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ARTICLES
Incorporating
Medical Acupuncture
Into Standard Medical Practice
James Rotchford, MD
The American
Academy of Medical Acupuncture (AAMA) has established standards of training
for licensed physicians interested in incorporating acupuncture into
their medical practices. The following outlines some of the drawbacks
and benefits of integrating acupuncture into a medical practice. For
physicians not trained in acupuncture, it also addresses issues regarding
the referral process for acupuncture. (In a recent article, Dr L. Li
also discusses his experiences in training and offered suggestions.1)
A review of acupuncture literature in MEDLINE revealed limited materials
specific to these subjects. I offer my suggestions based primarily on
my personal experiences and that of aiding colleagues in incorporating
acupuncture into their practices.
POSSIBLE
DISADVANTAGES IN
REFERRING PATIENTS FOR ACUPUNCTURE
Initial Physician Referral
Physicians are apprehensive when referring patients to someone with
whom they are not familiar and/or who practices an unfamiliar model
of medicine. Physicians practicing different medical models may cause
the patient confusion and a loss of confidence in the system. Such problems
may be avoided if physicians refer patients to alternative care providers
who know and respect the Western medical model and physician care.
Insurance Coverage and Affordability of Acupuncture
Problems with insurance coverage arise, but more and more insurance
carriers are covering acupuncture treatment. In the state of Washington,
worker's compensation pays for dry needling of trigger points. If provided
by a physician, this billing method might allow for some insurance reimbursement.
Many conditions exist for which conventional methods have not worked,
and the patient is willing to pay for other modalities. My experience
and research indicate that most responders (80%) will respond at least
partially after the first 3-5 sessions.2 A standard course of acupuncture
is 10-12 treatments.3 The fees for acupuncture itself can vary widely.
Office visits are generally billed separately when the care is provided
by a physician; office visit fees are a separate issue dependent on
the level of care provided. Thus, for many patients, acupuncture is
an affordable alternative.
Concern for Utilization of Scientific/Objective
Data vs the Latest Popular Trends
The acceptability of acupuncture has greatly increased in the medical
field during the last decade. The truth is that for much of medicine,
there is a lack of sound objective evidence of treatment effectiveness
and benefit. 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,
it may be that for a long time, some physicians and patients will reject
acupuncture simply because they do not understand how it works. Those
who dismiss acupuncture, however, are becoming a minority.
Possible Legal Liabilities
No case history per se exists on this subject, but a pertinent article
has been published.4 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 is clear they have no supervisory role.
Validation of Competitors' Services
Physicians may consider some acupuncturists as competition for patients.
In some states, acupuncturists have even pushed for legislation that
prohibits physicians from providing acupuncture unless they are trained
in a manner identical to their own. In so doing, those acupuncturists
are trying to deny physicians a role in this medical technique. They
are also undervaluing medical training and experience by promoting this
type of legislation. A physician's first concern, however, must be for
the welfare of patients. Therefore, physicians must refer if they believe
the risk/benefit ratio is suitable.
However, fragmented medical care is a legitimate concern and all referrals
to non-physicians should include a follow-up visit with the patient's
primary care provider.
Concerns of Delaying Effective/Proven Therapies
Physicians who refer patients to an acupuncturist rather than to a medical
specialist may be concerned that an effective and safe therapeutic option
is being neglected for their patient. In such cases, prudence dictates
a standard referral, if not before, at least in conjunction with the
acupuncture referral.
Concerns of the Usage of Limited Resources
Whether or not interventions are conventional or otherwise, physicians
are justified in their concerns of spending limited resources for minor
matters or untested procedures. Minor concerns if attended to properly,
as with preventive issues, can often delay or prevent more serious and
disabling conditions from occurring. Yet there is no supportive evidence.
Ultimately, it is often patient demand that determines physician response.
The conventional diagnosis of somatoform disorder is probably appropriate
for an even greater segment of patients receiving acupuncture than receiving
care in a primary care setting. Given the cost and harm that may arise
from caring for somatoform disorders in the standard medical setting,
acupuncture therapy seems a reasonable alternative. Since there are
no objective data to support this contention, more outcome research
is needed.
POSSIBLE
OBSTACLES OF INCORPORATING ACUPUNCTURE INTO A MEDICAL PRACTICE
Time Limitations
Most physicians are already challenged by the information they need
to assimilate. I slowly integrated acupuncture into my medical practice;
eventually I had to reduce the full scope of my family practice to pursue
my interest in acupuncture.
Possible Need to Restructure Practice
Office setting, staff, and working relationships with colleagues will
inevitably change as physicians incorporate acupuncture into their practice.
