Licenses Naturopaths, and a
© By Peter Chowka
(October 15, 2003) On September 22, in one of his last actions before he was recalled by voters in an unprecedented special election on October 7, California Governor Gray Davis signed the Naturopathic Licensing Act, which requires the state to begin licensing eligible naturopaths by the end of 2004. The legislation was approved overwhelmingly by both houses of the California Legislature after being introduced and shepherded through the legislative process by the powerful leader of the California Senate, John Burton (D-San Francisco).
The success of the effort to license naturopaths in the nation's largest state, with a population of 35 million, reflects the new power of the relatively small segment of the American naturopathic medical community that favors licensing and regulation of naturopaths (NDs) by governments. That power, demonstrated by the passage of the California law, as in most successful political campaigns, is due in no small measure to large amounts of money being injected into the process. In fact, until the California Association of Naturopathic Physicians (CANP), which led the lobbying for the licensing law, began to raise and spend sizable amounts of money, licensing NDs in the nation's largest state seemed almost unthinkable.
As reported here earlier, the naturopathic licensing law, SB 907, will bestow titles (like naturopathic doctor and ND) on and establish a well-defined scope of practice for NDs - but only for naturopaths who have the appropriate educational credentials to be licensed. The enormously larger number of "unlicensable" naturopaths in California (perhaps 50 times or more larger than the number of licensable naturopaths) will still be able to offer limited clinical services but will be restricted in how they can describe themselves. What they can do for their patients or clients will be less than what licensed naturopaths will be able to do.
Bastyr University in Kenmore, WA, the largest of the five accredited or candidate for accreditation North American naturopathic colleges, actively supported the California licensing proposal. The day after Davis signed the law, an article in Puget Sound Business Journal reported that Bastyr will pursue establishing a branch in California. Thomas C. Shepherd, president of Bastyr, was quoted as saying "California is a bellwether state and licensing our doctors there will have a ripple effect throughout the country. And, of course, it offers exciting new practice possibilities for our graduates, many of who come from California and would like to practice there."
One of the leaders of the CANP licensing effort, Beth Wotton, ND, the association's legislative chair and vice president for Northern California, wrote in an e-mail on August 30, "California has been trying to get licensure for many, many years. . .bills were introduced in 1993, 1994, 1995, and 1999 (most of these were study bills). I would like to think that the legislation is succeeding now because it's good public policy and because it's answering a well-established need for doctors who specialize in preventive medicine and health-promoting strategies that can improve health, decrease long-term healthcare costs, and reduce the incidence of chronic degenerative diseases, such as diabetes and heart disease. Realistically, I think it's succeeding because of the many pieces that fell together at precisely the right moment to create an environment conducive to passing this bill."
A Pioneering California ND Speaks Out
While most pro-licensing naturopaths were celebrating the news about California, some clinicians within the pro-licensing community itself were expressing concerns about the future of their profession. One of them is Robert Broadwell, ND, a senior member of the California naturopathic medical profession. At annual conventions of the American Association of Naturopathic Physicians (AANP), Broadwell has been accorded great respect as an "elder" and has often lectured on the history and philosophy of naturopathic medicine. Nonetheless, in a conversation on August 28, Broadwell - in this writer's opinion - struck a curiously detached note and appeared to have some mixed feelings about the current events. (Robert Broadwell is married to and is in clinical practice with Prudence Broadwell, ND, who was president of the CANP during the 1990s when the state licensing effort began in earnest.)
"I would feel great," Robert Broadwell said on August 28, "if I could honestly convince myself that the [California licensing] bill went through the legislature based upon its merits. But that's not the reality of politics. . .
"The progress is proportionate to the economic input. For example, I would say that in the average month in the last three years, the CANP has spent as much money as we had for any one of the three or four original years when we started working on legislation. In other words, in one month they were spending more than we had available for the whole year back in '93, '94, '95, '96, in through that period.
"It's taken a lot of money that the association [CANP] didn't have in order to hire the people that have the communication lines with some of the more influential people in state politics. . .Also, Bastyr and people that were financial backers of Bastyr have been helpful in promoting the economic aspect of fighting this kind of battle."
Our interview continued:
PETER B. CHOWKA: Is there concern about the California naturopathic licensing law itself - the scope of practice limitations, the need for oversight by MDs, etc?
