Natural Medicine is the Best Medicine

What naturopathic physicians are NOT

2011-10-04T08:47:00.000-07:00

Naturopathic physicians are NOT:

1. Doctors who prescribe herbs instead of drugs. Naturopathic medicine is not about using a natural substance in place of a medication. True naturopathic medicine is based on a philosophy that the human body is capable of healing itself, given the proper environment. In order to facilitate healing we use a range of therapies, anything from lifestyle changes (on one end of the spectrum) to drugs and surgery (on the other end), and many things in between. For more about naturopathic philosophy, see some of my other posts (here and here).

2. Homogenous. Naturopathic physicians, though we are all trained in primary care medicine, have a variety of sub-specialties, niches, and treatment approaches. Some ND's focus on treatment of musculoskeletal compaints and practice similarly to a Chiropractic doctor. Some of my colleagues specialize in mind-body medicine and use counseling, psychotherapy, or biofeedback as their primary treatment approach. Some practice conservatively, giving mostly medications. All of the above are therapies or modalities that we learn in naturopathic medical school. Other naturopathic doctors use esoteric therapies they learned outside of school. [Unfortunately, there is a huge double-standard in the medical world when it comes to judging our profession - a medical doctor who practices a bizarre, unproven therapy would be labeled a "rogue MD," whereas a naturopathic doctor who does the same would be automatically lumped with the rest of the profession.]

3. Dreadlocked hippies who couldn't make it into medical school. While some of my colleagues do have dreadlocks, and I suppose we are all somewhere on the "hippie" spectrum, all of us chose naturopathic medicine not because it was "easier" than medical school but because we believe it has the greatest potential to help people. Perhaps in Bastyr's 30 year history there has been a student who couldn't make it in allopathic medical school - but personally I know of not a single one. Many of my friends were pre-med/biology/chemistry majors, some who were already accepted (and granted scholarship!) to well-known medical schools. A few of my student-colleagues actually transferred out of an allopathic program to escape the corrupt, hierarchical structure that characterizes many medical schools. Many students end up in naturopathic medicine after years in another career path, some with advanced degrees already. Since we end up taking the same, or more credits than a medical school, going to Bastyr isn't exactly an "easy" option either!

4. Against conventional medicine. Though we prefer to use natural therapies to prevent and treat diseases, our naturopathic medical training tells us when it is appropriate to refer to conventional specialists. Dr. Bastyr himself, the namesake of our university, said "Give the patient what the patient needs." For most this will be nutrition, exercise, sunshine, counseling and perhaps some herbs or a manipulation. For some patients this will be major surgery or chemotherapy. Naturopathic physicians are uniquely suited to meet the patient where they are at.

5. The same as MD's. I consider medical doctors to be my professional colleagues, but not my equals. I fully recognize that medical doctors have training that exceeds my own in many areas, just as my training in natural therapies exceeds theirs. Naturopathic physicians are not trying to be medical doctors - we have our own set of professional and philosophical guidelines which inform our practice. We are naturopathic primary care specialists, nothing more and nothing less.

All naturopaths are against vaccinations, right?

2011-09-07T12:08:00.000-07:00

Continuing on the hot-button issues in the field of Complementary and Alternative Medicine (CAM) is that of vaccinations. Once again I'm going out on a bit of a limb with this one, because I'm presenting my personal views and not necessarily those of the profession as a whole. I can, however, share my experience of what I've seen most naturopaths advocate...

So all naturopaths are against vaccinations, right? Certainly there are vehement opponents of vaccination amongst naturopathic physicians. Conversely, our community of physicians also has a group who are vocal supporters of rigidly following the CDC schedule. Most naturopathic physicians, especially those who specialize in naturopathic pediatrics, take a third stance, which I call the knowledge-based approach.

The knowledge-based approach is based on educating the parents to make an informed decision on which vaccines to administer, and allows parents to choose the timeline. Naturopathic doctors clearly list the risks of each vaccine, based on actual scientific evidence, not heresay or celebrity endorsement. Physicians also clearly state the risks of each disease, and the potential consequences of not vaccinating. Parents are informed of which age group benefits from each vaccine (meningitis and pertussis are typically more deadly in early infancy), so they are aware of appropriate timing. Parents are given the CDC guidelines and explained the rationale behind the CDC schedule's timing. Physicians will often point toward alternative vaccine schedules if the parents are so inclined (like Dr. Sears' vaccine schedule).

The drawbacks to this approach are somewhat obvious - Yes, this explanation takes time! This is another reason why office visits to a naturopathic pediatrician are double or triple the length to a conventional pediatrician. It also requires intelligent and responsible parents to weigh many options and make difficult decisions, especially if they decide on an alternative vaccine schedule.

Sound like too much? Personally, I don't think so. Most parents are happy to be given hard data. It makes the decision less vague, less based on the nebulous fears of "what if I do this," or "what if I do that?" Parents, after all, only want what is best for their child.

So, after highly promoting the "knowledge based approach," here is my opinion with regards to vaccination:

1. Ignorance is never a valid reason to either vaccinate or not vaccinate your child. Frankly, I've been surprised by some of the experiences I've had with parents in the clinic. One parent brought in her 6-month girl (who was sick, of course), and when I asked her about the child's vaccinations she replied "I haven't decided whether to vaccinate yet." Yet? Parents should know that there is a window of protection given by certain vaccines, that some cannot be given at all after a certain age, and that some are most necessary in early infancy. Also, vaccines should be planned well in advance, because they cannot be administered when a child is ill.

On the other hand, I believe parents should be informed before they blindly follow a physicians recommendation to use a certain vaccine schedule. Friends, Facebook, and the Internet are a wealth of misinformation that are bound to leave an uninformed parent terrified (whether they vaccinate or not). Parents should also know what ingredients are in each vaccine, and whether the virus is "live" or not. They should also know what to expect, what to do if their child has a bad reaction, and what not to do under normal circumstances (like give Tylenol - but that's another blog post by itself).

2. All children should have a vaccine plan in place by the age of 2 months. 2 months is when the CDC recommends initiating the vaccine schedule (with the exception of those given at birth). If parents are going to delay vaccinations they should have a schedule completed - in writing - by the age most children begin vaccinations. One copy of the vaccine schedule should be kept at home (for planning and appointment purposes), and another signed copy should be given to the child's pediatrician. This is for practical and legal reasons - the child's physician needs to have documentation of any delayed vaccines both to avoid potential lawsuits and to always have record of when the child is due for what vaccine.

The document is also helpful for pediatricians in managing sick kids. Parents who plan to delay or refuse certain vaccines (like pertussis or those for meningitis) need to be aware of the warning signs of those diseases. The child's physician should educate the parents on what to look for, and to let the parents know that kids who are unvaccinated may need to be taken to urgent care a little earlier than a vaccinated child. This isn't to scare the parents, but rather to be practical so parents know what to expect. The child's vaccine schedule is incredibly useful for the physician when managing sick kids - it helps the doctor know what disease the child is likely to have or not have, and when the child may need to be referred to a specialist.

3. Every child should see a naturopathic physician. Just kidding. Picking a pediatrician should be based on many factors, and it is essential for parents to have a doctor they can trust. If you feel that your doctor isn't giving you the time you deserve - give me a call!

