During the depths of the COVID pandemic, Audrey Canaday’s health spiraled.

The Lenexa mom started having gastrointestinal issues almost overnight in May 2020. Her body stopped tolerating many foods and in less than two months her weight dropped to 77 pounds. Canaday’s 5-foot-6-inch frame could barely function.

Two stints in the hospital didn’t help and Canaday was left waiting weeks for an appointment with a gastroenterologist. Things got so bad, she had to move in with her parents, leaving her husband and three children — then 7 years, 4 years and 18 months old — behind. 

“I was in a severe state,” said Canaday, now 42.

That’s when she decided to see a naturopathic doctor. Her insurance wouldn’t cover the cost, but Canaday believed in the alternative approach to health care, which promotes helping the body heal itself through diet, lifestyle and natural treatments.

“I was willing to try anything that my husband and I felt like we could afford,” she said.

Canaday’s story is not unusual. Increasingly, naturopathic doctors are seen as a legitimate alternative to traditional or osteopathic physicians and, for some, a welcome change from the long waits, short appointments and complicated financial side of traditional health care.

Naturopathic doctors, who are already licensed as primary care providers in some states, argue that doctors trained in accredited, four-year naturopathic colleges are more than capable of taking on patients as fully licensed providers. And some policy makers are on board, too. 

Legislation introduced this year in Missouri and Kansas would effectively put naturopathic providers on par with primary care doctors, allowing them to perform exams, order screening tests and write certain prescriptions. 

But the medical establishment has pushed back. Naturopathic doctors, they warn, don’t have the same training as medical doctors and rely on methods that sometimes veer outside the lines of evidence-based science. They contend naturopathic providers shouldn’t be treated as if they are traditional doctors.

“Patients deserve care led by physicians — the most highly educated, trained and skilled health care professionals,” the American Medical Association writes in a statement on its website. “Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.”

Meanwhile, patients like Canaday are caught in the middle.

Back in 2020 when she was fighting for her health, Canaday eventually saw a gastroenterologist who diagnosed her with ulcerative colitis, an inflammatory bowel disease. She followed that doctor’s treatment plan, including certain medications. But Canaday believes it was her naturopathic doctor’s alternative approach, overhauling her diet and recommending supplements to help her body heal, that made her better.

“That is what turned my situation around,” she said.

Missouri and Kansas legislation

Naturopathic medicine is not opposed to traditional medicine or treatment. Naturopathic doctors who attend accredited schools are trained to prescribe pharmaceutical drugs. But the practice places a higher priority on less invasive natural treatments, some of which have been criticized as pseudoscience. 

While pharmaceutical drugs may be prescribed “to halt progressive pathology,” whenever possible naturopathic care turns to “safe, effective, natural substances that do not add toxicity or additionally burden the already distressed body,” according to the American Association of Naturopathic Physicians.

But the meaning of naturopathic medicine varies depending on where you live. In states like Missouri where naturopathic doctors aren’t licensed, anyone with an internet certificate could claim the title. But no one in the state, not even those with four-year degrees, has a legal right to call themselves doctors.

In states like Kansas, where they have been licensed since 2003, naturopathic doctors can see patients, but they aren’t allowed to prescribe most prescription medications and face other limitations, which providers argue shackle their ability to provide care. According to the state, only 51 naturopathic providers are currently licensed in Kansas, including 28 who practice there.

But in states like Oregon, where naturopathic doctors have been licensed since 1919, they are recognized as primary care providers, they accept Medicaid and some private insurance and can prescribe medications, order labs and other diagnostic testing.

Currently 23 states and three territories license naturopathic doctors at varying levels. And the profession is actively working to expand its reach. 

This year legislation was filed in six states, including Missouri, to begin licensing naturopathic doctors. And another six states, including Kansas, have seen legislation that would expand their scope of practice.

The Kansas bill, which would have given naturopathic doctors in the state expanded professional capabilities, like prescribing many medications, passed out of a state House committee, but failed in a 58-58 floor vote last month.

The Missouri bill would license naturopathic doctors in the state for the first time and allow them to perform many duties similar to a primary care doctor, including prescribing basic medications. To date, that bill hasn’t been scheduled for a hearing and it is unclear if it will be heard this session.

Rep. Mark Meirath, an Excelsior Springs Republican who cosponsored the bill, said he sees the legislation as a way to help expand the pool of available providers in the state, which is facing doctor shortages across rural communities.

“It just makes sense that we should give the people another safe option for their health care needs,” Meirath said. 

Medical establishment has concerns

But the medical establishment has long fought back against allowing naturopathic doctors to act like traditional physicians, calling into question naturopaths’ training and approach.

Testifying in January against the Kansas legislation, Rachelle Colombo, executive director of the Kansas Medical Society, told the state House Health and Human Services Committee that expanding the scope of practice of naturopathic doctors in the state would be “contrary to the best interest of patients.”

Under the bill, she said, naturopathic doctors “would be able to do traditional, conventional medical treatment, although they are nontraditional, alternative” medical providers. 

