The National Guild of Acupuncture and Oriental Medicine's Presentation to the White House Commission on Complementary and Alternative Medicine Policy

Presented by D.E. Kendall, OMD, PhD, December 4, 2000

Introduction

The National Guild of Acupuncture and Oriental Medicine (NGAOM) is grateful for the opportunity to share some of our views with the White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP) concerning issues on integrating complementary and alternative medicine (CAM) into service delivery. The NGAOM is a professional guild for practitioners of acupuncture and Oriental medicine organized under the auspices of the Office of Professional Employees International Union (OPEIU) of the AFL-CIO. Our goal is to provide a national focus that promotes health and well-being through the utilization of acupuncture and Oriental medicine, and to advance, protect and preserve the profession. To this end, the NGAOM recognizes the real-world physiological basis of acupuncture and Oriental medicine and promotes advancing the training of acupuncturists and Oriental medicine physicians through education and advocacy. The NGAOM also champions evidence-based modalities in order to obtain the highest possible clinical outcomes. Answers to the five questions received on integrating CAM into service delivery are provided following some introductory information on the NGAOM definition of Oriental medicine and its physiological basis, and a current status on acupuncture and Oriental medicine in the United States.

Definition: Oriental Medicine

Oriental medicine is a physiologically based primary health care approach that historically (3,000 or more years) has been a major part of world medicine. It utilizes a comprehensive medical model that is internally consistent with specific strategies for dealing with a wide extent of illnesses and health dysfunction. Tools utilized by an Oriental medical practitioner include a diverse range of clinical modalities. Most common are: herbal medicine; nutrition; heating therapy (including radiant heat and heat packs, some with and without herbs, and a technique of burning hairy fibers of common mugwort leaves known as moxibustion); manipulation and articulation of body joints; specialized manual pressure and massage methods; other physical means such as cupping and scraping; lifestyle counseling; exercise therapy and rehabilitation; movement and breathing exercises; preventative care; and a sophisticated needling therapy called acupuncture in the West. Acupuncture is used to treat ailments and conditions by stimulating certain critical locations on the human body in order to control and regulate the circulation of blood and vital substances, autonomic systems and endogenous mechanisms, to restore physiological balance. This includes restoring somatic, visceral, immune function and homeostasis, as well as promoting pain relief and tissue healing. The practice of acupuncture includes techniques of piercing the skin by inserting sterilized needles, and point stimulation by use of pressure, electrical, mechanical and thermal methods, to bring about desired therapeutic effects.

Promoting a Common Physiological Base

One critical goal of the NGAOM is to promote the best understanding of Oriental/Chinese physiology in order to establish a baseline for clinical practice and rational research, and to also provide a starting point from which more study can be continued. There can be a diversity in how clinical methods are applied, with different means applied to treat one disease, or a single treatment approach may be applied to treat different disorders. However, everyone has to have the same understanding of human physiology. Important to this task is to explain the Oriental/Chinese information using universally accepted anatomical and physiological terms. Fortunately, research in acupuncture and neurophysiology over the past two decades is providing sufficient insight to explain the Chinese theories in rational terms. This includes explaining how the logical insertion of fine needles can bring about medically useful restorative reactions in the human body to treat the ailments of humankind.

One of the most fundamental problems facing Oriental medicine and acupuncture concerns the Western confusion on what constitutes the physiological basis of this medical system. The ancient Chinese texts, especially the Yellow Emperor's Internal Classic [Huangdi Neijing] (600-300 BC), provides details on postmortem and physiological studies. The Chinese discovered blood circulation some 2600 years before William Harvey's experiments in 1628. Ancient Chinese physicians: identified and named all the major blood vessels, correctly noting which were veins and arteries; provided the first rudimentary description of the body's defensive system and lymphatics; identified and correctly noted the function of the internal organs, including the critical function of the lungs in breathing in vital air needed to support metabolic processes; and provided weight and size measurements of the organs. Additionally, they identified all the muscles in the body, including skeletal origins and insertions of the muscles, and identified the brain, spinal cord, and critical neurovascular connections in the body, including those to the optic nerves and to the heart. Although the ancient Chinese described features that are descriptions of brain and neural function, including propagated sensations provoked by needling, and sensory functions, they never described the peripheral nerves in any detail.

