Becoming What We Fight

Specialty Boards in American Naturopathic Medical Education

David J. Schleich, PhD

These days Elsevier publishes an annual guide to medical specialties of US biomedicine. Unless one is aware of the proliferation of such groups since the 1930s, the list is astonishing on first blush. The sheer number of such groups, though, is completely consistent with professional formation patterns. Professions specialize everywhere, all the time, over time, every time.

What’s Behind This Trend?

The rationale for these subdivisions of medical practice invariably revolve around 2 persistent factors which are discernible in the history of allopathic medicine once it became firmly ensconced in the regulatory and public policy sectors of civil society following Flexner. First, biomedicine strategists contended that “GPs” (general or family practice MDs, and later DOs) needed more than the standard educational preparation to keep up with the breadth and depth of escalating knowledge, techniques, and scope regulations across the many disciplines accumulating into what it meant to take care of families. Indeed, it was inevitable that family practice, itself, would become a specialty. Second, American legislatures and professional monitoring bodies, within a very few decades of the Carnegie Foundation’s report of 1910, were adopting an incrementally persistent, almost hyper-regulatory approach to letting these allopathic professionals complete their dominance over public health generally. This became especially poignant as a pattern and ramped-up trend as the American public hospitals gradually reneged on their earlier mandates to keep clinics teaching and community-based, open and efficiently accessible to everyone. A contemporary visit to any public hospital Emergency Room demonstrates that this social contract with biomedicine is severely fractured.

Also operating in this gestalt of professional practice and market opportunity (people have a concomitant vocation and avocation in medicine) are the elements of professional formation which are propelled by monopoly into a segmenting and differentiation of services (products of education and training). The process begins with the inevitability of a profession turning to civil legislative authority to demarcate its protected market turf. MDs are long known for circling the wagons against any other group wanting a piece of the highly profitable healthcare pie. Accompanying civil and legislative authority is the pervasive assumption of professional definition built upon 3 recurrent factors: the codifying of the knowledge of a particular group, the regulating of its operatives, and the state accreditation of their credentials (Figure 1). The MD “degree” and “licensing” location in civil society has established a dominant brand which, until recently, was unassailable. In this orthodox landscape, there are myriad minor providers whose non-allopathic brand credentials are not well known and less well understood, such as DHANP, FDHM(C), DHMHS, CNS, TNP, CTN, CNS, CN, BAMS, to name a very few.*

Figure 1. The Foundations of Professional Formation

In any case, the notion of “professional formation” is as compelling for the dominant allopathic doctors as it seems to be becoming for the emerging naturopathic doctors. While it is true that Flexner, over a century ago, emphasized liberal education, with its attendant humanistic values, as much as he emphasized competency in basic sciences, the goal of medical education – to produce physicians “prepared to lead lives of compassion and service as well as to perform with technical proficiency”¹ – is, many would argue, systematically threatened by this proliferation of specialists, as evidenced by the demise of family- or general practice. The proof in the pudding is that a family practice has little commercial value in the healthcare landscape as a “going concern” business with equity value to sell. This trend is well known, and in evidence by virtue of Elsevier’s growing guide. Even academic medicine, through the AAMC (Association of American Medical Colleges), reinforces the status quo of this model by describing for allopathic medical students early on in their educational pathway over 120 specialties and subspecialties they can think about as they move into the first years of their training and navigate headlong toward a lucrative livelihood.²

These specialist lists, our curriculum designers and academic administrators should note, are not new. Indeed, the historical record shows that the pattern of specialization has been emerging in the United States since the 19^th century, although accelerating more visibly in the fourth decade of the 20^th.³ Naturopathic historian, Dr Sussanna Czeranko, indicates that the “specialization imperative” reflects the reductionist paradigm of biomedicine, the parallel spheres of surgical and internal medicine, and a focus on organs (or parts of the body, rather than on the whole person).⁴ That this same trend is surfacing in the naturopathic profession may give pause to naturopathic educators, but it has taken root nevertheless.

In any case, governing this plethora in the biomedicine industry are more than 2-dozen broad specialty areas, with plenty of sub-specialties. For example, “family medicine” includes adolescent medicine, geriatric medicine, hospice and palliative medicine, sleep medicine, and sports medicine. So-called “internal medicine” has even more sub-specialties: adolescent medicine, adult congenital heart disease, advanced heart failure and transplant cardiology, cardiovascular disease, clinical cardiac electrophysiology, critical care medicine, endocrinology, diabetes and metabolism, gastroenterology, geriatric medicine, hematology, hospice and palliative medicine, infectious disease, and 8 more.

