Joshua Z. Goldenberg1, Bonnie S. Burlingham MPH2, Jane Guiltinan ND3, Erica B. Oberg ND MPH4
1 Bastyr University, Kenmore WA, USA
2 Washington State Hospital Association, Seattle WA, USA
3 School of Naturopathic Medicine, Bastyr University, Kenmore WA, USA
4 Bastyr University Research Institute, Kenmore WA, USA
Submitted: 19 September 2012
Accepted for publication: 14 November 2012
Abstract
Background
Naturopathic medicine (NM) is a distinct system of primary health care often considered a form of complementary and alternative medicine. Evidence-based medicine (EBM) is an approach to medicine which has gained increasing prominence over the past 2 decades. Like other health professions, as the influence of EBM grew in the global medical community, NM had to discover, explore and take stock of it through the lenses of its own unique culture, history and values. We conducted a phenomenological qualitative research study to explore attitudes toward EBM, probe for evidence of cultural change, and to investigate the drivers of said change within the naturopathic medical community.
Methods
Participants were selected by purposive sampling and interviews were based on semi-structured questionnaires focusing on the participants’ perceptions of research, EBM, and their relationship to the field of naturopathic medicine. All interviews were transcribed and then coded independently and in duplicate by two investigators who assigned thematic codes to relevant excerpts. Themes and a concept map were identified, reviewed, and analyzed by investigators. Atlas.ti (version 6.2) software was used for coding and concept mapping.
Results
Seventeen interviews were conducted of which 15 were available for transcription and ranged in length from 17 to 55 minutes. A total of 34 codes were identified, which we aggregated into three themes: (1) a spectrum of EBM definitions, (2) attitudes towards research and EBM, and (3) drivers of change. Interviewees used a spectrum of definitions for EBM which informed their reported attitudes toward it. While current attitudes toward research and EBM were generally described as favorable, “spectrums,” “subgroups,” or even “factions” were described representing a continuum of attitudes within the naturopathic community. Overall, the interviewees described a rapid cultural shift in attitudes from hesitancy to the cautious embrace of research and EBM. Numerous promoters of this cultural change were described with the majority of interviewees emphasizing the importance of influential people within the profession, research and EBM funding, and the desire for acceptance from the larger medical community.
Discussion
As a profession which developed from vitalism on the margins of the larger medical community, naturopathic medicine has grown rapidly in size and influence and, as it has entered new non-vitalistic (mainstream) practice environments, it has incorporated new peers and new role models. Research and EBM acculturation may represent a flashpoint example of a professional adolescence for naturopathic medicine. In which case a relevant question becomes, will the profession be able to adequately integrate the values of its youth/roots with the values of the EBM-driven medical community?
Introduction/background
Evidence-based medicine (EBM) is defined as the ‘‘conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’’ [1]. Naturopathic medicine is a distinct system of primary health care often considered a form of complementary and alternative medicine (CAM) [2]. Like other health professions, as the influence of EBM grew in the global medical community, naturopathic medicine (NM) had to discover, explore and take stock of EBM through the lenses of its own unique culture, history and values [3].
Naturopathic medicine has recently experienced significant growth. For example, in North America the number of graduates from accredited four year naturopathic medical programs has tripled in the past decade and NDs are now licensed in 16 U.S. states, the district of Columbia, two U.S. territories and five Canadian provinces [4]. Concurrent with this professional growth has been an increase in research interest, capacity and training within the naturopathic community. Naturopathic medical schools now incorporate training in research fundamentals, evidence evaluation, and have robust research institutes while naturopathic researchers have founded a peer reviewed research journal, organized regional research conferences, and set a profession-wide research agenda [4-7].
