[Moment of silence observed.]

          DR. GORDON:  Let's begin.  Good morning, everybody.  Congressman Pallone, who was going to be here this morning, will likely be here later on today.

          So we are going to begin.  We will move right into the continuation of the section on Education and Training.  They were scheduled to have, how much time, 15?

          MS. CHANG:  Fifteen minutes.

          DR. GORDON:  So we will give them 30 minutes, and take 15 of my minutes of the summation.  So we will begin with 30 minutes, then we will do a summation of that, and then we will be moving on to Access and Delivery.

          George and Joe, Joe.

          Session IV: Education and Training

       of Health Care Practitioners (continued)

          DR. GORDON:  Are we satisfied that we are okay with the traditional healing, which is where we ended up?  Do you feel you have a good sense, or do we need to go back over any of that before you continue?

          DR. BERNIER:  I think we came to a good closure on it.  It is a very difficult problem, clearly.

          DR. GORDON:  Okay, we will come back to that when I do the summation and see where we are.  Let's move ahead, then.

          DR. PIZZORNO:  What we are going to try to do is to finish the last of the recommendations, and then if we have time, to go back to the other recommendations, because as a result of several conversations, and George and I working together, we believe we can make some comments here that we think we heard from the Commission.  That will give direction to the Education Committee to fine tune these things.  We think we heard several solutions to what was recommended.

          DR. :  Well, let's move through the rest of them, and then we will come back as we go over them, and you can make the comments then.  That is probably easiest.

          DR. PIZZORNO:  That sounds good.

          No. 32, we are recommending that this be different than what you see in the document, because in many ways we felt that this was the center of a lot of the discussion yesterday.  It was more on No. 32.  We have some recommendations about how to do No. 32 somewhat differently.

          I am not going to say specific language, because we haven't worked it out, but what we would like to do is go along a couple of themes.  One is, I think we all agree that students who are enrolled in CAM institutions should be eligible for this same kind of financial support that students in other health care institutions have available to them.  I am assuming that is not controversial, because a lot of that is happening right now.

          There is an area where there are some kinds of loans that are only available to conventional medical students.  I want to clearly differentiate between students currently enrolled, and then after graduation, graduates being eligible for loan forgiveness programs.  Those are two separate issues.  I want to make sure we are not being confused.

          So Issue No. 1 is: The Commission recommends that CAM students should be eligible for state, and where appropriate, national fiscal support -- my mistake.

No. 32 is only about what happens after they graduate, and the language as presented here does not sound like the Commission would accept that.

          We would like to propose a somewhat different recommendation, which has three components to it.  One is that this loan forgiveness only be available to practitioners who have primary care licensing -- I am not saying direct access, I am saying primary care licensing; second, that it be done in the form of demonstration projects; and third, that it be done in communities where there is pairing with a conventionally trained medical doctor.

          DR. GORDON:  What was that again?

          DR. PIZZORNO:  That the idea of there being CAM professionals available in underserved or rural areas makes sense.  However, it only makes sense if they have primary care training, but not necessarily just direct access.

          Primary care training means they can do physical exams, have some emergency care capabilities, be able to do a PAP smear, things of this nature.  Whereas, those that simply have direct access don't have a broad enough range of skills to be appropriate in a primary care setting, in a rural setting, where there is not conventional care available; second, that this be done in the form of demonstration projects.  So rather than just blanket saying, we should we do this, let's get some funding for demonstration projects.

          Then, third, we recommend that they be paired, at least initially, with conventionally trained medical doctors, osteopathic doctors, in the community.

          DR. LOW DOG:  I would just fully support that.  I think that is an excellent approach, and I think that there are certain groups that are really ready to go into that next move looking at demonstration project.  I think that pairing, initially, is a good idea, and may not be necessary in the future.

          But I think for the demonstration project, I think that is just excellent.  Great recommendation.

          DR. PIZZORNO:  Joe?

          DR. FINS:  We had a conversation last night, and I think that this may be the Talmudic compromise, because what it does is, ethically, it does not remove a provider from an underserved area.  It is augmentation, and the hope is that with the demonstration project that one plus one is going to be equal to more than two.

          For anybody who has been on call 24/7 in a rural area, having another medical provider, maybe with a different skill set, who could take first call on an alternate night and have a little bit of cross-training back and forth, might be a tremendous value-added.

