who gets to practice what?

April 23, 2004

This is from Gene Bruno, president, AAOM, on the AT website at

http://www.acupuncturetoday.com/online/bottomline.html

It was written in response to an article last month arguing the rights

of chiros to practice acupuncture (but not oriental medicine). My

thoughts are interspersed.

Bruno writes, " In China, attempts to reduce the practice of acupuncture

to a therapeutic technique have resulted in utter failures.

Acupuncture, practiced without the benefit of the theoretical

principles which underlie it, and the logic which informs its treatment

plans, is at best minimal and perhaps detrimental in terms of patient

use. Some argue that it creates a clear case of endangerment. "

My thought: This does not seem to be accurate in light of the ongoing

german research, which shows excellent results for medical acupuncture

and sham acupuncture, both done without any traditional theory or dx.

In fact, most chinese research on acupuncture has been allopathic, not

involving pattern dx. Not only has the research shown this approach

not to be detrimental, but actually quite effective. The word

endangerment seems way over the top here. I understand the need to

stake our claim here, but making such statements does not seem helpful.

It does raise a good question, though. How are we to distinguish

ourselves as the deserving guardians of Oriental Medicine? I have said

before that I think this battle is a losing one. Medical acupuncture

appears to be at least as safe and effective as TCM. If we claim

otherwise, we will just draw even more scrutiny upon our own lack of

supporting research. We can't win the battle of who gets to insert

needles and upon what basis. We need to focus upon protecting our

right to practice at all. If we prove our methods effective, it

doesn't matter if other methods are equally effective. We get to keep

our piece of the pie. But if we continue to devote precious time and

resources to trying to prove other folks are dangerous and ineffective

(when the evidence overwhelmingly suggests otherwise), we will lose our

place at the table.

More and more, medicine will become evidence based. and the evidence

just does not seem to be on our sides. We should all band together to

do the research, rather than fight amongst ourselves. I don't really

understand why its so important to some people that the way we do

things is right and the way MD's do them is wrong. Part of

understanding chinese medicine is learning to accept irreconcilable

contradictions between schools of thought or famous physicians. Is it

possible to entertain the idea that western medicine is just another

school of thought. Perhaps we could call it the anatomical school.

Why is it such a stretch to accept that if acupuncture can be applied

successfully according to the five phases or the mirroring of Dr. Tan

or the zang-fu method of TCM or the auricular of nogier or the hand

needling of korea, that it could also work when applied according to a

neurophysiological model. I think we need to let go of this its our

way or the highway mentality when we cannot even agree on what is our

way. If we are willing to accept the diversity within the field, we

must accept that from outside as well. To be honest, things like NAET

and the use of tuning forks to balance chakras as well as countless

dubious electronic technologies concern me far more than the practicing

based upon a neurophysiological model. Are we prepared to purge the

heretics from within our ranks as well.

Bruno goes on, " Second, the fully expanded practice of Oriental

medicine adds to the study and practice of acupuncture the use of the

vast field of traditional Chinese herbal medicine. The use of herbal

medicine for the treatment of disease is based upon the same underlying

theoretical framework as the practice of all aspects of Oriental

medicine; therefore, the study of acupuncture and Chinese herbal

medicine combine synergistically to form the unitary practice of

Oriental medicine. This term is now widely accepted throughout the

world, and the degree in Oriental medicine is now the accepted degree

in the United States, Korea, Taiwan and numerous other venues. But the

separation of any of these therapeutic interventions from the body of

knowledge that underlies them is anathema to the proper and responsible

practice of this medicine, or indeed, any medicine. "

My thought: According to Unschuld, most acupuncture has been practiced

historically by those who were unfamiliar with any written theory, as

they were illiterate. Historically very few acupuncturists were also

herbalists. No harm seems to have been done as a result. In modern

times, many countries regulate acupuncture as a distinct medical

practice, separate from herbal practice and sometimes as part of

western medicine. This includes france, germany, japan. And in the

PRC, TCM docs are trained as either acus OR herbalists, rarely both.

Again, no harm seems to come of this. The case of absolute necessity

for not separating acupuncture from OM remains weak, IMO. It is thus

ironic that Mr. Bruno elsewhere in the article says, " The Council of

Colleges of Acupuncture and Oriental Medicine is already working

diligently on a degree at the doctoral level to continue the study of

acupuncture as a solitary practice well beyond even 3,000 hours of

study. In Japan, the practice of acupuncture is the practice of

Oriental medicine, and the training for acupuncturists is at least as

rigorous as the training for any other branch of medical practice. "

My thought: If acupuncture must be part of an integrated " oriental

medicine " for " proper and responsible practice " , why point to the

importance of standalone doctoral acupuncture programs and japanese

training (which does not include herbs) as part of your argument? In

Japan, despite our fascination with their " classical " meridian styles,

much acupuncture is actually practiced as a form of medical acupuncture

according to modern physiology. This is reported by shudo denmei in

his meridian acupuncture text. In addition, I highly doubt that " the

training for acupuncturists is at least as rigorous as the training for

any other branch of medical practice [in Japan]. " I think it takes two

or three years. Perhaps someone could comment more accurately on this.

