James K. Rotchford, MD MPH
Introduction
My story of becoming interested in acupuncture and incorporating it into a general medical practice could fill an entire book. Here is a one paragraph version.
I obtained my MD degree from the University of Washington in 1980. I then did a rotating internship at the Montreal General Hospital, a McGill University affiliated teaching hospital. I came back to Washington to work at a federally subsidized low income clinic on the coast of Washington. In this rural general practice numerous patients presented with painful conditions which were not readily responding to my therapy or the therapy obtained through referrals to specialists. In 1982 I went to a seminar in Vancouver to learn from a Canadian physiatrist how Transcutaneous Electrical Nerve Stimulation might help my patients with painful conditions. While there I learned some neuroanatomical acupuncture and to my surprise it worked on several patients. I became very interested in acupuncture as a result of these initial successes and enrolled in a course on medical acupuncture sponsored by the UCLA school of medicine.
I wasn’t the only Western physician to discover the benefits of acupuncture. Since the early 1980s there has been enormous growth in alternative forms of medicine. Acupuncture is one of the most rapidly growing areas of alternative medicine with both physicians and licensed acupuncturists providing therapy. There were an estimated 5 million visits in 1997. Recent events have accelerated the interest in acupuncture. In 1996 The FDA reclassified acupuncture needles as no longer experimental devices. In 1997 a National Institutes of Health Consensus Development Conference heightened public as well as professional awareness of scientific evidence as to acupuncture’s effectiveness in treating medical conditions.
The American Academy of Medical Acupuncture, founded in 1987 with fewer than fifty members, has grown to more than 1600 members currently—and membership is doubling every two to three years. I should point out that this organization includes only those with an M.D. or D.O. license (or equivalent) to practice medicine either in the U.S. or Canada.
Acupuncture is a very old medical art, and there are many approaches to learning and practicing it. Medical acupuncture is the term used to describe acupuncture performed by a doctor trained and licensed in Western medicine who has also had thorough training in acupuncture as a specialty practice. Such a doctor can use one or the other approach, or a combination of both, as the need arises to treat an illness. Indeed, I am directing this paper to licensed physicians who are open to the possibility of incorporating acupuncture into their Western medical practices.
Contemplating the Integration of Acupuncture into Western Medical Practice
Change, especially amongst medical professionals, is often a difficult and painful process. There are two possible changes being explored in this paper. The first is making referrals for acupuncture; the second is actually incorporating acupuncture into a standard medical practice. By discussing the drawbacks and advantages of making these changes, I hope to promote the changes and make them easier. The drawbacks associated with referring patients and with incorporating acupuncture are different enough that I will enumerate them separately. Whereas the advantages of referring and/or incorporating acupuncture into a medical practice overlap enough that I’ll combine them into one final list.
Possible drawbacks of referring patients for acupuncture:
1. At first you may have a hassle involved in knowing whom to refer to and what to expect.
Comment: Whenever physicians refer a patient for a procedure to someone they are not familiar with, they understandably have some apprehension, especially if the person they have referred the patient to has not had formal medical training or practices an unfamiliar model of medicine. In the case of different medical models which have different languages, the referring physicians might well worry that the patient will become confused and lose confidence in the care provided. Of course, such problems can be avoided if physicians refer patients to alternative care providers who know and respect the Western medical model and physician care.
2. Is there insurance coverage and can the individual afford acupuncture?
Comment: Depending upon locale and third party coverage reimbursement of acupuncture can be quite variable. Hence, it is difficult to make generalized suggestions. Medicare is clear about not covering any procedure which might even resemble acupuncture such as dry needling of trigger points.
There are many conditions with which conventional methods haven’t worked, and the patient would be very willing to pay $500 for a chance to see if they can be helped. My experience and research say that most patients who are going to respond (80%) will respond at least partially after the first three to five sessions. (1) A standard course of acupuncture is ten to twelve treatments.(2) The fees for acupuncture itself can vary widely but are generally in the range of $45-60. Office visits are generally billed separately when the care is being provided by a physician. The office visit fee is a separate issue dependent upon the level of medical care provided. Thus, for many patients it’s a viable alternative to try acupuncture.
3. Will patients/colleagues think that you are not so concerned with scientific/objective data as you are with the latest popular “craze.”
Comment: Over the last ten years the acceptability of acupuncture has greatly risen amongst medical colleagues. Often colleagues will see me for acupuncture or I care for their family members. The truth is that for much of what we do in medicine there lacks sound objective evidence of its effectiveness/worthwhileness. Although mechanisms by which acupuncture works (endorphins, altering brain metabolism/blood flow, local neural reflexes, local neurotransmitters, non-specific needle effect, suggestion, etc.) are gradually being elucidated, I suspect that for a long time there will be both colleagues and patients who reject acupuncture simply because they don’t understand how it works. Those who dismiss it out of hand, however, are becoming a minority.
