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International Natural Medicine Research with Dr Amie Steel

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International Natural Medicine Research with Dr Amie Steel

Imagine collaborative research initiatives that are simultaneously taking place in several international locations, all of which are aimed to not just validate singular natural medicines, but are looking at the bigger picture of validating naturopathy as a system of medicine and a professional that can contribute meaningfully to the health system. Does this sound too good to be true?

Well, in today's podcast, Dr Amie Steel joins us to share that this is not just possible, but is already underway with the formation of the International Research Consortium of Naturopathic Academic Clinics, or IRCNAC. Listen as Amie shares the vision for IRCNAC, how it was formed and what kinds of research can be conducted to help bring naturopathic research into the spotlight. 

Covered in this episode

[00:44] Welcoming back Dr Amie Steel
[02:40] Founding of the International Research Consortium of Naturopathic Academic Clinics
[07:02] Translating international standards of naturopathic practice through research
[10:54] Defining the research consortium and what purpose does it serve?
[15:24] Applicability of research methodology and design to integrative medicine
[21:24] Funding and participation in IRCNAC research programs
[25:56] Why is this kind of research so important to the profession?
[29:37] What types of research methodologies can IRCNAC enable?
[37:50] What is the long term goal of this research?

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Dr. Amie Steel, who's a naturopath of over 15 years experience, with a PhD in health services research. She's been involved in naturopathy in a variety of capacities including clinical practice, industry, policy development, and research, and academic activities. 

Amie is a post-doctoral research fellow with the Australian Research Centre in Complementary and Integrative Medicine (ARCCIM) at the University of Technology Sydney. Her role is based at Endeavour College of Natural Health Brisbane, where she's also associate director of research and manages the Office of Research. Welcome back to FX Medicine, Amie, how are you? 
Amie: I'm great Andrew, how are you? 
Andrew: I'm good, thank you. Now, I didn't read your whole biography out because, my goodness, you're a busy lady. And I'm not going ask how you have time for family, but what's driven you to do this? 
Amie: I care deeply about our profession, and I am driven by the desire to better understand our profession and to put naturopathy in a position where it can confidently engage with, you know, other parts of the health systems, and other parts of the society, and come out from the shadows where it’s been, where it's been sort of situated for, you know, many generations, and really take its place in the community. So that's really what drives me. I believe that we, as a profession, have a lot to offer and there's lots of different ways that we can contribute, and we haven't yet hit our full strength with that. 
Andrew: Good on you. 
Amie: So I'm doing my bit to make that happen. 

Andrew: Good on you. Now today we're going be talking about something new with regards to research opportunities, and indeed research focus. Can you take us through exactly what this is? Because it's a bit of a, let's say, confronting acronym. 
Amie: Yes, okay. So what we've been developing or what I've built with the help of international colleagues is a research collaboration, which it's called the International Research Consortium of Naturopathic Academic Clinics. And as you said, the acronym, IRCNAC, it’s a little bit clunky, but it serves its purpose, and it means what it says.  
Andrew: It's certainly memorable. 
Amie: It's memorable, that's right. 

So the consortium itself actually grew out of the leadership program that is run through ARCCIM. So ARCCIM has as a Naturopathic Leadership Program for research, its international program, it's got 12 fellows on it. About half of them come from overseas, about half within Australia. And these are all people who are contributing meaningfully to research around the world. There's members from India, South Africa, U.S., Canada, England, and Australia all involved. It's been running for a couple of years now, and every year...I'm a peer mentor on the program, so I'm not actively a fellow in the program, but I work at helping to organise and run the session. 

Andrew: Yep. 
Amie: And the whole purpose of the actual program, of the leadership program, is to help to bring together the strength that we have in research for naturopathy internationally and cross-pollinate and work together to pool our resources and build a really strong research program for naturopathy globally. 

