WHITE HOUSE
COMMISSION
on
COMPLEMENTARY and ALTERNATIVE MEDICINE
POLICY
+ + +
Draft Interim
Report
+ + +
Volume I Part 2
+ + +
Monday, July 2,
2001
10:10
a.m.
Jurys Washington
Hotel
Westbury Room
1500 New Hampshire Avenue,
N.W.
Washington, D.C.
P R O C E E D I N G S
DR. BERNIER: I think it would be helpful if the words "evidence based" was associated with the curriculum.
DR. PIZZORNO: George, I am going to take a slight disagreement with you, not because I don't agree with evidence based.
DR. BERNIER: It wouldn't be the first time.
DR. PIZZORNO: Actually, I think we have agreed on most things. Oh, well, anyway. I am absolutely committed to evidence-based medicine rather than conventional CAM.
DR. BERNIER: I think that is a great way to say it, the way I said it.
[Laughter.]
DR. PIZZORNO: So, give us some wording for the solution that if there is a practice out there that does not have evidence, but the medical practitioner must know about its presence, how do we tell them if it is not evidence based? You are saying if it is not evidence based, we can't tell them about it, we have to tell them it exists.
DR. BERNIER: I am sure we could make an exception.
DR. GORDON: George, I thought that what you meant was an evidence-based approach, so if there is evidence, that evidence is produced, if there is no evidence, one simply says that there is no evidence.
DR. PIZZORNO: Then, we are in agreement, that is fine.
DR. FINS: On this line, you know, the United States Public Health Service, all those things for prevention, and they have, you know, there is A, B, C, D, that might be a very helpful model, and different groups have different recommendations like the American College of Physicians, ASIM about mammography versus American Cancer Society versus U.S. Public Health Service.
There was this chart in the Annals of Internal Medicine a few years ago that sort of folded out for every period of life and who said what, and that might be a model worth looking at as an analogy for what we are talking about here.
DR. GORDON: Or another way to think about it might be to say that people always have some evidence on which they base their approach, so the question is what is the nature of that evidence and what is the quality of the evidence really.
That opens up to other kinds of evidence than perhaps conventional science has, so it is simply a matter of stating what evidence there is and making that available to people who are studying that approach.
DR. PIZZORNO: I think that is an excellent recommendation, George, so that this education clearly defines the level of evidence available for these kinds of practices.
Would that meet what your intent is? Okay.
Any other comments? Tieraona.
DR. LOW DOG: Is it appropriate to mention in there, in addition to just CAM curricula, that medical schools attempt to define the traditional practices that are practiced in their area in their patient populations?
It is a big issue for us in New Mexico being familiar with the indigenous populations there and the hispanic populations, so that there is an understanding of the different treatments and the different modalities that are used.
I mean it can be relevant. We had a child who a social worker was called in for child abuse because they had done coining on the child, which if anybody just would have understood what that was, a whole terrible thing could have been avoided.
So, because we are such a diverse culture in the United States, I would like to see just making some sort of recommendation.
DR. WARREN: What is coining?
DR. LOW DOG: The child had a bad like pneumonia, bronchitis, and they had taken the warm coins and had placed them to help break up the mucus and the congestion, and it didn't burn the child, but it left small rings on the back where you could definitely see. The social workers were called in. The child was held in protective custody for several days.
It was just a terrible sort of thing because it is just a very deep part of traditional Vietnamese healing, and nobody was abusing anybody, but because the ER staff didn't know anything about our very large Vietnamese population, they had no idea what this might have been from.
Again, I am just sensitive to a lot of the use of the Curandismo and the different diagnostics that hispanic people use, as well, and I think that it is something that has been really left out. I think it hits right to the heart of what CAM is, which is traditional practices, and we have many of those here in the states.
DR. PIZZORNO: Any other comments, recommendations?
[No response.]
DR. PIZZORNO: Great. We will nail that down and move on to the next one.
No. 2 on page 4 is parity of CAM professions and practitioners with conventional health care professions in access to educational and training funding and other resources. I would also add to that "comparable accountability." So, I think not just having access to funds, but also accountability for their education and the use of those funds.
Any comments about this recommendation?
DR. GORDON: Joe, just to open it up a little more to thinking about it, when a recommendation like this comes up with which I basically agree, and you begin to think about making this recommendation to Congress or to the administration, you start thinking about money, at least I start thinking about money and limited resources.
So, I am really opening this as an idea for discussion, do we want to make recommendations that we know are going to cost a lot of money and cause a lot of tumult, which we may, or do we want to make limited recommendations, how do we want to approach this as a commission, and it is applicable here, and there are several other areas where it is quite applicable, as well. I just raise that question.
DR. PIZZORNO: Tom, Tieraona, George, Joe.
MR. CHAPPELL: I think this is one of the highest priorities among our recommendations is to create equal access to all aspects of being a good practitioner, so it really, for me, it doesn't matter whether it is controversial or going to raise questions about additional funds.
As I said earlier today, I think we have to be proactive about raising and allocating more funds for this area of wellness and health, and so this would just go along with that. Perhaps we need to make a statement right upfront in our introductory section of our report that CAM practices and products are a value-added to what is available as described by 42 percent of Americans that are currently engaged in paying for these services, or the $30 billion that constitutes the marketplace for these services.
The value of these services has been already demonstrated by consumers, so I think the cry here is for better research, better education, better services, and the only way we can raise up the CAM professional is to give them equal access to the funds.
So, I see this as so fundamental I certainly wouldn't want to postpone it. I would like to just face it head on.
DR. PIZZORNO: Tieraona.
DR. LOW DOG: Mine is a simple question. Are you talking about licensed professionals only here, and is it all licensed professionals, just for curricular program development inclusion and loan forgiveness, I mean so massage and acupuncture, that is strictly what we are speaking is licensed providers?
DR. PIZZORNO: I think that you have raised a good question we should discuss, because clearly, there are those schools that are accredited or licensed by the states and have licensed practitioners.
There are other groups out there, as well. I think we should facilitate their evolution, as well. I think the idea of establishing an Office of Emerging Professions, for example, under the federal government, to facilitate the maturation of each of these healing arts, particularly those who aren't as far advanced as naturopathic medicine or acupuncture or chiropractic, to me makes a lot of sense. Again, it is up for this commission to decide on that.
George.
MR. DeVRIES: I see a lot of value in this approach, but I am also challenged by how it is going to be received in a report to basically say there has to be parity on all levels in a variety of areas.
I think if you compare medical physicians with dentists, you don't see dentists having parity, and yet you see significant access to resources, and it seems as if, while it may seem like settling for second best to take a more incremental approach, at least perhaps that is a start and heading in the right direction, and can be demonstrated over time, the value of an incremental approach and be grown over time.
DR. PIZZORNO: Perhaps one way of looking at it is rather than mandating exact parity, it would be to look at legislation which currently excludes CAM institutions from access to federal programs. That is a real issue, because so many clinical programs say only M.D.'s, only DO's get them, nobody else can have access to them, so may be an incremental step, but just remove the exclusions.
Joe.
DR. FINS: I think this is a tough one. I am not sure what you mean by parity with respect to resources. I mean you could say, well, NCCAM gets $100 million now, the NIH budget is $20 billion, so we should ramp it up to $19.9 billion.
DR. PIZZORNO: All in favor, say aye.
DR. FINS: But I think this really is going to be I think difficult to sell to people. I mean people have different amounts of training and there isn't parity in anything in our society. I think we need, I agree with George, a more incremental approach, and Joe was just saying, I mean as an idea, you know, there are ways of having collaborations to increase cost effective ventures in this new paradigm with health, but I think to go for parity, I mean I can't imagine the entities that represent organized medicine having a great deal of comfort with that.
Of course, I think if we are looking, and I don't think it is justified at this point. We heard testimony from different practitioners from the same discipline, from different schools, who couldn't agree on the number of hours one needed to train to be an acupuncturist.
So, I am not sure if there is a consensus or there is standardization yet to really say, you know, that they should have parity with entities that have formalized curriculum and a methodology and licensure, accreditation and re-accreditation, so I mean I think there are lots of issues here, that there is not equality, ready for parity.
I am in favor of integration, I am in favor of cross-training, I am in favor of collaborations, but parity seems a little too extreme.
DR. PIZZORNO: Dean, and then Tom.
DR. ORNISH: I know I am sounding like a mantra here, but I really think this would a perfect issue to table until October because there is a lot of controversy about it. You know, it is not a question of the merit of the idea as it is being mindful of the fact that you probably couldn't pick a bigger land mine than this one.
