Your Comments: Engel, Wilson, Traub and May on ND Incomes and the AANMC Survey

Summary: The Integrator article on the publication of an income survey by the Association of Accredited Naturopathic Medical Colleges provoked one round of responses, which now fuels another. Christy Lee Engel, ND, LAc,  comments on sustainability, poverty mentality and whether it's okay for a doctor to (merely) be middle class ... Michael Traub, ND answers a query about the percentage of income due to natural pharmacy sales ... Kevin Wilson, ND, compares pressures on new doctors with high debt to the way he grew his successful practice ... Bob May, ND, wonders whether the NDs would be better off promoting forms of payment which are more aligned with their philosophy than the typical 3rd party payment ...

1.   Sustainability, Poverty Mentality, Right Livelihood, "Enoughness" and the Role of Women

Christy Lee Engel, ND, LAc

Christy Lee-Engel, ND, LAc will be known to close readers of the Integrator as an insightful commentarist on integrative clinics - gained through her own hard-won wisdom - and a fine memorial note to her mentor William Mitchell, ND in January.

"I thought Bob May's [ND] comments about ND salary, the insanity  - well, that's what I call it, I think Bob said 'unsustainability' - of the high debt load that recent grads have, and his questions about the strategy of trying to join a dysfunctional system that other people are flocking to leave were right-on -- I'm very glad that he's on the WANP [Washington Association of Naturopathic Physicians] board.

"I also thought that the comments of Holistic Primary Care editor [Erik Goldman] comments about making a grown-up salary were interesting and provocative -- makes me think about 'enoughness' vs 'poverty mentality.' I never got into natural healthcare to be in a high income bracket (good thing, eh?) but to be of service and to create 'right livelihood.' So, 'middle-class' feels quite rich enough to me, and in fact I often think about how important it will be/is for all of us in this part of the income strata and above to figure out how to live well on less in order to share better with the other 99% of the world.

"Today I've also been thinking some more about the basic fact that most naturopathic physicians are women, which [Goldman] mentioned. I am reminded of the way you point out the reemergence of feminine/matriarchal energy that is one of the underlying dynamics of the profession. [See Integrator article here.]  I don't know about the other natural health professions; acupuncture school for example seemed to have more of a gender balance but it sure looks like the massage profession is mostly women. I think this fundamental aspect is much more important than the superficial acknowledgment we tend to give it, but I'm not clear yet how it's important, how we should be tapping that particular energy in the most beneficial way, how we could be using and amplifying its power to affect the systems (academia, healthcare, etc) that we've been trying to shoehorn ourselves into...

"Oh, one more thought -- from my perspective, most of the ND's I know who make lots of money do have very busy dispensaries -- seems like maybe 50% or more of their revenues --"

Christy Lee Engel, ND, LAc
Seattle, Washington
One Sky Wellness Associates

2.   The Percentage of Income from Product Sales

Michael Traub, ND, DHANP

The AANMC survey noted that one contributor to incomes in high yielding naturopathic medical practices is the sale of natural products. Engel mentions the topic. And former American Association of Naturopathic Physicians president  Michael Traub, ND, a participant in the initial forum weighs in with a perspective.

"Nice commentary.  I feel honored to be part of this esteemed group. 

"I agree with Eric that it would be instructive to see what percent of income comes from product sales.  For me, it's about 40% of my gross (used to be about 55% until I increased my office fees substantially).  Since products are usually sold for twice their wholesale cost, that would represent about 20% of my net income now."

Michael Traub, ND, DHANP
Kailua-Kona, Hawaii

Kevin Wilson, ND

Kevin Wilson, ND was last heard from here as a part of a forum on the impact of insurance coverage on naturopathic practice. Wilson has held numerous state and national leadership roles with his profession. The picture is off my own camera, from a campground near Mt. Adams. It is an honest friend who begrudgingly admits to liking to read one's newsletter ...

"Hi again, John. I am actually getting to look forward to your newsletter.

"I believe that many of us older ND's didn't respond just as Michael Traub suggested, we are too busy! I know that a fair number of us make more money than $80 K but frankly the question is of low priority to me. I do, however,  think it is an important question on several levels, many of which have been mentioned in the various comments. Of especial importance are the issues of professional and personal survivability. Can any one ND make it financially and does it make student loans really worth the effort? Can the profession continue to repopulate itself if the attrition from age and fiscal fatigue drive our numbers down?  Are the schools worth it and are they instilling the "confidence factor" in their graduates?

