Let's arrest the snaffling; a case of pilfered philosophy.

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What doesn’t kill a brand makes its stronger.

Fleur Brown (2/1/18)

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??????????? By and large the AMA and its Canadian counterpart, the CMA, consider Naturopathic Medicine to be, at best, a subordinate profession.? Some members of both contend that it is not even a profession if they think about Naturopathic Doctors at all. ?A few of the more skeptical and cranky among them don’t mind the moniker, medical quackbusters, such as Victor Herbert, Arthur Cramp, William Jarvis and Stephen Barrett, who were on alert about practitioners who knew little about disease etiology, much less healing protocols. Most conventional (sometimes referred to as ‘allopathic’) medical doctors, osteopathic doctors (at least the U.S. manifestation of that profession), mainstream nurse practitioners, and so on, are in the main disinterested, uninterested or both, since their livelihoods and professional hegemony don’t feel especially threatened. They know they are at the top of the healthcare hierarchy and that standardized knowledge and therapy, as delineated by them, have not, until recently, been challenged or questioned noisily.?

??????????? Naturopathic Medicine is heterodox, to cite Hans Baer (2022).? It took form in the early decades of the twentieth century.? Some MDs/DOs, critics claim, and especially in recent years, have been cherry picking or, at the very least, piggybacking on Naturopathic Principles and Philosophy.? By and large, though, it’s a good thing for patients that many current state budget projections of expenditure on conventional health care have questions like cartoon bubbles above proposed allocations.? It’s a good thing that pauses and disruptions in assumed protocols are getting aired.

??????????? The right of conventional medicine professionals to abscond with long practiced holistic therapies probably makes sense to them. After all, theirs is the orthodox profession in charge of most of the healthcare capital and cash flow arrangements in the land.? It makes sense, too, from the perspective of turf (which is what their advocacy and public relations mandates predicate their dominance on). To be sure, they got organized back in 1847 (in the era of ubiquitous blood-letting and heroic doses of unstandardized amounts of calomel ‘blue mass’ [mercury chloride] medical treatments).? Their chequered history, don't you know, , includes magnificent progress in dealing with acute presentation and over those same years in our understanding of the body, metabolic function, and the more pernicious aspects of chronicity. Of course they are at the top of the health care food chain.?

Today the AMA represents over 190 state societies and medical specialty associations (such as internal medicine, family physicians, obstetricians, gynecologists, emergency medicine doctors, and others). ?For most Americans, accessing medicine within the framework of CPT codes and ICD 10 means making appointments with conventional physicians; not with so-called "alternative and complementary" providers, licensed or not.??

??????????? Even so, things are not all rosy these days for the AMA.? For example, less than a fifth of the 1,341,682 physicians, medical students, residents and fellows in the U.S. today (250,253) are AMA members, of whom 22.5% are students and 24.7% are residents.?(Medpage, 6/2019.? Chris Vaughan (Sequence, May 2024) would beg to differ, documenting a “staggering 300% increase in membership” recently as part of the AMA’s “Members Move Medicine” campaign.? The numbers seem to be a moving target, the trends not up, or very much up, or some blend in between.

??????????? ?However, that is not our key observation here. What is concomitantly occurring, growth or no growth, is that there is unrest in the wheelhouse. For example, an increasing number of prominent, celebrity medical doctors are rethinking their training and wondering aloud about the long term effectiveness of the reductionist approach to health, a system which costs so much money, accompanied by diminishing returns. ?These and other, less visible MDs, comment publicly about how bolted they had been to an unchallenged hegemony of orthodox approaches to health care and promotion, so focused they have been on pharmaceuticals, heroic medical intervention, surgery and lucrative third party reimbursement.??? ??

