Let's have some discussion of any or all of these issues that are raised regarding credentialing and licensure.  Joe.

          DR. FINS:  Just this notion of evidence which is related to credentialing and licensure and assessment of practice, in the House of Lords report, in Chapter 7, there is an excellent discussion about the various kinds of analytical frameworks and the kind of information that they provide that might be helpful as we move forward.

          Related to what Group 4 was just talking about, I think it was in Part 3 or something you were talking about referral and information.  I am very concerned about this one issue.

          I am very concerned about people who are terminally ill, who have not received adequate end-of- life care in the mainstream, were given a false choice about continued, say, chemotherapy which was not efficacious, not receiving adequate pain and symptom management, were never offered the hospice option.

          They go to their CAM provider, and it is sort of a desperate situation, and I don't think the CAM provider should recapitulate the lack of referral that occurred in the traditional setting, so I really think it is very, very important that practitioners of all stripes recognize what might be a futile situation.

          I appreciate their ethical obligation to provide adequate palliative care and pain and symptom management, make a hospice referral.  I think that is critically important because it is just as egregious an error in the CAM realm as it would be in the traditional realm, and I think we have to recognize limits.

          I remember asking Dr. Atkins a question at one of the last meetings, have you ever had a treatment failure, and he said no, which I thought was the height of hubris and problematic, but I think that we don't want to perpetuate that kind of lack of referral.

          DR. GORDON:  So, that is continuing education.

          DR. FINS:  No, I think it is a deviation from accepted practice to not refer somebody.

          DR. GORDON:  I understand, but how does this fit into credentialing and licensure?

          DR. FINS:  Because the boards that look at practices would say this was not professional, this is not professional conduct.  It is a deviation from what the standard of practice should be.

          DR. GORDON:  So, is there a recommendation that you are making?

          DR. FINS:  That credentialing bodies and oversight bodies for practitioners, whether they are CAM practitioners or non-CAM practitioners, are sensitive and informed about palliative care and the importance of referring people to appropriate palliative care.

          I am very concerned that people who embrace CAM at the end of their lives are a desperate population, and they are perhaps more vulnerable to exploitation than people in other parts of the life cycle.

          DR. GORDON:  Okay.  Tom, and then Tieraona, Joe, George, and Effie.

          MR. CHAPPELL:  I wanted to address one of the questions for our group, and that is the one, No. 3, in terms of quality of CAM practices and products.  The focus here on this is on quality.

          I think this misses the needed intent.  I think the question needs to be addressed toward safety and efficacy or at least if we are going to talk about herbal remedies or supplements, it is more valuable from a consumer perspective to talk about safety and effectiveness because safety is covered in the question of quality.

          DR. GORDON:  Tom, the questions are more in the area of services, I think, and more in the area of research.  I would like to focus -- we just have a little bit of time on credentialing and licensure issues for these next minutes.  We will come back to that in the final meeting for sure and maybe in public information, as well.

          MR. CHAPPELL:  Good.

          DR. GORDON:  Next is Tieraona.

          DR. LOW DOG:  My question was when we were going through and you had recommended certification for all of these groups, could you expand on that a little bit?  I am not quite sure what you mean by that.

          MS. LARSON:  What we looked at was the "evidence" that we received from the groups.  Some of these groups do not have a license, but they do have a certifying body different than the organization that may eventually be able to lead to licensure.

          So, we sidestepped or did not deal with the issue of national standards.  It is we leave to the groups, such as the yoga group, that says we have standards, then, we certify that our teachers or our practitioners have done X, Y, and Z.  That is all we have done.

          DR. LOW DOG:  Can I follow up?

          DR. GORDON:  Sure.

          DR. LOW DOG:  I guess it is two parts.  One is that I think there is thousands of lay healers, however you want to define them, herbalists, naturopaths who have not gone through the training, that are out there practicing.

          Are you recommending certification for all of these people?  I guess that is my question.  I think it is an important question.

          MS. LARSON:  I don't think that there was a notion that there needs to be or should be certification.  We simply answered the question, you know, it is national standards or certification.  Yes, if this organization wants to create certifications with certain categories of expertise, yes, do it.

          DR. GORDON:  So, it is voluntary is what you are saying.

          DR. LOW DOG:  No recommendations for --

          DR. GORDON:  No, I don't hear a recommendation.  For certification across the board, I am not hearing that.

          George, go ahead.

          MR. DeVRIES:  I want to open an item up for discussion related to licensure, and it really relates to the issue of several specific provider groups.  I am thinking in the area of chiropractic, there is very consistent licensure state by state across the country, so that already exists.

          But if we look at several other provider groups, for example, massage therapy, we heard yesterday from AMTA that there is very inconsistent licensure across the country.  We know that is also true to an extent with acupuncture, and then we know with naturopathy, only licensed in about 11 states.

          We recognize that the regulation of health care licenses is a state prerogative, a state authority, however, believe that this commission can help these professions to take a strong step forward in perhaps recommending not the exact, shall we say, licensure statute that a state would enact, but really some guideposts, some minimums related to education and other issues that would support those professions in those states who are struggling to be viewed credibly by their local state legislature and to gain the foothold, the credibility to be able to enact legislation that would help them to become a licensed provider group in that state.

          So, what I want to open for discussion, and I am asking this commission to do, is make recommendations related to the areas of acupuncture, massage, naturopathy, that can provide guidelines, minimum guidelines that states can utilize as part of creating statutes for licensure.

          DR. GORDON:  That is fine.  We can talk about that right now.  I want to just make one addendum to that.  We can either formulate guidelines or simply make a recommendation that there should be guidelines that another body would later on decide on, because we may or may not consider it within our purview or within our possibility right now of doing that.

          So, let's have discussion on George's suggestion, and then we will come back to Joe and Effie.

          DR. PIZZORNO:  I would like to hear from Linnea because I saw her nodding.

          MS. LARSON:  I guess I am somewhat confused because this "subgroup" is that we have throughout it said yes, there should be standards, there should be standards of education, there should be undergraduate, postgraduate, and continuing education.

          We are not placing restrictions in terms of licensure because that is not under our purview.  We recognize that there are states, but we are pointing.  We also looked fairly closely at the excellent information that was given by the naturopathic physicians in terms of detailed analysis of what could be possible, but I don't feel, and our group did not feel or think, that it was our charge to spell that out.

          It is our charge to say yes, there ought to be standards and point a direction to it.

          DR. GORDON:  George, do you want to respond to that or anybody else want to respond?

          MR. DeVRIES:  Let Joe.

          DR. PIZZORNO:  Well, I am happy to hear that.  What was presented didn't sound to me like what you just said, and I think it is critically important that this commission come out with a position that says that when there are professions out there, they should have clear educational standards, clear standards of practice, and that licensing should be consistent with those educational standards.

          I think this commission should say it real clear.  Now, we don't have to specify whether it should be for profession by profession, but we need to clearly specify that there should be consistent education and licensing consistent with that education.

          MS. LARSON:  Maybe that was not spelled out word by word, that was the intent, and then we should be very clear about having those specific words in the recommendation.

          DR. GORDON:  George, do you want to respond?

          MR. DeVRIES:  Yes, and I appreciate Linnea's follow up.  Just clearly as we discussed earlier, we talked about the concept of loan and the forgiveness of the loan repayment for providers who are licensed.  As we talked about that as a foundational element for that particular way of funding education, I want to acknowledge that the concept of licensure for provider groups really is fundamental in their ability, in some cases, like with naturopathy, to practice in certain states and to be able to operate with authority in those states and to quality for reimbursement, which we haven't dealt with yet as a commission, but that is typically a line that is drawn by many health plans, which is are they licensed or are they not, and if they are licensed, there is an ability to work with those providers, to credential them and include them in reimbursement systems.

          MS. LARSON:  I would like to respond to that because I think that this is a process in which we are articulating a variety of positions and coming to a kind of common ground.

          Now, you moved into what will be our next discussion, which is reimbursement, but we are talking about standards of education, so that will inevitably lead to the logical extension of how do then we reimburse.

          DR. GORDON:  I am still not sure.  Are you recommending that there should be uniform standards of licensure for professions or not?  No.  So, you differ from what George was saying or not?  I am trying to clarify what the difference is between what George and I think Joe seemed to be saying and what your subcommittee said.

          MR. CHAPPELL:  As Linnea has said, we are very clear that we expect there to be standards, educational standards at all levels of education.  We believe that those standards need to be articulated by the professional groups.

          From there we moved into certification.  We believe that certification is a way to enhance consumer confidence, that those standards are in place, but we didn't touch licensure.

          MS. LARSON:  We were not given the question.

          DR. GORDON:  Okay.  Now, the question is now coming up.

          MS. LARSON:  Yes.

          DR. GORDON:  So, I think we need to spend a few minutes addressing this very important question that George and Joe have both raised about licensure.

          MR. CHAPPELL:  I would like to comment on it then.  I don't know how we, as a national organization, if that is what we are, or a policy recommending organization, would be able to provide any quality assurance for the licensing process because it is individualized by states.

          I think third party reimbursers might be able to do that, but I don't know how the educational content can be driven by that.

          DR. GORDON:  What we can do, and I don't want to take away from you, and I know, Tieraona, you need to speak, but what we can do or not do is make recommendations that there should be uniform standards of licensure and that professions that are licensed in some states --

          MR. CHAPPELL:  We put our emphasis on the word "certification," not licensure.

          DR. GORDON:  I understand.  Now, we are talking about licensure.

          MR. CHAPPELL:  And I personally don't -- I don't have an investment in licensure.

          DR. GORDON:  Okay.  The discussion now is about licensure, and it is open to anyone talking about it.  Tieraona, did you want to address it because you have had your hand up before?

          DR. LOW DOG:  I don't think so.

          DR. GORDON:  Okay.  Joe.

          DR. FINS:  I think there should be licensure and there should be standards, and that is where we have uniformity, that there is such a thing, but it does not need to be the same from state to state to state.  That, I think is where the two sides of the table link up.

          MR. CHAPPELL:  Would you repeat that, please?

          DR. FINS:  That we believe in standards, we believe in licensure or credentialing, but every state has its own prerogative at setting the standards.  I mean that is federalism, and it is the prerogative of the state to set standards.  We think the state should set standards, but it is up for them to determine what the standard is.

          DR. GORDON:  George, go ahead.

          MR. DeVRIES:  First of all, at least as I have seen it with both massage therapy and acupuncture, there is a distinctive difference between certification and licensure among states, and that while certification is good, there is a gulf and it is distinctively better when acupuncturists are able to be licensed or massage therapists are able to be licensed typically in a state.

          Second of all, the question was asked why would this commission recommend licensure, that states proceed with licensure of provider groups, or why would we come up even with some basic guidelines as minimums for the licensure.

          The reason I suggest that we consider it is that for some of these provider groups as they go and lobby their state legislatures to become licensed, to enact statutes that allow them to become licensed, it is a very difficult job for them, it is very expensive, there is opposition.  It is a grass-roots effort.  They don't have much money.  It is a struggle, it takes years.

          There is multiple cases of them failing to achieve certain things out there in terms of obtaining passage of laws to help them get licensed, and if this commission took a position recommending that the state legislatures license these provider groups, and to use reasonable criteria or guidelines in doing it, it would support those providers in the field as they are trying to work with their legislators to get licensed, to get statutes passed to be licensed.

          It would give them a tool to use in the field.  It is just my sense from experience is that they need these tools out there as they are working with their legislatures to get some kind of statute passed.

          DR. GORDON:  Effie, you had your hand up before.  Did you want to say something about this issue?

          DR. CHOW:  I think George already said that.

          DR. GORDON:  Okay.  Tom, and then Linnea again.

          DR. CHOW:  I have another issue.

          DR. GORDON:  I understand.

          MR. CHAPPELL:  I hear the advice, George, and I don't want to argue against licensure.  I want to say that what we were attempting to accomplish by focusing on credentialing was so that a naturopath in Maine would essentially practice the same standards in Oregon.  If I were a consumer, I could expect an M.D. to practice the same competencies, and so forth.

          So, we saw the professional organization being the maker of those standards, and we want, as an organization, to affirm the need for that from the consumer's point of view.

          Now, you are bringing up licensing as a provider-driven need, but as a consumer, I am not sure that that --

          MR. DeVRIES:  Well, just, Tom, to agree with, agree with you except that naturopathy is only licensed in 11 states, and this is about helping naturopathy to be licensed, not in 11, but in 22, 33, 45 states.

          MR. CHAPPELL:  I hear the recommendation.

          DR. GORDON:  So, your point is that without licensure, consumers don't have access to naturopathic physicians in those states.

          MR. DeVRIES:  That's right.

          DR. GORDON:  Veronica, and then Joe.

          DR. GUTIERREZ:  I think the problem with licensure goes back to what I have been saying from the first meeting I attended, and that is we need a definition of scope of practice, intent, and purpose.  There wouldn't be as many turf wars, there wouldn't be as much difficulty being licensed, certified, or at whatever level, if every group defined what their goal and mission was.

          DR. GORDON:  So, that would be part of the process of licensure, as well as part of the process of certification.  Okay.  Joe.

