WHITE HOUSE COMMISSION

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COMPLEMENTARY and ALTERNATIVE MEDICINE POLICY

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    Draft Interim Report

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Volume I Part 2

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  Monday, July 2, 2001

    10:10 a.m.

    Jurys Washington Hotel

Westbury Room

1500 New Hampshire Avenue, N.W.

Washington, D.C.

P R O C E E D I N G S

          DR. BERNIER:  I think it would be helpful if the words "evidence based" was associated with the curriculum.

          DR. PIZZORNO:  George, I am going to take a slight disagreement with you, not because I don't agree with evidence based.

          DR. BERNIER:  It wouldn't be the first time.

          DR. PIZZORNO:  Actually, I think we have agreed on most things.  Oh, well, anyway.  I am absolutely committed to evidence-based medicine rather than conventional CAM.

          DR. BERNIER:  I think that is a great way to say it, the way I said it.

          [Laughter.]

          DR. PIZZORNO:  So, give us some wording for the solution that if there is a practice out there that does not have evidence, but the medical practitioner must know about its presence, how do we tell them if it is not evidence based?  You are saying if it is not evidence based, we can't tell them about it, we have to tell them it exists.

          DR. BERNIER:  I am sure we could make an exception.

          DR. GORDON:  George, I thought that what you meant was an evidence-based approach, so if there is evidence, that evidence is produced, if there is no evidence, one simply says that there is no evidence.

          DR. PIZZORNO:  Then, we are in agreement, that is fine.

          DR. FINS:  On this line, you know, the United States Public Health Service, all those things for prevention, and they have, you know, there is A, B, C, D, that might be a very helpful model, and different groups have different recommendations like the American College of Physicians, ASIM about mammography versus American Cancer Society versus U.S. Public Health Service.

          There was this chart in the Annals of Internal Medicine a few years ago that sort of folded out for every period of life and who said what, and that might be a model worth looking at as an analogy for what we are talking about here.

          DR. GORDON:  Or another way to think about it might be to say that people always have some evidence on which they base their approach, so the question is what is the nature of that evidence and what is the quality of the evidence really.

          That opens up to other kinds of evidence than perhaps conventional science has, so it is simply a matter of stating what evidence there is and making that available to people who are studying that approach.

          DR. PIZZORNO:  I think that is an excellent recommendation, George, so that this education clearly defines the level of evidence available for these kinds of practices.

          Would that meet what your intent is?  Okay.

          Any other comments?  Tieraona.

          DR. LOW DOG:  Is it appropriate to mention in there, in addition to just CAM curricula, that medical schools attempt to define the traditional practices that are practiced in their area in their patient populations?

          It is a big issue for us in New Mexico being familiar with the indigenous populations there and the hispanic populations, so that there is an understanding of the different treatments and the different modalities that are used.

          I mean it can be relevant.  We had a child who a social worker was called in for child abuse because they had done coining on the child, which if anybody just would have understood what that was, a whole terrible thing could have been avoided.

          So, because we are such a diverse culture in the United States, I would like to see just making some sort of recommendation.

          DR. WARREN:  What is coining?

          DR. LOW DOG:  The child had a bad like pneumonia, bronchitis, and they had taken the warm coins and had placed them to help break up the mucus and the congestion, and it didn't burn the child, but it left small rings on the back where you could definitely see.  The social workers were called in.  The child was held in protective custody for several days.

          It was just a terrible sort of thing because it is just a very deep part of traditional Vietnamese healing, and nobody was abusing anybody, but because the ER staff didn't know anything about our very large Vietnamese population, they had no idea what this might have been from.

          Again, I am just sensitive to a lot of the use of the Curandismo and the different diagnostics that hispanic people use, as well, and I think that it is something that has been really left out.  I think it hits right to the heart of what CAM is, which is traditional practices, and we have many of those here in the states.

          DR. PIZZORNO:  Any other comments, recommendations?

          [No response.]

          DR. PIZZORNO:  Great.  We will nail that down and move on to the next one.

          No. 2 on page 4 is parity of CAM professions and practitioners with conventional health care professions in access to educational and training funding and other resources.  I would also add to that "comparable accountability."  So, I think not just having access to funds, but also accountability for their education and the use of those funds.

          Any comments about this recommendation?

          DR. GORDON:  Joe, just to open it up a little more to thinking about it, when a recommendation like this comes up with which I basically agree, and you begin to think about making this recommendation to Congress or to the administration, you start thinking about money, at least I start thinking about money and limited resources.

          So, I am really opening this as an idea for discussion, do we want to make recommendations that we know are going to cost a lot of money and cause a lot of tumult, which we may, or do we want to make limited recommendations, how do we want to approach this as a commission, and it is applicable here, and there are several other areas where it is quite applicable, as well.  I just raise that question.

          DR. PIZZORNO:  Tom, Tieraona, George, Joe.

          MR. CHAPPELL:  I think this is one of the highest priorities among our recommendations is to create equal access to all aspects of being a good practitioner, so it really, for me, it doesn't matter whether it is controversial or going to raise questions about additional funds.

          As I said earlier today, I think we have to be proactive about raising and allocating more funds for this area of wellness and health, and so this would just go along with that.  Perhaps we need to make a statement right upfront in our introductory section of our report that CAM practices and products are a value-added to what is available as described by 42 percent of Americans that are currently engaged in paying for these services, or the $30 billion that constitutes the marketplace for these services.

          The value of these services has been already demonstrated by consumers, so I think the cry here is for better research, better education, better services, and the only way we can raise up the CAM professional is to give them equal access to the funds.

          So, I see this as so fundamental I certainly wouldn't want to postpone it.  I would like to just face it head on.

          DR. PIZZORNO:  Tieraona.

          DR. LOW DOG:  Mine is a simple question.  Are you talking about licensed professionals only here, and is it all licensed professionals, just for curricular program development inclusion and loan forgiveness, I mean so massage and acupuncture, that is strictly what we are speaking is licensed providers?

          DR. PIZZORNO:  I think that you have raised a good question we should discuss, because clearly, there are those schools that are accredited or licensed by the states and have licensed practitioners.

          There are other groups out there, as well.  I think we should facilitate their evolution, as well.  I think the idea of establishing an Office of Emerging Professions, for example, under the federal government, to facilitate the maturation of each of these healing arts, particularly those who aren't as far advanced as naturopathic medicine or acupuncture or chiropractic, to me makes a lot of sense.  Again, it is up for this commission to decide on that.

          George.

          MR. DeVRIES:  I see a lot of value in this approach, but I am also challenged by how it is going to be received in a report to basically say there has to be parity on all levels in a variety of areas.

          I think if you compare medical physicians with dentists, you don't see dentists having parity, and yet you see significant access to resources, and it seems as if, while it may seem like settling for second best to take a more incremental approach, at least perhaps that is a start and heading in the right direction, and can be demonstrated over time, the value of an incremental approach and be grown over time.

          DR. PIZZORNO:  Perhaps one way of looking at it is rather than mandating exact parity, it would be to look at legislation which currently excludes CAM institutions from access to federal programs.  That is a real issue, because so many clinical programs say only M.D.'s, only DO's get them, nobody else can have access to them, so may be an incremental step, but just remove the exclusions.

          Joe.

          DR. FINS:  I think this is a tough one.  I am not sure what you mean by parity with respect to resources.  I mean you could say, well, NCCAM gets $100 million now, the NIH budget is $20 billion, so we should ramp it up to $19.9 billion.

          DR. PIZZORNO:  All in favor, say aye.

          DR. FINS:  But I think this really is going to be I think difficult to sell to people.  I mean people have different amounts of training and there isn't parity in anything in our society.  I think we need, I agree with George, a more incremental approach, and Joe was just saying, I mean as an idea, you know, there are ways of having collaborations to increase cost effective ventures in this new paradigm with health, but I think to go for parity, I mean I can't imagine the entities that represent organized medicine having a great deal of comfort with that.

          Of course, I think if we are looking, and I don't think it is justified at this point.  We heard testimony from different practitioners from the same discipline, from different schools, who couldn't agree on the number of hours one needed to train to be an acupuncturist.

          So, I am not sure if there is a consensus or there is standardization yet to really say, you know, that they should have parity with entities that have formalized curriculum and a methodology and licensure, accreditation and re-accreditation, so I mean I think there are lots of issues here, that there is not equality, ready for parity.

          I am in favor of integration, I am in favor of cross-training, I am in favor of collaborations, but parity seems a little too extreme.

          DR. PIZZORNO:  Dean, and then Tom.

          DR. ORNISH:  I know I am sounding like a mantra here, but I really think this would a perfect issue to table until October because there is a lot of controversy about it.  You know, it is not a question of the merit of the idea as it is being mindful of the fact that you probably couldn't pick a bigger land mine than this one.

          If you want to just put it out there and step on it, at least do it with your eyes open.  Maybe I am just getting old, but I really think that there is value in incremental approach, because otherwise we can take a polemic and end up with nothing, or we can try to say let's really be skillful about change.

          We heard this morning how it took five years from the time the patients' bill of rights was introduced before it got passed last month, and that is kind of a hard thing to argue against, the patient should have rights, you know, so I am taking more of a long view here, and I think that if we don't avoid these land mines, we are going to just end up with a lot of rhetoric and nothing to show for it, and I would really encourage us in the Interim Report to avoid those kinds of things if we can.

          DR. PIZZORNO:  Before I move on to Tom and Charlotte, could you give some examples of some incremental approaches that might be useful?

          DR. ORNISH:  Well, there are a lot of them.  I am more just trying to be the red flag and say look, you know, you don't wave a red flag in front of a bull and then say, hey, how come the bull is charging at me.  Just be mindful, be aware.  There are lots of incremental approaches.  I mean many, many things have been said already, I don't need to repeat them - demonstration projects are just one of many.

          I am just saying that our committee is a pretty pro-CAM committee as it should be, but if we hear people like George and Joe and other people who are raising these issues, we need to listen to them, and say, look, if they are raising these issues, you can be sure that AMA is going to be raising these issues and other organized medicine, and the stakeholders who view that there is a limited pot of money, and if you are going to be increasing the money for other people, it means you are going to be taking it away from them.

          Whether that is real or not is irrelevant, that is the perception, and I think that we ought to have an Interim Report that we can all agree on, that we don't have dissension in our committee, that we can say, yes, this is really good, that we don't make ourselves easy targets and then as we build up the groundswell behind our support, support behind what we are recommending, because it just makes sense like freedom of choice and the kinds of things that we heard about this morning, then, it becomes much easier to take it to the next incremental level.

          But if you try to do too much too soon, you go nowhere, that is all I am saying, just let's try to, for the Interim Report, just find consensus, and then for the October report, we can decide how much we want to go out on a limb.

          DR. PIZZORNO:  Thank you, Dean.

          Jim has a point of information.

          DR. GORDON:  I just wanted to mention as a point of information, what we have done with the draft of the Interim Report is to raise this as an issue without saying where we come down on it, so in a sense, we have done what you are suggesting, saying that it is an important issue -- at least I believe we have -- saying that it is an important issue, but it is not one we are addressing in the Interim Report, but that it is something, I think as we say pretty clearly, it is something that people have testified to wanting.

          DR. ORNISH:  I was only respectfully disagreeing with Tom when he said he felt so strongly about it should be in the Interim Report.

          DR. GORDON:  I understood that.

          DR. PIZZORNO:  Tom.

          MR. CHAPPELL:  I believe the problem word here is "parity," and at least in the interview that I had for today's meeting, I was talking about equal access, equal opportunity.  I have a hard time speculating that anyone in this room, or even anyone reading the report, would have trouble with the idea that a CAM practitioner should have equal access to the same sort of funds for education and development that another medical professional would.  So, it is really not parity, that is the problem word, it is equal access and/or opportunity.  Perhaps it is just equal access.

          I think if we don't put it in the Interim Report, we get criticized for suggesting elsewhere in the report that we have expectations when we haven't even thought to cover the basic homework of needed training, needed development, and more knowledge in general.

          I just can't imagine that anybody would want to deny the necessary steps of full development, so I would change the word, and I do think it really needs to be part of the Interim Report.

          DR. PIZZORNO:  Thank you, Tom.

          Charlotte.

          SISTER KERR:  I just want to say I agree with Tom, and I would also honor what Deans says, however, schools have met state requirements of credential for Master's programs, have national standards, say, like acupuncture schools, hey, you know, change parity maybe, but you certainly have equal access to funding.

          DR. PIZZORNO:  Joe, and then Jim.

          DR. FINS:  Just briefly.  To put this into context, the last line in the Interim is talking about the federal loan forgiveness, the scholarship programs that are now available to students of the conventional professions, well, this has been dramatically cut back and we have to contextualize how this will be received in the context of the diminution of resources for conventional practitioners and medical students to get these kinds of loan forgiveness programs.

          DR. PIZZORNO:  Jim.

          DR. GORDON:  I think what I wanted to say is that, by definition, the Interim Report is going to represent areas where we have consensus, so that is something that we have consensus, that we are going to have consensus  in the Interim Report.

          So, what I am suggesting, which I suppose goes with what Dean is suggesting, is that in those areas where we don't have consensus, that we really need more time and more discussion, and need to really grapple with these issues in a different way, and then we can figure out how we are going to deal with them.

          If we come to a consensus about this, then, fine, it could be in the Interim Report, but if there is not a consensus, my feeling is the Interim Report is the representation of our consensus at this time.

          DR. PIZZORNO:  Other comments or thoughts?

          MR. ROLIN:  I, too, disagree with the use of the term "parity," but I was certainly in favor of access, but it is just like we have said, when you get to the last part of that sentence there, when you are just seeking out and making that broad a statement, it is going to trigger the whole community as far as education and all that.

          So, access is a key.  I think it should be included, but, you know, inclusion to that extent, I don't know if I am comfortable with that or not.

          DR. PIZZORNO:  So, I think I am hearing here that the use of the term "parity," which implies exact equality, is problematic for a consensus from this group.  Now, I would personally go for it, but we want consensus.  I want to be clear where I stand on this.

          So, what other language can we use here we can develop consensus at?  Now, we may not be able to develop consensus, but we have a little bit of time, let's see if we can.  Tom and Buford both brought up the concept of access as being a better term.

          Now, that access can take many forms.  Equal access is one form, which is good.  We can also use the term "increased access," which is a lesser term, but it does open some doors.  To make a quick editorial comment here, clearly, the vast majority of health care in this country is provided by conventional medical professionals, however, a large amount of health care is being provided by the alternative medicine practitioners, and right now virtually all of the money for education, research, certification, advancement, et cetera, goes to conventional medicine.  That does need to change.

          I suspect there is consensus on that.  So, the question then is how we come up with language that we feel will be accepted, but will also induce change.

          Dean.

          DR. ORNISH:  I think for the purposes of an Interim Report, you want to avoid any relative comparisons.  In other words, instead of saying this should have as much access as that, which immediately, if you are "that," you feel like you are going to get that taken away to be given to this, you say adequate resources should be provided for education and training in research and complementary and alternative medicine, something along those lines, a positive statement without making reference to anything else.  That is just my belief.

          DR. PIZZORNO:  There is one recommendation.  Are there other recommendations about the kind of language we could use, that we could get consensus around?

          [No response.]

          DR. PIZZORNO:  Actually, I kind of like what Dean said.  That sounds pretty good to me.  Anybody else?  Joe.

          DR. FINS:  I would just add to that the word "accredited" or some sort of, you know, so we are talking about legitimate practitioners or people who are in accredited programs, or things like that.  The people should be engaged in accredited activities, you know, accredited educational activities.

          We get back to the licensure issue again.  That is why there isn't parity, because you can't answer that question.  You can't answer the question who is accrediting these people in all the circumstances we are talking about.  In some cases, you know, we can, I mean in the acupuncture case, we might be able to do that; in other areas, we can't.  So, making a broad sweeping comment about all CAM professions and practitioners, there is also a disservice to the heterogeneity.  I mean it says the Bastyrs are like the mail order naturopathic medical schools.

          DR. WARREN:  Even though they are both accredited by the state.

          DR. FINS:  And even though they are both naturopathic physicians, and I think having been to Bastyr, it is a disservice to -- you know.

          MR. DeVRIES:  Do you want to read what you have, that you are trying to get consensus on?

          DR. PIZZORNO:  Okay.  Also, Donald, I want to be real clear, institutions like Bastyr have different accreditation than institutions like the mail order people, I want to be very clear about that.

          DR. WARREN:  [Off mike.]

          DR. PIZZORNO:  You may want to check to see who they are accredited by.  Also, please use the microphone.

          Here is possible language that I derive from what Dean just said.  Adequate resources for CAM professions and practitioners to access educational and training, funding, and other resources.

          Tieraona.

          DR. LOW DOG:  I think that Joe's point there about accreditation or licensed or something, it is going to have to be addressed somewhere, and it is different than access.  I mean you can go see whoever you want, I would defend your right to the end to go choose who you want for your health care provider, but I am not sure that we want to really say just any CAM profession, because I am not sure that I want loan forgiveness and that for iridology school, and I don't want to pick on that, I am saying that there are certain things that in a limited pool of money, may have more value than others, and the groups that have gone through accrediting their schools, I think that any of those students should have the same access as any student has in the United States to get money to pay for their education.

