Patients Protected for Naturopaths from a Unexpected Source: Insurance Companies

As was noted today

Comparing the education that physicians and naturopaths obtain in order to prepare for their professions reveals a large difference between the two. Although both schools have a four year program - the similarities end there.

And that is the education for a degree.

Of course, as has been discussed at length at Science-Based Medicine and the Naturopathic Diaries, large swaths of naturopathic education is in pseudo-science: Homeopathy, water therapy, acupuncture and energy therapy that are not part of a standard medical education because they are fictions, divorced from reality.

There has not been a medical student this century, who, upon graduating, is even remotely ready to take care of patients.  The best you can say about a real (MD/DO) education is that it lays the groundwork for the real training to become a doctor.

The real education in medicine occurs in residency and fellowship, 3 plus years that more resembles the apprenticeship of a trade than graduate school.  Years of patient care under the supervision of senior physicians both in the hospital and outpatient setting is when you really learn how to be a doctor.

Naturopaths almost never have that training. The are sent out into the world with little education and less training in reality-based medicine.

And the few that have completed a residency

There are like 10 naturopathic doctors in the entire country that have had a three-year residency.

do naturopathic residencies, only reinforcing the pseudo-scientific basis of their practice. Not reassuring that

PacificSource Health Plans, for example, requires at least one year in a residency program that’s recognized by the Oregon Board of Naturopathic Medicine, which licenses naturopaths…

Not that ND’s recognize the near complete inadequacy of their skill set for patient care.

Some insurers in Oregon will not allow naturopaths to be primary care providers unless they have completed a three year residency,

which are, for the most part, insurmountable for a naturopathic doctor to obtain

In other words, having adequate training for competent patient care is insurmountable for naturopaths.

And

The Oregon Association of Naturopathic Physicians is asking insurers to consider allowing a certain number of years working in the field to qualify as a primary care provider rather than having completed a residency.

Not a real substitute for a reality-based residency. Look at any ND website and you will see little if any practice that assures a reality-based practitioner that any ND knows what they are doing.

The Oregon Legislature, by allowing ND’s to be be Primary Care Providers, has demonstrated no interest in quality, reality-based medical care. It is nice to see insurance companies stepping up to the plate. Who would have thought?

Invasion of the Chiropractors

Evidently Portland will soon have a problem to rival that of the homeless along the Springwater corridor: an expansion of Chiropractic clinics.

The Portland-area market is especially lucrative because of the city's health-focused outdoor culture, such as the biking, hiking and boating communities. And the influx of what are generally health-conscious Californians has added to that lure

And The Joint,

the largest provider of non-insurance, private pay chiropractic health care in the United States

is leading the charge.

The offer wellness plans and packages of discounted care and memberships and suggest

At The Joint our primary focus is on providing our patients with a pathway towards better health through ongoing chiropractic maintenance and preventative care.

Remember the call for the "new chiropractic"?

The new chiropractor should abandon

Life time chiropractic care in the name of "wellness"

The clinics base their therapy on

Routine activities regularly cause misalignments of the spine. These misalignments, otherwise known as subluxations or joint dysfunctions, create interference with the transmission of proper nerve communication through the spine and extremities. This can cause decreased joint motion, pain, discomfort and/or a lessening of the body's ability to function properly. Chiropractic focuses on conditions stemming from restricted joint motion, mainly of the spine and related nervous system, and the effects of these disorders on general health.

The 'new chiropractor" should not

Use of the term "subluxation" as a valid diagnosis.

It does look like the clinics try to limit their treatment to musculoskeletal problems. Although I did find the suggestion of using chiropractic for weight loss, supplements to "promote a health spine", treat ear infections and vertigo.

The new chiropractor should avoid

Claims of cures for visceral and other non-musculo-skeletal conditions

Whether some of the more sketchy aspects of chiropractic, like applied kinesiology, are used are only hinted at. The website have a sameness and 'unique' therapies offered are only suggested by the biographies of the DCs.

Of course, the new chiropractor should avoid

Biologically implausible diagnostic tests and therapies.

And, as seems to always be the case, they minimize risk with the misleading statement

Statistically, patient risk is substantially lower when receiving chiropractic care as opposed to medical care, where the use of prescription drugs and surgery pose a greater risk.

They say that these clinics will let

chiropractors focus on being doctors.

It looks more like they let chiropractors focus on being chiropractors.

Just what Portland needs.

Cupping in Portland

There has been a lot of electrons spilt on the subject of cupping this week, thanks to Michael Phelps. I have written about cupping in the context of use by the Portland Trailblazers and a review of the topic over at Science-Based Medicine. I did not have anything to add over the posts by Orac and Dr. Novella .

Then I saw, Why Portland docs think Michael Phelps's therapy is spot on.

Local reports do get my interest. 11 paragraphs of gullible reporting.

No real 'docs' were quoted in the story.

Dr. Loch Chandler, a naturopath with Providence Integrative Medicine, does cupping on patients five-to–10 times a week to help reduce pain, improve muscle function and enhance recovery from soft tissue injuries.

He is a naturopath who specializes in acupuncture at the Providence Integrative Medicine center, where they offer "therapeutic, acupuncture, naturopathy (including homeopathy) and dietary counseling." In my opinion it appears Providence is at the forefront of offering useless pseudo-science in Portland.

"The majority of my patients say they feel cupping helps," Chandler said. "Less than 10 percent say it didn't make any difference."

Which is always the case. Patients usually have subjective improvement after a pseudo-medical intervention. The fact that cupping, and most of traditional Chinese pseudo-medicine has no reality-based reason to work and does not work in well controlled studies. Pseudo-medical providers often prefer to follow the three most dangerous words in medicine, in my experience, rather than reality-based practice.

Cupping is generally used during acupuncture.

Combining two useless pseudo-medicines.  They have a ways to go before they beat The Onion.

Practitioners place special cups or glass containers on the skin and use heat or an air pump to create suction and pull the skin up and away from the muscles. Chandler said he moves the cups around, as opposed to "static cupping," which Phelps uses.

So both forms of cupping are equally effective? Why?  Wouldn't one be less effective?  Of course not.  Pseudo-medicines are like the citizens of Lake Woebegone, where where all the therapies are strong, all the diagnoses are good looking, and all the results are above average.  Only in pseudo-medicine are all the variations on a theme equivalent, like the infinite varieties of acupuncture.

The technique increases blood circulation and range of motion, said Ken Glowacki, associate dean of clinic education in the College of Classical Chinese Medicine in Portland, part of the National University of Natural Medicine.

Except it doesn't, although pseudo-medical providers like to repeat the same nonsense as if it will make it true. Of course, it is trivially true in that blood supply is increased to areas of trauma, like a bruise. At least they do not mention the pseudo-scientific concepts of qi and meridians.

Some patients even get the treatment for respiratory and digestive ailments to open up breast respiration.

For which there is zero good data for efficacy and even less data for plausibility of cupping in lung and gastrointestinal diseases. And what in the hell is breast respiration? It has to be a typo, but for what? I can't find "breast respiration" on google.

Since it brings blood capillaries to the surface, cupping often leaves welts, just like those dotting Phelps' shoulders and back. But it typically doesn't hurt, said Daryl Ewing, a lead physical therapist at Providence Sports Care Clinic in Portland.

It does not bring blood capillaries to the surface. That is anatomical nonsense. It ruptures capillaries, causing a great, big hickey, which in the right circumstances can have effects. Just not the form used by Traditional Chinese Pseudo-Medicine.  

One knock against the practice is that the science is relatively thin and patients may be feeling a placebo effect.

It is not thin, it is nonexistent and based on a fantastical understanding of disease, anatomy, and physiology totally divorced from reality.  And to deliberately offer placebo is considered unethical outside of clinical trials. So giving people unproven placebos is a good thing? Yep:

Whether the effects are real or a placebo, cupping seems to be working for at least one member of Team USA. Phelps won a record 21st gold medal yesterday.

