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CHA Blogs on the Little Hoover Commission Report

by Todd Luger, L.Ac.

December 10, 2004

This is a selection from the table of contents of the LHC report so readers of this series of blogs on the report can read the relevant sections of the report to see for themselves. It should be clear in most cases in what section of the report you would find the relevant citations. In other cases, I have noted where to look. You can get a PDF of complete report here.

The Scope of Practice ............................................................................................................15
The Move to Direct Access......................................................................................................17
The Debate Over Diagnosis ....................................................................................................19
And Which Diagnosis?.............................................................................................................20
Summary.................................................................................................................................25
Education..................................................................................................................................27
Arguments for Going Beyond 3,000 Hours .............................................................................32
Arguments Against Increasing Hours......................................................................................34
Summary.................................................................................................................................38
Continuing Education.............................................................................................................41
Summary.................................................................................................................................45
Examination..............................................................................................................................47
Summary.................................................................................................................................53
School Accreditation Practices............................................................................................55
Summary.................................................................................................................................61
Oversight Concerns ................................................................................................................63
Accurate Public Information.....................................................................................................63
Disease Protection...................................................................................................................64
Herb Safety..............................................................................................................................66
Board Structure.......................................................................................................................68

 

October 25, 2004 11:09:29 PM PDT


I have identified the following herb related issues in the LHC report, most from the section of the report starting on page 67.


1. licensing of non-L.Ac. herb sellers - the state may require laypersons who sell herbs to have licenses that will require training in ID, drug/herb interaction, etc. Will not affect LAc practice, but will affect chinatown herb shops, other herb sellers. could lead to greater credibility for chinese herbs.


2. required disclosures, consumer cautions and public notices - in addition or as an alternative, the state may require various notices be posted in places where herbs are sold. These notices will warn the consumer of risks and the generally unregulated nature of the industry. This more libertarian solution is preferable to me. We should take some responsibility but not allow herbs to be unnecessarily over-regulated. I think caveat emptor disclosures should be sufficient to protect public safety, but licensing of herb sellers would still be acceptable to me if it was the only way to protect our access to these substances.


3. Associated federal regulations - GMP, AA, DSHEA and the definition of traditional asian remedies - the report raises the issues of the definition of chinese herbs under federal law as well as the need to address certain federal concerns on a more local level. They acknowledge there is conflicting evidence on how chinese herbs are classified under federal law. This may result in chinese herbs being restricted for sale in the state. They could conceivably be classified by the state (asian remedies perhaps) and restricted for sale only by licensed herb sellers only upon prescription by an Lac. This would effectively end the practice of chinese herbology in CA outside our field. This would have unintended consequences and affect the local ethnic asian communities. Such a model could be extended to herbology in general. While this would have a economically protective effect on the field, the intent is supposedly protection of the public. However it would violate the spirit of the recently passed health freedom act and seems unlikely to be the route that would be supported by the current administration in the absence of any public need.


4. Purity, potency, safety issues: The state is concerned about herb safety and makes specific recommendations about required testing and disclosures. Certificates of Analysis may be required for all herbs to prove certain things (no heavy metals or ephedrines, for example). This touches upon topics like toxicity and standardization. This will make herbs more expensive if mandatory. I prefer voluntary standards with required disclosures, but again this would have to be acceptable to me if it was the only way to protect our access to these substances.


5 . Reporting of adverse events - a centralized mechanism is recommended. Very strict criteria should be developed in order to prevent over or under reporting. We also want to protect public safety, but do not want to feed the misplaced hysteria over drug/herb interaction. This reporting system will necessitate the development of procedures to insure compliance and accuracy


6 . Labeling of dispensed formulas and packaged products - use of latin botanical will be required on all products and formulas. This will necessitate the development of procedures and supplies to insure compliance and accuracy


7. Clarification of herb scope - vis a vis possible restrictions on substances and conditions: Current law does not state clearly enough what is in our scope. Our training only covers the therapeutic use of chinese medicinals, but our law appears to give us the right to use a much wider array of substances. LHC implies that the intent could not have been to allow us to prescribe substances for which we have no formal training. Further, any current or future expansion of scope to include prescription of substances based upon modern and/or non-OM concepts without a second degree (such as ND) is considered ill-advised by LHC.