          Loan forgiveness is a little bit of a different situation, and I don't think we have consensus on that, but I don't think anybody here would disagree that if you are going to go to school, you should have access for federal funds as loans that you can take out and repay.  I might even feel the same way about iridology school for something like that, if you don't pay it back, I don't care what you do with it, but loan forgiveness in that, what we are going to pay for I think is a different subject.

          DR. PIZZORNO:  Jim, Tom.

          DR. GORDON:  One thing I want to say is what we are peeling away is the various levels of this discussion, which becomes very complex, and I want to make sure that whatever recommendations we come out with in the Interim Report do not get us in over our heads, because I think the distinction here between repayable loans and loan forgiveness is huge.

          The distinction between, that we still haven't solved, is which professions do we include in CAM, and do we make that public money available for, is also a big area of discussion.  So, I just want us to be clear that there are real differences among these as we make these decisions.  These are decisions that really make a difference, and we may not have taken account of all of the things that we are deciding about, and we are just hearing them now.

          DR. PIZZORNO:  Tom, you are next, and then George.

          MR. CHAPPELL:  For me, the statement of access versus parity would sound something like provide access of CAM professions and practitioners to educational and training, funding, and other resources.  It is not a comparative at all.  It is just providing access.

          The marketplace will work that out.  That peels away all the comparators, but it establishes the fundamental principle that I feel that we are trying to do here.

          DR. PIZZORNO:  Thanks, Tom.  So, now we have two ways of wording this.  One is provide access for CAM professions and practitioners to educational and training, funding, and other resources, and the other is provide adequate resources for CAM professionals and practitioners to educational and training, and other resources.

          George.

          MR. DeVRIES:  This obviously may be a small land mine even within this room, but reality is part of the incremental approach in terms of the funding, part of the ability to sell this to Congress, part of the ability I think almost necessitates that the funding be limited to CAM practitioners who are licensed, and it would have to be provider types who can be licensed.

          DR. GORDON:  Could you say why you are saying that, George?

          MR. DeVRIES:  Well, I think part of it is you have a regulatory body in the states that is overseeing the licensure of these individual providers, and that provides part of the standards in terms of the profession, also in terms of the educational curriculum, and that draws down to the accreditation process of the school, ultimately even to the ability of the provider to get reimbursed, because even as we heard in testimony, very often -- well, I shouldn't even say very often -- but typically, the health plan, if they are going to cover CAM, it is going to be limited to providers who are licensed.

          So, that line draws across a variety of spectrums.

          DR. PIZZORNO:  Effie was next.

          DR. CHOW:  I would just like to reflect back on what Jim said, that we are reflecting what has been stated by people who testified, and that we are not really speaking only as commissioners, but we are really relaying the message of the people.

          So, in a sense, I think we have to be careful with words, but we can't water down everything because it is going to offend the Congress.  I am not saying that it needs to be in the Interim Report, but I think I would like to see we not neutralize things so much that we are not going to make great impact to, as well, and that we do have the obligation to reflect what the people have said, and the people have said some very strong things.

          We need to portray that, as well as the other, more mild things.

          DR. PIZZORNO:  Thank you.

          We are getting close to the end for this particular one.  I would like to, one, suggest some wording, and actually I really like the way Tom worded it, but also I would like to put one more piece on the table before finishing this, and that is do we restrict this language to licensed professions or not.

          I would like to start the conversation with a comment.  On the one hand, I certainly can see the value of restricting it to licensed professions, and it certainly resolves a lot of thorny issues about deciding who gets qualified and who is not, but on the other hand, I feel a very strong commitment to those other healing arts that have not yet progressed to the point of formal education, accreditation, licensing, and such, that we give them a helping hand up, so they can evolve, that needs to be handled.

          Now, as Joseph just said, this may not be the place to do it, but it is something that I think we need to do.  Those iridologists, for example, I have major doubts about whether it has any validity or not, but, you know, they need to progress to a point where we can determine it they have validity or not, because there may be something there that will be useful for health care.

          So, I would like to just kind of see is there something we can say or do we just postpone it for another time?

          Tieraona, and then Bill.

          DR. LOW DOG:  Well, I don't know, it seems like if you go to an accredited school, and I mean there are herb schools that are accredited by their states, where we don't have any licensure for herbalists, but it is an accredited school meaning that it has got ways of tracking faculty and students, and I mean I was part of that, so I know what we went through, but you are not licensed.

          I guess what I was saying earlier was I think anybody who is going through an accredited school should have the right to apply for federal funds that they repay.  I mean it is at a lower interest rate, and I don't know why you would separate that out from a vocational school or for anything else.  If it is an accredited school, and it has met accreditation, whether it leads to licensure or not, I think -- again, I have separated it out, I am saying that for repayment, you are getting a federal loan at a low interest rate -- I think anybody should have access to that just as a student.

          DR. PIZZORNO:  Tieraona, there is some language here I think we have to be careful about, and that is the term of accredited and licensed by the state to run a school.  A lot of people use the term "accredited" when a state says yes, that school can run, but that technically is not accreditation.  It is simply approval by a state to allow them to run.  Accreditation is a separate process that has direct ties to either the federal government or to there is an accreditation of accrediting agencies.

          So, I just want to say we need to be just a little careful about some of the terminology here.

          DR. LOW DOG:  I will leave the terminology for you, but if I can get repayment to go learn to be a plumber, I should be able to have access to that in a country that supports education as long as the school itself has met the criteria that it is able to educate, and it has follow up.

          That is very different than loan repayment, it is very different than licensure, it is very different than all of that, but I think people would have a hard time disagreeing, because you are paying back the money.

          DR. PIZZORNO:  Bill.

          DR. FAIR:  Well, I agree with Tieraona, and I know George is coming from the idea because we had this in our small group, that licensure is the only way to get reimbursement, as it was for the chiropractors.

          But I think that, I don't know whether the term "accreditation" or "credentialing," or whatever, but the standards for adequate education in a modality has to come from the practitioners in that modality.  The state can't set those standards, the state can license it.

          So, I agree that whether it -- again, I don't know whether it is credentialed or accredited or something like that, but if the practitioners in a given discipline like yoga and movement therapies, or herbal, or whatever, have established criteria that they would think would adequately train a person, it would seem to me that they should be eligible for the same benefits whether or not the state -- George, I may be misquoting you, but it sounded to me the main reason for licensing when we talked in the small group was for reimbursement.

          MR. DeVRIES:  I wouldn't say the main reason for licensure is reimbursement.  I am saying that licensure is a prerequisite to reimbursement, and licensure involves a variety of things related to basically the provider being able provide services, being legally empowered to make a diagnosis and provide care for patients.

          There is a variety of reasons you have licensure, but licensure is simply a prerequisite.

          DR. FAIR:  But the state is not setting those criteria, is the professional board, whatever it is, and then the state says, okay, they have gone through an accredited school or credentialed school, and therefore they are eligible for licensure.

          MR. DeVRIES:  Right.

          DR. PIZZORNO:  Let me take a stab at some language here, because this is going to be a little tricky, because I want to accomplish what Bill and Tieraona have said, but how to do the exact language is a little tricky, but I will just take a stab at it.

          Provide access of licensed or accredited CAM professions and practitioners to educational and training, funding, and other resources.

          DR. FAIR:  Joe, do you know the difference between credentialed and accredited?  I mean I don't know, I am just asking.

          DR. PIZZORNO:  Yes, I do.

          DR. FAIR:  What is it?

          DR. PIZZORNO:  In the strictly academic term, accreditation is a process of approval of an educational institution or program within an institution.  That strictly is accreditation, and it is actually independent of licensure, certification, et cetera.  That is strictly an academic definition.

          DR. FAIR:  What about credentialing?

          DR. PIZZORNO:  Credentialing, in general, licensing is done by states, credentialing is done both by states and by professional organizations, and depending upon the situation, in most situations, only credentialing by a state is meaningful, but there is some credentialing in some medical specialties that the medical specialty credentialing board is significant.

          SISTER KERR:  Does your statement include schools?

          DR. PIZZORNO:  I assume the term "professions" would include schools.

          So, can everybody live with this?  We will leave it to staff to maybe tweak the language a little bit more.

          So, I will say it again.  Provide access of accredited or licensed CAM professions and practitioners to educational and training, funding, and other resources.  I am including in professions, institutions, as well.  I think that is the intent, but maybe we should explicitly state that.

          Can everybody live with that?  Is there anybody that can't live with that?  Going - going - gone.  Okay.

          DR. FINS:  Hold on.  Hold on.

          [Laughter.]

          DR. FINS:  I think it is implicit in what you said, but the loan forgiveness component, that is tied to service to underserved is not something we are talking about here.

          DR. PIZZORNO:  We are not specifying anything.  We are just presenting a general concept.

          No. 3.  We have 20 minutes left for No. 3, and then we give it to Jim to make the summary.  This is on page 5, joint and cross-training of CAM and conventional health professions in undergraduate and graduate programs.  Again, we mean by "undergraduate," before they get their degree, and "graduate" is after they get their degree.

          I would just like to start this conversation by again reminding people of what I think is the direction we are moving in, and that is collaboration of these health care professionals, and I think joint training is one of the most effective ways in which we can accomplish that.

          Comments?  Dean.

          DR. ORNISH:  Well, it is one of those ideas that sounds great in theory, but it is hard in practice because it could be very easily viewed by the conventional training programs that you going to mandate that they take some of their resources and allocate them for CAM.  It is just another land mine.

          I am just the messenger, so don't shoot me here, but I am just telling you that is how it is going to get viewed.

          DR. PIZZORNO:  Okay.  So, let's be careful.  We are not mandating this, it is just something we are recommending.  By the way, this is doable, because we are already doing it.

          DR. ORNISH:  But the difference between a recommendation and a mandate is going to be lost on those constituencies, that's all.  Again just be aware of it.

          DR. PIZZORNO:  Joe Fins.

          DR. FINS:  It does pose a lot of logistical questions and problems on how to operationalize this.  Maybe if we just said, you know, like consideration of demonstration projects that would allow us to learn how to do this kind of thing, and leave it at that.

          It doesn't threaten any current training programs, and the details will be worked out, but I think this is the kind of thing where a demonstration project is an incremental, less threatening, more feasible step.

          DR. ORNISH:  I mean by analogy, it took us seven years in dialogue with HCFA before they would do a demonstration project of our program as an alternative to bypass or angioplasty, and we have done randomized trials, and we have done everything, and it still took seven years, and we are still just getting started, but the language demonstration project, for whatever reason, doesn't seem to push people's buttons, so I am agreeing with you.

          DR. PIZZORNO:  Jim, George, and David.

          DR. GORDON:  Just one thing that I would like to mention.  In this area in particular, there are a number of examples where we are already doing this.  We are doing this at Georgetown, for example, and have been for a number of years.

          Other medical schools, other CAM schools are doing this, so I think if we couch this in the language of what we are already doing, we will be moving along much more easily, and these are demonstration projects.

          Incidentally, NCCAM has a whole program to fund such demonstration programs already, so I think this is one of those places where we can take, just as I said in the notion of recommendations, that this recommendation will go down a lot more easily and be a lot stronger with the evidence that we already have accumulated of projects that are doing this.

          When it is cross-training, I think we also have to make clear, and I think the fear that will come up is, well, they are going to come in, those others are going to come in and take over my program, and I think there will be that fear from all sides.

          I think as we focus on making recommendations, we have to be pretty clear about what we mean.  This doesn't mean that the M.D.'s are going to come in and take over the school of Chinese Medicine, there are already M.D.'s who are teaching in schools of Chinese Medicine, or that the acupuncturists are going to take over the medical schools.

          This is one where I think we can go a long way, but we have to be careful in how we word it and describe it.

          DR. PIZZORNO:  George.

          DR. BERNIER:  I would strongly support it.  I think that it doesn't promise a whole lot of very specific things, and I think that maybe should be a model for what we put forth for the whole program, so I would support it.

          DR. PIZZORNO:  David.

          DR. BRESLER:  Well, again, I think here is something that can be looked at in the broader context because we don't have much joint and cross-training in conventional medical specialties either.

          In my field, which is pain medicine, if you were to bring a headache patient into the medical center and ask a neurologist, a dentist, a psychiatrist, and psychologist, an orthopedist, and a physiatrist, you would find very, very different diagnoses and treatments.

          So, I think this is an important consideration, I think we can thread it to a much larger issue that we also want to support.

          DR. WARREN:  My experience has been with postgraduate stuff where, as a dentist, we went into the osteopathic school and learned from teachers of osteopathy, manipulative medicine, but it didn't mean that we, as dentists, would take over osteopathy.  In fact, I think the dentists incorporating osteopathy into their practice has really strengthened the practices of osteopathy and the osteopathic field because we are now proponents of that treatment, and when we find something in our practices we can't handle, our limitations, then, we know who to refer to.

          It is really building a tremendous rapport and bridge between the osteopathic community and the dental community, but it is being funded, not by the schools, it is not being funded by the federal government, it is being funded out of our pockets, continuing education, 3- to $500 a day for education, and we pay it out of our pockets.

          I don't think we have to worry about the funding on this issue right here.  The funding on the postgraduate level will come out of the practitioner's pocket, and I think it is taken care of.

          DR. PIZZORNO:  Other comments from the group?

          [No response.]

          DR. PIZZORNO:  Just a comment.  At Bastyr, we get a tremendous amount of requests both for residencies and for student experiences in our teaching clinic, and we have developed an interesting policy that we are delighted to let them come into our teaching clinic if you will allow our students and/or residents have an equal amount of time in your teaching clinics, and they are saying yes.

          So, I think there is a lot more interest in this than people realize because the students and more and more the faculty want to see this happen.

          Any other comments?

          [No response.]

          DR. PIZZORNO:  So, let's look at this language.  We obviously don't want it to sound like a mandate, so we can use terms like "recommend" or "facilitate."  So, how about somebody giving us an adjective here?  Provide?  Okay.

          So, I will read the statement.  Provide joint and cross-training of CAM and conventional health professions in undergraduate and graduate programs.

          DR. BRESLER:  Encourage.

          DR. PIZZORNO:  Provide and encourage?

          DR. BRESLER:  Encourage.

          DR. PIZZORNO:  Just encourage.

          DR. BRESLER:  Encourage and support.

          DR. PIZZORNO:  Encourage and support.

          SISTER KERR:  [Off mike.]

          DR. PIZZORNO:  We have a differentiation in terms here between provide, and encourage and support.  So, what do we want?

          DR. GORDON:  I am not clear yet how this is different from No. 1.  I don't know that we have made it clear.

          DR. PIZZORNO:  No. 1, this is specific to cross-training.  That is people trained together and doing things of this nature.  The other is making sure that those subjects are being covered.  So, these are definitely different flavors.

          DR. GORDON:  What is the difference between cross-training and make sure it is covered?  Could you make it more explicit?

          DR. PIZZORNO:  For example, in a conventional medical school, you could have a two-hour course, which is a survey of alternative medicine, and I have been teaching at the University of Washington for over 10 years.  Conversely, you can have a student at the University of Washington Medical School enrolled for a quarter at Bastyr, and a student at Bastyr enrolled for a quarter at the University of Washington, or have a University of Washington resident go to the teaching clinic, an acupuncture resident go to the medical school for rotation.

          DR. FINS:  I think the difference, Jim, is that you are asking people from outside each other's CAMs to come into each other's CAM, and that is why I think it has to be done, the language has to be non-threatening, so encouraging versus requiring would probably go further with a little bit of honey.

          DR. GORDON:  I think it also has to be clearer exactly what we mean, too.  If I get taught acupuncture at Georgetown, that is not cross-training.

          DR. PIZZORNO:  Correct.

          DR. GORDON:  But if I go from Georgetown to traditional acupuncture institute, that is cross-training.

          DR. PIZZORNO:  And conversely, traditional acupuncture institute comes to Georgetown, that is cross-training, because they then are actually practicing together.  I think the key element here is training together, so that they will practice collaboratively.

          DR. GORDON:  And then if we both go to Joe Kaczmarczyk's outpatient clinic at the Public Health Service Hospital and work together?

          DR. PIZZORNO:  That would work.

          DR. GORDON:  That is also cross-training.

          DR. PIZZORNO:  That would work, yes.

          DR. GORDON:  I think we need to define, I just feel like it needs to be made much more explicit what we are talking about here, and how and why it is different from what we were talking about in terms of everybody having to know something about the other world view and the other practices.  It just feels like it needs to be really fleshed out, and a rationale has to be given, so that it makes sense, too.

          DR. PIZZORNO:  I guess I would look at the staff and say I think Jim has made some good points, do you have enough information to strengthen this wording or would you like some more from us, more guidance?  Michele, did you want to say something?

          MS. CHANG:  No, what I was hearing a little bit, it was that if we provided a little bit more background in terms of the intent and purpose of the curricula element that we are discussing, it might be helpful for people to understand both the difference and kind of the overall background and rationale that Jim mentioned.

          DR. PIZZORNO:  Joe.

          DR. FINS:  Something like recognizing the need for improved communication and collaboration between allopathic and non-allopathic providers, we encourage the joint collaborative ventures we are talking about.

