Friends of Naturopathic Medical Education
David Schleich, PhD
The cross-fertilization of philosophy and practice can lead the curriculum designer to theoretical frameworks in which our medicine can find safe harbors for analysis and comparison with other ways of understanding health. My recent comments about “complexity theory” are an example. These ruminations about “chaos theory” are another. To see whether these epistemological frameworks resonated at all with naturopathic physicians, I designed a little project. The methodology involved contacting 2 naturopathic physicians every month until I had collected and collated responses to a single question from 10 respondents. The initiating question: Why has the education of naturopathic physicians changed in the last 20 years? I was on the lookout for any 1 of the 10 (5 men and 5 women; 5 Americans and 5 Canadians) who might challenge the obvious assumption that any change had occurred at all. I interviewed each for 1 hour, 4 in person and 6 by phone. I approached 13 NDs to find 10 participants. There emerged some least common denominators among their responses. One was that tiny variations over time in how our education knowledge about the 2 theoretical systems I had been thinking about was more pervasive than I had thought. This was despite the lattice-work of programmatic accreditation standards and regulatory detail, state-by-state and province-by-province. An early respondent said, “the mere butterfly wing of a change in my attitude toward vaccinations eventually made a storm for me in how I practice.” (ND participant interview, March 14, 2013).
This idea of one small variable strongly affecting a larger system showed up more than once in those interviews. It became in the ensuing conversations, notwithstanding my care not to inject it into any new conversation at its outset, in fact, a reasonable idea that even though one could reasonably expect a consistent, underlying order in naturopathic medical education that was grounded in common standards among CNME-accredited schools, that is not what has happened. A parallel assumption, though, and one I did not communicate alongside the question, was that very simple or small system changes (in content, emphasis, or methodology, for example) might be at the root of later and very complex changes in naturopathic medical education which have occurred over the period of CNME accreditation.
A Single Flap of a Butterfly Wing
In “chaos theory,” this idea is known as sensitive dependence on initial conditions, an idea attributed to Edward Lorenz back in the 1960s. Lorenz demonstrated a half-century ago that “the slightest difference in initial conditions made prediction of past or future outcomes impossible” (Otto & Rouse, 2009, p.11). In this same frame of reference, though, there is the famous notion that “if chaos theory were true, a single flap of a single butterfly’s wings would be enough to change the course of all future weather systems on earth” (Otto & Rouse, p.13). Chaos theory corroborates that the conditions of naturopathic medical education, sufficiently articulated by, say, CNME standards, would allow some reasonable long-range predictions, but not guarantee continuity of content, or even philosophy. For example, the debate among educators about the coexistence of nature-cure with public health SOCs, in certain jurisdictions where naturopathic physicians have primary care status, is a tough equation, one that separates professional from professional. Not to worry; NDs are in good company.
James Gleick, for example, a pioneer in chaos theory formation puts it this way:
Believers in chaos–and they sometimes call themselves believers, or converts, or evangelists–speculate about determinism and free will, about evolution, about the nature of conscious intelligence. They feel that they are turning back a trend in science toward reductionism, the analysis of systems in terms of their constituent parts: quarks, chromosomes, or neurons. They believe that they are looking for the whole.(Gleick, 1987, p.53)
Chaos theorists embrace numerous disciplines such as engineering, economics, physics, and biology. Within their discourse is the position that any efforts we make to contain ideas or systems in deterministic frameworks does not make the deterministic nature of such systems predictable. Naturopathic physicians have long posited that the uniqueness of every patient is an expression of the vis and reductionist understanding of dynamic systems cannot factor in the subtleties which a tiny initial difference can make for health values in a person (Figure 1). Happily, contemporary science and mathematics (especially fractal mathematics) can begin to capture what naturopathic physicians have for decades considered to be the inspiring, promising, and infinite complexity of nature.
