Integrative, Collaborative, Naturopathic Primary Care

According to the World Health Organization (WHO)¹, the fundamental concept of primary health care is that everyone has the right to good health. They define primary care as a whole-of-society approach to bring services for health and wellbeing closer to communities, with three components¹:

Integrated health services to meet people’s health needs throughout their lives
Addressing the broader determinants of health through multisectoral policy and action
Empowering individuals, families, and communities to take charge of their health

Did you know that many naturopathic doctors (NDs) work as primary care physicians (PCPs)? In fact, naturopathic doctors play a crucial role as primary care providers in supporting whole-person health and working in an integrative and collaborative fashion with other healthcare professionals. Further, they can actively reduce the current shortage of primary care providers across the U.S.

To learn more about the different settings, we sat down with three naturopathic doctors who are members of the specialty naturopathic association, the Naturopathic Academy of Primary Care Physicians (NAPCP): Dr. Hannah Gordon, ND, FNP, RN is the Assistant Medical Director at International Community Health Services where she sees patients as a naturopathic doctor. She is also co-chair of the INM Primary Care Task Force and the President of NAPCP. Dr. Ian McLogan, ND, is NAPCP’s Vice President and practices at Natural Medicine of Seattle. Dr. Logan Rost, ND, MPH, sees patients at Family Health Centers and is an NAPCP Board Member as well as the first resident physician of the INM Primary Care Task Force.

What is a Naturopathic Primary Care Physician?

Gordon wants to see naturopathic doctors better included in the category of Primary Care providers alongside all other healthcare professionals. She notes that the curriculum of naturopathic medical education perfectly positions naturopathic doctors as PCPs. And Gordon should know. In addition to being a naturopathic doctor, she is a Registered Nurse and Nurse Practitioner. She has found that, when compared to the medical education of some other healthcare professionals, naturopathic education focuses on health promotion in addition to disease management.

“For naturopathic medicine, our curriculum focuses on health promotion. We have an extensive curriculum focusing on diet, nutrient therapy, counseling, and disease prevention,” Gordon explains. “We take pharmaceutical classes, herbal classes, and we look at how the body works. We look at the cellular level, at whole-person health.” She is quick to note that all healthcare providers have a role to play in primary healthcare. To better explain the strength of incorporating naturopathic medicine into the primary care setting, Gordon observes, “Most medical curriculum excels at disease management but is often lacking in the health promotion portion of the education. While health prevention is very much included in the curriculum, it’s important to note the difference between prevention and promotion. Our healthcare system needs more health promotion educated providers.”

According to the 2022 NAPCP Primary Care Position Paper ², ND PCPs seek to:

Promote individual and community wellness
Provide patient-centered education and advocacy
Prevent illness via proper utilization of screening evaluations and immunization practices
Diagnose and treat disease
Consult, co-manage, and refer appropriately for care that is necessary to maximize patient outcomes

How Naturopathic Doctors Use Integrative, Collaborative Medicine in Different Settings

Like other healthcare professionals, naturopathic doctors work in various primary care settings, including private clinics, as part of larger systems such as Federally Qualified Health Centers (FQHCs), Community Health Centers (CHCs), and hospitals. While private clinics may see patients with more health insurance coverage or a higher income, CHCs, and FQHCs may focus on underserved populations and qualify for Medicare/Medicaid coverage. What do all these healthcare settings have in common? They all provide essential opportunities for integrative and collaborative care.

Federally Qualified Health Centers and Community Health Centers

Gordon works at the FQHC International Community Health Services in two different capacities. She is the Assistant Medical Director for one clinic in the system and sees patients as a PCP. She finds that differing state laws governing naturopathic medicine can present challenges. “In some states, the prescriptive license, rights, and insurance coverage are minimal. Medicare is a huge hang-up.” Gordon explains. “In Washington, for instance, Medicaid includes NDs, but this is not for every state.” Two other limitations in Washington state include restrictions on certain scheduled drugs (like opioid medications). Additionally, on the federal level, Medicare does not include naturopathic doctors; however, there is some coverage under Medicare Advantage B.”

Now, Gordon is seeing more naturopathic doctors being hired by CHCs and FQHCs in Washington and Oregon. While she is doing her part to explain that the health promotion skills offered by naturopathic doctors can effectively round out in-house primary care services these clinics already provide, she is also hearing about another benefit: “ND PCPs can also be integrative medicine providers,” notes Gordon, referring to their ability to use naturopathic medicine safely alongside conventional medicine. “CHCs and FQHCs need primary care providers and, with the unique combination that naturopathic doctors can provide, we can adapt to the needs of the clinic or organization.” Community Health Needs Assessments, which are required by CHCs and FQHCs, tell the system what the community needs. In Washington and Oregon, we’re hearing the need for integrative, naturopathic, herbal, and Indigenous medicine. Each organization has to decide what their patients need.”

