OSCE time of year again

I would not ever want to be in the third year's shoes during the OSCE's (Objective Structured Clinical Examination).  I can clearly remember my experience last year and seeing the faces of some of the people after their exams, I feel their pain!  (My post last year stated that it was almost fun, but even after a year of seeing patients, it would take a lot of adrenalin for it to feel fun). 

One of my colleagues in 4th year took it upon herself to organize several mock OSCE's, which we nicknamed the "Moski's", in order to better prepare students for this important test.  Now, even the 2nd years do an OSCE that tests their physical and clinical diagnosis skills before they enter 3rd year.  I was happy to teach at each event and was impressed with the level of confidence some people have developed.

The OSCE's ensure a standard of safety in Primary Care and as stressful as it is having your every word and move scrutinized, they are a necessity in order to make ND's the best primary care doctors they can be.

The naturopathic Godfather

Today I met the Godfather of postmodern naturopathic medicine.  Dr. Joseph Pizzorno is an elder in the naturopathic community who graduated in the mid 1970's when there was only one naturopathic school in North America.  According to him, CAM is popular culture now in comparison to the persecution it suffered when he first started practicing.  He is currently the president of Bastyr University and also the author of the Textbook of Natural Medicine. 

So today, Dr. Pizzorno gave a presentation to CCNM students and staff about intestinal permeability.  As I am not a particular fan of this textbook, I was undecided on whether to attend.  However, who can miss the chance to see someone with such a reputation!  And, I have to say that the lecture was very educational and, as to be expected from someone with his number of white hairs, some controversial statements were made that only many years of experience could allow him to say.

Maybe the gray hairs creeping up on my head will help me after all!!

Continual Improvement

The format of the 4^th year internship at CCNM gives the interns more patient interaction compared to some of the other naturopathic medical schools (where the supervising ND does the initial patient intake and the interns only do follow-up visits or work in pairs instead of alone).  Although the supervisor does make an appearance during the visit at CCNM, is available for consultation and is ultimately responsible for the patient, there is still a lot of responsibility on the intern to gather the correct information to guide treatment.  As such, I remember the anxiety walking into that very first visit.  It actually took several months for that apprehension to turn into excitement to see a new patient.

New changes at CCNM are following the format other schools have done to progressively integrate students into clinical patient experience.  This experience will help the intern build the confidence required to be ready for that first and subsequent patients.  Already, the 1^st years have been doing an observation shift and the 2^nd years sit in on patient visits and have the opportunity take patient vitals.  Starting in January, the 3^rd years, under the direction of the 4^th year intern, will have the opportunity to perform physical exams, and help with diagnosis and treatment plans. Although the CCNM academic team met some resistance from the 4^th years in terms of our extra roles and extra responsibilities as mentors, I think the change will ultimately benefit CCNM graduates.  Additionally, the patient gets the benefit of a team approach to their health concerns. 

Peer mentorship, at the student level, is not well developed at any medical school yet but is an upcoming area of improvement in medical education.  Doctor as teacher is one of my favourite naturopathic principles and I believe is exemplified at CCNM in these new changes.

Maintaining Mentorship

Most highly skilled professions have some framework of mentorship set in place to ensure that things which are not easily picked up in the classroom, or from reading a book, are taught in a practical setting. Naturopathic Medicine is no different. Mentorship maintained naturopathic medicine in the United States in the years following the 1910 Flexner Report when naturopathic schools could not afford to operate (the Flexner Report also shut down many "diploma mills" and substandard medical schools which was a positive outcome. Unfortunately though, the recommendations were to only fund schools with a pharmacological and technological focus).

Mentorship at CCNM begins in 1st year as new students are introduced to the teaching clinic with days spent shadowing their supervisor. Second and third year students get more involved with patients each year as clinical supervisors and 4th year interns take mentoring roles. There are certainly times where patients are surprised at the additional students that come into the treatment room and occasionally, the 4th year intern is inadvertently put in the hot-seat with all eyes on her or him. At these times, there is the potential for everyone involved to share an awkward moment.

My love for teaching and background in instructing usually dissolves my concerns about others watching me in clinic. Additionally, I recognize that I am not perfect at this yet and I may say the wrong thing or make a small mistake with someone else watching. However, as the mentor, it can still be an additional source of stress.

