Doctors haven't made house-calls, as a practice, for a generation. Patients seek out medical care from physicians. They schedule appointments with their doctors, or they go to walk-in urgent care clinics, or they camp out in emergency department waiting rooms. They fill out questionnaires and answer questions in interviews about their symptoms. When given prescriptions, they purchase the medicines and begin their treatment. In some instances, patients might have to file their own claims for insurance reimbursement. Sometimes, when they do not obtain the care they desire, some patients will formally complain or initiate legal action. These activities give the impression that patients are actively involved in their medical care; yet, as a rule, they are not. Orthodox medicine is delivered, generally, in a one-way transaction. The physician dispenses; the patient follows directions.
There is popular recognition today that engaging the patient's active participation in medical care, healing, and maintenance of health could play an important role in therapy and recovery. Magazines pitched to women readers, particularly, have long advocated active patient engagement with the entire process of healthy lifestyle choices, diagnosis and treatment of disease and injury, and recovery. People are urged to deal with health proactively--to educate themselves about health and disease, growth and aging, diet and exercise. Consumers are urged to choose foods that provide health and aging benefits, assist the body in fighting disease, speed healing from injuries, or delay or diminish mental senility.
Large health care organizations, as does Kaiser Permanente, publish literature and offer brief educational courses on lifestyle, health, and disease. Public service advertisements on television encourage abandonment of unhealthy choices. Drug courts--in California, at least--often place defendents into rehabilitation programs that require followup and maintenance. The popular news media are always awash in stories about celebrities who renounce addictions, under rehabilitation, and work at healthier lifestyles. Faith-based healing gains new audiences.
Despite these signs of general awareness of the need for active patient engagement in choosing and maintaining health and fighting disease, one player is largely absent: orthodox medicine. Orthodox medicine is based on neurological and biochemical paradigms of physiology and disease and anchored in traditional Western scientific research methods and methods of clinical testing. These paradigms and methods marginalize the role played by the patient's choices and willful behavior.
The patient plays a more active role in complementary and alternative medicines (CAM). Complementary and alternative medicines include "folk medicine, herbal medicine, diet fads, homeopathy, faith healing, new age healing, chiropractic, acupuncture, naturopathy, massage, and music therapy".* (*1; also, 2, 3, 4) CAM therapies are sometimes based on an empiricism and theoretical explanation that have not been subjected to orthodox scientific testing. Few of their medical practioniers are licensed for medical practice as MDs in the United States, except for chiropractic and, more recently, naturopathy. If they are not licensed MDs, they are prohibited, for instance, from prescribing the large number of pharmaceutical medicines employed in orthodox medicine.
Related to CAM is integrative medicine. (5) Integrative medicine refers to medicine that combines proved therapies from CAM with orthodox medicine. Andrew Weil, M.D., a professor of medicine at the University of Arizona and author of widely read books and articles in popular magazines, is a well-known advocate of integrative medicine. Integrative medicine focusses on health as an active state with its own characteristics, not simply defined as the absence of disease. The patient plays an important role in disease prevention through active maintenance of her health and in healing through protocols of diet, exercise, and self-administered therapies. Integrative medicine is a specialization offered by a few orthodox medical schools. (9, 10)
Naturopathy has recently emerged in the U.S. as an important complementary and alternative medicine and component of integrative medicine. (6, 11, 13) Naturopathy has been an internationally recognized medicine since the 1980s. It is widely practiced in Europe. In France, Germany, and the UK, social and private medical insurances cover naturopathic medicine. In Britain, there are public hospitals to provide CAM therapies, including the naturopathic. (12)
Naturopathic therapies seek to revitalize and strengthen the human body's own health systems and capabilities to fight disease, especially the immune system, and to heal. It shares this characteristic with the Western tradition of Hippocratic medicine. It utilizes a repertoire of herbal remedies, drawn from Western and non-Western cultures. At present, most of these remedies are categorized (in the U.S. by federal statute) as dietary supplements, rather than "drugs", and are not, therefore, regulated as medicines requiring M.D. licensing to prescribe. As they have become more popular, they have provoked a movement within orthodox medicine and medical science in Europe and the US to bring them under orthodox medical testing and regulation (see the Codex Alimentarious Commission).