This could have major effects on the practices of those who rely on homeopathy, western herbs and other supplements. Since LHC does not want us to use these substances based upon modern concepts, we should lobby to expand the OM materia medica with these substances based upon consensus about their actions from an OM perspective. Committees could be formed for this purpose. For now, we need to seriously consider all the ramifications of allowing the prescription of non-TCM medicinals by clinic supervisors or even students. We have all availed ourselves of this gray area in the law and some of us even are formally trained in these non-TCM modalities. But is it legal and what serves the best academic purposes of the schools. In the past, we could say if we didn't recommend enzymes or glucosamine sulfate, who would? But based upon the main theme of the report, in such cases I suspect LHC would recommend referral to NDs, who are now duly licensed in CA to perform physical exam, lab tests and prescribe these very substances.


October 23, 2004 10:33:58 AM PDT

If one reads the appendices of the LHC report from UCSF, it appears
that LHC took a somewhat stronger stance than this expert adviser.
The UCSF report (PDF here) suggests expansion of the legal scope with necessary
educational requirements as one option. LHC considers that option but
in the end weighs against it. I would not say they outright dismiss
it as one option rather that they recommend others as more preferable.
UCSF notes something of interest and possible importance here,
though. They note that acupuncturists possess the linguistic and
multicultural skills that make them well suited to address certain
primary care needs.

With the well known GP shortage, this may be an opening for some kind
of add-on certificate in gatekeeper level primary care. UCSF also
notes that optometrists can get an add on drug prescribing certificate
as a model for our field. While LHC leaves open this option, it does
not recommend it. But the current governor might think this was a
clever private sector option for the healthcare crisis. Thus another
opening. Why require dual licensure if there is a model for an add-on
certificate that will insure public safety. In fact, perhaps we
should consider an add-on model that could also be applicable to other
fields like physical therapy and nursing so we could enlist alliances
under the common banner of helping to relieve the GP shortage.

Nursing schools would be a logical place to teach this type of
coursework. LHC seemed pretty firm that such coursework should not be
taught at OM schools. That would automatically make it seem that the
only option is some kind of add-on certificate, but at least there is
an option for which a strong case could still be made. That still
leaves a few pressing questions. Such as whether it would still be
acceptable for Lac to code for nonspecific pain complaints such as ICD
code 729.1 (neuromuscular pain) even if the authority to code for
actual diseases (like osteoarthritis) was lost. It is also perhaps
worth noting that while all this fuss was being made about titles and
education and scope by a few vocal lobbyists last year, an
occupational analysis by UCSF found that very few LAc ever ordered lab
tests or x-rays. However it was unclear how many Lac regularly
submitted insurance paperwork with diagnoses outside their scope.
Patients may have had such diagnoses made by an MD in almost all such
cases, but no formal transfer of records is typically done to verify
this.

UCSF also did allow that their were other reasons besides western diagnosis
to order lab tests and that it could be beneficial to the public for Lac to
have some limited scope in this area. Again, with an add-on
certificate. This latter certificate would encompass substantially
less material and yield less authority than a complete diagnosis certificate,
but it would still have to be done at a western med school in all
likelihood. Again, some general certificate that might be applicable
to several professions could be a great legitimizer here. So there
are some openings to insure the continuation of current practice for
those who rely on doing western diagnosis or billing insurance, etc.
Ironically, these add-ons will be necessary for those at any level of
the profession, including DAOM grads. Also, it is likely that those
who were allowed to practice with only 1350 hours education are going
to have a few years to do some very specific continuing education or retire
(herbology and red flag signs probably). LHC is clear that the previous level of
hours of 2350 in CA was more than adequate to protect the public.

Thus while all hope is not lost, I think the dream of an entry level
doctorate in OM is effectively over in this state and by extension,
everywhere else, as well.

I have quoted the LHC report at length on the matter of increasing educational requirements (pg 38):

"The number of educational hours should not be increased, and should be focused on traditional Oriental healing practices within a modern framework for patient safety. Specifically, the Acupuncture Board should implement the following policies:
Educate within scope. The State's required courses for licensed
acupuncturists within schools of traditional Oriental medicine should
only be for subject matter needed to competently and safely practice
the legal scope of practice.
Devote adequate curriculum to patient safety, including
coordination
. Once the new curriculum has been implemented, an
independent evaluation should be conducted to ensure that concerns
about minimum training needs have been met. Special attention
should be given to patient safety training, including:
Up-to-date infection control practices that meet the standards of
the National Institutes of Health, such as exclusive use of single use
needles.
Improving coordination with Western medicine, including
recognizing "red flag" conditions, and knowing when and how to
refer to and work with physicians.
Teach within area of expertise. Courses in physiology, chemistry,
biology and other sciences should be taken at colleges and
universities that are accredited to grant degrees in those areas. The
board also should separately consider requiring successful
completion of basic science courses as a prerequisite to educational
training in traditional Oriental medicine.


