When is a naturopathic doctor’s salary not a salary? When it’s actually the gross revenue from being self-employed. The AANMC did not include the disclosure that their naturopathic doctor “salary” figures in the 2020 Graduate Success and compensation report may include gross revenue instead of net income. Like a puzzle missing pieces, this report lacks the information needed to see the whole picture of naturopathic doctor income.
The salary that wasn’t
Potential naturopathic medical students who are looking to take out student loans for a doctor of naturopathic medicine degree should recheck their calculations. Once they graduate they may not earn nearly as much money as they might think, especially if they rely on the AANMC (American Association of Naturopathic Medical Schools) 2020 Graduate Success Report for information on naturopathic income after graduation.
The AANMC 2020 report states that naturopathic doctors earn an average $95K a year. However, according to email communications with the AANMC’s executive director, the figures shown as naturopathic doctor “salaries” on page 18 in that 2020 Graduate Success Report may include gross practice revenues, not just net income after expenses. Expenses can be 40% or more for a naturopathic doctor practice, so the actual income may be much lower. Plus, the “salary” figures by numbers of patients per week may include monies received for activities not related to clinical practice, including consulting and writing.
Furthermore, the term salary usually implies someone who is an employee, who receives a paycheck from a business owned by someone else (and where the paycheck is not tied to hours worked or patients seen). As the AANMC 2020 report makes clear, naturopathic doctors are heavily self-employed, especially when it comes to clinical practice. Salary is not the correct term to use here.
No one (well, no one that I am acquainted with) goes into naturopathic medicine for the money. But given the tuitions and debt loads, potential students should – and do – ask what they can reasonably expect to earn once graduated. Naturopathic medical schools have some hefty tuitions, currently starting around $40,000 a year[1][2]. And naturopathic students take out astonishingly high student loan amounts to pay those tuitions. The HEA group’s report (August 2023) showed that median student loan debt for a naturopathic degree ranged from $203,837 to $300,530 for the four naturopathic medical schools in operation in the United States. Once out of school, those loans have to be paid back.
Finding information on earnings for naturopathic doctors has been difficult, to put it charitably. In February 2020 when I published my article on financial outcomes for naturopathic medical school graduates, the only widely available survey on naturopathic doctor incomes was the AANMC 2015 Alumni Survey. (The other surveys in that article were publicly available; they were just hidden away in web archives and on unlinked pages.)
Then in June 2020 the American Association of Naturopathic Medical Colleges (AANMC) published their “2020 Graduate Success and Compensation Report“.
Unclear survey questions = unclear answers
This 2020 AANMC Graduate Success and Compensation Report (GSACR) was based on a survey of naturopathic medical school alumni in November and December 2019. There were more than a few odd things about the 2020 GSACR. One, it showed a higher compensation for NDs than that shown in previous naturopathic compensation surveys. Two, the 2020 AANMC survey used the term “salaries”, unlike surveys performed by National University of Natural Medicine (NUNM) and Boucher Institute for Natural Medicine (BINM). Salaries are usually received by employees, but NDs are overwhelmingly self-employed.
After the recent (August 2023) HEA Group report showed the low incomes received by naturopathic doctor graduates*, naturopathic doctors started comparing it to the 2020 AANMC survey. At that point I (and others) contacted the AANMC to find out what they meant by the term “salaries”. One individual had originally contacted the AANMC back in fall 2022 and at that time received the reply that the salaries were “gross revenue”, and they wanted to follow up on that reply.
Strangely, we heard back not from the AANMC, but instead from the executive director of the American Association of Naturopathic Physicians (AANP). This was not a case of mixing up acronyms. Instead, the AANP’s stated that both organizations had received multiple inquiries related to this issue, so they decided to answer everyone as a group. The AANP asked for a phone call to “understand the questions being asked and the problem trying to be solved”. (Email from AANP executive director, August 16, 2023.)
