How many people each year suffer some type of preventable harm that contributes to their death after a hospital visit?
| ||Fighting Above Their Weight Class: Notes from the Naturopathic Profession's 2011 AANP Convention||
Summary: I spent a better part of the week of August 15, 2011 with the naturopathic profession at their annual conference and related meetings. This report includes 11 short sections including: Jeffrey Smith's anti-GMO talk; Rick Kirschner's ideas from Dr. Oz on the profession's branding strategy; perspectives from Ian Coulter and nurse anesthetist Lorraine Jordan at the Science and Policy Summit; concerns relative to perceived boundaries between the profession and the products industry; outcomes of an exemplary whole practice research project on Group Health members with Type 2 diabetes; resignation of executive director Karen Howard, the voice of the profession for a decade; Bruce Milliman and the lack of position papers from the AANP House of Delegates; winners of annual awards; Letitia Watrous and applying the therapeutic order to pharmacy hours; and a coda for naturopathic students on what the profession may bring to the nation's integrative medicine movement.
Ian Coulter, PhD, the Rand-Samueli Chair for Integrative Medicine at UCLA hung this statement as a compliment on the naturopathic medical profession.
"You're fighting above your weight class."
Coulter's remark came during a keynote for a Science and Policy Summit involving that profession's top researchers, educators and professional leaders. The Summit was held at the Arizona Biltmore on August 15, 2011 just prior to the opening of the annual convention of the American Association of Naturopathic Physicians (AANP). Coulter added: "For such a small profession, you seem to be everywhere."
Coulter's phrase was bandied about through the week. AANP president Carl Hangee-Bauer, ND, LAc, repeated Coulter's comment from the podium. The fighting metaphor is neither inappropriate nor without its bruises. The American Medical Association supports opposition to new licensing of NDs and is working against expanded practice in the 16 states where NDs are regulated. In key states of Massachusetts, New York and Illinois, and in North Carolina and Colorado, licensing campaigns of over a decade in duration have not yet produced practice acts.
Yet the profession seems to have a role in the evolution of integrative practice beyond its numbers. Naturopathic doctors were prominent in two recent Institute of Medicine projects. Perhaps because of their small size, they have been particularly active in leading coalitions and consortia. Among these are the Integrated Healthcare Policy Consortium, the Coalition for Patients Rights and the Academic Consortium for Complementary and Alternative Health Care.
Carl Hangee-Bauer, ND, LAc, AANP president
I attended the AANP conference to give talks at the Tuesday Science Summit and then the following Sunday for a panel on naturopathy and integrative medicine for the Naturopathic Medical Students Association. In between I listened in to sessions and the buzz in the halls and pools on a press pass while enjoying time with many colleagues and friends. Here are some pictures from that exhibition. Note that because I am not a clinician and have no background in biochemistry or physiology, my chosen topics are dumbed-down from much of the conference content.
Alignment of interest note: I was significantly involved with this profession from 1983-1993, then much less so for the ensuing 17 years. In 2010, I helped co-found the Naturopathic Physicians Research Institute, a co-sponsor of the Science & Policy Summit.
1. Jeffrey Smith, GMO food risk and the power of the environment in ND thinking
Jeffrey Smith, author & organizer against GMOs
Respect for natural process in naturopathic practice is emblazoned in their core principal of assisting the vis medicatrix naturae
(supporting the healing power of nature). Environmental contributions
to disease and health often highlight their meetings.
Jeffrey Smith, author of Seeds of Deception and more recently of Genetic Roulette,
was among the keynoters. Smith received a standing ovation for his 90
minute talk with this assertive title: "The Documented Risks of
Genetically Modified Foods - Overwhelming Evidence of Harm."
both content expert and organizer. The brunt of his talk hammered on the
evidence the title advertised. Then he switched to his organizing hat, which he engages
through the Institute for Responsible Technology. His goal is to get the United States and other nations to ban GMO foods. His organization offers a Non-GMO Shopping Guide. Smith believes that a consumer revolt could be successful. A 2009 Nielson survey found
that the fastest growing claim for store brands was "GMO free." Smith
called upon the AANP to follow the lead of the American Academy of
Environmental Medicine which passed a position paper on GMO foods urging doctors to prescribe non-GMO diets.
