Jeremy Mikolai, ND
Martin Milner, ND
The time has come for the formation of a naturopathic specialty society in cardiovascular medicine. We assert that forming a naturopathic cardiovascular specialty society (NCss) and board certification is necessary because it will help the profession of naturopathic medicine (“the profession”) to officially establish, document, and publicize our expertise in integrative cardiovascular medicine, as well as increase and enhance training in naturopathic cardiovascular medicine (NCM) at our schools and for NDs in the field. Moreover, an NCss will help to integrate NCM into the greater medical community by increasing the communication about NCM with other sectors of the medical profession and by prioritizing and implementing heightened research efforts in NCM.
Appreciation for the benefits of complementary and alternative medicine–integrative medicine approaches to cardiovascular disease continues to grow among patients, physicians, scientists, and allopathic specialists.1-3 To our peril, NDs are being left out of the current conversations on these topics. For instance, the American College of Cardiology expert consensus committee on integrating complementary medicine into cardiovascular medicine contained no NDs; the report that they published in 2005 mentions techniques, botanicals, nutraceuticals, and other interventions that are the expertise of NDs yet makes no mention of naturopathic medicine by name, and no NDs contributed to the document or its writing.1
Background
Professional formation, or professionalization, is the process by which an occupation establishes the group norms of conduct and qualification for the members of its discipline. The creation of our national professional organization, the American Association of Naturopathic Physicians (AANP), in 1985 was our first major step toward professionalization of the entirety of naturopathic medicine in the contemporary era.4 Attempts at professionalization of disciplines within the profession also have good precedent. The Homeopathic Academy of Naturopathic Physicians was one of the earliest efforts in this vein. The establishment of the Oncology Association of Naturopathic Physicians (OncANP) in 2004, and subsequently the American Board of Naturopathic Oncology in 2006, represents the best and most successful example of efforts to use professionalization, by the means of naturopathic specialty societies, to integrate naturopathic medicine into the interdisciplinary care team movement in American medicine and to recognize naturopathic specialization through the process of board certification.5
The goals of specialty societies can be viewed as a type of internal accreditation process. Many of these goals are shared across disciplines, professions, even cultures. Thomas Boone, PhD, MPH, stated this point eloquently as it pertained to professional formation within the profession of exercise physiology: “Exercise physiology is evolving and will continue to do so for a long time to come. This is the natural progression of things evident in most established professions…. All professions are unfinished to some degree. The important point here is that a collection of individuals, usually members of a professional organization, are continually in pursuit of better procedures, guidelines, and policies.”6 For instance, the Royal College of Pathologists in the United Kingdom, the Accreditation Council for Pharmacy Education, the OncANP, and similar organizations of accreditation within professions express that their objectives include providing infrastructure to support training and education in their fields and offering a conduit for research and information about their discipline to authoritative bodies and to the public.5,7,8
Naturopathic and integrative cardiology is an emerging field with great promise and for which there is growing appreciation.1-3 Moreover, an important niche exists between primary care and allopathic cardiology that can be opportunely filled by NDs with special expertise in cardiovascular medicine. Like naturopathic oncologists, naturopathic cardiologists have the skills and the opportunity to educate patients about orthodox and complementary and alternative medicine treatments, their risks and benefits, the principles of safe adjunct care, the management of adverse effects resulting from allopathic care, and other topics that primary care providers and medical specialists may not perceive they have the time or expertise to discuss.9,10
To capitalize on the opportunities to fulfill this role on the interdisciplinary care team, the expertise of NDs in cardiovascular medicine must be increased. Like her sister organization, OncANP, an NCss affiliated with the AANP would have among its mission, vision, and purpose the following goals: to maintain a repository of information about NCM, to increase the communication between all sectors of medicine about integrated and NCM, to advance the continued training and education of its members and the profession in NCM, to support a unified NCM curriculum for students at naturopathic schools, to prioritize and sanction NCM research in the profession, to foster the integration of NCM into the greater healthcare system, and to create and maintain a board certification process for NDs desiring to achieve fellowship status in NCM.5
Strengths and Assets
It is a relevant part of this discussion to undertake a brief analysis of the strengths and assets, weaknesses and liabilities, and opportunities and challenges of attempts to organize an NCss. To train NDs with advanced expertise in any discipline, we must first provide our students with a solid foundation in that discipline.