Despite these developments centered on research and evidence accumulation, concerns within the profession have been raised regarding the application of EBM principles to naturopathy. Steel and Adams describe a tension felt by Australian naturopaths between what the investigators call traditional knowledge versus scientific information [8]. Some have gone so far as to claim that teaching and applying EBM would lead to the demise of the profession [9-11]. While seemingly extreme, it is important to give professional, economic and historical context to these concerns. Health care policy makers, regulators and payers do use information derived from EBM principles to make decisions about the legal status, scopes of practice and reimbursement of complementary and alternative professionals such as NDs [12, 13]. Most CAM therapies have not yet been validated by EBM principles and this has indeed been used as a tool to oppose recognition and reimbursement for many CAM groups including NDs [12, 14]. Additionally, some consider EBM to be an application of the philosophy of logical positivism, so it is important to note historically that NM went through a rapid period of decline and was almost extinguished as a profession during the ascendant period of logical positivism in the 1940s exemplified by the success of antibiotics and the cultural rise of ‘science’ in medicine [2, 15, 16].
Considering the aforementioned concerns, unease towards EBM acculturation might be expected within the naturopathic community. If true, naturopaths would not be alone. Qualitative study of conventional primary care medical doctors (MD) and their response to EBM acculturation has shown MD professional trepidation in terms of a feared loss of ‘art’ and ‘intuition’ in medicine [17]. Even more so perhaps, medical professions that espouse the philosophy of vitalism, often contrasted with mechanistic reductionism, may be particularly apprehensive. Chiropractic for example, struggles with EBM acculturation as well [18].
However, despite all arguments mentioned above, anecdotal reports within the profession indicate that while initially hesitant, naturopathic medicine has more recently embraced a culture of research and EBM. There is, however, a dearth of research on the matter. As a young but maturing profession rooted professionally in CAM and historically and philosophically in vitalism, naturopathic medicine’s cautious acculturation of the dominant medical culture of research and EBM may serve as a unique and interesting case study in profession-wide cultural change as well as in the interchange between a small vitalistic profession and a culturally dominant movement often considered positivist [2, 16]. We conducted a phenomenological qualitative research study to explore attitudes toward EBM, probe for evidence of cultural change, and to investigate the drivers of said change within the naturopathic medical community.
Methods
Qualitative Method
This study is based in phenomenology, a qualitative methodology to gain insight into the lived experiences of individuals [19, 20]. Without a foundational understanding of the lived experiences of the NM community, it becomes impossible to uncover the subtle circumstances that facilitate or inhibit change [20]. Elements of grounded theory influenced the study as well, as interview questions allowed for additional unstructured discussion and coding was based on the open coding technique developed for data of less structured interviews [21]. Qualitative methods have been used in many studies with NDs in order to gather information about why certain phenomena are present in this particular subset of medicine. For example, it has been particularly valuable in several clinical studies outlining ND beliefs and perceptions regarding demand for services, clinical training, and clinical practices [22-24]. We were specifically interested in understanding the experience of adopting/rejecting EBM in naturopathic medicine and what has facilitated or hindered this adoption from the perspective of those immersed in the field.
Participant Recruitment
A purposive sampling method was employed to select interviewees based on their experience within the naturopathic community and familiarity regarding its general attitudes towards research and EBM. An initial list of interviewees based on these criteria was selected by a panel of investigators familiar with the community (JZG, EBO, JG). This list was augmented with subsequent snowball sampling – recruitment of additional participants referred to or recommended by initial participants during the interview process. When evidence of distinct subgroups (for or against the adoption of EBM) was identified, additional interviewees were selected to ensure opinions from the non-dominant group were represented. Human subjects approval was sought from the Bastyr University Institutional Review Board (IRB) and IRB exemption status was granted (ID #11X-1304).
Data Collection
Seventeen interviews were conducted from August 2011 to January 2012. One interview was not fully completed and one was undecipherable for transcription, leaving 15 transcribed interviews for assessment, ranging in length from 17 to 55 minutes (median 39 minutes). The interviews were conducted in person or via Skype by a single investigator (JZG) using a semi-structured questionnaire (Appendix 1). The interview questions included information related to participants’ perceptions of research, EBM, and their relationship to the field of naturopathic medicine. Examples of questions include:
1. How would you describe your attitude toward research when you were a student?
2. How would you describe the naturopathic community’s attitudes toward research? Have you seen a change in these attitudes?
3. How would you define evidence based medicine personally?
Using a semi-structured questionnaire allowed for consistency and coverage of all main topics of the interview, while also allowing for flexibility for the interviewer to probe for more detail when necessary. All interviews were recorded and later transcribed by a single medical transcriptionist. All identifying information was removed from transcripts and interviewees were assigned study id’s for further analysis.
