Paging Dr. Alternative

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Peter Rapport lives in Prineville but saves his primary care visits for when he’s in Portland, attending to the antique store he owns here.

Given the current national shortage of primary care providers, which is especially dire in rural areas such as Prineville, Rapport’s need to travel for medical care is not as unusual as it once was.

But Rapport is not coming in from Prineville to see a medical doctor. Instead, he visits a practitioner he can’t find in Crook County – a naturopathic doctor (who also happens to be his ex-wife). In doing so, Rapport has joined a growing number of Oregonians who are choosing naturopathic doctors for their primary care, a move encouraged by state officials, but decried by some in health care as a potentially dangerous policy.

Oregon is naturopathic heaven. Home to the oldest naturopathic school in the country – the National College of Natural Medicine – the state has about 870 licensed naturopaths, and many more practicing naturopaths on a per-capita basis than any other state in the country (see chart).

Throughout the nation, the idea of naturopaths serving as primary care providers would draw looks of astonishment. Only 15 states license naturopaths, which means that in 35 states naturopaths can’t legally practice primary care, and are limited to providing alternative care.

Only two other states – Arizona and Washington – are on a par with Oregon in allowing naturopaths to prescribe drugs. The ability to prescribe pharmaceuticals is seen by many as instrumental to being able to provide complete primary care.

On Jan. 1, a new state law granted Oregon naturopaths the authority to prescribe nearly all pharmaceuticals. Previously, naturopaths could not prescribe most synthetic drugs. Legislators passed the bill hoping it would lead to more naturopaths filling the need for primary care providers.

That makes sense to Rapport, who says he used to see a primary care physician in Portland, but stopped when he grew dissatisfied with the care he was receiving.

“He told me one time, when I complained how long I had to wait in the waiting room, that he had 12 minutes per patient,” Rapport says.

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‘Take this medicine’

Rapport, 60, says he likes the naturopathic emphasis on natural remedies, and he especially likes the naturopath’s willingness to spend an hour or more with him to better understand how the rest of his life might be affecting his health.

“I go to a doctor and he says, ‘You’re overweight, you under-exercise, here take this (medicine),’ and he leaves the room,” Rapport says.

However, Northwest Portland physician Mark Crislip is more concerned about a naturopath saying, “Here, take this.”

An infectious disease specialist, Crislip thinks allowing naturopaths to prescribe virtually all drugs is a horrible idea. He says in medical school he had an extensive education in pharmacology and microbiology, and on every rotation during his residency he learned about drugs related to different specialties.

Crislip points to studies showing that prescribing mistakes, even among MDs, are among the most common and costly of medical errors. Anyone prescribing drugs, he says, needs to understand the possible side effects and interactions with other therapies. Naturopaths, he says, don’t receive enough education to have that depth of understanding.

“Things are always more complex than you think they are,” Crislip says.

But Crislip is even more alarmed by the move to have naturopaths serve as primary care providers. He’s afraid they might do more harm than good if they fail to properly diagnose patients with serious diseases, or if they treat them with alternative remedies when conventional medicines or therapies are what’s needed. He’s concerned that some naturopaths decry the use of childhood vaccines, and rely on alternative therapies – such as chelation for autistic children – that he believes are not supported by medical science.

“To my mind, it’s like if we had a shortage of pilots,” Crislip says of the lack of primary care providers. “Then we’d hire people who practice levitation? Their (naturopaths) primary curriculum is based on magic.”

Not all MDs agree with Crislip. Anne Nedrow, an internist at Oregon Health & Science University’s Center for Women’s Health, supports naturopaths taking on the primary care provider gap.

“I don’t think there will be any doubt that we will need them,” Nedrow says.

Nedrow says the naturopaths she has worked with showed an understanding of anatomy, physiology and chemistry similar to that of many MDs. The difference, she says, is “more of a culture of how you put it into practice.”

Nedrow says acceptance of naturopaths as primary care providers will grow as the primary care MD shortage becomes more acute, and also as baby boomers yield middle age to a younger generation more attuned to alternative medicine.

