Here's a couple of websites commenting on the fact that the state of Minnesota, the liberal bastion, has just passed a law designating practitioners of naturopathy as "doctors." I share their concerns. According to at least one interpretation, they'll be able to admit patients to regular hospitals and manage their care. To the extent that it's even imaginable, I find it frightening. On the other hand, in my state of Washington it's been the case for years that, by law, health insurance must cover such crapola as chiropractic, accupuncture, aroma therapy, massage therapy (yes, to the extent that it's the same as physical therapy, I have no problem, but there's all that other therapeutic touch nonsense...), and, of course, naturopathy. Far as I know, homeopathy, too, which is at the very bottom of the barrel, unproven-bullshit-wise. But that's not my point. My point is to give credit when it's due.
Seattle is home to Bastyr University, the mecca of "natural medicine." They claim the mantle of scientific research. And, contrary to what I'd have expected, it seems they actually do it. In the Seattle Times a couple of days ago were the results of a study they announced, on the efficacy of St. John's Wort for treatment of ADHD. It appears to have been an actual double-blind prospective study, and darned if it didn't show exactly what you'd expect real science to show: bupkis. So I congratulate them on being willing actually to subject their stock in trade to the science it requires.
I applaud Bastyr for doing the study and for publishing the results. I assume they'll continue doing so, even though I'd guess someone there must be worried they'll science themselves out of business eventually. We'll see. Meanwhile, it sets a standard for advocates of homeopathy, chiropractic,* Reiki,* accupuncture,* aroma therapy, etc etc ad nauseum to show the same kind of character and honesty and subject their modalities to the same rigorous and reproducible study. Good job, Bastyr.
*What I'd love to see done for those manipulative therapies is a randomized prospective study where the manipulations were divided into "approved" (or whatever you'd call it) and bogus, with neither patient nor provider knowing which was being foisted... er, sorry: provided. It would be tough to do. If you had actual "practitioners" giving the, uh, therapies rightly or wrongly, they could easily have different behaviors with the patients. So you'd need to have neutral people shown what to do for a given diagnosis and then do it not knowing whether they were shown the "real" stuff or deliberately wrong stuff. And although practitioners would object that only by years of training can they learn their craft, I'd think a single intervention for a single agreed-upon diagnosis could be taught. Stick a needle here, or there. Wave your hands there, or here. Crank on this, or that. Be fun to know, wouldn't it?
39 comments:
shame on you, minnesota!
"According to at least one interpretation, they'll be able to admit patients to regular hospitals and manage their care."
Really? That's interesting.
Does the MN Board of Nursing have statues relative to the obligation (or not) or registered nurses acting on the prescriptions of naturopaths? That might be the backdoor way to stop this nonsense in its tracks.
What medical staff organization would accept naturopath credentialing for inclusion on the medical staff, anyway?
But I wouldn't worry too much because of the reimbursement and risk factors that hospitals would have to assume. How many third party payers cover naturopath services and billed treatments? Under what codes? Do they participate in CMS?
What is the legal liability for hospitals?
I think the answers to those questions will keep most, if not all, accredited hospitals, from accepting naturopaths' patients.
The worrisome part to me is how patients will be suckered in and will forgo effective treatment, reliable and valid therapy and will of course, be the ones shelling out money, time and quality of life without effective advocacy.
Statutes, not statues, although maybe the Board of Nursing has some lovely ones.
Sorry for the typo.
Annie: in the comment about hospital privileges I was quoting from one of the linked blogs. I had the same thoughts as you, regarding liability, etc, and would doubt they'd be admitting and managing without some sort of required supervision. But who knows? It's not as if legislators think clearly about these things.
And people are already wasting time and health in turning to "alternative" therapies. (I love that word, "alternative." As if it really is. Like magic wings are an alternative to a parachute when jumping out of a plane.)
"The worrisome part to me is how patients will be suckered in and will forgo effective treatment, reliable and valid therapy and will of course, be the ones shelling out money, time and quality of life without effective advocacy."
Speaking as a past patient of both MDs and NDs, I hardly feel as though I've been "suckered in". My MD could be counted on to prescribe a pill to make my symptom go away, but my ND took the time to ask every conceivable question and addressed underlying issues my MD missed altogether, or didn't want to take the time to identify. The results? I constantly had to visit my MD for more pills to address symptoms without ever actually getting better, but once I saw an ND I got the real underlying problem treated and stopped having sympoms reoccur.