California began licensing doctors of naturopathic medicine (N.D.) to practice medicine in 2004.
California State law defines " 'Naturopathic medicine' [as] a distinct and comprehensive system of primary health care practiced by a naturopathic doctor for the diagnosis, treatment, and prevention of human health conditions, injuries, and disease."
It further defines " 'Naturopathy' [as] a noninvasive system of health practice that employs natural health modalities, substances, and education to promote health."
The naturopathic doctor may (among other matters) "dispense, administer, order, and prescribe or perform the following: ... Food, extracts of food, nutraceuticals, vitamins, amino acids,minerals, enzymes, botanicals and their extracts, botanical medicines, homeopathic medicines, all dietary supplements and nonprescription drugs as defined by the federal Food, Drug, and Cosmetic Act ..."
The naturopathic doctor may prescribe controlled drugs and substances only under the supervision of a licensed physician or surgeon.
Naturopathic doctors must have graduated from an accredited doctorate-granting naturopathic medical school and pass a licensing examination.
The California law establishing the N.D. requires recommendations (from the state bureau of naturopathic licensing) to the state legistlatuare by January 1, 2007 for a naturopathic formulary, prescription authority (of regulated drugs), procedures for intravenuous administration of drugs, protocols of patient supervision, and naturopathic childbirth attendance. (7, 8)
In the past decade, California has made changes in its medical establishment that have significantly enhanced the capacities of orthodox medicine to care economically for the medical needs of the people of the state. For instance, chiropractic medicine has become crucial to medicine administered within the context of the state's worker compensation laws. It provides therapies for injuries less expensively than orthodox medical care and has played an important role in reducing worker compensation system costs. Whereas chiropractic medicine was once considered a pseudo-medicine, it is now an integral part of the state's orthodox medical establishment.
Licensing naturpathic medicine is a similarly significant innovation. Naturopathic medicine's use of herbal remedies and dietary supplements and avoidance of invasive procedures and surgeries should reduce reliance upon the expensive pharmaceutical therapies, technological procedures, and surgeries for those conditions and diseases for which naturopathic medicine is appropriate.
Naturopathic medicine's focus on restoring and maintaining the health of the patient will bring the patient into active partnership with her or his physician. Naturopathic (and homeopathic) therapies for diseases may take several months or longer to produce their healing effects, in contrast to pharmaceutical drugs that might relieve symptoms in days. The education and consultation required for this naturalistic program brings a closer relationship to the physician. Such was the context for my own treatment by a naturopathic physician. I received homeopathic and naturopathic therapies that relieved me of lifelong afflictions of allergies, asthma, and several digestive disorders (which had previously been treated in orthodox medicine with incomplete success and undesirable side effects). The patient-physician partnership should be the basis for preventive medicine and healthy lifestyle guidance that would reduce the patient contact load in orthodox medicine.
Primary care naturopathic medical practice, conducted largely by solo practioniers and small medical groups, promises to provide humanistic care largely absent from the bureaucratic administration of medicine by California's increasingly centralized HMOs and large group practices. Integrative and naturopathic medicine should be an integral part of any reform of California's medical establishment that might be envisioned as part of, or result from, adoption of a universal, social medical insurance scheme.
Update. February 23, 2007. The Wall Street Journal article, "Faltering Family M.D.s Get Technology Lifeline," by Gautam Naik (WSJ, Friday, February 23, 2007, A1; online for subscribers at WSJ.com, here), profiles physicians who left hospital and large group practices to set up solo practices, because of their concern that physician-patient consultations were so brief and relations were so poor that the patients were not receiving adequate medical care.
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Contents for Issues of Medicine and Insurance
- Rationing
- Models of Delivery of Health Care
- Responsibility for Health
- Alternative Medicine
- Medical Insurance as Mortgage
Revised. February 23, 2007.
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