The “care” aspect of patient care can be challenging for doctors. This is especially true in the face of uncertainty like with chronic or idiopathic diseases. Patients tend to want to know why they are ill. (I know I did.) When patients feel questions are not sufficiently addressed by medical doctors they often look for answers in alternative places, like in the offices of naturopaths.
As such, it is essential to address the ethics of using CAM to diagnose and treat patients. What differentiates between ethical and unethical primary care practices? When, if ever, it is okay to lead a patient down a road of endless tests and treatments in order to find the “root cause” of a disease?
Today’s post comes from a medical doctor who has firsthand knowledge of patient harm that can result from naturopathic care. I encourage all who have asked “What’s the harm with naturopathy?” to read this post and then engage in a discussion regarding the ethics of CAM care.
For privacy reasons, the author requested this post be published anonymously.
Many years ago, I saw a patient in my office for osteopenia (low bone density). This is a pretty common problem, especially in women as they get older. This particular patient had several risk factors- she had a family history of osteoporosis, was thin with a BMI of 20, and had a relatively early menopause.
When I saw the patient in my office, I reassured her that she did not need medication for the osteopenia. I recommended calcium, vitamin D supplements, and weight-bearing exercise. I explained that her osteopenia was likely a result of genetics and an overall low peak bone mass (meaning she likely never had great bone density in the first place) from her relatively low body weight. We agreed that we would meet again in a year and perhaps recheck her bone density at that time.
I saw her back one year later. I was shocked when I walked into the room, because she had lost 20 lbs, putting her BMI at a dangerously low 17. She looked like someone who was chronically ill. She told me that she had been very concerned about her osteopenia, so she got a second opinion from not one, but two licensed naturopaths. In my state, naturopaths are licensed and can prescribe medications. Both of these naturopaths went to accredited schools.
Licensed naturopath #1 gave her multiple supplements, including a “special” calcium that she claimed was absorbed better, a yeast formulation, EPA-DHA, and several other herbs. All of these were sold through her office. She did blood tests for food allergies (please note, this type of IgG testing for food allergies is not validated, it’s basic quackery) and was told that she was allergic to milk, blueberries, yeast, avocados, corn, and wheat, among many other things. Despite the fact that she had been eating all of these foods for her entire life without difficulty, she was put on a strict diet and was basically subsisting on broiled chicken and rice, hence the weight loss.
Licensed naturopath #2 told her that she likely had parasites and a “leaky gut.” She sent off stool samples for ova and parasites. She suggested some sort of “gastric string test” to evaluate her stomach acid. She also recommended multiple supplements (conveniently for sale in her office).
Both of them recommended bioidentical hormones and salivary hormone testing.
She wanted to know my recommendations. She was feeling tired and draggy (not surprising, given that she was starving herself) and was significantly constipated. She had spent several thousand dollars on office visits, supplements and testing.
I was quiet for a few seconds. Finally I said, “Look. One year ago, you walked out of my office as a very healthy woman with some slightly low bone density and a recommendation to take two vitamins and exercise. You went to see two other doctors, and now suddenly you’re a very ill woman with supposed horrible disorders who is not feeling well and is significantly poorer. Do you want to continue down this path?”
She looked at me for a few beats and said, definitively, “No. No, I don’t.”
She never went back to the other doctors. She continues to have osteopenia and still does not need prescription medications.
The human body is complex, and in many ways still a mystery. A good primary care physician needs to be able to evaluate abnormalities and assess what needs further evaluation and what just needs watching. A good primary care doctor has to be willing to accept a certain amount of uncertainty about diagnosis and etiology of disease. As in this case, it can be hard for a patient to accept that some things just are how they are, and just need to be watched. And second opinions are great. If that’s what a patient needs to feel comfortable with the plan, wonderful. However, the ethical doctor is willing to say, “We don’t know what causes this. We don’t know what the ultimate outcome will be. Here’s what we need to do now and here’s what we need to watch.” The unethical doctor makes up diagnoses and orders expensive tests and sells useless supplement for cash out of their office. The unethical doctor is unwilling to concede that some things just don’t have answers, and that’s OK. The unethical doctor will prey upon the anxious patient, pretending to “listen” while actually exploiting their fears in order to make money.