I'll be seeing an ND as my primary care physician from now on, thank you very much. And bravo to Minnesota for regulating NDs so that only those who have attended medical school at an accredited naturopathic medical school can practice. See www.aanmc.org for a list of the only 6 schools in the US and Canada who are accredited and truly offer a comprehensive education in naturopathy.
anonymous: "proof" by testimonial. Exactly the problem.
In the UK we are fortunate enough to have Prof Edzard Ernst, who is a physician (internist) turned Professor of Complementary Medicine and spends his time doing systematic review and meta-analyses of CAM interventions. Predictably, his pointing out where the evidence is weak or non-existent (most things) has made him a Bogeyman for the AltMed crew, especially in the UK.
Ernst has a phlegmatic old-Europe temperament and has shown incredible restraint in not losing it when dealing with some of the CAM lot. For instance, he did a study of “remote energy healing” (healing “rays” from behind glass) which showed that volunteers non-healers got just as good results as “healers”. The CAM people objected that the volunteers might, unknown to them and the experimenters, have secret latent healing powers. Instead of telling the Alties to get a grip, Ernst repeated the study with the volunteers counting backwards in nineteens from 1000 to make sure they weren’t thinking healing thoughts while they looked at the patient through the two-way mirror. Results: volunteers still just as good as healers.
Another study he used to talk about was the one where they trained actors to make the same “moves” some self-styled energy healers did, and then compared the patients’ reports of their symptoms if the patients were blinded to whether they got an actor or a “healer“. The result was that, if anything, the actors did slightly better than the “healers”.
As the years have gone by it has become apparent that even Ernst is becoming frustrated with the evasions of the CAM people. He has written a whole series of articles pointing out their tricks for avoiding submitting their interventions to proper tests (see e.g. here) and has now done a whole book on CAM.
PS Enjoying having a roam round the blog, Dr S. Having hung out a lot with internists and anesthesiology/ITU types in my scientific life I have probably been given a rather prejudiced view of surgeons (!), so it is a helpful (and enlightening) redress to read a it about surgery here and over at Respectful Insolence. Is your book going to get a release beyond N America?
I see this is a classic example of individuals voicing their opinion without doing all their research.I have a couple of items to add to this conversation...
1. Have you happened to look at the philosophy of naturopathic medicine Dr. Scalpel...er, I mean Schwab? When you said, "I'd think a single intervention for a single agreed-upon diagnosis could be taught. Stick a needle here, or there. Wave your hands there, or here." clearly you have naturopathic medicine confused with allopathic medicine's linear thinking where symptom "X" needs drug "Y". Naturopaths don't just read a chart of sypmtoms to find the right drug to give their patient, they actually have to call on critical thinking skills while examining each patient holistically.
2. Have you not looked at an accredited naturopathic medical school's curriculum? It's almost identical to allopathic medicine with one of the largest exceptions being the philosophy and the therapies in which they are trained to use. Instead of drugs and surgeries (allopathic medicine's therapies) naturopathic physicians are trained in--gasp--nutrition and counseling as well as botanical medicine and many others.
3. I find it interesting that when science is used to challenge the reliability or effectiveness of an herb it's proposterous and just "proves what we've known all along--herbs don't work." However, science is used to challenge the effectiveness of drugs it is called solid research. Get real!
anonymous: your point three is so breathtakingly nonsensical that I find myself questioning everything else you said. I congratulated Bastyr for doing solid research. I commend any who'd subject their medicinals and methods to science. That was my point. What in heck was yours???
Dr Aust: thanks for an excellent comment, and for the links. I hope you found my post sampler, which links to some of my good stuff. A few of my UK readers have gotten my book there. Amazon carries it, although I suppose the shipping costs would be prohibitive.
"Naturopaths don't just read a chart of sypmtoms to find the right drug to give their patient, they actually have to call on critical thinking skills while examining each patient holistically."
God, this is hilarious. Examining them holistically for WHAT? Evil spirits? The phlogiston? An imbalance of chi? Unlike the evil allopathic monolith, which regularly conducts "statistical" "analysis" to see whether treatments actually work, naturopathic medicine seems to accept the fact that Mother Jones used a herb to treat something back when they thought the sun revolved around the earth at face value.