Comment: As a person who also both
writes/reports and organizes, I was taken with Smith's balance. On one side is the horror of industry leaping into the new with no respect for the whole. Smith's ultimate message of hope was compelling,
despite the disregard of basic safety in the food sector. Kudos for maintaining that frame of mind and practice. Here's hoping the NDs eventually pass such a resolution against GMOs. (See related note on AANP position papers, below.)
2. Pharmacy hours, Leticia Watrous, ND and the naturopathic therapeutic order
Letitia Watrous, ND: Applying the therapeutic order
In many states, naturopathic doctors have broad authority to prescribe prescription drugs. Sessions at the AANP that count toward required pharmacy C.E. hours to maintain one's license are typically mandatory, if not the attendee's favorite choice. This year, the convention offered a little different fare. In "How Do I Get Off These Drugs, Doc?" pharmacist Christie Fleetwood, ND, RPH set up a score of pharmaceuticals typically used in family practice. Each slide featured the drug's use and list of adverse effects. Fleetwood noted how often the down side included worsening the condition the agent was meant to combat. Letitia Watrous, BS, ND, known in the field as a nature cure-focused clinician, tag-teamed with Fleetwood. After the presentation of each class of drug, Watrous reminded attendees of the naturopathic therapeutic order. These are the steps, beginning with self-care, prevention and self-efficacy that can prevent or reverse the condition; the clinician only later and if necessary moves toward more harsh interventions such as pharmaceuticals. Known for an older style of practice that centers around constitutional hydrotherapy, Watrous then listed the types of approaches that can help patients answer the question in the talk's title.
Comment: I tend to be Jeffersonian regarding access to pharma: some laws are made to keep us from ourselves. The thinking: If a harsher drug is in a practitioner's armamentarium, the drug will tend to be used earlier than it might be if one needs to refer out for it. Natural approaches and therapies are less likely to be engaged as thoroughly. Many practicing naturopathic doctors disagree with me on this. Others admit the tendency exists in their practice. Regardless, the presentation of prescription drugs side-by-side with less invasive alternatives was intriguing. The AANP may find additional artful ways to expand this approach. Few who attended will not have noticed how much the naturopathic therapeutic order engages the patient similarly whatever the condition, or whatever the adverse effects of the pharma a patient may wish to avoid. (Note the link of this theme and the Levin/Bolles discussion of the problems in the FICO medication adherence business line.)
3. Dr. Oz, Rick Kirschner, ND and the profession's market positioning
Rick Kirschner, ND: Suggestions for branding
Best-selling author Rick Kirschner, ND, offered a keynote related to his new book, How to Click with People. He concluded with some unsolicited advice on how the profession might better click with the public in its marketing. Kirschner is a former AANP board member from the early 1990s. He designed the
organization's original logo. He urged the profession to drop their current brand: Physicians Who Listen.
He argued that the phrase not only focused too much on one aspect of
naturopathic practice but also was likely to alienate other types
physicians who also believe they listen. In fact, earlier in the week
the AANP Board of Directors set as a top priority the funding of a significant
branding initiative. Kirschner suggested the AANP take its lead from something
Mehmet Oz, MD recently said on his TV show. Pina LoGiudice, ND, LAc was a guest. Oz, while not mentioning that LoGiudice was a naturopathic
physician, referred to her as a World Expert in Natural Medicine. "There," Kirschner said, "I just saved you $100,000."
Comment: I believe the profession's brand has been
under its own nose since 1989. In that year, the AANP completed an
exhaustive two-year process to clarify the Definition of Naturopathic
Medicine. (The work product is not presently available on the AANP site and cannot be linked.)
That profession-wide process produced this simple brand: Naturopathic doctors treat disease by restoring health. Linked to Kirschner's suggestion, the brand becomes: World Class Experts in Natural Medicine - Treating Disease by Restoring Health. That's what a world class expert in natural medicine should do.
4. Framing the ND's research and policy relationship: Perspectives from the chiropractors and nurse anesthetists
Ian Coulter, PhD: Research and the chiropractors
A pre-conference, day-long Science and Policy Summit was convened "to determine directions in real world research in naturopathic medicine,
with a focus on informing governmental and corporate health policy." Two keynotes offered experiences of other disciplines. One was from Rand-Samueli's Ian Coulter, PhD, a health services researcher who was for 10 years president of Canadian Memorial Chiropractic College. While there he stimulated a good deal of research activity.