Data Analysis
The lead author read all 15 transcripts and developed a list of codes. Open coding allows for data to be broken down into codes before re-contextualing the codes to identify themes [25]. After a code list was created by the lead and senior authors (JZG, EBO), it was shared with a third investigator (BSB) who independently coded each transcript, assigning thematic codes to relevant excerpts that represented self-contained units of meaning. Two investigators (JZG, BSB) then compared codes on each transcript for agreement and category development. Disagreements were resolved by discussion of coder interpretation of the data in an iterative process which looked at the context surrounding the coded section and the intent of the statement. Themes and a concept map were identified, reviewed, and analyzed by investigators. The best examples to represent naturopathic medical attitudes towards research and EBM were chosen during this process. Atlas.ti software (version 6.2.25) was used for coding and analysis.
Results
Demographics
The interviewees were primarily naturopathic physicians (NDs) (n=13) although the sample included non-NDs (n=2) as well (although not NDs themselves, these individuals were highly involved in the naturopathic research community). The interviewees’ involvement in the naturopathic medical (NM) field ranged from 6 to 38 years (median 20, mean 20.6) and they included both members of the United States (n=12) and Canadian (n=3) naturopathic communities. Five interviewees are or had been members of a naturopathic medical school research department.
Themes
A total of 34 codes were identified from the transcripts, which aggregated into three themes that described the phenomena of EBM and culture change in naturopathic medicine among the 15 participants: (1) a spectrum of EBM definitions, (2) attitudes towards research and EBM, and (3) drivers of change. It became apparent that the interviewees used a spectrum of definitions for EBM which is important in terms of informing their reported attitudes toward it. While attitudes toward research and EBM were generally described as favorable, a continuum was present among subgroups. Overall, the interviewees described a shift in attitudes toward research and EBM from one of hesitancy to one of cautious embrace. Numerous drivers of this shift were described with the majority of interviewees emphasizing the importance of influential people within the profession as well as research and EBM funding in promoting this change.
Spectrum of EBM definitions
In order to understand the reasoning behind attitudes toward EBM and research and how these attitudes have changed over time, it is imperative to understand how interviewees define EBM and the beliefs they hold about how medical knowledge is gained. EBM was most commonly defined by participants in this study in the context of research (literature and clinical trials), with the caveat that it didn’t fully replace personal experience in terms of generating evidence and that it was never sufficient to rely solely upon it for clinical decision-making. That is, participant epistemologies tended to incorporate both physician experience and research findings as valid ways of knowing, with neither solely sufficient for patient care. The following quotes exemplify how participants value multiple ways of clinical knowing as well as the limitation of using clinical trial evidence alone when treating patients.
“I think it’s two tiered. One is the evidence based medicine… that would come from research. And then there’s this personal evidence based medicine that we have as a physician and that’s how we make discoveries too.” (Mahonia)
“As you know, I mean it’s rare that we have the definitive trial that answers the question for the patient in every room and so it becomes this sort of consolidation of the best available evidence to make our best educated guess on how to solve that question. And I think that that’s independent of practice environment.” (Taraxacum)
Some participants had a more cautious approach to the use of EBM. In their definitions, they discussed it as something to approach with skepticism. For example:
“It’s like everything else in life, you’re going to go to the research that supports what you’re doing and you’re going to ignore that which doesn’t quite fit your model… I think of evidence based medicine as… controlling single variables in clinical medicine, which is kind of irrelevant. It’s flawed. Seriously flawed.” (Hydrastis)
Homeopathy is one modality sometimes utilized by naturopaths. One ND who focuses on homeopathy expressed her skepticism this way.