Photo credit: piyaphantawong / FreeDigitalPhotos.net

What is homeopathy? (Insert controversy here)

2011-09-01T18:07:00.000-07:00

Easily the most misunderstood and explosively controversial subject in Complementary and Alternative Medicine is that of homeopathy.

Before I begin, let me say that I'm going out on a bit of a limb with this post, because I'm sure to tick off both advocates and vehement opponents of homeopathy with this discussion. As with all my posts, I welcome dialogue in the comments section. However, please keep it civil - there is enough hatred in the world as it is, there is really no reason to get so inflamed over a subject like homeopathy. I'm trying to present a neutral view of homeopathy for the readers so they can decide for themselves.

First, the history:

Homeopathy was founded by Dr. Samuel Hahnemann in the late 18th century as a reaction to the highly invasive procedures that were standard in the medical community at that time (bloodletting, purging, and the use of toxic metals as "medicines"). The story goes that Dr. Hahnemann became fascinated with the properties of Cinchona bark which was a relatively new medicine for the treatment of malaria. Hahnemann noticed that if he took the cinchona bark in the absence of malarial illness that it produced symptoms remarkably similar to malaria. This formed the basis of Hahnemann's theory of "similars" - that substances which produce a certain set of symptoms in an otherwise healthy person should be used to treat a sick person with those same symptoms. In other words: "Let likes be cured by likes" (Hahnemann's words, translated from latin).

Hahnemann noticed that large doses of the curative substance were not necessary to produce a reaction in a susceptible person. He experimented with cures by diluting substances further and further, a process called "potentizing" (I'll explain more later). Hahnemann claimed that diluting reduced the toxic effects of the drug, while still allowing the body to recognize the substance and produce a cure.

I should note here that Hahnemann calls the ability of the body to heal the "Vital Force" of a person. According to Hahnemann it is the vital force which recognizes a homeopathic treatment, and the vital force which precipitates change. Obviously this concept is a little outdated in modern science, but I think it can be a good metaphor for the way our bodies heal and produce homeostasis (see my article on The Vis Medicatrix Naturae). In my opinion, the vital force can include all the biochemical, mechanical, electrical, and neurological processes which cause change.

Hahnemann expanded his formulary from cinchona to hundreds of homeopathic remedies by testing out each substance on dozens of volunteers (mostly students). His dutiful subjects recorded each and every symptom they experienced when taking a particular substance, and these were compiled into a detailed Materia Medica. The symptoms that appeared consistently amongst subjects were noted in the process. These common symptoms are what dictate what remedy a patient should have. For example, a patient with a sudden onset high fever, throbbing and congested headache with a red face and dry mucous membranes would receive the homeopathic remedy Belladonna.

Okay back to potentizing - the least understood and most controversial aspect of homeopathy. Hahnemann originally diluted substances just a few times using a process of "potentizing". This involved "succussion," or vigorously shaking the substance by striking it (like pounding a glass bottle full of liquid against your hand). Homeopaths claim that each time the substance is diluted and subsequently succussed that it actually becomes stronger. They claim that the "energy" of the substance becomes transferred to the water (or ethanol) each time it is succussed. This is the part that scientists hate, because homeopaths often prescribe preparations that have been diluted so many times that there is a high likelihood that not a single molecule of the original substance remains.

The concept of high-dilution remedies is controversial even amongst homeopaths. Some believe lower dilutions to be preferable to high-dilution remedies. Personally, I think it is a misnomer to say that high-dilution (highly "potentized") remedies are stronger. I think it is more accurate to say that high-potency remedies are more specific. Potentized remedies elicit the greatest change in a person whose symptom picture fits precisely with the given remedy. Low-potency remedies are often given more broadly (like Arnica for bruising), and tend to act more superficially.

Obviously, for homeopathy to be scientifically plausible there must be some aspect of quantum-mechanics or some bio-physical force that has not been discovered. I can truthfully say that the mechanism of action for homeopathy has not been uncovered. Many scientific skeptics say that homeopathy works because of the "placebo" effect. Proponents of homeopathy say that the drastic change they see in patients cannot be fully explained by the placebo effect alone.

What does the research say about homeopathy? The research is decidedly mixed. Nearly all large meta-analyses of homeopathy for a given condition (e.g., acne) are negative. In some ways this makes sense - these double-blind placebo controlled trials typically give one remedy to every patient with acne (for example), regardless of the other symptoms that the patient exhibits. This completely goes against the whole theory of homeopathic prescribing - each remedy should be given to a particular patient based on the totality of the patient's symptoms, not on one symptom alone. Thus 30 people with acne would have 30 different remedies based on their particular characteristics. Currently there are very few research studies that use individualized remedies in a double-blinded fashion (I list several in my references section for anyone who is interested - one negative, several positive).

Interestingly, there is some research that does show therapeutic benefit. My favorite head-scratching article is on the use of homeopathy in vitro for prostate cancer. The authors used homeopathic Saw Palmetto and showed a 33% reduction in prostate cancer cell proliferation. Another article showed positive results when adding a homeopathic preparation to a plant growth medium in a double-blinded trial. The plants treated with one particular homeopathic showed increased growth over other treatments. These articles are particularly interesting because they have eliminated the possibility of the placebo effect.

What are my experiences with homeopathy? Because homeopathy is required curriculum in the naturopathic medicine program at Bastyr, I have some practice in prescribing homeopathic remedies. My experiences are similarly mixed. Some patients I have seen little to no change, whereas others have noticed a dramatic near-reversal of their condition. I have some patients who swear by homeopathy, others who never notice a difference.

Is homeopathy placebo? Efficacious therapy? Pseudoscience? A miracle pill?

Ultimately this is for patients to decide, and physicians not to judge. Homeopathy is extremely safe, and as long as it is not used in lieu of an obviously life-saving therapy, I will continue to support my patients in their use of it.

References:

MacLaughlin et al. "Effects of homeopathic preparations on human prostate cancer growth in cellular and animal models." Integrative Cancer Ther. 2006 Dec;5(4):362-72.

Jager T, et al. "Effects of homeopathic arsenicum album, nosode, and gibberellic acid preparations on the growth rate of arsenic impaired duckweed (Lemna gibba L.)." Scientific World Journal 2010 Nov 4;10:2112-29.

Chikramane PS, et al. "Extreme homeopathic dilutions retain starting materials: A nanoparticulate perspective". Homeopathy. 2010 Oct;99(4):231-42.

Alder UC, et al. "Homeopathic individualized Q-potencies versus fluoxetine for moderate to severe depression: double-blind, randomized non-inferiority trial." Evid Based Complement Alternat Med 2009 Aug 17. [Epub ahead of print] PMID [19687192]

Jacobs J, et al. "Homeopathy for attention-deficit/hyperactivity disorder: a pilot randomized controlled trial" J Altern Complement Med 2005 Oct;11(5):799-806.

Jacobs H, et al. "Homeopathy for menopausal symptoms in breast cancer survivors: a preliminary randomized controlled trial" J Altern Complement Med 2005 Feb;11(1):21-7.

