How many bosses can a program bear, anyway?
David Schleich, PhD
Some NDs may think that professional and political governance in our naturopathic medical education programs, of the kind that is routine in public sector higher education, is pretty much under control with Council on Naturopathic Medical Education (CNME) programmatic accreditation. However, almost all our programs (except the Canadian ones) now have both programmatic and regional accreditation affiliations, which unrelentingly over the years have added a growing dollop of political castor oil to our reality. While it has been the case for a long time that the influence of the external profession (i.e., physicians who are not employed by colleges in any way) has been less than the influence of the internal profession (i.e., physicians who are employed by the colleges in some way), the needs of the external profession are more significant than ever in our governance policies and actions. That influence has historically been expressed through didactic and clinical curriculum, although in recent years the early “roots” of the medicine have slipped from the core. For example, no naturopathic program in North America has serious curriculum units in balneotherapy. It is rare for students to learn tincturing and compounding. It is even rarer to find graduates who would bother to wild craft. The external NDs for whom these traditional roots are important have less influence now in terms of college governance.
These days, non-ND administrators and evaluators (meaning, non-NDs) have a lot to say about curriculum and our programs. There are no regional accreditors in the United States, for example, who have any personal professional experience in the natural medicine field. Even so, these individuals have much to say about our methodology, context, and accountability. If one includes the location of this growing panel of non-ND “accreditors” in the governance continuum, we have taskmasters for whose attention and favor we must vie and, at the same time, whom we have to educate about what we are doing and where we are going. They inadvertently contribute to this distraction from our roots by understanding “medical education” in the same frameworks as biomedicine. And because we strive to sustain access to Title IV and Stafford loans and want to assure the right of our graduates to try Naturopathic Physicians Licensing Examinations for entry to practice, we have to conjugate the governance of our schools through the same gauntlet. The challenge is that these laypersons (myself included) are mostly from the business and higher education realm and, invariably, know little about our history and even less about the healthcare terrain we face. Unfortunately, we need them more than they need us, as it were.
Let us delve more deeply, then, into how naturopathic medical education can cope within this complex scenario of multiple bosses: the expensive vortex of programmatic and regional accreditors, the transforming landscape of market influences (licensed states and provinces and unlicensed states and provinces), the accelerating cherry-picking by integrative medicine, and the evolving uneven nature of naturopathic medical scope.
To review, U.S. higher education is market-driven, as well as influenced by central and state governments that have high expectations of effective institutional governance. The way that regional and programmatic accreditors get a dog in the governance fight is through access to student loan support. In Ontario and British Columbia, Canada, access by diploma ND students to provincial and federal loans and grants is not contingent on CNME programmatic accreditation, as is the case for the five U.S. programs. The two Canadian schools, though, must comply with private vocational schools legislation for their students to be eligible for the provincial equivalents of such support. If either school, however, wants to attract U.S. students, then CNME accreditation is essential.
The American higher education sector is highly regulated but is by and large decentralized. At the same time as it is characterized by nongovernmental private sector activity (accreditation bodies are not government bodies but affiliated nonprofit agencies), students have access to a widely diversified funding system. There are other variables too, such as the U.S. legacy of land grant universities from the 19th century, the dominance of the American research university in professional degree programs, and the presence of associate’s degree pathways in community colleges in the postsecondary landscape, as well as by an expansion of access and participation since the end of World War II in postsecondary systems that have never included naturopathic medical education (Figure).