Blood circulation of nutrients, defensive substances, other vital substances, and vital air now known to contain oxygen, to all superficial and internal regions of the body by the vascular system, is considered one of the more critical features in health and disease. This idea is also true in Western medicine, but its importance has faded over the years. In supplying the superficial regions, major distribution (jing) vessels (mai) form collateral (luo) vessels, which further branch into arterioles, capillaries and venules (sun mai). These then connect to venous collaterals and finally distribution veins returning blood to the heart. At certain locations on the superficial body, collateral vessels supply critical neurovascular junctures now referred to as "acupoints" in the West. These critical junctures or acupoints are prime locations used in the practice of acupuncture. This physiologically rational concept suffered a tragic misfortune during the 1930s-1950s when the blood vascular system described by the Chinese in terms of "jingluo" was mistranslated by the West as "meridians." Even the word "mai," which clearly means vessel, was translated as meridian. This resulted in the vascular system to be replaced by imaginary or invisible pathways. The problem was further complicated by mistranslating vital air (qi) as "energy" for lack of a better word. Nutrients, defensive substances and other vital substances were also categorized as energy as well. The net result was a Western view of Oriental medicine that involves incomprehensible and physiological incorrect ideas. The idea of energy meridians casts Oriental medicine in a metaphysical light and has been responsible for years of misdirected research and education. It has also been responsible for much criticism of Oriental medicine with practitioners being accused of practicing metaphysical rituals (Ulett, Han, Han 1998) or participating in a religion (Breivik 1998). Some medical practitioners are so frustrated with the state of affairs they are reinventing acupuncture as medical acupuncture (Mann 1992, 1998; Filshie, White 1998).

The physiology of Oriental medicine is essentially the same as that of Western medicine, except for subtle differences in how it is viewed. This is especially true with respect to concepts of vitality (shen), how the body systems dynamically interact, and in how external and internal factors cause disease. Perhaps most important to the Oriental view is the highly integrated nature of the body involving neurovascular systems, the internal organs, and the external body, which includes the musculoskeletal system. These major systems of the body give rise to viscerosomatic (internal organ to body), somatovisceral (body to internal organ), and somatosomato (body to body) relationships important in health, disease and clinical practice. These relationships postulated by the ancient Chinese are essential to the application of needling therapy.

Current Status of Acupuncture and Oriental Medicine

Presently, some 39 states and the District of Columbia recognize the practice of acupuncture and Oriental medicine by way of licensure, certification or registration. Twenty-three states allow practitioners to treat patients without a prior referral from another primary health care provider, i.e. MDs, chiropractors or osteopaths. Two states require written authorization; two states require the practice of acupuncture; and five states require a prior diagnosis. Eight states have licensing laws pending. Two states allow practice through a ruling of the Medical Board of Examiners. Thirteen states have independent boards, and in 16 states, acupuncture is regulated by a medical board of examiners, 10 of which have an advisory committee of licensed acupuncturists. In the remaining states, acupuncturists are regulated by the department of commerce, regulatory agencies, professional regulations or occupational licensing, or by a board such as the board of regents or board of chiropractic. Three states require passage of their own state boards, while the remainder of the states require passage of an exam given by the National Certification Commission for Acupuncture and Oriental Medicine.