If there was truly truly any intent to sanction an entry level DAOM, why would they also say on page 26:

Allow for acupuncture-only licensure. To ensure public access to
acupuncture services – for instance, to promising addiction therapy –
a separate category of licensure should be created for professionals
who provide only acupuncture, and not the array of traditional
Oriental therapies. A reduced educational curriculum and
examination would have to be developed and implemented
.

OTOH, the possibility of getting the state to allow an add-on western diagnosis
certificate such as LHC has proposed and I have described below could actually result
in LAc's gaining access to a far greater scope of practice than we ever imagined. If a complete
western diagnosis certificate were available, it might be possible to get
limited drug prescribing add-ons and be able to independently practice
combined drug/herb therapy. There was no way any such extension of
power could ever happen under the basic acupuncture practice act
itself. Face it, for those who are interested, it would be a far
better education in Western Medicine, thus better for the public. Schools could
focus on Oriental Medicine and only those who wanted the add-ons would need to go
that route. LHC also recommends the development of private boards for
advanced certification, stating that is the normal route to
demonstrate expertise beyond basic competence in WM. Perhaps we
should work towards expanding our scope in this indirect way instead
of wasting resources trying to create what would effectively be a
lesser entry level status.

 

October 17, 2004 5:54:05 PM PD

LHC makes it clear we are not dealing with real legal precedents here when it comes to previous board rulings.  They were not decided by either a judge or jury in most cases.  Board rulings substitute in lieu of legal decisions, but they do not have the weight thereof.  Thus, they do not form a true legal precedent.  If the board rulings were not truly authorized, they have no standing at all and may be wiped away with a single pen stroke.  Most Lac do not order lab tests and most make diagnosis in order to get insurance payment, not to aid in treatment.  This is according to surveys and testimony taken by LHC.  LHC does not believe the state needs to grant rights that serve economic purposes only.  They claim that if we don't need lab tests to PRACTICE OM safely, then we don't need them at all.  Since the main claim to being allowed to practice OM is that it has this long history of safe and effective use despite the lack of any modern research, we cannot then turn around and claim that we can only be effective when using modern methods.  If we need modern methods to practice safe and effective, then our entire claim to legitimacy collapses.  

While I agree there are other reasons to make diagnosis and order tests that are still desirable, this really is an example of catch-22 meets the emperor wearing no clothes.  LHC has made it very clear.  The board and the state are NOT to be involved in promoting the profession of acupuncture at all.  Their sole role is public safety.  If you are saying we NEED the tests for reasons other than economic, then the profession will also collapse as there is no evidence to support much of what we do except our tradition.  If we don't NEED the tests for clinical reasons, then they are lost to us.  BTW, this will hurt the schools and those who have insurance based practices.  It will also hurt those with cash practices as they have to compete with former insurance based practices.  However I suspect that many of those who were making over 200-300 grand doing insurance will never be happy with 50 grand a year in private uninsured practice.  So they will leave the field.  So there could be a shakeout of practitioners.  There could also be a shakeout of schools and not all will survive.  Yes, there COULD be less students, but enough for the schools that remain.  

However there is another possibility and this seems to be one of the goals of LHC.  That many more possibilities for true collaboration between WM and OM will develop after the two professions are clearly delineated in the law.  In other words, the days of private practice as a a road to riches may soon be over, but there may be a lot more jobs available in places like Scripps and Kaiser once our role is clear.  I am not sure if LHC is right, but as one who much prefers a paycheck to a private business, I can only assume there are many others in the field who would be more than happy with a job instead of an office.  I think LHC feels that when we focus all our resources on developing OM in its own right, that is when doors will finally open.  The emphasis on science in our field by many who do not understand it has led to pseudoscience about energy fields dominating our press releases.  A truly serious presentation of OM could go a long way.  As for science, we can use it where its most important and LHC encourages this.  We can use science to prove OM works.  That is very different from using science in our OM practices.  If we do the research and prove things, then there will be more, not less, students at the remaining schools.


October 17, 2004 11:42:04 AM PDT

The number of hours of clinical diagnosis in ND school are similar to the number of hours of training in these areas for all other fields that allow western medical diagnosis, such as PA, LNP, MD, DO, ND, DC.  While it is correct that LHC only pertains to CA, that is where half the Lac are and this document could have ramifications for insurers in all 50 states.  Actually, CA laws about the environment, workers rights, taxes and healthcare have spread to many other states.  You may think they are bad policy and I may agree in some cases, but that does not change the matter that CA often DOES lead the way in these matters.  It may not affect the heartland or backwoods much, but most major metros follow suit to some degree over time.  

could be met w/o at least 1000 hours of focused WM education and all supervisors in clinic trained to guide students in all those areas. Since the current masters is 3000 in CA and the current DAOM another 1200 and since the required material cannot be covered in the masters, about 500 hours of the DAOM would have to be hardcore WM in order to get even to this level of making a basic western diagnosis (which I still don't think would cut it, having had the more extensive training myself).  So where would the advanced OM be?  

