M.D. vs. N.D. – Alaska physicians object to prescription privileges for naturopaths

In January, naturopathic doctors will begin another push to change a state law they believe frustrates patients who choose their form of care over conventional medicine.

Dan Young and his wife, Madeleine Morrison-Young, are trained in naturopathic medicine, which focuses on natural therapies. Some of the patients at their Eagle River practice also need prescription medication.

But Alaska law prevents the Youngs and dozens of other naturo-paths from writing prescriptions. That means their patients must schedule, and often wait for, an appointment with a medical doctor. This second visit means insurance companies or the patient will pay twice, Dan Young said.

"It's so incredibly inconvenient," he said.

The effort that began a year ago to change Alaska's law has been mired in misunderstandings, naturopaths say. Dr. Scott Luper, a naturopath in Fairbanks, said he has heard people mistakenly say the bill would give prescriptive rights to naturopaths who earn degrees through mail-order programs.

"That's just not true," Luper said, pointing out that since 1986, Alaska has required naturopaths to graduate from medical schools before becoming licensed.

The bill sparked a debate about who should prescribe medications. Some medical doctors wonder why a naturopath would want to prescribe drugs, since that doesn't seem to be part of naturopathy's philosophy of focusing on natural therapies, nutrition and preventive medicine. Naturopaths, on the other hand, argue that they are trained to prescribe drugs and that sometimes drugs are exactly what their patients need.

Last winter, naturopaths repeatedly flew to Juneau to support a Senate bill that would give them legal authority to prescribe medications and perform minor surgeries, skills they say they've learned through accredited, four-year medical schools. Doctors representing the Alaska State Medical Board and the Alaska State Medical Association also came to testify, however, and spoke against the bill.

Dr. David Head, chairman of the state medical board, testified that he has nothing against naturopaths and has consulted them regarding his own health. But in a letter to Gov. Frank Murkowski, Head said the board strongly opposed the bill and wanted it defeated. He said the board believes naturopaths' approach to healing is too simplistic and in direct conflict with science-based medicine.

"The danger of this approach is that patients with serious diseases will rely- solely on the treatments provided by practitioners of naturopathy, ignoring the treatments proven to be safe and effective by a science-based medical physician," he wrote.

Instead of changing the law, the final- bill set up a temporary task force of legislators and health care providers. They were told to meet three times before Dec. 1 and come up with recommendations for a new bill to be proposed in January.

But Dec. 1 came and went without any meetings. Sen. Ralph Seekins, the Republican from Fairbanks who sponsored the naturopath bill, said the task force "probably got lost in the election" this fall. Legislative staff members pointed to more problems, including a bill that didn't put a person in charge of calling any meetings.

In mid-December, Seekins took control and scheduled a task force teleconference for 9 this morning. The public is invited to listen to the meeting and can learn more by calling a Legislative Information Office.

"We've got two years to really hammer this out into a good piece of legislation," Seekins said.

Underdogs

The pending legislation calls attention to two types of doctors: medical or allopathic doctors, also called M.D.s, and naturopathic doctors, known as an N.D.s.

Medical doctors far outnumber naturopaths. As of December, the state reported more than 1,500 medical doctors licensed and living in Alaska. Only 40 naturopaths have licenses, and only 33 of those have Alaska addresses, living in Anchorage, Eagle River, Kenai, Homer, Fairbanks, Juneau and elsewhere.

"We're the underdogs," Young said. "We're making a resurgence. We're returning, so we're always under the magnifying glass."

The differences between the two professions extend to where and how they train, their philosophy of healing and what they're allowed to do according to Alaska law.

To be licensed in Alaska, medical doctors must graduate from a medical school and complete a minimum of two years of postgraduate medical training, often called a residency, said Leslie Gallant, executive administrator for the Alaska State Medical Board.

Alaska is one of about a dozen states that license naturopaths. To get a license, naturopaths also must graduate from a medical school and pass a licensing exam, but no residency is required. Some naturopaths want to be called "naturopathic physicians," but Alaska law doesn't allow them to use the word "physician" in their title.

Medical and naturopathic doctors attend different medical schools accredited by different organizations, but both complete at least four years of classroom and clinical training.

The first two years of training are similar for both types of doctors and focus on classroom studies of anatomy, biology and other sciences, said several naturopaths. Dr. Clyde Jensen, who has held executive positions at allopathic and naturopathic medical schools, testified before the Legislature that the two types of doctors have differing strengths, but most areas of their training are comparable.

Dr. Alex Malter, former president of the Alaska State Medical Association, disagreed.

"We are not convinced that the first two years of naturopath and medical schools are the same," the Juneau physician testified.

