KEYWORDS: Tori Hudson, ND; Institute of Women’s Health; Breast cancer/diet; Naturopathic medicine/innovators/medicine
In the Company of Powerful Women:
Tori Hudson and the Question of Whether We are Innovators or Luddites…
By Jacob Schor
Nearly three decades ago, I shared a physically intimate moment with Dr. Tori Hudson. After inducing me to strip off most of my clothing, she was all over me with her hands, touching me in places that made me gasp. More accurately her hand that held a washcloth wrapped around a chunk of ice was all over me, finding those sensitive spots that preferred to stay warm. A classroom of students, who would go on to eventually become NCNM’s class of 1991, watched Dr. Hudson and me; as I hooted and hollered, my classmates laughed with pleasure at my discomfort. In hindsight, I may not have been the easiest student to have in your class. That was the last time I volunteered my body for any classroom demonstration. Dr. Hudson will no longer admit she remembers our little interlude of iced-mitten-friction, but I like to think that we once had our own special moment. This is the same Tori Hudson who has contributed monthly articles to the Townsend Letter for the past 25 years. (I recently realized that Tori and I share another passion—not for each other but rather for sea kayaks; we both spend our off-time studying catalogs and longing for these sleek, elegant, long-bodied sea craft.)
We are fast approaching an important anniversary for Dr. Hudson. It is nearly 20 years since Dr. Hudson founded the Institute of Women’s Health and Integrative Medicine. Since then, this institute has held 78 seminars on topics related to women’s health. Assuming that 50-100 attendees have come to Portland for each of these three-day weekends, Dr. Hudson has deeply impacted the practices of nearly 5,000 doctors who have participated in programs put on by the Institute over those 20 years.
I think back to the single Tori Hudson conference I attended years ago. I suppose you could say that I once spent a romantic weekend with Tori—well, Tori and about 80 other colleagues who attended a seminar titled, “Excellence in Breast Cancer Care.” Currently the Institute holds four conferences per year. This coming year there are three-day programs covering pediatrics, menopause, women’s primary care, and fertility, and contraception: http://instituteofwomenshealth.com/future-conferences/.
I was one of a handful of men at the breast cancer program I attended. I could joke about the conference having been a great way to meet women, but I suspect such misogyny, even written in good humor, might not be appreciated. Even though this conference was years ago, I remember certain aspects quite clearly as the program reaffirmed some deeply held suspicions.
The first is that Oregon’s long history of licensing naturopathic doctors allows a level of collaboration between NDs and MDs that is unimaginable in unlicensed states. Both an oncologist and a breast surgeon that Dr. Hudson works with presented lectures. That was novel for me. In Colorado, where the practice of naturopathic medicine was still illegal, such collaboration would never have occurred. Now that Colorado naturopathic doctors have been legal for a few years, I can just begin to imagine this happening. In fact, I have now been invited to speak at a local cancer center several times. I thought the big reason to get licensed was to stay out of jail; the reality is that regulation fosters collaboration between professions and improves patient care. Who knew?
Second, while medical doctors are smart, naturopathic doctors may be smarter. While the two medical doctors provided much of the continuing education, I recall being disappointed in their information. Medical doctors have a tendency to talk about things, talk about studies; but all too rarely do they transform data so it truly informs my practice; they did not change what I do. The naturopathic speakers, on the other hand, provided intellectual information along with practical details that change what I do with patients. Cancer Treatment Centers of America cosponsored the seminar and sent some of their best NDs to speak. Paul Reilly, who at the time was still working for CTCA in Seattle, spoke about using the immune system to treat cancer. Michelle Ququandah, who was at the Philadelphia CTCA, spoke on preventing and treating the side effects of chemo and radiation. Michelle has since left CTCA, gotten married, and is living happily ever after in Southern France teaching Mediterranean cooking. (I said these were smart people) Tina Kaczor and Lise Alschuler were already a lecture tag team back then and presented one of those intellectually weighty lectures they pioneered years ago at AANP conventions. This was back before there were a gazillion references on supplements listed on PubMed. They identified and described the biochemical mechanisms and signaling pathways that hinder breast cancer and then identified which supplements could impact those pathways. Those two brilliant ladies earned a place in my heart with their practical intelligence. Their method of breaking down therapeutic challenges to target mechanism continues to fascinate me to the point that I have started calling their process ‘naturopathic translational medicine.’