??????????? They are going public about a new interest in natural medicine, and in the process have been scooping naturopathic philosophy, principles and practice. Likely, though, they don’t understand their behaviours as an opportunistic ladling out of goodies from the Naturopathic soup pot, an ethos which includes vitalism, holism, and natural protocols).? The ideas and practices they are discovering are, in fact, novel to mechanistic, reductionist biomedicine. Conventional providers go about their appropriations most likely unaware of the origins of their new ideas, ideas which aren’t new at all, actually.

? ‘Holistic’, ‘integrative’ and ‘lifestyle’ medicine approaches to care have long been the province of what Hans Baer’s ‘heterodox’ professions such as Naturopathy, Chiropractic, Homeopathy, Ayurved and holistic nutrition professionals, to name a few.?

??????????? Latecomer MDs (to non-reductionist ideas about what health is) get lots of bandwidth with their news, however.? Oblivious to the fact that many such approaches to care have been normal practice for NDs for over a century in North America alone, and for centuries in India, China and Indonesia and indigenous cultures globally, ‘holistic medicine’ or ‘integrated medicine’ clinicians are energized and renewed by this alternative path.? Their career trajectories, benefiting already from the orthodox grip on medicine and health care practice which the MD profession has developed over the decades (including a very large, quite sophisticated, well financed public relations engine and regulatory presence).? What? You mean I can get holistic care paid for in network and no out of pocket?

The stature of conventional doctors accords quick credibility to holistically-minded MDs and DOs as they go about producing and promoting services and products galore in the natural medicine field, a terrain heretofore eschewed and aggressively disparaged by their own medical associations and by the medical school curricula that prepared them for entry to practice in the first place and keeps their cash flow robust. ?

??????????? If we take a close look at its track record, the AMA has little or nothing to say about the epistemological bedrock of what some of their more holistically inclined colleagues are on about.? That recent publicity about metabolic disease, for example, derives from other professions doesn’t appear to corrugate their brows.? They are surprised, though, to learn that NDs actually know a great deal indeed about metabolic disease, about the perils of modified grains, about the massive and pernicious pandemic of harmful sugar and refined carbohydrate consumption in the food chain, about the escalating prevalence of chronic disease. And, boogey of them all, about over-consumption and default reliance on pharmaceuticals. ?Dr. Mark Hyman, MD’s, recent interview with Dr. Joseph Pizzorno, ND, about environmental toxins (Environmental Toxins: The Health Crisis you Can’t Ignore, Doctor’s Farmacy, July 17, 2024) is a case in point.

??????????? In this regard, NDs have long been the canaries, sounding not so subterranean alarms about these serious health problems affecting patients in care and health product consumers broadly.? NDs have been doing something about prevention (not understood as more testing, earlier) despite unrelenting, disparaging attacks by conventional medicine policy makers and regulators for over a century of the Naturopathic profession’s organized appearance in America from the days of Benedict Lust and Lindlarh, among others.?? ??

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The problem of the parallel problem

Alas, adding confusion and complexity to this mess, there is a parallel problem.? It is a conundrum padlocked to the persistent disrespect and escalating usurpation referenced above.? Naturopathic physicians themselves, in particular the substantially educated and trained, accredited, qualified and licensed ones around the world, have not been, until very recently, astute and practiced enough in claiming, much less declaring confidently and out loud, what they know and what they can do, and, into the bargain, what they are allowed to do. ?Truth be told, the recently developed World Naturopathic Federation has been tackling this challenge, as have international gatherings such as the International Congress on Naturopathic Medicine (since 2012). ?Largely, however, the public relations and media presence supporting these initiatives are slimly funded.?

?In the field, the causes and treatment of chronicity are on the minds of Naturopathic Physicians, many of whom are daunted by the immensity (time, money, focus) of the process of professional formation.? Contemporary NDs are under pressure in daily practice, especially in states where their scope moves inexorably toward primary care, and they experience the shove and drift toward disease care, rather than lifelong wellness.? Patients show up in their offices very ill indeed, but reimbursement doesn’t routinely follow for treatments aligned with the Naturopathic Therapeutic Order, nor does access to resources such as testing or hospital privileges which can help in that taxonomy of care.?? ????