Many “boards” which belong to the American Board of Medical Specialties date back decades, from the 1936 American Board of Internal Medicine, or the 1935 American Board of Orthopaedic Surgery, for example, to more recent boards in the 1970s. Then, there is the American Board of Physician Specialties (ABPS)… but that’s another story within the narrative of why medicine subdivides the way it does. The ABMS has been around since 1933, not that long after the biomedicine industry consolidated its position in the United States, the successor to a movement which was first proposed in 1908, just as naturopathic medicine itself was taking root in America. The first specialty board of record was the American Board for Ophthalmic Examinations in 1917. Seven years later came the American Board of Otolaryngology, followed by the American Board of Obstetrics and Gynecology in 1930, and the American Board of Dermatology and Syphilology in 1932. The rest is history. These early groups came hot on the heels of the growth in graduate medical opportunities, a development in the history of allopathic medicine which gained speed in the early 1930s as state after state began regulating allopathic medicine directly.⁵

Specialty Boards

From anesthesiology (palliative medicine, pain medicine, pediatric anesthesiology, sleep medicine) to internal medicine (cardiovascular disease, gastroenterology, hematology, nephrology, rheumatology, to name only a very few), through to urology, there are boards and more boards offering specialty certification for MDs and DOs. The American Board of Medical Specialties (ABMS) quickly embraced differentiation and segmentation. As referenced above, today there are some 2-dozen member boards.⁶ There is even a parallel Federation of State Medical Boards (FSMB). This complex medical regulatory machinery, like most accreditation processes, is voluntary. These agencies assess and oversee medical specialties by the dozens, in terms of compliance with continuing medical education, advocacy, training, and public relations. In some cases, there are even competing boards, such as those overseeing the emergence of so-called “integrative holistic medicine” (Dr Mimi Guernari’s ABIHM and Andrew Weil’s ABIM, for example). The former group is moving fast, with its E-Learning Library, certification and ND-MD degree development efforts, and an International Academy boasting a team which includes at least 2 prominent naturopathic physicians.⁷

Three well known examples of such agencies already operating in the naturopathic profession include the following:

1. Naturopathic Physicians Board of Aesthetic Medicine – www.npbam.com. This group concentrates on defining and overseeing national standards for training and post-graduate education related to spas and aesthetic modalities and protocols.
2. Pediatric Association of Naturopathic Physicians – www.PedANP.org. This group focus on naturopathic medicine targeting children.
3. Oncology Association of Naturopathic Physicians – www.OncANP.org This group has been operating for some time, generating clinical knowledge, research, and training about natural support for patients dealing with cancer treatment.
4. (proposed): Gastroenterology Association of Naturopathic Physicians

What This Means For Naturopathic Physicians

What naturopathic medical educators will want to note is that such specialization is inevitable in our educational pathways too, and our early entrants will be followed soon by many more. A particular burden for the AANMC will be to evaluate what this process entails in the coming years for the evolution of naturopathic medical education. That we are becoming what we have fought may be one outcome. Another may be that we avoid producing a generation of specialists who forget the roots and traditions of the medicine in their intense specialty practices.

Footnotes

∗FDHM(C) is Fellowship Diploma in Homeopathic Medicine; DHMHS is Diploma in Homeopathic Medicine and Health Sciences; TNP is Traditional Naturopathic Practitioner; CTN is Certified Traditional Naturopath; CNS is Certified Nutrition Specialist; CN is Certified Nutritionist; and BAMS is Bachelors in Ayurvedic Medicine and Surgery.

David 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).

References

1. Rabow, M.W., Remen, R.N, Parmelee, D.X. (2010). Professional formation: extending medicine’s lineage of service into the next century. Academic Medicine, 2010,: 85, 2, 310-317.
2. Careers in Medicine. AAMC Web site. https://www.aamc.org/cim/specialty/list. Accessed April 2, 2014.American Board of Medical Specialties. (2013). ABMS Guide to Medical Specialities. Maryland Heights, MO: Elsevier. http://www.certificationmatters.org/. Accessed April 9, 2014.
3. Weisz, G. (Fall 2003). The emergence of medical specialization in the nineteenth century. Bull Hist Med, 77, 3, 536-574.
4. Czeranko, S. (2014). Noted from a lecture presented at Boucher Institute of Naturopathic Medicine, May 5, 2014, Vancouver, B.C.
5. American Board of Medical Specialties. Who We Are & What We Do. ABMS Web site. http://www.abms.org/About_ABMS/who_we_are.aspx. Accessed April 29, 2014.
6. American Board of Medical Specialties. Certification Matters. http://www.certificationmatters.org/. Accessed April 9, 2014.
7. American Board of Integrative Holistic Medicine. http://www.abihm.org/. Accessed April 15, 2014.