Proposed amendments to the Naturopathic Physicians Regulation

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Over the past two weeks the BCMA has had the opportunity to review the proposed regulation and consult with a number of BC physicians. This review and consultation have informed and reaffirmed our concerns. We heard from hundreds of physicians from across the province, representing the breadth of the various BCMA sections including Oncology, Psychiatry, Immunology and Allergy, Paediatrics, Emergency Medicine, General Practice and Diagnostic and Laboratory Medicine. They identified many significant issues that warrant further examination by government. I cannot overstate the concern the BCMA membership has raised regarding the scope of these changes and the resulting negative impacts on patient care quality and safety.

 

The BCMA recognizes the commitment government made in its 2008 Speech from the Throne regarding Naturopaths. However, the safety of British Columbians must supersede the apparent rush to meet that commitment. As well the scope of the proposed changes exceeds was indicated in the Speech. Relative to changes in other health professions, government has chosen to allow naturopaths to extend their scope of practice far beyond their current scope and beyond what exists in any other jurisdiction in Canada.

 

Given the extent of the proposed changes, the lack of evidence provided by government for these changes and the risks to patient care quality and safety, the physicians of British Columbia are gravely concerned and cannot support the proposed expansion of the scope of activities for naturopaths. Therefore the BCMA makes the following urgent recommendation:

That the Ministry of Health postpone the approval of these regulations until such time as these significant issues can be addressed through a process that does due diligence and ensures the safety of British Columbians.

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Our concerns can be summarized into following six areas:

1. Process for stakeholder feedback

2. Adequacy of Training and Credentialing Standards

3. Efficacy and safety of the naturopathic approach

4. Proposed Restricted Activities

5. Use of “doctor”, “physician” and “diagnosis”

6. Conflict of interest of naturopaths and of government

 

1. Process for stakeholder feedback

Changes to the scope of practice in health care need to occur with due diligence in order to ensure that the regulated professional is competent to provide certain services in a safe and effective manner in keeping with established standards of care. This involves consideration of their knowledge base, an assessment of benefit versus risk of harm for the public and a review of education, training and credentialing standards. This process does not appear to have been followed here. Unlike previous scope discussions (e.g. the Health Professions Council (HPC) process in the 1990’s) and despite our requests to Ministry staff, no supporting evidence or background documentation was provided for any of the proposed changes to these regulations.

 

As well, given the extent and magnitude of the proposed changes, it is surprising that government posted the consultation request on December 12th, 2008 with no prior notice and an expected deadline for public comment by January 12th, 2009. Providing 30 days for input that included Christmas holidays is not a meaningful period of time for considerate feedback.

 

As you know, our association has shown its willingness to work co-operatively with government and other health care providers to ensure that the best interests of patients are upheld. Recently, in the scope of practice for the pharmacists review, we demonstrated the need to modify the proposed regulations in order to ensure patient care quality and safety, leading to the changes supported by government, the College of Pharmacists and the College of Physicians and Surgeons of BC, as introduced on January 1st, 2009.

 

This was a successful consultative process that addressed complex issues. We suggest that this provides model for how to change scope of practice for other health care professionals. It meets the dual requirements of ensuring protection of the public and enhancing British Columbians’ access to competent healthcare services.

 

2. Adequacy of Training

The BCMA has a track record of successful collaboration with government to achieve our shared objectives of improving health care access and quality. We share the objective of providing the citizens of BC with access to health practitioners with adequate training who are able to offer assessment, advice, and services supported by scientific knowledge.

 

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Examination of the naturopathic training and credentialing reveals serious concerns in regards to the validity of claims of meeting the standards expected from BC physicians. Beyond the statements of their Association and College, there is no evidence that naturopaths have sufficient training to provide the proposed expanded scope of services in keeping with established safety and quality standards.

 

Amongst the many examples of that, the only school of naturopathy in BC – the Boucher Institute of Naturopathic Medicine - received its first accreditation last month, December 2008, from a US based naturopathic regulator, in spite of having operated since 2001 and graduated students who have been licensed to practice in BC since that time.

 

In fact, nothing of significance has changed in regards to the naturopathic training and credentialing since the 2001 HPC review of the naturopathic scope of practice1. At the time the HPC stated that:

 

the wish to have an expanded scope of practice must be substantiated in order to be accepted, the there was sufficient evidence that negated the position of the Association of Naturopathic Physicians of British Columbia, (which became the College of Naturopaths of British Columbia) that medical practitioners and naturopathic physicians receive the same training,

 

“The clinical training that naturopathic physicians receive in the four-year curriculum is insufficient for anyone to become competent in the great number of areas which the College wishes to have included in the scope of practice.”

 

Naturopaths did not and still do not meet the standards required to provide British Columbians with primary medical care services. At the time, the HPC recommended that their scope of practice be established as:

 

“The practice of naturopathy is the prevention, diagnosis and treatment of diseases, disorders or conditions of an individual through the use of educational and natural therapies or therapeutics to support and stimulate inherent self-healing processes.”

