Education
David J. Schleich, PhD
We’ve been sparring with the biomedicine industry all along the professional formation continuum (education, research, licensing) for a very long time. We have also been joining some aspects of the mainstream’s strategies for a long time (civil accreditation, social closure, research). There comes a time, some say, when joining can be preferable to fighting the good fight.
Selectively joining is quite different, though, from capitulating or being inadvertently assimilated. The bigger picture is clear, in any case, that in the hugely competitive professional formation arena, there are convergence and assimilation afoot. On the one hand, conventional medicine is taking on many naturopathic modalities and calling them its own; on the other hand, naturopathic medicine is consistently maturing in terms of its demarcation of knowledge, its research activity, its licensing reach, and its brand.
What is stirring the landscape on the naturopathic side – alongside deep concern about the increasingly reported escalation of chronic disease – is both cost of delivery and the questionable effectiveness of the reductionist approach of the allopaths. The former concern, that is, the preparatory price tag to educate and launch grads, can be addressed by a closer look at how we might benefit from the privileges enjoyed by public-sector higher education in America and Canada.
Assuming compliance with programmatic (CNME) and regional accreditation standards, that price tag is much higher now than in the early days. The first 4 accredited programs of our era (National College of Naturopathic Medicine, John Bastyr College, Southwest College of Naturopathic Medicine, and the Canadian College of Naturopathic Medicine) would be much, much tougher to kick-start today. Starting up a naturopathic medicine program still means keeping one eye on communicating for candidacy (with a federally authorized programmatic accreditor in the United States – Canada has no such federal agency), and the other eye on cash flow when letting the clutch out. The cost is punishing if we expect to accelerate safely up the on-ramp of post-secondary education to join the growing confusion of traffic on the main medical education and licensing highway. There are added challenges in the 2020s: a digital free-for-all recruitment market – allopaths at the gate, like never before, with their confusing “functional” and “integrative” medicine regalia flying.
Potential students worry about what natural/holistic medicine is in today’s marketplace. Do MDs and DOs (in America) who are edging into naturopathic territory really buy into the philosophy, therapeutic order, and clinical practicalities of “holism” and “natural medicine”? And, will 4 expensive years of naturopathic medical school conjugate into adequate future earnings? They are well aware that ours is an era when the AIHM (the Academy of Integrative Health and Medicine), for example, is led in its academic operations by a highly credible naturopathic physician and routinely attracts healthcare professionals across numerous disciplines who want what we sell; that is, to be identified with holism.
Many healthcare providers are showing interest in this shifting landscape, aware as they are of the control biomedicine has long exerted over health funding, protocols, and certifications, and aware as they are that conventional medicine leaves no new market streams unattended. They also know that functional medicine, holistic medicine, and integrative medicine allopaths are not us. We may worry our way in this complicated market, but as long as we sustain our identity and manifest in clinical work the philosophy of the medicine, we will continue to make progress. However, if we forget who we are in this confusing marketplace contest, the slippery slope to identity-smashing assimilation will get slipperier.
For their part, the monolith that is the biomedicine profession and its supporting industries in North America worry about naturopathic doctors and others who systematically carve off pieces of their business, especially these days in the post-ACA world (section 2706 and all that). The biomedicine profession routinely recalibrates.What is particularly annoying is that these allopathic professionals do so with impunity. For our part, we routinely react.
Roszak predicted a half-century ago that we might. Robert Birnbaum, a higher-education scholar, said of Roszak’s remarkably prescient 1968 study, The Making of a Counterculture, that those not clear about identity and path would experience “adumbrations of existential despair.” (Birnbaum, 1970, p.197) In fact, the concerns Roszak presented were all about how mainstream groups (ie, corporations, professional bodies) from many fields will inevitably assimilate newcomers in a world where so many competing, confusing, same-sounding visions make it difficult to see the way ahead. Roszak reminded us – citing the work of Watts, Ginsberg, Marcuse, Brown, Goodman, and Leary, among others – that “ideas we once abandoned as exhausted may shortly turn out to be relevant” (p.198). Maybe we are worrying too much.
