Riddle me this

Does everyone know the “Serenity Prayer”?  It’s a favorite of 12-Step groups, and goes “God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”  If you’re the sort of person who prays, I think it’s rather simple and lovely.  It helps one keep a sense of perspective, which is an important thing to have.

Anyhow, I know there are a great many things I cannot change.  I will never look like Jake Gyllenhaal.  Billy Bush gets paid scads of money to chat with famous people, and I don’t.  They made a movie out of “Battleship.”  For these and many other reasons, I am forced to accept that the world will never be perfect as I would envision it.  Fine.

One of the things I know I have to accept is both the existence of naturopaths, and that they get to call themselves doctors.  I can rant and rant all I want, but it would be as like spit into the Atlantic.  Best I just learn to live with it.  Fine.

But would you like to know what drives me completely batshit?  That naturopaths are allowed to prescribe real medications in many states.  Whenever I am confronted with that fact in my professional life, it makes my eye twitch in a worrisome way.  To say I object to this practice would be to master the art of understatement.

Every time I have come across a “traditional” (read: real) medication as prescribed by a naturopath, it has always been prescribed incorrectly or inappropriately.  Every.  Single.  Time.  I have seen potent psychiatric medications prescribed with nary a thought to monitoring blood levels.  I have seen antibiotics prescribed for illness against which they are ineffective, and for stretches of time that defy all explanation.  (I will elide the specific conditions for which I have seen these medications prescribed, if you don’t mind.  I’m bracing myself for comments enough already as it is.)  The usages have been not so much off-label as off-planet.  They have done nothing to assuage my concern that naturopaths are not properly trained in pharmacology.

Can someone explain to me why naturopaths are allowed to prescribe medications, or even why they are inclined to?  I don’t pretend that clindamycin (to choose a random example) is “natural.”  Why would they?  I am at peace with their dispensing newt noses or tincture of moonbeam or whatever else it is they’re foisting on their credulous patients.  I promise I will never give my patients a poultice of butterfly tears, and will leave such interventions to them.  I would appreciate their extending a similar courtesy in my direction.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


    • I don’t know that Russell is advocating for the abolition of naturopaths. But he does seem rather hosed off that they can perform services for which they don’t have specific knowledge or training…

  1. Western ideas (or “prejudices”) with regards to how the body reacts to the spirit and how both react to the soul fail to take into account how anti-biotics affect non-corporeal infections.

    If we could have you hold a vial of “Truth” and then test your arm strength, we’d see that your arm flops down demonstrating a weakness to its proximity.

    • That picture leads me to believe that Russell is actually an 11-year old girl.

  2. Tagged as: alternative medicine, naturopathy, woo

    Amid all the political consternation of the day on top of a tough day at work, this made me inordinately happy.

  3. I’d give naturopaths a hell of a lot more credit if they’d admit that most of what they’re doing is playing off the placebo effect. And that if their patient doesn’t get Better, a doctor Ought To Be called.

  4. I think I just figured out how to not get bombarded with trolls when you blog about quackery:

    Make sure that every time you post, it’s on a day with a controversial and historic SCOTUS decision is being handed down.

  5. Ooooh! Here’s a fun one! Should the PPACA cover homeopathy? (Is the answer “just an infinitesimal amount”?)

    • The italicization is a bit too subtle there. Let me try that again:

      Naturopaths prescribe antibiotics?

      • And…the <u> tag isn’t supported. Well played, WordPress. Well played.

        I meant as opposed to proscribing them.

    • I don’t know what you meant to italicize, underline or otherwise highlight, but yes — in some states naturopaths are allowed to prescribe antibiotics, as well as a whole host of other real medications.

  6. I can’t explain and wouldn’t want to defend why naturopaths have prescribing privileges, and I certainly agree that prescribing without adequate pharmacological expertise is unprofessional and immoral, and should be illegal. I have no answer to your riddle.