 

3. Efficacy and safety of the naturopathic approach What is at issue as well is the evaluation of the efficacy and safety of the naturopathic approach itself. There is harm in allowing patients to trust and spend money on natural treatments that have not been rigorously evaluated yet claim significant health benefits that may also have significant risks for dubious benefits

 

The BCMA highlights two specific areas of concerns related to immunizations and cancer care that emerged multiple times during the consultation process with BC physicians.

 

1 Health Professions Council’s Post-hearing update of preliminary report: Naturopathic physicians, March 2001 – available at http://www.health.gov.bc.ca/leg/hpc/review/part-i/update-naturopath.html

 

Immunizations

The Section of Paediatrics has numerous reports of parents of children who refused immunizations based on discussions with naturopaths. Immunizations are one of the greatest health care successes of the 20th century, one of the foundations of public health in our province and it is clear that they are not supported by a number of naturopaths.

 

The BCMA is deeply concerned regarding public statements repeatedly made by the Naturopaths regarding immunizations. It is concerning that it is the policy of the BC Naturopathic Association to neither advocate for nor against vaccinations, leaving its members (including some that teach at the BC based Boucher Institute of Naturopathic Medicine) to provide personalized responses to patient queries on the web, including references to this being a difficult and controversial personal decision and that many experts agree that vaccination is not desirable. This is unacceptable and poses a grave public health risk.

 

Cancer Treatment

The BCMA has also heard great concerns raised by BC physicians working in cancer treatment. A number of naturopaths have discouraged patients from continuing or pursuing appropriate necessary oncologic therapy in favour of unproven highly suspect alternative therapies to the detriment of the patient. The BCMA would appreciate a strong statement from government condemning this practice.

 

In addition, medicine as a self-regulating profession constantly self-assesses and removes harmful or unbeneficial practices. A similar standard does not exist within naturopathy and other alternative health approaches. We call for a BC based arms length body to evaluate the “natural” assessments and treatments that alternative care providers use in BC. There needs to be an impartial review of the indications and contraindications as well as the required education and training to ensure that all alternative approaches meet the standard of “not allowed until proven safe and effective”.

 

4. Proposed Restricted Activities

Further clarification is required on a number of the definitions of restricted activities as we have identified in our submission on the overall definitions of restricted activities. Specific to the proposed regulations on naturopaths, the BCMA provides the following comments:

 

Restricted activities - Minor surgery 5 (1) ( (i) & (ii): perform a procedure on tissue below the dermis or below the surface of a mucous membrane

 

Section 6 © of the current Naturopathic physician regulations state “No registrant may practice surgery.” The proposed changes would expand that to allow minor surgery. The definition of what is proposed is unclear. As well the definition of minor surgery includes mention of “material risk to life” which is ambiguous and use of the term “superficial anatomical structures” which would normally mean within the dermis – yet this section includes the areas “below the dermis”.

 

Based upon our review naturopaths do not have sufficient training and experience to independently perform the wide range of procedures that this definition might encompass. Significant clarifications and limitations are required.

 

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Restricted activities – movement of a joint 5 (1) ©

This type of restricted activity encompasses significant risks and is being monitored for patient safety. Chiropractors have to undergo significant training to perform spinal manipulation and it is difficult to see how naturopaths can acquire the training for that in addition to all the other training that they claim to get in the four year curriculum.

 

The HPC concluded in 2001 that naturopaths are not adequately trained in this area as there was evidence that the alleged 200 hours of training to understand and practice manipulation is actually spent on other courses. There is no evidence that that has changed since.

 

Restricted activities – Injections 5 (1) (d) (i)

It is unclear by this section whether these injections are to include intra-articular, intrathecal injections, or contrast injections. It assumed the proposed regulation is to include them all that would not be in keeping with the competency standards.

 

Restricted activities – Instrument use 5 (1) (e)

This definition is unclear. Based upon our review naturopaths do not have sufficient training to perform the wide range of procedures that this definition might encompass. Significant clarification and limits are required.

 

Restricted activities –Use of u/s, electricity and x-rays 5 (1) (g)

This definition is unclear. Based upon our review naturopaths do not have sufficient training to perform the wide range of procedures that this definition might encompass nor is there indication for anyone other than a trained medical specialist or delegated person to be authorized to conduct these procedures. The risk of harm either during the procedure or due to the incorrect interpretation are significant and this area of practice must be restricted to competent practioners.

 

Restricted activities –Prescriptions 5 (1) (i)

The BCMA believes that government must seriously reconsider the granting of prescribing of Schedule I and II medications and the broad scope of testing proposed to be granted in these regulations. Despite claims to the contrary, naturopaths do not have sufficient pharmacotherapy training to be able to prescribe and/or manage medications. There is no evidence that anything has substantially changed since the 2001 conclusions of the HPC on that matter:

 

“The Council is not satisfied that naturopathic physicians are trained and educated to use the proposed Schedule 1 substances nor is it satisfied that the use of these substances is related to the practices of naturopathic medicine.”