Seriously? You are purport causality from the cupping to the winning of a gold medal? And how did he win all the prior golds with no pseudo-medical hickeys to help his swimming.

Like much of the reporting on cupping this week, the easy path of the standard narrative is preferred over critical thinking and real investigation.  Same as it ever was.

Chronic Pain: A Pseudo-Medical Trojan Rabbit

There is no argument that Oregon, and the US, has a problem with opiate addiction and chronic pain.

What to do about the problem is the question.

I have noticed that the pseudo-medical industrial complex has been aggressively positioning themselves as the solution to the problem.

In Oregon it is driven in part by the fact that we have the second highest rate of opiate abuse in the US.

As a result, Oregon produced the awful Health Evidence Review Board pain guidelines, which I discussed on SBM, which

open(s) the door to acupuncture, chiropractic, cognitive behavioral therapy, osteopathic manipulation and physical and occupational therapy.

Now the local pseudo-medicine school, the National University of Natural Medicine, is getting in on the act with Oregon Health Forum: Pain Management from Incidence to Intention Livestream.

The forum is co-sponsored by the Lund Report and the Quest Center for Integrative Health, the latter purveyors of osteopathic, naturopathic, and Chinese medicine.

And moderated by an ND and Lac.

I would bet that an evidence/science-based understanding of pain interventions are not going to be high on the list.

The press release says

NUNM Health Centers Executive Director, Michael Sorensen notes "Natural medicine therapies have been proven to help manage pain and can address the critical need to find ways to reduce opioid dependence.

And I wonder what natural medicine therapies he is referring to? Looking that the pseudo-medicines taught at NUNM I find

  • Acupuncture? No. As if sticking needles into people is natural.
  • Chiropractic and naturopathic manipulative therapy? No.
  • Herbs and Botanicals? No.
  • Hydrotherapy? No.
  • Homeopathy? No.
  • Exercise? Sure. But that's it.

All the good data suggests no efficacy for any the above for pain beyond placebo effect.

But given the nature of naturopathic education and training, immersed in all that is pseudo-science and pseudo-medicine, why would this roundtable be held under Naturopathic auspices? It would be like having a roundtable on problems in astrophysics sponsored by and held at an astrology school.

Because it is an in, a trojan rabbit that falsely legitimizes their practice. Pseudo-medical providers of all stripes repeat the same fiction: their interventions are effective for pain and are a solution to opiate addiction.

They will build a wall between patients and their pain and make the pain pay for it. 

Repeat a fiction often enough and people will believe it as fact.

PS

If anyone happens to get the content of the roundtable and can send it my way, I would be interested. But I am not going to buy a ticket that supports pseudo-medicine in any way.

ND's as PCP's

In dog years I turned 413 this week. Where did the time fly? I can still put on my socks in the morning standing on one foot, but that is about the last vestige of my youth that remains. Gone is hair, vision, and sanity.

Years ago I remember reading (I think it was in the History of Civilization) that there are some Sumerian clay tablets from 2000 BC complaining about the decline in standards, that kids don't respect their elders and don't have any work ethic. I keep that in mind when I want to complain the everything is going to hell in hand basket.

Because it is. Well some things are.

What would you do if you had people with no education in science-based medicine, instead having an education mostly grounded in pseudo-sciences like homeopathy, acupuncture, and hydrotherapy?  People with little or no post graduate training, when the bulk of medical education and training occurs in reality-based medicine.

In Oregon the legislature has made these under-educated, untrained pseudo-science practicing primary care providers. And I am starting to see the results.

My patient had traveled to Asia a few years ago and came back with a bump on his abdomen. It had waxed and waned in size over the years and he is concerned it may be a parasite of some sort.

Perhaps. I have seen a few odd subcutaneous parasites over the years, those that have wandered into the skin where it did not belong. I have seen a gnathostomiasis and a cystercercosis that caused a chronic subcutaneous nodule. There are a variety of other parasite that can cause the same symptoms:

Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

So may be it is a parasite, although the exposure history is not impressive. I will try to get it biopsied, which he has been hesitant to have done.

Before me he has been seen by an ND, and by the patients report had a negative saliva test for parasites (!), but did have a positive test whereby the ND held a variety of glass vials against the bump and that diagnostic maneuver was positive for parasites (!!).

"That is how she diagnoses parasites" my patient said.

Why didn't they teach me that in fellowship?  Sounds like a version of the wackaloon SCAM (Supplements, Complementary and Alternative Medicine) known as applied kinesiology. And since the test was positive, the patient was given a prescription for metronidazole (!!!). Look at the list above, there are not many parasites that treatable by metronidazole? It's a parasite, don't you know.

But standard ND practice and part of why ND should really be short for Not Doctor.

I sometimes get the impression that ND's do not understand that parasites have life cycles, exposure risks, and specific treatments. Like toxins, parasites are a nonspecific evil humor treated with antibiotic, again with antibiotic being a generic idea, not a specific drug with specific activity.

Thanks to EPIC, the electronic medical record,  I could look at the ND notes, but they were unrevealing concerning parasite diagnosis and treatment.  Perhaps it was a different ND, perhaps even they were embarrassed to document such nonsense. Nahhhh. The only documentation I could find suggested the patient had congestion of liver and kidney relieved by acupuncture. As if that is any better than parasite diagnosis by applied kinesiology.

I have been seeing a slight uptick in these kinds of consults as people with travel exposures are seeing ND's first rather than reality based providers, with all kinds of creative tests and treatments. And I expect to see more.

See. Some things really are going to hell in hand basket.

Rationalization

Naturopathic Diaries. http://www.naturopathicdiaries.com/ The truth ND's do not want you to know.

Disingenuous: Deconstruction of a naturopathic white paper. https://www.sciencebasedmedicine.org/disingenuous-deconstruction-of-a-naturopathic-white-paper/

Am Acad Dermatol. 2015 Dec;73(6):947–57; quiz 957–8. doi: 10.1016/j.jaad.2014.11.035. Mucocutaneous manifestations of helminth infections: Trematodes and cestodes. https://www.ncbi.nlm.nih.gov/pubmed/26568338

https://rhrplus.com/b2evolution/blogs/index.php/Jane/parasite-testing-through-kinesiology

Cross posted, with editing, from sfsbm.org.

From Physician Assisted Suicide to Death by Naturopath

The case of Ezekiel Stephan has been well described at Another child dead from quackery and Ezekiel Stephan: Another Pediatric Death by World View.

The child, unvaccinated, first developed pneumonia, then empyema (an infection between the lung and chest wall) and then meningitis (an infection of the brain).

As an Infectious Disease doctor I take routinely care of all these illnesses  and treated appropriately they are awful for the patient.  Ezekiel did not get the benefit of appropriate medical therapy.  He was treated with maple syrup, juice with frozen berries and a mixture of apple cider vinegar, horseradish root, hot peppers, mashed onion, garlic and ginger root. 

When the child was so rigid he could not be put in his car seat for travel but instead laid on a mattress in a mattress in the back of the car, they took him to a naturopath. As an aside, at that point given his meningismus, he probably had fairly advanced meningitis and every movement, such as car bumps, would have been excruciatingly painful.

By one report, the naturopath did not even examine the patient but was given a naturopathic remedy for meningitis, a tincture of echinacea to boost his immune system.  The naturopath appears to have been inspired by the infamous Tuskegee experiments and allowed the disease to run its natural course despite the availability of curative antibiotics

Without appropriate therapy, bacterial meningitis is 100% fatal, and, sadly, but not unexpectedly, the child died.

Anyone who understands the nature of naturopathy knows that naturopaths have no education, training, or experience that would allow them to recognize and treat serious illness. What data there is concerning naturopathic practice shows they do a poor job at providing the basics of primary care (screening and vaccination) and that those who use naturopaths are more likely to have, and in this case die of, a vaccine preventable illness. Ezekiel, it is noted, died in Canada.

