Should Naturopaths Be Able to Perform Complex Spinal Procedures?
I’ve covered this issue a few times on this blog. We have naturopaths with limited medical training who are performing complex interventional spine and surgical procedures. As I have reviewed their practice acts, IMHO many are violating these acts, but the medical boards that could stop this are asleep at the wheel. Let’s dig in.
What is a Naturopath?
First, I love the fact that naturopaths are trained to offer natural alternatives to traditional prescription medications. My wife, son, and daughter have seen a local naturopath. However, I would never ask that naturopath to inject my spine nor would I agree to train that individual in spinal injections. Why?
A naturopath is not the same thing as the physician down the street that went to four years of college, 4 years of medical school, and anywhere from 3-7 years of post-medical school training in residency and fellowship. This is a great discussion written by a naturopath who eventually got a Ph.D. about the difference in training between naturopaths and MD/DO physicians:
“Naturopathic students are not trained in medical standards of care…”
“Clinical training is mandated by the CNME to be no less than 850 hours of direct patient care. From my clinical training handbook at Bastyr, I discovered this benchmark is attainable only through accounting tricks. For example, time counted when students reviewed a case with peers or when we observed advanced students perform physical exams.”
Suffice it to say that even the best-trained naturopaths have only a fraction of the training of the average physician specialist. In addition, that training is in a well care setting, meaning that unlike being trained in a large university medical center, naturopaths get very little training in how to handle really sick patients or even how to detect when someone is heading that direction.
A National Problem
First, before I get into discussing any specific naturopath as an example, I have found violations of naturopathic practice acts all over the country. In addition, this issue isn’t limited to naturopaths. For example, we have at least two local chiropractors who are performing blind spinal injections which is a violation of their practice acts. I have found acupuncturists doing the same.
Second, why is this happening? One answer to that question, as you’ll see, is weak or complicit alternative medicine boards. The good news is that in the example above, the Colorado chiropractic board will take action, so they are the exception. The bad news is that most alternative health boards want to expand their practice acts, which is often not something they can achieve legislatively, so allowing alternative practitioners to practice medicine beyond the scope of their practice act is often an easy way to initiate change without hiring lobbyists.
Third, another answer to why this happens is weak medical boards or local medical practitioners who are afraid to speak out. As you’ll see below, the Utah medical board has had a few opportunities to get involved in one case but has so far declined to do so. In addition, medical practitioners are often fearful because they don’t want to get sued. For example, in the naturopath example I give below, Harry Adelson sued me when I dared give my opinion that what he was doing wasn’t up to snuff or covered by his practice act. The good news was that the judge threw out the case with prejudice in the first round because I and everyone else have first amendment rights to hold and express any opinion we wish. However, I can see why this threat makes many practitioners fearful to call out what they observe.
A Strong Statement from Brave Doctors
In 2019, about 20 interventional spine and regenerative procedural experts came together to produce a consensus statement on alternative medicine practitioners performing spinal and orthobiologic procedures. The signatories on that document included a who’s who of regenerative medicine with many of those physicians having academic appointments. They were all opposed to what is described here.
An Email from a Colleague
“I have a new patient who recently underwent liposuction and bone marrow aspiration with injections into cervical, thoracic, and caudal epidural; multilevel cervical facets and overlying ligaments/muscles; multilevel lumbosacral facets and overlying ligaments/muscles; L1-2 intradiscal; B shoudler, B hip, B knee and one great toe injections all using her “autologous stem cells.” Big procedure day, right? I definitely thought it was a lot of injections for one person for one day, but I’m most concerned by the fact that it was done by a NATUROPATH Harry Adelson…When I look him up, it appears he has a traveling practice… and is based in Utah but travels around (ie) Phoenix…Now Adelson is “training and certifying” other NDs in the techniques. THOSE people are setting up shop all over, including Scottsdale where I practice. Any thoughts?”
Practice Act Violations?
I have previously blogged on the concept that after my review and in my opinion, many naturopaths are violating their practice acts. What’s a “practice act”? That’s the state law that defines what each provider type can and can’t do based on training. For example, a physician practice act (MD/DO) authorizes just about any medical procedure. While a given physician may or may not have the training or get the hospital privileges to perform a certain procedure, the license and decades of training open up all possibilities to physicians.