If you want to just put it out there and step on it, at least do it with your eyes open. Maybe I am just getting old, but I really think that there is value in incremental approach, because otherwise we can take a polemic and end up with nothing, or we can try to say let's really be skillful about change.
We heard this morning how it took five years from the time the patients' bill of rights was introduced before it got passed last month, and that is kind of a hard thing to argue against, the patient should have rights, you know, so I am taking more of a long view here, and I think that if we don't avoid these land mines, we are going to just end up with a lot of rhetoric and nothing to show for it, and I would really encourage us in the Interim Report to avoid those kinds of things if we can.
DR. PIZZORNO: Before I move on to Tom and Charlotte, could you give some examples of some incremental approaches that might be useful?
DR. ORNISH: Well, there are a lot of them. I am more just trying to be the red flag and say look, you know, you don't wave a red flag in front of a bull and then say, hey, how come the bull is charging at me. Just be mindful, be aware. There are lots of incremental approaches. I mean many, many things have been said already, I don't need to repeat them - demonstration projects are just one of many.
I am just saying that our committee is a pretty pro-CAM committee as it should be, but if we hear people like George and Joe and other people who are raising these issues, we need to listen to them, and say, look, if they are raising these issues, you can be sure that AMA is going to be raising these issues and other organized medicine, and the stakeholders who view that there is a limited pot of money, and if you are going to be increasing the money for other people, it means you are going to be taking it away from them.
Whether that is real or not is irrelevant, that is the perception, and I think that we ought to have an Interim Report that we can all agree on, that we don't have dissension in our committee, that we can say, yes, this is really good, that we don't make ourselves easy targets and then as we build up the groundswell behind our support, support behind what we are recommending, because it just makes sense like freedom of choice and the kinds of things that we heard about this morning, then, it becomes much easier to take it to the next incremental level.
But if you try to do too much too soon, you go nowhere, that is all I am saying, just let's try to, for the Interim Report, just find consensus, and then for the October report, we can decide how much we want to go out on a limb.
DR. PIZZORNO: Thank you, Dean.
Jim has a point of information.
DR. GORDON: I just wanted to mention as a point of information, what we have done with the draft of the Interim Report is to raise this as an issue without saying where we come down on it, so in a sense, we have done what you are suggesting, saying that it is an important issue -- at least I believe we have -- saying that it is an important issue, but it is not one we are addressing in the Interim Report, but that it is something, I think as we say pretty clearly, it is something that people have testified to wanting.
DR. ORNISH: I was only respectfully disagreeing with Tom when he said he felt so strongly about it should be in the Interim Report.
DR. GORDON: I understood that.
DR. PIZZORNO: Tom.
MR. CHAPPELL: I believe the problem word here is "parity," and at least in the interview that I had for today's meeting, I was talking about equal access, equal opportunity. I have a hard time speculating that anyone in this room, or even anyone reading the report, would have trouble with the idea that a CAM practitioner should have equal access to the same sort of funds for education and development that another medical professional would. So, it is really not parity, that is the problem word, it is equal access and/or opportunity. Perhaps it is just equal access.
I think if we don't put it in the Interim Report, we get criticized for suggesting elsewhere in the report that we have expectations when we haven't even thought to cover the basic homework of needed training, needed development, and more knowledge in general.
I just can't imagine that anybody would want to deny the necessary steps of full development, so I would change the word, and I do think it really needs to be part of the Interim Report.
DR. PIZZORNO: Thank you, Tom.
Charlotte.
SISTER KERR: I just want to say I agree with Tom, and I would also honor what Deans says, however, schools have met state requirements of credential for Master's programs, have national standards, say, like acupuncture schools, hey, you know, change parity maybe, but you certainly have equal access to funding.
DR. PIZZORNO: Joe, and then Jim.
DR. FINS: Just briefly. To put this into context, the last line in the Interim is talking about the federal loan forgiveness, the scholarship programs that are now available to students of the conventional professions, well, this has been dramatically cut back and we have to contextualize how this will be received in the context of the diminution of resources for conventional practitioners and medical students to get these kinds of loan forgiveness programs.
DR. PIZZORNO: Jim.
DR. GORDON: I think what I wanted to say is that, by definition, the Interim Report is going to represent areas where we have consensus, so that is something that we have consensus, that we are going to have consensus in the Interim Report.
So, what I am suggesting, which I suppose goes with what Dean is suggesting, is that in those areas where we don't have consensus, that we really need more time and more discussion, and need to really grapple with these issues in a different way, and then we can figure out how we are going to deal with them.
If we come to a consensus about this, then, fine, it could be in the Interim Report, but if there is not a consensus, my feeling is the Interim Report is the representation of our consensus at this time.
DR. PIZZORNO: Other comments or thoughts?
MR. ROLIN: I, too, disagree with the use of the term "parity," but I was certainly in favor of access, but it is just like we have said, when you get to the last part of that sentence there, when you are just seeking out and making that broad a statement, it is going to trigger the whole community as far as education and all that.
So, access is a key. I think it should be included, but, you know, inclusion to that extent, I don't know if I am comfortable with that or not.
DR. PIZZORNO: So, I think I am hearing here that the use of the term "parity," which implies exact equality, is problematic for a consensus from this group. Now, I would personally go for it, but we want consensus. I want to be clear where I stand on this.
So, what other language can we use here we can develop consensus at? Now, we may not be able to develop consensus, but we have a little bit of time, let's see if we can. Tom and Buford both brought up the concept of access as being a better term.
Now, that access can take many forms. Equal access is one form, which is good. We can also use the term "increased access," which is a lesser term, but it does open some doors. To make a quick editorial comment here, clearly, the vast majority of health care in this country is provided by conventional medical professionals, however, a large amount of health care is being provided by the alternative medicine practitioners, and right now virtually all of the money for education, research, certification, advancement, et cetera, goes to conventional medicine. That does need to change.
I suspect there is consensus on that. So, the question then is how we come up with language that we feel will be accepted, but will also induce change.
Dean.
DR. ORNISH: I think for the purposes of an Interim Report, you want to avoid any relative comparisons. In other words, instead of saying this should have as much access as that, which immediately, if you are "that," you feel like you are going to get that taken away to be given to this, you say adequate resources should be provided for education and training in research and complementary and alternative medicine, something along those lines, a positive statement without making reference to anything else. That is just my belief.
DR. PIZZORNO: There is one recommendation. Are there other recommendations about the kind of language we could use, that we could get consensus around?
[No response.]
DR. PIZZORNO: Actually, I kind of like what Dean said. That sounds pretty good to me. Anybody else? Joe.
DR. FINS: I would just add to that the word "accredited" or some sort of, you know, so we are talking about legitimate practitioners or people who are in accredited programs, or things like that. The people should be engaged in accredited activities, you know, accredited educational activities.
We get back to the licensure issue again. That is why there isn't parity, because you can't answer that question. You can't answer the question who is accrediting these people in all the circumstances we are talking about. In some cases, you know, we can, I mean in the acupuncture case, we might be able to do that; in other areas, we can't. So, making a broad sweeping comment about all CAM professions and practitioners, there is also a disservice to the heterogeneity. I mean it says the Bastyrs are like the mail order naturopathic medical schools.
DR. WARREN: Even though they are both accredited by the state.
DR. FINS: And even though they are both naturopathic physicians, and I think having been to Bastyr, it is a disservice to -- you know.
MR. DeVRIES: Do you want to read what you have, that you are trying to get consensus on?
DR. PIZZORNO: Okay. Also, Donald, I want to be real clear, institutions like Bastyr have different accreditation than institutions like the mail order people, I want to be very clear about that.
DR. WARREN: [Off mike.]
DR. PIZZORNO: You may want to check to see who they are accredited by. Also, please use the microphone.
Here is possible language that I derive from what Dean just said. Adequate resources for CAM professions and practitioners to access educational and training, funding, and other resources.
Tieraona.
DR. LOW DOG: I think that Joe's point there about accreditation or licensed or something, it is going to have to be addressed somewhere, and it is different than access. I mean you can go see whoever you want, I would defend your right to the end to go choose who you want for your health care provider, but I am not sure that we want to really say just any CAM profession, because I am not sure that I want loan forgiveness and that for iridology school, and I don't want to pick on that, I am saying that there are certain things that in a limited pool of money, may have more value than others, and the groups that have gone through accrediting their schools, I think that any of those students should have the same access as any student has in the United States to get money to pay for their education.
