine for any heavy metal issues.  She accepted.  The tests were normal.  I called her and gave her the results.

I never heard from her again.  She transferred out of the practice.

That was my first experience.  I've had many others through the years...and most of them have been similar. In my experience, most patients that see NDs around here end up being diagnosed with one of several diagnoses- heavy metal toxicity, chronic Lyme disease, adrenal fatigue, or systemic candidiasis.  I'm not going to go into each of these issues, save to say that all of those diagnoses are controversial, so say the least.  Perhaps in another post.

I was also quite surprised that in addition to NDs being licensed to practice medicine in the state of New Hampshire, they are able to prescribe pretty much anything I can.  Here's a link to their formulary.  Then, I found out that licensed naturopaths are considered primary care doctors here.  Just like me.  So, silly me, I figured that their education and licensing process must be just like mine, right?  Well, here's a link to the requirements to get a naturopathic license in NH.  Here's a link to what's required to get a license to practice medicine in NH.  Keep in mind, in order to get a medical license in NH, you also have to submit an application to the Federal Credentialing Verification Service (FCVS).  Here's a link to the FCVS requirements.

Equivalent?  You be the judge.

Clearly the licensing requirements for MDs are much more stringent than for NDs.  But what about the education?  NDs claim that their education is actually more complete than traditional medical school, with more classroom hours.  Since I've only gone to medical school and not naturopathic school, I've had to take their word for it.

Until now.

There's a new blogger in town, and her name is Britt Hermes.  She attended Bastyr University, which is really the premier naturopathic school in the US.  She then practiced as a naturopath, and gradually became disillusioned with naturopathy and the practice thereof.  She's blogging about her experiences  and her move away from naturopathy, and in doing so has truly exposed the deficiencies in the education given at Bastyr.

Head on over to ScienceBasedMedicine for the full post.  It's long, but definitely worth your time to read.  Some highlights:
I recently scrutinized my transcript, course syllabi, and student clinician handbook. (Here is a table detailing my coursework into more readable categories based on my transcript; credits were translated to hours based on all of my courses syllabi.) I graduated with 1,224.5 hours of clinical training, of which 1,100 hours were in what Bastyr considers “direct patient contact.”.....
More on what Bastyr considers "direct patient contact"...
On a clinic shift, one faculty member (a licensed naturopath) supervised several naturopathic students. ...Each clinic shift had a specific structure that included three elements: shift preview, patient appointments, and shift review.
Shift preview and review took place in the first 30 minutes and final 30 minutes of shift. During these periods, primary students roundtabled their patients. The patient’s medical history, previous visits to the clinic, and previous naturopathic assessments were discussed. Patient cases were presented in a standardized S.O.A.P. (subjective, objective, assessment, and plan) format. The supervisor usually asked students about differential diagnoses and treatment protocols. Medical standards of care were almost never discussed on my clinic shifts, with notable exceptions for one or two of my supervisors who insisted on it, to the dismay of many students. I often heard statements such as, “the patient has a strong vital force and it is expected that the patient will heal in 3 to 4 weeks’ time with proper self-care and home hydrotherapy treatments.” Sometimes, the preview and review was attended by first-year students completing their Clinic Entry 1 requirements. These students generally did not contribute to the discussions but their time was considered “direct patient contact.”
Actual patient care accounted for three hours of a clinic shift.
Patient care visits were typically attended by two students, a secondary and a primary. Appointments lasted anywhere from one to two hours. During an appointment, the primary student charted the patient’s current medical complaint and relevant history. This charting included a typical medical intake, such as the seven attributes of the medical complaint, a review of systems, past medical history, medications and supplements taken, family history, social history, dietary patterns, and so on. Vital signs, like blood pressure and temperature, were usually taken by a student. The patient intake also included information thought relevant to naturopathic diagnoses, like toxin and heavy metal exposure, use of plasticware in cooking and eating, birth history, pesticide exposure through eating non-organic foods, food intolerances, religious affiliations, and a host of subjective assessments relevant for energy therapies (homeopathy, flower essences, UNDA numbers, etc.).
Let me tell you about direct patient care in medical school.  Let's take my internal medicine third-year clerkship.  It was 12 weeks long.  The first 6 weeks were all on the inpatient side.  We were part of a medical team on the wards, consisting of an attending physician, a resident, an intern (first-year resident) and the medical student.  We would typically arrive around 5 AM to start pre-rounds on our patients, and there were usually between 15 and 20 patients to a team.  Pre-rounding is where you check up on how your patient did overnight, examine them, check labs, etc.  After pre-rounding is morning report, which would be a didactic presentation of an interesting case.  Then comes formal ward rounds.  This is where the team rounds with the attending.  Presentations of the patient are made at the bedside.  A care plan is made for the day.  Interesting physical exam findings are shared among the team.  This usually takes at least 2 or 3 hours.  Then it's time for "lunch."  Lunch is always eaten in the lecture hall, because there's a didactic lecture during lunch.  After lunch, it's time to start doing any new admissions that have come in during the day so far. If you're the lucky team on call, this will last until 11 PM.  If it's just a normal day, it'll last until about 6PM.  At 6 PM, you do a final quick round on your patients, make sure they're figuratively tucked in for the evening, and then sign out their care to the night float team who will cover them until you come in at 5AM the next morning.

