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297.1

Medicine is hard. I graduated from medical school 31 years ago and while some aspects of the practice of medicine are easier, getting the correct diagnosis is tricky. I think my years in the skeptical world have make me a better physician because I am aware of all the cognitive errors that can lull me into a false sense of certainty about a diagnosis. I have discussed one of my cognitive epiphanies at SBM, the classic paper “Observations on spiraling empiricism: its causes, allure, and perils, with particular reference to antibiotic therapy.

I have yet to meet a medical intern, fresh from 4 years of medical school, who is even barely competent to diagnose and treat patients. It is why in medicine we have years of supervised training before we go into practice. Most of us have had four years of medical school, 3 to 7 years post-graduate training in residencies and fellowships to learn the basics of a speciality.

​Even with all that training and education, it is estimated that

Cases of delayed, missed, and incorrect diagnosis are common, with an incidence in the range of 10% to 20%.

When I first heard that I thought that was actually surprisingly good. Well done, I thought, wrong only 20% of the time.

Now contrast that background with the training of a naturopath, which has also been discussed at SBM: 4 years immersed in nonsense:

At our local naturopathic school they get 72 hours of pharmacology education, and twice (144 hours) as much training in homeopathy. The have the opportunity to do electives to broaden their knowledge: 144 hours in homeopathy, 36 hours in qi gong, 26 hours in Aruyveda, 24 hours in energy work and 12 hours in colonics.”

And then after 4 years of learning pseudo-medicine they usually go directly into practice with no post-graduate supervision. By the nature and duration of their training they are horribly unfit to make appropriate medical diagnoses or treatments.

So I read "Naturopathic Practice at North American Academic Institutions: Description of 300,483 Visits and Comparison to Conventional Primary Care with a bit of curiosity.

They looked at the diagnoses pulled from Electronic Medical Records (EMR) of 4 ND schools. Every disease has a numerical code, the ICD-9. Fever, my favorite, is 780.6. To bill insurance, every diagnosis has to have a code, and for all their shortcomings, EMR's are excellent for billing.

The first thing to note is that these ND schools are using (horror) medical diagnoses, not ND diagnoses. I suspect they are doing this for billing purposes.

So we have no idea what other, ND related, diagnoses were made. I once came across an acupuncturists note in the EMR. His EMR diagnosis was low back pain. His charting diagnosis was all about blocked meridians and abnormal tongues. Using an ICD-9 code from a medical EMR can hide a tremendous amount of pseudo-medicine, including ND pseudo-diagnosis and treatment.

I also has to wonder about the accuracy of the diagnoses. If 10-20% of the diagnoses made by doctors with real medical training are wrong, I get the heebie-jeebies when I think about the potential errors made by poorly trained ND's. The classic example is the Portland woman who died young of a heart valve infection under the care of ND's.

Naturopathic doctors spend more time with patients, offer patient-centered care, and are experts in health promotion

but a fat lot of good it will do you if they lack the training and understanding to recognize a curable infection in time to prevent death.

Although many of the codes are for symptoms, not a true diagnosis. A question would be what was done with the diagnosis of, say, fatigue. Are, hidden in the chart notes, mentions of adrenal fatigue and imaginary Lyme? High colonics and hair analysis. Were they treated with homeopathy or other pseudo-medical interventions? Were patients recommended my favorite goofy ND therapy, wet socks, for stuffy nose:

Take a pair of cotton socks and soak them completely with cold water. Be sure to wring the socks out thoroughly so they do not drip. Warm your feet first. This is very important as the treatment will not be as effective and could be harmful if your feet are not warmed first. Soaking your feet in warm water for at least 5-10 minutes or taking a warm bath for 5-10 minutes can accomplish warming. Dry off feet and body with a dry towel. Place cold wet socks on feet. Cover with thick wool socks. Go directly to bed. Avoid getting chilled. Keep the socks on overnight. You will find that the wet cotton socks will be dry in the morning.

 

Effects of the Wet Sock Treatment This treatment acts to reflexively increase the circulation and decrease congestion in the upper respiratory passages, head, and throat. It has a sedating action and many patients report that they sleep much better during the treatment. This treatment is also effective for pain relief and increases the healing response during acute infections.

And it is most odd. While you can code and bill for vaccinations, it wasn't part of the primary care in the ND clinics. As best I can determine, 0.6% of adult and 0.8% of children go to their PCP for vaccinations. At least as many as go to the ND clinic for lead toxicity as see a real doctor for vaccinations.

Unless a random and representative number of charts were reviewed for accuracy and quality of care, we have no idea what these diagnoses really represent over the need to have a medical ICD-9 code to bill. It is not the codes that are important, it is how they were determined and how they were used. Given the nature of naturopathy, I suspect the worst. I also suspect this will be cited in evidence as a reason for ND's to be PCP's. 297.1

Points of Interest 06/08/2014
Points of Interest 06/07/2014