In the first part of this series, we examined the definition of a primary care provider and the question of whether PCPs must perform a conventional allopathic, biomedical diagnosis. In the second part of this series, we will help define a PCP in terms of diagnostic and treatment procedures, prescription rights, immunizations, the "gatekeeper" structure, and hospital privileges.
Must a PCP, By Definition, Perform Specific Diagnostic or Treatment Procedures?
Invasive diagnostic procedures and surgical interventions developed by the conventional medical system can be performed by specialists as they are now. Doctor of Oriental medicine (DOM) or licensed acupuncturist (LAc) PCPs would need additional education regarding the ordering and interpretation of lab tests, the ordering of imaging diagnostics and the evaluation of imaging reports. Vaginal or prostate exams can be performed by specialists, or DOM/LAc PCPs could be trained to perform them. Listening to heart and lung sounds with a stethoscope could also be taught to them.
Over the next decade, I believe that evidence will emerge showing that for the majority of health problems the average American will face in their lifetime, the diagnostic and treatment procedures currently performed by a well-trained DOM/LAc may be more successful and cost-effective than those offered by any other type of health care provider.
Must a PCP, By Definition, Have Full or Even Partial Prescritive Authority for Pharmaceutical Drugs?
Prescription pharmaceutical drugs are not essential for the majority of the population most of the time. When needed, referral to a provider authorized to prescribe those drugs would be appropriate.
A question may arise about acute situations involving infection or pain when time is of the essence. With regard to infection and the use of pharmaceutical antibiotics, the current standard of care is being re-examined. Many sources tell the story of how pharmaceutical antibiotics have not been prescribed and managed appropriately by allopaths and osteopaths over the last half-century, resulting in an alarming and increasing number of resistant bacteria. Our profession has valid options for treating infections in many cases. Perhaps their use will become increasingly desirable over the next couple of decades, and the prescription of pharmaceutical antibiotics will be reserved for use by specialists in a much more restricted and carefully scrutinized manner.
In situations involving pain, when simple symptom suppression by pharmaceutical analgesics is appropriate, referral is an option. Once again, our profession has valid therapies for the treatment of pain that are the most effective choice available to the patient in a majority of cases. For patients with pain, except in acute traumatic situations in which prescription drugs are appropriate, it may be wiser to initially see a DOM/LAc rather an allopath or osteopath.
We should also be aware that the clinical trial system for testing the effectiveness of the use of pharmaceutical drugs that most take for granted is being questioned. In the August 28, 2000 issue of U.S. News & World Report, an article titled "Ineffecient, Corrupt and Unreliable: The System for Testing Treatments Is in Chaos" stated that "a variety of critics have declared that trials are rife with conflicts of interest, that the analysis of women is inadequate, and that study results can be all but useless because so many patients lie when they claim to have followed instructions." The article concludes, "It's clear that the current system has outlived its usefulness and is beyond repair." The article does not explore the impact that decades of using a flawed system may have had on understanding the effectiveness of the pharmaceutical drugs so widely used in America.
It is interesting to note that in the Managed Healthcare story mentioned in the first part of this article (editor's note: see the January 2001 issue of Acupuncture Today), as a result of chiropractors with additional training being used as PCPs, there has been a 55% reduction in pharmaceutical use over the last 12 months. The chiropractor PCPs are not prescribing prescription pharmaceutical drugs.
Again, I believe that over the next decade, evidence will emerge showing that for the majority of health problems faced by the average American, the treatment therapies and natural substances currently used by a well-trained DOM or LAc may be more successful and cost-effective than prescription pharmaceutical drugs.
Must a PCP, By Definition, Provide Immunizations?
While immunizations are a fundamental part of what allopathic PCPs do, there does exist a debate about such therapies that includes the benefits versus the risks, as well as whether immunizations should be mandatory or voluntary. That debate aside, an immunization is a simple medical procedure, an a DOM or LAc could easily perform it. A DOM or LAc could also refer the patient to an immunization specialist for such care.
Must a PCP, By Definition, Be a "Gatekeeper" for an HMO (Health Maintenance Organization) or MCO (Managed Care Organization)?
A PCP may orchestrate health care in any way it is delivered in the U.S. that does not involve an HMO/MCO. Furthermore, as mentioned above, chiropractors are currently being employed as PCP "gatekeepers" in Illinois in a very cost-effective manner. Nurse practitioners are being employed as PCP gatekeepers for HMOs and MCOs in several states. DOMs may evolve as gatekeepers in HMOs over the next few years in New Mexico. To summarize, a PCP is not be definition a "gatekeeper" in an HMO or MCO but may be employed as such.
Must a PCP, By Definition, Have Hospital Privileges?
Even for allopathic physicians, "hospitalists" are emerging to take over medical care in hospital settings. In some states, DOMs and LAcs currently have hospital privileges, and the trend will most likely grow. There are two components to be discussed with regard to hospital privileges: the ability to admit your patient to the hospital and the ability to attend to your patient once they are in the hospital. There is no logical reason why a well-trained DOM/LAc PCP should not have admitting privileges. Any DOM or LAc should have the ability to attend to their patients in hospitals.
It is not difficult to envision that eventually, there will be more Oriental medicine wings in hospitals in this country than there currently are in China. Perhaps one day, an Oriental medicine hospital will be created. Of note, in the aforementioned Managed Healthcare article in which chiropractors in the Chicago area are being used as PCPs, there was a "65% reduction in hospital costs over the first 12 months of the first year, and an 80% reduction in hospital costs for the program from inception to date (18 months)."
Not all DOMs and LAcs must be trained to be PCPs. However, those who want to be trained and employed as such have the potential to contribute to a new perspective to the American health care system that will certainly help create better health care for all.
With increased responsibility comes increased liability. Some have argued that this increased liability is reason for our profession to avoid participating as PCPs. May I suggest that those DOMs and LAcs who want to complete the additional education necessary to become a PCP and are willing to take on the additional liability should be encouraged and assisted to do so. There can be great benefit to all DOMs and LAcs from a network of our own PCPs. (As another article topic, our profession would be wise to initiate a full discussion, based on expert legal advice, of the liabilities that DOMs and LAcs are exposed to when working as "independent Oriental medicine providers" or "independent acupuncture providers.")
There has been anxiety expressed by a few in our profession that some are trying to drug us all into becoming "little MDs" and that in doing so, our souls will be sold and we will sacrifice all that is good in Oriental medicine. I do not believe that is true. While there is always the risk that what is valuable in Oriental medicine could one day be swallowed up by the conventional medical juggernaut and lost, we must remember that Oriental medicine has been a dynamic, evolving system of health care that will continue its evolution as it interacts with and assimilates what is best from conventional biomedicine.
It is my hope that we will evolve the Oriental medical system by evaluating and discarding our own "baggage" and incorporating what is best from all other health care systems, including conventional biomedicine. That has been the history of Oriental medicine over the past few thousand years, and I propose that we work together to insure that the evolution of Oriental medicine continues.
As we have been told, the Yellow Emperor learned from his teacher that there are three levels of physician healer. The lowest level heals disease after the symptoms have manifested; the middle level treats the patient to prevent illness from occurring; and the highest level heals society. Perhaps by evolving to a more primary role in health care in America, we may better contribute to the healing of our society.