The elephant and the mouse: a little squirming can be dangerous.
Back in my youth that clever satirical magazine, Mad, was required reading for those who eschewed barbers. Alfred E. Neuman reassured us that what we worried most about probably wouldn’t happen anyway. Well, where is Alfred when I need him in my late boomer years? There are two developments, well intended by some of the players by their own declaration, but which are worrying me nonetheless. Even though Alfred E. Neuman would tell me not to, I am worried, for example, that we probably have to be in a bigger hurry now than before to build the natural medicine professions because mainstream biomedicine is at the gate yet again, this time with the proliferation of so-called "integrative medicine" programs around America. Coupled with this new regalia are the board certification efforts evolving from the merging of the AHMA (American Holistic Medical Association) and ABIHM (American Board of Integrative Holistic Medicine) united a while back. The new group, the AIHM (Academy of Integrative Health and Medicine) is training allopathic professionals in an holistic approach to medicine. It is encouraging that this group differs from its predecessors in that among its leaders are naturopathic physicians. Even so, as the French put it with their legendary Gallic shrug, are we seeing here the phenomenon, plus ?a change, plus c'est la même chose ?
And, I am worried too, but for quite different reasons, that public sector and larger non-profit higher education in the United States may scan the health care education terrain a little more closely these days and notice potential new markets. They may well be drawn to assimilate and modify, as many post-secondary institutions did with osteopathy, post-graduate naturopathic medical education programming, adopting some of the branding and traditions of our sector.
My Neuman metaphor is a little labored, I know ... but the mainstream medical allopaths are elephant-big and the mainstream post-secondary public secondary sector and non-profit private post-secondary sectors are equally elephant-big; juxtaposed, we have the mouse-sized naturopathic profession and the tiny network of naturopathic schools in North America.
First things first. Let us consider the monolith that is the biomedicine profession and industry in North America and how it can consciously or unconsciously squirm a bit sitting on a couch in the professional parlor and unintentionally squeeze off the tiny naturopathic profession also sitting there, despite section 2706 of the Affordable Care Act. Indeed, the key agency of biomedicine, the AMA, has been trying to contain and dissipate the naturopathic profession since Benedict Lust, Henry Lindlahr and other naturopathic pioneering colleagues a century and more ago faced fines, imprisonment and worse for their philosophical and clinical beliefs.
Going forward, AIHM board certification is aimed at a broad spectrum of professional health care providers; among them, MDs, DOs, DNPs, RNs, NPs, PAs, Psychologists, Nutritionists, Dietitians, DDSs, and RPhs. Even NDs, DCs and ND other natural medicine professionals are invited, although it would seem that recognition of scope by the mainstream must be at least one very strong reason why a natural medicine professional would want such certification. In any case, the AIHM is championing via a cross-disciplinary board a far wider inclusivity than say, Andrew Weil’s Arizona Center for Integrative Medicine has managed or perhaps ever intended. Imagine, naturopathic professionals invited to a gathering of allopathic medical doctors, American-style Doctors of Osteopathy, nurses, chiropractors, PA’s, acupuncturists, psychologists, pharmacists, energy healers, and more. Should the naturopathic profession be worried?
A close read of AIHM materials demonstrates a sincerity which is less threatening than the antagonistic behavior of the American Medical Association or the earlier silence of the ABIHM. Not once, though, have the leadership of the ABIHM or the AHMA been at our side in a state legislature when we are petitioning for licensure for NDs. It remains to be seen if the leadership of the AIHM will journey to Albany, Austin, Atlanta or Tallahassee to join our cause. The history of social closure in medicine teaches us that we must go forward confidently, with growing numbers in our back packs, and a safer spot on the couch where the allopaths are spread out. We must be clear about who we are and about how we are differentiated from what the integrative medicine leaders purport to be. Marketing and branding messages must be managed with care. Key political messages must be fine-tuned, savvy, transparent and strong.
Having long felt that we must hurry forward to form and build the profession in North Happily, we are now able to practice within a regulated environment in jurisdictions in North America where NDs can practice within a regulatory framework already (Alaska, British Columbia, Alberta, Saskatchewan, Ontario, Nova Scotia, Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Pennsylvania, Rhode Island, Maryland, Minnesota, North Dakota, Montana, Washington, Oregon, California, Utah, Colorado, Arizona, Kansas, Hawaii, Puerto Rico, the District of Columbia and the U.S. Virgin Islands). The number of practicing docs is growing. There are nine accredited programs in play (National University of Natural Medicine, Bastyr University [two programs], University of Bridgeport, National University of Health Sciences, Maryland University of Integrative Health, the Canadian College of Naturopathic Medicine, and the Boucher Institute of Naturopathic Medicine. Every year more progress.
In the middle of all this change and challenge during the coming months and years, our naturopathic educational leaders will have yet another consideration to keep top of mind. They will want to notice (with more realpolitik in those same back packs) how increasingly tough it will be to avoid slamming into the same branding language we have been keeping safe all these years, now in wide play by the integrative medicine community, whom I think are “clever rascals”.
This tension is subtle at the moment, although it already affects the connection of the AANP, the AANMC and other related groups in ways not yet fully clear, to the very institutions fueling membership pools. For example, as NUNM, Bastyr, NUHS, UB, and MUIH offer naturopathic medical programs within larger program mixes, our resolve to keep professional formation front and center will need lots of fuel. BINM, Southwest and CCNM remain single program schools, and although the complexities and challenges of a quite different higher education structure in Canada are factors here, these institutions may well entertain differentiated programming to meet the juggernaut of the allopathic profession opportunistically assimilating modalities long eschewed by their political and regulatory arms.