The theories upon which acupuncture are based have likely been around since before history was first recorded, approximately 1,500 BC. Acupuncture is still part of the most widely practiced model of medicine in the world. Current modern research may be putting acupuncture into new western paradigms (endorphins, holograms, quantum physics, reflex arcs, etc.) which explain acupuncture in the language of Western Science. Nonetheless, the language and the principles of classical acupuncture will likely continue for the foreseeable future to be an important part of medical care.
4. What are possible legal liabilities?
Comment: There is actually no case history per se on this subject and I refer the reader to the article “Medical Malpractice Implications of Alternative Medicine.” (3) If physicians establish an appropriate diagnosis and provide the option of appropriate standard medical care, they are safe to refer patients to independent licensed practitioners for whom it’s clear they have no supervisory role.
5. Does fragmented care become an issue?
Comments: This is a legitimate concern and all referrals to non-physicians would benefit by a followup visit with the patient’s primary care provider.
6. Is the problem of validating a “competitor’s” services important.
Comment: I think it is valid for physicians to consider some acupuncturists as competition for medical care. In some states the acupuncturists have even pushed for legislation that prohibits physicians from providing acupuncture unless they are trained in a similar fashion. In so doing, they are effectively trying to deny physicians a role in this specialty of medicine. They are also undervaluing our medical training and experience by promoting this type of legislation. Our first concern, however, must be the welfare of our patients. Therefore, we must refer regardless of the cost if we believe the patient could be safely helped.
7. Will acupuncture delay effective/proven therapy?
Comment: General practitioners who refer patients to an acupuncturist rather than to a medical specialist may be concerned that a proven effective and safe therapeutic option is being overlooked for their patient. In these cases, prudence dictates a standard referral if not before at least in conjunction with the acupuncture referral.
8. Would we be spending limited resources for trivial concerns or untested procedures.
Comment: All physicians are justified in having this concern whether the intervention be conventional or otherwise. Preventive care has often been undervalued in our medical system and this is reflected in the often poor reimbursement provided for preventive services. It is my opinion that “trivial” concerns, if attended to properly, often can delay or prevent more serious and disabling conditions from occurring. Since there is virtually no data on acupuncture’s ability to prevent illness, it is still awkward to promote it for preventive reasons. Ultimately, it is often patient demand that determines physician responses.
The diagnosis of somatoform disorder is probably correct for even a greater portion of patients receiving acupuncture than receiving care in a primary care setting. Given the cost and harm that often comes from caring for somatoform disorders in the standard primary care setting, acupuncture therapy, I believe, is a reasonable alternative. There is no objective data, however, to support this contention. More research is clearly indicated.
Possible Drawbacks of Incorporating Acupuncture into a Medical Practice:
1. Plate is already too full.
Comments: Most of us are already overwhelmed by what information we need to assimilate. I started slowly in integrating acupuncture into my medical practice and at first was obliged to keep up in all areas of medicine, being a solo practitioner in a rural setting. Eventually I’ve let go of providing the full scope of family practice to pursue my interest in acupuncture. I have consulting privileges in medical acupuncture at my local hospital. I no longer do women’s exams and most other office procedures I refer out to colleagues.
2. Problems with partners and colleagues
Comments: If you are in a practice where colleagues share call and responsibilities, to spend your time providing acupuncture can be problematic. Most physicians in such settings set out specific days or half days to provide acupuncture and attend to collective responsibilities the rest of the time.
3. Double Liability
Comments: Physicians practicing acupuncture have the legal obligation to provide standards of care pursuant to a licensed physician. In addition, those using acupuncture take on the extra legal liability of providing a surgical procedure based on a poorly understood/accepted physiology. The likelihood of being sued for a complication of acupuncture is nonetheless small. The major liability for a physician remains a missed diagnosis or a delay in providing standard therapy.
4. Financial concerns
Comments: Acupuncture often requires more than the typical 10-15 minute visit. Physicians who have become accustomed to insurances, paying for medical care often become uncomfortable expecting direct payment from their patients especially when the charge is significant as is required for the time spent with the patient.
5. Possible need to restructure practice
Comments: Office setting, staff, and working relationships with colleagues will inevitably change as physicians incorporate more acupuncture into their practice.
6. What will patients and colleagues think?
Comments: It has been difficult for me to let go of this question. For me the better question is what is the next right thing to do. My experience is that in pursuing and answering this latter question my needs have been taken care of and my fears have gradually subsided.