A Modest Proposal: 253
With this hortatory backdrop in mind, and heeding the frequent calls for hurrying forward to form and build the profession in North America, some years back I once proffered a formula to scale and tip: 25 accredited naturopathic educational programs, licensing in 25 states and provinces, and 25K licensed, practicing professionals. In such a landscape there would be much less alarm about and reactivity to the constant attack by conventional medicine’s gatekeepers. Happily, we are well past the ”25” mark of jurisdictions in North America where naturopathic doctors can legally practice (Alaska, British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, Maine, New Hampshire, Vermont, Maryland, Minnesota, North Dakota, Montana, Massachusetts, Pennsylvania, Rhode Island, Washington, Oregon, California, Utah, Colorado, Arizona, New Mexico, Kansas, Connecticut, Hawaii, Puerto Rico, the District of Columbia, and the US Virgin Islands). The number of practicing docs in those jurisdictions, though, is a long way from 25K (more like 7K). And, with a half-decade to go in the formula, we are not closer to the third element of that formula: 25 programs across the continent. We were 8, and recently we began a drop to 7, with sharp threats to the single-program institutions among them, meaning that we could drop to 6 by mid-decade.
Nevertheless, the historical record concomitantly shows that we have persisted through thick and thin. Graduates are making it out there, as employed and self-employed clinicians, despite the prattle that their careers are compromised. An uptick in both research and scope expansion have helped differentiate us from what the integrative and functional medicine leaders purport to be. Third-party reimbursement is improving. In this fray, though, key marketing messages have to be spot-on in order to keep the ball rolling. Related, key political messages must be smart, and both of these latter messages will have to be precise, understandable, and duplicable in our digital free-for-all world.
There are clever rascals out there who claim more often today than they would have dared, even a decade ago, that they can do what our graduates do, and more besides. That they can duplicate what NDs do is, with rare exceptions, unlikely largely because of their reductionist, mechanistic mindset about what health and healing are. Within this squabble, patients and potential students wrinkle their brows trying to determine who’s who and what’s what. This tension can get pernicious. All the more reason to grow out applicant, matriculant and graduation pools with transparent definitions and claims in place. Single-program institutions can’t do that as safely as they used to because of the growing competition and the escalating costs of design and delivery of naturopathic medical educational programming.
NUNM, BU, NUHS, and soon SCNM, offer naturopathic medical programs within larger program mixes, the cumulative effect of which is to spread the fiduciary and financial exposure across the wider front. At the same time, even in the larger-mix institution, naturopathic medicine is not assured a place; witness the recent demise of the naturopathic program at Bridgeport University in Connecticut. Nevertheless, BINM and CCNM remain single-program schools and are more vulnerable than institutions with multiple programs in their mix. They are experiencing the pressure to grow differentiated programming to meet the juggernaut of the assimilation by biomedicine professions of modalities ironically long eschewed by their own political and regulatory arms.
One powerful tool available to us to meet these challenges is a closer look at the public sector. Someday soon, right here in North America, a public-sector university will – alongside our existing private nonprofit multi-program institutions – add naturopathic medicine to its mix. That will be accompanied by eventual government funding, government credentialing, and public sector branding.
What Hanna Has Taught Us
In this regard, Hanna (2000) alerted us 2 decades ago about what that looks like. He wrote, “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.” Hanna set out what those new models would look like, basing them on analysis of trends observed in emerging organizational practice (Hanna, 1998, p.94):
- extended traditional universities
- for-profit, adult-centered universities
- distance education/technology-based universities
- corporate universities
- university/industry strategic alliances
- degree/certification competency-based universities
- global multinational universities
His discussion of “extended traditional universities” was built on the work of Berquist (1992) and others and contemplated pretty much what has evolved in our time, which is a time of transformation when the “traditional, content-based organization and decision-making within the university” (p.99) will of necessity have to respond to an increasingly competitive higher-education environment, one in which our naturopathic colleges and naturopathic programs in small, comprehensive universities can have a place.