Hi Dr S. Yes, spotted the sampler and have just been reading the pancreas posts (I am an on-and-off pancreatic physiologist - not something one gets to tell too many people...).
I teach on one of those fashionable integrated PBL medical curricula (undergrad as of course medicine is and undergrad degree here in the UK) and have found the medical blogosphere really useful B/G for teaching - it is a great way to find out what MDs do, how they weigh up treatments etc etc. Of course, being married to a doctor is an even bigger help (my wife is an ex-internist and used to work in anesthesiology/ITU, hence the general trend of my medical pals). But the good blogs provide real insight, especially into how people in medicine think. I tend to plug the blogs heavily to the students.
Talking of surgically-related blogs, the UK one I used to read was Hospital Phoenix, but he has been off-air for a while now. Shame as he penned some insightful stuff.
Dr Aust: it's really nice to know some of the stuff is useful. Especially to a man of letters!
I used to read Phoenix, too. Perhaps he'll rise again. In my case, my first aim here was to convey what it's like to be a surgeon, and to impart some thoughts about specific diseases and organs; having done that, I feel I'll either be getting repetitious or become a nag. The latter is already happening.
I am a Dairy farmer whose cows sometimes get mastitis. This is when the cow's milk gets lumpy. We now use a homeopathic treatment and it works very well. Mastitis here one day, gone the next. My 800 cows seem very susceptible to the placebo effect.
While I'm here: if we are going to run all the alternative treatments through the shredder why don't we also subject doctors' treatments to the same rigorous examination? There is no scientific basis for about a third of all medical treatment in the US. Read the NY Times economics book of the year "Overtreated". Many may actually be doing harm. Makes you think Dr. Schwab!
It does make me think. Which is why I so strongly favor using those modalities that have been subjected to proper testing. I not only admit, I've written here about the fact that much of what we do is more handed-down wisdom than proven. But, as opposed to most "alternative" BS, "we" in mainstream medicine do constantly raise questions, re-think, re-test, and make changes as indicated.
That Bastyr study sounds like something Ben Goldacre'd pick up if he knew about it.
Is chiropraxy very different Stateside? It was made into a B.Sc. course at my uni while I was there and they seemed quite proud of it. And I'm pretty sure it can be 'prescriped' by GPs - at least I doubt it'd be possible to have it covered (partially) by insurance as it is if there wasn't some check on it.
(Nothing in English, I'm afraid. But I could try my hand at translating some of the outreach material tomorrow if it has any interest. http://www.sdu.dk/Uddannelse/Uddannelsesoversigt/Bachelor/Klinisk_biomekanik.aspx )
Sili: in the US, chiropractic knows no bounds, or so it seems. It's one thing to do manipulations for certain specific spinal problems. It's quite another to claim that virtually all illness can be treated by such manipulations. At every state fair, at many gatherings, one sees booths set up by chiropracters wherein they'll take some "measurements" of the victim's spine, and reel them in for treatments. They take whole body xrays of poor quality, make little measurements of angles (ignoring the positional effects) and diagnose all sorts of maladies. They advertise for prophylactic manipulations of children, recommend lifetime "treatments." They claim to treat asthma, allergies, diabetes, you name it, with bogus manipulations. There are some that limit themselves to treating some kinds of back pain; those, I think, may occasionally have something to offer.
And people are already wasting time and health in turning to "alternative" therapies. (I love that word, "alternative." As if it really is. Like magic wings are an alternative to a parachute when jumping out of a plane.)
Sid, it may be helpful to clarify the differences between “alternative” and “integrative.” Alternative for the purposes of medicine means replacing one thing for another. Integrative means working along side to support something. Reiki is an integrative modality that works to support whatever the doctor is doing. I’ve done it with pre- and post surgical patients with great results. The pre-surgical patients were calm and their blood pressure oftentimes remained low. Post surgical patients required less pain meds.
I can’t prove how or why this works. It’s a balancing energy that has a calming, healing effect on people. I’ve used Reiki on depressed patients, who were able to lower their meds with the approval and guidance of their doctors. I’ve used Reiki on ADD kids, who were then able to lower their Ritalin dosages or give it up all together with the approval and guidance of their docs.
I can’t guarantee these results in every patient. But I hope you don’t consider it a waste of time that they tried the therapy. Because, at the very worst, they are calmer and more in control of their emotions, and that aids in healing.
