We teaching in our schools: Naturopathic primary care

Re: What are we teaching in our schools: Naturopathic primary care
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Jared Zeff, ND
Message 1 of 18 , Dec 23, 2012
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Doctor Van Couvering brings up a significant point"  "1) in Oregon, NDs are going for "primary care doctor" status. Which means learning all the allopathic modalities or risking being sued for malpractice. And because those modalities take four years (and residency) for MDs to learn, and we're trying to learn them in addition to naturopathy, the ND stuff gets shunted aside."

I am a primary care physician.  I graduate NCNM in 1979 as a primary car physician.  In those days we all had to deliver a few babies in order to meet graduation requirements, because we were being trained and licensed as primary care physicians. I was not under the directives or standards of care of the Board of Medical Examiners.  I was not a medical doctor.  I was a naturopathic primary care physician, licensed in a different medical discipline, by an independent and separate Board of Naturopathic Examiners.  These two things are different: conventional primary care and naturopathic primary care.  It is not a new thing that naturopathic physicians are primary care physicians.  We always have been.  Now, there are some among us who want to redefine what that means, and who propose that the only model of primary care is the conventional medical model.  But this position is obviously wrong.  As a primary care physician, for 34 years I have been privileged to sign birth and death certificates.  This is in demonstration of the fact that we are and were primary care physicians.  Just because I can now prescribe a vast array of pharmaceuticals does not mean that I have to practice fundamentally in a different model to continue to exercise my primary care status.  It foes not mean that because I can prescribe pharmaceuticals I have to or am supposed to practice under the standards and guidelines of conventional medicine.  That is absurd.  What would be the point of that, of having a separate and distinct profession that is governed by the standards of a different profession?  Primary care means that I have primary responsibility for my patient, that I am not following someone else's protocols or requirements or decision algorithms in providing care for my patient; I bear primary responsibility; I am primarily responsible, over my own signature.

Primary care naturopathic practice is obviously different from conventional primary care, with different standards, tools and even thinking.  I practice under and within naturopathic medical philosophy.  I not  only know what that is, I have actually advanced it and helped articulate it for the 21st century.  I am appalled that some of my younger colleagues believe that as primary care providers, we are somehow supposed to abandon our root naturopathic philosophy and adopt as different standard of care if we want to become primary care practitioners.  WE ALREADY ARE PRIMARY CARE PRACTITIONERS, AND ALWAYS HAVE BEEN.  But we are naturopathic primary care physicians, and not other profession has the privilege or responsibility of defining what this means for us, only we have the privilege and responsibility of defining what naturopathic primary care is.

A medical doctor would be practicing outside their scope if they prescribed a botanical medicine and/or homeopathic medicine for a patient with a bladder infection.  But I am not, and If I feel it is appropriate to use an antibiotic, that is my privilege as a primary care, naturopathic physician.  I am certainly not required to.  Patients do not come to me because they want me to practice like a medical doctor.  what would be the point in having a separate and distinct profession, with separate licensure boards, etc., if that were the case.

Naturopathic primary care is a field separate form conventional primary care, and always has been, for over 100 years.

Jared L. Zeff, ND
Salmon Creek, Washington


c bye
Message 2 of 18 , Dec 23, 2012
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Jared,

I have a question. Are you saying that if a 90 yo came in with significant uri symptoms, your exam shows no air in one lung, peak flow is significantly diminished, you rx nat med, and she dies from pneumonia you would not be brought up by the Nat med board for not following standard of care, which is give a anti biotic? I ask because this was my patient scenario. I did Nat med, all turned out great, but I remember losing sleep over the fact that she would have a bad outcome. I was fearful for her and for me. Fearful that i would have been brought up by our board for not following std of care, and fearful that our profession would get a black mark that could be used against us.. I did have her sign a waiver stating that std of care was abx and that she wanted to proceed with herbs and hydro etc. I actually almost called you at the time about this case, but I remembered a lecture you gave once about not being afraid to use our medicine, that it works. This lecture is what gave me confidence that I was doing the right thing....and as it turned out I was.

So the question is, if we do not follow allopathic std of care ie this case, and we followed ND std of care, we would not be sued or lose our license ?