So what actually happened was a couple of years ago one of our research members, the fellows of the program, Dr. Joshua Goldenberg from Bastyr University, proposed a research project that he wanted to run, that he was planning on running through Bastyr University, through the Naturopathic Academic Clinical or student clinic that they have in that university. And he sort of put out to the other members of the program anyone else who wants to run the same project through their clinics, who could look at doing something like that. And Dr. Kieran Cooley from the Canadian College of Naturopathic Medicine put his hand up and said that they could do that. And I thought, well, we actually could do that through Endeavour as well. 

So we started talking about this research project idea, and very early on in the conversation, as it progressed beyond that week where we all meet over the ensuing months, was that the actual research question was on a specific health condition. But actually the methodology could be used in lots of research questions, for lots of health condition using the infrastructure within these student clinics. And that by having these across multiple sites, we'd actually add to the rigour and the representativeness of any research that was conducted. 

And so we took a step back and I proposed that we form a consortium of naturopathic academic clinics, with a memorandum of understanding, with an agreed upon mission and guiding principles that allowed more readily for colleges or educational institutions with naturopathic student clinics to link in and work together on specific research projects. 

So we put the call out, we drafted an MOU, we put the call out through the U.S, Canada, Australia, New Zealand, to all the contacts that we had and we had a real amazing support and interest. So that was kind of the birth of the consortium. And so we've now got all of the colleges who have agreed to participate involved and we have a consortium underway. 

Andrew: Okay, there's a vast difference in the model of practice from U.S. naturopathic physicians in I think it's 12 states? Might be more now. Canadian naturopathic physicians, and Australian naturopaths with regards to scope of practice, registration, and acceptability within the health care system. Does this research consortium allow you to conduct research that is applicable across the board? 
Amie: Well, it's interesting that you say that because one of the things that has come out from some of the work that's been done already for the World Naturopathic Federation, is that at least in basic principles and in core treatments being described there's not that much difference in North American and Australian practitioners. 

Andrew: Right. 

Amie: And in fact, whilst what you've just said is a commonly held belief. We actually don't know for sure that there is a lot of difference in practice. We believe that there's aspects that are quite different. In terms of, you know, in North America they tend not to prescribe individualised herbal medicines to the degree that we do in Australia, for example. They tend to use more proprietary product such as, you know, encapsulated or tabulated or even pre-formulated herbs in a bottle rather than...so there is some aspects of practice that are different.  
But actually, we don't have any firm information of the degree to which those differences are in place. And whether or not the actual prescription patterns vary that substantially. You know, I mean are they all still prescribing Hypericum perforatum  for depression even if some of them are doing it a liquid, and some of them are doing a proprietary formula tablet? You know, there is not actually any information that really confirms that commonly held belief to be true or not true. 

And so one of the things that things like the consortium will allow us to do is really look into that more closely and better answer it.  

Andrew: What about the issue of, and I say that those words again, scope of practice, with regards to, let's say, diagnosis? U.S. naturopaths are primary care physicians as are Canadian naturopaths, I think? Can they diagnose a condition and we not? 
Amie: Legally, there's nothing that can stop us from diagnosing a condition except in there's in some specific conditions of diagnosis which are limited in some states in Australia. 

Andrew: Right. 

Amie: But you can't treat someone without diagnosing them. It's just not possible. I mean the thing is what you can't do is you're not able to necessarily sign off on a medical certificate with a formal diagnosis. 
Andrew: So you can make a naturopathic diagnosis? 
Amie: Yes. Well, the thing is you can still even suspect a specific condition. Ultimately, whether or not from a naturopathic perspective, whether or not a name is given to a condition or to a person's health state or not, won't necessarily change the way that the naturopaths treats them. 

