Let Us Doubt Our Ever-Transforming Naturopathic Medical Education Model
David Schleich, PhD
Modris Eksteins (2012) argues in his recent book, Rites of Spring: The Great War and the Birth of the Modern Age, that we are no longer sure of anything. While advocating that there is nothing more deadly than certainty, Eksteins advises us not to doubt the authenticity and value of our own experience in a postmodern age characterized by moral ambiguity and doubt. He urges us not to doubt what it is yet possible to create, despite the vast lessons of two world wars that taught us about how subjective experience warps into narcissism. In many ways, to borrow Eksteins’ metaphor, the dominant biomedicine industry is intensely and subjectively self-absorbed and cannot imagine a different epistemology to guide it forward. The current assimilation of naturopathic and other modalities is, using Eksteins’ metaphor, unconsciously narcissistic. Because they are in complete charge of so many aspects of primary care and public health, allopathic entrepreneurs hijack ideas and principles from the sacred space that NDs have protected in the century since Flexner and even before. Those in the naturopathic medical education business may find value in Eksteins’ realistic enabling perspective on postmodern North America and Europe. Eksteins would probably contend that the naturopathic profession is better positioned in 2012 than it was in 1912 to emerge strong and defined, despite the unrelenting ascendancy of the biomedicine industry. And, Eksteins might find what Susan Skochelak calls “the 100 year echo” (2010, p. S26) relevant to his thesis and key themes.
Medical Education History Repeats Itself
By that phrase, Skochelak refers to a repetition in 2010 of the same kinds of inquiry and analysis about medical education as were occurring a century ago, when in 1910 Abraham Flexner’s report signaled a seismic shift in the design of medical education in North America. That year was pivotal in the evolution of Western culture, medicine included. As educators, we can handily tap into a growing contemporary literature that Skochelak references about the not-so-subtle changes occurring in medical education in North America today to understand what she means by those changes “echoing” what occurred a century ago. That review portrays MD educators as exercising ongoing, incremental, strategic thinking and planning to make their programs more effective. Ultimately, their success in doing so perpetuates their allopathic grip on credentials, resources, and legitimacy.
The several themes that Skochelak identifies in her meta-analysis of a wide range of studies appearing in various academic medical journals in recent years are not unfamiliar to naturopathic medical educators:
1. integrating the educational continuum
2. the need for evaluation and research
3. new methods of financing professional medical education and health services
4. the importance of leadership and communication
5. the growing emphasis on social accountability
6. the uses of new technology in education and medical practice
7. alignment with changes in the health care delivery system
8. future directions in the health care workforce
(2010, p. S27)
These eight themes originally came from the planning committee for a conference called “New Horizons in Medical Education: A Second Century of Achievement” put on by the American Medical Association and the Association of American Medical Colleges in 2010 (http://www.ama-assn.org/ama/pub/education-careers/new-horizons-medical-education/new-horizons-presentations.page). Skochelak went searching for those themes among studies in the previous decade.
For example, among those studies is a publication by Whitcomb (2000), who reminds us that social accountability and improved communication skills between patients and physicians, while paying attention to trends in healthcare delivery, are important parts of medical education. Yup, familiar theme; we have known that for a very long time too.
Another in this continuum of themes, a 2004 report by the Ad Hoc Committee of Deans, American Medical Association, points out that “clinical education has not kept pace with shifting patient demographics, health system changes, new practice realities, and the use of new technology” (Skochelak, 2010, p. S29). The publication suggests that new reporting tools can enhance patient-physician relationships and improve understanding and communication. Well, yes.
A recent study by the Carnegie Foundation on the need for reform in medical education most particularly points at the strong emphasis needed these days on “professional identity formation” (Cooke, Irby, & O’Brien, 2010). This is not surprising given that NPs, DOs, NDs, and others are responding where possible to patient demand by moving successfully into coveted primary care space long defended by the biomedicine monopoly. Biomedicine leaders know that in some corners of healthcare the MD is losing identity ground. Are MDs general practitioners? Are MDs interested in family medicine? Are MDs interested in underserved populations? Has the biomedicine industry broken what Ludmerer (1999) refers to as “the social contract” that gave them ascendancy in the first place?
