Katherine Bell didn't anticipate she would be walking into the middle of an ideological battleground last April. She just wanted to schedule what she thought would be a routine appointment for an ultrasound to check on a possible ovarian cyst. The 44-year-old Bell had been experiencing irregular periods, and her naturopathic physician, Dr. Tonya Fleck, wrote a referral to have a scan done. But when Bell called Dominican's radiology center to make an appointment, the receptionist told her the center wouldn't honor any referrals from Fleck.

Bell was perplexed, so she called Fleck back and soon discovered that she was not alone. In fact, since February 2007, all referrals to Dominican radiology by naturopathic doctors in Santa Cruz County have been denied unless accompanied by the approval of a conventionally trained physician. What's more, the Dominican clinic had accepted the referrals in years past. And it was happening in spite of the fact that the Naturopathic Doctors Act of 2004 established a licensing system for naturopaths and includes a chapter stating that board-certified naturopathic doctors "may order diagnostic imaging studies" without any secondary referral.

The stream of rejections from this particular center—and the abrupt nature of it—raised a red flag with Fleck and her colleague Dr. Audra Foster, both of whom attended four years of naturopathic medical school and have been licensed by the California Bureau of Naturopathic Medicine.

It just didn't make sense. All other area medical facilities, including the Watsonville Hospital, the Community Hospital of the Monterey Peninsula and Stanford Hospital, accepted naturopathic referrals after being sent a copy of state law and a short explanation of what naturopathic medicine is all about.

After a series of phone calls and emails, Foster and Fleck discovered that Dr. Kenneth Averill, who has directed the Dominican Breast Center since 1999, was issuing the rejection orders. (Dominican Hospital uses the center as its radiology clinic for ultrasounds and mammography services. The center was founded in collaboration with the Radiology Medical Group of Santa Cruz County, of which Averill is president.)

Foster was the first naturopath to look into the motives behind the rejections, but Fleck soon agreed to help her get to the bottom of the anomaly. What they found was not an oversight or misunderstanding on Averill's part but an intentional decision not to honor their referrals.

"This whole time, I'm just assuming he's not aware of what a naturopathic doctor is or what the California licensing laws are," says Foster.

Averill says the decision to stop accepting referrals from naturopaths came solely from him with no input from Dominican Hospital officials. He says it was an ethical decision, not a legal one.

"A primary tenet of naturopathy is that so-called 'natural' treatments are preferable to drugs or surgery," Averill wrote in an email to Metro Santa Cruz. "A delay in treatment to try 'alternative therapies' puts a woman's life at risk. Ethically, I would be uncomfortable being a part of that process. This is my office, my practice, and I am responsible for maintaining the high quality of care our patients have come to expect from us."

Second Opinion

Naturopathic doctors operate under the philosophical assumption that the root causes of illness include diet, stress level and habitat, and that those factors should be addressed before drugs are prescribed to suppress symptoms. Herbs, vitamins, and other natural supplements are usually given before synthetic drugs, and touch-based diagnoses are generally used before more invasive X-rays.

Both Foster and Fleck say they regularly refer patients to radiology clinics and conventional medical doctors when they believe the patient's condition warrants it, or if the patient needs prescription drugs. Naturopathic doctors have no problem working in conjunction with the tools of Western medicine, the two say—they just try older techniques, borrowed from the traditions of Indian, Chinese, Hippocratic Greek and Native American shamanist doctors, first. Fleck and Foster insist it is a mistake to consider naturopathy in opposition to Western medicine, because a truly holistic approach to health care must incorporate all available medical techniques.

"We work hand-in-hand with MDs," says Fleck. "Oftentimes, many of our patients come in having primary care from MDs, or working with some other specific specialist, maybe an oncologist because they've had cancer or an allergy specialist because they've been dealing with allergies, and oftentimes Audra and I are on the phone with their doctors working hand-in-hand. We want that, that's the way we choose to practice. A lot of medical doctors appreciate that and are open to it."

Fleck is quick to note that the real issue at hand is Averill's refusal to follow state law and his misconceptions regarding naturopathic medical training. "In his emails he was starting conversations around whether we were medically trained or not to be able to order these," says Fleck. "We're not interested in engaging in that conversation; that's already been determined. It's determined by the law. The first two years of our medical school training very much parallels conventional medicine. We're based in prescription medications, we learn all the same basic sciences and we have to take national board exams."

Yet Averill, who has been practicing in Santa Cruz for 14 years, has a different interpretation of the law. While he admits the law clearly states naturopathic doctors may order X-ray, ultrasound, mammogram and other diagnostic imaging studies, he sees nothing in the legal language that says he must accept the referrals. However, he hopes to work out an agreement with the naturopathic doctors to accept the referrals with an MD signature attached.

"Mammogram results may reveal conditions requiring the attention of a physician, therefore we would routinely send a copy of the report to the patient's designated physician as well as the ordering naturopath," he wrote. "I have tried without success, through Internet searches and email communications with a local ND, to get a better idea of what specific training NDs have had with regard to breast cancer treatment. My impression is that it is minimal to nonexistent."

A Growing Field

In order to legally claim the title "naturopathic doctor" in California, applicants must have graduated from one of four certified naturopathic medical schools. However, not everyone follows this law. Many minimally trained naturopaths refer to themselves illegally as "doctors." The state bureau has attempted to stop this practice by writing letters to the offending individuals, but it doesn't always work. Enforcement mechanisms are weak and the bureau has a small budget that is mostly dedicated to issuing licenses.

Despite the continued presence of unlicensed naturopaths, state officials are doing their best to lend credibility to the properly trained practitioners in this growing discipline. The field of naturopathic medicine, despite drawing on centuries-old traditions, is relatively new to California and the United States. There are 14 states with official accreditation programs, and naturopath proponents in other states such as New York are working on bills that would implement similar programs.

Bill Bond, interim executive director of the California Naturopathic Doctor's Association, has watched the field grow over the past couple of decades, with 200 naturopaths receiving licenses in California. He admits there are problems that still need to be resolved. As often happens with newly popular market niches, there are a lot of unreliable providers offering their services, he says. Ubiquitous online "diploma mills" crank out people who call themselves naturopaths, but have such limited training that they often end up doing more harm than good.

Fleck has even heard of patients dying under the care of insufficiently trained naturopaths.

Since Fleck and Foster are both sufficiently trained in a wide array of medical techniques, Bond says there is no risk of any harm coming to their patients. They are legally mandated primary care physicians, he says, and should be afforded the same rights as MDs in terms of radiology clinic access.

"It's not like it's a gray area [of the law]," says Bond. "There are other things being challenged in the law now. For instance, the law says that naturopathic doctors can prescribe natural products and that they can deliver substances intravenously. That's being considered a gray area because people are concerned that once you start delivering something intravenously it becomes a drug per se. So there are areas in the law that are gray, but this certainly isn't one of them."

While the law may be clear for Bond, enforcement mechanisms are weak at best. The state bureau doesn't have jurisdiction over private hospitals, such as Dominican, and any legal action would likely be very costly and require the involvement of the attorney general's office. According to Bond, this leaves lawsuits as the main mechanism of enforcement, although he believes everyone would prefer to avoid that route.

In Santa Cruz, both sides seem ready to compromise, with both Fleck and Foster saying they hope to avoid filing any lawsuits, and Averill saying he will accept the referrals with an MD signature.

"We're not pointing fingers at anyone. This isn't about personal issues," says Foster. "That's not our interest at all. Our interest is to state the facts and be able to practice without negligence for our patients. I do gynecology. I have to order mammograms. We're not trying to heal disease with just herbs or our own intuition. This is hard medicine."

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