Several of our naturopathic colleges and universities have good cardiovascular medicine programs, training grounds, and experiences available to their students. We will focus our discussion on one in particular.
The Heart & Lung Wellness Clinic at the Center for Natural Medicine, Portland, Oregon
Since 1999, the Center for Natural Medicine, in collaboration with the National College of Natural Medicine, Portland, Oregon, has provided a teaching clinic to train naturopathic interns and residents in cardiovascular and pulmonary medicine, the Heart & Lung Wellness Clinic (“H&L”). Presently, students in this training program serve a 6-month internship working as a 2-intern team, alongside a resident physician and under supervision by one of us (M.M.) The H&L is the only facility in the world offering naturopathic cardiology training and care in a private clinical facility under supervision by a professor of naturopathic cardiovascular and pulmonary medicine.11
The World’s First Center of Excellence in NCM
Thirteen years of maturation of our program have evolved H&L into the world’s first Center of Excellence in NCM. The mission of H&L is to provide the highest-quality patient care and the best training experience possible in naturopathic cardiovascular and pulmonary medicine.11
The H&L at the Center for Natural Medicine has developed a clinic system that enables us to offer our services at price reductions of 75% or more to members of our community who are in financial hardship. The Center for Natural Medicine has formed an alliance with a local cardiovascular imaging firm to offer an expanded and greatly discounted selection of cardiac diagnostic services, including resting and stress echocardiography, vascular ultrasonography, and in-home sleep studies. The addition of these services and discounts to our clinic allows us to provide a wider range of special cardiovascular care to our patients, a richer clinical experience for our trainees, and more affordable cardiovascular imaging for the uninsured and underinsured. We have established relationships with several prominent cardiologists in the region from Portland to the California San Francisco Bay area, and this further enhances our patient care and student training options.
We have expanded our training capacity, now teaching 48 student interns and 8 part-time residents per year in 24-week mentored rotations in naturopathic cardiovascular, pulmonary, endocrine, and primary care medicine. Two additional full-time residents receive their training through this program, including the heart and lung resident (affiliated with the National College of Natural Medicine) and Dr Milner’s private practice resident (affiliated with the Naturopathic Education and Research Consortium). The Center for Natural Medicine has begun work to develop a fellowship in NCM to further increase the opportunities for postdoctoral training and expertise in cardiovascular medicine.
The H&L is the largest naturopathic cardiovascular training facility in the world. Our clinic, personnel, and experience in providing training in cardiovascular medicine have solidified our institution as a Center of Excellence in NCM, as the premier training facility for NCM, and as an asset in the effort to establish an NCss. Soon, we will be making training opportunities available to physicians in the field.
Weaknesses and Liabilities
The overall limitation in the number of training opportunities in NCM is the most important weakness to the ends of creating a bona fide special focus in this discipline for NDs. At present, naturopathic trainees get little exposure and experience in the diagnosis and management of cardiovascular disease.
Too few postgraduate training opportunities exist for NDs in general, let alone in specialized disciplines. Insufficient experience during internship and the limited availability of residencies leave many NDs underprepared to address cardiovascular medicine confidently in primary care, much less as a special focus.
Individualism of practice in naturopathic medicine is simultaneously one of the profession’s greatest strengths and greatest weaknesses. The core and strength of our profession are in practicing individualized medicine, considering and treating the whole unique individual, and reconnecting that individual with the healing power of nature. Yet, the unintended result of that individualism is that the public forum is filled with inconsistent messages about the profession and naturopathic care guidelines, including cardiovascular care.
Opportunities for NCM
The process of professionalization requires us to examine, discuss, codify, and declare our positions on cardiovascular medicine to our profession, the medical community, and the public. It is important that we understand ourselves and our profession as it pertains to this rampant cause of chronic disease and death in our country. Specialty societies within our profession help us to find that understanding.