Naturopathic providers have also faced criticism for recommending and sometimes selling dietary supplements and vitamins that don’t face Food and Drug Administration scrutiny for safety or effectiveness. And they have been criticized for recommending homeopathic products, which federal drug regulators have in the past warned consumers against using.

Beyond those concerns, other criticism about naturopathic care has been far more pointed.

In testimony two years ago against a Missouri bill to license naturopathic doctors, which was passed out of committee before it stalled, a Kansas City doctor testified that she had seen an infant near death after being under the care of a naturopathic provider.

In written testimony before the House Professional Registration and Licensing Committee, Dr. Joanne Loethen, representing the Missouri State Medical Association, described a severely malnourished 12-month-old child who came to her practice weighing the same as a 4-month-old.

After testing the baby for food allergies, Loethen testified, the naturopathic doctor advised the  parents to “strictly avoid countless foods and formulas.” But the baby’s weight became stagnant and her development lagged.

“Rather than refer to a physician who specializes in growth failure and delays, or even to a board certified allergist if it was truly felt her food allergies were that severe,” Loethen said in the testimony, “the family was instead told to continue alternative remedies and avoid various foods.”

No regulation may be part of the problem

Supporters of states licensing naturopathic doctors contend that situations like the one Loethen described are precisely why states should be regulating the practice. 

“In states like Missouri where there is no regulation at all,” said Laura Farr, executive director of the American Association of Naturopathic Physicians, “anybody can call themselves a naturopathic doctor. As a patient you wouldn’t know if someone has graduated from a four-year medical school, or if it’s somebody who has gotten a five-week correspondence certificate.”

On the other hand, states that do license naturopathic doctors can require certain levels of education and training and establish other standards that protect patients. 

Missouri’s proposed bill establishes a board of naturopathic medicine that would determine the quality of education a licensee must have. The board would administer exams and establish continuing education requirements. And it would discipline providers for misconduct.

Emily Hudson, board president of the Missouri Society of Naturopathic Physicians, said many people who oppose the Missouri bill simply don’t understand the level of education naturopathic doctors receive.

“We are trained in evidence-informed medicine,” she said. “We want to provide good, safe, quality care. And keep patients safe.” 

Under current law, Hudson and other naturopathic providers working in the state can only serve as something like health coaches to the patients they work with. 

”We don’t act as physicians,” said Hudson, who lives in St. Louis. “We don’t diagnose. We don’t treat. I don’t do any physical exam. I don’t touch any of my patients. Basically, it’s generally health advice — speaking to people about the diagnoses they’ve already been given and how I can support them.”

Even in that limited capacity, Hudson said, her practice is full. She often works with medical doctors who refer patients to her for nutrition advice and other support. Patients who want to find a more holistic approach to their health also find her on their own.

“Many people are seeking naturopathic care,” she said. “They want more time for appointments, a more preventative approach. And more support for managing chronic conditions.”

All of those are at the heart of the naturopathic approach to health care, providers said. The practice emphasizes finding and treating the root causes of disease, and that often involves spending lots of time with patients, learning about their lives, including every part that could be affecting their health.

“We want to have 20 to 45 minutes, if not an hour, with our patients,” said Dr. Laura Rues, a naturopathic doctor in Johnson County. 

The approach, she said, pays off in healthier patients who require less expensive care.

Similarities to MAHA

Naturopathic providers still face steep resistance in states like Missouri and Kansas. 

But they have expressed hope that they might have allies in President Donald Trump and Health Secretary Robert F. Kennedy Jr. Kennedy’s rhetoric in favor of healthy eating and exercise and against highly processed foods match naturopathic principles.

And Casey Means, the doctor turned wellness influencer whom Trump nominated to be his surgeon general, has embraced functional medicine, which has similarities to the naturopathic approach.

Like the Make America Healthy Again movement, Kennedy’s political calling card, they both focus on healthy eating and lifestyle, including promoting vitamins and supplements marketed to support the body’s self-healing processes. 

In fact, last year, soon after Trump took office, Farr sent a letter on behalf of the American Association of Naturopathic Physicians noting the similarities and urging federal policy changes that would promote naturopathic practices. 

“For over a century,” the letter said, “naturopathic medicine has offered a distinct approach to health care, prioritizing disease prevention, health promotion and patient-center care.” 

The letter went on to say that naturopathic doctors employ “a range of evidence-based, cost-effective therapies that resonate deeply with the MAHA platform’s vision.”

To be sure, not everything matches up. For example, accredited naturopathic medical schools follow evidence-based science, including related to vaccines, Farr said. But many in the Make America Healthy Again movement, including Kennedy, shun them.

“Vaccines are taught in all of our schools,” Farr said. “There is a heavy emphasis on having a doctor-patient conversation … related to vaccines, but that’s about informed consent, part of any doctor-patient relationship. We are not getting involved in the vaccine political controversy.”

Farr also did not mention the Trump administration’s moves to cut funding for healthy food programs, food assistance, Medicaid and health insurance subsidies.

