Editors’ note: Britt Marie Hermies of NaturopathicDiaries.com returns to SBM to continue her series on naturopathy from the point of view of someone who has left that profession. If you missed it, the first post was “ND Confession, Part 1: Clinical training inside and out“. She has also contributed “The Wild West: Tales of a Naturopathic Ethical Review Board“.
Prior to renouncing naturopathic medicine and starting NaturopathicDiaries.com, I knew very little about the accreditation of higher education in the United States. I had the impression that accreditation signified that a program or school had the endorsement of the federal government for quality standards. When I first looked into attending naturopathic programs, I remember learning that they are accredited by the U.S. Department of Education.
For me, and I assume for many others, accreditation of naturopathic doctoral programs stood for a medical education of high quality that delivered career prospects similar to those available to primary care physicians who earn an MD or DO. Accreditation also meant I could take out federally-subsidized loans to pay tuition and cover living expenses. Because the $40,000 annual tuition at naturopathic programs was (and still is) comparable to regular medical school, my perception of the validity of naturopathic education at accredited programs made me feel that I was investing in a secure career.
It wasn’t until I graduated from Bastyr University and had been in private practice for several years that I learned the truth about accreditation. Naturopathic programs are accredited by an organization dominated by naturopaths; this authority has been granted to them by the U.S. Department of Education, and they make up their own standards. Leaders in the naturopathic profession can then use the accreditation status of naturopathic programs to convince the public that naturopathic medicine is safe and effective and convince students that they are matriculating into a bonafide medical school.
Using the term accreditation to cultivate false credibility
When I was a naturopathic “medical” student at Bastyr, I was under the impression that my peers and I would be able to earn a salary similar to a primary care physician. Naturopathic medicine seemed to be on the up-and-up. I thought I would be eligible for jobs working right alongside physicians in hospitals, medical clinics, and other non-clinical organizations. One of my dreams was to bring naturopathic medicine to institutions involved with health policy, like the World Health Organization and U.S. Centers for Disease Control and Prevention. I thought my credentials from Bastyr would be accepted as forward-thinking medical training, which would give me a cutting-edge advantage over others who seemed stuck in some sort of old medical paradigm.
Why did I believe this fantasy?
I believed I was going to medical school. Printed on numerous pages of Bastyr’s website and over its promotional material are phrases that attractively support this outrageous story:
- recognized by the U.S. Department of Education
- internationally renown
- ground-breaking research
- rigorous curriculum
- state-of-the-art clinical training
- well respected, nationally recognized degree
- all the same basic sciences as a medical doctor
- naturopathic doctors are primary care physicians
Just by focusing on this marketing language, Bastyr makes it exceedingly clear that its graduates will become top-notch medical professionals. In fact, Bastyr claims to be “the Harvard of naturopathic medicine” and boasts that the Princeton Review ranked its naturopathic medicine program as “one of the 168 best medical schools” in the U.S. (At the time that edition of Princeton Review was published in 2011, there may have been less than 168 “conventional” medical schools in the U.S., which would likely put Bastyr dead last.)
The fact that naturopathic programs, like Bastyr, are actually accredited through the U.S. Department of Education makes other selling points about naturopathic medicine more believable.
In reality, career prospects for naturopathic doctors are poor. According to an alumni survey [PDF] conducted by the National College of Natural Medicine (NCNM) in 2010, the median net income of NCNM graduates who completed a naturopathic residency and used their ND degree was $60,000 (n=43). These 43 respondents were in practice between 29 years and less than one year. The financial potential is slightly worse for NCNM graduates who did not complete a residency: median income of $50,000 (n=141). These earnings are dismal for any career requiring a doctorate, which in the case for an ND student, results in a punishing financial situation to pay off huge student loans.
I just don’t understand how the naturopathic schools, like Bastyr, can tell students they will get such great medical training, while naturopathic doctors are earning so little money using their degree.
