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Complement or threat? Naturopathic doctors aim to fill holistic healing niche

This is the first in a series of articles on the expanding scope of practice of clinicians who are not fully licensed physicians. Last July, members of the AOA House of Delegates debated the issue of who has the right to be identified as a “doctor” or a “physician.” And as they consider how to expand health care coverage while controlling costs, members of the U.S. Congress are weighing who can deliver primary care and which health professionals must be reimbursed by insurance companies.

Dr. Neal

Wendy Neal, DO, ND, performs osteopathic manipulative treatment on a patient at the Quest Center for Integrative Health in Portland, Ore. Dr. Neal attended a naturopathic medical college several years after graduating from osteopathic medical school so that she could learn more about complementary and alternative medicine. (Photo courtesy of Dr. Neal)

Embracing a holistic philosophy of healing that resembles osteopathic medicine’s, naturopaths tout themselves as primary care doctors who can help remedy the country’s burgeoning physician shortage. Tapping the public’s growing interest in complementary and alternative medicine, they have been increasing their scope of practice state by state, much as the osteopathic medical profession did in the 20th century.

Licensed in 15 states and the District of Columbia, naturopathic doctors have limited but expanding prescriptive drug authority and other practice rights, with Oregon and Arizona NDs having the broadest prescribing privileges. In Arizona, Hawaii, Oregon, Vermont and Washington, naturopathic doctors can call themselves naturopathic physicians. Last year, two states—Oregon and Hawaii—passed legislation expanding ND scope of practice.

Most recently, the health reform bill that the U.S. Senate approved on Dec. 24, 2009, contains a “nondiscrimination” provision that could require health insurers to cover naturopathic and other alternative treatments provided by licensed health care professionals who are not fully licensed physicians, points out Virginia M. Johnson, DO, who practices neuromusculoskeletal and osteopathic manipulative medicine in Santa Monica, Calif.

“Those trained in a limited paradigm of healing who seek additional practice rights—without commensurate education or responsibility—pose a threat to patients,” Dr. Johnson contends. “What’s more, as a fully trained and licensed physician, I feel this is a lot like identity theft.”

The superficial similarities between naturopathy and osteopathic medicine belie deep differences in training, according to Dr. Johnson and many other osteopathic physicians, who note that the apparent similarities have caused considerable confusion among patients and health policymakers. In a possible example of such confusion, as well as political maneuvering, California Gov. Arnold Schwarzenegger in late July 2009 approved budget legislation requiring California’s Bureau of Naturopathic Medicine to merge with the Osteopathic Medical Board of California.

Some osteopathic physicians, however, fault the osteopathic medical profession for failing to reinforce osteopathic medicine’s distinctiveness. These DOs contend that the profession’s movement toward the mainstream and away from osteopathic manipulative medicine has provided an opening for naturopathic doctors to promote themselves as the true holistic healers.

But not all osteopathic physicians are worried about naturopathic doctors’ practice rights. A number of DOs work cooperatively with naturopathic doctors, referring patients to NDs in some circumstances and receiving referrals from them as well. These osteopathic physicians point out that naturopathy as a profession has improved its training and credentialing standards, just as the osteopathic medical profession did decades ago. While anyone can claim to be a naturopath, a licensed naturopathic doctor must have a doctor of naturopathy degree from an accredited four-year naturopathic medical college and pass the Naturopathic Physician Licensing Examination (known as NPLEX), administered by the North American Board of Naturopathic Examiners.

According to the American Association of Naturopathic Physicians, the United States has four naturopathic medical colleges accredited by the Council on Naturopathic Medical Education (CNME):

  • the Bastyr University School of Naturopathic Medicine in Kenmore, Wash.
  • the National College of Natural Medicine in Portland, Ore.
  • the Southwest College of Naturopathic Medicine in Tempe, Ariz.
  • the University of Bridgeport (Conn.) College of Naturopathic Medicine.

In addition, the naturopathic doctoral program at National University of Health Sciences in Lombard, Ill., is a candidate for CNME accreditation.

Part of the team?

In 1919, Washington became the first state to establish licensure for naturopathic doctors. Today, with more than 800 NDs, Washington has more licensed naturopathic doctors than any other state.

Since 2005, Washington has allowed naturopathic doctors to prescribe vitamins, minerals, botanical medicines, homeopathic medicines, hormones and “legend drugs and controlled substances consistent with naturopathic medical practice.” As of November 2007, Washington NDs have been permitted to prescribe codeine and testosterone products.