ROBERT BROADWELL, ND: A lot of the graduates [of naturopathic medical schools] in more recent years have been taught to depend a lot on the formularies and the prescription items. My personal opinion is that anytime we go and insist upon prescription [drug] rights, what we're in effect saying is that our methods don't work, therefore we have to use the prescription drugs. My personal opinion is that they have no place in naturopathy. Naturopathy has no need for them [drugs]. I mean, if I have a person come in with a strep throat, just with homeopathic medicine, within 24 to 36 hours, I expect it to be all history. I have no need for antibiotics - I don't want them."
PBC: What you're saying points to one of the issues inherent in Complementary Alternative Medicine (CAM), which now seems to be the favored term. We seem to be moving away from alternative natural medicine and into an integrated, CAM model where previously alternative professions like naturopathy are now working very closely with, and are allied with, if not considered quite equal to, the allopathic medical system.
BROADWELL: Well, I think they're equal to but should be separate from.
PBC: In my view, they're equal to if not greater than, in terms of effectiveness. But when you look around, at how naturopathic education is evolving, at what the federal government is doing - the door has supposedly been opened to natural therapeutics but I wonder what is coming out the other end,
BROADWELL: One thing we have to be very careful of is what happened to the osteopathic profession when they were accepted in and they were commissioned in the services and all of that stuff. And osteopathy in any meaningful sense doesn't even exist today. And I think we're moving toward that in naturopathy. The more we insist on HMO-type care or the [insurance] coverage care, the more ridiculous it becomes. I refuse to use the term "complementary medicine" in any sense of the word. I provide an alternative in all cases except a few such as in the treatment of cancer where my primary activity is in overcoming the negative aspects of the chemotherapy, for example. I guess you could say that's "complementary." But in 99 percent of the cases that come in and out of this office on a daily basis, it's an "alternative to."
The only way complementary systems of medicine can function in any meaningful way is if the gatekeeper is the naturopath. Because the naturopath has a much better view of conventional medicine than the average MD has of what the alternatives are. So to be a meaningful gatekeeper, it would have to be someone knowledgeable on both sides.
PBC: I have great concerns in this area. I've done a lot of reporting on the federal government's role in the evolution of alternative medicine over the past 25-plus years. I was involved with several of the first advisory panels of the NIH Office of Alternative Medicine in 1992. I have mounting concerns about the direction of the whole endeavor.
My first entry point into alternative medicine was in the early and mid-1970s when it was definitely alternative medicine with a capital "A," when a lot of the original pioneers were still around, and when, for better or worse, it was a them and us situation. The issues seemed very clear then.
Now, things have gotten muddled. Alternative Medicine, or more specifically, CAM, has become a big business. The federal government - It amazes me when I think that the federal government simply through the NCCAM [National Center for Complementary Alternative Medicine] now spends $150 million a year on alt med or CAM. I have to wonder, what are they really doing with that money? When I look at a list of the projects that they fund, I have to wonder.
I recently reported a story on 714X, the innovative alternative Canadian cancer treatment. It appears to have been swallowed up and buried by the NCI'S CAM program which promised over two years ago that it would have the results of a preliminary review of best case histories treated with 714X and it still doesn't have them to this day.
Historically, this is how the Establishment works: They claim they're being nice, they open the door, they let the alternative people inside, and then you never hear from them again. What comes out the other end is a hybrid that has no relationship philosophically or pragmatically to what started.
BROADWELL: Someone was asking me the other day what we could do to keep naturopathy alive. And I said, from my own perspective, you're talking about something that's already dead. Because it's not being taught in a meaningful way in the [naturopathic] colleges today. They've become so preoccupied with their view of crediblity that they've been willing to give up on all of the basic premises. So that is what is going to be a problem for a long time to come.
PBC: Also the money issue is a big one. For example, when Bastyr started holding out their hand to the federal government and asking for multi-million dollar research grants - I think that may have been a Faustian bargain. I recall that the late Nobel laureate Albert Szent-Gyorgyi, MD, PhD (who discovered vitamin C in the 1930s) told me that the purpose of science and medicine today - and this was around 1980 that he told me this - has become "to get grants granted." And today I look at the alt med world and the naturopathic world in particular and I wonder how is it any different than what Szent-Gyorgyi was talking about 23 years ago.
