Sh*t naturopaths say, part 2: Naturopathic education and science

Well, Naturopathic Medicine Week 2014 (or, as I like to refer to it, Quackery Week) is fast drawing to a close; so I figured I’d end it with one last post. Since several of you liked my post a couple of days ago Sh*t naturopaths say and agreed with me when I suggested at the end that I ought to make this a recurring feature on the old blog here. So, how better to finish off Naturopathic Medicine Week 2014 than with another installment of Sh*t naturopaths say. In fact, I might even have to make it a tag. After all, I’m sure naturopaths will continue to provide me with quackery to deconstruct, and my only regret is that I didn’t think of this tag a long time ago. I’m sure it will serve me well in the future.

After I decided to do one more installments, I was immediately faced with the problem of choosing the next batch of pseudoscience and nonsense from the Read what naturopaths say to one another. Conclusion: manipulative, poorly trained, and a threat to public health subreddit. Sadly, I hadn’t exhausted what was there in my first post. But then I was made aware of this exceedingly “target-rich” environment by a naturopath named Michele Burklund entitled What Everybody Ought To Know About Naturopathic Doctors, and I knew that I had to start there, first, although a couple of key quotes from the subreddit will help me tie everything together.

I will admit that Burklund does have a bit of a sense of humor in that she includes a couple of pictures in her article. One, captioned “What a naturopathic doctor looks like” shows a woman whom I presume to be Burklund in a lab coat with a stethoscope around her neck. The other, captioned “what people think we look like” shows a model dressed up looking like shaman or aboriginal who is nonetheless obviously a model not just because the photo is credited to a Vogue editorial shoot. I couldn’t resist doing a quick Google image search, which led me straight to this photoshoot of Hailey Clauson shot by Sebastian Kim (second photo, to be precise), which is one of the more ridiculous photoshoots I’ve ever seen. I mean, look at the designer try to make a model look like she’s in some sort of prehistoric tribe. Very silly indeed, not to mention condescending (perhaps even a little racist), although I can see why Burklund would want to look like Clauson, given how gorgeous she is, even made up to look as though she’s a member of a prehistoric tribe. (One of these days I’ll have to compare myself to John Hamm in a post, because, you know, I’d really like to look like him. Or maybe John Slattery would be more realistic, given how gray my hair has become.) I can also see how appropriate that photo is, because just as naturopaths are fake doctors they’re also fake “shamans,” made to look as acceptable as possible to white, affluent people, hiding the superstitious, vitalistic, and pre-scientific nature of most of the treatments they like to use.

[NOTE: Since this post went live, it would appear that Burklund removed that photo and substituted one of her with her face painted, which is probably an improvement over the original, at least taken in context.]

Be that as it may, it’s obvious that Burklund wants to make fun of the image of naturopaths as witch doctors, which is self-deprecatingly great, but in reality, when you look at what naturopaths advocate and what they do, it’s hard not to conclude that they have much in common with witch doctors or shamans. As a commenter said in my earlier post, if you transplanted 16th century “healers” into present-day society and gave them access to drugs (and human beings to experiment on), the results would be much the same as what naturopaths do. I’d go a bit further and say that you could transplant shamans from aboriginal tribes or possibly even Egyptian priest-healers from 3,000 years ago and the result would be similar. The reason is that much of what naturopaths do is rooted in prescientific vitalism.

So back to Burklund’s point, which begins:

It seems like if you don’t live on the West Coast or in a large city people have absolutely no idea what naturopathic doctors are or the training they have. They will probably confuse a ND with a nutritionist, homeopath, health coach, witch, or some weirdo selling snake oil. ND’s are definitely the underdog in the medical system with roughly 5,000 practicing in the United States while there are 893,851 practicing MD’s. But that’s no reason to give up… some of the most inspiring people in the world came from situations that bet against them. The solution is education, if people really knew the training and education that naturopathic doctors have they would be lining up at their clinics begging for a fresh perspective on their health. That is where Naturopathic Medicine Week Comes in! Education is empowerment.

