The Future Isn’t the Same as it Used to Be: The AANMC and the Urgent Need for a Strategy for Fast Naturopathic Medical Education Growth
David Schleich, PhD
There are urgent tasks on the table for today’s naturopathic, academic leaders. The image: grow to as many NDs on the continent as there are DCs, at the very least; the reality: too many of our graduates are struggling. The imperative to create new schools and programs needs a strategy which creates and sustains more successful graduates in more jurisdictions before the opportunism inherent in the so-called integrated medicine initiative capture precious present and future ND territory.
There has been a long conversation among naturopathic doctors about concentrating on creating new naturopathic medical education capacity within existing public research universities and schools, as well as optimizing our current cohorts. Accompanying the debate on where to generate more seats has been the concern that science-based research incorporated into any higher education context for naturopathic medical education would, without careful shepherding, co-opt and dilute the medicine. Whatever the nooks and crannies of the discussion, though, the original and abiding intention to join the post-secondary “first-professional degree” niche has grown out of an awareness that the proprietary schools that initially dominated the North American medical education (allopathic and naturopathic) landscape in the 19th and early 20th centuries did not survive Flexner well. More importantly, those schools did not ultimately establish the naturopathic profession securely in the primary health care landscape in North America.
To help us through this urgency about how best to strengthen the numbers of successfully practicing NDs in North America, we can turn to a helpful, emerging literature filled with suggestions (Aakster, 1986; Bloomfield, 1983; British Medical Association, 1986; Frank, 1981; Rosengren, 1980; Wiesner, 1989) that has been charting a pioneering course through such confusion in recent decades. Within this literature there is a useful tradition of radical and progressive inquiry that takes aim at the medical industrial complex characterized by the elitism of the allopathic medical profession and the well-known and well-established link among it, the pharmaceutical and medical equipment and supplies industries, and the insurance industry. These sociologists, medical historians, and public policy scholars have written extensively about the hierarchies that exist among medical professionals who are connected to this so-called complex, and thus as we propel our schools more and more into the higher education niche, it would do us well to become increasingly familiar, as institutions, with the core ideas and conclusions emerging from that scholarship.
Doyal (1979) and Navarro (1976), for example, using political economy as a framework, describe for us the social context in which medicine operates. Ehrenreich (1978), Illich (1977), and McKeown (1979) have reminded us of the failure of allopathic medicine to deal with numerous health concerns. In any case, these sociological backdrops help us understand the nature and impact of the marginalization of the non-allopathic medical traditions which has discouraged us from getting the resources in motion to grow our numbers to a place of significant impact. Two decades ago, Ruzek (1986) outlined the social aspects of primary medical care which are in our favor, but which also are a place of confusion for the public. Fifteen years ago, Shroff called attention to the “risks of many technical diagnostic and therapeutic procedures” (1996) when compared with holistic medicine where the practitioner validates client feelings (Flood, 1995). As these dialogues and debates took place, the naturopathic medical education community was not in a place to contribute, much less pay attention. We cannot afford this absence any longer.
The urgency some feel about ramping up our numbers within this difficult arena revolves around refining and reshaping our template or model for new program creation. Many of our deans and program chairs are increasingly aware of how our curriculum and the very uniqueness of our professional location in civil society could be inalterably co-opted by being systematically assimilated into the mainstream post-secondary career preparation corridors of North American higher education. They are so busy keeping our programs viable that a coordinated effort to add more capacity has eluded us to date.
In order to keep to our original purposes of producing the best naturopathic medical education possible and graduating qualified clinicians to form the profession in North America, we will need to be present and active whenever an opportunity arises to train and place more naturopathic students. The great vulnerability, whether we expand our numbers or not, is that the biomedical and some allied health care professions will cherry pick our modalities and deliberately, or unconsciously, dissipate the cumulative momentum of naturopathic professional formation as a result.
The interconnectedness of the AANP, the CAND, the AANMC, the INM, and the CNME is instrumental to this work, and by extension the participation and energy of the state and provincial associations, but it is the AANMC that is best positioned to let the clutch out. In ways which operationally have not yet materialized on the action agendas of those organizations, but whose collective creativity and volition are the only places where this work can be done, the needed work begs attention. That work is the creation of a well informed, deliberate, and strategic plan for growing our numbers and is upon us. This is probably the most important window facing us this decade. It is likely with the AANMC where the task lands most heavily.
