Naturopathic Medical Education: So far, we’ve only just begun
David J. Schleich, PhD
Prediction is very difficult, especially about the future. (Neils Bohr)
In the widening circle of inter-professional medical education, there is a startling statistic afoot. Dr Michael Pitt, from the University of Minnesota School of Medicine, explains, “In 1950, the estimated amount of time … to double medical knowledge was 50 years. By 1960 it was 10 years … [In] 2020 [it will be] just under three months.” (Truong, 2018) It doesn’t stop, though, with that exponential burden on our traditional programmatic approach to packing as much knowledge into the heads of our naturopathic medical students as we can. In another corner of the future flooding in on us are Amazon and Apple’s disruptive technologies to stream health data to consumers directly, as precursors of diagnoses ahead. Add into the mix: why don’t we offer NYU’s free tuition to all students regardless of financial need? And, why not add another boulder to the backpack while we’re at it: the impossible cost of a medical education itself, not just in terms of money, but also in terms of the time it takes, namely 4 years of undergraduate preparation, including disciplines such as biology, physics, English, chemistry, and organic chemistry. No MCATs for naturopathic students, thank goodness (but if there were, that exam would encompass chemistry, biology, critical analysis skills, reasoning skills, biochemical foundations, psychology, and sociology, and would take 7.5 hours to write). The centerpiece of naturopathic medical education is the 4-year stretch of coursework and clinical practice, along with some community experience. It doesn’t stop there.
For allopathic students, there is residency work (3-7 years of hands-on experience at lousy pay), often accompanied by 1-2 years of fellowship in a subspecialty area. Not all naturopathic graduates do residencies, largely because the profession is denied access to the “Match.” In any case, before residency education for naturopathic graduates, if they land one, there is certification and licensure, along with the advent of lifelong CME (continuing medical education).
Time, Money, and Apps
Curriculum designers in the naturopathic medical programs are wondering not only about how long it takes and how expensive it is always becoming, but also about fundamental shifts in how the education can be accessed in light of these factors. Take, for example, the high level of technological literacy among our incoming students, and how to leverage that. Does this translate into mobile applications, simulations, and gaming being a part of the naturopathic learner’s experience anytime soon? Is the sage on the stage the only way to go? The app, Prognosis: your diagnosis, promises students that they can logically “unveil a disease in under 10 minutes.” Do our differential diagnosis courses manage that? This remarkable app has more than 400 different cases available in medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. The app is free, by the way, as many of our naturopathic medical students already know. It comes with advertisements, though. Go figure.
As well, there is the rapidly emerging presence of virtual reality and artificial reality in education. I tried as a layperson the Oculus Rift Headset to get inside a human bloodstream, and came away wishing I had gone to med school. What an odyssey! The University of California at San Francisco (UCSF) recently piloted the use of Virtual Reality glasses to learn anatomy. Virtual cadavers have a very long shelf life. Microsoft’s HoloAnatomy lets students dissect virtual subjects. Go figure again.
And did I mention Telemedicine and its impact on naturopathic medicine? Here come virtual check-ins, patients connecting routinely by phone or video chat, and the well-wrought skill of millennials practicing empathy over small screens. Could such skills be enhanced by hybrid learning designs in our programs that include watching lectures from home? One thing for sure, as our students frequently remind us, peer-to-peer sharing is huge (eg, Reddit and YouTube) and non-traditional learning formats and systems are on the rise, whether we like it or not. Just take 20 minutes sometime and watch an anime called Cells at Work! Watch Erythrocyte (yup, a red blood cell) doing her job befriending White Blood Cells and battling bacteria as she delivers oxygen, carbon dioxide, and nutrients to the far-flung corners of the human body.
Thus, against such huge content and skills design and delivery challenges and opportunities, educators in naturopathic medicine face not only the doubling, redoubling, and redoubling of medical knowledge within the 4 brief years of naturopathic degree work, but also the blur and headache of knowing that our naturopathic programs are not long enough, no matter what we do. So, should the “pack in as much as you can” and “trial by epistemological fire with NPLEX” be kept going?
Well, while the Rome of Education buzzes with change and smoke, the focus areas for strategy and action are now proffering dialogue about newer key dimensions of running naturopathic programs: how to parse and parcel the huge increase in medical knowledge into 4 years of residential medical school; technology transforming medical education and healthcare; changes in practice patterns; the changing role of the doctor; and medicine-science-innovation. At the AANMC we spend a lot of time wondering how to augment enrollment, deal with detractors, and figure out how to do fundraising. We’re getting better at digital recruitment strategies, it needs to be said.