Seattle family physician Lindy Griffin, DO, accepts NDs as part of Washington’s medical community. She believes that most licensed NDs in the state adhere to their practice limitations and are well-trained in their sphere of health care, which emphasizes dietary and wellness counseling, botanical medicine, and non-Western healing arts such as acupuncture.

“I have worked well my entire practice life with naturopathic physicians,” Dr. Griffin says. “Good naturopathic physicians know what they can do and what they can’t do and get help when they need it.”

Dr. Griffin maintains practice agreements with NDs, who refer patients to her for procedures they can’t perform and medications they can’t prescribe. In turn, she has referred patients to NDs for acupuncture and dietary counseling.

“Some patients need extensive dietary therapy. A naturopathic physician can spend 45 minutes with a patient to provide nutritional counseling,” Dr. Griffin says. “I don’t have the time to do that.”

In Washington, naturopathic doctors often provide primary care, points out Dr. Griffin. “To deny this would be to deny reality,” she contends. “The people in this state want naturopathic physicians. Not being cooperative would be foolish for DOs.”

In contrast, family physician Kelli M. Ward, DO, MPH, of Lake Havasu City, Ariz., does not seek collaborative relationships with naturopathic doctors. However, she treats patients who also see NDs, who in Arizona can prescribe drugs other than antipsychotics after completing pharmacology coursework and passing an examination.

“Sometimes patients come to me with lab orders or prescriptions written by naturopaths that the patients’ health insurance plans won’t cover,” says Dr. Ward, the president-elect of the Arizona Osteopathic Medical Association (AOMA). “These patients want me to write the prescriptions or order the tests instead. I will do so only if I feel that a medication or lab order is medically necessary.”

23 Responses

  1. Leslie Huzyk on Jan. 27, 2010, 4:53 p.m.

    Fascinating debate. Looking forward to the other articles…I would like to know more about the ND school curriculum and how it compares to the osteopathic medical school. also, I did not realize that a naturopathic doctoral degree is awarded by a chiropractic school. Interesting! it is recognized by the other schools? What kind of degree do the four other schools confer? Is it ND as well?

    Thanks, Ms Schierhorn!

  2. Angela Agrios, ND on March 15, 2010, 4:46 p.m.

    Hi Leslie,

    Here is a link from NCNM (one of the 4 accredited ND programs in the US) which lays out the course curriculum for the four year naturopathic medical degree:

    http://www.ncnm.edu/academics/Programs_08-09.htm

    Naturopathic degrees are not awarded by chiropractic schools. They are awarded by one of the four federally accredited naturopathic medical programs in the US – they are all listed out in the article. The degree is a naturopathic doctorate (ND). Each state has it’s own laws which determine licensure and practice scope.

    More information is available at:
    naturopathic.org

    I am happy that this dialogue has begun. It’s a terrific forum to improve communication and understanding between the DO and ND professions. I look forward to reading future articles and responding with any information that I feel might be helpful in clearing up confusion. The goal of all health care providers is help our patients regain health. We are of best service to our patients when we each know our strengths and limitations and are able to make appropriate referrals to other medical professionals based on an accurate understanding of their training and capabilities.

    Sincerely,

    Angela Agrios, ND

  3. Leslie Huzyk on March 16, 2010, 5:10 p.m.

    Thanks for the information…Not sure what I really meant by my second question!

    But I remain a little confused by this statement in the article: In addition, the naturopathic doctoral program at National University of Health Sciences in Lombard, Ill., is a candidate for CNME accreditation. Can you clarify that?

    I love my DO, but I also had a great experience years ago with an ND who treated me for neck pain and headaches. I appreciate that both DOs and NDs understand that often the body can heal without pharmacological or surgical treatment.

    As a baby boomer and all that implies, I also hope the dialogue continues!

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  6. James Huang, DO on April 13, 2010, 5:56 p.m.

    Perhaps the definition of “primary care provider” and/or “primary care physician/doctor” needs to be re-explored.

    When I take ER call for the primary care department at my hospital as a primary care physician, I attend to my patients who have the following: pulmonary emboli, DVT, sepsis, hip fx, SBO, DKA, COPD, CHF, Exac of Asthma, CVA, DIC, etc.

    Other health providers who state they are “primary care” should be capable to attend to these life-threatening cases in caring for their patient. If unable, are they really “primary care?”

    Sir William Osler wrote this: “The good physician treats the disease; the great physician treats the patient who has the disease.”

    This is the DO difference.

