TO THE EDITOR:
I just returned from a two hour session with a friend and colleague at the University of Vermont Medical School. Helen Longevin, MD, is an endocrinologist who is also trained in acupuncture and is an active proponent of complementary medicine. In fact, her job at UVM is in researching acupuncture. She was given the task recently of reviewing journals for possible inclusion in UVM’s medical library holdings. Proudly, I provided her with the Journal of Naturopathic Medicine. Today she gave me interesting feedback which I want to share. I offer it in respect and with the sole intention of improving our profession and advancing our relationship with the public and with the conventional medical community.
Dr. Longevin has a great deal of experience reviewing articles for peer-reviewed journals; specifically she did this during her fellowship at John Hopkins Medical Center for JAMA. Today she walked me step by step through the process of what makes a good peer-reviewed journal, and what makes a good article.
According to Dr. Longevin, a good article, including theoretical ones, need to be well supported, documented and easy to understand for physicians unfamiliar with the topic presented. Even for theoretical articles, theories need to be clearly stated as such and supported with data. In fact, every sentence in a reputable journal needs to be either 1) common knowledge by the audience, which is presumed to be physicians, not necessarily with expertise in the topic; 2) thoroughly explained or elemental science such as biochemical pathways; or 3) documented by citations. Citations, in turn, should be from recent, available journals (i.e., in English and reputable). When these are not available, foreign articles or textbooks may be cited, although this weakens the article. When no data is available (and the writer must have exhaustively researched this in order to make such a statement) this must be stated.
Dr. Longevin did not recommend our journal for inclusion in the library’s holdings. She used several examples from Dr. Jared Zeff’s recent article, “The process of healing: A unifying theory of naturopathic medicine” (Journal of Naturopathic Medicine 1997; 7(1):122-5), in explaining her evaluation.
She specifically pointed out the paragraphs on toxemia as problematic. First, the concept is not common knowledge by all physician readers, and its not describing indisputable elemental science. Therefore, it needs to be well-supported with citations. She walked me through every sentence in those paragraphs, and said that all of them needed to be documented. For example: “These products (toxins) are absorbed into the blood (needs citation or proof), become a cause of tissue irritation (again, needs a citation-what tissues? how? has it been measured?) and thereby the physical basis of most chronic inflammation (needs support), which ultimately will increase one’s susceptibility to acute disease (lots of proof needed here)” (page 124).
Even if this is theory, apparently there needs to be significant evidence supporting it. Otherwise, medical people just toss out the information, even if it is accurate. I happen to believe and use in practice with my patients the part about the effect of adrenal activity on digestion. But in a theoretical article, every sentence needs to be backed-up – otherwise we are in a sense making unsubstantiated claims.
It’s a laborious process, Dr. Longevin admitted, but if we’re going to hold up under scrutiny that we’re definitely going to face from the medical profession, we can’t take short cuts. She assured me, and I believe this, that we will only strengthen our profession by applying more rigorous standards to our research and our writing.
I think we’re in a position now with our profession to undergo some critical review. If we don’t, THEY will. I’m fortunate that I know some people deeply steeped in the medical research model here that are actually on our side, and want to train us in how to use their language-especially since we’ve stepped into the world of peer-reviewed journals they invented and are so good at creating. Despite the narrow focus of this letter I would like to say I enormously appreciate Dr. Zeff’s contribution and his attempts to bring unity into our field.
- Lorilee Schoenbeck, ND
- Champlain Center for Natural Medicine
- 2 Harbor Rd.
- Shelburne, VT 05482
TO THE EDITOR:
Dr. Schoenbeck’s sincere and thoughtful letter asks one of the most significant questions facing our profession: what is a naturopathic physician? Dr. Longevin’s observations regarding my article contains some criticisms and advice, though there is a significant difference in our points of view. But they point to a major problem in naturopathic medicine.
I hold an assumption which may no longer be valid – that naturopathic medicine is a separate and distinct branch of the healing arts, and as such has a body of knowledge separate and distinct from other branches of these arts. I practice neither complementary nor alternative medicine. I am not a holistic physician. I am a naturopathic physician. A naturopathic physician is a defined entity. As a separate and distinct branch of healing, we have separate and distinct assumptions, and a separate and distinct body of knowledge. We share a body of knowledge with other healing arts, such as the basic medical sciences. But, we are not the same. We are different. The most obvious difference is our understanding of suppression, either shared nor respected by standard medical doctors. Suppression is discussed in the AANP “Unifying Definition of Naturopathic Medicine” (1989) as harmful. We understand that it violates the process of healing, but may occasionally be necessary to save life. We understand that suppression of acute disease is a significant cause of chronic disease. Medical doctors, on the other hand, base much of their work on suppression – suppression of inflammation, fever, infection, etc. – and seek more and more powerful ways to suppress the symptomatic expression of disease, and see successful suppression as cure. We do not, or at least I do not. I see it as a significant harm, and the major iatrogenic cause of illness in our society.
Another difference is the recognition of toxemia. Although the concept of toxemia is not a part of the body of knowledge presented in conventional medical schools, as evidenced by Dr. Longevin’s comments, all first year naturopathic students are presented with this concept. Some of the presentation relies upon outdated materials, such as the naturopathic texts of 75 and 100 years ago – Lindlahr, Tilden, and so forth. But in my first year philosophy course, along with these, I recommend reading Drasar and Hill’s Human Intestinal Flora (1974), and demonstrate some of the biochemical pathways of the generation of metabolic toxins in the gut through dysbiotic bacterial action upon poorly digested food. This can be measured via such methods as urinary indican and urinary phenol tests, comprehensive stool analysis, etc. We teach the testable assumption that toxemia is a cause of disease.