??????????? There’s more which worries the Naturopathic profession.? The range, depth, quantity and persistence of Naturopathic Medical research into the effectiveness of traditional modalities is small compared to the massive reductionist and pharmaceutical investigations and publishing (and thus the public and political profile) of their allopathic colleagues.? Sheer numbers mean as well that Naturopathic clinical care is thinly spread within the largely orthodox, dominant allopathic market.? This lesser presence shows up in the urgent, cash flow and balance sheet challenges they experience in trying to delivery Naturopathic Medicine to patients.? Meanwhile, the Naturopathic profession continues to endure regulatory cuffs and bruises from the mainstream and from the shockingly ill-informed legacy media.? There are valuable standards espoused by Flexner and the Carnegie Foundation which continue to be the norm; however, there are outcomes to the hegemony of biomedicine which are unravelling.? The proscenium curtains of allopathic hegemony are getting thin, wearing out in places, fading in others; yanked at by outcomes data, cost, and growing patient awareness of the limits of conventional care in terms of lifelong wellness.? It’s time for integration, some cry.? What gets integrated and who lets the clutch of momentum in and out is a question which has many health care professionals crying, “enough, already” !

Enough is enough, ok

??????????? A sure way to do something about these imbalances and to step back and see what elements of the co-option of naturopathic modalities, protocols and philosophy by conventional medicine health professionals are sustainable, valuable for patients, and respectful for orthodox and heterodox health care professionals alike.? Meanwhile, Naturopathic Doctors and their new colleagues continue succeeding every day in producing natural medicine health care for more and more people. ?Word will get out about Naturopathic Medicine, Dr. John Bastyr, a Naturopathic pioneer was fond of saying.? In their current professional formation efforts, though, more attention seems to be paid by Naturopathic thought leaders, educational designers, associations and regulatory bodies to allopathic priorities (e.g. prescription rights) than celebrating and advancing more natural and traditional approaches to wellness (e.g. healthy nutrition, balanced lifestyle practices, hydrotherapy, botanical medicine, mind-body techniques) which eschew the automatic and profitable default to pharmaceuticals, high tech and surgical solutions.?

??????????? A valuable strategy, then, to boost the public image of the Naturopathic profession, is to report and celebrate more broadly and more often natural therapeutics successes.? This goal can be greatly helped by expanding the availability of the medicine.? It’s well and good that more conventional physicians are not defaulting so automatically to pharmacy.? It’s not so well and good that more Naturopathic Doctors are. Shifting into higher professional formation gear, though, can be accomplished by more NDs doing more, more often, in more places with traditional therapies.? Some thought leaders from the Naturopathic community suggest that adding thirty thousand new NDs in the next half century to the health care terrain is entirely doable and would go a long way to achieving this end.? They contemplate duking it out more ubiquitously in the health care terrain marketplace, calling attention to effectiveness and cost along the way, celebrating traditional modalities at the same time. ?The goal of more collaboration with MDs and American-style DOs, especially with those who are opting increasingly for ‘functional’, ‘lifestyle’, ‘holistic’ and ‘integrative’ protocols will help shift attitudes, practices and regulatory frameworks. Patients will love it.? Governments will love the reduced costs.

??????????? Perhaps so, some contend; however, diluting traditional principles and the uniqueness of Naturopathic philosophy must not be its price tag. A numerical goal of augmenting the population of NDs in the land to forty thousand or so would do wonders, if those NDs were consistently differentiated from the 1,500,000 MDs likely in full practice by then.? Even a smaller number might do the trick, since NDs are a community of health care professionals who, as John Weeks, the founder of the Integrator Blog, ?was known to declare, ?have historically punched well above their weight class.?