          DR. PIZZORNO:  Tom, I think it is important to emphasize the public safety aspect of this from the consumer perspective, because, as you say, in Maine, a consumer can go to a naturopathic doctor and they are well trained, and can expect a positive outcome.  Unfortunately, they can go two states over and go to somebody who calls himself an naturopath, does not have the training, and they are expecting the same kind of experience they got in Maine where there was licensing.

          So, it is an incredible consumer protection issue that when a title is used, that has licensure status, that that be used consistently.

          DR. GORDON:  We have 10 minutes left for this discussion, for all the discussion about licensure and credentialing.  I want to take sort of a pulse of where we are with this licensure issue right now.

          Is this something we want to take up at greater length later, is it something there is a consensus about at this point that we are looking towards standards, uniform standards of licensing for CAM professions -- I will ask that as a question -- or we just want to put it off and talk more about it later?  Joe.

          DR. JONAS:  I think we want uniform standards like, you know, credentials, like board certification, but each state can say what the standard is for licensure and what the elements are.

          DR. GORDON:  But there are two questions.  There is the elements of licensure and the fact of licensure.  Do you see what I am saying?  Let's say for naturopathic physicians, if there is no licensure at all, then, it doesn't make any difference what the standards are.

          Do we want to come down -- and I have a feeling we may not be ready for it yet, I just have the sense -- but the question that is in the air is do we want to come down and suggest that those professions who may be licensed in some states, to support their efforts to gain licensure with appropriate standards in other states.

          DR. FINS:  The paradox is that if you look at conventional medicine, the certification is a higher standard than licensure.

          DR. GORDON:  Right.

          DR. FINS:  And here, licensure, if you are not in the right state, is a higher certification than something that should be higher, so it's an illogical situation.

          DR. GORDON:  Linnea.

          MS. LARSON:  Just one last thing.  Simply, we are focusing on naturopathic physicians.  This had to do with many more groups, and we looked at the clarity, the logic, the documentation that naturopathic physicians gave and said let's look at this, but we also have other groups that we are making recommendations concerning.

          Certification often has little bit higher standards than licensure.  That is why I said let's look at this issue, but we also know that licensure for third party is tied to reimbursement.  So, it is answering the question certifying for all of these organizations, national standards.

          DR. GORDON:  The other thing that we need to say, though, Linnea, that is a separate issue, is licensing is also tied to ability to practice.  I have a feeling we need to have some more discussion about this.

          Other issues?  It is clearly in the air we need to find a way to come back to this, because it is a crucial issue.  Are there other issues related to licensure or credentialing?

          The one that I would like to sort of reemphasize is the one that relates particularly at this point to physicians, although it could relate to any other licensed professionals in the states, to creating a level playing field.

          I think this was mentioned in a couple of the groups' recommendations for those people who are using CAM approaches, that they have the same kinds of criteria, the same kinds of respect for them and the same kinds of expertise on the licensing boards as for the conventional physicians or conventional practitioners.

          That is, that if there is a nurse of a physician or an acupuncturist who is licensed, that the same kinds of standards be applied, that simply because they are using CAM approaches, they not be discriminated against in any way, and that CAM practitioners or experts be on the boards.

          I am sort of extrapolating from some of the recommendations.

          DR. CHOW:  On that part, it is the reverse.  The protection of the practitioners or the medical practitioner, nurse, medical doctors, I believe that is very essential.

          On the other hand, I think because we are nurses -- I am speaking about myself as a nurse -- and doctors or pharmacists, because they have the training in medicine does not make them experts in the other field.  I think that needs to be placed as a very strong issue, and that the same standards of training and licensing and certification should apply to the medical profession.

          In other words, no little weekend courses, no diminished courses.

          [A/V failure.]

          DR. CHOW:  So, I am saying that because we are nurses or M.D.'s, that studying another practice doesn't make us automatically more knowledgeable about that practice particularly when there are varying theories and principles, so that the certification and licensing of those professionals need to be as stringent as the CAM practitioners.

          DR. GORDON:  So, you are saying that somebody who is licensed --

          DR. CHOW:  Who is a nurse or an M.D. or pharmacist.

          DR. GORDON:  And if they practice CAM?

          DR. CHOW:  And they want to become a CAM practitioner, they should undergo the same stringent training.

          DR. GORDON:  I think this will be an issue of some debate.  For example, the example that we used to bring out this point was the example of acupuncture in particular, where Dr. Helms said, well, we have the international standard which says it is okay to practice acupuncture with this amount of training if you are a physician or even if you are not a physician, there is an international standard, and then Dr. Lao saying, well, a standard-setting body of a group of acupuncturists in the United States says there is another standard.

          So, what we have is conflicting standards of different groups, and if you look across the board at the different professions, we are going to find many, many different standards, not just for acupuncture, but for many, many different practices.

          It is going to be a major issue, and I think that it is a hard one, one that was not discussed in detail up until the present time, and since we have about three minutes left --

          DR. CHOW:  I would like to put that on the agenda to discuss that.

          DR. GORDON:  Let's see what we can do about addressing that.  One of the things I want to say, so that we can all take a deep breath, is that part of what we are hoping to do in October is come back to some of the issues that we have not resolved now, and I think it is much better for us to wait with issues where there is a lot of controversy or a lot of unanswered questions rather than try to hurry to a conclusion now, to give ourselves time and gather information and come back again in October and work on those issues.  So, this can be one of those issues.

          Joe.

          DR. PIZZORNO:  I think Effie has raised an important issue, and I would actually pursue it more from the standard of care rather than from the standard of education.

          For example, if I used an antibiotic, which I am licensed to do in the State of Washington, and I don't use it very often, but if I did, the standard of care I would be held to would be that of a naturopathic physician using an antibiotic.

          Now, if we have a medical doctor using an herbal medicine or an acupuncture or something of this nature, what is the standard of care that medical doctor is being held to?

          I think that needs to be established because right now while it is in the purview of the license, there is not a standard of care to determine when the public is being properly served, and I have substantial concern about that.

          DR. GORDON:  So, this is clearly an issue with many ramifications.

          DR. CHOW:  I think it goes back to Tom's point that everything we are talking about is really customer based, you know, driven, so the reason for our discussions is for more information on a positive level.

          DR. GORDON:  I think it is time for us to take a break.  What we have done, just to recap a bit, is we have a number of issues on which there are some general agreement, and we have several issues, particularly the last two that were raised, about which there is a lot of discussion, a lot of unresolved issues related to them that we can come back to at a future time.  So, this is a very good discussion.  I want to thank everybody, the continuing education chairs and the whole group, for their participation.  This has been great.

          [Applause.]

          DR. GORDON:  We are going to take a 10-minute break and then we are going to come back for the public comment session.  Incidently, thank you very much, those of you who are participating in public comment, all of  you.  We have gone about 15 minute overtime, so thank you for your patience.

          MS. CHANG:  Let me just let you know who will be the first six up to bat, so you will get ready to come up in 10 minutes.  Susan Silver, Margaret Huddleston, Robert Scholten, Rustum Roy, Diane Miller, Susan Bonfield Herschkowitz.

          [Recess.]

                Public Comment Session

          DR. GORDON:  The rest of the meeting today will be devoted to public comment.  We are going to be calling up the panelists in groups of six.  Each panelist will have three minutes.  Just as we were with the other speakers, we will be somewhat draconian in making sure it is only three minutes.

          After all the panelists have spoken, there will be an opportunity for Commissioners to ask questions after each panel of six has spoken.

          I will call off the panelists to speak in the order in which they are written, in which they signed up.

          First is Susan Silver.

          MS. SILVER:  Thanks, Jim.

          I am Susan Silver.  I am the program director of the Center for Integrative Medicine at George Washington University Medical Center right here in Washington.  I am the principal investigator on a project that I am going to describe to you that allows us to prepare and implement a model training program for medical students in CAM.

          The limitations of time are going to force me to give you the no-frills version, but I do want you to understand that we are specifically addressing the problem as follows, that medical students in our medical school and others are certainly well prepared in biomedicine and allopathic medicine, but they are almost entirely without information on CAM as it is practiced by Americans and as it is practiced around the world.

          In order for those physicians to treat their patients comprehensively, particularly given the increasing use by the population of CAM, they need to be able to evaluate and advise their patients on what they are using.  They need to know the questions to ask them, and in order to do that, they need to be familiar with not the practice of CAM modalities per se, but with the principles of practice and the integration of practice with conventional medicine.

          I am an investigator on a project that was funded just this past fall by the Department of Education, specifically, the Fund for the Improvement of Post-Secondary Education, FIPSE.

          It is a three-plus year grant that will let us work with our first year class, that is, our first year medical students of this year throughout their medical school career.

          Just briefly, what we are going to do is involve them in three distinct modules, as we call them, the first being experiential where they will become our patients and experience CAM through themselves.

          The second is didactic where they will actually participate in group discussions, and so on.

          The third is participatory where they will shadow out professional providers in our clinical practice at GW.

          We hope by exposing them over that long period of time to CAM as it is practiced, their knowledge of CAM will grow with their knowledge of allopathic medicine, and our greatest goal is to not only incorporate the program into our own medical school curriculum, but to make it replicable, so that it can be reproduced in other medical school settings and broaden the sphere that is impacted by teaching CAM.

          DR. GORDON:  Great.  Thank you.

          Next is Margaret Huddleston.

          MS. HUDDLESTON:  Thank you.  I am Peggy Huddleston.  I am a psychotherapist and author of this book Prepare for Surgery, Heal Faster, and a companion relaxation healing tape.

          I have developed a five-step protocol that shows people how to use mind-body techniques to prepare for surgery and to become much less anxious.  Actually, they become profoundly peaceful before surgery.  They use 23 to 50 percent less pain medication after surgery and  heal much faster.

          I have also developed a two-day training program for health care professionals for which they receive 13 1/2 CEUs that I have taught to professionals across the country.

          I am also the principal investigator of several research studies documenting the program at several Harvard teaching hospitals.  I have just completed a randomized, controlled study.  We picked patients having total knee-joint replacement because everyone said that is the most painful and the worst, so we picked that on purpose.

          We found that patients using this protocol, which involved a book and a tape, which wholesales a cost for a hospital $15.00, or usually the patient pays for it, wound up saving the hospital about $3,000.  The patients were much calmer the day before surgery compared to the controls, and they also left the hospital a day and a half sooner with the DRG, so it saved the hospital that money.

          We are also just starting two other studies at Mass. General with patients having open heart surgery and abdominal hysterectomies.  My program is currently used by hospitals, I guess it has already been used by more than 200,000 people around the country, self-guided, with patients using the book and the tape themselves.

          It is also being used now at hospitals across the country including NYU Medical Center in New York where I have trained 18 nurses there.  Several Kaiser Permanente hospitals are using it, UCSF Cancer Resource Center, Saint Barnabas Medical Center, the largest chain of 14 hospitals in New Jersey, and others that I have listed here.

          There is an article that I included for you, that was from the recent issue of OR Manager, that talks about Kaiser's results, the data they have collected, and how much the have found it increased patient satisfaction, and since Kaiser owns their own hospitals, to their delight, it was saving them about $1,000 per patient.  When the length of stay was normally four days, it was coming down to three days.

          I would urge the committee to provide more funding for this program.  If I have 30 seconds left, I will tell you what it includes, but tell me when the bell rings.

          MS. CHANG:  You will know.

          MS. HUDDLESTON:  The program has patients use a relaxation tape.  It is 20 minutes long, and they use it twice a day.  The second step is they take their worries and fears and turn those into positive healing imagery.  The third is they create a support group.  The fourth is they use healing statements that lessen the use of pain meds following surgery.  If any of you want a copy of the book, just give me your card and we will mail you one.

          Thank you.

          DR. GORDON:  Thank you.  It says that you enclosed a copy of an abstract of the research study.  I don't think we have that.

          MS. HUDDLESTON:  I decided not to, because I am about to submit it for publication.  I am just afraid maybe it won't be kept confidential, so I reneged the last second.

          DR. GORDON:  Okay.  Thank you.

          Robert Scholten.

          MR. SCHOLTEN:  Dr. Gordon, Commissioners, thank you for this opportunity to speak.  I am going to read my speech if you will forgive me.

          The concern and dedication that I observe here is laudable and I thank you very much for doing what you are doing.  I am a librarian by training and have been the information officer at the Center for Alternative Medicine Research at Harvard Medical School for four years.  I also coordinate our four CME courses that are given to over 1,000 people each year.  These CME courses are cosponsored by Stanford and UCSF.

          My remarks today concern access to information on complementary therapies by the students, conferees, researchers, and clinicians with whom I work on a daily basis.  Their requests are easily summarized - what is the aggregate of evidence for use of these therapies, where is this evidence located, if only anecdotal information exists, is it recorded, and how can I get  ahold of it, if the therapy is part of a historic tradition, is it documented authoritatively, and where.

          I think it is fair to say that access to information remains one of the most critical factors that allows successful integration of complementary therapies into our health care institutions.  While we are fortunate to possess numerous commercial and governmental databases that help information professionals provide data to our researchers, I believe the federal government can and should do more to coordinate access to important international resources and CAM practice that are not currently in the public domain.

          I therefore invite you, the commission, to consider the creation of a task force charged with the creation of an information strategic plan that is truly international and collaborative in nature.

          This task force should be equipped with a federal mandate and concomitant resources that would allow it to open negotiations with the World Health Organization, ESCOP, Ministries of Health of other countries, and other worldwide stakeholders.