The current range of practitioner responsibility includes supervised practice, treatment only after a medical doctor or chiropractic referral and prior diagnoses, and practitioners that are considered primary health care providers with the exception to provide service that includes necessary referral for immediate Western medical care. These levels of responsibility are reflected in different educational requirements from state to state. The requirements are as low as 1000 hours up to 2400 hours. Most school training programs meet this requirement, with a three- to four-year master's degree ranging from 2175 hours to as high as 3300 hours. The primary health care practitioner level of responsibility clearly requires a higher level of education and ongoing training.

Question: Should CAM be integrated with conventional medicine, and why or why not?

With respect to CAM, the NGAOM feels strongly that Oriental medicine, including acupuncture, should be integrated into conventional care to improve clinical outcomes and improve the efficiency of service delivery. There is little question to the efficacy of the high technology emergency and heroic medical procedures responsible for saving many lives every year. However, many disease, including the general malaise as a result of our high stress society; dysfunction; pain problems; and obsessive behavior problems affecting the bulk of the population, for whatever reason, do not always respond to conventional care treatments. There is no single medical system that can cure all the people all the time. Hence, it is incumbent upon society to provide the best of all possible treatment schemes to better serve the public. Conventional care is a major part of world medicine but for other systems, such as Oriental medicine, including acupuncture is also part of world medicine and has much to offer that would complement conventional care. When one medical system, with a very well-focused theoretical approach, is allowed to dominate, there is a risk that new ideas are shut out. This is especially true when different ideas are offered from foreign sources. By having a closed view on what constitutes medicine, there is a risk of getting out of touch with the patient population's concerns for safety and efficacy, resulting in less than desired clinical outcomes. For example, the physiological model of Oriental medicine has some unique views in how the body works in health and disease, and provides new insight in treating disease and dysfunction. These ideas are consistent with Western physiology but have yet to be considered important to conventional care.

All practitioners of Oriental medicine and acupuncture can testify that most of their patients have been to many conventional care physicians before trying Oriental medicine. Conditions of these patients cover a full range of human disorders and pain problems. If Oriental medicine, including acupuncture, was integrated into conventional care, a different opinion could be sought when a case was not responding without causing the patient to seek an independent Oriental medical provider. Consider the following case: a 55-year old male was dressing one morning after waking. While bending down to tie his shoes while seated on his bed, his whole body went into terrible spasms. Fortunately, his neighbor heard him fall on the floor and called an ambulance. The man was taken to nearest hospital where he was given pain medication and antispasm medication; was x-rayed; and examined by other diagnostic imaging techniques. After one week with no improvement, the man was asked to leave the hospital because they needed the bed for someone that had a more serious condition. The man needed to call an ambulance to take him home, since he was not able to walk and was still in incredible pain. On the way home in the ambulance, the driver suggested that the man consider getting acupuncture and drove the man to a nearby acupuncture clinic. The patient was wheeled into the clinic, and after a 35-minute treatment, he was able to stand up and walk out of the clinic on his own. After two more treatments, the man's condition was totally resolved. Consider the poor utilization of hospital resources over a week period with no results. Had there been an Oriental medical provider or acupuncturist on staff, it is possible this case could have been quickly resolved.

Potential cost savings alone with improved outcomes is another reason for integrating Oriental medicine, including acupuncture, into conventional care. There are many studies that indicate that acupuncture can be utilizes to reduce health care costs and improve treatment outcomes. A study of 29 patients with severe osteoarthritis of the knee were randomized to receive the course of acupuncture treatments or to be placed on a waiting list to receive acupuncture treatments starting nine weeks later. Of the 29 patients, seven were able to cancel the scheduled surgeries. The costs savings were $9,000 per patient.4 In another study, half of 78 stroke patients receiving standard rehabilitative care were randomly chosen to receive adjunct of acupuncture treatment. Patients given acupuncture recovered faster and improved to a greater extent, spending 88 days per patient in the hospital and nursing homes compared to 161 days per patient for the standard care alone. Cost savings were estimated at $26,000 per patient.5 Fifty-six patients in a study at a worker's compensation clinic were randomized to receive either physical therapy, occupational therapy, exercise or the standard care plus acupuncture. Of the 29 treated with acupuncture, 18 returned to their original or equivalent jobs, and 10 returned to lighter employment. Of the 27 patients who received only standard therapy, four returned to their original or equivalent jobs and 14 returned to lighter employment.

