Can Medical Doctors and Naturopaths Work Together?

 

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.

I responded:

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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Image credit: Photo by juan pablo rodriguez on Unsplash

21 Replies to “Can Medical Doctors and Naturopaths Work Together?”

  1. As the saying goes – “keep your friends close but your enemies closer”. I think there is some merit in your suggestion – it that what a spitball is? The biggest downside I can see is fame by association – naturopathy must be okay if my MD works with one. On the other hand the benefits of having somebody with the time and possibly inclination/people skills to inculcate lifestyle changes in those who might benefit is attractive.

    I make no estimation of your own people skills here.

    1. For sure, I worry about the implicit endorsement of the “woo” aspects of naturopathy by having a ND practice in a MD’s office. The balancing act there would have to be constantly attended to.

  2. In the broadest sense, I think this idea has merit, but I would define it even more narrowly than you suggest. Diet needs to be left to RD’s, and I’d never go with, “they can help when we can’t”–ugh. What I COULD imagine is, “after you see the RD and get an approved diet recommendation, I’d like you to work with our naturopathic (small ’n’ on purpose) support person to implement the diet and get the support you need for that and other lifestyle management”.

    It’s very important that the ND operates only as a support and as “wise counsel” if you will. Part of that would be to patiently explain why no goofy treatments are necessary.

    I’ve been commenting elsewhere under a different name about this and have actually suggested something like this and tried to start a conversation about it. My own experience with short office visits and a general disinterest in anything about my actual life would have driven me to woo long ago if I weren’t so naturally and educationally skeptical. I’ll ask my PCP about exercise (not because I’m stupid, but because I’m not sure what’s best at my age) and I’ll get, “30 minutes/day”, and it’s out the door. No discussion, no interaction, no support (does it occur to her that the reason I’m asking is that I’m not doing it and maybe a little pep talk from her would help?

    It’s also important to say that just because SBM has failed to make the case against woo wide enough to be effective, is no reason to roll over and play dead–and yet I am forced to agree with the gist of your argument given the reality of the widespread failure of education.

    Cheers!

    1. Really solid points, thanks Toad. As far as diet recommendations go, I wonder how many RDs out there have educated themselves about some of the more novel (and sometimes helpful) eating strategies, like the ketogenic diet. I don’t see why KD and other “extreme” but scientifically sound eating strategies should have to be under the purview of “alt med,” when RDs would be best poised to understand this stuff and communicate it in the most helpful manner to patients.

      You are right about this: it would be a mistake for the MD to say “sometimes the ND can help when we can’t.” My verbiage in the post is inferior to your suggested verbiage.

      I agree that short office visits are not usually compatible with good lifestyle counseling. It takes time to really get to know someone, in order to figure out what will resonate for them when it comes to a diet and exercise program. I find that one of the most powerful questions I can ask of someone who does no exercise is, “What did you used to like to do?” That’s how I can learn that my patient never liked “exercise” until getting a Wii as a present, which they used to love until moving, and now it’s in a box. It’s just a quick hop from that statement to, “Maybe I’ll dig that out of its box and get back into it.”

  3. Very interesting read. I have said that I am not necessarily opposed to alternative medicine per se. I can see people benefiting from certain supplements when used appropriately. I have told patients that I generally have no strong objections to them trying certain supplements, but I caution them that a) they need to know what they are taking, b) they need to tell their physicians they are taking it (can interact with meds or can be contraindicated in certain situations), and c) it is not a substitute for scientifically-proven therapy. However, I also caution them that there are supplements that are harmful especially in excess and that they have to ask themselves what the motivation is of someone who is actively selling them the supplements they “prescribe”.

    1. Great points, especially being skeptical of being found to be “deficient” in $400 worth of tinctures sold out of the office.

  4. No way, no how. I spent 12 years in primary care in New Hampshire, while NDs are licensed and can prescribe. They are out of control. All were anti-vaccine. Everyone who saw them had Lyme disease, heavy metal toxicity, adrenal fatigue, or candida. I spent so much time cleaning up their messes that it was unreal. I was constantly having patients come to me with these ridiculous lists of tests that their ND wanted me to order so insurance would pay for it.

    Fuck that. I reached the point where I finally refused to see any patients that were also seeing a naturopath. They had to choose- me or the ND. Some chose me, others didn’t. Never regretted the loss of a single one of those patients.

    1. PCD, I totally understand where you’re coming from. I don’t think there is anyone (except for maybe you) who gets more frustrated than I by the nonsensical stuff NDs do to our patients. While I would never work with a ND who believes that everyone has hypothyroidism, EBV, Lyme disease, etc, I would consider working with one who wanted to retrain as an evidence-based practitioner. Are you saying that this is a hard stop for you? You would not work with a ND under any circumstances?

      1. I would not work with one unless they went back to and completed med school and a residency, or if they went to PA school and became certified.

        Their education is so deficient that the only solution is starting from scratch.