Bell IR, et al. "Improved clinical status in fibromyalgia patients treated with individualized homeopathic remedies versus placebo." Rheumatology (Oxford). 2004 May;43(5):577-82.

Gluten-free backpacking meals

2011-08-16T15:22:00.000-07:00

As I discovered this summer, gluten-free dehydrated meals are extremely hard to find and very expensive (unless you want to live on jerky and spongy freeze-dried scrambled eggs). But good food doesn't need to be expensive or unhealthy - here are some of my favorite recipes that I tried out this summer. I bought most of the dehydrated ingredients on Amazon.com, where you can get good deals if you're prepared to buy in bulk. Since the food lasts nearly indefinitely I didn't mind the fact that I ended up with way more food than I needed.

All of these meals are non-gluten-free husband endorsed (he swore we ate better on our trip than we did at home). Many are dairy-free, soy-free and vegan as well.

Breakfasts:
Carrot Cake Oatmeal
- 1/2 c GF oats (Bob's Red Mill has certified GF oats), whirled in blender until 1/3 of original size.
- 2 tbs dried carrot, also whirled in a blender until it approximates shredded carrot. (I used Harmony House Foods for my dried vegetables.)
- 2 tbs raisins or other dried fruit
- 1 tbs dried coconut milk (a wonderful find on Amazon!)
- 1/2 tsp ground cinnamon
- salt to taste (1/8 tsp)

In campground: add boiling water to cover, stir well, let sit tightly for 5 minutes. Reheat if necessary. Serves 1-2.

Blueberry Almond Quinoa
- 1/3 cup instant Quinoa Flakes (found at PCC)
- 2 tbs dried blueberries
- 2 tbs slivered almonds
- 1 tbs powdered coconut milk
- 1 tsp sugar, or to taste (1 tsp is mildly sweet)

In campground: add boiling water to cover, stir well, let sit tightly for 2-5 minutes. Reheat if necessary. Serves 1-2.

Blueberry Mango Oatmeal
- 1/3 c GF oatmeal, whirled in blender until 1/3 size.
- 1 tbs dried blueberries
- 1 tbs dried mangoes, chopped
- 1/4 tsp ground nutmeg
- 1 tsp brown sugar
- 1/8 tsp salt

In campground: add boiling water to cover, stir well, let sit tightly for 5 minutes. Reheat if necessary. For a calorie-dense breakfast in the backcountry add 1-2 teaspoons of oil (light olive oil or other cooking oil). Serves 1-2.

Lunch & Dinner
Cashew Chicken
- 1 cup instant rice
- 1 7-oz pouch of canned chicken (a little hard to find, but I got mine at QFC)
- 1/3 cup dehydrated bell pepper (also Harmony House)
- 1/2 cup dehydrated mushrooms
- 1 cup unsalted cashews
- 2 tsp garlic powder
- 2 tsp ginger powder
- 1 tsp crushed red pepper
-1/2 tsp cumin
-3 tbs cooking oil.

At home:
In one plastic baggie mix cashews and spices, mix rice and veggies in another bag. Keep oil chicken in the pouch until at the campground.

In campground: "saute" cashews and spices in 1-2 tbs oil (careful! it burns quickly!). Add chicken pouch and 2 cups of water - bring to a boil and add rice/veggie mix. Cook until water is absorbed. Delicious! Serves 2-3.

Mashed potatoes & jerky (husband's favorite recipe)
- 1 2 oz package dried potatoes (I used Edward & Sons Organic Mashed Potatoes)
- 2 tbs shelf-stable parmesan cheese
- 1 tsp parsley flakes
- 1 tsp dried sage
- 3-5 strips gluten-free beef or elk jerky, torn into small pieces

In campground: combine with ~ 2 cups boiling water (until covered), stir well and enjoy. Also extremely tasty. Add black pepper to season if desired.

Sun dried tomato pasta
- 1/2 cup GF spaghetti (I like the corn spaghetti the best), packaged separately from sauce ingredients.
- 4 tbs tomato powder (Harmony House again)
- 1 tsp garlic powder
- 1/2 tsp salt
- 1/3 cup chopped sun-dried tomatoes
- 2 tsp basil (preferably freshly dried and fragrant)
- 1/2 tsp oregano
- 1/2 tsp thyme
- 1/4 tsp black pepper
- Parmesan cheese to taste

In campground: cook GF spaghetti according to manufacturer's directions. For sauce: add boiling water to tomato mixture to rehydrate, add to spaghetti and mix well. I noticed this turns out to be more of a pesto-like texture rather than a sauce, but still quite delicious. Serves 1-2.

Chicken chow mein
- 1 cup rice noodles, broken in 1/3's (use thin noodles for fast cooking)
- 1 7-oz pouch canned chicken
- 3 tbs dried shiitake mushrooms
- 2 tbs dried mixed vegetables
- 1 tsp GF chicken of vegetable bouillon (this can be tricky to find, I ended up using a vegan bouillon).
- 1 tsp garlic powder
- 1 tsp ginger powder
- crushed red pepper to taste, OR sliced dried hot pepper (like you find in Mexican markets).

In camp: bring 1 1/2 cups water to boil, add noodles and vegetables, simmer until noodles are cooked. Add chicken and heat through before serving. Serves 2.

Well folks - tell me what you think!

This is the best medicine...

2011-07-20T19:23:00.000-07:00

(A Rainbow at the Arctic Circle)

This blogger is going on vacation!

2011-06-26T15:03:00.000-07:00

Well readers, up until this time this blog has been devoted to all things philosophical and instructional in the world of naturopathic medicine. Time for a little change...

In celebration of my husband's graduation from physical therapy school (he beat me in the race to becoming a doctor first!) we have decided to take a long, adventurous road trip. This means several weeks away from Twitter, Facebook and Blogspot, while we enjoy the glorious creation of the Canadian Rockies and the Arctic.

The Arctic, did you say? Yes, for some reason we got it into our heads to take a roadtrip to the arctic circle (we'd like to drive to the arctic ocean, but the road just doesn't go quite that far). We'll be driving from Missoula, Montana to Inuvik in the Northwest Territories, passing through Alberta, British Columbia and the Yukon. Here's a little map of the route we will (hopefully) take:

There are a few extra challenges in our travels, since I'm gluten, soy, egg, and dairy intolerant. I'm packing a bunch of home-made backpacking meals just in case. I've had several requests to share these, but since they have gone un-taste-tested so far, I think I'll wait until after the trip to share my favorites.

Since this blog post really had nothing to do with primary care, prevention, or naturopathic medicine, I'll leave you with a few good articles about physician burnout and the importance of physician wellness:

First, an article published in the Lancet in 2009, titled Physician Wellness: a missing quality indicator. I'll quote their abstract: "When physicians are unwell, the performance of health-care systems can be suboptimum. Physician wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality health care."

Next, a document by the Medical Board of California on Physician Burnout: "burnout is characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. Preventing burnout--a responsibility of all physicians and of the healthcare organizations in which they work--entails the explicit promotion of physician well-being."

For all my readers: Peace and Health, and enjoy your vacations! You'll hear from me in about a month...

How do I find a well-trained naturopathic physician?

