Governance Is a Team Sport in the Naturopathic Medical Education World
David J. Schleich, PhD
Our naturopathic educational leaders work very hard to strengthen and expand the fundamental building block for professional formation, namely, the seven programs in the Association of Accredited Naturopathic Medical Colleges (AANMC) system. Growing the number of NDs in North America who can establish long-term practices means that establishing naturopathic medicine irrevocably in every state and province on the continent will happen. The current concern that the biomedicine and allied healthcare professions are presumptuously eroding the place of NDs in the rapidly emerging “integrative medicine” landscape can be countered powerfully with numbers.
As we propel this mission, though, more often than not those same leaders feel that they have to move faster to stay in the same place. Despite the increasing frequency, urgency, and duration, some contend that everything—from Council on Naturopathic Medical Education and regional accreditation reports to the funding of a naturopathic research agenda and residency education opportunities—progresses inches rather than catapults ahead. Costs rise, competition nips and gripes at the gates of the city, and states like Maryland and Iowa this very year said no to regulation. Yikes.
Even so, we stay the course. Along the way, we become more agile in the doing. On that common journey, though, we would be wise to join forces more strategically. One sector of our educational community who likely can help do more of the necessary capturing and sharing in the face of the competitive terrain before us are the governing bodies of our AANMC schools and programs. These professionals are uniquely positioned within our schools to be catalysts in the critical and broader strategy to establish the medicine in every state and province on this continent. Currently, though, those governing bodies of our colleges and of the universities that house naturopathic programs have had no historical formal way to systematically talk to each other. The same is true for routine contact by them with the nonprofit mutual associations within whose frameworks their graduates develop careers (e.g., American Association of Naturopathic Physicians, Canadian Association of Naturopathic Doctors, Council on Naturopathic Medical Education, and the dozens of state and provincial associations). Whereas the national voluntary medical associations in both countries (the American Association of Naturopathic Physicians and the Canadian Association of Naturopathic Doctors) have provided some needed elements of that role for many years, the time has come for the academic arm of professional formation to form up and play a newly aligned, coherent, and prominent role. Finding a place for NDs in the transforming healthcare landscape is one very important objective; securing a place for NDs in the higher education and research landscapes is another. They are interconnected, of course. The source of growth is also the sustaining arm of that growth.
Bringing together the trustees, directors, and governors (including ex officio officers) of the boards or advisory committees of our schools and programs for, say, an annual symposium about naturopathic medical education in the higher education terrain, with a carefully thought-out agenda, could be exactly the catalytic event we need these days to galvanize our fast and busy professional formation efforts. Under the auspices of the AANMC, directors and governors could come together to discover and share their collective wisdom and resources dedicated to important educational, operational, and policy issues. As the naturopathic profession shapes its place in civil society among often quite different jurisdictions (states, provinces, and internationally) and despite the opposition and interference of biomedicine and other professions, the need for a coordinated higher education approach in the educational and professional preparation of NDs is greater than ever. This is particularly important in terms of coherent learning outcomes, despite differences in state and provincial scope.
A coordinated body of trustees, directors, and governors could get behind a strategic approach that begins with a better understanding of the typology of higher education institutions in what is known as the voluntary or nonprofit sector (Salamon & Anheier, 1992), within which our schools actually exist. That way, together, we can get a clearer awareness, in turn, of the pitfalls that the corporate footprint of our institutions creates in an increasingly nonpublicly supported higher education landscape. The literature in this field of “higher education” and “professional formation” demonstrates that our nonprofit sector is characterized by such a wide diversity that variations and types scribble through the edges of an ongoing debate grounded in a “logic of social good and collective benefit, versus a logic of individual advantage or gain” (Reed & Howe, 1999, p. 1). Most of our colleges are a type of nonprofit mutual association and exist to help the profession succeed, but they also exist to produce access to naturopathic medicine for civil society when the allopathic healthcare institutions will not. Where they are located in civil society puts unusual pressure on them, different from that experienced by, say, the American Association of Naturopathic Physicians or the Canadian Association of Naturopathic Doctors. As well, such a broader sense of self will reduce interinstitutional rivalries and fears such as those that recently emerged when the Doctor of Naturopathic Medicine Centralized Application Service was not supported by Bastyr University (Kenmore, Wash., and San Diego, Calif.), National University of Health Sciences (Lombard, Ill., and Seminole, Fla.), and National College of Natural Medicine (Portland, Ore.).