  7. James Pendleton, NMD on June 22, 2010, 9:54 a.m.

    There’s a common conception that many DOs fell short academically and settled for osteopathic instead of medical programs. During my undergraduate days, interactions with other students reinforced this. While I was quite interested in the DO philosophy, the students that settled for DO programs did it as a “plan B” -and knew nothing about it prior. This was my experience in the early 90s and hopefully things have evolved. The DOs I shadowed would have nothing of my “holistic” ideas and were devoutly chasing the allopathic model for mainstream medical approval.

    After service in the military and a BS in microbiology I chose the naturopathic medical route via Bastyr University in Seattle. After 4 intense years at 28-31 credits a quarter, preceptorships, residency etc. I took the national boards and became a licensed naturopathic primary care physician. I am currently licensed in Arizona, California, and Washington with DEA and full prescriptive authority.

    Since then, I have nurtured a successful family practice in Kirkland, Washington, directed a VIP medical center in Abu Dhabi, United Arab Emirates, and participated in projects throughout Central/South America, India, Middle East, Southeast Asia…

    While naturopathic physicians are trained in the stabilization of acute situations, our true strength is the ability to address challenges -before the patient becomes entrenched in a dis-empowering model -where their symptoms are addressed but not the cause.

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  9. Avishek on Feb. 19, 2011, 8:51 p.m.

    I have a random question as an aspiring N.D. Can N.D’s perform research? Do any of you NDs who have replied to this perform research? I’d love to work with patients for sure, but in order to attain truth I must research as well. I do not know now if I should get a PhD then obtain an N.D.

    Also, about this article, I’m not fond of talk such as this, it deviates from our goals. Instead of getting too philosophical here I will say this, if one’s goal is to heal, to attain truth, then there are no threats except for tigers bears and lions. Of course there is a problem, and it must be fixed. One cannot be too utopian. Opportunity will certainly grow for NDs and DOs, but they must cooperate and be open to all ideas, and stop thinking so negatively such as Dr. Johnson does. Such contention is for what purpose? I’d like to see some more spiritually conscious doctors.

  10. DrARN on Feb. 22, 2011, 10:19 p.m.

    I work locum tenens for M.D.s who are away from their practice for a while and much of my work consists of refilling meds that I feel are still medically necessary, that were originally written by the M.D. So, some insurance co’s will pay when the M.D. writes the prescription but will not cover it if an N.D. refills it? There is no logic in this.

  11. WRS on March 5, 2011, 6:31 p.m.

    Unfortunately NDs don’t have the training to become primary care physicians – the clinical training is extremely lacking as is the basic science curriculum. Until these are totally revamped to be on par with real medical school, then they really shouldn’t be considered physicians from a patients perspective.
    I took a gander at James Pendleton’s web page and I can’t help but notice the misrepresentation. From the jargon of attending “medical school” to having over 10 years of clincal experience in “primary care medicine” – these are clearly used to mislead patients because these terms are used in association with MD/DO.

  12. Jessica Sideways on March 5, 2011, 9:01 p.m.

    Avishek, a ND degree is a first professional degree, like a DO, MD, JD or Pharm.D degree is. We *could* do research, but we’re not exactly trained for that in our professional curriculums. Which is why there exists DO/Ph.D programmes and research fellowships. If you’re interested in research, you might want to consider a new programme that is being offered by NCNM, a research degree in Natural Medicine.

    Thanks,
    Jessica, a future DO.

  13. Jeanine DuBois on June 17, 2011, 1:24 p.m.

    Acknowledging that each patient brings his or her own unique situation is very important. Some of us (like myself) cannot handle CNS drugs and need a gentle form of care that works with the body to heal itself. In such cases, an ND, possibly a DO or DC are actually MORE skilled than many non-holistic MDs to find a solution that doesn’t create more problems through reactions to pharmaceuticals. I feel sincere appreciation for the scope of providers to meet the scope of patients’ needs.
    –Jeanine DuBois

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  15. Doctor'sDr on Oct. 15, 2011, 5:08 a.m.

    Thankfully the wellness paradigm is shifting because our medical system has been broken and limping for a very long time. If you can’t learn to work with others, you’re asking to become extinct. There is room for the full spectrum of health care to exist. The gravest concerns I have are for the patients seeing conventional drug-prescribing doctors who continue to only treat symptoms (and adverse effects caused by the countless drugs they continue to prescribe), never even getting close to treating the person or the cause (or, perhaps, even knowing what that means). The conventional medical school curriculum doesn’t include any instruction or training on how to accomplish this – only instruction on how to push drugs, surgery, and other high-force/ invasive/ high-risk interventions. If the only tool you have is a hammer, then every problem is a nail. People deserve the full spectrum of choice to decide what is right for themselves.

