AMA's 2006 Resolution #209 against Naturopathy and all Alt Health providers

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REPORT OF THE BOARD OF TRUSTEES

B of T Report 2 - I-06

Licensure of Naturopaths

Presented by: Cecil B. Wilson, MD, Chair

INTRODUCTION

At the 2006 American Medical Association (AMA) Annual Meeting, the House of

Delegates (HOD) adopted as amended Resolution 209 entitled “Licensure of

Naturopaths.†Resolution 209, introduced by the Florida Delegation, calls on

the

AMA to work through the Scope of Practice Partnership (SOPP) and interested

Federation partners to oppose the licensure of naturopaths. Resolution 209

further requires that the AMA report back to the HOD at the 2006 AMA Interim

Meeting.

Testimony before the Reference Committee was unanimous in support of

Resolution 209. The Reference Committee concurred with the testimony heard and

therefore recommended adoption as amended. The HOD voted to adopt the

resolution

as amended. This informational report responds to the resolution.

RELEVANT AMA POLICY

The AMA has extensive policy related to scope of practice issues, but it

lacks any policy directly related to naturopaths. A sampling of AMA policies

most relevant to Resolution 209 are as follows:

• D-35.996 – Scope of Practice Model Legislation (AMA Policy Database).

D-35.996 states that “[o]ur AMA Advocacy Resource Center will continue to

work

with state and specialty societies to draft model legislation that deals with

non-physician independent practitioners’ scope of practice, reflecting the

goal of ensuring that non-physician scope of practice is determined by

training, experience, and demonstrated competence; and our AMA will distribute

to

state medical and specialty societies the model legislation as a framework to

deal with questions regarding non-physician independent practitioners’ scope

of

practice. (Res. 923, I-03)â€

• H-160.949 – Practicing Medicine by Non-Physicians. H-160.949 states that

“

[o]ur AMA: (1) urges all people, including physicians and patients, to

consider the consequences of any health care plan that places any patient care

at

risk by substitution of a non-physician in the diagnosis, treatment,

education, direction and medical procedures where clear-cut documentation of

assured

quality has not been carried out, and where such alters the traditional

pattern of practice in which the physician directs and supervises the care

given;

(2) continues to work with constituent societies to educate the public

regarding the differences in the scopes of practice and education of physicians

and

non-physician health care workers; (3) continues to actively oppose

legislation allowing non-physician groups to engage in the practice of medicine

without physician (MD, DO) training or appropriate physician (MD, DO)

supervision;

(4) continues to encourage state medical societies to oppose state

legislation allowing non-physician groups to engage in the practice of medicine

without physician (MD, DO) training or appropriate physician (MD, DO)

supervision;

and (5) through legislative and regulatory efforts, vigorously support and

advocate for the requirement of appropriate physician supervision of

non-physician clinical staff in all areas of medicine. (Res. 317, I-94;

Modified by

Res. 501, A-97; Appended: Res. 321, I-98; Reaffirmation A-99; Appended: Res.

240, Reaffirmed: Res. 708 and Reaffirmation A-00; Reaffirmed: CME Rep. 1,

I-00)â€

• H-275.986 – Combat Legislation Authorizing Medical Acts by Unlicensed

Individuals. H-275.986 states that “[t]he AMA (1) opposes the enactment of

new

legislation which would authorize the independent practice of medicine by

individuals who are not licensed to practice medicine and surgery in all of its

branches; and (2) supports the enactment of amendments to restrict current

statutes which authorize the independent practice of medicine by individuals

who

are not licensed to practice medicine and surgery in all of its branches.

(Sub. Res. 21, I-84; Reaffirmed by CLRPD Rep. 3 - I-94; Reaffirmation A-97)â€

• H-405.969 – Definition of a Physician. H-405.969 states that “[t]he AMA

affirms that a physician is an individual who has received a " Doctor of

Medicine " or a " Doctor of Osteopathic Medicine " degree or an equivalent degree

following successful completion of a prescribed course of study from a school

of

medicine or osteopathic medicine. (CME Rep. 4-A-94; Reaffirmed by Sub. Res.

712, I-94; Reaffirmed and Modified: CME Rep. 2, A-04)â€

• H-405.976 – Definition of a Physician. H-405.976 states that “[t]he AMA

urges all physicians to insist on being identified as a physician and to sign

only those professional or medical documents identifying them as physicians.

The AMA will review and revise its own publications as necessary to conform

to the House of Delegates' policies on physician identification and physician

reference and will refrain from any definition of physicians as health care

providers. The AMA supports seeking immediate modification of the social

security laws to change the definition of a physician to conform to AMA policy.

The AMA will seek legislation prohibiting the use of the term " physician " as a

descriptor other than in the context of a medical doctor (MD) or doctor of

osteopathy (DO). (Res. 243, A-91; Reaffirmed BOT Rep. I-93-25; Reaffirmed Sub.

