David J Schleich, PhD

Education

The Epistemological Details Under the Noise

In mid-1996 when I first joined the naturopathic community, Dr Lois Hare, then president of the Canadian Association of Naturopathic Doctors, called from Nova Scotia to encourage our little school in Toronto to train graduates to do research. Dr Hare knew then that we had to ramp up our research efforts in the profession, whether it be bench and practice-based projects or collaborations with research centers. In the ensuing two decades, we’ve made progress in Canada and in the United States. NIH grants, graduates in multi-discipline study teams, the advent of the Patient Protection and Affordable Care Act (PPACA) all generated a sense of momentum and optimism. The recent installation of a new administration in Washington, however, has dulled the enthusiasm of some who have been working so hard on professional formation.

All of the Council on Naturopathic Medical Education (CNME) programs have supported the work of individual naturopathic scholars in the profession-wide mission to grow the literature supporting naturopathic medical theory and practice. The energy spinning out into the profession from those theorists, writers, clinicians, teachers and writers is not unlike what must have been happening a century ago. During those early decades, there appeared an abundance of journals, articles, pamphlets and books expounding on every nook and cranny of naturopathic medicine. Today’s flowering continues this work, articulating in an ongoing way the methods of naturopathic medicine and validation, not only for the profession, but also for its students and for other health professionals moving steadily toward holistic practice. This is the very stuff of an epistemology of naturopathic medicine. Now along comes an administration wanting to defuse the PPACA; now along comes an MD heading up Health and Human Services who does not have non-biomedicine professionals on his radar. Our teachers and our scholars are worried. They are experiencing an ennui many of us have not seen before.

Understanding Our Unique Epistemology

Even so, the effort continues. Naturopathic scholars assert that the gestalt (or organized whole) of naturopathic medical knowledge truly accumulates into an epistemology that is greater than any of its major parts. There are debates and conversations about those parts. A recurrent conversation, for example, centers on biomedical knowledge, which the allopathic professions claim inappropriately as their own. No one doubts that it, too, is largely theoretical, despite its pragmatic manifestations, in that it comprises the knowledge and research conjugated through human and veterinary medicine, as well as through fundamental biosciences including biochemistry, biology, chemistry, embryology, histology, genetics, pathology, microbiology, and botanics.

We have long known that biomedicine is less concerned about the whole of its nature being greater than the sum of its parts, and appears to be more focused on the theory, knowledge and research of medicine, than on the actual practice of medicine, much less on its philosophical assumptions. We want to teach the new leaders in Washington about these truths, so that the serious shortcomings of American and Canadian national health care policy can benefit from a different point of view. Naturopathic doctors lament that their biomedicine counterparts don’t often question the paradigm of their own medical model. The national imperative, within the new administration, will shift quickly back toward establishing potential new drugs or on developing deeper molecular understandings of the mechanisms disease. In the Trump era, we worry that biomedicine will continue exploiting its familiar foundations of medical application, diagnosis and treatment. Despite these concerns, we have come too far in the last two decades to push in the clutch. More and more, our biomedicine colleagues on the ground are surprised by how much we know about their foundation.

Baer (1987, 1992, 2001) reminds us that biomedicine is simply the heterodox version of a medical system that he labels as the “American dominative medical model.” Biomedicine has been socially, economically and politically positioned for control for decades; however, in this new political era, some of the unforgiving data about chronicity and cost will not be lost on a new administration trying to balance budgets. Even the Trump administration, ultimately, is not immune from the social anthropologists, historians and political scientists among us looking more closely at the durability of any one group’s assumptions. That a dominant group can be ascendant in one generation and toast the next, is not without precedent. In this regard, there are numerous academic conversations in our naturopathic colleges and universities about the epistemology we’re considering here, and it behooves us to learn more about it.

For example, some social scientists and medical historians have looked into the theories of knowledge that underlie professions or disciplines and challenge some assumptions and certitudes. As a case in point, Power (2000) surprisingly asserts, “rarely questioned [is] the idea of science as essential to medicine.” Actually, there are scholars such as Wetzler whose poignant 1984 study with respect to the dominant position of science in the study and practice of medicine pointed out that there are numerous “myths” present in an epistemology that locates science dead center in the validation of a medical system. Naturopathic educators know this. They nod at his list:

the myth that educational processes are inherently beneficial;
the myth of the basic sciences or ‘physico-chemico-reductionism’;
the myth of excellence, in which standards are supposedly maintained by dubious or at least questionable educational methods and means of assessment; and
the myth of the false foundations (that no student can possibly deal with a clinical problem unless s/he has studied ‘all the basic sciences’)
(Wetzler, 1984, p.135).