It’s very ironic to me that MDs are decried as shills for “Big Pharma.” I’ve heard we get kickbacks for prescribing drugs and ordering tests (where are my kickbacks??? Where are my checks, I ask you??). I’ve heard that all we want to do is be “pill pushers.” I’ve heard naturopaths describe themselves as being more compassionate, better listeners, and treating the “whole person.” They claim to reverse disease. One of the naturopaths that the above patient saw even claims on her website that she promotes health, not just disease management with medications.
Now tell me, after reading the above story, who is the pill pusher in this scenario? Who is getting kickbacks? Who is the true, ethical primary care physician?
35 Replies to “The Morality of Practicing Medicine and the Licensed Naturopath”
I get extremely frustrated by supporters of SCAM who assert that doctors solely rely on over-medicating patients or resorting to surgery when more conservative measures may work better – which is patently not the case.
In Australia, there has been a significant shift by the medical community to being *more* conservative in their management of complex cases: of recommending *fewer* prescriptions, *fewer* diagnostic screenings and *fewer* surgical interventions. These are good things: they ensure patient safety, and they reduce burden on the healthcare system. This is now the focus of a multi-body recommendation by various EBM-groups called the ‘Choosing Wisely’ campaign. https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756
What I see as a corollary in the altmed scene is the exact opposite: countless bogus tests, numerous intrusive and limiting interventions that diminish patient agency and quality of life, and a sick sense of paternalism which sees practitioners needlessly intervene in what are likely self-limiting conditions.
This is now filtering into patient expectations: my dad (an orthopaedic surgeon) is frequently frustrated by patients who refuse to acknowledge recommendations like weight loss and physiotherapy in the management of self-limiting problems, or who are willing to spend thousands of dollars on naturopathic or chiropractic manipulations who whine at the waiting time for a (bulk-billed) x-ray or MRI. The culture of SCAM is making patients want the same paternalism, diagnosis and over-prescription that altmed advocates claim medicine is responsible for!
It’s interesting how quiet the naturopathy apologists have been about this post.
Along the lines of practice-morality or -ethics:
I find it very interesting that whenever an ND is sanctioned
by a State-level governing body wherever NDs are licensed,
they are only ever gigged on something that is
wrong within the realm of conventional medicine or commerce.
It’s as though the ND governing boards are responding to OUTSIDE pressures.
E.g. there’s the recent Washington State ND MacPherson who as been
charged with “unprofessional conduct”
for allegedly aiding “in sale of illegal hormone injections.”
I haven’t seen an ND, though naturopathy claims to be
a “distinct” practice governed by fundamental principles or values
or rules, ever get sanctioned based upon rules or moral codes which are
particular to naturopathy.
E.g. if there is a “hierarchy of healing” or
“therapeutic order”, if there is a
‘respect the vital force’ and all, if there is a particular WAY as they claim,
I’ve never heard of sanctions against violations of those things.
It seems to be a “do our stuff however you want in spite of
our guidelines just as long as you don’t bring outside heat our way. If you do,
we’ll fry you.”
For instance, nearby where I live in Connecticut, is an ND who
mainly treats autistic children by way of homeopathy, supplements, and basically
a Vega EDS machine which is illegal to use for diagnostic purposes.
If the client can’t come in, their urine is tested to determine the remedy and course
with a staff member hooked up to the machine as a proxy.
All that with no internal heat:
all fine in dandy in a state, CT, whose ND school terms naturopathy “health science.”
I love that idea of testing by proxy. I have a patient who sees a chiropractor who practices “applied kinesiology.” If she can’t make it it, he can test her by proxy by checking his own muscle weakness.
How can people be so gullible?
I quit naturopathy school for basically two HUGE specific things I could not stand and knew I couldn’t study to graduate as they become known to me in the curriculum [and a whole bunch of other things or should I say figmentations]:
homeopathy and AK.
Proxies for diagnosis and treatment.
And I’ll never forget the first time I came across craniosacral therapy in ND school, at an on-campus ‘New England ND convention’, as a hands-on workshop and I thought, being very familiar with the ruse of Scientology:
“oh shit, I’m in a cult.”
I can see the room it happened in, even now, in detail.