“Accreditation” associated rhetoric from the AANP and AANMC
Naturopathic professional organizations seem to rely on the U.S. Department of Education accreditation of ND programs to rationalize naturopathic medicine to public audiences. Usually, the rhetoric is focused on the following concepts: science-based, rigorous, and on-par with conventional medical school. There are two organizations responsible for broadcasting this information: the American Association of Naturopathic Physicians (AANP) and the Association of Accredited Naturopathic Medical Colleges (AANMC).
The AANP is the professional society of licensed naturopaths. One of the society’s main goals is to increase public awareness of naturopathic medicine, which includes promoting the notion that “naturopathic medicine is safe, effective, and cost-effective.” The AANP also states that it seeks to gain licensure for NDs in every state, so they “will be integrated into the nation’s health care system and be a part of all state and federal health care programs.” The AANP is responsible for major lobbying efforts at the federal and state levels.
The AANMC is an organization representing the seven approved naturopathic medicine programs in North America. This organization is different from the American Association of Medical Colleges (AAMC), which administers the MCAT and manages applications to medical schools and residencies. The AANMC appears to be more of a marketing and outreach organization for the naturopathic colleges. From its website, the AANMC’s mission is to “enhance the individual and collective success of member organizations in delivering high quality, innovative, and accessible naturopathic medical education and research.” The AANMC is located in Washington, D.C., and I can only assume this location helps them lobby for naturopathic issues at the federal government.
While each organization has a distinct purview, they are both active stakeholders in the naturopathic profession and lead the dissemination of information about naturopathic education and practice. I find their descriptions of naturopathic medicine misleading and often blatantly false.
In a 2011 lobbying document, the AANP describes the naturopathic degree as recognized by the U.S. Department of Education and Carnegie Institute as a “First-Professional Degree under Doctorate-Profession (Clinical), on par with MD and DO.” This document was used by naturopaths, including by myself as a student, to lobby for access to the same loans, scholarships, and residencies as MDs and DOs. I have seen recent lobbying material reproduce this description.
The Carnegie Institute, now called The Carnegie Classification of Institutions of Higher Education, is a group that categorizes schools and programs by the conferral of various post-secondary degrees. According to its website, the Carnegie Classification considers “degrees [to be] reliable artifacts of instructional activity” and works to categorize degrees for comparative purposes. If the AANP states that the Carnegie Classification of a naturopathic doctoral degree is in the same category as an MD or DO, one may very well believe that an ND degree is earned by learning a standard medical curriculum.
However, the ND degree is not classified as a first-professional degree by Carnegie Classification. Instead, it is classified as coming from a “special focus institution.” Institutions that also are classified as such include acupuncture schools, traditional Chinese medicine schools, theology programs, midwifery programs, and ITT Technical Institute.
First-professional degrees are considered comprehensive doctoral and professional programs that offer doctorates in the fields of humanities, social sciences, and Science, Technology, Engineering and Mathematics (STEM) fields, plus graduate degrees in professional fields such as business, engineering, law, and medicine. A doctoral degree in naturopathic medicine is not one of the first-professional degree categories classified by the Carnegie group.
As far as I can tell, the AANP has been lying to lawmakers about this supposed credential by the Carnegie Classification.
The AANMC is also complicit in putting out misinformation about naturopathic medicine. One of the most widely-disseminated bits of its propaganda is a chart showing a comparison [PDF] between the coursework hours of an MD student and an ND student in an “accredited” program in their first two years of training. One can make the following observations from the chart:
- ND students appear to take more hours of coursework in anatomy and embryology, biochemistry, physiology, and pathology
- MD students take more than five times as many hours in “systems-based courses” and more than twice as many hours in “other courses”
- ND students take more than twice as many hours in “clinical and modality training”
- MD students take 150 hours of coursework, and ND students take 151.5 hours
One could conclude from this chart that MD and ND programs have about the same number of coursework hours, and that differences in course categories shown on the chart might be explained by the different foci of the programs: natural medicine versus Western medicine.
Because the naturopathic programs are “accredited,” naturopathic medicine as a whole appears credible. Government accreditation can serve as a useful fact from which arguments against naturopathic medicine can be discredited and arguments in favor can be reinforced.