Burklund might have a point if what she was doing was actually educating about naturopathy, but that’s not what she’s about. She’s about trying to “prove” that naturopathy is just as good as conventional medicine, and she goes to ridiculous extremes to do it, in the process recycling every deceptive argument naturopaths make to try to make it appear as though they really and truly are “scientific.” It’s the same reason why she keeps using the term “naturopathic physician” rather than “naturopath.” Hilariously, she shows graph after graph that supposedly shows that naturopaths take just as much or more basic science as medical students in terms of sheer credit hours. Of course, credit hours mean nothing if what is being taught is substandard and/or being used in the service of teaching quackery.

And, boy, is there a lot of quackery in the curricula of naturopathy schools, as demonstrated by Burkland herself. She tries to differentiate what is taught in the seven “elite” schools of naturopathy; i.e., the accredited ones, which include:

  • Bastyr University
  • National College of Natural Medicine
  • National University of Health Sciences
  • Southwest College of Naturopathic Medicine
  • University of Bridgeport
  • Canadian College of Naturopathic Medicine
  • Boucher University

This is the table:

Naturopath

What leaps right out at me that differentiates real doctors from naturopaths is not so much the hours of basic science but rather the clinical instruction. Sure, Yale, Johns Hopkins, and the Medical College of Wisconsin (not sure why Burkland chose that one) have similar hours of instruction in basic and clinical sciences, including anatomy, cell biology, physiology, histology, pathology, biochemistry, pharmacology, lab diagnosis, etc., but conventional medical schools have more instruction in clinical clerkships in the main specialties, like family medicine, surgery, pediatrics, OB/GYN, etc. The difference is made up in naturopathy schools by the woo, with 500-600 hours of homeopathy, hydrotherapy, manipulative therapy, botanical medicine, naturopathic philosophy, and advanced naturopathic therapeutics (whatever that means). Let’s just put it this way. Naturopaths have taken around 750 hours away from the core clinical specialties and moved them to quackery like what I just listed above and 150 hours of “therapeutic nutrition,” or the “food as medicine” schtick. This leads Burkland to warn people against those “other” naturopaths who haven’t undertaken the rigorous coursework she claims for naturopaths like her.

Again, any training that includes homeopathy and traditional Chinese medicine as scientifically valid treatments cannot be considered either science- or evidence-based, concluding:

Upon graduation a naturopathic doctor will have completed over 310 doctorate level credit hours and over 1500 clinical hours seeing a minimum of 350 patients and 144 preceptorship hours (with our choice of an MD, ND, DC, or DO). Naturopathic doctors are trained as primary care physicians from the first day of medical school which is much different than M.D’s which choose a speciality upon completion of school.

Uh, yes, but that’s because a medical doctor isn’t considered fully trained until he or she has completed a minimum of a three year residency. That’s the minimum. For instance, internists do three year residencies, after which they can sit for the internal medicine board exam. Other residencies are longer. General surgery, for instance (and most surgical specialties, like urology or orthopedics, for example) are five year residencies, often with a year or two of research thrown in. Then many physicians add a fellowship ranging from one to four years after that to subspecialize. Even so, the least “differentiated,” least “specialized” primary care medical doctors have at least three years of residency. Many have a lot more. I’m referring to the residencies that used to involve 100+ hour weeks and call schedules ranging from every fourth night to every other night. The call and hours are less brutal now, but naturopathic residencies are nowhere near as rigorous, either in time or clinical practice, as the training for MDs. Jann Bellamy detailed this disparity very well not too long ago. It’s well worth a read. As she pointed out, the Council on Naturopathic Medical Education (CNME) only requires:

CNME requires a total of 1200 clock hours (15 weeks) of clinical training. Of these, only 850 hours (less than 11 weeks) must involve primary or secondary responsibility for patient care. The student must have at least 450 “separately scheduled patient interactions” during this training (including those in preceptorship). In 225 of these patient interactions, the student must be working in “primary capacity in assessment and/or treatment” under faculty supervision. No further definition of “patient interaction” is given, but, by way of comparison, a family practice M.D. will typically see 20-25 patients per day. Making the (likely safe) assumption that each of these constitutes the M.D. acting in a “primary capacity in assessment and/or treatment,” and using an average of 22.5 patients per day, the entirely of N.D. clinical education involving primary responsibility for assessing and treating patients is the equivalent of as little as 10 days of real-world family practice. Even being extremely generous, and counting all 450 “patient interactions,” that’s 20 days in a family practitioner’s office.