In this complicated landscape, naturopathic medical education programs must find a place and have a governance latticework to maintain that place. As shown in the Table, the complex scenario is best outlined by the Carnegie Classification of Institutions of Higher Education (McCormick, 2000):
Given that our trustees, directors, and governors are volunteers and that the key agencies of the profession—the American Association of Naturopathic Physicians, the Canadian Association of Naturopathic Doctors, provincial and state associations, the Association of Accredited Naturopathic Medical Colleges (AANMC), the Naturopathic Coordinating Council (NCC), the Canadian Naturopathic Coordinating Council, the CNME, and other groups—are supported by volunteers and very few professionally remunerated staff, it is not surprising that we find our own program and college governance bruised sometimes by the same governance challenges that public sector counterparts encounter in that complex monitored higher education terrain. One factor is that responsibility for governance of our naturopathic medical education is ideally shared across many jurisdictions to build a consistent professional profile; however, there is no such communication among boards. For example, those trustees giving thought to priorities for the program at University of Bridgeport (Bridgeport, Conn.) may not have the same approach or goals as the board of Southwest College of Naturopathic Medicine (Tempe, Ariz.), for example. If they do, it would not be because our various governing individuals and bodies talk to each other, because they do not.
Another factor is that those “governed” in our naturopathic programs often have a limited role in naming trustees. At the same time, those who become directors, trustees, or governors sometimes come from backgrounds that do not include a broad grasp of the college’s and the profession’s purposes to govern effectively. Historically as well, some college programs may have been hindered by naturopathic professionals with little if any experience in higher education, legal and accreditation matters, insurance, finance, or property management.
A further factor is that many trustees, as Carver (1997) has pointed out so eloquently, operate with baggage from a tradition of thinking that their job is to monitor operations rather than focusing on strategy, policies, and vision. For a long time, ND colleges, program boards, and advisory bodies had to be involved in the minutiae of running the schools. In such situations, though, directors run the risk of getting stuck in their college’s daily operation matters, and given the short time they have to be directors in the first place, they can inadvertently forfeit the opportunity to shape its mission.
What can be done to improve this increasingly contentious situation? For starters, each program can review board productivity and performance to gauge the degree of focus on naturopathic programming and professional formation. This can be challenging if the board has other focuses, such as do regional comprehensive university boards, which have other programs to keep an eye on too. If our naturopathic program directors and trustees were talking to each other, differences in vision and approach would surface eventually, and efforts to coordinate professional formation with consistent professional profile standards would be more within reach. If the AANMC, for example, had as part of its mandate and priorities governance training coupled with interinstitutional governance communication, likely many trustees would take advantage of such opportunities. If an opportunity existed across our seven programs for their board “directors” to regularly compare and share their vision, mission, purpose, and product ideas, the profession would be well served in the critical formative stages that we are currently experiencing.
The question behind this speculation is who has a right to define the naturopathic medical education mission of the profession? Should it be the AANMC, the NCC, or individual college governance groups? One theory maintains that those who have the best grasp of the essential didactic and clinical content of the profession—the faculty—should have a strong governance voice. Students, too, as the key customers of the college and investors in the future of the profession should have a meaningful say. What has been evolving overall have been lay boards, with student and faculty representation, but constrained by their not being a plurality.
Alongside the growth of our programs since 1956, most boards have been willing to charge the president, his or her administration, and the faculty with increasing responsibility for daily management of the college. Certain boards have persisted in the desire to have a role in daily decision making, from hiring to budgeting. As Carver (1997) attests, though, boards that insist on the right to make operational day-to-day decisions invariably generate conflict. What can arise are claims by the president or the faculty that the board is conflicted by micromanagement. Activist boards reject the accusation, however, arguing that it is their fiduciary obligation to be involved with what is going on at the college or within a program. There have been battles among stakeholders in our colleges, and sometimes the students and alumni have reacted with alarm and even negatively to both sides of the dispute and to the college as well. Clearly, governance fails when its controversies generate ill will for the college that it should and wants to be serving.
From another perspective, if a board drifts too far away from the college it governs, the institution could go off course, weakly tethered to the profession it serves. Alternatively, an inattentive board may choose to avoid micromanaging and unintentionally in its deference take less responsibility for the college’s mission, defaulting to the internal stakeholders, succumbing potentially to rubber-stamping to avoid conflict with the president, administration, faculty, or students and sometimes even with alumni. In such complex stews, confusion about who is in charge will only get worse with the growth of computer-based distance education. Ideally, our naturopathic medical education directors, trustees, and governors have to find a balance among the following types of questions, which beg an underlying question: must the board spend more time on plans and reviews of recent activities than on assessment and mission issues?