Also, at least half of the physicians surveyed in this and other developed countries both make referrals to complementary and alternative medicine providers and use these types of interventions in their practice.(4)
When I first started practicing acupuncture I often felt like an actor or at least someone in a new role. There were no role models or teachers that I could easily identify with. Supervised clinical experience was limited in the early 1980’s. This feeling of role playing persisted for the first couple of years after integrating acupuncture into my general practice.
Because few colleagues had an interest in acupuncture, I often experienced feelings of professional isolation. I became active in the American Academy of Medical Acupuncture and these feelings of professional isolation abated. They are still there to some extent because of my limited involvement at the hospital and my being in solo practice.
On the other hand, wonderful friendships have developed with those colleagues who share my interest in acupuncture
7. Confusion/stress about what is the best course of therapy
Comments: Knowing two different models of medicine can create extra tension when making recommendations to patients. I’ve personally dealt with this stress by openly discussing the options with my patients and letting them make the decision. The problem with this approach is that it’s time consuming and can be awkward. In my practice, now billed as medical acupuncture only, eighty percent of patients receive acupuncture. This is because the other twenty percent either don’t want the acupuncture or other therapy is clearly indicated.
I spend a lot of time explaining to patients the differences in the two medical models. Most people expect a physician to provide care quite similar to the care they received from other physicians. When one departs from the “standard” approach one spends a good deal of time justifying/defending both approaches or the “new” approach.
8. Competition/vulnerability with non-physicians for providing quality care to patients.
Comments: For me it can be uncomfortable to defend the quality of medical care I provide with acupuncture. Many non-physician acupuncturists will maintain that only their training and licensor justify anyone to provide acupuncture. In Washington State I can’t legally identify myself as an acupuncturist per se because of the acupuncture licensing laws. I am able to identify myself as a medical acupuncturist. But I’m a physician, and most medical specialists have no restrictions on how they identify themselves to the public. Some medical specialists have to compete with other medical specialists for acknowledgment of training and expertise. It is uncommon, however, for licensed physicians to confront political arbitrary intransigence in terms of the breadth of medical practice they are allowed to practice.
Advantages of Offering Acupuncture:
1. Patients may improve without the serious risks of some medical and surgical interventions.
Comment: Acupuncture is virtually safe with approximately one in 5,000 chances of a serious adverse effect. (5) It is especially safe as adjunctive therapy to standard “proven” therapies, with perhaps the greatest risk being a missed diagnosis or delayed therapy.
2. Satisfaction of seeing patients feeling better quicker.
Comment: Aside from the effects of the reassurance and encouragement we usually provide in a general medical practice and/or the results of therapy for acute trauma, we uncommonly have the opportunity to see our patients feeling better when they leave our offices than when they arrived. However, patients who have received acupuncture often feel better and have objective signs of improvement even before leaving the office. In part it could be due to the endorphins that are released through acupuncture. Nonetheless, the sense of well being and the immediacy of effect are noteworthy and satisfying to see in patients who have received acupuncture
3. Your “ethos” as a physician may improve since you will be seen as not giving up on problems unamenable to western standard approaches.
Comment: We have all experienced the situation where regular medicine has little to offer the patient but reassurance that all will get better with time or that one simply has to learn to live with the problem. Occasionally, some patients balk and feel dissatisfied and not cared for by such responses to their problems. By selectively and in an informed manner offering some of these patients the suggestion: “Perhaps acupuncture might help with this” you could avoid more costly and/or dangerous diagnostic or therapeutic interventions or just have happier patients.
4. You may increase the likelihood of getting a referral from the providers you refer to.
Comment: It has been my experience that once known in a community as being open to alternative forms of therapy, I have gotten a new set of referrals.
5. Use of acupuncture provides an opportunity to learn more about what conditions/patients might benefit from acupuncture.
Comment: Whether considering an alternative provider or medical colleagues as a referral option, I have often found that patient feedback is a valuable tool in my learning when and to whom I make my referrals. If you provide the acupuncture in your own practice the feedback is even quicker.
6. In a capitated insurance environment acupuncture could be a way of preventing/delaying expensive diagnostic or surgical interventions while providing prompt care to patients.
Comment: A patient comes in with signs and symptoms consistent with a mild carpal tunnel syndrome. You prescribe a splint and give appropriate patient education. The patient returns in two weeks and is still symptomatic. Prior to a referral to a specialist for nerve conduction testing and possible surgical intervention, you suggest a trial of three to five acupuncture sessions. If in one out of five of these patients you avoid a surgical procedure, a cost-effective intervention has occurred. For whatever reason, I’m confident more than one out of five of your patients with carpal tunnel symptoms will respond promptly and favorably to acupuncture.
7. Possible financial incentives of providing acupuncture.
Comments: Some physicians are looking for ways to provide supplemental income, given the squeeze from managed care organizations and insurance companies. Because acupuncture is still not widely covered, it is an area in which your fees can be based on simple marketplace forces.
