Virtually every corner of the medical industry houses an entangling drama between mission and money. There is the service, the need to make a living, and then the way making a living can transform into a production orientation dominated by the impulse to make more money. For integrative health and medicine, the drama is intense, whether in integrative centers owned by large institutions or solo practices in the community. The mission-money challenges get “curiouser and curiouser” for the licensed integrative practice fields that are not fully swept up into the thundering $3.3 trillion river of cash that annually rips through the dominant medical industry. An edginess sets in when, as the sick joke has it, you have just enough recognition to get into debt, but not enough to get out of it yet. So it is always interesting to explore new data on income and practice methods such as were recently published by the Association of Accredited Naturopathic Medical Colleges in it’s 2020 Graduate Success and Compensation Study.
The seven AANMC-member naturopathic medical programs in North America – 5 in the U.S. and 2 in Canada – each emailed the survey to their alumni. Of the total of 7,302 AANMC member schools’ alumni, 1,215 responded, yielding a response rate of 17%. (This response rate is ballpark, for instance, for the response rate for the National Certification Commission for Acupuncture and Oriental Medicine in a representative survey.) The rate posts a first order caveat emptor. Was there bias in who responded? Did successful practitioners not take the time? Were less busy practitioners, with time on their hands, over-represented? And what about any who may have dropped out of practice altogether? These data do not answer such questions.
The graphs and pie charts in AANMC report are intriguing – from demographic data through clinical specialties to income sources and totals. Note that while the report separates US from Canadian findings, I am only reporting the US findings here. (See the chart included here or for more thorough data, go to the study) The key finding is that the overall average “salary” of those who responded was $96,000. The mean salary, however, was significantly less, at $70,000.
It is worth noting that the work “salary” is used her only rarely in circumstances in which a set salary is paid by an employer. Here the term for the clinician respondents is almost always take home pay from an entrepreneurial, community-based practice.
The study stratified the income based on the number of patients per week the naturopathic doctors saw. The high earners saw between 40-59 patients a week, earned on average $146,000, with the mean at $109,000. Across the board, the high differential between average and mean suggested that high earners were pulling the average up and some low earners kept the mean down. I asked AANMC executive director JoAnne Yanez, ND, MPH what the main take homes were for her and her members:
“One of the good things was seeing the time to employment was fast – up to only 4 months after licensing on average. Another big take home was seeing the flexibility they have in how they practice – whether solo, or with groups, or supplanting their practice income with other forms, consulting or teaching. And many are able to vary the number of patients they see a week, for a higher quality of life.”
The average number of patient contact hours of respondents was 21 per week, or roughly 3 clinical days. These were supported by another 25 hours of study, preparation, and administration for an average of a 44 hour work week.
The study does not comment on whether the fewer hours are by choice or due to being less busy than they would like. Prior surveys of the profession have found that for many a schedule with fewer patient hours per week is more suitable to their personal and practice values. Fewer patients allows for the time intensiveness of naturopathic practices – both with patients and the amount of time to manage and treat the complex physiology and the complexity of whole lives in these whole person practices. The schedule can also allow for a healthier life with less burn-out than is common in conventional practice.
As an observer of the profession for 35 years, some remarkable finding are the high putilization of therapies that are offered through “injection” or via “intravenous” methods. These ranked second and third, respectively behind only “therapeutic nutrition” among the services offered. Roughly a third of respondent naturopathic doctors offer each.
That only 68% marked clinical nutrition as a service offered is also something of a surprise. Nutrition is historically at the heart of the naturopathic practice with its banners of “let your food be your medicine and your medicine your food” and “treat the gut.” An examination of what appears to be a word map of the literally hundreds of therapies the respondents said they offer includes multiple other terms that might overlap with “therapeutic nutrition” and thus push up higher the percent that use nutrition and diets therapeutically. Among these are “lifestyle medicine”, “diets”, “clinical nutrition”, “nutritional supplementation”, “nutritional counseling”, “diet and lifestyle support”, “health counseling”, “coaching”, “nutrition and lifestyle counseling”, and more.
The use of botanicals is another big question mark. Experience suggests that at least 90% of naturopathic doctors use botanical medicines. And yet these agednts don’t show up directly as an item except as prominent among the “other” category. In practice, botanicals are effectively part of the “therapeutic nutrition” many practice. In another section on “Areas of Focus” for instance, 45% noted “herbal medicine” while 29% marked “Acupuncture/Traditional Chinese Medicine.” The latter also includes herbs.
