Are NDs primary care physicians? Maryland says "no"

Are NDs primary care physicians?  Maryland says "no"

In Maryland, bills licensing naturopaths for the first time in that state recently passed in both the House (HB 402) and Senate (SB 314).  The Senate Bill is now before a House Committee, apparently for procedural reasons. The licensing legislation will likely go to the Governor soon and I have no reason to believe he won't sign this into law. 

The wheels of legislation were obviously greased for these bills after major amendments which severely curbed the scope of practice NDs wanted.  This allowed the bills to move through both chambers with lightening speed despite being rejected by the Maryland legislature in previous years. Just exactly who was behind this is not clear, although the Maryland Board of Physicians met with naturopaths last year and issued a report which the Maryland Association of Naturopathic Physicians thinks smoothed the way.  We're still on the case, with a more complete review coming up Thursday over on the Science-Based Medicine blog.

No one wants to see NDs licensed to practice, of course. But this particular legislation may actually cramp the style of Maryland NDs. If you look online, you'll find Maryland NDs claiming they specialize in treating ADHD. Others are offering "detoxification," "complete salivary hormone profile," dietary supplements based on your individual biochemistry, an "adrenal stress index test," and homeopathic remedies for treating chronic illnesses.  And, of course, the usual bashing of "conventional" medicine.   

As originally drafted, the Senate and House bills put NDs under the jurisdiction of a Naturopathic Board made up of 3 NDs, one MD or DO, and one consumer member.  Much to the chagrin of NDs, I'm sure, the bills were amended to put them under the jurisdiction of the State Board of Physicians, with only a Naturopathic Medicine Advisory Committee making recommendations to the Board. Even at that, the Committee consists of 2 NDs, 2 MDs or DOs and one consumer member.  NDs are specifically prohibited from calling themselves "physicians," a provision that most certainly frosts the Maryland Association of Naturopathic Physicians. All NDs must have a collaboration and consultation agreement with a physician and agree to refer patients to, and consult with, physicians and other health care providers.  ND patients will have to sign a consent form acknowledging the limited scope of naturopathic practice.  

All in all, it doesn't sound like the Maryland legislature bought the ND party line that they are educated and trained to practice with the same scope and with the same skill as primary care physicians, does it? 

Unfortunately, NDs would be able to see any patient of any age with any disease or condition. They can order and perform physical and lab exams, including phlebotomy and clinical lab tests and electrocardiograms (with overread by a cardiologist).  This will allow them to employ their nonsensical saliva tests and "live blood analysis," in-house if they want to.  They will also be able to order and interpret reports of diagnostic imaging studies.  NDs will be able to employ a good part of their pseudoscientific treatment armamentarium, including dietary supplements, homeopathy, and hydrotherapy.  Colon hydrotherapy was specifically removed from the bill's original version, although hydrotherapy is still permitted.  It is unclear whether this evidences legislative intent to prohibit colon hydrotherapy or it simply means they thought the term "colon hydrotherapy" was redundant.  

They won't be able to shoot patients up with their vitamin and mineral "cocktails" because they can't prescribe or administer prescription drugs.  (Vitamins and minerals become drugs once they are given IV.)  They can use transdermal and IM administration.  The physician board is directed to create a workgroup to study the development of naturopathic formulary.  Here again, their enthusiasm for expanding their practices will (we hope) be curbed by the fact that MDs, DOs, nurse practitioners and pharmacists will be in the workgroup along with them.  And there is a direct prohibition against including prescription drugs without further authorization from the legislature.

The physicians board will be formulating regulations to govern NDs, with the advice of the advisory committee.  And here lies an opportunity to rein in some of the more outlandish ND practices.  The bills already state that NDs cannot use false, deceptive or misleading advertising, a typical prohibition in all health care provider licensing statutes.  However, where the regulators are exclusively CAM practitioners themselves, obvious barriers to effective regulation appear.  For example, a naturopathic board would likely find advertising that "toxin" removal is necessary to your health unproblematic.  However, a state medical board might well find such a claim false, which it most certainly is.  Likewise, a medical board could enact regulations severely curtailing the claims made for dietary supplements, require full disclosure of the contents of homeopathic remedies (i.e, water), or prevent diagnosis and treatment based on non-standard lab tests, regulations a naturopathic board would be unlikely to enact.

Naturopathic practice is based on a "philosophy," unhindered by scientific plausibility or evidence of safety or effectiveness. The interface between this philosophy and science-based practitioners trying to write rules to protect the public health, safety and welfare should prove interesting.   What the State Board of Physicians report said, and how it may, or may not have been, fully informed in reaching its conclusions remains to be seen.  But if the physicians board didn't get the full picture, we'll be glad to fill them in when they sit down to compose the rules governing naturopathic practice.  

Points of Interest 3/27/2014
Points of Interest 3/26/2014