          Its principal goal should be to ease access to existing data, coordinate the creation of new databases on a collaborative basis, and set standards for data including an exchange specifically in the field of CAM.

          This task force should initiate an inventory and critical evaluation of the current state of information resources available to the English-speaking CAM researchers today.  This should include all governmental, quasi-governmental, and commercial initiatives.

          It should specifically seek to identify existing databases that remain largely inaccessible to scientists for one reason or another.

          Finally, they should survey scientists, clinicians, and information professionals in order to determine whether or not the current resources are considered adequate to their work, authoritative enough to allow proper prioritization of research projects, and clinical recommendations.

          I would --

          [Interruption.]

          MR. SCHOLTEN:  -- like to stop now.

          [Laughter.]

          DR. GORDON:  Thank you.

          Rustum Roy.

          DR. ROY:  Once I heard Tom Chappell's statement, which got all the clapping, I threw away my script, and I said, well, he said it all.  My position is basically that you have been concerned about education of the practitioner.

          At the end of your package for me, you will see a graphic like this from Arizona State University where I work, and you will see two cohort groups, the practitioners including all the CAM practitioners and the citizen-patient.  That is the last graphic.

          My remarks are confined entirely to the citizen putative patient.  I urge you to say, as everybody in this room, I don't need to tell any alternative practitioner, that half the equation is on the other side, it is the patient who is receiving whatever treatment is being offered that is the really key person, and the education of that citizenry.  This is a consumer-driven movement.  That is what Tom was saying, and it is not going to stop, it is going to go gang busters.

          We want to get systematic, more or less reviewed and checked out through the formal educational systems.  In college, we have got students at Penn State now.  We are starting at Arizona State in the regular, not medical student, regular student and K through 12, that can get the information they need.  It is going to be very generic, but it is going to be the kind of information which makes them much more informed, much broader.

          Today, the less wealthy and less educated citizenry don't get this information.  It is the wealthy that are getting the alternatives.  We have got to get it down.  So, I urge you to focus on that group.

          I am a hard scientist.  I worked with Andy Weil for four years on preparing the things you are talking about and in the CME material, my lectures are in that, and I think that we really can drive the system by going even broader.

          We have got 7 1/2 million students in college.  We have about three or four times that in high school.  We need to really access that cohort group.

          How to do it?  In 1982, Reagan had zeroed out the science education budget.  Science education was zero.  Today, it is $775 million a year.  I propose if you recommend to a joint NSF/public health group to do funding for education of the citizens in the craft that you practice, they really will need to be educated.  They are the people who are doing to do it.

          I end with Hippocrates.  Hippocrates said, "It is important to know the person who has the disease than the disease the person has."  I am going to say it is more important to educate the person who is supposed to be a patient than the doctor.  I am not going to say they shouldn't be educated, too, but let's educate the other half.  So, I am here to advocate that this commission recommend the education of the other half, and I know you are known for balance on that.

          Thank you.

          DR. GORDON:  Thank you.

          Diane Miller.

          MS. MILLER:  My name is Diane Miller.  I echo the consumer approach that I will be speaking about today.  I am an attorney.  I am the Executive Director for the National Health Freedom Coalition, former defense counsel for many healers, and the draft and lobbyist for the Minnesota Model of Legislation.

          Problem: Unlicensed healers are illegal.  They can be charged criminally.  This means that consumers don't get access to these healers unless the healers are willing to work in a vulnerable legal situation.

          There are thousands of unlicensed healers permeating throughout this whole culture, many in solo practice, without affiliation to national groups, with a broad array of backgrounds and talents, many of whom use a combination of skills to assist consumers.  Affiliations with institutions or national organizations is not desirable for many of these healers, and the consumers don't require it either.

          2.  Licensed practitioners and healers can lose their license.  They can be disciplined by their boards.  This means that consumers don't get access to these types of practitioners unless the practitioner is willing to practice in a vulnerable legal situation.

          There are thousands of these practitioners out there practicing, and they are usually practicing specific to their own personal interest in healing, having gotten their information from many resources and utilizing it to assist patients.

          3.  Very important from today's conversation, I would like to just say this, and I would like you to get more input on this.  Educational credentials or degrees are not the same as government delegated titles and regulation.  This is an incredibly important and complex area that needs legal attention.

          There are thousands of groups that promote the educational credentials and accreditation of schools and degrees.  Many of these groups also support the practice of their profession by non-degreed individuals.

          Many national groups are adopting policies, open practice policies, but continuing on a path of advancing various kinds of private credentials and excellence.  Many natural health disciplines acknowledge some of their greatest teachers do not have the credentials and degrees and do not want government to exclude them.

          The use of the least restrictive regulation is important to protect consumer choice, avoid using scope of practice laws, avoid defining CAM and practices, use including but not limited to language, don't use the word medicine, use the word health care.

          Minnesota has designed laws well thought out over the last eight years that makes it possible for consumers to access all healers, unlicensed and licensed, in a safe manner.  Consumers get really extensive information from their practitioners.  Practitioners can practice across many disciplines, but must abide by safe and professional conduct.  Consumers have a clear, quick recourse for complaints.  Don't get caught up.

          One last thing I will say is pluralism.  Federal homogeneity should be reserved only for those situations of harm.  Consumer expectations are based on location and culture in which they find themselves.  That is the beauty of culture.

          Pluralism is an important component of a strong society.  Free expression of rituals and traditions make for a rich culture.

          DR. GORDON:  Thank you.

          Susan Bonfield Herschkowitz.

          MS. HERSCHKOWITZ:  My gratitude to the Commission for giving me this opportunity to speak.  It is welcoming that conventional physicians are beginning to embrace and even be trained in natural medicine, however, it is misguided if the conventional medical community sees natural therapies through the prism of conventional medicine.  There are major differences between the two that must be acknowledge and incorporated into current and future approaches to our nation's health care.

          Natural medicine is not one size fits all medicine.  Unlike conventional medicine, natural medicine tailors remedies and treatment specific to each individual patient using information provided by the patient's body.

          Natural medicine does not treat just a disease, but examines and treats the patient's entire body.  Conventional medicine only looks at the disease and the specific part of the body affected by that disease.

          Natural medicine heals the body through a process that occurs over time because it taps the body's own abilities to heal.  This process requires patience from the patient.

          Natural therapies are most effective when used in partnership with other natural therapies, especially in patients with troublesome and chronic medical problems.  This partnership enhances the ability of each therapy to succeed in its healing task, and strengthens the body with more natural healing tools.

          Natural medicine is far less experimental than conventional medicine.  There are no invasive procedures used on the body or experimental drugs tested in the body.  The human body provides the clues of a disease and solutions to its treatment.

          Natural medicine is low tech and less expensive than conventional medicine, but appears to cost more because it is rarely covered by health insurance.

          Natural health providers trained in Western herbs can pre-test herb safety and effectiveness through simple, painless and non-invasive techniques that use the patient's own energy.  Unlike conventional medicine, an herb does not have to be ingested to discover whether it is safe and effective.

          Unfortunately, the conventional medical community remains skeptical and dismissive of natural medicine's benefits.  The Commission can erase the skepticism by becoming energetic partners with natural health care providers and their respective professional associations during its deliberations.

          Natural medical experts have the knowledge and skill needed by the Commission to complete its work.  Their professional associations work diligently to develop standards of training and care.  The Commission would serve its purposes more effectively and wisely by tapping onto this wealth of experience.

          Thank you.

          DR. GORDON:  Thank you.

          Questions from Commissioners?  Joe.

          DR. PIZZORNO:  A question to Susan Silver.  How much of your curriculum is part of the core curriculum required of medical schools, and how much of it is electives?

          MS. SILVER:  It is virtually all elective at this point because it is a pilot, and we were not able to impose a further burden on the existing medical students.

          The exception will be in the final module where they are actually participating with our own providers in our clinic, and they will get some elective credit for that, but the goal, of course, is to combine it with the core curriculum and have it become a part of that in the future.

          DR. PIZZORNO:  How many hours are you doing?

          MS. SILVER:  Well, the first module is really a treatment module, so it will consist of 12 treatment sessions after an assessment of the individual students' needs and goals, and so on, to enhance their health.

          Our hope, in fact, and we will measure this, is that the students who are notoriously compromised in their health as they go through medical school will incorporate some of these practices into their own lives, and we will measure, in fact, whether they maintain a higher level of wellness than their classmates who are not participating.

          The didactic sessions will be about 15 hours in the second module, and the third module, the participatory module, is about two weeks spent in our clinic and participating in case management sessions and team meetings, that sort of thing.

          DR. PIZZORNO:  Just one more question.  Are they given any training in how to work collaboratively with licensed natural medicine practitioners?

          MS. SILVER:  Well, we don't have a naturopath in our team, however, our clinical team consists of 13 different practitioners, so they are going to be exposed to a whole variety of CAM providers.

          If someone expresses interest particularly in naturopathy, we will facilitate that, but as it is, they will get herbal experience and traditional Chinese medical experience, as well as mind-body techniques and bodywork, and so on.

          DR. GORDON:  Tom, then Joe.

          MR. CHAPPELL:  Robert, you brought an interesting issue to light for me.  Is the fact that information is not available to medical doctors, one, that they don't know how to find the clinical data or that we are not recording the data as CAM practitioners?

          MR. SCHOLTEN:  I think the answer to that is both, but a good example of what I was referring to, the World Health Organization has a database of some 8,000 adverse reactions to herbal products, which currently is not accessible to any researcher unless you physically go to Sweden to look at it.

          They are also working on a classification for the therapeutic indices for herbal medicine, but I know that this initiative is cash poor and that they are desperately looking for help from the United States research community, so they can continue and complete that process.

          I think those are just two excellent examples of data that is already in existence or is trying to come into existence where we could help if we had the infrastructure in place to do so.

          In regard to the second part of your question, I think we could look at data, for instance, that exists in Germany on the prescriptions of herbal medicines.  There are millions of prescriptions that have been given to German citizens and presumably recorded, their outcomes are recorded, and to the extent that people can speak German, that information is helpful, but perhaps this is information that needs to be translated and made available to the English research community.

          DR. GORDON:  Joe.

          DR. FINS:  This is for Ms. Silver.  Based on your knowledge of this undergraduate medical education, in your estimation, how much curricular time would be required to achieve the kinds of minimal standards that we articulated in our recommendations earlier this afternoon?

          MS. SILVER:  I will probably know the answer to that better after we have tested this a little bit.  I described the length of time that we are expecting students in our project to spend, so I would expect that it will be that much time or perhaps --

          DR. FINS:  But you are talking about an elective, right?

          MS. SILVER:  We are talking about an extracurricular activity.

          DR. FINS:  I am talking about balancing the curricular restraints in a medical school with what you ideally would like them to know, what is the package that you think would be viable in your institution.

          MS. SILVER:  I don't have the answer to that yet.  I think that we have to pilot this program and get a better sense of the starting points of the students and the outcomes, and we will do that.

          We are testing their knowledge and attitudes all along the way, along with our wellness, and as the progress through medical school, I think we will have a better idea from the survey instruments we are using, as well as just feedback, whether they think that they are getting a balanced exposure that will be significant and sufficient for them as they go on and practice medicine or whether they would endorse a more comprehensive approach, but I don't think we know the answer to that yet.

          DR. GORDON:  Effie.

          DR. CHOW:  Thank you.  I really enjoyed the presentations.  Rustum Roy, of course, our discussion has been all on sort of the professionals, and so forth, and I am interested in that.

          Now, are you talking about public education or are you talking about specifically children in school, or can you elaborate on that?

          DR. ROY:  Yes, I think I shouldn't have said the other half, it's the other 99 percent.  Really, the opportunity is enormous, and I mean using the formal systems.  We now have through the web, through Andy Weil's lectures or Deepak Chopra on TV, education gets out, but I think, in fact, we should formalize that in college.  We are giving a course in Penn State this semester.  We will be doing it at Arizona State next fall for the general student.  Under the science education, what science should people get?  They learn about astronomy, but they don't learn about their own health, it's ludicrous.

          So, I am talking about doing it K through 12.  We know that system at Arizona State.  We have the biggest science education effort in the country.  We know how to get it in through K through 12 and in college.  That is what I think is our new system.

          You guys are doing it anyway through all the informal channels.  I want to formalize the education of the citizen-patient.  It is a very cheap program compared to less than one drug development will be for this enormous mass of citizens at all levels of the economy to get some information about alternatives.

          DR. GORDON:  Don.

          DR. WARREN:  For Diane Miller.  Is the Minnesota model working?

          MS. MILLER:  We don't know yet.

          DR. WARREN:  How long has it been in existence?

          MS. MILLER:  It hasn't gone into existence.

          DR. WARREN:  It hasn't gone into existence yet.

          MS. MILLER:  July 1st is when the office opens.

          DR. WARREN:  So, we really don't know if this idealistic model will work or not.

          MS. MILLER:  Right.  This statute was based on a statute that is 15 years old in Minnesota, and it has been used for unlicensed mental health practitioners, and we are the only state with an unlicensed practitioner statute.  That is the statute that it is.  So, they already have an office that has been functioning really well for 15 years, and they like the statute.  So, that is why the Department of Health study on CAM recommended that we use that model of legislation because it works so well.