And so from our perspective, being able to treat a specific condition or people who can present with a specific diagnosis is something that's more than able to be done through the naturopath. Because it happens all the time. People with endometriosis go to a naturopath. People with diabetes go to a naturopath. So it happens, it's just the degree to which a naturopaths legally, or even trained to a degree, would be able to give that definitive diagnosis. And that varies state to state in the U.S. anyway how much that scope of practice exists.  
Andrew: Okay, right.  
Amie: So I think we overemphasise the difference and I think one of the benefits of a project such as this is it gives us the opportunity to really dig into how much crossover there is. And understand what exactly quantifies those differences, but also really qualify the similarities. 

Andrew: So what exactly is this research consortium? 
Amie: The research consortium is a partnership or a collaboration of educational organisations in four different countries, two world regions, that are prepared to work together and have research projects conducted through them. So it's an agreement in principle that is then made in decisions...case by case depending on the research project. 

So at the moment, we've got...in Australia, there's Endevour College of Natural Health, and also the combination of Southern School of Natural Therapies and Australasian College of Natural Therapies that sits underneath The Think Institute banner. Bastyr University and Southwest College of Naturopathic Medicine and National University of Natural Medicine, so they're in the U.S. And there's also the Canadian College of Naturopathic Medicine in Canada. And in New Zealand, we got Wellpark College of Natural Therapies and South Pacific College of Natural Medicine

So it's the first time ever we've actually had these bridges being built…

Andrew: Yeah.

Amie: Between naturopathic educational institutions across the world. 
Andrew: Worldwide. 
Amie: Worldwide. 

Andrew: Yeah. Was that its prime directive to, you know, dare I say reach a consensus of research across the world? 
Amie: The prime directive was to enable research to happen at an international level, and to do that as effectively as we can. 

Andrew: Right. 

Amie: And to start to build the bridges for communication and collaboration that allows for multicentre research projects to be run for naturopathy. International multicentre research projects. This is really powerful stuff. 
Andrew: Yes, that's right, so this is what we really need, building a base for evidence-based naturopathic medicine. 
Amie: Yeah, I mean naturopaths who engage with research literature will probably have seen many, many times even when a nice clinical trial was done the research will rightly say, "This is only done in one site." 

So even though it had a good outcome, it needs to be replicated in other sites, and other populations to make sure that, you know, it stands true. And the ability to actually run something in multiple sites, not just in multiple sites, but in multiple countries really brings the capacity to have some very robust outcomes and to state with more confidence how well things work. 
And some of those other questions that you brought up earlier, which allow us to look at how similar or different treatment approaches are, and those kinds of things, will also mean that even when… if we have some of that information, and as I expect there’s going to be more for similarity than difference, even though, you know, it's attempting to focus on the difference, there's going be a lot of similarities. We know that the principles and philosophies that are naturopathy are consistent. 

Andrew: Yeah.

Amie: And so it might be exactly what they choose to use, they may differ but the fact that they're treating the cause, or the fact that they're focusing on the underlying issues and those kinds of things will be consistent anyway. Will mean that even when at a later stage there might be a project that conducted in just one country, we're on much stronger ground to be able to say, "Yes, this research was done in Canada, however, we already know from historical practice that the outcomes in Canada are very similar to the outcomes in Australia." 

So we can actually have some confidence in being able to transfer those outcomes across to the Australian population, and use those in lobbying and in presenting results. You know, one of the things that came out of the recent...the NHMRC (National health and Medical Research Council) review into natural therapies for naturopathy wasn't that there was no evidence. It was that because we didn't have the consistency of education standards, because we didn't have registration, the government in Australia couldn't be confident that the results that came from North America... 
Andrew: Could be applied. 
Amie: ...were relevant to Australia. 

Andrew: Right. 

Amie: So this is a really important project for being able to answer some of those questions that not only give us the capacity to do more research into the future, but also to draw upon the research that's been done in the past in other places. 

Andrew: Two sides of the coin here. Criticism of integrative medicine research usually revolves around the terms like ‘poor design,’ ‘bias,’ ‘small cohorts.’ This is obviously going answer some of those. 