I wonder if this change in dynamic is currently making it very difficult for some students to fulfill another type of required mentorship called preceptorship. This is where students spend time with a ND, DC, MD or physiotherapist in their private practice (or hospital). If you are currently a student in naturopathic medicine, here are a few points to consider when being mentored:

1. Firstly, if at all possible, pick a mentor who's style of practice you like. This is very important for preceptoring and will eliminate many unforeseen disharmonies and make for a much more enjoyable day.
2. Recognize your mentor's strengths. Certainly there are times when you may learn how NOT to practice but try to glean the best of what the mentor is offering.
3. Show appreciation. This is so important in order to successfully continue a constructive and receptive attitude towards mentorship and maintain the philosophy of passing down knowledge to the betterment of the profession.

Residency is another type of mentorship offered to naturopathic graduates and I hope to write about this at a later date.

Thorough Competency

Over the last three years of writing this blog and speaking with potential students, I have had many people express their fears about the unknown journey into naturopathic medicine. How difficult is the program? Since you learn so many things, is it possible to be effective at anything? Is it really harder than conventional medical school? Do you learn enough science? Is the art of medicine still taught?

I understand where these questions stem from as I certainly had many of them before entering the program. Although there is absolutely no substitute for experience, and everyone’s experience is different, one of my supervisors recently showed us five categories of competencies expected from naturopathic doctors by the American Association of Accredited Naturopathic Medical Colleges (AANMC). I found it interesting to see AANMC sum up everything we do into 5 areas and I thought I would share them with you.

Here is the Professional Competency Profile of a Naturopathic Doctor:

1. Naturopathic Medical Expert

• Integrate naturopathic philosophy, theory and principles with naturopathic medical knowledge in the care of patients and case management including the assessment, diagnostic and treatment phases.

• Develop, maintain and value a comprehensive knowledge base in naturopathic medicine.

• Conduct an assessment to formulate a naturopathic medical diagnosis.

• Effectively provide and manage patient care.

2. Naturopathic Manager

• Develop and maintain relationships in practice and the community consistent with the philosophy and principles of naturopathic medicine.

• Establish, develop and manage a practice.

• Exhibit strong personal management skills.

3. Naturopathic Professional

• Utilize knowledge of naturopathic history, principles and philosophy to guide professional engagement and development.

• Demonstrate ethics and integrity in professional practice and personal conduct.

• Serve the public through ethical practice, health promotion and disease prevention.

• Ensure professional competence through ongoing self-assessment and professional development.

4. Naturopathic Health Scholar

• Exemplify the principle of doctor as teacher in every patient and public interaction.

• Maintain and enhance professional competence through ongoing learning activities.

• Critically evaluate medical information.

• Educate patients, colleagues, other health-care providers and the public.

• Advance the practice of naturopathic medicine through the development, critical assessment and dissemination of research and information.

5. Naturopathic Health Advocate

• Promote the principles and philosophy of naturopathic medicine in advocating for sustainable, healthy environments and lifestyles for patients and society.

• Reflect a knowledge base that enables effective health advocacy.

• Influence others in accepting naturopathic medicine as an essential element in health promotion and disease prevention.

New Beginnings

As I came in to the school this week I saw a sea of new faces excitedly awaiting their journey in naturopathic medical school. CCNM is now set to graduate the most students per year of all the accredited naturopathic colleges in North America. I clearly remember how exciting that first month of school was and how it was such a paradigm shift for many people depending on their background. Very soon though, it becomes a lot of stress and an unbelievable amount of work. Even with the added responsibility that comes with treating patients as an intern, I would not trade those 1st year students places for anything!

As the summer comes to a close, it is easy for me to nostalgically look backwards instead of looking forward to the new beginnings I have too. For me, this is the last September I will ever be in school as next year my wife and I will be busy preparing to set up our practice. Also, next Monday the 4th year interns begin a series of new classes (ethics/jurisprudence, practice management, in office procedures) that prepare us to write our final board exams and ultimately for practice. More importantly, the fall brings many new patients to the clinic who either felt better through the warm, sunny months or obligations and distractions delayed them from addressing their health concerns until now.

Schooled by an MD!

I recently watched a debate on the effectiveness, safety and merits of complementary medicine. The panel included a medical doctor and a scientific sceptic on the con side, and two naturopathic doctors for the pro side. It was apparent to me early into the debate that the conventional medical community has a serious lack of understanding of what ND's actually do. ND's know what MD's do, and for the most part are familiar with the conventional medical school of thought, but so much of the time MD's really misunderstand what naturopathic doctors do.

There are some explanations for this. Certainly, there are some naturopathic doctors who muddy the waters and represent the profession in a way not typical of the profession as a whole. But, what makes naturopathic medicine most complicated is that the scope of practice is so large that some ND's may have an entirely talk-therapy based practice and on the other end of the extreme, some ND's may do primarily a sports medicine based practice.