Coulter concluded that most of chiropractic medicine's inclusion in policy came
via political action rather than via research outcomes. Yet Coulter then
described how an informal tax on members of the chiropractic profession
in Canada played a significant role in advancing research and fostering
better relationships with mainstream institutions.
In her keynote, Lorraine Jordan, CRNA, PhD, executive director and senior research director for the American Association of Nurse Anesthetists Foundation,
offered a remarkable story of use of research in that discipline. Under Medicare rules, nurse anesthetists
had to work under MD supervision. Yet 15 states had been granted waivers to practice independently. The nurse' policy objective was to be liberated from MD oversight nationwide. What was the research project to do this? The nurses internally raised the funds to compare independent nurse
anesthetist practice to independent MD practice and to MD-supervised nurse anesthetist practice. Before contracting the research to outside researcher, they purchased the data to internally examine it. The data looked good, yet they published nothing. They knew that to
have weight, this study had to come from someone outside their
profession. Because they wanted to
influence Congress, they selected a big name researcher with publication
experience in a journal widely-read on the Hill: Health Affairs. The
best outcomes were from nurses acting solo. Among the take-home messages from the Summit as summarized the next week by NPRI director Carlo Calabrese, ND, MPH: "Research may be
necessary for policy advances, but it's not sufficient."
Lorraine Jordan, CRNA: Research & nurse anesthetists
Comment: A comment from Coulter stimulated a substantive discussion among the college presidents and deans in attendance. Coulter used student resources (tuition) to get CMCC's research program rolling. However, he called such funding "unethical." Money from students was in-appropriate for that purpose, he thought. He urged "taxing" professionals who were already in practice. Some representatives of the naturopathic schools found themselves aligned with this view. I was surprised. How is it not ethical to invest in researching the kinds of whole practice outcomes that might help open doors for these students when they graduate and need jobs to pay off their massive student loan debt? I am intrigued by others' thoughts on this.
5. AANP executive Howard (2002-2011) steps down after a positive $640,000 turnaround on organization's bottom line
Karen Howard: Executive director
AANP executive director Karen Howard, the
face of the AANP since 2002, announced her resignation to Board members just prior to
the AANP conference. Howard took the AANP through a remarkable turn-around in the
organization's finances. Red ink of $276,000 at the end of 2002 became a
$402,000 positive balance at the end of 2010. This is on annual revenues
of just over $1.6-million. A ceremony in Howard's honor made clear how deeply loved and respected Howard has been by many in leadership. Other significant leaders are pleased with the upcoming change. These tend to focus on the lack of advancement at the federal level over the past decade of integration, and fewer advances in licensing than many anticipated.* [See CORRECTION and comment at the end of the article based on responses to initial language here.] Howard notes that she plans to take up "bigger and better things." For the time being, Howard will continue in her secondary role as executive director of the Association of Accredited Naturopathic Medical Colleges. Howard
may also have a continued role with the profession via a new naturopathic
foundation which she has incorporated with former AANP president Lise Alschuler, ND, FABNO and author and natural products formulator Michael Murray, ND.
Comment: As an interested participant-observer I have honored Howard's work and have also utterly astonished and confounded by some of her choices. It will be intriguing to see whether the profession will be able to get traction in the federal arena in the next years. Perhaps some issues that have been teed up will mature under her successor. A search is under way. A new AANP president Michael Cronin, ND takes over in January. One thing is certain: Howard has been the dominate player in the organized naturopathic profession for the last decade.
6. Clarity and disclosure needed in the naturopathic profession's relationship with the natural products industry
What is the optimal profession-industry relationship?
Comment: At various times during the week I became uneasy with the naturopathic
profession's boundaries relative to the natural products
industry. At least one speaker promoted his company's own product and indirectly puffed up his company without
any disclosure of conflict of interest. A leader with a significant industry involvement is heading up a product quality initiative. (In the natural products world, association with quality
initiatives is sometimes used in marketing.) Payments by industry for participation in the conference were obscured in income-expense reporting to membership as "convention activities" rather than exhibit fees. (The $347,000 of "convention activities" and $189,000 of Corporate Partners and $65,000 of "Advertising/Publications" amounted to $600,000 or 37% of the AANP's $1.6-million 2010 Budget.) A significant percentage of Board members are from the industry.