  5. This is a tricky one.
    I was a holistic nutritionist who left that world (as you may remember from my blog post).
    The benefits of long consultations and very personalized care is really one of the only transferable benefit I see from NDs. And maybe an insiders perspective as to what attracts patients to alternative care.
    The current state of the alternative education system is FAR too deep down a woo rabbit hole to start safely integrating NDs safely into real medicine.
    Of course there are those of us who see were we went wrong and understand how we can help medical doctors. But until a huge upheaval happens within the industry and their systems of education there is just too much risk for misinformation to slip through. This change can only happen for the inside.

    1. I think that if we work with folks like you, who understand the problem with where they were and know where they want to go, it could work. But the selection process would have to be rigorous, as I agree that safe integration would be challenging.

  6. Interesting. I have inside knowledge, I am a disillusioned naturopath (DN). For the last 5 years I have focused 100% on evidence based lifestyle recommendations for primary prevention. I focus on helping patients achieve WCRF/AICR guidelines (yes, avoiding supplements is on the list).

    Within the profession, it seems more like religion than medicine. ND’s speak about their belief that something works, or that they just ‘feel’ like their patient has Lyme disease. Coupled with a massive deficit in clinical experience, I cringe to think of the harm, of which financial toxicity is only one.

    ND conferences are more like a meeting of the Jedi council at a Star Wars convention, determining the current state of the force and who are the chosen ones (new bullshit treatments). Case studies are viewed as the top of the ND scientific food chain.

    I recall 5 years ago reporting a particularly quacktastic ND to their licensing board, and was told that they don’t have ethical standards in place for their members. This ND’s website is directly causing patients to make choices that will shorten their lifespan.

    My greatest fear is scope of practice with the current state of training. Lifestyle advice is fine, but I’ve seen dozen of cases over the years of frank orthorexia in patients after they’d seen (usually multiple) naturopaths for something as basic as what to eat (how about what you enjoy and with more vegetables!) ND’s are now pushing for lab and drug rx capabilities and even hospital access/rights.

    The thinking that integrative cancer can work is somewhat flawed and dangerous. The ND would essentially have to renounce their training and swear allegiance to EBM. When patients start blending cytotoxic therapies with the wootastic, they come to trust the ‘doctor’ that prescribes them the most appealing and tolerable treatment. Death is not usually part of the informed consent process for ND’s. I mean if you had a grade 4 glioma tumor, what sounds better, surgery, radiation and temodar, or a strict ketogenic diet with specialized (read expensive) turmeric.

    While marketing a 100% bullshit free clinic has its challenges, I describe my practice as “what your GP would tell you if they had an hour to sit down and cover nutrition, exercise, sleep, and stress management”.

    Crusty the ND

    1. Crusty, I wish we practiced in the same town; I would definitely send my patients to you. Amen to pretty much everything you said, and thanks for the insider perspective.

    2. As a completely mainstream EBM nutritional biochemist ( I review evidence for the feds) who as been asked to consult by NPs and chiros, I totally agree with everything you say and need to let you know it’s even worse with the chiros! Some of these scammers put on dinner events to snare patients with T2DM and neuropathy into signing up for costly “natural” cures. As I’m sure you also know, lab testing companies that measure indices of no known value (for huge amounts of money, usually not covered) have sprung up like weeds, providing these woo peddlars with supposed diagnoses these practitioners then use to justify selling their patients costly, useless, sometimes dangerous supplements right from their own offices. However, I am also discovering MDs who are running equally murky practices: several weeks ago, a colleague told me an oncologist treating her husband for prostate cancer recommended cleanses and apricot pit extracts! I swear I often feel I’ve fallen down a rabbit hole.

      1. Oh yes, the half-page ads from D.C.s promising to reverse diabetes in “as little as one week!” are frightening. One of these days I’ll plant a mole in a chiropractor-led seminar, just to see what the heck they say in there (although I suspect they may be mostly playing up the ketogenic diet, which is not crazy in itself – the crazy part is that they have little to no valid training in Endocrinology or Nutrition).

        Your comment about MDs who’ve gone rogue reminds me of these two posts:

        Why Subspecialist Physicians Go Rogue – Part I

        Why Subspecialist Physicians Go Rogue – Part II

  7. If you are looking for someone to help with lifestyle changes, wouldn’t it make more sense to hire a therapist? You wouldn’t even need a psychologist, necessarily. I feel sure there are cognitive-behavioral therapists out there who would be delighted to specialize in helping your patients learn to stick with an eating plan or manage chronic pain. Just tell your patients this person is a “wholistic coach” or something. Diet centers always seem to have counsellors or coaches of various levels of qualification, not to mention drug treatment facilities.

    1. Yes, I think it is all about branding. If we call the therapist a therapist, people will think, “I don’t need one of those (as you have pointed out in some of your spot-on comments on prior posts, Sadie).” But if we call the therapist a holistic coach, then to some people, that will sound appealing. I think that an appropriately trained therapist could serve a similar function to a naturopath who has trained under a medical doctor, in this regard.

      1. The advantage would be that a therapist is trained in the science and practice of behaviour change, rather than naturopathic nonsense. Talking to someone for an hour is great, but it’s a lot more useful if they actually know how to help you.

    1. Perhaps? Never really thought about it, as hypoPTH is not something that typically lends itself to quackery. But if something about it ever fires me up, then yes, I will.

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