Facts about naturopathic education
In reality, naturopathic education at accredited programs is not rigorous nor science-based. In my first post on SBM, “ND Confession, Part 1: Clinical training inside and out“, I detailed the clinical training I received and showed that naturopathic students are trained in a whole bunch of pseudoscience and very little actual medicine.
The American Academy of Family Physicians (AAFP) nicely summarizes the drastic difference between medical physician training from that of a naturopath’s in this PDF document. In my opinion, the AAFP was being overly generous in their comparison by using numbers that appear to be falsely inflated by the AANP and AANMC. The breakdown of my naturopathic training hours were not available to the AAFP when this document was made. If it had been, naturopathic training would look even more deficient.
The 1,200 clinical training hours in primary care medicine that the AANP, AANMC, and naturopathic programs claim are received by ND students are nothing of the sort. The patients seen are often the worried well, who present with nonspecific and elusive symptoms with no real health consequences. If an ND student didn’t get a chance to train on a patient with a heart condition, for example, he or she could just make a short presentation to their peers and supervisor on said disease.
Using my transcript and student handbook, I calculated that I received less than 600 hours in “direct patient contact”; I was required to observe [PDF] a minimum of 350 patients and be the primary student clinician for only 175 of them! (The Council on Naturopathic Medical Education (CNME) now requires programs to provide at least 450 contacts and 225 of those as primary.)
Pre-clinical coursework at accredited naturopathic programs is also not so rigorous or science-based, though on paper ND credit hours match an MD or DO program. Indeed, naturopathic programs teach classes with the same titles as those in medical schools. Naturopathic classes, including basic sciences courses, are almost entirely taught by other naturopaths or other practitioners of alternative medicine, such as doctors of naprapathy. The pediatrics courses assign reading from anti-vaccine authors, like Bob Sears, and overall the reading load seems quite low for what would be expected from MD and DO students.
The accredited naturopathic curriculum also includes a large amount of pure pseudoscience, with the most glaring examples being three quarters spent on homeopathy, but also many quarters in old-timey hydrotherapy and “naturopathic” manipulation, which is essentially old-school osteopathic manipulation mixed with chiropractic.
I think it is worth noting the incredibly low entrance requirements for naturopathic students at Bastyr University. There is no required minimum GPA and there is no medical or graduate school entrance exam, such as the MCAT which is required for medical schools or the GRE which is required for most graduate programs. I even knew one ND student who never completed his bachelor’s degree!
While naturopathic organizations say what they do about the credibility of naturopathic education and clinical training, students are taking out huge amounts of debt to learn pseudoscience as though it is real medicine. If naturopathic programs were not accredited by the U.S. Department of Education, students would not be eligible for subsidized loans, and the schools would likely not remain financially sound. Without accreditation, the sea of false information would seem a lot more unmistakeable to the general public.
What is U.S. Department of Education accreditation?
The United States government has little authority over post-secondary institutions (colleges and universities). Individual states oversee some aspects of the education provided in post-secondary schools, but for the most part, schools maintain a large degree of autonomy. As a result, the quality of education provided at such institutions may vary.
The U.S. Department of Education does not directly accredit schools or programs. Instead, it delegates this task to private accrediting agencies.
Private accrediting agencies are educational associations that oversee the accreditation of institutions or programs. They have adopted criteria they deem appropriate for evaluating whether or not post-secondary institutions and programs can provide a decent education.
There is a national database of private accrediting agencies that are approved by the Secretary of Education. The entire list of requirements for approval is published in the Federal Register.
After the Secretary’s approval, the private accrediting agency is responsible for setting the standards for the institution or program seeking accreditation.
The CNME is the accrediting agency for naturopathic programs in North America. The CNME functions like the Liaison Committee for Medical Education (LCME), which accredits medical schools in North America. According to its website, the CNME “advocates for high standards in naturopathic education and its grant of accreditation to a program indicates prospective students and the public may have confidence in the educational quality of the program.” The CNME accreditation standards are described in the 2014 edition of the Handbook for Accreditation of Naturopathic Medicine Programs.