A seventy-five year mission:

??????????? Imagine: 23 new, programmatically and regionally accredited ND programs for a total of 30 in America (contrasting with the 154 medical schools and 41 Osteopathic medical programs); a quintupling of transactional Naturopathic research; a doubling of the number of states and provinces on the continent where NDs can practice without censure. ?The history of Naturopathic Medicine suggests that this is not an unrealizable dream. The successful track record of our programs and institutions in the higher education arena, most particularly since the late 1970s, is inspiring in this regard, despite some welts and bruising along the way.?That history, though, is not well known by our newest matriculating cohorts and has been forgotten by many of those who have joined the profession since the 1990s.?There is, for example, the story of how Western States Chiropractic College ditched its ND program when Dr. W.A. Budden died only to kickstart it into being again seven decades later.? At the time (1956) Drs. Spaulding, Stone and Bleything started over, founding NCNM, the ‘mother ship’, (now in its sixtieth year, officially assuming university status on July 1, 2016 in the State of Oregon).?Nor do those new ND students seem to know a lot about the 1978 founders of John Bastyr College (Dr. Bill Mitchell, Sheila Quinn, Dr. Joe Pizzorno, Dr. Les Griffith) or why JBC branded itself differently than its parent school, NCN, or how CCNM (then known as OCNM) got its start at the University of Waterloo the same year.?That JBC deliberately took the shape it did and grew to become a multi-program university in the State of Washington by 1994 is an important legacy to know about and to understand.? That CCNM is now the largest degree granting, post-secondary degree granting institution in the world is also now well known. ?

We need another pivotal year like 1978 ?

??????????? Soon came Southwest College of Naturopathic Medicine in 1992 in Tempe, Arizona. Then the College of Naturopathic Medicine at the University of Bridgeport welcomed students in 1997 and two years later, in January 2000, the Boucher Institute of Naturopathic Medicine began in Vancouver, B.C. ? Right after that Dr. Fraser Smith, a graduate of CCNM, became the founding Associate Dean of the Naturopathic program at National University of Health Sciences in Lombard, Illinois in 2006. ?

??????????? Other institutions kept up the momentum: Maryland University of Integrative Medicine (MUIH) hired Dr. Beth Pimentel to be its founding Dean with the goal of launching a new ND program in 2017.?As well, on the other coast, Dr. John Scarenge, President of the Southern California University of Health Sciences, retained Rita Bettenberg, the former Dean of Naturopathic Medicine at NCNM to guide the building of a new ND program in north Orange County, with a target opening of 2018. ?In 2023 CCNM merged with Boucher Institute of Naturopathic Medicine. And as mentioned above, by the fall of 2024, the University of Western States also launched its new ND program.

??????????? Neither MUIH in Laurel, nor SCUHS in Whittier, in the end were able to let the clutch out and Bridgeport University’s program closed, but interest in growing post-graduate naturopathic education did not wither despite the drop in post-secondary student numbers in America and the disruptions of the SARS-CoVid-2 era.? This very year, the Florida Naturopathic Physicians’ Association is actively developing a new ND program in the American southeast in partnership with a large university with an existing, significant medical program mix. Thus, a quarter way into our new century, there remain seven strong ND programs on the continent (Toronto, Vancouver, Seattle, Portland, San Diego, Tempe and Chicago). And one more likely to let the clutch out by 2026.

??????????? After Flexner (1910) and the demise of dozens of medical schools, among them Lust’s American School of Naturopathy in New York and Louis Blumer’s ill-fated College of Naturopathy in Connecticut, surviving stand-alone naturopathic programs and others in Chiropractic colleges such as NUHS and WSCC went through very tough times. ?Lately, ?we have regained an earlier momentum, this time on firmer ground.?The first seven ?modern ND programs, with no government start-up support, took just over five decades to stake out and hold territory in the world of accredited higher education.?The next seven, and the next seven after that will take much less time.?They will almost certainly show up in large non-profit private universities and in public sector institutions too this time, surfacing in pairs and clusters in different parts of the country, one after another.?Given demographics and the nature of regional health policy, especially in the wake of the U.S. Affordable Care Act and the surging interest in holistic, natural medicine, new programs are likely in Florida, New York,? Texas, Quebec, Colorado, Pennsylvania, and Georgia.?????