    And, I somehow feel moved to share that the only times I’ve had a health care provider ask about and counsel me about my food intake and exercise/ activity level, both were naturopaths. I do find myself persuaded by many studies that how much I move and what non-pharm stuff I put in my mouth are significant determinants of my health. So I have come to appreciate naturopaths in my community not for “moonbeam” or “butterfly tears” bur for valuable health care that I see as genuinely complementary to what I receive from my MDs. My two cents….

    • Hi, Niki. It’s always so nice to have you comment. Thank you for sharing a more measured opinion than my perhaps a bit astringent one. I obviously feel strongly about the subject.

      My primary reaction to your comment is exasperation and frustration that nobody but naturopaths has addressed nutrition and exercise with you. That, my friend, is ridiculous. Your MDs (or NPs) should definitely be providing that kind of advice with you, and it’s because medical providers do fail in their obligations sometimes that people feel obliged to look elsewhere.

      I would never want to denigrate the care you’ve received, and by extension your decision to seek it. But what I wish had been the case is that you’d simply gotten the healthcare you needed from providers whose training I would presumably find more sound.

      • Hi Russell, Thank you for your kind reply. Upon reflection I’m realizing that I live in a city with not one but three complementary and alternative medicine professional schools who collaborate with our medical school, and I teach in a masters of clinical research program which draws faculty and fellows from those schools as well, so I am exposed to a particularly skewed sample of research-oriented CAM practitioners. I am realizing (in part from your post) that my experience is not the norm. And I really do share your concern for the safety of your patients– the examples you shared are horrifying to me, and it sounds like the tip of the iceberg of what you have observed.

        Tod and I were just talking about his hypothesis that it’s a variance issue, that naturopaths might display a wider variance and range of knowledge and skill. I suggested that the same might be true of MDs. I want to believe that the professional peer discipline process among MDs works and that patients get protected from care by MDs who are similarly out-of-scope and incompetent to the naturopaths in your examples.

        This line of conversation is also getting me to search my memory for disconfirming evidence (to my experience of naturopaths standing out as the only practitioners who’ve counseled me knowledgeably about food and exercise health impacts). The counter-example that just popped up for me is our beloved pediatrician who, after treating our younger son for back-to-back ear infections from 12-18 months, both referred us to the otolaryngologist for a surgery consult AND responded to my question about the possibility of a milk allergy (he had switched from mother’s milk to cow’s milk right at one year) with a very encouraging “it could be (that ear infections resolve with removing dairy from the diet) – we don’t have the data but I’ve seen it in my practice” and she encouraged us to try it and counseled us about what to look for in alternative beverages that would have the right balance of nutrients for our growing kid. (The specialist was ready to put tubes in, but we decided to wait and see and the ear infections did indeed cease when we took him off cow’s milk.)

        And, in the spirit of full disclosure, I probably should have added that the primary care MD I now see is indeed knowledgeable and proactive about nutrition and exercise with me– it’s just that it took me decades to find her. And it really was two brief consults a decade earlier with two different naturopaths that occasioned my own personal “ahah” moments on those two aspects of health “care”.

        I continue to look forward to reading your reflections on all things, Russell, life and health care (and the life and concerns of a health care provider). I look forward to your next post!

        • I do not labor under the delusion that the medical profession is not rife with incompetents, sad to say. There’s an old saw about what you call the schmoe who graduated last in his class in medical school (answer: “doctor”). I know way too many doctors to believe we are somehow immune to incompetence, or that our ability to police ourselves rids us of the out-of-date or inept. Hell, I know myself too well to believe doctors are infallible.

          For me, it’s a question of the frame in which the care is established and delivered. Allopathic medicine is premised upon the scientific method. Now, even the scientific method and statistical analysis can be manipulated and misused, so I don’t think it’s some magic formula that always gets things right. But it’s easily the best paradigm we have for answering questions about human physiology and disease.

