This post originally appeared on ScienceBasedMedicine.org on March 13, 2015. I am including the article here in its original form to help readers easily discover the truth about naturopathic education.
In 2011, I graduated from Bastyr University with a doctorate in naturopathic medicine. I passed the Naturopathic Physicians Licensing Examination (NPLEX) and landed a competitive, one-year residency in family medicine and pediatrics at an out-patient clinic in Seattle. When I completed my residency, I remained at this clinic for a brief time before moving to Arizona to practice until 2014.
During my time in Arizona, I realized that my profession had severely misled me. Naturopathic medicine is marketed as a “distinct form of primary health care.” This phrase is ubiquitous: it appears on the websites of naturopathic medical schools, on materials published by practicing naturopaths, and on lobbying documents to promote the unfettered licensure of naturopaths and to expand eligibility for federal loan repayment programs. Based on my educational and professional experience as an accomplished member of the naturopathic community, I can say that naturopathic medicine might be a distinct form of something, but it is not any form of primary health care. I am saddened to report that not only was I misled, but so were hundreds of legislators, thousands of students, and tens of thousands of patients.
Given my journey through naturopathic medical school, I can provide strong evidence and testimony of the quality and quantity of training at Bastyr University. I base what follows on my academic transcript, course syllabi, course catalog, and the student clinician’s handbook in addition to my personal experiences. It should come as no surprise to readers of ScienceBasedMedicine.org that naturopathic training is not as the profession presents. I’ll say it anyway: naturopathic education is riddled with pseudoscience, debunked medical theories, and experimental medical practices.
Naturopathic education exists in a bubble without critical oversight
The issue of this deceit boils down to the education and clinical training of naturopaths. The naturopathic profession perpetuates a series of false assertions to justify its advancement, which unfold in a closed-loop system that eschews external criticism. Two examples of this dynamic show that naturopaths are the sole regulators of naturopathic medicine.
First, the NPLEX, the naturopathic licensing exams administered by the North American Board of Naturopathic Examiners (NABNE), is written entirely by naturopaths and does not have the same level of transparency as the USMLE or COMPLEX-USA, which undergo an external audit process to maintain common standards, evidence-based rigor, and high-quality assessment. For more information see Melnick (2009).
Second, the Council on Naturopathic Medical Education (CNME) is an accrediting agency that approves naturopathic medicine programs in North America as designated by the U.S. Department of Education. This accreditation does not apply to what naturopaths were taught in school. It actually means that the CNME meets administrative criteria and conducts its own internal evaluation process of naturopathic programs which it approves. This evaluation is not reviewed or shared outside of the naturopathic community.
I will write a second post detailing the conflicts of interest laden in the widely advertised phrase, “U.S. Department of Education accredited school.” There is a lot to be dissected from the CNME’s Handbook of Accreditation and compared to the breakdown of clinical training hours I present below. I might even write a third post explaining how my clinical sciences coursework at Bastyr cannot possibly prepare a student to practice as a primary care physician. For now, the take home message is that naturopathic education exists in a bubble without critical oversight.
A proximal consequence of this insulated community is that naturopathic education remains mysterious to outside observers, and is falsely presented to the public as being on-par with MDs or DOs and capable of training primary care physicians. The ultimate consequence is that pseudoscience becomes legalized as medicine through political maneuvering.
What do Bastyr (and the others) and the AANP say about themselves?
Bastyr University promotes itself as a leader in natural health care. Bastyr states in its promotional material that the naturopathic medical doctorate is a nationally-recognized degree and that its curricula conveys international prestige as an evidence-based, rigorous, and comprehensive program. Most importantly, Bastyr claims to produce medically competent primary care physicians who are “capable of treating a broad spectrum of patients.”
Without going into much detail on this point, one can survey Bastyr’s website to get a sense of how its programs are advertised. Much of the descriptive information appears to be consistent with how the other “approved” naturopathic programs present themselves (Bastyr University California, National College of Naturopathic Medicine, Southwest College of Naturopathic Medicine, University of Bridgeport, Canadian College of Naturopathic Medicine, Boucher Institute of Naturopathic Medicine, and National University of Health Sciences). The language for their programs is all in striking parallel with how the American Association of Naturopathic Medicine (AANP) presents the profession publicly.