To be fair, a family practice residency includes a lot of inpatient rotations on the core specialty services, like medicine or OB/GYN and is not all clinic. However, residents generally maintain their own outpatient clinic during the course of the three year residency during their rotations and then rotate on various services where they cover clinic; by any reasonable measure they see and do a lot more than any naturopath trainee. Also, as Jann pointed out, much of what naturopaths learn has little or nothing to do with how to use prescription drugs, using instead for “treatments” like IV vitamin “cocktails,” hormone prescriptions, antibiotics for parasites or infections as part of “detoxification” therapy, or injection therapy for pain (neural, trigger point and prolotherapy). The sheer number of instruction hours in medical school does not a physician make, nor does the sheer number of instruction hours in a school of naturopathy make it as rigorous as a medical school.

Unfortunately, these arguments resonate, because numbers are easy to compare. It’s far easier to compare, for example, number of instruction hours among institutions than it is to compare the rigor of the programs and the appropriateness of what is taught. Let me tell you that the instruction in medical school is incredibly content-dense. An incredible amount of material is covered in a very short period of time, far more material per time period than in schools of naturopathy, I’ll warrant.

We can see the results of this sort of instruction in the Read what naturopaths say to one another subreddit, specifically the Defense of naturopathic medicine. The thread starts out with a naturopath asking for, well, let me just quote her:

Although I am generally a very non-confrontational person and avoid argument as much as possible, I would really like to have an arsenal of the most irrefutable, scientifically based evidence for naturopathic medicine, for those instances when I feel I need to defend our profession to those who will only listen to this sort of proof.

In that spirit, I am hoping to start a thread where you, my colleagues, will post links to the best studies proving that what we do works. If you don’t have links, journal/article information is great, too. The more iron-clad the study, the better (e.g. double blind, placebo trials, etc), but feel free to submit anything you feel is worthy.

Obviously I know what I do works, and obviously my patients know. This is for those who are hell-bent on denying, and may only be swayed by scientific proof.

Note the final sentence. “I know what I do works.” Taken in context, what this naturopath, Ruth Galbraith, says is basically: I don’t need no steekin’ evidence for what works. I know. But those pesky skeptics demand evidence! So could you guys spoon feed me some studies that I can use to deflect that criticism? Evidence here is not needed to support what Galbraith does in her practice, but rather as a shield and a sword to wield against those annoying skeptics who will only accept evidence from science and randomized clinical trials.

In response, one naturopath, Jim Prego, demonstrates one of the most massive cases of projection I’ve seen in a long time:

In my interactions with the above type of person, I have found that they are never swayed by the scientific proof they say they are only swayed by. Every person I have ran into that is against naturopathic medicine because “there is no research to support it” or “its not evidence based medicine”, etc, has always made excuses as to why they wont look at or belive any research I show them that dosen’t support their position. Thats why I have given up on doing it. They just have a position and they only will belive research that supports their pre-determined conclusion.

Or maybe Mr. Prego just isn’t very good at providing evidence to support his viewpoint that is of sufficient scientific quality to convince a skeptic. As I’ve said time and time again, show me the science. Show me the evidence. I keep looking, hoping that sometime someone will show me to have been wrong about some treatment in alternative medicine, for the simple reason that it would be cool if some of these modalities actually did something greater than placebo. I’m still looking.