Utilization of Oriental medicine and acupuncture as safe modalities in the treatment of the elderly may have potential benefit. Some studies have noted that as much as 80 percent of older patients in care homes are not provided adequate pain management. Acupuncture and other Oriental medical procedures can be beneficial in increasing range of motion; address incontinence problems; and provide pain management strategies. Oriental medicine has a long history of applying techniques and approaches to assist with the problems of aging. This also represents an additional area in which outcome studies and further research is necessary. In one study sponsored by the National Institute of Aging and published in the May 3, 1995 issue of the Journal of the American Medical Association, conventional exercise forms such as resistance flexibility training, walking and platform balancing were compared to the Chinese movement therapy known as tai ji quan. The tai ji quan practitioners recorded a 25 percent decrease in injuries from falls.

Question: What are the keys to successful integration of CAM with conventional medicine; how can they be translated into policy recommendations?

Better real-world education standards represent an important key to the integration of CAM with conventional care. These are discussed with respect to Oriental medicine and acupuncture under responses to the fourth question below. More important, however, is to overcome the cultural biases and fear of economic consequences on the part of Western medical practitioners if Oriental medicine and acupuncture, practiced by professionals other than medical doctors, are integrated into conventional care. These pressures have contributed to or reduced the desire on the part of conventional medicine to communicate with their Oriental medical counterparts, even when these two groups may be treating the same patient. Conventional care is covered by Medicare and other federally funded programs. These programs currently pay for medical doctors providing variant forms of acupuncture (needling therapy) such as neural therapy involving the injection of anesthetics into certain points of the body; trigger point therapy using either injections of anesthetics or dry needling; and other needling approaches described by terms other than "acupuncture." To cover professionally trained practitioners of Oriental medicine and acupuncture in the federally funded programs is not an economic risk to conventional care providers. These unwarranted fears must be overcome in favor of improving clinical outcomes to better serve the general public.

Formal WHCCAMP policy recognition of Oriental medicine including acupuncture as a complete, independent medical model that can work within the Western health care system for the improved outcomes and cost-effective benefit of the health care consumer, would help reduce barriers to integration into conventional care. This recognition could be an important key to provide better education of other health care practitioners in the area of utilization of acupuncture and Oriental medicine. It would also help improve interprofessional communication between Western practitioners, such as MDs, DOs, andRNs, and Oriental medical practitioners. This can lead to improved coordination of benefits and possibly reduce conflicting treatment or insufficient treatment to better serve the patient's needs. Additionally, the nature of training for Oriental medical practitioners typically takes place outside of most Western medical settings. This leaves the Oriental medical practitioner with little or no experience interacting with Western medical practitioners, or with being familiar with Western medical protocols, styles of communication or culture. This adds a potential psychological barrier for the Oriental medical practitioner to initiate communication with Western medical practitioners. WHCCAMP recognition of Oriental medicine and acupuncture would also stimulate changes in training approaches to help improve interprofessional communication skills. WHCCAMP recognition would stimulate improved public education with regard to when and how to utilize acupuncture and Oriental medicine.

Question: What other policy recommendations would you like to make to the Commission?

Other key areas where WHCCAMP policy could help the future integration of acupuncture and Oriental medicine into conventional care concerns areas controlled by the federal government. This involves the possible future employment of Oriental medical and acupuncture practitioners at the National Institutes of Health (NIH), the Veterans Administration (VA), and in the armed forces. Another problem involves using conventional care to dictate the government's position on acupuncture and Oriental medicine. The WHCCAMP must recognize that acupuncture and Oriental medical theories have to be provided by Oriental medical and acupuncture experts. WHCCAMP policy should dictate that the NIH must have, or utilize properly, qualified Oriental medical and acupuncture specialists in establishing government positions on this medical specialty.