Bonding With Diversity
Salamon and Anheier (1992) teach that voluntary or nonprofit organizations like our schools are organized or formalized to a certain extent as private, self-governing, non–profit-distributing, and voluntary organizations. Febbraro, Hall, and Parmegiani point out, though, that “the variety of labels, dimensions, and classificatory systems . . . has resulted in a Tower of Babel environment” (1999, p. 1) and call for “a common language, definition and classification system for those who wish to develop a greater understanding of the social and economic contributions of voluntary/nonprofit organizations” (1999, p. 1). It may well be that the board directors, trustees, advisors, or governors of our schools or programs may be the only sector of our educational collateral who can pull off a coherent system-wide strategy that can transcend individual college or program circumstances, all in the service of professional formation.
Inevitable diversity and differentiation are very present not only in the art and practice of our naturopathic professionals themselves who are out in the field practicing medicine or working in various healthcare agencies, but also in the curricula and learning outcomes of the educational institutions that prepare and continue to serve them after graduation (Skolnik, 1986, 1989; Smart, 1978). Competition for students, scarce research resources, and ranking status in the higher education sector are also very much part of this environment. A new focus by the AANMC on “directors” or “trustees” as trusted colleagues to guide collective strategy could change the grammar and lexicon of the conversation not only within the AANMC but even within the Naturopathic Coordinating Council.
In some cases, the nonprofit mutual association (e.g., a state or provincial voluntary medical organization) has been instrumental in the founding and nurturing of the nonprofit school. That there would be a natural and enduring collegiality is not entirely assured, though. The schools or faculties that graduates of National College of Natural Medicine, for example, have helped created over the years—Southwest College of Naturopathic Medicine (Tempe, Ariz.), University of Bridgeport College of Naturopathic Medicine (Bridgeport, Conn.), National University of Health Sciences, Boucher Institute of Naturopathic Medicine (New Westminster, British Columbia, Canada), and Canadian College of Naturopathic Medicine (Toronto, Ontario, Canada)—are themselves part of a different typology of higher education institutions than the 501(c)(6) entities manifesting in state and provincial associations, whose characteristics influence institutional development and local professional groups from a different perspective.
Working the Game
Meanwhile, as these drifts in the original interconnectedness of schools and programs with naturopathic agencies continue, our schools are increasingly seen by federal authorities and by scholars of professional formation as social enterprises, distinct in real ways from the other public and private sector higher education organizations present in the well-known Carnegie typology, organizations competing for Title IV and Stafford money and for National Institutes of Health and other foundation and private sector research money. The important point, in any case, is that our schools, as social enterprise institutions (Alter, 2004), are in tandem rather than in competition with nonprofit mutual associations representing the profession (Quarter, Mook, & Richmond, 2003)—all the more reason for the directors or trustees of these social enterprises to put their heads together routinely.
Another important landmark and goal in terms of the accelerating formation of the naturopathic medical community in North America is the enduring need for a verifiable and discernible coherence among curriculum, clinical education outcomes, and program standards. The Council on Naturopathic Medical Education does important work in establishing and maintaining this foundation; however, all the programs in the United States are linked to regional accreditors now too. The Canadian higher education structure does not have this kind of Department of Education (Washington, D.C.)–affiliated peer-review process. For this reason and because there are additional pressures created by the fiscal and jurisdictional pressures, the institutions in which the programs are operating may well welcome strategic coherence across the AANMC system, which at the moment does not easily occur. For example, Bastyr University’s governance priorities are, by virtue of its institutional context, going to have a different focus from, say, those of a single-program college. Extending this example, Bastyr University’s recent development of a branch program in San Diego was unilateral in execution, albeit beneficial in professional formation, creating much-needed capacity in southern California, but a clear signal of independent institutional initiative (on the part of the school and the California association) within the framework of naturopathic professional formation. Southwest College of Naturopathic Medicine and National College of Natural Medicine, the schools most directly affected by this new presence, were not aware of the project. Understandably, the state association in California has been eager to support Bastyr University as this important project manifests because capacity development will grow the profession in California. The applicant pool hiccup in the first two or three cohorts affecting other colleges will even out, no doubt. In the absence of collaboration, though, comes augmented competition, and raised eyebrows. However, had this initiative been part of the conversation of the AANMC, perhaps no real concern would have arisen. Ultimately, this kind of competition for students at a time when the overall pool has been flat generates capacity and efficiency for the whole profession. Some of our colleagues imagine a national strategy for proliferating educational capacity that is collaborative and sustained. Such an approach needs to live with the AANMC.
Where collective projects are in play such as the Naturopathic Foundations Project, the experience of drawing on the combined knowledge and skill of teachers, scholars, and clinicians from across the AANMC spectrum has had a strong energizing effect on the profession, even though its academic home was National College of Natural Medicine only. A far better home would have been the AANMC itself. Applying the collective wisdom and networks of the governing bodies of those same schools could strengthen the whole and mobilize more resources more often (Smart, 1978). Even so, we are simply not doing that consistently at the moment in the educational corridors of professional formation for naturopathic medicine.