Despite their complete lack of training, Oregon has granted naturopaths primary care provider status.

It is sometimes noted that in some states naturopaths practice medicine without a license. Whatever it is naturopaths do, with or without a license, it is not medicine.

Naturopathic practice is to medicine is what using an easy bake oven is to being a chef or guitar hero is to playing guitar in Led Zeppelin.

And it is patients who will pay the price.

At some point an equivalent disaster will happen in Oregon. Not that it hasn't occurred. I remember my first experience with naturopathy, the case that led to an interest in all things pseudo-medical.

I was called to see a case of gangrene. It was a 20 something female with a dead leg, wet gangrene, with a smell few get to know. A year earlier she had been diagnosed with a sarcoma that could have been cured with amputation. She opted instead for a naturopath who treated her with herbs and alkaline therapy. The cancer grew, advanced, and rotted. She continued to believe her naturopath when told that the rotting leg was good, it was a response to his nostrums. She was only in the hospital as she had a fainting spell and was brought in by a family member. She refused any intervention on her leg. That night the tumor eroded into her artery and she bled out and died.

When you have uneducated, untrained, and inexperienced practitioners who are immersed in fantasy-based diagnoses and therapies, do not be shocked in the coming years when naturopathic care results in another unnecessary death. It may be a child dying of a vaccine preventable illness. It may be from untreated cancer. It might be death from chelation. Again. But someone will die who should not.

The Oregon legislature has made it possible.  We have had physician assisted suicide for years in Oregon. Now we can add death by naturopath. 

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Chiropractors, Naturopaths, Concussions and Senate Bill 1535

The is a bill before the Oregon Legislature, Senate Bill 1535, that

Allows chiropractic physicians and naturopathic physicians to provide release for athlete who sustained concussion or is suspected of sustaining concussion.

Unfortunately, the Oregon  legislature has already granted naturopaths primary care physician status, so I expect this may well pass, despite the fact neither chiropractors nor naturopaths have much reality based education and training in medicine.

Let's go through the issues as to why it is a bad idea for the athletes of the state, most of whom will be children, to be cared for by ND's and DC's.

What is A Concussion

A concussion is a form for trauma, an injury to the brain. The brain floats in cerebral spinal fluid, which acts as a cushion. If the skull hits something, or is hit, hard enough by a fist or a football helmet or a wall, the cushion fails and the brain smashes into the skull. Trauma results.

The patient can then have headache, confusion, ringing in the ears, seizures, double vision and other neurologic symptoms. The number and severity of the symptoms depends on what part of the brain is injured and the severity of the injury.

Treatment is resting the body and the brain and avoiding re-injury. There may be long term sequelae to concussions, especially repeated concussions, such as depression, dementia and Parkinson's.  The brain is not forgiving when injured, physically, emotionally or spiritually.

It is a huge problem, with 300,000 sports related concussions a year in the US and this only counts concussions that led to a loss of consciousness, perhaps 10% of all concussions. Children are both more prone to concussion and, perhaps, long term sequela.

So concussion is a serious and widespread medical problem.  It may not be an optimal approach to have those with little or no education, training or experience in medicine care for children with concussion.  Except, probably, in Oregon.

Education

Chiropractors and naturopaths like to pretend that their 'medical' education is equivalent to medical school. Nothing could be further from the truth.

Chiropractic

During the public hearing it was offered that the education of a chiropractor is equal to that of an MD. While there are superficial similarities, the whole of chiropractic education is through the lens of chiropractic theory: that there are misalignments of the spine, subluxations, that block that body's ability to heal, and that chiropractors can identify and adjust these subluxations to restore health.

The whole underlying concept of chiropractic is a pseudo-science, with no basis in anatomy, physiology, or reality. As one review notes

Chiropractic and allopathic medicine differ the greatest in clinical practice, which in medical school far exceeds that in chiropractic school. The therapies that chiropractic and medical students learn are distinct from one another.

Medical education is grounded in reality; Chiropractic education is grounded in the fantasy of innate intelligence, subluxations and spinal adjustments.

Naturopathy

Naturopathy education also appears to be superficially similar in the number of hours devoted to the basic sciences. When compared to the education of a Family Practice Physician, it is clear that ND's have a fraction of the training required to become and MD/DO.

21,700 for FP education and training, 6400 for an ND.

Doesn't look so good, does it?

It more than the quantity of hours in education and training that makes a physician, it is also the quality of the content. ND curriculum is even more focused on pseudo-science than chiropractic: homeopathy, hydrotherapy, acupuncture, energy therapies, and more make up a significant portion of the naturopathic education.. Time spent studying pseudo-science and pseudo-medicine is time not spent studying and understanding reality-based medicine.  Those educated in the care and feeding of unicorns are not qualified to care for horses.

The naturopaths testifying at the hearing suggest that since they have been given primary care designation they should be allowed to diagnose and manage concussion as well. I would suggest that two wrongs do not make a right.

Training

No MD or DO is even remotely ready for independent patient care upon graduation from medical school. After graduation MD's and DO's have a residency to learn their speciality. Internal Medicine, Family Practice and Neurology residencies are three years; neurosurgery takes 7 years.  It is the residency, practicing under the guidance of senior physicians, is where doctors really learn their profession.

Neither naturopaths nor chiropractors have a residency; they usually go straight from school and into practice.  The few that do complete a residency do so in the field of naturopathy or chiropractic, further reinforcing their pseudo-medical trainging.

There is no subspecialty naturopathic training in neurology; chiropractors can be certified as a chiropractic neurologist in 40 days of internet classes, or 300 classroom hours. Compare that to the over 8000 hours (assuming a mythical 8 hour work day) it takes to be a real neurologist, much of which is spend in direct patient care.

It is why Dr. Steven Novella, a Yale neurologist, says

Chiropractic neurology appears to me to be the very definition of pseudoscience – it has all the trappings of a legitimate profession, with a complex set of beliefs and practices, but there is no underlying scientific basis for any of it.

and that

Chiropractic neurology does not appear to be based on any body of research, or any accumulated scientific knowledge.

Evaluating their education, training and practice, I would suggest that chiropractic and naturopathy are to real neurology and medicine what Guitar Hero is to Jimmy Page.

Literature

A search of the medical literature on PubMed for “naturopathic medicine concussion” yields zero publications.  There are no trials to suggest that the pseudo-medical practice of naturopathy can be applied to brain injury. Or any other real disease for that matter.

For “chiropractic concussion” there are 19 hits on Pubmed, out of the 7,511 medical publications on concussion. None of the article concern the competency or efficacy of chiropractors in the diagnosis and treatment of concussion.

There are no clinical trials demonstrating efficacy of chiropractic or naturopathic treatment for concussion. And there is no reason based on known anatomy and physiology to suspect that either  pseudo-medicine would have benefit in the the diagnosis or treatment of concussion.

Dangers

The Palmer School of Chiropractic recommends manipulation of the cervical spine for concussion, deps.

There is an association with cervical spine manipulation in the young and vertebral basilar artery stroke

Results for those aged 45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had ≥3 visits with a cervical diagnosis in the month before the case’s VBA date.

The association between cervical spine manipulation and stroke is consistent enough that the American Heart Association and the American Heart Association have released a scientific statement suggesting

Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients.

Complications fortunately are rare, as Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature, showed

Thirty-one articles met the selection criteria. A total of 12 articles reporting 15 serious adverse events were found. Three deaths occurred under the care of various providers (1 physical therapist, 1 unknown practitioner, and 1 craniosacral therapist) and 12 serious injuries were reported (7 chiropractors/doctors of chiropractic, 1 medical practitioner, 1 osteopath, 2 physical therapists, and 1 unknown practitioner).

but for an intervention that has no benefit, the risk should be zero.  Young people have died after chiropractic manipulationperhaps including the recent death of “Queen of Snapchat,” Katie May.