Currently, all medical research, including that involving acupuncture and Oriental medicine, is dominated by Western medicine. To date, most practitioners of acupuncture and Oriental medicine have been shut out of the research efforts. Even when they are included and responsible for developing the treatment protocols and actually treating the patients, they are not included in the published results. The major universities with or without teaching hospitals receive most of the research funds. The moneys are jealously guarded, and there is a strict hierarchy that dictates who gets their name on the paper even though they might not have participated in the actual study. WHCCAMP policy should recommend an increase in research funding to conduct studies either done exclusively by specialists in Oriental medicine and acupuncture, or utilize a team approach involving both Western and Oriental medical specialists. The critical importance of including qualified Oriental medical practitioners in designing research studies recently came to light when lack of an Oriental medical specialist led to a research mishap in Belgium, where inclusion of a toxic herb caused kidney damage in many research subjects. Research is directed to clinical efficacy with emphasis on clinical outcomes, cost-effectiveness and general theory of the Oriental medical model to help establish standards of care, a better understanding of optimal utilization, and possibly new therapies based upon the combined understanding of Western and Oriental medicine.

An integral part of the practice of Oriental medicine includes the use of Chinese herbs. The training and knowledge base of Oriental medicine in the area of herbal medicine is extensive, spanning thousands of years of development and, as such, represents the pre-eminent understanding of utilization, cautions and future research potential in the area of Oriental herbal medicine. It is essential that the WHCCAMP include Oriental medical practitioners in all policy-making decisions with regard to regulation, research and utilization of Oriental herbal medicines.

Oriental medicine and acupuncture, for the most part, is a highly effective, low technology approach in treating the ailments of humankind. Very little equipment is needed to support Oriental medical treatments. This makes Oriental medicine and acupuncture an ideal medical specialty suitable for treating military personnel, as has historically been done in China over the centuries. Hence, possible positions could be created for primary care Oriental medical specialists to serve in the armed forces. This could improve medical coverage for the military and reduce costs. Oriental medical specialists should also be able to treat patients in the VA hospitals to help reduce costs in those facilities as well.

Question: Given the significant (often conflicting) philosophical diversity among the multiplicity of schools or forms of acupuncture, how has OPEIU/the Guild contributed to the improved access to and delivery of not only acupuncture in particular, but also Oriental medicine in general?

Oriental medicine involves a wide range of treatment modalities and has promoted a rich diversity in treating similar disorders with different methods, or applying a particular treatment approach to treating different disorders. The main problem that has plagued Oriental medicine is the introduction of physiologically incorrect ideas, invisible or imaginary anatomical concepts such as meridians, and beliefs involving circulation of energy that violate the laws of physics. These bogus ideas are the result of popularizing very poor Western translations since the 1930s by one particular individual who had no training in either medicine, physiology or anatomy. Other translations that occurred before and after this period, however, show the reality of the Chinese medical theories. For some reason, most of the acupuncture and Oriental medicine schools doggedly hold on to these fundamentally incorrect energy-meridian ideas and continue to teach these basic errors. They refuse to do any research to look into the source of the mistranslations, and often personally assail anyone that opposes the energy-meridian concept. In addition, they insist on using Chinese terms (such as qi, yin, yang, etc.) to explain their theories without adequate explanation or understanding of the terms. The net result is the lack of a realistic physiological model for Oriental medicine with many people just making up their own interpretations. This practice has created the idea that Oriental medicine is a belief system or is metaphysical in nature.