However, there's also that side of things that speaks about holistic practice. And you know, the old chestnut that I throw in every now and again about the tongue-in-cheek publication of the use of parachutes to avoid injury from gravitational challenge. You can't apply a double-blind, placebo-controlled trial on that because the people in the placebo arm would die. 

Amie: Yep. 

Andrew: So help me here, is this sort of research applicable to single or simple interventions only, or can you look at a naturopathic intervention in its breadth and beauty? 
Amie: Well, it’s actually… I would go, it’s the other way, you can't look at single interventions in this model. 
Andrew: Got you. 
Amie: And there's two very important reasons for that. One is these are all being conducted through student clinics. So by and large...well, I think there is the capacity to just use the sites of these clinics and recruit and have experienced practitioners conduct projects through those sites. And so there is the possibility of doing those kinds of simple interventions and, you know, testing out a particular drug or a particular treatment. And just working with research leads in different locations and running a multicentre trial that way. So it's absolutely possible, and it would be supported through the consortium. 

Andrew: Right. 

Amie: But the main thrust that was the underpinning mission for the consortium was to actually support examination or exploration of naturopathic care as it occurs in the community. 
Andrew: Got you. 
Amie: And so the intervention is holistic care. Is naturopathic care. There's capacity for us to kind of look into how that's being applied, and what it actually looks like, what goes into it? How much...I mean people talk about naturopathic care being holistic. We can actually have the capacity to look at well, how much is diet and lifestyle recommendations being built into naturopathic treatment plans? Or are we just prescribing bottles of stuff in a green allopathy kind of way? 

Andrew: Yeah. 

Amie: And being able to look into some of those sort of things is absolutely possible. 
But for, you know, sort of like the first project that we're running through this, a big part of it is there is no rules prescribed...no structure given to the students who are providing the care. We're just looking at what people's health is when they start and looking at their health when they complete a program of treatment. And we don't provide any restrictions whatsoever into what that treatment program might look like. And that's important because the students are primarily there to learn, and if we start just dictating to them what they can and cannot prescribe they're not going to get that learning experience out of it.  
But also naturopathy is, at its absolute heart, individualised medicine. 

Andrew: Yes. 

Amie: So if you start providing structure to what that individualisation looks like it starts to separate more and more and more from what actually occurred in community and the only way we really... 
Andrew: It becomes green allopathy. 
Amie: Exactly, so we want to be able to support research that really follows the outcomes of care as it naturally occurs. You know, the first study that we're running through this is a naturalistic observational study. It's designed specifically to just observe what happens as a result of the black box of the intervention, which is the naturopathic consultation and treatment. 
Andrew: Does it place a requirement for standardised measurements of before and after, a baseline of intervention? 
Amie: Yes. 
Andrew: Ahh. So this is something that can be reproduced, questioned, answered, you know, by those people that are skeptical or just questioning, just querying the research outcomes? 
Amie: Correct. 

Andrew: Okay, this is exciting, this is brilliant. So how does it fit into other things that are happening globally though for naturopathy? Like other countries, Europe, U.K.? 
Amie: Well, one of the things...the last five years with the onset of the World Naturopathic Federation has just transformed the landscape of naturopathy globally. Absolutely transformed. 

I know...I've email addresses, interactions, and had dinner with naturopaths, professional leaders, academic leaders, researchers in every continent, it's amazing. We have an international community of naturopaths that never existed in any meaningful way before. I know who to go to if I'm going to go to a new country and I want to go meet someone. I've sat in a general assembly of the World Naturopathic Federation with naturopaths from Slovenia and Nigeria, and it's phenomenal. It's the most exciting time to be a part of this profession, and this just sits in amongst all of that.  
We actually presented this idea to the World Naturopathic Federation at the General Assembly, and they've endorsed it and they've offered, you know, some funding support for the administration of it. They're actually making it a part of their research program. 

Andrew: Wow. 

