Intergration concerns

[Guest guest]

All,

 

> 1) how the parameters of integration are defined

> 2) who determines the integration

> 3) what limitations are placed upon the practice of Chinese medicine

 

Through these questions Z'ev has taken the matter into the practical realm.

This means we need to analyze integration's potential effects on control of

professional and clinical authority. In other words, we need to look at

where the power to make the decisions involved may be.

 

Those things I see as facts all center on the disproportion of power between

the field and the culture's economic and political forces. Borrowing from

Dr. Unschuld's speech to the German medical association, these are four

characteristics of professional control:

 

1. Control of access to a body of knowledge,

2. Control of access to resources (e.g.: drugs, etc.),

3. Control of who can practice,

4. Control of what is paid for practice.

 

To begin we can look at each of these and assess where we stand.

 

Control of a Body of Knowledge: We don't have it and we aren't likely to

have it soon because we are not its source. The vast bulk of everything

known about Chinese medicine is in Chinese and we haven't a fraction of it.

Furthermore, as regards the trends of integration, the western profession is

even further " out of the loop " because (excepting a few individuals) we have

virtually no knowledge of what is happening in the Chinese language

journals or bureaucracies in which the idea of integration is evolving.

Since the field recognizes no standards for how claims of clinical validity in

Chinese medicine are made and supported, every claim about TCM is as

good as any other claim, leaving us in no position to assert authority.

 

I think there are some positive trends. From a meeting this summer experts

from both within and without the CM field developed a set of standards for

clinical trials in acupuncture. Once these are broadly promulgated it will

not be possible to ignore the matter and that should have some effect on the

research that gets done.

 

Control of Access to Resources: Again, we have some but not enough. The

FDA decision on the safety and efficacy of the acupuncture needle removed

one of the biggest potentials for outside controls over acupuncture practice,

but the herb products professionals use are mostly supplements and OTC

products that can be bought and used by anyone (and which are being

actively marketed to physicians). We have recently seen how mistakes made

by others (a physicians group in the UK if I remember correctly) resulted in

the banning of some medicinals. Although there was a political response

from the practitioner associations, I think it is clear that they had no

control (and probably not much influence) over the outcome.

 

Control of Who Can Practice: Again, we have some control. We control

access to practice through license exams. But we have no control over

anyone who has another license to practice. Except for a safety report here

and there that shows a better safety record for licensed acupuncturists than

for physicians, chiropractors,we have no evidence, and no way of gathering

evidence, that what we do is superior. We are in the position of getting our

research funding from institutions controlled by physicians and biomedical

standards.

 

Control of What is Paid: I think we have fairly little. Fees are driven by

the market and by the fact that there is generally no extensive third party

reimbursement. Although I am not aware of any unified tracking system

that allows us to make statements about people in practice, I believe the

general impression that there is a disproportionate number of part-timers in

the field and that their presence tends to create a downward pressure on

fees. Again, I don't know this to be true, but this is certainly not a rare

complaint among working clinicians. Theoretically, there are valid

arguments on either side. We could say that the part-time legion is a market

that encourages product development and creates a impetus for the

underemployed to work CM into the many crevices of the health care

system. We could say too that they dilute the force of social acceptance by

presuming that these practitioners have lower levels of success. I don't

think anyone knows for sure.

 

What Paul was pointing out in his speech was that even biomedical

professionals no longer meet these criteria of control (the title was the

``Deprofessionalization of Medicine'') because that control is really in the

hands of statistical management (insurance, HMO policy, etc.). Thus we

are looking at the issues of control in an economic environment where even

the established institutions are in transition. This uncertainty is

compounded by the fact that the field is not of one mind. At the same time

some are challenging physician's attempts to assert control, others are

transferring parts of the practice to them.

 

It seems to me that whether or not someone accepts these four criteria as

valid or complete, any practical assessment would lead to the conclusion

that as things now stand integration will be controlled by physicians on-the-

job, but that the ultimate source of authority will be so-called " evidence

based medicine " as currently practiced by the HMO's. I don' t think this is

by ny means the whole story but I think it does point to some of the areas

where we need to work if the field is to have a practical independence and

clinical authority.

 

Bob

 

 

 

 

 

 

 

 

 

 

 

 

bob Paradigm Publications

www.paradigm-pubs.com 44 Linden Street

Robert L. Felt Brookline MA 02445

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