David J. Schleich, PhD

Education

Every summer we convene a focus group to talk about what’s next. The group is volunteer, anonymous and eclectic, comprised of current students, recent grads, and alumni/ae. We meet on a weekend morning. They are enthusiastic, reflective naturopathic healers. Everyone speaks freely and a lot. Most come prepared, having been alerted to the topic ahead of time. Analysis is encouraged because synthesis, as we have learned, is essential to action (“analyzed,” from the Greek analusis: loosening up). We spend the morning gradually loosening ideas, very often achieving depth and breadth. The gathering usually meanders into the early afternoon.

The Provenance of Naturopathic Medicine

This year our ramp-up topic was “the provenance of the medicine.” We wanted to reflect on who has been taking care of the field of of naturopathy all these years. We set out to understand the worry today that naturopathy has lost its way. I explain that the provenance of naturopathic medicine has been checkered; that is, its origins and its history, and its custodians in the healthcare terrain, have all oscillated this way and that over the years. I provide an abbreviated history predicated on Czeranko’s Hevert Collection. I add that provenance accompanies other features of professional formation that tease out the identity for naturopathic medicine as a system, but also as a brand. Gasps all around. Brand?

I carry on, explaining that the philosophical underpinnings of naturopathy are strengthened by follow-throughs to provenance, such as the reduction of risk claim. I also point out that the allopathic industry makes the same claim at the same time that it’s established almost unassailable premium pricing. The biomedicine people a century ago knew about how to parley provenance into dominance in the marketplace. Their brand since then has been mostly Teflon. Explaining, I report that despite the stratospheric cost of US healthcare ($3 trillion this year alone), and the fact that allopathic medical error contribute >250 000 deaths to the annual US rate (compared with an accidental death tally of just under 150 000) (Makary, 2016), there is hardly a wrinkled eyebrow in the media. Despite the data, the orthodox medical profession still rules the roost.

The participants jump into the conversation. To address the massive chronicity issues of our time, one participant declares that these fundamentals (a familiar provenance, a tolerance for risk, and premium pricing) need to be up and running for us too. We’re already ahead of that relay race, I proffer, since risk in our medical system is zip compared to the pharmaceutical-surgical-vaccination-test-happy biomedicine terrain. If we are to achieve pluralism, equality, and equanimity in the highly commodified terrain of mainstream medicine, a veteran ND suggests, we have needed everything from accredited programming and licensing for graduates to a well-funded, patient-centered-outcomes research institute (PCORI). The group really lets out the clutch now.

A Changing Story

We get into why those who have held the space for naturopathy in the past and those who are leading the fray at the present are often at odds about where we’re headed and where we’ve been. The familiar refrain that we are becoming what we fight keeps everyone occupied for a full quarter-hour. I tug us into considerations of the key elements of professional formation in the days of our naturopathic pioneers. But we quickly return to the present era and a chorus of worry that we’ve lost our roots. The conversation ricochets from the Flexner days to the early formation of the AANP and CNME in the 1970s and 1980s. It becomes clear that as the naturopathic organizations have became larger and more complex, the story has changed. This was caused by the arithmetic, and then by exponential growth in the available information related to curriculum, licensing, regulations, and oversight.

As a case in point, the expansion of curricular materials between 1956 and 2017 is nothing short of astronomical. Examining a typical syllabus from the Western States School of Chiropractic and Naturopathy curriculum of 1955 in, say, botanical medicine, and comparing it with the current CNME- and NWCCU- approved syllabi of today, the difference in format, range of content, jargon, detail about assessment, and specifics about how each moment is spent are enough to make one wonder what actually did happen in the classrooms of 1956. Critical to overcoming the alarm about the thinness of the documentation in NCNM’s inaugural year (1956) compared with the most recent curriculum overhaul (rolled out in 2016) is recognizing that the provenance of the medicine 60 years ago was highly correlated with who was teaching.

We get sideswiped by a robust debate over who got to define the profession in the first place and whether those descriptors still apply. The best known modern-era exchange regarding professional definition occurred at Rippling River (just outside Portland) in November 1989. The documentation from that gathering is in paper files, and amounts to only a fraction of the number of files which capture the proceedings at Skamania Lodge in 2007, when the Foundations of Naturopathic Medicine Project formally launched. Significantly, among the keepers of the profession, the leader(s) of both consultations were the same, separated by 21 years. The main point here is that we would need to understand the structure and processes of the institutions that defined and described naturopathy at various stages in order to rely on the records themselves with equal confidence, notwithstanding the era.

