How to get privileges and what you better know before you begin to prescribe
By Christian Nix
When it comes to practicing herbal medicine in a mainstream setting, there are a number of important points to understand when it comes to prescribing formulas.
Some important questions to ask are - what method of prescribing and dispensing is most effective in this setting? How do you avoid the essential danger of herb-drug interactions? What are the essential formulas and how do you modify them for the greatest effect? How do I make my herbal pharmacy profitable? How is it possible to gain access to such a privilege in a hospital setting?
This piece will examine these issues and provide solutions to each of the above questions.
A Community-style clinic in a Hospital Setting
The model I will use as my example and from which I have drawn my career experience is a community-style practice, which I have modified to suit a hospital environment.
I have implemented this model twice – first in the rural highlands of Guatemala and most recently in Chicago.
The results are noteworthy enough that it no longer seems outrageous to simply declare straight out that this indeed is the future of holistic medical practice in North America.
To begin an investigation of best practices with regard to herbal medicine it should be stated at the outset what advantages exist inherent within the practice and prescribing of herbal formulas.
Herbal medicine is not better because it is natural. Nor are pharmaceuticals evil and detrimental simply because they are synthesized in a laboratory.
What is Good Medicine?
The best definition of "good medicine" is a substance which has its intended effects without producing unwanted side-effects.
The first essential point regarding the professional practice of herbal medicine is that polypharmacy formulas from the holistic Chinese medical model treat various patterns.
Many practitioners claim to know this, but still fail to implement their herbal practice on sound logic and professional methodology in pattern diagnosis and treatment.
Why is this important? Because it is pattern diagnosis that permits and promotes management of chronic disease.
And because it is chronic disease that is the plague of the 21st century and foreseeable future.1
The essential benefit of treatment according to pattern discrimination is that the patient gets everything he/she needs and nothing he/she doesn't need.
The ability to correctly diagnose patterns is the hub and axle of everything you will do in any clinical setting.
If pattern discrimination is important in private practice, it is even more essential in a mainstream hospital setting. I'll explain why.
Nowhere is the skill of pattern discrimination more valuable to your practice and to the patients you treat then in regard to herbal practice in a mainstream hospital setting.
Because acupuncture is actually no big deal.
What do I mean by this?
Four to six needles with enough proper stimulation is generally enough to aid most folks simply by acupuncture's inherent ability to move qi and restore (some) proper function and relieve liver depression qi stagnation.
But in the treatment and management of serious chronic disease, it is internal herbal medicine that is king.
Indeed, it is not realistic to believe that patients with serious chronic disease are going to recover or will have a significant turnaround in their condition until they receive herbal treatment to backup and reinforce their simple acupuncture treatment.
Acupuncture treats pain and stress so quickly and simply that there is no real comparison to any other technique, pill or procedure.
The simple fact of moving qi has profound and cumulative effects on every other aspect of any existing pathomechanism and the long-term course of any chronic disease.
If qi moves, blood moves. Blood and fluids move together.
If qi moves dampness is either eliminated or assimilated as healthy yin.
But no amount of acupuncture is going to re-balance the diametrically opposing patterns of patterns of repletion and vacuity, heat and cold (i.e. hot above, cold below), dryness and dampness that appear in a typical patient with diabetes mellitus – and that almost always means multiple formulas combined together.
Such conditions require internal medical treatment with herbs.
Methodology of Prescribing
It is not uncommon at peak hours in our Chicago clinic to have 6 to 8 patients in treatment simultaneously.
The rigor of your logic and diagnostic methodology must be iron-clad and utterly free of error.
If you can discriminate and recognize the 30 to 40 most common patterns and the ways in which they commonly combine and modify one another, then prescribing herbal formulas effectively is a manageable, if not an easy or simple affair.
In a community-style practice, emphasis is on frequency and simplicity of treatment.
For this reason and others related to safety, my clinicians and I only prescribe and dispense herbs for 3 to 4 days.
Typically this amounts to 12-24 capsules of 500 milligrams of powdered extracts, usually at a 10:1 extract ratio.