Accreditation reflects good organization, not good academics
Eligibility for accreditation has more to do with the administration, organization, and operation of an institution or program than education quality. A few requirements do directly impact curricula, but most do not.
The U.S. Department of Education states the purpose of accreditation is to help students and the public by:
- Verifying than an institution or program meets established standards
- Assisting prospective students in identifying acceptable institutions
- Creating goals for self-improvement of weaker programs and stimulating a general raising of standards among educational institutions
- Providing one of several considerations used as a basis for determining eligibility for Federal assistance
In other words, accreditation means prospective students and the public should be able to trust the institution’s description of its academic programs. The accredited agencies, like the CNME, are granted a great deal of responsibility because they are considered to be “reliable authorities as to the quality of education or training” offered by programs they accredit.
Because the U.S. Department of Education gives all of the accreditation standard-setting responsibility to private agencies, the standards that affect the educational curricula can be biased, possibly reflecting only the accrediting agency’s interests. Naturopathic medical programs are accredited by other naturopaths who run the CNME, which means that the curricula they pass meets only their own standards, and not widely-accepted, science-based standards of medical curricula.
Basically, naturopathic education is internally accredited.
Accredited conflict of interest?
The CNME was founded in 1978 by a naturopath Joseph Pizzorno. Pizzorno also founded Bastyr University in the same year and then served as the university’s president for the next 22 years. (He is also the co-author of the Textbook of Natural Medicine, which is widely used in accredited programs.)
Bastyr University’s founders were determined that their naturopathic program would be accredited. To achieve this goal, Pizzorno helped write the CNME standards for naturopathic programs [PDF] that would eventually be used to accredit Bastyr’s naturopathic program in 1987. (It is not clear from my research what the CNME was up to between 1978 and 1987.)
It seems to me, the CNME was formed purely out of aspirations for program accreditation and all that comes with that label, and not to ensure a high-quality medical education for naturopathic students.
Had accreditation been about guaranteeing a quality medical education, there was already an approved accrediting agency capable of assessing Bastyr’s medical program: the Liaison Committee for Medical Education (LCME, formed in 1942). But since Bastyr’s accrediting agency was formed by Pizzorno and the other founders in order to establish the standards for its own accreditation and its own brand of pseudomedicine, one can believe that Bastyr’s founders may have had something to hide from the LCME or other external scrutiny.
I find the CNME’s history rife with conflicts of interests. To be fair, the board of the CNME is currently composed of 11 members of which three are public members who are not naturopaths. However, when I looked into these public members, I found it fascinating that they all worked as administrators at chiropractic schools; two of them served on the Chiropractic Council of Education (CCE), the accrediting agency for chiropractic programs; one of them worked as an administrator for the University of Bridgeport, an accredited naturopathic program:
- Lansing Blackshaw, Ph.D. (nuclear engineering): Provost and Dean of Faculty at the University of Bridgeport from 1989-1995; Executive Vice President/Provost at New York Chiropractic College from 1995-2004; current member of the CCE appeals committee
- John P. Pecchia, M.B.A., C.P.A.: Currently Vice President for Business Affairs/CFO at Marnist College, which currently has an articulation agreement with New York Chiropractic College whereby students studying biology at Marnist can feed into NYCC’s chiropractic program; former Vice President for Financial Affairs and Treasurer at D’Youville College, which has a chiropractic program; former Vice President for Business Affairs and Treasurer at the New York Chiropractic College; former counselor since 2014 of the CCE
- Carl Saubert, Ph.D. (exercise physiology): former Vice President of Academic Affairs since 2014 of Logan University, a chiropractic school; former Vice President of Academic and Student Services at Cleveland College of Chiropractic; served in the Chief Academic Officers Group and the Institutional Assessment and Planning Administrators Group of the Association of Chiropractic Colleges
Why is it that the CNME has chosen only public members who had high-level administration positions at chiropractic institutions? Even though there are non-naturopathic, public members on the CNME board, these folks are currently or have been affiliated with yet another pseudoscientific, alternative medicine profession. This means that the entire CNME board comprises people who have vested interests in pseudoscience. Would the CNME board function differently if it had three non-woo woo medical doctors? I think, yes, but that scenario may very well be impossible.