          DR. GORDON:  I think it is important to keep it open enough because otherwise we run into potential turf battles and people will feel offended.  Tieraona is nodding her head.  She and I have probably each spent -- I have spent longer than she has -- but each of us has spent 20, 30 years studying natural medicine, so to say I can't teach natural medicine at Georgetown Medical School doesn't feel fair to me.

          DR. PIZZORNO:  That was not the intent of this at all.

          DR. GORDON:  No, I understand.  I am trying to make it explicit, so that what we are doing is we are encouraging the kind of pluralism, both within each discipline and also collaboration among the various disciplines, but it just needs to be spelled out, so that people don't get caught up in turf wars, so that we are honoring each person's training and each person's ability to do this, and at the same time we are saying and it is good for you to get to know each other, as well, as get to know how people with different kinds of training are working.

          DR. PIZZORNO:  It sounds good.

          Tom, and then George.

          MS. CHANG:  Joe, we are at the 10-minute mark.

          MR. CHAPPELL:  I am wondering if dealing with this at all doesn't dilute the imperative aspect of the first two, and maybe we shouldn't have this in here at all.

          I am concerned about having a report that uses words "encourage."  I mean I have seen so many executive reports that use "encourage," and there is no substance to it.  So, I look at that and say, well, I don't feel like encouraging that today.

          So, I am just feeling that deciding what we don't say at all is important in this process right now, and I don't feel this needs to be covered, that it couldn't have been covered additionally perhaps in the first piece as a support statement.

          I know, Joe, that you feel strongly about this, and I don't want to diminish the value of it, but I don't want to diminish the value of the real --

          DR. PIZZORNO:  Thank you, Tom.  I will respond to that in a second.

          Joe.

          DR. FINS:  I think there is a real difference here, Tom.  I think if we can foster this collaboration and have young residents working together, getting to know each other, working in each other's context in a non-threatening, encouraged way, it will build a whole new generation of people who know how to talk to each other.

          DR. PIZZORNO:  So, I guess the directions to staff, request of staff is to -- George.

          DR. BERNIER:  I think actually the verb "foster" would be a very good one, because that does mean a lot of different things.

          DR. PIZZORNO:  Charlotte.

          SISTER KERR:  I just have a comment.  It is my perception, just a little offering, may be rejected, I have a little concern about our consciousness to avoid land mines and are living out of fear in what we choose to say, and it is starting to feel a little bit like scaredy-cats.

          DR. PIZZORNO:  Hear, hear.  Ming, did you want to say something?

          DR. TIAN:  Yes.

          DR. PIZZORNO:  Please.

          DR. TIAN:  I have a question.  You mentioned cross-training or education.  Well, I can understand a physician wanting to learn acupuncture, will be easy to take 200 or 300 hours, and will understand acupuncture, but the physician is not telling everybody he is an acupuncturist, still a physician, correct?  All right.

          Then, the other way, even the acupuncturist does not have enough Western training, but he is very good, experienced acupuncturist, what kind of program to do the cross-training or education?  How could you send him to a medical school to learn the courses?  I will say that is only sharing information, and we should encourage this kind of exchange to learn each other, but it is not like a course.  I will say it is not a formal course, it is going to be difficult.

          For instance, he could be or she could be a very good healer, very powerful.  You are going to teach him anatomy, pathology?  You can mention that, okay, I treat arthritis in this way, you can mention that.  That is not medical training.

          So, I am a little bit confused.  Can we use some better wording to more clarify that, because if you encourage too much, then, it is going to mix.  The apple juice is apple juice, oranges is oranges.  We need the specialties.  It is very confusing.

          DR. PIZZORNO:  I think you have brought up a very good point, and that is our intent is not to use cross-training as a way of training the person in the other person's therapeutic modalities.

          The idea is exposure on how they practice to better understand they can practice collaboratively together, but not expecting one to learn the other.

          I think you brought up a lot of important issues about how to make that a valuable experience, so, for example, everybody is going it different, well, one way we do it is we send both a licensed practitioner and the student into medical clinic, and they then practice their natural medicine, acupuncture, naturopathic medicine, as the case may be, in that clinical setting, but they are side by side with conventional doctors, with medical students getting their training.

          So, they are understanding each other better, but they are not in any way expecting to be able to practice the other person's skilled modalities.

          So, we have to wrap this up.  I think there is a high level of consensus here that we need to do the cross-training.  The issue is make sure we explain why we are doing that more effectively.

          So, I think the staff, you have heard a lot from us about how to do that.  That is, this is about help within practice collaboratively, not cross-training in each other's modalities, and we will leave it at that.

          So, now I turn the gavel over to you, Jim.

          DR. GORDON:  I might just add to that last part that maybe cross-training is not exactly the best word to use, because it implies something that we don't agree with, we certainly don't have consensus on.

          DR. GORDON:  I am not going to go through -- well, I will go through much of the discussion, but perhaps not every detail.

          In the beginning, there was a discussion about what constitutes a good recommendation, and this is really to help us think through, not only the recommendations for credentialing, licensure, education, and training, but also to help us generally, and Linnea made some recommendations, and then Tom and I added to them, and basically, this is that our recommendations be clear and jargon-free, that they be achievable, that they be -- and Joe Pizzorno broke out a non-global meaning that there be a sense of the range in which these recommendations apply, that we not overgeneralize about them; that it would be possible to put the recommendations in a form in which they can be operationalized; that all recommendations that are made should be able to be evaluated in one way or another; that recommendations honor the traditions, the various traditions out of which the different systems of healing are coming historically and culturally, and also that the recommendations be based on experience from which we can extrapolate or generalize.

          We the moved on specifically to the areas of education and training, and what I found very interesting is we got into a number of discussions through this issue, which I suppose is appropriate since we are talking about education, that in a sense we are educating ourselves and coming back to definitional issues like what is CAM and when do we use that word, and when do you use integrative, and returning again to evidence based.

          What is clear is that those particular discussions are ones that we didn't -- at least we brought up the issues here -- we didn't resolve them, we are going to be coming back to those again in October, but I feel like we did move ahead in terms of understanding some of the difficulties that come up.

          For example, Veronica pointed out that when  you use medicine, it means something very different from when you use health care.

          Again, talking about evidence based, coming back, circling back to the discussion from this morning about what kind of evidence we are expecting from different approaches, and it is going to be different.

          We also talked some about the issues of understanding the evolution of this whole field.  I thought that was a really interesting discussion, and again I think this is going to frame, certainly will in some ways help to frame the Interim Report, and will be a major issue in the Final Report in terms of how we see our function and who we are at this particular moment in the evolution of medicine, the evolution of science, and the evolution of this culture.

          We talked about education.  There was general, I think strong consensus that all conventional health care professionals need to know more about the field of CAM including some of these definitional difficulties, some of these historical questions about where different approaches have come from, and we talked a little bit about the interesting difference between approaches like nonsteroidals and glucosamine, and because of where they enter into the discourse about medicine, one is defined as conventional, and the other is defined as CAM.

          I think that all of this is part of the material that we have to get across -- this is a little bit of my interpolation -- all of this is part of the material that we want to get across to students in conventional professions about CAM.

          There was also very strong agreement again that CAM professionals need to know about the sort of theory and practice of conventional medicine.  We had few specifics, kind of specific categories in which the knowledge needs to be taught, or perhaps better said, a few specific qualities that the teaching has to have.

          One is that practitioners need to know their limits, just as conventional physicians or nurses or psychologists need to know their limits, so CAM practitioners need to know their limits, and they need to know where the different practices come up against each other.

          There needs to be enough to know, so that people can refer to one another.  That is clear.  That needs to be basic in all curricula.  We need to know, and as the material is presented, the students at every level need to know the level of evidence that is available for everything that is taught, and we had the very interesting and specific discussion that there may be approaches for which there is little evidence that could be published in a peer-reviewed journal, but that doesn't mean that a conventional practitioner or a CAM practitioner shouldn't know about these approaches, and shouldn't know what evidence there is and is not, and on what the practice is based.

          Finally, there needs to be an attention to, and a knowledge about, traditional practices in every community, and I think this is something that we can put this in the Interim Report, I think it is something we need to come back to, or perhaps all of these as we look at the Final Report.

          There needs to be much greater knowledge and not only -- I mean I would add, too, that, in general, there needs to be an understanding of traditional systems of healing, and I think this is important whether or not you are in an area right now where there are traditional systems of healing that are particularly important demographically.

          We then moved on and there was an emphasis on demonstration projects in these areas and on highlighting what we are already doing in these areas.

          We then moved on to issues of access to educational and training, funding, and other resources, and I probably don't have the exact words down, there is a general agreement that all those who are in accredited schools, who are learning health professions, whether they are conventional of CAM professions, should have access to loan opportunities and scholarship opportunities that any students have access to.

          There is a real question about loan forgiveness programs for service in underserved communities, and that seemed like one of those issues that we want to come back to.  Although we understand the importance of expanding the pool of people who are available to serve in underserved communities, we want to come back to any discussion about specific recommendations for loan forgiveness programs.

          There was also a very interesting discussion about licensed and unlicensed professions, and it seemed like the criterion would not be whether the profession was licensed, but whether the school was accredited as far as being able to take out a loan for one's education.

          We then moved on to the whole issue of joint and cross-training of CAM and conventional health practitioners, and I think that we actually brought some clarity to this area, as well as to the other areas.  What we are talking about is not an insistence that everybody be qualified to do everything, and that everybody has to learn to do or that anybody has to learn to the ability of another practitioner to be able to do that practice.  This is not particular grammatical, but the goal is enough experience of one another, of one another's practices, and of one another's educational methods to have a feeling for what those other systems are, so that we can better communicate with one another, refer to one another, and understand the frames of references of each other, and that what seemed to be clear from the discussion is that this is not a matter of mandating it at this present time, at least this is my sense of the consensus, but that this is something that needs to be strongly encourage, understanding that encouraged is not as strong as mandate at this present time.  This again may be one of those issues that we may want to revisit in terms of looking at the details.

          So, that is my summary.  Is that pretty fair?  Yes, Veronica.

          DR. GUTIERREZ:  One thing I didn't hear you say, that I took note of that Joe said, was a simple increment would be to remove the limitations or exclusions from the legislation.

          DR. GORDON:  Right, thank you.  So, we are talking about access.  Joe, do you want to give us the exact words that you used on that?

          DR. PIZZORNO:  There is quite a bit of federal legislation that does provide support for higher education in health care, and much of it, if not almost all of it, is restricted to M.D. and D.O. schools.  So, removing that restrictive language would open up other institutions to apply.

          It doesn't mandate that they get the funding, but it makes them eligible to apply for the funding.

          DR. GORDON:  Thank you.  Anything else?  Bill.

          DR. FAIR:  You had mentioned limitations, knowing your limitations, and I would hope that would apply to physicians also, because I think this idea of residency programs, and so forth, what we are going to have is a jack-of-all-trades and masters in none by M.D.'s thinking they are CAM doctors.

          DR. GORDON:  Yes, that was explicit.  The limitations are all of us.  It is hard for some of us to believe, but we do have limitations.

          It is extremely important, this whole issue, and I think that in the Final Report, we are going to want to go into this at some length, and my hope is that as we go into this in the Final Report, that we may get beyond some of the quarrels that are presently there between people who have different levels of training in different approaches, because if you recognize your limitations, then, you know that if you are doing something part time, and there is somebody who has been doing it full time for 40 years, she is likely to know more about it than you are.

          DR. FAIR:  Well, that is the way I would couch it, in terms of better health care.  I mean the medical oncologist that is spending full time on medical oncology is likely to be much better than the man or woman that is doing medical oncology and nutrition and exercise and counseling, and so forth, so I think that what we are saying is that every patient deserves the best care that they can get, and that means the appropriate specialists.

          DR. GORDON:  Right, exactly, and in terms of education, that everybody needs to know what their education equips them to do and what the limits are of that education and training.

          We are on time.  We are going to take a 15-minute break and then we will come back to the second part of this discussion.  Thank you.  Thank you, Joe.

          [Recess.]

          DR. GORDON:  We are going to move into the second part of this discussion on Credentialing and Licensure.  Joe P. and Joe K., take it away.

          DR. PIZZORNO:  Again, I want to remind the Commissioners we are going to go through a three-step process here.  First, we want to ensure we clearly understand what the questions are; second, we will answer the question what are the characteristics of a good recommendation in this area; third, we will attempt to develop a consensus over a list of recommendations that we will be making here.

          Is everybody clear with that process?  Okay.

          Licensing.  I think there is two key questions we need to answer in this area.  One is, is it the purview of the White House Commission to consider and make recommendations regarding credentialing and licensing of CAM providers?  Second, if so, what recommendations shall we make?

          I think those are two key issues facing us.  We will talk about some answers to those questions.  First, though, let's talk about what are the characteristics of a good recommendation, i.e., how do we know a good recommendation when we see one.

          In the area of credentialing and licensing, what are some recommendations people have about what the characteristics are of a good recommendation?

          [No response.]

          DR. PIZZORNO:  I will prime the pump.  Recommendations should be there to protect the public safety, making recommendations in this arena to protect the public safety.

          What other characteristics would a good recommendation have?

          DR. LOW DOG:  Preserves freedom of choice.

          DR. PIZZORNO:  Preserves freedom of choice.  What else do we have?

          MR. DeVRIES:  Education, scope of practice, which is really part of protecting consumer interests.

          DR. PIZZORNO:  So, something that links education to scope of practice.  Would that be a way of saying it?

          MR. DeVRIES:  Links licensure to scope of practice and education.

          DR. PIZZORNO:  Links licensure to scope of practice and education.

          What other recommendations do we have?

          [No response.]

          DR. PIZZORNO:  I do have some more in my little notes here, but I am hoping to drag them out of the rest of you.

          DR. LOW DOG:  Keep priming that pump.

          DR. PIZZORNO:  Okay.  I will prime the pump again.  To ensure accountability of practitioners.

          DR. WARREN:  Doesn't that go along with public safety?

          DR. PIZZORNO:  That could be considered part of the same thing, yes.

          DR. GORDON:  I think when making recommendations about licensure, one has to take account of the interface and interaction with already existing authorities for licensure and already existing laws.

          DR. PIZZORNO:  So, it takes into account existing law and licensure.

          DR. GORDON:  As well as our own scope of authority.  I think this comes back to some of the recommendations that Linnea made in the beginning, is what we are saying, what is going to be the effect of what we are saying.  That is, do we have sort of a legitimate right, I mean we can make recommendations about anything, what is our own scope of authority.

          DR. PIZZORNO:  So, be consistent with our own scope of authority.

          Bill.

          DR. FAIR:  Again, I don't want to split hairs, but I am not really sure in my own mind the difference between accreditation and credentialing, and I think that the idea of licensing just brings us right on the toes of the states, and I don't think that is a good position for us to be in going on what Tom said this morning.

          I think that it would be necessary, actually essential for each modality to develop their criteria that are necessary to make sure that practitioner is fully trained in that modality, but it seems to me that to take the issue of licensing on head first could chance the whole argument.

          DR. PIZZORNO:  So, let's get to that.  Clearly, we can't mandate to the states these kinds of activities.  We can provide guidance, however.

          George.

          MR. DeVRIES:  The reality is you are not going to take the states head-on, we are not doing that at all, and that is not what this discussion is about, but it is actually making guidance and recommendations to the states.  This Commission has received a letter from the Chairman of the National Governors Association since our last meeting, basically saying he is interested in the work that this Commission is doing in making recommendations to states regarding what is going on within the Commission.

          So, this is not about mandating something a state does, this is not about taking states head-on.  It is actually fulfilling our role as a federal commission, which is making recommendations in the global spectrum.

          Especially, as we consider the broad range of issues of access, delivery, education, reimbursement, that as we continue to talk about, that licensure plays a role at some level in each of these areas, and that making a recommendation for a state to consider in considering everything we have talked about is really all we are doing.

          I believe it fits well and would be received well by the governors or by the states across the country because it is not coming as a mandate, but it is rather providing a source of expertise in the area of complementary health care, to provide guidance.

          DR. FAIR:  You have had much more experience in this area than I have had, but is it likely that a state would push for licensure if accreditation standards were not up to snuff or not been done?

          DR. PIZZORNO:  No, not likely, no.

          Any more recommendations about characteristics of good recommendations?  I should say that differently.  Any more Commissioner thoughts about criteria for good recommendations?  That is better.

          [No response.]

          DR. PIZZORNO:  Okay.  Let's begin to start talking about these recommendations.

          DR. GORDON:  I just want to make explicit the one that Bill raised, because I think it is an important one, which is that we are not walking into mine fields when we are not prepared to do the de-mining.

          DR. PIZZORNO:  Sounds good.

          DR. GORDON:  I am just making that as a characteristic, and then I think the issue that you raised is one that we need to discuss, but I think we all have to be clear that this is one of those areas that is one of the more problematic ones that we are dealing with.

          DR. PIZZORNO:  I have got a couple of comments to start this with.  I have been surprised by a suggestion that the Commission appears confused about the issue of education and credentialing, and I am concerned that we have allowed a strident minority group of anti-government, anti-standards spokespersons to distract us from a very clear directive we received from the Congress and the President.  Please recall Executive Order 13-147, which explicitly stated four directives for recommendations.