In a practice in which colleagues share call and responsibilities, time
spent providing acupuncture can be problematic. Most physicians in such
settings establish specific days or half days to provide acupuncture,
and attend to collective responsibilities in the remaining time.
Double Liability
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 appropriate standard therapy.
Financial Concerns
Acupuncture often requires more than the typical 10-15-minute visit.
Physicians accustomed to insurance companies reimbursing for medical
care may be uncomfortable expecting direct payment from their patients
for supplemental services.
Concern of Colleague and Patient Impressions
Perhaps a more thoughtful issue is what is the next right thing to do.
My experience is that in pursuing and exploring this issue, my needs
have been taken care of and fears have gradually subsided. I believe
that perhaps half of the physicians in the United States and other developed
countries make referrals to complementary and alternative medicine providers
and use these types of interventions in their practice.5
When I first started practicing acupuncture, there were no role models
or teachers to identify with. Supervised clinical experience was as
limited in the early 1980s as it is today. Feelings of "role-playing"
persisted for the first few years after integrating acupuncture into
my general practice; also not uncommon are feelings of professional
isolation. Participation in professional acupuncture organizations/societies
can help ease this reaction.
Confusion/Stress Regarding the Most Effective
Course of Therapy
Knowing 2 different models of medicine can create extra tension when
making recommendations to patients. Though time-consuming, it is best
to openly discuss the options with patients and help them to make the
decision. In my practice, now identified as Medical Acupuncture and
Pain Management, 80% of patients receive acupuncture; the others reject
it or it is not indicated.
Many people expect a physician to provide care similar to the conventional
care received from other physicians. When dealing with an alternate
approach, it can take extra time justifying/defending the new approach.
Competition/Vulnerability with Non-Physicians for
Providing Quality Care to Patients
Many non-physician acupuncturists will maintain that only their training
and licensing justify providing acupuncture. Most informed physicians
disagree. Nonetheless, in Washington State, a physician cannot legally
identify himself/herself as an acupuncturist because of the acupuncture
licensing laws. However, most medical specialists have no restrictions
on how they identify themselves to the public. Medical specialists sometimes
compete with other medical specialists regarding training and expertise.
It is uncommon, however, for licensed physicians to confront possible
political exclusion from an area of medical practice.
ADVANTAGES
OF OFFERING ACUPUNCTURE
Patients May Quickly Improve Without the Serious
Risks of Some Medical and Surgical Interventions
Acupuncture is extremely safe, with approximately a 1 in 5,000 chance
of a serious adverse effect.6 It is especially safe as adjunctive therapy
to standard proven modalities, with perhaps the greatest risk being
a missed diagnosis or delayed therapy.
Aside from the effects of reassurance and encouragement that a physician
usually provides and/or the therapy results for acute trauma, physicians
do not commonly see rapid improvement in their patients' conditions.
In contrast, many patients who receive acupuncture quickly feel better.
Your Physician "Ethos" May Improve Since You May Be Viewed
as One Persevering on Problems Not Amenable to Standard Approaches
Most physicians have encountered the situation in which conventional
medicine has little to offer the patient but reassurance that all will
improve with time, or the prognosis that one simply has to learn to
live with the problem. Occasionally, patients balk, feel dissatisfied,
and do not feel cared for by such responses to their problems. By selectively
and informatively offering some of these patients acupuncture, the common
situation in which the patient demands more costly and/or dangerous
diagnostic or therapeutic interventions may be avoided.
My experience has been that once known in a community as being open
to alternative forms of therapy, new referrals (even for standard medical
care) have increased.
Using Acupuncture Provides More Knowledge
Regarding Patients/Conditions/Referrals
Whether considering an alternative provider or medical colleagues as
a referral option, patient feedback is a valuable tool in learning when
and to whom to make referrals. If you provide the acupuncture in your
own practice, the feedback is even quicker.
Possible Financial Incentives of Providing Acupuncture
Some physicians are searching for ways to supplement their income, given
the constrictions from managed care organizations and insurance companies.
Because acupuncture is still not widely covered, fees can be based on
simple marketplace forces.
In a capitated insurance environment, acupuncture may be a way of preventing/delaying
expensive diagnostic or surgical interventions while providing prompt
care to patients. Considerable evidence exists that acupuncture provides
more than a placebo effect.
Challenge/Satisfaction of Education Concerning
an Entirely Different Model of Medicine
Most physicians enjoy learning, and clearly there is a lot of new information
to be assimilated when learning acupuncture. Because acupuncture is
a surgical procedure, it builds on what physicians have already learned.