One interesting point made by one of the naturopathic doctors was that, currently (because of the relatively few ND's by comparison), the largest population of doctors that practice natural medicines and therapies are actually medical doctors. This hit home when Dr. Lawrence Palevsky, MD came up from New York and gave a guest lecture on Pediatrics at CCNM earlier this week. It was fascinating to hear his perspective on the antecedents to conventional medical thought and its methodology for the treatment of childhood diseases. It was almost shocking to hear a Medical Doctor use every naturopathic tactic possible to avoid prescriptions of antibiotics, acetaminophen (Tylenol) and even present an informed choice on vaccines. I was reminded of the necessity of childhood fevers and shown, in tremendous detail, the great harm in handing out fever suppressing drugs like candy - and I learned this from a medical doctor! There is hope for much more integration of conventional and naturopathic medicine in the near future.

A New Leaf

Today we completed the first of two days of clinic orientation. While biking to school this morning, the routine was so familiar, and our final exam marathon still so fresh in my mind, that I did not feel ready to be back at school. However, after the morning introductions, I realized that although the setting was the same, everything was different now. We are not only students, we are now health care providers. In fact, we were informed that 44% of the patients that visit the clinic here at CCNM reported that their ND intern was their primary health care provider. What a phenomenal responsibility!

We are turing over a brand new leaf in our journey. I understand that we are forever students and our next step is a 12 month long internship with 1035 clinical hours, case management documents, competency checks, more assignments, and still a few required classes. Even so, our focus has now shifted from excelling in class and passing exams to getting people to feel better. And, they do! We were shown some encouraging data that CCNM is accumulating, which reinforces what we all have known to be true: naturopathic medicine helps many people.

Calm before the final storm

There is only a week and a half to go before the final exams of 3rd year. This will be the last set of final exams we will write. Sure, after graduation next year there will be licensing exams and provincial exams, which may be very difficult, but this is a huge mile stone. Beginning on April 19, our grand finale is 11 exams in 9 days.

I'm hoping to begin to live more of a balanced life once clinic starts in May. These past 3 years have been a tremendous sacrifice for my family and sadly my health to some degree as exercise was too often put low on the priority list. I really do understand now that becoming a ND is a calling and not just a profession.

Recently, I was talking with a prospective student who was debating between conventional medical school and naturopathic medicine. She told me her opinion of the strengths of each but explained that she had heard that naturopathic medical training was more difficult than conventional because of the additional types of medicine we learn. As such, she was concerned about the intensity of the program. Although I am unable to directly compare from personal experience, I can be fairly certain that if a person believes naturopathic medicine will be easier than conventional medicine, they may take a serious blow to their perceived academic ability. This is why I believe the "calling" has kept me going. If it was "just a profession" I would have stuck to my day job!

TCM and Acupuncture Progress

As would be expected before entry into clinic, completing 3rd year means completing quite a few practical exams. Still remaining is our emergency medicine practical, in-office procedures practical, manipulation (chiropractic) practical, and the one that I am studying daily for, the Asian medicine acupuncture practical.

I did not know until recently that not all the accredited Naturopathy schools offer Traditional Chinese Medicine (TCM) and Acupuncture as part of the curriculum. Well, CCNM has a very intensive TCM and acupuncture program. Just to give you an indication, here is how the final exam will happen. First, we are presented with a case and need to determine a correct TCM diagnosis based on symptoms as well as pulse and tongue diagnosis. Then, we are required to select points that correspond appropriately to the case. We are required to know the actions and indications for about 225 of the approximately 400 total acupuncture points we have learned. Finally, we are required to locate and correctly needle 5 indicated points (within half a fingernail width of their specific location on the body) all within a 15 minute time frame. I would have never thought this was possible when I started in first year!

OSCE Follow-up

What an experience! If it wasn't for the nearly crippling anticipatory anxiety, I could almost say it was fun - the kind of exhilaration that happens during an important performance. Being sequestered in a meeting room for an hour, in a group of nine, prior to the official start of the exams did not help. However, I heard many other groups used much better coping tactics than mine did and they were able to laugh off some of the tension. I will never forget the walk down the stairs to the clinic. Our group walked in silence and I felt like I was in the movie Gladiator right at the scene where they were waiting to get rushed out into the Colosseum.

However, once I entered the first room and began talking to the patient, things began to flow more naturally. All the hours of preparation and studying pathologies, redflags for life threatening conditions and physical exams was integrated into somewhat of a smooth patient experience.