The AANP is the professional association of licensed naturopaths. It issues position papers on various topics, maintains the naturopathic code of ethics, organizes an annual conference, and spearheads legislative efforts. My experience participating in the AANP’s 2011 DC Federal Legislative Initiative (DC FLI) highlights how the profession disseminates misleading information for political advancement and how this information is replicated down the line.
Naturopathic medical students and doctors from all over the country gather annually in Washington D.C. for DC FLI. The three-day long political event includes lectures on topics such as the details of nutritional supplement regulation and the industry’s relationship to naturopathic medicine, how chiropractors gained licensure in all 50 states and what we could learn from them, how to practice naturopathic medicine in an unlicensed state, and how to lobby successfully, complete with mock congressional visits. The last day of DC FLI is spent meeting with congressional aides and group lobbying for our “asks.”
When meeting with congressional aides, our success depended on us having succinct information about our naturopathic training. One of the most disseminated documents was a chart produced by the AANP that compared our educational hours to the educational hours of a student of medicine (MD) and a student of osteopathic medicine (DO). The education chart was part of a series of documents titled “naturopathic education facts” and claimed that because of the sheer number of hours spent in lectures and in clinics, naturopaths were adequately qualified to practice medicine as fully licensed physicians. It is very popular among naturopaths to use such an educational chart in an attempt to justify that naturopaths are well qualified healthcare providers. The charts are often featured on practice websites and on the websites of organizations that promote naturopathic medicine. On my former practice website, I used a chart that was distributed at DC FLI. Different versions of the chart can be found all over the internet.
When I practiced as a naturopath, I never thought to fact check any of these educational comparison charts. I accepted this information as truth and was thrilled that someone else had done the tedious work for me. This was mental laziness on my part, because the charts supported what I already knew at the time to be “true.” Now that I’ve come to a major realization about how I and others have been deceived, I think it is important to put out real data and accurate descriptions of naturopathic education for the purpose of making better “facts.”
Method to count hours and false equivalencies
I’ve found several charts comparing naturopathic education to the education of other health care providers. They are all a bit different in how hours are categorized for comparison, which tipped me off that there was some manipulation of the data. Some charts simply break down hours into two categories: didactic and clinical; while there is usually an accompanying table describing a further break down into other categories. Other charts attempt a more seemingly-detailed accounting of hours, but issues remain. In one chart, NDs are listed as having 100 hours of coursework in pharmacology, while MDs/DOs receive only 70 hours. As Orac and Jann Bellamy have already shown, this wiggle room gives ND training a false upper (or equivalent) hand because dubious coursework is inappropriately lumped into other legitimate categories. Here are some of these charts: 1, 2, 3, and 4.
Yet, what good are such charts and their unknown data inputs when I can show what it took for me to earn my ND degree? Furthermore, what does a credit hour mean for comparative purposes when pseudoscience or experimental therapies are being taught in a supposed clinical science course?
I recently scrutinized my transcript, course syllabi, and student clinician handbook. (Here is a table detailing my coursework into more readable categories based on my transcript; credits were translated to hours based on all of my courses syllabi.) I graduated with 1,224.5 hours of clinical training, of which 1,100 hours were in what Bastyr considers “direct patient contact.”
After breaking down the clinical training hours and assessing the quality of the medical training, I believe the quantity and quality of the training provided by Bastyr University is scant, lacks the application of medical standards of care, and includes pseudoscientific diagnostic methods and treatments of real and fake diseases.
My naturopathic clinical training numbers
The majority of clinical training for ND students at Bastyr is completed in the university’s two teaching clinics: the Bastyr Center for Natural Health located in Seattle, WA and at the small health clinic located on the Bastyr campus in Kenmore, WA. Sometimes temporary community clinics are set-up throughout Seattle for additional training. A clinic rotation is scheduled in 4 hour shifts, once per week, for an 11-week quarter.
My 1,224.5 clinical training hours can be broken down as follows:
- 1,100 hours of primary care medicine training in “direct patient contact” including
- 748 clinical training hours on “patient care shifts”
- 44 hours on counseling shifts
- 176 hours on physical medicine shifts
- 132 hours spent shadowing any kind of health practitioner (ND, MD, DO, DC, LAc, homeopath, PT, PA, NP, etc.)