Happy holidays to all, enjoy all that is sacred to you

Cynthia Bye, ND
Vancouver WA



James Prego, ND
Message 3 of 18 , Dec 23, 2012
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Cynthia, I challenge you to find anywhere where there is a standard of care for NATUROPATHIC DOCTORS that says we have to prescribe an antibiotic for anything.

I have no doubt you can find them for MDs, but I know you will find none for NDs.

Jim ' an ND not an MD' Prego ND
Islip NY


Dr Bye
Message 4 of 18 , Dec 23, 2012
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So in this scenario if the pt had died you feel confident there would be repercussions?
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Dr Bye
Message 5 of 18 , Dec 23, 2012
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Make that no repercussions.


James Prego, ND
Message 6 of 18 , Dec 23, 2012
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My point wasnt having anything to do with the outcome of a hypothetical case.  my point (and jared's too) is that NDs are NOT held to MD scopes of practice, because that is not who we are, AND there are no ND scopes of practice that force NDs to use antibiotics.

Jim Prego ND
Islip NY


Jennifer Karon-Flores
Message 7 of 18 , Dec 23, 2012
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I am going to jump in here, as I struggle with whether to prescribe antibiotics from time-to-time, as Dr. Bye so succinctly illustrated in her case. One thing I did learn at NCNM (one thing among thousands of things) is that ANYONE can bring LAWSUITS against me at ANY TIME for ANY REASON (emphasis from my jurisprudence class). Scary, but true. So, to think that any one prescribing decision, particularly when I appropriately chart my PARQ and patient decisions, could be my undoing, is crazy-making. I do the best I can, with the information I have at the time, based on my training and the patient's desires. That is the best I can do.

There are decisions that keep me concerned beyond work hours (thankfully those are few and far between). But, cultivating good rapport with patients and their families is my best defense against lawsuits. In addition, I consult MD specialists as needed, give patients their options along with a good PARQ, and chart, chart, chart everything that happened in the visit.

Jennifer Karon-Flores, ND
Portland, OR


Dr Bye
Message 8 of 18 , Dec 23, 2012
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Dr Bye
Message 9 of 18 , Dec 23, 2012
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Jim, You said your " point wasnt having anything to do with the outcome of a hypothetical case." Well My point was. I personally would like to better understand where we stand legally in these situations. What you imply is that as long as we follow our training we are not to be held to the allopathic standard of care. So if this elderly pt with pneumonia died because I chose Nat med instead of antibiotics I would not have any legal back lash. I really would like to hear from some of our elders as to whether there is any precedence regarding this issue. We should all understand where we stand legally. Not that we should practice in fear but we live in a litigious society. That is why MDs order so many unnecessary tests.

Cynthia Bye, ND
Vancouver, WA


drtimgerstmar
Message 10 of 18 , Dec 24, 2012
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Not being a lawyer, here is my understanding.

My understanding is that if you do something that brings you up before the state, that you will by "experts". That is, the prosecution will bring in experts in your field - ie - medicine to "comment" on what you did.

So in your example, say you didn't treat someone with antibiotics and they went into sepsis or pneumonia and died. The state decides to bring you up on charges, so they convene "experts" to comment on your case.

Let's be realistic, who are they going to call. MD's. What will the MD's say? That you didn't follow standard of care for treatment of the infection. Of course it's THEIR standard of care, not ours, but that doesn't really matter. So the point of standards of care for MDs and such is that say the same situation and someone died, the case comes up, the MD experts roll out the standard of care and if the MD in question followed it, boom, case dismissed.

I would assume that you, in your defense, would be able to rebute with ND's who would talk about how we are different, and using herbs or whatever is a classical tradition, etc. Or scrounging through Pubmed, etc to look for justification.

The outcome? I have no idea. Honestly, probably not good. And I think we are taking risks when we treat potentially fatal situations with "our" medicine. That doesn't mean I don't think we should do it. But there is risk.

And I think this stuff can make you crazy if you let it. One person said something along the lines of "anyone can sue you for anything, anytime" and that's true, but it's also true for anyone in any profession in our society. I think if you stay in that fear place it's going to totally destroy you as a doctor.