The OSCE's at CCNM consist of 3 patient visits that are each 18 minutes long. Then following each case we have 5 minutes to write up how the case would be appropriately managed and answer questions on our understanding of the patient's condition. Although 18 minutes is certainly not enough time to investigate the root cause of many diseases, it is sufficient time to rule out whether the patient has an emergency situation. As the first principle in our oath is, "First do no harm," having the ability to quickly evaluate the severity of a patient's symptoms and provide a medical diagnosis (Primary Care responsibility) and management plan is essential to every ND's training.

OSCE Time

Next week, the third year class will undergo the Objective Structured Clinical Examinations (OSCE). Passing the OSCE's are another one of those checks we require before entering into clinic in May...a really, really big check!

These exams were implemented 3 years ago as part of the continued progress towards ensuring ND's are ready for the field of being a Primary Care Doctor. The exams are the summation of all of our Primary Care knowledge up to this point and also tests our ability to clearly and effectively interact with patients. Although I am certainly under a lot of pressure right now, I can say that I'm proud that Primary Care is taken so seriously.

More on this topic after I pass!

The Learning Curve

As most of my colleagues in 3rd year at CCNM will be simultaneously pounding out the last details of their Relevant Clinical Inquiry Assignment (RCIA) due tomorrow morning, I have paused for a moment to reflect on the journey. Maybe I'm pacing myself, or still recovering from burn-out, but I just needed to take a moment and see the forest through the trees.

At this point in 3rd year, the focus is about checking off mandatory requirements before clinic in May. Number of clinic observation hours complete- check; number of patients - check; case management file - check; preceptorship hours - check; Gynecological practical exam - check; Male Genitourinary and DRE exams - check; RCIA - check. Check, check, check...It took a lot of planning ahead and coordination to get those checks while still managing to study and go to classes and I have certainly gained a tremendous amount of experience in the process.

Looking back, last year I needed to believe that 3rd year would be easier. Now it wasn't really easier, especially this final semester, but the learning curve was different. When I talk to my second year colleagues, I realize that the learning curve in second year is the steepest and sets a high standard of work ethic that just makes third year more manageable. Third year fills in the details and is the clinically relevant stepping stone that is required before we begin our internship in May. It is more practical and if I can relax enough to admit it, it is more fun! And, on that note, I have school work to get back to.

Beyond Compartmentalization

This semester has the largest spectrum of health philosophies I have encountered yet as a CCNM student. On the one hand, we have courses that teach scientific best practices and algorithms like Emergency Medicine, Primary Care, Radiology and Phlebotomy, and on the other there is the "energetics" of Homeopathy and Traditional Chinese Medicine. It is enough to make anybody's head spin!

Although one way to deal with this disparity is to compartmentalize the information and put up walls between the modalities, I find that selecting and assimilating a patient centered approach from what works from each modality is ideal - best practices first of course. For example, the most important skill I have learned from homeopathic medicine is the art of interviewing. Hands down, there is no better or more thoroughly investigative interview process than in homeopathy. The techniques are so involved that many critics credit the process to the cases of success.

This is a situation that is most likely unique to naturopathic medical school and I believe it will ultimately give ND's a corresponding unique approach to health care.

Need an Adjustment?

Before beginning university, and before I knew about naturopathic doctors, I originally considered becoming a chiropractor. As I had several sport injuries, I was the patient of quite a few chiropractors across Canada.

This year's manipulation classes finally allow us to complete the final thrust involved in performing a spinal adjustment (or any other joint). Until now we have set the foundation and framework in place by learning: anatomy, physical medicine, orthopedic tests and motion palpations, observed manipulations but did not get to perform the actual adjustment on each other.

The teaching assistant for my practical group sessions is a chiropractic doctor and she busted the myth that it takes a strong male to have good adjustments. Instead, technique is everything! I find getting that perfect adjustment is instant gratification for both practitioner and patient.

I personally know several excellent chiropractic doctors and revere them as musculoskeletal experts much in the same way that a family doctor might revere an orthopedic surgeon. In the future, any difficult musculoskeletal case that I came across, I would not hesitate to refer my patients to them.

What I like about receiving adjustments from a naturopathic doctor (in comparison to other practitioners that can adjust) is that we are well trained in the adjustments that are required for the most common musculoskeletal conditions, take ample of time with each patient, and are not limited to only one form of treatment. Metaphorically, we do not need to hammer something that instead needs a different tool.

A Learning Environment

There are occasions where I am reminded of how privileged I am to be in a learning environment where education rather than egos are encouraged. I was reading a story in a conventional medical email newsletter about how hierarchy is maintained by embarrassing (or worse) the new MD residents. Maybe it is because my school is 80% women but I have to say that I was again impressed by the atmosphere maintained during potentially awkward clinical requirements.

