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The Naturopathic Physician in America

By

Graduate Students:

Jennifer Vedder

With Contributions By:

Nicole Celin

Ashlee Dedek

Megan Crane

Directed By Prof. Brian F. Blake, PhD

Consumer-Industrial Research Program

Cleveland State University

Advisory Committee:

Laura Farr, OANP

Julie Chinnock ND, HRI

Eric Blake ND, Adjunct Faculty NCNM

Phillip Donovan, Northwest Public Affairs, LLC

December, 2010

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I. Background and Project Objectives

A. Background

The Oregon Association of Naturopathic Physicians (OANP) is an organization dedicated

to helping provide quality naturopathic medical (NM) care to Oregon residents. OANP is

composed of licensed naturopathic doctors (NDs), students enrolled in a NM program, and of

associate members.

In pursuing its mission, OANP serves the ND community by providing a platform for

interaction among NDs, by keeping practitioners current on the latest trends and changes in and

NM care, and by launching a variety of initiatives for the benefit of the NDs their patients.

OANP also works with Oregon legislators and insurance companies to educate them on issues

pertinent to the medical needs of Oregon.

Helfgott Research Institute (HRI) is a non-profit organization established in 2003 and

located at the National College of Natural Medicine. As HRI states, its mission is “to conduct

rigorous high quality research on the art and science of healing, specifically working to

understand natural forms of medicine.” HRI is structured as a nexus for naturopaths of all

disciplines to synthesize diverse knowledge bases and experiences to generate new, innovative

solutions to health problems.

Preliminary discussions took place among Laura Farr, Executive Director of OANP, Julie

Chinook ND of HRI, and Brian F. Blake PhD of the Consumer-Industrial Research Program of

Cleveland State University. Discussion led to a project sponsored jointly by OANP and HRI and

implemented by Dr. Blake and a team of researchers/graduate students in the University’s

Consumer-Industrial Research Program.

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B. Project Objectives

Inputs were sought from a panel of faculty at the National College of Natural Medicine

and from Phillip Donovan of Northwest Public Affairs, LLC, as well as OANP and HRI. The

project was launched with a steering committee composed of OANP’s Laura Farr, HRI’s Julie

Chinook, and CSU’s Brian Blake with Eric Blake ND as a specifically tasked liaison.

The project is composed of two interrelated components, one pertinent to Oregon’s

General Population and the other to America’s ND community. The goal of the latter is to devise

a detailed research design which would, when implemented in the manner recommended, meet

the following objectives:

a) Profile the ND community in America in regard to a variety parameters:

Engagement in particular professional activities

Professional goals and interests

Provision of alternative treatment modalities

Form of reimbursement

Involvement in a primary care role

Reliance upon various forms of medication in prescriptions

Income from NM and other income streams

Demographic characteristics

Licensures and certifications beyond the ND

b) Chart the diversity of NDs in the above regards and identify sectors or “types” of NDs

that compose the contemporary ND community in America.

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c) Assess the needs and priorities of each ND type/sector in order to learn how to serve

their distinct interests.

d) Identify graduates of ND programs who are not presently involved in NM. Who are

they? Why are they no longer active?

e) In conjunction with information from the Oregon General Population survey explore

the viability of mutually beneficial referral networks with non-ND healthcare providers.

C. This Report

This paper:

Specifies a data collection and analysis framework that will generate data to

accomplish the above objectives

Sketches the kinds of informational outputs that can be expected when the

recommended procedures are executed

Flags a number of “caveats” that OANP/HRI should keep in mind contracting

with outside vendors for data collection and/or analysis tasks

There is no need to illustrate how many of the informational outputs can be derived from

the questionnaire responses. Multivariate statistical tests in addition to cross tabulation and

univariate projections are undoubtedly well known to HRI researchers. Several specialized

applications of multivariate statistics within the consumer/marketing research arena, however,

may be less familiar. Therefore, COMPONENT REPORTS outlining the outputs from these

specialized analyses have been prepared and accompany this report.