And children are injured by manipulation when the correct diagnosis is missed.

Other (serious adverse events) leading to permanent neurological consequences have been reported. However all of these were attributable to a misdiagnosis leading to the inappropriate application of SMT (spinal manipulation therapy) with unfortunate consequences.

Yes. A child crippled by a useless intervention for the wrong reason is an unfortunate consequence. Given the lack of medical training by DC's and ND's,  further unfortunate consequences would seem inevitable.

If stroke were due to a medication, the medication would receive a black box warning at a minimum or be pulled from the market. The major Chiropractic organizations deny that chiropractic can cause strokes and continue to snap the neck, which can result in the same forces and injury as a hanging. But that is typical of pseudo-medicines: they never recognize that their intervention could be dangerous and alter or abandon practice accordingly.

The data suggesting a link between chiropractic manipulation and stroke is complicated and incomplete. However in medicine, but not chiropractic or naturopathy, the precautionary principle is applied:

if an action… has a suspected risk of causing harm to the public, in the absence of scientific consensus that the action or policy is not harmful, the burden of proof that it is not harmful falls on those taking an action.

and the action avoided.

The majority of chiropractors are of the opinion that spine manipulation is a treatment for concussion, even though the brain is distant from spine.

Most respondents agreed or strongly agreed that manual therapies may be appropriate in certain circumstances in adults (80%) and minors (80%).

But when all you have is a hammer, everything is a nail.

While there is no naturopathic specific treatment for concussion, naturopaths do have their own naturopathic manipulation.

It should give anyone concerned with the health of children a frisson of terror at the thought of concussed children being evaluated and managed by naturopaths and chiropractors.

Conclusion

Naturopaths and Chiropractors lack the education, the training, and the understanding of medicine and neurology to diagnose and treat concussion. Their therapies are at best useless and can result in strokes in one of our most vulverable populations, children.

Senate Bill 1535 should not pass.

Let The Infections Continue

The results are in from the hearing to adopt a rule in Oregon that

would require Oregon licensees practicing acupuncture to follow clean needle technique and require the use of only disposable, single-use acupuncture needles.

It was decided not to adopt the rule.

Instead of making best practice a rule,

the OMB determined it would be most appropriate to partner with the OAAOM to establish clean needle technique as the standard of care in the acupuncture profession through educational outreach rather than rulemaking.

Education? As often as not education does not alter practice.

Widely used CME delivery methods such as conferences have little direct impact on improving professional practice

Nor do practitioners always follow guidelines.

A few weeks ago I saw a patient with S. aureus bacteremia that was probably due to acupuncture through eczema on the skin. I discussed the case over at Medscape. Although the patient clearly told me the acupuncturist put the needle in his forehead through obvious eczema, an acupuncturist noted in the comments

Regarding your comment about needling through eczema, it is unlikely. Acupuncturist will never needle through a skin lesion - no exception.

The literature on infections from acupuncture is clear with a quick Pubmed. The videos and photographs of acupuncture from a Google search gives an ID doctor the heebie jeebies. I would not be sanguine that practitioners whose understanding of disease and its treatment revolves around mythical meridians and qi will be punctilious about infection control and good technique.

I have been involved with quality control for 26 years and the best ways, unfortunately, to change practice for the better are to make the practice a rule, link payments to the practice or publicly report the practice.  

The approach by the OMM is likely to fail.  And supports my contention that pseudo-medical providers never change or abandon practice to increase patient safety.  So it appears that acupuncturists will continue to use poor technique. And I will continue to see the occasional infection denied by the acupuncturist. Same as it ever was.

Public Hearing On Acupuncture Needles

The Oregon Medical Board Newsletter arrived today and in it was the announcement of a public hearing on proposed rules for acupuncture. The hearing is tomorrow at noon and they will accept written comments until noon tomorrow (12/5/15) to Nicole.Krishnaswami@state.or.us.

A modified version of what follows was submitted to the OMB.

OAR 847–070–0021 has two parts. It

  • requires Oregon-licensed acupuncturists to follow clean needle technique standards and

and

  • use only disposable, single-use acupuncture needles.

Using disposable, single-use needles is imminently reasonable. There have been outbreaks from Hepatitis B to MRSA to Mycobacterium tuberculosis associated with acupuncture. How many of the outbreaks are due to needle reuse or poor technique is variable and uncertain. But with the potential risk for the inadvertent spread of infectious diseases from reusing needles, there is no good reason not to require disposable, single-use acupuncture needles.

The other rule, to require acupuncturists to follow clean needle technique standards is more problematic.

As head of Infection Control for 25 years and an Infectious Disease physician, if you watch the practice of acupuncture it will make your skin crawl. Watch any video on the web demonstrating acupuncture and, if watched with the critical eye of infection control, you will be appalled. Technique is always deficient and it is fortunate that it is difficult to cause complications and infections from acupuncture.

The practice of acupuncture is often horribly deficient when compared to modern medical practice.

The Clean Needle Technique is an interesting document. Published by the Council of Colleges of Acupuncture and Oriental Medicine, it is offered as a web courseThe YouTube video, from the viewpoint of infection control, demonstrates technique that is a major improvement over the usual techniques used for acupuncture

I would prefer wearing gloves and avoiding the palpation of the skin with the bare hand after the alcohol cleaning to totally minimize risk from the procedure. They compare acupuncture to a subcutaneous or intramuscular infection, but given the number of needle used and how long the needles are left in I am not certain that is a fair comparison. Infection control has the most benefit when it considers unusual events, not the usual.

The more philosophical consideration concerns risk/benefit of acupuncture. The authors of the clean needle approach are unduly optimistic about the effectiveness of the interventions discussed in their guidelines. Acupuncture with its dozens of variations, cupping, moxibustion, gua sha and the rest of traditional Chinese medicine have never demonstrated efficacy in the treatment of any illness.

And they should have no efficacy since they are not based on a modern understanding of anatomy and physiology, but are based on the pre-scientific fictions of qi and meridians.

Extensive evaluations, beyond the scope of this discussion, on the lack efficacy of acupuncture and traditional Chinese medicine can be found at Science-Based Medicine, the Society for Science-Based Medicine and Oregonians for Science-Based Medicine, where I am, respectively, an editor and President.

Medicine is about risk vrs benefit. If the benefit is zero, as it is for the interventions in the Clean Needles manual, then any risk is unwarranted and unacceptable.

It is an interesting ethical question as to the appropriateness of improving the safety of interventions that are not based in reality and do not and cannot have any efficacy. It is perhaps not unlike mandating all cigarettes have filters.

Some of the suggestions in the Clean Needles manual are odd to the medical ear. For fainting, one intervention suggested is

Acupuncturists may use a finger to press Du 26 (Renzhong) to help revive the patient; calling for medical help may be necessary in some cases.

It is inevitable that patients will continue to use a wide variety of pseudo-medicines.  There is a long history of pseudo-medical providers resisting changes to improve patient safety. To my knowledge, there has never been a pseudo-medical intervention that has published the results of a quality initiative that improved patient safely. 

The issues with the Clean Needles manual aside, the Clean Needle guidelines are an important step forward in patient safety.  They need to be implemented.

Oregon Naturopaths as Primary Care Providers: What THEY do not want you to know.

I ran across A Win-Win for Oregon: Naturopathic Doctors as Primary Care Providers over on the Lund Report.

Written by an ND, it is wrong from the opening paragraph.

Naturopathic doctors who absolutely meet the standards of care as required by the state are an underutilized resource and diagnose and treat the entire gamut of conditions.

Naturopaths may meet the standards required by the state, but they lack virtually all the requirements needed to diagnose and treat the entire gamut of conditions seen as primary care providers.