2011-06-18T13:30:00.000-07:00

Despite my many blog posts about our educational level, I realize that there is still some misinformation about naturopathic physicians. Many people want access to naturopathic medicine and well-trained naturopathic physicians, but it is still a little confusing as to who's who. Here's my guide to finding a legitimate naturopathic doctor and supporting our profession:

1) Check out the American Association of Naturopathic Physicians (AANP) website: www.naturopathic.org. Click on the link "find a naturopathic doctor near you". This is the quickest and easiest way to find a licensed naturopathic physician. All ND's listed on the AANP website have graduated from 4-year medical schools.

2) The AANP maintains an up-to-date list of which states license naturopathic physicians. Why is this important? In unlicensed states any person can call themselves a "naturopath" regardless of their training. Are you in an unlicensed state? Be extremely cautious when interacting with someone who claims to be a naturopath or naturopathic doctor. Always ask where they received their training (it should be from one of 6 schools: Bastyr, Boucher, Bridgeport, Canadian College of Naturopathic Medicine, National College of Natural Medicine, or Southwest College of Naturopathic Medicine). Note that there are many "diploma mill" type colleges that offer "Naturopathic Doctor" degrees. These are typically online or distance learning courses, and these graduates can only call themselves "doctor" in unlicensed states. These graduates have not had hands-on coursework (like a cadaver lab, or training in minor surgery or physical exam techniques), or supervised interaction with real patients (minimum 1,200 hours for licensed ND's). There are qualified ND's in unlicensed states; most practice very conservatively (as a "healthcare consultant" or something similar), and simultaneously hold a license in a licensed state. This is because there is no governing body in that state.

In licensed states, you can simply search for any Naturopathic Physician or Naturopathic Doctor to find a well-qualified medical professional. Ask around to find one that suits you - many ND's have additional training in certain areas, or tend to focus on a specific patient population (like pediatrics, or physical medicine/body work, or cardiology patients). Different naturopathic physicians have different personalities just like everyone else.

3) Get involved! Are you in an unlicensed state? Call/e-mail your state senator or representative and ask to draft legislation requiring the licensure of naturopathic physicians. Check the AANP website for updates regarding the status of your state. Currently New York, North Carolina, Massachusetts and Pennsylvania have legislation in the works, in addition to Maryland, Virginia, Colorado and Iowa - states whose legislative sessions have ended for the year.

Remember, you can make a difference when it comes to a patient's right to choose appropriate, effective, preventive healthcare.

So what's the difference, really? (Naturopathic Medicine and the Therapeutic Order)

2011-06-03T11:27:00.000-07:00

This morning I had a fascinating conversation with a current medical student who wants to transfer from her allopathic school to Bastyr's ND program. This young woman wants to be a primary care provider, and after much soul-searching decided it was in the best interest of herself and her future patients to study naturopathic medicine rather than the current medical model taught at allopathic school.

All this talk brought up a good question: so what is the difference really? What makes naturopathic medicine different from conventional medicine? What is the advantage of studying naturopathic medicine?

I touched upon this a little bit in my last post on naturopathic medical education. First, naturopathic physicians are experts in the treatment of primary care conditions, since our entire education focuses on primary care. Secondly, naturopathic doctors have extensive training in natural treatments options not taught in a traditional medical school, including hundreds of additional hours in botanical medicine, nutrition, osseous manipulation, homeopathy, and counseling. (Don't believe me? Check out the curriculum on Bastyr's website)

But the most striking difference between an allopathic primary care physician and a naturopathic physician is the philosophy that governs the treatment of our patient. Naturopathic medicine is characterized by six philosophical principles: 1) Treat the Whole, 2) Treat the Cause, 3) The Healing Power of Nature, 4) Prevention, 5) First Do No Harm, 6) Doctor as Teacher. I have previous blog posts on each of these (follow the links).

Now many healthcare practitioners will argue that these principles are not unique to naturopathic medicine, but that they follow these maxims as well. What is unique to naturopathic medicine? The Therapeutic Order. The Therapeutic Order is a set of guidelines to help physicians follow the philosophical principles. The goal of treatment is to completely resolve the patient's symptoms and address the underlying cause while using the least force possible. Here is my illustration:

The Therapeutic Order helps physicians prioritize treatments and ensure that the least harm is done to the patient. Naturopathic physicians recognize that good health is the natural state of the body, and that disease results as a disturbance in the body's environment. The first step of the Therapeutic Order aims to address what we call the "determinants of health," the things which are necessary to create an environment of optimal health. These include things like adequate hydration, a healthy whole-foods based diet, sufficient exercise, a clean space to live in, safe and nourishing relationships, and a fulfilling spiritual practice. Naturopathic physicians seek to re-establish this foundation because any disturbance in the determinants of health will inevitably create disease, or "dis-ease". There is much more to say about the determinants of health, so perhaps I will devote an entire blog entry to this in the future...

The next step in the order is to stimulate the Healing Power of Nature, or the Vis Medicatrix Naturae. Sometimes re-establishing the foundation of health is not enough to correct pathology. I like to think of this as the body's version of Stockholm Syndrome - sometimes the body has been held hostage by pain and pathology for so long that simply restoring the foundation is not enough to provoke a healing response. In this case we can provide encouragement for the healing process to begin - things like constitutional hydrotherapy (I'll explain later), acupuncture and homeopathy have been used by healers for centuries. I would also like to add prayer to that list, as prayer is a modality (one that I particularly like) that can also stimulate the healing process.

Next is to aid damaged organ systems. The American lifestyle that many of us practice (sometimes unwillingly!) can lead to sluggish or damaged organs because we are inhaling or ingesting products that are difficult for the body to process. Some examples: air pollution leading to lung damage, processed foods causing gut permeability, over-the-counter drugs producing kidney or liver deterioration. Naturopathic physicians have many tricks to rehabilitate organ systems (things like probiotics and flavonoids for the gut, or Silybum marianum for the liver).

The next step in the therapeutic order is to restore structural integrity to the body. This is the one step of the therapeutic order that can really fit anywhere in the order, and can be addressed at any point in the disease process. Structural misalignment of the spine and extremities can cause significant strain, and may be an obstacle in the path to cure. The goal of treatment is to realign the physical structure using the least force necessary. This may be a manual adjustment (similar to a chiropractice adjustment), a simple stretch, or a more subtle visceral manipulation.

Step up from this is our naturopathic symptom relief. This is what many people believe naturopathic medicine is about: using herbs, nutrients and natural products to reduce discomfort. As you can see, symptom relief is pretty high up the therapeutic order - natural symptom control is not curative, and does not fulfill the ultimate goal of naturopathic physicians: to see all our patients regain complete, optimal health, without the use of any substance. Using things like herbs and nutrients may be helpful for a period of time to decrease pain, or to suppress pathology until the foundation of health can be re-established. Some people, of course, may always need symptom relief for one reason or another, and this is completely appropriate as long as the underlying cause is not neglected.

Next in the therapeutic order, similar to the last step, is synthetic symptom control. This step constitutes the bulk of conventional medication, which typically prescribes pharmaceuticals for a myriad of conditions. When natural methods are either unavailable or insufficient, synthetic drugs may be used to relieve pain, lower blood pressure, suppress inflammation, etc. Naturopathic physicians are well versed in the appropriate use of pharmaceuticals, and will prescribe them when necessary to aid in healing the patient.