"Training for naturopaths is less rigorous than that for medical doctors, in both length and depth of study. Its emphasis on natural healing does not allow students sufficient time to fully learn the in-depth pathology, physiology and pharmacology needed to treat most medical conditions."

Naturopaths acknowledge there is a difference in the third and fourth years of medical training. Those years focus on clinical training, which medical doctors typically get in a hospital and naturopaths complete in outpatient clinics. It's during this phase that naturopaths focus on the philosophy of their craft: healing through nutrition, botanical medicine and prevention.

Like medical doctors, naturopaths are trained to do annual exams that include measuring weight and blood pressure and other checkups, Luper- said. Women who see Morrison-Young for an annual visit can expect pap smears and breast exams. The Youngs' staff also draws blood for laboratory tests.

Naturopaths say they are trained to do minor surgery such as stitching cuts and removing moles but not major surgeries such as removing gallbladders. They call themselves primary-care providers who work in outpatient clinics and say they know when to send patients to specialists for more complicated procedures and medications.

"I work with M.D.s all the time," Young said. "We're trained to refer."

What's different about the Youngs' office is the types of therapies it offers. On a recent Friday afternoon, Katherine Holloway sat on a futon in Morrison-Young's office. On the wall hung Dan Young's diploma from Oregon's National College of Naturopathic Medicine, one of six naturopathic colleges in the Lower 48 and Canada that are accredited or seeking accreditation

Holloway started seeing naturopaths last summer when she was having ongoing stomach problems. She said she likes visiting Morrison-Young because the doctor explains why she's having health problems instead of just writing a prescription for symptoms.

"I get excited every time I come over here, just because I get to learn about myself," she said.

Young started the recent visit by asking how much water Holloway regularly drank. Then they talked about diet and how much energy she had.

"Naturopathic physicians start with diet," Young said. Then they turn to other therapies that promote health. Sometimes naturopaths choose manipulation of muscles and bones. Other times it's hydrotherapy, such as using hot and cold water. Some naturopaths, including Young, receive specialized training in acupuncture.

Young and other naturopaths said drugs aren't their primary method of treatment.

"We are more inclined to use prescriptions as a last resort and are less likely to put our patients on multiple drug regimes," Dr. Mary Minor, a longtime Anchorage naturopath, wrote in a letter to a nursing publication that recently discussed the Alaska legislation.

Prescribing drugs 

Naturopaths typically focus on medicine that comes from nature. In the Youngs' office, an entire room is filled with containers of herbs and bottles of botanical extracts that they mix to create tinctures for treating a variety of problems.

But at times, naturopaths say, they need to prescribe conventional drugs. In Alaska, medical doctors, nurse practitioners, physician assistants, dentists and optometrists can prescribe medications for their patients. Naturopaths cannot.

Luper said naturopathic and medical doctors have the same training in drugs and what they do in the body, but naturopaths have less training in how to use these drugs and how they work along with other medications.

Luper said he knows he lacks skills to prescribe many types of medications and wants legal authority only to prescribe the ones he's comfortable using. He told the Legislature about safety records in states with prescriptive rights for naturopaths. In those states, the rate of complaints and disciplinary actions against naturopaths was lower than those against physicians, he said. One legislator countered that the difference could be attributed to medical doctors performing more difficult, risky procedures than naturopaths do. Luper acknowledged his point.

A recent search of disciplinary actions showed the state has suspended 10 physicians' licenses and revoked one since 2000. The Division of Occupational Licensing has opened 14 investigations involving naturopaths since they were first licensed in the mid 1980s. Six of those cases involved naturopaths illegally prescribing drugs. All were told to stop, said Rick Urion, the division's director.

But no naturopath's license has been suspended or revoked in Alaska, he said.

Changing the law

A change in the law could alter naturopaths' habits in several ways.

Some states that license naturopaths allow them to prescribe certain drugs. In Oregon, for example, naturopaths can prescribe drugs included on a pre-approved list, called a formulary, Luper said.

Legislative hearings last winter discussed formularies and other possibilities, such as having naturopaths and medical doctors work in a collaborative agreement, similar to the way physician assistants work in Alaska. Such an agreement could require a naturopath to review a particular drug with a medical doctor. The two would come to an agreement about how the naturopath will use that medication, if at all.

Luper said he thinks these agreements are a good idea.

"My belief is the more time that I spend interacting with other professions, the more those other professions will come to respect and recognize what I do," he said.

While not initially excited by the idea of collaborative agreements, Minor wrote that integrating different types of healing could be a new trend in medicine.

Luper, the Youngs and other naturopaths ended the year by trying to move the task force forward so another bill can address these concerns.

"We're ready to sit down and talk," Morrison-Young said.