My $.02:
1. Keep working on your skills, you can always get better.
2. If you feel slightly stretched/over your head, you're probably in a good place. If you feel majorly over your head and/or paniced, get help (either refer or call in someone else to assist)
3. Have a good relationship with the person. If this is the very first time you're seeing the person and it's life or death, or very, very serious, probably best to be very conservative (read go with more allopathic standard of care). If you've been together a while and know and like each other, and you know what they want, it's a different story.
4. The more serious the situation, the closer you stay in touch with them. That probably means sleeping with your cellphone.
5. Yes, chart well.

If legally I'm off base, please, please correct me!

Best,
Tim Gerstmar, ND
Redmond, WA


tanianeu
Message 11 of 18 , Dec 24, 2012
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>
> My understanding is that if you do something that brings you up before the state, that you will by "experts". That is, the prosecution will bring in experts in your field - ie - medicine to "comment" on what you did.

> Let's be realistic, who are they going to call. MD's.

This is probably the case in unlicensed states. But I do not believe it is the case in licensed states. You will be brought before YOUR state naturopathic medical board - which in that case would be all NDs, AFAIK. Now Cynthia's question was whether a board of our peer NDs would decide we had done something wrong. I have faith that in the case she describes, a board of NDs would not say she had done wrong. But I am curious if anyone knows of any actual similar cases.

I see some of the discussion here in this thread confusing scope of practice and standard of care. Just because it is in our scope of practice in Oregon to prescribe antibiotics, does not mean that it is our standard of care.

I find this an excellent discussion to have. I was completely unclear on all of this as a student, and no one clarified the ramifications at the time. Now I have a colleague who went to practice in Texas as an ND/LAc. NDs are unlicensed in Texas, and acupuncturists have the misfortune to be governed by the Texas Medical Board (the MDs). Guess what kind of hell she caught? She was brought before the medical board and harassed... as were all the local NDs.

Now in the scenario that Jennifer Karon-Flores describes, a lawsuit, that is a different matter and something that frankly I had never thought about before. Assuming it were tried in civil court, the other side could certainly bring MD expert witnesses, and it would theoretically be a matter of whether the jury believed that naturopathic medicine was harmful superstition. I wouldn't trust a random sample of Americans to have a majority favorable impression of naturopathic medicine. But I've never heard of such a trial. Has anyone??

I would think that the majority of such lawsuits would be settled by malpractice companies out of court. And on that count, I certainly wonder about the weaselly language I have seen in some malpractice company documents (specifically, NCMIC) about not covering "therapies unapproved by the FDA" or some such wording I can't remember exactly offhand.

Again, I wonder if anyone has ever heard of such a settlement or case?

Finally I would like to comment that, as a physician generally working with the under-served, I have observed closely the OANP's campaign to have NDs continue as PCPs/providers for the Oregon Health Plan in the shakeup that is currently occurring. The OANP have made statements in the media that NDs are governed by the same standard of care that MDs are. This startled me. With the current discussion, I could see some sort of dangerous outcome happening where standards of care to participate with certain insurance plans were established. But maybe I am just being paranoid. Thoughts?

Thanks for this discussion.

Tania Neubauer, ND, LMT
Portland, Oregon


Eric Yarnell
Message 12 of 18 , Dec 30, 2012
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I was told by a lawyer that basically it is going to come down to convincing a jury. So, how would you feel as a juror, hearing that someone had pneumonia and they were never even offered antibiotics that could have saved their life? (This is a hypothetical case, I'm not saying anyone on this list has done this or suggested they would.) They aren't going to really be swayed too much by our talk of "that's not our standard of practice." The tools are out there, we know about them, and if our tools weren't working and we didn't even offer other more invasive options, that is almost certainly going to look bad.

Naturopathic licensing laws aren't really clear in my opinion, and it certainly doesn't (in WA state anyway) say anything about standards of care. I don't think MD laws say that either; I think this idea of standards of care has evolved as a way to assess whether someone acted appropriately or not. I would personally look unfavorably on a case of a patient with a serious disease like acute asthma or pneumonia who was only given an herb or homeopathic or craniosacral or hydrotherapy without any education about the risks of not doing the drug options. If a patient is given neutral education and refuses such therapy, then a patient refuses. But it has to be done right and without dogma. A jury that heard and reads the notes saying, "I educated the patient that their pneumonia could potentially be lethal and antibiotics could cure them, and the patient refused and would only accept natural therapies" is going to be much more positively disposed I suspect.