In this regard, the accreditation documents relating to NCNM, from the state higher-education licensing agency of, say, 1985, do not compare at all with what is expected, produced, and inspected 32 years later. For starters, the mono-hierarchical structures of the time contrast with today’s more complex play occurring among federal, state, and regional academic accreditors. It is complicated to drill down into and among what the various reporting authorities, supervisory departments, and individuals want to see, how often and in what formats, and in what year. There is also the input and oversight – fiduciary and voluntary – of those with advisory and policy roles which are part of the AANP, AANMC, CNME, the boards of the various institutions that house our programs, NABNE, NPLEX, state associations with legislative authority, and state associations in the public domain. We concur that the incrementalism of these individuals, groups, organizations, and formal bodies persists less successfully in institutional memory than within the narrative richness of the tales told by those who created and administered naturopathy’s agencies and organizations in earlier days.

The Need for an Anchored Definition

By the mid-morning break, we were all befuddled by the poly-hierarchical nature of what we know about our various programs, councils, associations, and boards. Lytle (1980) speaks to this huge challenge in his remarkable U of Maryland doctoral thesis, illuminating the vicissitudes of provenance and accompanying content. Overall, we later conclude that we pay more attention to the stories from our profession than to the actual archival material that establishes the provenance of the profession across all of those early years. The stories of Sensenig, Broadwell, Boucher, Bastyr, Farnsworth, Lust, Snider, Zeff, Stone, Bleything, Pizzorno, Warren, Cosgrove, and others are top of mind. The evaluation report of 1985 from the Higher Education Council in Salem, OR, is not.

The group decided that the differing accounts of who was keeping naturopathic medicine alive during that period are unreliable as fundamental anchors for a definition of the medicine and for an organizing ground for further professional formation. In contrast, modern biomedicine has positioned itself so well in civil society that it has clear, ubiquitous definition and is virtually immune from any serious attack related to safety and efficacy. Ranging from extraordinary statistics related to acute care success, to suspect data and therapeutic claims attributed to statins, for example, the key messages of allopathic medicine begin with an assumption of quality and rigor, despite mounting data to the contrary. In huge swaths of the country, allopathic medicine is the only show in town.

With the mention of statins, one participant claimed the floor to talk about them. He referenced the widespread use and defense of statins as an example of the unwarranted but unchallenged hegemony of allopathic medicine. He explained that statins may be drugs, but they get off as easily as accounts of stents, in terms of safety and value. Statins may not be coronary stents implanted percutaneously, or coronary artery bypass grafts performed surgically and assisted by heart-lung machines, he says, but both categories of intervention are just fine, in the minds of millions of patients in the United States.

The 43 million Americans who take statins (Pencina et al, 2014) do so because they’re persuaded that the reduction of risk has been reliably achieved by cardiologists. After all, high-intensity statin therapy (eg, rosuvastatin 20 mg/d, or atorvastatin 40-80 mg/d) reduces LDL-C by 50% or greater, don’t you know. That approach to cardiovascular care constituted a $125 billion dollar business, and Pfizer rode the bandwagon until 2011 when its patent expired. But if you need a stent, we can do that too, the allopaths announce, for about $35 000 in the United States, or $3950 in Poland.

The Challenge of Successful Branding

My before-lunch job is to keep the group zeroed in on the question of how mainstream medicine does such a good job of convincing everyone that it has the reduction-of-risk variable so well covered. We get bogged down in detail. The reduction of risk, to be acceptable and believed, means that outcomes are documented, quantified, and published. One participant tells us that chlorhexidine gluconate really works in reducing microbial skin burden before surgeries, thus reassuring insurance-covered patients that skin-colonizing flora such as methicillin-resistant Staphylococcus aureus won’t mess up a good surgery. There we have reduction of risk that is bound up in published research, she says.

So far, then, the group had decided that provenance and risk reduction are in play for the biomedicine world. We have those in our repertoire, too, but they seem to be a secret all over the block. So, we turned then to the matter of loyalty of patients (and governments and insurance companies) to allopaths because their origin isn’t suspect, because their claims to safety and efficacy are pronounced, and because they control the levers of health promotion.

It’s complicated, though. The biomedicine hegemony is being chipped away at, another participant declares. She brought data. As Shelly Reese points out in her article about Press Ganey’s research, nearly 16% of patients are at “high risk for defection from their current physician/practice.” (Reese, 2014) Among the 19% of patients unhappy with their doctors, 74.6% were “likely to leave.” In a related study, Sinaiko (2014) determined in a tier-ranking study that patient loyalty was not a given. There were more citations and references proffered, but the point was not lost on the participants that loyalty is hard to win, and even harder to sustain, even for allopaths.