          So many complementary or alternative providers… well, I’m not sure what frame they use to establish their treatment protocols. How are their methods validated? What kind of scrutiny is applied to their treatments? How do they test and retest, how do they measure the efficacy of what they do? I have yet to hear an answer that is at all satisfactory.

          If the CAM providers in your area are committed to research and work with “traditional” medical schools, then who I am to deride them? They’re working within the same frame that I am, just with a different collection of gewgaws and potions. I know my regimens don’t always work, and I’m willing to admit the possibility that sometimes theirs might. But unless they arrive at their destination using the same processes that I understand and respect, it will be hard for me to take them seriously.

          • Russell, when you use Allopathic medicine to describe evidence-based medicine, the $CAMsters win.

            I’m not sure who came up with this first, but it is still true:

            Q: What do you call alternative medicine that works?
            A: medicine!

          • Fair enough, Liz. I used “allopathic medicine” merely because I (respectfully) have some of the same concerns about osteopathic manipulation, and wanted to be specific about the perspective from which I deliver care. But you’re correct that “evidence-based medicine” is probably the better term.

            In any case, I’m all for incorporating whatever is effective in the care of my patients into the regimens I prescribe or recommend. All I ask is that the methods prescribed have been subjected to the same rigorous scrutiny as the medications I prescribe.

          • It’s just that reading or hearing an actual trained physician using the word “allopathic” is like fingernails on the blackboard to me.

            But I’m probably hypersensitive this week, because I’ve been reading too much anti-vaccine literature. I need a unicorn chaser..

          • > I’ve been reading too much anti-vaccine literature.

            I admire you your tenacity. I had to quit. It was giving me medical problems.

  7. I was at a Palliative Care conference a couple weeks back with a naturopathic provider (I refuse to use the honorific term) in the vendor hall. I was shocked even to see them allowed in the building.

  8. Russell, what do you think about the PPACA provision that Republicans only get coverage for naturopathy?

  9. How do these people get malpractice insurance?

    I would think that this would be a more-than sufficient deterrent, given that malpractice insurance is prohibitive for standard doctors. Hasn’t somebody sued a naturopath into debtor’s prison yet?

      • Oooh a research project! I’ll ask a couple of skeptical* attorneys I know.

        *skeptic, in the sense that Tim Farley (@Krelnik) uses it:

        “Skepticism is the intersection of science education and consumer protection. We help people learn from science to avoid spending their money on products and services that do not work.”

    • I imagine much more goodwill on the part of the allopathic patients than in the current-paradigm-of-science-based ones.

      That could be my prejudices bubbling up to the surface again, though.

      • OK, something has clearly changed in the connotations of the word “allopathic” since I first learned it. My understanding has always been “allopathic = MD, osteopathic = DO, homeopathic = witch doctor.” But clearly that word does not mean what I think it means. Can someone please enlighten me? Seriously?

        And I think you’re right, JB. It’s probably a similar dynamic that prevented a lawsuit when that Gaskin woman (perhaps you remember my home birth post? it attracted some notice?) was responsible for the death of an infant, but didn’t get sued.

        • I figured he just said allopathic instead of one of the other pathics, which he meant to say. My understanding is the same as yours.

          I am actually a fan of DO’s, though… not so much of homeopaths. By far, the most communicative doc I ever had was a DO, and I’ve noticed some personality difference (if nothing else) with Clancy’s DO colleagues (she’s an MD). That can’t hurt when it comes time to sue or not to sue.

          • I’ve worked with some great DOs, and respect much of their training. I don’t want to paint with too broad a brush. But I have concerns that the manipulations they perform are no more evidence-based than other, wackier forms of CAM.

          • To be fair, I also have the advantage of coming home to a doctor who can critique the doctor I just saw, so I don’t have to worry too much about the weird stuff.

