Monday, March 30, 2009

Standars of Care in Naturopathic Medicine

Standards of Care in Naturopathic Medicine

I. Introduction
A. The purpose for standards of practice is to:
1. Provide criteria that will provide guidelines for the daily practice of naturopathic medicine.
2. Identify to the public the responsibilities of the naturopathic physician and to give surety in maintaining public safety.
3. Ensure that the interests of public health are maintained.
4. Provide guidelines to state boards, licensing and federal agencies with which to evaluate professional actions.
5. Provide a template for newly licensed states to develop standards based criteria on licensing laws.
6. Provide assurance of uniform agreement among the naturopathic profession as to the principles and practice of naturopathic medicine.
7. Periodically review and, where necessary, modify standards of practice and care in order to assure public safety, compliance with public health standards and accommodate the ongoing advances in medical practice.

B. Definition of terms:
1. Standards: that which is established by custom or authority as a model, criterion, or rule for comparison of measurement.
2. Care: supervision, charge; in the care of a doctor.
3. Practice: the use by a health care professional of knowledge and skill to provide a service in the:
i. Prevention of illness.
ii. Diagnosis and treatment of disease.
iii. Maintenance of health.
iv. Service: to be of assistance, to render aid.
v. Standards of Practice: the established authority, custom or model by which the health care is delivered by the naturopathic physician shall include, but not be limited to:
a. Prevention of illness/disease.
b. Diagnosis and treatment of illness/disease.
c. Maintenance of health.
d. Standards of Care: the established model, criterion or rule by which the physician undertakes their supervision or care of the individual patient.

C. Naturopathic medicine is defined as follows:
1. Naturopathic doctors (NDs) are primary care physicians clinically trained in natural therapeutics and whose philosophy is derived in part from a Hippocratic teaching more than 2000 years old: Vis medicatrix naturae---nature is the healer of all diseases. Their practice is based on the same basic bio-medical science foundation that allopathic practice is; however, their philosophies and approaches differ considerably from their conventional counterparts. Naturopathic physicians diagnose disease and treat patients by using natural modalities such as physical manipulation, clinical nutrition, herbal medicine, homeopathy, counseling, acupuncture, and hydrotherapy, among others. They choose treatment based on the individual patient, not based on the generality of symptoms. This approach has proven successful in treating both chronic and acute conditions.
2. The six principles that guide the therapeutic methods and modalities of naturopathic medicine include:
a. First Do No Harm - primum non-nocereNaturopathic medicine uses therapies that are safe and effective.
b. The Healing Power of Nature - vis medicatrix naturaeThe human body possesses the inherent ability to restore health. The physician's role is to facilitate this process with the aid of natural, nontoxic therapies.
c. Discover and Treat the Cause, Not Just the Effect - tolle causamPhysicians seek and treat the underlying cause of a disease. Symptoms are viewed as expressions of the body's natural attempt to heal. The origin of disease is removed or treated so the patient can recover.
d. Treat the Whole Person - tolle totumThe multiple factors in health and disease are considered while treating the whole person. Physicians provide flexible treatment programs to meet individual health care needs.
e. The Physician is a Teacher - docereThe physician's major role is to educate, empower, and motivate patients to take responsibility for their own health. Creating a healthy cooperative relationship with the patient has a strong therapeutic value.
f. Prevention is the best "cure"Naturopathic physicians are preventive medicine specialists. Physicians assess patient risk factors and heredity susceptibility and intervene appropriately to reduce risk and prevent illness. Prevention of disease is best accomplished through education and a lifestyle that supports health.

D. Scope of practice:
1. The scope of a naturopathic physicians practice is eclectic and dynamic in nature.
2. The naturopathic physician is trained to understand and utilize a wide variety of therapeutic modalities and selects the treatment that in their opinion, best serves the patient's condition.
3. The types of therapeutic modalities a physician may choose from include, but are not limited to:
a. Acupuncture [with additional certification]
b. Botanical medicine
c. Clinical nutrition & nutritional counseling
d. Electrotherapy
e. Homeopathy
f. Hydrotherapy
g. Light and air therapy
h. Massage therapy / neuro-muscular technique
i. Natural childbirth [with additional certification]
j. Naturopathic manipulative technique
k. Orthopedics
l. Physical medicine
m. Psychotherapy and counseling
n. Soft tissue manipulation
o. Surgery
p. Use of appropriate pharmacological agents

4. The naturopathic physician is obligated to keep up with the changes in medicine, which may be accomplished through continuing education seminars, preceptorships, post graduate study, internships or residency programs (see education section VII A).