Loan forgiveness is a little bit of a different situation, and I don't think we have consensus on that, but I don't think anybody here would disagree that if you are going to go to school, you should have access for federal funds as loans that you can take out and repay. I might even feel the same way about iridology school for something like that, if you don't pay it back, I don't care what you do with it, but loan forgiveness in that, what we are going to pay for I think is a different subject.
DR. PIZZORNO: Jim, Tom.
DR. GORDON: One thing I want to say is what we are peeling away is the various levels of this discussion, which becomes very complex, and I want to make sure that whatever recommendations we come out with in the Interim Report do not get us in over our heads, because I think the distinction here between repayable loans and loan forgiveness is huge.
The distinction between, that we still haven't solved, is which professions do we include in CAM, and do we make that public money available for, is also a big area of discussion. So, I just want us to be clear that there are real differences among these as we make these decisions. These are decisions that really make a difference, and we may not have taken account of all of the things that we are deciding about, and we are just hearing them now.
DR. PIZZORNO: Tom, you are next, and then George.
MR. CHAPPELL: For me, the statement of access versus parity would sound something like provide access of CAM professions and practitioners to educational and training, funding, and other resources. It is not a comparative at all. It is just providing access.
The marketplace will work that out. That peels away all the comparators, but it establishes the fundamental principle that I feel that we are trying to do here.
DR. PIZZORNO: Thanks, Tom. So, now we have two ways of wording this. One is provide access for CAM professions and practitioners to educational and training, funding, and other resources, and the other is provide adequate resources for CAM professionals and practitioners to educational and training, and other resources.
George.
MR. DeVRIES: This obviously may be a small land mine even within this room, but reality is part of the incremental approach in terms of the funding, part of the ability to sell this to Congress, part of the ability I think almost necessitates that the funding be limited to CAM practitioners who are licensed, and it would have to be provider types who can be licensed.
DR. GORDON: Could you say why you are saying that, George?
MR. DeVRIES: Well, I think part of it is you have a regulatory body in the states that is overseeing the licensure of these individual providers, and that provides part of the standards in terms of the profession, also in terms of the educational curriculum, and that draws down to the accreditation process of the school, ultimately even to the ability of the provider to get reimbursed, because even as we heard in testimony, very often -- well, I shouldn't even say very often -- but typically, the health plan, if they are going to cover CAM, it is going to be limited to providers who are licensed.
So, that line draws across a variety of spectrums.
DR. PIZZORNO: Effie was next.
DR. CHOW: I would just like to reflect back on what Jim said, that we are reflecting what has been stated by people who testified, and that we are not really speaking only as commissioners, but we are really relaying the message of the people.
So, in a sense, I think we have to be careful with words, but we can't water down everything because it is going to offend the Congress. I am not saying that it needs to be in the Interim Report, but I think I would like to see we not neutralize things so much that we are not going to make great impact to, as well, and that we do have the obligation to reflect what the people have said, and the people have said some very strong things.
We need to portray that, as well as the other, more mild things.
DR. PIZZORNO: Thank you.
We are getting close to the end for this particular one. I would like to, one, suggest some wording, and actually I really like the way Tom worded it, but also I would like to put one more piece on the table before finishing this, and that is do we restrict this language to licensed professions or not.
I would like to start the conversation with a comment. On the one hand, I certainly can see the value of restricting it to licensed professions, and it certainly resolves a lot of thorny issues about deciding who gets qualified and who is not, but on the other hand, I feel a very strong commitment to those other healing arts that have not yet progressed to the point of formal education, accreditation, licensing, and such, that we give them a helping hand up, so they can evolve, that needs to be handled.
Now, as Joseph just said, this may not be the place to do it, but it is something that I think we need to do. Those iridologists, for example, I have major doubts about whether it has any validity or not, but, you know, they need to progress to a point where we can determine it they have validity or not, because there may be something there that will be useful for health care.
So, I would like to just kind of see is there something we can say or do we just postpone it for another time?
Tieraona, and then Bill.
DR. LOW DOG: Well, I don't know, it seems like if you go to an accredited school, and I mean there are herb schools that are accredited by their states, where we don't have any licensure for herbalists, but it is an accredited school meaning that it has got ways of tracking faculty and students, and I mean I was part of that, so I know what we went through, but you are not licensed.
I guess what I was saying earlier was I think anybody who is going through an accredited school should have the right to apply for federal funds that they repay. I mean it is at a lower interest rate, and I don't know why you would separate that out from a vocational school or for anything else. If it is an accredited school, and it has met accreditation, whether it leads to licensure or not, I think -- again, I have separated it out, I am saying that for repayment, you are getting a federal loan at a low interest rate -- I think anybody should have access to that just as a student.
DR. PIZZORNO: Tieraona, there is some language here I think we have to be careful about, and that is the term of accredited and licensed by the state to run a school. A lot of people use the term "accredited" when a state says yes, that school can run, but that technically is not accreditation. It is simply approval by a state to allow them to run. Accreditation is a separate process that has direct ties to either the federal government or to there is an accreditation of accrediting agencies.
So, I just want to say we need to be just a little careful about some of the terminology here.
DR. LOW DOG: I will leave the terminology for you, but if I can get repayment to go learn to be a plumber, I should be able to have access to that in a country that supports education as long as the school itself has met the criteria that it is able to educate, and it has follow up.
That is very different than loan repayment, it is very different than licensure, it is very different than all of that, but I think people would have a hard time disagreeing, because you are paying back the money.
DR. PIZZORNO: Bill.
DR. FAIR: Well, I agree with Tieraona, and I know George is coming from the idea because we had this in our small group, that licensure is the only way to get reimbursement, as it was for the chiropractors.
But I think that, I don't know whether the term "accreditation" or "credentialing," or whatever, but the standards for adequate education in a modality has to come from the practitioners in that modality. The state can't set those standards, the state can license it.
So, I agree that whether it -- again, I don't know whether it is credentialed or accredited or something like that, but if the practitioners in a given discipline like yoga and movement therapies, or herbal, or whatever, have established criteria that they would think would adequately train a person, it would seem to me that they should be eligible for the same benefits whether or not the state -- George, I may be misquoting you, but it sounded to me the main reason for licensing when we talked in the small group was for reimbursement.
MR. DeVRIES: I wouldn't say the main reason for licensure is reimbursement. I am saying that licensure is a prerequisite to reimbursement, and licensure involves a variety of things related to basically the provider being able provide services, being legally empowered to make a diagnosis and provide care for patients.
There is a variety of reasons you have licensure, but licensure is simply a prerequisite.
DR. FAIR: But the state is not setting those criteria, is the professional board, whatever it is, and then the state says, okay, they have gone through an accredited school or credentialed school, and therefore they are eligible for licensure.
MR. DeVRIES: Right.
DR. PIZZORNO: Let me take a stab at some language here, because this is going to be a little tricky, because I want to accomplish what Bill and Tieraona have said, but how to do the exact language is a little tricky, but I will just take a stab at it.
Provide access of licensed or accredited CAM professions and practitioners to educational and training, funding, and other resources.
DR. FAIR: Joe, do you know the difference between credentialed and accredited? I mean I don't know, I am just asking.
DR. PIZZORNO: Yes, I do.
DR. FAIR: What is it?
DR. PIZZORNO: In the strictly academic term, accreditation is a process of approval of an educational institution or program within an institution. That strictly is accreditation, and it is actually independent of licensure, certification, et cetera. That is strictly an academic definition.
DR. FAIR: What about credentialing?
DR. PIZZORNO: Credentialing, in general, licensing is done by states, credentialing is done both by states and by professional organizations, and depending upon the situation, in most situations, only credentialing by a state is meaningful, but there is some credentialing in some medical specialties that the medical specialty credentialing board is significant.
SISTER KERR: Does your statement include schools?
DR. PIZZORNO: I assume the term "professions" would include schools.
So, can everybody live with this? We will leave it to staff to maybe tweak the language a little bit more.
So, I will say it again. Provide access of accredited or licensed CAM professions and practitioners to educational and training, funding, and other resources. I am including in professions, institutions, as well. I think that is the intent, but maybe we should explicitly state that.
Can everybody live with that? Is there anybody that can't live with that? Going - going - gone. Okay.
DR. FINS: Hold on. Hold on.
[Laughter.]
DR. FINS: I think it is implicit in what you said, but the loan forgiveness component, that is tied to service to underserved is not something we are talking about here.