Res. 712, I-94; Res. 241, A-97)â€

• H-405.992 – “Doctor†as a Title. H-405.992 states that “[t]he AMA

encourages state medical societies to oppose any state legislation or

regulation

that might alter or limit the title " Doctor, " which persons holding the

academic degrees of Doctor of Medicine or Doctor of Osteopathy are entitled to

employ. (Res. 138, I-87; Reaffirmed: Sunset Report, I-97)â€

• H-480.964 – Alternative Medicine. H-480.964 states that the “[p]olicy

of

the AMA on alternative medicine is: (1) There is little evidence to confirm

the safety or efficacy of most alternative therapies. Much of the information

currently known about these therapies makes it clear that many have not been

shown to be efficacious. Well-designed, stringently controlled research

should be done to evaluate the efficacy of alternative therapies. (2)

Physicians

should routinely inquire about the use of alternative or unconventional

therapy by their patients, and educate themselves and their patients about the

state of scientific knowledge with regard to alternative therapy that may be

used

or contemplated. (3) Patients who choose alternative therapies should be

educated as to the hazards that might result from postponing or stopping

conventional medical treatment. (CSA Rep. 12, A-97; Reaffirmed: BOT Rep. 36,

A-02)â€

• H-480.973 - Unconventional Medical Care in the United States. H-480.973

states that “[o]ur AMA: (1) encourages the Office of Alternative Medicine of

the National Institutes of Health to determine by objective scientific

evaluation the efficacy and safety of practices and procedures of

unconventional

medicine; and encourages its members to become better informed regarding the

practices and techniques of alternative or unconventional medicine; and (2)

utilizes the National Institutes of Health’s National Center for

Complementary and

Alternative Medicine’s classification system of alternative medicine, " Major

Domains of Complementary and Alternative Medicine,: in order to promote

future discussion and research about the efficacy, safety, and use of

alternative

medicine. (BOT Rep. 15-A-94; Reaffirmed and Modified by Sub. Res. 514, I-95;

Appended: Res. 505, A-00)â€

• D-640.997 – Advocacy Training. D-640.997 states that “[o]ur AMA, in

collaboration with national medical specialty and state medical societies, will

develop programs to enhance physician advocacy skills relating to non-physician

legislative and regulatory scope of practice initiatives and quality of

patient care concerns. (Res. 612, A-00)â€

• E-3.01 – Nonscientific Practitioners. E-301 states that “t is

unethical to engage in or to aid and abet in treatment which has no scientific

basis

and is dangerous, is calculated to deceive the patient by giving false hope,

or which may cause the patient to delay in seeking proper care. Physicians

should also be mindful of state laws which prohibit a physician from aiding and

abetting an unlicensed person in the practice of medicine, aiding or

abetting a person with a limited license in providing services beyond the scope

of

his or her license, or undertaking the joint medical treatment of patients

under the foregoing circumstances. Physicians are otherwise free to accept or

decline to serve anyone who seeks their services, regardless of who has

recommended that the individual see the physician. (III, VI) Issued prior to

April

1977; Updated June 1994 and June 1996.â€

DISCUSSION

Background of The American Association of Naturopathic Physicians (AANP) is

the national professional association that claims to represent “licensed or

licensable naturopathic physicians who are graduates of four-year, residential

graduate programs.†AANP claims to have over 2000 members including

students, supporting and corporate members, who “collectively strive to

expand access

to naturopathic medicine nationwide.â€

The AANP identifies six “naturopathic medical schools†in North America

that are either “accredited or [are] a candidate for accreditation by an

agency

of the United States Department of Educationâ€: (1) Bastyr University,

Kenmore, WA; (2) Boucher Institute of Naturopathic Medicine, New Westminster,

British Columbia, Canada; (3) Canadian College of Naturopathic Medicine,

Toronto,

Ontario, Canada; (4) National College of Natural Medicine, Portland, OR; (5)

Southwest College of Naturopathic Medicine & Health Sciences, Tempe, AZ; and

(6) University of Bridgeport College of Naturopathic Medicine, Bridgeport, CT.

Five of these schools (the exception being Boucher Institute of Naturopathic

Medicine) are accredited by the Council of Naturopathic Medical Education

(CNME). The CNME is currently recognized by the U.S. Secretary of Education as

the national accrediting agency for programs leading to the Doctor of

Naturopathic Medicine (N.D. or N.M.D.) or Doctor of Naturopathy (N.D.) degree.

It is

notable that CNME lost its recognition as a national accrediting agency by

the U.S. Department of Education in 2001. It reapplied for recognition and, in

September 2003, was granted a two-year recognition by the U.S. Secretary of

Education. It was granted renewal in 2005 and its next scheduled review for

renewal of recognition is scheduled for spring 2008.