Whatever its forms along the way, the higher-education culture has always had the attention of the naturopathic profession. Naturopathic college founders knew from the get-go that naturopathic medicine needed the affirmation and credibility of a university credential at the first professional-degree level (demanding undergraduate preparation, especially in the basic medical sciences) and social closure for its graduates. What is different these days is that instead of our yearning, like a stream for the sea, for the higher-education community to listen to our entreaties to invite us in as equals, they may very well suddenly say yes and even overwhelm us with rapid assimilation. Just ask the osteopathic profession how that felt back in the early 1960s when it started in Michigan. In the larger picture of professional formation (numbers, branding, inclusion), this may not be something to worry about. In terms of specific schools, our naturopathic leaders may shudder, concerned about losing our roots and direction; however, 7 programs could also become a dozen in short order.
This does not presage smooth sailing. Historically, this kind of blending has been fraught with complex factors. In the United States, the educational elements of naturopathic medical education are more favorable than in Canada. Degree-granting is not monopolized by the public sector. In Canada, though, without a federal mandate in education, provincial endorsement of the degree credential or access to student loan programs is more aggressively challenged by the allopathic lobby. Even so, that duality is shifting.
For example, in Canada, although it had never fit directly into the higher-education models in Ontario until the late 1990s, CCNM’s leaders in the late 1990s and early 2000s propelled it steadily toward accreditation by the provincial post-secondary authority (called the Post-Secondary Education Quality Assessment Board) within the framework of 2000 legislation in Ontario, making it possible for some private career colleges to issue degrees. The chiros got there first, but CCNM eventually got there too in 2013. Meanwhile, out on the Canadian west coast, BINM is currently seeking provincial degree-granting authority for all the same reasons.
Significantly, and part of the tension referenced above, Ruch (2001) 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.” They are, though, sustainable and legitimate.
The differences between our colleges, though, and public-sector institutions do not appear to stem principally from our schools being nonprofit, private, and 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) and from the extent we commit to research. In this regard, our colleges’ administrative and academic processes show a pattern of unrelenting movement toward a location in the higher-education realm. The Helfgott Research Institute at NUNM and CCNM’s Ottawa-based research division are exemplary in the progress they have brought in recent years to this important dimension of post-graduate institutional identity.
Understanding the Higher Education Realm
What is the higher-education realm really like overall? Most of our teachers and graduates have their own university experiences as reference points. There is, as well, a wide range of literature about aspects of the nature and development of universities as institutions which can illuminate the path forward. There is, for example, the relationship of the university to society (Partington, 1987; Belshaw, 1974; Niblett & Butts, 1972; Winchester, 1986). Within the university community, there are issues of autonomy (Jones, 1996; Skolnik & 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, 2003), and the matter of academic freedom (Bruno-Jofre, 1996; Shils, 1973, 1978; Russell, 1993). Governance and diversity in the university community have been top of mind for decades (Huisman, 1998; Skolnik, 1986; Birnbaum, 1983; Jones, 1996) and 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 NUNM and CCNM that have softened the worry about moving into the public sector, or the maturing of our own educational and professional formation practices, 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 to better comprehend why we’re doing what we’re doing, and to guide that professional formation as carefully as we can in the rapidly emerging integrative medicine education complex.
Altbach (1996) talked about this back in my first year in the naturopathic field. He wrote that “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 which, once studied, will reduce antipathy and misunderstanding” (p.1). The first public-sector institution to champion naturopathic medicine will open a floodgate. Not only will the profession have stronger institutional support, the cohorts looking our way will grow promptly. The sheer numbers will keep the allopathic monolith from flattening us the way it did traditional osteopathy in very recent history. The implications for the current naturopathic post-secondary establishment, though, cause some fretting.
Likely, the administrative support for recruiting and sustaining our cohorts will become embedded in institutions whose resources are vastly greater than what we can muster. Additionally, the reach of our credential will spread among the program mixes of public-sector institutions accustomed to supporting their graduates in placement, practicum support, and research with their superior cash flow. In the United States, private-sector nonprofit universities like NUNM, BU, and NUHS will have a role; however, their constrained finances will make it tough to compete in terms of facilities, finding and keeping the best faculty, and professional formation. Everything changes. Students will know the difference, in any case, between real-deal education in naturopathic medicine and some diluted, assimilated version. That’s why our messages, our curriculum content, and our philosophical loyalties have to be so carefully stewarded.
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David J. Schleich, PhD, is President Emeritus of the National University of Natural Medicine (NUNM), where he served from 2007 to 2019; former president of Truestar Health; and former CEO and president of CCNM (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).