Obviously the exact dosage depends on the patient's size, condition and what formula and concentration I am prescribing.
This dosage is:
strong enough to show effects
short enough to catch and prevent interactions if any arise unforeseen
requires the patient to return in a timely manner for treatment for the next dose
allows for revision of the patient's patterns and re-evaluation of their formula and dosage
lowers the cost to something quite reasonable when compared with the sale / purchase of an entire bottle
Internal medicine with herbs is essential for the vast majority of patients we see in our clinic.
Sending patients away with 3 to 4 days of medicine allows them to continue treatment until the next visit.
It empowers them and they like this.
For a lot of people, taking herbs is much better than taking pharmaceutical drugs and pills.
This low-dosage approach wins both compliance and great confidence and enthusiasm from many patients.
When they feel their condition improving, they are compelled to return for treatment and to continue their journey to better health.
The Dangers of Herb-Drug Interactions
It is certainly no joking matter to consider possible adverse herb-drug interactions when you are working in a hospital based mainstream setting.
But, based on experience the truth of this danger is greatly exaggerated.
With a little good sense and diligence, the likelihood decreases to almost nil; and by prescribing for only brief periods of say 3 to 4 days at a time, any possible adverse effects can be recognized and any dangerous interactions avoided.
A survey of literature and expert opinion reveals less than a dozen true "red flags" for possible herb-drug interactions. The trick of course is recognizing these red flags.
This is a difficult but not impossible obstacle to overcome. The hospital-based practitioner must have a good system in place and use good judgment, erring on the side of caution.
Have an emergency hotline or phone number that patients can call and a plan to deal with a patient who is in crisis. It is better by far to have them wake you in the night than having the patient call the hospital emergency room.
It is worth having a simple background understanding of herb-drug interactions – and the way in which conventional pharmaceutical medicines can potentially harm patients when herbs interfere.
An important term to know is ADME, which stands for: Absorption, Distribution, Metabolism, Elimination
The three primary factors which determine possible herb-drug interactions have to do with:
Therapeutic index (narrow)
This topic is actually simple to understand; but it is also a serious matter.
Dr. Greg Sperber offers a short course on this material through Blue Poppy Distance Learning. Go to BluePoppy.com and check out these two resources for more:
Nine Drugs to Worry About When Combined With Chinese Medicine
Seven Steps to Avoid Herb-Drug Interactions
These two short courses are sufficient to give necessary information and confidence – not only for prescribing in-clinic, but also to present your information to physicians you might be working with in a way that shows you have done your due-diligence.
Formulas for Hospital-based Herbal Practice
Because of the structure and nature of hospital-based practice – by which I mean the speed and volume of patients and speed of treatment – the prescribing of herbal formulas is and must be a tight system utterly congruent with the patient's presenting patterns and easily reviewable for errors in logic.
Fundamentally this requires:
Excellent diagnostic skills in pattern discrimination
Memorization of the most effective formulas for multi-pattern presentations (I cannot recall ever having seen a patient with less than three patterns)
Because the overwhelming majority of patients in the modern era suffer from chronic disease and because chronic disease is fundamentally a mixed vacuity/repletion scenario, it is essential to be well-versed in the uses and effects of a core group of harmonizing formulas.
The core pattern of imbalance in chronic disease is liver-spleen disharmony.
But the various additional patterns which manifest as a result of this core pattern require high-level understanding and appreciation of holistic pathophysiology.
Furthermore liver-spleen disharmony is not the only pattern of mixed vacuity / repletion.
There is also:
Liver and spleen
Liver and stomach
Stomach and Spleen
Stomach and intestines
Constructive and defensive
Qi and Blood
So, you must know the major harmonizing formulas and use these with the overwhelming majority of patients with chronic disease; and you must also know the formulas that can be added to modify these harmonizing formulas.
One of the best sources for learning how to work in this "modular format" is Eric Brand's book, A Clinicians Guide to Using Granule Extracts.