          The text starts with the recommendations shall address the following, and the fourth directive is guidance for appropriate access to, and delivery of, complementary and alternative medicine.

          President Clinton further emphasized this in his press release when he talked about the Commission, and two phrases to me stand out quite clearly.

          One is hold complementary and alternative therapies to an appropriate standard of accountability, and we need to set a national agenda for the education and training of health care professionals in this field.  I think that is very, very clear.

          The standard in the U.S. health care system for the past century has been to bring into the system health care practitioners through education, credentialing, and regulation.  The only rational way to provide appropriate access to, and delivery of, complementary and alternative medicine is through the same process, just as has occurred for all other practitioners whether they be physical therapists or osteopathic doctors.

          There is in my mind no question but that we must provide recommendations on how to do this.  Whether to do it or not is not an option, as this would clearly violate the explicit directives we have received.

          I also would like to go further with some thoughts about this.  I think a free-for-all, such as will be tried in Minnesota, is not consistent with our mandate.  If the public does not have a clear pathway to educated, credentialed and regulated CAM professionals, they will only be left with those who are uneducated and disinclined to accountability.

          Not requiring education and licensure further permanently ghettoizes responsible. trained alternative medicine practitioners.

          I think one of the key reasons for the excellent safety record and successful integration in Washington State has been accredited institutions and licensing of all CAM providers.

          So, I think I am clear about where I stand.

          Bill.

          DR. FAIR:  I'm sorry to be so dense about the difference, but is it that individuals are credentialed and institutions are accredited?

          DR. PIZZORNO:  Correct.  In general, institutions are accredited, individuals are credentialed, licensed, et cetera.

          DR. FAIR:  I am happy.

          DR. PIZZORNO:  Great.  Thank you, Bill.

          I also want to emphasize that I think there is a surprising amount of commonality of the Commission in this area, and I went through and read the interviews of all the Commissioners, and I counted 14, if I got it right, and of those 14, 9 discuss licensure, and all 9 supported licensure.  So, I think we have to recognize we have a lot of agreement here.

          I am just going to read those phrases.

          One.  Recommend standardization of requirements state to state regarding licensing, certification, education for practitioners.

          Second one.  To ensure public safety, recommend national standards for accreditation and licensing of practitioners in all states consistent with federalism and the role of states in regulating medical education and licensing.

          Another one.  CAM professional societies must set standards and states must license and oversee CAM practice.

          I think a clear message here is not only do we have to do licensing, we must fully engage professions that are being licensed.

          Next.  At the federal level, develop model laws or regulations to define minimal competency.  States could then develop even higher levels if they wanted.

          Next.  More public education information needed about states' guidelines, regulations, and licensing of several CAM modalities.  Final Report should address matter of state responsibilities in these areas.

          Another one.  Dire need for better quality control.  The issue of licensing is integral to this expectation.

          Another one.  Requiring people to be licensed and have national standards needs to be explored.  Standards should only be established by the group that practice this approach, not by those who know nothing about it, not by the government, but by those who are efficient and proficient to determine standards.

          Finally, it is important for the federal government to take leadership and encourage credentialing and licensure in all 50 states for licensable CAM providers.

          So, I am going to start the conversation with a strong statement.  How about others responding to this and also making their own thoughts?  Tieraona.

          DR. LOW DOG:  I suppose licensure.  I support that, but I can't support it to say that we have to mandate that.  So, while I support moves toward licensure for those who wish to do that, I am in full support of that, and I actually think it furthers the professions, I do.

          However, I am concerned about making that mandatory.  I do think that informed disclosure, disclosing your training, who you are, what you do, what you believe, what your philosophy is, and creating systems of accountability within the state, so that if someone is harmed, that appropriate actions can take place, but in my own state, you are going to make all the Curanderos illegal.  They will be practicing illegally because there is no licensure for Curandismos, and I am not sure that they would want it anyway, because there is no training system for that.

          It is not so much that anybody has really challenged it because of the state that we live in.  I am concerned, though, if you make a statement saying that everybody has to be licensed, that you are going to set a precedent to go after these people, though.

          I think one has to be careful in this area.  As I said, for me, the freedom of choice and the freedom of access is very, very important.  Maybe that is just because of the American spirit, however, I do think we need to have things in place, such as informed disclosure.  You need to clearly state who you are and who you are not.

          I think there has to be mechanisms in place for accountability, but I am not sure that you are going to get consensus from me on some mandatory language for licensure.

          DR. PIZZORNO:  George.

          MR. DeVRIES:  This is not about mandatory licensure.  This is about an encouragement to expand licensure.  So, if states don't choose to license, it doesn't mean that something changes in New Mexico.  Joe and I have talked about this repeatedly, that this is not about mandatory licensure.  This is about an encouragement to states to expand licensure where appropriate for particular provider groups.

          Joe, we may even want to come up, like we have done previously today, and come up with a possible recommendation and float it here right now and see if people are comfortable with it, that covers some of these things and gives a certain amount of comfort level.

          But I think it is focusing in the area -- we don't have to focus in the area of chiropractic, because they are already licensed in all 50 states, but it is a model of licensure that is very successful, but in the areas of acupuncture, massage, naturopathy, these are, for example, areas that are licensed in some states, but not in others.

          This would simply be an encouragement to states to expand licensure in these particular areas, and to evaluate, where appropriate, licensure for other provider groups, but there is nothing mandatory about it, and there is nothing about that if New Mexico decides to create a licensure statute for a particular provider group, that that somehow excludes other practitioners from doing what they do under law.

          DR. PIZZORNO:  Thank you, George.

          Tieraona, I think you have raised a very valid point, and I am going to make some recommendations after we have had some conversation, that I think will alleviate your concerns, and hopefully they will; if not, we will modify it some more.

          Jim.

          DR. GORDON:  Could you say what you mean about it doesn't -- that last part is really important, that it does not exclude other practitioners?

          MR. DeVRIES:  I think what I am saying is, let's take the State of Minnesota where a number of us were at for the town hall meeting, is we are not making a recommendation that Minnesota repeal its law.  We are making a recommendation saying to the State of Minnesota, or to all states, that there is value in licensing CAM providers, and that this is a valuable way of allowing certain provider groups to practice in their state.

          It by no means is saying, we are not saying with that recommendation that you should repeal the Minnesota law.  We are just simply saying you should add potential licensing statutes for certain provider groups in addition to what you already have.

          DR. PIZZORNO:  Charlotte.

          SISTER KERR:  I just wanted to add the comments.  Many of us know the NCCAM recently had a conference with the Royal College of Medicine in England, and they identified this statement that in both countries, UK and America, there is a major concern in both countries over licensure of CAM practices.

          A balance needs to be struck between (a) effectively regulating professions and preventing harm to patients, and (b) respecting individual rights of access and freedom of choice.

          I think that is where we are.

          DR. WARREN:  Is licensure going to restrict access?

          DR. PIZZORNO:  That is a good question.  Is licensure going to restrict access?

          DR. WARREN:  I think it would.

          DR. PIZZORNO:  I think it would change access.

          DR. GORDON:  I am just sort of pushing for everybody who has questions about this, to raise as many questions as we can, so we can get them out on the table.

          DR. PIZZORNO:  Don, would you talk more about that?

          DR. WARREN:  Well, licensure, there is some people that practice certain alternative therapies, that really have no desire to be licensed, but if you have licensure in that state, even though that person may not ever want to be licensed, you grandfather them in.  Why are they being licensed?  They are being licensed to possibly get reimbursement from insurance.  That's it, and to be governed, be regulated.  Now, they are unregulated, so you pretty well have free choice, and the marketplace takes care of that.

          DR. PIZZORNO:  Dean.

          DR. ORNISH:  What I started to say was that it sounded like we had consensus.  If you went through everyone's interview and everybody was saying that they are in favor of licensure, and particularly if it is clear that it is an encouragement for licensure, and not mandatory, then it sounds like we can move on, but I wasn't going to suggest we table this until October just in case you are wondering.

          Clearly, as the field evolves -- it is like the Wild West, you know, with no rules, no laws, and you say, well, yeah, we want freedom to do anything we want, anytime we want, but we have all agreed as a society that we have speed limits.  We have all agreed that they are balanced with freedom of choice, you know, protection from certain things like getting hit by a car when you go into an intersection or having somebody tell you something and there is no basis for it.

          So, I would like to think that the field has evolved to the point where we can all agree that we can recommend that the states increase licensure, and if there are some outlaws who just say I don't want to be licensed, then, they can continue to be outlaws, but I think there needs to be some kind of -- is there anybody who doesn't agree with what you have proposed in that regard?

          DR. LOW DOG:  I think we need to be careful with things like outlaws.  I think that that language itself is very inflammatory especially to traditional practitioners.

          DR. ORNISH:  I was using an old Wild West metaphor. I apologize if it sounds like I was casting asparagus, I didn't mean to be.

          DR. LOW DOG:  All right.  Only because I think that a group of people that often are under-represented in these types of commissions are traditional peoples, and we did get responses from them, but there wasn't an overwhelming number of them that were present here.

          I know my state is unique, but it is 51 percent hispanic and indigenous peoples, and none of those people that are healers in those communities are licensed, and there is no way you could begin to license them, but the communities themselves recognize them as their healers, so the communities support them.

          So, I don't think it is a matter of renegade or outlaw, but I think that it is a complicated issue.  I said to begin with I am in favor of licensure, I think it moves modalities forward, but I want us to be careful of how we word what we are doing because of those groups of people that might be harmed or persecuted if we establish licensure, and they are not licensed, but they certainly are practicing traditional medicine.

          DR. ORNISH:  My question was are you comfortable with the language that Joe proposed.  Is there anyone who is not comfortable with that?  That is my only question.

          DR. PIZZORNO:  Actually, I haven't proposed any language yet.

          DR. ORNISH:  Somebody was saying, they were qualifying it to say that the states would be encouraged -- maybe it was George or Joe or someone -- the states would be encouraged to increase licensure for other CAM modalities.

          Tieraona, is that something that you would be comfortable with, or is that also something that you would be concerned about?

          DR. LOW DOG:  I am over here pondering and reflecting.  You know, it is that kind of seven-generation thing, that the decisions we make today, how is that going to affect us seven generations from now, and everybody is upset with sort of the medical system the way it is, licensed or not licensed.

          I think that we need to be clear of our own personal agendas that are here and what we are moving forward and why we might be pushing particular agendas, and I think we really need to own that, and that licensure benefits certain groups more than it would others, and I just think we need to be honest about that and clear.

          I am not opposing licensure, I am just saying I want us to be careful that the language is not exclusionary for those groups that may not be at a place where they can be licensed.  There would be no way you could do it.

          DR. ORNISH:  I just have to respond.  I don't have a personal agenda about this.

          DR. LOW DOG:  [Off mike.]

          DR. ORNISH:  Okay.  I just wanted to know, my question was if it were put in the terms that we have been discussing, that the states would be encouraged to increase licensure for CAM providers, would that be acceptable to you?  That is all I am trying to ask.

          DR. GORDON:  I want to respond to that because I think it is premature to ask the question, and I really think that we need to explore what licensure may mean, look at some of the history of what it has meant for some people who may not fit neatly into a particular profession, and then make our decision, because on the surface of it, it sounds perfectly reasonable, but I know that there are a lot of other issues, and I think we really need to give time to those issues before we move ahead.

          DR. PIZZORNO:  So, let's go around.  I see several hands.  Let's go Bill, Tom, Charlotte, and then Joe, and then George.

          DR. FAIR:  I would like to ask Dean, he certainly said a lot of things that were very valuable, but, Dean, what is the difference between having credentialed individuals that have graduated from an accredited school with standards approved by their peers versus licensure?  What is the difference?

          DR. ORNISH:  Well, if you have accredited schools, then, I am not really sure what -- it seems to me a fine point -- who is doing the accreditation?

          DR. FAIR:  The board of herbalists, or whatever, and who does the accreditation for physicians?

          DR. ORNISH:  The Board of Medical Quality Assurance does it for physicians.

          DR. FAIR:  Right, so it would be the board of whoever --

          DR. ORNISH:  That is a state function, so how is that different than licensing?  Your license to practice medicine came from the State of New York.

          DR. FAIR:  But the standards are being set by the practitioners.

          DR. ORNISH:  Exactly, and that is all I am suggesting is that the practitioners themselves come up with standards that the state then serves the regulatory function for.  I mean it is the same thing in medicine.

          DR. FAIR:  But I guess you need a state, that is what I am saying.  Would the accreditation be enough, and it would encompass some of the --

          DR. ORNISH:  Let's say for the sake of discussion that you have a group of people who say that if you -- you can be breatharians, it's the Breatharian Society -- and they say you don't really need anything, you can just exist on air, and they all get together and they agree on that, and they come up with their own credentialing, and everybody says, wait a minute, that's crazy, but it's within its own domain.  They say, well, that's okay, we believe that and we are going to credential people to be breatharians.

          Does the state have any function at all in that?

          DR. PIZZORNO:  I would like to move on to Tom.  I would like to make one comment to you, Bill, and that is, accreditation is an academic activity that provides credentials like degrees.  Licensing is separate, because it is a state mandate.  States in the Constitution have the responsibility for control of practice of medicine, and most states -- we can get some technicalities -- but most states have a Medical Practice Act, which is what is called exclusionary, and that is, if you are not practicing under that Act, you must be excluded from that Act, you get prosecuted for practicing medicine.

          So, for example, Curanderos, that Tieraona was talking about, technically could be prosecuted for practicing medicine, so there needs to be protection for those who are practicing either by defining them by licensing or specifically excluding them from the Medical Practice Act, but this requires actual legal action in a state, legislative action.

          DR. FAIR:  Naturopaths can't practice in New York State.

          DR. PIZZORNO:  That is correct.

          DR. FAIR:  So, are they not reputable people, are they breatharians?

          DR. PIZZORNO:  It is a significant political challenge.

          DR. GORDON:  Who says breatharians aren't reputable?

          DR. PIZZORNO:  Tom.

          MR. CHAPPELL:  I am wondering if the issue of licensing doesn't belong in the Information Section of our discourse, and not in this particular section, because first of all, as I have said before, I am not really keen on policy statements that begin with the word "encourage."

          Secondly, I do think we have heard a lot about how this is a state domain, and I would like us to be informational in our Information Section about this being the domain of state law.

          Third, I would like to honor sort of the diversity of communities involved in CAM care.  I think it is really important.  I mean we are the dominant culture, and so we come up with these things that we think are right, but we leave behind the concerns and sensitivities of other cultures.

          You know, when we discussed this last time, I asked the question whether a Native American healer would expect reimbursement from a system.  I knew the answer to that.  The answer is no, they don't expect it, because they don't do it for reward, they do it for their community, and they are selected by their community as having a gift, and therefore, it is their obligation to provide that gift to the community.

          So, it is a lot different and complicated, and I am just wondering whether licensing isn't something we should leave to the states and to the third-party providers, and not to us.

          DR. PIZZORNO:  Thank you, Tom.

          Charlotte.

          SISTER KERR:  Again, I would just support Tom and also what Jim Gordon said.  I think this is premature.  In the statement I read from the UK conference, I think it was very important, that this to me somehow is such a deep issue, although at the level it seems like a very cognitive left wing kind of decision, and particularly the cultural diversity, the hispanic community things we heard, that wonderfully dedicated doctor in New York, the African-American community, there is certainly issues here about how they do access, but also, we have not heard that international piece.

          I know, for one, the United Kingdom has done this very differently forever, since whenever, what is it, 14-whatever, another King somebody said you could do whatever the heck you wanted or something.  The Herbalist Charter, Tieraona is saying.

          So, somewhere in me, this has something very deep and very profound.  It has something to do with this evolution of healing and the new scientific paradigm to me, so I really see this struggle.  For me, it is very, very real.  I am not ready at all to say too much about it.

          DR. PIZZORNO:  Thank you.

          Joe, and then George.

          DR. FINS:  I totally agree with Tom.  I think it is informational to lay out the reasons why you might want to consider licensure, and then say it is the purview of the states, because it would be overstepping to say otherwise.

          In answer to the question of why there is licensure versus simply accreditation, I think the state is sort of the adjudicator of disputes between two bodies that would provide accreditation, but there might be disagreements.  It is a minimal standard or it adjudicates disputes.

          I do think it is related to reimbursement, and I think it is probably a sine qua non, but the most important thing I want to say is that I think that the traditional healers are very close to the practice of religion, and you wouldn't want to do anything that would somehow abridge the Bill of Rights and the right to express oneself religiously, so, you know, Tieraona's sensibility here I think was right, because you are sort of encroaching upon something that is far more fundamental, and it is the right to pray and to worship as you choose, and the relationship between healing and medicine in these areas is very close.

          DR. PIZZORNO:  Thank you.

          George, and then Veronica.

          MR. DeVRIES:  Again, I just want to reiterate that this is only about an encouragement of states to license provider groups, and not necessarily to create a mandate.  Again, the question of why be licensed, you know, the reality is if you look at naturopathic services and naturopathic physician, in order to make that examination, to create a diagnosis, to provide treatment, unless that person is licensed, they are technically practicing medicine without a license, and that is the purpose of the licensure, it legally allows that person to practice their profession.