October 17, 2004 11:14:37 AM PDT

LHC has left the door open to use codes other than ICD-9 in order to
make insurance claims.  But are there any?  It was suggested to me
that a set of codes applicable to OM are currently being tested.  They
are the ABC codes.  But I believe these codes are not diagnostic
codes.  They are procedure codes and should be compared to CPT codes,
not ICD-9.

An alternative set of diagnostic codes unique to OM would allow us to
make claims for lung wilt due to yin vacuity (BTW, another coup for
the wiseman crowd; the only way to use codes of this nature is with a
standard vocabulary.  We can't agree amongst ourselves what to call
things, but we want insurers to reimburse us anyway. uh-huh).  In
order to develop the OM diagnostic codes, we need to have professional
standards of care so there is some inter-rater reliability to these
diagnosis  It does no good to label something if the definition of the label
is allowed to shift at the whim of the practitioner.  This gets back to how do
we prove our diagnoses exist in the real world and that we can
reliably identify and treat them?  The sole answer is research, which
brings us full circle to the issue of EBM (evidence based medicine). 
LHC has suggested that our scope may need to be restricted based upon
the existing evidence. That it must be explicit about what we can and
cannot treat.  Several times the report alluded to the fact that we can
treat all areas of the body as if this may not be appropriate.  

Perhaps some of this sounds familiar, as it resembles a lot of what I
have been writing on the CHA list for years.  We need research to prove our diagnosis
are real, our formulas are active, our strategies are effective and all
three of these are intimately linked.  If we do not do these things,
we may see ourselves go the route of the chiropractors, limited to treating a
few pain complaints, at least if you want reimbursement.  I won't
claim to have vision, but I can see the writing on the wall.  So
what's next.  I hope we don't put our heads in the sand and just hope for the
best, forestalling necessary research under the pretense that
something else is more important.  Because if we have nothing to bring
to the table when we are stripped of our rights to use current ICD9
codes, then it could be months or years before the problem is rectified.  

The time is now to work to avoid any or all of the nightmare scenarios
that are possible.  First, people said sit tight and wait for LHC. Now
the same people are saying sit tight and wait for the legislature.
The position of the LHC was predictable, though.  As is the response
of the legislature.  We need a contingency plan now.  The beauty is
that research can only help, even in the best case scenario, so why
not?  We should support the society for acupuncture research as the
current best organized entity working towards this goal. 
We should also consider creating a new nonprofit entity with a board
to work on developing
professional diagnostic standards and codes, demonstrating interrater
reliability of diagnosis, validity of zang-fu paradigm and clinical efficacy
of herbology for a wide range of complaints.   

October 17, 2004 9:50:35 AM PDT

anatomy 125
cadaver lab 40
physiology 125
biochem 125
pathology 125
clinical and physical exam 250
orthopedic exam 150
x-ray 125
lab diagnosis 125

T these are about how many hours are devoted to the fundamentals of western diagnosis in ND school in the first two years (other subjects are homeopathy, herbs, nutrition, etc.) the second two years coordinate with clinic the specific diagnosis of complaints by body system (derm, gyn, cardio, etc.)

While the first 1000 hour covers the fundamentals of diagnosis, it is really the 500 hours of specialty classes plus 1000 hours of clinic in which one really learns western diagnosis  Assuming there is some overlap in a few science classes (which would probably not transfer into such a certificate program anyway), you would need more like 2000 hours of clinic and class to get your Western diagnosis certificate.  Testing out would not be an option as clinical competency must be determined over time.  And we cannot expect an easy way out.  That would just be another example of corruption to the state regulators.  I just don't see how we can make a case to keep this supposed "right" w/o a very extensive (and no doubt expensive) add-on certificate from a med school.

This will also affect CEU providers as certain courses will be prohibited as outside scope (anything that involves western diagnostics, for example).  Others maybe prohibited as not serving the public, but only the profession.  Practice management CE is likely to be banned, for example.

October 17, 2004 9:27:57 AM PDT

ANONYMOUS: "I think the general theme is that we should only do what we are
trained to do. So if we bring our education up to general community
standards and demand BA or BS for entry and teach what is needed, I do
not think they will see they anything problematic. What they clearly
refute is the level of training we get being sufficient to make a
diagnosis."