"Erik Goldman brings up a very interesting point about hours worked in a week. I don't know any ND's who see patients 40 hours a week. Many don't have the patients to fill that time, at least at first. Some have unrealistic ideas about what they should make and others take their medicine to heart and try to live a balanced lifestyle that works in the long run but may not in the short term particularly for the new doc on the block. Practicing naturopathic medicine does seem to take more psychic energy and time that cuts into profit making. Embracing managed care has the allure of more patients but takes a bite out of the income. Cash only practice is more directly remunerative but takes longer to build that patient base. I think that the schools or us old timers need to express to our new colleagues that diferent phases of one's career require different strategies.

"I know that I will sound like some old codger but I have found that some of the new docs that have studied with me are unrealistically impatient about their practice. It takes years in a community to build a practice, to generate the interest and trust in you personally. Perhaps, this is an essential error in our thinking, we are family based medicine but we are trying to make it in a managed care type of atmosphere. I may not be expressing this correctly but I do know that my practice took a long time to start but now it rolls on of its own momentum. Fortunately, I was not so terribly burdened by the current student loans so I had a little more leeway. So, I do understand the impatience and immediate need for serious income but that isn't in sync with how a good naturopathic practice gets established generally speaking.

"I could say that I did it right but I mostly feel lucky and I know that at first I worked all the time, was available as much as humanly possible and sat in the office waiting for any calls or people to fall in the door, seemingly forever some weeks. But all told, it has paid off. I want to be encouraging because this is good work and I want the medicine to thrive along with my newer colleagues. Patience and hard work does pay off eventually. This is not to lower our expectations but to possibly put naturopathic medicine back into a context that fits it rather than fitting it into a broken context. Thanks for your work, John."

Kevin Wilson, ND
Beaverton, Oregon

Bob May, ND

The income discussion prompts Bob May, ND a consultant and former executive with a complementary and alternative medicine managed care firm, to begin to explore what the questions might be which would guide NDs toward a practice model which is more aligned with their principles.

"I agree that the bulk of the 81% have dropped out – and, I think it raises questions about the long term viability of the profession.  As does the need for mandates like ECOP [Every Category of Provider*], in Washington, which most CAM providers feel is so essential to defend.  Is ECOP really necessary for naturopathy to survive, or does naturopathy need to distinguish itself from mainstream care so that ECOP isn’t necessary? 43 million Americans supposedly choose alternative care and pay out of pocket. What are they looking for and what do NDs and other CAM professions have to offer?

"In particular, I’d like to see NDs define the terms of what the best care model is – rather than be defined by insurance mandates and CPT codes. Didn’t the Eisenberg studies identify a number of the factors that prompt consumers to spend so much on alternative care?  One of those, I know, was 'time' - time with the practitioner, a variable that mainstream medicine doesn’t even acknowledge. What are the other factors that address the real wants/needs of the consumers? 

"Creating a practice model that addresses those priorities might assist NDs, and other CAM professions, in being financially successful in greater numbers.  But, in my opinion, the duration of office visits is crucial, and not included in CPT definitions – and this is also the area of greatest frustration for NDs.   For the majority of care, office visits need to be an hour, or half hour at least, during which the patient gets whatever the ND has to offer.  For instance, don’t segregate physical medicine from consultations – that is not how naturopathic medicine was traditionally practiced, and that is specifically what is being lost with integration - along with the healing effect of counseling and ND/patient relationship that is not included in the CPT system.  

"How much would an hour of naturopathic physician time need to be worth for an ND to make a good living and still draw cash paying patients?  What if there was a code for holistic practice that allowed NDs to do all the eclectic mix of things they are trained to really do without having to fit the current allopathic definitions of care?  It certainly sounds like the CPT system needs to be changed, but that is like turning an ocean liner.  Can naturopathic medicine maintain its integrity until the ship begins to turn? I think the profession needs to seriously engage these questions.

"Thanks for the forum."

Bob May, ND
Seattle, Washington

* The every category of provider law (ECOP) was passed in Washington State in 1995 and required all plans in the state to include every category of provider.