In a move that many see as a major step forward for the naturopathic profession nationwide, California governor Gray Davis signed a bill recognizing graduates of the nation’s 4-year graduate-level naturopathic medical schools as independent, licensable medical practitioners in the state of California.
SB 907, a bill that took years to craft, moved through the state’s legislature with little impediment and was signed into law by Gov. Davis on September 22, despite opposition from the California Medical Association.
The bill creates a framework for licensure of naturopathic doctors (NDs) as independent practitioners, establishes a state oversight bureau akin to other state medical boards, and defines the profession’s scope of practice, which includes limited prescribing rights and natural childbirth under the aegis of an MD or DO. The law takes effect on January 1, 2004, and the California Association of Naturopathic Physicians is hoping that the first licenses will be granted within a year. Passage of SB 907 makes California the 13th state to license NDs.
“We’re delighted. I think it is the best possible outcome from a very difficult negotiation process,” said Sally LaMont, ND, executive director of the California Association of Naturopathic Physicians (CANP). “Passage of SB 907 allows NDs to formally function as doctors, and to participate in public health programs, integrative healthcare teams, and research endeavors. It is a critical first step to including NDs in HMOs, insurance plans, and government health programs.”
Prior to SB 907, NDs in California could function as “naturopathic practitioners” under SB 577, the state’s health freedom act. But they were not recognized as doctors, not permitted to diagnose or treat disease, and prohibited from entering a patient’s body in any way (i.e., intravenous or intramuscular injections) or performing physical examinations. They also had to obtain informed consent from patients after stating that they are not physicans and not licensed.
“We practiced as ‘consultants,’ but we were not allowed to exercise the scope of practice in which we were trained. Further, there was no accountability,” explained Tara Levy, ND, CANP’s public affairs committee chair.
Ending a Medicolegal Limbo
Under SB 577, NDs practiced in a medicolegal limbo, added Dr. LaMont. “If we were practicing according to the full scope of our training, we were not just a-legal, we were frankly illegal. It was illegal for us to even use stethoscopes, order blood draws, and basic lab work.”
The new law clarifies the status of NDs as doctors able to make medical diagnoses, perform physical examinations, order lab tests, blood draws, and diagnostic images, and utilize the full spectrum of natural therapeutics, including nutrition, botanical medicines, homeopathics, and hormone therapies. They are also permitted to prescribe a limited number of drugs, under the aegis of MDs.
The law also creates a naturopathic bureau within the state’s Department of Consumer Affairs, comprised of 3 NDs, 3 MDs, and 3 members of the public. The bureau will administer licenses, establish rules and regulations, and take disciplinary actions when needed.
One of the strongest features of the licensure act is that it draws a distinction between NDs, who undergo 4 years of intensive medical training according to a standardized curriculum that shares much with conventional medical schools, and other natural medicine practitioners who call themselves “naturopaths,” but do not have the same level of training.
Under the new law, other practitioners may still use terms like “naturopath,” “naturopathic practitioner” or “traditional naturopath,” but only graduates of the 4-year schools may use the term “ND” and refer to themselves as “doctors.”
“Doctors” But Not “Physicians”
California NDs may not, however, legally call themselves “physicians.” This provision was at the insistence of the California Medical Association (CMA). The state’s Medical Practices Act defines the term “physician” as the exclusive province of MDs and DOs, and CMA’s Board of Trustees demanded that the new bill incorporate this principle. “Just as chiropractors, dentists, psychologists and doctors of oriental medicine may call themselves doctors but not physicians, we believe NDs should adhere to the same rules. We don’t want to confuse the public,” said Bryce Docherty, CMA’s associate director of public affairs.
CANP was willing to accommodate that stipulation, and made other concessions to CMA, including acceptance of a number of practice scope restrictions. CMA was opposed to NDs doing minor surgery, childbirth services, or using prescription medications in any form. The final bill reflects many of these concerns.
The practice scope defined under SB 907 is more limited than the current scope in other states like Oregon, Washington, and Arizona, where NDs are recognized as fully-fledged primary care physicians. The California law does not allow NDs to do any surgery requiring sutures or general/spinal anesthesia; with the exception of hormones, medical devices, and epinephrine, they may only prescribe under the oversight of an MD or DO; and may only do deliveries in collaboration with ob.gyns (though the ob.gyn need not be physically present during the procedure). To offer childbirth services, NDs must meet similar credentials as nurse midwives. Scope of practice provisions pertaining to office procedures, prescribing privileges and childbirth are subject to review and revision in 2 years.
