This is a longer article on issues around naturopathic continuing education in Washington state. The first article is here.
If you’re in a hurry, here’s the bottom line: In a follow up to new rules on continuing education for naturopathic doctors, the Washington state board of naturopathy wrote that at least 1/3 of continuing education courses for NDs should come from CE providers who “ensure substantiation of naturopathic principles” (which they do not define, for the record). In the same letter that contained this statement, the Washington board of naturopathy (BON) noted their concern that “allopathic doctrine” (which the BON doesn’t define, either) is leading to “erosion” of the practice of naturopathic medicine.
This misguided insistence on naturopathic principles displaces continuing medical education based on evidence and scientific research. And it also raises serious questions about the nature of the real-life relationship between the naturopathic establishment and mainstream medical science.
Washington NDs have protested, as I show below.
These are not the CEUs that WA NDs seek
In a recent article I discussed that many Washington state naturopathic doctors (NDs) would like to take all (or almost all) their continuing education (CE or CEU) hours from evidence-based sources used by MDs, DOs, ARNPs and PAs. Instead, the Washington state board of naturopathy now requires Washington NDs to reserve 1/3 of their CE dollars and time for courses that provide “substantiation of naturopathic principles”, provided by a select group of naturopathic organizations. These are called “Category 1” continuing education hours.
As I discussed in that article, the CE offered through these naturopathic-focused organizations or their approved providers did not focus on primary care. The “naturopathic-focused” CE included courses that promoted anti-vaccination viewpoints as well as promoting COVID-19 treatments that likely violate guidelines from the FDA, FTC, CDC, and the WA state Department of health, and overall was not evidence-based. Promoting naturopathic principles should not be used as a cover for providing education that directly contradicts standards of care and public health guidelines.
Washington NDs also noted that CE offered through these organizations was often very “niche”, focusing on extremely specific unconventional therapies that did not apply to the conditions they saw in their practice. Washington NDs deserve continuing education that meets their needs for evidence-based information that speaks to their scope of practice.
Washington state NDs ask for evidence-based CE
Once they found out about the new CE rules, Washington state naturopathic doctors pushed back. One of the most consistent requests has been for Category 1 include CE approved by the Oregon Board of Naturopathic Medicine (OBNM). The OBNM pre-approves CE accredited by the Accreditation Council of Continuing Medical Education (ACCME) – the accreditation body for mainstream conventional medical education. Accepting Oregon CE providers for Category 1 would allow Washington state NDs to count hours for courses through, say, University of Washington towards those required 10 annual hours.
In response the Washington state board of naturopathy looked at the OBNM’s accrediting process. Because Oregon accepts CE approved by the ACCME, the Washington state BON declined to accept Oregon’s naturopathic accreditation on the grounds that:
The board feels strongly that naturopathic accrediting organizations are the best means to ensure substantiation of naturopathic principles in continuing education content. Without such affirmation, the practice of naturopathic medicine is at risk of erosion of the very fundamentals that set it apart from allopathic doctrine.”The Washington State Board of Naturopathy, in a letter dated March 9, 2021 (provided with permission)
Strangely, the Washington board of naturopathy apparently did not look at Oregon’s accreditation process before issuing the new CE rule. Thus it’s not clear why they didn’t accept Oregon’s ND CE approval in the first place.
When the new rules were issued the BON did not discuss why or how they arrived at the rules, or how they selected the continuing education providers that they did. While some hearings were held it’s not clear how many NDs knew of them.
What naturopathic principles are the Washington BON referring to? Chances are good the BON means the “six principles of naturopathic medicine“. Originally defined in 1989 at the Rippling River, OR convention of the American Association of Naturopathic Physicians , these are a set of pleasant-sounding but amorphous assertions such as “first do no harm” and “doctor as teacher” and “treat the cause”.
These naturopathic principles do not include any discussion of evidence, science, or how to determine what is or is not safe and effective patient care. It’s all well and good to proclaim “first do not harm”, but how do you determine what is and is not harmful? How do you determine what is “the cause” of a condition? How do you determine what is accurate information to give the patient?
And as one naturopathic doctor has noted, these six principles were reached mainly because they were the only items the profession could agree upon at that time (or any time, historically speaking). Nor are these concepts unique to naturopathic medicine.
In their discussion of how these principles of naturopathic medicine emerged , Snider and Zeff note that the AANP’s committee’s
first point of unanimous consensus was to define the profession by its principles, not by its modalities.Snider P, Zeff J. Unifying Principles of Naturopathic Medicine Origins and Definitions. Integr Med . 2019;18(4):36-39.
However, the practice of naturopathic medicine in Washington state is not defined by vague “naturopathic principles” but by very specific laws that state what NDs can and cannot do – the “modalities” they may employ, such as botanical medicine and nutrition, or various medications as appropriate.
As such, continuing education for naturopathic doctors, as for all other healthcare professionals, needs to be guided by the evidence on how to safely, effectively care for the patients they see with the tools, methods, and treatments that they are legally allowed to use. With their broad scope that includes primary care and prescribing many of the medications used in managing primary care conditions, Washington state NDs need CE that covers those areas especially.
