more on LHC

[Guest guest]

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 dx, 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 dx be replaced with a clear wording that restricts this

practice to traditional OM methods. And that ordering lab tests used

for western dx 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 dx 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 px 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 dx 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, opthalmoscopes, 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 hx 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 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

casers regardless of one's phsyical 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 pointis 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 half assed western dx, but also by shifing 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 independentOM

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 implcitly suggets 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.

 

[Guest guest]

Although I agree that our practice of medicine should be OM this restriction on

ordering

lab tests is ridiculous and dangerous. In fact I don't know why any person

shouldn't be

allowed to get their own tests. (Economics?) I have referred many patients who

otherwise

would not have known if they had or didn't have high cholesterol, HIV or HepC.

I think the bureaucracy is out of touch with the needs of our patients. Many

patients don't

have doctors and only get tests when we suggest it to them. I myself have no

personal

doctor and rely on my dentist for the few prescriptions for antibiotics I've

needed.

I wouldn't know who to turn to should a patient need (or want) EKG. And how many

days

and weeks would a patient wait for an appointment with a GP doctor out of the

phone

book? How many times must we send patients to the emergency ward in order to get

even

the simplest assessments?

 

doug

 

 

 

 

, " " wrote:

>

> 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 dx, 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 dx be replaced with a clear wording that restricts this

> practice to traditional OM methods. And that ordering lab tests used

> for western dx 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 dx 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 px 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 dx 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, opthalmoscopes, 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 hx 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 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

> casers regardless of one's phsyical 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 pointis 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 half assed western dx, but also by shifing 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 independentOM

> 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 implcitly suggets that advanced studies in OM should be

> OM oriented, not WM.

>

>

 

[Guest guest]

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 px who work

purely from a western orthopedic or allergy model; will they be

outside scope now?).

>>>>>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. The problem is however in daily practice

one must make a dx every time one fills a hicfa form. Also as you say if we are

to understand what we treat and followup on results in any meaningful way, or be

able to direct our own research, we must be able to order tests, even if we are

not going to " make a diagnosis. " These are life and death issues for us as an

independent profession. If we loose these privileges we will loose our

profession and become a secondary technical trade. We will loose the war on

evidence base medicine and with time our entire profession/trade

Alon

 

 

 

[Guest guest]

, " Alon Marcus "

<alonmarcus@w...> wrote:

 

> >>>>>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.

 

Alon

 

A lot of people want to believe that what you wrote above is their

main theme, but I think a close reading of the entire report in

context and not just selecting lines that seem to support this reveals

otherwise. They not only say over and over gain 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.

 

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 dx or the methods used

to make that dx 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 realy 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 dx 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 anythng less

than the most basic nursing degree being acceptable.

 

[Guest guest]

They not only say over and over gain 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).

>>>>>There is nothing stronger than actual precedent in law. If we are to giveup

our right to diagnose we will be pushed to an irrelevant force in US health

care. There is no chance to change healthcare in the US, especially to

accommodate LAc. We have been ordering tests and making dx for almost 20 years

and if we loose this you better find a new job. PCOM will have 10 students a

year. There are plenty of LAc out there, if we are not to mainstream the market

cannot support any more. If we loose are ability to practice as primary care

than will become second tier practitioners and then i can promise you even in CA

very few will make a living (and don't fool yourself without tests there is no

primary care). It is obvious from the report that they cannot even make a direct

recommendation. We need to take the report as a warning sign nothing else.If

need to do everything we need to, and that means increase the basic education,

to secure our profession. Thinking we can create our own world is committing

suicide.

Alon

 

 

[Guest guest]

, " Alon Marcus " <alonmarcus@w...>

wrote:

 

> >>>>>There is nothing stronger than actual precedent in law.

 

LHC makes it clear we are not dealing with real legal precedents here. They

were not

decided by either a jusge 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 the

precedent

you desire. 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 dx 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. 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 hx 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 dx 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 px. There could also be a shakeout of schools and only a few

will

survive. But I'd bet anyone that when the dust settles, PCOM is left standing.

Yes, there

COULD be many less students, but enough for the few 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 put this doctor wannabe mentality behind us and focus all

our

resources on developing OM in its own right, that is when doors will finally

open. You

cannot deny that 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

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 PCOM.

 

[Guest guest]

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 hx 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.

 

>>>>>>Well it may be. We are safe now because the reality is we practice 3ed

tear medicine. However, the more we grow the more primary med is going to be

practiced and china has already shown you cannot practice safely in the modern

world without modern medicine. That is why they do what they do. If we do not

use this to support our professional growth we are dead

Alon

 

 

[Guest guest]

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

>>>You are dreaming. The power struggle is only going to increase. I for one am

glad i do have to start my career now. Western med will never embrace OM as a

real full scope medicine. We are the only profession that can do it.

Unfortunately we do need to dramatically change the focus of the schools

alon