8. Challenge/satisfaction of learning about an entirely different model of medicine.
Comment: Most physicians enjoy learning. Clearly there is a lot of new information to be assimilated when learning acupuncture. Because acupuncture is a surgical procedure, it only amplifies what physicians have already learned. And acupuncture is quite versatile. Physicians can provide quite effective acupuncture for a wide range of medical issues without ever departing from a western medical paradigm. Indeed, some medical colleagues strongly believe that it is unnecessary to learn traditional oriental theories to practice good acupuncture.(6)
9. Satisfaction of being able to listen to patients in an expanded way.
Comment: For me the medical history comes alive in new and exciting ways as a result of my studying oriental medicine and acupuncture. With oriental medicine not only what the patient tells you but the context in which they tell you is very important. If you enjoy literature or listening to a good story, I’m confident that you will experience a new satisfaction in taking a thorough medical history if you incorporate some basic oriental medical principles.
10. Satisfaction of hands-on care.
Comment: In modern medicine based on the need for “objective” data the importance of hands-on diagnostic evaluations has been eroded. My interest in acupuncture and oriental medicine has clearly involved my touching patients more than I previously did in general practice. For me this hands-on approach has been valuable and quite satisfying.
11. Possibility of being more creative and unique in caring for a patient.
Comment: Practitioners of western medicine first obtain a diagnosis and then provide the prescribed therapy. This whole process often is impersonal and more and more it’s becoming standardized. By contrast, practicing acupuncture from an oriental medical model physicians can only personalize and be creative in the care they provide.
12. Less likely to become bored with one’s work
Comment: This is the flip side of my last point. I have yet to meet a physician who has delved into the oriental model of providing acupuncture who became bored or disillusioned with their work. This is in contrast to the number of colleagues I’ve known who are burned out or disillusioned in their standard medical practices.(7)
13. Expertise increases with time.
Comment: In the western paradigm staying current with recent research and advancements is a prerequisite for providing quality care. For a surgeon, keen coordination and eye sight are also important determinants. Although staying up to date is important in being a physician practicing oriental medicine, true progress comes primarily from hands-on experience. Hence, almost inevitably as they become older and wiser the physicians practicing oriental medicine improve the quality of care they provide.
14. Can justify spending more time with a patient.
Comment: In addition to the office visit code one can also bill separately for the procedure of acupuncture. This has permitted me to spend more time with my patients. I enjoy giving my patients the time to tell their stories and they appreciate the opportunity to tell them. Standard financial pressures and settings used to interfere with my ability to spend time with patients.
The foregoing lists are by no means exhaustive. It is important to consider other drawbacks and advantages from incorporating acupuncture into your individual medical practice. Different settings and individual physician differences are expected to alter the above lists. Jonas, amongst other authors, has also explored the challenges in addressing complementary or alternative medicine.(8)
Conclusion:
On one level, the decision to provide medical acupuncture or refer patients for acupuncture is a simple one of risk versus benefit.(9) Given the safety of acupuncture compared to nearly all other medical interventions, it often becomes reasonable to provide patients with the option of acupuncture if current therapeutic options are not working, are expensive, or are more dangerous. Nonetheless, the above presentation of drawbacks and advantages demonstrates that it is a more complicated issue for physicians to change their behavior with regard to providing or recommending acupuncture for their patients. I hope this discussion will help my colleagues in contemplating the incorporation of medical acupuncture into their medical practices.
Bibliography:
- Rotchford J. Medical Outcomes Research and Acupuncture. The American Academy of Medical Acupuncture Review 1991; 3(1):3-6.
- Kaplan G, LaRiccia P, Pian-Smith M. Acupuncture: Another therapeutic choice? Patient Care 1999; June 15, 1999:149-176.
- Studdert DM, Eisenberg DM. Medical Malpractice Implications of Alternative Medicine. JAMA 1998; 280(18):1610-1615.
- Jonas WB. Alternative Medicine. J Fam Pract 1997; 1997(45):34-37.
- Rotchford, J. Attributable Risk and Acupuncture Events. 1999 Symposium Proceedings pp 317-330; American Academy of Medical Acupuncture, 1999.
- Gunn CC. The Gunn approach to the treatment of chronic pain: intramuscular stimulation for myofascial pain of radiculopathic origin. 2nd ed New York: Churchill Livingstone; 1996.
- Nelson AR. Medicine: Business or profession, art or science? American Journal of Obstetrics and Gynecology 1998; 178(4):755-759.
- Chez RA, Jonas WB. The challenge of complementary and alternative medicine. American Journal of Obstetrics and Gynecology 1997; 177(5):1156-1161.
- Rotchford J. Letting the horses run. Patient Care 1998; 1998(Oct 30th):123-124.