So naturopaths want to be licensed to practice "primary care". I've come down pretty hard on this idea, but one of my colleagues is asking me to reconsider for some pretty good reasons.
If we license them as PCPs, then they must be held to the same standards as MDs, meaning they must provide insurers including medicare with PQRI data on quality measures and outcomes, and they must buy malpractice insurance (and lots of it). I have a feeling that as when they have bad outcomes and are found to not be following the standard of care, the trial lawyers can make a few more boat payments.
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That has not been the case in jurisdictions which have done so. The various "alternative reality" practitioners have been set up as answerable to their own regulatory boards. These have (AFAIK) been total rubber stamps, up to and including cases of patient death.
Unfortunately, the regulatory boards for such things being made up of rubber-stamping NDs is just the tip of the iceberg. Big problems abound:
1. The Standard of Care in Naturopathy is very ill defined. As medical malpractice is heavily based on violations of the SOC, where do you even begin to litigate this?
2. Legislation that I've read granting legitimizing power to NDs delineates that punitive action against transgressors can only result from NDs performing procedures expressly forbidden to them (i.e. surgery or something). No language to address procedures that were well within the normal range of practice for NDs that lead to harm. See above.
3. Litigation potential will largely depend on the *amount* of medical malpractice insurance NDs are required to carry. Why do you say 'lots of it?' How would this coverage compare to certain high dollar MD specialties (OB, Neuro, etc.) Unless NDs are truly required to carry a comparatively large amount of MI, most attorneys won't bother with them. I guess I can't see what would compel Joe Q. Lawmaker to require NDs to have coverage on the high side--especially as their entire marketing push is on natural, healthy, noninvasive, harmonious treatment.
4. Again, my past reading of statutes in other states indicates that these laws only attempt to regulate licensed NDs. Unlicensed NDs are not held to these standards, and no action will be taken to prevent them from continuing to practice as they always have done. Can you even imagine the same standards for an 'unlicenced MD'?
Unless these issues are addressed thoroughly, I can't get behind the extra level of licensure, as it seems to afford all kinds of unearned legitimacy and none of the corresponding responsibilities or standards of care that are minimally expected of MDs.
I would think that the idea behind increased overall isn't about damage an ND would do through treatment. It's about what the ND would miss!
I agree entirely with your overall point though.
A few years ago, an ND in Utah was charged with practicing medicine without a license after he killed someone in his care. Utah does license NDs, this one just failed the test. His lawyer argued that he would not be in trouble if Utah only gave him a license.
That is chilling- the quack could kill with impunity if he had a license.
The evolution of naturopathy toward just another flavor of primary care might take several decades. So don't bet on any schadenfreude in your lifetime.
Nurse practitioners recenly became independent practitioners in some states. Still their malpractice is a mere fraction of what an MD pays.
I agree with everyone here. Aren't christian scientists pushing for their "healers" to be covered by various state insurance plans? Aren't they also protected from medical malpractice? Idiot lawmakers can easily do the same for NDs.
Defense attorney: "The Standard of Care in Naturopathy is very ill defined. As medical malpractice is heavily based on violations of the SOC, where do you even begin to litigate this?"
Jeffrey Feiger: "Oh yes, let's see. Where should I begin? My client's loved one would still be alive if he received even the minimum of standard of care. Let's start there. We are asking for $20 million."
(OMG, I'm actually identifying with Jeffrey Feiger)
Ah, but unless the practitioner deviated from the treatments NDs are allowed to provide, you can't go there without putting the entire profession on trial. If you're simply trying to sue this single practitioner for damages, and the defense can demonstrate that 1. The patient willing sought treatment from this practitioner, who 2. accordingly treated the patient with the faithfully applied principals and modalities that he or she learned at Bastyr University, I don't think you have a case.
IANAL, though, so I'm certainly not presenting my concept of how something like this might play out as anything like an informed opinion.
I know a lot of you focused on the probability of litigation, but the cost is much more than that. If the N's (I refuse to call them doctors) are diagnostically deficient (and PalMD's previous post kind of shows that), then proper treatment will be delayed. Or better yet, what about prevention (reducing A1C reduces the risk of CVD). And there will be costs for more procedures and treatment because everything got delayed. And...it just goes on.
I see the cynical aspect of allowing these woo-pushing naturopaths to be licensed, but it will take years to clean them out of the system. In the meantime, they'll be harming patients, taking Medicare, Medicaid and private pay money that could be used for real medicine, and then blame Big Pharma for everything that went wrong.
They are quacks, and as such, keep them on the quacking fringe.
Small quibble with M. Simpson.
In general, lowering A1C improves microvascular outcomes such as kidney disease and blindness. Control of BP and LDL-C improves macrovascular outcomes such as coronary disease and stroke.
And somewhere up-thread someone talked about A1C levels.
It's true that too-intensive lowering in some sets of patients appears to increase mortality, but A1C goals of 7.0 are not too low in anyone's book. 6.5 is also probably not too low. Aiming for 4.5-5.0 may indeed be too low for many patients.
I think I recall reading about the EPIC (European Prospective Investigation into Cancer and Nutrition) study showed a relationship between Type II diabetes and cardiovascular events such as MI. Of course, it may be that it's not a causal relationship, instead the same conditions that lead to one lead to another.
I make a more causal relationship because apparently healthy individuals that develop Type II diabetes have a much higher risk for CVD.
So, maybe our quibble is really tiny, but I'd need a peer-reviewed journal article testing this hypothesis. :)
To further muddy the A1C waters, there is talk of using a new measurement to assess blood sugar control: the estimated average glucose, or eAG:
http://professional.diabetes.org/GlucoseCalculator.aspx
For an A1C of 7.0, the eAG is ~154 mg/dL. That's higher than the 'healthy' range of 90-120 mg/dL, but better than 250, 350 or 500 mg/dL (which is where every person with diabetes would be, I suspect, if the 'natural' medicine practitioners had their way).
Having been at 490 mg/dL (and in full-blown ketoacidosis) when I was diagnosed with type 1 diabetes, I can tell you that the only things that helped were insulin, an IV of saline and a highly trained staff of REAL doctors. I shudder to think of an ND waiting around to see if I'd read a book first before deciding to 'heal' me.
I don't think that patients dying and crushing naturopaths under lawsuits and insurance is exactly a positive outcome. One problem is that patients desperate/stupid enough to go to a naturopath with serious problems are not going to follow-up with lawsuits very often, nor are dead patients. The main problem is of course the large number of sick or dead patients. Medical licensing boards should exclude unqualified practitioners up front, not just after a series of entirely predictable catastrophies.
Patients have the choice to seek out treatments that won't work, but this doesn't mean anyone should be forced into legitimizing the treatments.