Of course, it doesn’t take long for a naturopath named Daniel Crupper to make charges of corruption, ignoring the lack of evidence for naturopathic interventions themselves:

…when we look at the reality of our position we must really understand what game we are playing and how it is played. Right now the game is called “Evidence Based Medicine” and in every major medical school across the nation that is the phrase used to teach MDs and DOs that what they are doing is the best medicine and that our medicine is fold medicine with no scientific evidence behind it. We could complain that their system isn’t fair (because it isn’t) or that it fails to look at individuals outcomes (because it doesn’t) but that misses the point. That is akin to sitting down at a blackjack table and arguing that the odds aren’t fair and we should all play poker. Those complaints won’t make a change. The point is the current medical system is the controlling system and therefore chooses how medicine is defined. To be able to overcome that system we need to understand it’s rules and beat them at their own game. Unlike Ruth, I am argumentative and take any confrontation as a challenge. I like to look for holes in the current model and specifically in the “evidence based medicine” argument. I also like to look for research articles that uphold naturopathic medical values. That is the way we beat them at their own game! 1) There is already a tremendous amount of “evidence based” research in our favor that never comes forward because there is no company marketing it. Steve Austin does a great job of compiling nutrition literature every year and presents it at the AANP conference. For instance, last year he had journal reference for topics such as increasing water intake decreases colon cancer 92%, flaxseed lignan decreases BPH and likely cancer, antioxidants create 25-45% hearing improvement, antioxidants statistically improve arthritis and psoriasis, the list goes on and on! He specifically asked if anyone would be willing to start a compendium of “evidence based” botanical research. 2) I like to tell challengers how naive it is to believe the “evidence based” medicine they hear about when it is funded by the company that stands to gain from it. I start using recent evidence of research tampering and fear tactics to prove my case. For instance, the use of medical ghost writers for research…

Increasing water intake decreases colon cancer by 92%? WTF? This is research I have never heard of; so I did some searching. What I found was a study that concluded that water consumption did correlate (although in a barely statistically significant manner) with a lower risk of colon cancer in women and that “water consumption was marginally associated with a decreased colon cancer risk among men as well (OR for > 4 glasses/day versus < or = 1 glass/day, 0.68; 95% CI, 0.38-1.22; P = 0.16)” and another study that found no statistically significant effect. I finally located the study. It’s small, and it found a statistically significant effect only for men; for women it wasn’t statistically significant. Also, it wasn’t clear if the effect was due to exercise (which is associated with more water intake) or the water intake itself. All in all, the evidence for this assertion is thin gruel. Of course, even if this observation held up, then science-based practitioners would recommend more water intake. It would cease to be “alternative” or “naturopathic” medicine and be just medicine, which is as it should be.

Later in the same e-mail, Crupper admits it’s all about the marketing:

Oh, and one more thing. I agree with Dr. Godby that we need a marketing campaign so that people know who we are. However, I think it would be wise if we had our “evidence based” arguments in order so that when people start asking us questions pertaining to the current medical model we have research to argue within that construct. Otherwise, to the public, we come away sounding like we are trying to make excuses for why it isn’t fair to judge our medicine by the current standard. If we are armed to the teeth with “evidence based” retorts we sound better educated at their own system than they are. Then we are ready for a marketing campaign.

Notice a theme here? Crupper sees science and scientific evidence as nothing more than a tool to “prove” that naturopathy is evidence-based. I’ll give him credit for recognizing the perils of special pleading (“we come away sounding like we are trying to make excuses for why it isn’t fair to judge our medicine by the current standard”) as a logical fallacy, but it’s only strategic. On the other hand, some naturopaths live by special pleading. Jim Prego, for instance:

So, because MD/DOs do something, why do we have to? Yes, they are the dominant system, but why let them define the terms for OUR sucess? They choose how their medicine is defined, not ours. To use your analogy, Blackjack might be the big popular game but if I am a poker player and I show up at a blackjack table, I will just leave and go to the poker table. If there is no poker table, and I am motivated enough, I will open a casino for poker players without trying to make it look like blackjack, or trying to convince the blackjack die-hards that poker is just like blackjack.

In other words, screw evidence-based medicine. We naturopaths don’t need it and don’t want it. It’s a “game.” There’s the difference between naturopathic education and “science” and medical education and “science. Unfortunately, I fear some of the attitude of naturopaths is infiltrating itself into conventional medicine in the form of quackademic medicine.