Steven H. Stumpf, EdD

Integrative medicine must be bilateral in spirit and practice. Without having completed the standard course of training a physician is no more qualified to teach Traditional Chinese Medicine than an acupuncturist is qualified to teach biomedical science. The best current example of integrative medicine is a medical practice that employs qualified practitioners from each discipline to collaboratively triage the patient and integrate treatment in accordance with discipline-appropriate diagnoses.

Our manuscript titled Divining Integrative Medicine (authors S Stumpf, S Shapiro and M Hardy) describes issues that must be weighed in finding a suitable and widely acceptable definition for integrative medicine. The mansucript was accepted recently by Evidence-based Complementary and Alternative Medicine and will be published shortly. The journal is available online at no cost which is a tremendous advantage and the Web2.0 way. When the manuscript was in peer review the question was posed why I used the term "divining" in the title, a word considered old-fashioned, out of context. I explained I was having a little fun playing with “defining” while trying to make our point about how the absence of definition leaves it to the consumer and medicine in general to figure out what exactly is integrative medicine. Make no mistake about it. As authors we firmly believe integrative medicine is here to stay. We also recognize there will be many changes before the final discipline is established…or should I say before the discipline is finally established? I was pleased to receive my first comment from Sonya Pritzker, a licensed TCM provider and a UCLA doctorate student interested in medical anthropology (she read a pre-pub draft). Words mean a lot to Sonya. I hope you will read what she has to say on the question of not only what exactly is integrative medicine but the importance of methodology in arriving at a suitable definition.

On February 8 2008 ACAOM (Accreditation Commission on Acupuncture and Oriental Medicine) announced it would discontinue efforts directed toward a professional doctorate as the entry-level degree for the acupuncture profession; the result of an "absence of consensus from educators and other communities of interest". Link here to the announcement.

In 2002 ACAOM approved and sponsored a post-graduate degree called the DAOM (Doctor of Acupuncture and Oriental Medicine). Two DAOM programs have been accredited and one has been advanced to candidacy status. The world of doctorate degrees in health professions practically requires an advanced degree to comprehend the distinctions. There is much at stake when a health profession strives to attain "doctor" status. Putting things simply, many physicians feel their degree erodes with every non-physician profession that claims the doctor title. By contrast, non-physicians who can now become "doctors" with their first-professional, entry level degrees believe they have attained greater stature. [MDs attained pre-eminence in medicine - a profession at least 4,000 years old - less than 100 years ago].

Who are these non-physician doctors? They are not PhDs therefore they are not academic. Their degrees are considered clinical, professional or terminal. Terminal degrees are purposeful only for their profession. They represent professional or clinical expertise, as compared to academic degrees which represent the ability, even the responsibility, to create knowledge in a given field. Professional or clinical doctorates in health professions include PsyD, DPT, DNP, AuD, DDS, DO, OD and MD.

What does it mean when a profession such as acupuncture pursues then abandons the entry-level professional doctorate degree? What is the difference between the DAOM and the first-professional degree that might have been?

The DAOM is a post-graduate degree for licensed acupuncturists who wish to pursue "advanced" knowledge. If the "communities of interest" had enthusiastically endorsed the first-professional degree this would have necessarily phased out all existing degree programs, including the DAOM. All existing schools would have been compelled to "move up" to the new standard. If this sounds logistically untenable consider that Audiology just completed this exact process over a seven year transition phase. Today there are more than 100 AuD programs.

There are approximately 50 AOM colleges. Many of their representatives spoke at an October 2007 public hearing to comment on the new ACAOM standards for accreditation. Here are some of the key issues that emerged (from the transcript).

The new standards (available through the ACAOM website, you need to create a login) are considerably more rigorous than the existing standards for the Master degree (the current entry-level degree) and the existing post-graduate doctorate. The proposed guidelines would have raised the bar considerably in many areas outside academics such as Governance (CEO must have appropriate experience and credentials) and Board membership (public members must have no links to profession or other members, especially as family or associates). Most comments were directed towards educational standards. My comments are highlighted.