And there are times when alternative therapies are appropriate. Example: I’m going through the fun throes of menopause, and the hot flashes are enough to drive me buggy. Since I have fibroids, I can’t take any HRTs. Nothing could be done for the hot flashes until I started taking liquid iodine forte from Biotics. It took about a month to get into my system, and I’ve been hot flash free for 2 years. To say that I consider this a blessing is an understatement. Just ask any woman over 50.
Even though I’m looked at as being a biodegradable Birkenstocks, tie-dyed leftover from the sixties, I’m quite conservative and not an advocate of putting naturopaths or chiros on the equal playing field of docs. It’s plain idiocy.
Lynn: the question is why Reiki works. Certainly the "energy" explanations is outside any known physics or physiology. So the presumption would be it's the attention, the support, the relaxation of having a caring person attentive to one's fears. Which is why I said I'd love to see a study comparing "legit" Reiki with some sort of similar but not "proper" maneuvers. I'd predict the outcomes, just as dr aust described of other "healers" in an above comment. If, in a proper study, it can be shown to have effects other than those seen with a placebo control, then I'd buy it. But I'd also look for an explanation based on what's knowable: magical energy fields aren't. Far as I know. To me, things that can be shown to have value above placebo effect ought to be explainable in terms consistent with provable physiology. Until then, I'll assume your successes are explained by your positive attitude, your calming demeanor, and your general admirable human qualities. And your smile.
As to iodine: it could well have specific and testable medicinal effects. In fact, based on studies I prescribed (suggested, since it didn't require a prescription) it for some women with breast pain due to fibrocystic condition. If various "natural" remedies have medicinal properties, it ought to be testable just like any other medication. If it works, then it's neither "alternative" nor "complementary" nor "integrative." It's medicine.
I recently took a course on the philosophy if science (retch) and we were examining the application of the term 'science' to pseudo-scientific crap. The underlying problem with all of this is that naturopathic medicine is unfalsifiable by principle and that they work on such case-by-case momentum.
I'm quite perplexed by extending the term 'Doctor' to pracitioners within these fields because of the legitimacy the title can confer (thanks, Liana)-- it can be misleading. RAG at TheChloroformRag recently made a post alluding to this and I share the same concerns.
It's a bit of a personal issue for me as my mother's herniated disk was missed by an accupuncturist who couldn't tell their ass from their head.
I am concerned that homeopathy, chiropracty, accupuncture, REIKI and other unscientific crap is not being addressed in many medical programs. I have a friend who is an occupational therapist, which required two years of graduate work, and don't remember her ever telling me that these things were addressed in her classes.
Science education in America is dangerously weak, even among people who obtained science related degrees.
My attitude toward alternative therapy is much like yours. Show me the study!
Preferably a double blind study that accounts for placebo effects. A double blind study is really the only way to tell if therapy works.
The popularity of alternative medicine is rooted in it's appearance of simplicity and its claims of almost magical healing quality. This magical quality of alternative medicine feeds magical thinking in people.
Magical thinking occurs when a person does not understand the possible causes for their situation. Magical thinking is easy, it does not require people to look at reality and face hard issues. Sickness disease and medical treatment are full of hard issues, hence the attempt to escape reality by magical thinking.
The medical profession is not blame free in this however. There is a lot of confusing and contradictory information coming out of the medical community. The reasons for this are legion. There are drug companies manipulating studies for marketing purposes. There are class action lawyers creating fear, uncertainty and doubt so they can scam some money. There are armies of policy makers (life style police) who use medical studies to bully people into the life style that is in "style" today.
In the face of that kind of information overload,noise and lies I can understand why people pick the magical thinking route. It feels safe, easy and gives people a false sense of control. They do not have to deal with all the stuff described above. That is nice except for the fact the magical thinking and alternative medicine may kill them.
Thank you, doctor.
That's obviously crazy talk. I've never heard of that being an issue here in Denmark - but with these things there's usually a dark underbelly. That said, I've only ever heard of people going to chiropractors because of bad backs and the like. It seems fairly woo free - much like physiotherapy and massage.
But I guess that explains why they call the course "clinical biomechanics". Far as I can tell they have an academic line as well as a practical one - with the option of doing both masters and Ph.D.s. So presumably there's some genuine research into what works and why.
Oh! - and before I forget.