The NGAOM has sought out participating members that have invested much time and scholarship into understanding the basic Chinese theories and explaining these in modern biomedical terms. This has involved investigation of the real world aspect of Chinese medical theories, including a comprehensive biomedical explanation on how acupuncture works. Setting the record straight on the true physiological basis of Chinese/Oriental medicine is a major goal of the NGAOM. Any medical system must have a defensible understanding and application of the accepted basis of human physiology. Incorporating these ideas into practitioner training will lead to improved access and delivery of Oriental medicine, including acupuncture. It is our position that the public is best served by practitioners trained in Oriental medical theory and application that is consistent with the real world of physiology, and to render service as a primary health care provider � Eventually, over time, all practitioners would be educated at the primary health care provider level and be able to efficiently work within the conventional care environment, render a diagnosis that is consistent with Western biomedical understanding, have the ability to utilize Oriental medical modalities, (be) knowledgeable as to when Western treatment is either necessary or more effective, and (have) the ability to communicate effectively with all other medical professionals. It does not include, nor does it need to include, the practice of modalities unique to Western medicine. The ability to formulate a diagnosis consistent with Western biomedical understanding is essential for patient safety, improved communication within the health care system, and development of future research, to improve overall service delivery.

Contrary to this opinion, some schools are promoting technician level training where certification can be obtained in either acupuncture, herbs, or Oriental medicine. These would not be primary health care providers and would perhaps need supervision while working in a conventional care environment. However, on the other hand, there are some acupuncture and Oriental medicine schools that have made inroads to working within Western medical and hospital facilities in the training of students. This process is encouraged by the NGAOM to facilitate better communication between practitioners of Western and Eastern medicine and improve the quality of training of Oriental medical practitioners. The wide range of capability represented by the schools show a need for national licensing standards. Also, standards of care are beginning to be developed but are not firmly established. There are few board specialties offered by the Oriental medical and acupuncture profession. The National Board of Acupuncture Orthopedics is but one example of a board specialty modeled after medical specialties.

Question: What policy recommendations does OPEIU/the Guild have for the commission to improve access to and delivery of acupuncture and the spectrum of Oriental medicine for the populations such as the underinsured, uninsured, poor and medically underserved?

The NGAOM recognizes the seriousness of problems in providing medical coverage for the medically underserved. The crowded county hospitals in Los Angeles county alone demonstrates the magnitude and urgency of the problem. The cost in maintaining these county hospitals is staggering where patients exclusively receive high-cost Western medical care. This same situation is common in other parts of the country. For the most part, these individuals have to wait several hours in the lobby area of the hospital before receiving attention. Most are suffering from problems that could be suitably treated by use of acupuncture and Oriental medicine. These hospitals and their associated teaching universities (UCLA and USC for Los Angeles county) are funded by county and state taxes, and perhaps federal grants as well. A WHCCAMP policy should require these hospitals to integrate acupuncture and Oriental medicine care into their programs. Well-experienced practitioners could be hired on staff, and arrangements could also be made with local acupuncture and Oriental medical schools to allow supervised interns to treat the medically underserved.

WHCCAMP policy should � encourage Western medical teaching hospitals to participate with local acupuncture and Oriental medical schools in allowing interns to treat the medically underserved in the teaching hospital. This would provide a low-cost solution in treating the medically underserved and would also allow acupuncture and Oriental medical interns to be exposed to terminology, diagnosis, and protocols used in conventional care. WHCCAMP policy should also encourage acupuncture and Oriental medical schools to also develop programs where the medically underserved can be treated by supervised interns in their own school clinics. These patients would be charged a lower fee, or charged no fee, depending on their economic status.

Many of the indigent and homeless people that fit into the category of the medically underserved have current and former alcohol and drug addiction problems. Alcohol and drug addiction is a difficult and costly social problem typically involving a multiple Western treatment approach. Oriental medicine has several highly effective and low-cost treatment protocols involving the use of acupuncture or electroacupuncture that have demonstrated the capability of playing a significant role in recovery. WHCCAMP policy should also support treatment-on-demand and the inclusion of acupuncture and Oriental medical treatment within drug treatment programs, especially where federally funded programs exist.