Way back in 1995, Everett Rogers in his book Diffusion of Innovation 1 explained how technology spreads; he explained in a way, who would be the first and who the last person to buy a new iPhone. The same principles might be applied to the spread of new knowledge. The way Alschuler and Kaczor brought up some new information made me conclude our profession adopts new in an innovative manner. Let me explain.
I remember this conference distinctly because it was held shortly after the Women’s Healthy Eating and Living (WHEL) data were first published. Their publication triggered a huge shift in what we tell patients about diet and breast cancer.The WHEL trial had followed 3,088 women diagnosed with breast cancer. About half the women, (n=1,537) were encouraged to eat more vegetables, fruits and fiber and far less fat (5 vegetables, 3 fruits plus 16 ounces of vegetable juice per day). The control group was encouraged to simply follow the ‘Five a Day’ guideline the government promotes.
When the WHEL trial was begun in the late 1990s, these recommendations were the ‘best diet’ for breast cancer patients so we actively encouraged our patients to follow this eating pattern, believing it would help. It didn’t. After 7.3 years follow up, the rates of cancer recurrence or death from breast cancer varied by only decimals of a percentage point between the groups of women; there was no statistical difference nor even a hint of a trend suggesting benefit. (Comparing diet group vs. control group; for recurrence 16.7% vs. 16.9%, for death 10.1% vs. 10.3%) 2
Our years of encouraging women to eat all those fruits and vegetables and juice had done little good.
Listening to both Alschuler and Kaczor speak about how they were altering their views in response to these WHEL results made me think of the Roger’s book. Our profession appears to have more than the expected number of what Rogers called, early adopters. An early adopter is the person who embraces new technology or, in my interpretation, new ideas, before most other people do. In terms of medicine, early adopters would be those who change their treatments quickly based on new and innovative research. According to Rogers’ theory, early adopters make up 13.5 percent of the population.
Remember the early days of Helicobacter pylori? Recall that although Marshall and Warren discovered this bacteria in 1982 and solidly linked it to stomach ulcers, it took years for general practitioners to abandon the idea that stress caused ulcers and to start testing for and treating H. pylori. Six years after Marshall and Warren’s landmark paper, only 44% of doctors had “… noted this relation.”3 It wasn’t until 2003 that the majority of physicians in the world accepted the H. pylori theory and begin treating ulcers appropriately.4 Marshall and Warren, by the way, were awarded the Nobel Prize in 2005 for their discovery.
Back in the mid-1980s at National College of Naturopathic Medicine (NCNM), I recall that our instructors were already teaching H. pylori treatments and debating the best approach. The speed with which we had incorporated this new knowledge into practice suggests that as a profession, we are all early adopters.
Early adopters, while eager to explore and accept new options, are not the most daring of people and are not especially prone to taking risks. According to Rogers, a much smaller segment of the population serves that role. He estimated that one person in 40 is an “innovator.” Rogers also labeled individuals at the opposite end of the spectrum, calling them “laggards” and “Luddites.” Laggards are slow or reluctant to embrace new technology because of disinterest or financial constraints. Luddites actively fear or loathe new technology, especially those forms they believe threaten their jobs.
The WHEL trial told us that eating lots of fruits and vegetables and cutting out fat does little to help breast cancer patients. I went to the Hudson Breast Cancer Conference pondering what our profession would do with the WHEL information. Now, a decade later, I can actually look at the shifts in our dietary prescriptions and trace them back to that conference, in particular to the Alschuler and Kaczor presentations.
As we could have guessed, the laggards among us simply ignored the data and went on promoting vegetable juicing and high vegetable and fruit consumption as the cure for breast cancer. The Luddites continue to talk of BigPharma conspiracies and how they must have manipulated the data to keep cancer rates high. They continue their long-honored tradition of not letting the facts get in the way of their beliefs. On the other hand, the innovators among us looked at the data and used them to catalyze a shift in our paradigm. This whole digression about slackers and Luddites is to explain what Alschuler and Kaczor did in their lecture all those years ago.
