Editorial: The Underlying Value in Shades of Gray

As we go to (virtual) press with this issue, the legislative session in Olympia is in its final days for 2013. This means much of my focus for the past few weeks, and that of our Governmental Affairs Committee Chair Dr. Adam Geiger, has involved reviewing bills and monitoring political activity impacting our profession. So far, the number of relevant bills has been minimal this year – and most of our current political efforts involve more regulatory agencies than legislators and bills.

The language of legislation, and the laws that arise from it, are often the curious end product of a wide variety of formative factors. To say that a law is the product of a committee is an understatement. Bills are written and rewritten – often by individuals and groups with differing interests. Deals are struck to add and delete provisions, compromise is routine, and the final product is quite different from the original proposal.

All of this can produce laws that are implicit rather than explicit – with more shades of gray than distinct black and white. This can be confusing and frustrating. It can also be intentional and valuable, and that is what I would like to highlight: The importance of understanding and valuing the legal shades of gray that define our profession.

Over the last 20 years, the status of NDs in Washington has changed dramatically. We have expanded our scope of practice and prescriptive authority, are legally recognized as primary care providers, and have instituted a State Board of Naturopathy. However, our core statute, RCW 18.36A, is essentially the same law that was passed in 1987, and it is still relatively vague in many aspects of its language. In particular, this comes up in relation to ‘scope of practice’ and the questions that result as our doctors venture into new areas of the ever-evolving healthcare arena.

Why isn’t our law more specific?
It is understandable that RCW 18.36A can be frustrating for someone looking for explicit definitions. It is not written to be explicit –and we do not want it to be categorical, either. Here is why: Once a law or regulation begins to make specific provisions, it also sets a precedent for everything that is not specified. In other words, by defining what can be done, a law also defines what can’t be done. The chiropractic profession did this some years ago in Washington by putting into statute a list of approved devices. That certainly made things clear – at the time. But when new devices came on the scene, it meant the law had to be changed. Compare this with the practice acts for MDs, DOs and ARNPs, where there is little specification as to what is within scope and one begins to have a greater appreciation for our profession’s shades of gray. The ‘list approach’ is something our profession needs to avoid.

Questions about scope of practice issues have been occurring with greater frequency since the creation of the new Board of Naturopathy in 2011. When the board receives inquiries from doctors questioning whether a particular procedure can be implemented, the board is required to make a decision. The problem with this scenario is that the board relies on RCW 18.36A for guidance, along with assistance from state attorneys and staff who generally don’t know much about our profession. The risk in this process is that the board, with all good intentions and effort, may not have the time or interest to thoroughly investigate every question. The chance that they could reject and thus set a precedent that will limit future decisions for the profession is too great.

What’s the alternative?
This is where the value of having a functional and capable professional association becomes very important. The alternative to taking individual questions directly to the state board is to bring the questions to the WANP to collectively consider and explore how we as a profession comprehend new procedures within the context of our law. This is necessary because ND involvement as well as medical techniques, procedures and technology are constantly evolving. Currently, there is no definitive list describing what is within naturopathic scope in Washington, nor should one exist.

For some time now, Governmental Affairs Chair Dr. Adam Geiger has been interested in developing position papers to enable our doctors to practice preventative medicine to the full extent of their education and training. Such papers would include a clinical rationale and supportive research citations to provide a baseline for decisions made by the state board and regulatory agencies.

When an individual doctor takes an issue directly to the Board of Naturopathy or Department of Health, it is a bit like a young child going straight to their parents to ask permission for every new activity they undertake. This is certainly prudent in some instances, but it also a swift way to get rejected. Contrast this with a well-developed position taken by a recognized professional association and presented with the review and approval of the WANP board, and the likelihood of success increases dramatically.

Increased sophistication.
What I suggest we need is an increased level of political sophistication and awareness among NDs. Ideally, this will be coupled with increased membership and involvement in the WANP, because a robust membership makes our efforts possible, and our collective voice creates the most potential for future success in our profession. Greater involvement would also include an active role by those who have a question about scope of practice, or who are practicing in uncharted territory relative to where our profession has been. Bringing your questions and passion to the process will directly influence the development of position papers that are needed to advance the role of NDs in our healthcare system.

The development and evolution of our medicine is an ongoing, living process. Please help spread the word. If we commit to being collectively involved, we have a strong opportunity to create the future we want for our profession. Let’s build on our strengths by utilizing the structure and process of the WANP, and proactively considering the answers we want and the best way to support them before taking issues to the authorities. Creating one’s own reality can have many interpretations. But in this case, we do have the opportunity to impact how RCW 18.36A is interpreted and, as a result, shape how our profession will develop in the years ahead.

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