Saying the quiet parts out loud
As the AANP (American Association of Naturopathic Medicine) states, students at the naturopathic schools are trained “in the same biomedical and diagnostic sciences as MDs and osteopathic doctors (DOs).” And numerous students can attest that we did indeed saturate ourselves in conventional basic and medical sciences. The naturopathic schools have drawn students, and the profession scope expansion and licensure, through promoting the science-based training of its graduates.
In this light, the board of naturopathy’s statement regarding “naturopathic principles” as well as “allopathic doctrine” is more than unsettling. It raises serious questions about how the board sees the relationship between naturopathic medicine and mainstream medicine. Does the latter fundamentally “erode” the former? Is the board of naturopathy stating that the same mainstream medical science that it claims for its credibility, is at odds with its very nature? If so, this may call into question the basis for the very scope and privileges that the profession now enjoys in the state of Washington.
The naturopathic profession very well may need to have a discussion on why so many of its practitioners prefer mainstream medical education once they take on primary care practice. And there does need to be a frank discussion on how much research has or has not substantiated therapies used in naturopathic medicine. But the board cannot skirt these issues by arguing that continuing education for NDs should focus on mantras such as “doctor as teacher” rather than solid evidence and science.
So who are these “naturopathic focused CE providers”?
Washington state naturopathic doctors are now required to take 10 CE hours a year through the following groups. Of note, none of the groups below appear to include any requirement similar to the ACCME’s requirement to “Ensure Content is Valid”. And while one group has relatively rigorous procedures to weed out conflict of interest, one group has no criteria published and a third has criteria that are in the middle.
- The Washington Association of Naturopathic Physicians (WANP at wanp.org). The WANP does not appear to accredit any CE that is not offered directly on its site or through its convention, and its criteria for CE approval are not publicly available. It does accept sponsorship from commercial interests.
- The American Association of Naturopathic Physicians (AANP). Its criteria for CE approval are found here: https://naturopathic.org/page/CEApproval
- The AANP allows commercial sponsorship of CE hours. All CE offered to registered AANP (naturopathic.org) site users show they are “sponsored” by commercial vendors, typically for supplements and unconventional lab tests.
- The AANP in the past has offered CE on such matters as using homeopathy to prevent pandemics; its 2022 convention featured a course on “managing” COVID and Long COVID with homeopathy .
- Like the WANP, the AANP does not appear to accredit any CE other than that offered on its site. Some organizations state they offer CE accredited by the AANP, but as the AANP site does not appear to list any third-party CE vendors, it is impossible to verify this.
- The North American Naturopathic Continuing Education Accreditation Council (NANCEAC) at https://www.fnmra.org/NANCEAC-Continuing-Education was created by the Federation of Naturopathic Medicine Regulatory Authorities (FNMRA) to try to standardize the CE approval process and bring some rigor to it. Its criteria can be found here: NANCEAC-Forms
- While NANCEAC’s efforts are a definite step in the right direction, it does not appear to have any criteria that discuss the scientific evidence base or factual accuracy for the continuing education it approves.
- A list of NANCEAC continuing education providers shows that at least three providers are focused on homeopathy. These three all have various personnel in common, oppose vaccination, and promote homeopathy and the long-debunked theory of vitalism.
- It appears that if NANCEAC accredits a provider, it does not review content of the courses offered.
- Very recently NANCEAC added a CE provider focused on ND primary care, as well as the Canadian College of Naturopathic Medicine.
Again, none of the above require CE providers to “Ensure Content is Valid”, which the ACCME does. These naturopathic accreditors do not make sure the content supports “safe, effective patient care”. They do not ensure that content is “based on current science, evidence, and clinical reasoning,” and that “All scientific research referred to, reported, or used in accredited education in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.”
Other groups authorized to provide CE are the accredited schools (e.g. Bastyr University, National University of Natural Medicine, etc.). However, these tend to provide relatively few CE compared to the other three. I have not looked at their criteria for approving CE.
Substantiate naturopathic principles? or protect public health and safety?
The mandate of the Board of Naturopathy is to protect the public’s health and safety and to promote the welfare of the state by regulating the competency and quality of naturopathic physicians.From the site of the Washington Board of Naturopathy at https://doh.wa.gov/licenses-permits-and-certificates/professions-new-renew-or-update/naturopathic-physician/board-naturopathy accessed 8/10/2022.
If the Washington state board of naturopathy wants a principle to adhere to, it should be the principle that the board needs to honor their mandate to protect public health and safety. Promoting continuing education that is not evaluated according to effective criteria for weeding out unsafe and ineffective treatments will not honor that mandate. What will honor the board’s mandate is education that lets Washington state naturopathic doctors fulfill their obligation to practice safely and effectively, in the service of the public health.
 Snider P, Zeff JL. Definition of naturopathic medicine. American Association of Naturopathic Medicine Position Paper Select Committee on the Definition of Naturopathic Medicine AANP House of Delegates, Rippling River, Oregon. Published online 1989. Accessed 8/21/2022 at https://cdn.ymaws.com/naturopathic.org/resource/resmgr/documents/governance_docs/definition_naturopathic_medi.pdf
 Snider P, Zeff J. Unifying Principles of Naturopathic Medicine Origins and Definitions. Integr Med . 2019;18(4):36-39. https://www.ncbi.nlm.nih.gov/pubmed/32549831