They did two things. First, they responded to the research and the current state of knowledge and shifted their priorities. While the benefits of diet for treating breast cancer had tanked, at the same time, there were still some gems hidden in the data that they picked out and held up for us; in particular that eating broccoli, losing weight, and exercising all impacted breast cancer survival. All were associated with better outcome in the WHEL women. They found the gems hidden in the data, highlighted them, and used them as leverage to move us toward a new paradigm, which at the time was in its infancy. In hindsight, it seems easy to look back and see the key studies that shifted our practices. But back then, a decade ago, these ideas were hard to see. Now we speak easily of the interconnection between weight, obesity, insulin, IGF-1, glycemic control, and AMPK activation. Back then, we were counting vegetables and juicing carrots.
That lecture effectively moved our understanding forward via a study that many practitioners had been seeing as a failure.
It is not often that lectures stick with me the way that one did. This is the sort of information that Dr. Hudson has been able to elicit regularly from her speakers for years; it is little wonder that her Institute has been so successful. Is there a secret to her success? Yes, it’s got something to do with intelligence, discrimination, and wisdom; but I should refrain from writing anything too complimentary least anyone think I have ulterior motives. That hydrotherapy class was long ago.
It doesn’t hurt that these conferences are not geared to make money. “These conferences are,” in Dr. Hudson’s words, “… lean conferences with small profits…. Any profits that do accrue go toward supporting residency salaries.” Dr. Hudson, we should note, has for many years employed naturopathic residents in her office. In fact, back in 2005, Dr. Hudson partnered with Margaret Beeson, ND, of Billings, Montana to form an organization, the Naturopathic Education and Research Consortium (NERC), that is dedicated to increasing postgraduate residency and training opportunities across the country.
According to Dr. Beeson, “Residencies are crucial to the advancement of our profession…. graduates need paid opportunities to hone their skills in a supervised setting with seasoned naturopaths who can support and educate beyond medical school.” Residencies “… are the foundation for passing on the wisdom of medicine as both art and science.”
It’s rare, actually hard, to imagine a conference that has me still pondering the contents of its lectures 10 years late. Dr. Hudson has done something really special with her Institute. We all should be taking greater advantage of what they offer.
A review of Everett Rogers’ book Diffusion of Innovations (1995) is posted on
with the online version of this article.
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. Orr G. A Review of Diffusion of Innovations by Everett Rogers (1995). March 18, 2003. Available at http://web.stanford.edu/class/symbsys205/Diffusion%20of%20Innovations.htm.↩︎
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. Pierce JP, et al. Influence of a diet very high in vegetables, fruits, and fiber and low in fat on prognosis following treatment for breast cancer; the Women’s Healthy Eating and Living (WHEL) randomized trial. JAMA. 2007 July 18; 298(3): 289-98.↩︎
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. Thomsen AS, et al. [Knowledge about about Helicobacter pylori and antibiotic treatment of peptic ulcer. A model study of information dissemination and implementation of the new knowledge in clinical practice] [Article in Danish]. Ugeskr Laeger. 1999 Nov 29;161(48):6630-4.↩︎
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. Huang J, et al. Has education about Helicobacter pylori infection been effective? Worldwide survey of primary physicians. J Gastroenterol Hepatol. May 2003; 18(5): 512-520.
BOOK REVIEW:
A Review of Everett Rogers’ Book Diffusion of Innovations (1995)
By Greg Orr
March 18, 2003; http://web.stanford.edu/class/symbsys205/Diffusion%20of%20Innovations.htm
Much has been made of the profound effect of the “tipping point”, the point at which a trend catches fire – spreading exponentially through the population. The idea suggests that, for good or bad, change can be promoted rather easily in a social system through a domino effect. The tipping point idea finds its origins in diffusion theory, which is a set of generalizations regarding the typical spread of innovations within a social system. In an effort to judge the truth and power of epidemic spreading of trends, I read Everett Rogers’s scholarly and scientific Diffusion of Innovations (1995), which has become the standard textbook and reference on diffusion studies. What I find in this comprehensive and even-handed treatment is an insightful explanation of the conditions that indicate that an innovation will reach the much-hyped tipping point. In this review, I will outline these basic characteristics of an innovation and its context that correlate with its diffusion. Furthermore, I will show the ways in which these understandings improve our capacity to take efficacious action to speed it up. At this point, I will be able to evaluate the claim that the tipping point makes it easy to spread change.