  16. KevinB4U on Feb. 21, 2012, 7:54 p.m.

    This distinction between DO and ND is where I am still struggling. This is where I really need help.

    I only want to become a primary care physician for underserved populations around the world by using the most noninvasive and holistic approaches possible: dietary changes, lifestyle practices, Ayurvedic, Chinese, and all the multiple numerous modalities out there.

    For years, I´ve refused to even consider allopatric medical school because of the destructiveness of that broken model. I don´t want to be a pill-popping-prescribing doctor. I only want to work with patients in diagnosis and treating the entire person. It´s the human connection with the special medical skills that matter most to me.

    Right now, I´m sort of lucky (even though I am still lost): the State is giving me full funding for 6 years of medical school, an additional year for residency, plus one more year to set up my own private practice.

    I´ve applied to Bastyr University primarily because of many reasons. First and foremost, I strongly believe in their teaching-student approach, as well as the medical philosophy. I worked for 10 years in corporate slave jobs, sacrificing my health, my life, and my values of work-life balance for what really turned out a waste of my life.

    I have decided it is not worth spending the last half of my 30’s half exhausted, dragging from class to class without any opportunity to explore lif-fulfiling activites (like playing with my foster kid) and not even building a foundation for a long productive second-half of my life through wellness-based healthy lifestyle. My 20’s are gone, as is the healthy body that came with it thanks to that career. In my early 30´s became alarmed at how rapidly I discovered my body was aging, and quit that life to travel the world. Over the past several years, I´ve spent much time thinking and exploring my childhood dream of becoming a doctor.

    Bastyr´s integrated emphasis on 22 classroom hours a week, online self-paced, holistic training, first-year clinical training stretching out through the entire 4 year program rather than only at the end really appealed to me. This is where I can take and enjoy intense classes without needing to pull all-nighters, or observe patients half awake immediately forgetting it the moment my head hit the pillow. THIS balance is how I want to spend the next few years pulling myself and my health together, tending my organic vegetable garden, maximizing my already considerable energy with raw living foods, detoxifying the Standard American Diet, training for the Ironman, and basically truly enjoying the medical school experience by doing what I love: learning.

    That is, I´m not above pursuing the DO degree. In fact, I´d very much like to obtain that training, too. The extra clinical hours would be worth it, for sure. I´d love to learn more of modern medicine, especially in procuring and using advanced technology diagnostic tools that could help me build my part-time traveling practice dream.

    What frustrates me is the dichotomy between NDs and DOs. Can´t they be the same practice? Isn’t there a way to obtain training and skills of both disciplines without requiring EIGHT years of medical school?

    I´d be happy to add two, possibly a residency third year of in DO training to the ND training program. I´m extremely lucky to have been awarded full funding for the entire 6 years.

    But none of the DO colleges will even consider giving advanced standing to practictioners of medicine in other professions. All the ones I´ve looked at explicitly require starting again at square one. I don´t want to do that. And, no, I´m not even considering allopatric medicine, thank you very much. If a chiropractic wanted to obtain a DO, where could they go?

    Please keep in mind, I don´t even intend to practice pcp/family medicine as a fulltime career. I´m happy to earn enough to cover the costs to stay licensed, and get the thrill of sharing the rest for free wherever I go. Since I´m getting the education for free, I plan to practice for free or at very low patient cost while otherwise occupied in my travel agent career.

    To me, medicine is medicine: the entire patient, the environment, the lifesytle, energy maximization, and personal choices especially nutrition and self-happiness through self-care.

    Could someone out there please advise on how to pursue this holistic vision and still be accepted and permitted to be a licensed physician? Could I take the COMLEX exam through self-directed study, mentorshiop, proceptorships, residencies, etc without needing to spend more redundant time in the classroom?

    Advice please?

    Thank you all so much for listening.

  17. D Sofija on Sept. 22, 2012, 9:29 p.m.

    Kevin, your comment is completely true and inspiring –

    I am currently mustering up the courage to put the brakes on my corporate finance slave lifestyle and follow my dreams to be an ND and serve people with real medicine (let REAL food by thy medicine).
    Just like you said…
    “THIS balance is how I want to spend the next few years pulling myself and my health together, tending my organic vegetable garden, maximizing my already considerable energy with raw living foods, detoxifying the Standard American Diet, training for the Ironman, and basically truly enjoying the medical school experience by doing what I love: learning.”