CMA Sought Veto
Still, in the end, the CMA remained opposed to the bill. According to Mr. Docherty, the Association’s Board of Trustees asked the governor for a veto.
“The only thing CMA was willing to support was a licensure and title act that would clearly establish a regulatory body within the state to protect citizens treated by naturopathic doctors, and that would establish a class of ‘professional’ naturopaths meeting the high educational standards established by the bill.”
Mr. Docherty said CMA representatives visited Bastyr University in Washington state, arguably the best known of the 4-year naturopathic schools. “We were impressed with their program to the extent that we were comfortable with the idea of licensure and title, but at the end of the day, we were not convinced that there is enough biomedical science to support a lot of what is in naturopathic medicine, and to validate the scope of practice they were requesting. The scope under the bill which passed is still pretty broad for a profession that is so new.”
He stressed, however, that CMA is not inherently opposed to naturopathic medicine. “NDs do have a role to play, albeit a complementary one. We recognize that allopathic medicine is not the be-all, end-all. But we don’t want NDs to think that their profession is the be-all, end-all either.”
Rebecca Patchin, MD, an anesthesiologist/pain management specialist who serves as the chair of CMA’s Council on Legislation, was directly involved in negotiations with CANP. She explained that CMA’s opposition is rooted in a standing policy against recognition of new allied health professionals. “Our historical policy is that we oppose additional non-physician allied health professionals beyond those already recognized. There are many physicians in our membership, who, if asked, would not see the need to expand of the number of non-physician providers.”
Dr. Patchin was among the CMA delegates to visit Bastyr, and said she found “no inconsistencies between what we saw and what they claim in their manuals and books as the scope of their training.”
Though CMA remains opposed to the bill, Dr. Patchin said she knows of no CMA plan to introduce future legislation that would reverse or attenuate SB 907.
Redefining Professional “Turf”
CMA was not the only professional constituency with which California NDs had to negotiate. Dr. LaMont said the state’s chiropractors were deeply concerned about the extent to which NDs would be able to practice physical medicine modalities. Acupuncturists and oriental medicine practitioners sought to limit NDs’ use of these modalities. Psychologists were opposed to inclusion of psychotropic medicines in ND prescribing rights. Other practitioners who use the term “naturopath” were afraid they would be prohibited from practicing. All of these concerns are included in the final language of SB 907 (see sidebar).
Dr. LaMont recalls the negotiations as long, complex and sometimes contentious. “We were really caught in a crossfire. It was difficult, but in the end, I think we ended up with a very good bill.”
One point of near unanimous agreement between CANP and CMA is that the new law will facilitate collaborative practice between NDs and MDs.
“Absence of licensure was a real barrier from a liability standpoint. MDs were generally reluctant to bring unlicensed professionals into their offices. Licensure opens opportunities for MDs to have truly integrative ‘CAM’ specialists in their offices who are familiar with conventional medical terminology and differential diagnosis, but also knowledgeable about nutrition, botanical medicine, drug-herb and drug-nutrient interactions,” Dr. LaMont told Holistic Primary Care.
CMA’s Mr. Docherty agreed. SB 907, “encourages collaboration, and we do encourage that.”
The ultimate impact of the California bill remains to be seen. Currently there are less than 200 licensable NDs in the state, and fewer than 3,500 in the entire nation. But the numbers have been growing steadily in recent years, and Dr. LaMont predicted that California licensure will encourage an influx of NDs from neighboring states. She added that Bastyr University administrators are currently doing feasibility assessments in California’s major metropolitan areas with an eye toward opening a new California campus.
SB 907 does have national ramifications. California is a bellwether state for many health care trends, and SB 907 could serve as a template for licensure efforts in other states. NDs in Flordia, Idaho, North Carolina, New York, and Pennsylvania are already organizing and in some cases drafting proposals. One week after Gov. Davis signed California’s bill, NDs in Washington, DC, held a hearing on licensure, which, according to Karen Howard, executive director of the American Association of Naturopathic Physicians, has support of the DC Board of Medicine and the Department of Health.
Though it remains to be seen how it will all play out, Dr. LaMont told Holistic Primary Care that, “licensure of NDs in California should serve as a potent catalyst in transforming our disease management system into the true health care system it must become.”