We were bumping right through the lunch hour when we got to premium pricing – a big component of successful, sustainable branding. According to the US Bureau of Labor Statistics, the cost of medical care was 3030.91% lower in 1950 than in the current year. (www.in2013dollars.com) Participants quickly calculated that this translated into an average inflation rate of 5.27% (ie, what cost $1000 for medical care in 1950 costs $31,309.07 today; compare this to average cost of living: $1000 in 1950 vs $10,146.22 today). The data kept coming. How mainstream medicine has been able to sustain premium pricing has been the creation of third-party payers. Money paid directly for health care by consumers decreased by 37% between 1960 and 2014; government payments increased 25%, and insurance payments increased 12%. It gets more interesting than that when, as 2 participants pointed out, one factors into spending (accounting for inflation) how much an individual actually had to pay out-of-pocket. Mainstream medicine has all these bases covered. Clever rascals.

We have much to learn from the lattice-work of supply, demand, and pricing in the health services landscape. For example: Families with 100% coverage spent an average of 16% more on healthcare than families with 75% coverage, 22% more than families with 50% coverage, and 58% more than families with 5% coverage. (justfacts.com) And, on that same platform of delivery, the increased spending that occurred under the plans with higher coverage had “little or no” effect on health outcomes except for the poorest 6% of the population. In hospital settings (where costs typically exceed the maximum out-of-pocket costs that the patient has to pay), the plans had no effect on spending.

We ate lunch while we talked and were well into the early afternoon when a number of the participants had to bail. Significantly, the conversation had emphasized once again how densely complex the question is about how our profession can find safe harbor in the American healthcare system. Naturopathic medicine has beachheads all over America and Canada, we decide. However, many hinterlands await.

Refs:

Czeranko, S. (2014). The Hevert Collection: Origins of Naturopathic Medicine. Portland, OR: NCNM Press.
Czeranko, S. (2015). The Hevert Collection: Philosophy of Naturopathic Medicine. Portland, OR: NCNM Press.
Czeranko, S. (2015). The Hevert Collection: Principles of Naturopathic Medicine. Portland, OR: NCNM Press.
Edmiston, C. E. Jr., Bruden, B., Rucinski, M. C., et al. (2013). Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control, 41 (5 Suppl), S49-S55.
In2013Dollars. Medical care priced at $1,000 in 1950 à $31,309.07 in 2017. Available at: http://www.in2013dollars.com/Medical-care/price-inflation/1950. Accessed August 1, 2017.
JustFacts. Healthcare. 2017. Available at: http://www.justfacts.com/healthcare.asp. Accessed August 1, 2017.
Lytle, R. H. Subject Retrieval in Archives: A Comparison of the Provenance and Content Indexing Methods. [Ph.D. thesis, University of Maryland, 1979]; Intellectual Access to Archives: 1. Provenance and Content Indexing Methods of Subject Retrieval. American Archivist, 43 (Winter 1980), pp. 64-75; Intellectual Access to Archives: II. Report of an Experiment Comparing Provenance and Content Indexing Methods of Subject Retrieval. American Archivist, 43 (Spring 1980), pp. 191-207. Available at: http://americanarchivist.org/doi/pdf/10.17723/aarc.43.2.c4777576733114rp. Accessed August 1, 2017.
Makary, M. A. & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i12139.
Pencina, M. J., Navar-Boggan, A. M., D’Agostino, R. B., et al. (2014) Application of new cholesterol guidelines to a population-based sample. N Engl J Med, 370, 1422-1431.
Press Ganey. (2013). Protecting Market Share in the Era of Reform: Understanding Patient Loyalty in the Medical Practice Segment. PressGaney Web site. http://img.en25.com/Web/PressGaneyAssociatesInc/PerfInsights_PatientLoyalty_Nov2013.pdf?elq=3bb05efe8c5d489aaec22cd9dc054052. Accessed August 1, 2017.
Reese, S. (July 10, 2014). Just How Loyal Do You Need Your Patients to Be? Medscape Web site. http://www.medscape.com/viewarticle/827690_1. Accessed August 1, 2017.
Sinaiko, A. D. & Rosenthal, M. B. (March 11, 2014). The Impact of Tiered Physician Networks on Patient Choices. Health Services Research, 49, (4). Available at: http://dx.doi.org/10.1111/1475-6773.12165. Accessed August 1, 2017.

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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).