FRASER SMITH, MATD, ND
Working in integrative practice settings is an increasingly relevant possibility for naturopathic graduates. Last month we discussed the phenomenon of allopathic practitioners adopting therapeutic modalities that have been traditionally part of naturopathic practice. This month, we look at the opportunities to prepare our students for entering an integrative setting.
What’s in a Name
“Integrative medicine” is a term that has broadened and yet retains a distinctly parochial sensibility. The term was for some time the moniker of physicians and practices that were built around an MD who was using, as Andrew Weil might diplomatically put it, “useful” therapies from outside the mainstream allopathic toolkit.1 I like to think of this as the “super-doc” model, as my colleagues, Drs Robert Shiel and Ezra Cohen, would describe it2: The MD is at the apex, uses nonstandard therapies, and might be aided by allied practitioners. It looks a lot like any medical practice in its structure, even if the therapies can run quite outside the norm.
A Continuum of Integration
This definition has thankfully broadened, and while there is still a sense that “integrative medicine” is MD centric, the broader meaning refers to a system where practitioners with different skill-sets and orientations to practice work collaboratively based on patients’ needs. That, of course, begs a whole series of clinical decision-making, case management, and reimbursement issues, but it can be a way of being for a practice group. An insightful taxonomy of “integration” was proposed by Boon et al, who describe a continuum of integration.3 To very simply paraphrase a carefully articulated paper, this continuum ranges from mere parallel arrangements, wherein practitioners share a space and might do some corridor consults and cross-referral (eg, “You might want to see our acupuncturist”), to highly integrated groups that have clinical roundtables and agreed-upon guidelines for where to send patients within the practice. Somewhere is the middle are collaborative groups – not fully integrated, but more than office mates. The depth of philosophy of healing, the complexity of the structure, the practitioner enmeshment in process and communications, and the expectations for outcomes all increase up the ladder to integration. If you are headed in this direction, Boon’s paper is worth a read.3
There are excellent opportunities at all of these levels, and not all groups of associates want to work at the level of complexity situated at the far right of Boon’s spectrum of integration. For a few years I spent every Thursday at a Community Health Center in Toronto that was part of CCNM’s satellite clinic system. This center had a medical service that had 2 physicians and 2 nurse practitioners. On Thursday afternoons they had staff meetings or were off, which meant that the 3 interns and I had use of the exam rooms. We would communicate with the site administrator, and sometimes I would chat with the medical staff about this or that patient. One day, one of the nurse practitioners said, “Hey, Fraser, I have this patient with strange headaches and really weird symptoms that are not responding to the medication – we thought this would be perfect for you.” These practitioners were reading about nutrition and other topics on their own, and we were invited to do an in-service for the entire center about naturopathic medicine. So, I suppose we were cordially “parallel,” and that was fine. Many of the practices and values (such as mutual respect) that apply to highly integrated settings are equally applicable to more casual practice arrangements.
The Broader Context
The term “Integrative Health” is in vogue. A few years ago, what was the National Center for Alternative and Complementary Medicine – a funding Center at the National Institutes of Health (NIH) – has evolved into the National Center for Complementary and Integrative Health (NCCIH). Having a funding center at the world’s largest governmental research funding agency is no mean feat. Here is how NCCIH defines “integrative health”:
Integrative health care often brings conventional and complementary approaches together in a coordinated way. It emphasizes a holistic, patient-focused approach to health care and wellness—often including mental, emotional, functional, spiritual, social, and community aspects—and treating the whole person rather than, for example, one organ system. It aims for well-coordinated care between different providers and institutions. (NIH, July 2018)4
This sounds like a great opportunity for a naturopathic physician. A 2020 survey by the AANMC (Association of Accredited Naturopathic Medical Colleges), replied to by over 1100 alumni across North America, shows that a multi-practitioner setting is a pathway taken by over half of graduates in both the United States and Canada.5 While this group setting is probably often with other naturopathic doctors, this trend toward practicing in a group is already in full motion. Even local to this writer, there are several hospital-based systems that have an integrative program that includes, or has included, naturopathic physicians. The programmatic outcomes for naturopathic medical programs typically express some commitment to preparing students to work in “health systems,” and this is important, for to work in an integrative setting is often going to mean appreciating what practitioners with different means and procedures do.
Coursework & Integrative Practice
It would seem that there are 2 major elements of preparation for our students. One is the clinical and patient care reasoning that is involved in helping patients receiving care within a matrix of healthcare providers. The other is the interpersonal skills in working at different levels of the continuum that Heather Boon and her colleagues describe, especially higher orders of integration.