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II. Methodology

The recommended research procedure is covered in the COMPONENT REPORT: A

Procedural Framework to Profile America’s NDs, submitted separately. Here we present but an

introduction to that methodological report.

A. Five Questions

The procedures developed for this project were structured so as to be able to answer five

questions in the affirmative:

Are we listening to the right people?

Are we listening to enough of the right people?

Can we trust what they say?

Do we understand what they are telling us?

Does the information provide guidance for action?

B. Right People?

By the “right people” we mean that respondents provide a representative sample of the

population. To ensure a representative sample we must:

a) Specify the population clearly. Here the population is composed of persons who

graduated with an ND degree from an accredited institution in the US in the last ten years

and/or who are members of state or national level ND organizations. Those who are

currently students in an ND program are excluded.

b) Devise a viable “sampling frame”, e.g., a listing of population members that does not

leave out important sectors of the population and is reasonably up-to-date and is free of

errors (e.g., missing addresses, duplications). Here the sampling frame is being devised

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by HRI staff by integrating lists of graduates since 2000 from the five major NM colleges

in the USA, membership lists from state level organizations of NDs, and the membership

list of the American Association of Naturopathic Physicians.

c) Draw a probability (“random”) sample of respondents from the list. Here the sampling

approach is a proportional random sample stratified by state.

d) Use of appropriate techniques so that a high response rate is achieved. Evidence

consistently shows that surveys with low response rates yield samples unrepresentative of

the population in numerous ways. Steps taken to increase response rates are based upon

well-established “best practices” in survey research. These are, among others:

(1) pre-notification

(2) multiple (3) waves of questionnaire

(3) guarantees of anonymity of responses

(4) a questionnaire that (thanks to programming five alternative “tracks” through

the questionnaire) does not contain items irrelevant to a respondent and should be

fairly easy to answer

(5) a credible source/sponsor

(6) a stated goal that ties into the value orientation of respondents

(7) an incentive to respond, here a personal copy of study results

e) When the responses are actually obtained, assess whether subsamples should be

“weighted” so as to adequately represent the population. Here, the design is set up to

weight respondents so that the obtained samples are proportional to the states’

contribution to the national population of NDs.

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C. Enough Right People?

A sample must have enough cases to estimate the population with adequate precision.

How many is enough? It depends on: a) how much variability there is in the population on the

issue of interest; b) how precise should the estimate be to be useful for the intended purposes

(e.g., 2% vs. 5%), c) how great the chance of being wrong (10%? 5%? 1 %?) on the estimate

that can be tolerated. Standard formulae are used to balance theses three to wind up with the

correct number of cases for a given analysis.

Beyond the above, the sample size needed depends on how the sample is “sliced up” for a

particular analysis. For example, if we are to split the sample into two groups (e.g., West Coast

NDs vs. the rest of the nation), we would need an adequate number of cases in both groups to

make a separate projection for each group. So the total sample needed for a survey in which the

sample is to be sliced many ways in the analysis can be substantially larger than is needed when

the sample is not to be sliced up.

Finally, the sample chosen from the sampling frame must also consider the anticipated

response rate. Suppose the above considerations suggest a random sample of 500 cases is

adequate. If the anticipated response rate is 50%, then we would need to choose 1,000 cases.

The project considered several credible scenarios and then “did the math” to wind up

with an appropriate sample size.

D. Trust Responses?

Are respondents engaging in overstatements? Are they displaying one or another

response bias that distorts their data? The ND survey does not include “lie scales,” consistency

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checks or other indicators that a particular respondent’s answers are suspicious. The General

Population Survey does, however.

In processing this data, the analyst should be particularly alert during the data cleaning to

look for those patterns that usually signify “garbage” (e.g., systematic alternation of answers to a

block of questions) and eliminate the suspect respondents. Later in preliminary analyses basic

intercorrelations among key variables should be calculated to make sure that variables that

should correlate (in the eyes of knowledgeable and experienced NDs) actually do correlate.

It is hoped that the nature of the questions, the stated goal of the survey, and the type of

respondents militate against over finding widespread “noise” and distortions. The General

Population Survey may be another question.

