Unschuld on Professional Control

[Guest guest]

At 5:49 PM -0500 11/8/01, Robert L. Felt wrote:

>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

>

 

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