Monique Aucoin,1 BMSc, ND, Matthew J. Leach,2 PhD, and Kieran Cooley3 BSc, ND
Dear CAND Journal Editor and author of “Comment on ‘Evidence-based practice attitudes, skills, and usage among Canadian Naturopathic Doctors: A summary of the evidence and directions for the future,’”
Thank you for your Letter to the Editor1 in response to our recent article “Evidence-Based Practice Attitudes, Skills, and Usage Among Canadian Naturopathic Doctors: A Summary of the Evidence and Directions for the Future.” We are pleased that our article has sparked further discussion on the topic of evidence-based practice/medicine (EBP/EBM) in the Canadian naturopathic community.
We were surprised that the reader felt the article had somehow suggested that “Naturopaths” engage with EBP/EBM less frequently than medical doctors. Our article simply highlighted that Naturopathic Medicine has been criticized for being in opposition to EBP from many outside the profession, from the media, and occasionally from members within the profession. We further added that this criticism is not fully substantiated. In fact, our article focussed heavily on the findings from our recent survey, which suggested that Canadian Naturopathic Doctors’ (NDs’) self-reported use of EBP was moderately high and that the sources of evidence used were consistent with the framework of EBP. In addition, when these findings were compared with assessments of other professions, the levels of EBP engagement reported by Canadian NDs was higher than levels reported by chiropractors, osteopaths, herbalists, and yoga instructors.1 Your statement does highlight a gap in knowledge regarding direct comparisons between different professions on attitudes, skills, use, or even approach to EBP/EBM.
Of course, as with all clinical skills, opportunities should be provided to enable clinicians to refine and optimize those skills. Accordingly, our team is currently delivering a continuing education course to support EBP engagement among Canadian NDs. This course was co-designed with 22 Canadian NDs to ensure the interests, needs, and preferences of the profession were taken into consideration. We acknowledge that the reader may have inferred that by offering this course, we were in some way suggesting that Canadian NDs were using EBP inadequately or that there is a need to increase EBP use among Canadian NDs. This was certainly not the case. In fact, 93% of Canadian NDs responding to our recent survey expressed an interest in improving their EBP skills,2 and our course is largely a response to this call.
While the roots of EBP originate in the medical world, we do not believe that EBP is incompatible with naturopathic practice, nor that it is in absolute discord with a vitalistic world view3 or the scientific world view that comes across in Flexner’s words. We believe that it is possible to take the beneficial aspects of EBP to improve the patient experience, such as continually reassessing current practices and striving for clinical improvement. While an over-reliance on scientific evidence could potentially result in care that is inconsistent with naturopathic philosophy, it is not necessarily predetermined. In fact, we are convinced that it is indeed possible to incorporate the best available scientific evidence with other sources of evidence in a way that is consistent with naturopathic philosophy and principles. We also acknowledge that attention to this balance, and acumen in finding congruence between the knowledge, experience, and needs of patient and clinician alongside evidence from research is critical. So much so that this very issue is explicitly addressed in our EBP course. Evidence-based medicine should not be conflated or confused with a reliance on (imperfect) randomized controlled trials for health-care decisions4,5 where issues of individualization, cultural appropriateness, or evidence on pharmaceutical-style interventions might dominate the literature or attention of health-care providers.
As a final point, the reader referred to a statement in our article about the need to increase skills in identifying bias. While the authors are confident that NDs are skilled in this area, we suggest there are always opportunities for refreshing, updating, or improving, as with all skills and continuing education. Although we are speculating, due to training and experience, many NDs may be aware of some sources of bias inherent in research designs (e.g., expectation, sampling), personal biases (e.g., recency or familiarity), or other biases that may influence clinical or research evidence, such as conflict of interest or industry involvement (which is what we believe the reader was referring to); they may not be as familiar with biases such as residual confounding, attrition bias, or reporting bias, which require a higher level of research literacy. It is these technical sources of bias that we were suggesting NDs could benefit from learning more about.
We genuinely appreciate the reader taking the time to respond to our article and engage in a conversation about the role of EBP in Naturopathic Medicine. We hope that other readers will also reflect on the role of evidence in this field and join in the conversation.
Warm regards,
Monique Aucoin, Matthew Leach, and Kieran Cooley
1 Canadian College of Naturopathic Medicine, Canada
2 Southern Cross University, Australia
3 Canadian College of Naturopathic Medicine, Canada; University Technology, Sydney, Australia; National Centre for Naturopathic Medicine at Southern Cross University, Australia; Pacific College of Health and Science, USA.
Not applicable.
We have read and understood the CAND Journal’s policy on conflicts of interest disclosure and declare the following interests: MA, KC, and ML are involved in the creation and delivery of continuing education on EBP skills for Naturopathic Doctors that may involve direct or indirect personal benefit.
This research did not receive any funding.
1. Welder G. Comment on “Evidence-based practice attitudes, skills, and usage among Canadian Naturopathic Doctors: A summary of the evidence and directions for the future.” CANDJ. 2021;28(4):14–15. https://doi.org/10.54434/candj.101
2. Leach M, Aucoin M, Cooley K. A national cross-sectional survey of Canadian naturopathic physician doctors’ engagement, preparedness and perceptions of evidence-based practice. Submitted to PLOS One. 2021.
3. Coulter I, Snider P, Neil A. Vitalism—A worldview revisited: A critique of vitalism and its implications for integrative medicine. Integr Med (Encinitas). 2019;18(3):60–73.
4. Nichol AD, Bailey M, Cooper DJ, POLAR, EPO Investigators. Challenging issues in randomised controlled trials. Injury. 2010;41 Suppl 1:S20–3.
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5. Frieden TR. Evidence for health decision making—beyond randomized, controlled trials. N Engl J Med. 2017;377(5):465–75.
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Correspondence to: Monique Aucoin, 1255 Sheppard Ave. E., Toronto, ON M2K 1E2, Canada. E-mail: maucoin@ccnm.edu
To cite: Aucoin M, Leach MJ, Cooley K. Reply to “Comment on ‘Evidence-based practice attitudes, skills, and usage among Canadian Naturopathic Doctors: A summary of the evidence and directions for the future.’ ” CAND Journal. 2021;28(4):16-17. https://doi.org/10.54434/candj.102
Received: 15 November 2021; Accepted: 15 November 2021; Published: 15 December 2021
© 2021 Canadian Association of Naturopathic Doctors. For permissions, please contact candj@cand.ca.
CAND Journal | Volume 28, No. 4, December 2021