Prescriptive Rights for NDs

The recent announcement that Ontario naturopathic doctors will be granted expanded prescription rights has initiated discussion around natural medicine’s role in our health care system. Discussion, including both positive and negative statements, is a good thing as it sheds light on what, in my humble opinion, is an important topic. A recent opinion piece entitled, “Naturopathy a prescription for quackery,” published by the National Post was particularly critical of the naturopathic profession. What I find most offensive about this article is not that it challenges the idea of prescriptive rights for naturopathic doctors, but that its arguments are not factually based, and therefore serve to spread misinformation about the naturopathic profession. Although clearly meant to be inflammatory in nature, Mr. Gavura’s post provides an excellent opportunity to educate individuals about naturopathic medicine and our reasons for seeking prescriptive rights. In the following lines I wish to address, what I feel, are some of Mr. Gavura’s most unfounded objections to naturopathic doctors receiving prescriptive rights. (Objections are quoted from his op-ed piece and are only numbered for ease of reading).

Objection #1: “… the Ontario government is poised to give another type of magician — the naturopath — prescribing rights.”

To become a naturopathic doctor an individual requires at least 8 years of education, including an university pre-medical degree and four years at an accredited naturopathic institution, such as the Canadian College of Naturopathic Medicine (CCNM) or the Boucher Institute of Naturopathic Medicine. In order to become licensed a naturopathic student must pass rigorous standardized North American Board exams and jurisdictional board exams. Naturopathic medicine is currently regulated as a health profession in six provinces and is governed by regulatory colleges similar to medical doctors, pharmacists and dentists. To refer collectively to a health profession as “magicians” insults and negates a licensed naturopathic doctor’s skills and knowledge which have been acquired through years of hard work and extensive training.

Objection #2: “… reams of evidence discrediting their approach to patient health”, “… unscientific and incorrect idea of health.”

What and where are these “reams of evidence”? No references are given to support this blanket statement. One of the most common criticisms leveled at natural medicine is a supposed lack of evidence-based research supporting its use, leading to the assertion that it is “unscientific.” In fact, there are more and more clinical studies coming out each day examining the effectiveness of natural medicine. The department of Research and Clinical Epidemiology at the Canadian College of Naturopathic Medicine “is currently conducting seven clinical trials and fifteen systematic reviews of the literature including guideline development for patients.” Recently, Canada Post discovered the numerous benefits of naturopathic medicine. Results from the Canada Post study were so positive that there is now a specific program designed to train naturopaths in treating the unique concerns of postal workers.

Objection #3: “… popular naturopathic treatments include reiki (magical energy healing), even hydrotherapy (flushing the colon with water). Given the questionable curriculum …”

Reiki and colon hydrotherapy are not part of the curriculum of the ND program.

Mr. Gavura goes on to dismiss the use of Traditional Chinese Medicine, a key modality of naturopathic medicine. Even the World Health Organization aims to “support and integrate traditional medicine into national health systems.” Clinical evidence exists of acupuncture’s benefits and its mechanism of action has begun to be explained through scientific methods.

Objection #4: “Canada’s only naturopathy school is not affiliated with any university, medical school or publicly-funded hospital.”

Firstly, Canada actually has two naturopathic schools, which I referred to earlier in this post. Secondly, CCNM has collaborated with numerous institutions, including the Hospital for Sick Children and John Hopkins University, to name but two.

Objection #5: “… a credulous approach to evidence leads naturopaths to advocate all types of bizarre treatments for real medical conditions: cleansing diets for eczema, ginseng to treat cancer”

Here, again, it is science – which Mr. Gavura decidedly believes to be absent in naturopathic medicine – that will prove the legitimacy of these natural therapies for the above proposed uses. Hypoallergenic diets have been shown effective in both the prevention and treatment of atopic dermatis/eczema. And ginseng is best known to be effective in gastric cancer treatment, although its anti-inflammatory properties may prove effective for other types of cancer as well.

And what about therapies that naturopathic doctors have long been using before they became “scientifically proven” and popular in the conventional medical community, such as probiotics and fish oil? Did the effectiveness of these therapies cease to exist prior to being backed up by scientific evidence? No one can argue the health benefits of proper nutrition and exercise in the prevention of numerous illnesses, from cardiovascular disease to cancer. Having extensive training in these areas provides naturopathic doctors a unique ability to educate patients about preventive medicine.

The double-blinded placebo controlled study is viewed as the “gold standard” in evidence-based medicine and rightly so as it has been an indispensable tool in the advancement of medical research. However, it too is fallible and has its limitations, as witnessed in complications arising from various pharmaceuticals (for example, Vioxx). Naturopathic medicine is a holistic medicine. Naturopathic doctors treat the individual, not the disease. If a patient I am treating does not fit into the limited inclusion criteria defined by a clinical study should I still prescribe that particular medication purported to have benefit for a particular condition even though it may not apply to the individual? May be, but may be not. The point is that sometimes the double-blinded placebo controlled study isn’t the “be-all and end-all” and, as clinicians, we need to go beyond the research to the individual person. Can you fault a health care professional for trying to treat a person holistically, for choosing to believe that the patient sitting in front of him/her is more than just the symptoms they present to his/her office with?

After extensive analysis and review, HPRAC, the government’s advisory council, determined that naturopathic doctors have the training and qualifications to safely prescribe. The main reason for seeking prescriptive rights is due to the fact that more and more natural substances are being placed on prescriptive schedules. For example, doses of vitamin D above 1000 IU, the herb rauwolfia and L-carnitine are currently all restricted. For the safety of patients it is agreed that these substances should not be available over-the-counter; however, who best to prescribe these natural therapies if not the profession who is uniquely trained to use them? If a patient comes to our office with high cholesterol, for example, we are not seeking prescriptive rights to be able to prescribe a statin drug. The goal is not to change the manner in which naturopathic doctors currently practice, but rather to ensure we are able to practice as primary care providers and that the tools we traditionally use to practice are not taken away from us.

The list of substances available to naturopathic doctors has yet to be determined and will ultimately need to be approved by Ontario’s health ministry.

There are good and bad, competent and incompetent in every profession. Can you trust statements that paint everyone with the same brush? Perhaps some of the above objections come from a fear of the unknown. If there is any truth in that I invite any one who shares these objections with Mr. Gavura to have a conversation with their local naturopathic doctor.

I also wonder how much of this stems from territorial concerns. Some medical doctors voiced concerns about nurse practitioners or pharmacists receiving prescriptive rights, some chiropractic doctors voiced concerns about physiotherapists being granted the ability to order imaging studies, and on and on. What about what is best for the patient and working together in the best interests of the patient? Some patients may choose strictly allopathic medicine, some may choose strictly natural medicine, and likely even more may choose an integrative approach, the best of both worlds. At the very least they should be offered fair and objective information, free from any fear-mongering, to be able to make an informed choice.

As Stuart Chase said, “For those who believe, no proof is necessary. For those who don’t believe, no proof is possible.” Perhaps conventional and natural medicine represent different paradigms, one no worse or better than the other. Regardless, we each still have the same ultimate goal – the health of our patients. Why don’t we focus on that?

For further information please visit the Ontario Association of Naturopathic Doctors‘ website.