Our multi-program, regional universities, and our colleges, have successfully sustained programmatic and institutional accreditation at the same time as they have done what they can to help out with some of the complex needs of professional formation such as placement, career differentiation, painfully slow growth in residency education, and making their communities more aware of what NDs are and what they can do. However, as institutions in the middle of such work, they do not converse nor have they created a forum for such dialogue. Their mandate is shared by our existing agencies and despite brisk conversations on occasion, there is no strategy on the table. While it is desirable that our institutions become stronger players in the higher education landscape, there is no broad forum where those institutions delegate the authority to manifest a growth strategy in the most pragmatic, post-secondary sense. The AANMC is our most valuable tool for discussing how best to incubate and support the emergence of new program capacity. We cannot rely on the spontaneous spawning of another Bastyr, SCNM, or NCNM because of the huge cost and the long lead times necessary for achieving accreditation.
The philosophical and professional formation foundations and mission of our colleges and programs would benefit from such dialogue about the design and governance of new programs within larger institutions that do not have a history in the naturopathic universe. CCNM, Boucher, and SCNM still maintain single program frameworks, but their future program colleagues will come from multi-program institutions with differing imperatives and far less corporate savvy about how to give priority to the growth of a single profession.
For as long as any of us can remember, there has been talk from the field about the desirability of new programs in states such as California, New York, and Florida, as cases in point. The advocates for these new programs think of them as being either stand-alone institutions or degree programs within an existing university, but in any case CNME-accredited. The implications for the academic and educational organizations that are essential to support bona fide naturopathic degree programs are many, including activity we have not broadly supported in the past such as governance development, teacher education in the natural medicine disciplines, student advocacy, and collective research agendas.
There are difficult, fascinating, and challenging questions to ask and answer: what are the interdependent roles of the AANMC and the CNME in incubating this planning dialogue and eventually these new program manifestations? How quickly must the AANMC realize increased financial resources and become organizationally separate from the AANP in the same way our existing colleges are not structurally linked to state associations? From which talent pools will we draw medical academics and academic administrators to build, fortify, and defend new programs in institutions not familiar with the terrain of our medicine and our philosophy? How will the staff of these new programs guard against the inevitable hijacking of modalities so long and with so much effort preserved by naturopathic doctors, but which the nearly four dozen so-called “integrated medicine” programs around the country will scoop in some version with a second thought?
We have to get very good, very soon, at understanding the culture of higher education in America in order not only to ask these questions, but also to find the time and brain power to chart courses of action and stay those courses. Our leaders are already active in navigating into these higher education terrains. For example, Dr. Paul Mittman, President of Southwest College for more than a decade, recently earned his EdD and by making that effort exemplifies the kind of leader who can swim in the cranky universe of programs in diverse institutions which are circling around us. Dr. Bob Bernhardt, the longest serving President in CCNM’s history, has also recently completed his PhD at the University of Toronto and has kept CCNM safe in the prickly post-secondary arena in Ontario. That Dr. Fraser Smith, founding dean of the naturopathic program at NUHS, is also working assiduously on a PhD is a further example of the commitment of our academic leaders to drink in the skills and knowledge needed for us to thrive in the post-secondary, higher education terrains on our flight path. As these long-time leaders in the profession deepen their knowledge of the primary cultures within the academy, they model the importance of understanding the culture, which is likely to be where we create our much-needed new capacity.
In this regard, Hanna (2000) gives us an insight into what that world looks like: “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, 2000, p. 94)
Hanna’s notion of those trends and characteristics complement Bergquist’s (1992) earlier outline of the “four primary cultures within the academy” and, as Hanna points out, anticipate a fifth, “entrepreneurial” one. Bergquist’s taxonomy of cultures includes 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 Bergquist, Tierney, Clark (1983, 1998), and others, and contemplates 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. As we move into these conversations, we move into a world where we can get our important work done safely.
Whatever its forms along the way, the higher education culture has always been a fertile place for the naturopathic profession, even though we have had no single success so far in establishing a strong naturopathic program within a large, comprehensive university. We began where we could and our early 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. This approach is not inconsistent with what every other major profession has done in the last century to gain credibility and credentialing. Coupled with an affinity for the higher education realm is the imperative of routinely collecting and systematizing the knowledge of the profession.