          I think we need to, though, demonstrate its efficacy before we make a sweeping comment about any kind of entitlement.  We need to prove that in these times of emerging scarcity -- I think we really have to kind of regroup a little bit and think about the whole project in light of the national emergency we are in, and all the other claims -- everything has to be proven to be valuable.  I think that the demonstration project is a step in that direction.

          DR. PIZZORNO:  Any other questions?

          MS. GUTIERREZ:  Where does that leave the chiropractor, since we don't do pelvic exams?

          DR. PIZZORNO:  Actually, it is excellent you brought that up, Veronica.  The idea is, and a corollary to this would be, in those states where chiropractors have primary care training, they could practice independently in rural areas, or at least with a trained medical doctor.  If they don't have primary care training, this would not apply to them.

          The same would apply for acupuncturists.  Acupuncturists may have direct access, but no primary care training.  That is the compromise we are talking about here.

          MS. GUTIERREZ:  Define "primary care training" for me.

          DR. PIZZORNO:  I will let Tieraona define "primary care," because we have had this conversation several times now.

          DR. LOW DOG:  I think each state is quite different, because different states list acupuncturists as primary care, in New Mexico now.  So different states have different language on that.

          I think that when you are looking at a demonstration project, you want to take the group to begin with that is probably going to have the most chance of success.

          I think if you asked 100 people on the street, what do you expect your primary care provider to be able to do for you, I think you would get a pretty general feeling: They are supposed to be able to take care of my general health; I should be able to get my woman's exams each year from them; I should be able to have a breast exam; I should have a pelvic exam, basic lab tests; that is supposed to be the person that is able to give me my prescription for my high blood pressure medication; they should be able to meet those kinds of basic needs.

          Then I think that there are all kinds of ancillary folks around that, specialists.  I mean, we like the specialists too, but we don't choose them really to out into the rural areas because their skill set is also limited.

          So primary care, being able to take care of the general health of the average person, really from childhood up through elder age, because that is the reality of people out in rural areas, is that you see the whole scope.

          DR. PIZZORNO:  So, as I read this, again the Committee has to work on some languaging, in a state like Oregon, I believe a chiropractor would be included.  In a state like Washington, they would not be included.  That is the way I read how something like this would work.

          MS. GUTIERREZ:  Well, that is an interesting model on primary care, but in fact for purposes of Medicare, chiropractors are considered primary care, and there are a lot of patients that come into our offices who don't think of primary care as pelvic exams and prescriptive drugs, but spinal care, chiropractic care for chronic conditions, for general health and well-being.

          We see a lot of people on a lot of issues.  There is a whole group of people that don't see the allopathic model as their first choice for primary care, so I think this issue needs a lot more work.

          DR. PIZZORNO:  I am going to challenge you here.  Veronica, we need to draw a line.  We are not going to put a massage therapist out in rural Washington and expect them to provide primary care, and frankly, that is probably too much to ask of the average acupuncturist too.  Where do we draw the line?  How do we draw the line?

          So, Veronica, why don't you say something on that?

          MS. GUTIERREZ:  Well, I don't know how many states massage therapists are licensed in or any other provider group.  I know that the naturopaths are not licensed in 50 states, but chiropractors are.  So I think we should promote what is in the best interest of the public as opposed to singular professions.

          DR. PIZZORNO:  Well, I thought that we were trying, as I understood, to avoid the singular profession identification.

          Joe Fins?

          MR. CHAPPELL:  I think that George called on me.

          DR. PIZZORNO:  Oh, I'm sorry.

          MR. CHAPPELL:  I guess my question is why we draw the line?  Why don't we let the community draw the line and make their choice?  Why do we have to define this part?  Isn't a community going to make its own selection, its own choice and decide what it wants?  Why do we have to set up a more restricted set of eligibility requirements for the funding?

          DR. PIZZORNO:  Okay.  Joe?

          DR. FINS:  I think the lessons of the last three or four weeks suggest that there is a role for government in protecting the public safety.  I honestly think that it is up to the government to say, we are not going to spend dollars on providing access for things for people and individuals that don't provide the basic safety net.

          So, I think what we need to do is to say that, yes, we are going to take this incremental step, but we are not going to be expansive, and anybody who calls themself a CAM provider is not going to be eligible, and that the organizing body that controls this demonstration project will set up criteria.

