Remember the bad old days when the AMA used to talk about the "cult of chiropractic"? Or the really ancient times when MDs barred DOs from admitting patients?
If so, there is an air of deju vu all over again in Sacramento where California legislators are considering a bill to grant increased prescribing and other privileges for naturopathic physicians.
Naturopathic physicians -- also known as naturopathic doctors, or NDs -- "are trained at accredited, 4-year, post-graduate, residential naturopathic medical programs," notes the . "The training consists of comprehensive study of the conventional medical sciences, including anatomy, physiology, pathology, microbiology, immunology, clinical and physical diagnosis, laboratory diagnosis, cardiology, gastroenterology, gynecology, etc, as well as detailed study of a wide variety of natural therapies."
Residency training is not required for ND licensure, although some NDs do participate in residencies.
The Playing Field
There are currently 16 states, as well as the District of Columbia and Puerto Rico, that license NDs for medical practice. "In these states, NDs practice as independent primary care general practitioners, with the ability to diagnose and treat medical conditions, perform physical exams, and order laboratory testing," the website says.
When NDs were first licensed in California in 2003, they received restricted licenses that require them to be supervised by an MD or DO when writing prescriptions. That restriction "was put in place as a temporary measure to allow a regulatory subcommittee to determine what the independent formulary for naturopathic doctors should be," the association said in an email to 鶹ý.
But in the real world, the ND association argues that the restriction severely limits NDs' ability to practice because most MDs and DOs are not interested in supervising NDs so they can prescribe for their patients. "This restriction places significant limitations on NDs ... who have extensive didactic, practical, and continuing education training in conventional pharmacology," the association said.
Moving Ahead in the Legislature
The bill passed the state senate's Business, Professions and Economic Development Committee by a vote of 5-2 on May 26, and then passed relatively easily through the state senate by a vote of 21-9. It is now headed to the state assembly for consideration.
So what would it do?
- Expand the kinds of imaging studies a naturopathic doctor can order
- Authorize a naturopathic doctor to perform operative procedures relative to superficial lacerations, certain superficial lesions, and superficial abrasions
- Authorize a naturopathic doctor to prescribe, administer, or order Schedule IV, V, and unclassified prescription drugs without physician supervision
The MD Response
Many MD groups in California are concerned about the bill, although few are discussing their concerns publicly. One exception was the Medical Board of California, in Sacramento, which shared a letter the board sent on May 14 to State Sen. Marty Block (D-39th District [San Diego]), the bill's sponsor.
"Although NDs may be well qualified to practice naturopathic medicine that utilizes natural medicine and treatments in a natural approach, NDs do not receive the education and training in naturopathic education programs to safely perform minor procedures and prescribe without physician supervision," wrote Kimberly Kirchmeyer, executive director of the Medical Board of California, in the letter. "Physician supervision helps to ensure that the patient care provided by an ND includes physician involvement and oversight."
"By expanding the scope of practice for an ND and not requiring physician supervision, patient care and consumer protection could be compromised," Kirchmeyer continued. "For these reasons, the Board opposes this bill."
Other groups were more reticent to discuss their concerns. The California Academy of Family Physicians declined to speak with 鶹ý. Kaiser Permanente, an HMO and medical group with a large California presence, confirmed it was opposed to the legislation but declined to discuss the matter further.
The California Medical Association (CMA) did not respond to several requests for comment, but the CNDA said the medical association's objections "are related to confusion between a licensed naturopathic doctor who has attended a U.S. Department of Education-accredited 4-year post-graduate medical school, passed national board exams, and is licensed and regulated by the state, with a naturopath who is a lay person with no formal training and no regulation by the state."
Not all practicing physicians are opposed to the bill.
, a family physician in Pasadena, Calif., who practices with four NDs, testifed at a committee hearing in April that he "is continually impressed with the rigor of their clinical training ... I've never had an opportunity to be concerned because they were undertrained in any area, including pharmaceuticals."
Several NDs who testified at the hearing pointed out that because they cannot prescribe without supervision, they also cannot independently reduce a medication dose when a patient is getting better, since in order to change dosage they have to legally be able to prescribe the drug.
Driven by Physician Shortage
Block told 鶹ý that ironically it was the CMA that drove him to write the bill. "For my first 2 years in office, the CMA would bring a delegation in and tell me to vote against single-payer [healthcare] in California because we didn't have enough primary care physicians to care for everybody if everybody got covered," he said in a phone interview.
"Frankly, they were right, and now that the federal government passed the [Affordable Care Act] and we have coverage for most everybody, we don't have nearly enough primary care physicians in California," Block continued. "So do you just let people be covered and not have care, or do you find other ways to care for people?"
Although he is a proponent of putting more money into AAMC-accredited medical schools and using loan forgiveness to encourage more primary care physicians to practice in underserved areas, "that's not going to make up for the [physician] shortage, and that's where we have to expand the scope" of providers such as naturopathic physicians to let them do more than they are doing now, Block said.
He noted that tens of thousands of Californians currently have NDs as their primary care physicians, and yet if someone has a [nagging] cough or gets diarrhea and needs a prescription, "these doctors' hands are tied. Instead, they have to send patients on referral to an MD, and it often takes weeks or months to get an appointment and a lot of patients just don't go at all."
Block also said he recognized that NDs do not have training equivalent to MDs and because of that, "we're not asking for equivalent scope. This bill allows them to prescribe level IV and V drugs but not drugs that have potentially more harm. It allows them to remove warts and skin tags from parts of the body that aren't the face, but doesn't allow them to do major surgery."
If it is passed by the state assembly and signed by the governor, the law would become effective at the beginning of next year, Block said.
This story was updated to reflect that some naturopathic physicians do undergo residency training.