The CNME has already run into trouble with the U.S. Department of Education. In January 2001, the CNME’s accreditation status was revoked due to a failure to respond appropriately to violations of standards at the Southwest College of Natural Medicine in Arizona. The CNME was not allowed to appeal the decision, but could reapply. In 2003, the CNME was once again approved by the Secretary as an accreditation agency for naturopathic medicine programs. In 2011, CNME was re-approved by the Secretary for the maximum term of five years. At the end of 2015, the CNME is coming up once again for review.
Naturopathic medicine is the fox guarding the hen house
Naturopathic program accreditation is a self-serving process that seems to be hiding something. As Jann Bellamy describes, this system results in the naturopathic curricula existing in a self-contained loop, divorced from mainstream medical standards. Naturopaths teach other naturopaths and unilaterally control the content of the program. There is no outside evaluation of course content taught at these schools, other than by its own accrediting agency. Although the CNME deems their accreditation review of the schools as external, they make a point to mention in the handbook [PDF] that:
The Council limits access to the evaluation team report to team members, Council members, the Council’s executive direction, and the chief administrative officer of the naturopathic medicine program, who is encouraged to distribute the report among the program’s community as the program considers appropriate.
Indeed, Bastyr’s webpage on accreditation provides PDFs of their regional accreditation self-study reports, but does not provide the reports prepared for CNME’s accreditation.
The sole purpose of the CNME, it seems to me, is to keep naturopathic schools accredited, rather than ensure a quality education for students who are under the impression that they are in a medical program to become real primary care physicians.
What’s to gain by becoming accredited?
Accreditation by an approved agency entitles the institution to establish eligibility to participate in Title IV programs. Programs authorized under Title IV of the Higher Education Act allow students in those programs to utilize federal aid services, such as loans, grants, and federal work study programs to pay for school. This is very important for institutions offering expensive degrees.
All accredited institutions and programs are entitled to Title IV programs, unless it is specifically noted otherwise. The CNME accreditation has such a note, stating:
Title IV Note: Accreditation by this agency does not enable the entities it accredits to establish eligibility to participate in Title IV programs.
Despite this note, naturopathic students at accredited schools are allowed to borrow absurdly large sums of money with unsubsidized student loans, Perkins loans, graduate PLUS, and private loans. I am still researching how this works, but I believe this is a more recent option for ND students.
According to the AANMC website:
ND students may qualify for up to $40,500 per three-term award period. The ND aggregate is $224,000.
It has been my understanding that these figures are based on what medical students typically need to borrow to attend medical school. The Yale School of Medicine website page on financial aid confirms how much its medical students can borrow:
Depending on your need…medical students may borrow $40,500 [per year].
The total amount Federal Direct Loan you may borrow as a graduate or professional student is $138,500 (medical students may borrow up to $189,125).
Although Bastyr calls itself an internationally-recognized school with a world-leading reputation in natural medicine and research, Bastyr is not Yale nor Harvard. It has no business charging students this much tuition for an education that consists of homeopathy, chiropractic techniques, botany, Chinese and Ayurvedic medicine, counseling, nutrition, and then a little medicine. Most of these other modalities, as NDs like to call them, are not shown to be efficacious and many can be harmful.
But even with high tuition fees, there is no way Bastyr can afford to provide a “standard medical curriculum” to its students. Using data from 2009, Jann Bellamy determined the following financial conundrum:
It takes between $75 and $150 million dollars to start a medical school. Average annual instructional costs per U.S. medical student is $73,544.41 (2009 cost). According to Bastyr’s website, it has 1,108 students currently enrolled in 22 degree-granting programs, including Ayurvedic (ancient Hindu medicine), acupuncture and oriental medicine. There are 462 students currently enrolled in Bastyr’s N.D. program. If these were medical students, the total annual instructional cost should be just under $33 million. Yet Bastyr’s total expenditures for educating over 1,000 students enrolled in 22 degree programs are just under $30 million per year.