E. Understand Responses?

To facilitate interpretation of the data the questionnaire was designed for the application

of particular multivariate statistical tools that allow us to “look underneath” overt answers to find

dimensions that underlie those answers. Use of these dimensions help greatly to address the

question: “What did they mean by that answer?”

For example, suppose a substantial number of NDs say that they place a high priority

upon devoting time to directly educating the public about health care. Do the NDs endorsing this

priority so do because it is “good for business,” because they want to advance the availability of

cutting edge naturopathic care to those in need, or both? The dimensional analyses help answer

this question. Suppose we find that those endorsing the public education priority also

overwhelmingly place a priority upon: (a) using newly developed treatment approaches with

patients, and (b) conducting systematic research on new medical theories or treatment modalities.

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Suppose further that those endorsing the use of their time for public education efforts also tend to

place a relatively low emphasis upon being so financially successful that they can retire early. A

dimensional analysis would help us to interpret respondents’ answers by spotting patterns of

responses that facilitate interpretation of survey results. Here, the pattern would argue that NDs

who believe in their devoting times to public education are not motivated principally by revenue

generation but rather by the desire to further knowledge about advancements in NM care.

F. Guidance for Action?

Unlike the General Population Survey, the mission of the ND Survey was not intended to

make specific decisions. Rather, the goal was to be the first comprehensive description of the ND

community in America. Who are NDs? What are they doing? What do they want? Until these

questions are answered there can be no meaningful discussion of the profession’s launching

concerted action toward defined goals.

If the ND community is to be effectively served by the professional organizations like

OANP and AANP, and if calls for action are to be issued to the ND community, then there are

particular information we need to obtain from the survey. To enhance the “actionability” of the

descriptive data obtained in the survey, the survey must:

a) indicate the clarion calls that can galvanize the NDs to take action. Accordingly, the

project estimated the communication items to which each sector of the ND community

resonates.

b) find vehicles that can “get the message” to the NDs sectors of interest. Here we code

the ND organizations through which each ND can be contacted.

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c) understand the great diversity that exists among NDs. We cannot plan for the “average

ND” when there is so much variation around the average. We must appreciate differences

in the professional roles, the forms of medical care extended, and other nuances of an

ND’s life. To this end, the project segments NDs into diverse sectors, then provides a

multifaceted profile of each sector. The profile of each should reveal appropriate action

for a given sector.

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III. Sectors of the ND Community

Who are America’s NDs? … How many distinct “types” of NDs are there? … What are

their professional goals? … Upon which forms of NM care do they focus? … Many questions,

but previously no solid information on which to base an answer.

The “COMPONENT REPORT: Sectors of the ND Community” addresses these and

related questions. The questionnaire for the ND survey is structured so as to gather the data

needed for a “segmentation analysis” that will empirically divide the national ND community

into its constituent segments. Each segment is composed of NDs who are quite similar in key

factors but who are different from NDs in other segments in regard to those key factors. Some of

these sectors account for the lion’s share of the NM care delivered in America. Some sectors, on

the other hand, are less central to the delivery of NM care at the present time.

The reader is referred to that COMPONENT REPORT. It should be kept clearly in mind

that the “results” reported are based upon “numbers pulled from the air;” the analyses are

intended solely to show the nature of the segmentation outputs that will be done.

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IV. Working with ND Sectors

As we look at the different types (segments) of NDs, we must ask:

Which segments form the backbone of NM care delivered in the USA? Which

are more peripheral?

How can professional organizations meet their distinctive needs and

interests?

The ND Survey answers the first question by finding which segments have a larger share

in terms of

a) the number of NDs practicing in America at the present time (“percent of NDs”)

b) the number of patients receiving NM care currently (“percent of NM patients”), and

c) the number of hours of care delivered in the US at the present time (“percent hours”).