          DR. GORDON:  Any other questions?

          [No response.]

          DR. GORDON:  I have one comment and one question.  The comment is -- and this is for everyone on this panel, as well as in the audience -- at our next meeting on March 26th and 27th, we will deal with issues specifically of public information, which many of you are raising here on this panel, and also issues related to wellness, so the 26th will be public information, the 27th will be wellness.

          I have a question for Rustum Roy, which is do you have a step by step plan that you could provide us as a guideline for formulating, perhaps formulating a recommendation to the National Science Foundation, Department of Education?

          DR. ROY:  Either the Department of Education or jointly with the Public Health Service, I will be happy to provide you with that, at least what worked in the past in my political experience in Washington.  I think that is a very viable one, and the National Science Foundation would be eager to take it, or the Department of Education, not favoring anybody.  I don't think it is an NIH kind of thing.  It is not a research thing.

          But in the education side, we have a lot of track record, we know how to do it.

          DR. GORDON:  So, anything that you could provide us that would give us guidance, because one of the issues that we deal with here is as we are getting ready to make recommendations for our interim report, is acceptability and feasibility.

          I am asking this of you in particular, but also of others who come on the panels, if there are thoughts that you want to give us, and I know when we go to Minnesota in March, we will be hearing a lot more about how you implemented the Minnesota Act and what organization was necessary for that.  But any information any of you can give us about implementation, feasibility, political hurdles, support for different proposals that you have, that will make our job a lot easier in terms of making recommendations.

          DR. ROY:  Jim, I would be happy to send you my version.

          DR. GORDON:  Great.  Charlotte, did you have your hand up?

          SISTER KERR:  I had the exact same question of Dr. Roy, as well as, do you know who anyone who implemented this, particularly K through 12, any program?

          DR. ROY:  On health.

          SISTER KERR:  For the citizen-patient.

          DR. ROY:  Zero.  That is what we have been looking at, at Arizona State.  We don't know of anything remotely like it, and we are puzzled.  We used to have health education.  It became phys. ed., then, it became sex ed., and all that, but here is this whole world.  Our dream is globalization of the information base, something like the Harvard Group wanted, the globalization of knowledge.

          Every student is so eager for this stuff, they are interested, and it is relevant to the citizenry, it's the only thing that is going to lower costs, why Congress likes it, it is the one hope on a massive scale to cut that 10 increase in HMO costs every year.

          DR. GORDON:  Diane, did you want to make a comment about that?

          MS. MILLER:  I did.  We have a junior college that has part of it as their curriculum for general students as, you know, alternatives in CAM and what their impacts are, and also there is a bill before our legislature to take pop machines out of the school.  I just thought I would tell you that.

          DR. GORDON:  So, we would welcome, if there is a curriculum that you think would be interesting for us to look at, please send it, and Robert Scholten, if you have come up with anything in that area, too, we would really appreciate it.

          SISTER KERR:  And also anyone that you may know.  We heard of an example this morning from Berkeley of taking the sodas out, changing the food, and Beverly Hills -- I keep saying Berkeley, I think of Berkeley as the sixties, you know -- but any of those models we would be very interested in receiving.

          DR. GORDON:  Thank you very much.

          MS. CHANG:  The next group of speakers, if you could please come up at this time, and that would be Michele Forzley, Victoria Mary Goldsten, Brenda Jasper, Emily WhiteHorse, Bruce Nordstrom, and Brian McAulay.

          DR. GORDON:  Michele Forzley.

          MS. FORZLEY:  Good afternoon, everybody.  I always feel like we leave the international arena until the last of the day, and here I am again at 5:00.  I am not going to speak from my written remarks because I have decided that it is not going to be very helpful for you at this moment.

          When I left the office at 3:30, having finished writing them since lunchtime, I thought, oh, I have got it all figured out, but no, indeed, I didn't get it on paper as well as I would like to.  So I am going to look at your Question No. 1 on your sheet of instructions to speakers, and it says, "Can uniform standards of education, training, licensing, and certification be applied to all practitioners?"

          No is the answer.  You will never get it through politically because every state is not going to relinquish its control over the regulation of medicine, it doesn't happen.  Europe tried to come up with uniform standards across national lines.  They didn't succeed.  Instead, they came up with a system of harmonized standards.

          This is the same thing I mentioned to you the last time I was here in talking about access and delivery, and a harmonized standard allows for some level of uniformity, if you want to call it that.  It allows for some general guidelines to be developed by commissions such as yours to seek to achieve some level of credibility, competency, et cetera, whatever you think are the goals of those standards, yet, permitting the states to come up with their unique brand of whatever they think it is.  Okay?

          It is going to be very difficult to divest states of their power, particularly medical boards, right?

          Next, there is a larger community that will be benefitted by your work in this regard, and that is the health care community as a whole, never mind the CAM practitioners who you are first to address.  Doctors, nurses, and all health care professionals suffer -- as do lawyers, by the way -- and other professionals from the requirements of state licensing that differ from state to state.  It is not licensing generally, but it is licensing from state to state.

          Now, we have to worry about the advent of telemedicine, which is practicing electronically on internet.  So, where can you look for some guidance?

          Number one, the Europeans in 1992 wrote Directive 51, which came up with a whole system of harmonizing education and training.

          Number two, you can look at the International Treaty on Telemedicine, which I wrote, along with Committee 2 of the International Bar Association, which seeks to do this internationally, so that medicine can be practiced electronically.

          Third, there is a tremendous body of work which identifies the equivalencies in education and licensing standards between states within the United States.  The work is done by Alternative Link, Incorporated, who I am sure has presented here before, so there is no need for you to figure out what the equivalencies are.

          You need to come up with what method of harmonization you are going to employ, what rules you will follow to accomplish that.

          Lastly, don't forget to teach people about how to run a business, because that is what is going to make the success of a CAM practice, that they know how to run a business, because that is what it is until we come up with a system of reimbursement that provides enough money for CAM practitioners to do what they do well, and why people go to them.  It isn't going to pay for them to have a seven-minute acupuncture session.

          So, until then, they are running a business.  Thank you.

          DR. GORDON:  Thank you.

          Victoria Mary Goldsten.

          MS. GOLDSTEN:  Thank you.

          Hello.  I am Victoria Goldsten, a Registered Doctor of Naturopathy, licensed massage therapist, and licensed nurse in Washington, D.C.  I also practice in the State of Maryland.  I am here on behalf of traditional naturopathy across the United States.

          As traditional naturopaths or true naturopaths we treat the human condition with naturally occurring substances such as homeopathics and herbs.  In addition, we use physical modalities such as our hands and voices in a variety of treatments such as guided imagery and acupressure.

          It is important for the Commission to know that true or traditional naturopathy does not cross the line into conventional medicine and prescribe conventional drugs or perform minor surgery as medical doctors and naturopathic physicians do.  We as naturopathic doctors and naturopathic practitioners are strongly against this process for this is the job of qualified medical doctors.

          The directors of the American Naturopathic and Holistic Association and the Washington Institute of Natural Medicine in the D.C. metro area, the College of Naturopathy in California, and the College of Metaphysical Studies in Florida also wish to convey to you that this is their opinion as well.  The general consensus of traditional naturopathic schools and service organizations is freedom of choice by the consumer.

          We, as traditional or true naturopaths, have a strong commitment to health care.  In this promotion of health care, it is extremely important that we continue to be afforded the right to continue our practice.  In order for this to happen, we respectfully request our federal government strongly support broad guidelines in educational licensing and professional licensing process.

          Educational licensing must allow for vocational schools, degree programs, and most importantly, apprenticeship training in naturopathy. It is of utmost importance that the apprenticeship component not be overlooked.  This style of learning provides a hands-on component like no other.  We would like to see this style of program not be eliminated and not be under the same stringent guidelines of higher educational facilities.  Apprenticeship training creates affordable, safe, compassionate, and experienced practitioners.

          Here in Washington, D.C., the educational licensing commission has forced an apprenticeship program in naturopathy to shut down based upon a newly enforce D.C. requirement that the program meet the same standards of vocational schools or colleges.

          At its inception, the program was informed by the District that it could function under the exempt category due to its apprenticeship status.  In the neighboring states of Virginia and Maryland, a friendlier approach has been adopted, allowing apprenticeship program to fall under the exempt category.

          We wish to see these states as examples for all states across the nation.  If overly restrictive licensure eliminates this apprenticeship component, affordable and accessible natural health care will not be available to all of those who need it and want it.

          If strict licensure eliminates this apprenticeship component, the good of the general public will not be met.

          Thank you.

          DR. GORDON:  Thank you.

          Emily WhiteHorse.

          MS. WHITEHORSE:  Good afternoon.  My name is Emily WhiteHorse.  I am here on behalf of the Association of Physician Assistant Programs.  As a PA practitioner and educator who has embraced the inclusion of CAM for over 10 years, it is truly an honor to be here today in the presence of this distinguished committee.

          There are approximately 40,000 practicing PAs, 10,000 PA students, 126 accredited programs.  Over the past five years alone, the number of PA programs has doubled.

          As mid-level health care practitioners, we come face to face with patients who use or are interested in CAM.  Presently, our biomedical educational model does not include CAM as an accreditation standard although in 1998, 52 percent of 80 programs that responded to a survey indicated that they did include instruction in CAM.

          In PA education, we have struggled with whether or not to include it, however, with the ongoing patient demand and the use of CAM, the questions have now become how do we include it in an already labor-intensive program and how do we determine what information is needed.

          Evidence supports there is a fundamental change occurring in the values, beliefs, and expectations of the people who make up our culture regarding health, healing, and disease.

          Health care systems are developed around and function from an explanatory model, which is culturally bound and based on the overall beliefs and values of the culture.

          Clearly, we are on the brink of change.  Our culture is redefining its beliefs and expectations of health care, health care practitioners, and the entire health care system.  It appears that this paradigm shift represents a world-view shift from a mechanistic, reductionist one to a holistic one.

          While it is important to focus on identifying and understanding CAM, we also need to ask the questions:  what is it that our patients really want from us as providers and from our health care system?

          If they are asking that we become more holistic in our overall approach to health and illness, then, does our job as medical educators become the integration of holistic concepts and principles into the educational model of health care practitioners, concepts which include CAM?

          A first step could be the creation of a committee or task force to address these and other concerns facing the education of medical practitioners as a whole.  In the spirit of holism and cross-disciplinary cooperation, this task force could bring together educators and practitioners with the goal of establishing minimum requirements for all of medical education regarding CAM.  A need for clear and consistent guidelines and consensus seems warranted.

          All of this, however, rests upon whether CAM is included as an acceptable standard of care in our health care system.  Without support from organizations like NIH and this commission, and continued national and government support and recognition of the potential CAM holds, its inclusion in medical education as an accreditation standard and program curricula or on board exams remains uncertain.

          As a result, future practitioners will continue to struggle in the same way that we as practitioners today struggle with the lack of formal training regarding CAM.

          In closing, I would like to thank the commission for the opportunity to speak on behalf of APAP, and to also offer our assistance and cooperation in future deliberations of this important issue.

          Thank you.

          DR. GORDON:  Thank you very much.

          Brenda Jasper.

          MS. JASPER:  Thank you.  On behalf of the Association of Physician Assistant Programs, the only national organization in the United States that represents PA educational programs, I thank you for this opportunity to share our educational model as an example of integration of CAM into existing educational programs.

          APAP's mission is to assist physician assistant educational programs in the instruction of highly educated PAs in numbers adequate to meet society's needs.  Physician assistants are health care professionals licensed to practice medicine with physician supervision.

          As a part of our comprehensive responsibilities, PAs exercise autonomy in conducting histories and physicals, diagnosing and treating illnesses, ordering and interpreting tests, counseling on preventive care, assisting in surgery, and in most states, writing prescriptions.

          The PA profession grew out of a recognized need for educating health professionals that were trained in the medical model that would work with physicians and extend access to care, particularly in medically underserved areas and health professions shortage areas.

          The curriculum in PA educational programs is geared toward primary care and focused to provide the appropriate education in an intensive and uniquely designed manner.  Over the profession's 35-year history, we have established educational accreditation, national certification for practitioners with support of the National Board of Medical Examiners, the AMA, the American Academy of Family Physicians, and the American College of Surgeons, and the American Academy of Pediatrics.

          Although all accredited programs must meet the same rigorous educational standards, they have the flexibility to offer a variety of academic degrees.  Implementation of core curriculum is flexible within all of the PA programs.  What a physician assistant does varies within training, experience, and state law.

          In addition, the scope of practice for PAs corresponds to the supervising physician's practice.  Referral to the physician or close consultation between the patient, the PA, and the physician is done for unusual and hard-to-manage complicated cases.  Physician assistants are taught to understand their limitations as an important part of PA education.

          PA education is tightly structured and focused, and is recognized by many as innovative, efficient, and effective with an average of two years prerequisite education, 25 to 27 months of didactic and clinical education.

          The accreditation standards have historically embraced the latest innovations and trends in medical practice over the years, and to add to our rigorous curricula content areas such as multlcultural impact on care are included in our educational model.

          DR. GORDON:  Thank you very much.

          Brian McAulay.

          DR. McAULAY:  Thank you for the opportunity to share information with you about chiropractic education, its state, and how the profession can best serve the American people.