“Evidence based: what a lovely term. That seems like a great idea, but… the scientific method limits what we might define as our anecdotal personal experience about medicine. So in homeopathy, it’s all driven by that. We have our provings and we have our clinical experience and that’s how the materia medica and the repertory [classic homeopathy texts] is built based on those things, which again admittedly are extremely anecdotal and there’s a lot of garbage in both materia medica and repertory as a result. But the drive for this kind of controlled trials seems again just impossible to have it be even practiced within the homeopathic community… It sounds like it’s a good idea, but it actually seems quite rigid to me.” (Pulsatilla)
One of the shared perceptions amongst participants was that definitions of EBM were devoid of physician experience, and as such, limited. The caution that emerges in defining EBM appears to not necessarily come from a fear of accumulating evidence based on clinical trials, but rather that value in other forms of evidence might be discounted – a fear identified in conventional medical environments as well [17].
Attitudes towards research and EBM – from hostility to support
As described by the participants, when the profession initially began to encounter evidence-based medicine, community attitudes toward research and EBM were often hostile.
“I remember trying to teach classes about evidence-based medicine and, you know, you have people walking out and people shouting.” (Withania)
“You had very senior naturopaths just behaving like children and saying I hate researchers.” (Withania)
In explaining why these initial attitudes were negative, interviewees often expounded that ‘research’ and ‘science’ had historically been used against the profession and that there was a fear that EBM would be used the same way.
“There was a lot of faculty at the time, ten years ago, who felt like research was being used to keep them down. Like it was being used to — I don’t want to say persecute but — to kind of treat naturopaths in a condescending manner. To say well there’s no evidence that your stuff works so you’re not important and your profession is not important… [There was a fear that] EBM was going to be used to suppress natural medicine.” (Calendula)
However, all but one interviewee described a major profession-wide shift in attitudes toward EBM over the past 10-15 years. This was described as a shift moving from a position of hesitancy and hostility toward a position of openness and support.
“That [negative] attitude has completely shifted in the last ten years.” (Calendula)
“So I really feel like around the late ’90s you had the beginning of a spark and then it has blossomed greatly since then.” (Matricaria)
“So there’s no doubt that in the student population, there’s been considerably increased desire and I would say among the faculty of the school, there’s increased requirement or desire to have some evidence-based component.” (Avena)
Interviewees also universally (with one exception) described a variation of attitudes within that shift. This was referred to by various interviewees as: “spectrums,” “cohorts,” “subgroups,” and “factions.” This continuum or grouping was described as being both generationally specific as well as crossing generational lines.
“Well, some of the people who were considered pioneers in the [NM] field — they’ve been — I have experience with a handful of them at least and many are pretty hostile and don’t like the term [EBM] and don’t like research in the field and some of the things some of the younger people are doing.” (Achillea)
A primary cause ascribed to this hesitancy was that older generations had more experience with ‘research’ and ‘EBM’ being used against the profession.
“The community had a range from a lot of curiosity and interest in scientific research to maybe some of our forbearers who had experienced the word ‘science’ being used as a bludgeon against naturopathic medicine.” (Schisandra)
Additionally, the younger generation was said to represent a different type of student than in previous decades – one that was younger, more demographically similar to allopathic medical students, and more science-oriented.
“I think attitudes definitely changed, and I would say the student body has become more and more and more science-oriented as well as younger.” (Piscidia)
“I think the new cohort of students is far more interested in research and they’ve heard more of these buzzwords. They’re also far more demographically similar to the students that go into, say, MD programs.” (Matricaria)
However it was also pointed out that while there may be a cohort effect in general, many of the older generation were highly active in promoting a positive attitude towards research and EBM.
“There are a lot of members of the older generation that are leaders in the research field.” (Silybum)
Grouping of attitudes were described as not just generational but also as crossing generational lines. Interviewees tended to describe individuals with a more hesitant attitude towards research and/or EBM as those associated with the following descriptors regardless of generational cohort: “homeopathy,” “nature cure,” “traditional,” “hydrotherapy,” “softer touch,” “traditional herbalist,” “the naturopathic gathering,” “conspiracy theory believers,” “energy medicine,” and “MDs who became NDs.” These individuals may best be described as holding what previous qualitative researchers of the naturopathic profession have described as ‘holistic’ as opposed to ‘scientific’ worldviews [26]. When acknowledging this present-day difference in attitudes (and perhaps worldviews) towards EBM in the naturopathic community, one interviewee found value in this diversity.