5. In the event the physician belongs to a specialty society, they are obligated to maintain the standards of education set by that society.

6. The naturopathic physician has an obligation to critically and without bias evaluate new therapeutic agents and methods that may be of benefit to their patients.

7. The naturopathic physician is encouraged to continually evolve his or her manner of practice of health care in order to provide increased benefit to his or her patients.

E. A naturopathic physician is trained to be a primary care physician that specializes in natural medicine. Individual physicians may choose to specialize in certain methods, modalities or areas of practice within the scope of a general practice. In those instances the physician is obligated to:
1. Notify the patient and colleagues of the nature of any such practices and any limitations to such stated modalities and/or therapeutic approaches.
2. This may be accomplished by notification at the time of first visit; on the physicians letterhead or business card; or by advertisement.
3. Any physician who has a limited practice is obligated to make appropriate referrals if requested by the patient or deemed necessary by the physician.
4. A naturopathic physician trained as a primary care, family practice physician may choose to emphasize or specialize in a specific area either singly or within the scope of a general practice.

F. Code of ethics: See guidelines

G. Naturopathic physicians are trained as primary care natural medicine physicians and have a responsibility to the patient to provide the best health care available. The patient can expect his or her health care to include some or all of the following:
1. Thorough history and appropriate physical examination
2. Appropriate laboratory and radiographic analysis
3. Accurate diagnosis
4. Lifestyle and risk assessment
5. Diet and nutrition analysis and counseling
6. Preventive medicine programs
7. Appropriate follow up
8. Appropriate referral when necessary

H. Patients are entitled to:
1. Expect the physician to comply with state, local and public health guidelines by naturopathic physicians.
2. Receive treatment with respect and dignity.
3. Be treated with respect for privacy.
4. Receive honest and ethical treatment.
5. Confidentiality.

I. The American Association of Naturopathic Physicians through its membership and House of Delegates is responsible for the development, on going review, modification and implementation of standards of practice and care. These shall be subject to review every 5 years or at the discretion of the Board of Directors.

II. Patient Evaluation
A. Record Keeping
1. All naturopathic physicians should keep clear and concise chart notes documenting patient care.
2. It is important that the record be legible, orderly, complete, and that abbreviations/symbols employed are commonly used and understood.

3. There are several important reasons for keeping charts, which include:
a. Documented visits to assure optimal on-going care.
b. Documented communication with other health care professionals.
c. Use in clinic or office research.
d. Important administrative and legal documents.
e. Basis of a peer review process.

4. It is recommended that the Problem Oriented Medical Record, also known as the SOAP format, be used as the standard form for keeping records.

B. Types of data collected; and whom it may be collected from:
1. The individual affected (patient)
a. Family, friends.
b. Medical records may be obtained from previous physicians, or other health care providers for the purpose of patient evaluation.

2. Subjective: The History: a written record of the patient history should include the following. Patient intake forms may be used for these purposes and should contain:
a. Identifying data: name, age, sex, relationship status, and occupation.
b. Chief Complaint: recorded in the patients' own words and a priority from most to least important may be assigned.
c. Present illness: state the problem(s) as it is at the visit, clarifying the time course in a chronological manner. Include any concurrent medical problems.
d. Past Medical History: previous illnesses, surgeries, medications, hospitalizations, childhood illnesses, accidents or injuries, and pregnancies.
e. Current Health Status: Allergies (drugs, food or inhalant), current medications and supplements (prescription and OTC), immunization history, tobacco, alcohol or recreational drug use, exercise and leisure activities, sleep habits, diet (breakfast, lunch, dinner, snacks), disease screening and environmental hazards.
f. Family History: diagramming familial tendencies, genetic predispositions and infectious diseases.
g. Psychosocial: Brief biography, family/home situation, occupation, lifestyle, emotional make-up, stressors, and typical day’s events.
h. Review of Systems: Placed in a structured system-by writing out the positive findings and the pertinent negatives.

3. Objective
a. Physical exam, mini mental status exam, and lab findings. A standard format includes: patient’s general appearance, vital signs and the results of the focused or comprehensive examination.
b. Results of laboratory studies completed during or soon after the patient visit may be included.

