By Kate Masters
VM – For the past 15 years, Virginia’s naturopathic doctors have been on a quest for licensure by the state’s Department of Health Professions — a step that’s been taken by 23 other states and would allow them to diagnose and treat patients like many other medical providers.
That goal has brought the debate around the field of naturopathic medicine — widely defined by practitioners as a system that emphasizes prevention and self-healing through natural therapies — to the state’s General Assembly. Most recently, both the House and Senate considered bills during the 2020 legislative session that would have mandated the Board of Medicine to develop regulations for licensing naturopathic doctors in Virginia.
While both bills failed in committee, the Senate instructed the Board of Health Professions to conduct a study on regulating naturopathic doctors — one that concluded with a unanimous recommendation for licensure by the board’s Regulatory Research Committee during a meeting in August. But the effort ran into another dead end less than two hours later, when the full board met and voted narrowly — 5-6 — against licensing.
“It was a little disappointing,” said Sarah Giardenelli, a naturopathic doctor and licensed acupuncturist in Leesburg who serves as president of the Virginia Association of Naturopathic Physicians. “I’ve never seen another profession go through this — where the research committee recommended licensing and the full board voted against it. It certainly didn’t feel right to us at all.”
Amid an ongoing global pandemic that’s led to significant revenue losses for many primary care providers, Virginia’s naturopathic doctors plan to carry their fight for licensure into 2021, arguing they could play a critical role in expanding access to care for patients.
Del. Sam Rasoul, D-Roanoke, who sponsored the House version of the legislation in 2020, said a new bill would be filed in the upcoming General Assembly session. It’s likely to share similarities to previous versions, which proposed a significantly expanded scope of practice for NDs, allowing them to examine and diagnose patients, order clinical laboratory tests, and administer intravenous medication, among other treatments.
“It’s sad to see that politics is what drove this decision, rather than the sound, objective information that was presented by the committee,” he added. Rasoul was referring specifically to objections from physicians’ groups like the Medical Society of Virginia, state chapter of the American Academy of Pediatrics and seven other medical associations that signed a letter opposing licensure for NDs. The medical society, in particular, has long said licensing would give naturopathic practitioners a level of credibility that the profession doesn’t deserve.
“Licensure connotes a level of training that has some scientifically and medically backed substance to it,” said Clark Barrineau, assistant vice president of government affairs for the Medical Society of Virginia. “And for better or worse, that substance in naturopathy isn’t out there for anyone to evaluate right now.”
‘We’re a glorified health consultant’
It’s a view that naturopathic doctors — most spread among the roughly 18 practices listed in Virginia — are fighting against as they work towards licensure.
Virginia did license providers until 1972, when, according to the state’s most recent study, an ND member of the Board of Medicine recommended deregulating the industry. More than 30 years later, in 2005, the state’s Board of Health Professions first re-examined the issue, with NDs arguing that their title comes with a specific level of education and experience.
The board’s 2020 study points out that every other state to license NDs— including neighboring Maryland and D.C. — requires practitioners to hold a degree from a four-year program certified by the Council on Naturopathic Medical Education, an accrediting agency that’s recognized by the U.S. Department of Education.
They also have to pass the NPLEX, or Naturopathic Physicians Licensing Examinations — a two-part exam that includes questions on basic biomedical subjects such as anatomy, physiology and genetics. A second section involves diagnosing patients, interpreting lab results and administering treatments, including plant-based medicines and supplements. Some states also require NDs with certain specialties to pass additional clinical exams in areas such as acupuncture, minor surgery and pharmacology.
“The main point is that we have the training and education and breadth of experience that’s needed,” said Maria Rodriguez, a naturopathic doctor who lives in Northern Virginia but practices in D.C., where she’s licensed.
With her practice in D.C., Rodriguez said she can examine and diagnose patients, which includes ordering and interpreting her own clinical lab tests. The city’s regulations define naturopathic medicine as treatments using “air, water, heat, cold, sound and light,” along with more specific therapies ranging from exercise and ultraviolet light to diathermy — a therapy for joint and muscle conditions that uses high-frequency electric currents to “deep heat” tissue, according to the FDA.
“I actually have a pretty limited scope,” Rodriguez added. “I’m allowed to prescribe natural hormones, so I will do that, but otherwise we have fairly limited prescriptive privileges.” In Virginia, on the other hand, the lack of licensure means she can’t legally perform even routine physical exams.