Patients, too, are interested in integrative medicine. And this trend is reaching conventional doctors, too. “More healthcare providers are educating themselves or getting additional certificates in integrative medicine, herbal medicine, and physical medicine,” Gordon observes. “And that’s because patients want it.”

Dr. Logan Rost, ND, MPH, works at the FQHC Family Health Centers, out of their Tonasket, Bridgeport, and Brewster Medical Clinics, located in rural parts of Washington State. There, she finds many opportunities for both integrative and collaborative patient care. Other healthcare providers refer patients to her for naturopathic questions. In contrast, she refers patients to other healthcare providers with experience in a specific area or access to specific settings (such as internal medicine doctors with hospital access). “We refer patients back and forth, do consults, and care for patients together. We co-manage care. It’s been wonderful to work in an integrative, truly collaborative setting,” Rost notes.

Rost enjoys working at an FQHC; patients come to her in many different ways and with varying approaches to health. “Some patients have no idea that I’m a naturopathic physician. They come to me because I have an opening in my schedule, and they just need to see a medical provider. They don’t necessarily care what degree that provider has,” Rost explains. “But some patients have zero interest in conventional medicine and want to establish care with me as a specialty naturopathic doctor.”

Like Gordon, Rost can function as a PCP or specialty naturopathic doctor. And there is another advantage. “Because I work in a rural area, I find there is a desire for naturopathic medicine and providers who can straddle the divide between “natural” medicine and conventional medicine and speak with patients about how they want to address their health.” Often, patients are excited to learn that it’s even possible to see naturopathic doctors at FQHCs. “Especially in rural areas, it’s hard to find naturopathic doctors working in clinics that accept insurance specifically for low-income or underinsured patients.”

When it comes to collaborating with other healthcare providers, Rost finds it well worth the effort. “The point is to give our patients the best care possible to meet their needs. It’s about making them feel heard, recognized, and supported around how they want to achieve health and well-being. The goal is always just good patient care.”

Private Clinics

McLogan works at the all-ND primary care clinic, Natural Medicine of Seattle. There, he finds great opportunities to integrate naturopathic medicine with conventional medicine. “The metaphor that I like to use for integrative medicine is, it’s really hard to play jazz if you don’t know the scales,” explains McLogan. He uses established frameworks for preventative medicine, including following yearly guidelines for screening exams, lab workups, and treatments for different conditions. But then, he builds upon this framework using individualized medicine to meet patients where they are. “Oftentimes, medications are covered by insurance, and supplements are not. Supplements are often quite expensive,” McLogan explains. “I present a number of different options, including the standard of care for patients. I integrate all parts of care and take the best from everything using the framework that exists.”

He finds patients are grateful for his explanations of the treatment options for different conditions and for empowering them to decide how they want to combine these options. And while he acknowledges that his patient base may have a certain level of privilege and education that better allows them to do their medical research (and understand it), only some people want to figure it out on their own.

“I see a number of allied health professionals as patients, including nurses, firefighters, and EMTs,” says McLogan. “Certain subpopulations really appreciate knowing what the options are and having it fully explained to them.”

When collaborating with different healthcare professionals, he focuses on building relationships with specialists he trusts who have a good track record. This collaboration also provides the opportunity to educate other healthcare practitioners about naturopathic medicine.

And how does this collaborative approach benefit patients? When NDs have medical information from their other healthcare providers, that allows NDs to recommend treatments that will work alongside any current conventional therapies. But sometimes, it’s the conventional doctor’s approach that needs explaining. “Their specialist visits may be very brief and intense. I can be a resource to debrief and review these findings. Patients are really responsive when I’m as engaged in their care as possible,” McLogan notes. For him, keeping the lines of communication with other doctors open means many faxed progress reports and updates to specialists. In other words, his role as a naturopathic doctor often means both managing and interpreting patient care with their specialists.

How Naturopathic Doctors Can Help Reduce Primary Care Physician Shortages

It’s no secret there is a severe shortage of primary care physicians across the U.S. And, as the Association of American Medical Colleges (AAMC) notes, it won’t get better any time soon. The aging population will need more medical care, but many doctors will soon retire. The AAMC estimates that the U.S. could see a shortage of up to 48,000 primary care physicians by 2034.³

Although some barriers remain, ND PCPs have great potential to reduce this vital shortage⁴. “There’s a primary care shortage. We have NDs that can work in primary care. The two biggest hang-ups are the scheduled drugs and Medicare. If those two things weren’t an issue, we could get hired a lot easier,” notes Gordon. She finds herself frustrated with healthcare provider egos (in both conventional and naturopathic medicine) that result in competition, putting one type of medicine above another. Ultimately, this approach is not forward-thinking or helpful when solving this shortage crisis. All PCPs must play their part—and that includes naturopathic doctors.

“Regardless of our naturopathic degree, we can help fill gaps in patient care,” Rost adds. “We are a valuable part of the health force in providing primary care to patients.”