III. Diagnosis

A. In the establishment of the diagnosis, the naturopathic physician may utilize the following types of diagnostic criteria:
1. Conventional medical diagnostic criteria.
2. Other diagnostic criteria may be used, including those of non-western medical traditions such as Ayuvedic, Traditional Chinese, etc.

B. All diagnostic criteria must be consistent with other health care disciplines that utilize the same criteria.
1. The physician may use a combination of conventional and other diagnostic methods.
2. Any physician utilizing diagnostic criteria which are other than conventional and/or experimental is also encouraged to apply conventional forms when:
a. Another health care provider is also evaluating the patient for the same or a related condition, in order to maintain continuity among the different disciplines of medicine and to assure quality patient care.
b. When faced with a life threatening or degenerative illness when there is the possibility that interventional therapies may be needed.
c. The physician knows that the patient will need referral for the same or other illnesses.
d. At the patient's request.
e. As required by state laws.

IV. Plan
The naturopathic physician develops a specific written treatment plan for each patient that is:
A. Rational:
1. Based on identified needs.
2. Realistic in its goals.
3. Practical in light of the patient's condition and situation.
4. In the best interest of the patient.
5. Logical in sequence and internally consistent.
6. Prioritized to the patient's most pressing conditions.
7. Compatible with other therapies the patient may be undergoing.
8. Cost effective.
9. Flexible to accommodate new developments/ findings.
10. Experimental only with informed consent and only in areas of doctor expertise.
B. Based on proper assessment, including:
1. Ruling out / identifying life-threatening or hidden conditions with appropriate history, examination and testing, including referral for specialized evaluation, when appropriate.
2. Allowing for timely on-going reassessment.

C. Based on naturopathic principles including:
1. Stimulating the patient's vital force to promote healing or, in special instances, supplementing or replacing the action of the vital force when the patient is unable to respond to curative treatment.
2. Removing the cause of conditions, when known.
3. Choosing treatments that pose the least risk of patient harm.
4. Individualizing treatments to the whole patient, including referral to appropriate adjunctive health resources for specialized therapies.
5. Educating the patient to participate responsibly in his or her own health care and to learn principles for building of health and preventing future disease.
6. Involving, when appropriate, others significant to the patient in the treatment plan.
7. Prevention of disease.

D. Self-critical:
1. A mechanism for timely evaluation of plan effectiveness.
2. A mechanism for timely modification of failed plans, including referral to other appropriate practitioners.
3. Appropriate intervention with conventional pharmacological agents when necessary.

V. Assessment of patient’s progress
A. Responsibility
The physician, in concert with the patient, ultimately determines progress. Family members may be involved, with patient permission, in assessment of progress, and may be consulted by the physician to aid in these determinations. Although final assessment must rest with the physician, this is only meaningful when the patient understands and accepts the advice of the physician. If the patient disagrees with the physician over assessment of progress, which cannot be resolved by the application of objective criteria, the patient should be encouraged to seek a second opinion.

B. Development of the Assessment:
1. Assessment of medical progress includes two aspects; the subject and the objective. It is expected that the physician will use both aspects of assessment of the patient’s progress when appropriate. Subjective evaluation of assessment is primarily the determination of the patient: Such assessment is solicited and recorded by the physician, and is a gauge of progress.
2. Objective measurement of progress occurs in several forms. The first form is in determining the restoration of function or decrease in symptom. This assessment can be done by physical measurements, function scales, etc. Another method is by laboratory or radiographic analysis.
a. Objective assessment of progress is the use of conventional diagnostic and laboratory methods. These should be employed when necessary, at the discretion of the physician.
b. Objective assessment may also include the traditional or empirical such as pulse, tongue, iris, reflex point, or whichever of the traditional methods the physician employs, including experimental as supplemental to objective assessment methodologies.
c. A fourth kind of objective assessment would include the experimental forms. Physicians experiment with methods of assessment, as appropriate. Experimental methods should be used in conjunction with conventional and traditional methods of evaluation. (See guidelines for education and research.)
3. Assessment: The assessment should begin with an “abstract” of the history and physical, recapping the findings in a way that supports the differential diagnosis or working diagnosis. Included should be some explanation of the analysis and reasoning that went into the decision. This may include:
a. The type of care needed, including immediacy, acute, chronic, long or short term.
b. A discussion of naturopathic considerations including Tolle Causum, Vis Medicatrix Naturae or Vital Force.
c. The patient's ability to respond to treatment should also be assessed by the physician. The judgment is based on past medical history and the physician’s subjective assessment.