“I do think that there is a core of people who are never going to be interested or open to evidence-based medicine who come to our profession… to practice an anti-establishment type of medicine that fits with their beliefs and their beliefs are, you know, the plants talk to me, or I feel the vibration that’s right for this person and why would I possibly need evidence for that. As a matter of fact, it would dilute the power of it because you could never do that… And I don’t think that we’re ever going — I mean unless it’s the conscious wish of the admissions [departments of the schools], we’re never going to get rid of that particular group. And maybe we shouldn’t because it’s always good, we always challenge each other.” (Matricaria)
Drivers of change
When asked why a shift in attitudes towards research and EBM had occurred, interviewees offered numerous explanations that were coded into 15 common themes, and were associated with both internal and external drivers of change (Table 1).
Table 1
| INTERNAL DRIVERS OF CHANGE (n) | EXTERNAL DRIVERS OF CHANGE (n) |
| Influential people– NDs (12) | External credibility (10) |
| Increased leadership and capacity (8) | Funding (8) |
| Internal credibility (7) | Influential people – non-NDs (8) |
| Increased exposure and opportunity (7) | Increased exposure and opportunity (7) |
| Network of researchers (2) | Global EBM change (3) |
| Positive results in research trials (2) | Patient demand (1) |
| Student loans (1) | “CAM is cool” (1) |
| Incurable diseases (1) |
Thematic codes associated with internal and external drivers. The number of interviewees ascribing a particular driver to the change in attitudes is provided to convey its prevalence.
Internal
The most commonly ascribed internally driven reason for change was the impact of influential people on the profession. Profession leaders from across generations were continuously referenced as making a large impact on moving the profession in a direction more embracing of research.
“[These leaders were] strong, vocal advocates who insisted that the only way that the medicine would improve would be through research.” (Piscidia)
Calendula paraphrased an influential speech made by one profession leader at an NM conference:
“Research is self-reflection. We have to reflect on ourselves. Not everything we’re going to do is going to be perfect, and if you’re not willing to examine yourself do you really deserve to be a doctor?”
However the steps taken by these leaders were described as difficult ones.
“You know [certain professional leaders] were really the primogenitors of the research efforts at [an ND training institution]. They bled. You know, they worked very, very, very, very hard to develop a research culture there.” (Schisandra)
The internal environments at NM institutions were ascribed as causes of changing attitudes as well. Silybum recounted that there was “institutional promotion [of research and EBM] within the curriculum.” Laboratory facilities were built and infrastructure was strengthened. The organizing body of the profession, the American Association of Naturopathic Physicians (AANP), began hosting a research track at its yearly conferences and NDs undertook secondary research degrees such as the MPH, MSc, and PhD. These research-trained NDs eventually took leadership positions in the NM institutions, which furthered the shift in attitudes within the community.
“It’s kind of become the educational standard to get more [research] training and those people have been taking faculty leadership positions or other leadership positions within our community and continue to advocate [for research].” (Taraxacum)
“And as the group [of ND researchers] grows, you have more people who can support research ideas… So instead of just being a couple of people, you have a group of 20, and that group can handle more work with clinical naturopaths to try and help them be involved in research. So if you have a network of researchers or clinicians who are interested in research then a lot can be done.” (Melissa)
With this training as well as increasing access to NIH funding for faculty development (a series of R25 research curriculum grants and T32 training grants awarded to Bastyr University and National College of Naturopathic Medicine), more and more members of the profession were able to engage in research or research literacy training.
“So a big part, and to this day it’s an issue, is training faculty so that they are more open to research themselves. Not making them researchers, but that they actually understand that there might be some importance in evidence and how to evaluate that and not just to be hostile towards it or neutral or I don’t care, I will never look at it.” (Matricaria)
Internal credibility was also a commonly ascribed cause of the shifting attitudes.