A lot of people want to believe that what is written above is the
main theme of the report, but I think a close reading of the entire text in
context and not just selecting lines that seem to support this reveals
otherwise.  They not only say over and over again that we are not
trained to do these things.  They also make it very clear that it was
not the intent of the legislature that we do these things, that we do
not need to do these things to practice pure OM effectively and that
they do not think these things should ever be part of our profession
(not agreeing, just reporting).  While one brief line refers to
postgrad certification in physical exam and lab testing as a possible
option, the entire thrust of the rest of the report is not in this
direction.  What is repeatedly called for is dual licensure for those
who want it all.  In addition, the fact that they believe that very
extensive training is necessary to do WM exam and testing properly,
the certification route would probably be hundreds of hours of class
plus supervised clinical training.

I quote at length starting from page 25:

"Keep licensure focused on traditional Oriental medicine.
Consistent with existing “intent language” and legal opinions, the
statute should clarify that licensure is for the practice of traditional
Oriental medicine as an alternative and a complement to Western
medicine. Practitioners interested in mastering both Eastern and
Western methods should continue to seek licensure under both
systems
.

Define primary care practitioner. The statute should make it clear
that acupuncturists are primary care practitioners within the context
of traditional Oriental medicine, and are responsible for referring
patients to primary care practitioners in the conventional medical
system when appropriate. The law should make it clear that the
definition does not impose requirements on health care providers
regulated by the Knox-Keene Act.

Authorize and define traditional Oriental diagnosis. The scope of
practice should include an explicit authorization to conduct
traditional Oriental diagnosis. Practitioners who are already licensed
and choose to perform biomedical tests in making any diagnosis
should be required to complete specific continuing education
requirements and take a supplemental examination
." 

Basically lets get real here, what does an RN or PA need?  We are
talking about 1000 hours of WM to qualify.  They even mention in NH,
one must be an RN or PA to be an LAC (is that true? even if not, it
underscores their position).  But I cannot reiterate this more
strongly. LHC sees no role at all for western diagnosis or the methods used
to make that diagnosis in the field of OM, now or ever.  This was pointed out
to me by Tom Haines, dean at PCOM, after I had only read the exec
summary and skimmed the report in areas of interest.  It was only
after reading the entire report in order from cover to cover that I
saw that Tom is right.  The report includes extensive appendices and
huge amounts of testimony was supplied from the profession along
exactly the lines you state.  I really think think there will be little
interest in another long round of inquiry and testimony.  It will now
come down to which of the LHC recommendations are taken, not whether.
For example, we can license herb sellers or clarify the disclosure
laws, but the status quo is not an option anymore.  

With regard to western diagnosis and exam, I think LHC is also clear.  Its
not part of OM and is not necessary to practice (in my experience,
most patients are under doctor's care and the others who are not can
usually be triaged for urgent care based upon q and a alone).  Since
LHC clearly thinks dual licensure is the best route and they also do
not think western science and med classes should be taught at OM
schools at all (they think the necessary WM classes should be taught
at WM or mainstream colleges), any certification route would have to
have a really high bar to meet their goal.  It would have to be done
at a med school probably.  I would doubt if this would fly though.
Because it would be like creating a subclass of western diagnosticians
for the sole use of our profession.  I can't really see anything less
than the most basic nursing degree being acceptable.

October 17, 2004 8:56:11 AM PDT

Actually I was wrong about the LHC report not mentioning physical
exam.  In the midst of a long discussion on education, LHC blasts the
passage of AB 1943 last year for a number of reasons.  AB 1943 was a
CA bill passed last year mandating programs of no less than 3000
hours, up from the old 2350, I believe.  LHC pointed out that each
increase in educational requirements has been ostensibly to fulfill
the scope of practice.  However, LHC maintains that the Acupuncture
board incorrectly interpreted scope of practice for many years in
order to elevate the status of the profession.  LHC singles out the
requirement of AB1943 that would add 240 hours of "clinical medicine,
patient assessment and diagnosis" to the curriculum as an example of
increasing "requirements in areas of practice where the legal
authority to provide that service is unclear".  This would include
physical exam used in WM but not in OM.  While this statement is
diplomatically vague, their final recommendation is not.  It says OM
coursework "should only be for subject matter needed to competently
and safely practice the legal scope...".

Now I don't disagree about the usefulness of being able to
order lab tests.  I have been a loud trumpeter of the cause of
integrative med for a long time.  However arguing that we needed to do
it all was really a matter of necessity more than common sense.  I
never felt OM training was adequate to ground one in this area.  I got
an undergrad degree in physiology and also studied western physical
and laboratory exam quite extensively at naturopathic school.  For
those who are unaware, the accredited naturopathic schools actually
teach as much if not more physical and lab exam than regular med
schools.  But acupuncture schools do not and cannot without shorting
the study of OM itself.  And our law apparently does not grant us this
right anyway. The argument of necessity or convenience is a slippery
slope.  That is the same argument that could be used for any
overextension of anyone's scope.  That a Chiropractor should be able to do
acupuncture because they can do a form of it safely and it is
convenient for their patients.  Where is the line drawn?  There is one
line in the report even questioning clinical counseling as outside our
scope.  