          I serve as president of Sherman College of Straight Chiropractic in Spartanburg, South Carolina.

          Chiropractic is based on the premise that the body's innate physiologic capabilities are affected by and integrated through the nervous system.  Chiropractic is a science and art devoted to the location, analysis, and correction of vertebral subluxations.  These are misaligned vertebrae of the spine that interfere with the ability of the nervous system to control and coordinate the various organs and systems of the body.

          Many health-conscious people make chiropractic a regular part of their health care regimen, along with such other sound practices as exercise, good nutrition, and stress management.  Chiropractic is a separate and distinct field that does not compete with the practice of medicine nor the use of alternative therapies.

          The education required to become a licensed Doctor of Chiropractic is rigorous, it is similar to that required for M.D.'s.  All students entering chiropractic college must have completed 90 semester hours of prerequisite courses at an accredited undergraduate college.  That is the equivalent of three years.

          Once enrolled in chiropractic college, students complete approximately 4,600 hours of instruction.  This is typically accomplished through approximately 13 academic quarters, requiring three and a half years of full-time study and residence, or the equivalent of five years of study at a traditional semester system.

          The chiropractic profession has grown and prospered in this country based on the public's demands for these important services.  The profession has traditionally received limited federal support.

          For that reason, I recommend the Commission pursue the following initiatives to ensure the availability of quality chiropractic care for the American public:

          First and foremost, I believe we ought to formally recognize the value and appropriateness of chiropractic's meta-therapeutic health care paradigm that focuses on enhancing performance and function, rather than treating diseases or conditions.

          Second, I would like to see us provide student loan and debt relief for chiropractic college graduates who practice in underserved areas of the country or care for underserved segments of the population.

          Thirdly, I think we ought to provide direct federal funding to support chiropractic college education with investments in facilities, training, and technology, as is currently done in the nation's medical schools.

          Chiropractic colleges must benefit from such national initiatives as Congress' approved doubling of the NIH budget from 1999 to 2003 to ensure qualify education of a far greater spectrum of the nation's health care providers.

          Lastly, I would like to see federal funds allocated for chiropractic college-based research programs.  Supporting the paradigm of chiropractic research that explores ways to help people avoid serious health problems and enjoy greater function and performance compared to traditional biomedical research would help reduce our nation's dependence on expensive medicine interventions once disease states and conditions have manifested.

          DR. GORDON:  Thank you.

          Bruce Nordstrom.

          MR. NORDSTROM:  Thank you for the opportunity to be here this afternoon.  My name is Bruce Nordstrom.  I am a practicing chiropractor in the District of Columbia.

          The American Chiropractic Association has submitted to the Commission detailed information on the issues being discussed here today.  I would like just to highlight some of those issues.

          In developing policy recommendations to Congress, the American Chiropractic Association encourages the Commission to consider the following:

          All CAM providers should be held to equivalent criteria as other licensed health care providers in the areas of education, licensure, oversight from licensing boards, and public opinion.

          Care must be taken that the principles of each CAM practice be maintained and not supplanted by allopathic philosophy.  As an example, prevention and wellness are principles of the chiropractic profession, and should be utilized as cost effective mechanisms as they have been shown to be in the past, and not discouraged.

          All CAM providers who have direct access to patients should possess the ability to differentially diagnose and refer to and/or comanage the patient's treatment if the condition is beyond the scope of their expertise.

          Students studying at accredited CAM institutions must be provided the ability to observe and, where appropriate, comanage a broad spectrum of conditions and/or diseases as is typically seen in teaching hospitals.

          While some chiropractic colleges and medical teaching institutions have had occasional collaborative activities, typically, there is a lack of cooperation from the medical institutions.  This is particularly egregious given that most of these institutions are support by state and federal taxes.

          These public institutions should provide any accredited institution, traditional or CAM, the opportunity to broaden the student practitioner's knowledge and clinical expertise.

          Any guidelines utilized for CAM, whether condition- or modality-specific, must be developed through consensus by the profession, and reflect mainstream practices.

          It is imperative that guidelines be treated as such, and not as absolute limitations on services.  Unfortunately, this currently takes place with many third party payers.  The ultimate judgment regarding the propriety of specific procedures must be made by the practitioner in the light of individual circumstances presented by the patient.

          Thank you, and we stand ready to help wherever we can.

          DR. GORDON:  Thank you for coming again and for your testimony.

          Questions from Commissioners?  Joe.

          DR. PIZZORNO:  This is to either of the ladies from the APAP.  How many hours of CAM education are you providing, and what are you actually accomplishing with that education, what are you trying to accomplish?

          MS. WHITEHORSE:  In a study that I did in 1998, to look specifically at what we were doing in the education field in terms of CAM, the average or the mean number of hours spent by the 80 programs that responded, of the 107, was an average of 4.5 hours.  The range ranged from 1 hour to a total of 60 hours.

          The presentation of that material varied.  Most of the times it was in lecture format.  The other thing that is important to know that one of the things I differentiated in that study was whether it was considered formal education versus elective, formal meaning that it was in a required course, attendance was required.  So those numbers that I am giving you reflect formal rather than elective.

          In terms of the topics, one of the things that was submitted to the Commission, it lists all of the modalities that were covered.  There was no consistency to any of them, it really was program-specific, faculty-specific, which is one of the things that we are trying to work on and ideas that we can get from the Commission in terms of having some consistency for us.

          DR. GORDON:  Let's try to follow up on that for a second.  Have you sent us that survey?

          MS. WHITEHORSE:  In the response that we sent t you from APAP, there are some of those statistics quoted, but I can certainly get you copies of the actual survey.

          DR. GORDON:  We would like to the survey.

          MS. WHITEHORSE:  Certainly.

          DR. GORDON:  I am not sure, you are asking for us to provide guidelines for what should be taught, or explain a little bit more about what you would like us to do.

          MS. WHITEHORSE:  I think that, as PAs, I don't want to just talk about us as PAs because as part of the conversations that we had or I had an opportunity to sit in on earlier today, it is the whole issue of education and how do we incorporate this into the educational model.  So, we are dealing with the same questions that M.D.'s are and other health care providers.

          I guess my recommendation or our recommendation is to have some kind of a task force, which is somewhat what you are doing, is to come up with some basic guidelines, whether they be core competencies, core concepts, that we can follow in terms of establishing as an accreditation standard throughout all of PA education rather than it having one school teach it, one school not, so that there is more of a consistency.

          DR. GORDON:  You don't currently among the PA schools have that kind of task force operating?

          MS. WHITEHORSE:  No, we don't.

          DR. GORDON:  Any reason why not?

          MS. WHITEHORSE:  I think that the interest is beginning to come.  I think the interest is there.  I think some of the barriers that we run up against is that we have a very labor-intensive program, and the question is where are we going to put it in the curriculum.

          So, we are forced to teach based on our accreditation and our curriculum guidelines and standards, and in those standards, CAM is not in there, so we are teaching to our accreditation standards.

          DR. GORDON:  Thank you.

          Don.

          DR. WARREN:  Dr. McAulay, did you say that you did not recognize CAM or did I misunderstand you?

          DR. McAULAY:  I hope you misunderstood me.

          DR. WARREN:  Okay.  That was right at the first of your talk.  It just kind of caught me off-guard.

          DR. McAULAY:  No, I am sorry if I misled you in that way.

          DR. GORDON:  Linnea, is your hand going up?

          MS. LARSON:  This is real quick.  Thank you for your testimony in December, Michele, and thank you for today.  I do not recall if you gave us the material in December about the harmonization policy and how long that took for the European community to come up with, et cetera, but I would really like you to give me a brief understanding of how long did that take.

          DR. GORDON:  I would like to add to that also.  I would like to get a sense of what kind of reception this concept gets.

          MS. LARSON:  That was my second question.

          MS. FORZLEY:  You mean reception from the Commissioners or from the European community?

          DR. GORDON:  If you are talking with different licensing boards in different jurisdictions, how does the notion of harmonizing appeal to them since there is so much desire for individual differences and for individual autonomy.

          MS. FORZLEY:  I am sorry, I can't answer that last question.  I can tell you that in Europe, in 1992, the first directive was issued, and this is an example of how thick, how many pages the original directive plus subsequent amendments are.

          Now, remember this covers all trades and professions to harmonize educational requirements over all trades and professions including health care professions, and it was specifically determined by what is called a Written Question to the Commission, in 1998,  that it applies to CAM practitioners, which was very interesting.  It is the first thing I found in my research on Europe.

          So, this is an evolving process that is really founded in the reason why Europe has formed a common community, which is really based in trade, and what they are doing is they are effectively evolving into a federation as we are, as opposed to moving away from it.  They are combining rather than dissembling.

          So, we have a federal system that says what is federal, what is state power.  They all had state power, and they keep moving towards what is federal, and they have left still to the states to determine health care policy and procedure, but because they have a principle that says we want to permit to work in France, and then they go work in Germany or wherever they want to work, we need a way in order for Germany not to say to a French whatever that he can't practice because his education, training, licensing, and credentialing isn't equivalent under the German system.

          So, they came up with this very system, and it is the same system, by the way, that was adopted by the International Telemedicine Treaty, which is before the World Health Organization, as a way to harmonize national scope of medicine practice laws, because most other countries do not have state scope of medicine definitions, they have national registration, because there is only one place you go.

          Here, we have 51 states -- I never remember anymore -- 50 or 51 states, boards that approve you to practice medicine or nursing or whatever, but nationally, in most countries, it is one.  So, we have a system to put them all together under one roof, so to speak, without taking the political power away from people who want to hold onto it.

          So, I urge you to really look to a harmonizing system because I think you will spin your wheels on a uniform system.  Personally, I believe that we should have a national registration system for all our professions, but do I think it is realistic in the next years, no, I don't.

          If the ABA can't decide, if the American Bar Association can't decide that lawyers should practice across state lines, I doubt the health care professionals will agree to it either, but you can do something else, which is really needed, and another benefit of this is that you will give the different associations representing modalities something to look at when they go to their state legislator to lobby for what they are trying to get.

          They spend a lot of time and trouble trying to define what they are as compared to something else, and they don't have the ability, the competence, they don't have the money to pay for it, they don't have the political power to do it, so it is very difficult.

          I think you would do a lot to help all of the modalities if you came up with a set of standards and guidelines as recommendations, guidance.

          DR. GORDON:  Linnea, did you want to follow up on that?

          MS. LARSON:  Mostly, I wanted a little bit more clarity about the concept than the definition of harmonization.  I think you did kind of provide that in the testimony in December, but it is a concept which is based on trade, the ability to do trade throughout the European community.

          MS. FORZLEY:  Well, it's the right to work.  It says that I have the right to work in D.C. and in Maryland, if I live here, and Virginia, and that is probably important for me if I work here.  I am confronting it myself.  I just moved here.  I can't practice in Maryland or D.C. or Virginia because I am not licensed here.  I have to go take a bar exam in Maryland, I have to pay lots of money to three states to get licensed.

          Okay.  Well, so that's the same thing that happens to a doctor or a nurse or anybody, and it is going to happen to CAM practitioners.  The European community was based on a concept of trade, free trade, rather than what the United States was based on, which was really freedom, personal freedom, which I think is important to remember that consumers are driving the CAM revolution, and it is based upon their consciousness, of their ability to choose what they want to do, and because we have this presence of consciousness today, it is happening and despite what we may want to do.

          So, we have to look at how are we going to allow it to happen, how are we going to not impede it in some way.  Now, the other side of the coin is the right of the person to earn a living, which is also what it is about, and my right to select who I have heal me.  That is where I think our personal freedoms come in based on our system.

          I hope I have answered that question for you.

          DR. GORDON:  I think there is still another piece, and maybe you can just provide this in writing.  What is harmonization?

          MS. FORZLEY:  Well, it's not -- let's look at what is uniform.  Uniform says that if I am, let's say, an acupuncturist, I have to have X education, Y training, Z experience, and I pay a fee, and I go through this procedure to get licensed in State A.

          If I have a harmonized system, I have something that says to State A and State B you must write a law that says you have to have a maximum of this.  You can write a law that says you can have less than this, but you can't make them have more than this.

          So, it is setting sort of a roof on what the states can say they must have.  So, a state can say, well, you know, you only need two years instead of the required three if you want to practice this or that, but the national guideline or harmonized rule says you have got to have three, and that is really where I think your value is as a commission, is because you have this overview of what they all should have.

          DR. GORDON:  If you could provide the specifics of that at least for health care, that would be very -- do you want more than that, Linnea?

          MS. LARSON:  I wanted the clarity of the definition, then, an example.  That's all.

          MS. FORZLEY:  Is that enough?  Do you understand?

          DR. GORDON:  It would be great to have it in writing, whatever you have in that sheaf of papers that could help us.

          MS. FORZLEY:  Okay.  I just want to point out to you that there are established international principles of law, sort of interpretation of law, that are called Rules of Harmonization.

          I can give you a textbook on it.

          DR. GORDON:  Well, maybe a few pages, a Cliff Notes version.

          MS. FORZLEY:  I will try.

          DR. GORDON:  Thank you.

          MS. FORZLEY:  And thank you all.

          DR. GORDON:  Joe.

