MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The German Heilpraktiker (a phenomenon vaguely equivalent to the ‘naturopath’ in English speaking countries) has become a fairly regular feature on this blog – see, for instance here, here, and here. The nationally influential German Medical Journal, a weekly publication of the German Medical Association, recently published an article about the education of this profession.

In it, we are told that the German Ministry of Health has drafted a 9-page document to unify the examination of the Heilpraktiker throughout Germany. The German Medical Association, however, are critical about the planned reform. The draft document suggest that, in future, all Heilpraktiker should pass an exam consisting of 60 multiple choice questions, in addition to an oral examination in which 4 candidates are being interviewed simultaneously for one hour. The draft also stipulates that Heilpraktiker may only practice such that they present no danger for public health and only use methods they muster.

The German Medical Association feel that these reforms do not go far enough. They claim that the authors of the draft have ‘totally misunderstood the complexity of the medical context, particularly the amount of necessary knowledge necessary for risk-minimisation in clinical practice’. They furthermore feel that the document is ‘an effort that is in every respect insufficient for protecting the public or individuals from the practice of the Heilpraktiker’. They also state that it is unclear how the document might provide a means to test Heilpraktiker in respect of risk-minimisation. The Medical Association demands that ‘the practice of certain therapies by Heilpraktiker must be forbidden. Finally, they say that ‘the practice of invasive methods and the treatment of caner by Heilpraktiker must be urgently prohibited’.

The German Heilpraktiker has been a subject of much public debate recently, not least after the ‘Muenster Group’ suggested a comprehensive reform. (I reported about this at the time.)

For those who can read German, the original article from the German Medical Journal is copied below:

Das Bundesministerium für Gesundheit (BMG) will gemeinsam mit den Ländern die Heilpraktikerüberprüfung bundesweit vereinheitlichen und Patienten besser schützen. Dafür haben Bund und Länder einen neunseitigen Entwurf erarbeitet. Die Bundes­ärzte­kammer (BÄK) zeigt sich angesichts der Pläne besorgt und übt deutliche Kritik.

Der Entwurf sieht vor, dass zur Überprüfung der Kenntnisse von Heilpraktikern künftig eine Prüfung verpflichtend sein soll. Diese soll aus 60 Multiple-Choice-Fragen bestehen, von denen der Anwärter innerhalb von zwei Stunden 45 korrekt ankreuzen muss. Darüber hinaus ist ein mündlicher Prüfungsteil von einer Stunde vorgesehen – bei vier Prüflingen gleichzeitig.

Zusätzlich stellt der Entwurf klar, dass Heilpraktiker nur in dem Umfang Heilkunde ausüben dürfen, in dem von ihrer Tätigkeit keine Gefahr für die Gesundheit der Bevölkerung oder für Patientinnen und Patienten ausgeht. Sie müssten zudem „eventuelle Arztvorbehalte beachten und sich auf die Tätigkeiten beschränken, die sie sicher beherrschen“, heißt es in der Präambel des Bund-Länder-Entwurfes, der dem Deutschen Ärzteblatt vorliegt.

Der Bundes­ärzte­kammer geht der Text nicht weit genug. Die Autoren der Leitlinie für die Prüfung haben laut BÄK „die Komplexität des medizinischen Kontextes“ völlig verkannt, „insbesondere das Ausmaß des notwendigen medizinischen Wissens, das für eine gefahrenminimierte Ausübung der Heilkunde notwendig ist“, so die Kammer weiter. Die jetzt vorgelegten Leitlinien für die Überprüfung stelle „eine in jeder Hinsicht unzureichende Maßnahme zum Schutz der Bevölkerung oder gar einzelner Patienten vor möglichen Gesundheitsgefahren durch die Tätigkeit von Heilpraktikern dar.

Es sei nicht nachvollziehbar, „wie auf der Grundlage dieser Leitlinien eine Überprüfung von Heilpaktikeranwärtern unter dem Aspekt einer funktionierenden Gefahrenabwehr erfolgen soll“, so die Kammer weiter. Sie fordert, dass Heilpraktikern bestimmte Tätigkeiten verboten werden. „Konkret sieht die Bundes­ärzte­kammer insbesondere den Ausschluss aller invasiven Maßnahmen sowie der Behandlung von Krebserkrankungen als zwingend notwendig an“, heißt es in der Stellungnahme.

Der Bund-Länder-Entwurf ist Ergebnis einer Debatte darüber, was Heilpraktiker dürfen oder künftig nicht (mehr) dürfen sollten und wie die Regeln für den Gesundheitsberuf aussehen. Eine Expertengruppe, der „Münsteraner Kreis“, hatte unlängst Vorschläge für eine umfassende Reform erarbeitet. Das Thema war zuletzt in der Öffentlichkeit und auch der Ärzteschaft heftig diskutiert worden.

END OF QUOTE

So, how well should alt med practitioners be educated and trained?

The answer depends, I think, on what precisely they are allowed to do. Medical responsibility must always be matched to medical competence. If a massage therapist merely acts on the instructions of a doctor, she does not need to know the differential diagnosis of a headache, for instance.