Amie: And the World Naturopathic Federation work with the World Health Organisation, and to represent naturopathy in the global sphere. It's the larger picture of where naturopathy is going and us being able to answer some of these questions that you're talking about is just fantastic. 

But looking into being able to branch the consortium out to include India and possibly somewhere in Africa as well to kind of really bring it across into the third and fourth world region if we can. 

Andrew: Okay, so you mentioned funding before, and you've received in part something from the World Naturopathic Federation. What about, who else is funding it? Can it be called to bias? Can it be called to have issues with, you know, pecuniary interest from industry rather than profession? 
Amie: No, it's a project of passion for the three of us who have set it up. So Joshua, Kieran, and myself, we're just doing it as part of what we do basically. Kieran is, similar to myself, is director of research in the Canadian College of Naturopathic Medicine. And Joshua Goldenberg is a lead researcher from Bastyr University. So the three of us are just kind of doing it for free basically, so part of our role. 
Andrew: Passion. 

Amie: You know, passion, absolutely. And the thing is that it's something that we...I mean we will benefit from it because we'll be able to run really exciting research programs. But it's open to anyone who wants to run research through the consortium. They just have to contact and we've got an email address, which people can actually send through a request. We're setting up the infrastructure for them to do an expression of interest to say they'd like to run a project through it, and that expression of interest is going to be sent out to all of participating colleges and then those people can say, "Yes, I'm happy to be involved in that." "No, that timing is not going to work for our institution. "That topic is a bit sensitive here, we don't really think we should be a part of it." Whatever it might be, they've got the option to opt in or opt out. 

But it's just open and, you know, there's no charge to it or anything like that it's just... 
Andrew: We'll definitely be putting this information up on the FX Medicine website. So any of your listeners who are interested in doing research, please look at fxmedicine.com.au website and you can get further information there, contact with Amie and the other players in the international consortium. 

Andrew: What type of research will and won't be able to be conducted through the international consortium? 

Amie: Well, as I said in its main operation, which is when it's actually run through the academic clinics with students providing the care as part of their normal care environment, things like an RCT is not going to work. You're not going to be able to randomise people to receive the care or not receive the care, and you're not going to be able to really insert a specific treatment intervention. The intervention is going to be naturopathy, and naturopathic care as its delivered in community.  
Having said that, there is still, as I said, that capacity if a company wanted to...or a funder or some kind of sponsor wanted to run a particular type of trial where they wanted the site to run the clinic and they wanted to run in multiple countries to be able to contact the local, you know, institute in that country and say, "I'd like you do this in multiple countries. How can you help with that? What would be involved?" 

Andrew: How do you separate yourselves from pecuniary interest though with that like...? 
Amie: That's the thing, the type of funding, category three funding, which is industry-based funding. It's just a basic agreement that all researchers have. We have them at Endeavour. I know that CCNM and UNM have them. And it's just an agreement that basically says, "We agree to do this type of...". I mean, when we do it through Endeavour (The Endeavour College of Natural Medicine), we have a summary protocol to put together. You tell us the sort of research you want done, we tell you how we think it's going to work, and then if everyone's in agreement that that's all going to happen then the sponsor signs an agreement that says, "We don't actually get involved. We hand the funding over to allow the project to happen, you give us updates in every couple of months”. But other than that it's hands off. And from our point of view, we register all of our clinical trials with the Clinical Trials Registry, which means they have to get published. We can't not publish them even if it’s negative.
Andrew: Right, this is good stuff. 
Amie: These are fundamental good practice approaches.

Andrew: Yeah. 

Amie: Which separates that. And we have an agreement, our research services agreement, that say that whilst there might be a 12 month... the sponsor can request a 12-month lag in publication just in case something comes out that’s really problematic and they need to get their house in order before it goes out. After that 12 months all bets are off, we get to publish. 