          DR. FINS:  I just point out, being patriotic, that we have had a single currency in this country for more than a year, but I do want to ask the folks from the PA universe how they would respond to a hypothetical, a PA, who is a physician assistant, decides to work for a naturopathic physician in Washington State, would that be a deviation from your ethical norms, would that be adequate supervision?  How would your organization view that individual?

          MS. JASPER:   First of all, it is based on the state legislation as to whether a PA can practice in that state under a naturopath that would determine whether we could.  PA practice is generally guided by the physician that they work with, and our duties are determined by the agreement that is reached between those two practitioners in terms of our skills and our expertise.

          DR. FINS:  Just to follow up, to bring up the issue of harmonization again, suppose there was a kind of a dissonance in training, there was an overlap, for adequate supervision, would that concern you?

          MS. JASPER:  No, I don't -- because PAs are taught to, first of all, understand our limitations and to accept where we don't understand what we know, and say "I don't know," and be able to make decisions as when it is appropriate to refer and to seek consultation and guidance.

          DR. FINS:  I think it is an interesting question.  We have a changing definition of perhaps what physician is under some state laws.  Your mandate is really, the presumption is that you are going to work with a conventionally trained physician.

          MS. JASPER:  An M.D. or a D.O.

          DR. FINS:  Right, exactly, and naturopathic physicians in some jurisdictions are called physician, so they present a problem.

          MS. WHITEHORSE:  Your assumption is correct, that the model that we function with is really conventional and really is biomedical, and when we say that we work with physicians, it generally is an M.D. or a D.O.

          I don't know that we have actually ventured into PAs working with other providers that also use the term physician, as you alluded to, with a naturopath.  I think that that is going to be an up and coming issue for us as a profession, especially based on what the recommendations of this Commission are in terms of recognizing other practitioners of health care, but presently, it is really M.D.'s and D.O.'s, and if a PA practices an alternative modality.

          For example, in the State of Pennsylvania, it is right in our laws and our regulations that we cannot do acupuncture.  I mean that is actually specifically outlined.  Now, that is for our state.  For another state, you know, when the Board of Medicine sat down to write up our guidelines, they specifically said for some reason that we couldn't do that.

          So, it is somewhat state to state regulated, but to the best of my knowledge, it is M.D.'s and D.O.'s.

          DR. FINS:  I just think it brings up a whole other category of professionals who work under supervision, who are related in their responsibility, their liability to the person who is prescribing, a nurse who is conventionally trained, who works under a CAM practitioner or PA, so it is a whole other level.

          It would be helpful to us if you could simply take this hypothetical and think of responses and ways you would address it and ways that we might be able to maximize utility and minimize the down side, because I think it would be instructive for other hierarchical supervisory relationships between different kinds of professions.

          DR. GORDON:  You had a question, Tom?

          MR. CHAPPELL:  Yes.

          DR. GORDON:  Go ahead.  I am sorry, didn't see your hand.

          MR. CHAPPELL:  I am sorry, I thought the Chair had recognized me.  I have a question on physician assistants.

          At the present time, your role as a physician assistant in a clinic would be to receive the patient and maybe provide some care, but may also refer to a physician within that clinic, is that correct?

          MS. JASPER:  Yes.

          MR. CHAPPELL:  So, if you were trained with sufficient core competencies in the knowledge of CAM practice, and that clinic was integrative, do you see yourselves being able to be in a role in which you could continue to refer to any array of practitioner in that integrated clinic?  Would you see that as a competency that would be appropriate to the role and standard of a physician assistant?

          MS. JASPER:  We have discussed that, and we feel that that would be most appropriate as primary care providers, that there is a general core standard in our accreditation guidelines for PA education that would say certain things must be included.

          It may vary in programs because programs have the individuality of determining how it is integrated into the curriculum.  Therefore, the PA, based on its actual practice, could then determine the level of their practice and the level of their responsibility for making those referrals.

          MR. CHAPPELL:  And so it's possible.

          MS. JASPER:  It is, yes.

          MR. CHAPPELL:  Thank you.

          DR. GORDON:  Any other questions?

          [No response.]

          DR. GORDON:  Thank you.

          MS. CHANG:  Our final group of speakers, if you would come up, please.  David Molony, Kathleen Quain, Shula Edelkind, Colleen Smethers, Christina Walker, and Dr. Chi Chow.

          DR. GORDON:  Thank you for your patience and perseverance.  David Molony.

          MR. MOLONY:  Good afternoon, Commissioners.  My name is David Molony.  I am an Oriental Medicine professional and the Executive Director of the American Association of Oriental Medicine.

          The Oriental Medicine profession is, by far, the most comprehensive, far-reaching, credible, and accepted CAM field of medicine in the United States.  We have, in place, national education, accreditation and certification examination standard in acupuncture, herbal medicine, and bodywork.

          The training for the majority of new practitioners is a comprehensive three- to four-year program, with the graduates having a solid grasp of our entire field, and the capability to refer within that field.

          This, combined with a level of conventional medical training that provides them with the capability to refer to general, specialist, or hospitalist conventional practitioners as appropriate, rounds out the training.

          Due to the continued improvements in our education and the history of low claims, our malpractice rates for a $1 million/$3 million policy have dropped steadily to less than $650, about one-third of what they were 10 years ago.

          The demand for our services becomes obvious when one looks at the other fields of medicine grasping for patient share, bypassing our recognized and accredited educational programs in favor of abbreviated continuing education courses that do no provide the knowledge, skills, and abilities needed to achieve the consistent outcomes that we have come to expect from our field.

          It is easy when a biomedical or chiropractic physician fails to diagnose or treat properly with acupuncture due to this limited training to fall back on the very things the patient has come to acupuncture and Oriental Medicine to avoid, namely, drugs, more chiropractic, or surgery.  How many patients have trusted their minimally trained CAM doctors to later become disenchanted with the results, thinking that it was the acupuncture that failed?  Acupuncture is not continuing education, it is continual education.

          We have fully entered the modern world of credibility, liability, and responsibility, with educational standards, practice guidelines, regulatory oversight by our licensing boards, and the professional peer review process that all provide overlapping avenues of accountability to the consumer.

          While there may be some place developed by all professions working together for intercollegial trade of aspects of our prospective fields, there must also be respect for a comprehensive education in each.  In this scenario, there must be ethical boundaries shared to develop a knowledge base of what is best for the patients.

          We hope that you all reflect deeply on the facts and concerns expressed in this presentation here today, as it is your commitment to our country and to the people of United States to do what is best, beyond the many strong currents pulling you in many directions.

          I would like to thank the Commissioners for their hard work and their ready humor.

          DR. GORDON:  Thank you.

          Kathleen Quain.

          MS. QUAIN:  I am a psychotherapist, social worker, president of the Foundation for Health and the Environment, and I direct.

          Through education, people can learn to live with more health in their daily lives.  Through policy and communication that supports prevention --

          DR. GORDON:  Could you come a little closer to the mike, too.

          MS. QUAIN:  Sorry.  I have a design that matches what you are saying you need, so this is part, the curriculum, and I have this master plan for health, that I don't know where it goes, so I am just telling you that.

          So, through education, people can learn to live with more health in their daily lives.  Through policy and communication that supports prevention, we can stop health problems before they happen.

          For example, preventive measures for diseases such as breast and prostate cancer should be public knowledge.  Health insurance companies could tap a huge untapped market if they covered prevention.

          CAM practices and interventions could be reimbursed through a federal program that develops health, carries the concept of waste reduction as a respected way of thinking to the populace, and employs collective stress management techniques to reduce violence.

          Through television that is designed to create health, the media, media outlets, health channels, and information technology, health could be organized and disseminated as a popular and effective outreach.

          State-of-the-art television programs could be developed to create positive results within mainstream populations.  Health-based programming could replace horrific images that children see now within the media.  Scientifically based imagery could facilitate healing where healing is indicated.  Elementary through high school health education could incorporate prevention to directly reverse the violence crisis that has become evident within our childhood population.

          A new report entitled "In Harm's Way" published by Greater Boston Physicians for Social Responsibility, in partnership with the Clean Water Fund, says that millions of children in the U.S. exhibit learning disabilities, reduced IQ, and destructive, aggressive behavior because of exposure to toxic chemicals, including pesticides during early childhood or even before birth.

          The report states that neurodevelopmental disabilities are widespread, and chemical exposures are important and preventable contributors to these conditions.

          "In Harm's Way" reviews scientific and medicine information on a range of toxins to which most or all American children are exposed, and draws links between them and to the rising number of children diagnosed each year with abnormal brain development or function.

          The gospel of peace teaches us to detoxify our bodies so that the Spirit of God can go inside of our bodies and we can feel peaceful.  To sustain our souls, all public policy must consider the injury to our health from the misuse of toxic pesticides.

          CAM practice and intervention could be applied to public health threats, such as the West Nile Virus.  An economical, safe, and national preventive treatment program could combine technology that supports human nature and the health in nature.

          The U.S. Coast Guard has successfully used the Mosquito Magnet when toxic pesticides were not effective on the mosquito-infested islands.

          DR. GORDON:  We are going to have to ask you to stop.

          MS. QUAIN:  Okay.

          DR. GORDON:  Do you want to have a concluding sentence or two?

          MS. QUAIN:  Yes.  I just wanted to say that the Pope's message last week spoke of nature's intrinsic value and that, above all, nature's metaphysical concept has been forgotten.

          Thank you.

          DR. GORDON:  Thank you.

          Shula Edelkind.

          MS. EDELKIND:  Colleen Smethers and I are together, so I would like to let her go first.

          DR. GORDON:  Are you Colleen Smethers?

          MS. SMETHERS:  I am.

          DR. GORDON:  Whichever way you would like to do it.

          MS. SMETHERS:  My name is Colleen Smethers, and I am here on behalf of somebody else, Karen Scott, who testified before this commission at a town hall meeting in Sacramento in September of last year.

          She was asked to come back with more information, and her chronically ill condition did not allow her to come today, so she has asked me to read her statement.

          Her statement of September is in Section 3 of our somewhat large handout that we gave you.

          Her statement is:  Can accredited medical schools routinely teach courses in progressive and alternative medicine and have a physician lose his license for correctly applying what he learns?  The answer is absolutely yes.

          As an example is the case of San Francisco's Dr. Robert Sinaiko, a respected board-certified allergist and immunologist, who was using the latest advances in medicine to help people suffering from multiple chemical sensitivity, chronic fatigue, ADHD, and autism.

          Despite this doctor's excellent record of improving quality of life for these patients, and despite the fact that no patient was harmed or complained, his medical license was put under such restrictive probation by the California Medical Board, he was forced to close his practice.

          In Dr. Sinaiko's Medical Board hearing, the prosecutor insisted that no research supported Dr. Sinaiko's treatments.  They completely ignored the studies presented from mainline, peer-reviewed medicine literature.

          The Medical Board instead followed their own experts offering no supporting evidence.  The Medical Board of California has arrogated to itself the right to decide which medicine they prefer, based not on scientific fact, but on opinion.  Both the California Medical Association and the Center for Public Interest Law have written amicus briefs supporting Dr. Sinaiko's case and protesting the actions of the Medical Board.

          From the California Medical Association's amicus brief, and I quote, "If the Medical Board just wants to get the doctor at any cost, this decision shows how it can be done."

          The consequences to the doctor and his patients have been devastating.  Dr. Sinaiko has had his reputation ruined and been assessed over $50,000 for the prosecution of himself, and he has been forced out of practice.

          Many of Dr. Sinaiko's patients now are unable to find help for their medicine problems.  In desperation, patients are having to travel out of state.  Karen is one of those that has to do that.  Without Dr. Sinaiko's care, many patients' conditions have worsened and many others describe their health as having substantially deteriorated.

          Few physicians have sufficient financial resources to fight the state-funded Medical Board.  Faced with a reputation in ruin, emotional devastation, and finally being required to pay the exorbitant cost recovery charges, most doctors just give up.  The Board wins by default whether or not this is a fair or legal process.

          Strong federal legislation prohibiting state boards from setting the standard of practice and choosing sides in scientific controversy, as well as declaring cost recovery unconstitutional is urgently asked.  As the system stands now, it is clearly open to abuse.  Every day, doctors and their patients are paying an unacceptable price.

          DR. GORDON:  Thank you.

          Shula Edelkind.

          MS. EDELKIND:  Thank you.  I am sure you are all aware of the fact that the Federation of State Medical Boards, which controls medical doctors, M.D.'s, calls all the CAM treatments questionable, and would like to rid the country of all of them whether in the hands of doctors or anybody else.  Certainly, this can be seen on the internet on their own web sites.

          Doctors who read the scientific literature and use it to help their patients do so at the risk of their medicine licenses.  They are the heroes and sometimes the martyrs, as we just heard, of medicine today.

          We could create a separate medical board for alternative medicine, but many doctors use both allopathic and alternative treatments.  What board would police them?  Who would define which camp a new treatment belongs to?

          We could add people from the alternative or the CAM community to existing medical boards.  But people are not the problem - it is the system itself.  The medical board system is broken.

          Compare it to our criminal justice system.  If you can see this, and it is in your handouts, this is the criminal justice system, one of the best in the world in Section 7 of your handout.

          Now, look at what we do to our doctors.  In this system, the administrative law system, the medical board itself trains the judge.  The medical board can be the plaintiff where no victim is needed, conducts the investigation, is the jury, can set and carry out the sentence.