I'm not a med. student, but I hope you won't stop posting for fear of repeating yourself.
I think what dr Aust says about blogs being a good tool for student is true, and if you lack for topics you could perhaps have an "Ask dr Cutsemup" sorta column where students could ask you about general surgery. That'd give a chance to rehash some topics from new angles, perhaps.
faded: agree with everything you said.
sili: thanks for the suggestion. I might do it!
What baffles me is how devoted people get to these alternative methods...it's almost religious. I know a lady (a smart, succesful lady) who visits a naturopath. A few years ago, her (adult) daughter became extremely ill with stomach pains. She took the daughter to her naturopath who prescribed various herbal remedies. Her daughter's condition steadily worsened, she took her back, they got more herbs...this went on for a few days. Then her daughter died from the ruptured appendix -- which a simple surgery would have cured completely. This alone is awful and tragic. But what is truly stunning is that this lady is still completely devoted to naturopathy.
(And before anyone asks, yes, this "doctor" had indeed gone to an accredited school and actually had MULTIPLE degrees from there)
It's a sad, and hardly unique, story. For that woman to reject naturopathy now would be to have to blame herself. So it's not surprising she hasn't.
I go to a lupus support group, mostly to show the newly-diagnosed that life does go on; I've had it 18 years. So.
Someone in that group who was very into alternative therapies invited a woman to address us. Naturopath, I guess, but whatever, she came with glossy pretty brochures with glamor shots of various herbs that she was selling. She said she too had lupus, so she knew what we were suffering with. And then she said if you placed a sprig of *this* herb--turn to page x, folks, that one there, see--between your big and next toe for so many days, you would be cured--CURED!--of your lupus!
It was all I could do not to burst out laughing. I looked at her and thought, yeah, hon, and how many times has it cured you? Just how on earth stupid do you think we are?
This was right after the cult in SoCal offed themselves in the wake of Halley's Comet, and it didn't help that she creeped us out using that group's buzzwords and phrases in dissing her own body as she spoke. Weirdest afternoon I ever spent, and it nearly dissolved our lupus group. Most of the members quietly utterly refused to come back till the leader left who'd invited the quack.
I have a funny story about CAM. My wife decided that she needed acupuncture for her neck pain. She went to a lady down the road from us that was licensed. She paid I think 80$ for the treatment. Later that evening I was looking at her and she had a big sore on her forehead, and she also had a bad headache. She went back the next day to see the woman. Now the night before she was mad, and I thought she would demand her money back. When I came home I found out she had gotten some more acupuncture to treat the sore and headache cause by the first treatment and some dragon breath pills(which smelled like concentrated celery), for like 60$.
I am on the other side of the fence and really can't believe in these untestable or unwilling to be tested therapies. There was a lecture recently given in our school by a proponent of CAM, he was a family doc and a licensed hypnotist. He talked for 2 hours about all the alternative therapies, but completely ignored the issue of efficacy. His evidence for hypnotisms benefits were his own testimonials. And that is my main problem, all these CAM therapies rely on human testimonial as evidence. That is great if people think they feel better how about if they actually are? The other thing is people are willing to shell out big $$ for CAM. The lecturer pointed this out and said in so many words we would be wise to learn one and cash in. I think my limit will be to learn enough so that I can make recommendations for safe CAM practitioners, because as evidenced by my wife they are not all benign even within their scope.
anonymous: good comment. Thanks.
"I am a Dairy farmer whose cows sometimes get mastitis. This is when the cow's milk gets lumpy. We now use a homeopathic treatment and it works very well. Mastitis here one day, gone the next. My 800 cows seem very susceptible to the placebo effect."
Speaking as a mother who breastfed both of her children, I can attest that mastitis often resolves quickly on its own -- and in my experience, one day of mastitis is not unusual. I can't imagine that dairy cattle are much different as far as that goes.
To be sure you're actually seeing some improvement from the remedy rather than just confirmation bias, you might want to do a scientific study. Doing it by yourself, it would be hard to double-blind, but you've got a big enough herd that you should at least be able to do a Mythbusters-worthy test. Divide them into three groups. One gets the homeopathic treatment whenever they get mastitis. One gets a placebo. One gets nothing. Follow them for, say, a year, or whatever would be long enough to reasonably expect a lot of them to get mastitis. Track duration of the condition using as objective a measure as you can find. Then you'll really know if that homeopathic remedy is worth the money you're spending on it, or whether you're just seeing what you want to see.