Answers to the second question will be obvious once we see the richness of the segment profiles

which cover the NDs’ attitudes and values, professional attributes, patient base, and other

factors. The ND Survey is designed to yield an answer to this question separately for each

segment and for the American ND community as a whole. One of the more interesting and useful

analyses concern the professional interests and goals of the various sectors.

The reader is referred to the “COMPONENT REPORT: Working with ND Sectors.”

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V. National Portrait

A. Introduction

Here the ND Survey was designed to provide a picture of NDs around the country. This

is akin to national polls reported in the popular media.

Note that the accuracy of this portrait hinges upon the representativeness of the data.

Thus, the data must be weighted to ensure geographical (state level) representativeness. Other

bases of weighting (e.g., by college where trained) may be rendered less useful due to “noise” in

the data (e.g., “dirty” alumni lists) to the unavailability of the really useful information about the

ND population, or to the potential lack of coverage of all ND sectors (e.g., in listings of an

organization’s membership).

B. Factors Covered

The ND Survey questionnaire covers the following about NDs. Additional factors

descriptive of the patient base of America’s NDs are discussed in the next part of this report.

1) Professional Activities

a) work status (e.g., part-time, unemployed)

b) involvement in: direct provision of health care (both NM and other),

administrative/managerial activities (both NM and other), public education,

research, work outside the NM realm

c) size of medical organization in which one practices/manages, in terms of the

number of NDs present.

2) Goals and Interests

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Preference for or against 20 professional objectives, e.g., “to own a large clinic

serving a large number of patients,” “to devote some time to directly educating the

public about health care,” “to travel extensively to other parts of the US or other countries

to learn about emerging concepts or procedures of naturopathic medicine,” “to make sure

my activities as an ND do not interfere with my time with family and friends.”

3) Treatment Modalities

Usage of 23 (plus “other”) forms of treatment on a regular basis, e.g.,

electrodermal testing, Ayurvedic medicine, microcurrent, Reiki.

4) Prescriptions Issued

Usage of four forms of prescriptions, e.g., those requiring a DEA registration.

5) Reimbursement/Income

Includes gross vs. net individual income as a naturopath, as well as acceptance of

insurance vs. a cash basis (for those in practice).

6) Licenses and Certifications

Fifteen are listed, e.g., DEA registration, advanced cardiac life support

certification, midwifery license.

7) NM College

8) Where Licensed/Registered

This is by state within the US, plus the District of Columbia and out of country.

9) Demographics

Included are: age, ethnicity/race, gender, and marital status

10) Career Satisfaction

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The reader is directed to the “COMPONENT REPORT: A Procedural Framework to

Profile America’s NDs” for the questionnaire.

C. Analysis

The respondents’ answers can be analyzed via the traditional “head count” approach,

calculating the number and percentage of respondents giving alternative answers.

The next step-up is a “cross-tab” approach, cross tabulating answers by one or more

factors, e.g., answers to the question about net income between those with smaller vs. larger

practices in the West Coast vs. Southwest states.

It is not necessary to describe the nature of such analytic outputs. Given the expertise of

the HRI staff, providing a COMPONENT REPORT on such analyses would be foolish.

A great number of analyses of greater depth with more rigorous statistical procedures will

suggest themselves when the real data are available. For example, what type of practice or career

path is associated with greater job satisfaction?

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VI. NM Patient Base

A. Introduction

Respondents to the ND Survey describe their patient bases. Those providing direct NM

care answer in terms of their own patients, while those operating as managers/administrators (but

who do not themselves see patients) describe the patient base for their organization.

B. Factors Covered

The patients are described in regard to:

1) total number of patients

2) change in patients seen in last year

3) frequency of 23 (plus “other”) conditions or symptoms, e.g., allergies, hormonal

imbalances, environmental toxicity

4) frequency of nine specific areas of health care, e.g., geriatrics, pain management

5) frequency of six specific goals patients have when seeing them, e.g., to remedy a

current disorder, to learn how to live a healthy lifestyle

6) demographics- age, marital status, race/ethnicity, income

C. Analysis

A profile of patients seeking NM care can be drawn. An even better assessment, at least

for the state of Oregon, can be obtained by doing comparable analyses for respondents to the

General Population Survey who have seen an ND.