Anyway, I practice in what I consider to be a non-CYA mode. I have patients come in with blood pressures of 180/120 (had one just two weeks ago I'm thinking of) and I first try to treat them naturopathically if they refuse drugs after I educate them. But I do tell them this is a dangerous blood pressure. I tell them their various options. If the patient has other serious risk factors (elderly, history of heart disease or CHF, kidney disease, etc.) I push harder to get the pressure down immediately with drugs or Rauvolfia. I have had patients refuse (including one elderly gentleman with a history of a stroke, crazy situation). I chart all that, chart that I told him he should definitely take medications, but he did settle for a Rauvolfia tincture along with many other therapies. He's still alive today, still on no medications, BP still 140/90, two years later. Anyway the point is we can practice reasonably without going to the extremes we see sometimes in mainstream medicine and be reasonable.

Eric Yarnell, ND
Seattle, WA


Eric Yarnell
Message 13 of 18 , Dec 30, 2012
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See, I don't find this scary. The truth is anyone can bring a lawsuit against anyone at any time for any reason anywhere in the US. They trip outside your building and decide to sue you. They decide you've defamed them and sue you. Whatever. I just can't live my life worrying about such things. I practice the best medicine I can and don't really think about all this legalistic stuff. Because otherwise you're right, you would go crazy and you would not be able to practice.

And I must strongly recommend again to everyone the Medical Malpractice Myth by Tom Baker, a great book which goes into the research on malpractice and shows very, very solidly that the cause of most malpractice lawsuits is poor communication and NOT medical error or malpractice, that most actual malpractice cases never go to trial because patients are afraid and lack the financial resources to sue, and that most times such cases that do get filed are settled out of court with minimal to no impact on the doctor. Anyway don't take my word for it, read the book it's really good. The system is definitely broken, but I believe it is broken in favor of doctors in a pretty horrible way and not that somehow all sorts of frivolous lawsuits are ruining medicine as is constantly claimed by the AMA. Think for a minute about the studies showing that over 100,000 people die every year in hospitals in the US alone due to improper treatment (ie malpractice), but we certainly do not have 100,000 doctors losing their licenses for malpractice every year; not even remotely close. Here's another article on this issue: http://www.slate.com/articles/health_and_science/medical_examiner/2006/07/the_medical_malpractice_myth.html

Eric Yarnell, ND
Seattle, WA


Eric Yarnell
Message 14 of 18 , Dec 30, 2012
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Yeah I just don't think that's true Jim. Sorry (but it doesn't much matter). If you know a treatment exists and a situation occurs in which it really could save someone's life and you don't even mention it, you are going to go down. No jury in the world is going to accept your argument. I don't accept that argument. The reality is you can refer them to get the therapy, you can pressure them to accept the therapy if you know it would be proper but the patient resists because it is "allopathic," no matter what your scope of practice. Luckily this almost never comes up and most of the time your rapport with your patient avoids any legal messes.

And I really do think at the end of the day, those who will "hold" us to whatever standards are juries, not other NDs, not MDs, not lawyers, not judges. And the laws and rules that juries will have to guide them are very vague, and people will base their decisions on their common sense as a result. So again, it depends on the details of how the case was handled, how patients are educated, how it is charted, etc. And we do a really good job of this generally.

Eric Yarnell, ND
Seattle, Wa


Melanie Whittaker
Message 15 of 18 , Dec 30, 2012
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I think I have to agree with Eric. In many ways ND are held to the MD standards. I have continually seen patients asking to see and MD-ND for the 20 years I have been in practice. That is the public, the people who would be on a jury. The conventional medical community is still the generally accepted standard in this country.  This standard has a lot of influence on people’s attitudes.

I know an ND who lost a malpractice suit brought on by the former patient’s family after she died of cancer. It was not written in the chart that she was referred on to an MD. That is what the judgment was based on. Common sense would tell you this patient was referred on. Where is the ND ‘standard’ here? It is not just the patients we need to consider.

Patients need to be kept out of harms way if it is within our power. It is within our power to educate and refer them on if we don’t want to handle the case.