- 25.5 hours for Clinic Entry 1 and Clinic Entry 2 courses
- 99 hours for the course clinical laboratory diagnosis, called Lab Rotation
748 clinical training hours in “Primary Care”
To provide a picture of what naturopaths mean when they claim to be primary care physicians, I think a description of a typical patient appointment and how training is structurally organized at the Bastyr teaching clinic is telling.
On a clinic shift, one faculty member (a licensed naturopath) supervised several naturopathic students. Usually, there were at least two “primary” students and one “secondary” student on a shift. The terms primary and secondary refer to how many quarters the student has spent in the teaching clinic. By definition, a secondary student has spent less than four quarters in the clinic and is a novice clinician. A primary student has spent more than four quarters in the clinic and is considered advanced. This amount of time does not equate with clinical skill. I knew many incompetent primary student clinicians. Each clinic shift had a specific structure that included three elements: shift preview, patient appointments, and shift review.
Shift preview and review took place in the first 30 minutes and final 30 minutes of shift. During these periods, primary students roundtabled their patients. The patient’s medical history, previous visits to the clinic, and previous naturopathic assessments were discussed. Patient cases were presented in a standardized S.O.A.P. (subjective, objective, assessment, and plan) format. The supervisor usually asked students about differential diagnoses and treatment protocols. Medical standards of care were almost never discussed on my clinic shifts, with notable exceptions for one or two of my supervisors who insisted on it, to the dismay of many students. I often heard statements such as, “the patient has a strong vital force and it is expected that the patient will heal in 3 to 4 weeks’ time with proper self-care and home hydrotherapy treatments.” Sometimes, the preview and review was attended by first-year students completing their Clinic Entry 1 requirements. These students generally did not contribute to the discussions but their time was considered “direct patient contact.”
Actual patient care accounted for three hours of a clinic shift. Patient care visits were typically attended by two students, a secondary and a primary. Appointments lasted anywhere from one to two hours. During an appointment, the primary student charted the patient’s current medical complaint and relevant history. This charting included a typical medical intake, such as the seven attributes of the medical complaint, a review of systems, past medical history, medications and supplements taken, family history, social history, dietary patterns, and so on. Vital signs, like blood pressure and temperature, were usually taken by a student. The patient intake also included information thought relevant to naturopathic diagnoses, like toxin and heavy metal exposure, use of plasticware in cooking and eating, birth history, pesticide exposure through eating non-organic foods, food intolerances, religious affiliations, and a host of subjective assessments relevant for energy therapies (homeopathy, flower essences, UNDA numbers, etc.).
Diagnosis: naturopathic philosophy required
The diagnosis process in naturopathic medicine is an interesting one. A differential diagnosis was usually reviewed, based on the patient’s history and clinical exam findings. For example, the complaint of heartburn could have included a differential diagnosis of gastroesophageal reflux, H. pylori infection, peptic ulcer disease, angina, and irritable bowel syndrome (amongst other relevant diagnoses).
However, the differential could have also included possible naturopathic diagnoses such as IgG food allergies/intolerances (gluten!) or systemic Candida overgrowth. Lab testing and imaging was also considered during this discussion.
Treatment then encompassed recommendations for the medical and the naturopathic diagnoses as a singular, interwoven diagnostic report. In fact, if a patient’s diagnosis seemed like it was only based in medical science, the students, supervisors, or even the patients themselves would sometimes complain about the lack of naturopathic philosophy.
The treatment plan
The patient care treatment plan is a mainstay of naturopathic medicine. It may include any, or all, of the following: a referral to a medical specialist, homeopath, acupuncturist, nutritionist, another ND or other provider; a medical prescription such as an antibiotic, birth control, or steroid; a botanical formula in the form of a tea, tincture, or poultice; a homeopathic remedy or energy medicine; home or in-office hydrotherapy recommendations such as contrast (hot/cold) showers, enemas, or sitz baths; nutritional and exercise recommendations, and so forth. The options seemed endless. A patient might have received any treatment recommendation!
Many supervisors would limit the number of recommendations in an attempt to rein in plans that seemed to run wild. Other supervisors would have certain requirements to consider, such as if a homeopathic remedy were offered, another therapy must also be included.
To the best of my memory, I was rarely asked about the medical standard of care for a diagnosis and treatment plan. The treatments offered to patients were usually abundant and seemed like a toss-up.