        • From Kimball Attwood at Science Based Medicine (Homeopathy & Evidence-Based Medicine)

          “Allopathy” was the term coined by Hahnemann to dramatize the contrast between homeopathy and its competition. According to Hahnemann, “allopathic” medicine sought to give only medicines that suppressed symptoms:

          Frequent Science-Based Medicine commenter Jan Willem Nienhuys (I don’t remember if he’s an MD or not)

          A small aside: Weil refers to “allopathic medicine”. The term “allopathic” is pathognomonic for brain rot. Originally it was coined by Samuel Hahnemann to indicate the evils of 18th century medicine, as opposed to his homeopathy. The etymology for “allopathy” was medicine that does always something inappropriate. More specifically: treatment with bloodletting, purgatives, emetics, klysmas, cupping, artificial ulcers, scarification, acupuncture, moxibustion, cauterisation and etching, and “drugs” consisting of crazy herbal mixtures and/or metallic compounds (such as lead or copper oxide), in general, “dangerous, violent medicines”. In short, what we nowadays call naturopathy.

          The chiroquacktors use the word allopathy a lot to disparage medicine (as opposed to their fantasy world).

        • Wait, allopathic means current-paradigm-of-science?

          Okay, then the fault was mine for misunderstanding.

          I assumed that “allopathic” meant “fake” because I assumed that the real term for medical science was “medical science” and it was only the wacky shit out there that required latin names.

          Yeah, I completely misread that. MY FAULT! (Here’s from the wikipedia: It was coined by Samuel Hahnemann (1755–1843), a homeopath, in 1810. Although “allopathic medicine” was rejected as a term by mainstream physicians, it was adopted by alternative medicine advocates to refer pejoratively to conventional medicine.)

          It sounded like it referred to something bad so I ran with it. I just didn’t parse that it sounded bad because it was a pejorative term generated by the nuts.

          Mea culpa. I’m sorry.

        • The case I remember was the child who died from drinking Odwalla Organic Apple Juice that had not been properly cooked… and I, for the life of me, could not imagine *NOT* suing the company until they had to sell the copper in the fixtures.

          The parents did not sue.

          I imagine that their reasons had analogies to religious faith. Nothing else makes sense to me.

  10. NDs are allowed to prescribe drugs and want to because they want all the privileges that MDs have without having to earn them. Perhaps this is because they need patients while many MDs are turning them away.

    NDs have a very successful marketing/lobbying campaign going on across N. America in which they proclaim that they graduate from 4-year naturopathic “medical schools” where they get the same education that MDs get in their medical schools. They tell you the number of hours they spend in classes with titles like “pharmacology” and that they are trained as primary care physicians.

    Many NDs actually believe this. They think because they use a few approved drugs that they really do provide “science-based therapies” completely missing the fact that science-based therapies are based on evidence while most of their “remedies” and “therapies” are pulled from a hat, have never been adequately studied much less proven safe and effective or have been shown to be useless and dangerous.

    I have a blog on this: http://rosemary-jacobs.blogspot.com
    Here is what got me interested in the topic. http://rosemaryjacobs.com/naturopaths.html. Be sure to scroll to the photo at the bottom.

    Admittedly this is very frustrating and NDs right now have politicians advocating for them, but, call me naive, I think that if we can get the facts to the public, NDs can be prevented from using legend drugs and impersonating MDs.

  11. So this has been percolating in my brain all night… but I need an answer to a question before I can really hammer it out.

    Around what year was the “break-even” point for medical science? That is, at what point did it officially start doing more good than harm? I imagine it’s not before antiseptic practices were adopted by the medical community… or is that a bad assumption on my part?

    I ask because there probably is a break even point (and I’ve heard it suggested that it was around 1910) and if that is the case, then it would make sense that a homeopath (who, essentially, does nothing at all) would think that his medical science is preferable to allopathic medicine prior to this break-even point.

    But that argument hinges on when the break-even point was reached… and I don’t know when that would be.

    • I think that depends a lot on how good is measured; whether in individual outcomes or as an aggregate.
      From the planetary view, I think old Terra might be a bit better of if humans still had a lifespan of about 52.
      Those somewhat older than myself might take issue with that notion.