While emphasizing that her organization was not endorsing MAHA or any other political movement, Farr said she sent the letter to point out that parts of the new administration’s proposed policies closely align with what naturopathic medicine promotes.

Her letter asked the administration to:

- Direct the Centers for Medicare and Medicaid Services to require states to credential licensed naturopathic physicians. Currently only some states’ Medicaid programs cover the alternative doctors.
- Allow the Veterans Health Administration to hire naturopathic doctors.
- Protect patient access to compounded medications “including those utilizing natural substances and botanical ingredients.”
- Promote “Food as Medicine” programs and appoint naturopathic doctors to boards and task forces that oversee those programs.

As for her assessment of what the MAHA movement has accomplished so far?

“It’s a mixed bag,” Farr said.

On one hand, the administration invited a naturopathic medical school representative to participate in a recent meeting about how nutrition is taught in medical schools, an important step in medical education, Farr said. On the other hand, Trump recently issued an executive order that promotes the use of glyphosate, a chemical used in weed killer and widely implicated as causing cancer.

But, still, Farr said, any new dialogue about nutrition, lifestyle medicine and food as medicine is “a breath of fresh air.”

“It’s something naturopathic doctors have been talking about for decades,” Farr said. “It finally feels like the rest of the world has caught up.”

Read the original article here. 

Emmayln Pratt has been surrounded by firefighters her whole life, growing up in Kearney, 30 miles northeast of Kansas City. 

Her father is the local fire chief, and he’s part of a long line of firefighters in the family. 

Currently, 26 jurisdictions (23 states plus the District of Columbia, Puerto Rico, and the U.S. Virgin Islands) have licensing or registration laws for naturopathic doctors. (Map courtesy of the American Association of Naturopathic Physicians.)

By Lucas Thomae
While a pre-med student at UNC Chapel Hill, Amy Hawkins had always thought she would continue her education at a traditional medical school. She questioned that path after seeing a loved one struggle to stay healthy despite consistent medical care.

As her ailing grandmother suffered from chronic obstructive pulmonary disease, Hawkins said that she saw a medical system that was more concerned with treatment of symptoms than prevention of disease.

“She was just continually given more and more and more steroids and became less and less healthy,” Hawkins said.

After graduating from UNC in 1995 with a degree in biology, Hawkins took a different path than what she’d initially planned,  instead pursuing her interest in herbal medicine. In 2007, she earned a doctorate in naturopathic medicine from Bastyr University in Washington and started her own practice in Seattle soon after.

Naturopathic doctors look to identify and stop the underlying causes of disease rather than treating symptoms. They avoid prescription drugs when possible, and their treatment methods may include providing diet plans or herbal medicines and supplements.

Naturopathic doctors are trained as primary health care providers and attend four-year naturopathic medical schools. (There are five accredited institutions in the U.S. and two in Canada.) Graduates from these schools then have to sit for the Naturopathic Physicians Licensing Examinations to become licensed.

These doctors are licensed health care providers in the state of Washington, where Hawkins worked for five years. They are recognized as primary care physicians and have the authority to prescribe medications and work in hospitals. The same is true for naturopathic doctors in Oregon, Arizona and nearly a dozen other states.

That is not the case in North Carolina, although naturopathic doctors here have advocated for licensure for years. They argue that licensure would increase patients’ access to a more affordable form of health care while simultaneously protecting North Carolinians from unqualified medical providers. A new bill making its way through the General Assembly this session would establish such a licensing board.

Hawkins returned to North Carolina, her home state, in 2012 to be closer to family. She said the move “was not the best decision for [her] career,” since she lost the primary care and prescribing privileges afforded to her by licensure in Washington. Hawkins set up a new practice in Wilmington where she specializes in women’s health, but the scope of her practice is severely limited compared with what she used to be able to do in Washington.

Now, as president of the North Carolina Association of Naturopathic Physicians, Hawkins hopes that will soon change.

Healing Arts Commission
There have been several attempts to license naturopathic doctors over the years, but an unwillingness from state lawmakers to create new licensing boards has prevented much movement. The latest strategy from the sponsors of House Bill 557 — and its companion, Senate Bill 513 — is to group several kinds of alternative health care providers into one licensing board.

Dubbed the “North Carolina Healing Arts Commission,” this board would license and regulate naturopathic doctors, music therapists and reflexologists. Each group has separately advocated for licensure in past legislative sessions.

The American Music Therapy Association defines music therapy as “clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship.”

Reflexology is an alternative medical practice which involves the application of pressure to the feet, hands and ears. The Reflexology Association of America claims that these techniques “stimulate the complex neural pathways linking body systems, supporting the body’s efforts to function optimally.” There are 15 certified members of the North Carolina Reflexology Association. 

There are 14 members of the Music Therapy Association of North Carolina, according to its website. Appalachian State University has a degree-granting program in music therapy. 

Naturopathic doctors are the biggest group, with the state association estimating that there are about 40 licensable doctors in the state.