Physicians can provide quite effective acupuncture for a wide range
of medical issues without ever departing from a Western medical paradigm.
Indeed, some physicians believe that it is unnecessary to learn traditional
Oriental theories to practice good acupuncture.7
Satisfaction in Listening to Patients in Expanded Ways and Hands-on
Care
With Oriental medicine, not only what patients tell you but the context
in which they tell you is very important. If a physician enjoys literature
or listening to a good story, and he or she has become familiar with
acupuncture theories, a new satisfaction in taking a medical history
may be experienced.
In modern medicine, the importance of hands-on diagnostic evaluations
has been eroded by the need for objective data. Practicing acupuncture
and Oriental medicine requires touching patients more often than in
general practice. This hands-on approach can be valuable and quite satisfying
for patients and physicians alike.
Practitioners of Western medicine first obtain a diagnosis and then
provide the prescribed therapy. This process often is impersonal and
is becoming more standardized. By contrast, in practicing acupuncture
from an Oriental medical model, physicians must personalize and be creative
in the care they provide.
Less Likely to Become Bored With One's Work
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 have known who
are "burned out" or disillusioned in their standard medical
practices.8
Expertise Increases With Time
In the Western paradigm, staying current with recent research and advancements
is a prerequisite for providing quality care. For a surgeon, keen coordination
and eyesight are also important determinants. Although staying current
is important for a physician practicing Oriental medicine, the emphasis
is clearly on hands-on experience. Hence, quality of care improves as
physicians continue to practice and gain expertise in acupuncture.
Justification of More Patient Time
In addition to the office visit code, one can also bill separately for
the procedure of acupuncture, allowing more time with patients. I enjoy
giving my patients the time to tell their stories, and they appreciate
the opportunity to chronicle them. Standard financial pressures and
settings can interfere with the ability to spend time with patients.
The extra acupuncture fee allows more time spent with a patient.
CONCLUSION
The advantages and drawbacks of incorporating acupuncture into a medical
practice listed above are not exhaustive. Different settings and individual
physician differences will have profound influence on the outcomes of
incorporating acupuncture. On one level, the decision to provide medical
acupuncture or refer patients for acupuncture is a simple one of risk
vs benefit.9 Given the safety of acupuncture compared with nearly all
other medical interventions, it is often reasonable to provide patients
with the option of acupuncture if current therapeutic options are not
working, are expensive, or more dangerous. It is a complicated issue
for physicians to decide whether to provide or even recommend acupuncture.
Jonas, among others, has explored the challenges in addressing alternative
or complementary medicine.5,10 It is hoped that this discussion will
aid colleagues in deciding whether to integrate acupuncture into their
practices.
REFERENCES
-
Li L.
Becoming an integrated physician: first step is acupuncture training.
West J Med. 1999;171:210-211.
-
Rotchford
J. Medical outcomes research and acupuncture. Am Acad Medical Acupuncture
Rev. 1991;3:3-6.
-
Kaplan
G, LaRiccia P, Pian-Smith M. Acupuncture: another therapeutic choice?
Patient Care. 1999:149-176.
-
Studdert
DM, Eisenberg DM. Medical malpractice implications of alternative
medicine. JAMA. 1998;280:1610-1615.
-
Jonas
WB. Alternative medicine. J Fam Pract. 1997;45:34-37.
-
Rotchford
J. Overview: adverse events of acupuncture. Medical Acupuncture.
1999;11(2):32-35.
-
Gunn
CC. The Gunn Approach to the Treatment of Chronic Pain: Intramuscular
Stimulation for Myofascial Pain of Radiculopathic Origin. 2nd ed.
New York, NY: Churchill Livingstone; 1996.
-
Nelson
AR. Medicine: business or profession, art or science? Am J Obstet
Gynecol. 1998;178:755-759.
-
Rotchford
J. Letting the horses run. Patient Care. 1998:123-124.
-
Chez
RA, Jonas WB. The challenge of complementary and alternative medicine.
Am J Obstet Gynecol. 1997;177:1156-1161.
AUTHOR INFORMATION
Dr James K. Rotchford is in private practice in Port Townsend, Washington.
Dr Rotchford is a Founding Member of the American Academy of Medical
Acupuncture (AAMA), and is President of the Medical Acupuncture Research
Foundation (MARF). He acts as Web Dragon Master for the AAMA home page
(www.medicalacupuncture.org).
James K. Rotchford,
MD, MPH
1334 Lawrence St
Port Townsend, WA 98368
Phone: 360-385-4843
Fax: 360-379-1441
E-mail: kimber@olympus.net
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