          The doctor often must pay the board for his investigation and his prosecution.  This so-called "cost recovery" was ruled unconstitutional for teachers recently, but it continues in practice for doctors.

          As Americans, we should be ashamed.  An axe murderer has a better chance of a fair trial than a healer with no injured patients.  I think we can do better than that.

          One.  Correct these overlapping responsibilities, all this stuff on this side of your chart.  And it all must be public.  This sort of thing can only thrive in the dark.

          Two.  Only allergists should pass judgment on allergists, and only acupuncturists on acupuncturists.  A psychiatrist should not decide if an immunologist did his job right, as happened in the Sinaiko case, and a gynecologist should not evaluate a brain surgeon or vice versa.

          Three.  Change the focus of the board.  We do need to protect the public from doctors with substance abuse problems, incompetence or criminal intent.  But we must now allow the medical board to be used as a tool to outlaw treatments.

          It is not okay to denigrate a treatment by dismissing it or ignoring existing research, by claiming that none of it is sufficiently valid, significant, supportive, conclusive, acceptable, or all of the other non-quantifiable criteria.

          It is not okay to exclude clinical experience or to exclude testimony by misusing the Daubert rule, which they do now.

          The Sinaiko case was used to destroy a safe, low-dose allergy treatment used in England for over 30 years, called EPD.  It is no longer available.  There is no more access in the United States.  You can see this in your handout.

          As a consumer of medical care, in conclusion, I believe it is worthless to legislate access to anything if we cannot protect the doctors able to provide it.  That includes both CAM and any other treatments.

          DR. GORDON:  Thank you very much.

          Christina Walker.

          MS. WALKER:  Thank you.  I come today to talk.  I wear like three hats.  I am a nurse, I am a student in a CAM program, I guess if you want to call it, it's a Ph.D. program in energy medicine, and I am also a practitioner of CAM, so I wear three hats, and everything you brought up today in the commission, I am thinking is a blessing because I kind of hit the bumps with each one of these areas that you have talked about today.  So, I just want to talk about some holes that I still see in practicing CAM or as a student of CAM.

          My Ph.D., they said I am supposed to be an expert in energy medicine.  That is what they tell me.  I said okay, I am not quite sure what that means.  I have 45 credit hours, and still not quite sure how I am going to practice it under my license of nursing.

          Through my research, which I have done through self-observation and observation of clients, and in that I mean I had to actually be a consumer of every alternative medicine therapy there is, write a report how did I feel, what did the patient feel, and through that, I came up with two questions.

          At what level of the energetic body organism were these therapies affecting?  You have said that you are in a paradigm right now, and we are.  CAM therapies work on the physical body, but they also work on the energetic body, so there is two bodies involved in CAM therapies.

          So, I ask myself, okay, so when I get an acupuncture treatment, what level is being treated?  When I take homeopathy, what level of my energetic organism is being treated?  When I get hands-on healing, what level of my organism is being treated?  No one was able to answer that question for me, and through my research I did end up with a woman, Christine Schenk, in Europe, who was also on that harmonizing board that the attorney had spoken about.

          The next questions I came up with were what are the side effects and adverse reactions of these therapies, and how do they manifest in the physical body, because I also got very sick.

          So, some of the side effects of CAM therapy that Christine Schenk has noticed in Europe after 20 years of them doing the work there, is sleeping disorders, constant fatigue, backache, constipation, dizzy spells, hot flushes, chills, circulatory problems, depression, changes in eating habits, and lack of concentration.

          So, then what happens is the patient ends up at the physician, and they have got all these complaints, and he is on the first line of duty to find out what is wrong with the patient, not knowing, because the patients don't tell their physicians either, that they have had CAM therapies.

          At the level of the organism of CAM therapy, if we look at hands-on healing, that is considered surgery in the energy body, and that is very, very heavy work, and I am a little concerned when Reiki practitioners, who have taken a weekend course, can hang out a shingle and start working on my chakras and manipulating my energy system when it is surgery.  That is what happens in the organism.

          In the disks, with rotation, they hold the consciousness of the energy body organism, and in that, if a patient goes to a consciousness, let-me-lift-my consciousness type of week on seminar, they come out with changes in behavior, and they end with the psychotherapist, and he is not quite sure what to do.

          The last is the layers, and homeopathy would affect different layers of the organism, so when you give homeopathy to the patient, what level of the organism energetically are you affecting there?

          DR. GORDON:  Thank you.

          Chi Chow.

          DR. CHI CHOW:  I am Chi Chow, a licensed acupuncturist practicing in New York.  I am the founder and current president of the New York Institute of Chinese Medicine located in Mineola, New York.

          I am also a former commissioner of what is now ACAOM, the Accreditation Commission for Acupuncture and Oriental Medicine, and a former board member of the Illinois State Acupuncture Association.

          I was originally trained as a Western M.D. in China, and have practiced and taught both Western and Chinese Medicine for more than 30 years.

          As someone who has an extensive background in both Western and Chinese Medicine, and who has been involved in training practitioners of both disciplines, I would like to emphasize to you that, while complementary in many ways, Western and Eastern medicine practice are very different in approach.

          While it is true that a Western M.D. would not require too much time to point a location of the acupuncture point, or to insert the needle in the proper way, but a much deeper level of understanding is required to perform a proper diagnosis and to outline a proper treatment plan according to Chinese traditional medicine theory.

          Without this deeper grounding in TCM, the more superficial knowledge of needling and of the herbs is at best ineffective and at worst can be dangerous to the public.  I only have to cite the recent highly-publicized case of a European M.D. inadequately trained in Chinese herbology causing harm to his patient by give the herbs in quantities that would never have been sanctioned by a qualified Chinese herbalist.

          The standards of training in our profession in the U.S. are made by ACAOM, the Accreditation Commission for Acupuncture and Oriental Medicine, which is the only national accrediting agency recognized by the U.S. Department of Education for the approval of programs preparing acupuncture and Oriental Medicine practitioners.

          The amount of training that is required to become a competent entry-level practitioner of acupuncture or Oriental Medicine has been exhaustively studied and has been set by ACAOM at a minimum of 1725 hours, or about three academic years, for acupuncture and at a minimum of 2175 hours, or about four academic years, for Oriental Medicine.  So, this is actually is pretty comfortable for us to have the training.

          We have 43 schools have accreditation.  Also, we have a council of Chinese Medicine and acupuncture for the school training, and also have the NCCA to do the certificate, and also have the ACAOM.  Those organizations in national cooperate very good for the training of acupuncture and Oriental Medicine student.  We feel very comfortable.

          DR. GORDON:  I am afraid I am going to have to call time.  Is there a final sentence or two?

          DR. CHI CHOW:  Like my point is this setup is very comfortable for training the acupuncture, but for M.D. and chiropractor, only have 300 hours.  That really is not enough, and it didn't have any fundamental idea.  Acupuncture is not only to give a needle to a point.  They have the underlying theory.  If you don't have the theory, you don't diagnose.  That is nothing.

          DR. GORDON:  Thank you.

          Questions?  Tom.

          MR. CHAPPELL:  If I understand the acupuncture  requirements of 200 or 300 hours by an M.D., that is for the knowledge, not for the practice?  The practice still requires 1,500 hours?

          DR. CHI CHOW:  I think there is a difference from certificate license and acupuncture license.  M.D., they only get the certificate, but they can practice, and also they can get reimbursed from the insurance.

          The licensed acupuncture we have 1,000 hours training.  Most of the insurance, they don't pay.

          MR. CHAPPELL:  I need clarification on this point.  My understanding is that an M.D. cannot practice acupuncture on 200 hours of training.

          DR. CHI CHOW:  No, they can.

          MR. CHAPPELL:  You are saying they can?

          DR. CHI CHOW:  They can.  Also, the insurance pay them.

          MR. MOLONY:  It depends.  Legally, they can.  I think that is the difference that she is talking about.  I think when she is talking about they can't, I think it means that there really isn't the competency there to do a proper diagnosis and treatment at 200 hours.

          The 1,500 hours was the World Health Organization developed two different levels for physicians.  I think the 200 hours was a general basic knowledge of acupuncture, which might be enough for referral or something of that nature, and then the 1,500 hours would have been for a general practitioner being able to see any patient that comes off the street, and do a credible job with acupuncture.

          MR. CHAPPELL:  The Commission needs to understand that only 200 hours is required for the M.D. to practice acupuncture.

          MR. MOLONY:  That is what has been accepted by most state legislatures at this point if only because there has been -- I mean it hasn't been accepted because there is anything other than a 200-hour program that they have all taken.

          It hasn't been because the educational criteria has gone through that said that where there is like when you have acupuncturists getting credible educational standards with an accreditation commission and taking the certification examination, and, you know, there isn't a general proof of competency there for that.

          It is assumed because of the way the medical boards work, and their licensure statutes read that they can do anything anyway, so what does it matter, we will just give it to them at 200 hours it seems to be.

          MR. CHAPPELL:  Thank you.

          DR. GORDON:  One thing, I think that even though he testified earlier, it might be useful for the Commissioners, with your permission, if we heard Dr. Helms also respond for a moment since he is still here.

          Is that all right with everyone because this is one of those issues that we are going to require more deliberation about, but since Joe Helms is here, we might hear a couple words from him.

          So, Joe, do you want to come and pull up a chair at the table?

          DR. HELMS:  First of all, David Molony misrepresents what the WHO document shows.  We were both at the meeting.  You weren't in the committee as it was being developed, but we were at the same meeting when the standards were being established and voted on.

          There are two levels of physician training recommendations in acupuncture in the WHO guidelines.  The first is 200 hours that I discussed in my presentation yesterday.  That has been internationally agreed upon as the minimum expected standards for exposure to history, philosophy, point location, needling technique, diagnosis, and applications for integration of acupuncture into medical practice.

          That has been uniformly accepted in the states, in Europe, in the Pacific Rim countries, in all countries where Western medicine is practiced.

          The 1,500-hour program that was an addendum to the meeting came as a consequence of a specific request that there be a specific denomination in the WHO guideline for physicians who wish to follow the complete traditional Chinese Medicine training equivalent to that of a non-physician trainee.

          So, it is simply a physician who elects to do the complete TCM training.  That would include full TCM diagnostic capabilities and herbal diagnosis and therapy.  So, we are actually not talking about a two-standard for physicians, we are talking about physicians who wish to have the full training of the TCM.

          DR. GORDON:  Thank you.  Other questions or follow up, any of the panelists?

          MR. MOLONY:  I wanted to thank Joe for that clarification.

          DR. CHOW:  Being that you are back on the panel here, what is the diagnosis that you use then to work with acupuncture?

          DR. HELMS:  This might be a distinction that is worth presenting at this point.  The distinction that I tried to make yesterday, but apparently didn't make clearly enough, between what we are calling medical acupuncture and what is called traditional Chinese Medicine, which as you and I know is no more traditional than 1959 in Maoist China.  It was assembled at that point by a team of primarily herbalist physicians as opposed to acupuncture physicians.

          It is a combination of herbal medicine and acupuncture with a herbal diagnostic base.  So, when one studies TCM, one studies a diagnostic context that is founded on the desire to prescribe a herbal product as the primary treatment and to use the acupuncture points to reinforce the herbal product.

          Hence, the diagnostic paradigm is quite specific to that concept, and it is a very effective concept, it is a very effective approach particularly for chronic internal medicine problems.

          In contrast to the TCM herbal model, there is an acupuncture energetic model that is based on the energy flow through the acupuncture channels.  Each channel is associated with an organ, the organs combine in specific ways.  The organs have responsibilities above and beyond what we consider the responsibilities in physiology.  The symptoms and signs that the patients present make sense in the context of the expanded sphere of influence of the organs, which comes from the tradition of acupuncture, and is not unique to TCM, but comes from the long tradition of acupuncture.

          That thus provides a physician with an expanded context of comprehending the patient's symptomatology.  Understanding the organ system with which a problem is related allows the acupuncturist then to create an energetic input to assist in its modification.

          Diagnosis includes all Western appropriate diagnosis, as well as pulse diagnosis, tongue inspection, palpation of points, palpation of body heaters, as is taught in the tradition of acupuncture, not unique to TCM.

          This model of using the expanded body of knowledge based on the syndromes of the organs, based on the functions of the organs from the tradition of acupuncture is easily absorbed into a physician's consciousness, who already is thinking of the physiology and pathophysiology of the organ.  It simply adds this information in to expand his comprehension of the patient's presentation, link it with the appropriate acupuncture channel and dynamic, understanding where the points are, and how to move the energy through the certain systems.

          This is an approach to acupuncture that can be well taught and well comprehended, well appreciated, and well applied with a strong 200-hour program, and this has been agreed nationally, statewide, and internationally.

          DR. GORDON:  Thank you.  Other questions?

          DR. CHOW:  May I?

          DR. GORDON:  Sure, go ahead.

          DR. CHOW:  I am not quite sure, and maybe this isn't the time to explain it, but when you talk about an herbal diagnosis, how is that different from a regular diagnosis?

          DR. HELMS:  The context of herbal diagnosis is the eight principles diagnosis.  That is not the primary approach for medical acupuncture, but it is the primary approach of organizing symptomatology and signs in TCM.  That is a model, while it is acknowledged, is not the primary diagnostic model of medical acupuncture.

