Naturopathic Medicine and Scope of Practice

ND Regulation Aug 01, 2020

I apologize for the prolonged absence. Like the vast majority of the world, the last few months pulled me away from what I had planned for 2020.

I'm returning to writing about what you need to know before enrolling in naturopathic medical school. For now,  I am focusing on practical issues that have the biggest impact on practice. I'm starting with the scope of practice. In my experience, one of the biggest sources of later disillusionment with naturopathic medical practice stems from the gap between the marketing of naturopathic medicine and the reality of what naturopathic doctors can and cannot do in practice across the US and Canada. While the COVID-19 pandemic has upended naturopathic practice along with the rest of healthcare, forcing colleagues to practice online in the main, as far as I know scope of practice has not seen any changes due to the pandemic. (And as far as I know, NDs have not been asked to step in for conventional medical providers in any capacity, though I do know of some who are volunteering with their local public health departments.)

Abbreviations: ND = naturopathic doctor; MD = medical doctor; DO = osteopathic doctor; ARNP = advanced registered nurse practitioner; PA = physician assistant; PCP = primary care provider. "Major national naturopathic organizations" refer to the American Association of Naturopathic Physicians (AANP), Canadian Association of Naturopathic Doctors (CAND), and the American Association of Naturopathic Medical Colleges (AANMC). US = United States, CA = Canada. Canadians have provinces rather than states, ministries rather than departmentments, and professional colleges rather than state boards of naturopathic medicine. I am more familiar with US laws that I am Canadian, but have tried to address both situations.

What is Scope of Practice?

"Scope of practice" refers both to what a healthcare provider is trained to do competently, and what they are legally allowed to do by their state or provincial regulations. It includes:

  • What categories of conditions a provider may diagnose, treat and manage, and how they can do so. Washington state NDs, for instance, cannot provide prenatal care unless they are also trained and licensed as midwives.
  • What tests a provider may order, or interpret; what medications they can prescribe (if any); what procedures they can carry out, such as suturing lacerations, implanting IUDs, or removing suspicious moles.
  • Who a provider can see (Colorado limits the ability of NDs to provide care for children under two, for instance);
  • Scope of practice is typically set by state/provincial laws, with state professional boards  (provincial professional colleges for Canadians) and the departments/ministries of health involved to varying degrees in determining how it is actually implemented.
  • Depending on the state, changing scope will usually involve getting legislation through the state legislature, and possibly additional rule-making by the state department of health and professional board. This can take years, so be aware that the current scope of practice in a particular jurisdiction  is very likely to be the scope of practice you will have when you graduate.

Scope of Practice Affects How You Practice

Scope of practice -  both the training aspect, and the legal aspect - is an under-appreciated but key factor in how well you can carry out your dream of serving others as a naturopathic doctor. It is also a complex subject. MDs and DOs have the fullest scope of practice, with other healthcare professions having a subset of those privileges: With MDs and DOs, it's usually a case of "allowed to do anything related to medicine unless explicitly forbidden". For other healthcare professions, it's more like "forbidden to do anything except what is explicitly allowed".

The arguments about what non-MD and non-DO professions should be allowed to do are fairly fierce (bring popcorn), and involve the scopes of many healthcare professionals, from nurse practitioners to psychologists to pharmacists. Yes, the debate has roots in medical politics. But it's also rooted in a valid and ongoing debate about how much training, and what kind of training, is needed for competence in various aspects of healthcare. All parties agree that a healthy awareness and respect for the limitations and strengths of one's training, and legal scope that reflects that training, are crucial to the practice of all healthcare professions.

It's critical to have an accurate idea of a profession's scope of practice before signing up for it. Unlike MDs and DOs, other healthcare professions' scope of practices vary from jurisdiction to jurisdiction, and naturopathic doctors' scope of practice is no exception. In my experience,  while the national naturopathic associations acknowledge that scope of practice limitations exist, they skirt discussing the details. Even in states where NDs take insurance, or participate in Medicaid, or can prescribe (nearly) any medication legal in the US, there are still significant differences between their scope of practice and that of MDs and DOs. I'm not disputing that there shouldn't be a difference. I'm here to point out that potential students need to be fully aware of that difference, and what it means for their professional career.

This last bit is critical. Scope of practice limitations - both training-related and legally-related - have a domino effect on many other aspects of both naturopathic training and practice. If you can't (for instance) lance a nailfold infection (paronychia), you won't learn how to do it. And when a patient comes in with one, you will need to send them to urgent care to have it seen. Meanwhile, if an urgent care clinic has a position open - where they see paronychias - they are less likely to hire you, because you can't take care of that condition.