?????????Such growth, of course, will face the very high cost of starting modern post secondary programs. Start-ups are not for the faint of heart.?Hough (1992), in this connection, wrote persuasively over thirty years ago about the financing of higher education, pointing out that those who would support emerging professions and vocations would find the money to “keep pace with trends in student interests and numbers” (p. 1353).?Two years before Dr. Michael Cronin launched Southwest, Hufner (1991) was adding to the higher education literature about college finances by reminding academic leaders about another feature of financing colleges and universities, namely the growing “claim for accountability” in regarding public financing (for the private and not-for-profit sector this means Title IV and Stafford student loans) and concomitant services to the public in sustainable, affordable forms. These important trends were never lost on our early, prescient leaders. Spaulding, Pizzorno, Cronin, Warren, Wang, Sensenig, Smith, Vitale and Scaringe never once expected state and other public money subsidies of the kind which have given mainstream medical schools their huge leg up for so long.?They were aware, too, that non-profit private sector schools would be nipping at the gates to the post-secondary city, especially in terms of training allied health providers in ‘natural’ modalities to strengthen medical systems, make them more sustainable, and counter desperately dangerous chronicity rates threatening to cross well into the three billion dollar range in terms of annual cost.? ?

??????????? While building the first seven stable naturopathic programs decades after the heady, early years of the twentieth century when pioneers such as Lust and Lindlahr were so active, the later champions had to contend with not only the vulnerable state of educational finances in support of professional formation, but also with parallel and persistent expectations that the colleges would stay solvent and accountable to the profession.?In addition, there is the accumulating concern that our modalities and with them chunks of our identity are, as pointed out above, in danger of being sideswiped by integrative medicine programs and fellowships appearing with market precision out of the biomedicine complex.

?Financing post-secondary education is a delicate, high art

?????????In those same corners of the literature about the financing of higher education, there has long been an accompanying conversation about the difficult challenges of advancement and fund-raising as key revenue-generators for the higher education sector, including our corner of it (Fisher, 1989; Clark, 1998; Duderstadt, 2000).?Duderstadt, for example, explained two decades back, “It has been suggested that some universities, from a financial perspective, look more like banks than educational institutions, since their most significant economic activity involves managing their endowment investments and capital expansion” (p. 171).?Many ND leaders have been hard at work building advancement capacity, including choreographing modest endowment funds.?Significant progress has been made since the early 90s at?BINM, CCNM, BU, NUNM and Sonoran University regarding not only plant and property developments which have involved exactly such advancement efforts, but also program differentiation.? No longer are Naturopathic colleges settling for single-program offerings.? Using Naturopathic principles and philosophy as engines for curriculum development, new programs in nutrition, research, mental health and global health are thriving.?

?????????Also darting around the prospects for growing the profession is literature about the enormous impact of information technology, not only on related instructional costs and management and learning information systems, but also on the larger issue of funding those capital costs to sustain key instructional, operational and research strategies (Hanna, 2000).? Contemporary students learn differently than the passionate pilgrims of naturopathic medical education who assembled in Kansas in the mid-seventies, longing for a campus of their own. ?The yearning for Naturopathic medical education is strong and growing; the methodologies for delivery are transforming at breakneck speed.

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?The taxonomy of accountability we face

??????????? In addition to considerations of finance, the literature of higher education articulates a taxonomy of accountability across more than money matters.?Hufner’s “level-specific” and “function-specific” accountability model is quite useful for those in the naturopathic medical education sector.?Hufner has written a lot about the essential?characteristics of higher education, alongside lots of other descriptions and discussions pointing us at important variables which Naturopathic curriculum designers have top of mind.

