PAs and LAcs: is there a model here?

August 20, 2008
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At the risk of reinforcing the “us” versus “them” stereotype (i.e., Eastern versus Western medicine) I describe my recent interaction with two primary care physicians who support acupuncture in principle and action. Despite this, they were flummoxed with a proposal I made to them that LAcs (Licensed Acupuncturists) should work as primary care providers (PCPs) in safety-net clinics where there is a tremendous need for providers available to triage the avalanche of patients seeking care every day. Here is a report on the issues confronting safety-net clinics.

I attended a dinner sponsored by the California Academy of Physician Assistants. The event was one in a series of dinners hosted by CAPA across the state to promote the utilization of PAs in group practices. Five speakers represented PAs and MDs working in group practices. I sat at a table with two physicians that occupy the role of Medical Director in safety-net community clinics. The Medical Director makes the decision whether or not to hire non-physician providers, for example LAcs.
I asked several key questions: (1) what do you know about acupuncture licensing and practice? (2) Have you hired an acupuncturist or been treated by one? (3) Are you aware acupuncture is identified as a primary care profession in California? [click to review legislative language]

and (4) What do you think about hiring LAcs to function as primary care providers (PCPs) under physician supervision once they have completed a one year post licensure certificate primary care program? Their responses follow.
LAc licensing and practice? Both MDs knew nothing about the education and licensing requirements for acupuncturists. Neither accepted the suggestion that an LAc was a peer in terms of education and licensing, even if the LAc had completed a doctorate (i.e., DAOM or OMD) program.
Know any LAcs? One physician has hired an LAc in his community clinic. However, he pointed out he had to hire a supervisor who could interpret “TCM-speak” and supervise the LAc. He hired the LAc because he believed the service was in demand among safety-net clinic patients. The other MD is not exactly in a position to hire LAcs although his support would be extremely important for dozens of clinics) but sees one for his own pain issues and believes the medicine works.
Acupuncture as primary care profession? Neither MD has any knowledge of this and found the statement hard to accept.

LAcs working as PCPs in safety-net clinics?
“If they want to be MDs then go to medical school” said one. “Do they have the training to do that?” asked the other. Both found this idea very difficult to accept.
I advanced my own idea that has been percolating for a few years; LAcs working as PCPs in limited roles in safety-net clinics. The ideas are simple and straightforward.

There is a shortage of PCPs working in safety-net clinics. As one of the doctors put it, “I cannot hire a family practice physician at $120,000 when Kaiser is paying $140,000 with a superior benefits package”. Recent discussion has considered expanding the scope of practice for Nurse Practitioners (NPs) so they might work as PCPs in these clinics. [read proposal to expand NP scope of practice]. While this is a great idea it is flawed by the likelihood that NPs are no more inclined than are MDs to work for wages offered by safety-net community clinics below what they make in their chosen profession, even if they could function like an autonomous physician. The market argues for self-interest.
It is widely believed that a high proportion of LAcs are unemployed or under-employed; that is they are unable to support themselves in their profession once licensed. Explanations for this phenomenon are many from blaming the AMA to blaming the AOM schools. Nobody really knows what are the employment facts for LAcs. The leading organizations in Acupuncture and Oriental Medicine appear more inclined to keep it that way. The NCCAOM conducted a recent survey for which outcomes have been forthcoming more than a year. Not only would it be nice to know what were the outcomes, it would be nice to know what was asked (items) of whom (stratification).
It is an observable truth that AOM schools are disinclined to prepare their graduates to work in mainstream medicine. This conclusion is drawn based on several axioms. There is the widespread belief actively promoted within AOM that TCM is fundamentally oppositional to mainstream medicine. It is empirically true that LAcs do not work in mainstream medicine nor do they have a place within mainstream US healthcare. Graduates of AOM schools are not trained to work in mainstream medicine.
Acupuncturists have one option upon graduation; work in private practice. A 2001 publication – the only one of its kind – carefully described the poor employment prospects for LAcs in neutral language. [review the Dower study here].