My clinical training included such a small amount of pharmacological experience that it hardly seems worth mentioning. I spent far more time learning how to write a prescription for botanical medicines than how to prescribe appropriate pharmaceutical medications. Once I was in practice, I specifically befriended a pharmacist at a local pharmacy in Seattle so I could ask questions about drugs, dosages, interactions, and protocols. I still am very thankful for her help.
The no-standard standard of care
There are no naturopathic standards of care. Students and residents at Bastyr University have compiled documents explaining the diagnosis and treatments for a variety of diseases, which are available to students and faculty on the university’s online portal. A review of these documents reveals a large degree of untamed variability that is reflected in naturopathic medicine.
For example, the entry on angina includes a variety of treatment options: nutrient therapy with selenium, CoQ10, magnesium, and niacin; limiting fat intake; removing sucrose, alcohol and caffeine from the diet; botanical medicine in the form of doses of ginger, ginkgo biloba, aconite, and bromelain; at home exercises; recommendations to address a type A personality; a detoxification diet; colon hydrotherapy (i.e. enemas); castor oil packs; food allergy elimination; juice fasts; hormone replacement therapy; lifestyle changes; and monitoring of uric acid levels. Of the documents I’ve reviewed, all fail to mention any standard of care, which for some conditions, at a minimum should include an immediate referral to the emergency room or medical specialist. I know it sounds cynical, but naturopathic medical care is like picking treatments out of a magical hat.
I think it is also interesting to note that in lieu of four patient care shifts, a student had the option to take homeopathy shifts instead. This means that 176 hours of the required 748 patient care hours can be spent purely in homeopathic training. But given that very little medicine was actually taught in clinical rotations, perhaps the substitution doesn’t even matter.
44 clinical training hours in naturopathic counseling
Naturopathic counseling included education and training in the basic principles of psychology, counseling, mental illness, substance abuse, and motivational interviewing. Students were required to take 132 lecture hours of counseling-related courses and one clinical rotation that is completely dedicated to naturopathic counseling. On these shifts, no vitals were recorded and no physical health concerns, other than mental health, were covered by the student or the supervisor.
I believe the education and training in counseling for primary care is important, but I do not believe that training in counseling counts as training in primary care.
176 clinical training hours in physical medicine
Naturopathic physical medicine is modeled after the chiropractic theory of vertebral subluxations. Diagnoses are usually based on the invented disease process of a vertebra falling out of alignment with the rest of the spine, causing specific health symptoms, even organ system problems. Naturopathic medicine has repackaged chiropractic theory as “physical medicine and naturopathic manipulation.” We were taught how to assess, diagnosis, and treat vertebral subluxations in our naturopathic manipulation series and hydrotherapy courses. Physical medicine rotations include treatments such as colon hydrotherapy, alternating hot and cold water treatments, or soft tissue massage in addition to what is essentially chiropractic adjustments.
Sometimes patients with chronic diseases, such as fibromyalgia and naturopathic diseases, such as adrenal fatigue, chronic Lyme, and multiple chemical sensitivity, received hydrotherapy treatments in order to help “stimulate the vis” (one’s life force). Naturopaths widely believe that treatments with water, heat, and cold can stimulate the immune system, detoxify, and promote healing.
Bastyr naturopathic students were required to take 198 lecture hours of naturopathic manipulation and physical medicine courses and complete four physical medicine rotations (176 hours). While some primary health care concerns may be covered in a physical medicine shift, the diagnosis and treatment of vertebral subluxations plus the training in hydrotherapy and naturopathic manipulations cannot qualify as primary care training.
132 clinical training hours in preceptorship
In naturopathic education and training, student precepting has a broad definition that can mean anything from the student shadowing, assisting in medical (or naturopathic) diagnosis or treatment, or providing administrative/front desk support. Based on these loose requirements, there is no guarantee that these 132 clinical hours resulted in patient contact or contributed to clinical training. These hours may be spent with a medical doctor, osteopath, naturopathic doctor, homeopath, chiropractor, acupuncturist, or anyone else deemed appropriate by Bastyr University.
Eighty-eight of these 132 hours were required to be spent with a naturopath, and a student was limited to 44 hours of precepting with non-naturopathic providers, including medical doctors.