?Hufner’s Function-Specific Accountability Model: starting new programs

·???????? Measured against the standards of recruitment and performance set out in the professional competency standards espoused by the AANMC

·???????? Measured against the credentials essential for faculty appointments as medical academics by the CNME accreditation body (teaching, research, learning)

·???????? Public accountability

·???????? Level of research activity, measured by publications and by percentage of the profession participation.

·???????? Reliability of curriculum outcomes as preparation not only for medical practice, but also for entry to practice via external licensing exams.

·???????? Financial solvency and reinvestment resources of the host institution.

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??????????????Against this complex backdrop of planning and expectations, how can we generate twenty-one new programs on this continent fast enough to hold our position in the emerging models of care? Because of the formidable and unforgiving cost, the length of time between announcing a program and attracting the first class, and between being eligible for candidacy and getting candidacy, starting new programs poised to solve these problems is more complex and expensive than it used to be back in 1956, 1978, 1992, 1997 and 2006, even though that is exactly what we have been doing (2024).?

??????????? Those programs are unlikely to be the stand alone, single program colleges we have been familiar with.?Rather, they will be programs within existing post-secondary institutions, perhaps non-profit and even for-profit. In this regard, the AANMC may well wish to promote program growth with equal enthusiasm in all three sectors:?non-profit, for-profit and public sector, as conversations grow about start-up modeling.?

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Let’s not rule out for-profit post-secondary institutions quite yet

It is highly probable that the CNME will be asked to review its preference for non-profit entities, not unlike the LCME’s having been challenged to accept for-profit D.O. colleges such as Rocky Vista University, with campuses in Colorado, Utah and Montana.? The Parker, Colorado school was founded and is owned by Yife Tien, COO of the American University of the Caribeean (AUC) located in St. Maarten, itself a for-profit, higher education entity.?Ross University operates an LCME accredited medical program in the Caribbean and has been successful in attracting high profile medical educational professionals including, some years back, the former Dean of Naturopathic Medicine from Bastyr University.

??????????? And, there is another variation in the private post-secondary arena, with some relevance for naturopathic medical education.?Geoffrey Cox wrote years ago enthusiastically about the “promising signs” that on-line instruction, in fact entire on-line university programs, [were] doable “with quality and integrity” (Cox, 2000).?He and his colleagues at Unext at the time predicted, long before Facebook and LMSs, the imminent strength of “technologies that emphasize the best pedagogical theories, such as asynchronous, on demand learning.”?Unext and Cardean were such for-profit, private institutions in the early days, more than twenty years ago, “There is nothing inherent about a for-profit structure that limits an institution’s ability to provide quality education” (Cox, 2000).? On-line learning is more prevalent than ever now, as we all know.

??????????? To achieve the numbers and persistence of new entrants to the profession will require leaders whose ideas of what Naturopathic Medicine needs to anchor itself in this rush of competition and assimilation are themselves embedded in its traditions and uniqueness.? Conventional medicine late adopters of natural medicine approaches to healing, prevention and lifelong wellness know a good thing when they see it.? We have our work cut out for us keeping up with our own past.? Looking back feels less scary than looking ahead, though.? ??

?REFERENCES

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Clark, Burton R. (1995).?Places of Inquiry.?Berkeley, California: University of California Press.

Cox, G. (November/December, 2000).?Why I left a university to join an Internet education company.?Change.?12 - 18.

Clark, Burton R. (1998).?The entrepreneurial university: demand and response.?Tertiary Education and Management,?4, No. 1, 5-16.

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Fisher, J. L. and Quehl, G. H. (1989).?The President and Fund Raising.?New York: American Council on Education, MacMillan.?238.

Gorostiaga, Xabier, S.J. (1999).?In search of the missing link between education and development.?In Philip G. Altbach, (Ed.).?Private Prometheus.?Greenwood Press: Westport, Connecticut.

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Hufner, Klaus.?(1991).?Accountability.?In Philip G. Altbach (Ed.).??International Higher Education: An Encyclopedia.?Volume I.?New York: Garland Publishing, Inc., pp. 47-58.

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