          The issue, Don, you talked about access, and just to say in particular where licensure really enhances access for the patient, you know, if you compare California with Washington for naturopathic services, in terms of a patient's ability to obtain naturopathic services in Washington, they are licensed providers.

          There is a university, there is many in private practice, the access, there is open access.  Much of the law that got passed, mandating coverage, had a lot to do with the fact that the CAM practitioners of all types were licensed, and that has really enhanced access, where if you look in a place like California, where there is no licensure for naturopathic services, the access is very limited because you really have to go a licensed provider who has naturopathic training, really a medical physician if you want to get those services.

          So, I am just saying the ability to access those services is significantly better in Washington than California as just one particular narrow example, but even another example is, in fact, CAM practitioners who even if they are not licensed, if they are only certified or registered versus being licensed, when a provider is licensed, the ability to be able to access that provider and receive services as a licensed provider is far different than even when they are registered or certified, very often having to go through and obtain physician referral when they are certified or referred.

          I am really talking more in the perspective of a health plan perspective now, and just trying to give a sense there of really the value that comes from the licensure process and how that actually helps to improve access by the patient to the services.

          Again, it just ultimately comes back to a recommendation of the states to consider licensure statutes for certain areas, such as massage therapy, acupuncture, naturopathy services, much like what chiropractic has accomplished in all 50 states, and not creating a mandate for licensure under either those provider groups or other practitioners, such as Minnesota, where the law allows.

          So, just kind of in summarizing it, I think that is really the recommendation, at least I would be encouraging.

          DR. PIZZORNO:  Thank you, George.

          Veronica.

          DR. GUTIERREZ:  From a little different perspective, I support full disclosure, freedom of choice, public health and safety, and I recommend that we promote a national minimal standards of care, body program document, because what hasn't been mentioned, and which I think is really important, is patient expectations.

          I don't know what everybody around this table does, but I have been a patient for a naturopath, traditional Chinese Medicine.  I am going to go to an acupuncturist.  I am trying through my own personal experience to understand what is happening.

          One thing that I have said at almost every meeting that I feel is really important is the intent and purpose of every procedure that is out there for the public to access.

          Joe and I have been going on since December.  I have been asking him, Joe, what is the difference between naturopathic manipulation and a chiropractic adjustment, and he has been working on that, and he is one of the most intelligent people in his profession, I am sure, but it is not an easy issue, and hasn't been resolved yet.

          So, I think that the patient has the right to know what to expect when they walk through the door of any provider group.  I know the states have the final say, but I think that it would be fully appropriate for us to say with the help of the organizations or the colleges or the training schools, whatever they call themselves, to develop national minimum standards of care.

          It would also I think help eliminate a lot of turf wars because I have been involved in the politics of chiropractic for 37 years.  I tell you, you want to change your scope of practice or somebody wants to infringe on what you consider your scope of practice.  That is a lot of energy and a lot of money, and really, the public doesn't benefit at all, whatsoever, from the whole process.

          DR. PIZZORNO:  Thank you.

          Linnea.

          MS. LARSON:  I think it was in February that we actually addressed some of these issues under Education and Licensing, and our small subcommittee actually came to a decision about national accreditation, and also came to some conclusion about discussion about licensure and moving towards it.

          I also want to make one small, but I think it is a very important point, the only thing that licensure does is protect against negligence.  That is what it does, and it defines a scope of practice.  Those who say they are going to do this, if you don't do this, sins of commission and sins of omission if you do something and if you don't.  It is a regulatory function, and the boards are the licensing agency, are comprised of the professionals.

          I just wanted the non-negligence is the issue.

          DR. PIZZORNO:  Thank you.

          I would like to give Jim and Effie a chance to talk, and then I want to make four recommendations to focus our conversation.

          DR. GORDON:  What I would like to say is that in the testimony we have heard, especially in the testimony we have heard in the town halls, but we have heard it elsewhere, as well, licensure doesn't just operate that way.  Licensure also operates to bring people up on charges who are accused of practicing without a license.

          So, for example, in New York, we heard of people who were practicing body-oriented therapies like Feldenkrais or Alexander, who either had been or were concerned about being brought up on charges because they were not licensed as massage therapists, and there were a couple of instances of people who had been brought up on charges.

          So, this is a real issue.  If licensure were just used the way you say it was, that would be one issue, but there are many, many people who testified that they do not want licensure, and furthermore, many of them don't want to be included in the health care system.  They see themselves as either spiritual or educational, and therefore, want to stay outside of the health care system, and the danger of licensure, and I say this as somebody who can also see the benefits.  It is not like I am all on that one side, but I trying to illuminate there are real dangers to licensure, and the danger is always that one particular profession or part of a profession gains control of licensure and uses it to maintain a monopoly.  We have testimony on the history of licensing in the health professions that made that very clear.

           What I am concerned about is -- what William James said -- a premature foreclosure of our accounts with reality on this score of licensure, that it is a very complex subject.

          I just want to make sure that we are all aware of the complexities before we jump into this, and that we understand what we are doing, as well as what we are not doing.

          DR. PIZZORNO:  Thank you, Jim.

          Effie, and then David, and then I want to make some recommendations.

          DR. CHOW:  Thanks, Jim.  I believe in licensure for identified appropriate -- and that is also a problem -- for appropriate practices, and it goes back again, and we don't have the definition of CAM.  We are in a muddle as to what it is.  We assume everything is licensable.

          There are things, you know, like CAM is really dealing with the life system, not really just medical system, and I think we get caught up all the time moving into the medical model, licensing is for medical model.

          So many of the practices are just helping people feel better, and in feeling better, they get healed, and how do you license that, and that people that comes in just to talk because nothing else has worked.

          So, I think I agree that it is a really, really deep and dark subject, and we really need to be careful before we really make strong recommendations about licensing.  I know there is a lot of energy workers, licensing is difficult.  There are spiritual workers.

          So, anyway, I believe in licensing, but I think we really need to take a look at for what criteria.

          DR. PIZZORNO:  Thank you, Effie.

          David.

          DR. BRESLER:  Maybe there is a middle of the road position there for us.  As I recall the testimony that we took, we heard from a lot of practitioners and providers who were eagerly pursuing licensure, and we also heard from many who said don't regulate us at all, stay away from us, we don't care whether we get reimbursed or not, we just want to continue to provide care to our patients and our clients.

          Perhaps the type of recommendation we could make to the state is to encourage them to learn from other states' experiences where the professions who want to be licensed have been licensed and what have been the positive aspects of that and the negative aspects of that, and to somehow keep track of the unlicensed professions who don't want to be, but so that they can still provide information to consumers who have interests or concerns about those, as well.

          Maybe we need to get some more information from these professions as to who wants to be licensed and who doesn't, and it may be not be as big a problem as we think.

          DR. PIZZORNO:  Thank you.

          DR. FAIR:  Joe, can I say one thing?  I want to thank Dean Ornish for his contribution.  It was a real breath of fresh air to the discussion.

          [Laughter.]

          DR. PIZZORNO:  Thank you, Bill.

          MR. ROLIN:  Joe?

          DR. PIZZORNO:  I will you what.  Anybody who has not spoken thus far may speak before I speak again, so, Buford.

          MR. ROLIN:  I wanted to hear the comments before I said this, just coming back from the Native American perspective, whether it's in New Mexico, Washington State, New York, Florida, or where I am from, Alabama, we are sovereign nations, and we are talking about an issue here that could certainly impact us if it was just left in the generic term of traditional healers, because we in no way attempt to regulate our traditional healers on our reservation.

          As Tom pointed out earlier, they don't expect any kind of monetary funds for that.  Gifts, yes, and we have our own systems that we use in the ways of taking care of that, but when it comes to Western medicine, as far as our clinics and our hospitals, we require all of our professionals to be credentialed, and they, of course, are credentialed in the state of their residence,  where they are practicing medicine and are providing service to an Indian community.

          But when it gets to the point of when you say traditional healers, and just to a state, I have some real concern with that, in that aspect of it, because at this point, our traditional healers receive no monetary  compensation.  I just wanted to make sure that I was on record with that.

          DR. PIZZORNO:  Yes.  Anybody else who hasn't spoken yet, who would like to have a chance before I lay some recommendations to further fan the flames of discussion?  Ming.

          DR. TIAN:  I have a suggestion regarding the CAM.  I think the definition of the CAM is not quite clear yet, so probably we should recommend it to protect some kind of healing art, we didn't quite understand.  Why we need to protect them, because we don't quite understand yet.  If we lost this tradition, everybody is going to be medical doctor, it is going to be very boring.

          [Laughter.]

          DR. JONAS:  I would be very interested to hear more details about what happens when a traditional healer comes into the hospital where there are licensed practitioners, and this type of thing, and then how that is managed, if anything, because I think this is, you know, here, we are talking about kind of the crossroads of culture.

          The middle ground that I see that is essential, sort of like there is a kind of a standard of education that we want to have everybody know, at least about self-care and lifestyle and certain professions, they know the basics of complementary medicine.

          I think there is also a middle ground here, and we are talking about professional standards that protect against deception and fraud, and I think there ought to be some kind of basic standards about deception and fraud, and that is not licensure.  That is not the ability to practice a certain scope of practice, which then is largely an economic and access issue.  Those are two different things.

          I think that one could at least say that there are important standards of professional conduct in terms of holding oneself out as any kind, whether it is in education, whether it is in energy medicine, whether it is in traditional healing that requires certain professional and ethical aspects, and several of them are listed at the end in terms of disclosure, for example.

          I would suggest those apply to really all practitioners in some way, and it is different, it is not licensure per se.

          DR. PIZZORNO:  Julia, would you like to say anything?

          MS. SCOTT:  No.

          DR. JONAS:  Buford is next.

          DR. PIZZORNO:  He has already spoken.

          DR. JONAS:  He is responding to my inquiry.

          DR. PIZZORNO:  Okay.  Please do.

          MR. ROLIN:  As far as the hospitals, there are several hospitals in New Mexico now that do have set aside for the traditional healers to come in, and they do collaborate with the Western medicine, as it is referred to in that sense, only if the family wishes.  That is the first and foremost concern.  If the family wishes to integrate the two, fine, then, they will.

          Here again, the patient is given the opportunity to make that decision, and they are given a choice right there, and they don't have to, but I know specifically two hospitals in Navajo Nation where they have the traditional healers there, but beyond that, normally, the traditional healers work within the community, they go to see them there.

          It is now since more and more the tribes are being introduced to Western medicine, they want to know more about the collaboration of the two, and if, in fact, it can work in a way that can help our people.

          That is the way it is utilized now, but it is their choice.  You have to choose between Western medicine or your traditional healers.

          Did I answer your question?

          DR. PIZZORNO:  Thanks, Buford.

          I would like to make four recommendations now, and we are getting near the end of our time.

          1.  Suggest national guidelines for education and licensing standards developed in collaboration with CAM professions.

          2.  Recommend licensure consistent with educational standards.

          3.  Support the states in their licensing work by working in collaboration with the LCME, AAMC, and Federation of Medical Licensing Boards.

          4.  Allow those who want to practice without licensure to do so, but ensure the public is appropriately informed about their credentials or lack thereof, and not confuse or mislead the public by using titles or credentials of licensed professions.

          So, I want to be real clear.  I think the public should have complete freedom to go to anybody they want to, but they must be fully informed about that, and my concern is I see people out there professing to have credentials they don't have, and the public then, assuming a level of safety that does not exist.

          So, I think the licensing has several reasons why it is valuable.

          It protects the public safety and provides accountability to the consumer.

          It protects the practitioners from prosecution from the Exclusive Medical Practice laws.

          This is clearly for the benefit of the professionals, provides legitimacy to professions with education and practice standards.

          It improves public access to qualified and competent CAM practitioners because it is the pathway for insurance coverage.

          What do you all think about this?  Dean.

          DR. ORNISH:  I think if you allow the fourth one to go through, you are going to be -- I am just, you know, the red flag identifier -- it is a pretty radical suggestion.  I am not suggesting that it is a good one or a bad one.  I am just saying that it's a big land mine.

          The fourth one is you allow those who want to practice with licensure to do so as long as they tell people that they don't have a license.  That is a radical suggestion.

          Again, you can argue for it or against it.  I think it is something we should defer to October because you are going to push some major buttons otherwise, that's all.

          DR. PIZZORNO:  Other thoughts?  George.

          DR. BERNIER:  Who would be in charge of notifying patients that their physician wasn't licensed if the physician hadn't told them?

          DR. PIZZORNO:  I think that is a good question.

          DR. BERNIER:  Would there be an all-points bulletin, something sent out?

          DR. PIZZORNO:  The problem with once you don't have licensure, and regulation of the unlicensed practitioners, controlling or paying attention to the harm from that experience is very, very tough.

          I think in situations where you have traditional healers that are in a community, as mentioned, that community provides control.  Where that community does not exist, I have major concerns.

          Tieraona.

          DR. LOW DOG:  In the Interim Report, it has, "All practitioners, CAM, as well as conventional, should disclose to their public their qualifications, education, and training, together with their certification and/or licenses to practice."  This is sort of what I think the staff said at this point, because it says it is ongoing, but this is what it says sort of for the Interim Report.

          "Then, all practitioners should have enough basic education in conventional medicine, as well as their own disciplines, so that they know their limitations in diagnosing, treating" -- blah, blah, blah.

          I think that instead of getting into making statements about people should be able to practice without licenses -- instead of going down that road for the Interim Report, why can't we just leave these two, because I think we need to come back.  I think there is common ground here.  I think there is.  I think we just haven't found it.  But I think there is going to be language that will get us to where we want to go, but for the Interim Report, do we have a problem with just saying that?  These are unresolved issues.  It seems like what we have agreed to so far are those.

          DR. PIZZORNO:  Comments?  Charlotte.

          SISTER KERR:  It is truly a comment.  I think in this matter, we are, as a commission, called to a prophetic role.  You may remember my quote that the prophet's job is one of imagination, and a more earthy quote is a man without imagination is like a man who doesn't sweat, he is full of toxins.

          I think in this matter, I thought Joe Fins did a great job, there is something in here that is very deep at the level of the spirit, that we all agree we want to protect, and yet there is this other place that we need to be of such pure of heart to speak.  I think we need to have some more time for our imagination here.

          DR. PIZZORNO:  Tom.

          MR. CHAPPELL:  I am trying to look at this from the consumer's eyes, and the interest on the part of the consumer I believe is can I trust this person, what do I need to see for trust symbols.  That is my operating question as a consumer.

          I know that there are legal matters to be contended with, reimbursement matters, and I don't minimize the importance of those, but as I think about how this unfolds, that is going to be my driving question is what do I need to know as a consumer about this care provider, so that I can trust them.

          The institution that they have their degree from or the association or profession that they are a part of, those all mean something to me, I think, and especially as education unfolds and information unfolds, that is going to become more important, but the licensing piece still hangs out here unattached for me, and I can't seem to justify it.

          DR. PIZZORNO:  Another piece to add to our thinking is just as the point was brought up I think quite well earlier this afternoon about taking incremental approaches to things, we should recognize that each of these professions and lay healer groups and individual is at different stages in their evolution and maturation as groups and individuals, and what may be appropriate for some groups is not appropriate for others.

          So, I don't think we can assume one solution will cover all, but I think we can come up with some pretty good guidelines to help facilitate resolution in these areas.

          DR. ORNISH:  I just want to clarify that when I say table it until October, it doesn't mean we have to be silent about it, and I think that the language that is in the draft report is really quite good, because it is not taking a position, it is saying we have heard from some people who think that there should be no restrictions at all, we have heard from others who think differently.  We will be considering those points of view in our Final Report.

          In a way it allows us to sidestep the land mines, but it also allows us to get feedback from people before we have taken a position that might mitigate in one direction or another, or might influence what we finally do in October.

          DR. PIZZORNO:  Julia.

          MS. SCOTT:  I really support especially the last two comments by Tom and Dean.  I just don't feel a level of comfort around the table on this issue.  I think the language that is in the draft report is about as far as I can go on this until we have some more discussion.

          DR. PIZZORNO:  Bill.

          DR. FAIR:  Well, I, too, am uncertain about this, but I never thought of the dangers until Jim brought it up, and I just wonder if it would be worthwhile either at the next meeting, have some legal eagle that is an expert in this area, or in the interim, searching this out and sending something to the committee members to see what the feeling would be from those who know about the legal ramifications of licensure.

          DR. GORDON:  I think we can certainly try to pull together some more information.  It is partly legal and historical, but it is also what happens in practice that is the issue, so we can perhaps pull together both some of the testimony we have received and bring in some information from other people.

          One thing I want to say is the general consensus around the table, and before we got to this particular table, has been that we really want to devote as much time as possible to talking among ourselves rather than have too many people or indeed any people come in.

          So, if we can provide that as a general rule of thumb, I am not saying nobody should ever come in, so I think that we can provide some more information and obviously welcome any Commissioners who want to offer us more information, too, about some of these issues.

          I do think that this is one of those areas where there were a lot of unintended consequences, and they were already playing themselves out in a number of different ways, and the more information we have, the better.

          DR. PIZZORNO:  Ken, did you have something to add to this?