Since 2004, the Foundations of Naturopathic Medicine (FNM) Project, under the leadership of Dr. Pamela Snider, has been busy doing just that, engaging in a strategy to codify the distinct knowledge of the profession, and within a model that resonates with the higher education framework so important to professional formation. The research framework, the processes of the FNM, and its attractiveness to donors and sponsors are all grounded in higher education standards which have not gone unnoticed by that sector of the corporate world watching the formation of naturopathic medicine, a lucrative and powerful sector. The president of Essiac Canada International, Mr. Terry Maloney, who bankrolled the initial activity of the FNM Project, continues to do so largely because “this research and writing project is up there with the best of anything the Harvard C.A.M. boys are doing; I want to help make sure naturopathic doctors keep in the game.” (T.P. Maloney, January 5, 2004). It is not surprising that Seroyal and Metagenics, respected suppliers to the naturopathic profession, also came forward shortly thereafter with equal financial gusto to support the project’s “rich research outcomes which can help make naturopathic medicine unassailable” (Dr. J. Bland, June 2007). Carmen Fortino, CEO of Seroyal, put it bluntly, “We have to make sure the world knows that NDs are here to stay” (C. Fortino, May 2008).
Clearly, the profession’s leaders and partners want to support efforts to embed the medicine in institutionally and programmatically accredited, degree-granting colleges and universities dedicated to the institutionalizing of naturopathic medical education and the proliferation of the profession. It is important to remember though, the FNM Project did not ever find a home within the AANMC, where it most naturally gravitates in terms of mission. Rather, its academic home is within a single institution and the funding apparatus is conjugated through that institution’s 501(c)(3) mantle. It is a foothold, but it is not the future. These kinds of ad hoc relationships beg strategic redefinition not only to create more smooth sailing as our colleagues go about their work, but also to clarify who is doing what for the cause.
A further, quite different but telling, example comes from Canada where the higher education terrain is not the same as the United States’. CCNM’s and BINM’s diploma programs do not fit snugly into the higher education worlds of Ontario and British Columbia. CCNM’s leaders over the years had to create a hybrid version of a post-secondary credential which bridged the higher education world and the world of the private career college, at the same time as satisfying the standards of the U.S.-based CNME programmatic accreditation body. CCNM can, like CMCC (its chiropractic colleague in Toronto), contemplate getting authority to issue a credential more like their U.S. counterparts from the provincial post-secondary authority within the framework of Ontario 2000 legislation making it possible for some private career colleges to issue degrees. The chiros have managed to get there, but CCNM’s present credential still does not transfer equitably among other degree-granting institutions because of the arrangements that have emerged in that province for nonprofit, private colleges. That a career college in an American state will chart a similar runway for a naturopathic credential is not out of the realm of possibility; in fact, within the present administration, community colleges in the U.S. are studying “natural medicine” career paths for their students with more alacrity than ever.
Ruch (2001), a social historian, comments that such hybrid institutions “have more in common with multi-campus, public, non-profit universities than they do with traditional proprietary schools” (p. 24). The Carnegie Classification of Institutions of Higher Education (McCormick, 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 from 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. It is not surprising, then, that new programs will seek the same kind of realm to find a home. We simply have to be talking about and planning for these contingencies so as to control our own professional formation agenda.
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 in 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) and not specifically to the self-interested needs of the profession whom its graduates join. 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, Ecker & 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; 1990).
Whether it is the early leadership and success of research activity at Bastyr and Southwest, the creation and growth of the Helfgott Research Institute at NCNM, or the growing sophistication and reach of the research program at CCNM, the pool of academic leaders we need in this multi-faceted environment must learn as much as they 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. 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). Even if, as Altbach also claims, higher education as a field of study “lacks an institutional base” (p.2), for our purposes its resources nevertheless include important contextualizing features such as the nature of governance or the “study of formal systems of education” (p. 3), or the interest in higher education financing. What is critical is that on the agendas of the AANMC, the CAND, the AANP, the INM, and the CNME these urgent conversations appear often and be well supported with information, current intelligence and money. What is equally urgent is that we make room for medical academic career opportunities which include support for the formal training of our academic leaders in the various cultural aspects of higher education. The place where these imperatives need a strategic framework for action is the AANMC.
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).
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