The other source for solid fundamentals in this method of prescribing and combining formulas is the Hospital-Based Acupuncture Training program by Barefoot Medicine Training, where you can learn more about both of these topics:
Community Acupuncture for Pain and Stress
How to be a Barefoot Dr. in the West
Make Your Herbal Practice Profitable
The simplest way to a run a profitable herbal pharmacy is to dispense capsules in concentrated granule extracted formulas.
Charge by the capsule and keep the prescription sufficient for 3 to 5 days. No more.
Not only does a prescription done in this manner reduce any miniscule possibility of herb-drug interactions, it is also a good way to motivate your patients to return for more treatment and to renew their prescription.
For example: If I prescribe Bu Zhong Yi Qi Tang for 3 days for a 140 lb. female patient with a disease complaint of IBS and the patterns of liver-spleen disharmony, damp-heat and central qi downward fall, I might start at 4 capsules of 500 milligrams each of a 10:1 extract.
That comes to 12 capsules for a 3 day supply.
At .33 cents per capsule or $1 for 3 caps, I am charging $4 for her prescription.
This is $1.33 for the patient per day. Quite affordable. Once she feels the difference such medicinals make, it is an easy bet she will return – or if she does not return after 3 days when her prescription runs out – that she will think of my clinic when her symptoms return or she has a flare up.
This system of low dosage is safe and makes great sense in terms of marketing. It avoids the chance that she could have an herb-drug interaction from something he/she is taking but did not bother to mention on her intake form (always best to hedge yourself against this possibility as there are simply too many patients taking too many pills for them to remember); and it reinforces the patient's need and desire to return for frequent treatment – a major pillar of a successful mainstream practice.
Gaining Hospital Access for Herbal Practice
I have written elsewhere about the important benefits of owning your clinic and providing an outsourced service versus working as an employee of the hospital or of a physician group.
Let me explain this again in brief because, with regard to herbal practice, it may be the only way to go that will allow you to use the full range of your skills.
First of all, setting yourself up as an outsourced service to mainstream hospitals shows initiative and that you are business savvy.
It tells the administration or decision-maker that you are in business like a pro. Second, it is dirt simple to create an LLC these days.
Next, as an outsourced service – something not at all uncommon these days – you will be granted the kind of scope commensurate with your full legal right and no one is even likely to question you about this.
This brings up the value of knowing as much as you need to about the legality of practice in your state or given situation. Know the laws and don't fool around.
The confidence of your self-presentation exists in direct proportion to your understanding – by which I mean the rules of the game both legal and political.
As I have said since the beginning of my career, your best posture in the Chinese or holistic medical world is as a teacher.
Learn how to teach and use every opportunity to get yourself out and in-front of others who will benefit from your expertise.
There is tremendous interest and real thirst for the kind of knowledge that you have if you take the time to learn how to communicate it correctly.
Communicating your knowledge correctly means avoiding any New Age nonsense and reaching your audience and others where they are not where you want them to be.
The fact that we knew our stuff going in and were willing to inform and to listen, to share and to inquire; that our legal structure was in place – all of these things made inclusion of our herbal practice privileges a foregone conclusion.
There was simply nothing for them to consider or against which they might object.
Steps You Need To Take
Now that we have reviewed the various aspects of herbal medicine in a mainstream hospital setting and answered a number of questions, its time to take action.
In order to get started, you should take note of the following steps:
If you want privileges prescribing herbal medicine, form your own legal entity. An LLC is fine.
Then get clear on the points mentioned and of course be sure to know your state laws as well as any hospital policy or history that might aid or hinder your attempt.
Show that you know and understand the issue from their perspective (as a pharmacist or physician might) and then teach constantly and confidently about what you know and plan to do in a way that addresses and acknowledges their concerns.
These three steps will help you get started on a path that is sure to be the future of herbal medicine.
World Health Organization. Preventing chronic diseases: a vital investment. WHO press, Geneva Suisse. 2005
Christian Nix has launched the first Hospital Based Acupuncture Residency Training program in North America and his Community Pain and Stress Center is the first private model of community-style practice to be integrated into a major hospital system. His new book, Tao of Integration is a fresh look at much of the misapprehension hindering professional quality integration in medicine. Christian travels and teaches throughout the world.