The opinion piece is filled with half truths and appealing platitudes. But it is what is not mentioned, what THEY do not what you to know, are the facts that reveal NDs should not have been declared primary care providers by the legislature.

One constant is that naturopathic medicine is founded in science—NDs are required to study the basic, biomedical and clinical sciences for two years.

Although allegedly grounded in science, science is ignored in vast swaths of ND education. Practices divorced from reality such as  homeopathy, acupuncture, colonics, and energy medicine, are the basis of ND education. Pseudo-science is baked into the ND education. And time spent in the pseudo-sciences is time not spent in reality based medicine. For a sobering description of the reality of ND education, I refer you to the Naturopathic Diaries, written by an ND, a graduate of Bastyr.

As persistent myths are clarified about our practice, licensed states have doubled, active NDs in the field have tripled, and NDs in Oregon are licensed primary care physicians.

Less a clarification of persistent myths and more successful advertising. The licensure of NDs by Oregon is, unfortunately, the medical equivalent of legislating astrologers to be the equivalent of astronomers or alchemists to be the equivalent of chemists.

Our foundation is anchored in natural healing, including botanical science, nutrition, hydrotherapy, physical medicine among others.

Among others. As usual they fail to mention all the pseudo-medicines that are the lifes blood of the ND practice. A perusal of ND websites finds almost every curious practice imaginable, from homeopathy to craniosacral therapy to plant stem cell therapy to the O-shot to detoxification. There is no ND that avoids pseudo-medicines and no pseudo-medicine not used by some ND in Oregon.

In the past 20 years there has been an increasing focus on other therapies our patients require—pharmaceuticals, for example, broad lab testing, and a proliferation of natural research.

Questionable and unvalidated lab tests, from Lyme to saliva tests to hair analysis to live blood analysis to biomeridian analysis, are also part of the ND pseudo-medical armamentarium. Just as there is no pseudo-medical intervention unused in ND practice, there is no pseudo-scientific test not utilized.

NDs know from clinical experience and years of education the interactions that can arise between a prescribed herb and, say, a diabetic medication.

Years of education? Compared to their MD/DO counterparts ND education is lacking in reality based practice and few have the extended post-graduate training required by MDs to learn their profession. No medical student has ever been ready for patient care upon graduation; it is why there are residencies. Most NDs go straight from school to practice with a fraction, 15,000 fewer hours, of training compared to a Family Practice physician. And since many of the ND training hours are not in science-based medicine,  the 6000 hours of ND training are a fraction of the realty-based training needed for competent patient care.

NDs, unlike their medical counterparts, practice whole-systems medicine.

Except that their whole system approach is not based in reality. Part of the appeal of ND's is their philosophy, which is superficially attractice but fails when its implementation is examined. NDs have excellent advertising, with all the appeal, and reality, of a light beer commercial.

Besides being educated in pseudo-science and practicing virtually every pseudo-science imaginable, NDs also treat diseases that do not exist (chronic Lyme, chronic Candida, adrenal fatigue, toxins as examples) with therapies that do not work or are dangerous, such as chelation and colonics.

Naturopaths are generally anti-vaccine and oppose mandatory vaccination laws. As a result, children are significantly more likely to be diagnosed with a vaccine-preventable disease if they receive naturopathic care.

When compared to MD's, naturopaths do an inferior job at primary care, falling short in cancer screening and vaccination.

NDs have unethical practice. Many naturopaths sell unneeded supplements and homeopathic nostrums from their clinic or website, a fundamental conflict of interest avoided in the MD practice. MDs are inaccurately accused of being under the influence of Big Pharma, but it pales in comparison to the sales of Big Supplement for profit in the typical ND office.

NDs have no quality improvement. There has never been a change or abandonment of an ND/alternative medical practice because it has been demonstrated to be useless or dangerous. Naturopathic practice, like all alternative practice, is immune to data even when it improves patient safety.

Naturopaths claim to stress prevention and consider the whole patient, but that's only what every good MD does. What NDs do that is good is not special, and what they do that is special is not good.

And the author uses, to my ear, the slightly creepily racist term "Western medicine." There is no Eastern, Western, Alternative or Allopathic Medicine. There is just medicine: interventions that have been demonstrated to be effective in the care of patients. And most of the ND interventions have failed to demonstrate effectiveness or even to be based on scientific reality.

There is little doubt that the court of public opinion is changing in favor of naturopathic medicine. What has changed in recent years to shift the perception of naturopathic medical care from "alternative" to "primary" care?

I think it is because ND's have become very good, as this article demonstrates, at obfuscating the truth about ND practice. Half truths and an appealing natural philosophy in place of an honest, complete description of ND practice.

Insurance coverage is another. NDs are covered by Medicaid through the Oregon Health Plan and CareOregon. With the exception of Oregon Health COOP and LifeWise, insurance carriers still balk at covering natural medicine. Aetna, for example, recently served notice to NCNM that it did not recognize our status as primary care providers in Oregon. That company's logic, despite federal and state legislation to the contrary, stems from recognizing NDs only as "alternative care" practitioners, not as PCPs. For companies like Aetna, this categorization guarantees that naturopathic doctors will continue to be reimbursed significantly less for performing the same services as medical doctors.

It is clear from their education and practice that whatever it is that NDs do, it is not performing the same services as medical doctors and their payment appropriately represents this reality. That my premiums are wasted on the practice of pseudo-medicine even at a reduced rates is shameful.

We can ameliorate the critical shortage of PCPs. The state of Oregon recognizes us. The Affordable Care Act recognizes us…At the same time, NDs who absolutely meet the standards of care as required by the state, are an underutilized resource. We believe that the rising chronicity rates in America, coupled with an acute shortage of PCPs, is a strong argument that it's time to remove all the remaining barriers to quality standards of care from all licensed, qualified providers. The team of practitioners at NCNM is ready and able to take action in support of every patient's health.

In every aspect of their education, training, and practice naturopaths are not qualified to be a primary care providers, despite the legislature declaring it so. There are enough difficulties getting real, useful care reimbursed. Those limited resources should not be wasted on naturopathic care.

There is a shortage of primary care providers in Oregon. The wrong solution is paying providers who are educated in pseudo-science, trained in pseudo-science and practice pseudo-science. As Simon Singh noted, just because there are issues with the airlines does not mean we should use magic carpets.

And now you know.

Oregonians deserve better.

A liquid that was almost, but not quite, entirely unlike tea.

Cross posted from sciencebasedmedicine.com.

Those of you in the know recognize the title from the Hitchhikers Guide to the Galaxy, among the funniest and most quotable books of all time. If you have not read the five books in the trilogy, get to work. Consider it a homework assignment.

I bit off more than I can chew for this entry. I usually plan on about 8–10 hours over 4 –5 days to write these entries. So I had this idea. Now that naturopaths have been declared primary care providers by the Oregon legislature I thought it would be good to look over all the websites in Portland to see, in their own words, what naturopaths were offering. I figured there would not be that many sites to review. How many naturopaths could be in Portland?

So I went to the Oregon Board of Naturopathic Medicine Licensee Directory and entered Portland into the search box. And?

578 hits.

There is not enough beer time in the world

Holy Cannoli. I thought there would be 30, which is the number infesting Eugene, the second most naturopathed city in Oregon. There is no way that I could do a comprehensive review of that many websites in the limited time I have to devote to the blog. But my brain is not unlike an oil tanker with blog entries, it takes a long time to change direction and I had nothing else mentally lined up to write about.

I started a spreadsheet and have made it through the first 36 names on the list representing 24 website. Excel is wrong tool, that is for sure. I should have used a database. Sometime in the (hopefully) not too distant future I need to do a comprehensive assessment of ND (and DO and Lac) websites in Oregon as a project for Ore4SBM.org(blatant plug).

