Long MUST READ re: CA crisis

[Guest guest]

CLEARING ROOTS OF MISUNDERSTANDING

© 2005 Joe Reid LAc OMD Reproduction permitted in entirety only without

alteration or omission; no sales permitted.

Please freely distribute (unless it becomes a teaching tool in Fred's or any

other seminars in which case I want big bucks!)

http://www.jreidomd.blogspot.com jreidomd

This essay adds to my previously published essays and postings, and is in

response to significant developments in the Legislature, and significant

postings via Holly B from the CSOMA board, and Todd L. of Pacific College of

Oriental Medicine San Diego (speaking on his own behalf rather than as a

formal College PR, I presume)

To Holly, thank you, it's about time that CSOMA improved the prior stance

evident online. We are in agreement on the serious wrong of attempting to

replace a democratically representative professional Board with a

Department Bureau for the sole purpose of more easily carrying out political

agenda to squash a profession. I hope you and the CSOMA Board as well as

all Licensed Acupuncturists and students also come to a better understanding

of the major problems with AB1113 as it now stands.

 

In Chinese Herbal Medicine forum, Todd has championed emerging

biotech, while expressing (along with the formal stance of PCOM) desire for

both sun-setting the CAB, and eliminating by statute the established

precedent wherein Licensed Acupuncturists have the capacity to electively

choose to evaluate / diagnose for the purpose of necessary decision-making,

which is clearly a self-evident fact given the reality of patients electing to

seek

primary or secondary care from an Acupuncturist.

 

In Todd's forum post of 5/6/05, he wrote in part " Would just assume see " The

correct phrase is actually --just as soon --. I suspect he knows that, and I

would just as soon find out that it was a typo. Why would I nitpick? Because

the sad fact is that a great deal of the larger problem of the challenges

confronting the profession stems directly from nuances of language, whether

deliberate or merely ill-informed.

 

Pursuant to the proposed California legislation, SB233 and AB1113, attention

is now directed to the facts that, (among other faults) there are two severe

conceptual flaws in the developed backgrounder and proposed solutions by

the Joint Committee staff, namely traditional and gatekeeper, and additionally

there is verbiage which appears to deliberately confuse persons unschooled

in linguistic nuance (diagnose within scope), by which special interests both

within and outside the profession seek to gain and assert control for either

purely selfish economic reasons or out of fear of living up to responsibility

for

their own protocols.

 

ENGLISH AND LOGIC 101 : DIAGNOSE WITHIN SCOPE (– please read it

slowly until you get it -)

Authorization - to diagnose within scope of practice - is NOT the same thing

as including diagnosis as part of the scope of practice. The difference is that

to diagnose within a scope actually means to LIMIT it to whatever that scope

is elsewhere defined as. Scope merely references broader content of the Act

taken as a whole. Which renders this Amendment meaningless and useless,

except as a preparatory clause to subsequently be expounded upon to the

probable detriment of established professional practice – while ignoring

evidence of public safety in total violation of the public trust.

 

The situation is so much simpler for other healthcare specialties that have a

focus on certain body areas or systems. It is easy to define the scope of

chiropractic as relating to the spine, podiatry the feet, physical therapy as

rehab for musculoskeletal injury, and psychiatry for mental/emotional

disorders. Oriental medicine, directly referenced in legislative intent, is

actually a broad and comprehensive set of health-care and medical practices.

 

Note, that they did not license Traditional anything, or anything specifically

Chinese or Asian. Before anyone accuses me of prejudice, know that the

town I live in is predominantly asian, and I don't even have to leave my home

to speak to Chinese-Americans. The people who initiated acupuncture

legalization in California and the first Licensees were a diverse group of

people including more than a few anglo-americans who deliberately set legal

verbiage broadly so as to encompass much of the realm of holistic medicine.

It was understood that holistic was not only in the very same spirit as oriental

medicine, but it was really one and the same thing, as oriental medicine was

indeed evolving everywhere it was practiced, and it had in fact become a

global development. I know this because some of those leading pioneers

were my teachers.

 

Mainstream doctors had their input back then, and first of all insisted that

some practices already considered part of acupuncture such as injection of

herbal solutions did not have enough established safety to be done by

anyone, and additionally declared that prescription of other than over-the-

counter pharmaceutical drugs and invasive surgery were solely in their

domain, because after all, drugs and surgery constitute their biggest income,

and they truly believe that no other system could possibly work. Next, within a

few years physicians went along with statutory change (in 1979) to allow

patients direct access to Licensed Acupuncturists without need for prior

referral. The background document prepared for the Joint Committee

repeatedly phrased this referral in a derisive tone as a note, as if they were

saying a child didn't need a permission-slip once it was established that the

school food was harmless. In fact they did learn that risk to the patient is

negligible. It was only after a number of years that they gradually realized

that

although there was little danger to patients by Acupuncturists, it stood to

reason that their own incomes could potentially suffer a slight decline when

patients actually found benefit from those Acupuncturists.

