Friday, April 10, 2009

Quacks in BC

"The regular docs treat the symptoms, whereas the naturopath tries to find the CAUSE."
So, they've done it. So-called naturopathic physicians will now be able to do the following:
  1. prescribe non-controlled medications (eg. they can prescribe Tylenol #3, all antibiotics, all mood altering medications - antidepressants, antipsychotics, mood stabilizers including lithium, immune suppressants such as prednisone, methotrexate), "after completing a certification training". A list of medications they cannot prescribe is attached at the end of the legislation (seems to be mainly narcotics / sedatives / chemotherapy agents)
  2. order Xrays / Ultrasounds (but no CTs)
  3. perform minor surgeries at or below dermis
  4. perform allergy challenge testing and desensitization
  5. insert finger/instrument/device into any body cavity, whether natural or artificially-created
Now, do naturopaths have the training for any of this, particularly minor surgery? For all their self-serving rhetoric, they do not have any hospital experience in their training, nor any mainstream medical exposure. No clerkship. No call. No residency. No OSCEs. Just dodgy self-regulation. And homeopathy.

Of course, I will not and cannot deny that many treatments in use today derive from natural sources. Digoxin, a very old drug used in heart failure, was isolated from Digitalis purpurea, a poisonous flowering plant also known as foxglove. That doesn't make homeopathy - a practice without any kind of rational pharmacological basis - a valid form of treatment, however, nor does it excuse the sort of rhetoric that seeks to set naturopathy apart from "allopathic" (i.e. mainstream) medicine:
  1. Vis medicatrix naturae: the body has the inherent capacity to heal in the proper therapeutic environment. NDs believe in the recuperative power of the organism, given the correct climate for healing. Determining the correct individualized therapeutic environment is at the core of naturopathic medicine.
  2. Tollum causum: remove the cause. Instead of treating the symptoms of disease the ND tries to cure the cause of the disease.
  3. Prima non nocere: do no harm. The ND is trained to use therapies that will not cause adverse side effects or cause secondary problems (i.e., iatrogenic disease) as serious or more serious than the original disease.
Regarding Vis medicatrix naturae, it's certainly true that the body has an inherent capacity to heal itself, but that "proper therapeutic environment" is absolutely key. For example, penicillin for a pharyngeal infection caused by Strep pyogenes is necessary to prevent secondary glomerulonephritis, the cause of which is related to the body's natural immune response to the bacteria. Untreated strep throat can also lead to rheumatic fever; proper treatment is certainly required. One wonders, then, what naturopaths think is unique about this principle.

The second principle is a frequent canard offered in support of naturopathy; that naturopaths treat the cause of disease rather than the symptoms, something that is supposedly the opposite of an MD's approach. This, of course, is simply non sequitur, which is not to say that purely symptomatic treatment is never warranted. On the other hand, naturopaths have a habit of inventing causes to explain a wide variety of non-specific symptoms:

Of course, Candida is everywhere and on you all the time. Most of the time it does nothing. To see what an actual bought of candidiasis looks like, simply Google "oral thrush". To see whether you might suffer from Candida "overgrowth", watch this video.

As for their last principle, "do no harm", it's nice to know that naturopaths have discovered the Hippocratic Oath. It's unfortunate, however, that they are under the delusion that adverse effects and problems secondary to treatments can be avoided. Since they seem mainly to cater to the worried well, however, most of their "treatments" are comparatively benign (if not entirely ineffective). I hope they behave responsibly enough to avoid going beyond their limited training and so avoid the aforementioned iatrogenic disease.


Deborah said...

I'm honestly really surprised at you, Josh. It is just that kind of closed-mindedness and arrogant "self-serving rhetoric" coming from my medical doctor that drove me to see a naturopathic one who would actually listen to me instead of preaching at me and shutting down everything that didn't lie along allopathic lines.

You've clearly never been to a naturopath before, so perhaps you might allow me to explain some of the differences.

Vis medicatrix naturae and Tollum causum do differ significantly from what medical doctors hold. MD's tend to treat maladies as isolated problems. They don't look at the whole body and how it might be contributing to the situation or providing the grounds for it to occur. Using your strep example, say, MD's wouldn't try to figure out why recurrent infections might be occurring - they'd prescribe the penicillin and be done with it. ND's take a holistic approach and don't take the symptoms in isolation. They take an inventory far more detailed than any I've ever been given by a medical doctor, and then, once addressing the symptoms work on boosting your immune system to decrease the likelihood of it reccurring.

