25 Cubed Or Back to the Future, Again

David J. Schleich, PhD

Back in my youth, that clever satirical magazine, Mad, was required reading for many boomers, most particularly among those of us who eschewed barbers. Alfred E. Neuman reassured all and sundry that what we worry unnecessarily about are things which probably won’t happen anyway. I am worried these days that the pressures on the profession are increasingly urgent and that we have to ramp up our efforts. The allopaths are everywhere talking about “integrative medicine,” a phrase which is a kind of “new regalia” for their early adaptors. The AHMA (American Holistic Medical Association) and ABIHM (American Board of Integrative Holistic Medicine) have united under the AIHM (Academy of Integrative Health and Medicine). Going forward, AIHM certification and education are to be aimed at a broad spectrum of professional healthcare providers, including MDs, DOs, NDs, DCs, LAcs, DNPs, RNs, NPs, PAs, psychologists, nutritionists, dietitians, DDSs, RPhs, and others. The AIHM has kick-started via a cross-disciplinary board whose collective eyes are on a far wider group of healthcare professionals than, say, Andrew Weil’s Arizona Center for Integrative Medicine ever intended or could tolerate. Imagine the naturopathic profession invited to a certification party of nurses, chiropractors, physician assistants, acupuncturists, psychologists, pharmacists, energy healers, and more. Should the profession be worried, Alfred?

The monolith that is the biomedicine profession and industry in North America will move inexorably forward by sheer force of dominance and volume, whether it is bumping into our world or not. It can unconsciously shuffle a bit in the parlor of “holistic health education,” and unintentionally shove off the couch the tiny naturopathic profession, despite Section 2706 (the non-discrimination provision of the Affordable Care Act) and the post-ACA world. The historical record shows that the AMA has been willfully and strategically trying to harm our profession since Benedict Lust and his pioneering colleagues a century and more ago faced fines, imprisonment, and worse for their philosophical and clinical beliefs.

Having long felt that we must hurry forward to build the numbers and presence of the profession in North America, I proffer a modest formula: 253 … (25 cubed): 25 CNME and regionally-accredited naturopathic educational programs, 25 states and provinces licensed, and 25K practitioners seeing patients without fear of attack by the dominant profession whose gatekeepers can’t tolerate competition. Happily, we are already at 25 jurisdictions in North America where naturopathic doctors can practice (Alaska, British Columbia, Alberta, Saskatchewan, Ontario, Nova Scotia, Maine, New Hampshire, Vermont, Maryland, Minnesota, North Dakota, Montana, Washington, Oregon, California, Utah, Colorado, Arizona, Kansas, Connecticut, Hawaii, Puerto Rico, the District of Columbia, and the US Virgin Islands). The number of licensed, practicing docs is approximately a nudge over 6000 and growing steadily. We are a third of the way to that goal with our 8 programs in play, and with 2 more likely on the way.

The AIHM Has Changed the Landscape

A close read of AIHM materials demonstrates a sincerity which is refreshing compared to the historical indifference of the ABIHM and the AHMA, although the latter group did share a conference venue with the AANP once, several years back. Notable is that neither of those latter 2 bodies has ever been at our side in state licensing efforts, despite believing, as they do, in holism in medicine. It remains to be seen if the newly-formed AIHM will journey this year to Albany or Harrisburg or Boston to help us lobby for recognition of naturopathic doctors. In any case, the historical record shows that we cannot count on the allopathic professions and must, on our own steam, move confidently and with growing numbers to make our case. We must bring to those efforts clarity about who we are and how we are differentiated from what the so-called integrative medicine leaders claim to be. Our key marketing and political messages must be managed with care. Wherever possible, we will want to avoid colliding with the same branding language used by the integrative medicine people. Even a cursory look at their language in use will alarm anyone who knows how hard we have had to work to hold the space for such ideas as “holism” and “energy medicine” and “mind – body – spirit” all these years. I have labeled them “clever rascals” before in this column, and they are still exactly that in so many jurisdictions.