While the current number of licensable naturopathic doctors in North Carolina is small, Hawkins believes that setting up licensure would attract more practitioners to the state. She says that naturopathic doctors in North Carolina have been steadily leaving to practice in states where they can be fully licensed, like Washington, Oregon and Arizona.

Whether licensure will happen this year depends upon North Carolina lawmakers, who over the past decade have frowned upon creating boards and commissions. In 2012, the legislature contemplated eliminating more than 50 state boards and commissions and downsizing 40 more. Eventually that effort ran out of steam. Nonetheless, the General Assembly has been reluctant to add any regulatory bodies. 

The companion bills introduced this year in the state House and Senate that would do that seemed to be on track in April and May. But the proposed legislation has been at a standstill in committees since then.

Naturopathic medicine is nothing new
Naturopathic doctors have been licensed in Washington and Connecticut for more than a century, and in just the past decade seven other U.S. states have passed legislation to set up licensure for these doctors. Supporters of a similar bill in Wisconsin, the most recent state to create a licensing board, cited the need for regulation as the driving factor for their 2022 law.

Pushes for licensure also are gaining traction in response to an increased demand for alternative medical services and products. There has been a growing acceptance of the practices among the public and scientific communities. The National Center for Complementary and Integrative Health, one of the 27 centers and institutes making up the National Institutes of Health, has a mission statement to “define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care.”

Susan DeLaney, a 1975 graduate of UNC Chapel Hill’s nursing school and a practicing naturopathic doctor in Carrboro, said that public perception of alternative medicine has grown dramatically more positive in recent years.

DeLaney attended the National University of Natural Medicine in Portland after graduating from UNC, then she spent some time in India to continue her studies. She returned to North Carolina in 1987 to practice naturopathic medicine.

“When I first came [to North Carolina], I was considered a quack,” DeLaney said. “But I must say that things have really changed in the past 36 years.”

DeLaney pointed toward acupuncture as an example of an alternative medicine practice which grew in popularity and was regulated to great success.

Acupuncture, a pain management practice derived from Chinese medicine that involves inserting small needles into the skin, first appeared in the U.S. in the early 1970s and since has become largely accepted by the public. Acupuncturists work in hospitals around the country and have become increasingly integrated into cancer care. North Carolina began regulating acupuncturists in 1993, and as of March 2022 there are 677 licensed acupuncturists in the state.

Herbal supplements, a common component of naturopathic medicine, have also exploded in popularity over the past few decades. According to a report from the Nutrition Business Journal, the herbal supplements industry has grown from $4.2 billion in sales in 2000 to $11.3 billion in 2020. The biggest annual change in that growth came during the COVID-19 pandemic, when the industry grew 17.3 percent in 2020 alone.

Still, naturopathic medicine has its fair share of detractors.

The American Academy of Family Physicans’ website states that it opposes licensure of naturopathic doctors. The statement, last updated in September 2022, claims that “naturopathic theory and practice are not based upon the body of basic knowledge related to health, disease, and health care that has been accepted widely by the scientific community.”

The AAFP did not respond to an email asking whether this was still their position.

Britt Marie Hermes, a former licensed naturopathic doctor, is one of the most outspoken critics of the practice. In an April 2020 article published in the Skeptical Inquirer, Hermes said she left the profession after discovering her boss had been attempting to treat cancer patients with a non-FDA approved drug.

“I concluded that naturopathic medicine is a scam,” Hermes wrote. “I was a fake doctor.”

DeLaney said that dangerous incidents like the one Hermes described are why regulation is needed. Rather than disavowing naturopathic medicine as a whole, she argues that practitioners who engage in unsafe or misleading practices should be held under stricter scrutiny by law.

“This is an issue of public safety,” DeLaney said.

A solution to healthcare shortages?
Supporters of licensure say that it not only will protect North Carolinians, but also make primary health care services more readily available to them.

As the licensure bill is written, practitioners would be allowed to use their primary care training and provide basic services like ordering laboratory tests and diagnostic imaging. They would not be allowed to prescribe drugs, perform surgical procedures or diagnose and treat cancer.

Data from the North Carolina Department of Health and Human Services shows that 92 of the state’s 100 counties have some level of shortages of primary medical care providers. The areas with the greatest need are in the eastern part of the state.

“I believe [licensing naturopathic doctors] will add providers in those rural areas where they’re really needed,” Senate Bill 513 sponsor Joyce Krawiec (R-Kernersville) told NC Health News.

However, most members of the North Carolina Association of Naturopathic Physicians are near the state’s urban centers. Hawkins, the president of the association, who is based in Wilmington, is one of the few naturopathic doctors serving the eastern part of the state. She said licensure will make the profession more attractive and draw practitioners to where they are needed most.

The bill doesn’t mention insurance, but Hawkins said licensure could pave the way for insurance companies to start covering naturopathic medicine in the state. That would remove another financial barrier to receiving care.