I assume that toxemia should be “common knowledge of the audience,” which I presume to be naturopathic physicians. Clearly, this concept is not common knowledge of Dr. Longevin or her medical colleagues. Nor would I expect it to be. This concept, and the science behind it, is taught at naturopathic medical schools. The biochemistry toxemia, published in the conventional literature, is ignored by standard American medical science. It is ignored not because the science is not there, but because it does not fit the dogma of modern American medicine. This information is neither new nor “unscientific”. It has recently been recognized as a mechanism in the generation of gut cancer even in the Merck Manual (16th edition), though the model was clearly elaborated 20 years ago.
I do not pretend that these concepts are really common knowledge among our colleagues, because I see in practice that they are not, and for me this is the real issue. They are rarely if ever discussed in our college clinics. I see that many of my colleagues have abandoned what I consider the fundamentals of naturopathic medicine for the acceptability of conventional medical assumptions and relationships.
I wrote my article primarily because I wanted to present to my colleagues what I considered a significant observation about the working of our medicine. This is expressed in what I called “the hierarchy of therapeutics,” and what is called “the therapeutic order” at Bastyr University. There is an order to the process of healing, which requires certain things to be done before others to maximize the effectiveness of the therapeutics. It is this order of application, which is most often violated in practice. The current therapeutic goal in naturopathic medicine often seems to be to make the correct diagnosis, in standard medical terms, and treat with the correct set of supplements, or the correct homeopathic remedy or botanical tincture, or refer correctly if the patient is really ill, but ignore the vis medicatrix naturae and how it functions. This is tragic, in my opinion, because we could all be curing the difficult cases rather than referring them for suppressive treatment. Instead, our students are taught that this basic naturopathic medicine is not possible, not acceptable, not valid, and not scientific.
The assumptions of “scientific” and “unscientific,” also require some examination. The scientific method is simple, and contains four elements: the statement of a problem, the formulation of a testable hypothesis, the testing of the hypothesis, and the observations or conclusions derived from the testing. For the most part, journals are the common forum for the presentation of such observations. What I presented was a theory, based upon my observations and tested in my practice for nearly 20 years. I presented it as a model of process, and ended my article with the statement that I thought this was testable. My concern is not to rebut Dr. Longevin’s criticism. I am concerned, though, about this profession and its future. I believe that we are in a process of abandoning our foundational truths for the sake of compatibility with standard medicine, insurance payers, and HMO’s. If we do so, we lose the power and richness of our medicine. It was to my colleagues that I wrote an article regarding the workings of our medicine, to stimulate thought and criticism of the ideas I presented. I put forth what I think of as a unifying theory of how our medicine works, which organizes our therapeutics upon the natural processes of healing. I wrote it not to convince medical doctors that we are valid or scientific, but to inform my colleagues and stimulate dialogue around the subject. My article was for naturopathic physicians, who, it seems to me, are increasingly taught that we are a kind of sub-branch of conventional medicine, “complementary,” secondary and supportive.
I recently received a letter from a third year student at National College who was concerned that she was being instructed to treat “serious infections,” such as strep, with antibiotics. Many of us have demonstrated that we can effectively and efficiently treat strep without the suppressive effect of antibiotics, by eliminating the susceptibility in the host and stimulating the immune function. But our students are being taught to see themselves as somehow a kind of “junior” medical doctor, someone who uses gentle treatments in minor illness, but who must transfer seriously ill patients to the “real” doctors, the MD’s; they are becoming naturopathic physicians who don’t know how to treat infections without antibiotics. Ironically, one of the real values we have to offer the world is that we know how to successfully treat antibiotic-resistant infections.
Let me cite the case of an eight-year-old girl whose mother brought her in with chronic strep infections. She had been off and on antibiotics for several years, and was about to go on a maintenance antibiotic due to these infections. Coincidentally, she had retinitis pigmentosa. I recommended specific dietary changes, and instituted hydrotherapy treatments. The chronic strep ceased: she did not need antibiotics. And her eyes began to improve. She could see at night again. I have followed her case for a year and a half, and her eyes function normally now. My explanation involves the reduction of toxemia through improved digestive efficiency. I cannot prove that toxemia had anything to do with the retinitis pigmentosa, though this is testable. But this is the second case of RP I have seen, and both responded with cessation of the degeneration and continuing improvement, following the application of this basic naturopathic approach.
It is this example that I find my greatest concern for our profession. I see my younger colleagues abandoning our historical methodology for that which is “approved” by conventional science. I see some of our institutional instructors teaching that we can not treat strep except with antibiotics, or cancer except by conventional methods, and that we must refer “serious” cases. The girl with retinits pigmentosa has no hope. She is discarded, sacrificed on the altar of acceptability, so we can appear credible to medical doctors. The truth is that our methodologies are extremely effective and powerful, if our doctors know how to use them. Unfortunately, many do not, they are not well taught, some of our teachers do not believe in them, and the result is obvious.
I am not writing for medical doctors. We fundamentally differ in our underlying assumptions about health and disease, and I have never seen a medical doctor change her mind about our methods and theories by any citation of science. The science was available in the 1950’s regarding toxemia, well established in the 1970’s, and even in the Merck Manual in the 1990’s (albeit in a limited way). It is ignored not because it is unscientific, but because it does not fit the dogma of modern, American medicine. My concern in writing my article was to add a little to help preserve and strengthen this profession, to stimulate thought and maybe even research. I do not give a damn whether the “scientific” medical community agrees with our methods or not. My concern is for the sick people who come into my office, most of them walking away from the failures of standard “scientific” medicine. I am concerned about the tendency I am increasingly seeing in this profession to abandon our traditions because they are not acceptable to Dr. Longevin.
Jared L. Zeff, ND