Paging Dr. Alternative

State pushing naturopaths to fill shortage in primary care

By peter korn

The Portland Tribune, Apr 1, 2010, Updated May 7, 2010 (14 Reader comments)

L.E. BASKOW / TRIBUNE PHOTO

Jill Stanard, director of clinical operations at the National College of Natural Medicine in Portland, measures tinctures for dispensing at the clinic. The college offers graduate programs in classical Chinese medicine.

Peter Rapport lives in Prineville but saves his primary care visits for when he’s in Portland, attending to the antique store he owns here.

Given the current national shortage of primary care providers, which is especially dire in rural areas such as Prineville, Rapport’s need to travel for medical care is not as unusual as it once was.

But Rapport is not coming in from Prineville to see a medical doctor. Instead, he visits a practitioner he can’t find in Crook County – a naturopathic doctor (who also happens to be his ex-wife). In doing so, Rapport has joined a growing number of Oregonians who are choosing naturopathic doctors for their primary care, a move encouraged by state officials, but decried by some in health care as a potentially dangerous policy.

Oregon is naturopathic heaven. Home to the oldest naturopathic school in the country – the National College of Natural Medicine – the state has about 870 licensed naturopaths, and many more practicing naturopaths on a per-capita basis than any other state in the country (see chart).

Throughout the nation, the idea of naturopaths serving as primary care providers would draw looks of astonishment. Only 15 states license naturopaths, which means that in 35 states naturopaths can’t legally practice primary care, and are limited to providing alternative care.

Only two other states – Arizona and Washington – are on a par with Oregon in allowing naturopaths to prescribe drugs. The ability to prescribe pharmaceuticals is seen by many as instrumental to being able to provide complete primary care.

On Jan. 1, a new state law granted Oregon naturopaths the authority to prescribe nearly all pharmaceuticals. Previously, naturopaths could not prescribe most synthetic drugs. Legislators passed the bill hoping it would lead to more naturopaths filling the need for primary care providers.

That makes sense to Rapport, who says he used to see a primary care physician in Portland, but stopped when he grew dissatisfied with the care he was receiving.

“He told me one time, when I complained how long I had to wait in the waiting room, that he had 12 minutes per patient,” Rapport says.

‘Take this medicine’

Rapport, 60, says he likes the naturopathic emphasis on natural remedies, and he especially likes the naturopath’s willingness to spend an hour or more with him to better understand how the rest of his life might be affecting his health.

“I go to a doctor and he says, ‘You’re overweight, you under-exercise, here take this (medicine),’ and he leaves the room,” Rapport says.

However, Northwest Portland physician Mark Crislip is more concerned about a naturopath saying, “Here, take this.”

An infectious disease specialist, Crislip thinks allowing naturopaths to prescribe virtually all drugs is a horrible idea. He says in medical school he had an extensive education in pharmacology and microbiology, and on every rotation during his residency he learned about drugs related to different specialties.

Crislip points to studies showing that prescribing mistakes, even among MDs, are among the most common and costly of medical errors. Anyone prescribing drugs, he says, needs to understand the possible side effects and interactions with other therapies. Naturopaths, he says, don’t receive enough education to have that depth of understanding.

“Things are always more complex than you think they are,” Crislip says.

But Crislip is even more alarmed by the move to have naturopaths serve as primary care providers. He’s afraid they might do more harm than good if they fail to properly diagnose patients with serious diseases, or if they treat them with alternative remedies when conventional medicines or therapies are what’s needed. He’s concerned that some naturopaths decry the use of childhood vaccines, and rely on alternative therapies – such as chelation for autistic children – that he believes are not supported by medical science.

“To my mind, it’s like if we had a shortage of pilots,” Crislip says of the lack of primary care providers. “Then we’d hire people who practice levitation? Their (naturopaths) primary curriculum is based on magic.”

Not all MDs agree with Crislip. Anne Nedrow, an internist at Oregon Health & Science University’s Center for Women’s Health, supports naturopaths taking on the primary care provider gap.

“I don’t think there will be any doubt that we will need them,” Nedrow says.

Nedrow says the naturopaths she has worked with showed an understanding of anatomy, physiology and chemistry similar to that of many MDs. The difference, she says, is “more of a culture of how you put it into practice.”

Nedrow says acceptance of naturopaths as primary care providers will grow as the primary care MD shortage becomes more acute, and also as baby boomers yield middle age to a younger generation more attuned to alternative medicine.

“The baby boomers have this fairly rigid idea of how they want to get their medical care,” Nedrow says. “The Generation Xers don’t.”

TRIBUNE PHOTO: L.E. BASKOW • Naturopath Rebecca Asmar meets with patient Diana Meyer during a visit at the Bambu Clinic in Southwest Portland. Asmar provides primary care to many of her patients.

Philosophical decision

While some might see naturopath primary care providers as moving in on the turf of MDs, a number of naturopaths say that’s the last thing they want to do. Many, in fact, say practicing like an MD is antithetical to why they became naturopathic doctors in the first place.

“MDs have a pretty clear philosophy that primary care itself (involves) managing the patient’s drug portfolio,” says Rebecca Asmar, naturopath and owner of the downtown Portland Bambu Clinic. “I have no interest in doing that.”

Despite the new prescribing powers given naturopaths, Asmar, who sees many primary care patients, would rather find other solutions more compatible with traditional naturopathy. If medications are needed, she refers her patients to MDs.

“We don’t have to give a pill to have an impact on a patient,” Asmar says.

But traditional naturopathy takes time that many primary care MDs simply don’t have, because insurers won’t allow them to spend an hour with each patient. Like many naturopaths, Asmar will not bill insurance for her patients. She recognizes a “cash only” policy limits her clientele, but she says it’s the only way she can practice the way she wants.

“It’s not only a financial decision, it’s also a philosophical decision,” she says.

Even the limited number of insurers that cover naturopathic primary care won’t pay for all the natural remedies naturopaths depend on, Asmar says.

Scott Ekblad, director of the Oregon Office of Rural Health Care, says that lack of insurance coverage for naturopathic care is one of the major hurdles keeping naturopaths from providing primary care where the need is greatest – in rural areas of the state.

Medicare doesn’t reimburse for naturopathic care, he says, and many rural communities have a high percentage of Medicare patients.

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