Now an increase to 4000 hour entry level doc might make a place for
such studies (but probably at the expense of chinese language and
classics), but I think LHC has made it clear that WM is not the domain
of our profession.  Not at the masters level or at the doctoral level;
not with any number of hours.  That if one wants to be an integrative
practitioner, one must pursue a dual degree; they says this a number of times.
It is a key theme in the report. An option now in CA is the ND degree which does allow
western diagnosis and exam and lab tests.  For those who want it all,
pursuing an ND or collaborating with one is the way to go.  In fact,
my private practice in OR forced me to collaborate as all WM diagnosis is
illegal there for LAc.  So my experience prior to CA was of the nature
now recommended by LHC.  My focus in the last few years on an
independent integrative practice has been due to 3 artificial pressures.

1.  my erroneous belief that CA law allowed us to basically practice
naturopathy by allowing western diagnosis, lab tests and prescribing of
supplements other than chinese herbs (yes, in all likelihood,
clarifications of our scope will eliminate our rights to prescribe non
TCM supplements as is the case in OR - since we are not trained in
their use, they are not part of OM and any use is thus predicated on
either other folk traditions or modern science, they are outside our
scope).

2.  the absence of any other licensed healthcare professional in the
state with formal medical training.  Thus necessity dictated that I
sometimes ordered lab tests I would rather have referred to an ND for.

While the LHC report is a mixed bag, there is no doubt that the intent of
the authors is to limit us to OM.  They also recommend some kind of
mandatory WM examination of patients undergoing acupuncture for
chronic undiagnosed complaints.  One silver lining is that it does get
us back to brass tacks.  The focus of learning to treat pain should be
the classical works on bi syndrome plus the tui na techniques of old,
not Travell's trigger point therapy.  Practices like NAET and AK are
definitely called into question.  If western med is not the area in
which the profession will expand, then it will be in the realm of OM
itself.  LHC recommends getting rid of unnecessary WM in the current
master's curriculum.  What will replace it in order to keep the 3000
hours in place.  The schools will look for other subjects to fill the void.  

Is now the time I never thought would come, when there may actually be
a place in the master's curriculum for chinese language and classics
and even a mandate from the government to pursue that route?
Certainly there is a logic to it all.  We are the supposed experts in
OM, but as a profession we are unwilling to pursue the deeper study of
our own medicine, which is only possible if a large number of us learn
to read chinese and do profuse translation.  So we look to our
existing strengths (like science in my case) to shore ourselves up.
Others overlay OM with spirituality or energy medicine, but none of it
is really OM.  People (like me) pride themselves on their skill at
searching the medline or the internet, but sidestep the huge and
obvious gaps in such searches as most such data relevant to OM is
beyond the realm of the english language (perhaps more than 90%).
Perhaps the profession should focus deeply on the study of OM and
leave all the WM to someone else.

Recent research and publication scandals in WM leave me even more
disillusioned with much of the existing scientific research.  Vested
interests at both NIH and prominent journals.  But even more
disturbing is that drug companies may bury ten studies that show a
drug is dangerous until they get one that shows it to safe and
effective.  I still think good research has been done in WM and can be
done in OM, but much of what we think we "know" could be wrong.
Consider the past few years and HRT, phen-fen, SSRIs, now vioxx.
There is no doubt in my mind that drug companies have buried numerous
studies showing increased suicidal ideation with SSRIs.  We should
probably get our own house in order before we jump too quick into theirs.

BTW, I have been invited to speak at the Scripps natural supplements
conference in january in SD.  My co-lecturer will be Pamela Richter,
DPharm, L.Ac.  She will speak about a model she has been developing to
predict possible drug/herb interactions and safely avoid them.  She
shows how in most cases, time of administration can eliminate all
risk.  I will present the idea of collaborative drug/herb prescribing
for maximum therapeutic benefit.  Using examples from the chinese
research literature about combining drugs and herbs to lower side
effects and maintain drug benefits.  The emphasis will be the need to
work as a team to do this and monitor with lab tests as necessary.