None of these, except the non-disclosure, is necessarily problematic. Yet I could not help but wonder what these naturopathic leaders would think if they were presented a report on the AMA and pharma that included similar characteristics. Hyper-vigilance and boundary clarity on these relationships makes a
good deal of sense for the AANP, for many reasons. Among these is the criticism that most NDs run in-office pharmacies and many patients end up with a bag full of supplements. (Notably, a fine case is made for these pharmacies in this Integrator column by clinician and residency leader Margaret Beeson, ND.) The beginning of a solution will be to have all speakers routinely announce potential conflicts in the conference schedule, in speaker bios and in slides at the beginning of their talks. This should be so even if they think they are not
speaking about their product line. Meantime, it will be interesting to see what the AANP Task Force on Quality will accomplish.
7. Disciplines Research: Group Health pilot finds whole practice by NDs beneficial for improving self-care for Type 2 diabetics
Ryan Bradley, ND, MPH: Key diabetes project
The highlight of the research track was a preliminary report by Ryan
Bradley, ND, MPH on a project in which naturopathic care, as practiced in individualized ways by members of the discipline, was found to have various positive outcomes. The study on 40 patients with Type 2 diabetes was led by Dan Cherkin, PhD, of the Group Health Institute. Bradley was a co-investigator. Some of the remarkable characteristics of the study were:
- No selection bias The subjects were, as Bradley put it,
"naturopathically naive." They were Group Health members whose diabetes status met
inclusion criteria to ND care. The individuals did not self-select.
- No requirements for treatment protocol The involved providers were given no protocol on what therapies or approaches they would use. They were to practice just as they do. The outcomes thus began to capture the "discipline."
- Very few visits While Group Health allowed up to 8 covered visits, both
average and the median were close to just 4. This compares to roughly 20-30 visits in other successful lifestyle interventions such as the Diabetes Prevention.
- Self activation outcomes Self-care changes and self-efficacy changes were
at 6 and 12 months.
- Biomarker Hemoglobin A1 was not significantly reduced in the 12 month study
period although the trend was positive. One observer called the findings, while not statistically significant, "strong" for a pilot of that size.
The research was supported by NCCAM via an R21 grant. Bradley anticipates reporting the outcomes in greater detail at the October 26, 2011 one-day research symposium at UCLA.
Comment: While not quite as compelling as the Seely-Herman study reported in 2010, this is a great direction naturopathic research. This is the kind of real world and " disciplines research" that the new NCCAM strategic plan would seem to support. Reductive researchers will cringe: But we don't even know what the NDs were doing! Yet stakeholders such as hospitals or employers or insurers or individual consumers who may buy "naturopathic care," this is just what is needed. That they only used 4 of 8 known, covered visits speaks of a solid ethical footing.
A fun side-story. While presenting a poster at the 2006 North American Research Conference on Complementary and Integrative Medicine, I had a chance to introduce Bradley to former NIH CAM research leader Wayne Jonas, MD, now CEO of the Samueli Institute. Jonas charged Bradley and the naturopathic profession in general with taking up the flag of doing whole practice research. Jonas specifically suggested diabetes. Bradley mentioned he had a project cooking. Good for Bradley, and for the profession to see that work coming to fruition. Notably, Bradley received the 2011 AANP research award for his Feeding the Rainbow to Investigate Endothelial
8. Position papers, AANP House of Delegates: Where do NDs stand on key issues?
Bruce Millioman, ND: Revitalizing the House and the profession's voice
For the third straight year, members of the AANP House of Delegates
struggled over the publication of position papers. Since 1987, the House
has published nearly two dozen position papers on various topics. Yet for most of the past decade, these have not been visible to the public. (Notably, unlike the work of the House of Delegates for other national physician organizations, that of the AANP's House is largely invisible via the web.) The papers
were opened to a member-only site following a battle in 2010. The
reason: Individuals fighting for state licensing have from time to time
needed to defend statements in the papers. At the 2011 meeting, veteran Bruce Milliman, ND was elected new Speaker of the
House. Milliman is
a proponent of the House gaining increased authority and of either re-publishing the papers or
modernizing some if necessary before then publishing them. Milliman will also assume a
position on the Board.
Smith's call to the naturopathic profession to take a position against GMOs reminded
me of the profession's near silence on most key topics in the last
decade of robust integrative health activity. It will be interesting to
see where the profession, through its House of Delegates and under new leadership, will choose to be heard.