Naturopathic medicine might also be a more acceptable solution to people who distrust conventional medicine. Hawkins said many of her patients don’t feel comfortable with traditional providers. It was something she noticed when she first began practicing in eastern North Carolina, and it’s a trend that she says was exacerbated by the pandemic.

“There’s a growing distrust of the standard medical system, and unfortunately the outcome of that is that people don’t seek medical care when they need it,” Hawkins said.

By accepting naturopathic doctors into the medical “safety net” of the state, Hawkins hopes that the medical community can begin to build trust with naturopaths and patients.

“If we’re licensed, then we’re part of the system,” Hawkins said. “The MDs and the DOs and the nurse practitioners and the PAs are more comfortable with those referrals. They know us, they trust us, they know we’re licensed — and they know it’s a safe place to send their patients.”

View the article here.

Wisconsin is in the early stages of integrating naturopathic medicine into its health care safety net.

Gov. Tony Evers signed a bill earlier this year allowing naturopathic doctors to get licensed, joining 22 other U.S. states. Naturopathic medicine emphasizes preventive and natural techniques including therapies involving herbs, massage, acupuncture and more.

In July, Evers established a Naturopathic Medicine Examining Board to regulate the practice. The board’s members include Dr. David Kiefer, medical director of UW Health’s Integrative Health Consult Clinic, who said he looks forward to the day medical and naturopathic doctors have integrated practices.

"The more health care providers that we have working on prevention and helping people to stay well rather than let diseases progress, the better," Kiefer said in a February interview with Wisconsin Public Radio’s "The Morning Show." "The more of us that are working in this together in a collaborative way, I think it will help the people of Wisconsin."

Some naturopathic doctors urge herbal remedies, exercise or mind-body nutrition. In other states, naturopathic doctors attend accredited naturopathic medical schools and specialize in clinical nutrition, acupuncture, homeopathic medicine, botanical medicine and counseling.

Creating regulations over naturopathic medicine will take at least two years, said Jill Crista, a Naturopathic Medicine Examining Board member and past president of the Wisconsin Naturopathic Doctors Association. The timeline includes establishing rules, creating a licensing exam and continuing education requirements.

Naturopathic doctors licensed in other states may practice in Wisconsin but with limitations. The new law allows them to diagnose and treat patients, perform minor procedures and order lab tests and imaging studies. They can’t prescribe medications.

At least 16 naturopathic clinics exist around the state, according to the Wisconsin Naturopathic Doctors Association.

Katarina Meister is a naturopathic doctor who works at Lakeside Natural Medicine in Milwaukee's Shorewood neighborhood. She's licensed in Washington and moved to Wisconsin in October to start practicing.

"With the license, I’ll be able to function fully as a primary provider," Meister told WPR's "The Morning Show." "(Patients will) be able to see a provider that has medical training, and has a holistic background and expertise in naturopathic medicine."

Lakeside Natural Medicine opened in 2011 and has multiple naturopathic doctors. Meister said she can provide nutrition and lifestyle advice to patients now but looks forward to expanding her duties further. She is encouraged by the state creating standards and regulations around naturopathic medicine.

"For that license, people will need to take a national licensing exam, they will have to apply for licensure and will have to continue education," she said. "It will be safer for patients to seek out naturopathic care."

Read the article with links here.

Naturopathic doctors are currently regulated in 23 states, plus the District of Columbia, Puerto Rico, and the Virgin Islands. There, the physicians can perform physical exams and order lab work.

Lawmakers in New York are currently discussing legislation that would license naturopathic doctors in the state, provided they have the right training.

Right now, naturopathic doctors in New York, like Amy Cole, can only work as consultants. Cole says as a naturopathic physician, she tries to identify the underlying causes of an illness, often by addressing someone’s diet and using natural substances.

“The example I always give to people, because this is a question that comes up a lot, is if I have someone coming in to me with, let’s say, acid reflux, I’m not saying to them ‘let’s take this herb instead of this acid reflux medication.’ I’m saying ‘why do you have the acid reflux in the first place?’ ” says Cole.

Teresa Figueroa has been a patient of Cole’s for the past several months. The two have been working to address Figueroa’s hot flashes, which she believes have dramatically decreased since seeing Cole.

“I would much rather go to her as my primary doctor than a primary in New York State, but unfortunately, we can’t do that,” says Figueroa.

Cole has been practicing for 11 years. Before that, she went to an accredited naturopathic medical school, where she underwent a national exam. She says being licensed in New York would help her better treat patients and give people a better idea of a doctor’s medical training.

"Right now in the state of New York, anybody can call themselves a naturopath or a naturopathic doctor, and there are some people who may have done a weekend course or a 10-week online course and are using that term,” says Cole, “The problem with that is that there is no distinction between someone who has done that versus someone who has gone to eight years of school and passed national licensing examinations.”

Both the State Senate and Assembly versions of the bill are in committee.

View the article here.

The WNDA has been one of several recipients of the AANP's State Grants for Licensure initiative, which has released $153,000 to support licensure efforts since 2016. The AANP would also like to thank Standard Process, NCMIC & Fullscript for their generous contributions to the State Grants initiative, which helped Wisconsin achieve licensure!