October 16, 2004 5:09:48 PM PDT

One disturbing aspect of the LHC report has repercussions for the
healthfood industry, chinese herb shops and the burgeoning health
freedom movement.  That is the recommendation to license sellers of
herbs.  This is a clever way to sidestep the CA health freedom act.  It
does not require a license to write an herbal prescription, but
requires a license to sell the herbs in that formulas  They recommend this
only for unlicensed herbalists.  Licensees would be exempt.  Licensing
sellers would ensure at least one part was responsible to the law for
the herbs sold.  In theory, a licensed herb shop could reject filling
a formula because of suspected drug/herb interactions.  Again, this
would not affect licensees within their scope.  

As an alternative which is perhaps more likely under the current
regime, they want to make explicit that unlicensed herbalists MUST
follow the disclosure rules of the health freedom act or risk
prosecution. I think a fair middle ground would be to license herb
sellers for those who want big daddy's protection but still allow
others to sell herbs unlicensed as long as they make full disclosure
of their training or lack thereof.  That's really the way I think
licensing of anything should always be.  Optional.  It really allows
democrats and libertarians to live in the same world.  Personally I
like my physicians licensed, but not my barber or my mechanic.  OTOH,
I am glad I have had access to many and sundry unlicensed teachers
over the years.  Both can exist in a world of informed consent and
then the only ones who are injured are those who choose to take risks.
 

October 16, 2004 4:29:00 PM PDT

I have been reading the full text of the little hoover commission
report.  Some of the more important recommendations are summarized
below.  Currently there is a moratorium on new rules in CA, but this
will not last forever.  Most of the issues on my mind refer to the the
recommended rollback of most of the previous rulings on western
diagnosis and primary care.  While the board has repeatedly ruled in
ways that expanded the latitude of western diagnosis, the LHC believes they
did this without legislative intent and for reasons having mostly to
do with status and economics.  LHC recommends that previous rulings on
western diagnosis be replaced with a clear wording that restricts this
practice to traditional OM methods.  And that ordering lab tests used
for western diagnosis also be clearly prohibited.  The goal of LHC is
encourage the development of a distinct OM profession that can
collaborate with western med.  

So the idea that we need to order lab tests in order to track progress
rather than make diagnosis is also implicitly rejected.  If such tests are
needed, one should refer to an MD, ND or DO.  If one wants to perform
such tests, one must either get one of these licenses or do additional
certification.  While the summary mentions the option of postgrad
certification in lab tests, a close reading of the full text shows
this is clearly not what LHC considers best.  The general theme
running through the report is that we should not be training students
towards the goal of becoming an independent integrative practitioner,
but rather fully focus on OM and train towards the goal of
collaborative integration with others who are trained in western med.
 In other words, if you want to do it ALL, you will now need to get
ALL the degrees, not just use any single license as a basis for any
style of practice one chooses (how will this affect OM practitioners who work
purely from a western orthopedic or allergy model; will they be
outside scope now?).

This brings me to physical exam.  One of the current hot button issues
in the PCOM clinic is the issue of physical exam.  There are some who
are arguing that none should we be doing more of this, but even that
we must be doing more of it in order to protect ourselves against
liability.  However, while LHC is crystal clear about lab tests and
also about restricting us to OM diagnosis methods, it does not specifically
address the issue of physical exam.  Arguably, some forms of physical
exam were accessible to ancient physicians, such as palpation of body
parts.  However invasive exams (like GYN) were not done, nor were
rectals.  Nor were exams requiring modern devices like stethoscopes,
BP cuffs, ophthalmoscopes, etc.  My reading of the LHC report suggests
to me that their intent was also to recommend the prohibition of any
form of exam that was not part of traditional OM practice.

This all raises the issue of how one would recognize ominous signs
necessary for referral to an MD.  PCOM has put considerable emphasis
on training students in recognizing certain presenting s/s, but also
in some cases, by listening to the chest, looking in the ears with a
scope or even ordering lab tests.  We do dipstick urine tests onsite,
for example.  Where is the line to be drawn?  A few days ago, a
patient of the clinic who I had not seen before presented with a long
standing breast mass that was now quite painful.  She was feverish and
cachexic.  I knew from her history that she had been advised for lumpectomy
and biopsy over a year ago and had refused.  She now appeared
metastatic.  

A colleague of mine who is a med school grad (but not a licensed
physician) insisted it was essential that breast exam be done.  I
consented in light of the very gray and dire matter.  He performed the
exam with a female intern and assistant.  I did not observe.  He
confirmed what was already clear.  The tumor had all the
characteristics of cancer.  Here's my point.  If my colleague had come
up with a more ambiguous physical finding, it would still be a matter
for referral.  I think it would be very unsafe to not refer in such
cases regardless of one's physical findings.  There is just not
enough time to learn proper physical exam during internship and also
learn herbology, etc.  So if one needs to refer anyway in such cases,
why do we need to do the physical exam?  