Consistent with our philosophical principles, future naturopathic doctors will increasingly be expected to adapt to new knowledge, therapeutics, changing patterns of illness and health systems, team approaches to care, and cost-effectiveness, to name the most frequently discussed concerns which go along with these dialogues and forums about the future of the profession. We already kind of know the paths ahead, and kind of recognize many of the right answers to recurring questions. In any case, our curriculum will be in continuous flux as we continue to develop outcomes which include the real healthcare needs of our country, such as healthy aging, evidenced-based care (a curious term), environmental threats, and sound nutrition acumen coupled with orthomolecular savvy as a counter to the massive overuse of pharmaceuticals.
First Come the Values
This much we do know: The present and future practice of naturopathic medicine has to service community-centric practice, and celebrate both generalist and specialist skills. Bearing these goals in mind, we want to do everything we can to equip our graduates with commonly held, clearly articulated values, because these, in turn, lead to choice and action that serve the well-being of individual people rather than health maintenance organizations and pharmaceutical interests. And, in this mix of intentions lies the notion of service learning, predicated on compassion and empathy.
Another notion – that of a team approach to health care – is tricky terrain for our profession, long beleaguered by detractors in the mainstream. Biomedicine considers our doctors inferior, by and large, even though they’re increasingly interested in the success of natural medicine. While we watch our backs for integrative businesses that cherry-pick modalities and proffer substitutes not deeply grounded in principles of psychobiosocial and spiritual healing, we also need to entrust our graduates with professional tools which work, ranging from differential diagnosis to the remarkable power of the wet sheet wrap. Politically, it is also tricky footing for our graduates to sustain a healthy aversion to treatment approaches which eschew prevention and lifelong health self-determination. Our graduates, after all, have to make a living too, and after having spent so much time and money, deserve social closure as much as the allopathic doctor in network.
In order to keep to our original purposes of producing the best naturopathic medical education possible and graduating qualified clinicians to form and build the profession in North America, we will need to be present and active where an opportunity arises to add educational capacity. By “capacity” I mean programs to train more students and add to our numbers. The great vulnerability these days are the shifts in demographics and the assault on our scope. As we try to expand, the biomedical and some allied healthcare professions continue to invade the cumulative momentum of naturopathic professional formation. The loss of the naturopathic program in Bridgeport is symptomatic of a larger assault on the viability of the profession, through the lens of university administrators whose interest is in program mix and not in professional formation. Cash flow talks. Matriculation statistics yell.
Common Tasks of our Key Agencies
The interconnectedness of the AANP, the CAND, the AANMC, the INM, and the CNME, is instrumental and core to this work, and by extension the participation and energy of every state and provincial association. In ways that operationally are dulled by demographics and placement rates as we build a professional workforce, we will need to be more deliberate and strategic than ever about how to grow our numbers. The end of the second decade of this new century is a decisive nexus of pressures, among which the cost of education, the growing competition from the biomedicine industry, and the confusion in the health marketplace about what we do are top contenders for our attention.
On the front line of this effort are the multi-program regional universities – Bastyr, NUHS, and NUNM – as well as the single-program institutions – SCNM, CCNM, and BINM. They all continue to successfully sustain programmatic and institutional accreditation at the same time as they work with tight resources to help meet the complex needs of professional formation, such as making their communities more aware of what naturopathic physicians are and what they can do. CCNM has a regional edge at the moment, with its degree-granting mandate, the favorable US-Canadian dollar exchange rate, the demise of the UB College of Naturopathic Medicine (UBCNM) in Bridgeport, and the burgeoning market for naturopathic medical education in the Great Lakes basin and the American northeast.
Nevertheless, the larger mandate of professional formation is shared by our existing agencies, and the conversations have been brisk. Biomedicine has no such numbers pressures, frankly, although they do face having lost the moral high ground in the past generation, witnessing, as we have, tragedies such as the improper prescribing of immunomodulatory drugs (eg, thalidomide in Germany that caused massive phocomelia) and opioids (eg, fentanyl, oxycodone, hydrocodone, hydrocodone that caused tens of thousands of deaths from overdosing), and the astronomical toll in lives lost due to nosocomial and iatrogenic diseases.
