The Promise and the Problem

ND Education Jan 13, 2020

I became a naturopathic doctor (ND) because I wanted to serve people through helping them improve their health. I chose a profession that promised that it would train me in “the art and science of both natural and conventional medicine” and give me the education needed to become a primary care provider. I chose it specifically because it promised to combine conventional medicine with natural medicine, and to set the latter upon a scientific foundation.

And I did fulfill a good portion of my aim, going on to set up my own practice, focused on serving those who were underserved, especially the LGBTQ community. I took insurance & Medicaid, wrestled with EHRs and meaningful use, answered calls on weekends and at night, and enjoyed working with patients. I enjoyed the year that I spent supervising student naturopathic clinicians at Bastyr teaching clinic. While I am no longer in practice, I am still passionate about medicine, about primary care, about public health – especially the health of the LGBTQ community and other marginalized groups.

Illusory promises

Unfortunately, the promise that brought many of us into naturopathic medicine – Be the doctor you want to have! Help people heal naturally! Become a first-contact primary care provider! – proved illusory, for many (if not most) of us. Training, philosophy, treatments, financial outcomes, and integration into the healthcare community: all of these diverged, minimally at first and more significantly later, from the pictures presented at the interviews and by the school websites and brochures. The treatments that we had to offer patients, as well, were increasingly chipped away at by study after study questioning both their effectiveness and in many cases, the grounds for thinking they were effective at all. This applied not only to homeopathy (which I admit struck me early on as bad Victorian pop psychology dressed up as a placebo), but to numerous other therapies, including many herbal medicines and the uses of many vitamins and supplements. Some have proven effective, and are worth using. Others are being quietly relegated to the clearance sale bin of fads past their sell-by date.

At the time that I entered naturopathic school (mid-2000s), there wasn’t a lot of readily accessible information about the naturopathic profession. While there is now more accurate info on naturopathy online, it’s still difficult to find information about many areas of the profession. Surveys are sporadically performed. But they tend to have ambiguous questions and vague answers. Or they get buried. How many naturopathic doctors practice homeopathy? What are attitudes towards vaccination? How many NDs are still in practice five years after graduation? What, exactly, is naturopathy about? No one even seems to have a clear picture on how many NDs are in practice across the US and Canada. And even in the face of increasingly negative press, the naturopathic institutions keeps silent about issues affecting the profession.

Why speak out?

When I started supervising student clinicians at Bastyr at the beginning of 2018, I didn’t have answers to these questions, and others. I still don’t have the answers. But since summer 2018 I have learned enough to suspect that the answers are not going to be forthcoming, at least not from the schools and official naturopathic organizations. There is a culture of silence in naturopathy, regarding discussing the realities of the profession both with the outside world, and its members. And that is concerning. That silence is concerning for those who seek naturopathic medical services. It is concerning for those who are in the profession or considering it. And it is concerning for those in the larger healthcare community and the community at large.

Naturopathy has increasingly been able to forge better relations with the conventional medical community. Those bonds can be, and are, endangered by the refusal to clearly address the problems in the profession.

So, in my opinion, I have an obligation to discuss what I know about the realities of naturopathic training and practice. Yes, I know other naturopaths, both still-practicing and no-longer-practicing, have blazed the way here. I owe them a debt. But I’m sure another voice won’t hurt.

Speaking out to effect change

I will inevitably be asked why am I writing this. Am I trying to “get back” at Bastyr, or take down the profession?

No.

I bear no ill-will towards Bastyr University, either as a student or employee. As a student, my instructors, clinical supervisors, and mentors put in a lot of work to help me learn what they knew about practicing naturopathic medicine. (This holds true despite my notes about a lack of clear treatment protocols in many classes.) As a clinical supervisor at the teaching clinic, I felt I was treated well, even though I held views that were at odds with many in the profession. The students I taught were eager to learn, well-prepared, and discussed the areas where they disagreed thoughtfully. I left, as far as I know, on good terms with the administration there.

My concerns about the profession don’t cancel out the positive experiences I had with Bastyr, or with many of my colleagues. However, the positive factors don’t negate my concerns about the naturopathic profession. They also don’t negate the concerns I have about what is not discussed in naturopathic medical education, or in the profession at large, whatever the reasons for that silence.