“I think the healthiest way to put it is that we’re a glorified health consultant,” added Leah Hollon, a naturopathic doctor who also graduated with a masters of public health from Virginia Commonwealth University and opened her own clinic in Richmond eight years ago. It’s frustrating for many in the industry, who say the lack of regulation creates unnecessary barriers for both patients and providers.
“Right now, without licensing, I’m not even able to use basic evaluation and management insurance codes so patients can try to submit their claims for reimbursement,” Giardenelli said. In written testimony to the Regulatory Research Committee, multiple NDs pointed out that they had to ask their patient’s licensed physician to order diagnostic tests they were recommending — a process that, at best, forced patients to schedule multiple appointments with different providers, and, at worst, ended in outright refusal.
“I do not always have established relationships with all of their providers, and sometimes these providers are not willing to order the labs or to consider other ideas I may have suggested for our shared patients,” Giardenelli added in her written testimony. “I cannot blame them; it is truly odd for me to ask another provider to basically do my job for me.”
‘It suggests a level of backing that we think, candidly, could cause some harm’
Opponents of licensing, though, often bristle at the idea that NDs in Virginia have the expertise to practice autonomously and refer to themselves as doctors or physicians. While NDs often note that the Council on Naturopathic Medical Education is recognized by the federal government, Barrineau pointed out that recognition as an accreditation agency by the DOE doesn’t mean that the government has approved or endorsed the curricula of programs it oversees.
One frequent criticism is that naturopathic education is accredited almost exclusively by other naturopathic doctors, without the extensive and multidisciplinary third-party oversight required for most medical and nursing education. In 2014, the American Medical Association developed a module aimed at “assist[ing] physicians in countering the advocacy efforts of naturopaths seeking licensure and/or expansion of their current scope of practice.” It highlighted findings from other state studies of the industry, including a Colorado report that found the NPLEX Part II, the licensing exam, “does not adequately measure clinical competence.”
Barrineau said that results in programs that focus heavily on things like homeopathy — a treatment involving tiny doses of natural substances that has little scientific evidence to back up its effectiveness, according to the National Center for Complementary and Integrative Health.
Naturopathic medicine can involve a host of treatments depending on the practitioner and the scope of practice allowed in different states, from clinical nutrition to botanical supplements to massage. But the American Medical Association has harshly criticized many of the therapies common within the industry, writing that “the lack of randomized controlled trials and other forms of rigorous scientific inquiry into naturopathic treatments has not gone unnoticed by the medical and scientific communities.”
“The reason we oppose the effort is that if they can say ‘I am licensed by the Commonwealth of Virginia,’ it suggests a level of backing that we think, candidly, could cause some harm,” Barrineau said.
Much of the opposition to licensure in Virginia has also come from other naturopathic practitioners — ones who haven’t gone through a CNME-accredited program or, in some cases, received any form of third-party training. Often called “lay” or “traditional” naturopaths, many oppose licensure on the grounds that it would restrict their ability to practice. But many also say NDs blend natural remedies with conventional medical treatments in a way that can be harmful to patients.
“Allowing them to practice medicine without going to medical school is essentially giving them a license to kill,” Julie Coombs, a member of the American Naturopathic Medical Association — which opposes licensure — said in public testimony to the committee in August. “They think that putting a natural substance such as turmeric in an IV makes it naturopathy, when in fact it does not.”
Coombs was referring specifically to a case of naturopathic medicine gone wrong — a patient who died after receiving a turmeric infusion from a licensed ND in California.
It’s the kind of example that makes many NDs in Virginia cringe. Giardenelli pointed out that one major advantage of licensure would be the establishment of a regulatory board that could discipline and even de-license providers who harmed patients or ventured outside their scope of practice.
The BHP’s study found that in licensed states, the number of disciplinary proceedings for NDs were generally equivalent with other medical providers. In some cases, they involved providers advertising themselves as NDs without the necessary credentials. Giardenelli said licensing would help prevent that by reserving the title for providers who graduated from an accredited program — a step she said would also help patients distinguish between NDs and traditional naturopaths.
The issue remains a significant point of contention between NDs and many licensed medical groups. Another frequent criticism is that licensure would enable NDs to treat children or patients with specialized needs — groups that require a different level of care than healthy adults. The Virginia chapter of the American Academy of Pediatrics testified against licensing on the same grounds, calling training for NDs “considerably less rigorous than the training for pediatricians in allopathic and osteopathic medicine.”
“We are concerned that children would instead be taken by their parents to naturopathic providers who are not trained to provide this care and potentially serious medical issues could be overlooked,” added Dr. Barbara Boardman, chair of the Virginia AAP’s advocacy committee.
