Two Roads in A Wood: it’s time to decide whither Naturopathic Medical Education

David Schleich, PhD

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I shall be telling this with a sigh

Somewhere ages and ages hence:

Two roads diverged in a wood, and I—

I took the one less traveled by,

And that has made all the difference

Robert Frost, 1916

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I got the crossroad blues this mornin’, Lord

babe, I'm sinkin’ down

And I went to the crossroad momma

I looked east and west

Robert Johnson, 1936

Those who frequent woods on hikes know that a crossroads is not the same as a road diverging, although they have some things in common.?When we need to get somewhere, though, we may be presented with one or the other on our journey. ?And if we need to get to where we think we’re going?fast, we might be presented with a conundrum whichever it is, particularly if we’re not quite clear about where the road we’re actually on has taken already taken us or predisposed us to a particular destination.?

Time to dig out our GPS if we have a signal out there and recheck that the final address we have keyed in is still our real destination or is even accessible from the point of divergence. With good data in hand, our choices can be neater, simpler, and clearer. Nevertheless, depending on whether it is a crossroads or a fork in the road, there?are?choices to be made: left, right, forwards, or backwards.?A wrong choice means we may not end up where we thought we were going or it may take us longer to get to where we think we are going.? ?

In this regard, not infrequently I’ve heard naturopathic medical colleagues talk about our being at a?crossroads?more than I’ve heard them say that we are at a?fork?in the road.?Most Naturopathic Deans would welcome a simple crossroads or fork in the road set of choices.?Their reality, though, looks more like a maelstrom of status quo, blended learning, biomedicine primary care, inter-professional certification, reclaiming nature-cure or even simple zeal for an exclusive, specialist niche in the face of heavy duty competition with conventional medicine and its derivatives of contemporary naturopathy, namely ‘lifestyle medicine’, ‘functional medicine’ or ‘integrative medicine’.

If we’re intent on going forward, or at the very least, have to go sideways, or even backwards, then choose we must.???Yogi Berra advised once that when we come to a fork in the road, we should take it; instead, I suppose, of wandering along choiceless and hoping for the best.?Such non-choice won’t be much help for naturopathic medical education as we head into the next half of the third decade of what not that long ago used to be a very new century, the profession’s second century if one considers Benedict and Louisa Lust to have been catalysts for the current iteration. If we go back further, say to Juste, Kneipp, Schroth or even Allinson.?

If we pause long enough to consider the options, any one of the four possible directions, depending on the condition and nature of the road, will rapidly impact where we end up.?The future could be friendly, or not.? The signs are worrying, the stakes are high, our patients await and we need a place in the landscape of health care design and delivery which is assured.?

Four choices at the juncture

Naturopathic medical education proffers choices at this stage in our professional formation journey.?Assuming that an urgent objective is to increase the trajectory of growth of licensable naturopathic doctors in North America before we get assimilated by holistically-inclined biomedicine professionals, and assuming that there is a concomitant strategy and accompanying effort to license a growing number of graduates, then the professional formation highway will be busier and busier. To accomplish the goal of being strong in the health care marketplace, strong in the regulated spaces of the health care professions, and strong in clinical and research effectiveness, we have to be busy in all three channels at the same time.

Historically, ND programs have begun in stand-alone institutions (NUNM – formerly NCNM, Bastyr University – formerly John Bastyr College, CCNM, Sonoran University – formerly Southwest College) or as programs within existing multi-program institutions?? (NUHS).?There no ND programs have been started in public-sector universities or colleges.?However, as some of the more noteworthy vestiges of the A.C.A. (remember the Affordable Care Act?) such as “medical home” and “integration” settle in for the long haul and the data accumulate about inflammatory food sourcing and the pervasive tangle of pharmaceutical intervention and worrying side effects, a public sector post-secondary launch is increasingly likely.? As the term “C.A.M.” erodes into disuse (complementary and alternative medicine – that is, complementary to and alternative to what, exactly), the entrance of vitalism into the fermenting, even churning debate about chronicity and metabolic disease is visible and inevitable.?That changes everything.?

Should a public sector institution ferret out that some form of “natural medicine - ?holistic medicine - integrative medicine” curriculum might well ‘complement’ formally its program mix in the form of a Naturopathic Medical program, then the competition would heat up visibly. They might not call it “Naturopathic”, but naturopathic it would be.? There are already public sector institutions on the lookout for areas of program growth in health education during their constant search for new tuition streams, bragging rights for research and innovation grant applications.? Their marketing scouts sniff the very real potential for assimilating existing curricula into the increasingly lucrative “integrative medicine” club.?The potential institutional paths are possibly these:

1. Continue to develop and offer programs in private, not-for-profit institutions.
2. Develop and offer programs in private, for-profit institutions.
3. Develop and offer programs in public institutions.
4. Develop and offer programs in all three: ?public and private, for profit and not-for-profit institutions.

