Natural Medicine is the Best Medicine: "So you're going to be, like, almost a doctor, aren't you?"

Thursday, May 19, 2011

"So you're going to be, like, almost a doctor, aren't you?"

I talk about Bastyr and naturopathic medicine a lot. By now all of my friends and most of my family's friends are well-versed in naturopathic medicine, our role as primary care providers, and my educational level. I was having one of these conversations with a family-friend (my parent's generation) who finally asked me "so, you're going to be, like, almost a doctor, aren't you?" Ouch.

After nearly four years of medical school, dozens of 12-hour days, hundreds of patients seen, and more information than I can possibly fit in my brain, I certainly hope I will become a doctor. This brings up a common misconception: that naturopaths are quacks who get online degrees and don't know what they are talking about.

So what is our educational training?

Naturopathic physicians attend four-year graduate schools that are nationally accredited by the Council for Naturopathic Medical Education (CNME). The CNME is recognized by the U.S. Department of Education, which classifies the ND degree as a Doctorate-Professional degree, on par with MD and DO. Currently 6 schools in the US and Canada are accredited through the CNME to provide naturopathic medical education.

The naturopathic program consists of at least 4 years of study with over 4,100 clock-hours in the classroom or clinic. A minimum of 1,200 hours are spent in clinical education with direct patient contact under supervision.

The first two years of the ND program are very similar to an allopathic program. We learn all the basic sciences including anatomy, biochemistry, immunology, microbiology, histology, pathology and physiology. Here is a breakdown of the curriculum:

University of Washington medical students average over 70 credits per year (72 and 78 credits for the first and second years), which is similar to Bastyr's ND program (74.5 and 77 credits for the first and second years, respectively).

The main difference in education between allopathic and naturopathic physicians in the the area of specialization. By definition naturopathic physicians are specialists in natural treatment of primary care conditions. From the beginning of our education we focus on primary care - diseases and conditions that a practitioner would encounter in an outpatient clinic. We touch upon emergency medicine, surgery and high-force pharmaceuticals (like chemotherapeutic drugs) in the context of referrals and co-management. However, unlike allopathic students we do not go through rotations in these areas. While MD students do rotations in specialty fields in their 3rd and 4th years (like Oncology, Obstetrics, Surgery, etc), ND students do clinical work in naturopathic primary care only*. We see people in an out-patient setting, directly managing the care of "our" patients under the supervision of a licensed naturopathic physician.

Also, naturopathic medical education differs in that we have a broad scope of practice with multiple modalities that we can offer our patients as treatment. Throughout our education we have multiple courses in pharmacology, botanical medicines, homeopathy, counseling, nutrition, and naturopathic manipulation. In the state of Washington naturopathic physicians can prescribe most medications, perform minor surgery, offer counseling services (just like a licensed mental health counselor), offer nutritional advice (like a dietician), and perform osseous manipulations of the spine and extremities (like a chiropractic physician).

Naturopathic medical students also take board exams comparable to the USMLE boards taken by allopathic students. These tests are called the NPLEX exams - naturopathic physician licensing examinations, and are governed by NABNE. Only students from accredited schools of naturopathic medicine are eligible to sit for these exams. Students must complete two sets of examinations, one after the first two years of the ND program (the basic science boards), and one after graduation (the clinical science boards). Just for a comparison, our basic science boards are similar to USMLE Step 1 exam, and the clinical science boards are similar to the Step 3 exam. The USMLE Step 2 exam, which evaluates physical exam and clinical skills, is similar to our Clinical Entry exam, which is governed by the school (Bastyr) itself - we must do a complete intake, physical exam, and differential diagnosis on a standardized patient (actor), graded by a member of the clinical faculty. We must pass this exam (after our 2nd year) in order to see patients in the clinical setting.