That goal has brought the debate around the field of naturopathic medicine — widely defined by practitioners as a system that emphasizes prevention and self-healing through natural therapies — to the state’s General Assembly. Most recently, both the House and Senate considered bills during the 2020 legislative session that would have mandated the Board of Medicine to develop regulations for licensing naturopathic doctors in Virginia.

While both bills failed in committee, the Senate instructed the Board of Health Professions to conduct a study on regulating naturopathic doctors — one that concluded with a unanimous recommendation for licensure by the board’s Regulatory Research Committee during a meeting in August. But the effort ran into another dead end less than two hours later, when the full board met and voted narrowly — 5-6 — against licensing.

“It was a little disappointing,” said Sarah Giardenelli, a naturopathic doctor and licensed acupuncturist in Leesburg who serves as president of the Virginia Association of Naturopathic Physicians. “I’ve never seen another profession go through this — where the research committee recommended licensing and the full board voted against it. It certainly didn’t feel right to us at all.”

Amid an ongoing global pandemic that’s led to significant revenue losses for many primary care providers, Virginia’s naturopathic doctors plan to carry their fight for licensure into 2021, arguing they could play a critical role in expanding access to care for patients. 

Del. Sam Rasoul, D-Roanoke, who sponsored the House version of the legislation in 2020, said a new bill would be filed in the upcoming General Assembly session. It’s likely to share similarities to previous versions, which proposed a significantly expanded scope of practice for NDs, allowing them to examine and diagnose patients, order clinical laboratory tests, and administer intravenous medication, among other treatments.

“It’s sad to see that politics is what drove this decision, rather than the sound, objective information that was presented by the committee,” he added. Rasoul was referring specifically to objections from physicians’ groups like the Medical Society of Virginia, state chapter of the American Academy of Pediatrics and seven other medical associations that signed a letter opposing licensure for NDs. The medical society, in particular, has long said licensing would give naturopathic practitioners a level of credibility that the profession doesn’t deserve.

“Licensure connotes a level of training that has some scientifically and medically backed substance to it,” said Clark Barrineau, assistant vice president of government affairs for the Medical Society of Virginia. “And for better or worse, that substance in naturopathy isn’t out there for anyone to evaluate right now.”

‘We’re a glorified health consultant’

It’s a view that naturopathic doctors — most spread among the roughly 18 practices listed in Virginia — are fighting against as they work towards licensure. 

Virginia did license providers until 1972, when, according to the state’s most recent study, an ND member of the Board of Medicine recommended deregulating the industry. More than 30 years later, in 2005, the state’s Board of Health Professions first re-examined the issue, with NDs arguing that their title comes with a specific level of education and experience. 

The board’s 2020 study points out that every other state to license NDs— including neighboring Maryland and D.C.  — requires practitioners to hold a degree from a four-year program certified by the Council on Naturopathic Medical Education, an accrediting agency that’s recognized by the U.S. Department of Education. 

They also have to pass the NPLEX, or Naturopathic Physicians Licensing Examinations — a two-part exam that includes questions on basic biomedical subjects such as anatomy, physiology and genetics. A second section involves diagnosing patients, interpreting lab results and administering treatments, including plant-based medicines and supplements. Some states also require NDs with certain specialties to pass additional clinical exams in areas such as acupuncture, minor surgery and pharmacology. 

“The main point is that we have the training and education and breadth of experience that’s needed,” said Maria Rodriguez, a naturopathic doctor who lives in Northern Virginia but practices in D.C., where she’s licensed. 

With her practice in D.C., Rodriguez said she can examine and diagnose patients, which includes ordering and interpreting her own clinical lab tests. The city’s regulations define naturopathic medicine as treatments using “air, water, heat, cold, sound and light,” along with more specific therapies ranging from exercise and ultraviolet light to diathermy — a therapy for joint and muscle conditions that uses high-frequency electric currents to “deep heat” tissue, according to the FDA.

“I actually have a pretty limited scope,” Rodriguez added. “I’m allowed to prescribe natural hormones, so I will do that, but otherwise we have fairly limited prescriptive privileges.” In Virginia, on the other hand, the lack of licensure means she can’t legally perform even routine physical exams.

“I think the healthiest way to put it is that we’re a glorified health consultant,” added Leah Hollon, a naturopathic doctor who also graduated with a masters of public health from Virginia Commonwealth University and opened her own clinic in Richmond eight years ago. It’s frustrating for many in the industry, who say the lack of regulation creates unnecessary barriers for both patients and providers. 

“Right now, without licensing, I’m not even able to use basic evaluation and management insurance codes so patients can try to submit their claims for reimbursement,” Giardenelli said. In written testimony to the Regulatory Research Committee, multiple NDs pointed out that they had to ask their patient’s licensed physician to order diagnostic tests they were recommending — a process that, at best, forced patients to schedule multiple appointments with different providers, and, at worst, ended in outright refusal.