Of course, using the term cult is like invoking Nazis as a label — Godwin’s Law and all — but, that’s what I thought and felt and that’s the web I found myself stuck in after I was promised “health science.”
But, I’m an old fogey and speaking of a time around the year 2000.
“When I was young…” [think of Bill Nye’s Old Man voice].
I never understood the mistrust some people have of MD’s alongside the uncritical support of ND’s. The ND’s this poor woman went to clearly do not know what “first do no harm” even means. The laundry list of supplements and protocols they “prescribed” clarifies their lack of knowledge or concern with the health matter at hand.
I am almost finished my MD, and I remember arguing with classmates early in my training about CAM. Many of them were extremely opposed to patients seeking alternative care, and I felt that perhaps it was acceptable if there was no direct harm. A quick skim of naturopathic college websites does present the image of a legitimate education. However, as I’ve continued on in training I have recognized many more of the complexities involved in “integrative” health care, or patients who prefer to follow primarily with an ND, chiropractor, etc. I have seen incredibly sad stories in which alternative care has failed to recognize serious pathology, and has caused serious harm (necessitating extensive medical treatment or utilization of resources). Where I train, the medical system is relatively transparent. We are trained to document carefully, and patients can easily access their charts. There are multiple care providers, especially in hospital settings (PT, RNs, MDs, dietitians) and in most private practices there are several allied health team members. I feel that this also helps create a standard as there are multiple observers and role players assessing a patient’s clinical status.
I wonder about the ethics and moral basis for failing to provide appropriate care to patients, and yet still profiting. I hope the blind faith in unproven and arbitrary treatment approaches is a result of cognitive dissonance; alleviating the extreme psychological discomfort that would result from realizing that these “treatments” are costly, ineffective and exploitative. I deeply hope that in the future, if naturopathy continues to exist and grow as a profession that some amount of transparency is developed, and that at the very least, there is not one sole care provider who can never be questioned or observed. The story of this patient strikes me, as if she chose to not follow with you, she may even have died without any witness.
So you are in your 4 year. The last year and all clinical phase. You should have just finished USMLE part 1.
I never had CAM discussions with others during medical school. It never entered my vocabulary. There is countless studies on the efficacy of acupuncture for pain management. The mechanism on how it worked was brought to light in the late 80s and insurance will pay for it. If acupuncture works for pain management and people do not need oxycontin or a similar med percoset oxy/Tylenol then I as a psychian am happy it works to a degree. Don’t throw out all CAM because some doesnot work.
Some years ago I attended an ACB meeting where a similar case was described in a child. The toddler had diarrhoea which was probably self-limiting and the GP didn’t prescribe anything. The mother took the child to a doctor who was into this fake IgG “allergy” testing, and the tests showed reactions to just about every food imaginable. (I’m not kidding. The slide was packed with words and I couldn’t see a food that wasn’t on it in the time it was on show.) The mother tried to eliminate all these foods.
Two years went by. The little boy was by then in nursery school. He was undersized, underweight, lacking energy, quiet and withdrawn. The nursery teacher was concerned and persuaded the mother to go back to the original GP. Much investigation followed. (The topic of the session was the unrecognised cost to the NHS of “alternative” medicine.)
In the end a diagnosis of simple malnutrition was arrived at, and the full extent of the restricted diet horror exposed. The child was put on a normal diet with no exclusions. He shot up several inches in two or three months, gained a significant amount of weight, and became a normal cheeky little pest in nursery school. The diarrhoea never recurred.
I’d ban the lot of them, personally. Homoeopaths too.
I have an illness with few treatment options. Many patients fall into woo. One woman I love dearly who can afford it has a naturopath, accupuncturist, yoga instructor, weekly cleanses, massages, etc. She is vegan, gluten free and still as sick as any of us, still searching for that missing toxin to cleanse from her system so she may be pure and healthy. In the meantime, she has denounced mainstream medicine as quackery.
Naturopathy needs to be stopped.
Interesting to note that 20 is a low BMI and 17 is dangerously low, linked with osteoporosis. Modern food faddists would have you believe that you can’t have *too low* a BMI.
Here’s an interesting article regarding it. http://www.ncbi.nlm.nih.gov/pubmed/17125421
What really strikes me is that BMI is the modifiable risk factor with the biggest impact on bone density- more than calcium intake, exercise and vitamin D.