Should presidential and administrative reviews of events at the college and approving items brought to the board by the administration suffice as summaries for the board?
Should the board engage in systematic discussion of big picture questions and issues related to the college’s mission or focus mainly on keeping finances and enrollment well monitored?
Whom should the college be serving by virtue of its policies and priorities: the internal employee stakeholders, the alumni and the demands of professional formation, or the students? How does the answer to this question shape the destiny of the profession across time?
How well are students being prepared for the challenges that await them, and what responsibility does the board have for this? What evidence is there that the students as “customers of our colleges” and as “investors in the profession” are being well served?
Who could benefit from college services but do not use them? What would it take to extend the college’s resources, purposes, and benefits to them?
These are operational questions that can consume most of the board’s time. Unfortunately, sometimes our boards find themselves not having the time and focus they need for the tasks of organizing their own business and clarifying their own role and responsibilities. Whereas the board may want to point the college in strategically brilliant directions, this requires effective planning, analysis of internal and external trends, projections, and continuous revision of master plans.
Alas, the record shows, though, that our naturopathic medical education boards never talk to each other about these important matters. They isolate themselves and spend most of their time dealing with present problems or discussing problems of the past. They suspect the boards of other colleges, mired as we have been in competition for a tiny applicant pool and in the unrelenting attack by biomedicine in the arena of regulation and public policy. When this happens, we may well be collectively giving up an opportunity to shape the future.
In fact, the boards of our naturopathic medical colleges have no mechanism to talk to each other and rely on management to keep the respective college aligned with external constituencies. Going forward, the AANMC may want to take the lead in defining and facilitating reliable ways of communicating with the profession and with those who can affect or use the talents of graduates. Boards simply must find ways of staying in touch with the prevailing political currents, and linking with each other will help to share and compare how those concerns play out in different regions of the country. When trustees fail to grasp the needs of students, the requirements of employers, or the politics of social change, governance breaks down, and effectiveness erodes.
At the same time as they deal with these big picture challenges, our boards have to be attuned to the college staff’s values and aspirations, most particularly where the ND program is a single program among many. The special nature of academic culture also needs to be addressed by our governance colleagues. None of our colleges has an academic medical career path in place for teachers, and there is much to be learned collectively about how to achieve this. For example, is there a place in such a career pathway for tenure and collective bargaining? Forging a permanent academic culture is a challenge for naturopathic medical education governance. Down the road, in fact, the effort of ND governors, directors, and trustees will have to galvanize to appreciate not only the nuances of academic culture but also its centrality to the success of the profession we serve.
Our governance colleagues know they dare not settle only for rising enrollments and balanced budgets. The urgency of professional formation in a time when biomedicine hypocritically feeds on our traditions under the mantle of “integrative medicine” puts more pressure than ever on our governing bodies not only to guide response but also to define direction. The profession asks for more vigilance than ever to assure that our roots are safe, that they survive as ever-deepening traditional modalities, and that our educators welcome with wisdom and detail new ones. Governance is about understanding the profession’s history and its destiny. Governance is about a bond of trust between the board and those who administer, those who teach, and those who support both. The actors in this drama are inevitably going to bump into the furniture on this dense and competitive stage. Our stage, we must keep in mind, is not just about healthcare and the mischief-making of the American Medical Association; it is also about the severe disadvantage that can occur in the labyrinth of academic and accreditation committees if the players can see only in part. Our students and the market demand agility and excellence at the same time. Our nimble competitors can take advantage of our relatively slow forms of governance if we do not refine them, ramp them up, and drive headlong toward a future that is friendly despite everything.