Andrew: Why is this type of research so important for naturopathic medicine as a profession? 
Amie: Well, the types of research questions that we get to answer, because as I said, this answering the question. Not “does Hypericum work for depression. But does naturopathic care help people who have depression, do they have a change in their symptoms”? 

And so the ability to kind of capture that holistic care. And it's similar to what would happen out in community but it's in a much more contained space, so it's much more accessible for researchers in managing their logistics to get a lot of students going through. So you're not essentially doing a research project of, do people who go to these four practitioners get better? You've got, you know 20, 30, 50, 100 practitioners providing the care in the different locations. So it means any variability in treatment kind of comes out and gets evened out and then you're really getting a sense of the overall accumulation of naturopathic care.  
There's lots of other types of research questions that can get embedded in these sorts of projects as well, which is really exciting. The sort of project that we're looking at running as our first project, we're going to be able to answer the questions, not just are there differences in practice, as I said earlier, in prescription approaches. But also what's the naturopathic diagnosis as the underpinning treatment? And is there a cluster or a classification of, you know, categories of types of presenting approaches that might influence the type of treatment that's being prescribed? If a naturopath's identifying adrenal fatigue or adrenal exhaustion it might be part of the problem, is that influencing their treatment in different way than maybe someone that might be more allergy based or something like that, and that they're going to take a different approach even though the presenting compliant is still headaches or whatever it might be? 

Andrew: I'm just going to guess here that the data input of this, when you're trying to tease about other confounders of care or outcome, the data input is going to be the decider on what data you get out. On what answers you get, that's a massive job. 
Amie: It's huge, it is. And so you know, it's coming across as... Dr. Joshua Goldenberg at Bastyr who was the kind of the brain...is the lead on our first project. In his mind, he's going to be looking to start his project within about six months. It's taken us two years to get here because we went through this whole process of developing a consortium at the backend. 

Andrew: Yeah. 

Amie: And then we've had to develop all the infrastructure that works. Not the infrastructure, the practicalities and the logistics of running these things through multiple projects at the same time. 
So there's a lot to that, you know? Even in terms of the way that student clinic interactions work very, it's very slight, the amount of time that a student practitioner spends with a supervisor before making, you know, prescriptions, and all sorts of things vary somewhat across campuses and across countries. 

So there's lots of variations in all of that, but at the same time there's also a lot of consistency. So it's just figuring out a lot of that stuff that we're being able to answer some really exciting questions as a result. 

Andrew: This is going to answer so many questions. I guess my one thing that I'm going, "Oh, please," is what about longitudinal studies? Because that's going to be the hard one to achieve, isn’t it? 
Amie: Yes, well, I mean we're not going to start with longitudinal studies. 
Andrew: Oh, gawd.  
Amie: But I think we absolutely have the capacity to go there once we get sort of the shorter term ones under way. 
Andrew: How do you eat an elephant? One bite at a time. 

Amie: Yes, I think one of the things that we've taken for the approach is as light touch for the students as possible. So where things like call backs come in… I mean part of it it's taking a very pragmatic approach, which is what occurs in reality and practice. 

Andrew: Right. 

Amie: And in reality and practice, if someone stops going to a naturopath, they might get a phone call from the practitioner asking them why and why not, and what's going on, but they also may not. 

Andrew: Right. 

Amie: And so if someone ends up going twice and not the third or fourth time, then that kind of fallout is part of what happens in treatment anyway. 
But there's an entire methodology that's being built for this type of clinical research, which is pragmatic clinical research. Which is different to the highly experimental RCT design. 

Andrew: Yeah. 

Amie: So it sits across the two, and its perfectly situated for naturopathic research and holistic research in that sense. You know, making sure that you have validated instruments that are being used. Patient-reported outcome measures become really important, but also if there's going to be pathology tests and that has to be...the studies themselves have to be set up. So the students are essentially recruiting participants and getting them to agree, and then when the participants agrees, their contacts are then made available to the research team to kind of collect the additional data that's required about the patients' outcomes. 