          DR. FISHER:  No.  Could you repeat your Recommendation No. 3, because nobody has made any comments on it, just before we get on with the next subject?

          DR. PIZZORNO:  Assuming that we get to the point of recommending licensure at least as appropriate for the states, there are several ways in which we can facilitate this for the state.

          So, for example, establish national guidelines for education, practice standards, in collaboration with CAM professional organizations, and recommend to LCME, AAMC, and Federation of Medical Licensing Boards that they adopt the licensed CAM professions, nationally accredited curricula as models for CAM education, licensure, and practice standards.

          The main purpose here was to make sure that the CAM professions are working with not only the states, but also all the conventional licensing organizations, so we have a consistency of standards, so we follow the same procedures everybody else has.

          Joe.

          DR. FINS:  I just want to respond to Jim's comment about the investigative process by some of the boards.  I think, you know, language in here, which I don't see again as I skim it, something like due process, you know, regard for due process and adequate representation of CAM folks on those boards.

          The other point is -- I just open this up as an issue -- it seems again the heterogeneity of different groups in different parts of the spectrum and evolution, it seems premature to talk about licensure for groups that don't have consensus in their own professional organizations.

          So, in tandem with talking about states working with groups, we should also talk about the groups working within their own disciplines as a precursor to some more formalized recognition.

          DR. PIZZORNO:  Any other comments from Commissioners?

          [No response.]

          DR. PIZZORNO:  Jim, I will turn it over to you for summary.

          DR. GORDON:  Thank you, Joe.  Thank you for summarizing a number of issues and bringing them ahead.

          I feel like this is a situation where what we have done is we have gone to the next level in understanding the issues that we are dealing with, and we have seen a tremendous amount of diversity in the Commission's responses.

          We began by talking about some of the issues that are involved in making any recommendations about licensure and credentialing.  Joe outlined a number and other contributed, as well.  These include protecting public safety, preserving freedom of choice.  Licensing in any event would match scope of practice and education, ensuring accountability, taking into account existing arrangements for licensure in the states; being consistent with our own scope of authority as a White House Commission, and making recommendations to states potentially as something that we may want to do, that we have been asked at least by the National Governors Association.

          I think what we have come up with here is real legitimate concerns on a number of different sides, and I think Joe and George articulated some of the advantages of licensure both in ensuring accountability in giving wide access to professions, for example, naturopathy, giving wider access, the significantly increased access in a state like Washington where there is licensure versus a state like California, where you can't have easy access to naturopathic physicians, and you have to work with people who are licensed in other ways who may know about naturopathic medicine.

          The distinction was made again that the idea would be to encourage licensure rather than mandate licensure, and at the same time, not repeal or come out in any way against freedom of choice.

          There are a number of different ways of doing that including the possibility of talking about national minimal standards of care as another variant on the idea of licensure.

          The difficulty, though, that several of us raised are some of the unintended consequence of licensure, and I think what we pointed out is particularly those of us who have worked with traditional healers or have worked with people who are unlicensed and don't want licensure, as well as those of us who have attended some of the meetings where these people have spoken, is there are very clear feelings on the part of traditional healers from many different cultures, a sense of ambivalence about the whole issue of licensure.

          In fact, in Minnesota, we heard very clearly a sense that somehow any licensure, attempt to license CAM professions was probably going to work against the freedom of traditional healers and of traditional people to work with their healers.  So, this is a very real concern.

          Then, another issue that I raised, that we heard a good deal about, particularly in New York, is those who are concerned that by the narrow definition that may come with licensure, they will be excluded from practicing.  So, for example, somebody who does therapeutic touch or Reiki or Alexander, an Alexander teacher will be persecuted or prosecuted because they are not licensed as massage therapists or others who have direct licensure to touch the body or to even work off the body.

          Joe made recommendations about national guidelines for licensure, licensure consistent with educational standards, and working collaboratively with the various licensing groups at the state and national level as three recommendations, and the fourth, that practitioners would still be allowed to practice as long as they inform the public about their qualifications and their credentials, and their scope of practice.

          What I heard in response to that is although people could see the wisdom in those recommendations, there was substantial uneasiness around the table about proceeding with those kinds of recommendations at the present point for a variety of different reasons.

          There was, I heard, not a considerable agreement that the two recommendations that are in the Interim Report really reflected most accurately where we are now, and that we needed more in-depth discussion and indeed more information about issues of licensure, so we could address them in October.

          Joe.

          DR. FINS:  I am just wondering, we haven't talked at all about accrediting institutions.  We talked about practitioners, individuals, but we haven't talked about clinics as entities that are one level above, and I am wondering if that gets covered anywhere.

          DR. GORDON:  Clinics rather than educational institutions.

          DR. FINS:  Yes, a clinic, like JAACO is to hospitals as blank is to a CAM clinic.  Have we missed that somewhere in the spectrum?

          DR. GORDON:  We might, especially given time constraints, why don't we come back to that when we talk about access to services and bring up that issue there rather than address it in this phase here.  You are right, we have not really addressed that.

          That reflects where we are with this issue right now.  Let's take a 10-minute break and then we will come back and discuss information and dissemination of information.

          [Recess.]

          DR. GORDON:  We need to get started.  We have an hour for David and Corinne to work with us through the issues related to information.

          DR. BRESLER:  We have about an hour to talk about what is, for me, the one subject where I feel personally most conflicted of all, and that is about information dissemination.

          We have got less than an hour in which to do it, so let's give it the best shot we can and hopefully, we will find that we have greater consensus on these issues, or at least all of you have greater consensus than I personally feel that I do.

          They say that the pen is mightier than the sword, and I think when we talk about information dissemination in CAM, it is a particularly touchy issue.  Information is what leads people to have certain beliefs and attitudes about these interventions, and I wonder in some circumstances whether the information itself, in terms of those beliefs, may be more powerful than the intervention itself.

          To the extent that CAM practices rely on the placebo effect or positive expectant faith or positive beliefs in efficacy, to the extent that those of us who are determined to pursue true science, you know, are we really doing these indigenous practices a service in perhaps questioning the fundamental beliefs that underlie the efficacy of these treatments.

          So, information, for me, is something that has to be really addressed quite seriously when we talk about CAM, and I think it is one of the greatest concerns that consumers have, that is, getting accurate information about these particular modalities and practices.

          I am not trying to open another can of worms, but it is of great concern to me that we be responsible in the recommendations we make in terms of how information is being treated, because as I said, I think it can affect a great deal of what CAM is all about.

          With that said, we are going to really focus in the time that we have on two primary concerns.  One is issues related to the Internet and the media, print media, and so forth, and again, I think underlying that is people are getting a lot of information, is that information accurate, is that information safe, is that information useful or helpful.

          The second thing that we will discuss today is basically how regulatory agencies can deal with the issues of improper information or incorrect information.  To me, DSHEA, our discussions about DSHEA really come under that rubric more than under research.  That was a little confusing to me why it was discussed under research rather than truth in labeling, which is what seems to me is what it is more about, but fortunately, we have already had that discussion, and we don't need to talk about DSHEA in the context of this.

          I will refer you to your workbooks, if you would.  Basically, Corinne and the staff have done an excellent job at really focusing on some of the major concerns and issues.  Let's just go through them one by one, and hopefully, let's see if we have some consensus on some of these issues.

          The first issue that came up was a great deal of concern.  We heard lots of testimony about people accessing the Internet, and there is no question that people are.  The concerns that we have is how accurate is that information, how dangerous is that information, how useful is that information, and so on.

          I will just open the discussion now.  I hope all of you have read through this material in your guidebook, but I will open the discussion now to this first issue, which has to do with the quality, accuracy, accessibility, and timeliness of information on the Internet.

          Comments?  Joe.

          DR. PIZZORNO:  This is really tough because obviously, the Internet is a wonderful tool for information dissemination, and it is also very easy to disseminate bad information.  It appears to be based on an announcement, some of you may have seen two weeks ago from the FTC, that they did indeed bring to fruition several of these cases that they had told us they are going to be bringing to fruition.

          A concern I have is that they spent a huge amount of money doing this.  How do we establish some kind of process by which the truly fraudulent web sites are handled in a cost effective manner, and yet we don't get in the position of censoring people who happen to have ideas that are different from the mainstream?

          DR. BRESLER:  Comments from Commissioners?

          [No response.]

          DR. BRESLER:  Well, I have some thoughts about it, that I will just throw on the table and maybe other people will have other thoughts about it, too.

          When you think about how the peer review process works in a sense, and this is a fairly well time-tested process in medicine, we say that research is judged by a panel of our peers who are knowledgeable and familiar with it, and staff members have I thought drafted a nice position paper recommending a joint venture between public and private sectors consisting of rotating interested parties who would set up a board of standards, which would review it, kind of like the Good Housekeeping Seal of Approval, or something like that, a joint venture between again government and private representatives who have interests in these areas, and various types of information would be reviewed, if we are talking Internet sites in particular, a set of standards of accuracy, of ethical presentation of information, of disclosure, of self-serving interests, things of this sort.

          To the extent that those sites met those standards, they would get the Seal of Approval or some sort of -- I mean again, this has to be teased out a little bit, but in a sense, isn't that what we do when we read manuscripts for publication in a journal?  It is reviewed by a panel of sorts.

          Other thoughts or comments about this?  Bill.

          DR. FAIR:  I had just jotted a few things down in no particular order, but it seemed to me what we really need is a clearinghouse for CAM information, which would give some description to the uninitiated, a description of the CAM modality, something about the supporting evidence which identifies the clinical and scientific or even anecdotal evidence for its usefulness, a description of the qualifications required for a practitioner of the modality, list of books or other resources tied in with the NCCAM site, and provide some information on the conventional and cost effectiveness of CAM modalities, and have some hyperlink, hypertext things where you can click and check onto other CAM-certified sites, which means, that there would have to be some sort of a board oversight to make sure that they are not fake sites, that they are really providing good information.

          This board would establish content standard for the certified CAM sites, and then I think also what is important is establishing a centralized source for media CAM context.  I mean Jim has done this very well, but often in an individual area, they will just pick whoever seems to be a CAM practitioner, and you may get a lot of hocus-pocus or trying to sell their own potions or something like that.

          The other area which was mentioned is that a lot of people don't use the web still, and those who do, it is sometimes very complicated, so we would have to make this easy, and we also have to I think provide some training to librarians on CAM, so that they can access it and serve as teachers to those who are coming in the library and not used to working with the Internet on their own.

          Lastly, I think that ensure information about CAM is available to address the needs of special populations - elderly, children, and minority, and is presented in such a way to respect the cultural and linguistic diversity in the country.

          That is sort of an overview of some of the things.

          DR. BRESLER:  Well, these are, in fact, the issues that we are going to go through. I would like to see if we could get a general consensus on them one at a time, because I think we may be in more agreement about these particular issues and can get through them fairly quickly.

          Basically, the first issue is about a board that is going to set standards.  In terms of a national clearinghouse, that is the third one, something centralized within the federal government, a central clearinghouse of information.

          Can we just take them one at a time and just stay with the first one?  Does it make sense, do we have a consensus that it would be a good idea to look at a joint venture between the government and the private sector and interested organizations, nonprofit, and so forth, to set up a board of standards in some sort of way that can kind of quickly overview a lot of these things, and put its seal of approval or not, just as information like from a peer review board for an editorial journal?  Let's just stay focused on this particular issue.

          Comments or feelings, pro or consensus?

          DR. FAIR:  Well, again, if it was done well enough, it was the best game in town, just by the competition, you would wipe out the sites that were providing inappropriate information or false information, if it was really done high class and had the links to the other good sites, and provided timely information, I think that would be an excellent way to go.

          DR. BRESLER:  Other comments?  Does anybody have any objections to pursuing such a notion?  Wayne.

          DR. GORDON:  Before Wayne speaks, I would like to make sure that we hear all the objections because this is one of the recommendations that is in the Interim Report, and again it is important that we talk about all the pros and construction.

          DR. JONAS:  I am trying to find my notes on this because I made some notes actually about this in the main report, because it was in the main report, but I had some real reservations about having a government-sanctioned central authoritative information source.

          First of all, I am not sure the government can do it.  Second of all, I am not sure if people would believe.  Third of all, I am not sure if we would want to spend government money trying to come up with something that may or may not provide the kind of information that is accurate and that is useful for patients.

          What tends to happen --

          DR. GORDON:  Let me clarify.  Are we talking about the joint government-private venture in sort of creating Good Housekeeping Seal of Approval or are you talking about something else like a government clearinghouse?

          DR. JONAS:  I think both of those are linked because if you had a clearinghouse, then, that automatically has the imprimatur of the Good Housekeeping Seal, so you really can't separate them in my mind.

          It happens.  I mean it is going on.  There are clearinghouses that provide that type of information, however, it is quite risky and what tends to happen is that you tend to get very conservative information, and legitimately so, because the information that comes out of that is looked at as something that has potential public health, wide public health impact.

          So, it is very much like the RDAs that come out.  They are very conservative, you know, they are incremental changes in, you know, well, now you need 60 milligrams of Vitamin C, well, no, 100 milligrams now, we will drop it back down to 60 milligrams a few years later based on kind of minute assessment of the studies.

          My fear is that this the type of thing that this would fall into, and it would get dominated, maybe appropriately so, by scientists who are looking at the current hard data and saying we can or cannot make recommendations about these areas, and the vast majority of them may be, you know, there are no recommendations that can be made, and then you might get one or two things like that, and it wouldn't be all that valuable.

          I think patients would probably find it didn't help them very much.

          DR. BRESLER:  Do you have the same concerns about government-sponsored consensus panels?

          DR. JONAS:  Yes.  An example is the Acupuncture Consensus Panel.  Individuals go out to get acupuncture for a variety of reasons, but if you go to the consensus panel and the report of that, it says that acupuncture works for two things:  postoperative dental pain and chemotherapy-associated nausea and vomiting.

          Now, that is not very useful for most patients.  It may be scientifically sound, and is scientifically sound based on the criteria that were used, but it is not very useful for patients.

          So, these are some of my concerns about this.

          DR. BRESLER:  Other comments?  Tom.

          MR. CHAPPELL:  I just want to clarify.  Are we talking about information dissemination in general, or are we structuring this question around the technology of the Internet?

          DR. BRESLER:  I see two aspects of it.  Number one, what is the information that people need to have that they are not getting.  Number two, what information are they getting that is inaccurate, incorrect, or misleading.

          MR. CHAPPELL:  Thank you.  I do think they are separate, and I would like to focus on the first part of the issue, which is our responsibility to disseminate CAM-related information to the general public.

          I am thinking, for instance, of the amount of research that is being done by the government, and will continue and hopefully expanded by the government, on CAM-related services and product.

          Therefore, it just seems like a natural to me that it would be a government body, a CAM-interested government body, and not a quasi-public/private.

          I don't see the need to sort of pass this responsibility out of the government into the private sector because that will involve lots of questions of trust as to what the agenda is, and what is the governance system?  There is no suggestion here about the governance system, where does the authority come from.  So, I do have some reservations about the recommendation as is presented.

          DR. BRESLER:  Jim.

          DR. GORDON:  I want to make just a couple of points.  Wayne, I share your dismay at the conservative nature of many of the recommendations, and also at the lack of information that has been posted.

          I would just say the amount of information is inadequate to the public need at this point, significantly inadequate.  There are a tremendous number of questions that people have.

          First, the Office, now the National Center for Complementary and Alternative Medicine, has a mandate in the law to provide information and to provide a clearinghouse.  People want to look to as authoritative a source as possible.

          My feeling is that it is our responsibility to make some recommendations, not just to NCCAM, but to the government in general, to help increase the amount, the validity, the accessibility, the usefulness of that information, and if indeed there is not enough or it has been too conservative, I think that it is time to really come up with I would say some general recommendations now, and then some very specific recommendations about how to move this whole agenda ahead.

          One of the testimonies that we heard last time was from Brian Berman, talking about the Cochrane Collaborative, and talking about the kinds of information that they have accumulated, and their willingness and their capacity to provide that information in a usable form.

          I see that we can successfully use private contractors of a variety of different sorts to provide different kinds of information.  I see this as one of the most important problems that we are facing.  Especially people with life-threatening illness want to have this kind of information.

          We have some of this information coming out from our Cancer Conference up on our web site for the Center for Mind-Body Medicine.  It is very useful.  It is just one condition, and it is not nearly as much as people with cancer need.  They need even more than we have, and we have a fair amount up there.

          So, I just feel like if we don't do it, and we don't take the leadership, it is not going to happen, and it is unlikely to happen nearly as well as we can make it happen if we shape it.

          DR. BRESLER:  Finish this point, and then Tieraona.

          DR. JONAS:  I guess my question would be, okay, there was a mandate, and still is a mandate, for NCCAM, for example, to provide a public information clearinghouse, so here is an authoritative body that sorts through and provides information, not just on research and literature, they also provide other types of information.

          So, where is the need then?  I mean here we have one mandate, there is a fair amount of money going into this, they have a clearinghouse.  If we were to recommend setting up another clearinghouse, or another authoritative body, what difference would that be from what currently goes on in NCCAM?  Do you see what I am saying?