“For 200 years or 250 years we were saying homeopathy, yeah it works but now we’re having a new breed of people saying but why does it work?” (Avena)
“When I retired, there were many things that I was doing that I didn’t know how efficacious they were or not. You know? I mean if it worked on a few people then I keep on doing it. When it didn’t work then I need to know what’s going on there, you know. So it wasn’t just a profession needing to be valid in the eyes of the overall medicine field, but it was me as an individual physician being able to look at somebody, my patient in the eye and say listen, this particular product or this particular herb has studies on it and it says …” (Mahonia)
Although mentioned less often, some interviewees pointed to the growing network of NDs involved in research and the self-supporting nature of that network. Some spoke to the effect of published trials that showed a positive effect of naturopathic medicine which helped alleviate fears that research was going to discredit the field. One interviewee suggested that higher student loans forced recent graduates to pursue patients less familiar with and/or open to naturopathic medicine and to see patients in shorter visit times – it was suggested that both might cause an increased reliance on evidenced-based tools rather than more traditional and less researched naturopathic ones.
External
External drivers of change included a desire for external credibility and increased research funding.
“I think that [the naturopathic universities] also realized that they needed to put more effort into research or we would not be considered a valid profession if we couldn’t say that our therapies had some kind of positive effect.” (Mahonia)
“[Conducting research] makes us look like a more legitimate profession.” (Matricaria)
At the same time it was argued that this validation would help improve access for the profession to healthcare environments and reimbursement.
“The only way that naturopathic medicine would get a foothold in the public health system was through research.” (Piscidia)
“As opportunities for insurance reimbursement happened and things like that, you know, insurers are asking, where is the evidence base?” (Taraxacum)
Research and development funding was often described as an essential external driver of change and one that resulted in professional development that in turn led to further internal drivers such as increased capacity and opportunity. As such it seems to have acted both externally and by extension internally.
“Some of those [more hesitant] attitudes [towards research and EBM] came from the faculty, but in the last few years, I think attitudes have changed and people have become more open, cynically probably because they were seeing NIH [National Institute of Health] dollars and [asking] how can we get a piece of that pie.” (Achillea)
“The faculty has also shifted their attitudes [towards research and EBM] and I credit our R25 research education grant with that. Because we’ve had funding from the NIH for the last four years to train faculty so that they’re not afraid of research. They actually like the statistics now and they can read a paper instead of skimming the abstract.” (Calendula)
While most of the people mentioned as influential people were NDs themselves and were therefore listed as internal drivers of change, many were either non-naturopaths who took positions at the NM institutions or members of the larger CAM community that had broadly influential roles in CAM in general. One outlier to this trend was the mention of an insurance commissioner who promoted insurance coverage of NDs in Washington State.
An additional external driver mentioned by three interviewees was the global shift towards EBM within the larger allopathic medical community. One interviewee suggested that patients were demanding more research and evidence based therapies from their naturopathic practitioners. One interviewee posited that a larger cultural shift towards CAM, “CAM is cool” (Piscidia), may have led to more research-interested students enrolling in NM schools instead of conventional programs. Interestingly, one interviewee suggested that being faced with an incurable disease led many NDs to begin to consider the value of research.
“I’m going to float the idea that what substantially changed the attitude of we don’t have anything to prove, we can cure any disease, was the AIDS epidemic in which any ND that was worth their salt was trying to help people who are HIV positive and had developed AIDS. And I think everybody honest just realized we didn’t have any effective therapy and these guys died.” (Piscidia)
Apprehension
While the changing attitudes in many regards were described as self–reinforcing, some people also described apprehension and hesitancy regarding this abrupt cultural shift. As discussed above, this fear seems to have come from a place of worry that, while EBM and research may at first appear professionally benign or beneficial, once acculturated, they might be used against the profession as ‘science’ had in the past. Additionally, there seems to be a fear that EBM and research would lead to standardization and concomitant loss of individualizability of care – an important naturopathic axiom.
“There’s definitely some skepticism among our faculty with evidence-based medicine mostly because — again it’s this concept of a wolf in sheep’s clothing.” (Calendula)
“I think that there is a fear of research leading to kind of this loss of philosophy, this loss of souls, loss of individualizability of the practice.” (Taraxacum)
These drivers of change are conceptualized in Figure 1 below.
Fig 1.