Andrew: Yep. 

Amie: And then basically doing chart extraction after the fact, going back into, you know, case files, or client files and pulling out the other information that's been documented by the practitioner over the course of the treatment. 

So there's two aspects of care, one is liaising with the patient in some form or another, over the course of whatever the observational period is. And the other is going into the client's file, after it's all said and done, and pulling out the necessary information. 

So there's actually not that much interaction between the student and the research team, because the student's got enough to deal with already, they're learning how to be in clinic. 

Andrew: What about the issue of blinding? And I guess where I'm going here is not just blinding for the patient. A double-blind, placebo-controlled trial. But also not divulging the agents used in an intervention. I guess this is more specific when you're seeing if a one or two agents are going to have an effect in a disorder. But does that taint the research in any way if you discuss what aspect of naturopathic care you're researching? 
Amie: Well, this is where that line between experimental versus pragmatic research comes into play. 

Andrew: Right. 

Amie: Because the practitioner never prescribes something without knowing what it is that they're prescribing. And the fact is the practitioner is not being asked to prescribe anything in particular, they're just being a naturopath. And then prescribing whatever they feel is appropriate. The only thing we're asking them to do is diligently maintain their case files so that we can the information we need at a later date. 
Andrew: Is the term that I'm using more appropriate for intellectual property things where you want to say, "I have researched this and I have found that it's successful," so it's "mine?" 
Amie: Yes, like patenting kind of stuff. 
Andrew: Yes. 
Amie: It probably gets more into the traditional RCT design, which I said is still possible to be run through IRCNAC, through the consortium. It's just not through the student clinic, it's just using the rooms of the student clinic to run a specific trial. 

Andrew: Yep. 

Amie: So the idea of blinding...then double-blind means that both the patient doesn't know whether they're receiving the treatment, also the practitioner doesn't know if they're prescribing the treatment, the active treatment. 

Andrew: Yep. 

Amie: And so that's, you know, next to impossible in a holistic care approach. A trained practitioner will know if they're practicing as a naturopath or not. If they're prescribing through naturopathic principles or not. 

So that's just not possible in this sort of environment. I guess this is where the idea of the hierarchy of evidence comes out as well. One of the things I always find...you know, when they talk in research about the RCT being the gold standard, and the meta-analysis of RCTs as being like the pinnacle point to get to. 

One of the things I find to be one of the most common misconceptions is that everything that sits below the RCT is not worth doing. Whereas, you know, the Egyptians never built a pyramid with just the capstone. 
Andrew: Yes, nice. 
Amie: And so you need those layers of foundation to build on, to get to those final points. And so the sort of study that, you know, the cohort type study that we're talking about that's being really effectively run through the student clinic, sits around the middle of that hierarchy of evidence. It's above a case study, but it’s below an RCT. 

And you know, the overall validity of the hierarchy of evidence is something that, you know, I don't want to get into the controversy of that. But if we take it as given that that is an appropriate hierarchy, then the observational study, like we get through this, answers really great questions around naturopathic care. And it provides a really great foundation for taking aspects further for the specific interventions. 
So for us to be able to...in a large suite of treatments that might be available for a naturopath, and there's lots of them. You know, even for people who present with, you know, stress for a really generic kind of idea. There's all sorts of herbs and vitamins and diet and lifestyle practices that a naturopath may be employing to prescribe to their patients who present with stress, or headache, or insomnia, or whatever it might be. And so for us to be able to then prioritise which ones of those... 
Andrew: Are worthwhile. 
Amie: ...are worth even taking further to do an RCT as a standalone thing? 
Andrew: Right. Ahh, so it gives you a focus to jump further with, that's what you're saying? 
Amie: That's right. So we get 200 people who have gone to 8 different clinical sites around the world, and we can identify what specific herbs, and nutrients, and practices, are being prescribed. We can actually through statistical analysis identify which ones are getting the better results. And is there a connection between a herb, or even better, a cluster of herbs. Or a combination of herbs and nutrients, or whatever it might be, that's getting a better result than people who are not getting prescribed those particular things? 