Richenda Power (2000) weighs in on this discussion. She provides a remarkable compendium of definitions associated with the art and science of holistic medicine in her book, A Question of Knowledge. The juxtaposition of commentary about the primacy of science in theories of knowledge attached to specific medical systems, separated by almost twenty years, is quite instructive for us as we contemplate an epistemology of naturopathic medicine which we have to have in hand as our unaware political leaders play havoc with the health system. Whereas Wetzler (1984) challenged the unquestioned centrality of science in the study and practice of mainstream western medicine, Power (2000) found “few statements that contained direct claims for holistic medicine being an art,” (p.128) but rather discovered a much larger representation of material on the science of holistic medicine. She points out, though, that such material was invariably “used as powerful symbolic capital in political struggles between groups of health workers.” (Power, 2000, p.129)

Conversation and Debate

This academic conversation is important in the social-scientific debate which is opening up like some giant transcontinental maw in Washington and in state and provincial capitals across the continent. The debate includes reports of statements such as: there is knowledge other than the scientific; we need a new form of science and medicine; and instinctive common sense and experience are good enough; and medicine is not scientific anyway (Power, 2000). Such discourse has been occurring for many decades and from various locations in the wider debate about the nature of health and about what is the ideal approach to promoting and sustaining lifelong wellness.

Leavell and Clark’s widely circulated 1965 model of prevention is a very good example of the shifting terrain underlying the debate about which theory is best and why. Their study, essentially an interpretation of the natural history of disease process, constituted an important element in the larger paradigm of medicine. The model’s intensity gradient has three stages very familiar to the ND and the MD: sub-clinical/unapparent disease, diagnosis, and death. Consistent with the ND’s understanding of the occurrence of disease over time, and thus the opportunity for prevention, is this sequence: prepathogenesis (before the disease occurs), early pathogenesis (small changes in cells and body tissue), demonstrable but early disease (disease that can be recognized by diagnostic processes or screening), advanced or manifest disease (disease clearly identifiable), and convalescence (period after the disease has run its course).

Even with this model in mind, NDs are most focused on primary prevention; i.e. making people more resistant to infection and slowing the progress of a particular disease via education, supplements and mind/body alignment techniques such as meditation and stress reduction. The allopathic, or biomedicine doctor, the argument goes, tends to have a different beginning point with patients. Which beginning, middle and end of a treatment trajectory is affordable? Which is sustainable? Our politicians will want to know.

Shifting Views on Science in Healthcare

During this same period, Nixon (1984) described the paradigmatic shift, emerging at the beginning of the 1980s more strongly than in the previous two decades, from the reductionism of a strictly biomedical perspective on health to “an integrative, humanistic or holistic approach.” (p.27) In the context of this shift in paradigm, the unassailable position of science in health design and delivery, as well as in the education of doctors, was open to question. Relevant here is the work of Adler and Shuval (1978). Citing them almost a decade later and with the benefit of the work of other scholars from the same period, Carpenter (1986) notes that medical students report feeling “subject to negative pressures concerning the scientific element in medical training” during their studies. As their training progresses, he explains, the very “centrality of science for medical practice” is of decreasing importance “for the competent physician.” He explains, though, that at the core of scientific medicine are techniques not anathema to naturopathic medicine such as inspection, palpation, percussion, and auscultation.

The allopathic and the naturopathic doctor each looks, touches and listens. Each has lab tests and instruments to aid in physical and clinical diagnosis. Indeed, these similarities have been true from the days of Frederick Gates and William Osler who anticipated a time when all medicine, natural or scientific, could be “reduced to an exact science.” (Bliss, 1999) Osler was declaring as early as 1892 in his The Principles and Practice of Medicine that the rigor he and others felt must accompany scientific medicine was frequently not present in such fields as naturopathy, homeopathy and osteopathy. Today, such a claim would not be uncontested.

Osler contended that “medicine must rest on science.” (Bliss, 1999) Osler, as a clinical physician, wanted a scientific underpinning to “working at the bedside” focused on the “whole patient,” not unlike the naturopathic physician who is trained to develop a relationship with the patient that includes a comprehensive awareness of the person’s physical, spiritual and mental makeup. Boon (1995, 1996), and Gort (1986, 1988) before her, identified the contemporary manifestations of this tension between holistic and scientific practitioners, and indeed between holistic and scientific naturopathic practitioners. The holistic practitioner’s spiritual and physical words are “not separate, but manifestations of a single life force.” (Boon, 1996) Consequently, symptoms, whether physical or spiritual, command the same attention. Their scientific counterparts, however, to iterate the epistemology, base their medical practice on a biomedical model, which reduces all pathology to a cellular or molecular level. For the latter, the scientific method is the route to curing a disease; for the former, environmental and spiritual factors are key considerations in a treatment protocol.