Only after completing all 4,100 hours, passing both sets of board exams, and getting a diploma is a naturopathic student eligible for licensure. This is in contrast to some so-called "naturopaths" who receive online or distance-learning degrees. In all 17 states that license naturopaths, only those who graduated from an accredited 4-year school can call themselves naturopathic physicians or doctors.

So to clarify, YES, I am going to be a doctor! A naturopathic doctor, that is.

References:
Source: "Basic Science Curriculum." UW Medicine. University of Washington, 2011. Web. http://uwmedicine.washington.edu/Education/MD-Program/Current-Students/Curriculum/Basic-Sciences-Curriculum/Pages/default.aspx. 19 May 2011
Source: "Program Tracks and Curricula for Doctor of Naturopathic Medicine." Bastyr University.
Bastyr University, 2011. Web. http://www.bastyr.edu/education/naturopath/degree/curricula.asp. 19 May 2011.
Association of Accredited Naturopathic Medical Colleges. AANMC, 2011. Web. http://www.aanmc.org/. 19 May 2011.

(*with a few exceptions - we can do adjunctive care for cancer patients, but not primary treatment).

Labels: Bastyr, board exams, medical school, medical student, naturopathic education, naturopathic medicine, ND, NPLEX, primary care physician, USMLE

14 Comments:

At June 18, 2011 at 6:08 AM , Allie said...: Excellent post. I'm glad to have come across it. I will be applying to ND school this Fall and have received are you going to be a 'real' doctor from a couple people, the stigma and ignorance (for lack of a better word) about the profession is quite frustrating. Though, I try to be a good advocate and explain it to them. Again, good post.
At January 28, 2012 at 2:56 PM , drkathygraham said...: Erika Krumbeck, you are a brave woman! I came to your site from the SBM blog where I saw your commentaries and the follow-up ad hominem attacks that followed.

I like the way you think and I will start following your blogs. I have been practicing as an ND for the past 19 years. Here are my thoughts regarding the topic of your blog post: http://drkathygraham.wordpress.com/2012/01/06/woo-woo-voo-doo-quackery-and-snake-oil/

I had to laugh at myself when I saw a doctor on SBM ask you a question regarding pheochromocytoma and beta-blockade administration. His implications were clear: naturopathic physicians are stupid, naturopathic physicians do not know how and when to refer to medical doctors, and naturopathic physicians cause harm.

About 10 years ago, I saw this 30 some year old woman who presented with abdominal pain, headaches, extreme anxiety, palpitations, a resting pulse of 90-100/min, and a BP of 150/90. The reason I clearly remember this, is because I had asked her to go back and see her MD so that he could do a blood and urine test for pheochromocytoma, as you know, a very rare condition. Instead, the MD wanted to put her on Propranolol and laughed at her request for the tests I had asked for, and of course, ridiculed me. The tests were never done. The patient refused the beta blocker, and she ended up with a diagnosis of Generalized Anxiety disorder that improved with botanicals, nutrient therapy and counseling.

This pheochromocytoma question on the SBM blog that the doctor asked you, was a non sequitur. There is no situation that I can ever think up, where a naturopathic doctor would need to know whether a beta blocker was contraindicated in a patient with pheochromocytoma. A better question would have been, what symptoms would a patient have for you to suspect pheochromocytoma in order for you to refer the patient to a medical specialist?

That wasn't the first time I had been ridiculed by MDs in my town for sending patients back to them requesting further diagnostic testing for conditions I wanted to rule out. I don't hear much ridiculing these days since I have referred patients back to their MDs for testing, where previously undiagnosed thyroid cancers were discovered, previously undiagnosed breast cancers were discovered, multiple H. pyloris infections were found (one was a child with a 6 year history of the bug who had seen a pediatrician for years!), etc., etc., etc.

The reason I bring this up, is because one (of many) of the concerns these SBM docs have, is that a naturopathic physician will miss a diagnosis and fail to refer appropriately. In the past, I have experienced the exact opposite problem with MDs. They felt I was bothering the patient with my requests for unnecessary testing, and burdening our socialized healthcare system with these ridiculous requests when I would refer the patient back to them.