Therefore, the naturopaths didn’t just take her money and prescribe useless supplements. They actively harmed her by having her lose weight.
As a naturopath, I actually agree with the article for the most part. The trap everyone (pro- and anti- conventional medicine as well as pro- and anti- natural medicine) is the trap of generalisation. I have had brilliant MDs that I have referred clients to regularly over the years. I have also seen many clients who have been damaged by conventional medicine and responded and recovered with natural medicine. I have also known my fair share of naturopathic quacks. I can tell you that I have certainly experienced some absolutely atrocious ‘care’ from a couple of forever-remembered MDs myself, having to tell them exactly what to do in consultation with me and what to prescribe! So maybe everyone had better get off their high horses and start communicating as humans.
We are really not so different and, working together, could achieve even better outcomes for our patients. I have never recommended many tests and certainly don’t use any machines or gadgets, however I rely on good clinical skills, a mastery of establishing rapport and trust to truly understand who it is that is sitting in front of me and what it is they want and need and are prepared to do – and, perhaps most importantly, knowing my limits.
Naturopaths are not all unethical immoral quacks. I, too, am frustrated by those who are gullible enough to believe a piece of equipment will diagnose and treat with the prod of a button, or that giving dozens of tubs of nutritional supplements will cure everything. A few give a bad name to our profession, as do a few MDs for the medical profession.
Hi Diana, Thank you for taking the time to comment. However, I know it is more than “just a few” that give a bad name to the naturopathic profession. This is easy to see- research the number of ND’s advertising fake diagnostic tests, homeopathy, bogus cures, and the treatment of fake diseases. “Just a few bad” naturopaths suggests that only a small handful to naturopaths subscribe to these unethical practices. In fact, it is the norm for naturopaths to practice how/what they were taught in schools like Bastyr.
I’m sorry, but we really are that different. I went to medical school, you did not. I did a 3 year residency in Internal Medicine at a major medical center, you did not. I practice evidence-based medicine, you do not.
We should now await a response from Diana outlining her medical accreditations and her alma mater. I may grow a beard in the interim however.
You’d do well to remember who has the medical education and who doesn’t.
Actually that is not how cooperative medicine works and in major centers you will have many others help with alternative care. Good doctors listen and if it makes sense incorporate. Nothing is discard as you wrote. Not by a good and well educated medical doctor.
I agree that a few MDs give their profession a bad name; relatively speaking very, very few. But I have to correct a couple of points you raise. Many—most?—self-described naturopaths give their field of endeavour (not profession) a bad name. And of course, the vast majority of naturopaths are simply in the game for the money.
You also shoot yourself in the foot when you claim to have told an MD what he should be prescribing for your putative illness. If that were true, then what justified your decision to consult him in the first place—if you already knew the cure? Your logic is as sound as your pseudo-scientific medicine.
Naturopaths are infamous for obfuscating, re-tailoring, and misinterpreting scientific facts to suit their beliefs. From textbooks to self-help books, web sites, articles in “peer-reviewed” journals, and the marketing literature on dietary supplements, the examples are virtually endless. The contagion of naturopathy is driven by marketers eagerly accepting of whatever naturopaths promulgate. No matter the lack of evidence for a substance in the management or treatment of disease or maintenance of health, in the hands of a naturopath, it becomes a “nutritional” supplement. As one of the most common examples, because a flavonoid may have shown some biological activity in a laboratory animal, all flavonoids, whether conclusively demonstrated to be of value in the treatment of disease or not, become “bioflavonoids”. While I have yet to see bioalkaloids, biocoumarins, bioquinones, or bioacetogenins, the marketing is in before the safety and efficacy of a substance is established for its ethical prescription.
The same sort of marketing ploy is found in the term “Ayurvedic”. Capitalization of the first letter in ayurvedic is entirely without merit, but it lends authority to an ancient, unscientific and archaic practice of diagnosis and treatment. Go to India and you will quickly find that from one school or tradition of ayurvedic medicine to the next, a patient will receive a different diagnosis and treatment, with practitioners vehemently claiming that their school of ayurvedic medicine is the best.