    • Your question makes me wish I had paid more attention in my history of medicine class. I really don’t know when the “break-even” point (as you say) came, and suspect it was more like a gradual shift than a particular moment. If I were to give any one person and his work credit for bringing about the change, I’d say Louis Pasteur.

      • Oh, I’m a huge fan of vaccines!

        I’m merely wondering about the point at which we finally learned enough about medicine to know what we’re actually doing when we’re actually doing stuff… and, prior to Lister, doctors would do such things as wear the same white coat in the morgue where they did post-mortems as they did in the birth room. (The blood-spattered coat was a sign of status, you see.)

        In a pre-Lister universe where doctors did not want to change their coats because they were a doctor, damn it, and they wanted to *LOOK* like a doctor… homeopathy might not be as crazy as it is in 2012.

        • And, I suppose I should explain, I’m a big fan of trying to figure out how and why stuff that is obviously (to me) “bullshit” (for lack of a better word) might be held onto sooooo tightly by people who strike me as folks who ought to know better. Why would homeopathy have such a strong following? Why don’t more people see it the way we see alchemy or the humors or phrenology?

          There is usually a decent reason (even if it is wrong).

          • Good health outcomes–and, even more, patient satisfaction–track very closely with “feeling listened to.” And modern physicians largely don’t listen, for both cultural and economic reasons. I have a friend who is a GP (yes, there’s still a few of those), and she tells me that insurance reimbursement rates are built on a model of 4-and-a-half minutes spent per patient. What’s more, she says, in actual practice, more than half that four and a half minutes is spent on paperwork and supporting documentation for reimbursement. Moreover, as medical specialization increases, doctors take a more and more mechanistic approach to healing. (One of my favorite medical statistics is that physicians let their patients speak for only 23 seconds, on average, before interrupting them and redirecting the conversation).

            All these “fringy” practitioners spend more time with the patient than traditional doctors. And the ones that succeed are the ones with good social skills: they listen to patient complaints, express empathy, and prescribe “treatment” in response to these conversations. And I would bet that the majority of doctor visits are for things that would have resolved on their own anyway.

            Russell has hinted at this many times in his writings: how often, for instance, does a doctor prescribe antibiotics for a viral infection? How often are medicines or diagnostic tests ordered more for their theatrical effect than their medical effect?

            I’m not a believer in chiropractic, but I know many people that loooooove their chiropractor. And a chiropractor spends, on average, about a half hour with a patient per visit. And he massages them, and touches them, and asks them for feedback.

            So, it’s not really a mystery to me why these “alternative” practitioners persist: they are giving patients what they really want–empathy and human interaction.

          • If that’s the root of it, and it wouldn’t surprise me for a second if it was the root of it, then we’re going about health care reform the wrong way entirely.

          • I suspect that Snarky is largely right.

            I am very lucky to work in a practice that sets aside ample time for well checks. Whether or not we have a lot of time during sick visits depends a little bit on how busy we are, but we feel it’s the trade-off we have to make because we value being very accessible. And I pride myself on getting patients in and out efficiently. But I always, always, always ask parents before they leave if 1) all of their questions have been answered, and 2) if there’s anything they’d like to go over or add. I’m not saying this makes me Deeply Awesome, but I like to think it provides my patients with a sense that I’ve paid attention to what brought them in in the first place.

            And yes, a great deal of what I see patients for would go away on its own. I joke a lot with my colleagues that what I do is make mystic gestures over people while they go about getting better regardless.

          • From Voltaire:
            “The art of medicine is to entertain the patient while nature cures the disease.”

            We’re going about health care reform the wrong way.

          • I guess that there was part of me that was hoping that it had ceased to be a good zinger.

          • Oh, it’s a serious overstatement at this point. (Try explaining to a diabetic that his insulin is mere entertainment, or to a cancer patient that nature will get around to curing her melanoma any day now.) But a lot of what we do is little more than hand-holding.

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