The Mechanism of Diffusion
Diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system (5). Given that decisions are not authoritative or collective, each member of the social system faces his/her own innovation-decision that follows a 5-step process (162):
1) Knowledge – person becomes aware of an innovation and has some idea of how it functions,
2) Persuasion – person forms a favorable or unfavorable attitude toward the innovation,
3) Decision – person engages in activities that lead to a choice to adopt or reject the innovation,
4) Implementation – person puts an innovation into use,
5) Confirmation – person evaluates the results of an innovation-decision already made.
The most striking feature of diffusion theory is that, for most members of a social system, the innovation-decision depends heavily on the innovation-decisions of the other members of the system. In fact, empirically we see the successful spread of an innovation follows an S-shaped curve (23). There is, after about 10-25% of system members adopt an innovation, relatively rapid adoption by the remaining members and then a period in which the holdouts finally adopt. I will review Rogers’s assessment of the factors affecting the adoption of an innovation with the goal of elucidating how the earlier adopters of an innovation profoundly affect the innovation-decisions of later adopters.
The innovation-decision is made through a cost-benefit analysis where the major obstacle is uncertainty. People will adopt an innovation if they believe that it will, all things considered, enhance their utility. So they must believe that the innovation may yield some relative advantage to the idea it supersedes (208). How can they know for sure that there are benefits? Also, in consideration of costs, people determine to what degree the innovation would disrupt other functioning facets of their daily life. Is it compatible with existing habits and values? Is it hard to use? The newness and unfamiliarity of an innovation infuse the cost-benefit analysis with a large dose of uncertainty. It sounds good, but does it work? Will it break? If I adopt it, will people think I’m weird?
Since people are on average risk-averse, the uncertainty will often result in a postponement of the decision until further evidence can be gathered. But the key is that this is not the case for everyone. Each individual’s innovation-decision is largely framed by personal characteristics, and this diversity is what makes diffusion possible. For a successful innovation, the adopter distributions follow a bell-shaped curve, the derivative of the S-shaped diffusion curve, over time and approach normality (257). Diffusion scholars divide this bell-shaped curve to characterize five categories of system member innovativeness, where innovativeness is defined as the degree to which an individual is relatively earlier in adopting new ideas than other members of a system. These groups are: 1) innovators, 2) early adopters, 3) early majority, 4) late majority, and 5) laggards (262). The personal characteristics and interaction of these groups illuminates the aforementioned domino effect.
Innovators are venturesome types that enjoy being on the cutting edge (263). The innovation’s possible benefits make it exciting; the innovators imagine the possibilities and are eager to give it a try. The implementation and confirmation stages of the innovators’ innovation-decisions are of particular value to the subsequent decisions of potential adopters.
Early adopters use the data provided by the innovators’ implementation and confirmation of the innovation to make their own adoption decisions. If the opinion leaders observe that the innovation has been effective for the innovators, then they will be encouraged to adopt. This group earns respect for its judicious, well-informed decision-making, and hence this group is where most opinion leaders in a social system reside (264). Much of the social system does not have the inclination or capability to remain abreast of the most recent information about innovations, so they instead trust the decisions made by opinion leaders. Additionally, much of the social system merely wants to stay in step with the rest. Since opinion leader adoption is a good indicator that an innovation is going to be adopted by many others, these conformity-loving members are encouraged to adopt (319).
So, a large subsection of the social system follows suit with the trusted opinion leaders. This is the fabled tipping point, where the rate of adoption rapidly increases. The domino effect continues as, even for those who are cautious or have particular qualms with the innovation, adoption becomes a necessity as the implementation of the innovation-decisions of earlier adopters result in social and/or economic benefit. Those who have not adopted lose status or economic viability, and this contextual pressure motivates adoption (265).
The last adopters, laggards, can either be very traditional or be isolates in their social system. If they are traditional, they are suspicious of innovations and often interact with others who also have traditional values. If they are isolates, their lack of social interaction decreases their awareness of an innovation’s demonstrated benefits (265). It takes much longer than average for laggards to adopt innovations.