BROADWELL: They get preoccupied also with insurance. Any insurance contract is between the patient and the insurance company. I have not billed an insurance company in over 35 years. Absolutely refuse to. The people who come here, they pay up front, we give them a super bill which is made out, coded, and everything for their insurance company, but everything is for their reimbursement. In other words, the hassle is between the two parties to the contract. I'm an outsider. So I refuse to get involved in that. And people are still waiting to get appointments as new patients. So I don't think it's damaged the practice.
More from the interview with CANP's Beth Wotton, ND:
PETER B. CHOWKA: Will licensing in California change the way (licensable/CANP member-type) NDs practice?
BETH WOTTON, ND: With licensure, NDs will be able to practice as doctors, diagnosing and preventing disease by performing physical examinations and laboratory evaluation, and treating through natural therapies and limited prescribing privileges. In addition, NDs will be able to accept referrals from and make referrals to other health professionals and become part of the healthcare system in a very real way.
PBC: A quick review of the latest version of the naturopathic licensing legislation shows that licensed NDs, in order to prescribe pharmaceuticals, will have to - however you term it - work under or be monitored by MDs. Assuming this requirement is retained after the Assembly-Senate conferencing on the bill next week, does this present any problems or issues for NDs? And is this caveat (MD review/overview of naturopathic practice) unique to California as compared to other licensed states?
WOTTON: NDs will have independent prescribing authority for epinephrine for allergic shock, natural and synthetic hormones, and durable medical devices (e.g., knee braces, barrier contraception). The bill mandates a subcommittee composed of NDs, MDs, and pharmacists to evaluate the education and training of NDs in this area and will make recommendations to the legislature in two years. In the meantime, NDs will prescribe other medications under physician supervision similar to those restrictions required of nurse practitioners. This is uncharted territory for NDs as the other states which allow NDs to prescribe pharmaceuticals grant them independent prescribing authority. It is our hope that this arrangement will formalize the collaborative relationship that naturally forms between NDs and MDs and provide an opportunity for education on both sides.
How important was the role of money and funding in the legislative
process? It is well known that the AANP's and CANP's past efforts
in these areas have been hampered by inadequate funding. Reports
are that the CANP's efforts in recent months have been much better
funded. How did that happen? Where did the money come from?
PBC: What is the CANP's budget these days (I assume that is public information)? Can you estimate or do you know exactly how much the lobbying and licensing efforts cost?
WOTTON: I believe our budget has been somewhere in the range of $250,000/year - but I don't know how much of that has been ear-marked for governmental affairs.
PBC: A source at Bastyr told me several weeks ago that not all of the organizations that represent the so-called unlicensable NDs opposed SB 907. Can you be specific on that. Also, did the California Medical Association (CMA) ultimately oppose or support the bill?
WOTTON: CANP has been in dialogue with the California Naturopathic Association for years (Angela Burr-Madsen and Ed Madsen). Out of respect for naturopathic practitioners who have chosen non-doctoral level education and paralleling the findings of the UCSF's Center for the Health Professions study on naturopathic practice, SB 907 leaves the terms "naturopathy," "naturopath," "traditional naturopath," and "naturopathic practitioner" in the public domain so that these individuals will have a means by which they can describe their practice.
CMA and CANP have been in negotiations for several months and have made great strides in coming to understand each other. CANP took many amendments in response to issues raised by the CMA, however, not enough to bring CMA to a neutral position on the bill. They remain opposed unless amended and would like the scope of practice cut from the bill. Taking this action would defeat the purpose of the legislation and CANP was unwilling to make this compromise.
PBC: Can you describe what SB 907 as law would mean to the so-called unlicensables.
Wotton: SB 907 does not impact the gains made by SB 577, the health freedom bill passed last year, and allows naturopaths to practice as they are trained to do under the Medical Practice Act. Ideally, SB 907 means that another tier of naturopathic practice is available to consumers that will give Californians access to the full spectrum of naturopathic medicine.
PBC: Do you anticipate that licensing NDs in California will have an effect on other states that may be considering licensing?
WOTTON: Yes - I think other states are watching California closely. NDs are recognized on a national level as primary care doctors of natural medicine. NDs have been advisors to the White House Commission [on Complementary Alternative Medicine Policy] Report, the National Council on Complementary and Alternative Medicine, the Institute of Medicine, and, most recently, the Medicare Advisory Council. With natural medicine, public health, and environmental health all converging, NDs are the logical choice for infusing the current healthcare system with cost-effective tools and principles for preventing chronic disease and optimizing health.