One powerful tool available to us to meet these challenges is to understand the looming possibility, a significant catalyst in fact, and that is the likelihood of a public sector university adding naturopathic medicine into its program mix. In this regard Hanna (2000) gave us an insight almost two decades ago on what can happen. He writes, “The university will be less inclined to base important decisions about programs and priorities strictly upon considerations of content and program quality” (p. 93) and more upon “what students, the adult marketplace, and the university publics generally say they want from their university.” Earlier Hanna set out what those new models would look like, basing them on analysis of trends observed in emerging organizational practice:
- extended traditional universities
2. for-profit, adult-centered universities
3. distance education/technology-based universities
4. corporate universities
5. university/industry strategic alliances
6. degree/certification competency-based universities
7. global multinational universities
(Hanna, 1998, p. 94)
Hanna’s notion of those trends and characteristics complement Berquist’s (1992) even earlier outline of the “four primary cultures within the academy” and, as Hanna points out, anticipate a fifth, an “entrepreneurial” one. Berquist’s taxonomy of cultures includes the following: managerial, developmental, negotiating, and collegial . Tierney (1998) adds to this valuable insight into higher education culture by pointing out the importance of “strong, congruent cultures” (p. 11) and by commenting about what constitutes “weak, incongruent, or disconnected cultures” (p. 13) in the higher education sector. Hanna’s discussion of “extended traditional universities” builds on the work of Berquist, Tierney, Clark (1983, 1998) and others and contemplates pretty much what has evolved in our time, and that is, a time of transformation when the “traditional, content-based organization and decision making within the university” (p. 99) will have to respond to a competitive higher education environment, one in which our naturopathic colleges and naturopathic programs in small, comprehensive universities will also have to thrive.
Whatever its forms along the way, the higher education culture has always attracted the naturopathic profession. College founders felt rightly that naturopathic medicine needed the affirmation and credibility of a university credential at the first professional degree level (requiring undergraduate preparation, especially in the basic medical sciences) and context. What is different these days is that instead of our yearning, like a stream for the sea, for the higher education community to include and welcome us as equals, they may very well overwhelm us with rapid assimilation. In the larger picture of professional formation, this will not be a bad outcome. In terms of specific schools, some of our naturopathic leaders report already feeling the shudders.
This has not always meant smooth sailing. For example, in Canada, although it has never fit directly into the higher education models in Ontario until recently, CCNM’s leaders propelled it steadily toward degree granting authority (rather than a diploma) by the provincial post-secondary authority (called the Post Secondary Education Quality Assessment Board) within the framework of 2000 Choice and Excellence Act legislation making it possible for some private career colleges to issue degrees. The chiros got there first, but CCNM got there too. Significantly, and part of the tension referenced above, Ruch comments that such hybrid institutions “have more in common with multi-campus, public, nonprofit universities than they do with traditional proprietary schools” (p. 24). The Carnegie Classification of Institutions of Higher Education (2000) provides a separate category for such institutions, calling them “specialized institutions” typically awarding “a majority of degrees in a single field”. The differences between our colleges, though, and public sector institutions do not appear to stem principally from our schools being nonprofit, private, and from public sector institutions being nonprofit, public. Rather, the essential differences issue from what Ruch (2001) calls the “language of accounting and the law and practices of taxation” (p. 25). In this regard, our colleges’ administrative and academic processes show a pattern of unrelenting movement toward a location in the higher education realm.
What is that realm really like? Most of our teachers and graduates have their own university experiences as reference points; however, also valuable to understanding where our naturopathic colleges are located in the larger development and purposes of the university in the United States and Canada is the wide range of literature about aspects of the nature and development of universities as institutions.
There is, for example, the relationship of the university to society (Partington, 1987; Belshaw, 1974; Niblett and Butts, 1972; Winchester, 1986). Within the university community there are issues of autonomy (Jones, 1996; Skolnik and Jones, 1992; Winchester, 1985; Sibley, 1983), differentiation and diversity in its higher education systems (Huisman, 1998; Baldrige, Curtis, Eker & Riley, 1977; Clark, 1996; Geiger, 1985, 1986, 1988,1991 ; Goedegebuure, Lysons & Meek, 1993; King, 1970; Patil & Taillie, 1982; Rhoades, 1990; Smart, 1978; Trow, 1995), and the matter of academic freedom (Bruno-Jofre, 1996; Shils, 1973, 1978; Russell, 1993). There is also the matter of governance and diversity in the university community (Huisman, 1998; Skolnik, 1986; Birnbaum, 1983; Jones, 1996) are also essential elements in understanding the development of the university and its attraction for our naturopathic schools. Related literature discusses the value of research (Boyer, 1991; Geiger, 1986; Clark, 1995; Schwartzman, 1984) and important issues of accountability (Hufner, 1991; Banta, 1993; Skolnik, 1994; Cutt; 1989).
Whether it’s the early leadership and success of research activity at Bastyr and NUNM and CCNM, we need in this multi-faceted environment to understand as much as we can about the nature and functioning of the larger universe of higher education in order better to comprehend why we’re doing what we’re doing, and to guide professional formation as carefully as we can in the rapidly emerging integrative medicine education complex manifesting in organizations such as the AIHM. As Altbach (1996) further comments, “In this complex environment and in an atmosphere of controversy about higher education, there is a great need for expert knowledge and data about all aspects of higher education” (p.1). The work of the AIHM is aimed at already licensed MDs and DOs principally, although this group welcomes participation by many professional cohorts. In this uncertain terrain we have to keep handy detailed memory of the record and accompanying behavior of the AMA and the allopathic profession historically during this transformation. The energy of program growth will propel more licensing of our grads and more grads making a living. Those sheer numbers will keep the allopathic monolith from shoving us off the bench or even because of its sheer size, flattening us the way it did traditional osteopathy in very recent history.
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