Charting is a legal record.  Educate, chart, and people will do what they will anyway no matter what practitioner they see. That has been proven over and over.

Melanie Whittaker, RN, ND


drpetra13
Message 16 of 18 , Dec 30, 2012
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Re-stating Dr Gerstmar's caveat, I am (also) not a lawyer. Based on innumerable conversations with a dual-licensed friend and professional colleague (pharmacist-lawyer), here are my thoughts. Some of these points have been by others as well.

Who you are judged by (and therefore what standards are applied) depends upon the legal setting. Called before the state licensing authorities, this is likely to be NDs in licensed states. In unlicensed states, almost certainly this group will consist of MD/DOs. In lawsuits or criminal proceedings, your legal team is likely to call experts from natural medicine (NDs, MDs, or DOs), while the other team will bring in experts with conventional or allopathic viewpoints. Anything not documented in the chart (or elsewhere) is assumed to have not happened. The court decision will come from the jury, or possibly a judge – lay persons in either case, who will decide which experts to listen to.

The majority of malpractice suits are settled, with a sealed outcome, long before going to trial – patients, providers, and insurers all desire a speedy settlement. Providers are not always happy about these settlements, but the reality is, insurers generally take charge of decision-making once a malpractice suit has been filed.

Dr Yarnell makes an excellent point about why malpractice lawsuits are filed – research shows that most of these are filed as the result of poor bedside manner, or lack of apology from the physician. My personal experience supports this. [Tangent] Seventeen years ago, I nearly died after my surgeon's office mishandled a post-op bleed (his staff and PA failed to recognize the severity). Over the years, many conventional MD/DO friends have asked me why no lawsuit. Reason? The surgeon was initially unaware of my situation, but went (far) above and beyond the necessary to right things and prevent this from happening ever again. He also apologized to me repeatedly. After a protracted recovery, Bastyr's clinic ultimately restored my health. I continue to experience health effects of the bleed. Nonetheless, I simply never considered suing the surgeon because of his actions from the moment he learned of my situation.

There is, however, another reason for NDs to be concerned when treating potentially fatal illnesses. Excellent bedside manner clearly helps minimize lawsuits overall. However, in cases where patients die, it is their survivors who decide to file (or not) malpractice suits. As family members may not share their loved one's preference for natural approaches….

Petra Eichelsdoerfer, ND,CN,RPh
Bothell, WA


SG
Message 17 of 18 , Dec 30, 2012
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I think Dr. Zeff was originally making the point that new NDs are constantly wanting to compare our knowledge and "standard of care" with that of MDs. They give MD standard of care way too much respect. I have only seen patients be harmed by MD standard of care, not helped. my PARQ usually tells of the side effects of MD standard of care. yes, i do tell patients when we can use antibiotics but do PARQ on that (meaning the negative side effects of antibiotics and a plan for that if they desired that option) as well as give my naturopathic plan.

I saw countless times in school people trying to impress the greater medical community by watering down our curriculum. it was the STUDENTS who wanted this. In my opinion, students have way too much say in the direction of naturopathic teaching at NCNM. I second the notion that there is an idea in the schools of keeping the paying customers (students) happy. of course part of it is the idea that the younger generation feels entitled. how can we change that? i saw first year students wanting to change our education in order to impress MDs, first thru third year students wanting to limit homeopathy (likely because they just didn't want the extra class time and tests). And oregon NDs seem to be so happy to have a larger formulary this year in exchange for nearly doubling the number of CEs they have to get. I personally am glad that I can't prescribe drugs of abuse. I don't want patients coming to me for that. I have had people call and when I tell them on the phone that I cannot prescribe pain medication or benzodiazapines or Adderall, they don't make an appointment. hallelujah! can you imagine trying to work with one of these patients who is just coming because savvy MDs have fired them as patients (or they are selling the drugs on the street)?