Fractals and Never-Ending Patterns
The Fractal Foundation, an organization reporting widely on this work, suggests that our ecosystems, social systems, and economic systems are interconnected. Its proponents explain that by understanding the metaphor and actuality of fractals, “we can hope to avoid actions which may end up being detrimental to our long-term well-being.” (www.fractal foundation.org )
Fractals, like the complex but repeating detail of human health tissues and systems themselves, are macro and micro at the same time; they are never-ending patterns (Figure 2):
Fractals are infinitely complex patterns that are self-similar across different scales. They are created by repeating a simple process over and over in an ongoing feedback loop. Driven by recursion, fractals are images of dynamic systems – the pictures of Chaos. Geometrically, they exist in between our familiar dimensions. Fractal patterns are extremely familiar, since nature is full of fractals. For instance: trees, rivers, coastlines, mountains, clouds, seashells, hurricanes, etc.
(www.fractalfoundation.org)
Two of my 10 respondents talked at length, independently of each other, about such familiar patterns repeating in the intricacies of human body systems. One physician explained that “even the smallest of changes in one of the body’s systems can make a very big difference in the whole system’s behavior; count on it and understand it in your diagnosis and treatment. My patients have a chaos zoo of behaviors I have to be sensitive to. (ND participant interview, April 9, 2013).
The Difficulty of Predicting Outcomes
One final respondent unexpectedly added much to my growing collection of observations and related data about chaos theory, even though I did not introduce the term or the idea as part of my question with him, either. He asked me early in the conversation about something called “the Cantor set” in health care systems. He explained that his allopathic colleagues admitted candidly in their interactions with him, as did he with them, that some outcomes cannot be predicted, most particularly in health. Thus, the cause and effect scaffolding of reductionist medicine is not always helpful, they all agreed. “They get it,” he declared, “that they need parallel processes in medicine to build in some redundancy to their usual approaches.” (ND participant interview, January 22, 2013)
He described one case:
Sometimes you do everything right with a patient who has diabetes, for example. Sometimes a simple suggestion can make a dramatic change in a diabetic patient’s behavior, while at other times the patient won’t change her diet, monitor her blood glucose, or take care of her feet, no matter how much time or effort you devote to her. Nonlinearity and complexity make it difficult, if not impossible, to predict the specific results of patient education. The wider the time-frame, the less you can forecast behavior and outcomes.(ND participant interview, January 22, 2013)
This conversation, in January of this year, reminded me of an old “total management quality” idea from my early days in the higher education world, in which a technique called “statistical process control” (SPC) was commonly employed in education systems and in the health care administration systems of the day. As the respondent and I delved into the ideas at hand, he asked me if I knew anything about chaos theory. There it was again. We talked longer than the hour I had set aside.
Hutchinson (1994) had long ago taken these very ideas into the realm of chaos theory, complexity theory, and health care quality management. I dug out my notes from those days. The literature is abundant on this fascinating intersection of secular science, mathematics, and naturopathic medical education and philosophy. Health colleagues in the allopathic world have long been familiar with these intersections too, but they find a more embracing audience among naturopathic physicians, it seems. In the nursing world, too, these ideas have found their way into curriculum. For example, over a decade ago, Michael Walsh wrote:
This reductionist approach leads some doctors into seeing patients as malfunctioning bits of anatomy and physiology rather than as whole persons. This problem was neatly summed up by a busy consultant overheard admonishing his registrar in a hectic outpatients [clinic] for wasting time talking about the patient’s problems and how they were affecting his life: “We’ve only got time to get on and deal with the bits we can fix,” was his comment. A mixture of pressure of work and reductionist philosophy ensure that patients do not get treated as whole people, only as “bits we can fix.”
(Walsh, 2000, p.92)
Naturopathic medicine is growing as a medical system. Theoretical frameworks attending philosophical ideas and pragmatic methodologies of treatment are cropping up more and more as we sortie out into the broader world of orthodox medicine and higher education. Our physicians are welcome in the chaos and complexity circles I have encountered.
David 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
- Otto, H.J. F., Rouse, M. (2009). Principles of Elementary Education. Westport, CT: Greenwood Press.
- Gleick, J. (1987). Chaos: Making a New Science. New York, NY: Viking Penguin.
- Hutchison, D. (1994). Chaos Theory, Complexity Theory, and Health Care Quality Management. Quality Progress, 27,11, 69-72. ASQ web site. http://asq.org/qic/display-item/?item=12921. Retrieved June 9, 2013.
- Walsh, M. (2000). Chaos, complexity and nursing. Nursing Science Quarterly. 11,3, 91-93.
- Fractal Foundation. www.fractalfoundation.org. Retrieved June 19, 2013.