(cont'd in next post)
At January 28, 2012 at 2:57 PM , drkathygraham said...: (cont'd from previous post)

Today I am lucky. The MDs in my town now are on the ball and very thorough, so that when I see a patient, most have already seen many specialists and have had umpteen zillion tests done before they see me.

There are a few things I have read on SBM that I do agree with. More RCT studies need to be done on some of the naturopathic modalities to show (or not show) the level of their efficacy. However, as you know, many modalities that we use don't fit into the cookie cutter mold of the RCTs and will forever exist in the world of empirical evidence as cited in this blog that I wrote: http://drkathygraham.wordpress.com/2012/01/14/is-homeopathy-nonsensical-3/

I also agree with these SBM docs that say naturopathic physicians shouldn't be primary care physicians. Physicians? Yes. Primary? No. I realize I am probably one of the only NDs in North America that believes this. Until NDs have the legal right to refer to medical specialists and order radiologic testing, an ND cannot be a primary healthcare provider.

I also know that our licensing board in BC is working hard to acquire those privileges (i.e. specialist referral and radiologic testing), but until then, I will not and cannot consider myself a primary care doc. When we get those privileges in British Columbia, I will reconsider my stance.

Have you written anything about your opinions on ND primary care in any of your blogs? If so, could you please direct me to them? If not, I'd be interested in reading your take on the matter.

In my opinion, both skepticism and open-mindedness are important in order to assist patients.

Good luck with your studies and future career! There is definitely a wonderful place for the practice of naturopathic medicine in helping many people live longer and healthier lives.
At January 28, 2012 at 6:48 PM , Anonymous said...: This is gretemike from the SBM blog.

The premise of this blog entry seems to be that a ND is a "real" doctor. If that is the case, then why shouldn't NDs be primary care physicians?

The answer, of course, is that a ND is not a real doctor. And that was Dr. Robert's implication in the SBM blog.

It would be very interesting to have a group of medical school graduates and a group of Bastyr graduates take the medical boards and compare the results. I can never arrange such a thing, but Erika can on her own try some of the test questions I referenced.
At January 28, 2012 at 9:18 PM , Erika Krumbeck said...: drkathygraham - I do believe ND's should be primary care physicians, but you are right - only if they have appropriate prescriptive authority, as well as the authority to order labs, imaging, and refer. I do not think we should have hospital privileges, since our education does not include many interventions that are obviously life-saving in a hospital setting.

gretemike: In Washington state, where I am, ND's ARE considered primary care physicians. As far as the State of Washington is concerned, ND's are "real doctors". Patients can choose an ND as their primary care provider under their insurance plans.

In Washington we DO have the authority to order labs, imaging, refer, and prescribe almost all prescription medications (obviously not chemotherapeutics, and some legend drugs).

gretemike: I used the USMLE Step 1 exam to study for our Basic Science Boards, and I am now using the USMLE step 3 exam to study for our Clinical Science Boards. I typically do pretty well, though there are some subjects I don't know as well (hospital interventions, chemo, etc). Remember that our ND education only covers conditions seen in a primary care setting.
At January 28, 2012 at 9:19 PM , Erika Krumbeck said...: (see my reply below)
At January 29, 2012 at 8:27 AM , drkathygraham said...: I was unaware that NDs in Washington state were able to make specialist referrals and order imaging tests. Does that include CT scans and MRIs?

Are there any other states in the US that have all of the medical privileges that your state does?

In that case, I amend my comment: I do not believe NDs should be considered primary healthcare providers except in those states and provinces that have complete medical privileges like Washington state has.

Erika, I agree with your position regarding hospital privileges for the reason you state.

@gretemike. In a perfect world, NDs should be considered primary care physicians, but legislation does not allow NDs in most states and in all provinces (at the present time) those medical privileges necessary to practice as such. I maintain my opinion regarding ND primary care because of legislation only, not because of lack of naturopathic education, skill or intelligence.