If, however, practitioners independently diagnose diseases (and alt med practitioners often do exactly that!), they must have a knowledge-base similar to that of a GP. If they use potentially harmful treatments (and which therapy does not have the potential to do harm?), they must be aware of the evidence for or against these interventions, as well as the evidence for all other therapeutic options for the conditions in question. Again, this would mean having a knowledge close to GP-level. If there is a mismatch between responsibility and competence (as very often is the case), patients are exposed to avoidable risks.

It is clear from these considerations that an exam with 60 multiple-choice questions followed by an hour-long interview is woefully inadequate for testing whether a practitioner has sufficient medical competence to independently care for patients. It is also clear, I think, that practitioners who regularly diagnose and treat patients – usually without any supervision – ought to have an education that covers much of what doctors learn while in medical school. Finally, it is clear that even after an adequate education, practitioners need to gather experience and work under supervision for some time before they can responsibly practice independently.

In any case, uncritically teaching obsolete notions of vitalism, yin and yang, subluxation, detox, potentisation, millennia of experience etc. is certainly not good enough. Education has to be based on sound evidence; if not, it is not education but brain-washing. And the result would be that students do not become responsible healthcare professionals but irresponsible charlatans.

Of course, alt med practitioners will argue that these arguments are merely the expression of medics defending their lucrative patch. But even if this were true (which, in my view, it is not), it would not absolve them from the moral, ethical and legal duty to demonstrate that their educational standards are sufficiently rigorous to avoid harm to their patients.

In a nutshell: an education in nonsense must result in nonsense.

 

9 Responses to How should alt med practitioners be educated and trained?

  • I think what Prof David Walker wrote in his report for the UK Government on the regulation of herbal medicines and practitioners is very relevant here:

    Practitioners

    Having taken into account the evidence available and the views of representatives of the sector, I consider that, despite strong calls by many for statutory regulation, there is not yet a credible scientific evidence base to demonstrate risk from both products and practitioners which would support this step. There is also very limited evidence of effectiveness of herbal medicines in improving health outcomes. This makes it difficult to establish the boundaries of good practice which would be required for both educational qualification and for the implementation of statutory regulation.

    The herbals sector must recognise that its overall approach (including the rationale for use of products and methods of treatment, education and training, and interaction with the NHS) needs to be more science and evidence based if in order to be established as a profession on the same basis as other groups that are statutorily regulated.

  • Dr. Ernst, I think you missed a “not” in the last sentence, the take-home message…

    But even if this were true (which, in my view, it is not), it would (not) absolve them from the moral, ethical and legal duty to demonstrate that their educational standards are sufficiently rigorous to avoid harm to their patients.

    Still, I fear alt med practitioners will all but take this message home… Self-righteousness is included in their (brain-washing) education. They are not only taught nonsense, but also to never let go of it.

  • , all Heilpraktiker should pass an exam consisting of 60 multiple choice questions, in addition to an oral examination in which 4 candidates are being interviewed simultaneously for one hour.

    Is the German Ministry of Health mocking the Heilpraktiker? If I remember correctly the examination for a trainee driver’s licence is more stringent in my province.

    It might be fun to record the one hour interviews which might turn into gladiatorial contests as the various candidates vigorously defend their favourite therapies.

    Would a national-level certification increase the “face validity” of the Heilpraktiker? If so, I’d think the idea could do some real damage to the health of the German population.

  • How should the following be educated and trained: alternative architects, alternative builders, alternative electricians, alternative gas fitters, alternative vehicle mechanics, alternative tyre suppliers, alternative aircraft parts suppliers, alternative Health & Safety inspectors, alternative Trading Standards inspectors?

  • So the question becomes:
    “What is it about healthcare that renders it susceptible to the ambitions of those who do not want to go to the trouble of qualifying for the practice they profess and wish to carryout (or for some reason are not able to) – notwithstanding that regulatory systems for healthcare professions have been established precisely to protect patients from fraud and foolishness?”

    As a corollary it can be noted that the term ‘quack’ originally applied uniquely to healthcare – there is no equivalent for alternative practitioners of other professions, unless ‘heretic’; ‘kaffir’; ‘unbeliever’; ‘un-clear’ etc are used for those professing alternative religions. At which point we really are getting metaphysical – and surely metaphysics cannot be regulated.

    It is essential for patient protection that it is clear whether or not a practitioner is registered as being qualified in a standard regulated profession, or not. If not, they should not be falsely regulated, and should be left to their imaginations. If patients are attracted to such practitioners, so be it – providing governments make the issues clear, and do not fudge in order to secure economic advantage. That would be tantamount to taking advantage of vulnerable and gullible patients.

    • I would suggest that the low monetary cost of entry and the fact that the healthcare field has enough “wiggle-room” in the regulatory climate that one is often not seriously constrained makes the area desirable for many.

      This probably does not hold for the true believers but I suspect it does for many such practitioners, even those who are not intentionally fraudulent.

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