 

Legislators can perhaps be excused for not yet being properly briefed on

what diagnosis is and is not. On the other hand I have been repeatedly

frustrated and dismayed to see others fail to understand that diagnosis is

primarily for decision-making, NOT treatment. The way the International

Classification of Diseases is set up is according to a hierarchy of specificity,

with non-specific symptoms like a patient complaint of pain on the (outer)

level. Because that's what the patient already knows, taken alone it doesn't

usually indicate a differentiation sufficient for you to base decisions on, and

you didn't use much professional skill to elicit that information. Still, that

non

or semi-specific diagnosis of pain is the default that you start with, and if

you

have confidence that you can make an appropriate decision from that, either

to refer to another doctor or to initiate treatment, then in doing so you are

electing to assume a certain level of risk. A lot of diagnosis (done by any

doctor) starts out as provisional. That doesn't mean that it is wrong, or that

it

shouldn't be paid for. You are paid for your professional time at market-

established rates. If it leads to resolution of the problem, then you've still

done an appropriate job. If it doesn't (and remember there are no guarantees

of specific outcome in any medicine), then the patient will typically seek

another doctor (it happens every day in all approaches to health-care), or if

there are adverse consequences, then the patient may have recourse via

malpractice or civil suit.

 

A continued problem generally warrants search for a deeper level of

diagnostic specificity, and the decision-making continues. Professionals in

practice are obliged to make many decisions. Some of us decide that we are

more comfortable sticking to physical rehab type cases, for example because

our individual development has evolved in that way, and we find that we can

evaluate and treat to a higher level of specificity than, for example cases

which are more properly categorized as internal medicine. Other practitioners

are confident that they can, for example " work with atrial fibrillation, " as an

example I overheard recently (I know nothing of their personal background or

qualifications). I personally would be reluctant to touch such a hypothetical

case without having received a direct request from the patient's cardiologist

with agreement to coordinate care, and I would prefer that it was inpatient for

appropriate monitoring of effects post-treatment. Others may have confidence

at a different level of comfort with risk, but if upon seeing the patient they

want

to limit their recognition to a strictly TCM diagnosis, they do so having

elected

to take on that risk, without 1) - meeting reimbursement criteria established

nationally to cover the gamut of medical specialties, and in effect opting out

of

the healthcare payer system, and 2) – possibly without meeting minimal

standards for referral or triage for the purpose of public safety. If such a

practitioner chooses to meet even the most basic of recognition choices to

prevent imminent mortality, this is still nonetheless diagnostic decision-

making. It still mandates using International Classification (ICD) terminology,

and it is still best characterized as a professional activity of Evaluating for

the

purpose of Decision-Making (which in many cases would meet criteria as a

CPT Procedure). This is the fundamental essence of diagnosis, and this in

my opinion is inarguably the strongest and most equitable phrasing yet

proposed for any possible Amendment to the California Business and

Professions Code. Make no mistake; the motives behind many of the current

legislative moves (especially by Joint Committee members) are above all

driven by desire to effectively prevent normal utilization of ICD diagnostic

codes and CPT procedures necessary for safe practice and appropriate

reimbursement.

 

California Licensed Acupuncturists have a 25 year history of performing

evaluation and decision-making with proportionally far fewer adverse

incidents of far lesser severity than Medical Doctors. This alone is why there

is NO justification for legislative diminution of professional capacity. This

brief

discussion is in no way a complete lesson in CPT, ICD and practice

management, but it's a start. If you think this is all stupidly complex, blame

the

AMA, but don't tell me that I can't or shouldn't be paid for doing what I and

other peers have safely and legally done for more than several years.

 

TRADITIONAL

The use of the word traditional was and is NOT in the Acupuncture laws of

California, but became popular in the 1980's as a way to distinguish an

idealized natural / folk medicine and set it as far apart as possible from

modern high-tech everything. This was largely in reaction to Voll's electro-

acupuncture and its variants, and this opposition could generally be

described as either asian-purist or anglo-luddite, and mostly stemmed from

superficial observation without understanding the real nature of response

testing systems, which are primarily about information gathering and in any

case are entirely non-invasive.

 

The word traditional is fundamentally linked to culture and nationalism, and

schools latched on to this as a way to promote their own teaching as a " pure "

training. The FACT is that acupuncture was legally established in California

as a way to allow the pluralism of medical and healthcare practice of several

different cultures ( " acupuncture was to be a framework for the practice of the

art and science of oriental medicine " ), and their immigrants and descendants

as well as non-asians who saw value in these diverse approaches.