The placebo effect is not the only confounding effect you need to be wary of.
Right. Don't know much about cows, but for nursing moms, in many cases the treatment is to continue nursing and it goes away.
Regarding "It's a sad, and hardly unique, story." of a tragic ruptured appendix.
Had it been another anonymous poster who viewed naturopathic medicine in positive light Sid would say "anonymous: "proof" by testimonial. Exactly the problem."
I smell a rat. Had this really happened the press would have been all over this appendicitis story.
Show me the evidence: where, when, and who.
Ben: so you are implying the commenter is lying? And that there aren't others? I guess that's one way to deflect.
Over many years in my practice, I saw several similar cases. Because I'm legally prevented from providing names and details, you can call me a liar, too. But there was a young girl with a ruptured appendix in similar details, other than I was able to save her from as close to death as I've ever seen a child with a ruptured appendix. I had a patient whose chiropracter husband manipulated her back until she was paralyzed from undiagnosed metastatic breast cancer. A patient I cured of breast cancer when it occurred in one breast and she agreed to traditional methods, chose "natural medicine" when another developed in her other breast. She died of that one. I could go on, and on and on, and so could every doctor who's been in practice for more than a few years. And we all have failures, too, because no therapy is 100% effective in all situations and time-frames of diagnosis. But at least our therapies are tested, and re-tested, and constantly improved. Virtually all "alternative" therapies, when subjected to proper testing, have been found ineffective. But they continue to be used.
As I've said many times, there's no such thing as "alternative medicine." There's medicine that works, as proven by proper testing, and there's everything else. If it's testable and shown effective, it's not "alternative," it's medicine.
Sid,
Based on your thoughtful, considered writing style, I do not doubt for a moment the examples you provide took place.
Did any of these cases involve licensed naturopaths? You do not mention them specifically.
I suspect the earlier 'nice lady, poor child' story is bogus. I will readily admit my mistake given evidence to the contrary.
As you say, medicine is medicine.
If a doctor of any stripe missed acute appendicitis, that person is an incompetent hack.
You must have an abundance of licensed naturopathic doctors in the Evergreen State. Would it be worth your while to call some of them, maybe even the Bastyr Clinic in Seattle, and describe acute appendicitis symptoms? I wonder how many will get it right and refer you to the ER. Would it ethical for anyone to try something of the sort?
"Ben: so you are implying the commenter is lying? And that there aren't others? I guess that's one way to deflect."
And saying this would be another.
I was the original commenter with the story about the woman and her daughter who died of appendicitis. I was not lying. This woman is a dear friend of my parents. I am not going to provide details of my name, her name, or our location because I don't want her to accidentally stumble upon this. This was never in the press because, as you can see in my first post, the child was an ADULT at the time and therefore there was no question of neglect. I doubt any of the friends who were privy to the details of this story felt like calling our tiny local newspaper in the midst of our grief to share the "real" story. That seems like a cruel and exploitative thing to do to this woman's family. I'm sorry I can't provide you evidence of the veracity of this story, but courteous relations with family friends is more important than proving a point on the Internet.
Anon,
If a hack doctor killed anybody, especially someone close to me, I would have done everything possible to prosecute and punish that doctor.
It's criminal NOT to do something about it.
What about others who may also die under his/hers incompetent care?
Do you think enough time has passed to get over being "courteous" and do what is right?
Courteous relationship trumps negligent homicide every time.
Look at the Flanagan family in Colorado http://seattletimes.nwsource.com/html/localnews/2004024299_miracle20m0.html
They brought charges against a quack that sent him to prison, but now, the neighbors are really mad because the Flanagans disturbed the tranquil peace of their quaint little village.
How dare they!
I certainly see your point about punishing the naturopath. If it had been my family member, you bet your *ss I would have been talking to a lawyer and seeing what I could do. In this situation, I don't see what I can do since I was not a relative of the deceased. The mother is a minor local political figure and shares offices with the prosecutors so I don't see them doing something to cross her (and she's certainly not inclined to take any action against the naturopath), I don't have any grounds for bringing a lawsuit myself, and naturopaths don't have to go through any sort of licensing board in this state. I think any sort of action would have to originate from the family and they can't be swayed.
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