Scope of practice limitations play a part in regulations that determine who can fill out various forms for disability evaluations, permits for handicapped parking, and so forth. These effects of scope limitation (together with insurance and payer coverage that varies from mostly decent to inconsistent to non-existent) are a huge part of why the employment market for naturopathic doctors is nothing like what it is for MDs, DOs, PAs, or ARNPs. This in turn is why, per the AANMC's latest report, the majority of NDs in Canada and the US are in private or group practice settings and have some form of ownership in the business. As most  'group practices' consist of people who rent rooms together in a building, while remaining independent practitioners, what this means is the majority of NDs are self-employed.

How To Evaluate Scope of Practice in a Jurisdiction

If you are considering becoming a naturopathic doctor, think about what you would like to do in your practice, and where you see yourself practicing. If you don't know what is involved in primary care practice, shadow someone who provides it. If both NDs and MDs/DOs/ARNPs/PAs are available in your area, shadow them all. Even if you are going to set up a boutique practice catering to a niche demographic, start by learning about primary care.  Patients will show up with all sorts of conditions at your office, and primary care is a field worthy of immense respect. And whether you agree with how conventional primary care is conducted or not, it's the standard to which you will be compared, and you should know about it.

Next, look up the regulations and scope of practice for naturopathic doctors in the state or province where you are considering practicing if you were to become an ND.  And check the scope of practice for NDs in the state or province where you are considering attending naturopathic medical school; that scope will limit what you can be trained in. How do you find out the scope of practice, though? It's not as easy as just searching the internet; information is scattered across various state and provincial sites, buried in laws and regulations.

While they do mention scope, neither the AANP nor the AANMC appear to have readily-accessible links to state regulations that I have found. The AANP does link to state professional licensing boards, but from there you have to hunt for the information on scope.  The CAND has a page discussing the overall regulation of NDs in Canada. The only all-in-one table for naturopathic regulations from a major naturopathic organization I have found is at the Federation of Naturopathic Medicine Regulatory Authorities (FNRMA). This table provides links to the texts of the legal statutes governing naturopathy in each jurisdiction in the United States and Canada.

Be aware that in many (most) states, the laws may not fully describe scope of practice, as much is determined through rule making at the department of health and the state naturopathic boards. You will therefore need to also contact the state/provincial department of health and the naturopathic licensing board to get a fuller picture.  And also be prepared to find out that even long-standing licensed states have never fully clarified the scope of practice for naturopathic doctors in some areas that are common in general and primary care practices.

You can also look at state naturopathic association sites and see what new legislation they are proposing. Chances are good they will be doing so, and usually the proposed legislation involves adding practice privileges. Which ones are they looking to add? Why are they looking to add those privileges?  You'll notice, by the way, that many proposed scope expansions include obtaining or expanding prescribing rights. Again, ask why.

Typical scope of practice issues to clarify ahead of time:

Prescribing rights - the term is used not only for pharmaceuticals, but also for over-the-counter supplements. What are you allowed to recommend/prescribe? How can you administer it? Even if you are not looking to prescribe medications you need to know what non-pharmaceutical substances you can legally recommend. Some states/jurisdictions have very detailed lists of what you can recommend or prescribe; if it is not on that list, you can't write for it, and that includes natural substances. Others have general categories that you are allowed to write for.

This may seem odd, given that untrained health-food store personnel  enthusiastically recommend various pills, powders and liquids for whatever ails you. Regardless, healthcare providers fall under different rules. Once you are a naturopathic medical student, let alone a licensed ND, it's giving medical advice if you tell someone to even drink a cup of peppermint tea for any health-related reason whatsoever.

Ask about a naturopathic doctor's ability to order tests and imaging, and any restrictions on those. Are there any procedures that are not allowed, such as ones typically performed in most general practices, including caring for minor injuries.  Can you order typical tests and imaging used for preventive and general care, such as mammograms, pap smears, standard imaging, and basic blood work? If you have a patient that needs a restricted procedure, test, or medication, how will you ensure they can obtain the care they need? As noted above, these can be crucial for good patient care.

Are there any restrictions in who you can see, what you can discuss, areas you can address?  Ontario, CA NDs cannot discuss vaccinations; Washington state NDs cannot manage cancer unless the patient has a conventional oncologist managing their care. (To be clear, patients absolutely should have a conventional oncologist on board when cancer is involved.) Any restrictions on how you can represent yourself? Any language you must avoid?  Canadian practitioners, especially, face additional restrictions in marketing.

Will you need a practice supervision agreement with an MD or a DO for various privileges (such as in California, for prescribing rights)? Are there any extra exams required to engage in various procedures or services (e.g. prescribing, minor surgery?) While you are at it, find out what the continuing education requirements are, the fees for license issuance and renewal, and any other regulations that it would be good to know about ahead of time.