“The baby boomers have this fairly rigid idea of how they want to get their medical care,” Nedrow says. “The Generation Xers don’t.”

 

TRIBUNE PHOTO: L.E. BASKOW • Naturopath Rebecca Asmar meets with patient Diana Meyer during a visit at the Bambu Clinic in Southwest Portland. Asmar provides primary care to many of her patients.

 

Philosophical decision

While some might see naturopath primary care providers as moving in on the turf of MDs, a number of naturopaths say that’s the last thing they want to do. Many, in fact, say practicing like an MD is antithetical to why they became naturopathic doctors in the first place.

“MDs have a pretty clear philosophy that primary care itself (involves) managing the patient’s drug portfolio,” says Rebecca Asmar, naturopath and owner of the downtown Portland Bambu Clinic. “I have no interest in doing that.”

Despite the new prescribing powers given naturopaths, Asmar, who sees many primary care patients, would rather find other solutions more compatible with traditional naturopathy. If medications are needed, she refers her patients to MDs.

“We don’t have to give a pill to have an impact on a patient,” Asmar says.

But traditional naturopathy takes time that many primary care MDs simply don’t have, because insurers won’t allow them to spend an hour with each patient. Like many naturopaths, Asmar will not bill insurance for her patients. She recognizes a “cash only” policy limits her clientele, but she says it’s the only way she can practice the way she wants.

“It’s not only a financial decision, it’s also a philosophical decision,” she says.

Even the limited number of insurers that cover naturopathic primary care won’t pay for all the natural remedies naturopaths depend on, Asmar says.

Scott Ekblad, director of the Oregon Office of Rural Health Care, says that lack of insurance coverage for naturopathic care is one of the major hurdles keeping naturopaths from providing primary care where the need is greatest – in rural areas of the state.

Medicare doesn’t reimburse for naturopathic care, he says, and many rural communities have a high percentage of Medicare patients.

Another obstacle, Ekblad says, is that the health care providers in a rural area usually cover for each other on call or take rotations at the local hospital. Naturopaths generally need the support of the local MDs.

But Laura Farr, executive director of the Oregon Association of Naturopathic Physicians, says she knows of “several dozen” naturopaths providing primary care in rural Oregon communities, some even without acceptance by local MDs.

It’s hard, Farr says, but the economics can work – in Oregon.

“I think people have a pioneering side to them here and they have a tendency to buck conventional norms and to look for answers outside the box,” Farr says. “Those clichés that define Oregon also hold true for why naturopathic medicine is so popular here.”

Bedrock of care

That popularity does not extend throughout the country. Kimball Atwood, a Boston-area anesthesiologist who led a successful campaign against naturopathic licensing in Massachusetts, says he is alarmed by some of the therapies used by naturopaths. Asked for an example, he points to three deaths that occurred when a controversial drug called colchicine was dispensed out of a Portland alternative health clinic in 2007.

Colchicine has been used by naturopaths to relieve chronic back pain, and a bad batch of the drug was found responsible for the three deaths.

“Any MD looking at that would go ‘Oh my god, who would do that?’” Atwood says, of prescribing colchicine for back pain.

Ironically, however, it was a Portland physician working at the clinic alongside naturopaths who prescribed the drug that led to the deaths.

Nevertheless, Atwood would rather see nurse practitioners and physician’s assistants, rather than naturopaths, fill the gaps in primary care.

“They are much better trained to do that kind of thing,” he says. “They actually have legitimate clinical experience in hospitals and real doctors’ offices during their training. Their training is rational.”

Daniel Newman, who works at the Rising Health clinic in Vancouver, thinks naturopaths are, in some ways, better suited for primary care than many medical doctors.

Newman is one of the few health care practitioners in the country who qualifies both as an MD and a naturopathic doctor. He says his medical school training emphasized hospital care, but his training at Portland’s Northwest College of Natural Medicine focused on outpatient care – the bedrock of primary care.