The examples are endless:  the patient has signs of hepatitis, but I
cannot detect liver enlargement.  I still refer.  The patient has a
severe earache and I do not visualize any discharge.  I still refer.
My point is that we are not experts in physical exam and no amount of
extra training will make us so.  In fact, I think one of the points of
the LHC report is that the public is done a disservice not only by
acupuncturists doing mediocre western diagnosis, but also by shifting undue
resources to training in this area and thus taking time away from OM
studies.  This report does diminish the scope of acupuncture in CA,
but also strengthens the establishment of a truly independent OM
profession.  In some way, this report is largely a vindication of
purist approach to OM.  While advocating integration between the
various medical fields, it pretty much advocates purity within the OM
field.  Not just one style, but only styles based on traditional
concepts.  It is definitely a rejection of the Kendallian crowd,
NOMAA, et. all.  It is a coup for the language and classics advocates
as the report implicitly suggest that advanced studies in OM should be
OM oriented, not WM.

I believe the report implicitly rejects the idea of an entry level
doctorate in CA.  I believe it also rejects an expanded scope for
those with DAOM degrees.  At least in the area of WM.  They reiterate
over and over again that it only confuses the public and thwarts
integration to grant any WM type of scope to our field.  Andrew Weil
even submitted testimony against any L.Ac. use of doctoral titles at
all for this very reason.

The board composition will be restricted to public members or will be
majority public.  the past board minutes reveal that the board has
spent all its time attending to economic interests and none to public
safety.  However LHC recommends getting rid of the board altogether,
which is very likely.

New herb regs will affect labeling and sales.  Chinese herb sales may
be restricted to L.Ac. offices or licensed herb shops only.  Complete
Botanical names must be on all labels of dispensed products.


October 6, 2004 8:56:26 AM PDT

LHC has made it very clear.  They are advising the state to eliminate any pretense that we are allowed to make western diagnosis  And further, we will be stripped of our right to order any and all lab tests.  If we want to do that, the LHC suggests we go to medical school or get specialized postgrad certification.  This is quite reasonable, as current training, even at the 3400 hour PCOM program, heavy as it with western science, does not provide adequate education in western diagnosis  It is possible that those who achieve a DAOM in a program that does teach these methods could have this aspect of the scope restored.  But I would not hold my breath as ACAOM has not mandated enough western med in the DAOM program to satisfy state regulators on this accord.


October 6, 2004 8:37:07 AM PDT

an interesting statement from the LHC report.  it suggests to me that the state of CA has no intention of ever mandating an entry level doctorate as master's training meets the needs of the scope.  They have chosen instead to clarify (and basically restrict) our scope to the current level of training instead.  They are thus tacitly supporting (for now) a multi-tiered profession (as the second tier has already been authorized).  As you know, I have also supported multi-tiers, the main ones being my positions on limiting unnecessary societal costs and minimizing government regulation into the practice of any profession.  With regard to herbology, it is already legal to practice it as an unlicensed herbalist in CA.  So it would seem ludicrous to mandate an entry level DAOM for ourselves when the state has already decided that no formal education is necessary to legally practice herbology.  These laws are all about acupuncture and really have little or nothing to do with herbology.  Dave Molony of AAOM likes to point out that most states that licensed acupuncturists do not include herbology in their scope.  However as long as you have no need to practice acupuncture, the state cannot constrain your herbal practice.  Just give up your license.  Roger Wicke has proved that this is legal in all 50 states and has an ongoing challenge to anyone who can show a case of prosecution for practicing herbology as long as one does not claim to be a physician (HINT:  juries have acquitted all such defendants over the past 200 years with zero exceptions).  Whatever ACAOM or NOMAA decides, I suspect few if any states will ever mandate an entry level DAOM as it serves no public need (as goes CA, so goes the country).  We are the only state so heavily controlled by democrats and we rejected it.  Republicans will have nothing to do with such chicanery and they control most statehouses.  I think the most telling statement below is the one that refer to using the board to try and increase professional status.  I have always thought this was reprehensible and now it has been made clear that the state of CA will have no hand in the disgusting ploys of some in our field to consolidate power. From page ii of the executive summary.

"The profession has sought to elevate its standing through the
regulatory process. While educational requirements were recently
raised, the profession asserts that still higher minimum standards
are needed to achieve "parity" with Western primary health care
providers. The purpose of the government's educational
requirements, however, is clear and limited to preparing entry-level
practitioners to perform their scope of practice. They are not
intended to serve as a measure of professional status or to favor one
sector of the profession over another."

 

 

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