Just to reiterate: all providers have scope limitations. Cardiologists do not (usually) run obstetrical specialty tests, for example. Ophthalmologists are not typically found managing ventilators in the ICU.  Family medical docs routinely refer out for specialty care but routinely keep the balls in the air with patients with multiple complex comorbidities. (Say that five times real fast.) There are many medications, tests, imaging and procedures that should be ordered and evaluated only by specialists trained in their use, even if it is legal for you to order them.  What you are trying to find out here is if the legal scope will allow you to use the garden-variety, common general-practice testing, imaging or treatments that are consistent with naturopathic medical training -  the "what you are trained for" scope.

Unlicensed states

If you are not licensed or registered to practice in a particular state,  then technically you have no scope of practice in that state. Somewhat more than technically, you are not allowed to practice medicine without a license, and just what that means varies from state to state. Some states do not seem to bother going after unlicensed complementary and alternative medicine providers, as long as no one dies and you're not engaging in prescribing medications or performing surgery or invasive procedures or exams. In other jurisdictions you may easily end up on the wrong side of a charge of practicing medicine without a license.

I practiced in a licensed state. I know colleagues who do practice in unlicensed states ethically, staying within legal bounds and providing good care for those who see them.  Nevertheless I myself think that it requires an enormous balancing act to honor the limitations while still providing good patient care. It can be difficult to stay within those boundaries. Some unlicensed states will not allow you to perform exams - even listening to lungs. You will not be able to order any testing, diagnose an illness, or recommend and carry out treatment. Drawing blood, or ordering labs that require blood draws, may not be allowed. (I suspect this is why so many alternative medical tests involve either saliva or urine, which can usually be obtained without running afoul of state laws.) NDs in unlicensed states appear to focus on nutritional advice and lifestyle coaching, plus perhaps homeopathy and botanical remedies, and what others call "nature cure".  Some find this satisfactory, others find it limiting.

Here is a rule of thumb I would use when considering practicing in unlicensed states: imagine that you have a client whose condition has worsened and you tell them to go to the ER. You send your notes and call ahead to let the ER know. Are you concerned that you will be charged with practicing without a license? Will your notes show that you were in effect diagnosing, treating, or managing a condition? If the answer is yes, then it may be best to avoid practicing in that state.

For this reason, many NDs practice under a license for a second healthcare profession, such as acupuncture. Still others practice in the same office under the supervision of a licensed conventional provider, who provides any care that the ND cannot, but I don't know how common this is. (This is different from practice agreements in licensed states, which don't necessarily require the supervising provider to be on-premises.)

Another issue NDs face in unlicensed states is that the same states that tolerate naturopathic doctors practicing without a license, are also open to traditional naturopaths and various other alternative healers practicing without a license as well. Your quarter-of-a-million education will be lumped in with someone else's two-semester online certificate, and you will be considered to be on approximately the same level. It becomes much harder to be taken seriously. This can compromise your ability to obtain timely and appropriate care for your patient if they need a referral, to go to urgent care, or simply for you to reach back out to their regular provider and discuss some findings or observations.

Finally, be aware that having a license in one jurisdiction does not give you practice privileges outside of that jurisdiction. This is true for all medical professionals in the US - no matter how many states you are licensed in, you can't practice in any other state until you obtain a license.  Conventional medical professionals are careful to obtain licensure before they put their stethoscope on in a new place. Because of this, the overall public may regard your setting up shop without a license as questionable, even if you otherwise obey all state laws in what you do.

Summary: Scope Out the Scope before You Sign Up

The take home here is that you must be aware of how scope of practice regulations  will support - or restrict - your career as a naturopathic doctor. Don't settle for vague descriptions, get specifics. If you are told that "we are working on increasing scope of practice and have a bill out before the legislature”, realize that many state associations have a yearly or bi-yearly ritual of putting a bill before the legislature. Ask for a timeline of all the bills introduced regarding naturopathy in that state, along with their outcomes.  All the bills - not just the ones that were approved. You will see that it can often take years of trying to obtain first licensure and then to obtain scope expansions. You should not plan on scope being expanded by the time you graduate. Instead, work out how you would practice with any limitations in place now. And make sure that the vision you have for your future matches up to what is actually available.

Regulated States and Regulatory Authorities, https://naturopathic.org/page/RegulatedStates#

Naturopathic Regulatory Authority General Information Link https://www.fnmra.org/ras

Les Witherspoon

Formerly practicing naturopathic doctor. Views are my own and do not speak for any employers or clients, nor for the profession at large.

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