So, we have seen potential adopters’ uncertainty about an innovation is assuaged through a stepwise social process. The tipping point is marked by opinion leader adoption. Well-informed opinion leaders communicate their approval or disapproval of an innovation, based on the innovators’ experiences, to the rest of the social system. The majority responds by rapidly adopting. This analysis suggests that the spread of an innovation hinges on a surprisingly small point: namely, whether or not opinion leaders vouch for it.
Affecting the Diffusion of an Innovation
Now that we know the mechanisms of diffusion, we have a basis for considering what efforts are most successful in encouraging the spread of an innovation. It used to be assumed that the mass media had direct, immediate, and powerful effects on the mass audience (284). But diffusion theory argues that, since opinion leaders directly affect the tipping of an innovation, a powerful way for change agents to affect the diffusion of an innovation is to affect opinion leader attitudes. I will examine the potency of the mass media and persuasion of opinion leaders in encouraging the diffusion of an innovation.
The mass media’s most powerful effect on diffusion is that it spreads knowledge of innovations to a large audience rapidly (285). It can even lead to changes in weakly held attitudes. But strong interpersonal ties are usually more effective in the formation and change of strongly held attitudes (311). Research has shown that firm attitudes are developed through communication exchanges about the innovation with peers and opinion leaders. These channels are more trusted and have greater effectiveness in dealing with resistance or apathy on the part of the communicatee.
Persuading opinion leaders is the easiest way to foment positive attitudes toward an innovation. Rogers explains that the types of opinion leaders that change agents should target depend on the nature of the social system. Social systems can be characterized as heterophilous or homophilous. On one hand, heterophilous social systems tend to encourage change from system norms. In them, there is more interaction between people from different backgrounds, indicating a greater interest in being exposed to new ideas. These systems have opinion leadership that is more innovative because these systems are desirous of innovation (289). On the other hand, homophilous social systems tend toward system norms. Most interaction within them is between people from similar backgrounds. People and ideas that differ from the norm are seen as strange and undesirable. These systems have opinion leadership that is not very innovative because these systems are averse to innovation (288).
For heterophilous systems, change agents can concentrate on targeting the most elite and innovative opinion leaders and the innovation will trickle-down to non-elites. If an elite opinion leader is convinced to adopt an innovation, the rest will exhibit excitement and readiness to learn and adopt it. The domino effect will commence with enthusiasm rather than resistance.
For homophilous systems, however, encouraging the diffusion of an innovation is a far more difficult business. Change agents must target a wider group of opinion leaders, including some of the less elite, because innovations are less likely to trickle-down. Opinion leaders who adopt innovations in homophilous systems are more likely to be regarded as suspicious and/or dismissed from their opinion leadership. Often, opinion leaders in homophilous systems avoid adopting innovations in hopes of protecting their opinion leadership (295). Generally, in homophilous systems, opinion leaders do not control attitudes as much as pre-existing norms do. Change agents must, if possible, communicate to opinion leaders a convincing argument in favor of the innovation that accentuates the compatibility of the innovation with system norms. The opinion leaders will then be able to use this argument, which will hopefully resonate with the masses, to support their own adoption decision.
Successful efforts to diffuse an innovation depend on characteristics of the situation. To eliminate a deficit of awareness of an innovation, mass media channels are most appropriate. To change prevailing attitudes about an innovation, it is best to persuade opinion leaders. Further, what we find is that in homophilous social systems are likely to frustrate change agents with their resistance to innovation. It is only for heterophilous social systems that pushing an innovation to the elusive tipping point is a relatively easy thing to do.
Conclusion
Why has the tipping point become such a popular idea? Carefully researched analysis has shown that it is an undeniable phenomenon that once understood provides simple and valuable prescriptions for efforts in encouraging diffusion. There seem to be many innovations that are valuable for the masses, yet to date have resisted diffusion. For example, we still use the QWERTY keyboard despite the development of another keyboard that allows much faster typing for the average user. Also, there are many social ideals that a large number of people are very interested in spreading. In particular situations, such as our own relatively heterophilous nation, the research suggests that there is a reasonable chance that, given concerted effort, support for these valuable products and ideas may be pushed to the tipping point. And as our communication networks become denser through technological advance, the diffusion process is happening faster and faster. So, it seems that understanding and utilizing diffusion networks can aid strategy aimed at quickly inducing system-wide change.↩︎
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