DR. PIZZORNO: We are not specifying anything. We are just presenting a general concept.
No. 3. We have 20 minutes left for No. 3, and then we give it to Jim to make the summary. This is on page 5, joint and cross-training of CAM and conventional health professions in undergraduate and graduate programs. Again, we mean by "undergraduate," before they get their degree, and "graduate" is after they get their degree.
I would just like to start this conversation by again reminding people of what I think is the direction we are moving in, and that is collaboration of these health care professionals, and I think joint training is one of the most effective ways in which we can accomplish that.
Comments? Dean.
DR. ORNISH: Well, it is one of those ideas that sounds great in theory, but it is hard in practice because it could be very easily viewed by the conventional training programs that you going to mandate that they take some of their resources and allocate them for CAM. It is just another land mine.
I am just the messenger, so don't shoot me here, but I am just telling you that is how it is going to get viewed.
DR. PIZZORNO: Okay. So, let's be careful. We are not mandating this, it is just something we are recommending. By the way, this is doable, because we are already doing it.
DR. ORNISH: But the difference between a recommendation and a mandate is going to be lost on those constituencies, that's all. Again just be aware of it.
DR. PIZZORNO: Joe Fins.
DR. FINS: It does pose a lot of logistical questions and problems on how to operationalize this. Maybe if we just said, you know, like consideration of demonstration projects that would allow us to learn how to do this kind of thing, and leave it at that.
It doesn't threaten any current training programs, and the details will be worked out, but I think this is the kind of thing where a demonstration project is an incremental, less threatening, more feasible step.
DR. ORNISH: I mean by analogy, it took us seven years in dialogue with HCFA before they would do a demonstration project of our program as an alternative to bypass or angioplasty, and we have done randomized trials, and we have done everything, and it still took seven years, and we are still just getting started, but the language demonstration project, for whatever reason, doesn't seem to push people's buttons, so I am agreeing with you.
DR. PIZZORNO: Jim, George, and David.
DR. GORDON: Just one thing that I would like to mention. In this area in particular, there are a number of examples where we are already doing this. We are doing this at Georgetown, for example, and have been for a number of years.
Other medical schools, other CAM schools are doing this, so I think if we couch this in the language of what we are already doing, we will be moving along much more easily, and these are demonstration projects.
Incidentally, NCCAM has a whole program to fund such demonstration programs already, so I think this is one of those places where we can take, just as I said in the notion of recommendations, that this recommendation will go down a lot more easily and be a lot stronger with the evidence that we already have accumulated of projects that are doing this.
When it is cross-training, I think we also have to make clear, and I think the fear that will come up is, well, they are going to come in, those others are going to come in and take over my program, and I think there will be that fear from all sides.
I think as we focus on making recommendations, we have to be pretty clear about what we mean. This doesn't mean that the M.D.'s are going to come in and take over the school of Chinese Medicine, there are already M.D.'s who are teaching in schools of Chinese Medicine, or that the acupuncturists are going to take over the medical schools.
This is one where I think we can go a long way, but we have to be careful in how we word it and describe it.
DR. PIZZORNO: George.
DR. BERNIER: I would strongly support it. I think that it doesn't promise a whole lot of very specific things, and I think that maybe should be a model for what we put forth for the whole program, so I would support it.
DR. PIZZORNO: David.
DR. BRESLER: Well, again, I think here is something that can be looked at in the broader context because we don't have much joint and cross-training in conventional medical specialties either.
In my field, which is pain medicine, if you were to bring a headache patient into the medical center and ask a neurologist, a dentist, a psychiatrist, and psychologist, an orthopedist, and a physiatrist, you would find very, very different diagnoses and treatments.
So, I think this is an important consideration, I think we can thread it to a much larger issue that we also want to support.
DR. WARREN: My experience has been with postgraduate stuff where, as a dentist, we went into the osteopathic school and learned from teachers of osteopathy, manipulative medicine, but it didn't mean that we, as dentists, would take over osteopathy. In fact, I think the dentists incorporating osteopathy into their practice has really strengthened the practices of osteopathy and the osteopathic field because we are now proponents of that treatment, and when we find something in our practices we can't handle, our limitations, then, we know who to refer to.
It is really building a tremendous rapport and bridge between the osteopathic community and the dental community, but it is being funded, not by the schools, it is not being funded by the federal government, it is being funded out of our pockets, continuing education, 3- to $500 a day for education, and we pay it out of our pockets.
I don't think we have to worry about the funding on this issue right here. The funding on the postgraduate level will come out of the practitioner's pocket, and I think it is taken care of.
DR. PIZZORNO: Other comments from the group?
[No response.]
DR. PIZZORNO: Just a comment. At Bastyr, we get a tremendous amount of requests both for residencies and for student experiences in our teaching clinic, and we have developed an interesting policy that we are delighted to let them come into our teaching clinic if you will allow our students and/or residents have an equal amount of time in your teaching clinics, and they are saying yes.
So, I think there is a lot more interest in this than people realize because the students and more and more the faculty want to see this happen.
Any other comments?
[No response.]
DR. PIZZORNO: So, let's look at this language. We obviously don't want it to sound like a mandate, so we can use terms like "recommend" or "facilitate." So, how about somebody giving us an adjective here? Provide? Okay.
So, I will read the statement. Provide joint and cross-training of CAM and conventional health professions in undergraduate and graduate programs.
DR. BRESLER: Encourage.
DR. PIZZORNO: Provide and encourage?
DR. BRESLER: Encourage.
DR. PIZZORNO: Just encourage.
DR. BRESLER: Encourage and support.
DR. PIZZORNO: Encourage and support.
SISTER KERR: [Off mike.]
DR. PIZZORNO: We have a differentiation in terms here between provide, and encourage and support. So, what do we want?
DR. GORDON: I am not clear yet how this is different from No. 1. I don't know that we have made it clear.
DR. PIZZORNO: No. 1, this is specific to cross-training. That is people trained together and doing things of this nature. The other is making sure that those subjects are being covered. So, these are definitely different flavors.
DR. GORDON: What is the difference between cross-training and make sure it is covered? Could you make it more explicit?
DR. PIZZORNO: For example, in a conventional medical school, you could have a two-hour course, which is a survey of alternative medicine, and I have been teaching at the University of Washington for over 10 years. Conversely, you can have a student at the University of Washington Medical School enrolled for a quarter at Bastyr, and a student at Bastyr enrolled for a quarter at the University of Washington, or have a University of Washington resident go to the teaching clinic, an acupuncture resident go to the medical school for rotation.
DR. FINS: I think the difference, Jim, is that you are asking people from outside each other's CAMs to come into each other's CAM, and that is why I think it has to be done, the language has to be non-threatening, so encouraging versus requiring would probably go further with a little bit of honey.
DR. GORDON: I think it also has to be clearer exactly what we mean, too. If I get taught acupuncture at Georgetown, that is not cross-training.
DR. PIZZORNO: Correct.
DR. GORDON: But if I go from Georgetown to traditional acupuncture institute, that is cross-training.
DR. PIZZORNO: And conversely, traditional acupuncture institute comes to Georgetown, that is cross-training, because they then are actually practicing together. I think the key element here is training together, so that they will practice collaboratively.
DR. GORDON: And then if we both go to Joe Kaczmarczyk's outpatient clinic at the Public Health Service Hospital and work together?
DR. PIZZORNO: That would work.
DR. GORDON: That is also cross-training.
DR. PIZZORNO: That would work, yes.
DR. GORDON: I think we need to define, I just feel like it needs to be made much more explicit what we are talking about here, and how and why it is different from what we were talking about in terms of everybody having to know something about the other world view and the other practices. It just feels like it needs to be really fleshed out, and a rationale has to be given, so that it makes sense, too.
DR. PIZZORNO: I guess I would look at the staff and say I think Jim has made some good points, do you have enough information to strengthen this wording or would you like some more from us, more guidance? Michele, did you want to say something?
MS. CHANG: No, what I was hearing a little bit, it was that if we provided a little bit more background in terms of the intent and purpose of the curricula element that we are discussing, it might be helpful for people to understand both the difference and kind of the overall background and rationale that Jim mentioned.
DR. PIZZORNO: Joe.
DR. FINS: Something like recognizing the need for improved communication and collaboration between allopathic and non-allopathic providers, we encourage the joint collaborative ventures we are talking about.