Regardless, the bottom line for me is always the same: is the patient getting well? is this happening without harm to the patient? is the patient getting the best medical care possible? - be it found in conventional medicine, naturopathic medicine, both or neither.
At January 29, 2012 at 7:29 PM , Anonymous said...: A ND is not a MD. That's literally true and obvious of course, but since it's true then there are obviously differences between the two. And those differences mean everything. A quick glance at Bastyr's curriculum via their website shows a heavy dose of homeopathy. And homeopathy is really not respectable, for reasons discused to death on the SBM site. There's other stuff that's different too, like the addition of colloidal silver to the formulary in Vermont. The point is that the stuff that makes NDs different is demonstrably bogus. Even Erika had some reservations about homeopathy in one of her posts on SBM (which I found quite intriguing).

If homeopathy (and colloidal silver and the other stuff mentioned on the SBM blogs) is as bogus as it seems, then it's a shameful waste of time and money at best and an unforgiveable distraction from potentially beneficial treatments at worst - a strike against the core value of doing no harm. Hence the high level of emotion that often accompanies the discussion.

In any case if it is true as the MDs of SBM say, that you lack sufficient education, then I hope for you both all the luck in the world.

-Gretemike
At January 30, 2012 at 7:46 AM , drkathygraham said...: @Gretemike I appreciate your respectful manner of discussion.

As for myself, I do not use colloidal silver, but I do use homeopathy. As a naturopathic student 22 years ago, I was by far and away, the most skeptical of this "bogus" type of medicine in my class. I have already posted the link above regarding my thoughts on homeopathy:
http://drkathygraham.wordpress.com/2012/01/14/is-homeopathy-nonsensical-3/

In general, naturopathic medicine is the safest medicine on the planet.

I too read SBM, but to exercise the critical thinking and skeptical part of my brain (or just when I feel like I need a good dose of masochism :) ).

I have altered a few things in my practice for the better because of reading SBM, but on the whole my practice remains the same.

Open-mindedness is just as important as skepticism, for without both, the best possible medical care is not possible.

Good luck to you to, gretemike.
At January 30, 2012 at 8:58 AM , Erika Krumbeck said...: Yes, for me it is a matter of throwing the baby out with the bath water. Though I don't understand homeopathy, and still consider myself a skeptic, it isn't enough reason to discard the totality of my education.

I just got around to reading drkathygraham's blog post on her own experiences with homeopathy. My comment was going to be much the same - I don't understand it, I'm still skeptical, but quite often homeopathy just works! And when it works it seems to lead to a dramatic difference in patients (I mean changes in lab values, objectives signs, even a different demeanor and affect). I don't understand it!

I don't know any ND's that use colloidal silver (maybe topically??)
At February 2, 2012 at 3:44 PM , Anonymous said...: People who wish to be NDs are often those that claim to be "open minded". The only truly open minded people are those able to be skeptical of their own views in order to accept in new information. Those who wish to be NDs seem to have difficulty with that concept, which is necessary for a real doctor. You may need to question your existing diagnosis of a patient to be able to abandon it when contrary new information comes in. The same should be true of your diagnosis of the education you are paying for.

re: " I do believe ND's should be primary care physicians, but you are right - only if they have appropriate prescriptive authority, "

i.e. your ego is leading you to wish to be able to practice what you are not qualified to do but wish to pretend you are. Despite the nonsense you've been fed, you know a fraction of what real MDs do, and know much that is false. Yet of course its easier than getting an MD, and you can remain "in denial" since you are surrounded by clueless people that also know as little as you do, and patients who won't know enough to correct you.

You don't exhibit enough critical thinking skills to be able to competently assess your educational background, let alone be trusted with a patient who may turn out to be far more ill than you realize since you won't know enough to realize it, and there are myriad ways NDs can rationalize the limited set of explanations they do have for diseases to pretend they do know whats going on.