And what about “antioxidants”? People who have bought into the marketing typical of naturopaths are shocked to learn that in high doses, vitamin C is a pro-oxidant, just as they are when they realize that the antioxidant hypothesis of aging, let alone the usefulness of any substance with antioxidant activity in the treatment of all manner of disease, is just that: no more than an idea but for which a fortune is being made and spent on in vitro assays of dubious value.
I know where the chronically ill people are coming from. I’m a chronic pain patient (I have IIH and survived a flesh-eating bacteria) and I’ve been desperate for relief. A lot of people will welcome woo because the promises are sooo attractive. I’ve been guilty of it myself. The woo pushers also know that chronically ill people are desperate enough to spend anything and try anything. I’ve seen it in the support groups a LOT; it’s happened so much that the MLM’ers and woo pushers will tell their reps to go into the chronic illness support groups and pose as “someone with that’s been CURED!” They hang out in the group and when people are at their lowest, the woomeister will say “I know what will help you, PM me!” and then offer up their “miracle cure.” It’s disgusting and makes me want to hit someone.
Wow, that is really low. I should add that anecdote to my patient reference page. Thanks!
Speaking of low:
I think doctors in general need to up their act. There are some very shoddy doctors out there. It appears you are not one of them. People being people, of course there are some shoddy natural health care professionals too. However, because doctors are so closely linked to Big Pharma, to Big Money and to an effort to monopolise health care, I suggest that they do more harm than we do. Yes, this is a bad case scenario, but I suggest there are far more, much worse case scenarios, with many doctors. We ALL need to care and be mindful.
It is an argument that keeps coming up: Naturopaths are good because doctors are bad. That is what you are basically saying? The reason it is a fundementally flawed argument is because health care and health services need to rise or fall on there own integrity. Care provided need to be measured and assessed. The best tools we have for this is science. Bring some science to the table in support of your profession.
“naturopaths are good because doctors are bad”
Ben Goldacre’s classic response to this argument that keeps coming up is “The fact there are problems with aircraft design doesn’t mean magic carpets can fly”.
“However, because doctors are so closely linked to Big Pharma, to Big Money and to an effort to monopolise health care, I suggest that they do more harm than we do.”
In other words, your position is “Physicians do more harm than naturopaths because CONSPIRACY THEORY!”? Really?
Unlike naturopaths who will hitch their wagon to any old piece of quackery so long as there is a buck to be made in it.
Is this your website:
Everything in that post is BS. As a matter of fact, your entire website is a joke, one sentence of pseudoscience and logical fallacy after, all sorts of vague assertions wit no science to back it up. Please show us, with peer reviewed references, exactly what toxins cause exactly which cancers and at what concentrations they become carcinogenic. I can’t wait for ensuing hilarity.
I have to correct at least some of the mindless word salad above:
“However, because natural care salesmen are so closely linked to Big Supplement , to Big Money and to an effort to monopolise fake and usless health care, I suggest that natural care practitioners do more harm than real doctors do.”
There, that makes much more more sense then what spweed out if your rectum and onto the keyboard.
You see, real doctors treat real diseases with proven medicine, whereas you snake oil scam artists treat self limiting conditions and the worried well with nonsense, unproven faith based treatments like homeopathy. Now come back when you actually have some proof of your bullshit otherwise why don’t you just slither off into your snake oil hole of homeocrappy.
I wish you did not post that link. That is one of the most infuriating things I have ever read. A homeopath saylng that doctors do not learn the causes of diseases? What the hell did I do then in my 15 years of university from basic science to clinical. What do homeopathy do? An online course for a few mknths or year? And they have the gall to say they have studied the real causes of diseases. The government should censor these people.
I would argue that it is the other way around. Naturopaths are closely hitched to vitamin companies. Naturopaths make a significant amount of money prescribing vitamins and quack cures to their patoents. It is considered unethical for am md to sell what they prescribe. So how is it that md are so controlled by big pharma. It pisses me off when people like you say this because then the naive public start to think that MD are making money off prescribing. I think naturopaths should not be able to profit from prescribing.
Please explain how doctors are linked closely to big pharma. How do doctors profit from prescribing medicine. (Unlike naturopaths and homeopathy who unethically make money off their prescriptions)
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