But Hollon said the goal of responsible NDs is to work collaboratively with other providers, including referrals to specialists and emergency care if a patient came in with a serious condition.
“I would never work with a cancer patient who didn’t have an oncologist, for example,” she added. “It’s extremely unethical and irresponsible. Even if I was in a licensed state, it would be unethical because with oncologists — that is their specialty. They often know about drug trials that are available that I don’t know about.”
‘I think there is a lot of room for providers like us to come in and serve as these frontline practitioners’
Many NDs worry that misinformation, including a tendency to pit naturopathic practitioners against doctors and other conventional providers, is one of the biggest barriers to state regulation. In a letter ordering the licensure study, Sen. Louise Lucas, D-Portsmouth — the chamber’s president pro tempore — pointed to the “confused information related to the stance of NDs on certain care health care practices.”
“One particularly relevant and concrete example: a [Department of Health Professions] representative mistakenly mentioned in one of our conversations after committee that medically trained NDs have an ‘anti-vaccination standpoint,’” she wrote, “which is inaccurate as in states where vaccines are included in their scope of practice, NDs are administering them as outlined and in keeping with basic healthcare practices.”
And while many of Virginia’s biggest medical groups are united in their opposition to licensure, the same view isn’t held universally. More than a dozen licensed providers, including cardiologists, registered nurses, pharmacists and physical therapists, also testified in favor of licensure for NDs. Dr. Cliff Morris, a cardiologist based in Chester, said he had worked collaboratively with them for more than 10 years and been impressed not only by the amount of time NDs devoted to each patient, but the preventive health services they were able to provide.
“They treat and see the entire person holistically,” he said, adding that “more specifically, I wish that I had received instruction in therapeutic nutritional counseling during my conventional medical training, but it was not in my curriculum.
Like many NDs in Virginia, Morris also said licensing the industry could help address the “social and economic burden” in communities with shortages of primary care providers — a common thread in testimony from patients and other practitioners. More than a dozen counties across Virginia are labeled as “health professional shortage areas” in primary care, with some of the most acute need among low-income communities in rural counties such as Northampton on the Eastern Shore and Tazewell in the far southwestern corner of the state.
Giardenelli pointed to Oregon, where naturopathic doctors are licensed as primary care practitioners and covered by most major insurance plans. While not every ND wants to practice primary medicine, even the AMA acknowledged that some naturopathic programs studied important and multidisciplinary topics such as the effect of diet on managing blood sugar levels — an important aspect of preventive care.
“We focus a lot on prevention and spend a lot of time on individual visits, so I think our skill set is more suited to things like chronic illness,” Rodriguez said. “But honestly, with the way the health care system is headed, as we get more and more licensed and as the shortage of primary care doctors continues to grow, I think there is a lot of room for providers like us to come in and serve as these frontline practitioners.”
Of course, it will largely depend on whether Virginia ends up adopting licensure for NDs — and how the state defines their scope of practice. Some states, like Rhode Island, license the industry but specifically stipulate that NDs are not recognized as primary care providers and are “not responsible for the overall medical care of any patient,” according to the BHP study. Medicare and many state insurance plans still don’t cover naturopathic medicine, though that could change if providers became more ubiquitous across Virginia.
Rasoul’s original bill, after several committee amendments, would have precluded NDs in Virginia from practicing obstetrics or osteopathy — a field reserved for fully licensed doctors, or DOs, whose treatments sometimes involve musculoskeletal manipulation to treat injuries or illnesses. But it would have opened the door for them to perform physical exams, order labs, and prescribe supplements and other non-prescription drugs.
It’s still not clear whether lawmakers will push for the same scope of practice in the 2021 session. After the full Board of Health Professions defeated licensure in August, several NDs suggested they might opt for a more pared-down approach, which could include allowing them to practice under a collaborating agreement with a licensed physician — similar to nurse practitioners in Virginia with less than five years of clinical experience.
“I anticipate given what’s happened in other states, it will probably be a gradual licensure,” Hollon said. “And I think that’s a safe way to prove oneself and prove one’s profession.” But Rasoul also tied the COVID-19 pandemic — and his own experience with the virus — to the role that NDs could play within Virginia’s medical system.
“My body is still recovering,” he said. “And I wish there was more of a proliferation of naturopathic doctors who could sit here and talk to me about how I can manage the inflammation, make sure I am rebuilding my immune system, and focusing on that more holistic model.”
“At the time, we didn’t have much or any real medication to help,” he added. “So, COVID has taught us the need for expanding our horizons.”