25.5 clinical training hours for clinic entry 1 and clinic entry 2
The courses Clinic Entry 1 and 2 provided no actual clinical training. The course Clinic Entry 1 required first year naturopathic students to visit the Bastyr Center for Natural Health (BCNH) three times as a patient, and to also attend three patient case preview/reviews. Personal reflection papers for these experiences were required. There was no direct patient contact whatsoever.
The course Clinic Entry 2 covered the structure, organization, and policies of the BCNH. The course was designed to “aid the student’s transition from the classroom, into the clinic,” by introducing the student to personnel, by covering clinical requirements for graduation, and by familiarizing the student with pertinent paperwork such as student timesheets and absence forms. Additionally, professional conduct, HIPPA regulations, and charting were reviewed. At the end of the course, the student was required to complete an exam on a standardized patient. This exam was practiced throughout the year in an entirely separate course, called Physical Clinical Diagnosis Lab. Clinic Entry 2 did not include any clinical training or patient contact. The inclusion of Clinic Entry 1 and 2 in clinical training hours appears to be for the purpose of inflating clinical training hours.
99 clinical training hours in clinical laboratory diagnosis, “lab rotation”
In “Clin/Lab” Diagnosis, we learned laboratory diagnoses of clinical diseases. We were taught methods of lab analysis, testing protocols, interpretation of laboratory results and the clinical application of this information. We were also taught clinical laboratory skills, such as microscopy, KOH prep, vaginal wet mounts, semen analysis, stool analysis, and phlebotomy. While this class was related to primary care training, there was no direct patient contact. We used each other’s arms to learn phlebotomy and practiced analysing each other’s body fluids. I remember feeling more than a little self-conscious as I walked to the bathroom to collect a urine or a vaginal swab. I agree that these hours contribute to training, but they do not contribute to direct patient contact hours.
Quality of clinical training and competency evaluation
Our student clinician handbook contained a list of broad medical categories such as cardiovascular disease, hepatobiliary disease, and female gynecological disorders, for which students were required to demonstrate medical competency. Medical competency in these areas was based on the number of appointments a student clinician had with a patient with that category of disease. The number of appointments varied. For example, competency for cardiovascular disease required treating two patients with any type of heart/circulatory disease. Competency for hepatobiliary disease required treating just one patient with any liver or gallbladder disease. Any patient needed to be seen twice to achieve competency.
While students were required to see a variety of primary care conditions in order to graduate, the majority of students never had the opportunity to see an actual patient suffering from such conditions.
Some diseases were very common in the teaching clinic. To the best of my memory, these included irritable bowel syndrome, anxiety, food allergies, fibromyalgia, chronic fatigue, adrenal fatigue, chronic Lyme disease, chronic mononucleosis, chronic back pain, and esophageal reflux.
Less common diseases included hypertension, asthma, hypercholesterolemia, anovulation and menstrual problems, and acute illnesses such as the flu, pneumonia, bronchitis, gastroenteritis, and conjunctivitis. Students used to fight over seeing acutely ill patients as these patients were so rare!
Patients suffering from serious diseases, such as diabetes, cancer, and HIV/AIDS, could only be seen on specific clinic rotations. If students were unable to have direct contact with a mandatory health condition required for competency (due to a lack of patients and a lack of variety of disease in the clinic overall), students could present to fellow students on their clinic shift on the disease/condition to earn competency. A presentation usually lasted about 10 minutes and would cover the basic etiology, differential diagnosis, and naturopathic and/or medical treatments of a condition.
Students were required to achieve physical exam benchmarks, such as a cardiovascular exam, a respiratory exam, a prostate exam, or a neurological exam. Students were only required to complete one exam in each system and may perform the exam on another student if a patient was not available or the student never had the opportunity to perform the exam on a patient. It was not uncommon for students to perform prostate and gynecological exams on each other in order to complete the required examination for competency. And in fact, the instructor of our advanced gynecology class (an elective course) asked the female students taking the course to act as standardized patients. When I learned this, I was happy that I did not register for the weekend elective course. The lack of actual patients to practice examinations significantly hinders naturopathic clinical training.