It gives us a really great way of being able to learn more about the sort of treatment that might have more effects than other aspects of our care as well. Without it becoming a simplistic, it's this one herb, or it's this one treatment. The most limiting factor in Australia is feet on the ground with research, without a doubt. 

The amount of times I have practitioners come to me and say, "We should be doing research on this and on that” and I agree with them. There are so many areas, it's an amazing time to be a researcher in naturopathy because you can point your feet in any direction and there's research questions that need to be answered. And the biggest challenge that we have is trying to prioritise which ones to answer first. 

So what I've been putting my energy into over the last few years is building infrastructure, like the consortium, like PRACI, which I know we've talked about before, that supports research to be done as easily as possible so that with the few people that we have that are doing the actual research work we can get them really amazing outcomes. 

Andrew: Amie, one last question before we go. I mean this, seriously, this just seems so exciting for adding to the base of research so that you can move forward and you can say, "We can now have the data to tease apart those interventions." Not single. But those care aspects that worked, those that were common, those that showed favour. I have to ask the question that is down the track in the future, will this enable change at the government level to say, "We have offerings for you for health care savings. We can change your wastage of money on useless interventions, or inventions after the fact where you're picking up the pieces." Do you think this will change health care spending? 
Amie: It is probably the most important contribution that we as a profession can make to that change, you know? The machinations of government policy is a mystery at best and problematic at worst. 

But the sort of evidence and research that they need...for us to be able to go to the government...as I said before, with the NHMRC review for herbal medicine, they came out and they said, "There is evidence for herbal medicine. There is no evidence that the evidence that the herbal medicines that are showing to be evident are actually used and prescribed by herbalists and that people going to herbalist get better." 
Andrew: Really? 
Amie: So they said for naturopathy that there is evidence for naturopathy but because our issues with our inconsistent or a lack of defined regulatory and education standards mean that they can't necessarily transfer those findings into the Australian context. 

This is the sort of evidence where we can say it's not hypericum that's making the magic in this situation, it's not the B vitamins, it's not to say they're not part of it, but it's the naturopath. It's the prescription of these products made in a judicious, thoughtful, holistic, individualised manner from the perception of someone who truly understands naturopathic principles, that's what makes the difference. You can't just take some of these things and give them to someone who doesn't know what they're doing and just prescribe it to someone who has a diagnosis. That's not how you get the best outcome. 

By gathering data in this kind of way, we're getting the sort of information that doesn't just support natural medicine, it supports naturopathy as a system of medicine, and as a profession that can contribute meaningfully to the health system. 
Andrew: Amie, I'm not religious, but Amen to that. 

I am just so excited about what you're offering for the naturopathic community and profession around the world. I think everybody should take heed of this, and look at the fxmedicine.com.au website for further details on how they indeed might be involved in furthering research into international naturopathic care. 

Well done, Amie, good on you, thanks for joining us on FX Medicine. 
Amie: Thank you, Andrew, thank you very much. 
Andrew: This is FX Medicine, and I'm Andrew Whitfield-Cook. 

Additional Resources

Dr Amie Steel
International Research Consortium of Naturopathic Academic Clinics
Australian Research Centre in Complementary and Integrative Medicine (ARCCIM)
Endeavour Office of Research
Dr Joshua Goldenberg
Bastyr University
Dr Kieran Cooley
Canadian College of Natural Medicine (CCNM)
World Naturopathic Federation
Endeavour College of Natural Health
Southern School of Natural Therapies
Australasian College of Natural Therapies
Southwest College of Naturopathic Medicine and Health Sciences
National University of Natural Medicine
Wellpark College of Natural Therapies
South Pacific College of Natural Medicine

Other podcasts with Amie include:


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