          We don't need to recommend them what they are, but the testimony can be reviewed.  It will be people with doctoral degrees, post-graduate training from an accredited university with cross-training, et cetera, et cetera.

          It just can't be anybody who is out there.  I mean, people can be harmed by not having access to providers who are appropriately trained, and primary care is a comprehensive skill set.  What we are doing here is we are trying to demonstrate the utility.

          The assumption is that we have a hypothesis that perhaps a pairing of naturopathic doctors and family practitioners and internists in a rural community will be value-added.  It is a speculation.  It is a hypothesis.  It has yet to be proven.  That is what this kind of project would seek to demonstrate.

          DR. PIZZORNO:  Thank you, Joe.  Jim and then Linnea.

          DR. GORDON:  I think this is an inspired idea.  I think what it does is it advances something that is sensible and yet very profoundly revolutionary, and it is something that can be done and that will be responsible and that people will respond to.  So, I see it as a great idea.

          I just want to say I really appreciate the work of the dialogue here yesterday, and the work that you and George, and whoever worked with you over the night, did in formulating this.  It just seems like a really good idea, and I think it will work.  It will work on a public level, as well, that we will be able to get public support for it.  So, that is why I want to go with it.

          The other thing I want to say, just, in my other role as chair, is, we have 16 minutes left.  If we need a lot more discussion about this, then what we need to do is to refer it back to you and let you refine it, listening to the concerns the people have had here, and bring it back to us in December.

          If everybody is ready to go, great.  If we are not, let's just let it go, because we have at least four more items we have to get to.

          DR. PIZZORNO:  Thank you, Jim.

          DR. BERNIER:  I think it is clear that we as a subcommittee have to have another meeting.  I think we learned a lot from yesterday's experience and a lot from last night's.

          DR. PIZZORNO:  Okay, we are going to move on.  Thank you for your input.  We will work on the language.

          Oh, I'm sorry.  I said Linnea could talk.  Sorry.

          MS. LARSON:  My only comment was to say to Tom, to clarify what some of the federal programs are and how we were thinking about how to get this done.  It was an issue about marketplace, et cetera, but I think we need a little bit more clarification of your workgroup to do the work on that.

          DR. PIZZORNO:  I think we could put some language in that kind of sets, here is the general standard and let each community, as defined by states, determine how they are going to do it and what is practitioner appropriate, because it is going to be different, state by state, depending upon the licensing, training, and things of this nature.

          So, let's provide environment, let's say here is what we are trying to create, but let each community do it the way they wish.  I think that should work well.

          Okay, let's move on to Issue No. 6, which is basic or core CAM curriculum for conventional health care professionals at professional schools, post-graduate, and continuing education levels.  We have three recommendations here.

          Oh, and a comment I want to make from yesterday's conversation about the February meetings, please realize a lot of the language in here came out of the February meetings.  There was some assumption that we didn't use what was there.  We used the February meetings, July meetings, et cetera.

          So if you look on the three draft recommendations, after what happened yesterday, I don't know if I should say this or not, but I think these are non-controversial.

          Recommendation No. 33 recommends that a basic curriculum which surveys the CAM modalities, and which probably should say CAM systems and modalities, and ensures basic skills in collaborating with or supervising CAM professionals should be developed for conventional health care professionals in professional schools, post-graduate training programs, and continuing education programs to increase knowledge and understanding of CAM in order to enhance and protect public health.

          I am going to read all three of these because they all tie together.  No. 34, the Commission recommends that the curricula in CAM-funded principles should be developing at conventional health care professional schools in conjunction with CAM experts and CAM institutions.

          No. 35, the Commission recommends that conventional health care providers interested in practicing a CAM modality or system of healing should obtain the necessary education in post-graduate or continuing education programs, or at accredited CAM institutions.

          So is there anything in any of these three people can't live with?  Jim, and then Dean.

          DR. GORDON:  The addition I would have, and it is really that there should be more of an emphasis on self-care in these descriptions of CAM, because I think it is too easy, especially in the context of medical education, to see CAM as simply another technique that one uses, like one uses another herb instead of a drug, and I think there needs to be some sense, even in the recommendation, that we are talking about a philosophy and a way of looking at the world, and not just about what are drug or herb interactions, even though that is also important.