C. Physician Response
1. A patient's progress measured against the physician's prognosis will determine the physician's response to treatment.
a. If assessed progress is deemed appropriate, the treatment plan should be continued. Treatment might be discontinued when sufficient progress had been achieved, or revised, based upon the patient's response.
b. Lack of appropriate progress could indicate the need for reevaluation of the treatment plan, or it may indicate need for reevaluation of the condition or underlying basis of the condition being treated.
c. In cases where no progress is made, at some point the determination to refer the patient for consultation with another physician may be necessary. This prerogative always lies with the patient, but is also the responsibility of the physician. If the physician determines his or her treatment plan has reached the limit of time or expertise, or is endangering the well-being of the patient, and after which no further progress could be expected, referral is appropriate. The timing of this determination is based in part upon the prognosis in the patient's case. It is assumed that a referral for this purpose will be made in a timely manner, to preserve the health of the patient.

VI. Patient Participation in Health
A. Patient's Rights: recognizing that patients are inheritantly responsible for their own health, the naturopathic physician is committed to the patient’s right of:
1. Informed consent.
2. Having all information provided for them to make informed and educated decisions.
a. The naturopathic physician is obligated to present the patient with all the options for medical care in an unbiased manner.
b. The physician has the right, and may choose to express their opinions as to the quality of the different types of health care options, or if requested to by the patient.
3. Freedom of choice in health care.

B. Choice of medical care is understood to ultimately be that of the patient.
1. Recognizing that the decision for treatment is ultimately the patients.
2. Although the input of the physician is crucial in treatment decisions, he or she is strongly encouraged not to make the choice for the patient.

C. Physician's role in patients illness is to:
1. Provide guidance to the patient, which may include the use of printed educational or informational materials, counseling or referral to appropriate agencies.
2. Provide optimal care, which may include referral to institutions or physicians who can better provide those services.
3. Inform patients of their progress, through family or individual conferences, periodic or yearly evaluations, by letter or phone consultation.
4. Refer patient if no progress is being made in their treatment after a reasonable length of time.
5. Change treatment protocol based upon reevaluation of the case.

D. Appropriateness of Patient Participation
1. The naturopathic physician encourages patient participation in their own health care as it is recognized that such participation leads to better compliance and a faster recovery.
a. The physician must assess whether the patient has the ability to participate; this assessment should include:
i. Ability of the patient to understand the nature of the illness.
ii. Ability of the patient to understand the medical options available and their consequences.
iii. The patient's mental status.
iv. Ability of the patient to make an informed consent.

E. Setting Priorities and Goals
1. Determination
a. The physician, patient or a combination of both may set the goals and priorities.
b. If in the opinion of the physician, the patient makes a choice that may be harmful, the physician may:
i. Refuse to participate further in the health care of the patient. This is accomplished both verbally and in writing.
ii. Refer the patient to another physician.
2. Family Participation
a. Family members may participate at the discretion of the patient and physician.
b. In the event that the patient is unable to make choices for themselves or participate in their health care, their spouse, parent, eldest or designated child or court appointed guardian or advocate may participate on their behalf.

F. Revising Treatment Plans
1. Treatment plans should be reviewed at periods determined by the physician. These commonly occur at each visit but should be reviewed in the event the patient fails to progress.

VII. The Role of the Naturopathic Physician in Health Promotion
A. Prevention
1. Naturopathic medicine emphasizes the prevention of disease. This is accomplished through education and the promotion of healthy lifestyles. The naturopathic physician assesses risk factors and hereditary susceptibility to disease, and makes appropriate interventions to prevent illness. Naturopathic medicine asserts that one cannot be healthy in an unhealthy environment, and strives to create a world in which the individual may thrive (see the Definition of Naturopathic Medicine).
2. Naturopathic physicians therefore have a wellness orientation.
a. Encourage the individual towards independence and self-direction.
b. View health optimization as the ultimate goal rather than crisis intervention.
c. Assist the individual to identify, testing out, and evaluation of constructive patterns of living.
d. Reinforce positive behavior patterns.

