Education

David J. Schleich, PhD

Recently I was in Butler, NJ, to confer with local leaders about the importance of that nifty little town in the naturopathic profession’s early history. Regrettably, the only fragments of that special period of Benedict and Louisa Lust’s Jungborn, and the launch of naturopathic medicine in America, manifested in 2 small postcards in a binder on a local museum shelf. Only the tiniest sprinkle of people living in Butler had any inkling of the special role in naturopathic medical history of their unique Garden State town, once just a short train ride for Jungborn-bound patients on the Susquehanna and Western Railway out of New York. What they did know about, though, was the American Hard Rubber Company a century ago, as famous then and now for its prescient, reclaimed materials manufacturing, as Jungborn was and is, in a smaller circle, for its equally prescient naturopathic health care.

An expedition into the hinterland of Butler – to where tens of hundreds of patients came over many years for naturopathic care, and from which clinical experiences arose a robust literature about therapeutic order and natural approaches to health and healing – led to an abandoned valley in the Ramapo Mountains there in northern New Jersey. The original grounds of the Jungborn were bifurcated long ago by a highway. The small river and the dam and walled pond, so central to hydrotherapy and other modalities at Jungborn, were overgrown and in abject disrepair. I was put in mind of George Bernard Shaw’s famous admonition, as only he could frame such a sentiment, that “we learn from history that we learn nothing from history.” At the same time, George Santayana, the philosopher and poet, equally adept with rhetoric, has something more optimistic to share, namely, that “those who fail to learn from history are doomed to repeat it.”

There exist rich categories of the literature of the history of medicine which naturopathic scholars and, more recently, their integrative medicine colleagues are doing their best to keep top of mind in curricula for the modern era. There are lessons in that history which can definitely help in the current confusion among patients and doctors alike about the place of allopathic medicine in the integrative medicine movement and in holistic medicine itself.

When we look closely at the most important aspects of the evolution of biomedicine, and at the same time blend in naturopathic medical education’s record and current trajectory, we get a different take on the emergence in mainstream medicine of so-called “integration.” The political and turf warfare in orthodox versus heterodox medical systems can be understood better by knowing what came before. The 2 approaches to medicine can probably collaborate after all.

Lessons learned from our history can help our academic leaders and teachers – in mainstream as well as in naturopathic medicine – make better sense, for the emerging generation of doctors, of the knot of political, social and epistemological roots that swirl around contemporary health systems in America and beyond.

What is especially valuable about the Jungborn legacy, clobbered as it has been by neglect, is that we see in its record quite clearly the misstep of the current biomedical model. It is an understanding of health which systematically excludes extrasomatic etiological factors in its disease equation. Some naturopathic scholars point out that the mainstream medical system, especially since the time of Flexner, conceptually understands the human patient as a biological organism such that, in Cartesian phraseology, “were there no mind in it at all, the body would not cease to have the same functions.” Indeed, the paradigm teaches that restored health is achieved by the appropriate physical intervention to combat illness, whether that intervention be chemical, electrical, or surgical. Biomedicine professionals maintain that such interventions will counteract the pathogenic agent and neutralize it or, as the phrasing goes, supplement a deficiency. Medical disciplines, then, are in this model ultimately reducible to the language of chemistry, biology, and physics. Sound familiar?

What the Jungborn Teaches Us Today

Alas – and this is the lesson of the Jungborn that needs to be retaught – the “diseased body -vs- the sick person” remains the central question of our time. Harkening back to that era, the unity of disease, as a theoretical framework for action among early naturopathic doctors, made it inevitable that the promissory note of biomedicine would likely fall short in our country, resulting in the highest chronicity rates in the world, not to mention out-of-control costs. The naturopathic doctors at the Jungborn a century ago had a different view. They felt that the patient (to use the reductionist lingo of the biomedicine doctor) is at a minimum a biospiritualpsychosocial system, bio active, psycho active, eco active, and spiritually active. The contemporary integrative medicine market is opening up to this understanding, slowly but surely. Thus, the value of calling to the attention of New Jersey historians the rich history of natural medicine they have missed celebrating for a long time now. The American Hard Rubber Company’s famous Ace combs notwithstanding, the abandoned dam at the Jungborn is equally symbolic of what could have been a different future.