Naturopaths usually have very restrictive practice acts. That means that they are usually limited to minor in-office procedures. These are the sorts of things that your family doctor would do in the office. So basically things like removing stitches or lancing a boil or removing an embedded splinter. In some practice acts, they are allowed to inject joints or tendons. However, I have found no naturopathic practice act that authorizes a naturopath to perform x-ray guided spinal injections or other procedures like liposuction or bone marrow aspiration. That makes sense, as your local family doctor would never do these things in their office.
Harry Adelson, ND
I have gotten many emails through the years from angry colleagues on Harry Adelson. They’re all are in the same general vein. How can the state of Utah allow a naturopath to perform procedures that ordinarily require physician subspecialist training? Why isn’t the Utah medical board getting involved?
Harry is a Naturopath in Park City, Utah. IMHO he’s performing spinal and other procedures without adequate training. While Harry asserts that he found physicians to train him to perform everything from x-ray guided disc injections to liposuction to bone marrow aspiration, in my opinion, the problem is that when performing these procedures, you need a basic medical education that was gained in a large university medical center. Why? For when the proverbial stuff hits the fan. Meaning, you need to be able to do things like resuscitating a patient if one of these procedures goes bad. Or recognizing a serious complication early when hours or days matter to reduce the chances of serious harm caused by the complication. You only learn that stuff in medical school in a medical center.
Let’s take injecting bone marrow concentrate in a knee. We have the world’s largest registry experience on that topic going back about 16 years. Because we have tens of thousands of cases tracked, we can do things like report rare complications like deep venous thrombosis (DVT or blood clot in the leg) caused by the procedure. While the good news is that these complications are very rare with BMC injection (1 in 550 for a DVT) versus about 30% with knee replacement (1 in 3), they do rarely happen. Is a naturopath going to be able to recognize this issue? Not IMHO based on their training. Will they know which tests to order? Will a local imaging center even accept the script to run the test? If the patient has a DVT they often need urgent IV or oral anticoagulation. However, a naturopath can’t write the prescription for these meds. If they don’t have a clear DVT but one is suspected, oral anticoagulants like Xarelto are in order, but again, a naturopath can’t write that script.
You see the conundrum here? The naturopath can’t really diagnose a DVT or start therapy, but the naturopath caused the complication by performing the procedure.
The Utah Naturopathic Act
Harry practices in Utah. That practice act allows for minor office procedures. In particular, based on my reading of the act and IMHO, nothing in the Act authorizes a surgical procedure like liposuction. Yet Harry routinely performs this procedure as shown in the email above. In addition, the act clearly states that “spinal anesthesia” is off-limits for a Utah naturopath. IMHO that means that deep spinal injections like injecting a disc are also off-limits. However, as you can see above, Harry does this as well.
A Medical Board Asleep at the Wheel?
Several colleagues have filed complaints with the Utah naturopathic board against Harry and gotten nowhere. I could expect that to happen given that the naturopathic board (on which he serves) would want to expand its practice act. That’s just typical of many alternative health boards I have observed.
However, complaints submitted to the Utah medical board should get somewhere as IMHO, Harry is practicing medicine without a medical license. However, the Utah board is asleep at the switch. Complaints there just cause the medical board to send it to the naturopathic board. Rinse and repeat-endless loop ahead.
I tried calling a physician on the Utah medical board to get his sense of what’s going on. What I was told was that naturopathic board complaints go to the naturopathic board, but if a complaint came to their board they would handle it appropriately. So not sure what to make of that response other than he did seem sympathetic to the argument that the naturopathic act did not authorize intradiscal injections under fluoroscopy. So far, what he told me would likely happen, hasn’t happened.
The upshot? I have blogged several times on this topic because IMHO this is a dangerous situation. Naturopaths do not have the training needed to perform these procedures safely. While anyone could be trained, the problem is what happens when the procedure doesn’t go as planned or you get a complication? Time will tell whether Utah or other medical boards get called out on this one.