Table 1. The Carnegie Classification of Institutions of Higher Education
| Doctorate-Granting Institutions |
| Doctoral and Research Universities—Extensive: These institutions typically offer a wide range of baccalaureate programs, and they are committed to graduate education through the doctorate. During the period studied, they awarded ≥50 doctoral degrees per year across ≥15 disciplines. |
| Doctoral and Research Universities—Intensive: These institutions typically offer a wide range of baccalaureate programs, and they are committed to graduate education through the doctorate. During the period studied, they awarded ≥10 doctoral degrees per year across ≥3 disciplines, or ≥20 doctoral degrees per year overall. |
| Master’s Colleges and Universities |
| Master’s Colleges and Universities I: These institutions typically offer a wide range of baccalaureate programs, and they are committed to graduate education through the master’s degree. During the period studied, they awarded ≥40 master’s degrees per year across ≥3 disciplines. |
| Master’s Colleges and Universities II: These institutions typically offer a wide range of baccalaureate programs, and they are committed to graduate education through the master’s degree. During the period studied, they awarded ≥20 master’s degrees per year. |
| Baccalaureate Colleges |
| Baccalaureate Colleges—Liberal Arts: These institutions are primarily undergraduate colleges with major emphasis on baccalaureate programs. During the period studied, they awarded at least half of their baccalaureate degrees in liberal arts fields. |
| Baccalaureate Colleges—General: These institutions are primarily undergraduate colleges with major emphasis on baccalaureate programs. During the period studied, they awarded fewer than half of their baccalaureate degrees in liberal arts fields. |
| Baccalaureate and Associate’s Colleges: These institutions are undergraduate colleges where most conferrals are below the baccalaureate level (associate’s degrees and certificates). During the period studied, bachelor’s degrees accounted for ≥10% of undergraduate awards. |
| Associate’s Colleges |
| These institutions offer associate’s degrees and certificate programs but, with exceptions, award no baccalaureate degrees (this group includes community, junior, and technical colleges). This group includes institutions where, during the period studied, degrees represented <10% of all undergraduate awards. |
| Specialized Institutions |
| These institutions offer degrees ranging from the bachelor’s to the doctorate and typically award most degrees in a single field. The list includes only institutions that are listed as separate campuses in the 2000 Higher Education Directory.b Specialized institutions include the following: |
| Theological seminaries and other specialized faith-related institutions: These institutions primarily offer religious instruction or train members of the clergy. |
| Medical schools and medical centers: These institutions award most of their professional degrees in medicine. In some instances, they include other health profession programs, such as dentistry, pharmacy, or nursing. |
| Other separate health profession schools: These institutions award most of their degrees in such fields as chiropractic, nursing, pharmacy, or podiatry. |
| Schools of engineering and technology: These institutions award most of their bachelor’s or graduate degrees in technical fields of study. |
| Schools of business and management: These institutions award most of their bachelor’s or graduate degrees in business or business-related programs. |
| Schools of art, music, and design: These institutions award most of their bachelor’s or graduate degrees in art, music, design, architecture, or some combination of such fields. |
| Schools of law: These institutions award most of their degrees in law. |
| Teachers colleges: These institutions award most of their bachelor’s or graduate degrees in education or education-related fields. |
| Other specialized institutions: Institutions in this category include graduate centers, maritime academies, military institutes, and institutions that do not fit any other classification category. |
| Tribal Colleges and Universities |
| These colleges are, with few exceptions, tribally controlled and located on reservations. They are all members of the American Indian Higher Education Consortium. |
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
Carver, J. (1997). Boards that make a difference: A new design for leadership in nonprofit and public organizations. 2nd ed. San Francisco: Jossey-Bass.
McCormick, A. C. (2000). The Carnegie Foundation for the Advancement of Teaching, 2000 edition. Menlo Park, CA: The Carnegie Foundation for the Advancement of Teaching.
Rodenhouse, M. P. (Ed.). (2000). 2000 Higher Education Directory. Falls Church, VA: Higher Education Publications Inc.