DR. GORDON: I think it is important to keep it open enough because otherwise we run into potential turf battles and people will feel offended. Tieraona is nodding her head. She and I have probably each spent -- I have spent longer than she has -- but each of us has spent 20, 30 years studying natural medicine, so to say I can't teach natural medicine at Georgetown Medical School doesn't feel fair to me.
DR. PIZZORNO: That was not the intent of this at all.
DR. GORDON: No, I understand. I am trying to make it explicit, so that what we are doing is we are encouraging the kind of pluralism, both within each discipline and also collaboration among the various disciplines, but it just needs to be spelled out, so that people don't get caught up in turf wars, so that we are honoring each person's training and each person's ability to do this, and at the same time we are saying and it is good for you to get to know each other, as well, as get to know how people with different kinds of training are working.
DR. PIZZORNO: It sounds good.
Tom, and then George.
MS. CHANG: Joe, we are at the 10-minute mark.
MR. CHAPPELL: I am wondering if dealing with this at all doesn't dilute the imperative aspect of the first two, and maybe we shouldn't have this in here at all.
I am concerned about having a report that uses words "encourage." I mean I have seen so many executive reports that use "encourage," and there is no substance to it. So, I look at that and say, well, I don't feel like encouraging that today.
So, I am just feeling that deciding what we don't say at all is important in this process right now, and I don't feel this needs to be covered, that it couldn't have been covered additionally perhaps in the first piece as a support statement.
I know, Joe, that you feel strongly about this, and I don't want to diminish the value of it, but I don't want to diminish the value of the real --
DR. PIZZORNO: Thank you, Tom. I will respond to that in a second.
Joe.
DR. FINS: I think there is a real difference here, Tom. I think if we can foster this collaboration and have young residents working together, getting to know each other, working in each other's context in a non-threatening, encouraged way, it will build a whole new generation of people who know how to talk to each other.
DR. PIZZORNO: So, I guess the directions to staff, request of staff is to -- George.
DR. BERNIER: I think actually the verb "foster" would be a very good one, because that does mean a lot of different things.
DR. PIZZORNO: Charlotte.
SISTER KERR: I just have a comment. It is my perception, just a little offering, may be rejected, I have a little concern about our consciousness to avoid land mines and are living out of fear in what we choose to say, and it is starting to feel a little bit like scaredy-cats.
DR. PIZZORNO: Hear, hear. Ming, did you want to say something?
DR. TIAN: Yes.
DR. PIZZORNO: Please.
DR. TIAN: I have a question. You mentioned cross-training or education. Well, I can understand a physician wanting to learn acupuncture, will be easy to take 200 or 300 hours, and will understand acupuncture, but the physician is not telling everybody he is an acupuncturist, still a physician, correct? All right.
Then, the other way, even the acupuncturist does not have enough Western training, but he is very good, experienced acupuncturist, what kind of program to do the cross-training or education? How could you send him to a medical school to learn the courses? I will say that is only sharing information, and we should encourage this kind of exchange to learn each other, but it is not like a course. I will say it is not a formal course, it is going to be difficult.
For instance, he could be or she could be a very good healer, very powerful. You are going to teach him anatomy, pathology? You can mention that, okay, I treat arthritis in this way, you can mention that. That is not medical training.
So, I am a little bit confused. Can we use some better wording to more clarify that, because if you encourage too much, then, it is going to mix. The apple juice is apple juice, oranges is oranges. We need the specialties. It is very confusing.
DR. PIZZORNO: I think you have brought up a very good point, and that is our intent is not to use cross-training as a way of training the person in the other person's therapeutic modalities.
The idea is exposure on how they practice to better understand they can practice collaboratively together, but not expecting one to learn the other.
I think you brought up a lot of important issues about how to make that a valuable experience, so, for example, everybody is going it different, well, one way we do it is we send both a licensed practitioner and the student into medical clinic, and they then practice their natural medicine, acupuncture, naturopathic medicine, as the case may be, in that clinical setting, but they are side by side with conventional doctors, with medical students getting their training.
So, they are understanding each other better, but they are not in any way expecting to be able to practice the other person's skilled modalities.
So, we have to wrap this up. I think there is a high level of consensus here that we need to do the cross-training. The issue is make sure we explain why we are doing that more effectively.
So, I think the staff, you have heard a lot from us about how to do that. That is, this is about help within practice collaboratively, not cross-training in each other's modalities, and we will leave it at that.
So, now I turn the gavel over to you, Jim.
DR. GORDON: I might just add to that last part that maybe cross-training is not exactly the best word to use, because it implies something that we don't agree with, we certainly don't have consensus on.
DR. GORDON: I am not going to go through -- well, I will go through much of the discussion, but perhaps not every detail.
In the beginning, there was a discussion about what constitutes a good recommendation, and this is really to help us think through, not only the recommendations for credentialing, licensure, education, and training, but also to help us generally, and Linnea made some recommendations, and then Tom and I added to them, and basically, this is that our recommendations be clear and jargon-free, that they be achievable, that they be -- and Joe Pizzorno broke out a non-global meaning that there be a sense of the range in which these recommendations apply, that we not overgeneralize about them; that it would be possible to put the recommendations in a form in which they can be operationalized; that all recommendations that are made should be able to be evaluated in one way or another; that recommendations honor the traditions, the various traditions out of which the different systems of healing are coming historically and culturally, and also that the recommendations be based on experience from which we can extrapolate or generalize.
We the moved on specifically to the areas of education and training, and what I found very interesting is we got into a number of discussions through this issue, which I suppose is appropriate since we are talking about education, that in a sense we are educating ourselves and coming back to definitional issues like what is CAM and when do we use that word, and when do you use integrative, and returning again to evidence based.
What is clear is that those particular discussions are ones that we didn't -- at least we brought up the issues here -- we didn't resolve them, we are going to be coming back to those again in October, but I feel like we did move ahead in terms of understanding some of the difficulties that come up.
For example, Veronica pointed out that when you use medicine, it means something very different from when you use health care.
Again, talking about evidence based, coming back, circling back to the discussion from this morning about what kind of evidence we are expecting from different approaches, and it is going to be different.
We also talked some about the issues of understanding the evolution of this whole field. I thought that was a really interesting discussion, and again I think this is going to frame, certainly will in some ways help to frame the Interim Report, and will be a major issue in the Final Report in terms of how we see our function and who we are at this particular moment in the evolution of medicine, the evolution of science, and the evolution of this culture.
We talked about education. There was general, I think strong consensus that all conventional health care professionals need to know more about the field of CAM including some of these definitional difficulties, some of these historical questions about where different approaches have come from, and we talked a little bit about the interesting difference between approaches like nonsteroidals and glucosamine, and because of where they enter into the discourse about medicine, one is defined as conventional, and the other is defined as CAM.
I think that all of this is part of the material that we have to get across -- this is a little bit of my interpolation -- all of this is part of the material that we want to get across to students in conventional professions about CAM.
There was also very strong agreement again that CAM professionals need to know about the sort of theory and practice of conventional medicine. We had few specifics, kind of specific categories in which the knowledge needs to be taught, or perhaps better said, a few specific qualities that the teaching has to have.
One is that practitioners need to know their limits, just as conventional physicians or nurses or psychologists need to know their limits, so CAM practitioners need to know their limits, and they need to know where the different practices come up against each other.
There needs to be enough to know, so that people can refer to one another. That is clear. That needs to be basic in all curricula. We need to know, and as the material is presented, the students at every level need to know the level of evidence that is available for everything that is taught, and we had the very interesting and specific discussion that there may be approaches for which there is little evidence that could be published in a peer-reviewed journal, but that doesn't mean that a conventional practitioner or a CAM practitioner shouldn't know about these approaches, and shouldn't know what evidence there is and is not, and on what the practice is based.
Finally, there needs to be an attention to, and a knowledge about, traditional practices in every community, and I think this is something that we can put this in the Interim Report, I think it is something we need to come back to, or perhaps all of these as we look at the Final Report.
There needs to be much greater knowledge and not only -- I mean I would add, too, that, in general, there needs to be an understanding of traditional systems of healing, and I think this is important whether or not you are in an area right now where there are traditional systems of healing that are particularly important demographically.
We then moved on and there was an emphasis on demonstration projects in these areas and on highlighting what we are already doing in these areas.
We then moved on to issues of access to educational and training, funding, and other resources, and I probably don't have the exact words down, there is a general agreement that all those who are in accredited schools, who are learning health professions, whether they are conventional of CAM professions, should have access to loan opportunities and scholarship opportunities that any students have access to.