Both of these skills-sets could be addressed in coursework. Some theoretical basis and knowledge of the literature about successful integrative practice would seem fitting for a naturopathic medical education, so that graduates are ready to train or practice in different levels of integrative practice. On the clinical reasoning side, knowledge about case management and the processes of healthcare systems is needed. Larger, hospital-anchored health systems are complex organisms, and anyone who is part of them has to work within their system, be it using their EPIC system or getting familiarized with how referrals work within the group.
Real Exposure
To the extent that we can give interns opportunities to experience integrative care settings, we can accelerate the learning of how to work within them. The various naturopathic medicine programs all have external sites that are at host organizations and/or staffed by a variety of naturopathic and other practitioners. This provides the experience of trying to best determine who patients should see and what they need and, of course, what they want. It also allows for the building of skills in communication and the constructive management of conflict. When a group of practitioners, especially those with different approaches, are working with the same patient, toes will get stepped on, errors in communication (eg, “I thought you meant I would manage this, not ‘co-manage’”) will sow seeds of confusion, and egos will assert themselves. Difficult and deep conversations will happen in groups that can stick it out and mature together as a team. Fortunately, many of our interns can dive into integrative settings, and the more we can arrange this, the better.
Playing Nice
We sometimes learn the best lessons about appreciating what other practitioners can do from practice itself. Most naturopathic students I have polled in class about their attitudes toward allopathic physicians have acknowledged the need for their help in managing various health conditions. In practice, as people with intracranial masses, advanced cancer, or DSM Axis I disorders, to name a few, begin to appear in a new graduate’s practice, it becomes rapidly apparent that medicine as a whole has a whole lot of knowledge and extended treatment modalities that any doctor, alone, does not. That is the beginning of wisdom in some ways. However, continued practice with getting exposure to so many people who are unaware of how to access their own ability to heal can then have the effect of confirming the decision to study naturopathic medicine in the first place. To help students prepare for an integrative setting, clinic exposure to multi-practitioner settings could help prepare them for the reality that they must be confident but not pretend to have all the answers, ie, be neither deferential nor defensive. This is something of an affective type of competency, and it requires a degree of emotional intelligence as well as tact.
Genuine Value Added
In spite of the need to be a colleague among colleagues – a high-functioning spoke on a wheel with the patient in the center – there remains the question of relevance. What does the naturopathic doctor bring to the table? Is it more advanced laboratory analysis skills or a deep knowledge of nutrition? Is it some understanding of the process of healing and how to facilitate it, or perhaps a consistently whole-person approach to all but the most localized problems? We can help our students understand this. Not only can that awareness help them to market their skills to an existing integrative practice, but it can enable them to feel secure in the knowledge that their skills and perspective on health are extremely valuable.
The Great Wide Somewhere
Like the main character in Beauty and the Beast, many of us as graduates want to escape our medical home town and explore the greater world of medicine. It remains to be seen to what degree the health care industry will embrace an integrative approach. It is still possible that incentivized outcomes at reasonable costs for medical groups will make the naturopathic physician increasingly in demand. Patient expectations regarding ease of access to multiple options is another driver. A generational shift where younger physicians are increasingly open and often appreciative (or at least not dismissive) of other medical approaches can pave the way for more integrative practices. The integrative wave may not turn out to be as extensive as some hope, but it is likely to be significant. And it’s worth acknowledging that many respectful and reciprocal relationships between naturopathic doctor and medical doctor develop as a byproduct of good naturopathic practice. Sometimes the patient is the weaver that pulls various practitioners into the same web of healing. Communication and understanding among practitioners in a community is worth more than shared real estate. In any event, the attitudes, knowledge, and skills that enable integrative practice are befitting for our students as they venture into that great wide somewhere of their future.
References:
- Frontline. Interview: Andrew Weil, M.D. November 4, 2003. PBS Web site. https://www.pbs.org/wgbh/pages/frontline/shows/altmed/interviews/weil.html. Accessed December 22, 2020.
- Personal communication, National University of Health Sciences; 2013.
- Boon H, Verhoef M, O’Hara D, Findlay B. From parallel practice to integrative health care: a conceptual framework. BMC Health Serv Res. 2004;4(1):15.
- National Center for Complementary and Integrative Health. Complementary, Alternative, or Integrative Health: What’s In a Name? July 2018. NCCIH Web site. https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name. Accessed December 22, 2020.
- Association of Accredited Naturopathic Medical Colleges. 2020 Graduate Success and Compensation Study. June 1, 2020. AANMC Web site. https://aanmc.org/reports-and-research/2020-graduate-success-and-compensation-study/. Accessed December 22, 2020.
Fraser Smith, MATD, ND is Assistant Dean of Naturopathic Medicine and Professor at the National University of Health Sciences (NUHS) in Lombard, IL. Prior to working at NUHS, he served as Dean of Naturopathic Medicine at the Canadian College of Naturopathic Medicine (CCNM) in Toronto, Ontario. Dr. Smith is a licensed naturopathic physician and graduate of CCNM.