Lastly is the highest step in the order, high force interventions. This includes chemotherapy, radiation therapy, and any surgery. Some naturopathic physicians call this "suppress pathology". Though we use this step as a last resort, it may be the most appropriate for certain patients. Surgery, chemotherapy, and radiation can be life-saving, life-prolonging, or hugely quality-of-life improving measures for many patients. When pathology is unlikely to resolve on its own, these interventions may be a good choice.

Lastly I should point out that although naturopathic physicians clearly prioritize treatment by starting at the bottom of the therapeutic order, in actuality treatment may begin at any step at any time. It was Dr. Bastyr, the namesake of my university, who said (in my paraphrase) "always give the patient what the patient needs". Whether that be water or chemotherapy, naturopathic physicians are experts at creating an individualized treatment plan that is perfect for each person.

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

2011-05-19T15:18:00.000-07:00

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

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

So what is our educational training?

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

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

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

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

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

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

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

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

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

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

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

Lobbying in DC!

2011-05-02T09:44:00.000-07:00

This morning I am in Washington DC preparing to speak with my senators and representative about naturopathic medicine.

Every year the American Association of Naturopathic Physicians, the AANP (www.naturopathic.org), hosts an event called the DC FLI, where hundreds of naturopathic medical students and naturopathic physicians travel to DC to support federal legislation for ND's.

Naturopathic physicians are primary care and preventive medicine specialists. ND's are fully trained primary care providers, completing 4-years of medical school and over 1,200 hours in direct clinical patient contact. In fact, the U.S. Department of Education considers the ND degree as a First Professional Degree, on par with MD and DO. Naturopathic students, including myself, receive federal funds for student loans, yet somehow do not qualify for federal loan repayment programs. We also are excluded from the Public Health Service Act, and are not eligible for residencies paid by the federal government (the majority of residencies that MD and DO graduates participate in).

With the enormous healthcare disparity in this country, naturopathic physicians (including myself in just 13 months) are willing and qualified providers of primary care. Considering the fact that less than 4% of medical students plan on pursuing primary care, it is essential that naturopathic physicians be utilized to fill the gap.

In the state of Montana, where I plan on practicing, 40 out of 56 counties have a Health Professional Shortage Area (HPSA) designation, meaning there are not enough primary care providers to fill the need for the county. Additionally, 12 of the counties in Montana are absent of a single primary care provider. I am an eager and willing future physician who could fill a very real need in the state of Montana.

Please consider contacting your members of Congress to support me, my profession, and a solution to the current healthcare crisis. Patients have a right to have access to healthcare.

Follow this link to send an e-mail to your members of Congress, it is incredibly easy and takes less than two minutes (come on, you know you have 120 seconds to spare).
http://capwiz.com/naturopathic/issues/alert/?alertid=44021501

In Health,
Erika

My story...

2011-04-18T19:32:00.000-07:00

I have had several requests to speak a little about myself and how I came to Bastyr and the ND program. I would love to share with you my journey to naturopathic medicine...

I was born and raised in a Swedish-American family in the Pacific Northwest. My relationship with nature grew at an early age, and thanks to the encouragement of my parents much of my childhood took place outdoors. I spent my summers picking blueberries and wild strawberries in Sweden, swimming and playing in Lake Washington and hiking to alpine lakes in the Cascade mountain range. Winters were dominated by my love of snow, with plenty of adventures by skiing, snowshoeing and sledding. These activities laid the foundation for my appreciation of nature, and eventually led to my decision to become a naturopathic physician.

As a right-brained child, I gravitated to various art and music classes. At age 6 I joined an internationally touring children’s choir, and at age 8 I began learning classical piano. I took drawing, painting and ceramics classes throughout my youth to feed my desire for creativity.
Music and art became my therapy during adolescence, a healing power that I still value.

As a teenager I retained my love of the arts but also discovered the pleasure of solving puzzles, especially in math and science. I followed both of these passions throughout my undergraduate education at Gonzaga University where I finished my bachelor’s degree with a double major in visual arts and biology. Originally I planned to become a medical illustrator but soon realized that a career in an isolated cadaver lab was not for me. I realized that I love people and that I thrive in an environment where I can develop relationships with others. Because my biology degree closely mirrored the premedical curriculum, I started thinking about attending medical school to pursue a field where I could help and heal others. Taking some time off of school, I moved to Nashville after graduation to participate in an AmeriCorps program in a low-income health clinic.

In 2005 my family and I had our lives dramatically changed when my father had a major stroke. After weeks of hospitalization and months of physical therapy, his insurance stopped paying for rehabilitation. At this point my parents turned to several alternative therapies, including acupuncture, warm-water physical therapy and Feldenkrais. On one weekend home I had the opportunity to take my father to his acupuncture appointment with Dr. Yuanming Lu, who also happened to be a professor at Bastyr University. My parents, wanting me to move back home to Seattle, encouraged me to check out the naturopathic medicine program at Bastyr. In 2006 I visited Bastyr and immediately fell in love with the campus, the community, and the philosophy of naturopathic medicine. My eyes were opened to a completely new type of medicine - a natural, holistic and truly patient-centered model of practice.

At the same time it was becoming apparent that I had my own health issues that were getting progressively worse. After multiple rounds of imaging and medication trials to find the cause of my stomach pain, I was finally diagnosed with Irritable Bowel Syndrome and was told by my medical doctor that there was nothing more I could do. Being a motivated patient, I searched for answers on my own, and learned of the link between food sensitivities and IBS. After my doctor refused to do the testing, I called the Bastyr Center for Natural Health, and the year before I began the ND program I had my first experience as a naturopathic patient. I learned that I had multiple food sensitivities, including gluten, soy and dairy. Eliminating these foods from my diet, in addition to other naturopathic therapies, changed my health and changed my life. I am happy to report that I am now 99% symptom-free, and my health continues to improve year after year.

In 2007 I began my education at Bastyr University in their Doctor of Naturopathic Medicine program. The journey continues to amaze me, and every day that I am in school I fall more deeply in love with this incredible medicine. I am excited to become a Physician, a Counselor and a Healer, and I am honored to be a part of the lives of patients as they are transformed.

“A restricted diet should be part of standard of care for all children with ADHD”

2011-04-15T14:05:00.000-07:00

Whaaaaaat? This was my response as I read this summary article in BlackBag, a free medical app that has dozens of medical news articles delivered daily to your smartphone or ipod. The title of the summary article was exactly as I typed it above, and the author’s conclusions were based on a study recently published in the Lancet, an excellent randomized controlled trial now known as the INCA trial (“The Impact of Nutrition on Children with ADHD”).

For years naturopathic physicians have been huge proponents of the allergy (or, more accurately, the “intolerance”) elimination diet. In fact, elimination diets have become such a mainstay in naturopathic medicine that it has become a bit of a running joke in school - when in doubt, the answer to a test question is always “eliminate gluten” (worth 1/2 credit, at the very least).