B. Public health
1. The naturopathic physician follows the guidelines of the public health service.
a. Reporting diseases, including observing and being subject to all laws and regulations relative to reporting births and all matters pertaining to the public health with equal rights and obligations as physicians and practitioners of other schools of medicine.
b. Keeping up with public health data.
i. Center for Disease Control updates.
ii. State health department updates.
c. Informing the public of health policy.
2. Methods by which prevention and maintenance of health may be achieved.
a. Employ a variety of naturopathic interventions to assist individuals to achieve their optimum health.
b. Periodic screening for common risk factors such as:
i. Elevated serum (blood) cholesterol
ii. Hypertension
iii. Obesity
c. Periodic screening for specific diseases such as:
i. Cancer
ii. Coronary artery disease
iii. Diabetes
iv. Glaucoma
v. Osteoporosis
vi. Thyroid dysfunction
d. Immunization
i. See AANP position paper
ii. Informed consent
e. Preventive methods
i. Natural foods diet, allergen avoidance
ii. Antioxidants
iii. Quality air and sunshine
iv. Avoidance of environmental hazards (sunburn, fluorescent lights, VDT's, etc)
v. Hygiene and sanitation
vi. Elimination of body wastes (optimizing bowel function, etc)
vii. Exercise and posture
viii. Botanical and homeopathic medicines
ix. Stress reduction and management
x. Mental hygiene
xi. Self actualization
f. Health education
i. Identify the learning needs of the individual.
ii. Use appropriate teaching techniques to meet the individual's learning needs.
iii. Evaluate the teaching carried out.

VIII. Guidelines for Education and Research
(These recommendations do not supersede established state guidelines.)
A. Continuing Education Recommendations
1. Continuing education shall be recommended of all naturopathic physicians, including those who practice in unlicensed states. The physician should complete a total of 30 hours which may come from the following sources:
a. Professional level courses which pertain directly to the medical aspect of naturopathic practice.
i. These include approved C.E. hours in licensed states.
ii. Business courses are not applicable.
b. Independent study which includes preparation time for those who teach medical students or for professional level courses. This does not include public talks, preparation time for handouts or visual aids.
c. Group study with case review, one hour for every three hours.
d. Preceptorships with licensed physicians or institutions, one CE for every three hours.
e. Involvement with examination writing, cut scoring, review and research, one CE for every three hours.
2. Each physician shall keep a record of continuing education activities.
a. This may be done by the state Boards of Naturopathic Examiners.

B. Research Guidelines
It is recommended that guidelines are:
1. Clearly explained to the patient verbally and in writing and include:
a. What the protocol involves.
b. What other treatment options exist.
c. The length of time of the protocol.
d. The level of safety/risks of the protocol or its individual parts.
e. The cost of the protocol.
2. The studies must be humanitarian in that they do not knowingly or by neglect cause bodily harm or significant emotional harm to the participants.
3. Review of the study to determine the potential for harm.
a. The review committee shall consist of three or more physicians or specialists in the related field(s) which shall review and approve the study.
b. At least one member of the review committee shall be knowledgeable in the area of research design.
c. The physician in charge of the study shall be responsible for obtaining approval from an appropriately qualified review committee and for keeping written documents of their approval until completion and publication of the study.
4. Documentation of Research
a. Case studies: documentation follows standard charting procedures. It is recommended that case study protocol and their results be kept on file so that they may be used for providing the basis of further study and research. Charting should include careful and detailed follow-up.
b. The following documentation is recommended for formal research studies:
i. Statement of purpose.
ii. Summary of pertinent literature review.
iii. Study design and protocol.
iv. Screening requirements for participants.
v. Participant consent forms.
vi. Analysis of methods.
vii. Raw data.
viii. Data analysis and conclusions.

C. Critical Review of Studies and New Methods
1. Introduction: Critical review of new methods in medicine need to take into account any potential for causing harm to the public. The naturopathic medical profession endeavors to avoid unnecessary judgement of new methods and theories but rather to review them critically, embracing those which stand the test of time and scientific scrutiny.
a. Peer review - as per section VIII B3.
b. Peer review infractions:
i. In the event that a physician conducting a case study or formal study protocol does not meet the guidelines under section VIII B., the Research Review Committee (RRC) of the AANP may undertake a review.
ii. The RRC may notify the physician that they are in violation of the research guidelines and may take other actions as appropriate.

D. Publication
1. There are no additional standards for publication of research in naturopathic medicine other than those that already exist. Articles submitted to the different publications, including the Journal of Naturopathic Medicine, shall follow the guidelines established by those publications.
2. The naturopathic physician is strongly encouraged to publish the results of any research conducted. For those physicians who are conducting clinical trials with unproven or marginally proven therapies or diagnostic procedures, the profession of naturopathic medicine considers it crucial that the results of their studies be made available for other physicians to examine in a critical and unbiased manner.