One area of interest relates to the use of pharmaceuticals in the practice of naturopathic primary care in states such as Washington, Oregon and Arizona. In the word map, one sees “Naturopathic Primary Care” and “Pharmaceutical” and even “Vaccines” yet the report does not directly speak to this seemingly useful area, given the profession’s interest in integration into the primary care workforce. Also related to integration with conventional practice, of respondents, 40% said payments were a mix of cash and insurance. Just 3% said insurance only. Thus 57% are still operating without connection to the dominant payment structures and entanglements.
The clinical services were also examined, as noted, with questions focused on “Areas of Practice” rather than “Services Offered” . What are the types of conditions or populations on which the services are applied? The word map in the report again creates a very broad swath. The foci mentioned speak to the way individual naturopathic graduates tailor their services. Just about everything seems to be on the list: pain, oncology, neurology, family medicine, mold, Lyme disease, sports medicine, hormone replacement, allergies, fertility, pediatrics and more. The AANMC chose to cluster together a group of six where there is a “strong relationship of these areas of focus – these areas are likely to be practiced together.” The mix is digestive disorders-nutrition-women’s health- insomnia/fatigue/fibromyalgia-mental health/mind body medicine-immune support (See figure).
Debt Load, Inclusion, and Procedures
Conventional medical education in the United States floats on governmental subsidies and on additional infusions from philanthropic sources and major foundations. Wrapped around this are systems of payment and inclusion that – while often frustrating and arguably structurally damaging to creation of healthy outcomes – create “employment” securities. The AANMC report pegs this average full-time MD/DO salary for family medicine at $225,000. Student loan debt for MDs/DOs may be high. The medical school portion for MDs averages $196,000. Yet the web for re-payment is secure. Practice insecurity is more likely related to mind and soul: burnout from work in the belly of the medical industry and the ethical questions that may arise about whether all that pharmaceutical-focused medicine is helping move people sufficiently toward health.
The issues for NDs concerned about their debt burden are of a different ilk. The present survey does not include any information on student loan debt. The AANMC survey from 2015 did – pegging it at $167,000. Yanez, when asked, did not provide a ballpark figure that the AANMC uses. My experience with the field suggests the level is often at least $250,000 today with some reporting substantially more overall education debt. A state of Oregon survey on the debt of health professionals across a score of fields put the average medical school debt of a medical doctor from Oregon Health and Sciences University at $221,000. In the same report, the graduate of the naturopathic medical program at National University of Natural Medicine was higher, at $232,000.
The growth in debt raises questions about the extent to which the choices of “Services Offered” and the “Areas of Focus” are being shaped by financial pressures and interests. Graduating NDs must pay off the debt and, in most cases, do so while finding “employment” not through “getting a job.” They must build a practice. For most, the focus is on cash payments. This context may explain the apparent move away from the general practice of naturopathic family medicine toward practices that increasingly involved with procedures such as injections and intravenous methods and the therapeutic nutrition model typically linked to revenues from in-office pharmacies. Success is typically with practice specialization that can be used as a “brand” for the necessarily entrepreneurial naturopathic doctor to find success.
Comments: The Role(s) of the Naturopathic Doctor
On July 11, 2020, Whole Health Institute director Tracy Gaudet, MD delivered a keynote at the American Association of Naturopathic Physicians’ online annual conference. Gaudet, the founding director of the massive 55-system Veterans Administration Whole Health program, celebrated the naturopathic profession’s principles, it’s whole person approach, focus on lifestyle medicine, and engagement with behavioral determinants of health. Gaudet went so far as to say that, had she known of the field when she was exploring healthcare from her psychology and sociology background, she might have chosen the field. She portrayed naturopathic medicine as deeply aligned with emerging whole health principles and practices at the VA and now with the new WHI initiative. Ironically, as an attendee noted at teh chat box, despite expressed interest, naturopathic doctors are not formally accepted as practitioners in the VA system. (Gaudet said she and current director Ben Kligler, MD, MPH have been working on that.)
Gaudet’s favorable perspective raises questions: are these new models meant to make a living with higher levels of procedures at cross purposes with the idea of naturopathic practice that appeals to Gaudet in shaping a whole health future?
This is important. Goals of the AANMC study included “creating a profile of the ‘successful’ naturopathic professional; i.e. one satisfied with their career and career choices” and “supporting incorporation of findings into academic and clinical curricula.” What might the influences on naturopathic educators be if the VA was open and affirming? What if success were defined by being the optimal naturopathic graduate to actually be “employed” as part of the workforce to advance the whole health model?
The mainstream of medicine is slowly awakening to historic, whole-health naturopathic values and principles. Yet at the same time, the naturopathic field appears to be, due to constrained opportunities and debt pressures, clinically aligning around entrepreneurial models of care and service offering targeted to a necessarily upper income, cash-dominant marketplace. One has the uneasy sense for the naturopathic profession that in some realm of time and space, two ships may be passing in the night.