          So, that is really what I would include, both in Nos. 33 and in 34, and that there be practical experience of these approaches, that it not simply be something where somebody does a lecture, this is this, this is what Chinese medicine is.  So, that is my addition.

          DR. PIZZORNO:  Thank you.  Dean.

          DR. ORNISH:  Joe and I were just talking that I know Bill Fair, who certainly is an ardent proponent of CAM, has expressed some concerns that there is such limited time in the medical school curriculum that he said, you know, I don't know that urologist necessarily needs to spend a lot of time learning about CAM, any more than a CAM practitioner needs to spend much time learning how to do prostatectomies.  So, I just want to raise this as an issue.

          Certainly it is like anything else, given unlimited funding, given unlimited time, it would be great.  The question is, any time you put something into a medical curriculum, you are taking something out.  If we are, in effect, mandating or strongly recommending that something go in, then even getting in an hour nutrition lecture takes years in the curriculum.

          Then you can say, well, that is part of the problem, but it is a real issue and it is something you can't just take for granted; we will just add that, because it is a zero sum game there.

          DR. PIZZORNO:  Donald?

          DR. WARREN:  In No. 33, I had something quick.  It says, "or supervising CAM professionals should be developed for conventional health care professionals."

          Does that mean that we look at the aspect of solo practice for a CAM practitioner as being pretty much mandated by the conventional health care practitioner?

          DR. PIZZORNO:  I don't think this defines practices or requires management or doesn't require management.  There are just some situations where it is appropriate for a conventional practitioner to be supervising a CAM professional, and in those situations they need to know what they are doing.

          Joe?  I'm sorry, Jim.

          DR. FINS:  Just to address both of those comments from Don and from Dean, I think educational time is scarce, and I think what the group intended here was basically to allow the allopathic practitioner to be able to work with and understand what was going on, not a completely huge world view, but to understand the relationship.

          Really, in the service, the final point here is to enhance and protect the public health.  So, we are not training the allopathic doctor to become a CAM practitioner -- that is not the skill set -- but just enough so they are familiar with it.

          As far as supervision, there may be times where there is a supervisory relationship, but that we are not in any way mandating.  That is why it is collaborating or supervising.  There may be people who are in your office who are in a joint practice, so you need to know a little bit about their work and their activities.

          DR. PIZZORNO:  Jim and Conchita.

          DR. PAZ:  I think it is entirely possible to include some of this into the curriculum.  The students over at University of New Mexico are already starting to experience that within their classes in various aspects.

          So, even though right at this time it is rudimentary probably, but I think in order to develop it further, it can be incorporated at various points in the curriculum, not necessarily a very comprehensive type of approach, but certainly incorporate it.

          DR. PIZZORNO:  Jim.

          DR. GORDON:  I feel very strongly about this.  I think that already medical schools are doing their best with the support of NCCAM to integrate these approaches, these techniques, and this perspective into all aspects of medical education.

          It can be done.  We are doing it at Georgetown, which is one of the more conservative institutions on the planet, and we are integrating it into everything from anatomy and physiology to surgery and OB/GYN, and we are integrating an experience.

          We can't expect physicians to know anything about self-care unless they learn it themselves.  How are they ever going to learn?  We can't expect them to help their patients with nutrition unless they learn something about nutrition.  So, we are saying it has to be part of the curriculum.

          Amazingly, once it is being said, very conservative faculty are going along with it.  They say, of course, students should know something about it.  The whole world is shifting, and for us to go back and say, we really don't need to know much about it.

          Phil's point, incidentally, is that he doesn't expect physicians necessarily to become acupuncturists, not that he doesn't expect them to know and have some basic experience of self-care and self-awareness and nutrition.

          DR. ORNISH:  I just want to clarify, I am not suggesting that this not be part of the curriculum.  I am just saying that we need to be mindful of the obstacles that are there, and I think it is worth distinguishing between having an awareness of what CAM is, which I think is something all physicians should have, versus being trained in CAM modalities as part of the general medical training.

          I am certainly in favor of the former, but I don't think you are in favor of the latter, either.

          DR. GORDON:  There is no time to train people to be acupuncturists, even if we wanted to, I agree; but I think there are certain fundamental principles and practices that should be part of every student's education.

          DR. PIZZORNO:  Conchita, one final point, then we need to move on.  Thank you.