          DR. GORDON:  I don't know if there needs to be another body.  I think there may need to be another body of information that is made available or information made available in a way that is more usable.

          For example, discussions on the state of the art of many, many different practices, discussion for clinicians, discussions on information about different products, practices for patients, discussion about the state of the art of research in a variety of different areas for researchers.

          DR. JONAS:  That is quite a bit different than what Cochrane is doing or what NCCAM is doing.

          DR. GORDON:  I understand.  That is what I am saying.  I am saying that there is a huge need for this information.  I have it, my patients have it, reporters who are calling me up have it.  We have it when we think about doing research, and I see it as this is an area that we can really shape what is offered, make recommendations.  It may be NCCAM in some instances, it may be NLM, it may be other agencies that would provide it, because I think we have that opportunity now.  If we pass it up, then, I don't know that -- because our mandate is to look much broader and then to make the recommendations.

          DR. BRESLER:  Thank you, Jim.

          It is my feeling, too, that I think the public wants somebody to step up to the plate on this issue, and not just review what existing research is out there, but they want to know whether an Internet site is giving them credible information or not, or whether this news magazine is biased in some way.

          I think they want the Surgeon General or somebody, some reputable representative of the government in some kind of way, some sort of sanctioned authority to step up to the plate and bite off this issue one way or another.

          Tieraona.

          DR. LOW DOG:  Well, I am hearing several different things.  One is about setting up this group that will review all these sites and somehow give it a rating.  I am not sure.  I have real problems with the Internet, but I am not sure that is the answer.  I am not sure that sort of giving sites that, because I am not sure it wouldn't stifle sort of things that are on the edge, but that may have value.

          I am concerned about what group of people you are going to get in there, that are going to rank those sites.  That is really under the purview of the FTC.  Their job is to look after fraudulent advertising, so that is what they go and do, and I think they should be encouraged to do that.  If people are fraudulently making claims or selling products, then, they should handle that.

          The second part of that is the discussion of dissemination of information, and that is important because -- instead of saying we are going to go and number all these sites and tell you if they are good or bad, to provide a site that is well publicized, perhaps with links to other sites, that provides probably conservative, somewhat conservative information about different CAM modalities that consumers can go and check, what is the research behind it, what do we know about it, and I think NCCAM is doing some of this, ODS is doing it, I mean there is a number -- Cochrane again, but if you review much of that, that is fairly conservative, too, the findings of these things.

          But I think that that is okay, because I think it sort of says where the science is today, and I think the government does need to be somewhat conservative in it.  If you leave the FTC to sort of sift out a lot of the other stuff on the Internet, and encourage perhaps more rigor in their perusal of those sites, without sort of giving this stamp of approval, which I do have some concerns about, I think you are still going to let people have a lot of information out there including perhaps cutting edge or more fringey information, but then you will have a site or a link of sites that are more conservative, but are really based on very good evidence.

          DR. BRESLER:  I don't think the intention was to rate sites and give them a stamp of approval.  I think the intention was to develop standards for Internet sites of accuracy, of ethical behavior, of documenting claims and representations, things of that sort, and inviting sites who meet those standards to use that designation or to apply for that designation that they meet those particular standards.  It is a way of identifying the sites that generally agree to follow these basic standards set by this joint venture.

          DR. LOW DOG:  Okay.  I wasn't clear.  I was reading about no site will not be required to have a rating, so all sites will have to have a rating, and sites that have been reviewed and found in compliance with the criteria can do so, so I was confused.

          DR. GORDON:  It is confusing because again, it is an issue where there have been many recommendations made by the public, and what we are using this meeting for is to really sharpen where we are on the spectrum, and that is really listening to all the recommendations that have been made and then coming up with our own consensus if we can on the issue.

          DR. BRESLER:  Tom.

          MR. CHAPPELL:  I am having a little trouble.  Jim, with what I heard you advocating, which I agree with completely, I don't see that in harmony with this Issue No. 2 recommendation unless I am just plain missing it.  So, I just am seeking some clarification.

          David, are you looking for feedback on Issue No. 1 in the report?

          DR. GORDON:  What has happened is that we have confused Issue No. 1 and Issue No. 3.  So, what I was talking to primarily is Issue No. 3.

          MR. CHAPPELL:  Well, I agree completely with that.  I don't feel we should be passing the accountability that we have as a government on information development and dissemination to an outside body.  If it is a partnership, that authority still has to remain with the government, and I feel very strongly about that.

          So, the way this is written is not clear enough for me, Issue No. 1 as being a partnership, but it isn't establishing governance sufficiently for me.  I am fine with the partnership.  Integrity is the issue here, and how are we going to protect the integrity of the people that produce this information and disseminate it.

          I think the technology is a totally separate issue, and I do agree with Tieraona that the FTC is the regulatory body for this, and they should be encouraged to just do that.  I don't want to make up new problems.

          DR. BRESLER:  The way I read it anyway, it was clearly written as a partnership between the government and the private sector and various organizations to develop the standards.

          I guess the first issue here is do we believe that certain standards should be set for communicating accurate information about CAM.  I think that is the number one issue, that some group of individuals or organizations should review information and let people know whether they think this is accurate and honest, up to date, and so forth.

          Tieraona.

          DR. LOW DOG:  Can I just ask for clarification?  One is I support Issue No. 3 and the recommendations there.  No. 1, I again need clarification just from a legal point of view.

          If a site is not selling you anything, it is just information, it is not selling you anything, isn't that protected under freedom of speech?  I mean does it have to conform to certain standards or is it just freedom of speech like a book that you can put out creative thoughts?

          Now it is different if it is trying to sell you a product and it is saying all this stuff to sell me something at the end of it, but isn't there something about -- I don't know, but it would seem like on the Internet, that is just an extension of freedom of speech if are you are writing information.

          DR. FAIR:  I would think you are probably right, but there is nothing that says that that link has to be made between the site, even though if it is not selling anything, may not be of value to the person that is looking for the information.

          I mean just because they are not selling something, it doesn't mean it has to be tied into this overall information system.

          DR. BRESLER:  Can we come back to the first number?  I want to stay with this because we can wander all around this issue, too, but the question is again, and I will put it to the Commissioners, the question is, do you feel that there should be some body of experts that can determine standards for accuracy and information about CAM, and that people who have Internet sites, and so forth, it is not mandated, but they can request approval, they can run their information through this group, and this group says yes, we think the evidence supports it, we think it is up to date, we think it is accurate information.

          The question is we have heard lots of testimony from consumer groups saying they want this, they want to know where the accurate information can be found.  Is this a recommendation that we feel comfortable making?

          George.

          DR. BERNIER:  On page 8 and 9 in the draft report, this is really scary language.

          DR. BRESLER:  Are you looking at the briefing book or the draft report?

          DR. BERNIER:  I was looking at the draft report.

          DR. BRESLER:  We are in the briefing book.

          DR. BERNIER:  Sorry.

          DR. BRESLER:  Tom.

          MR. CHAPPELL:  My answer to the question you asked is yes, absolutely, but I do not think that Issue No. 1 recommendation accomplishes that, period.

          DR. BRESLER:  Do you have other suggestions?

          MR. CHAPPELL:  Just to develop the thought that you articulated, but this doesn't do it.

          DR. BRESLER:  Other comments?  Bill.

          DR. FAIR:  We seem to be talking about the research primarily.  I think we need a site where people are interested in chelation.  They can log on and find out what chelation is and what are the pros of chelation.  We don't have to say this is good or bad, just list the pros or cons or whatever else comes under complementary medicine, what technique is involved, and so forth, and so on.

          Then, it seems to me that the National Center does a pretty good job, PubMed does a pretty good job of research.  If we had a tie into those other links, there would be a clearinghouse where one could get the information about a particular technology, and if they wanted to go on further and deeper research, they could click the link, and there it would be.

          DR. BRESLER:  Other comments about this issue?

          [No response.]

          DR. BRESLER:  What I would like to do is just come back at it because we are going to approach it a couple more times as we finish this first issue, and we may be able to knock off a couple of the other ones that we all feel pretty much the same about.

          The No. 2 issue up here is about Privacy of CAM Information on the Internet, and when people visit Internet sites, and they happen to leave a cookie in their own computer or information about themselves, it goes onto the sites.

          How do the sites use that information?  This is a privacy issue.  A lot of consumers that we heard testimony from had concerns about visiting sites for fear that they employers, their insurance companies, others would get that information that they were researching an illness that they might have, and they were frightened to go on line for fear of being discovered that way.

          The second issue really is do we want to make recommendations about the way that Internet sites protect the privacy of individuals who visit those sites in order to get information.

          Comments?

          DR. GORDON:  The first thought that comes to mind is whether this also fits under some general sense of guidelines for sites that are being visited.  I don't mean to just dive back into that question, but it doesn't seem like it is necessarily separated.

          This is an ethical issue.  This is your privacy.  It may be the kind of issue for which some public/private group wants to make some -- maybe we can start with making some recommendations, and there may need to be some follow up.

          But just the way false information is an ethical issue or information where you don't disclose your financial interest in the information that you are providing is an ethical issue, similarly, this one.

          DR. BRESLER:  Let me see if we can knock this off fast.  The recommendation is very simple.  It is to encourage CAM sites to disclose if users are tracked and how the information is going to be utilized, they have to disclose that, and secondly, to explore the necessity of developing, amending current legislation or regulations to assure the protection of privacy of CAM health information seekers on the Internet.

          Do people have any concerns about these recommendations?  Do we have a general consensus of this?  Does anybody have any objection to these?

          [No response.]

          DR. BRESLER:  Good.  Again, I want to just hold off on the third one and the first one, because they are both related to this notion of centralizing information of some kind of body having to do with information, the same thing with the fourth.

          Related to media contacts, again, this is something, I don't know, maybe because I live near Hollywood, but in my experience, all it takes is for one Hollywood movie to reflect a CAM modality in an unfavorable way, and it is going to affect a lot of people's utilization, in much the same way that all it takes is one celebrity in Hollywood to say that they used pixie dust to cure their cancer, and a lot of citizens are going to stop conventional therapy and go get pixie dust.

          This is just the way the media influences our culture, and again, I think it is something certainly worth considering.

          Comments about this issue about the media?

          DR. GORDON:  I think that this issue is also a function of our recommendation, at least tentative recommendation, to have a central office at the level of the Secretary of HHS, and that this would be a place where media contact -- just like now, media contacts go to each federal organization, but if they were a central office, that could be a central place for them.

          DR. BRESLER:  Since you brought it up, and since it is one of the recommendations, do people have comments or thoughts about a central office in the Department that can handle dissemination of information in this way?

          DR. FAIR:  Again, I think it is the one-stop shop.  Tieraona has been talking several times here about a place where people who could get information on, say, the hundred or 50 most widely used herbs, the pros and cons, the indications, and so forth.

          So, if someone wants to use mistletoe to great their cancer, and there was a central clearinghouse that they could get the information in an easy way, that would be a real service, I think.

          Maybe we could put it in the branch of the government that never makes a mistake, like the IRS.

          DR. BRESLER:  Right.

          [Laughter.]

          DR. BRESLER:  Other comments from Commissioners?

          [No response.]

          DR. BRESLER:  Do we have any objections to the notion of there being a central clearinghouse for information within the Department level?

          DR. JONAS:  Do I need to reiterate mine?

          DR. BRESLER:  Wayne's objections are duly noted, and again we will come back toward the end of our discussion.

          DR. JONAS:  Go ahead.  Let them try.

          DR. BRESLER:  Let's take something a little more benign.  We have also discussed using -- we have heard testimony along this line -- using the library system as a great source of information to the public who may not have access in other ways.

          Most libraries have Internet access, and the question is, is the librarians need to be brought up to speed about CAM and about the information sources that are available, so that they can bring the public up to speed, too.

          Joe.

          DR. PIZZORNO:  I don't think we have to worry about this because they are already very knowledgeable, because it is one of the most common questions they get, so I don't think we have to worry about it.

          DR. FINS:  The other institution that is not mentioned here is the Library of Congress.  You know, it is sort of the definitive library.  Maybe there is some sort of collaborative venture that could be established with them, as well.

          DR. FAIR:  I would like to take the opposite view, though, from Joe.  It hasn't hit East Hampton, I can tell you that from personal experience.  They can't give you any information.

          DR. WARREN:  I think if you go to Rural America, you don't see this.

          DR. FAIR:  Rural America doesn't usually include East Hampton.

          DR. WARREN:  Rural America includes the hills of Arkansas, and they go for books, and that's about it.  They don't look at the Internet.  I mean there is a large population out there that has no access to it, they don't even have access to a library.

          DR. BRESLER:  I am trying to push this through here.  Do we have consensus that we want to encourage the Library of Congress, the library system to utilize its resources to make CAM information more widely available to the public, and also to provide additional training to those librarians in this area?  Is there any objection to that?  Charlotte.

          SISTER KERR:  Just a comment.  It is like a reverse thing.  Remember when the report was the governors wrote a letter, today, somebody reported on that?  I see this as a way -- at least I don't think we are saying this at this point -- how we might make recommendations that affect keeping public libraries open, because of the impact they are having on public health.  In my city, we are closing libraries, and it's a big deal.  You understand what I am saying like a reverse of how we might make state and local recommendation?  Thank you.

          DR. BRESLER:  Again, this is another area where down the line we could consider very creative ideas like incentivizing the private sector in various ways to support the library system.  I think our current administration would be kind of open to these ideas of working with the private sector to support this sort of thing outside of exclusive government support.

          Any more comments about the library system?

          DR. GORDON:  One quick comment.  I think this is very exciting.  I think that the libraries can be a wonderful source both through books and pamphlets and through the Internet of information about CAM and especially about the self-help aspects of CAM.  I think we can do a lot of good in this area, and it would be very helpful in giving people much more information.

          DR. BRESLER:  Any other discussion about the library system?

          [No response.]

          DR. BRESLER:  Can we move on?  There were recommendations about making CAM information available to people with limited literacy skills.

          Again, comments from Commissioners about this recommendation?

          DR. GORDON:  I think this fits very much with the public library recommendation, and it is a way to reach out even beyond those who ordinarily come to libraries.

          DR. FINS:  This dovetails with an initiative that I think is going on at Emory and with the AMA Institute, whatever their foundation side is, looking at literacy, and it is generic problem, and there may be some linkages to sort of tie in with them, looking at ways to help people make these choices.

          They looked at how people comply with generic medications, not CAM modalities, and it was really problematic, the level of understanding people had, which is just another issue that I want to just harken back to.

          On Recommendation 1(b), you say conduct a public education campaign.  It teaches people how to evaluate CAM information.  It brings up the issue of scientific literacy.  We should be focusing on education.  This again may be an area where this administration, focused on education, might be consonant with that, because people need the basic skills to make these determinations, especially if it is about self-treatment and about wellness, and doesn't involve the intermediary of a professional practitioner.  So, I think that might be another linkage area.

          DR. BRESLER:  Other comments?  Tom.

          MR. CHAPPELL:  I am trying to imagine how this information delivery occurs to some of these special groups that we are talking about, and I don't think we want more literature piling up in government offices or government buildings.

          These populations don't necessarily use the Internet, so my question, I am thinking how does CAM become real to them.  I am thinking about people who go out and just promote and educate about CAM in rural communities.

          These are ombudsmen or advocates or they are teachers, but they are promoters of this, and on any of these issues, whether it is 7 or 8 or 6, you know, it would be great to have countywide people whose job it was to go into the school systems or wherever they might go and educate.

          DR. BRESLER:  Again, we do this on certain public health issues like HIV, don't we?  When we have certain public health concerns, we do have public health educators who go into the rural communities, into school systems, other kinds of places.

          MR. CHAPPELL:  Great, perfect model.  I think it needs something like this, because it has to be made real, and too few of us can read something and get it.  I mean it needs to be engaged.

          DR. BRESLER:  Other comments?  Joe.

          DR. FINS:  Thinking about Tom's desire to do stuff with the marketplace, I mean pharmacists are probably very close to where a lot of this information would be really relevant.  Maybe we could have some --maybe Steve could comment on this -- but some sort of educational program for pharmacists, with the Pharmacy Association, so that they also become educators, especially about drug interactions and the like.

          DR. GROFT:  I know the pharmacists are definitely interested, and they have initiated some programs to start to educate the practitioners more and more I think.  Tyrone has been a very avid supporter of doing this for botanicals, and I expect to see this increasing more and more as we go on.

          DR. BRESLER:  We have about 20 minutes to finish our discussion this afternoon.  We still have a lot to cover.

          Effie, and then Jim.

          DR. CHOW:  I was looking up there for indication of grocery stores, you know, like for populations, specific racial, ethnic, cultural populations, limited literacy skills.

          The schools, what about the schools, dissemination of information through the schools, and the churches, the grocery stores, public areas?

          DR. BRESLER:  A lot of that will be covered in the wellness discussion tomorrow about getting to the schools, and so forth.

          DR. CHOW:  Oh, I see.  Okay.

          DR. BRESLER:  Jim.

          DR. GORDON:  I just wanted to say that I think this is really a very important area, and again this is one of those areas that we should be focusing on with specific recommendations in October when we come back to it, if we can enunciate a few general principles here.