According to AANP, “[a] licensed naturopathic physician (N.D.) attends a

four-year graduate level naturopathic medical school and is educated in all of

the same basic sciences as an M.D. but also studies holistic and nontoxic

approaches to therapy with a strong emphasis on disease prevention and

optimizing

wellness. In addition to a standard medical curriculum, the naturopathic

physician is required to complete four years of training in clinical nutrition,

acupuncture, homeopathic medicine, botanical medicine, psychology, and

counseling (to encourage people to make lifestyle changes in support of their

personal health). A naturopathic physician takes rigorous professional board

exams

so that he or she may be licensed by a state or jurisdiction as a primary

care general practice physician.†(emphasis added) Moreover, the AANP, in a

position paper on scope of practice, adopted November 1, 1989, states the

following: “[n]aturopathic practice includes the following diagnostic and

treatment

modalities: utilization of all methods of clinical and laboratory diagnostic

testing including diagnostic radiology and other imaging techniques;

nutritional medicine, dietetics and therapeutic fasting; medicines of mineral,

animal and botanical origin; hygiene and public health measures; naturopathic

physical medicine, including naturopathic manipulative therapies; the use of

water, heat, cold, light, electricity, air, earth, electromagnetic and

mechanical

devices, ultrasound, and therapeutic exercise; homeopathy; acupuncture;

psychotherapy and counseling; minor surgery and naturopathic obstetrics:

(natural

childbirth). Naturopathic practice excludes major surgery and the use of

most synthetic drugs.â€

State Activity regarding Licensure and Regulation of Naturopaths. Twelve

states now license naturopaths (Alaska, Arizona, California, Connecticut,

Hawaii, Maine, Montana, New Hampshire, Oregon, Utah, Vermont, and Washington),

while two states allow for licensure limited to those individuals who qualify

under a grandfather clause (Florida and Virginia). In addition, three states

(Alabama, Kansas, and Minnesota) and the District of Columbia have opted to

regulate naturopaths, while two states (South Carolina and Tennessee) have made

it illegal for any person to practice naturopathy.

The 2006 legislative session was inundated with efforts by nonphysician

practitioners attempting to expand their scopes of practice. Naturopaths were

particularly active, with nine state legislatures grappling with either

licensure or expansions on existing statutorily or regulatorily defined scopes

of

practice (Florida, Hawaii, Illinois, Massachusetts, Minnesota, Missouri, New

York, Tennessee, and Virginia). Notably, no new legislation licensing or

expanding established scopes of practice of naturopaths was enacted this year.

The AMA’s Advocacy Resource Center (ARC) continues to monitor and track

naturopaths’ legislative and regulatory activities at the state level.

Moreover,

ARC staff will continue to collaborate and assist the state medical

associations and national medical specialty societies that request assistance

with

respect to the activities of the naturopaths.

AMA Activity since Adoption of Resolution 209 (A-06) 37

Resolution 209 asks that our AMA work through the SOPP and interested

Federation partners to oppose the licensure of naturopaths. Since the AMA’s

2006

Annual Meeting, the following has been accomplished pursuant to Resolution

209’

s resolve:

• The SOPP steering committee has reaffirmed its commitment to including

naturopaths in the study called for by Resolution 814 (I-05), entitled

“Limited

Licensure Health Care Provider Training and Certification Standards.†The AMA

and its staff recognize the urgency in completing this project and therefore

the analysis of naturopaths, as outlined in Resolution 814, is expected to

be completed in advance of the start of the 2007 legislative session.

• The SOPP steering committee has formed a small working group charged with

investigating the issues surrounding the licensure of naturopaths and

determining what additional advocacy resources are needed for state-level

advocacy.

• The ARC has scheduled a discussion on licensure of naturopaths at its 2006

State Advocacy Roundtable Meeting. This meeting is attended by government

affairs and lobbying staff of state medical associations and national medical

specialty societies, as well as the American Osteopathic Association. ARC

staff anticipates a strategic discussion on licensure of naturopaths. This

discussion will be very helpful to the AMA, SOPP, and Federation partners as we

move forward in developing necessary advocacy materials on the issue of scope

expansions and licensure of naturopaths.

CONCLUSION

The AMA will continue to play an active role as a convener within the

Federation with respect to scope of practice issues. Through the ARC, the AMA

will

continue to monitor the legislative and regulatory activity of naturopaths at

the state level, as well as assist the Federation as needed. The SOPP

steering committee will continue to be responsive to the resolve of Resolution

209,

by addressing naturopaths in the first tier of nonphysician practitioners

being studied pursuant to Resolution 814 (I-05) and by forming a working group

to discuss the issues surrounding licensure of naturopaths, as well as their

efforts to expand already existing state scopes of practice. Finally, the ARC

will continue to address these issues at its legislative conferences, in an

effort to ensure that patients continue to receive the highest quality of

care.

References for this report are available from the AMA Advocacy Resource

Center.

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