          DR. PAZ:  One of the things to kind of keep in mind is that some of these changes are coming about because the students are requesting them.

          DR. BERNIER:  Most of the change is coming about because students have requested it.

          DR. PIZZORNO:  Okay, George.

          DR. BERNIER:  I come from a school that has never been judged to be too liberal, but we have really made some enormous strides during the last year in terms of exposing our medical students to the CAM philosophy and approach.  Whether any of them will ever end up practicing CAM modalities is hard to say, but I think it is critical that everybody knows that CAM is out there and that it is part of the medical life.

          So, thank you.

          DR. PIZZORNO:  Now we are going to move to the final recommendations under Issue No. 7.  That is George.

          DR. BERNIER:  This deals with the post-graduate and continuing education for CAM practitioners resembling the ability -- what's available for conventional health care providers.  The draft recommendation is that the Commission recommends that opportunities and funding for post-graduate and continuing education resemble that of conventional health care providers should be developed for CAM practitioners providing primary care to enhance the competency and quality of health care.

          Any comment on that?

          SISTER KERR:  My only question there was why did you say for CAM practitioners providing primary care?  Why not just CAM practitioners?  It is a bit back, I guess, to some of the discussion you all had before about who is doing primary care.  Then, states are different, in California acupuncturists are primary care, legally defined.  We aren't.

          DR. BERNIER:  Does anyone have thoughts on that?  Joe?

          DR. FINS:  I think we are talking about GMP funding and tapping into that source.  I think it raises the same set of questions that we raised earlier about loan forgiveness.  I think that, again, given the massive scope of recommendations in the entire report and the fact that we are facing a deficit and all those kinds of things, I think we need to focus in on the thing that will demonstrate the utility first and foremost.

          So, I think that this may be something that we will evolve toward.  Maybe this goes into the background piece, that, should the demonstration project be effective and show utility, these are the kinds of additional resources that might be marshaled prospectively, going forward.  But it should not be a recommendation, I think, at this point because we have not demonstrated the utility of it.

          SISTER KERR:  I disagree, totally.

          DR. GORDON:  I didn't understand.  Are you suggesting there be demonstrations in this area?

          DR. FINS:  No.  I am saying that you are tapping into funds here that are for residency training programs, as I read here.

          Is that right, George, post-graduate?

          DR. BERNIER:  Post-graduate, yes.

          DR. FINS:  It is really funds for residency training.  What we need to show is that people who have that set of training really have a positive impact through the demonstration projects.  If we show that, then this might be a direction that we would move towards.

          DR. LOW DOG:  I think the recommendation is unclear where the funding would come from.  I think that if you want to go to a master's degree or a doctorate degree.  I know this from my own family, from my own kids, there is certainly funding available.  You can apply for loans, and you can get scholarships and things like that.

          To me, the recommendation isn't really spelling out residency, and it is not specifying GMP.  I think that if that is what you are saying, that needs to be more clear.  I think that the opportunities for post-graduate training and continuing education should be for anyone in any profession, but I would argue that there are funds already available for people to go and to get funding.

          If they are being discriminated against for that, then you should be able to get the loans just like you would to go to university and get your master's degree.  I would support that fully, to be eligible for loans, and if that is not the case, then I think a recommendation should be made, that if you are an acupuncturist and you are going to do further training, that you should be able to get a loan for that, just like my son who wants to go get a master's degree, he will have to take a loan out for that.

          If you are saying something separate about residency, I think we just need to clarify that and put that in a second recommendation, if it is coming from GMP.

          DR. BERNIER:  Okay.  How would you phrase that?      DR. LOW DOG:  I am not on your committee.

          [Laughter.]

          DR. LOW DOG:  I have to do my own committee, George.  But what I am saying is, it seems like there are two issues here.  One is, if you are a chiropractor, an acupuncturist, massage, whatever type of practitioner you are, if you want to further your education, I think that you should be eligible for the funds to do that.  I think that there should be funds.

          If we are talking about GMP, and residencies, and all of that kind of stuff, I think that is a little bit of a separate issue, and I think you need to have two recommendations so that everybody is covered by this.

          I would also say that it is difficult when we can't get national education standards, when we can't get people to agree on even what the education is, it is hard then to try to set up residencies, post-graduates, because everybody is different, nobody wants to agree.  This is coming back yesterday, to trying to come to some agreement for national standards.