“I do not always have established relationships with all of their providers, and sometimes these providers are not willing to order the labs or to consider other ideas I may have suggested for our shared patients,” Giardenelli added in her written testimony. “I cannot blame them; it is truly odd for me to ask another provider to basically do my job for me.”     

‘It suggests a level of backing that we think, candidly, could cause some harm’

Opponents of licensing, though, often bristle at the idea that NDs in Virginia have the expertise to practice autonomously and refer to themselves as doctors or physicians. While NDs often note that the Council on Naturopathic Medical Education is recognized by the federal government, Barrineau pointed out that recognition as an accreditation agency by the DOE doesn’t mean that the government has approved or endorsed the curricula of programs it oversees. 

One frequent criticism is that naturopathic education is accredited almost exclusively by other naturopathic doctors, without the extensive and multidisciplinary third-party oversight required for most medical and nursing education. In 2014, the American Medical Association developed a module aimed at “assist[ing] physicians in countering the advocacy efforts of naturopaths seeking licensure and/or expansion of their current scope of practice.” It highlighted findings from other state studies of the industry, including a Colorado report that found the NPLEX Part II, the licensing exam, “does not adequately measure clinical competence.”

Barrineau said that results in programs that focus heavily on things like homeopathy — a treatment involving tiny doses of natural substances that has little scientific evidence to back up its effectiveness, according to the National Center for Complementary and Integrative Health. 

Naturopathic medicine can involve a host of treatments depending on the practitioner and the scope of practice allowed in different states, from clinical nutrition to botanical supplements to massage. But the American Medical Association has harshly criticized many of the therapies common within the industry, writing that “the lack of randomized controlled trials and other forms of rigorous scientific inquiry into naturopathic treatments has not gone unnoticed by the medical and scientific communities.”

“The reason we oppose the effort is that if they can say ‘I am licensed by the Commonwealth of Virginia,’ it suggests a level of backing that we think, candidly, could cause some harm,” Barrineau said.

Much of the opposition to licensure in Virginia has also come from other naturopathic practitioners — ones who haven’t gone through a CNME-accredited program or, in some cases, received any form of third-party training. Often called “lay” or “traditional” naturopaths, many oppose licensure on the grounds that it would restrict their ability to practice. But many also say NDs blend natural remedies with conventional medical treatments in a way that can be harmful to patients.

“Allowing them to practice medicine without going to medical school is essentially giving them a license to kill,” Julie Coombs, a member of the American Naturopathic Medical Association — which opposes licensure — said in public testimony to the committee in August. “They think that putting a natural substance such as turmeric in an IV makes it naturopathy, when in fact it does not.” 

Coombs was referring specifically to a case of naturopathic medicine gone wrong — a patient who died after receiving a turmeric infusion from a licensed ND in California.

It’s the kind of example that makes many NDs in Virginia cringe. Giardenelli pointed out that one major advantage of licensure would be the establishment of a regulatory board that could discipline and even de-license providers who harmed patients or ventured outside their scope of practice.

The BHP’s study found that in licensed states, the number of disciplinary proceedings for NDs were generally equivalent with other medical providers. In some cases, they involved providers advertising themselves as NDs without the necessary credentials. Giardenelli said licensing would help prevent that by reserving the title for providers who graduated from an accredited program — a step she said would also help patients distinguish between NDs and traditional naturopaths.

The issue remains a significant point of contention between NDs and many licensed medical groups. Another frequent criticism is that licensure would enable NDs to treat children or patients with specialized needs — groups that require a different level of care than healthy adults. The Virginia chapter of the American Academy of Pediatrics testified against licensing on the same grounds, calling training for NDs “considerably less rigorous than the training for pediatricians in allopathic and osteopathic medicine.”

“We are concerned that children would instead be taken by their parents to naturopathic providers who are not trained to provide this care and potentially serious medical issues could be overlooked,” added Dr. Barbara Boardman, chair of the Virginia AAP’s advocacy committee. 

But Hollon said the goal of responsible NDs is to work collaboratively with other providers, including referrals to specialists and emergency care if a patient came in with a serious condition.

“I would never work with a cancer patient who didn’t have an oncologist, for example,” she added. “It’s extremely unethical and irresponsible. Even if I was in a licensed state, it would be unethical because with oncologists — that is their specialty. They often know about drug trials that are available that I don’t know about.”

‘I think there is a lot of room for providers like us to come in and serve as these frontline practitioners’

Many NDs worry that misinformation, including a tendency to pit naturopathic practitioners against doctors and other conventional providers, is one of the biggest barriers to state regulation. In a letter ordering the licensure study, Sen. Louise Lucas, D-Portsmouth — the chamber’s president pro tempore — pointed to the “confused information related to the stance of NDs on certain care health care practices.”

“One particularly relevant and concrete example: a [Department of Health Professions]  representative mistakenly mentioned in one of our conversations after committee that medically trained NDs have an ‘anti-vaccination standpoint,’” she wrote, “which is inaccurate as in states where vaccines are included in their scope of practice, NDs are administering them as outlined and in keeping with basic healthcare practices.”