The questions I had asked (in a contact form on the AANMC’s site) were as follows:
On page 18 of your 2020 graduate success study, can you please clarify whether the figures shown are for:
My questions submitted to the AANMC, early August 2023
- Gross revenue as defined as “the total amount your business receives without accounting for any expenses” – e.g. the gross revenue of a clinic or an ND who is an independent contractor before overhead and expenses and obviously before taxes.
- Income (W-2 income for US citizens) received as an employee before taxes?
- A mixture of both?
- I understand it is “personal income” in that it is not joint income for a married couple or partnership or household income.
Can you share how the questions relating to income were phrased on the survey?
Also, can you share the following: The median income for all NDs in the survey who were working, not just those working full-time; the percentage of respondents who saw 11 or more patients a week; the percentage of respondents who were working at all, in any capacity, and in any field; and the median number of patients seen by all respondents who were seeing patients, including respondents who saw less than 11 patients a week.
Only after a few rounds of emails did the executive director of the AANMC reply. The answers from the AANMC were unclear, with the AANMC at times calling the figures in the report “revenue” and at other times “income”. Notably, the AANMC refused to answer whether or not the figures shown were for gross revenue before expenses, or for net income after expenses.
Finally, the AANMC wrote that the survey question was
How much income do you earn annually for each job? (Personal, gross, pre-tax income).
Email from the executive director of the AANMC on August 22, 2023
The issue with this wording is that other (non-AANMC) surveys of naturopathic compensation used the term gross income to mean gross revenue. And many people also use the two terms interchangeably. For someone who owns a business, runs a private practice, or is otherwise self-employed, “gross income” means “all revenues received before expenses are deducted”. “Gross income”, for employees, means “wages before taxes and deductions”.
If the 2020 AANMC survey questionnaire had additional instructions for the question, the AANMC didn’t include those.
The AANMC then stated:
We recognize that some people will have answered with their patient generated revenue and others, total revenue generated with the use of their degree.
Email from the executive director of the AANMC on August 22, 2023
Mixing revenue with income does not equal “salary”
Why does it matter that the “salaries” may have included gross revenues as well as net income? Because gross revenue is going to be much higher than net income. Naturopathic medical practices (like all healthcare practices) have a high overhead ranging from 40% to 60% [3]. For example, $70,000 gross revenue from a private naturopathic practice will be from $28,000 to $42,000 in net income, before taxes. Using gross revenue together with net incomes to calculate net income will artificially inflate the results, and can make the reported “salaries” look higher than they are in reality. This is misleading.
You can’t toss revenue and income together, take a median and a mean, and call the results a “salary”.
Also, including “total revenue generated with their use of degree” in the same figures used to show “salary by number of patients per week” is also a no-no. First as I noted above, combining revenue (gross) with income (net) inflates the figures. Second, combining compensation for non-clinical activities such as writing, consulting, teaching, or working in an integrative pharmacy is going to distort the figures as well. If a respondent is seeing 10 patients a week and working part-time elsewhere on the side, their income from the side job should not be included with their income from seeing patients.
Good surveys ask good questions to get good data. This is not a good survey.
Good survey questions make it plain what information they are looking for. This provides guardrails to keep respondents from giving answers that aren’t what the survey is looking for. And well-done reports make it clear what is being reported. The fact that the AANMC will not clearly state whether the figures labeled “salaries” are actually gross revenues before expenses are deducted is concerning, to put it mildly.
The amount of time it has taken to find this information is also concerning. This information should have been in the report – or the report should not have been issued with this poor quality data. As it was, it took a number of rounds of emails with the AANMC and another participant, and repeated questioning, before the AANMC provided the survey question and the vague wording above.
“Was that in there?” When references don’t contain the information cited
I want to briefly describe another concern with the 2020 AANMC Graduate Success and Compensation Report. It’s the (mis)use of references for the income comparison chart on page 20. The page 20 chart supposedly shows income by number of patients seen for acupuncturists, naturopathic doctors, medical doctors and chiropractors. However, when I checked the references, I could not find where the AANMC report got the figures shown. One of the references[4] for acupuncturists was quite clear that its figures were gross income. Another reference[5] was a survey of how much graduating osteopathic medical students expected to earn – not income from practicing DOs! The reference from the American Academy of Family Physicians showed net income, not gross revenues[6].
