Shannon Hirst,1 ND, and Traci Pantuso,2 ND, MS
Recently, the Board of Naturopathy (BON) in Washington State (WA) updated the continuing education (CE) requirements for WA Naturopathic (ND) license renewal. The requirements went from 20 credits per year to 60 credits every two years, with 15 being pharmacology content1 (Table 1). These changes to the CE requirements for license renewal in Washington State have created quite a commotion.
TABLE 1 Continuing education requirements for Washington State Naturopathic Doctors (ND) prior to 2021 and from 2021 onward.
At face value, it appears this increase in CE is a routine update for a state where NDs have a primary care scope of practice that includes prescriptive rights, routine conventional diagnostic tests, and some conventional interventions.1 However, a unique stipulation of these 60 credits is that 20 (33%) of them must be satisfied through content approved by a select few naturopathic organizations chosen by the BON.1 These 20 credits were assigned their own category, called Category 11 (Table 1). The ND organizations designated to approve these credits are the American Association of Naturopathic Physicians (AANP), its state affiliate, the Washington Association of Naturopathic Physicians (WANP), the North American Naturopathic Continuing Education Accreditation Council (NANCEAC), and the Accredited Naturopathic Medical Schools.1 There has been significant pushback against requiring naturopathic CE hours, and active attempts to amend this rule have now entered their second year. At the time of writing, they remain unresolved. The authors believe this ongoing debate is of interest to the entire ND profession, and this commentary is intended to inform and promote discourse among the international naturopathic community regarding issues of policy, scope of practice, and professional integrity.
Washington State was one of the first states to regulate naturopaths, and it is served by its own BON. The BON is an authority within WA’s Department of Health that regulates the safety and competency of NDs in the state. It is made up of four naturopaths and two members of the public. The BON has been working on updating the CE requirements for a number of years. In response to the CE updates, licensees raised concerns with the BON about the content and quality of CE that is necessary to practice with a primary care scope of practice and the ability for Category 1 naturopathic CE to efficiently fulfill these needs. The primary care scope of practice in WA state for NDs includes routine diagnostic and treatment interventions,2 in contrast to the more specialized scope of practice for Canadian NDs.3 The BON responded in a letter with the following statement: “the Board feels strongly that naturopathic accrediting organizations are the best means to ensure substantiation of naturopathic principles in continuing education content. Without such affirmation, the practice of naturopathic medicine is at risk of erosion of the very fundamentals that set it apart from allopathic doctrine” (Chad Achstgen, ND, Chair, Board of Naturopathy, State of Washington Department of Health, letter, March 19, 2021).
After the BON made its position clear, WA ND licensees were surveyed through Survey Monkey regarding practice and CE preferences to provide data to the BON. The survey allowed open-ended responses to the BON assertion that mandating naturopathic CE would inhibit erosion of the naturopathic profession.4 The results of the survey demonstrated that 91.2% of the 125 ND survey respondents are providing primary care services to their patients, that they generally approve of increasing CE credits for licensure and agree with conventional definitions of primary care, and that they participate in a wide array of CE courses that include both conventional and naturopathic content.4 The majority of respondents, however, remain opposed to the Category 1 requirement and expressed concerns specifically over the BON statement that the profession is at risk without it.4 A rebuttal letter with over 100 licensee signatures was sent to the BON subsequent to the survey urging the BON to reconsider its position.
The question these survey results bring up is this: how is it that naturopathic licensees are both making use of naturopathic CE and also deeply opposed to requiring it? As unique providers in a greater healthcare system, it might be logical to ask under what circumstances CE specific to that unique field would not be required? Valid concerns were raised about the limited catalogue of CE offerings compared with conventional content on multiple platforms and the equitable pricing of naturopathic materials. Many licensees also pointed to the static nature of naturopathy due to lack of field-specific research. However, the authors believe that the primary care scope of practice status of WA licensees, with the clear legal and ethical responsibilities such status carries, is the source of the fundamental resistance.