ND’s have used the elimination diet to treat everything from IBS to hypertension, often with astounding results. In pediatric practices elimination diets are routinely prescribed for recurrent otitis media, constipation and a variety of behavioral problems, including ADHD. I’ve heard my professors tell stories of children who had dramatic changes on restricted diets to the point where the children were nearly unrecognizable - bouncing off the walls and breaking furniture on one occasion, and playing quietly the next.

This summary was published just as I was finishing my preceptorship with a pediatrician in Seattle, an MD with an excellent reputation and known for being alternatively minded. I learned a great deal about the medical management of children in that preceptorship, and I am very thankful for that opportunity. It was striking to me, however, to see the large number of children on stimulant medications for ADHD. These medications carry significant risks, from anorexia and weight loss to addiction, abuse and diversion, not to mention the black-box warning for increased likelihood of sudden cardiac death. I give credit to the pediatrician - he never took this lightly, and always made the prescription only after a lengthy discussion of risks and benefits with the parents.

I sent the original article to him; I sincerely hope that medical doctors like him see the scientific validity of elimination diets and the huge benefit this intervention could have in terms of risk reduction.

And, for my medical doctor readers out there who have no idea how to counsel their patients through an elimination diet: please feel free to contact a naturopathic physician near you. The American Association of Naturopathic Physicians has an excellent website: www.naturopathic.org, click on the link that says “Find a Doctor,” and search for an ND in your area.

Reference:
Pelsser LM, Frankena K, Toorman J, et al. Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Lancet 2011; 377: 494-503

Naturopathic medicine: the best preventive medicine

2011-03-02T16:29:00.000-08:00

I strongly believe that prevention is the answer to our current healthcare crisis.

I have heard a lot of discussion in the media lately saying preventive services are too expensive and significantly add to the enormous cost of healthcare in this country. As I’ve mentioned in a previous post, the concept of prevention has become confused with screening. Most primary care physicians now only practice screening, not prevention. Screening is not cost-saving even though it is certainly life-saving, as it allows for early detection of many diseases. Preventive medicine is, by definition, cost-saving, since it prevents diseases that need to be treated at all. Though preventive services may cost a couple hundred dollars for extra visits to a primary care physician, this is a tiny drop in the bucket compared with the cost of treating, say, cancer or cardiovascular disease.

The art of preventive medicine seems to be lost in much of the allopathic community. This is more the fault of the healthcare system rather than the physicians. Because of poor reimbursement rates for primary care, most physicians have extremely short patient visits which simply do not allow enough time for a discussion of prevention. Physicians are paid for the diagnosis or management of a condition that the patient currently has; any extra time spent with a patient is not reimbursed (with a few exceptions).

Many medical doctors also have limited training in therapies like nutrition, exercise prescription, or the preventive effects of many botanicals and micronutrients. With the huge influence of the pharmaceutical industry in medical schools, discussion of disease treatment typically focuses on the use of drugs (or surgery). The result: more patients are prescribed drugs than lifestyle changes.

For a naturopathic physician, prevention is foundational to our practice. In fact, prevention is one of the six philosophical principles of our profession. Bastyr University describes this principle as such: “Naturopathic physicians emphasize disease prevention, assessment of risk factors and hereditary susceptibility to disease and making appropriate interventions to prevent illness. Naturopathic medicine strives to create a healthy world in which humanity may thrive.”

Prevention is a huge passion of mine. Though I am happy treating people when they get sick, I would much rather forestall my patients from getting ill in the first place. Naturopathic medicine is unique in that we have the tools to develop an individualized health plan that promotes wellness and prevention of future diseases.

Naturopathic medicine is the solution!

Docere - Doctor as Teacher

2011-02-04T13:20:00.000-08:00

We are in the age of passive medicine.

Our current medical model reimburses physicians for investigating/making a diagnosis, and managing treatment of that particular diagnosis. Physicians get paid for the diagnosis or treatment, not for the amount of time spent with patients (with some exceptions). This leads to short patient visits and very little time discussing the rationale behind the treatment or the implications of the diagnosis. The result is what I call "passive medicine," because the patient has almost no active role in the healing process.

The role of the naturopathic physician is to fulfill the original meaning of the word doctor. "Doctor" derives from the Latin "docere," which means "To Teach". The process of education shifts the role of participation back to the patients so they can take control of their own health.

Bastyr University describes the principle of Docere as such:

"Naturopathic physicians educate the patient and encourage self-responsibility for health. They also acknowledge the therapeutic value inherent in the doctor-patient relationship."

This definition of Docere is really describing empowerment. Naturopathic physicians teach so patients can reclaim authority over their own bodies. Empowered patients are savvy healthcare consumers and are better able to stay safe and prevent mix-ups in the medical system. Educated patients also tend to have more success in completing treatments, and feel more confident in their health.

The concept of Doctor as Teacher is really about shifting the balance of power back to the patient. Personal empowerment is the only prescription that can create permanent change leading to better health.

The Vis Medicatrix Naturae - Vitalism, Evolution, Creation or Homeostasis?

2011-01-11T12:33:00.000-08:00

I love the philosophical principles of naturopathic medicine: Treat the Whole, Treat the Cause, Prevention, First Do No Harm, and Doctor as Teacher. I find these concepts easy to discuss with patients, colleagues and my peers in the medical profession.

Then we get to The Vix Medicatrix Naturae, translated The Healing Power of Nature. Opponents of naturopathic medicine have used this philosphical principle to label naturopaths as "vitalists," a term which many in the scientific field equate with quackery or fraud. I would like to offer multiple interpretations of this principle.

Bastyr University provides the following explanation for the Vis Medicatrix Naturae: "Naturopathic medicine recognizes the body's inherent ability, which is ordered and intelligent, to heal itself. Naturopathic physicians act to identify and remove obstacles to recovery, and to facilitate and augment this healing ability."

In this definition there is no mention of the concept of vitalism, despite the use of the term by many who are antagonistic to naturopathic medicine. Vitalism, as defined by Merriam Webster dictionary is "1. a doctrine that the functions of a living organism are due to a vital principle distinct from physicochemical forces 2. a doctrine that the processes of life are not explicable by the laws of physics and chemistry alone and that life is in some part self-determining." Vitalism is a theory which forms the foundation of many branches of traditional and alternative medical approaches (for example, the concept of "qi" in Traditional Chinese Medicine, or the concept of the vital force in Homeopathic medicine).

Bastyr's definition of the Vis Medicatrix Naturae also provides room for the concepts of evolution or supernatural creation. Creationists can accept the "order" and "intelligence" to be governed by a higher power or deity. Evolutionists can appreciate that much research has shown evolutionary advantages to many nonspecific symptoms like fever and inflammation. The "intelligence" of the human body, to an evolutionist, is simply a result of natural selection that favors organisms that have mechanisms for healing tissues, combating infections, and restoring disrupted processes.

The concept of homeostasis may also be relevant to the discussion of the Healing Power of Nature. All physiologic processes aim to create and maintain homeostasis in the body. The maintenance of homeostasis is a dynamic process, where each change in the body is countered by a "force" which precipitates movement back to equilibrium.

Regardless of philosophical views, the role of the naturopathic physician is to support each individual in their path toward better health. Naturopaths should encourage the self-healing ability of the body by removing barriers to cure and assisting the process for swift recovery.