Missing information leaves holes in the data
When crucial information is left out of a report or paper, it makes it difficult to see the whole picture – or even see part of the picture accurately. The 2020 AANMC Graduate Success and Compensation report also lacks numerous pieces of information.
- Show how many respondents for the survey as a whole were not using their degree at all, or were not employed. That information is given for parents – so it’s odd they did not provide it for all respondents.
- Give how many respondents saw at least 11 patients a week. That would let readers know how many NDs are practicing “full time”.
- Show median patient numbers for the respondents as a whole, or even just for those who saw 11 patients or more a week. This would let readers get an idea of how many patients a week are typical for those NDs in practice.
- Discuss why eleven patients a week was chosen as “full time”. That is a very low number and I am not sure in what universe it would be considered full-time.
- Show median hours worked for the survey respondents as a whole. This, again, would let readers get an idea of the typical number of hours worked.
- Define “hours worked” – time spent seeing patients? Time spent running a clinic, including admin time? All time worked on any job?
- Show the percent of survey respondents for each band of “patients per week”. For instance, how many saw 11-19 patients a week? 20-39?
- Show how much supplement sales contributed to income from clinical practice. This was done in the 2010 National College of Naturopathic Medicine report[7]
These missing items make it impossible to determine typical naturopathic doctor patient loads and hours worked from this survey. There is no reason that the naturopathic profession should not have this information. Other healthcare professions do.
This many missing items raise questions about why they were not included. This is especially true when some of this material is reported for one group of respondents (parents) but not others.
In the first email from the AANP, the AANP executive director stated:
Some of the questions that have been asked requesting follow-up information are outside of the scope of our surveys, and some would require consultation with the research firm contracted to do the surveys.
Email from the executive director of the AANP, August 16, 2023
Usually it’s not outside the scope of a survey to show what percent of respondents gave particular answers (e.g. patients seen, hours worked) Nor should it be outside the scope to state, on the survey itself, what the definitions were that were used for income and hours worked.
It’s not just what you earn with a degree. It’s what you owe in student loans for that degree.
Finally, the survey does not discuss the student debt loads taken out to finance naturopathic education. This is a major omission. And while MDs, DOs, nurse practitioners and physician assistants have numerous opportunities for public service loan forgiveness to pay off their students loans, naturopathic graduates do not. There are scattered positions open here and there, not near enough to provide the same level of opportunity.
Missing information misrepresents naturopathic doctor incomes
However it came about, I believe that this report inaccurately represents naturopathic doctor incomes. I wrote the AANMC that I believe the report needs to be withdrawn or heavily amended (e.g., removing the misleading compensation figures on pages 18 and 20). In my opinion, using the 2020 AANMC Graduate Success report to recruit students for the naturopathic profession is tantamount to misrepresentation of financial outcomes for naturopathic doctors.
The AANMC and its board needs to examine how it was this report was produced so poorly, and why these issues were not caught before or after the report was published. And while it’s not clear from the emails from the AANP if the AANP itself was involved in producing this particular report, the AANP and its board also need to do some self-examination on any part they may have played. Certainly the AANP should not disseminate this report further.
* HEA Group report: The data can be downloaded from the report page at https://www.theheagroup.com/blog/grad-schools-debt. If you open up the report in Excel and sort by debt to earnings ratio, you will find the four currently operating naturopathic medical schools in the bottom ten: National University of Natural Medicine, Bastyr, National University of Health Sciences and Southwest College of Naturopathic Medicine & Health Sciences (now Sonoran University of Health Sciences).
[1] https://bastyr.edu/admissions/tuition-fees accessed August 23, 2023
[2] https://studentservices.nunm.edu/tuition-and-fees/ accessed August 23, 2023
[3] The 2010 NUNM/NCNM survey broke out gross income (revenue) and net income, showing overhead was in the 60% range for full time practices.
[4] https://www.ocom.edu/images/pdf/Professional-Development_onesheet_030717.pdf