Earlier this week, I completed my first gynecological exam under the supervision of a practicing ND. I was politely interrupted to stop once or twice to perfect my technique and kindly given a reminder when I hesitated or forgot the next step. Maybe it is because most ND's are female that ND students are taught a very thorough, yet patient centered gynecological assessment, where each step is performed with maximal patient comfort in mind. I realize it is not neurosurgery but it is enough to remember the first time through, given the circumstances!

My point was not that we are sheltered, because where safety is concerned the standard is strictly maintained, but that we were presented with the best atmosphere, free from unnecessary attitude in which we could learn a skill.

Stone Tree Clinic

As the start of clinic is quickly approaching, and graduation is just over a year away, I am beginning to seriously plan where and how I will practice. We have been very fortunate at CCNM to be able to hear perspectives from successful naturopathic businesses. Today, Dan Clements who operates Stone Tree Clinic in Collingwood Ontario with Dr. Tara Gignac, ND spoke to our class about the business model, operations and philosophy of their clinic.

I realized the importance of being exposed to a variety of practice models which will ultimately shape what my practice will look like and how well it will serve the public. As I have already said before, I could not agree more with the idea that the profession as a whole is stronger, and we are able to help more people, when naturopaths are able to be successful in their practice. I really appreciated Dan's encouragement and acknowledgement of our skills as primary care practitioners as well as the skills he highlighted that set us apart from any other health care provider.

What was most inspiring to me was that the Stone Tree Clinic operating model allowed for a balance in life, time for family, keeping healthy and options like taking a working sabbatical in South America to bring health care to the less fortunate.

Visit, stonetreeclinic.com to see a different approach to health care.

For those interested Dan's blog specifically about practice management visit, alternativehealthpractice.com

The Business Side

I have a huge interest in the business side of naturopathy. I think that if an ND can be successful in their business then they are able to help more people, positively impact their community, pay their share of taxes to this great country and donate to the charities they like. So when our business professor invited Dr. Eli Camp to speak about building a practice, I was sure to attend. Dr. Camp (a graduate of Southwest College of Naturopathic Medicine) provided us with an overview of the extensive planning and work it takes to set up a business. She instilled that this is not something we want to try to figure out after graduation as there is so much to know about what happens on the business side of being an ND.

The course was filled with plenty of tools and tips from her business experience.

Check out Dr. Camp's business website: www.biznaturally.com

The Disappearing Male

Silicon in hair products to make our hair shine, vinyl toys for our children to chew on, phthalates to make colognes last all day, flame retardants in our pillows... the list goes on. In fact there are thousands of chemicals sold that end up inside our house and almost none of them have been tested for long-term safety.

CCNM was priveledged to have Rick Smith (who is the Executive Director of Environmental Defence and author of, Slow Death by Rubber Duck) speak on the effects of common chemicals. As he made clear, pollution is not something out there like big smoke stacks, but right inside us: we are polluted!
The Canadian Government's recent 180 turn on the hormone disruptor Bisphenol-A (BPA) is an indication that, with public pressure, changing the influence of the chemical giants is possible. Removing BPA from baby bottles is an excellent start, but the problem is much bigger. The problem is about a regulatory system that failed, about 85% of chemicals that have never been tested, and about the unknown (since it will take decades to see the effects of this toxic legacy).

The CBC documentary, The Disappearing Male, showed that baby boys are the first ones to be effected by chemical hormone disruptors. Even in adulthood, male reproductive problems can be linked to petroleum byproducts. However, consumers have great power and vote everyday with what they purchase.

Check out toxicnation.ca for information on how to go toxic free. Naturopathic doctors are very educated in this area and can work with you towards removing the pollution from your body and providing you with resourceful ways to minimize your exposure.

HBBH Business Workshop

Naturopathic Doctors (ND's) face unique business challenges after graduation including the fact that, in Canada, Naturopathic Medicine is not covered by the Provincial Government's health care system. This means that in order for ND's to do what they were trained to do, they are required to become an entrepreneur. The latest statistics show that about 20% of ND graduates do not work in the field. What is really sad is when an excellent, caring doctor has to close up their practice.

I cannot imagine trying to begin a practice without knowing what I learned this weekend (and this is only the 1st of 4 seminars). Health of Business, Business of Health (HBBH) is taught by Andre Belanger and Dr. Dickson Thom. These 2 men are very passionate about helping ND's succeed in their business and ultimately want to ensure that ND's are able to help others. Planning and preparation is key. Don't wait until you graduate to take these courses.