Classification and Vision
Scholars have long studied the variable of governance in educational institutions and professional formation (Quarter, Richmond, Sousa, & Thompson, 2001; Quarter, Mook, & Richmond, 2003; Ritchie & Weinberg, 2000; Salamon, 1987; Salamon & Anheir, 1992). Governance in the social economy where our schools live differs in substantive ways among programs and schools in the public and private sectors, and the only way we are going to avoid stumbling blocks that create distrust and unnecessary competition is to have our governors talk to each other across jurisdictions. Richie and Weinberg (2000) and others help us understand this complex interplay among the stakeholders in such institutions by presenting a typology that attempts to describe the nonprofit social enterprise, which is what our schools are, more accurately. The table “Classification by Funding Source and Orientation” shows the fine line between our schools as “market-based organizations” and as “civil society organizations” (Quarter, Mook, & Richmond, 2003, p. 22). Since 2001, the AANMC and the Naturopathic Coordinating Council have been very busy building the profession within this fabric of public sector, market-based, and civil society organizations. In the past decade, much has been accomplished by the AANMC and by individual colleges. There have been both development and sharing of information about our schools and programs. There has been an effort to coordinate efforts to assemble strong pools of students who are to become NDs.
The AANMC, going forward, is probably the best vehicle we have in place to collectively deepen and broaden the educational vision and reach of our programs and add significant capacity to the profession. Various projects could be undertaken or further developed that would propel this kind of regrouping. These include the following:
- A strategic lobby and advancement effort to advance naturopathic research
- A fine-tuning and expansion of the central application service
- A synchronized strategic lobby and advancement effort for residency education
- Better funding for deepening support for college academic and clinical officers initiatives
- Development of a Council of Trustees
- Inclusion of Naturopathic Medical Student Association representation on the board
- Development of a “council of teaching faculties,” including faculty, curriculum, and academic leader exchanges, also focusing on expanded professional development programs for teachers capped by a professional naturopathic medical educator designation
- Collective support to complete the Naturopathic Foundations Project
- A coordinated national job exchange system
- Formal liaison with other healthcare educators and health education counselors and educational organizations
A guiding body composed of directors, trustees, or governors would have a more global perspective on what to do about institutions of higher education in need of program diversification to remain fiscally solvent. Perhaps our future as higher education institutions lies not in limiting the program mix in the institutions in which our programs operate, but in stretching to create and sustain a multiplicity of “programs” under the banner of “natural health sciences” in a multiprogram institution that looks very much like a small university. Perhaps the guiding body would recommend a SWAT team of program development champions who would incubate programs in high-growth areas such as Florida, Texas, the Northeast, and the central Midwest. The competition, they might point out (although we know about this already), is about to come from the larger university-based integrative medicine movement and its unrelenting and strategic assimilation of our modalities. In this regard, we might be less worried that the modern research universities are poised to create programming that would dilute naturopathic medicine and change it in ways not dissimilar to the co-opting of osteopathic medicine. The historical record of biomedicine is that it has dominated every modality and health initiative of every major profession in the past 100 years, beginning with whatever content they decide is important to their mission.
The prevailing epistemology of the universities, though, most certainly precludes their being able to teach the practice competencies grounded in the philosophy and principles of naturopathic medicine, and herein lie our greatest strength and opportunity. We must keep naturopathic medicine thriving, despite such threats.
Whatever transpires, there can be no complacency about cash flow, about maintaining enrollments with traditional offerings, and about continuing to attract high-quality staff and students. The AANMC can strengthen our change-sensing radar and fine-tune it to be more comfortable with a strategic rather than a reactive approach. That approach would be characterized by flexibility, quick response, agility in the marketplace, and (above all) respect for the principles underlying our educational values and naturopathic medicine itself. If we simply focus on patching, reengineering, and retooling the pieces of our various processes (e.g., the recruitment process, the admissions process, our various academic appeals processes, the curriculum delivery process, and the development of a research agenda), we will miss the larger opportunities that a transformative strategic approach can generate in a short order of time. The naturopathic colleges and programs in North America historically have exhibited “diseconomies of scale” that manifest in locked up budgets, constrained growth and development, and the historically disproportionate dependence on constantly escalating tuition. The AANMC can be a place where these complex issues are thought about and acted on system-wide. Shall we?
David Schleich, PhD is president and CEO of NCNM, former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Previous posts have included appointments as vice president academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd), and the University of Toronto (PhD).
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