Because the breadth (but not depth) of whack-a-loon pseudo-science on display in these websites is truly amazing. That this hodgepodge of providers and therapies are now primary care providers in Oregon would be funny if the topic, health, was not so fundamentally serious.

I will say that every ND does come across as a caring, compassionate provider, committed to their patients. If I were unaware of the content of their practice I would be impressed. They are so relentlessly evangelical I wonder if ND students only travel in pairs wearing white shirts. A good topic for a musical: The Book of Naturopathy?

I also wonder if there is an official template for Naturopathic website as there are remarkable similarities in content. I have often compared Naturopathy to the practice of magic, the Harry Potter kind, i.e. wishful thinking for what is, in reality, impossible. You know, the naturopathic school curriculum.

The naturopathic sleight of hand

However, these websites are masters of modern magic, the Penn & Teller kind. Magic, the kind whose intent is to fool the observer, consists of:

  • Palm: To hold an object in an apparently empty hand.
  • Ditch: To secretly dispose of an unneeded object.
  • Steal: To secretly obtain a needed object.
  • Load: To secretly move a needed object to where it is hidden.
  • Simulation: To give the impression that something that hasn’t happened, has.
  • Misdirection: To lead attention away from a secret move.
  • Switch: To secretly exchange one object for another.

A good template if you need techniques to distract the reader of the website so that they do not notice that, as practiced, there is little in the ND practice that isn’t pseudo-science. Nope. Nothing to see here.

Most sites mention the philosophic principals of naturopathy:

I. The Healing Power Of Nature

II. Identify And Treat The Cause (Tolle Causam)

III. First Do No Harm (Primum Non Nocere)

IV. Treat The Whole Person

V. The Physician As Teacher (Docere)

VI. Prevention

All of which sound great if you did not know the reality behind the application of these principles.

They like to mention that, yes, they are real doctors with training equal to MDs. Whilenaturopathic studies compare favorably in the number of hours in school, however they fail to mention that the bulk of the education is in the pseudo-sciences that comprise the naturopathic education. And, with no post-graduate residency, they lack the experience for real patient care that MD/DO have.

Britt Hermes and the AAFP make it very clear that NDs have barely a whiff of proper medical training. It is all magic.

  • Palm: Mention the ND education hours.
  • Ditch: Ignore the lack of residency.
  • Steal: We can prescribe and do minor surgery.
  • Load: Note that you have a doctorate and a philosophy.
  • Simulation: A medical education.
  • Misdirection: The state says we are primary care providers. And we have a philosophy.
  • Switch: We are real doctors.

You can get a doctorate in other forms of science fiction as well, but at least they have the decency to teach in English Departments.

So the websites use a bit of prestidigitations to try and hide the fact that:

An ND education is almost, but not quite, entirely unlike a real medical education.  But is like a buttfull of coffee.

Now you can see where I was going with the title.

More time ≠ better medicine

Many sites mention that each patient is unique and as a result visits will take an hour or two to evaluate the patient.

The huge time spent on each patient is trumpeted by NDs as a plus, but is further evidence that they really do not know what they are doing.

There are a finite number of diseases in humans and they have patterns. Good, experienced physicians recognize these patterns quickly, especially for common diseases in primary care. Medical students and interns are notorious for taking hours to evaluate patients because they are learning and do not know what they are doing or how to interpret the information they are gathering.

Of course NDs, with an education consisting of pseudo-medicines like homeopathy, acupuncture and hydrotherapy and no post graduate training, never get the opportunity to see and learn these patterns. So it is not a surprise they take hours to see a patient. It is the hallmark of the inexperienced novice.

And it fundamentally disrespects the patient, wasting the patient’s time as the ND flails about trying to come up with a diagnosis and treatment plan.

Hanging with a bad dumb crowd

When mentioned (many sites give no specifics, preferring upbeat platitudes to mentioning the true nature of their particular ND practice) every site offers one or more pseudo-medicine. My father always suggested you can judge a person by the company they keep. And ND’s keep company with the pseudo-medicines.

There are the usual suspects: homeopathy and acupuncture predominate, no surprise, as well as hydrotherapy, reiki, energy therapy, and all the other common SCAMs. Many sites were in the supplement sales racket, being in the pocket of the supplement industry. Pseudo-medicine and unethical sales are the norm on all the sites I visited, two areas where NDs differ from MDs since for physicians:

In-office sale [and I would add internet sales – Ed.] of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own.

And then there are services that make these supplements seem reasonable by comparison.

There is a female predominance in ND practice on the sites I visited and as a result a focus on female issues. Some services would be creepy if offered by a male, like Holistic Pelvic Care™ and some services are just what the…!?! Like:

The The O-Shot® where:

the platelet rich plasma is injected into an area near the clitoris and upper vagina

And Plant Stem Cell Therapy:

Theory of Action: These same plant growth stimulating factors that can cause the plants to differentiate and produce specialized mature cells may stimulate the immature cells in the tissues of the human body to replace, repair, and regenerate lost tissue, organ, and system function.

And on and on and on.

Cut a naturopath, she will bleed pseudo-medicine. It is their life’s blood.

Look on their works, ye scientifically literate, and despair

This is a further validation of the observation that every practicing naturopath, in the words of their own websites, has a practice often fundamentally divorced from reality and NDs have no qualifications to be primary care providers.

NDs are almost, but not quite, entirely unlike physicians.

And the Oregon Legislature has made them equal to real doctors.

 

 

NPR: Embracing Anecdote

The awful NPR report on the use of pseudo-medicines to treat pain in Oregon was nicely discussed over at Science-Based Medicine by Dr. Novella.

The NPR article was reproduced without comment on the Lund Report, which calls itself "Oregon's most vital source of health news."

In the comment section of SBM Windriven used the term embracing anecdote, a description of NPR report and much of the basis of pseudo-medicine. I have said before that one anecdote is more powerful than a dozen randomized placebo controlled double blind studies.

The NPR starts with the story of Doris Keene who had chronic pain. Exactly want the pain was and how long she had it is not clear. Sciatica is mentioned, a disease that more often than not improves with time. So it would be nice to know if that were indeed the diagnosis and how long she the process, but as is so often the case with anecdotes, the important specifics are never mentioned.

She was given Vicodin and muscle relaxants and they did not help. That does not surprise me. Having had a ruptured disc and 9 months of pain I can tell you: nothing helps the pain.

Ms Keene increased her medication with little effect on the pain but she did get addicted. One nice thing about being on call 24-7 is I could only take a Vicodin on the Friday and Saturday nights when I was not working so addiction from self-medication was never an option.

When she is cut off from the medications she went to Quest Center for Integrative Health, which NPR describes as

a pain management center in Portland

but  the services on the website would suggest that, with 4 acupuncturists, two naturopaths and a reiki practitioner, they are, in my opinion, a general purpose pseudo-medical clinic not grounded in medical reality.

"There should be an array of things for people to choose from," Eisen says, "whether it be chiropractic care, or naturopathic care, or acupuncture, nutrition, massage.

Ms Keenen had a response to her first session that would a faith healer proud and suggests a similar reason for her improvement:

"I come in here wearing back braces, and knee braces and a crutch, and Dr. Dave told me, 'Get rid of them! They're just weakening your muscles,' " Keene says. "And when I could walk out of here after the first acupuncture [treatment], I wanted to grab him and kiss him."

And that description makes me wonder about several issues.

Just what was the cause of pain? Why all the braces? Seems overkill for sciatica

There is a tendency for some patients to minimize their illness. Others dramatize them. This seems on the dramatic end of the scale to me. And some patients become medicalized, their illness and treatments becoming a key part of their identity. I get that sense as well. Patients do get into care that is dysfunctional, where the interventions serves to worsen the patient and make them dependent on their provider. It is how much of the chronic Lyme industry works.

They note

acupuncture treatments ease her pain at least as effectively as the Vicodin and muscle relaxants she once depended on.