Parts of this long sequence of studies—such as the fascinating 2004 Family Medicine supplement on undergraduate medical education (Bazell, Davis, Glass, Rodak, & Bastacky, 2004)—begin to address these concerns. That supplement specifically describes a national medical education demonstration project funded by the U.S. Health Resources and Services Administration through Title VII money in which the key focus was how education had to pay attention to trends in healthcare delivery because of patient demand. Yup. Sounds familiar.
Naturopathic Education Models
In any case, as one reads through these studies, there is little doubt that the biomedicine industry has been busy of late reviewing the educational foundations of its grip on this country’s allopathic medical system. It is useful, then, for us to take a good look at where the assumptions came from that drive the direction of their and our own current naturopathic medical education models. Those insights might help us move forward confidently in an arena where some of our colleagues are primary care physicians and some are not; not yet.
While these close reviews of curriculum are occurring, naturopathic college leaders always seem to make room for the philosophy and traditions of their college alongside reengineered curriculum. And, of course, there is the looming context of whatever state or province their graduates are headed to after graduation and Naturopathic Physicians Licensing Examinations. Just as these leaders are sensitive to philosophy, roots, and traditions in curriculum, naturopathic medical educational planners have always made it a priority to balance the didactic component of the curriculum with the corresponding practicum and clinical components. That same aspect of balance also shows up in the various studies reviewed by Skochelak already referenced. In that regard, MD educators are examining closely the best timing and venues for medical students to have contact with patients too. They have the benefit of hospitals and residency opportunities galore, of course, but we are working on that too. Beyond Skochelak, this challenge has been the subject of other related studies from allopathic medicine too (Chipp, Stoneley, & Cooper, 2004).
Just as in the Skochelak continuum of studies, student and intern communication skills, cultural competency challenges, and individual support have long been important goals of naturopathic curriculum designers too. We have been working hard in all our schools on enhancing very good communication skills to develop effective patient-physician relationships and esprit de corps to inform what Schon (1987) calls the “practicum” element of professional curriculum. Indeed, much of the recent literature about medical education suggests that that same priority persists in allopathic medical education as well (Hall, Keely, Dojeiji, Byszewski, & Marks, 2004). They explain that the dynamic within professional schools arises first out of the need for medical faculty to show interns “how to work with patients, families and colleagues” (Hall et al., 2004, p. 120) and out of the relationship between students and faculty themselves. Duderstadt (2000) confirms this element in the nature and form of medical education and adds that it is in sharp contrast to undergraduate programs, where esprit de corps is less pronounced and present.
Duderstadt (2000) makes a further point that during the process of coaching senior medical students in communication and professional methodology—while recognizing the nature of the relationship between students and faculty in this process—professional schools also have an accompanying tendency to include increasingly more specialized material. The resulting knowledge overload, Duderstadt goes on to emphasize, “has led to major restructuring of the curricula in many professional schools, notably medicine and business administration” (2000, p. 105). These pressures exist in the naturopathic medical education field too alongside ongoing questions about the underlying assumptions informing what knowledge is to be codified and within which philosophy, the nature cure approach of the early practitioners or the scientific medicine approach of the allopathic medical faculties. These are tough questions to answer; tougher answers to implement.
Merging the Past With the Present and Future
An important theoretical foundation for discerning what form the education of these cohorts’ educational planners in both campuses might take, in view of the often contrary imperatives swirling around the curriculum, is careful consideration of the place of science alongside tradition in our medicine. As a litmus test of the credibility and professionalism of the nature and form of their medical education, many of the professional NDs working as educators in our colleges have often said in numerous forums (such as our conferences, the Association of Accredited Naturopathic Medical Colleges, and the Naturopathic Coordinating Council) that old wisdom, often referred to as elder knowledge, should not give way to fads and the pressure to integrate with the allopaths at the cost of those roots and those traditions. Meanwhile, “integrative medicine” beckons.
Colliver (1999) contextualizes the enduring benefit to our schools of this kind of ongoing strategic conversation among the various academic and board leaders of the schools. The founders of the Canadian College of Naturopathic Medicine (Toronto, Ontario), for example, were concerned that “elder knowledge” must not be “lost to the fog of time and anecdote” and that “world views such as scientific medicine and fads like PBL [problem-based learning] must not omit the importance of the elders of the profession in transmitting knowledge” (Hersov, 1978, notes from an unpublished lecture).