Given this climate, with naturopathic medical education as a key traditional hub for natural medicine programming and practice, the pressure on existing programs to grow is enormous. This comes at a time when the constraints are also large. Strategies about how best to incubate and support the emergence of new program capacity are not strategically or broadly undertaken. The departures of Maryland University of Integrative Health (MUIH) and UBCNM from the naturopathic space are cases in point. At the same time, it is highly unlikely that the profession can spawn another JBC, NCNM, CCNM, or BINM in short order. NUHS and UBCNM, on the other hand, grew programs within existing institutions. They had an on-ramp.
The philosophical and professional formation foundations and mission of our colleges and programs within universities is the way to go. The earlier stand-alone college models, from which the profession regained momentum in the late 1970s, are no longer the likely path of formation because of the cost, the long lead-time for accreditation programmatically and regionally, and the ongoing cost of operations. CCNM, BINM, and SCNM still maintain single-program frameworks, but their future program colleagues will come from multi-program institutions with conflicting imperatives and far less corporate savvy about how to give priority to the growth of a single profession. Not exactly hostile territory, but it’s terrain where biomedicine has a strong position and will eschew newcomers routinely.
Grow We Must; Grow We Can
For as long as any of us can remember, there has been talk from the field about the desirability of new programs. Especially vital is growth in the northeast and the southeast. Bastyr launched its San Diego campus in the southwest. In the same region, Southern California University of Health Sciences began initial work to do the same, and over in the northeast, Maryland University of Integrative Health went so far as to hire an experienced ND to launch the program. In the end, the latter 2 institutions stepped back from launching, heeding the demographic detail that suggested long playout times to get programs to solvency. The advocates for these new programs had the right idea; they were thinking about them as degree programs within an existing university and CNME-accredited. The implications for the academic and educational organizations which are essential to support bona fide naturopathic degree programs are many, including activity we haven’t broadly supported in the past, such as governance development, teacher education in the natural medicine disciplines, aggressive branding, and student recruitment in channels we haven’t approached as resolutely before. For example, NUNM and Bastyr benefit from their bachelor’s degree students matriculating into ND and DSOM programs, its undergraduates becoming familiar in their junior and senior years with the professional opportunities in the field.
To address these remarkable challenges, there are sharp agenda topics ahead, such as determining the proper role of the AANMC and the CNME in incubating these programs. These 2 critical naturopathic professional agencies have contemplated becoming more active in governance training, as well as in coordinating more actively a research agenda for the profession. In this critical work, questions arise such as: from which talent pools will we draw medical academics and academic administrators to build, fortify, and defend new programs in institutions not familiar with the terrain of our medicine and our philosophy? How will the staff of these new programs guard against the inevitable cherry-picking of modalities which the dozens of “integrated medicine” programs around the country are likely to do without thinking twice about it?
We have to get better, and soon, at understanding the culture of higher education in America in order not only to ask these questions, but also to find the time and brain power to chart courses of action and stay those courses. Dr Paul Mittman, President of SCNM, earned his EdD as part of the long game of leading a major naturopathic college. That type of specific career action exemplifies the kind of skills acquisition our leaders will increasingly need as we swim in the cranky universe of programs in diverse institutions that are circling around us. Dr Bob Bernhart of CCNM earned his PhD from the Ontario Institute for Studies in Education, which includes strong straining in educational design and delivery, as well as in institutional leadership. Dr Fraser Smith, founding Dean of the naturopathic program at NUHS, completed his MATD with this same goal in mind, focusing as he has on developing leadership skills in the growing field of workplace learning and performance. MATD training includes work in e-learning, instructional design, educational technology, and learning development. Exactly! Dr Christine Girard, the new president of NUNM, completed her MPH degree as part of a broader education in the professions and their practice in the broader healthcare landscape. As these longtime leaders in the profession deepen their knowledge of the primary cultures within the academy (that is, the world of universities and higher education), they model the importance of understanding the culture where we likely have to create our much-needed new capacity.