In addition, the authors believe that the field of naturopathic care is indeed at risk of erosion, but not due to WA NDs not being required to take 20 CE units from naturopathic-approved organizations. After much thought and deliberation, the authors have come to the conclusion that the real threat to the profession is the ongoing failure to fully address potential field-specific conflicts of interest (COI). This has created a breakdown of trust within the profession itself. “The central goal of conflict-of-interest policies in medicine is to protect the integrity of professional judgment and to preserve public trust…”5 Without consensus on a patient-centred, preventive ethical structure in naturopathic medicine, there is a lack of a reassuring standard for the professional integrity of naturopathic CE materials. The authors would go a step further and suggest that an additional goal of COI policies is preserving trust within the profession itself.5 While most people are familiar with this concept as it relates to financial conflicts, as they are the most responsive to regulation, a conflict can really arise from any interest, legitimate or improper, that impacts the primary interest of providers when they are in their professional role.5,7
In conventional medicine, primary interests are clearly declared in altruistic terms such as patient welfare or scientific integrity.5,7 In contrast, the recently released World Naturopathic Federation Health Technology Assessment for naturopathy describes the profession as defined by philosophies, principles, and theories.8 Patient welfare as a primary interest is not overtly declared or expanded upon beyond the naturopathic principles. This omission creates vulnerability to COI in naturopathy—vulnerabilities both shared with the greater healthcare community and those unique to the field. Examples of additional unique COI vulnerabilities in naturopathy include lack of consensus on naturopathic standards of care, substantial student loan debt in the context of a primarily entrepreneurial profession within healthcare,9 and a general lack of field-specific research.8 Even the financial investments in naturopathy are unique, coming from sources such as supplement companies, manufacturers of alternative laboratory tests, and compounding pharmacies, all of which have varying levels of outside regulation or research and few established boundaries for their involvement in educational materials.
In the absence of well-established ethical structures and ND-specific standards of care, it is difficult to ascertain the degree to which any number of these interests could shape CE content, and in what ways. It is easy to see where NDs with primary care scope of practice and shared legal and ethical interests with conventional medicine would find themselves reluctant to be required to navigate this landscape in its current form.
Ethics and underlying COI frameworks exist to reinforce the altruistic root of the conventional medical profession, where significant resources have been invested into developing consensus.5 They form the consistent backbone for conventional policy decisions in regulation, education (including CE), and professional conduct.5 The field of naturopathic medicine has not yet undergone the same self-reflective process as conventional medicine of declaring its purpose and ethical tenets in relationship to the public. Naturopathic medicine is unique, but it has not yet defined itself beyond its principles and theories, unlike conventional medicine. This is a serious, unfinished, issue that impacts not just CE but the sustainability of naturopathy as a whole. It is surmountable, however, and represents a profound opportunity for the profession to invest intellectual labour in developing an ethical framework for itself that is unique, preventive, and patient-centred—all concepts that naturopathy has hoped to espouse. It would be no small undertaking, but in committing itself to the process of declaring fundamental ethical tenets, the field would be offering a promise of significant goodwill to both the public and those within the profession itself.
1Sammamish Valley Natural Medicine, Woodinville, WA, USA
2Bastyr University, Seattle, WA, USA
Not applicable.
We have read and understood the CAND Journal’s policy on conflicts of interest and declare that we have none.
This research did not receive any funding.
1. Continuing competency rules for naturopathic licensees Washington State Legislature WAC 246-836-080. Accessed May 30, 2022. https://app.leg.wa.gov/wac/default.aspx?cite=246-836-080
2.https://app.leg.wa.gov/wac/default.aspx?cite=246-836-210
3.https://www.cand.ca/common-questions-education-and-regulation/#regulation-in-provinces-and-territories
4. Hirst S, Pantuso T. Continuing education survey results of WA State naturopathic doctors. Annual Meeting Bastyr Research Day; Kenmore, WA; virtual poster presentation, June 2022. [Accepted]
5. Conflict of Interest in Medical Research, Education, and Practice. Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Washington (DC): National Academies Press (US); 2009.
6. Carlat DJ, Fagrelius T, Ramachandran R et al. The updated AMSA scorecard of conflict-of-interest policies: a survey of U.S. medical schools. BMC Med Educ 2016;16: 202. https://doi.org/10.1186/s12909-016-0725-y
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7. Thompson DF. Understanding financial conflicts of interest. N Engl J Med. 1993;329(8):573–576. https://doi.org/10.1056/NEJM199308193290812
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8. Lloyd I, Steel A, Wardle J (Eds.). 2021. Naturopathy, practice, effectiveness, economics safety, Toronto, Ontario: World Naturopathic Federation. Accessed 5/26/2022. https://worldnaturopathicfederation.org/wp-content/uploads/2021/12/Health-Technology-Assessment-HTA_eBook-1.pdf
9. Relman AS. Dealing With Conflicts of Interest. N Engl J Med 1984; 310:1182–1183. https://doi.org/10.1056/NEJM198405033101809
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Correspondence to: Traci Pantuso, Bastyr University Research Institute, 14500 Juanita Drive NE, Kenmore, WA 98028, USA. E-mail: Tpantuso@Bastyr.edu
To cite: Hirst S, Pantuso T. Contested continuing education changes in Washington State highlight problems within the naturopathic doctoral (ND) profession. CAND Journal. 2022;29(3):7-9. https:/doi.org/10.54434/candj.118
Received: 01 June 2022; Accepted: 28 June 2022; Published: 22 September 2022
© 2022 Canadian Association of Naturopathic Doctors. For permissions, please contact candj@cand.ca.
CAND Journal | Volume 29, No. 3, September 2022