There is a real question about loan forgiveness programs for service in underserved communities, and that seemed like one of those issues that we want to come back to. Although we understand the importance of expanding the pool of people who are available to serve in underserved communities, we want to come back to any discussion about specific recommendations for loan forgiveness programs.
There was also a very interesting discussion about licensed and unlicensed professions, and it seemed like the criterion would not be whether the profession was licensed, but whether the school was accredited as far as being able to take out a loan for one's education.
We then moved on to the whole issue of joint and cross-training of CAM and conventional health practitioners, and I think that we actually brought some clarity to this area, as well as to the other areas. What we are talking about is not an insistence that everybody be qualified to do everything, and that everybody has to learn to do or that anybody has to learn to the ability of another practitioner to be able to do that practice. This is not particular grammatical, but the goal is enough experience of one another, of one another's practices, and of one another's educational methods to have a feeling for what those other systems are, so that we can better communicate with one another, refer to one another, and understand the frames of references of each other, and that what seemed to be clear from the discussion is that this is not a matter of mandating it at this present time, at least this is my sense of the consensus, but that this is something that needs to be strongly encourage, understanding that encouraged is not as strong as mandate at this present time. This again may be one of those issues that we may want to revisit in terms of looking at the details.
So, that is my summary. Is that pretty fair? Yes, Veronica.
DR. GUTIERREZ: One thing I didn't hear you say, that I took note of that Joe said, was a simple increment would be to remove the limitations or exclusions from the legislation.
DR. GORDON: Right, thank you. So, we are talking about access. Joe, do you want to give us the exact words that you used on that?
DR. PIZZORNO: There is quite a bit of federal legislation that does provide support for higher education in health care, and much of it, if not almost all of it, is restricted to M.D. and D.O. schools. So, removing that restrictive language would open up other institutions to apply.
It doesn't mandate that they get the funding, but it makes them eligible to apply for the funding.
DR. GORDON: Thank you. Anything else? Bill.
DR. FAIR: You had mentioned limitations, knowing your limitations, and I would hope that would apply to physicians also, because I think this idea of residency programs, and so forth, what we are going to have is a jack-of-all-trades and masters in none by M.D.'s thinking they are CAM doctors.
DR. GORDON: Yes, that was explicit. The limitations are all of us. It is hard for some of us to believe, but we do have limitations.
It is extremely important, this whole issue, and I think that in the Final Report, we are going to want to go into this at some length, and my hope is that as we go into this in the Final Report, that we may get beyond some of the quarrels that are presently there between people who have different levels of training in different approaches, because if you recognize your limitations, then, you know that if you are doing something part time, and there is somebody who has been doing it full time for 40 years, she is likely to know more about it than you are.
DR. FAIR: Well, that is the way I would couch it, in terms of better health care. I mean the medical oncologist that is spending full time on medical oncology is likely to be much better than the man or woman that is doing medical oncology and nutrition and exercise and counseling, and so forth, so I think that what we are saying is that every patient deserves the best care that they can get, and that means the appropriate specialists.
DR. GORDON: Right, exactly, and in terms of education, that everybody needs to know what their education equips them to do and what the limits are of that education and training.
We are on time. We are going to take a 15-minute break and then we will come back to the second part of this discussion. Thank you. Thank you, Joe.
[Recess.]
DR. GORDON: We are going to move into the second part of this discussion on Credentialing and Licensure. Joe P. and Joe K., take it away.
DR. PIZZORNO: Again, I want to remind the Commissioners we are going to go through a three-step process here. First, we want to ensure we clearly understand what the questions are; second, we will answer the question what are the characteristics of a good recommendation in this area; third, we will attempt to develop a consensus over a list of recommendations that we will be making here.
Is everybody clear with that process? Okay.
Licensing. I think there is two key questions we need to answer in this area. One is, is it the purview of the White House Commission to consider and make recommendations regarding credentialing and licensing of CAM providers? Second, if so, what recommendations shall we make?
I think those are two key issues facing us. We will talk about some answers to those questions. First, though, let's talk about what are the characteristics of a good recommendation, i.e., how do we know a good recommendation when we see one.
In the area of credentialing and licensing, what are some recommendations people have about what the characteristics are of a good recommendation?
[No response.]
DR. PIZZORNO: I will prime the pump. Recommendations should be there to protect the public safety, making recommendations in this arena to protect the public safety.
What other characteristics would a good recommendation have?
DR. LOW DOG: Preserves freedom of choice.
DR. PIZZORNO: Preserves freedom of choice. What else do we have?
MR. DeVRIES: Education, scope of practice, which is really part of protecting consumer interests.
DR. PIZZORNO: So, something that links education to scope of practice. Would that be a way of saying it?
MR. DeVRIES: Links licensure to scope of practice and education.
DR. PIZZORNO: Links licensure to scope of practice and education.
What other recommendations do we have?
[No response.]
DR. PIZZORNO: I do have some more in my little notes here, but I am hoping to drag them out of the rest of you.
DR. LOW DOG: Keep priming that pump.
DR. PIZZORNO: Okay. I will prime the pump again. To ensure accountability of practitioners.
DR. WARREN: Doesn't that go along with public safety?
DR. PIZZORNO: That could be considered part of the same thing, yes.
DR. GORDON: I think when making recommendations about licensure, one has to take account of the interface and interaction with already existing authorities for licensure and already existing laws.
DR. PIZZORNO: So, it takes into account existing law and licensure.
DR. GORDON: As well as our own scope of authority. I think this comes back to some of the recommendations that Linnea made in the beginning, is what we are saying, what is going to be the effect of what we are saying. That is, do we have sort of a legitimate right, I mean we can make recommendations about anything, what is our own scope of authority.
DR. PIZZORNO: So, be consistent with our own scope of authority.
Bill.
DR. FAIR: Again, I don't want to split hairs, but I am not really sure in my own mind the difference between accreditation and credentialing, and I think that the idea of licensing just brings us right on the toes of the states, and I don't think that is a good position for us to be in going on what Tom said this morning.
I think that it would be necessary, actually essential for each modality to develop their criteria that are necessary to make sure that practitioner is fully trained in that modality, but it seems to me that to take the issue of licensing on head first could chance the whole argument.
DR. PIZZORNO: So, let's get to that. Clearly, we can't mandate to the states these kinds of activities. We can provide guidance, however.
George.
MR. DeVRIES: The reality is you are not going to take the states head-on, we are not doing that at all, and that is not what this discussion is about, but it is actually making guidance and recommendations to the states. This Commission has received a letter from the Chairman of the National Governors Association since our last meeting, basically saying he is interested in the work that this Commission is doing in making recommendations to states regarding what is going on within the Commission.
So, this is not about mandating something a state does, this is not about taking states head-on. It is actually fulfilling our role as a federal commission, which is making recommendations in the global spectrum.
Especially, as we consider the broad range of issues of access, delivery, education, reimbursement, that as we continue to talk about, that licensure plays a role at some level in each of these areas, and that making a recommendation for a state to consider in considering everything we have talked about is really all we are doing.
I believe it fits well and would be received well by the governors or by the states across the country because it is not coming as a mandate, but it is rather providing a source of expertise in the area of complementary health care, to provide guidance.
DR. FAIR: You have had much more experience in this area than I have had, but is it likely that a state would push for licensure if accreditation standards were not up to snuff or not been done?
DR. PIZZORNO: No, not likely, no.
Any more recommendations about characteristics of good recommendations? I should say that differently. Any more Commissioner thoughts about criteria for good recommendations? That is better.
[No response.]
DR. PIZZORNO: Okay. Let's begin to start talking about these recommendations.
DR. GORDON: I just want to make explicit the one that Bill raised, because I think it is an important one, which is that we are not walking into mine fields when we are not prepared to do the de-mining.
DR. PIZZORNO: Sounds good.
DR. GORDON: I am just making that as a characteristic, and then I think the issue that you raised is one that we need to discuss, but I think we all have to be clear that this is one of those areas that is one of the more problematic ones that we are dealing with.
DR. PIZZORNO: I have got a couple of comments to start this with. I have been surprised by a suggestion that the Commission appears confused about the issue of education and credentialing, and I am concerned that we have allowed a strident minority group of anti-government, anti-standards spokespersons to distract us from a very clear directive we received from the Congress and the President. Please recall Executive Order 13-147, which explicitly stated four directives for recommendations.