How Naturopaths are educated

2011-01-08T15:40:00.000-08:00

A great post on the education of naturopathic physicians: http://advice-answers-choices.blogspot.com/2009/07/how-are-naturopaths-educated.html

Treat the Whole AKA psychoneuroimmunology and its effects on physiology

2010-11-08T14:25:00.000-08:00

Another philosophical principle that guides naturopathic physicians is called Tolle Totem or "Treat the Whole".

Naturopathic physicians have long been advocates of treating the whole person, including mind, body and spirit. Addressing the emotional, mental, and physical problems simultaneously is often the key to uncovering the true cause of a disease (see my last post about treating the cause!). This is one reason why ND's have counseling in our scope of practice. We are trained in motivational interviewing, cognitive behavioral therapy, and sometimes biofeedback to help our patients bridge this gap between mind and body.

New scientific evidence is also showing support for our long-held theory. The branch of science is called psychoneuroimmunology, and it studies the link between the psyche, the nervous system, and the immune system.

Some interesting recent findings: researchers at UCLA found that social rejection was linked to an increase in inflammation in the body! Since inflammation is tied to diseases like depression, asthma, heart disease, and cancer, some are suggesting that rejection or other social stress can be a cause of these illnesses.

Another reason to treat the whole person!

Slavich GM, Way BM, Eisenberger NI, Taylor SE. Neural sensitivity to social rejection is associated with inflammatory responses to social stress. Proc Natl Acad Sci U S A. 2010 June. 107 (44)
http://www.pnas.org/content/early/2010/07/26/1009164107.abstract

Tolle Causem

2010-10-25T14:11:00.000-07:00

One of the 6 prinicples of naturopathic medicine is Tolle Causem, or Treat the Cause. The ultimate goal of a naturopathic physician is to identify and treat the cause of the patient's disease or symptoms.

Conventional physicians will often claim to do the same thing. I recently saw an advertisement for a medication for GERD (also known as heartburn) that claims to treat the "cause" of heartburn by preventing the stomach from making stomach acid.

Do people with heartburn really have a deficiency of Tums or Prilosec? Wait a second...does stomach acid actually cause heartburn? Why do we even have stomach acid?

According to MDConsult.com (a great resource for you aspiring physicians), stomach acid is a requirement to break down proteins into smaller pieces for easier digestion. Stomach acids also help the body absorb certain minerals and vitamins (did you know that long-term suppression of stomach acids can lead to osteoporosis?). Having stomach acid is also a vital part of our immune system (not very many bacteria can survive in that acid!), and decreasing your stomach acid can leave you vulnerable to infections by nasty bacteria like E. coli and others.

In fact, stomach acids are not the cause of GERD. Heartburn is actually caused by a weakness or relaxation of the muscle that separates the stomach from the esophagus. When this muscle relaxes, stomach acids come up into the esophagus and cause heartburn.

The job of a naturopathic physician is to figure out why this is happening, and to treat the true cause (not just give a bunch of drugs).

Note: this information is not intended to diagnose or treat any condition. Always consult your physician (preferably an ND) before making any medication or lifestyle changes. Remember, this is a blog, not a virtual doctor.

Prevention versus screening

2010-10-18T13:20:00.000-07:00

What is prevention? The standard of care for preventive medicine specialists in conventional medicine is determined by the USPSTF (The US preventive services task force), which is an independent panel of experts in primary care (like internists, pediatricians, gynecologists, etc). The USPSTF determines when screening exams are necessary, which medications to take for prevention, and how to counsel patients.

The USPSTF comes up with guidelines based on a review of the scientific evidence, and publishes them in the form of “recommendation statements”. For example, the USPSTF determines at what age mammograms, physical exams, DEXA scans, blood tests, etc., are necessary. These are called “screening” tests because they are done for virtually every person of the recommended age and gender. The hope is that by screening millions of people, we can catch a few people who might actually have a certain disease (and thereby save lives).

Is this prevention? Screening exams, by definition, find people who actually have disease. A mammogram, for example, shows when a woman actually has breast cancer, it does not show that a woman might develop breast cancer in a few years. And it certainly doesn’t tell people how to prevent a disease from occurring in the first place.

Why is this important? Naturopathic physicians are experts in prevention, not screening (though we do a lot of that too). We want to work with our patients years before they get cancer, to talk about how to prevent it to begin with, not how to treat it when they already have it! We want to work with our patients to figure out the cause of their high blood pressure or high cholesterol, not just give them a drug to lower it.

Naturopathic physicians are the true preventive services task force! (We should get some fancy uniforms or something)

Evidence-Based Naturopathic Medicine (a continuation of my last post)

2010-10-04T14:20:00.001-07:00

It’s been a long time since I’ve posted and I apologize. Summer happened!

This post will be about evidence other than double-blind placebo-controlled trials. Naturopathic physicians often have to use alternate forms of evidence since funding for trials of natural remedies is often seriously lacking.

First we have the most general form of evidence: historical use. Some people argue that historical use has no place in evidence, but I would like to counter that. The fact is, historical use of medicines (herbals in particular) followed their own form of “scientific” rigor. That is, midwives, herbalists and healers passed down their knowledge word-of-mouth, and remedies that continued to work through the generations were passed down, whereas ones that were harmful were not. There is, of course, the chance that all of these remedies were simply acting as placebo, which is entirely possible. Even if it is placebo, however, we cannot say that the remedy doesn’t work (just the mechanism is different).

Next we have case-studies and evidence from personal experience. Case studies (published or unpublished) are very interesting to illuminate the exact presentation of a patient before and after a specific treatment. We can use case studies to speculate on what the mechanism of action of a particular intervention is. Though it is difficult to take a case study and project this to a general population, nevertheless it is still useful when we encounter a patient with a similar presentation. Similarly, we have evidence from personal experience in practice. Much of scientific research is based on what practitioners have seen work consistently in practice (for example, Omega 3 oils were used in naturopathic practice many years before research confirmed their validity for use in inflammatory processes). This is the value in working with experienced practitioners who can truthfully say that a particular nutrient, drug, herb, or other treatment modality has worked for them for 20+ years.

In our naturopathic education we generally learn the historical use of a treatment first. I find this to be a good foundation to lay the rest of our knowledge upon. After this we take our knowledge of biochemistry and physiology to make an educated guess as to whether the historical use seems plausible. When combined with repeated case studies or a long history of personal experience, we can start to become more convinced that a particular intervention will work. Of course, when using these treatments in a clinical context, we must always take the individual patient into account, and tailor the treatment plan for that singular person.

What happens when scientific research contradicts personal experience or historical use? Well, we have two options: 1) reframe or alter our current model for the particular disease and treatment, or 2) evaluate the research for consistency between what/who we are treating and what the research states.

Whew, that was a lot, and I could write a whole lot more. Questions? Feel free to post them under the comments section.

Is naturopathic medicine science-based?

2010-05-27T11:00:00.000-07:00

I had a great question about naturopathic medicine and science:

You say that your medicine is evidence-based. Would you define "evidence" in the same way that the traditional medical model would (peer-reviewed journals, RCTs, meta-analyses, etc.)? Are all of your treatments supported by research?

Thanks Anonymous! I'll do my best to answer your question...