1. Educators expressed concern that three years of college be a prerequisite for admission. Maintaining the current level at two years was supported by more than one speaker. Shouldn't the preliminary degree at least be a bachelor?
2. There was strong resistance against moving closer to integration with "western" medicine. For example, one speaker recommended that instead of requiring doctorate students to "practice" with the "multi-disciplinary team" that the bar instead be lowered to only having to "communicate" with this integrated team. A faction within AOM reads any movement toward integrative medicine as an attack on Chinese Medicine.
3. One speaker questioned the purpose in raising the bar by strengthening students' research knowledge. Research, especially evidence-based medicine, is a sensitive issue. There is a considerable literature in CAM (Complementary and Alternative Medicine) and AOM. However, it is almost exclusively generated by PhDs and MDs with acupuncturists conspicuously absent.

The profession of acupuncture is not ready to turn out doctors. The field does not have consensus to do what is necessary to raise its own educational standards. Objections to tightening in favor of maintaining loose admissions standards, opposition to training graduates to work in mainstream medicine, and low regard for the value of building a cadre of home-grown researchers, all point to the field's unwillingness to meet doctors' standards. The post-graduate DAOM, anemic and malnourished, is further marginalized.

Ultimately, this was an exercise in trying to direct the profession towards higher and more conventional standards in health professions education. ACAOM lost this round. Who won?

I am always surprised when I encounter professionals unfamiliar with how their profession is governed. The common arrangement is to establish three organizations that represent the profession's principal internal stakeholders: the association of colleges (CCAOM), the association of licensed professionals (AAAOM), and the accreditation body (ACAOM). The public interest is represented by the state (or national) licensing agency which in theory holds regulatory sway over the internal groups.

Healthcare providers across disciplines are more likely to not know than know who these groups are and how they interact. Acupuncture and Oriental Medicine (AOM) is comparatively young as a licensed health profession in the USA. Acupuncture is a profession struggling to organize itself politically and educationally. The number of US licensed acupuncturists - approximately 20,000 - is actually quite small. There are more than 600,000 physicians.

While healthcare is a business, healthcare education must be very careful to reinforce the perception that academic credibility comes before business. The various governing bodies inside a profession should work together to ensure this principle can never be questioned. The number of acupuncturists and AOM educators prepared and willing to occupy seats on the three AOM organizational boards is very few. The number of trained educators in AOM is probably fewer. Drawing "regulators" from a small and insulated pool is a good way to maintain the status quo and poses an easy target for "super" regulators.

Many health professions programs seem to arrive at a tipping point in their history when educators' interests take precedence over business interests. Conventional medicine experienced this at the turn of the 20th century when release of the Flexner Report changed everything.

In our recent article, Diving Integrative Medicine, published online we argue that external scrutiny can be expected to increase in AOM education as integrative medicine receives closer scrutiny. The justification for pointing the microscope at AOM will be framed around the need to ensure that standards across health professions education are comparably rigorous. The recent abandonment of the first professional doctorate degree was in large part rationalized by the colleges' reluctance to implement greater rigor.

"Divining Integrative Medicine" is the second publication on integrative medicine in a series on the importance of raising standards within acupuncture education.

I attended the most recent meeting of the California Acupuncture Board (June 20 2008) where a new Acupuncture and Oriental Medicine (AOM) college received temporary approval despite the college President's statement that his occupational goal for his students was "training missionaries". The school is owned by a religious organization that only provides classes in the Korean language. Presumably, all the students are international, although the President stated they all "lived here".

Apparently, nobody thought to ask the obvious follow-up question to determine if the students, before living here, came from abroad in order to enroll in the program.

A second item on the Board's agenda had to do with evaluating and accepting transfer credits. The Board's Executive Director had proposed that transfer credits should not be accepted unless an original transcript was provided by the school where the credits were purportedly earned. Incredibly, representatives from several California schools insisted this decision should be left to the AOM colleges bypassing Board regulation. You can read a letter signed by four school officials
arguing for this position. Note the specious references to the University of Toronto and Berkeley.