Providing a rigorous, standard medical curriculum to students at Bastyr is not financially feasible, and it is clearly not happening. Students, like me, have been taking out hundreds of thousands of dollars in student loans to pay for an education that is masquerading as a credible medical degree. The public should be aware that this situation is not sustainable, and at some point, the cat will be let out of the bag.
The naturopathic profession needs to choose an identity
In my opinion, naturopathic schools and professional organizations are misleading the public, students, and politicians. They are capitalizing on misconceptions about accreditation status and using this term to suggest similarity to real medical programs. Accreditation through the auspices of the U.S. Department of Education enables naturopathic programs to stretch the truth on how they represent their medical curricula. On the one hand, the naturopathic profession claims they are a distinct form of primary care medicine, which can reduce costs and make us all healthier. On the other hand, it claims that naturopathic medicine is on-par with the standard medical curriculum and that NDs are trained just like medical doctors. Who are naturopathic doctors from accredited programs trying to be?
Rhetoric coming from the naturopathic profession is sticking. Naturopaths have been able to steadily gain licensure in the United States and Canada. In many states where they are already licensed, naturopaths are expanding their scopes of practice to include prescribing drugs and performing minor surgeries. Even mainstream medical and media sources online reproduce false information about naturopathic medicine:
- WebMD on Naturopathic Medicine:
a licensed naturopathic doctor (ND) attends a 4-year, graduate-level naturopathic medical school. He or she studies the same basic sciences as a medical doctor (MD).
- The University of Minnesota’s Center for Spirituality and Healing on Naturopathic Medicine:
Naturopathic practitioners have a Doctor of Naturopathic Medicine (ND) degree from a four-year graduate medical college with admission requirements comparable to conventional medical schools. The ND degree requires graduate-level study in conventional medical sciences, such as cardiology, biochemistry, gynecology, immunology, pathology, pharmacology, pediatrics, and neurology.
- A highly circulated article published in The Huffington Post by Michael Standclift, N.D. on Naturopathic Medicine:
Applicants to accredited naturopathic medical colleges need a bachelor’s degree and a competitive GPA in scientific prerequisites, just like applicants to “conventional” medical schools.
- The American Medical Student Association (AMSA) has a Naturopathic Advisory Board, which states that:
The Department of Education classifies the Naturopathic Doctor degree (ND) from CNME schools as a Doctor’s degree – Professional practice, along with MD and DO degrees.
These statements are just not true.
(Also, why does the AMSA have an ND advisory board? I know from my experience with outreach at Bastyr, that naturopathic students thought if they could get in with medical students who tend to be more open minded about CAM than practicing physicians, we would establish relations that would foster into stronger professional ties. I hope leaders at the AMSA read more about naturopathic medicine and reevaluate their openness to NDs.)
If naturopathic schools aim to convince politicians and the public that their medical programs are as good as standard medical schools, then naturopathic schools need to achieve accreditation from the Liaison Committee on Medical Education or invite external review from a special task force composed of real medical doctors and scientists. Nothing short of these options will convince me that Bastyr’s naturopathic program is on to some cutting-edge fusion of science and traditional medical wisdom.
One thing’s for sure. Naturopathy can’t be both real medicine and naturopathic medicine. Naturopaths need to stop confusing the public with misrepresentations and lies about naturopathic doctoral degrees and unanimously decide exactly who they are—medical doctors (MD) or not doctors (ND).
Britt Marie Hermes is a naturopathy apostate: she practiced as a licensed naturopathic doctor in the United States for about three years, but then left the profession to pursue a science-based career. She is now a Master’s of Science student in Medical Life Sciences at the University of Kiel. Her research interests include inflammatory and genetic diseases, like psoriasis and Crohn’s. She lives in Kiel, Germany, with her husband, who is a doctoral candidate in archaeology, and their two dogs. She recently started the blog Naturopathic Diaries: Confessions of a Former Naturopath.