I have spent a ridiculous amount of time contemplating why people seek out quackery and what I can do to save them from getting hurt (at worst) or just spinning their wheels (at best). If it wasn’t for my frustration with alternative medicine, this blog might never have been borne. Thanks to the existence of Hormones Demystified, I do get some thought-provoking reader emails. This piece was inspired by such an email.
A few months ago, I had an email exchange with “Leslie,” a disillusioned naturopath who had this to say [HD: any potentially identifying details have been changed]:
I realize I made a mistake; sadly it’s been difficult trying to switch careers with the amount of debt I’m in. So I try my best to stay away from all the usual BS with a ten foot pole. I think of somehow navigating my way back to MD/DO school. Then I read posts like yours about “why your doctor wants to quit.” It is a bit disheartening to say the least.
If I can offer some unsolicited advice: take the training you’ve received and make something great out of it. The road to become an MD/DO is a 7-year minimum commitment. Never mind the investment of time, energy, and emotion – think about the financial toll it would take. If you already have significant debt, you would have to commit to a high-paying specialty and a low cost-of-living area in which to settle. Which of course means that you are not doing 7 years – no way can you be a pediatrician in San Francisco or a psychiatrist in NYC. You’re doing at least 8 years (dermatology), maybe 9-11 years (specialized surgery). I don’t know how much energy you have, but I’m semi-crusty and can’t imagine going through all that at this stage of my life.
Perhaps you can find an MD or DO who would be willing to mentor you, kind of like a residency for a year or two? Maybe you could practice while you shadow that doc for an extra couple hours each day? Maybe you could try specializing in something (athletic training/fitness optimization through good diet, sleep, exercise)? I don’t know. But maybe there’s something you could pick in your field that you love, and do that.
Leslie wrote back:
Recently I met with another ND friend who thinks a bit like me and he did what you have suggested. He observed with an MD specialist while in school and now works under him as a midlevel provider and has become very competent in that specialty. Listening to him made me think of what you said in your email. I may try that – it’s a useful compromise. I do currently focus on diet and lifestyle which I’m very comfortable with. But I crave the competency that I was promised in ND ed and have the desire to separate myself from the degree and most of what the field stands for. Being a skeptical person who is also an “ND” does a number on your head.
I wonder how many others like Leslie are out there? Given the enormous popularity of Naturopathic Diaries, the blog of a naturopath who renounced her degree and now crusades against quackery, I suspect there is – at the very least – a large, silent minority. Should the MD/DO community reach out to these folks and figure out a way to work together? Or should we be focusing our efforts on delegitimizing the ND degree to the point where applications to naturopathy schools dry up and the institutions are shuttered? I honestly believe that there is no clear answer to this question. I look at it like the current quagmire in Afghanistan. Assuming that coalition forces are not leaving anytime soon, should we expend all our energy stamping out the Taliban and ISIS, which seems nearly impossible? Or should we recognize that the Taliban aren’t going anywhere, so we need to figure out the least objectionable way to work with/contain a group we find abhorrent. Neither of the options looks good to me, but it sure doesn’t seem like anyone has noodled a third choice.
Did you just compare naturopaths to terrorists?
Ugh, I knew someone would go there. Listen, I’m just trying to make a colorful analogy. On the x-axis of distasteful behavior, terrorists are pretty far to the right of naturopaths. Happy? In the interest of compromise and keeping patients safe, though, I wonder if it would be reasonable to:
Hire a reasonable, well-vetted naturopath in-house.
What?! HD, what have they done to you?
I’m just spitballing here, so don’t take my head off yet. People are going to seek out alternative medicine, regardless of what we do. Recognizing that, we can provide them a known quantity alternative, or we can wish them luck as they leave our office for the lion’s den. It’s somewhat analogous to illegal drugs: the politicians who have voted to legalize marijuana don’t necessarily want more people to use it. But, they recognize that people are going to use it anyway, so why not regulate the product, keeping people safer and making money through taxes for the state?
So many cancer patients seek out alternative medicine as a complement to their medical standard of care that some oncology clinics now work more closely with alternative medicine providers. Are these arrangements successful? I don’t know [HD: if you know a doctor who is working closely with a naturopath, please ask him/her to reach out to me via email – I’d love to interview them]. Do these arrangements have the potential to lend credibility to nonsensical “treatments?” Absolutely. But I do think that, with a lengthy mentoring process and close oversight, it would be possible for a naturopath to serve as a capable complement to the oncologist. For example, there is data about the use of intermittent fasting and the ketogenic diet for combatting the side effects of chemotherapy. If a naturopath with interest and expertise in this area were to focus narrowly on helping the patient through a rough bout of chemo, that would be a win-win-win for the patient, doctor, and naturopath. While a doctor or oncology nurse could acquire this type of knowledge, it might be a more efficient use of their limited time to outsource this work to a naturopath.
Moving on, I’ve written before about the challenge of sorting out a patient’s constellation of nonspecific symptoms in a typical 15-20 minute office visit. Many of these patients will not have a quantifiable “disorder.” Rather, they need to fully embrace a myriad of lifestyle changes to get on the road to feeling better. Unfortunately, it is hard to adequately communicate this to people in a short amount of time without them being dissatisfied with the visit; they view it as “once again, no answers.” It is these patients who often seek out an alt med provider. Instead of leaving them to their own devices, why not say, “We have a naturopath who works with us; sometimes she can help when we can’t?” Perhaps the patient will be more receptive to lifestyle advice from the naturopath and will take steps to improve sleep, diet, exercise, and stress management. If expectations of the naturopath’s scope of practice are clearly set up front (e.g. no superfluous hormone testing, no systemic Candida treatments), could that work?
If we’re going to get in bed with NDs, we have to mentor them closely.
I know a primary care provider (not a naturopath) who has cultivated a naturopathic style of practice. This PCP orders a boatload of unnecessary tests and tends to offer patients useless advice along the lines of, “Stay away from gluten so your thyroid will heal itself.” This PCP makes my job so much harder, as I have to undo much of what he’s done before I can repair the damage. I spoke with one of his MD partners, essentially asking, “WTF?” The MD was somewhat aware of the extent of this clinician’s nuttiness. However, the MD said that having the wannabe naturopath in the office has been helpful, in that the MDs will send some of their toughest patients to this provider. Even though some of his advice tends to stray out of the realm of evidence-based medicine, apparently he does a good job helping to take care of patients with nonspecific complaints.
Is this a win? Well, clearly the MDs could be doing a better job of mentoring and quality control. Patients believe what this pseudo-naturopath tells them, as being employed by our well-respected organization lends credibility to whatever he says. On the other hand, we are keeping patients away from alternative medicine providers who could be hurting them to a much greater extent.
If medical doctors establish an ancillary pipeline between naturopathic schools and medical practices, perhaps we could (re)educate these impressionable youngsters before they disappear into the unregulated void of quackery. I bet if you give me a smart, well-intentioned, science-minded graduate with a ND degree, I am pretty sure I can train her the same way I’ve trained nurse practitioners to be excellent diabetologists.
What do you all think? Am I crazy? Naive? Do the obvious negatives outweigh the potential positives? Are there other downsides of such an arrangement I haven’t considered? If you’re a person who thinks naturopathy has something to offer, would you appreciate your medical doctor having a naturopath in-house? If you are a doctor, would you ever consider training a ND to work in your office? Comment below!
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