What the Universities Want
In this regard, Hanna (1998) gives us an insight into what that that brave new world looks like: “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 (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
Hanna’s notion of those trends and characteristics complement Berquist’s (1992) earlier outline of the “four primary cultures within the academy” and, as Hanna points out, anticipate a fifth – an “entrepreneurial” one. Berquist’s taxonomy of cultures includes the following: managerial, developmental, negotiating, collegial. Tierney (1988) adds to this valuable insight into higher education culture by pointing out the importance of “strong, congruent cultures” (p.11) and by commenting about what constitutes “weak, incongruent, or disconnected cultures” (p.13) in the higher education sector. Hanna’s discussion of “extended traditional universities” builds on the work of Berquist, Tierney, Clark (1992, 1998), and others and contemplates a time of transformation when the “traditional, content-based organization and decision making within the university” (p.99) will have to respond to a competitive higher education environment, one in which our naturopathic colleges and naturopathic programs in small, comprehensive universities will also have to thrive.
Whatever its forms along the way, the higher education culture has always been a fertile place for the naturopathic profession, even though we have had no single success so far in establishing a strong naturopathic program within a large, comprehensive university. We began where we could and our early college founders rightly felt 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 context. This approach is consistent with what every other major profession has done in the last century to gain credibility and credentialing. Coupled with an affinity for the higher education realm is the imperative of collecting and routinely systematizing the knowledge of the profession.
Inexorable Drift Toward the Higher Education Sector
The sailing ahead is choppy but navigable. For example, in Canada, although it has never fit directly into the higher education models in Ontario until recently, CCNM’s leaders propelled it steadily toward accreditation by the provincial post-secondary authority within the framework of 2000 legislation that made it possible for private career colleges to issue degrees. The chiros got there first, but CCNM got there too, with its first professional degree. BINM in British Columbia is actively seeking the same outcome in that province. 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.”
The differences between our colleges and public sector institutions, though, do not appear to stem principally from our schools being nonprofit, private, and from public sector institutions being nonprofit, public. Rather, the essential differences issue from what Ruch calls the “language of accounting and the law and practices of taxation” (p.25). In this regard, our colleges’ administrative and academic processes show a pattern of steady movement toward a location in the higher education realm. It is not surprising, then, that new programs will seek the same kind of realm to find a home.
Whether it’s the early leadership and success of research activity at Bastyr and SCNM or the creation and spectacular growth of the Helfgott Research Institute at NUNM and CCNM’s research arm in Ottawa, the pool of academic leaders we need in this multi-faceted environment must understand as much as they 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. As Altbach (1996) further comments, “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” (p.1). Even if, as Altbach also claims, higher education as a field of study “lacks an institutional base” (p.2), for our purposes its resources nevertheless include important contextualizing features such as the nature of governance or the “study of formal systems of education” (p.3), or the interest in higher education financing. What is critical is that on the agendas of the AANMC, the CAND, the AANP, the INM, and the CNME, these urgent conversations appear. What is equally urgent is that we make room for medical academic career opportunities that include support for the formal training of our academic leaders in the various cultural aspects of higher education.
Altbach, P. G. (1996). Research on higher education. Global perspectives. Education and Society, 1, 1-12.
Berquist, W. H. (1992). The Four Cultures of the Academy: Insights and Strategies for Improving Leadership in Collegiate Organizations. San Francisco, CA: Jossey-Bass Publishers.
Carnegie Foundation for the Advancement of Teaching. (2001). The Carnegie Classification of Institutions of Higher Education, 2000 Edition. Menlo Park, CA: Carnegie Foundation for the Advancement of Teaching. VII-IX, XIV, XIX-XXI, 156-157. http://www.carnegiefoundation.org.
Clark, B. R. (1998). The entrepreneurial university: demand and response. Tertiary Education and Management, 4 (1), 5-16.
Hanna, D. E. (1998). Higher Education in an Era of Digital Competition: Emerging Organizational Models. Journal of Asynchronous Learning, 2 (1), 66-95. Available at: http://wikieducator.org/images/2/2f/Higher_Educ_in_Era_of_Digital_Competion.pdf. Accessed July 2, 2019.
Ruch, R. S. (2001). Higher Ed, Inc.: The Rise of the For-Profit University. Baltimore, MD: Johns Hopkins University Press.
Tierney, W. (1988). Organizational Culture in Higher Education: Defining the Essentials. Journal of Higher Education, 59 (1), 2-21.
Truong, K. (2018). What needs to change in medical education to prepare clinicians of the future. MedCityNews Web site. https://medcitynews.com/2018/10/what-needs-to-change-in-medical-education-to-prepare-clinicians-of-the-future/. Accessed July 2, 2019.
David J. Schleich, PhD, is President Emeritus 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).