Licencing health professionals is one of the major ways in which healthcare is regulated. The primary goal of such regulation is to protect the public from fraud and quackery and to maintain high standards of practice and professionalism. But what happens when fringe practitioners, such as chiropractors or naturopaths, gain licensure?
Two recent incidents in Canada highlight the dilemma of regulating unscientific practitioners, and the menace this can potentially pose to the public. The first relates to the ability of naturopaths to call themselves “medically trained.” Scott Gavura wrote about this case in New Brunswick last week. Briefly, a naturopath claimed he went to “medical school” and was therefore medically trained. As Scott pointed out:
The College of Physicians and Surgeons of New Brunswick recently an investigation and found that 41 per cent of the province’s naturopaths were using restricted terms like “physician” and “medical practitioner” in contravention of New Brunswick’s Medical Act.
But what happened when a complaint was filed with the naturopathic board that regulates naturopaths? They decided the saying he went to “medical school” was not misleading because his naturopathic college was also listed on the website. This, of course, is nonsense. Anything that blurs the lines between real medical training and the pseudoscientific farce that naturopaths engage in is inherently misleading. The public, in fact, is highly confused about the true nature of naturopaths. I have had people on multiple occasions argue that naturopaths are legitimate because they can call themselves “doctor” and they get “medical training,” etc.
I don’t see how there is any other way to interpret this other than as a deliberate attempt to portray themselves as legitimate doctors, to position their practices as primary medical care – and it’s essentially working. But the deeper problem here is that this is allowed to happen largely because the regulation of naturopaths is largely in the hands of other naturopaths.
This is the bait and switch that often happens when fringe practitioners push for licensure. They argue to politicians that it will regulate the profession, and thereby protect the public and raise standards. That is what regulation is supposed to do. But once they have licensure, the foxes are put in charge of the hen house. Regulation is used to protect the profession and practitioners – not the public.
Let’s turn to the second case, also in Canada, this time in Ontario and dealing with chiropractors. As reported in The Globe and Mail, regarding recent criticisms of how chiropractic is regulated:
The College of Chiropractors of Ontario (CCO), they contend, is putting members’ interests above those of the public and has allowed assertions, including the ability to prevent cancer, to go unchecked. Some believe that, for the sake of public health, CCO council members who hold “vitalistic” views should resign.
The criticism stems from a case in which an Ontario chiropractor, Brian Nantais, claimed in the advertising for a workshop, that nerve blockage:
weakens the body, weakens the cells, weakens the immune system, weakens the very things that fight cancer.
The obvious implication here is that chiropractic manipulation of the spine can help treat cancer, which is not science-based on any level. To make such a claim is nothing short of fraud. The CCO heard the complaint and determined that all that needed to be done was for Nantais to add the word “may” in front of these claims, because they found the claims plausible, if unproven.
Again – the deeper problem here is that there are four chiropractors on the CCO board who are vitalists, like Nantais. Chiropractic has its origins in the vitalistic notion that a life force (called innate) travels through through the nerves of the body, and blockages of nerves can impeded the flow of innate and cause illness. Unblocking this vital force unleashing unlimited healing power. A century of subsequent medical science has determined that such claims are without any basis.
Nantais continues making such claims. For example, he claims to be able to :
An allergy is an adverse immune system raction [sic) to a substance that is normally considered harmless to the human body. Dr. Nantais’s approach is to evaluate your spine & Nervous System to determine if you have nerve interference. If nerve supply is diminished, the goal of Dr. Nantais is to restore your body to heal at 100%, and therefore decrease your allergy symptoms naturally. NO DRUGS!!!
And of course, if you believe this vitalistic premise, you can put any disease or illness in place of allergies and make the same claims.
The end result of licencing practitioners who are not science-based is that fraud and pseudoscience now has the imprimatur of legitimate medicine, the public is largely confused about the true status of these practitioners, and the regulatory process is used to promote rather than prevent harm to the public.
There are solutions, however. The “nuclear option” would be to simply end licensure of fringe professions that are not adequately based in reality. This is the option I advocate, and is the only true solution that adequately protects the public and promotes high standards of health care. But I also recognize that realizing this option is politically difficult.
It is also true that within chiropractic at least there are practitioners who at least advocate for evidence-based practice, and themselves are critical of vitalistic and non-evidence-based chiropractors. Among them is :
The early November story prompted what Dr. Ammendolia, an assistant professor at the University of Toronto and a chiropractor himself, called a “huge outcry in the profession that something needs to give and something needs to change.”
Both Dr. Ammendolia and Professor Joe Schwarcz, director of McGill University’s Office for Science and Society, have suggested what I also have advocated – that these professions should be regulated by an outside body that can hold them to objective science-based standards. This would mean disciplining practitioners who harm or deceive patients, and setting evidence- based standards of practice (not just claiming to for promotional purposes). It also allows for clear policing of the scope of practice.
Having objective science-based regulation would go a long way to mitigating the harm done by licensing fringe practitioners, and could force them to eliminate at least their most harmful practices. This should also include regulating what claims they are allowed to make, and this brings us to the second measure – making clear distinctions between real medical practitioners and “alternative” practitioners.
We already have a standard for medical training and practicing as a primary care physician. There is no reason to establish separate, and far weaker, standards. All this does is confuse the public and allow charlatans to pretend to be doctors.
You are a medical doctor if you have an MD. No other health practitioner should be allowed to call themselves a “doctor” or claim to have medical training, or claim to provide primary care. (As an aside, there are already regulations in place for nurse practitioners and similar allied professions, so that is a separate issue.)
Further, regulation should prevent scope of practice creep. Practitioners are tireless at lobbying for a greater scope of practice, like the ability to prescribe drugs or be reimbursed for annual physicals or general health maintenance. Finally, they should not be allowed to claim to treat or cure diseases.
Together these regulations would allow these professions to continue to exist, but protect the public to some degree against deception and fraudulent practice. Chiropractors can still provide symptomatic treatment for uncomplicated acute lower back strain – the only indication for which there is adequate evidence for efficacy. I’m honestly not sure what would be left if all the pseudoscience was stripped from naturopathic practice.
One thing is clear – at present these non-medical professions are generally poorly regulated, putting the government in the position of sanctioning and promoting health fraud and collaborating in making the public more vulnerable to deception and exploitation. This is the exact opposite of what health regulatory bodies should do. This needs to be fixed.