Those planning the education of contemporary doctors can benefit from the detail and recurrent patterns which show up in the historical record, not only of naturopathic medicine and of other systems that are not from the biomedicine sector, but also of generic medical education. There are parallel paths between the ascendancy of the allopathic professions in civil society and the form and content of medical education itself. Here are some key categories that yield valuable insights:

• teaching of anatomy
• evolution of bedside teaching and apprenticeship within a professional curriculum
• last century’s rush toward new forms of medical teaching
• the ever-expanding routine of medical education
• the place of social determinants in medical practice

Those who have studied the history of medicine broadly can attest to the substantial and enduring value of the scholarship in medical history, indeed to its very language. Immanuel Kant is so right in his exceptional wisdom about the density and interdisciplinary interrelatedness of content in this regard. Sensing such patterns helps us to discern not only momentum, but also what Kant described as “a regular movement” in that continuum. It’s complex terrain, mostly chaotic because of money and the politics of the orthodox system, as well as seemingly repetitive and exasperating; however, a high-altitude perspective actually reveals steady, slow progress in the end. Translation: the naturopathic profession is in better shape epistemologically and politically than it has ever been.

All our detractors wouldn’t be so vociferous were that not so. And, the internal conflict between “drifting to allopathy” and “losing our traditional roots” is a symptom not of a wretched schism, but of a yearning, like a river for the sea, for continuity and balance in theory and practice. Even the allopaths know the jig is up for what they think health is, and that they must learn from their history as well as from the cumulative impact of research coaxing them away from a reductionist paradigm into a more holistic one. For example, the recent Functional Medicine international forum in early November 2018 in London had as its theme, the “evolution of medicine,” focusing directly on the need for integrating professional medical systems, modalities, and philosophies.

During worried moments when I witness some of the unrelenting bruising efforts of our critics and detractors, I am reminded of Machiavelli’s dictum, that “human events ever resemble those of preceding times.” Close reading of all the events, people, institutions, and organizations in the naturopathic story will point out the greatest aspect of our history and contribution of the medical profession, which is that we have been more moral than scientific at times, but that both are strong in our brand, in our identity, in the product of our product, and in the outcomes for our patients. By knowing more about who we were once, and how we got to the present, we are less strangers in the strange land of integrative medicine dominated by orthodox systems. As we become more skilled in building our future, having learned from what we endured, the better we can understand and respond to the sometimes guild behaviors of the allopathic enterprise and its partners in high tech and pharmacy, rascals as they are, who persist in plopping in our path barriers and criticisms.

Whatever we keep on doing to keep naturopathic medicine robust and relevant, every plan along the way must be informed by what Socrates once called “these several actions with the whole soul.” Specifically – and if we know our history – the “whole soul” of naturopathic medicine cannot be as easily slammed by the reductionist approach to medicine which conveniently forgets and forgives bloodletting and calomel in the same breath as it enables an opioid pandemic and 40 million metformin prescriptions a day.

The at-once highly complex and beautifully simple principles of the naturopathic medical approach – so alive in Butler, NJ, a century ago, at the same time as the American Hard Rubber Company was cranking out combs and material for the war effort – are increasingly of interest to healers across the professions. In our work to form the profession, there are 3 imperatives:

• designing and accrediting the educational preparation for practice of ND students
• recognition of our graduates by civil authority
• codifying of our knowledge, secure in its derivation, relevance, and application

Let us turn to those historical benchmarks, some of which are reflected in the miniscule fragments of those 2 Butler Museum postcards. Those little cards talked about natural healing for the ages, using water, air, sun, and pure food. They referenced trained, experienced doctors, their intern assistants, and the universal acceptance of the healing principles of Kuhne, Kneipp, and others. They referenced treatments based on the moral and intellectual discipline of the new profession of naturopathic medicine.

Early Principles of Our Naturopathic Forebears

Nineteenth-century medical education was as much about moral and intellectual discipline as it was about professional preparation. As Lisa Rosner put it, “Education made a good man, whereas medical improvement made a knowledgeable doctor.” (Rosner, 1997) The depth of information arising from the early research and teaching of Vesalius, Harvey, and von Haller, to drill a bit more deeply into this notion, was not meant for the exclusive use of the medical doctors of their time. As Rosner further points out, “medical knowledge was universal.” For example, the historical literature shows that from the Renaissance forward, anatomy was a central subject. By the end of the 17^th century, bedside clinical experience joined anatomy as essential in medical education. Hermann Boerhaave, a prominent late-18^th-century “medical man” at the University of Leiden, routinely delivered clinical lectures in the tiny ward of Caecilia hospital (12 beds). This model, more theoretically fashioned than practical, was soon transformed into an apprenticeship design, in which medical students were often legally contracted to a “master.” That “attending” doctor, in turn, was a member of the local doctors’ guild, and thus the apprenticeship led to entry to practice. The pattern we see historically is familiar today in our own naturopathic medical education:

The first few years [of a medical apprenticeship] are mostly spent doing small tasks and waiting at table … until [the apprentice] gradually becomes accustomed to wielding the razor, opening veins, applying plasters and at most bandaging a wound or fracture … and [seeing on occasion] a few operations performed by his master. – (Rosner, 1997, p.149)

New forms of medical teaching appeared in university contexts (eg, Leiden, Edinburgh, Philadelphia, Gottingen, Pavia, Ingolstadt, Stockholm), most of which we recognize as part of naturopathic medical education structure in our own era. Differentiated “disciplines” emerged (anatomy, surgery, chemistry, botany, physiology, pathology, hygiene, dietetics), since no one “medical man” could master them all. Boerhaave’s dozen beds gave way to universities linking up to hospital wards for instruction … so-called “hospital schools,” the most famous of which were in London. Significantly, the allopathic profession effectively blocked naturopathic medical students from such resources very early on, and persisting well after Flexner and the blurring of “science” with “art” expanded sharply.

Eventually came what Schon (1987) has described as prototypical professional education (specifically, basic sciences followed by applied sciences followed by a practicum). As this model expanded, its cost grew exponentially. Enter government and professional bodies and the rapid rise of regulation and control. Alongside this development came – especially in France at the time – the emergence of 2 different kinds of licenses: the doctorate in medicine [only available at approved medical schools] and the “license for Officiers de Santé.” Bifurcation of the latter led to, say, the Heilpraktiker category in Germany and the relegation to “public domain” of certain health providers in America, excluded from mainstream licensing and credibility as regulation took root and university study coupled with the standardizing of curriculum and assessment. It isn’t hard to see why the orthodox group see themselves as the real deal, and all heterodox providers as subservient.

The Important Rise of Basic Medical Sciences

The history, then, sheds light on why we have had such a time establishing, say, the CNME, state and provincial licensing, access to state funding for students (Title IV and Stafford loans, for example) and so on. Factored into this dense terrain is the rise in importance in medical education of the basic medical sciences, the skills and content dimensions of which are assumed in the naturopathic profession’s own curriculum design. We joined that process, emulating, for example, the explosion in volume, as well as in breadth and depth of specific training. As a benchmark, Stanford University Medical School grew its curriculum dramatically at the same time as the naturopathic profession hung on in the Pacific Northwest. Stanford added 900 hours to the 4-year medical course between 1945 and 1960. Each new course, taught by a specialist in the field in the tradition established in the 18^th century, attempted to provide students with all a practitioner needed to know.

Inevitably, scientific training took precedence over clinical work for allopathic students. The naturopathic profession prided itself in applied knowledge (manifesting in the long tradition of “elders” who tutored and mentored, often as volunteers, in our fledgling schools in that era). Clinical training, though, became increasingly difficult to access for naturopathic students because the larger context of medical education excluded them from teaching hospitals.

Once again, history teaches us that we have good instincts. As Rosner further points out,

Even if clinical training is carried out effectively, a university hospital does not truly prepare students for what they will experience in practice. Patients in a university medical centre are often there precisely because they have serious or unusual ailments; in treating them, students learn little about the most common ailments. – (Rosner, 1997, p.158)

One can connect the dots, with such an historical perspective, to the affinity naturopathic professionals have in states with more robust “licensing” for primary care physician status, despite the accompanying challenge of needing to access high-tech medical centers in order to procure labs and procedures, and the challenge of how to balance prescriptive rights with abhorrence for the dangers of pharmaceutical invasiveness. At the same time, naturopathic professionals worry – as they treat the patient as a whole human being – that the role of social determinants in understanding patients’ presenting conditions and the power of the third-party reimbursers in defining appropriate care are eroding the principles that Lust and others in Jungborn a century ago tried for many years to emphasize.

We circle back, then, to the notion that naturopathic professionals sometimes see themselves as holding ground that is more moral than scientific; yet, the latter descriptor is increasingly essential in the healthcare landscape, sometimes, though, at the expense of the former. The allopathic profession has protected itself strategically from charges of moral failure (for example, iatrogenic disease, the vaccination debate); however, many of its members understand that their own history has lessons for them too.

The people in Butler, NJ, have inherited the social and professional outcomes of this kind of protracted debate, as have people all over America. The difference is that there is an archeological jewel in their midst – Jungborn lost in the overgrowth next to Highway 23. And, like all lost places, much can be found there if one only digs a little.

References:

Rosner, L. (1997). The Growth of Medical Education and the Medical Profession. In: Loudon, I, (Ed.). Western Medicine: An Illustrated History. New York, NY: Oxford University Press; p. 147.
Schon, D. (1987). Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions. San Francisco, CA: Jossey-Bass, Inc.

David J. Schleich, PhD, is president and CEO of the National University of Natural Medicine (NUNM), 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).