The text starts with the recommendations shall address the following, and the fourth directive is guidance for appropriate access to, and delivery of, complementary and alternative medicine.
President Clinton further emphasized this in his press release when he talked about the Commission, and two phrases to me stand out quite clearly.
One is hold complementary and alternative therapies to an appropriate standard of accountability, and we need to set a national agenda for the education and training of health care professionals in this field. I think that is very, very clear.
The standard in the U.S. health care system for the past century has been to bring into the system health care practitioners through education, credentialing, and regulation. The only rational way to provide appropriate access to, and delivery of, complementary and alternative medicine is through the same process, just as has occurred for all other practitioners whether they be physical therapists or osteopathic doctors.
There is in my mind no question but that we must provide recommendations on how to do this. Whether to do it or not is not an option, as this would clearly violate the explicit directives we have received.
I also would like to go further with some thoughts about this. I think a free-for-all, such as will be tried in Minnesota, is not consistent with our mandate. If the public does not have a clear pathway to educated, credentialed and regulated CAM professionals, they will only be left with those who are uneducated and disinclined to accountability.
Not requiring education and licensure further permanently ghettoizes responsible. trained alternative medicine practitioners.
I think one of the key reasons for the excellent safety record and successful integration in Washington State has been accredited institutions and licensing of all CAM providers.
So, I think I am clear about where I stand.
Bill.
DR. FAIR: I'm sorry to be so dense about the difference, but is it that individuals are credentialed and institutions are accredited?
DR. PIZZORNO: Correct. In general, institutions are accredited, individuals are credentialed, licensed, et cetera.
DR. FAIR: I am happy.
DR. PIZZORNO: Great. Thank you, Bill.
I also want to emphasize that I think there is a surprising amount of commonality of the Commission in this area, and I went through and read the interviews of all the Commissioners, and I counted 14, if I got it right, and of those 14, 9 discuss licensure, and all 9 supported licensure. So, I think we have to recognize we have a lot of agreement here.
I am just going to read those phrases.
One. Recommend standardization of requirements state to state regarding licensing, certification, education for practitioners.
Second one. To ensure public safety, recommend national standards for accreditation and licensing of practitioners in all states consistent with federalism and the role of states in regulating medical education and licensing.
Another one. CAM professional societies must set standards and states must license and oversee CAM practice.
I think a clear message here is not only do we have to do licensing, we must fully engage professions that are being licensed.
Next. At the federal level, develop model laws or regulations to define minimal competency. States could then develop even higher levels if they wanted.
Next. More public education information needed about states' guidelines, regulations, and licensing of several CAM modalities. Final Report should address matter of state responsibilities in these areas.
Another one. Dire need for better quality control. The issue of licensing is integral to this expectation.
Another one. Requiring people to be licensed and have national standards needs to be explored. Standards should only be established by the group that practice this approach, not by those who know nothing about it, not by the government, but by those who are efficient and proficient to determine standards.
Finally, it is important for the federal government to take leadership and encourage credentialing and licensure in all 50 states for licensable CAM providers.
So, I am going to start the conversation with a strong statement. How about others responding to this and also making their own thoughts? Tieraona.
DR. LOW DOG: I suppose licensure. I support that, but I can't support it to say that we have to mandate that. So, while I support moves toward licensure for those who wish to do that, I am in full support of that, and I actually think it furthers the professions, I do.
However, I am concerned about making that mandatory. I do think that informed disclosure, disclosing your training, who you are, what you do, what you believe, what your philosophy is, and creating systems of accountability within the state, so that if someone is harmed, that appropriate actions can take place, but in my own state, you are going to make all the Curanderos illegal. They will be practicing illegally because there is no licensure for Curandismos, and I am not sure that they would want it anyway, because there is no training system for that.
It is not so much that anybody has really challenged it because of the state that we live in. I am concerned, though, if you make a statement saying that everybody has to be licensed, that you are going to set a precedent to go after these people, though.
I think one has to be careful in this area. As I said, for me, the freedom of choice and the freedom of access is very, very important. Maybe that is just because of the American spirit, however, I do think we need to have things in place, such as informed disclosure. You need to clearly state who you are and who you are not.
I think there has to be mechanisms in place for accountability, but I am not sure that you are going to get consensus from me on some mandatory language for licensure.
DR. PIZZORNO: George.
MR. DeVRIES: This is not about mandatory licensure. This is about an encouragement to expand licensure. So, if states don't choose to license, it doesn't mean that something changes in New Mexico. Joe and I have talked about this repeatedly, that this is not about mandatory licensure. This is about an encouragement to states to expand licensure where appropriate for particular provider groups.
Joe, we may even want to come up, like we have done previously today, and come up with a possible recommendation and float it here right now and see if people are comfortable with it, that covers some of these things and gives a certain amount of comfort level.
But I think it is focusing in the area -- we don't have to focus in the area of chiropractic, because they are already licensed in all 50 states, but it is a model of licensure that is very successful, but in the areas of acupuncture, massage, naturopathy, these are, for example, areas that are licensed in some states, but not in others.
This would simply be an encouragement to states to expand licensure in these particular areas, and to evaluate, where appropriate, licensure for other provider groups, but there is nothing mandatory about it, and there is nothing about that if New Mexico decides to create a licensure statute for a particular provider group, that that somehow excludes other practitioners from doing what they do under law.
DR. PIZZORNO: Thank you, George.
Tieraona, I think you have raised a very valid point, and I am going to make some recommendations after we have had some conversation, that I think will alleviate your concerns, and hopefully they will; if not, we will modify it some more.
Jim.
DR. GORDON: Could you say what you mean about it doesn't -- that last part is really important, that it does not exclude other practitioners?
MR. DeVRIES: I think what I am saying is, let's take the State of Minnesota where a number of us were at for the town hall meeting, is we are not making a recommendation that Minnesota repeal its law. We are making a recommendation saying to the State of Minnesota, or to all states, that there is value in licensing CAM providers, and that this is a valuable way of allowing certain provider groups to practice in their state.
It by no means is saying, we are not saying with that recommendation that you should repeal the Minnesota law. We are just simply saying you should add potential licensing statutes for certain provider groups in addition to what you already have.
DR. PIZZORNO: Charlotte.
SISTER KERR: I just wanted to add the comments. Many of us know the NCCAM recently had a conference with the Royal College of Medicine in England, and they identified this statement that in both countries, UK and America, there is a major concern in both countries over licensure of CAM practices.
A balance needs to be struck between (a) effectively regulating professions and preventing harm to patients, and (b) respecting individual rights of access and freedom of choice.
I think that is where we are.
DR. WARREN: Is licensure going to restrict access?
DR. PIZZORNO: That is a good question. Is licensure going to restrict access?
DR. WARREN: I think it would.
DR. PIZZORNO: I think it would change access.
DR. GORDON: I am just sort of pushing for everybody who has questions about this, to raise as many questions as we can, so we can get them out on the table.
DR. PIZZORNO: Don, would you talk more about that?
DR. WARREN: Well, licensure, there is some people that practice certain alternative therapies, that really have no desire to be licensed, but if you have licensure in that state, even though that person may not ever want to be licensed, you grandfather them in. Why are they being licensed? They are being licensed to possibly get reimbursement from insurance. That's it, and to be governed, be regulated. Now, they are unregulated, so you pretty well have free choice, and the marketplace takes care of that.
DR. PIZZORNO: Dean.
DR. ORNISH: What I started to say was that it sounded like we had consensus. If you went through everyone's interview and everybody was saying that they are in favor of licensure, and particularly if it is clear that it is an encouragement for licensure, and not mandatory, then it sounds like we can move on, but I wasn't going to suggest we table this until October just in case you are wondering.
Clearly, as the field evolves -- it is like the Wild West, you know, with no rules, no laws, and you say, well, yeah, we want freedom to do anything we want, anytime we want, but we have all agreed as a society that we have speed limits. We have all agreed that they are balanced with freedom of choice, you know, protection from certain things like getting hit by a car when you go into an intersection or having somebody tell you something and there is no basis for it.
So, I would like to think that the field has evolved to the point where we can all agree that we can recommend that the states increase licensure, and if there are some outlaws who just say I don't want to be licensed, then, they can continue to be outlaws, but I think there needs to be some kind of -- is there anybody who doesn't agree with what you have proposed in that regard?
DR. LOW DOG: I think we need to be careful with things like outlaws. I think that that language itself is very inflammatory especially to traditional practitioners.