Though there are many types of scientific research, I generally split research into two main categories: 1) single agent trials, and 2) research based on clinical practice (e.g., case studies, retrospective studies, etc.).

The gold standard of scientific research is double-blind placebo-controlled trials. This is the final stage of research that pharmaceutical companies go through before they can legally sell their product to consumers. Double-blind trials (for the lay reader) means that each patient enrolled in the study gets either a sugar pill (placebo), or the active pill, and neither the patient nor the person who gives the patient the pills knows which one is active or placebo. Only the person analyzing the data knows who received which pill. Double-blind placebo-controlled trials are important because they take the “placebo effect” and observer bias out of the equation, so theoretically only the biochemical effects of the pill are recorded.

Do natural medicines undergo the same research as pharmaceuticals? The answer is yes and no. Natural medicines do undergo double-blind placebo-controlled trials, but the number of people enrolled in these trials are generally much less than pharmaceutical trials. This is mainly due to the difference in funds (pharmaceutical companies fund their research with their multibillion dollar sales). As my research methods professor once told me, the easiest way to show no difference between two groups is to enroll too few patients in a trial. There are thousands of herbs, foods and nutrients potentially used by naturopathic physicians - some of these have undergone rigorous double-blinded studies (like St. John’s wort), others have not (like Yarrow).

So why do we use natural medicines that do not necessarily have research supporting them? This is a tricky subject. In naturopathic medical school we learn the biochemical and physiologic mechanisms of herbs, drugs, nutrients and foods. Most of the time the research supports our use of these natural medicines, but sometimes it does not. Why? Because there are many problems with single-agent trials and natural medicines:

As stated above, there is a huge discrepancy in funds for research, which means we cannot study all natural medicines, and many medicines studied have poor enrollment. This leads to false negative effects of these agents.
Many of the agents studied are used improperly, or in dosages comically low. What would the allopathic community say if we studied the effects of aspirin on pain at a level of 0.1 mg? Similarly many studies of natural medicines (herbs in particular) use doses at a fraction of the therapeutic level. Similarly, many studies used improper forms of the herbs (e.g., Echinacea purpurea instead of Echinacea angustifolia), or attempted to study herbs or nutrients for conditions in which they were never intended to treat (like vitamin C for tumor reduction).
We rarely use single agents! Often our treatment plans are multi-factorial, and rightly so. A common treatment for a patient may include dietary changes, prescription for exercise, counseling, and multiple herbs or vitamins. Many of these interventions have shown to have a synergistic effect, but this is nearly impossible to study in a double-blinded trial.

I don’t want to give the impression that naturopaths dismiss all scientific research. When research trials are well designed and show positive or negative results, all good naturopaths use that knowledge to influence their clinical practice. Research is extremely helpful at elucidating which natural medicines are most helpful for certain conditions, and at mapping out the biochemical reactions.

Whew...this turned out to be a much longer post than I intended. I would like to talk a bit about how we use research based on actual practice to make many of our clinical decisions, but I think I will save that for my next post.

Starting the discussion...

2010-05-10T15:18:00.000-07:00

Glad to hear I have some questions! I really want to do justice to the questions, so bear with me if it takes a while to fully answer them.

Here's a good one:

You talk about allopathic medicine though you don't mention osteopathic medicine... you describe natural medicine as often times I hear osteopathic medicine described. How are they the same? Different?

Can a naturopathic doctor admit a patient to a hospital? Can they write orders in a hospital?

Tom MD

In this blog I generally I lump Osteopathic and Allopathic medicine in the same category, even though they are not the same. There is a much longer story regarding the roots of osteopathic medicine and the divergence of the profession from the historical osteopathy. It is my understanding that many osteopaths do not practice consistent with historical osteopathy. However, that is not my story to tell...if there is a well versed osteopath out there who would like to tell that story, I will let them tell it.

(I realize that people who are not familiar with the history of osteopathic medicine are really confused at this point. Go ahead and google the history of osteopathic medicine and see what comes up. I'll wait...)

Perhaps this is a good time to talk about the philosophy of naturopathic medicine. Naturopathic medicine isn't defined by what we do, but rather what we think. Naturopathic physicians guide their practice by the use of our philosophical principles. These principles include:

1) First Do No Harm (Primum Non Nocere)
2) Utilize the Healing Power of Nature (Vis Medicatrix Naturae)
3) Treat the Cause (Tolle Causam)
4) Treat the Whole (Tolle Totem)
5) Doctor as Teacher (Docere)
6) Prevention (Preventare)

These six principles are what guide the practice of all naturopathic physicians. It is my understanding that these six principles are unique to the philosophy of naturopathic medicine, unlike allopathic and osteopathic medicine (though many physicians utilize these principles without being aware of it!).

Tom, I realize I may not be answering your question fully. Please feel free to respond. I don't want to speak for osteopathic physicians, however, because that is not my specialty.

At this point in time there are very few naturopathic physicians who have hospital admitting privileges. I am not sure if that will change in the future, it is entirely possible. That said, I don't think that naturopathic physicians are necessarily appropriate for the care of patients who are in an acute state, since the focus of our education is really primary care (not emergency medicine!). I just wish our patients had access to some of the life-saving natural products that are available elsewhere in the world (like injectable milk thistle for amanita mushroom poisoning!).

... In future posts I think I will try to flesh out some of those philosophical principles a little more clearly, so if they don't make sense yet, just hang in there.

Natural Medicine is the Best Medicine...

2010-04-26T15:14:00.000-07:00

Who am I? I’m a 4th year Doctor of Naturopathic Medicine (ND) student at Bastyr University in Kenmore, Washington. Bastyr University is one of 7 accredited naturopathic medical colleges in the United States and Canada (check out the Association of Accredited Naturopathic Medical Colleges, www.aanmc.org). At the time of this posting, naturopathic physicians are licensed in 17 states and territories in the U.S. and Canada, as well as the U.S. territories of Puerto Rico and the Virgin Islands.

To quickly summarize, naturopathic medicine is evidence-based medicine founded on philosophical principles that emphasize treating the whole person, finding the root cause of disease, and focusing on prevention. Naturopathic physicians are trained in four-year medical schools and learn the same system of diagnosis as allopathic physicians, but choose to treat their patients with a variety of therapies, including botanical medicine, vitamin/mineral supplementation, hydrotherapy, counseling, dietary recommendations, and physical manipulation.

The purpose of this blog is to discuss the role of naturopathic medicine in our current healthcare system. I truly believe that naturopathic physicians are the best primary care providers in the United States. Future posts in this blog will address the role of naturopathic medicine in prevention of many chronic diseases that causes significant morbidity and mortality in this country. I also aim to discuss the cost-benefit ratio of naturopathic care versus the current medical model, as well as issues of access to primary care providers. I also hope to further discuss naturopathic philosophy and the utilization of our naturopathic principles.

You, the reader, are encouraged to use this blog as a discussion board. Any questions that are thoughtfully and respectfully asked will be answered and posted for others to see. What I won’t allow is any naturopathic bashing, or for that matter, any disrespectful comments about my naturopathic OR allopathic (conventional medical) colleagues. Any such comments will be promptly removed.

Let’s start the conversation!