Conceptual model of the drivers of changing attitudes towards research and EBM. Community attitudes are acted on by both external and internal drivers. Certain forms of external drivers, such as faculty funding, act directly on community attitudes and on internal drivers. The way EBM is defined by members of the community informs their attitudes towards it. As change occurs there is both reinforcement of and hesitancy towards the change.
Limitations
There are limitations to this investigation. While relatively large for a qualitative study, our sampling scheme was purposive and was not exhaustive. Snow-ball sampling is never ideal to obtain a balanced and representative sample of any community, as it hinges on relationships that already exist and inherently creates a sampling bias. However, snow-ball sampling was the best option for this study to find participants who had the most experience with EBM research in naturopathic medicine and could speak to its development over time. We did try to insure adequate sampling of non-dominant opinion groups, but the possibility of unexplored information sources remains. Additionally, as our key informants were selected from North American naturopathic communities, our results may not be applicable to naturopathic communities in other regions.
Discussion
Evidence based medicine was defined differently by interviewees: some included non-clinical trial knowledge as valid forms of evidence in their definition, while others thought EBM was necessarily exclusive of these other ways of knowing. As a whole, attitudes within the naturopathic community do indeed appear to have shifted relatively rapidly, moving from one of fear and hesitancy about research and EBM to one of cautious embrace. The shift does not appear to be entirely cohesive. Older ND cohorts with past personal experiences of ‘science’ and ‘research’ being used against the profession were described as more wary of research and EBM. Conversely, younger cohorts of naturopaths, who did not share these experiences and who may be more demographically similar to conventional (MD) medical students, tended to be more open to research and EBM. However those hesitant do not appear to be against change as a concept. Their concern appears to be more related to fundamental changes to the philosophy of naturopathic medicine and the disappearance of knowledge passed down through generations if it wasn’t considered “evidence-based.” The drivers of this cultural change seem to primarily be the impact of influential opinion leaders/advocates in the field, the availability of research and development funding and the desire for credibility or acceptance from the larger medical community.
An Eriksonian life stage model may be helpful in understanding how this dramatic and swift cultural change is impacting the naturopathic community [27]. In such a model, the young but rapidly growing profession could be viewed as in its adolescent life stage. According to Erikson, the major psycho-social crisis of this stage is the conflict between identity and role confusion. The significant relationships are those of peers and role models and the existential questions are: who am I and who will I be? As a profession which developed from vitalism and was always on the margins of the larger medical community, naturopathic medicine has grown rapidly in size and influence and, as it has entered new non-vitalistic (mainstream) practice environments, it has incorporated new peers and new role models. If research and EBM acculturation is indeed a flashpoint example of this life stage’s challenge, we wonder in what way naturopathic medicine will emerge from this psycho-social crisis. Will the profession be able to adequately integrate the values of its youth/roots with the values of the larger medical community? Will it forge an identity synthesis in regards to research and EBM or will it struggle with role confusion?
Conclusion
This qualitative evidence suggests that there has been a rapid and extensive cultural shift within the naturopathic medical community. With change often comes resistance. We have identified subgroups where this resistance appears to be more prevalent. However, while we respect the historical, professional, and philosophical concerns raised against EBM as discussed above, we posit that the philosophy and tools of EBM at core are not innately contrary to naturopathic medicine. As Vickers has stated, it is precisely within an EBM paradigm where all players are in theory equal before the evidence and such a paradigm is far more amenable to CAM then power-vested professional interests [11].
Funding/Conflict of interest
JZG, EBO, and JG are members of the naturopathic medical community.
This project was funded by grant# BU-CSR-Y2-013 from the Bastyr University Student Research Center.
Works Cited
1. Sackett, D.L., et al., Evidence based medicine: what it is and what it isn’t. BMJ, 1996. 312(7023): p. 71-2.
2. Hough, H., C. Dower, and E. O’Neil, Profile of a Profession: Naturopathic Practice, in Center for the Health Professions, University of California. 2001: San Francisco, CA.
3. Trinder, L. and S. Reynolds, Evidence-based practice : a critical appraisal. 2000, Oxford ; Malden, MA: Blackwell Science. vi, 249 p.
4. NPRI. Naturopathic Medicine. 2011 [cited 2011 Jan 15th]; Available from: http://nprinstitute.org/naturopathic-medicine.