DR. ORNISH: I was using an old Wild West metaphor. I apologize if it sounds like I was casting asparagus, I didn't mean to be.
DR. LOW DOG: All right. Only because I think that a group of people that often are under-represented in these types of commissions are traditional peoples, and we did get responses from them, but there wasn't an overwhelming number of them that were present here.
I know my state is unique, but it is 51 percent hispanic and indigenous peoples, and none of those people that are healers in those communities are licensed, and there is no way you could begin to license them, but the communities themselves recognize them as their healers, so the communities support them.
So, I don't think it is a matter of renegade or outlaw, but I think that it is a complicated issue. I said to begin with I am in favor of licensure, I think it moves modalities forward, but I want us to be careful of how we word what we are doing because of those groups of people that might be harmed or persecuted if we establish licensure, and they are not licensed, but they certainly are practicing traditional medicine.
DR. ORNISH: My question was are you comfortable with the language that Joe proposed. Is there anyone who is not comfortable with that? That is my only question.
DR. PIZZORNO: Actually, I haven't proposed any language yet.
DR. ORNISH: Somebody was saying, they were qualifying it to say that the states would be encouraged -- maybe it was George or Joe or someone -- the states would be encouraged to increase licensure for other CAM modalities.
Tieraona, is that something that you would be comfortable with, or is that also something that you would be concerned about?
DR. LOW DOG: I am over here pondering and reflecting. You know, it is that kind of seven-generation thing, that the decisions we make today, how is that going to affect us seven generations from now, and everybody is upset with sort of the medical system the way it is, licensed or not licensed.
I think that we need to be clear of our own personal agendas that are here and what we are moving forward and why we might be pushing particular agendas, and I think we really need to own that, and that licensure benefits certain groups more than it would others, and I just think we need to be honest about that and clear.
I am not opposing licensure, I am just saying I want us to be careful that the language is not exclusionary for those groups that may not be at a place where they can be licensed. There would be no way you could do it.
DR. ORNISH: I just have to respond. I don't have a personal agenda about this.
DR. LOW DOG: [Off mike.]
DR. ORNISH: Okay. I just wanted to know, my question was if it were put in the terms that we have been discussing, that the states would be encouraged to increase licensure for CAM providers, would that be acceptable to you? That is all I am trying to ask.
DR. GORDON: I want to respond to that because I think it is premature to ask the question, and I really think that we need to explore what licensure may mean, look at some of the history of what it has meant for some people who may not fit neatly into a particular profession, and then make our decision, because on the surface of it, it sounds perfectly reasonable, but I know that there are a lot of other issues, and I think we really need to give time to those issues before we move ahead.
DR. PIZZORNO: So, let's go around. I see several hands. Let's go Bill, Tom, Charlotte, and then Joe, and then George.
DR. FAIR: I would like to ask Dean, he certainly said a lot of things that were very valuable, but, Dean, what is the difference between having credentialed individuals that have graduated from an accredited school with standards approved by their peers versus licensure? What is the difference?
DR. ORNISH: Well, if you have accredited schools, then, I am not really sure what -- it seems to me a fine point -- who is doing the accreditation?
DR. FAIR: The board of herbalists, or whatever, and who does the accreditation for physicians?
DR. ORNISH: The Board of Medical Quality Assurance does it for physicians.
DR. FAIR: Right, so it would be the board of whoever --
DR. ORNISH: That is a state function, so how is that different than licensing? Your license to practice medicine came from the State of New York.
DR. FAIR: But the standards are being set by the practitioners.
DR. ORNISH: Exactly, and that is all I am suggesting is that the practitioners themselves come up with standards that the state then serves the regulatory function for. I mean it is the same thing in medicine.
DR. FAIR: But I guess you need a state, that is what I am saying. Would the accreditation be enough, and it would encompass some of the --
DR. ORNISH: Let's say for the sake of discussion that you have a group of people who say that if you -- you can be breatharians, it's the Breatharian Society -- and they say you don't really need anything, you can just exist on air, and they all get together and they agree on that, and they come up with their own credentialing, and everybody says, wait a minute, that's crazy, but it's within its own domain. They say, well, that's okay, we believe that and we are going to credential people to be breatharians.
Does the state have any function at all in that?
DR. PIZZORNO: I would like to move on to Tom. I would like to make one comment to you, Bill, and that is, accreditation is an academic activity that provides credentials like degrees. Licensing is separate, because it is a state mandate. States in the Constitution have the responsibility for control of practice of medicine, and most states -- we can get some technicalities -- but most states have a Medical Practice Act, which is what is called exclusionary, and that is, if you are not practicing under that Act, you must be excluded from that Act, you get prosecuted for practicing medicine.
So, for example, Curanderos, that Tieraona was talking about, technically could be prosecuted for practicing medicine, so there needs to be protection for those who are practicing either by defining them by licensing or specifically excluding them from the Medical Practice Act, but this requires actual legal action in a state, legislative action.
DR. FAIR: Naturopaths can't practice in New York State.
DR. PIZZORNO: That is correct.
DR. FAIR: So, are they not reputable people, are they breatharians?
DR. PIZZORNO: It is a significant political challenge.
DR. GORDON: Who says breatharians aren't reputable?
DR. PIZZORNO: Tom.
MR. CHAPPELL: I am wondering if the issue of licensing doesn't belong in the Information Section of our discourse, and not in this particular section, because first of all, as I have said before, I am not really keen on policy statements that begin with the word "encourage."
Secondly, I do think we have heard a lot about how this is a state domain, and I would like us to be informational in our Information Section about this being the domain of state law.
Third, I would like to honor sort of the diversity of communities involved in CAM care. I think it is really important. I mean we are the dominant culture, and so we come up with these things that we think are right, but we leave behind the concerns and sensitivities of other cultures.
You know, when we discussed this last time, I asked the question whether a Native American healer would expect reimbursement from a system. I knew the answer to that. The answer is no, they don't expect it, because they don't do it for reward, they do it for their community, and they are selected by their community as having a gift, and therefore, it is their obligation to provide that gift to the community.
So, it is a lot different and complicated, and I am just wondering whether licensing isn't something we should leave to the states and to the third-party providers, and not to us.
DR. PIZZORNO: Thank you, Tom.
Charlotte.
SISTER KERR: Again, I would just support Tom and also what Jim Gordon said. I think this is premature. In the statement I read from the UK conference, I think it was very important, that this to me somehow is such a deep issue, although at the level it seems like a very cognitive left wing kind of decision, and particularly the cultural diversity, the hispanic community things we heard, that wonderfully dedicated doctor in New York, the African-American community, there is certainly issues here about how they do access, but also, we have not heard that international piece.
I know, for one, the United Kingdom has done this very differently forever, since whenever, what is it, 14-whatever, another King somebody said you could do whatever the heck you wanted or something. The Herbalist Charter, Tieraona is saying.
So, somewhere in me, this has something very deep and very profound. It has something to do with this evolution of healing and the new scientific paradigm to me, so I really see this struggle. For me, it is very, very real. I am not ready at all to say too much about it.
DR. PIZZORNO: Thank you.
Joe, and then George.
DR. FINS: I totally agree with Tom. I think it is informational to lay out the reasons why you might want to consider licensure, and then say it is the purview of the states, because it would be overstepping to say otherwise.
In answer to the question of why there is licensure versus simply accreditation, I think the state is sort of the adjudicator of disputes between two bodies that would provide accreditation, but there might be disagreements. It is a minimal standard or it adjudicates disputes.
I do think it is related to reimbursement, and I think it is probably a sine qua non, but the most important thing I want to say is that I think that the traditional healers are very close to the practice of religion, and you wouldn't want to do anything that would somehow abridge the Bill of Rights and the right to express oneself religiously, so, you know, Tieraona's sensibility here I think was right, because you are sort of encroaching upon something that is far more fundamental, and it is the right to pray and to worship as you choose, and the relationship between healing and medicine in these areas is very close.
DR. PIZZORNO: Thank you.
George, and then Veronica.
MR. DeVRIES: Again, I just want to reiterate that this is only about an encouragement of states to license provider groups, and not necessarily to create a mandate. Again, the question of why be licensed, you know, the reality is if you look at naturopathic services and naturopathic physician, in order to make that examination, to create a diagnosis, to provide treatment, unless that person is licensed, they are technically practicing medicine without a license, and that is the purpose of the licensure, it legally allows that person to practice their profession.
The issue, Don, you talked about access, and just to say in particular where licensure really enhances access for the patient, you know, if you compare Cali