As for Atwood’s concern that some naturopaths will miss important diagnoses or not know when they need to refer a patient to an MD, Newman doesn’t agree.

“You could ask the same questions about conventional MDs,” he says. “What I’ve seen is naturopaths are acutely aware of what their limitations may be. The vast majority I’ve seen are overly cautious.”

 

TRIBUNE PHOTO: L.E. BASKOW • Iraq War veteran Darren Janeck has needles inserted into his ears during a weekly acupuncture clinic at Colonial Heights Presbyterian Church. Acupuncture is among many alternative therapies used by naturopaths.

 

Data on prescribing medications appears to back up Newman’s observation. Naturopaths have had the authority for years to prescribe pharmaceuticals that were naturally based. In a 2008 survey by the Oregon Association of Naturopathic Physicians, 86 percent of naturopaths indicated they prescribed pharmaceuticals, but more than half wrote fewer than 10 prescriptions a month.

Atwood isn’t convinced, and warns that naturopaths “should be careful what they wish for.”

“If they get to the point that they get legal parity with MDs, they’re not going to have that time anymore,” Atwood says. “They’re going to be pushed into the same corner we are.”

Tribune reporter Peter Korn wrote this story while participating in the California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communications & Journalism.

 

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Primary care providers in short supply

 

Three counties in Oregon have no primary care providers at all. Zero. A number of other counties outside the Portland metropolitan region have only a few. Multnomah County, by contrast, has 1.87 primary care providers for every 1,000 residents — and there are still many residents in the Portland area who cannot find a primary care physician willing to see them.

The lack of primary care providers in rural areas translates into poorer health. Nearly half of the rural areas in Oregon experience health issues such as high numbers of avoidable hospitalizations and low birth weight babies. In some cases, these outcomes are poor even when a hospital is situated nearby.

But more primary care physicians aren’t likely to move to rural areas, despite state inducements that include forgiving medical school debt, says Phil Miller, who tracks physician trends at Irving, Texas’ Merritt Hawkins & Associates, a national physician recruitment firm. There are simply too many reasons primary care MDs don’t want to move to rural areas.

The problem begins with the overall shortage of primary care physicians, and the root of that problem is money, which increasingly goes to specialists, not primary care doctors.

Miller says the average family practitioner MD now makes $173,000. Compare that with orthopedic surgeons, who make $481,000 on average, or radiologists, who average $391,000 a year.

And the shortage of primary care doctors is coupled with another problem that keeps primary care doctors in cities — their spouses. Most physicians are now married to professionals, Miller says. And those professional wives and husbands can’t find the work or lives they want in rural communities.

“If they’re married to a neurosurgeon, that’s out,” Miller says. “And if you’re an architect married to a doctor, what are you going to do in a small town?”

By contrast, according to officials at Portland’s National College of Natural Medicine, established naturopaths earn an estimated $80,000 to $90,000 per year, but many newer practitioners are making less than $30,000.

Miller sees primary care MDs as becoming even rarer in rural areas in the years ahead. Whether it is naturopaths or nurse practitioners, he says, somebody other than doctors must take up the slack.

“The answer is going to be non-physician providers,” Miller says. “The question is which ones are going to be most appropriate.”

— Peter Korn

 

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Education: Residencies are major difference

 

Debates about naturopathic doctors as primary care providers often come down to comparing educations.

MDs typically follow college with four years of medical school, which leads to residencies — usually three or four years for primary care physicians. During these residencies, physicians gain experience in their specialties by working with patients alongside experienced physicians.

Naturopathic doctors also must first complete college. Naturopathic education consists of four years at a naturopathic college, which combines conventional medical education with an emphasis on natural treatments. Naturopaths are not required to undertake residencies and are free to practice after graduation from the naturopathic college, but residencies are available to a minority of students.

Oregon Health & Science University, the state’s medical school, graduates about 125 new physicians each year, but as few as a quarter to a third end up as primary care providers. The National College of Natural Medicine, in Southwest Portland, graduated 77 naturopathic doctors last year, all potential primary care providers.

— Peter Korn