I have spent time thinking before writing this. I have also sought counsel from others as well. However, I and I alone am responsible for the contents of this blog. My intent is to bring about needed change. You cannot change what you do not name.

I am doing this for the students I taught. To work with them was a joy. I worry about their future in this profession. They were sold a vision of themselves as respected healthcare providers in a scientifically-based profession. And I am doing this for the patients I saw. Patients looked to naturopathic medicine for answers, both on how to treat their conditions, and the larger questions about why they were ill. To deliver on its promise to practitioners and patients that it “combines the wisdom of nature with the rigors of modern science”, naturopathy needs to evaluate itself with scientific rigor, using scientific criteria.

It’s not that there aren’t good things about being an ND – there are. I cherished my time in practice. I enjoyed teaching. I will always be enormously grateful for having had the privilege to serve those who entrusted me with the care of their health. I am indebted to my ND colleagues who serve their patients professionally, with regards for the science and with respect for the scope of ND training and practice. And I owe a significant debt to those in the greater medical community – MD, DO, ARNP, PA, RNs, MAs – who helped guide me in through the complex maze of medicine and today’s healthcare.

The problem of the “gotchas”

Naturopathic medicine suffers from what I call “Yes, but….” syndrome. Yes, there are good things about becoming and being an ND. But…. those “buts” contain major “gotchas”.

Gotchas about how the training actually compares to MDs, and what it does and does not prepare graduates to do. Gotchas I have spent time thinking before writing this. I have also sought counsel from others as well. However, I and I alone am responsible for the contents of this blog. My intent is to bring about needed change. You cannot change what you do not name.about the science-to-not-science ratio in the curriculum and what what science says in actuality about naturopathic therapies. Gotchas about the legal standing and overall place of NDs in the healthcare system and society at large. Gotchas about how too many NDs practice in ways that negatively affect the profession as a whole. Gotchas about the realities of practice and the chances of using the degree for longer than a few years. Below are some of these gotchas, and how they affect both practitioners and patients. The patients are the reason for the practitioners… but the effects on the practitioners ripple downstream.

Students and practitioners

For students, these gotchas result in an estimated half of graduates abandoning practice a few years after graduation. Long term, only about 20% of NDs appear to stay in practice [1]. Survivors often turn to risky therapies such as IV therapy or “cannabis-based medicine” to try to keep the lights on, or end up working another job and practicing part-time.

There are wide variations in how NDs practice and the views they hold about illness, science and medicine, depending upon when, where and how they were trained. Thus the quality of graduates varies enough that it can be difficult to give a blanket assessment of how ND as a profession practice and perform. Varying state scopes of practice and participation in the larger healthcare system affect what different NDs can do as well. Some depend upon homeopathy and herbs, while others can use conventional treatments. Unfortunately, the more reckless and more controversial members of the profession tend to get much of the notoriety. Thus ND graduates often find they are regarded dubiously by much of conventional healthcare, regardless of how they personally practice.

One issue not often discussed is that NDs are a “pack of lone wolves”, more competitive than cooperative. Therapies don’t get researched and published, they get packaged into webinars and sold. And the therapies themselves vary widely in how much evidence supports their use. Some are frankly implausible, others are based upon isolated studies strung together by speculation. Together with the other factors, the result is little or no professional cohesion, except perhaps in the reluctance to set standards or discourage a particular practice. One consequence of this is a lack of reproducible therapeutic protocols that can be taught to students and shared with others in the profession. Every ND has their own approach, and students are generally expected to assemble their own therapeutic protocols as well, with inspiration from case studies and “clinical pearls”. Needless to say, this takes time, energy, and perhaps a sizable over-estimation of one’s competence.

Patients and the public

For patients and society at large, these gotchas may be less obvious, but can still impact individuals and the public severely. And patients are the whole reason for the naturopathic profession to exist in the first place. Nothing that can happen to us as healthcare providers outweighs the harm that can come to our patients.