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Patient characteristics are included in the ND segmentation, so we will find that the

patients treated will be different from one ND segment to another. Hence, cross-tabulating

patient characteristics with ND segment membership would be informative.

Who does seek NM care? What ailments or issues do they have? What do they want to

accomplish by going to an ND? How much of each kind of NM care do they receive?

We will find out when the data are in!!

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VII. Referral Networks

It is obvious that a referral system is a well oiled and firmly established institution for

MDs and other conventional physicians. This system feeds potential patients to conventional

specialists via referral from conventional primary care physicians. Beyond this institutionalized

system, non-physician HCPs (like acupuncturists or physical therapists) regularly recommend

particular conventional primary care physicians and specialists to their clients/patients.

The institutionalization of this structure in American society makes it difficult for

emerging medical disciplines to offer services to potential patients.

What might be done by NDs at the local and at the national levels to expand the

distribution of NM care? Consider proactively taking steps to construct referral networks for

NDs. The reader is referred to (pun intended) the “COMPONENT REPORT: Referral Networks:

The Lifeblood of Medical Practice”.

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VIII. NDs’ Leaving the Field

The ND Survey project attempts to sample ND graduates who are not practicing in the

NM field. The issue is not about ND graduates who are seeking, unsuccessfully at present, to

secure employment in NM care. Rather, we are looking at persons with an ND degree who are

not engaged in NM care and who are not looking to be.

Who are they? What happened?

The ND Survey profiles these “Inactives” in regard to:

1) demographics- gender, race/ethnicity, age, marital status, gross and net income (2010)

as an ND

2) licenses/certifications held

3) college of training as an ND

4) passage of NPLEX

5) state of licensure as ND (if any)

Further, the Inactives are to be asked why they are not involved. Several reasons are

provided (e.g., low financial compensation, licensure impossible where one lives, dislike of

business aspects of ND practice) as well as the option of “other” with the request to “Please

explain in your own words”.

See the “COMPONENT REPORT: A Procedural Framework to Research America’s

NDs” for the questionnaire items.

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IX. Caveats

The following note is also part of the “COMPONENT REPORT: Awareness and Image

of Naturopathic Physicians: Oregon Public.” It is presented here also because it pertains to the

ND Survey as well as to the General Population Survey. We feel that it is important to keep in

mind if and when contracts are to be negotiated with an outside vendor

Caveat Emptor

If the data collection and/or analytic procedure described here are presented as an RFP to

commercial research vendors for bids, it is quite possible that OANP-HRI will be met with one

or more of the following responses:

1) “This is too academic. Professional services do not do all these steps.”

2) “These procedures are very expensive; we can do it just as well using less expensive

procedures.”

3) “Happy to do so. But it will be expensive.”

Each of these responses is almost undoubtedly self-serving and erroneous. It is true that many

commercial firms do not go through steps as cautiously and systematically (e.g., employ multiple

waves in online data collection, be so thorough and cautious in establishing reliable and valued

segments). It is also quite true that many research vendors will “charge an arm and a leg” for

such a service.

However, with 30+ years of experience as an independent consultant, as owner of a

million dollar research firm, and partner of a multi-million dollar market research corporation,

Dr. Blake knows that a rigorous and thorough design like this can be, and is, performed with a

very healthy profit margin for a vendor.

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Further, beware of “proprietary techniques” that are billed as a panacea for multiple ills.

Many tools stated to be “propriety procedures” are actually spins of standard technique and/or

long on graphic displays but short on statistical validity. If a vendor trumpets the applicability of

a wondrous propriety technique, have it checked closely by a statistically trained specialist at or

working with OANP/HRI to verify that it is actually distinctive and valid.

Similarly, beware of vendors who say that they have a standard way of conducting an

analysis that they are averse to altering, particularly for segmentation and/or image/preference

mapping. Cookie-cutter approaches contribute to a vendor’s bottom line, but may not (and often

do not) meet a client’s unique information needs.