 

The focus of naturopaths should remain on the natural substances that are at the core of the foundational beliefs of that profession.

 

6 Restricted activities –Allergies 5 (1) (k) and (l)

Perhaps more than any other area this proposal caused the most serious concerns among our members. This section lead to the incorrect interpretation that limitations on method only apply in the less risky situation of an individual who has no known previous anaphylactic reaction, but that any method is acceptable if the individual has had a previous anaphylactic reaction.

 

It is well established that a significant risk of injury and death can occur in the setting of allergy testing, even with individuals who have no known previous anaphylactic reaction. Re-exposing someone who has known reaction in the past to the same allergen is extremely dangerous unless done by a trained and experienced practitioner in controlled circumstances. Including this activity in the list of restricted activity is unadvisable and we recommend the removal of items (k) and (l).

 

5. Use of “doctor”, “physician” and “diagnosis”

The proposed regulation includes a change in policy that would permit naturopaths the use of the titles “doctor” and “physician” without a qualifier. Without such a qualifier by any profession, there is a potential for the public to be confused about the training and qualifications of the person providing care.

 

This goes contrary to the Ministry’s position adopted from the Health Professions Council in the scope of practice review portion of its “Safe Choices” report:

 

“Reserved titles afford a means for consumers to identify the different types of health care providers, to distinguish the qualified from the unqualified and to differentiate those practitioners who are regulated from those who are not. Titles must adequately serve the public in describing the practitioner and the services being provided and must distinguish the practitioner from others performing services outside the jurisdiction of the regulatory body.”

 

The commonly accepted interpretation of “doctor” or “physician” within a clinical setting is for someone with a medical degree. This is recognized in the legislation across Canada (see attached summary compiled by the Canadian Medical Association). It appears BC would become the only province in Canada permitting such broad use of the title. The BCMA strongly recommends that the titles of “doctor” and “physician” without qualifiers must be reserved for registrants of the College of Physicians and Surgeons of BC.

 

Another concern is the replacement of “naturopathic assessment” with “diagnosis” within the regulation. Diagnosis refers to a specific process within conventional medicine - i.e. what is included in the International Classification of Diseases (ICD-10) published by the World Health Organization (WHO) and the classification system of the American Psychiatric Association (APA) - the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

 

These are standard diagnostic systems understood and used by a wide range of health professions (pharmacists, nurse practitioners, nurses etc). Based on the established standards, naturopaths do not possess the competence required to conduct a medical assessment and make ICD-10 and DSM-IV diagnoses. In fact, they use an entirely different set of terms and paradigms to assess patients, which would be more appropriately indentified as “naturopathic assessments”.

 

6. Conflict of interest of naturopaths and of government The BCMA has two concerns regarding the potential conflict of interest that naturopaths and government will be in as a results of these proposed changes:

 

1. Fiduciary relationship between naturopaths and patients

2. Creating preferred access based on ability to pay

 

Naturopaths will be in the unique position in British Columbia to not only prescribe insured medication and order tests, but to also sell products directly to patients and charge for their visits. In contrast, the College of Physicians and Surgeons of British Columbia has a strict policy regarding conflict of interest.

 

The BCMA believes that the College of Naturopaths should immediately enact a similar policy in support of the fiduciary relationship between naturopaths and patients. There needs to be regulation of the ethics of the relationship between naturopaths and companies making natural products, dietary supplements, homeopathies, and medicinal herbs.

 

The following is an excerpt from the College of Physicians and Surgeons of BC policy on Conflict of Interest https://www.cpsbc.ca/files/u6/Conflict-of-Interest.pdf as it applies to medical practitioners (physicians) in the province of BC:

 

“Physicians should consider first the interests and wellbeing of their patients and avoid any situation that is, or may be reasonably perceived as, a conflict of interest. In any situation where there is potential for conflict of interest, members should seek direction from the College. In certain cases, the College may grant approval on the basis of specific conditions and restrictions. The following guidelines should assist physicians who are concerned about conflict of interest in their medical practice.

 

1. Promoting and selling medical or non-medical products or supplies in the office Promoting and selling medical or non-medical products to patients for a profit is not only unethical, it constitutes a direct conflict of interest. Such transactions might reasonably be perceived as self-serving, and may compromise the fiduciary relationship between physicians and their patients.”

 

A second concern is that naturopaths will also be unique in terms of their ability to charge patients for the services they traditionally have provided while now having access to insured acts. We understand that details around payment for insured services are occurring at the Ministry of Health, but again this circumstance is unusual.

 

In effect this establishes a “second tier” for primary care services. Those British Columbians who can pay may obtain faster access to these services (i.e. prescription and lab services).

 

Certainly where other fees have been attempted by some groups in this area, the Ministry and Government have been quick to condemn them, so it is unclear why this situation is being considered as permissible. Therefore the BCMA is seeking some clarification in this matter to ensure that there is an equal application of policy in British Columbia.