Bruno follows with, " Third, the promotion of adopting of a sterile

group of interventions and practices by other professions is not

acceptable to most medical fields. Why, then, should it be acceptable

to Oriental medicine? For a comparative example, we could extract

adjustment techniques from the study of chiropractic. It is foolish to

assume that 100 or 150 hours is not sufficient for any reasonably

skilled medical professional in any other field to learn to perform

chiropractic adjustment by rote. Would the field of chiropractic then

suggest that licensed acupuncturists throughout the country study

adjustment technique for 100 hours, then practice as much of that

medicine as they felt they could comfortably deliver? "

My thought: In fact, many acus in CA do perform spinal manipulation,

claiming it is allowed under our oriental massage provision. I believe

Alon will confirm this. However, there is minimal to no training and

supervised clinical practice of spinal manipulation. I do not dispute

that manipulation is part of tui na, but if we are to do it, then

should we not be trained in it to a reasonable number of hours. The

same goes for the ordering of lab tests, x-rays, etc. There is little

academic or clinical training in these areas. Same for the

recommendation of western herbs and other supplements to " promote,

maintain and restore " health, legal under CA law. Yet also no training

in these areas. While many people believe it is legal to prescribe

anything that is sold in a healthfood store, actually it is technically

illegal to treat any illness with herbs unless your scope of practice

explicitly allows it. So, for example, the rx of western herbs and

most other supplements is illegal in OR for acus. I won't debate this

last statement. It was worked out with lawyers from NCCAOM when I was

at OCOM. Talk to them. In some states, scope does not allow herbs at

all. But in others with broad herbal scopes, there are acus who never

studied herbology or took a board exam in herbs. Should those acus now

be banned from herbal practice w/o more schooling. And yet we seem to

do all these things safely, just as it appears medical acupuncture is

performed safely across the world. Do we really want to open this can

of worms. We might be the ones who end up worm food.

Chinese Herbs

FAX:

April 23, 2004

I think, actually, that Dr. Amaro, the chiropractor who in his AT

article suggested calling acupuncture as practiced by M.D.'s and D.C.'s

by a different name, i.e. not Chinese medicine, had a politically

realistic solution to the problem. I don't think, practically

speaking, we can stop the adaption of acupuncture by other professions

at this point. We need to, as you've suggested, stake out our own

turf.

In the past, chiropractic/M.D. training was quite deficient in

acupuncture. In Colorado 20 years ago, folks like myself who were

trained in Chinese medicine couldn't advertise as acupuncturists, while

chiros and M.D.'s could. There were some incidents of punctured organs

from chiropractors at that time, (I knew two cases of pneumothorax and

one of a punctured kidney!). By speaking with the chiropractic board

about this, when I was president of the Acupuncture Association of

Colorado, along with a few colleagues, we were able to get an agreement

to change chiropractic advertising (no more use of the term

acupuncturist), and to improve standards of training. After that, for

awhile, chiropractors only used the 'tai-shin' and laser or electric

devices.

Action could have been taken on a more national scale, perhaps, 15

years ago, but now the best we can do is define our turf, and agree to

label M.D. and chiropractic acupuncture separately, including what is

treated. As more people experience acupuncture, it may actually

benefit us from the exposure. . . as long as they are reasonably

trained and people have a good experience with it.

While acupuncture and herbal medicine may be separated in Japan and

China, I don't think it is a good idea to separate them here in

America. I think we need to identify with Chinese herbal medicine and

its vast knowledge base in order to give ourselves something to hang

our hats on. It is fine if people want to concentrate on one or the

other, but I think separating the acupuncture and herbal professions

will weaken our stance as health professionals in this country. I

think, ultimately, the doctorate degree status will be where it is at.

I see us potentially as " Chinese naturopaths " , and hope we can have the

same standing as naturopaths (i.e. alternative docs) in Western health

care.

On Apr 23, 2004, at 1:55 PM, wrote:

> It was written in response to an article last month arguing the rights

> of chiros to practice acupuncture (but not oriental medicine). My

> thoughts are interspersed.