Sometimes, specific minor medical procedures could be performed in a patient visit. This depended on the available time and the willingness of the supervisor. Procedures I was allowed to perform during visits included: Tb testing, immunizing children and infants, gynecological exams, a prostate exam, sports clearance physicals, well-child exams, intramuscular injections of vitamins and minerals, and an ECG. Minor office procedures, such as suturing, could only be performed on one specific rotation (called Minor Office Procedures) under the supervision of a medical doctor. I was lucky enough to get enrolled in this rotation, and so I had clinical practice performing these procedures. I also took another elective shift, called IV therapy, where I was able to practice formulating, mixing, and administering IV therapies.
There were also clinical competencies for the naturopathic counseling and the physical medicine rotations. The counseling competencies were mostly subjective, such as “student can establish a therapeutic relationship with the patient” or the student can “articulate the therapeutic process.” The physical medicine competencies included demonstrating orthopedic exams and knowledge about physical medicine treatments including: hydrotherapy, electrotherapy, manual therapies, and chiropractic adjustments. It is notable that there were no competency requirements for IV therapies, pharmacology, or minor surgery, and there was no clinical training in emergency medicine (although we were asked basic questions about emergency medicine on the NPLEX). However, there were lengthy competencies for homeopathic medicine!
Lastly, there were graduation requirements that stipulate the number of patient contacts required by each student. Each student needed to have 350 patient contacts, which averaged to about 16 to 17 patients per rotation. Roughly half (176) of these patient contacts must have been as a primary student. Many clinic rotations lacked the necessary patients to reach 350 contacts. I remember students complaining about not having enough patient contacts prior to graduation due to a lack of patients at BCNH. It was possible we might not see any patients during a clinic shift, so we would present on health conditions and complete physical exams on each other for competency.
Conclusion: naturopaths are not qualified to practice primary care
I recognize that it is my opinion, and probably also the opinions of the editors and readers of SBM and other similar venues, that naturopathic “doctors” or “physicians” are not qualified to practice primary care. Yet I hope that my description of the clinical training provided by Bastyr University propels this claim closer to the realm of fact. I find it extremely troubling to have been the victim of so many layers of deceit: the naturopathic medical school promotional material, the education and clinical training, the AANP’s political efforts, and the information promulgated by my former naturopathic peers, colleagues, and elders. (Yes, naturopaths consider some in the older generation who are “influential” to be so-called elders.)
I sincerely hope that I can help shed light on the truth, which is why I decided to start my own blog and recruit others who share my sentiments.
I will continue to write about the many issues in naturopathic medicine. There are gross conflicts of interest in how naturopathic medicine is regulated: the NPLEX exam remains mysterious (though I have submitted exam questions in the past and have some insight to how the exam is put together), the quality of the clinical course work is lacking, and the AANP disseminates false information to lawmakers and naturopaths who don’t think to perform basic fact checking.
In short, naturopathic clinical training is not on par with medical or osteopathic doctors and is in fact far less, in terms of quantity and quality — and also less than nurse practitioners and physician’s assistants. Of the hours that Bastyr provided to me and my classmates in purported primary care training (748 hours), one quarter of this time was spent in case preview and review. The remaining 75% (561 hours) contained dubious diagnostics and experimental treatments that were so embedded within a pseudo-scientific and pseudo-medical practice that the student clinician loses the ability to assess what is truth and what is make-believe. When homeopathic remedies are presented on the same level as antibiotic treatment, the naturopathic student is lost, and I don’t blame them.
I think it is quite apparent that the 561 hours of what I calculated to be “direct patient contact” in clinical training are nothing of the sort that would instill confidence in anyone that naturopathic education can produce competent primary care physicians. There is no way that such training produces better, cheaper or more effective health care than what is currently available. Yet, this is exactly the rhetoric fed to federal and state lawmakers about naturopathic medicine, and it is wrong.
If naturopaths are going to continue to argue that their scope of practice should reflect their training, then they need to accept that their scope of practice should be severely, severely, severely dialed back or they need to conduct a massive overhaul of their training, as the DOs did in the 1970s. Furthermore, naturopaths are not required to complete residencies (except for those practicing in Utah who need one year of residency), which is where any physician will argue the real practice of medicine is learned over the course of multiple-year post-graduate training in a teaching hospital.
Realistically, if I were to practice naturopathic medicine according to my training at Bastyr University, I honestly do not even know what I would be qualified to do.
Melnick, Donald E., 2009. Licensing Examinations in North America: Is external audit valuable? Medical Teacher 31:3, pp. 212-214. DOI: 10.1080/01421590902741163