Certainly there are open-minded practice groups where LAcs work on a multi-disciplinary team however this writer would hold that these situations are the exception and not the rule.
Yet, if LAc’s received the kind of training a PA undergoes, it is entirely feasible that LAcs might be sufficiently prepared to work in safety-net clinics where the need is greatest for PCPs.
How?
Enroll LAcs with PCP experience and/or knowledge to complete a one year long training program wherein the student is immersed in 4 week clerkships in primary care and selected specialty care mainstream medicine settings. Include didactic training in primary care medicine leveraging online educational models and graduate with a certificate in primary care practice. Locate the primary care clerkships in safety-net clinics that agree to hire program graduates. The PC LAc works full-time, under physician oversight, like a PA, triaging patients for specialty clinics (diabetes, ophthalmology) and treating within his own scope of practice.
Why would this work?
Safety-net clinics need primary care providers to break the log jams in clinical triage. The clinics need to hire at salary levels below that of MDs ($120,000) and NPs ($90,000). Unemployment among LAcs is so high that a waiting workforce would jump at the opportunity to earn a living. Additionally, there is a cadre of dissenting LAcs who actually believe working within mainstream medicine is a good idea.
I recognize many of the same characteristics in AOM today as when I joined the USC PA program in 1986. The PA profession was divided.
One faction wanted to remain isolated, under the radar. This group was populated by PAs for whom medicine was a 2nd or 3rd career. They were older and happy to be practicing medicine instead of selling real estate or teaching middle school. They feared facing off with NPs for stature on the multidisciplinary medical team. They wanted to retain the 16 month certificate program that prevailed among at least a third of PA training programs. They easily found jobs. Life on the periphery of mainstream medicine was not so bad.
The other faction wanted a BS entry level professional degree. They wanted to write prescriptions. They liked working with physicians and aimed for autonomy in practice. They were “pre-med drop outs” who did not want to give up their dream to work in medicine.
The PA profession changed during the next decade. Today the BS is the entry level degree while two-thirds of PA programs offer master level training. PAs are on par with NPs in every aspect.
AOM is caught in a similar struggle. The isolationists want to maintain a nominal “peer” status with physicians, a belief unsupported by the most basic metrics of success. Instead of focusing efforts on finding an entry point for LAcs into mainstream medicine, AOM leadership – co-opted by the AOM schools – is focused on maintaining the status quo where the odds a licensee will be able to make a living is the same as tossing a coin.
The opportunity to join mainstream medicine is right there right now. Who will seize the moment and blaze a new path leading to membership in the medical profession?
The National Guild of Acupuncture and Oriental Medicine (NGAOM) is pursuing initiatives that lead to more work opportunities in mainstream medicine. NGAOM is also working to redirect the California Acupuncture Board towards this goal, along with constructing a curriculum leading to the PC LAc certificate. Positions taken by the NGAOM are in the distinct minority within the profession. Hopefully, that will change as opportunities to work in mainstream medicine open up for LAcs.

One Response to “PAs and LAcs: is there a model here?”

  1. I am writing this reply almost six months later. I have tremendous respect for the author of the comment to my original post. My positions with regards to Traditional Chinese Medicine have become more entrenched. TCM is an invention that bears little resemblance to Chinese medicine. Tom Martin, LAc, does a better job than I can of addressing Al’s concerns about throwing out the baby with the bathwater.
    http://www.integrativeacupuncture.org/article.html

    The website below gives an indication of where this profession is heading if leadership continues to promote fantastic theories while at the same time avoiding integration with mainstream medicine.
    http://www.intramuscularstimulation.com/2.htm

    I recently visited my ophthalmologist for a check up. A Chinese doctor was working as his MA. We had a conversation about Chinese medicine and the principles of TCM. She said she did not believe in qi, meridians or yin/yang theory. Maybe she was simply saying what she thought I wanted to hear. I asked her why Chinese docs like herself do not speak out about TCM’s “principles”. She said in China there is no orange chicken. But in the US people expect orange chicken to be on the menu.

    Finally, of late I often quote Richard Dawkins, a contemporary evolutionary biologist, when TCM is advanced in a discussion. “Either it is true that a medicine works or it isn’t. It cannot be false in the ordinary sense but true in some ‘alternative’ sense.”

    There is no orange chicken.

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