 

This also brings up a problem with one of Leeland Yee's other bills that

replaces " oriental " with asian, in that oriental is a non-specific term with a

broader meaning, whereas Asian refers to specific countries and immediately

invokes nationalism and prejudicial bias, as well as clearly ostracizing non-

asian practitioners and patients. Like society in general, several of the

different factions would prefer that the others didn't exist. The more dogmatic

purists are increasingly confused by dovetailing of some of these different

approaches with each other and with various aspects of modern western

allopathic medicine, as well as homeopathic dosage-dependent,

psychoanalytic and body-mind convergence theory (with a tradition of over

200 years and inclusion of much of the so-called Chinese herbal

pharmacopoeia – remember spices have been in trade since long before the

middle ages), and other indigenous shamanistic / herbal systems with

traditions possibly stretching back many thousands of years. No medicine

anywhere in the world has ever stood still as a fully developed complete

system. Individual practitioners may well find a specialty or particular

approach that they feel meets all their needs, and will consequently refer or

simply not attract patients more suited to other approaches. No one can learn

and master everything (except perhaps Me, Master of None, which of course

then compels me to teach). People always tend to draw exclusionary lines

based on whatever level of understanding they've reached, and their desire

to let prejudiced bias further their own economic greed. People of broad

mindset and broad life experience have wisdom to share and counsel that is

quite different from people whose need to dominate and control stands in the

way of genuine understanding.

 

The things that require consideration on the side of adapting to the socio-

economic realities of this day and age, are :

1) protection of public safety by integrating with the rest of the healthcare

system and the actual patients who also live with and utilize the rest of that

healthcare system, and,

2) protection of our own right to be paid as and in the same manor as all

medical professionals.

 

Consideration on the side of countering unrestrained biomedical high-tech

(stem-cells, nano-machines, cloning, transfusions and transplants, isolated

chemical-constituent research, and animal based studies) requires and leads

to and from :

1) protection of the right to a greater holistic view that reductionist analysis

so

often obscures, and,

2) protection against depraved violation of the rights and dignity of the entire

natural world (because it's not your damn planet, monkey-boy! (sorry, couldn't

resist that Bonzai reference)

 

Paternalism has been cited as one of the features of mainstream western

medicine that drives people to alternatives, but oddly enough it also shows up

in alternative practitioners who feel threatened by people daring to diagnose

and treat themselves; - yes we've seen people who've screwed themselves

up, but nothing in comparison to the many, many more who've been far

greater screwed by mainstream doctors. In contrast, the chief flaw of

alternative practitioners can typically be classified as proffering useless

over-

treatment of conditions that the patient already has power in his/her own self

to correct. Yet, if the person lacks the knowledge, training, experience, and

confidence to invoke those self-healing mechanisms (or God / Higher Power /

Universal Creator blessings / gifts / natural capabilities), then they will

typically seek out professional assistance. Unless, of course if legal and

economic barriers have been erected to inappropriately prevent such access.

Nevertheless, as the world approaches goals of efficiency through evidence-

based protocol, any health-care practitioner capable of performing and

documenting evaluation of function, and promoting measurable gains will in

doing so fulfill a valuable role. This is how we can fit in.

 

Really, the only thing that counts as traditional - is continual

acknowledgement of the validity of an evolving past leading into the present

now, and effort to perceive greater patterns of inter-relation (which is the

essence of a holistic view) Holistic is not the antithesis of analytic; - Just

as

analysis does not preclude intuitive leaps, the more different ways you

analyze and synthesize - the closer you get to holism.

 

GATEKEEPER

In addition to the aforementioned usage of note instead of referral, the

background document prepared for the Joint Committee is rife with absurd

prejudice and misrepresentation. It repeatedly attempts to equate primary

care (the practitioner a patient chooses or happens by chance to go to first for

any particular concern) – with a gatekeeper (which is strictly a term pertaining

only to managed care, in which a patient is compelled to go only to a

specified doctor, who alone has been given the right by corporate

management to dictate preauthorization for reimbursement purposes)

Licensed Acupuncturists will almost certainly never be gatekeepers. It is

appropriate to point out here that implementations of managed-care have

been determined to fall considerably short of the touted expectations, and

gatekeepers a proven straw man fronting for the funneling of health-care

dollars away from actual patient care into the pockets of managers and

shareholders. We ARE already primary care providers, and we don't need to

be GRANTED a right to continue a 25 year record of relative safety. In fact,

we may well have legal justification to obtain INJUNCTION against any

eventual implementation that could intrude on our right to practice our

profession.

 

If it comes to that, I may well spearhead a roll-call of each and every

California

Licensed Acupuncturist to be held accountable for their stance in either

supporting the profession or contributing to its demise. Who are you and what

do you stand for?

May 8, 2005 Joe (writing – it's a hell of a drug;-) Reid

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