And you do this six days a week.  One day off for good behavior.

The next six weeks are luxurious in comparison, because they're outpatient.  You work alongside a primary care physician in his or her office.  So, it's much better hours.  We'd start around 7AM with hospital rounds on their patients, then see patients in the office until 5 PM, and then go back to the hospital to check on any inpatients or do any admissions.  But we got both Saturday and Sunday off!

By the way...the internal medicine rotation is considered to be one of the "easy" rotations, schedule-wise.  During my surgery and OB/GYN rotations, for example, there were days where I didn't even bother going home for 2 or 3 days at a time, because it just wasn't worth it.

And check this out:
Our student clinician handbook contained a list of broad medical categories such as cardiovascular disease, hepatobiliary disease, and female gynecological disorders, for which students were required to demonstrate medical competency. Medical competency in these areas was based on the number of appointments a student clinician had with a patient with that category of disease. The number of appointments varied. For example, competency for cardiovascular disease required treating two patients with any type of heart/circulatory disease. Competency for hepatobiliary disease required treating just one patient with any liver or gallbladder disease. Any patient needed to be seen twice to achieve competency.
While students were required to see a variety of primary care conditions in order to graduate, the majority of students never had the opportunity to see an actual patient suffering from such conditions.
Some diseases were very common in the teaching clinic. To the best of my memory, these included irritable bowel syndrome, anxiety, food allergies, fibromyalgiachronic fatigue, adrenal fatigue, chronic Lyme disease, chronic mononucleosis, chronic back pain, and esophageal reflux.
Less common diseases included hypertension, asthma, hypercholesterolemia, anovulation and menstrual problems, and acute illnesses such as the flu, pneumonia, bronchitis, gastroenteritis, and conjunctivitis. Students used to fight over seeing acutely ill patients as these patients were so rare!
Patients suffering from serious diseases, such as diabetes, cancer, and HIV/AIDS, could only be seen on specific clinic rotations. If students were unable to have direct contact with a mandatory health condition required for competency (due to a lack of patients and a lack of variety of disease in the clinic overall), students could present to fellow students on their clinic shift on the disease/condition to earn competency. A presentation usually lasted about 10 minutes and would cover the basic etiology, differential diagnosis, and naturopathic and/or medical treatments of a condition.

They were considered to be competent in treating all cardiovascular diseases by seeing two patients with any type of cardiovascular disease?  This is incredible.  Also, please take note of what Britt says about the dearth of patients with serious disease.  This is incredibly important to note.  You can't be a good primary care doctor unless you've seen a lot of serious disease.  Here's the thing.  Any idiot can diagnose and treat 90% of what we see on a daily basis in a primary care office.  The problem is with the other 10%.  Those are the patients with strange presentations of either common or rare illnesses.  You need to have seen a ton of stuff to be able to accurately diagnose a patient who is presenting in this way.

Now, I posted above about patient contact during my third year medicine rotation.  In the fourth year, I did a medicine sub-internship.  This is basically where as a fourth-year student, you pretty much function as an intern.  So it was more of the crazy rounding schedule above, plus some.

Once I graduated, the training wasn't finished.  Internal medicine is a 3 year residency.  You're not supposed to work more than 80 hours a week (what a luxury!) but in truth, we often did.  By my calculations, going off of 80 hour weeks, I had more than 11,000 hours of patient care in my 3 years of residency.

Naturopaths don't do a residency.

Tell me again how they're qualified to call themselves primary care physicians?

Do you want to see the doctor who is considered competent to treat all cardiovascular disease after seeing two patients with hypertension?  Or do you want the doctor who has completed over 12,000 hours of training in internal medicine alone, not to mention several thousand hours of surgery, OB/GYN, psychiatry, pediatrics, family medicine, and neurology?

Your choice.  Your decision.  After all, it's your life.  Literally.