          DR. BERNIER:  Thanks, Tieraona.  Ming?

          DR. TIAN:  I think it was very important to provide any support for CAM practitioners to learn conventional medicine and to have post-doctorate training, but, again, in this you are talking about providing primary care, you ask CAM practitioners to do that, that seems to be too much, because you have to go back to medical school to do that.

          Also, for instance, as an acupuncturist, that is an expert, a specialist.  The specialist does not want to take the responsibility to do the primary care, because there is too much responsibility.

          So, it is impossible, because the training in this country for acupuncturist is 1,750 hours, something like that, for non-physician training to be a licensed or a registered acupuncturist, compared with the system in China, it is different, the typical government five years formal training would be 5,000 to 6,000 for Chinese medical doctors, and also they have training.

          I don't like interrupting people, but we have already cut down the time for summary to 15 minutes from 30 minutes, and I want to make sure that we are all on the same page.

          The other thing that I want to emphasize is that even though Tieraona is not on this committee, in effect we are all sort of ex-officio potentially on all the committees.  The way we are going to help the committees move ahead is by helping them where we have a strength or an idea or an interpretation, they need our input on this.

          So, let me go through these and see where we are, because I think we are going to be giving you back a few things, as you well recognize.

          No. 26.  Once the last part of that statement was eliminated, the part from "by amending" on, there was general agreement to No. 26.

          If everyone can read the first part: "The Commission recommends that appropriate access to funding and other resources for CAM faculty curriculum program development at CAM and conventional accredited institutions and by licensed professions should be made possible."  There was agreement for that.

          No. 27.  There was this general sense of agreement, but more detail was needed, and the question about the research was how we are going to put this together with research recommendations here.

          If it seems I've left out something, or something seems awry, please just let me know.  I am just going through this.

          DR. GORDON:  Okay.  Thank you, Joe.

          No. 28 --

          DR. KACZMARCZYK:  Jim, excuse me.  Was No. 27 accepted with changes?

          DR. GORDON:  That is what I understood.

          DR. KACZMARCZYK:  Just asking for clarification.  Thank you.

          DR. GORDON:  Just asking for more detail, more sort of about what it might be like.

          No. 28.  There were a lot of questions about this, and the general sense was this needed to be sent back and reworked, and there needed to be a discussion about pilot projects, staging states' rights, et cetera, those were three of the major issues that were raised for No. 28.

          DR. PIZZORNO:  Jim, I think the message that we heard loudly was there should be some kind of an incremental process here.

          DR. GORDON:  Yes.  That is what I meant by staging.

          No. 29.  There was basic agreement, but again a sense of more detail being needed.

          DR. PIZZORNO:  Jim, could I stop you there?  There was a conversation that George and I had on this, and that is -- and this may be something that the Commission needs to discuss in general -- is, we felt to go much further in this, we were starting to become prescriptive, and we thought we were supposed to not be prescriptive.

          So, we are not sure how to do this in a manner that doesn't cross over some kind of a boundary here for what the Commission could be doing.

          DR. GORDON:  Joe?

          DR. FINS:  I think perhaps in the background section you could flesh out the need and maybe give an example, and yet have the recommendation of people being aware of the kinds of issues that you raise, but not initially saying how it occurs but as background to the recommendation.

          MS. CHANG:  I also have a note that this one was suggested to be merged with No. 27.

          DR. GORDON:  No, with No. 30.

          MS. CHANG:  Was it No. 30?

          DR. GORDON:  With No. 30.

          Any other suggestions about this?  It is clear that it needs the merging, Joe's suggestion about background.  Anything else on this?

          [No response.]

          DR. FINS:  Again, in the background piece, I would really very much like something mentioned about the needs of dying patients and how the practitioner needs to be aware, the CAM practitioner, of that vulnerable population.

          I completely agree with Joe's point from yesterday, that that oncologist who is giving a patient who is dying another round of chemotherapy and not making a referral to the hospice, so too, needs to recognize the limits of his or her intervention.

          DR. GORDON:  I will tell you my feeling about that is that there are many, many vulnerable populations for many different reasons, and I don't think it serves us to keep singling out one population.

          I think we can talk about vulnerability, give a number of examples, pe