There is more. In addition to defending a place within ACA 2076, and carving out more spots in state legislative agendas, our naturopathic educational leaders may want to drill even further down into the tremendous catalytic energy of establishing naturopathic programming within existing post-secondary institutions. As they do so, there is an accompanying worry that our Naturopathic Medicine roots will be diluted and even compromised if we establish programming in institutions whose frameworks and context are historically biased to a biomedicine epistemology. There will arise a tension, subtle at first, but inevitable, as market interest begins to attract philosophical debate, especially when a potential host institution begins to hire in genuine naturopathic physicians. The impact won’t bubble up only in new institutions bringing naturopathic curricula into their program mix; as well, existing institutions such as NCNM, Bastyr, NUHS, UB, and soon Southwest (with its potential MPH program) and MUIH, which offer naturopathic medical programs within larger program mixes, will have to keep resolved to sustain professional formation front and center. BINM and CCNM remain single-program schools, although the pressure – even with the complexities and challenges of a quite different higher-education structure in Canada – will grow to differentiate programming to meet the juggernaut of the MDs assimilating modalities long eschewed by their political and regulatory arms.

The Inevitability of a Public Sector ND Program

Sometime soon, somewhere, a public sector university will begin an ND program. We simply have to be ready for that. It will change everything. Not only will this ratchet up the rate of new programs being established in the country, it will challenge cohort markets in certain parts of the country short-term. In the long term, though, it will increase the overall applicant pool for Naturopathic Medicine nationally. Also, if we do our jobs right with those branding messages, another phenomenon will kick into place as demand for bona fide natural medicine training becomes better understood.

In this regard, Hanna (2000) gives us an insight into what can happen. He writes, “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.” Earlier, Hanna set out what those new models would look like, basing them on analysis of trends observed in emerging organizational practice:

  • 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, 1998, p. 94)

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 include the following: managerial, developmental, negotiating, collegial. Tierney (1998) 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 (1983, 1998) and others, and contemplates pretty much what has evolved in our time – and that is, 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 attracted the naturopathic profession. College founders felt rightly 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. What is different these days is that instead of our yearning – like a stream for the sea – for the higher-education community to include and welcome us as equals in terms of actual degree offerings, they may very well seem at first to overwhelm us with rapid assimilation because of the sheer power of their resources, and reach into applicant pools. In the larger picture of professional formation, this will not be a bad outcome. In terms of specific schools, some of our naturopathic leaders may shudder a bit.

First Professional Degrees, Finally

Historically, this kind of transformation has not been smooth-sailing. 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 (called the Postsecondary Education Quality Assessment Board) within the framework of 2000 legislation, making it possible for some private career colleges to issue baccalaureate degrees. The chiros got there first in that province, but CCNM got there too. Significantly – and part of the tension referenced above – Ruch (2001) comments that hybrid institutions which begin to offer specialized, previously non-public sector-degree programming “have more in common with multi-campus, public, nonprofit universities than they do with traditional non-profit private and related proprietary schools” (p. 24). Carnegie’s Classification of Institutions of Higher Education (2001) 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 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). In this regard, our colleges’ administrative and academic processes show a pattern of unrelenting movement toward a location in the higher education realm.

What is that realm really like? Most of our teachers and graduates have their own university experiences as reference points; however, also valuable to understanding where our naturopathic colleges are located within the larger development and purposes of the university in the United States and Canada is the wide range of literature about aspects of the nature and development of universities as institutions. There is, for example, the relationship of the university to society (Partington, 1987; Belshaw, 1974; Niblett and Butts, 1972; Winchester, 1986). Within the university community, there are issues of autonomy (Jones, 1996; Skolnik and 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, 1995), and the matter of academic freedom (Bruno-Jofre, 1996; Shils, 1973, 1978; Russell, 1993).

Governance and diversity in the university community (Huisman, 1998; Skolnik, 1986; Birnbaum, 1983; Jones, 1996) 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). All these characteristics of higher education will flood into our naturopathic medical education sector.

When Market and Philosophy Run in Parallel

Whether it’s the early leadership and success of research activity at Bastyr and NCNM and CCNM, 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 better to comprehend why we’re doing what we’re doing and to guide professional formation as carefully as we can in the rapidly-emerging integrative medicine education complex, manifesting as it is in organizations such as the AIHM. 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). The work of the AIHM is principally aimed at already-licensed MDs and DOs, although this group ostensibly welcomes participation by many professional cohorts. We simply have to keep the past record of biomedicine in mind during this transformation. The energy of program growth will propel more licensing of our grads and more grads making a living. Those sheer numbers will keep the allopathic monolith from flattening us the way it did traditional osteopathy in very recent history. Unless, that is, I’m worrying needlessly. Maybe only Alfred E. Neuman can say for sure.

David_Schleich_HeadshotDavid J. 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).

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