As for Prima non nocere, you seem to have misread. The ND is trained to use therapies that will not cause adverse side effects or cause secondary problems (i.e., iatrogenic disease) as serious or more serious than the original disease. It doesn't say that secondary problems and side effects never happen, it says that they shouldn't be worse than what they are trying to cure, which is a big difference.

And now...into the issue at hand...

I must point out that many doctors are not exactly schooled well in medication either. Pharmacists devote many years of study exclusively to medication. Medical Doctors, not so much.

I've been in situations where the doctor was completely unaware of what a medication actually does. Up to me to do my research, march in there with a list of side-effects that quite frankly, she should have known about if she was prescribing the thing and demand to be switched. And sadly, this is not an isolated case. Bottom line - you have a question about medication? Contact a pharmacist, it's what they're trained for.

And now, perhaps what is most important. Chronic fatigue syndrome and systemic candida are unfortunately very real. I should know. I suffer from them. And no, it wasn't a "quack" naturopath telling me I had them, it was me doing my research. It was me approaching my medical doctor, a very closed-minded woman who eshewed any and all altenative forms of medicine and basically told me to shut up because they didn't exist and that there was nothing she could do for me. It was her caring more about preserving her tunnel-vision viewpoint than caring about trying to help her patient.

Is that the kind of doctor you want to be, Josh?

My advice to you is this. You (meaning MD's and ND's) are both after the same thing, which is making people healthy. Yes, you go about it differently, but it's the same thing. As long as an ND doesn't make someone worse and delay/prevent allopathic care that might help (which, having worked with them and gone to them, I've never seen happen), then there is no harm. Not all patients are the same, and not all of them all are going to fit nicely into an allopathic viewpoint.

In your career, you'll be working with patients who also see naturopathic doctors and being open minded will serve you well. Play nice.

Josh said...

No, it's true, I have never been to a naturopath. I am sorry that you have had bad experiences with your doctor, but I don't believe that merits characterizing my post as "closed-minded", "arrogant", or "self-serving". I must further take issue with the term "allopathic", which was coined by the founder of homeopathy as a pejorative term to describe the state of mainstream medicine in the early 19th century, a time when it was probably fully deserving of such critiques.

But it's simply not true that MDs "don't look at the whole body". That, indeed, is a large part of the training, as is the consideration of the many potential causes of the presenting symptoms to come up with a differential diagnosis. If, in the strep example, the patient mentioned an unusual frequency of certain types of infections, we might investigate whether a serious immune deficiency was the cause. There are no shortage of other examples, and the goal is to be able to differentiate between signs of something serious and problems which are isolated and limited in nature. The entire purpose of this exercise is to determine the cause of an illness to whatever extent possible and treat it. Purely symptomatic treatment is pretty much the last resort. It is, frankly, a non sequitur to suggest that physicians treat symptoms rather than the cause of illness; the modus operandi is the exact opposite.

For that matter, it is absolutely not true that naturopaths in particular "use therapies that will not cause adverse side effects or cause secondary problems (i.e., iatrogenic disease) as serious or more serious than the original disease". Physicians try to avoid this as much as possible and I stand by my comment that this is a canard with no basis in fact offered by naturopaths to differentiate themselves from "allopathic" medicine. In fact it's quite obvious that not making things worse is something to be avoided. That's not to say that bad outcomes don't happen - they do - and that's why "conservative management" is often preferred to rushing ahead with a potentially risky treatment.

It's quite true that pharmacists know more about drugs than physicians. They're supposed to, and that's why they get called when a difficult question about treatment comes up. Hospitals work on the basis of consults, questions, and a team approach to care. If you don't know the answer, you page the resident-on-call or the hospital pharmacist or you track down the charge nurse to clarify some aspect of a patient's history.

On the other hand, we (meaning my med class) are currently in our dedicated pharmacology unit which we actually take with the pharm students. Some drugs we're already familiar with and all of them we will learn about again and again over the next three years. Unlike naturopaths, we will actually be responsible for being familiar with a wide variety of commonly used drugs during clerkship and residency. And for anything we don't remember, that's why we have the CPS, pharmacy consults, and infectious disease consults when a question about antibiotics comes up.

I don't want to get into Chronic Fatigue Syndrome, but systemic candida in particular is not a diagnosis and does not correlate with any kind of lab results. A systemic fungal infection would be very serious and cause for hospitalization, possibly in the ICU. Candida albicans hangs out on our skin pretty much all the time; infection is really quite obvious and often affects mucous membranes in immunocompromised people. It does not cause a catch-all of non-specific symptoms. I certainly hope that a naturopath would not attempt to prescribe an antifungal agent based on such a diagnosis, as it would be inappropriate and either do nothing or cause secondary problems. More info here (note that this site shows quite plainly that MDs can be quacks too).