People like you who wish to take the easy way out and get an ND rather than an MD are fooling themselves and will fool their patients.. to death in some cases. If you aren't smart enough to get an MD, become a nurse. Yet I doubt you will since the clueless people scamming you at your "school" who are stupid enough to either teach the nonsense they teach there, or to work at a place that does, will try to tell you that you are perfectly qualified.
At February 2, 2012 at 3:47 PM , Anonymous said...: If you go to a school that teaches 2+2=5 as if it made sense, that is reason enough to question the other things they teach there.

If you don't understand homeopathy for the nonsense/placebo it is, which takes very little time, you understand far too little about science to make any claim of being remotely qualified to be a doctor (even if some incompetent docs fall for homeopathy).

You've been scammed, likely in part by people that are well meaning but deluding themselves into thinking they know more than they do.
At February 2, 2012 at 3:52 PM , Anonymous said...: The only truly open minded person is one able to be skeptical of their own views or they can't accept new better views. NDs show little evidence of being real skeptics rather than being gullible.

Anyone who falls for homeopathy doesn't understand enough about science to be practicing medicine.
Yet I suspect you would never be "open minded" enough to consider such a statement since your desire to practice medicine and to refuse to take the time to do the hard work to learn real medicine will prevent that.

re: "In general, naturopathic medicine is the safest medicine on the planet"

Wow is that absurdly illogical. It is filled with bogus treatments that prevent real treatment from being sought. You folks are in such incredible denial that you refuse to consider that your ignorance and lack of ability to think logically about evidence is harming and even killing people.
At February 8, 2012 at 9:15 AM , drkathygraham said...: Here's my question for you and for other skeptics, that I continue to wonder about. For those patients whom conventional medicine has not been able to help relieve suffering for, what is your angst about a medicine that improves the quality of life for these patients? I'm talking about patients that have seen numerous specialists, have had every diagnostic test done under the sun, have been prescribed upwards of 10 pharmaceutical medications, and STILL feel extremely unwell. These patients will then seek out naturopathic care, and many will experience relief of their suffering and great improvement in their quality of life because of this type of healthcare.

The closest I have come to reading an answer for my question was written by an infectious disease specialist on SBM. His bottom line was that the ends did not justify the means, because the means for him, was placebo.

I had always (falsely) assumed that all doctors wanted their patients free of suffering and to live a life of quality. I was wrong.

I would be first in line to admit that all the treatments I prescribe are bogus if I didn't see the relief of suffering in so many people.

Dr. David Katz said it best in this article: http://www.huffingtonpost.com/david-katz-md/questioning-the-guardians_b_884473.html

"When the going in medicine gets tough, a clinician can tell their patient "tough luck," but that to me seems wrong. Instead, I believe we should tough it out by our patient's side, and help make decisions when the next logical thing to try is far from clear".

If adopting an only "science based medicine" point of view to the exclusion of all else would help relieve the suffering of all people, I'd adopt this point of view in a heartbeat. That's just not the case.

The other issue you raised was one of harm. Naturopathic doctors are trained to refer patients for conventional medical care when this is appropriate. The issue of harm could be debated at length, however, I'm not sure that Erika's blog is the appropriate place for a discussion like this. Suffice it to say, that after having worked for 10 years at a critical care teaching hospital in the conventional medical field, having personally witnessed numerous heartbreaking iatrogenic deaths in this environment, having seen some (potentially fatal) misdiagnoses by MDs while working as an ND, being aware of 1200+ pages on PubMed regarding iatrogenic conditions, and on the other hand, reading the handful of heartbreaking cases on SBM regarding harm caused by NDs, I maintain my opinion:

In general, naturopathic medicine is the safest medicine on the planet. This isn't "absurdly illogical". It is a fact.

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Thursday, May 19, 2011

"So you're going to be, like, almost a doctor, aren't you?"

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