5. Cramer, G., et al. Enhancing Education in CAM Evidence-Based Practice through Collaborative Relationships with Research-Intensive Partners. in International Congress on Education in Complementary and Integrative Medicine. 2012. Georgetown University Washington, DC.
6. Kreitzer, M.J. and V.S. Sierpina, NCCAM awards grants to CAM institutions to enhance research education. Explore (NY), 2008. 4(1): p. 74-6.
7. Standish, L.J., C. Calabrese, and P. Snider, The naturopathic medical research agenda: the future and foundation of naturopathic medical science. J Altern Complement Med, 2006. 12(3): p. 341-5.
8. Steel, A. and J. Adams, The interface between tradition and science: naturopaths’ perspectives of modern practice. J Altern Complement Med, 2011. 17(10): p. 967-72.
9. Adams, J., General practitioners, complementary therapies and evidence-based medicine: the defence of clinical autonomy. Complement Ther Med, 2000. 8(4): p. 248-52.
10. Jagtenberg, T., et al., Evidence-based medicine and naturopathy. J Altern Complement Med, 2006. 12(3): p. 323-8.
11. Vickers, A.J., Message to complementary and alternative medicine: evidence is a better friend than power. BMC Complement Altern Med, 2001. 1: p. 1.
12. Pelletier, K.R., et al., Current trends in the integration and reimbursement of complementary and alternative medicine by managed care, insurance carriers, and hospital providers. Am J Health Promot, 1997. 12(2): p. 112-22.
13. Watts, C.A., W.E. Lafferty, and A.C. Baden, The effect of mandating complementary and alternative medicine services on insurance benefits in Washington State. J Altern Complement Med, 2004. 10(6): p. 1001-8.
14. Ernst, E., How Much of CAM is Based on Research Evidence? Evid Based Complement Alternat Med, 2009.
15. Starr, P., The social transformation of American medicine. 1982, New York: Basic Books. xiv, 514 p.
16. Goldenberg, M.J., On evidence and evidence-based medicine: lessons from the philosophy of science. Soc Sci Med, 2006. 62(11): p. 2621-32.
17. Tracy, C.S., G.C. Dantas, and R.E. Upshur, Evidence-based medicine in primary care: qualitative study of family physicians. BMC Fam Pract, 2003. 4: p. 6.
18. Villanueva-Russell, Y., Evidence-based medicine and its implications for the profession of chiropractic. Soc Sci Med, 2005. 60(3): p. 545-61.
19. Dew, K., A health researcher’s guide to qualitative methodologies. Aust N Z J Public Health, 2007. 31(5): p. 433-7.
20. Collingridge, D.S. and E.E. Gantt, The quality of qualitative research. Am J Med Qual, 2008. 23(5): p. 389-95.
21. Corbin, J.M. and A.L. Strauss, Basics of qualitative research : techniques and procedures for developing grounded theory. 3rd ed. 2008, Los Angeles, Calif.: Sage Publications, Inc. xv, 379 p.
22. McCarty, R.L., et al., Building bridges: qualitative assessment of a clinical faculty exchange between a naturopathic and an allopathic medical training program. Explore (NY), 2011. 7(4): p. 249-53.
23. Wardle, J.L., J. Adams, and C.W. Lui, A qualitative study of naturopathy in rural practice: a focus upon naturopaths’ experiences and perceptions of rural patients and demands for their services. BMC Health Serv Res, 2010. 10: p. 185.
24. Novak, K.L. and G.E. Chapman, Oncologists’ and naturopaths’ nutrition beliefs and practices. Cancer Pract, 2001. 9(3): p. 141-6.
25. Denzin, N.K. and Y.S. Lincoln, Handbook of qualitative research. 2nd ed. 2000, Thousand Oaks, Calif.: Sage Publications. xx, 1065 , 57 p.
26. Boon, H., Canadian naturopathic practitioners: holistic and scientific world views. Soc Sci Med, 1998. 46(9): p. 1213-25.
27. Erikson, E.H., Identity and the life cycle. 1980, New York: Norton. 191 p.