In particular, an NCss would provide our profession with a voice in discussions and decisions about cardiovascular medicine and integrative medicine from which we are presently excluded. Whether we agree, disagree, or desire to contribute thoughts, evidence, or nuance to a discussion among the major bodies of expertise around the world, this organization would provide voice and authority to our profession in those venues. Furthermore, the establishing of an NCss, alongside the OncANP, would give our profession specialty societies in both disciplines pertaining to the leading causes of death in our country.
An NCss will provide our profession with a voice in integrative cardiovascular medicine, a body to help decide on and uphold standards of competency in NCM, and a path of training and certification pursuant to those competencies. Improvements in our competencies and communication will lead to enhanced training of our students and our physicians and greater opportunities to build bridges between medical professions, to serve in positions on interdisciplinary care teams, and to increase the integration of natural medicine into the allopathic medical paradigm. We have seen these types of opportunities manifest already as a result of professional formation and through the work of the AANP, OncANP, and others.
Challenges for NCM
In facing the challenges that will arise during our attempts to establish and maintain an NCss, we will find ourselves largely in well-charted waters. Many of our challenges will be similar to those that had to be overcome by other pioneering organizations in our profession such as the AANP, OncANP, and our state professional associations.
Our first challenge is to secure and improve on core training in cardiovascular medicine for our naturopathic students when they are in school. High-quality training experiences and opportunities will be necessary to create foundational knowledge, as well as to cultivate the interest in NCM that is necessary to maintain and increase its importance in our field.
As is so often the case in undertaking institutional change, the greatest challenge is limitation of resources. Like all venerable naturopathic organizations before it, an NCss will have to be constructed from the ground up. In our efforts, we are fortunate to find ourselves the progeny of those leaders who have built the professional institutions that we have. Following in their footsteps, we find our potential journey a little easier, and we will meet the same inevitable successes in our sustained and unified efforts.
Jeremy Mikolai, ND is a 2010 alumnus of the National College of Natural Medicine (NCNM), Portland, Oregon. He is in his third year as the heart and lung resident at the Center for Natural Medicine at NCNM. Dr Mikolai is an adjunct faculty member at the Helfgott Research Institute at NCNM. For more information, visit CNMWellness.com, or e-mail [email protected].
Martin Milner, ND is a 1983 alumnus of the National College of Natural Medicine (NCNM), Portland, Oregon. He is the medical director of the Center for Natural Medicine at NCNM. Dr Milner has been a professor of cardiovascular and pulmonary medicine at NCNM since 1986. E-mail [email protected], or visit CNMWellness.com.
References
- Vogel JH, Bolling SF, Costello RB, et al; American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine). Integrating complementary medicine into cardiovascular medicine: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop and Expert Consensus Document on Complementary and Integrative Medicine). J Am Coll Cardiol. 2005;46:184-221.
- Guarneri M, Mercado N, Suhar C. Integrative approaches for cardiovascular disease. Nutr Clin Pract. 2009;24:701-708.
- Maizes V, Rakel D, Niemiec C. Integrative medicine and patient-centered care. Explore. 2009;5:277-289.
- American Association of Naturopathic Physicians. About us. http://www.naturopathic.org/content.asp?pl=9&contentid=9. Accessed June 2, 2012.
- Oncology Association of Naturopathic Physicians. About OncANP. http://www.oncanp.org/about.html. Accessed June 2, 2012.
- Professionalization of Exercise Physiology Online. Comment on the book: Boone, T. The Professionalization of Exercise Physiology: Certification, Accreditation, and Standards of Practice of the American Society of Exercise Physiologists (ASEP). Lewiston, NY: Edwin Mellen Press; 2009. http://faculty.css.edu/tboone2/asep/Professionalization.html. Accessed August 29, 2012.
- Royal College of Pathologists. Benefits of membership. http://www.rcpath.org/the-college/benefits-of-membership. Accessed June 2, 2012.
- Accreditation Council for Pharmacy Education. Information for: deans/faculties: accreditation. https://www.acpe-accredit.org/deans/accreditation.asp. Accessed June 2, 2012.
- Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.
- Vogel JH, Krucoff MW, eds. Integrative Cardiology: Complementary and Alternative Medicine for the Heart. New York, NY: McGraw-Hill; 2007.
- Center for Natural Medicine. Heart & Lung Wellness. http://cnmwellness.com/heart-lung-wellness/. Accessed June 2, 2012.
