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The modern rebirth and standard-setting of the naturopathic medical profession in the late 1970s and 1980s predated the emergence of the 2, MD-dominant fields of “integrative medicine” and of “functional medicine.” The naturopathic profession had only approximately 600 licensed doctors in 1985, a figure that has slowly grown to 5000 nearly 3 decades later. Yet as detailed in a Huffington Post column1 and in a related piece at the Integrator Blog,2 the roles of this vanguard in the emergence of these 2 movements has been huge. Naturopathic doctors are the core staff educators at the Institute for Functional Medicine (IFM) and the Academy of Integrative Health and Medicine (AIHM). At Cancer Treatment Centers of America, they pioneered integrative oncology. Members of that profession, as successive presidents of the Society for Integrative Oncology, led developments of the gemstone publication for that organization, guidelines for integrative treatment for women with breast cancer.3 The nation’s blueprint for pain treatment as published by the Institution of Medicine in 2011 was substantially influenced in an integrative direction by a naturopathic physician acupuncturist.4 Also on the clinical side, naturopathic physicians are on the front lines in modeling integrative patient-centered medical homes.5
The list goes on. The first science-based, heavily referenced textbook on the natural medicine field was coauthored and edited by 2 naturopathic physicians, one of whom serves as editor of this journal. The first hospital-based natural products formulary was developed by a naturopathic doctor at North Hawaii Community Hospital. The top integrative care research economist, presently at the RAND Corporation, is a naturopathic physician. The field birthed leading advocates of, and formulators for, for whole systems, outcomes research models. Graduates of naturopathic schools steered European standardized extracts into the US botanical market. A global service learning model for integrative practitioners was developed by the naturopathic physician founders of Natural Doctors International. In addition, the most significant, successful interprofessional collaborations in the field—the Integrative Health Policy Consortium and the Academic Consortium for Complementary and Alternative Health Care—were substantially shaped by naturopathic physicians and individuals whose careers included long periods in early leadership of the field’s emergence.
The Huffington Post article asked what the optimal position of the profession should be going forward. Should they focus on guild advancement knowing that due to their small numbers, only a tiny minority of patients will ever receive care from a naturopathic doctor? Or should they build on this pattern to continue to educate members of other professions to their care, model, their clinical principles, and their therapeutic order?
Comment: Okay, as a person who spent 1983 to 1993 with the naturopathic profession and had a hand in some of this, I am a deeply biased reporter. Tough questions. The best direction I have heard yet came out of a mid-January breakfast meeting with an energetic and activist 5th-year naturopathic student who was about to graduate with $293 000 in student-loan debt. We began turning over in our minds the idea of a profession-wide reconciliation process. My electronic dictionary teaches me that this powerful word with deep resonance in postapartheid South Africa has multiple useful meanings. On the one end: “To resign, submit, accept—as in reconcile to one’s fate.” Then there are these: “Accommodate new results with existing theories.” Better yet: “To harmonize, bring into consonance or accord—as in one’s goal with one’s abilities.” The last definition offered: “To patch-up or make-up.” If we drop all guild consideration and view this simply from a public health perspective, what is the highest and best use of this powerfully accomplished naturopathic profession for fostering human health?
Under Oregon’s former physician governor John Kitzhaber, md, the state’s Health Evidence Review Commission convened an interprofessional task force to set a strategy for back pain care in the state’s Coordinated Care Organizations (CCOs). Included with a group of pain leaders from dominant institutions were long-time chiropractic policy leader Vern Saboe, dc, and the former president of her state’s acupuncture association, Laura Ocker, lac. The goal: Set a plan to reduce the state’s record-breaking use of opioids.
The strategy recommended then approved for implementation on January 1, 2016, was a remarkable turning point for US pain treatment.17 In “From Pills to Pins,” an Oregon official explains, “The only thing that might have been covered in the past was narcotics. But treatments such as acupuncture, chiropractor, massage therapy, physical therapy, and rehab would never have been covered.”18 These practitioners would be covered Medicaid providers in CCOs and the goal was to use them early instead of as an afterthought.
Just before the plan was to go into effect, officials stopped the train. Why? Ocker shared that “the only thing I’ve heard is that this is a delay in implementation only, due to need for a fiscal analysis. I’m not sure why. At the last minute, when things were all rolling forward and about to go into effect, suddenly someone came in and said ‘we need to do a fiscal analysis,’ but the folks I’ve talked to on the state level are still thinking of this as an implementation delay only.” Saboe suggested that the postponement of implementation might be linked to examining a new opioid replacement strategy believed to potentially cost less. Ocker says she “remains optimistic” that the recommended nonpharmacologic strategy will be put in place.
Comment: The excitement in the Oregon possibility is that a governmental unit it not merely stating that nonpharmacologic approaches may be useful. Rather, they would be using more conservative strategies first, as the chiropractors advocate. Or, to reiterate the phrase favored by the naturopathic doctors and noted above, the recommendation would be changing the therapeutic order by guiding people first to nonpharmaceutical strategies. Here’s hoping the opportunity opens shortly, that data are collected, and that the chips fall where human-centered care—versus pharma-centric—would like them to fall! I show my bias.
Perhaps the most outspoken voice promoting the shift of the dominant medical industry toward a value-based system is former Centers for Medicare and Medicaid Services administrator, Don Berwick, md. Berwick recently used his annual keynote at the Institute for Healthcare Improvement (IHI) to push the assembled leaders in new directions. He urged 9 steps19: (1) stop excessive measurement; (2) abandon complex incentives; (3) decrease focus on finance; (4) avoid professional prerogative at the expense of the whole; (5) recommit to improvement science; (6) embrace transparency; (7) protect civility; (8) listen—really listen; and (9) reject greed. The comments on the last 2 provide some of the flavor. For “listen really listen” he clarifies: “These terms—coproduction, patient-centered care, what matters to you—they’re encoding a new balance of power: the authentic transfer of control over people’s lives to the people themselves.” And regarding greed: “For whatever reason, we have slipped into a tolerance of greed in our own backyard and it has got to stop. We cannot ask for trust if we tolerate greed. The public is too smart.”
Comment: The act of advancing the integrative health model requires finding values alignments with which one can dance. Berwick’s views are always provocative. At the 2009 Summit on Integrative Medicine, he crossed over from the mainstream and confidently propounded “8 Principles for Integrative Medicine.”20 Four years later, he drew from what he called “mentoring” from a set of integrative health and mind-body leaders in his annual IHI 2013 talk.21 He urged the field to look beyond value-based care to “salutogenesis.” He called for a 30-year plan and began to create an image of true health-focused systems in a mission of health creation. Now, 2 years later, these 9 steps.
What are we to make of them? A cluster of these moves related to the damning influence of capitalist medicine (financing, incentives, greed, and, likely, transparency and professional prerogative). Another pirouette is required for the challenges for the MD guild of stepping down from deification into team care (civility, listening, definitely professional prerogative, and, likely, transparency). A challenging 2-step is required by the demoralization from present management strategies (excessive measures, complex incentives).
As a set of dance steps, there is much here that can keep one excited, and off each other’s toes. Yet overall, the tone feels like that of a practitioner who, when the patient is already shuffling toward the exam room door, advises: Stop smoking, reduce meat, walk more, add fiber, find a hobby, take yoga, spend less time at work, and try nonviolent communication. Is anyone really listening?
This column is offered in collaboration with The Integrator Blog News & Reports (http://theintegratorblog.com), a leadership-oriented news, networking, and organizing journal for the integrative medicine community. For more information on these and other stories, enter keywords from the articles in the site’s search function.