Which, they noted early on, was not much. So it sounds like she exchanged a placebo opiate and a poor relationship with her MD for a placebo pseudo-medicine and a caring, but deeply pseudo-scientific, environment. 

But the story is not not spun that way. It embraces an anecdote to suggest that Ms. Keenen received benefit from the pseudo-medicine rather than natural history of the disease or, perhaps, getting out of  dysfunctional medical care.  But as is so often the case, the information required to really know what is happening is lacking. 

And if NPR, and most mainstream media, does such an inadequate, uncritical report on a topic about which I know something, it alway makes me wonder about the validity of rest of their content.

As of 2016 Oregon is going to pay for pseudo-medical placebos like those received by Ms. Keenan, which I have discussed before.

In Oregon, to paraphrase Simon Singh, we have had problems with airplanes. So we are going to use flying carpets instead.

Spit Take

This was on the Oregonian website: Naturopathic clinic designated as top tier primary care facility. Good thing I was not drinking when I read the headline.

The article has, by the way, my favorite picture of acupuncture technique, because not only are there no gloves on the hands of the acupuncturist as her fingers are next to the needle, there is a box of (unused) gloves behind her on the shelves. I use this photo in every acupuncture talk and the audience always responds with disgusted laughter.

But how could a naturopathic clinic be a top tier primary care facility?

Remember, in Oregon, naturopaths are designated in the statues as primary care providers. This is like designating pi as equal to 3.14, but it is the law of the land here in Magic Kingdom of Cascadia. It does not matter that naturopathic education and training in real medicine are about the equivalent buying a Fisher-Price Medical Kit Playset and declaring yourself trained as a doctor. According to the state, playing doctor is enough to make you a doctor.

So what then is the requirements to become a top tier clinic?

Core Attributes

– Access to care: Patients get the care they need, when they need it.
– Accountability: Recognized clinics are responsible for making sure patients receive the best possible care.
– Comprehensive: Clinics provide patients all the care, information and services they need.
– Continuity: Clinics work with patients and their community to improve patient and population health over time.
– Coordination and integration: Clinics help patients navigate the system to meet their needs in a safe and timely way.
– Patient and family-centered: Clinics recognize that patients are the most important members of the health care team and that they are ultimately responsible for their overall health and wellness.

There is almost nothing in the core attributes concerning the actual appropriate diagnosis and treatment of diseases. It is all about service and coordination of care, the infrastucture for providing care, not the actual medical care itself.   This is something that medicine has not always been all that good at in the past. 

If you go through the standards, there is almost nothing about adhering to science-based medical care and standards.  Use homeopathy, acupuncture, energy and water therapy and other fantastical interventions?  Not even relevant to the designation.  And so not only can the naturopathic college get a designation, so can A Natural Path, an ND clinic in Seaside Oregon.

No good deed ever goes unpunished. Just as evidence-based medicine can be misused to make pseudo-medicines appear effective, the goal to provide better medical care can be misused by those with no medical training at all.

As I read the standard, for something as fundamental as childhood vaccinations, a clinic does not actually have to give vaccines, they just need to

offer(s) or coordinate(s) recommended age and gender appropriate preventive services based on best available evidence.

Not actually give the vaccine, just offer and coordinate. Although they do have metrics for meeting minimal vaccination standards for children and adults. I will have to investigate this further as well and am trying to see if I can access the submission forms of the ND clinics.  I have not heard back from the state as I write this.

As far as the designation as a top tier primary care facility it does not matter in the least, as in the case of naturopaths, that the providers have no education or training in real medicine and that their entire paradigm of medical care is rooted in pseudo-science and fantasy. It is almost all about the service provided, not the quality of medicine practiced.

The designation is like restaurant sanitation grades. It offers important information about the infrastructure of facility but says nothing about the quality of the cooking. And in the case of an ND clinic, it is like getting the Just Like Home Dinner Play Food.

Oregon Health & Pseudo-Sciences University

Growing up my alma mater was University of Oregon Medical School. Since then it has undergone two name changes. First to Oregon Health Sciences University and then to the current Oregon Health & Sciences University, OHSU.

Perhaps they need one more name change, since they are not always that interested in the Science part of their name.

Some background.

Portland has a trifecta of pseudo-science schools: Naturopathic (National College of Natural Medicine), Chiropractic (University of Western States) and 'Oriental' (Oregon College of Oriental Medicine.

Lucky us.

All three are steeped in pseudo-science and pseudo-medicine, removed from known reality. As examples, the naturopathic school teaches homeopathy, the chiropractic school the subluxation complex and the Oriental school acupuncture. Reading the curricula of the schools suggests that there is no pseudo-medicine stone left unturned.

In the 1980's OHSU received a grant to study low back pain in conjunction with the chiropractic school. As Cindy Lauper noted, money changes everything.

Why worry about standards, reality, plausibility, and science when there is money to be had. The Oregon Collaborative for Integrative Medicine was born, the OCIM.

The Collaborative was formally established in 2003 as the Oregon Collaborative for Complementary and Alternative Medicine as the result of a National Institutes of Health R25 CAM Education grant awarded to OHSU. UWS, OCOM and NCNM were all subsequently awarded follow-up R25 education grants.

With OHSU and Pacific University joining up with the troika to, among other plans, to become the integrative  Island of Doctor Moreau.

Standing beside the traditional MD/PhD or MD/MPH will be the ND/ MD, the MD/DAOM, the ND/DC, the ND/PhD, the DAOM/MPH and countless other combinations to build new vanguards of cross trained clinicians focused on inclusivity and collaboration

It is like the chemistry department at University of Oregon working with an alchemist, the astronomy department working with an astrologer, and the physics department working with a perpetual motion inventor. But for millions of dollars, why not?

As best I can tell they have wasted at least 1.5 million dollars in NIH money. That is a lot of money, and I am not at all shocked that standards fell before the onslaught of Benjamins.

The result of this money? Uncertain.

This section of our website is in development, please check back soon to learn about the enormous breadth of research that has been done and continues to be done in integrative medicine and health…

That is true, there has been and continues to be a enormous breadth of research in pseudo-medicine. Most of it poorly done and the high quality studies demonstrating no utility of the pseudo-medicines promulgated by the OCIM.

And now they are proud to announce a Fellowship in Integrative Medicine.

My motto: with you integrate cow pie into apple pie, the cow pie is not improved, the apple pie is made worse.

OHSU continues down the road to OHPSU.

State Increases Pseudo-Medicine Coverage

Oregon has a problem with prescription pain pills. Oregon leads the nation in the abuse of such drugs, federal statistics show, with the state's rate of prescription drug abuse 39 percent higher than the national average.

Why that is, I do not know. As an Infectious Disease doctor I prescribe a narcotic about once a year. There are a real problems with the treatment of chronic pain and while I am aware of the issues and the changes over the last 25 years, it does not impact my practice, so my knowledge of the issues is basic

I am also well aware of the Oregon Health Plan, OHP.

OHP was intended to make health care more available to the working poor, while rationing benefits.

Given limited resources, part of the plan has always included a prioritization of treatments and diagnostics, paying for interventions that give the most bang for the buck. Not a perfect way to ration care and as is always the case, no good deed goes unpunished.

Another effect of limiting care, according to the Bend Bullitin, may be that

OHP members who suffer back pain have been left with no choice but to take drugs, and the policy could be contributing to Oregon's high rate of narcotic abuse

since other interventions are not paid for.

New guidelines were recently updated by the Health Evidence Review Board and as a result

The new guidelines open the door to acupuncture, chiropractic, cognitive behavioral therapy, osteopathic manipulation and physical and occupational therapy.

To be picky, they do not say chiropractic, but "spinal manipulation",  although the codes suggest chiropractic manipulation.

As best I can tell, they relied on two reviews Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society from 2007 and Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline from 2007.