As an example of how the literature certainly helps in examining such information, Cabal assists with commentary about “whether science should involve research or simply teaching; or whether students should be taught and educated or simply trained” (1993, p. 29). In this regard, Flexner (1930), best known as a reformer of medical studies, also wrote later in his career about the related matter of “styles” of higher education institutions. He included in his descriptions reference to classical approaches in the German and English universities, for example, which he in turn compared with North American institutions. Whether, as Cabal points out, the institutional philosophy was “classical” or “primary” or “derived,” one strong variable, also echoed in Skochelak’s review, has long been on the minds of naturopathic medical educators and planners, and it is that our institutions of higher education are inevitably going to differ “in the priority that each places on scientific research” (Skochelak, 2010, p. S31). Here, then, lies yet another research interest that we share with the allopaths; that is classroom and clinical education methodology.
Research on the best way to teach in the classroom and in the clinic has also long been on the naturopathic medical education agenda. The Association of American Medical Colleges report (AAMC, 2005) cited in Skochelak’s work points out a very sharp parallel with concerns that we face every day as we build in clinical education opportunity: “[O]pportunities for students’ clinical skills development [are] threatened by the fact that clinical teaching sites need to compete for economic viability in the contemporary health care market” (Skochelak, 2010, p. S30). In our case, this issue (reflected in several of the themes cited herein) has a long history grounded in a pragmatic approach “regarding the capacity of the experimental paradigm to establish causality” (Norman & Schmidt, 1992, p. 557) a central approach in scientific or allopathic medicine and pivotal in the educational reforms of Flexner’s era. We are feeling aspects of that complex issue even today.
An important refinement of this concern, however, is also reflected in the documents of the Canadian College of Naturopathic Medicine, which has grown to be the largest stand-alone naturopathic college in the Association of Accredited Naturopathic Medical Colleges system. Its history includes an early recurring debate about the “urgency for our teachers to learn as much as they can about what to teach to make good practitioners and how to teach in the classes and in the clinic” (Le Plante, 1979, minutes of a college board meeting). In this regard, Campbell and Stanley help us get clear on the importance of applied experimentation in educational research. They explain:
[The experiment] is the only means for settling disputes regarding educational practice [and is] the only way of verifying educational improvements, [and is] the only way of establishing a cumulative tradition in which improvements can be introduced without the danger of a faddish discard of old wisdom in favour of inferior novelties. (Campbell and Stanley, 1966, p. 2)
Mangan (2000) adds to this conversation, explaining that in the first half of the last century basic science departments were organized by discipline (e.g., anatomy, physiology, and pathology). “[B]y utilizing the scientific method to solve problems relative to their discipline” (Norman, Vleuten, & Newble, 2002, p. 337),
the key facts and concepts of basic science found their way into the practice of medicine. Furthermore:
[T]he basic science content was being defined by interdisciplinary groups and taught in more integrated ways with the expectation that this would enable students to be better able to recall, integrate and utilize their basic science knowledge in clinical situations. (Norman et al., 2002, p. 337)
Guiding Our Education Evolution
Our naturopathic college programs have generally organized their basic science curricula by discipline, much as allopathic medical schools have done. As Skochelak has pointed out, we are both revisiting that structure. Historically, though, the disciplines tend to be in silos in the curricula of both groups’ educational preparation programs: anatomy, immunology, physiology, pathology, etc. Our faculty historically have wanted to integrate the basic sciences into naturopathic medicine itself.
Significantly, just as the allopathic medical schools, motivated by a focus on assessment, introduced either objective structured clinical examinations or grade point average examinations that utilized “standardized patients,” so too many of our college programs have moved along the same continuum with the goal of introducing more authenticity to the valuation system. Higher education literature frames this tension as follows: “The change of focus, from what the teacher thinks should be taught, to what the student should learn to become a competent physician, represents a desirable and significant transition from a teacher-focused curriculum to a student-oriented curriculum” (Schon, 1987, p. 149).
This debate in the literature accelerates into a more fundamental issue of relevance to our schools in our evolution from a system of proprietary profession-driven institutions to a higher education model (Mangan, 2000). What is especially important is that we keep abreast of what the biomedicine educational institutions are considering, not only to see where we differ or are the same but also to assess where our respective professions may intersect, or collide.
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).