This profession is hurting because of fundamental issues reflected in these topics. In a profession where as many as half the graduates are unable to support themselves it seems the Board should be doing everything in its power to prevent the proliferation of more unemployable acupuncturists. Instead the Board approved a school where the goal is not even to practice acupuncture.

And what about transcripts? Transcripts have to be originals. To permit anything else is completely irregular in higher education. The Board is housed under the Department of Consumer Affairs whose mission is to protect the consumer. The Board's role includes ensuring "excellence in practitioner training and education".

I believe there is a place for acupuncturists in mainstream medicine as primary care providers. Acupuncturists acquire a fundamental understanding of illness and disease in the Chinese Medicine model. As an allopathic medical system there are many parallels with western biomedicine. One of the missing learning strategies is extended clinical experience placing acunpuncturists in clinical settings with mainstream medical providers. We believe most of the current clerkships in mainstream settings are nominal and, if employment is a valid outcome measure, these experiences are wholly insufficient to prepare LAcs to work in mainstream medicine.

How might licensed acupuncturists (LAcs) be prepared to work in mainstream settings? We believe a one year program wherein LAcs are immersed in mainstream clinical rotations might do the trick. If the graduates of such a program were able to work in a community clinic, where the need for primary care providers is tremendous and where physicians generally work on a part-time basis, we are confident there are many LAcs that would jump at the opportunity.

We are just as confident such a program would be strongly resisted by the groups that are presently guiding the profession towards continued isolationism and maintaining the status quo wherein virtually any group can establish an AOM college and admissions practices are unaccountable.

How long can this system sustain? How long can the California Acupuncture Board continue to function to the benefit of professional schools instead of consumers?

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.

Venice Family Clinic (VFC) is a long-standing community clinic with two locations in the Santa Monica and Venice neighborhoods of Los Angeles, California. Many people are surprised to learn that VFC serves a diverse and poor population of Westside adults, women and children. After all, the Westside is far better known for movie people and fine restaurants than it is for underserved and under-insured communities. There are many poor families and individuals living on the Westside for whom VFC is the only provider of quality healthcare, in part because it is a training site for UCLA Geffen School of Medicine healthcare students.

Provider coverage and timely treatment are a common challenge for many community clinics also referred to as "safety-net". For many people these clinics are the last resort for healthcare. Budgets have razor thin margins and there is tremendous reliance upon providers in training. Physicians "triage" each patient that comes into VFC making a referral to the appropriate "service". Wait time for follow through is always an issue.

A pair of forward-thinking integrative physicians at VFC, Myles Spar and Mary Hardy, wanted to test whether referral to treatment might be enhanced with an integrative and innovative Chronic Pain Clinic. "Integrative" is the term that has emerged for describing a blend of mainstream medicine with Complementary and Alternative Medicine (CAM). The two physicians proposed teaming chiropractors, acupuncturists, and an osteopathic doctor with themselves to offer services within the CAM providers' scopes of practice to VFC patients.

Blending CAM with mainstream medicine is not so unusual. The Wilshire Boulevard corridor in West LA is home to dozens of integrative practices featuring MDs, LAcs and DCs offering a range of remedies. However, the Chronic Pain Clinic at VFC is the first I have been involved with or read about that extends the model to underserved populations.

My role is data management and analysis. Together with the integrative MDs and the VFC administrative team we were able to demonstrate positive outcomes in the first Phase of the project to earn a prestigious LEAP award from the California HealthCare Foundation.

You can read about the award here.

In a recent post I discussed ideas for cross-training acupuncturists to function as extenders to primary care providers and deliver care within the scope of their license. My inspiration comes from 10 years helping develop two USC Physician Assistant degree programs and my experience with the VFC chronic pain program. I am confident cross-trained LAcs can fulfill the triage function reducing the wait period while continuing to deliver quality healthcare to the families and individuals who rely on safety-net clinics for their primary care.

The question of how CAM providers can blend in with mainstream medicine remains open. The VFC chronic pain program is demonstrating one way that benefits patients and the clinics seeking to serve them.