As Schon (1994) reports, despite the philosophical paradigm of any one group’s location in either an orthodox or a heterodox medical system, “the greater one’s proximity to basic science, the higher one’s academic status.” Professional schools of medicine, in such a context and within such an epistemology, would strive to train healers and socialize them as biotechnical problem solvers. Routinely, they would follow a sequence that immersed the student in medical science and then in supervised clinical practice. Glazer (1974) describes this approach as a “yearning for the rigor of science-based knowledge and the power of science-based technique.” This fascinating polarity hugely influenced the development of naturopathic medical education in North America. The existence of a distinct tension between professional orientation—itself not consistent across the profession and often regionally diverse—and student socialization has been discussed from a somewhat different perspective by Boon (1996) in her analysis of the scientific and holistic worldviews of both students and practitioners.

Gieryn’s (1983) discussion about the practical problem of constructing some kind of boundary between science and “varieties of non-science” is an important theoretical discussion about the claims to authority that science insists upon. Naturopathic physicians and their teachers seem attracted to such a source of authority, but define their eclectic professional therapies inside and outside of such boundaries. There are even continuing claims that the profession has not embarked on rigorous research about key modality areas in its repertoire such as individualized nutritional therapy (Vickers & Zollman, 1999) or chronic diseases in general (Haynes, 1999). A persistent equivocation in the broader field of clinical practice and the continuing influence of practitioners on their educational institutions’ priorities have influenced the development of the profession and those very educational institutions which prepare them for practice in a growing number of regulated states and provinces.

Certainty and Uncertainty Ahead

Meanwhile, there is the ever present pharmaceutical industry, alert at the ramparts of public health and health promotion and with arms crossed (or akimbo, depending on stock value). They, too, are watching what the new political bosses in Washington and Ottawa will have to say. Big Pharma is ever ready to develop medications based on empiric observations and known disease mechanisms. Recent advancements in the genetic etiologies of common diseases will likely continue to spur pharmaceutical development and be of interest to a segment of the naturopathic profession. However, these are the same rascals who brought us Harvoni at the cost of a grand a pill, take it or leave it. These are the same business people who loathe the ambiguity about vaccines in the marketplace. In this regard, it is fascinating to wonder how the emerging notion of “personalized medicine” will take shape in the fuss and rattle of so-called integrated medicine. The naturopathic profession’s enduring reputation for high-touch patient care coupled with respect for the importance of research needs to be communicated more strongly than ever in our new political climate.

The health industry is a well-oiled monolith. Its continuum is known to the naturopathic profession and, more particularly, known to our research colleagues interested in advancing the medicine. A typical pathway translates from basic science discovery through to adoption (Table 1) and demonstrates the complexity and density of the biomedicine framework of North American health systems. We have to push through any recent ennui and keep this essential work going forward.

At about the same time as I joined the naturopathic community, Robert Duggan, cofounder of the Traditional Acupuncture Institute in Columbia, MD, (now Maryland University of Integrative Health) captured the key filament in this quest, notwithstanding who won the electoral college vote:

In Baltimore, Wolfe St. runs between two groups of buildings: The Johns Hopkins Medical School on one side of the street, representing the finest in medical skill and technology, and the Johns Hopkins School of Public Health on the other, symbolizing a humanistic, community-based approach to healthcare. When differences between the two schools were more pronounced than they are now, people joked that Wolfe Street was the widest in the world. Our culture needs a blend of what’s on both sides of that street.
(Duggan, 1995, p.241)

We and our elected representatives have to repeat Duggan’s wisdom as often as it takes.

Table 1: The Translational Continuum

Basic Sciences Discovery	Early Translation	Late Translation	Dissemination	Adoption
Promising molecule or gene target   Candidate protein biomarker   Basic epidemiologic finding	Partnership and collaboration (academia, government, industry)   Intervention Development   Phase I and II trials	Phase III trials   Regulatory approval   Partnerships   Production and commercialization   Phase IV trials – approval for additional uses   Payment mechanism(s) established to support adoption   Health services research to support dissemination and adoption	New drug/assay/ device/ behavioral intervention/ educational materials training:   To community health providers   To patients and public	Adoption of advance by providers, patients, public   Payment mechanism(s) in place to enable adoption

 

From the President’s Cancer Panel 2004-2005 report, Translating Research into Cancer Care; Delivering on the Promise.

[References]

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David J. Schleich, PhD, is president and CEO 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).