And while many of Virginia’s biggest medical groups are united in their opposition to licensure, the same view isn’t held universally. More than a dozen licensed providers, including cardiologists, registered nurses, pharmacists and physical therapists, also testified in favor of licensure for NDs. Dr. Cliff Morris, a cardiologist based in Chester, said he had worked collaboratively with them for more than 10 years and been impressed not only by the amount of time NDs devoted to each patient, but the preventive health services they were able to provide.

“They treat and see the entire person holistically,” he said, adding that “more specifically, I wish that I had received instruction in therapeutic nutritional counseling during my conventional medical training, but it was not in my curriculum.

Like many NDs in Virginia, Morris also said licensing the industry could help address the “social and economic burden” in communities with shortages of primary care providers — a common thread in testimony from patients and other practitioners. More than a dozen counties across Virginia are labeled as “health professional shortage areas” in primary care, with some of the most acute need among low-income communities in rural counties such as Northampton on the Eastern Shore and Tazewell in the far southwestern corner of the state.

Giardenelli pointed to Oregon, where naturopathic doctors are licensed as primary care practitioners and covered by most major insurance plans. While not every ND wants to practice primary medicine, even the AMA acknowledged that some naturopathic programs studied important and multidisciplinary topics such as the effect of diet on managing blood sugar levels — an important aspect of preventive care.

“We focus a lot on prevention and spend a lot of time on individual visits, so I think our skill set is more suited to things like chronic illness,” Rodriguez said. “But honestly, with the way the health care system is headed, as we get more and more licensed and as the shortage of primary care doctors continues to grow, I think there is a lot of room for providers like us to come in and serve as these frontline practitioners.”

Of course, it will largely depend on whether Virginia ends up adopting licensure for NDs — and how the state defines their scope of practice. Some states, like Rhode Island, license the industry but specifically stipulate that NDs are not recognized as primary care providers and are “not responsible for the overall medical care of any patient,” according to the BHP study. Medicare and many state insurance plans still don’t cover naturopathic medicine, though that could change if providers became more ubiquitous across Virginia.

Rasoul’s original bill, after several committee amendments, would have precluded NDs in Virginia from practicing obstetrics or osteopathy — a field reserved for fully licensed doctors, or DOs, whose treatments sometimes involve musculoskeletal manipulation to treat injuries or illnesses. But it would have opened the door for them to perform physical exams, order labs, and prescribe supplements and other non-prescription drugs. 

It’s still not clear whether lawmakers will push for the same scope of practice in the 2021 session. After the full Board of Health Professions defeated licensure in August, several NDs suggested they might opt for a more pared-down approach, which could include allowing them to practice under a collaborating agreement with a licensed physician — similar to nurse practitioners in Virginia with less than five years of clinical experience.

“I anticipate given what’s happened in other states, it will probably be a gradual licensure,” Hollon said. “And I think that’s a safe way to prove oneself and prove one’s profession.” But Rasoul also tied the COVID-19 pandemic — and his own experience with the virus — to the role that NDs could play within Virginia’s medical system.

“My body is still recovering,” he said. “And I wish there was more of a proliferation of naturopathic doctors who could sit here and talk to me about how I can manage the inflammation, make sure I am rebuilding my immune system, and focusing on that more holistic model.”

“At the time, we didn’t have much or any real medication to help,” he added. “So, COVID has taught us the need for expanding our horizons.”

View the Virginia Mercury article here.

In support of the AANP’s number one advocacy goal of achieving licensure of naturopathic doctors in all 50 states by 2025, the AANP is awarding advocacy grants to state associations of naturopathic doctors. Since 2016, the AANP has awarded $115,500 in grants to state associations, and it has pledged another $25K to support licensure efforts in 2020.

This year, applications are limited to states seeking regulation of NDs (not those seeking scope expansions). Preference will be given to AANP members and to states that are closest to crossing the finish line to licensure.

The AANP is pleased to maintain this commitment to materially support state association advocacy efforts. In conjunction with AANP staff, the State and Federal Affairs Committee will award grants based on the information and insights provided in the application.

Who can apply? States seeking regulation of NDs (not those seeking scope expansions). Applications are limited to one per state! 

Previous Applicants: If your state association submitted a grant earlier this year, you do NOT need to fill out a new application. AANP staff will be sending you a copy of your previous application and asking for updates via email.

New Applicants: If your association did not apply for a grant earlier this year, you can access the application by clicking the link below. 

 

How much is the grant for? For this funding cycle, $12,500 is available, and the maximum grant amount is $10,000.00. Individual state grant amounts are determined based on the information and insights provided in the application. Preference will be given to AANP members and to states that are closest to crossing the finish line to licensure.

When can I apply? Now! The deadline for this round of grants is close-of-business Wednesday, October 21st, 2020.

How do I apply? Use this link to apply.

If you have any questions, please contact us at engagement@naturopathic.org!