The complex question of whether we, in the non-profit private sector, can afford to be active in all three channels at the same time is less urgent if a sustainably funded opportunity presents in one or more of these pathways at any one point soon.?If the cash flow is there, and the educational accreditation body (CNME) is ready to do the hard work of checking out capacity, quality and sustainability, the next cluster of questions among planners will be all about growing a concomitant national (or even international) cohort of qualified teaching and administrative personnel. Conventionally trained MDs, DOs, advance training nursing professionals will have more than content to rethink.? They will find themselves repurposing what they think health actually is.? The crossroad and fork metaphors can help us defog this many layered matter.?So, back to those notions for a bit to sort out the itinerary.?

Are we at a crossroads or not?

Let’s reflect on that frequently used, short perspective phrase, that?we are at a crossroads.?We hear this at conferences, in editorials, in book prefaces, in articles appearing in refereed journals or serial publications, in our naturopathic classrooms and outside those classrooms:?naturopathic medicine is at a crossroads. If we literally think of Robert Johnson, America’s King of Delta Blues, at the crossroads where legend has it that he made a Faustian bargain, exchanging his soul for mastery of the guitar, we can picture two roads intersecting (the myth is that where highways 61 and 49 meet up in Clarksdale, Mississippi, not far from the junction of the Mississippi and Yazoo Rivers, Johnson made his deal).? Just as Johnson’s legendary vocals and guitar skills ignited the pervasive influence of rock ‘n’ roll, we yearn for the day when naturopathy is the norm of healthcare, and not allopathic disease management systems.? His death was not reported for three decades.? We do not want to make any deals with biomedicine which obscure our demise for a generation.?The track record of biomedicine philosophy and andragogy dominating learning outcomes for, say, traditional American Osteopaths, or advanced training nursing professionals in some states, would alert us to take our chances on our own.?

Alright, let us conjecture that we’ve come upon yet another crossroads, where a different biomedicine thruway is looming.? There have been many in the history of professional formation as Abraham Flexner’s study settled into the post-secondary landscape. The well-trod thoroughfare of the allopathic medical professions (both the dominant and the subordinate ones) looks safe, well built, and continues to go somewhere.?It must be the best route since there are so many on it and the traffic moves unrelentingly, assumptions about validity, social closure and profitability well in hand.? It’s definitely a paved road with very few potholes. It is pretty straight, well signed and striped, two lanes in both directions; very busy indeed.?

Here we are, though, crossing it at right angles.?We may well be on a less travelled byway, in what’s left of the CAM road, and as luck and hard work would have it for those paying the toll, perhaps recently paved too, or, at the very least, with the gravel oiled.?If the former, it will have carefully demarcated center lines these days, because traffic is picking up.??A reliable road for naturopathic and other non-allopathic professional groups is robust in America (less so in Canada, some would argue, where regulatory organizations in B.C. and Ontario are providing traditional naturopathic practitioners with very different trip tiks). The work of the W.H.O. and the emergence of the WNF (World Naturopathic Federation), its organizing efforts at the 2012 International Congress on Naturopathic Medicine having materialized strongly, ?haves meant that naturopathy has had to brave less bumpier surfaces. ?

At such a crossroad, the naturopathic traveler would be well advised to listen closely to Johnson’s 1936 Vocalion record version before deciding to cross over and keep going, to turn right or left onto the bigger road, or even to turn back.?Listening to Johnson, our naturopathic travelers will hear the distress in the blues singer’s voice.??The distress might well derive from the pressure the choices themselves, attaching to the moment.?The driver may consider: cross the road when it’s safe, and keep going straight ahead, not tempted to get caught up in the Biomedicine throng roaring by. Or, naturopathic travellers may come to a full stop and exercise great care before dashing across.?

Then again, they may have decided to hang a right or a left before tromping down on the accelerator and ramping up to compete with whose travelers don’t much like being interrupted in their momentum. Then again, after that full stop, our naturopathic traveller may well opt to turn around the go back because there is no safe break in the traffic before him or the road ahead seems to lead in the wrong direction, or even nowhere at all, at least in terms of the foundational principles of naturopathy.

Supposing, though, that our naturopathic driver comes upon a fork in the road instead.?The choices might seem no easier on first blush.?Even though there presents a dimension of choice and chance, at least it boils down to right or left, but forward in both cases.?The easy aphorisms of the final two stanzas of Frost’s famous poem look more friendly than the Faustian crossroads possibilities Johnson faced.?While it is true that Frost and other writers (poets, philosophers) of his era are dismissed by some deconstructionists (who relegate poetry’s value to serving ideology) as “relics of a repressive society,” a close read of Frost’s 1916 poem, alas, suggests ontological and epistemological complexities of another kind which remind me so much of the identity travails of the naturopathic profession.

Both paths are in a yellow wood, both are leafy, and both seem similarly used, albeit by travellers who are increasingly less infrequent.?Our traveller, however, stands there, and not wanting to be stuck or to interrupt the journey, risks becoming inert and potentially getting nowhere.?At the same time, she doesn’t want to second guess herself later on, worrying about having made the wrong choice and losing, irrevocably, the other option.?The naturopathic traveler could always backtrack, but in the post-A.C.A. health care terrain where conventional medicine lately has been appropriating the principles and practices of Juste, Lust, Kneipp, Lindlahr and others , backtracking can be risky indeed.?What it boils down to, in fact, is that the road not taken is, once the choice has been made, the “other” path.?What would we have found along that other path??Robert Frost, ironically, indicates that he “shall be telling” sometime in the future that he “took the one less traveled by”.?Right; but we know from Frost’s own words that the two roads “equally lay/In leaves” and “the passing there/Had worn them really about the same”.?