9. A repeated theme of potential over-prescribing
Alan Gaby, MD: Vitamin D over-prescribed
Nutrition expert Alan Gaby, MD offered
a keynote on topics in therapeutic nutrition. Gaby
challenged the argument that people should routinely take 10,000 IU of
Vitamin D daily. He took apart the research supporting high dosing
with a fury that made this observer wonder if the science around any
natural product could withstand such scrutiny. Gaby is comfortable
up to 2000 IU, still above the Institute of Medicine recommendation in
the November 2010 IOM report. Gaby later responded to query by stating that he likes a controversy, but does not stir them gratuitously. A warning against over-prescribing was also raised by thyroid specialist Alan Christianson, ND in a pharmacy lecture entitled "integrative thyroidology."
Comment: The controversies, and particularly the recommendations to limit doses, both speak to maturation in the naturopathic discipline. Like many in the room who are no longer spring chickens, I was listening as an interested party relative to both agents.
10. Awards: Field, Emerson, Benda, Bradley, Edwards and Barton
Shiva Barton, ND, LAc: ND of the Year
The AANP has expanded its basic awards in recent years to include a corporation award, a "Vis" award and this year a "naturopathic champion." The winners were:
- President's Award: David Field, ND, LAc Field is a long-time Northern California clinician and mentor who played a significant role in licensing in his state. He holds California License #1 as a naturopathic doctor.
- Corporate Award: Emerson Ecologics Emerson was cited for its product quality work. CEO Andy Greenawalt honored the firm's vice president, Lise Alschuler, ND, FABNO, a past-president of the AANP.
- Champion: Bill Benda, MD Benda is an emergency room doctor and writer who graduated from the original, residential Arizona fellowship in integrative medicine. Benda was the first MD to serve on the AANP board.
- Research: Ryan Bradley, ND, MPH Bradley was honored for his project entitled Feeding the rainbow to Investigate Endothelial Dysfunction, engaged via the University of Washington.
Vis: Louise Edwards, ND, LAc The award is to honor an individual whose contributions have most advanced the vis medicatrix naturae, or healing power of nature. Edwards is a clinician and educator who teaches at multiple schools.
Louise Edwards, ND, LAc: Vis award
- Physician of the Year: Shiva Barton, ND, LAc Barton is a long-time clinician and political leader in Massachusetts who for many years has stimulated clinical dialogue through his annual Clinical Pearls segment at the conference and through a widely-used ND forum called NatChat.
Comment: Fascinating to see that each of the ND clinicians who received awards are also acupuncturists.
Coda - A message to the Naturopathic Medical Students Association: What will NDs bring to the table?
Where will today's students take the profession?
The day after the formal closure of the conference, I filled in for my colleague and Integrator
adviser Pamela Snider, ND to moderate a presentation before the
Naturopathic Medical Students Association (NMSA). The NMSA day was entitled Exploring the Spectrum of Healing: Naturopathy and Integrative Medicine.
Our panel focused on philosophy. I asked her for her core message so that I might try to impart it. Snider, the executive editor
and organizer of the Foundations of Naturopathic Medicine Project, responded: "It's not whether
naturopathic physicians will be integrated with conventional medicine.
It's happening. We will be. The question is what we will be when we are
integrated. What will we bring to the table?" The core work, to Snider, is bringing forth the
fundamental philosophy, including the devotion to supporting the vis medicatrix naturae. This is what she believe distinguishes NDs. Says Snider: "We need to apply ourselves to operationalizing the vis."
Summary: Operationalizing the Vis. Nice phrase. This captures the problem
set for anyone who is working to ensure that the integrative practice movement will
mean more than grafting a few therapies to a disease management paradigm.
Snider's concept of "operationalizing" can be applied to all paradigm
change issues. These may arise in research, scheduling, payment or practice. Ultimately the value to the health system will not be in whether there is integration, but what, in fact, happens at that intersection. This means operationalizing core principles that go beyond expanding the toolkit for reactive disease management. Neither the naturopathic profession, or the rest of us linked to a similar destiny in this whole system change for our culture and medicine, will lack challenges.
* CORRECTION and comment
on ND licensing in the Howard era
The original version of the section on accomplishments in naturopathic licensing during the Howard era (#5,
above) stimulated a strong response from Howard and calls for correction from
Board members and a past president. The original language read:
"These [who are displeased with the Howard era accomplishments] tend to focus on the lack of
advancement at the federal level over the past decade of integration, and the
minor advances in licensing. Only 2 small states have gained regulation (Minnesota, North
Dakota) despite the greater cultural openness."