          DR. CHOW:  I would like to hear, being that we have the opportunity here, I would like to hear more from David and Chi Chow.  Would you please elaborate on the concepts that you people expressed?

          DR. CHI CHOW:  I think TCM, the theory both herb and the acupuncture, they share the fundamental.  It is not just only for the herb medicine, no, but the same thing.  Acupuncture also used the diagnosis, same eight principles, and the treatment principle, all those with the herb, same thing.  The TCM, fundamental.

          I think if you want to be a success and treat acupuncture, you have to have the same fundamental of TCM, and then you can make a proper diagnosis, a proper treatment.

          DR. HELMS:  If you are working in an herbal context, whether you are using needles or herbs, the eight principles diagnosis applies to that model of therapy.  There are other models of diagnosis and organizing treatments that do not require that level of comprehension, because when herbs are not being used in the treatment, it is not necessary to think through the problem in that context.

          That is the distinction that I am making.  Yes, they share a common foundation, but TCM, as derived from Communist China in the fifties and sixties, is primarily a herbal approach to therapy with acupuncture to support it.  It is not a criticism of the quality of acupuncture or the quality of the medicine, but it is quite a different approach from the energy moving through the channels that is linked to medical acupuncture.

          DR. GORDON:  David, you can respond briefly, but I really think that this is a very deep discussion, and I want to give other people a chance to ask questions of other panelists, as well.

          So, David, if you had a brief response, that would be fine.

          MR. MOLONY:  It is just that I don't see how 200 hours or even 300 hours could provide more than an extremely basic information on what is necessary to do acupuncture diagnosis and treatment processes.  It is less than a semester of class.

          It has been part of what is, and I think that over a period of time, hopefully, that there will become more discussion on this subject, and we will all start to work towards having an integrated field of use of acupuncture within our fields, as I actually talked about in my presentation.

          DR. CHOW:  I just want to sort of complete this in that not only acupuncture, but I think in other practices of CAM, and that was what we brought up before, about the adequacy of other professions taking the training, and this merits an ongoing dialogue on this.

          DR. GORDON:  I think this is going to be an ongoing discussion, and clearly, there are differences of opinion and also different standards that have applied in different jurisdictions.

          Joe.

          DR. FINS:  I think it is instructive.  We have distinguished panelists here who are all experts in acupuncture, and they don't necessarily agree on the standards or the extent of the curriculum.

          So, one of the problems I think is that the premise that we have used, especially for Group 4, you know, for CAM practitioners, would be that professional body, that society, we would turn to them to regulate themselves and help them develop standards.

          Without a consensus of what the standard is, that delegation doesn't seem feasible, so I think it is just something that we have to take under advisement.

          DR. GORDON:  Tom.

          MR. CHAPPELL:  We also say in Group 4 that communities need to be dialogical and that the entity that we are talking about creating is an office here really needs to be facilitated in bringing about some agreement or some common ground on that.

          DR. FINS:  I think we need a consensus and compromise, and I think as the field has matured, there is a need for people to work together and understand what the motivations are for the different -- maybe it is going to be 350 hours, and, you know, we will all be happy with that.  I don't know the answer to that, and I don't mean to minimize the eloquence of all of your positions, but I think that there is going to be a need for some sort or standardization if this thing is going to mature.

          DR. HELMS:  Only one reply to that is that the approach to acupuncture and the application of acupuncture from someone who is practicing acupuncture as an exclusive TCM practitioner, and a physician who is incorporating acupuncture into his practice, is quite different.  The educational entry requirements are quite different, the education process is quite different, and the application is quite different.

          The regulation is different, and one body should not necessarily have influence over the other body as long as each body is self-regulatory for the quality of the training, the verification of the credentials, and the public safety involved in its performance.

          MR. CHAPPELL:  Let's assume that that is the way it is, that there is sufficient difference in educational philosophy and approach, then, we need to have sufficiently differentiated names of practice.

          DR. HELMS:  Hence, we use the name TCM for those who are fully qualified in Chinese Medicine, and medical acupuncture for physicians who are using just the acupuncture component.

          MR. CHAPPELL:  For the sake of the consumer, then, we simply need to be cognizant of whether or not that is a sufficient differentiation or whether promotion of the full difference as an educational matter can be brought forward.

          DR. HELMS:  It has served well for 20 years.

          DR. GORDON:  David.

          MR. MOLONY:  Perhaps the question is not necessarily whether one aspect of acupuncture can be taught in that period of time, but it may be that what happens, as when almost anybody comes out of knowing one particular aspect of something, pretty soon they read about other things, and they think that they can work with all of them, say that, you know, I am not a five elements practitioner, but say that somebody came out of your course and wanted to do five elements, would read up on it rather than actually study or focus on it.

          That is where we have to work together to start to develop criteria and standards to make it so that everybody is on the same page when they are talking with the public.

          DR. HELMS:  In reality, that doesn't happen.  There are plenty of continuing education programs available for physicians in the subdivisions of acupuncture, whether it is five elements, whether it is herbal prescribing, following the full TCM model, whether it is any of the microsystems that are involved.

          There are ample continuing education programs that are well attended.

          DR. GORDON:  Joe, and then I would like to make a point, and then I would like to ask a question about Dr. Sinaiko.  So, go ahead.

          DR. FINS:  I think this argument -- or I shouldn't say argument -- this discussion, the details are important, but the details are less important than the sociologic phenomenon that we are seeing here, and I think it has been really valuable to hear the different perspectives.

          It may be delineation of who is doing what.  I agree with Tom, for consumer protection people have to know what they are actually getting, because I am sure the consumers are not going to distinguish between the various entities that they are subscribing to, but I think that as groups come together and things become mainstream, it is really important to foster a mechanism of dialogue, whatever it is.

          I think that maybe one of the major recommendations, that we can help foster this dialogue in a collegial way, so we have more than six minutes to figure it out, and to adjust as the field emerges and changes.

          I think it has been very, very informative and I personally thank you for your candor in sharing your various perspectives.

          MR. MOLONY:  I would like to propose that we start talking formally with each other at this point.

          DR. CHOW:  I think that is a great suggestion.

          DR. GORDON:  I want to add one other principle that I think may be important.  This is confessional.  I am licensed to practice medicine and surgery.  Now, there are certainly some surgeries I might do, like an incision and drainage.  I am unlikely to want to do abdominal surgery, and I am highly likely if I suspect an acute abdomen to refer the patient somewhere else.

          So, I think one of the principles that we have to begin to invoke is a certain sort of befitting modesty about what all of us can and can't do.  Aside from discussion and collaboration and dialogue, I think that is a kind of internal process.

          I don't know exactly how we put that in our recommendations, but I think that part of the spirit of this work is knowing what we can do for all of us, and what we can't do, and whatever we can do to facilitate that --

          DR. HELMS:  Educate personal ethics.

          DR. GORDON:  Whatever we can do to facilitate that process or encourage people to say, and I feel like that is beginning to happen, encourage the different CAM practitioners and conventional practitioners rather than being draconian and saying, well, you have to have this in order to do that.

          We want to encourage a sense of appropriateness to the training of what people are doing.  So, I just bring that out.

          I do want to thank you all, and thank all on this panel, and also thank you, Joe, for staying around and contributing.

          I did want to ask a question about Dr. Sinaiko, because we have heard about him in now I think in five different locations, so I have a personal feeling for him.

          What is happening at this point, number one, and number two, I may not have heard completely clearly, what would you recommend that we suggest to state medical boards?  We had Dr. Winn here.  Did you hear his testimony earlier, who was executive vice president of the Federation of State Medical Boards.

          He said that they were busy creating new standards and including distinguished CAM practitioners and scholars in the creation of standards for physicians across the board, in medical boards.

          So, I would like to know two things.  One is where is Dr. Sinaiko now, how is he doing, and also do you have specific suggestions that you can give us and/or give to the Federation of State Medical Boards?

          MS. EDELKIND:  To start with, Dr. Sinaiko, the appeal process is going to be beginning sometime in the near future, and we will be involved in that, and probably this time next year we will be able to, if there is another meeting like this, we will be able to update you on that.

          At this time, the Union of American Physicians and Dentists, the American Association of Physicians and Surgeons, the California Medical Association, and the Citizens for Health Freedom are all negotiating how they are going to work together and also I believe the Townsend letter, the staff is very interested.  So, there are a lot of people that are finding their way in how they are going to be working and cooperating with us.

          This has pretty much become one of the biggest medical board cases in California history, and one of the very few medical cases where all of these organizations have shown this type of interest.

          As far as the prosecution of the case itself, the prosecutors broke every rule of ethics we could find, and that is going to also be dealt with sometime in the near future, probably at the state bar level.

          But as far as the medical board, in California, and, of course, I am not familiar with the rest of the country, but California arrogates to itself the idea that whatever they do, the rest of the country is going to follow, you know, as California goes, so goes the rest of the country.  I come from Georgia, so I can say that.

          But in any case, yes, they have a new Committee on Alternative Medicine, and originally, this grew out of a Medical Right to Practice Act that was desperately fought for and very widely supported, and totally gutted before it was passed.  That was S.B. 2100.

          By the time it was passed, instead of being a Medical Right to Practice Act, which would have allowed doctors who practiced various kinds of CAM to practice it, it became a let's study this for three years bill, and in the meantime, don't you dare.

          Now, that is really what it is and where it stands right now.  There is a committee theoretically in California, and they have had a couple of meetings.  I think there are four people, Colleen might know better than me, that are actually on this committee, and on the first meeting, only three of them even bothered to come.

          None of them have any CAM experience whatsoever, and on the very first meeting they talked about how all doctors that practice chelation need to be stopped and what their disciplinary procedures for doctors and non-doctors practicing CAM -- well, I guess they are more interested in doctors practicing CAM -- what their discipline should be.

          So, this is apparently in California, not so much a committee that is bringing in the idea of alternative medicine into the community of doctors, but rather let's see how we are going to punish them, how we are going to find them, how we are going to weed them out, and get rid of them.

          There is also a feeling, you know, if you are not a doctor, we can get rid of you that way, too, because you are practicing medicine without a license.  If you have looked on the Federation of State Medical Boards web site, the definition of practicing medicine is so broad that I think that if you put a band-aid on your child, you are practicing medicine.  So, it is really pretty scary.

          DR. GORDON:  So, what would be very helpful to us is if you could provide us with some of these facts that you are just describing now about what steps are or are not being taken, and who the participants are, because we have an ongoing dialogue with the Federation of State Medical Boards, and I would like to bring this up with them.

          The other issue is any specific recommendations that you may have for the functioning of state medical boards in this area, for the review of cases that come to them.

          MS. SMETHERS:  I would just like to add one comment.  Shula and I have been involved in this case since 1997, simply because we were so outraged at what was happening with Dr. Sinaiko, and the reason that was, because we know the kind of a physician he is.  I am a clinician, or was a clinician before I retired myself, and I had worked with him in clinics to some degree, knew of him on a lot of other levels, how he practiced and how he cared for his patients, and we became very outraged that this could happen to somebody of his caliber.

          Up until then, you always don't really know for sure what the truth is.  So, since we have been involved in this, he has become the poster boy for a whole population of physicians that the same kind of thing has happened to, and we have become aware of them simply because we have been involved in this case.

          What is happening in California I understand we are not just the only place that this is happening, but it seems to be a hallmark of states that these kinds of things are happening, and it is a real threat to people who need the broader spectrum of care, not just the allopathic standard of care, in order to deal with their health care problems.

          I feel for the patients because they are the ones that are being short-changed, as well as the physicians.  They have nowhere to go.

          DR. GORDON:  Thank you for sharing that with us.  We would welcome other examples of physicians or others in other states who are going through this kind of process.  That would be very helpful for us.

          MS. SMETHERS:  I would be happy to.

          DR. GORDON:  Tom, and then Effie.

          MR. CHAPPELL:  I wanted to thank Kathleen Quain for bringing the perspective of the quality of the environment as linked to our health.  It is very helpful to be reminded of that.

          DR. CHOW:  Actually, that was a comment I wanted to make, too, because my feeling was that environment wasn't represented enough in these panels, and so I appreciate that.

          One last request.  David, can you provide us with that World Health document which states about the number of hours for physicians, and so forth?

          MR. MOLONY:  I will make sure you get a number of copies of it.  I want to state that the Education Committee of the World Health Organization meeting that Joe alluded to earlier, the committee came out with 700 hours, and then by the time it got to the larger committee, it was back down to 200 hours, which happens to be the length of his course.

          DR. GORDON:  I want to thank all of you for coming.  I want to thank also the Commissioners who are here at the end.  That's great, I really appreciate the energy and enthusiasm.

          [Applause.]

          DR. GORDON:  And also our staff, who have been here before, during, and after.

          [Applause.]

          DR. GORDON:  Those who are here, those who are there, and those who are still outside, working outside.  So, thank you, everybody.  We look forward to seeing you again, and please be in touch with us.

          [Whereupon, at 6:30 p.m., the meeting adjourned.]

                         + + +

                     CERTIFICATION

This is to certify that the attached proceedings

BEFORE:   White House Commission on Complementary

             and Alternative Medicine Policy

HELD:     February 22-23, 2001

were held as herein appears and that this is the official

transcript thereof for the file of the Department or

Commission.

DEBORAH TALLMAN, Court Reporter