>

> Bruno writes, " In China, attempts to reduce the practice of acupuncture

> to a therapeutic technique have resulted in utter failures.

> Acupuncture, practiced without the benefit of the theoretical

> principles which underlie it, and the logic which informs its treatment

> plans, is at best minimal and perhaps detrimental in terms of patient

> use. Some argue that it creates a clear case of endangerment. "

>

> My thought: This does not seem to be accurate in light of the ongoing

> german research, which shows excellent results for medical acupuncture

> and sham acupuncture, both done without any traditional theory or dx.

> In fact, most chinese research on acupuncture has been allopathic, not

> involving pattern dx. Not only has the research shown this approach

> not to be detrimental, but actually quite effective. The word

> endangerment seems way over the top here. I understand the need to

> stake our claim here, but making such statements does not seem

> helpful.

April 24, 2004

In a message dated 4/23/04 4:56:19 PM, writes:

> " If we prove our methods effective, it

> doesn't matter if other methods are equally effective. We get to keep

> our piece of the pie. But if we continue to devote precious time and

> resources to trying to prove other folks are dangerous and ineffective

> (when the evidence overwhelmingly suggests otherwise), we will lose our

> place at the table. "

>

The following are the personal opinions fo David Molony, and not of any

organizations or anything else I may now or ever participate in. Jeez, what a

world

we live in.

I don't think that we are talking styles of acupuncture being effective or

ineffective, but comparisons of amount of training, both didactic and clinical.

There are certainly " cookbook " recipies for a specific symptom that can be

done to great effectiveness by almost anyone, just a cataract surgery can be

performed in Eastern Europe by techs with great results. However, patients come

in

with variations of symptoms which need a more specific diagnosis and followup

diagnosis and adjustment to treatment. This sort of thing does not work well

with cookbook recipies. While the German research showed that it didnt seem to

make a difference, Austrialian research showed that length and quality of

training made a big diference in both safety and effectiveness.

Not being familiar with who the professional acupuncturists were in Germany,

what their actual didactic of clinical training was, how they were allowed

to adjust treatment to changes they saw in patients and other variables, I am

unsure of exactly what their research means, especially given that German

doctors have such a variable education in acupuncture from almost none to full

Chinese 5 year docs.

" We should all band together to

do the research, rather than fight amongst ourselves. I don't really

understand why its so important to some people that the way we do

things is right and the way MD's do them is wrong. "

This is not the AAOM's complaint, if you read it again. The complaint is that

they are undertrained and practice infrequently, generally, and thus are much

less effective and more prone to injure someone. The problem with that is

that if " their doctor " gives them acupuncture and it doesn't work, how can a

mere

acupuncturist who is not a doctor or an MD do it? Thus drugs or surgery are

the only options. This is not ethical and to me, and perhaps that is why AAOM

is pointing this out. To be truthful, many acupuncturists use the

neurophysiological model at times, and once again, it is not the model, it is

the

training. Dr. Gun's ideas are useful, sometimes. I wish he trained

acupuncturist's.

" My thought: According to Unschuld, most acupuncture has been practiced

historically by those who were unfamiliar with any written theory, as

they were illiterate. Historically very few acupuncturists were also

herbalists. "

Herbs were intrinsic to the culture. A medical person/acupuncturist only knew

a couple hundred herbs well and may have stuck more to formulas than an

herbalist who uses individualization of many more herbs, just as the

acupuncturist

does for points. But then again, I am talking about the people actually

practicing and not the academics and theorists whose focus has always been to

learn

more and more about less and less.

While I trust Unshuld in many ways, I do know that Jet Li used both

acupuncture and herbs in his historic movies. har

" No harm seems to have been done as a result. In modern

times, many countries regulate acupuncture as a distinct medical

practice, separate from herbal practice and sometimes as part of

western medicine. This includes france, germany, japan. And in the

PRC, TCM docs are trained as either acus OR herbalists, rarely both. "

France, Germany, and Japan all have docs doing acupuncture and drugs(herbs).

In Japan, it is my impression that acupuncture was made a trade school for the

blind because of the blind masseurs and their propensity to deal with

physical medicine seemed to fit. That they expanded beyond that is a tip of the

hat

to the human capacity to expand one's capability through insights. In the PRC,

doctors of TCM are either " focused " of acupuncture or herbs. My wife was

focused on herbs in her training because in her view herbs were the most

difficult

to enter and were the most respected focus of the choices, and it was more

difficult to get into herb programs than acupuncture, at least in Nanjing.

When

I met her, she ran the acupuncture department of the hospital I was doing

herb rotations in.

" My thought: If acupuncture must be part of an integrated " oriental