This statement relative to licensing accomplishments was incorrect on a number
of counts. I have spent a few days sorting
through what actually happened in this period and why I wrote what I did. It's complicated, at many levels.
A better summation would have been: "The NDs
gained licensing for the first time in North Dakota and Idaho, converted
registration to licensing in Kansas, and earned registration in
Minnesota. In addition, they passed licensing in
the District of Columbia. Passage of a law in California is more appropriately attributed to work in an earlier era."
Here are the changes as I have reconstructed them, and my thinking.
Kansas (registration 2002, licensing 2011) Kansas NDs
became eligible for regulation at the end of 2002 through the work of Medhi Khosh,ND and Farhang Khosh, ND, prior to the Howard era. This was successfully converted to licensing
in 2010. I should have been noted this.
(licensing 2003) The long-battle for
California led by Sally Lamont, ND, LAc, current AANP president Carl
Hangee-Bauer, ND, LAc, 2011 president's award winner David Field, ND, LAc and
supported by David Matteson, Sandi Cutler and Pamela Snider, ND, all then from
Bastyr University, came to fruition in Howard's first year as AANP Executive
Director. California became the 13th state to license NDs. I did not attribute it to
the Howard era as the long, strategic "little Flexner" process was a huge labor. Snider, Eddie Morris, Clyde Jensen, LaMont and others developed a successful $130,000 funding proposal to the Arkay Foundation. The funds went to the UCSF Health
Professions group to complete a study of the naturopathic profession. Snider served on the UCSF committee. (I had the opportunity to support this work through a series of long calls from the primary author, Holly Hough, PhD.) The UCSF study was published in 2001 and was a key chess piece in the ultimate passage. The work also included some
significant inside politics, led by Cutler, Matteson and Lamont, also not related to the Howard era.
(licensing 2004) While the District of Columbia is not a state,
achieving licensing in D.C. was a significant strategic advance and merited
noting in my original.[I have been told since that this was also a conversion from a registration.]
- Idaho (originally protected practice via a Supreme Court decision, licensing 2005) In
was celebrated as the 14th state to license NDs. I had a faulty recollection that there had been earlier legislative recognition that was actually via the Court. After 6 years, a licensing Board has not yet been established. Idaho leader Todd Schlapfer, ND hopes a change will come with the new year.
- Minnesota (2008 registration) I originally reported Minnesota as a license. The AANP release
correctly noted Minnesota
as the 15th state to "regulate" NDs. The bill is a registration, like
the original Kansas
bill. The profession hopes to eventually step this up to
licensing as was accomplished in Kansas.
Some oppose the strategy out of concern that registration, hardly appropriate for the primary care physician-level practice, may be a precedent for a
spread of registration in other states.
Dakota (licensing 2011) North Dakota
is celebrated by the profession as the 16th to license NDs. (In fact, North Dakota became
the 16th to "regulate," not license.)
My original, brief summation of the work was clearly in error. Because the
context was a sentence in which I was describing perspectives of those who have
not been happy with AANP executive director Howard's term, I feel it appropriate to
have not included California as work in which she had a significant stamp. A very high level of work had been completed prior to her taking the AANP
helm. Better to have noted my reasons with an asterisk at the outset. The
better summation of state licensing accomplishments linked to the Howard era would be, as noted above:
gained licensing for the first time in North Dakota and Idaho, converted registration to licensing in Kansas, and earned registration in Minnesota. In addition, they passed licensing in
the District of Columbia. Passage of a law in California is more appropriately attributed to work in an earlier era."
While the successes were in small
states, this review certainly speaks to more accomplishment by members of the profession than my
original language. For that I apologize. My synopsis was colored by my own
disappointment that the profession hadn't advanced further. It was also colored by faulty memory: I forgot it was the Supreme Court and not the legislature in Idaho and erroneously recalled Stanley Beyerle, NMD had an earlier success in Kansas, before he died. My perspective may also underestimate the challenges of the AMA's
Scope of Practice Partnership, noted at the top of this article. Hopefully with
the AANP's relatively recent addition of former Pennsylvania state legislator Gene McGill as AANP
director of state government relations more advances will come in the near
|Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......more||
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