They evidently did not review the literature to show that acupuncture is a theatrical placebo, has no basis in reality-based medicine and that most positive effects are probably due to bias

results should be interpreted in the context of the limitations identified, particularly in relation to the heterogeneity in the study characteristics and the low methodological quality in many of the included studies.

and that chiropractic is no better other therapies

High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.

not, as was mentioned in the newspaper, that

Large, randomized trials have shown that for chronic back pain, acupuncture and chiropractic therapy are equally helpful, said Dr. Richard Deyo, professor of evidence-based medicine at Oregon Health & Science University. He served on a task force that advised the Health Evidence Review Commission. "Different people respond to different things," he said. "The outcomes tend to be very similar, in the short term at least."

It is more accurate to say they are  equal placebos, since short term improvement is just what one would expect from a placebo that does nothing to the underlying process.  And placebos are unethical.

As noted many times here and at Science-Based Medicine, evidence based medicine is inadequate at evaluating interventions that are not based in reality

And this also ignores the question of the state paying for practitioners of magical pseudo-medicines and all the associated useless interventions and beliefs espoused by chiropractors, naturopaths and traditional chinese medicine practitioners.

Hardly seems like a good use of Oregon resources.

They suggest possible benefit

The expense of a broader range of treatments could be offset by a decline in narcotics use,

and I hope they do some epidemiologic studies to show benefit of adding pseudo-medicines to OHP,  although I am sure the cost is worth the benefit.

The Consequences of Naturopaths Receiving PCP Designation


Naturopathy has undeserved legitimacy in Oregon. There are two naturopathic schools in the NW.  Oregon has a Board of Naturopathic Medicine, naturopathic physicians have prescriptive privileges and the legislature, with House Bill 3301, has given naturopaths the status of primary care providers (PCP) as of 2016.

The result?  A class action suit filed by Oregon Association of Naturopathic Physicians against Health Net Health Plan of Oregon  alleging unlawful and discriminatory practices and seeking reimbursement for those who used an naturopath as a PCP.

As one naturopath noted “much of the alleged discrimination stems from ignorance about naturopaths’ training and licensure.”  When one understands naturopathic training and licensure, it becomes clear why insurance companies would be hesitant to pay for naturopathic care.

The state may have declared an naturopath a PCP, but like legislating the value of pi, legislating reality does not make it so.

-  The best and brightest do not attend naturopathic school, with an undergraduate GPA around 3.2 and a 66% acceptance rate to naturopathic school. Compare that to medical school, with a 3.7 GPA and a 3% acceptance rate.

-   Naturopathic educational foundation consists of imaginary pseudo-medicine: homeopathy, hydrotherapy, acupuncture, energy therapy, and more, all interventions divorced from reality. 

-  Naturopaths have little or no post graduate training, when real physicians learn their profession. Naturopaths receive around 1200 hours of clinical training compared to around 3000 hours in medical school followed by 10,000 hours for an internal medicine or family practice residency. Naturopathic clinical training primarily reinforces naturopathic pseudo-medicine, not learning science-based medicine.

- Once in practice, anything goes.  Naturopaths are proud of the fact that “There is no naturopathic-specific standard of care.” Naturopathic websites demonstrate a diverse hodgepodge of pseudo-medical diagnoses and treatments, much of it divorced from scientific reality.

- Naturopaths are generally anti-vaccine and opposed the mandatory vaccination law. As a result, children are significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care.

- When compared to MD’s, naturopaths do an inferior job at primary care, falling short in cancer screening and vaccination. 

- Unethical practice. Many naturopaths sell unneeded supplements and homeopathic nostrums from their clinic or website,  a fundamental conflict of interest.

- No quality improvement.  There has never been a change or abandonment of a practice because it has been demonstrated to be useless or dangerous.  Naturopathic practice is immune to data.  

In every aspect of their education, training, and practice naturopaths are not qualified to be a PCP, despite the legislature declaring it so. As a practicing physician I have enough issues getting real, useful care reimbursed.  Those resources should not be wasted on naturopathic care.  The class action suit is like worrying about discrimination of astrologers by astronomy departments. 

There is a shortage of primary care providers in Oregon.  The wrong solution is paying providers who are not qualified and are extensively trained in ineffective pseudo-medicine. Just because there are issues with the airlines does not mean we should instead use magic carpets.  Oregonians deserve better.

Addendum 

A longer of this post, with references, can be found at sciencebasedmedicine.org.

2015 Summary

The 2015 Oregon Legislative session ended mid-July. Time for a summary of the results on bills that were considered by the legislature last year related to science-based medicine.

ACUPUNCTURE

House Bill 2966: Directs Oregon Medical Board to study regulation of and reimbursement for acupuncture services. In committee upon adjournment of the 2015 session.

Senate Bill 631 Provides comprehensive health care coverage to all individuals residing or working in Oregon, includes acupuncturists as providers.

In committee upon adjournment of the 2015 session.

CHIROPRACTIC

House Bill 2523: Requires managed care organization to allow chiropractic and naturopathic physicians to serve as attending physician.

In committee upon adjournment of the 2015 session.

Senate Bill 631 Provides comprehensive health care coverage to all individuals residing or working in Oregon, includes chiropractors as providers.

In committee upon adjournment of the 2015 session.

Senate Bill 280: Adds a chiropractor to Board of Medical Imaging. Signed in to law. Perhaps we will have a practitioner on the Board who can find non-existent subluxations on x-rays.

NATUROPATHY

House Bill 3301: “Naturopathic medicine” means the discipline that includes physiotherapy, natural healing processes, [and] minor surgery and primary care and has as its objective the maintaining of the body in, or of restoring it to, a state of normal health.

Signed into law, effective January 1 2016.

Naturopaths are now designated as primary care providers. For some consequences of this law, see The Consequences of Naturopaths Receiving PCP Designation.

Senate Bill 631 Provides comprehensive health care coverage to all individuals residing or working in Oregon, includes naturopaths as providers.

In committee upon adjournment of the 2015 session.

House Bill 2523: Requires managed care organization to allow chiropractic and naturopathic physicians to serve as attending physician.

In committee upon adjournment of the 2015 session.

VACCINATION

Senate Bill 442: Limits vaccine exemptions.

3/11 Amendment allowed to die; other amendments pending. In committee upon adjournment of the 2015 session.

Unfortunately the legislature did not have either the will or the courage of the California legislature, which passed strict limitations for vaccine refusal. There was a measles death this year in an adult with a compromised immune system in Washington. I hope we do not see a similar result in the coming months.

Senate Bill 520. Permits pharmacists to administer vaccines to individuals at least seven years of age.

Signed in to law.

LYME

Senate Bill 916:

As of the end of April, “a) Permits health care workers to diagnose and treat Lyme by the International Lyme and Associated Diseases Society guidelines and protect those who do from disciplinary actions.”

has been amended to read

“Delete lines 4 through 19 of the printed bill and insert: “SECTION 1. The Oregon Health Authority, the Oregon Medical Board and the Oregon State Board of Nursing shall study clinical guidance regarding Lyme disease and the health outcomes related to the clinical guidance and shall report findings to the appropriate committees of the Legislative Assembly no later than March 1, 2016”

In committee upon adjournment of the 2015 session.

This will likely return in the future.

OTHER

Senate Bill 298: Includes the fiction “Using touch to affect the energy systems or channels of energy of the body;” which do not exist.

The above language removed and they added “(b) “Massage,” “massage therapy” and “bodywork” do not include the use of high velocity, short-amplitude manipulative thrusting procedures to the articulations of the spine or extremities.” was added. Chiropractors protecting their turf.

Signed into law.

As an aside, Oregonians for Science-Based Medicine started late in the 2015 legislative session and was associated with a steep learning curve. We hope to have increased activity in the 2016 legislative year and beyond.