Missed diagnoses or replacing effective treatment with ineffective treatment are obvious concerns, though I believe that better training has reduced their incidence. In general, the NDs I know from the schools in the western US rely upon conventional medical guidelines and procedures for both diagnosis and deciding when to start conventional treatment. Vaccine-hesitancy as well as vaccine-hostility is still a definite issue in the profession and has serious implications for public health. A vaccine-hesitant MD is seen as an outlier; a vaccine-hesitant ND is unfortunately still typical of the profession.

Many therapies used are reasonably harmless, and NDs are well-trained in the safe use of botanical medicines and nutritional supplements. However, the use of invasive therapies and procedures such as intravenous treatments and injection therapies (e.g. prolotherapy) is growing and is a significant concern. And even if it does not directly harm, and does not replace or interfere with effective therapies, an ineffective therapy has costs in time, money and effort.

The lack of professional cohesion in the naturopathic profession has several consequences for patients. Naturopathic doctors who cause harm are rarely disciplined [2], leaving them to proceed unchecked. An inability to reach consensus among NDs leads to a lack of standards of care; a reluctance to share knowledge makes it difficult to research therapies to see if they are effective. The end result is a lot of unproven therapies, often built upon so-and-so’s experience and someone else’s speculations. All of these impact patients, and the public, directly and indirectly.

Good medicine can and does result when NDs practice in cooperation with conventional medicine, focusing on approaches that work together with modern scientific treatments. But when naturopathic medicine is presented as an alternative, when it calls into question the basis of modern medicine, harm results. Many patients come to NDs with a pre-existing distrust of conventional medicine. NDs can and do help build bridges in these circumstances that allow patients to move forward with needed tests, medications, surgeries, therapies. But attitudes and comments that deride conventional medicine as somehow inferior can increase patient distrust. The result can be a disaster, both for the patient and for the public at large.

Closing thoughts

When Bastyr was founded in the late 1970s, it had a mission to bring science and naturopathic medicine together. Naturopathic doctors would become a vital part of the medical team. Some 40 years later, the promise is still only partially fulfilled.

So what next? What do we do?
This blog is in a way my response to that question. There are folks that are working inside the naturopathic institutions, trying to make change. My decision has been to start bringing these questions out for public discussion. Naturopathy is not well. In order to diagnose what is wrong with it, the symptoms need to be laid out. For various reasons, I do not believe the national naturopathic institutions are going to carry out this work anytime soon, though I think the schools are attempting to do so. Until the last school closes down, the national organizations will still be insisting that everything is “just fine”.

There is a lot here to cover. To start with, I am going to lay out what I think prospective students need to know. I will look to lay out reforms that I believe are needed, and talk about what those who are in the profession can do (or keep doing) to help the profession move forward.

So if you’re looking at becoming a naturopathic doctor and going to one of the accredited schools, please read on to learn what you need to know to make an informed decision.

1-15-2020: Updated to add source for “long-term only about 20% of NDs appear to stay in practice”.

1-15-2020: Updated to add note from Canadian colleagues regarding my statement on NDs rarely being disciplined.

1-22-2020: Post publish date changed to date post was made public on Facebook and Twitter. This was to allow comments, as the original date post was published (12/26/2019) meant the “close comments by 14 days” setting cut off comments.

Comments are now live. You can also comment on this post on the Facebook page for EBM-ND.

https://www.facebook.com/ebmnd/


[1] Source: Bob Mays, in a discussion on the AANP 2004 data on outcomes for naturopathic grads: “I agree that the bulk of the 81% [ that did not respond to a 2004 AANMC survey on outcomes] have dropped out -– and, I think it raises questions about the long term viability of the profession.” http://theintegratorblog.com/index.php?option=com_content&task=view&id=239&Itemid=189

[2] Some of my colleagues, especially those in Canada, believe this is too broad a statement and they believe that Canada disciplines NDs more stringently. They also point out that I have not provided examples. Which is true, I have not. At this time WA state does not provide, to the best of my knowledge, public announcements of cases where someone loses their license, though it is publicly searchable. I have at times been told about practitioners who lost their licenses, mostly due to prescribing issues. Other times I hear about it when it makes the news. The latest WA state newsletter, from September 2019, does show numbers of licenses revoked in a 2-year timeframe. There are other cases that have been discussed, such as the case of Britt Marie Hermes’ former boss (see naturopathicdiaries.com.)

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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