MDs don't care at all how much formulary you have or how many CEs you take. it won't make them respect you more. Their mind is made up, if they think we're quacks, that's what they think. if they accept that their patients see us, they accept it.
In washington, we don't have so much drama over this issue (at least i don't personally experience it with our board), and we have a big formulary, are considered primary care doctors. AND we can get any CEs we want--don't have to have a certain number of "ethics", etc.

patients won't come to us because we know the allopathic standard of care. they come because we know something better than allopathic standard of care. we are way better at curing people than MDs--even way better at resolving symptoms (with no side effects). we need to get this across to students and the schools.

whether or not we use constitutional hydrotherapy or iridology or other "nature cure" things is beside the point. I don't use those at all, but I feel i do respect naturopathic treatment plans as being superior to allopathic. I practically never use pharmaceuticals. i would feel fine getting people off statins whether I could prescribe it or not (that is a big argument for having an extensive formulary--that we can prescribe them to get people off them--something i never quite understood).

anyway, i second Dr. Zeff's observations. i dont' think it is changing because of the danger of being sued. i think it is changing due to uninformed students who don't have enough experience with our powerful form of medicine.

p.s.(i don't think we could all deliver babies during school however, when schools are graduating 100 people a year--it's just not feasible anymore, so i understand why some things have changed. I wish they didn't change but the big push is to have a bigger and bigger student population every year. something I think is misguided, but...)

Sheryl WAgner ND
Vancouver, WA


Sam S
Message 18 of 18 , Jan 2, 2013
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Interesting perspectives!

I think students want to use what they think will work... not that hard to understand. If you can prove to them clinically that natural therapies are more valuable than they suspect, that is all a student needs. This requires patient interactions with doctors who really know and use these therapies effectively an a wide range of patients. This was not my experience.

There is something to be said for familiarity with a medicine. Patients who are familiar with a medicine will trust it more, and even the placebo effect will work better. Also, ditto with doctors who are confident in using an approach. Realistically, 99% + of the medicine happening out there is AMA medicine. For better or worse, most patients are familiar with conventional medicine. Most patients' trust level diminishes if their physician is not very well versed in the dominant paradigm. Imagine a nutritionist saying "I believe in the alkaline diet, and I don't know much about anything else..." Trust levels drop, unless the patient is already dedicated to that diet. This is not a master nutritionist, just an alkaline diet advocate. Are we a masterful healing profession, or advocates of a philosophical perspective? "Standard of care" has evolved over years, with a lot of research, expert panels, and clinical experience. We all know that many of the research and expert panels were funded by the industry, but knowledge of "standard of care" inspires confidence when you break it.
BTW-Lack of mastery is also true with doctors who just use drugs and surgery, although because they are the norm, they experience less mistrust.

My biggest request of the naturopathic profession and naturopathic schools is this:
It is easy to find tons of clinical experience, clinical guidelines, etc with conventional medicine if you look. I jumped into a conventional practice in Arizona seeing 25+ patients per day after just about 0 experience at the Bastyr clinics and 8 years as a health consultant in New York, never ordering a single lab or prescribing a single drug. I have the support of the internist who owns the clinic and 2 SCNM naturopaths who are more used to conventional medicine. For all intents and purposes, I am acting as an internal medicine doctor, cramming in as much naturopathic medicine as I can in 15 minute insurance visits (which has made me very popular by the way :).
It is harder to get that kind of immersion in our medicine.

To the point:
How can we develop confidence and familiarity with natural medicine in our graduates when it is not the cultural norm, and our clinical experience is variable but mostly inadequate? I've seen 3 positive outcomes with homeopathy in 3 Bastyr clinical years and 8 years of private practice. They were dramatic, but my lack of positive experience and confidence combined with patient unfamiliarity makes it really hard for me to tend to use it.

Are there natural medicine fellowships or post-grad intensives that would be geared for someone like me? If not, can they be developed? Nat chat is great, but it doesn't substitute for immersion, and there are only so many Dr. Zeffs out there...

As a Naturopath, I think of myself as someone who is a well grounded in using the best healing modalities available on the planet. This, to me, means: most useful, doable, reliable, most deeply effective, for the patient as well as on the global level. If there is a modality out there that would offer benefit to my patients, which I could learn to employ in my practice with my patients, and that won't cause long term problems for the planet, I will endeavor to use it. But it has to be something that patients will actually do and that I will feel good about using.
But first, I have to see it work, over and over again.
This is what I needed, and those students need: Clinical immersion training in what they have seen work.

My 2cents
Sam Schikowitz ND LAC
Peoria Az.