  18. Marin on Dec. 10, 2012, 11:41 a.m.

    An important variable to this discussion is the presence and growing popularity of traditional naturopaths- those who are educated within and truly practice within a classical naturopathic paradigm, rather than co-opting an allopathic model paradigm. Just as medical doctors and nurses had to evolve and struggle for their credibility not too long ago, traditional naturopaths are setting standards and establishing a growing number of accredited schools. No longer are Bastyr, National Medical, Southwest Medical, etc the “only” schools for classical hands-on traditional naturopathic education. We find that a growing number of clients and patients are helped more by traditional naturopaths whereas “medical’ naturopaths could not help, being limited as they are to the very limited biomedical model. We know of numerous “Bastyr” graduates who are now attending nursing school to pay off those $100,000.00 loans because they cannot make it work in the profession, due to their lack of actual classical naturopathic training and their weak performance in comparison to true medical doctors.

    This field will only continue to grow- recent surveys of schools show successful full employment and exponential growth of enrollment.

    The American Naturopaths Association can give more information: http://americannaturopathsassociation.org/

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  20. Andrea O'Connor NMD on April 18, 2013, 4:36 p.m.

    I am a naturopathic medical doctor in Phoenix, Arizona, this designation I was awarded in part of our licensing in Arizona, and attending SCNM in Tempe, AZ. I had training in the Urgent Care setting and at a very conventional endocrinology practice.
    I had training in traumas at the Urgent Care, and biopsies in the endo practice, but I admit, we were allowed no access in the hospitals. So, yes the training does differ, but I think most of us make great family practice physicians, and I refer to D.O.’s all the time, I like to work together with MD’s and DO’s, and likewise, many of my patients are MD’s and surgeons!

  21. James Pendleton NMD on June 19, 2013, 11:26 a.m.

    In the state of Washington naturopathic physicians are primary care physicians with the authority to prescribe medication and order laboratory exams. They also take most major forms of insurance, are required to have malpractice coverage, and must meet continuing education guidelines. This is all easily verifiable with the Washington State Department of Health.

    A perspective naturopathic physician’s entry into an accredited naturopathic medical school requires a 4 year undergraduate pre-med degree foundation with the prerequisite years of organic and general chemistry, physics, and biological science. A naturopathic physician then undergoes at least four years of intense training in both allopathic and complimentary forms of medicine. Besides the years of gross anatomy, pharmacology, and laboratory diagnosis, naturopathic physicians also learn about nutrition, herbs, and physical treatment modalities. After the first two years of this training candidates take national basic science boards. Upon completion of a naturopathic medical program, candidates are then allowed to take the final comprehensive clinical portion of the national boards. With passing scores in each section, candidates may then apply for licensing in the 17 states and several territories that regulate naturopathic physicians. These states may require further examinations –Arizona requires a further extensive pharmacology board exam.

    In the states where naturopathic physicians are not regulated, anyone –with little or no training -may call themselves one. As these as-yet unlicensed states move towards regulation, they require a standard of patient care, continuing education, and malpractice coverage.

  22. Frank on July 2, 2013, 12:12 a.m.

    … health providers who state they are “primary care” should be capable to attend to these life-threatening cases in caring for their patient. If unable, are they really “primary care?” …

    Well I suppose that is the question isn’t it? Where does primary care end and emergency care start? Having lived through a bilateral pulmonary embolism I would argue that when we start talking something like a PE … or … stroke, heart-attack, sepsis (past a certain point) we are beyond “primary care” and “I’ll call the family doctor tomorrow.” But then you did seem to imply you were treating these “primary care” issues as an attending at the local ER.

    I few years back the evening of hemorrhoid surgery I had to have an indwelling catheter placed. The ER’s instructions were to see the family physician in 4 days for removal. Interestingly enough the family practice MD referred me back to the ER. An MD with all those glorious rotations can’t remove a urinary catheter. Where does that fit on the sliding scale of who can call themselves a primary care doctor?

    The whole “ND can’t do ‘primary care'” in licensed states is an assertion painted with an overly broad brush-stroke and often times sounds like little more than the allopathic medical community being more worried about defending its turf than patient care.

  23. bommi reddy on July 11, 2013, 9:55 p.m.

    I am california licensed practicing veterinarian and also an M.D.about to apply for residency. But recent turn of events in my life are encouraging me to apply for N.D school to become a naturopath. I am wondering if they’ll give me any credits for the courses I have done in Vet school and Med school. Can any one give me some clues.
    Appreciate your response
    Reddy

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