How Naturopathic Doctors Can Help Address Health Inequities

An essential part of reducing health inequities is addressing the social determinants of health (SDH), a concept acknowledging the influence that non-medical factors can have on health.

The WHO ⁵ notes that SDH can have a greater influence on health than health care or lifestyle choices: research suggests SDH accounts for between 30-55% of health outcomes. ⁵ They also note that SDH influences health inequities, pointing to a universal truth: across the world and at all income levels, the lower the socioeconomic position, the worse the health.⁵ The WHO provides several examples of SDH, including ⁵

Income and social protection
Education
Unemployment and job insecurity
Working life conditions
Food insecurity
Housing, basic amenities, and the environment
Early childhood development
Social inclusion and Non-discrimination
Structural conflict
Access to affordable health services of decent quality.

Regarding how naturopathic doctors working in primary care can help reduce health inequities, Gordon points to the importance of asking the right questions: “Learning more about your patients, their demographics and their determinants of health, is all part of being a primary care provider. Asking questions like, ‘Are you safe at home? Are there guns in the house?’ are key.”

This allows naturopathic doctors to recommend treatments that are possible for the patient to achieve. As Gordon notes, “A great treatment plan isn’t beneficial if the person can’t do it. Let’s say I teach you how to eat kale. But what if you don’t have kale access? Or you’re working 12-hour shifts and have three kids to feed?” asks Gordon. “That’s a stress level you can’t fix with high blood pressure meds or herbal medicine. We must include people’s daily lives in a way that also includes their health.”

Rost adds further examples of treatment recommendations from all kinds of healthcare providers that include assumptions about patients. An exercise recommendation won’t work without a safe place to move your body. Recommending more social and spiritual connections won’t work without enough time to engage in these activities.

Gordon also advocates for naturopathic doctors to get involved in the communities they serve. By volunteering in the community, naturopathic doctors learn first-hand about the barriers their patients may face. Such community involvement can also present opportunities for naturopathic doctors to collaborate with those outside the healthcare system. “We need to work with community centers, social workers, nurses, and network with care managers,” says Gordon. “We work with shelters, but we need to work with other people too.”

Regarding the potential for community advocacy, Rost notes, “When we see patterns of lack of access in communities, naturopathic doctors can become advocates. How do we change our communities’ access so people can get those determinants? These are often things that are affected by social and financial inequity and cause health disparities and inequities.”

INM Primary Care Taskforce

Since 2018, the Institute for Natural Medicine’s Primary Care Task Force⁶ has been leading the charge to improve health outcomes for underserved populations and expand the primary care workforce in Oregon and Washington State by adding naturopathic physicians. The task force promotes naturopathic physicians as one possible solution to the primary care physician shortage in the Pacific Northwest region. So far, the task force has formed partnerships with several stakeholders, including the Washington Association of Naturopathic Physicians (WANP), the Naturopathic Academy of Primary Care Physicians (NAPCP), the Northwest Regional Primary Care Association (NWRPCA), the Oregon Association of Naturopathic Physicians (OANP), Bastyr University, and the National University of Natural Medicine.

In addition to ND workforce development, the task force is also exploring creating more naturopathic primary care residency opportunities in rural areas and piloting a nutrition education program to track health outcomes for diabetes and high blood pressure.

References

1. Primary health care. World Health Organization. Accessed January 6, 2023. https://www.who.int/health-topics/primary-health-care

2. Position Papers. Naturopathic Academy of Primary Care Physicians. Accessed January 6, 2023. https://www.ndprimarycare.org/position-papers

3. Aging patients and doctors drive nation’s physician shortage. AAMC. Accessed January 6, 2023. https://www.aamc.org/news-insights/aging-patients-and-doctors-drive-nation-s-physician-shortage

4. Inclusion of Naturopaths in Northern Ontario Primary Care: A Proposed Solution for The Health Human Resources Shortage. CANDJ. Accessed January 6, 2023. https://candjournal.ca/index.php/candj/article/view/127

5. Social determinants of health. World Health Organization. Accessed January 6, 2023. https://www.who.int/health-topics/social-determinants-of-health

6. INM Primary Care Task Force. Institute for Natural Medicine. Published May 20, 2022. Accessed January 6, 2023. https://naturemed.org/community-resources/inm-primary-care-task-force/

This article is provided by the Institute for Natural Medicine, a non-profit 501(c)(3) organization. INM’s mission is to transform healthcare in America by increasing both public awareness of naturopathic medicine and access to naturopathic doctors for patients. INM believes that naturopathic medicine, with its unique principles and practices, has the potential to reverse the tide of chronic illness that overwhelms existing healthcare systems and to empower people to achieve and maintain their optimal lifelong health. INM strives to achieve this mission through the following initiatives:

Education – Reveal the unique benefits and outcomes of naturopathic medicine
Access – Connect patients to licensed naturopathic doctors
Research – Expand quality research of this complex and comprehensive system of medicine