Yikes.?So, to explode our poetic metaphor here into a naturopathic conundrum, the road we might describe later on as having been less travelled (because of our philosophy, restricted license, harassment by the property guards of conventional medicine, access to funding, or whatever) and thus the one we were on or was more familiar, comfortable and safe and thus we chose it, is actually a road which, at the time is equally traveled (or so the poem goes).??We may pride ourselves in taking the road “less travelled” and may say that that choice “has made all the difference”, but the truth is that we simply don’t know which is which and it may not be enough later on to claim that we screwed up our courage and took the less well beaten path of the health professions to our detriment.

There we have it.?Two metaphors which capture the vagaries and vicissitudes of our era.?Whichever road type we apply to the question, we are in a forest of naturopathic medical education; in fact, we are in an even larger wilderness of chronicity issues, exponential costs, professional competition and political ambiguity.?As we journey toward improving conditions and process clarity for professional formation, we have to make a choice because we’ve come to a crossroads or to a fork, metaphors for political, social, environmental and economic realities of the terrain we are traversing.? We may well find ourselves, as Theodore Roszak warned us to eschew more than a half century ago, in a place where we risk hugely assimilation; where on the well paved, well fueled, well signposted biomedicine highway we risk selling out. Despite the nomenclature, branding and claims, the medley of conventional medicine variations (lifestyle, functional, integrative) carries a cargo of reductionist priorities, its familiar and profitable insurance codes, as well as its rejoinder that evidence-based medicine rocks on.?

Perhaps it’s easier to avoid crossroad choices, whereas roads with forks can come up suddenly and unexpectedly.? Perhaps it’s easier to stay on our own road, trusting the old map of our philosophy and principles, wherever they may take us.? Turning back is tough.? We may have very little time (or patience) in our choosing one fork or the other, since both seem equally passable, but what lies beyond is unknown.?

It’s perhaps easy, too, to make the case that modern Naturopathic Medical Education is getting too frenetic.?This year more electives.?This year more attention to the dictates of primary care.?Traditional naturopathy is behind us, and not before us.?Our students and their clinical professors eschew homeopathy in clinical rotations.?Our state associations bear down on legislative efforts to augment a pharmacopeia, or to expand controlled acts.?With one eye on making a living and the other on the biomedicine profession whose integrative, collegial vanguards speak warmly of inter-professional collaboration at the same time as their AMA takes aim in every state legislature where we show up, our naturopathic medical educators have very difficult choices to make.? The health delivery landscape is complex, profitable and sharply competitive.? There’s only so much room on the road through.

Let’s consider short-termism as one way to mitigate this urgency.?The fear that our naturopathic medical education (curriculum content and methodologies) are not preparing our graduates for the post ACA universe in America has a long history.?Some contend that this drum is being banged louder and louder.? Do we add more biomedicine to our curricula at the expense of time spent on traditional approaches to health????Others contend that modern naturopathic medicine has to adapt or we risk losing relevance and market share.? Even as our teachers and researchers work very hard to address these tough questions, we still are left with the problem of capacity.? Capacity on many fronts:?school facilities, qualified faculty, skilled administrators, career and job placement.?The luxury of contemplating which way to turn doesn’t fit well into a tight budget year when keeping up with what we intend is second-guessed by thinking again, as if for the first time, about those intentions.?

Nevertheless, in the past two decades we have made unquestionable progress in naturopathic medical education.?Despite the forest of challenges around us, our people are motivated, better resourced than before, quicker on the uptake to address new issues, and committed to principles which the allopathic integrationists, certified lifestyle medicine practitioners and functional medicine doctors wish were second nature to them too.

There two other tidbits to consider in our reflections here.? First, I’ve gone to where those two highways in Johnson’s legend are supposed to meet and these days that crossroads is at least a half mile from the one that would have been around in Johnson’s day.? There are no actual crossroads.? Go figure.? The second is that I think Frost’s decision was taken without regret.? I have always admired Frost’s blend of idealistic monism, centered in spirit as it is, and scientific positivism (conventional medicine has long staked this territory) locked into the idea that our world is nothing but matter. ?I contend that his sigh (“I shall be telling this with a sigh

Somewhere ages and ages hence”) was one of relief, I reckon.

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References

Roszak, Theodore.? (1969). The Making of a Counter Culture: Reflections on the Technocratic Society and Its Youthful Opposition.? New York: ?Doubleday.

https://www.udiscovermusic.com/stories/devils-music-myth-robert-johnson/ ??Accessed: August 21, 2024.

Stanlis, Peter J.? (2008). Robert Frost: The Poet as Philosopher.? Wilmington, DE: ISI Books.?