          The other thing I just wanted to share with people, and I will be happy to talk more about it later, in Kosovo, where sometimes it seems easier to spread information about CAM and self-care, we are doing this, we are working with all the mental health professionals in the country to teach people skills of self-care.

          So, it is possible to do, and it is a very interesting process, and I would be happy to talk more about it in October or any other time.

          DR. BRESLER:  Charlotte.

          SISTER KERR:  This really follows up on what Jim is saying, but I had put in a comment to someone that I still think we need to hear more from CDC, and this is maybe October, but I think it is all fitting in with this and still a part of the public health piece.

          DR. GORDON:  Charlotte, can you just say just in a moment what you would like to hear from CDC on this issue?

          SISTER KERR:  Well, I would like to hear -- I have not heard, and I don't know if I missed it in the thousand speakers, but I did not hear clear claiming by the public health community of how they were relating to CAM, and the language for my opinion from the public health, treating the body politic, and the historical framework of what public health is, is in my opinion CAM, the original CAM.

          CDC is exciting, a lot is going on and the world has changed about what that is, and we need to hear from them.  I think they have got some good new ideas.

          DR. BRESLER:  Other comments?  Wayne.

          DR. JONAS:  I find myself wondering how all these other recommendations would be implemented other than to say, gee, you all ought to do this, and if there is going to be a central source for providing this information.

          Perhaps it should be more than just a clearinghouse of information, but should be something that is actively developing with these various groups information and communication efforts through these various modalities, which would be much different than what our current models of clearinghouse in the federal government are like.

          DR. BRESLER:  But are there other precedents like the way that the HIV campaign was coordinated between various agencies and the private sector?

          DR. JONAS:  Yes, I think there are some models that are, in fact, more than what your standard clearinghouse is like, and that is actually one of them that we could look at as examples for developing this.

          DR. BRESLER:  Good.  Other comments?

          DR. GROFT:  I think one thing to remember with information centers or clearinghouses, it depends on what you define as their role and their task, and you put that in the contract, and that is what has to get done.

          I look at what a number of the institutes have done as far as producing fact sheets, and they are very, very good fact sheets on various disorders.  I think it is a matter of just extending that out into what you want and what an office wants who is going to support that activity.  Then, you get what you want.

          DR. JONAS:  I agree.  Again, NCI is another example where they provide much more dynamic interaction and public information than simply a clearinghouse.

          DR. GORDON:  One of the things I would ask, Steve, is if you and the staff, with help from Wayne and others, can pull together some examples of the best practices that can help us see where we need to be headed with this.

          DR. BRESLER:  I would like to make sort of a global suggestion.  Would it not be appropriate as this particular office is being designed, that that office not be empowered to do all these 10 things right here on this list, to bite off the question, do we want to set up a standards panel to evaluate Internet sites?  What about the accuracy of information?

          Maybe this is the charge of such an office, to be able to handle these particular kinds of issues.

          Comments?  Tieraona, Tom.

          DR. LOW DOG:  Yes, if they could handle it, I think that is a great idea, and I would just like to go back to the Issue No. 1.

          There is a typographical error there that basically said no site will not be required to have a rating.

          DR. BRESLER:  That is a typographical error.

          DR. LOW DOG:  Right, but that changed a lot of things for me.  No site will be required to have a rating is a totally different thing, and I actually support that.  What you are saying there is it is voluntary, the site can put it on if they meet the criteria, and I just wanted to say that earlier, that was a big problem for me was because it seemed like you were saying every site had to have this rating, and I was concerned about that.

          So, if you are saying it is voluntary, you meet the criteria, and you want to put that rating on your site, because you are making a higher standard of information, I am in full support of that.

          DR. BRESLER:  That was the intention.

          DR. LOW DOG:  I just wanted to go on record with that.  Thank you.

          DR. BRESLER:  Quickly, Tom.

          MR. CHAPPELL:  I would rewrite all of these starting with No. 3, the creation of the center, and then I would subsume all of these as acts and roles of that center.

          What that does, again, it reduces the number of recommendations we are trying to make here, which I think is also a goal.

          DR. BRESLER:  Can we look for consensus here?  How do people feel about this as a position for us?  Let me just ask.  Any objections to it?  Wayne.

          DR. JONAS:  Let them try.

          DR. BRESLER:  Comment, Joe?

          DR. FINS:  We are not talking about the Central Office and the Office of the Secretary, we are just talking about a central office.

          DR. BRESLER:  In the government.

          DR. FINS:  Okay.

          DR. BRESLER:  Comments about this, Wayne?

          DR. JONAS:  Just one other item on page 9, at the top, again, looking at land mines and red flags, verify CAM information in a timely manner and facilitate  balance report, and often by providing referrals to experts in different areas of CAM.

          I am on page 9 of the report.

          DR. BRESLER:  No, we are not looking at that one.

          DR. JONAS:  So, I will save that until tomorrow.

          DR. BRESLER:  Yes.

          DR. JONAS:  Okay.

          DR. BRESLER:  Can we move on in the little bit of time we have left to discuss the second issue, which is concerns about information that comes through advertising, marketing, and labeling, and we have bitten off four issues here

          Did I skip 9 and 10?  I thought those could be subsumed under the office.  Was that the general intention?

          DR. GORDON:  I think the general intention is to subsume under the office and that we may well have more discussion in October of some of these issues, but we have a kind of structure that you have established at this point.

          DR. BRESLER:  So, let me just open.  I hope everybody has read these recommendations from your briefing book about our concerns about information that comes through - advertising, marketing, and labeling.  Again, we have already discussed DSHEA, so let's stick with these other issues.

          Comments from the Commissioners about this issue?  Tom.

          MR. CHAPPELL:  I think the recommendation is well justified here, and the FDA has responsibility for the claim substantiating in the file with DSHEA, but the FTC has the responsibility of compliance.

          DR. BRESLER:  With marketing and advertising.

          MR. CHAPPELL:  Yes, with advertising.  I think anything we can do to beef this up is great.

          DR. BRESLER:  Good.  Other comments?  Joe.

          DR. FINS:  While I totally endorse Issue No. 2, about the Spanish-speaking population, I think it needs to be also made more generic for other vulnerable populations.  It is said there, but it really has a real focus on the hispanic media because we heard from Dr. Huerta back in March, so there are other populations that are equally vulnerable.

          DR. GORDON:  I have a question, and it is really just that.  Are we content with the way the FTC is monitoring the fraudulent claims?  I am not saying we have to answer this question now, but do we not want to take a look at what is actually going on and seeing if the monitoring is in line with our sense of how CAM claims or other unconventional claims ought to be monitored?

          MR. CHAPPELL:  It is woefully insufficient.

          DR. GORDON:  In what sense, Tom?

          MR. CHAPPELL:  The products and the claims that are going on out there, and I am not even talking about the Internet.  The watchdog is just not sufficient.  Actually, competitors bring claims against another brand, and then the issue is sort of negotiated and resolved lawyer to lawyer, and I am not really clear on what the FTC does to intervene and to seek compliance, but I do know that the amount of inappropriate claims that are going on out there is huge, and the best way to do something about it is for a competitor to complain, and even at that, it is tough, it's a long process.

          We need teeth in the system.

          DR. BRESLER:  Bill.

          DR. FAIR:  But it would seem to me that as far as, if I understand this correctly, the clearinghouse,  you know, if it is a false claim, we just don't even include it in the access to the clearinghouse.

          My concern is not so much the false claims from the herbal products, but it is from some of the ethical pharmaceutical houses.  I mean George and I were talking about this earlier.  If you read the reports in the lay press during the meeting of ASCO, the American Society of Clinical Oncology, you would think that cancer was being cured next week, I mean the way these were coming out.

          Gleevec, you know, it is the greatest thing since night baseball, well, the response is three months, for instance, things like that.  I think that medicine has become such a business anymore, that the false claims are just not limited to people making false claims for herbs.

          My thinking would be is include the good sites as links to this clearinghouse thing, and the other sites, unless you are prepared to go and do battle with them, just forget about them, they are not in the link.

          DR. GORDON:  What we are addressing here is the issue of the FTC, Bill.  Do you not think the FTC should be prosecuting or disciplining people for fraudulent claims?

          DR. FAIR:  Yes, I do.  Maybe I misunderstood.  That is different from what we were talking about.

          DR. GORDON:  That is a separate issue from the clearinghouse and links.

          DR. FAIR:  Right.

          DR. BRESLER:  Tieraona.

          DR. LOW DOG:  I agree.  I think that the FTC needs to be more aggressive in its review of many of these sites, or it is not even just the Internet, it's anything where there is false claims being made, but that is because it is illegal, and they should just be encouraged to step up their job, and then I think the clearinghouse provides good information, and I think they are just two separate things.

          One is just saying that the FTC has done, in the Commission's opinion, a poor job for whatever reason, and in all fairness, this is a huge, huge, huge area.  I mean I don't know how that one group could possibly keep up with it.  Internet sites come and go just by the day, and it seems very hard to me.  I don't have a good answer.

          DR. BRESLER:  Tom.

          MR. CHAPPELL:  We don't want to limit the recommendation to the Internet.  I would be the Internet, mail order, and retail stores.

          DR. BRESLER:  Radio, the media.

          MR. CHAPPELL:  I'm sorry, I was thinking about the product, but you are right, all media.

          DR. BRESLER:  Other comments around this issue?

          [No response.]

          DR. BRESLER:  The staff has asked me to express to you their interest in really being open to a lot of creative ideas about this information dissemination notion, and I think we can look elsewhere in our culture to get some good ideas.  Think about the voter ballots, for example, and proposition issues where you have constituencies that have very vested interests in the outcome.  Each present their positions in a very clear, supposedly unambiguous way to voters, and provide the voters with information on both sides.

          Maybe on some of these controversial issues where the jury is still out, there is the opportunity to do a similar kind of thing, but I guess what we would ask is just open your eyes and look around, and see what other precedents might exist, and let's see if we can find a way to get really good, clear information out to the public, and also identify the information that is misleading or fraudulent.

          Joe.

          DR. FINS:  I am just wondering if there is a role for the FCC and the FTC collaboratively and whether or not there is a way that we could sort of suggest that they have public service announcements related to CAM kinds of issues, the benefits, as well as the interactions.

          DR. LOW DOG:  The good, bad, and the ugly.

          DR. FINS:  The good, bad, and the ugly, but, you know, sort of if you are going to carry advertising, for example, that relates to drug supplements or something on the radio, then, you also have to carry a requisite amount of PSAs.

          DR. BRESLER:  Other comments on this issue?

          DR. FAIR:  Being from Florida, I will take the CAM chads.

          [Laughter.]

          DR. GORDON:  I do have one question.  Do we feel the FTC has the sort of appropriate guidance to be a good arbiter of what is fraudulent and not fraudulent on CAM sites or indeed conventional sites?  That is a question.

          MR. CHAPPELL:  David, I didn't know if you were going to cover Issue 3.

          DR. BRESLER:  Yes, there were two other issues that I think we ought to look at.

          MR. CHAPPELL:  I don't agree.  This is kind of a bleeding heart issue.  I don't think there is an action here that we can do anything about, so I don't agree with the recommendation.

          DR. BRESLER:  We are talking about the way the deceptive practices can affect legitimate companies.

          DR. GORDON:  Could I just ask again that question about whether the FTC needs guidance?  This is one of those areas where CAM expertise, just the way we have suggested for the FDA, that CAM expertise might be helpful in deciding on fraudulent claims.

          DR. BRESLER:  Joe.

          DR. PIZZORNO:  Speaking from experience, actually, the FTC does search out appropriate experts.  I have been an expert witness twice for the FTC on fraudulent claims.  The one that was mentioned, I took part in one of those.  My concern is not that they don't access proper expertise, but looking at what it costs them to prosecute that one web site.  They don't have the resources to do all this.

          I think they are able to do it, and they are asking the right questions, but they don't have the resources.

          DR. BRESLER:  Effie.

          DR. CHOW:  How about the associations working, the associations and all the different CAM practices, and so forth, working with the FTC, et cetera, for aiding in the quality of information?

          DR. BRESLER:  In the hopes of generating a consensus for now, it seems to me and to Corinne that we could include No. 3 under No. 1, just subsume it under No. 1 and however those fraudulent claims are handled, by whatever regulator agency, if there is an impact on other providers, let them deal with it.

          Since we don't seem to have a consensus on it at the moment, can we just subsume it under 1 and drop it off the list?  Does anybody have any concerns about that?  Tom?

          MR. CHAPPELL:  My concern is that I don't think the government should be providing funds for damage in the marketplace.  This is just life, you know.

          DR. BRESLER:  I don't think it says that, Tom.

          MR. CHAPPELL:  You don't think it says that?

          DR. BRESLER:  No.

          MR. CHAPPELL:  Okay.  I thought that is what it said.  It says to provide adequate funding --

          DR. BRESLER:  To explore the impact.

          MR. CHAPPELL:  -- to enforce current requirements.

          DR. BRESLER:  It seems to me it could be subsumed under 1.

          MR. CHAPPELL:  Okay.

          DR. BRESLER:  And we don't have to waste our time on it.

          Does anybody have any concerns about doing that?

          DR. JONAS:  I have a slightly different issue.

          DR. BRESLER:  Is it related to the deceptive advertising issue?

          DR. JONAS:  Well, it is in a sense.  It was more of a general comment.  Michele pointed out that one of the things that I had requested earlier in general, but also this is a good example, is for us to get more information about which agencies would be responsible for these different activities.  For example, advertising, marketing, labeling, et cetera, those are all dealt by different agencies, and they have specific mandates in those agencies, and to know how to go about doing that, and then facilitate that process, I think would perhaps be useful.

          Again I am not exactly sure how this would perhaps be any different than what a coordinating office that was responsible for these types of things in the area of information might do.  I mean the process would be I think similar in the sense of working with agencies in various groups that are doing this already to facilitate their addressing of CAM.

          DR. BRESLER:  Maybe the staff can help us get that additional information, so we can target our recommendations a little bit more specifically.

          DR. JONAS:  Did you want to elaborate on that, Michele?

          MS. CHANG:  No, that is pretty much what I was suggesting that we look at, but we are also out of time on this discussion.

          DR. BRESLER:  What do you suggest we do with this last issue about consumer information on CAM practitioners' level and scope of training?

          DR. GORDON:  I suggest we give it five minutes anyway, and then I will sum up very quickly, because this is a relatively easy session.

          DR. BRESLER:  Comments on No. 4?

          MR. CHAPPELL:  It's a good idea.

          DR. GORDON:  Yes.

          DR. BRESLER:  Is that the general consensus?

          DR. GORDON:  I see this potentially as a function of that central information source in the government.  This is just the basic kind of information that everybody wants and needs.

          DR. BRESLER:  Comments on the part of Commissioners on this one?

          [No response.]

          DR. BRESLER:  Well, thank you all very much.

          DR. GORDON:  Thank you, David, for moving us on.  I think that in looking over these two large areas, which we moved through -- Tieraona, do you have something to say?

          DR. LOW DOG:  Encourage states and local governments to make information on state guidelines, requirements, and licensure of CAM providers readily available.  Should there be, when you are looking at information because of what we were saying earlier about licensure and not licensure, should there be information available that if -- my patient has asked me before if you are unhappy with your massage therapist or if you are unhappy with something that happened, who are you supposed to contact.

          They don't know who they are supposed to contact.  If they have a grievance, who do you contact?  Don't you think that is relevant information that somebody should know?  If you are asking for all the rest of this, don't you think as a public service that they should just know who they are supposed to contact?

          DR. BRESLER:  A can of worms.  Comments?

          DR. PIZZORNO:  I concur, because the states do have people for them to contact, and that should be a part of that list.  It makes a lot of sense.

          DR. BRESLER:  Other comments?

          [No response.]

          DR. BRESLER:  Jim.

          DR. GORDON:  In dealing with the issues of providing information, there was a general agreement that No. 3, having a central federal location for providing information of a variety of different kinds about CAM practices, products, practitioners, research, et cetera, is something that we developed a consensus on, and that that office or entity or clearinghouse will deal with virtually all of the other issues related to information as time goes on.

          There was some I think as yet unresolved disagreements about the advisability, although a generally favorable sense I felt, once the grammar was cleared up, of having some kind of public/private venture that would issue or create certain kinds of standards to which Internet sites and other sources of information could voluntarily ascribe.

          Is everybody with me on that, that syntax?  That there is a sense that that would be a very useful thing for us to do, and we may want to talk more about this tomorrow, as well, when we come to the recommendations, because that is one of the recommendations, so I would urge everyone to look at that one.

          It is also clear that there is a significant need for the provision of information to the public beyond any kind of centralized web site and beyond any kind of code of ethics and standards for Internet sites and other media sources, that there needs to be a significant activity and outreach to the public, and a variety of different means are suggested including the use of libraries as a way to reach people, perhaps public service announcements, that there be an emphasis on both encouraging working somehow -- and this is kind of vague at this point -- dealing with the issues of both literacy and scientific literacy, and helping people to think through the kinds of decisions that they are making at various points of contact.

          Schools were mentioned, pharmacists were mentioned, grocery stores, as well as libraries, and we made a commitment, and the staff made a commitment to help us identify some of the ways that information has been provided to the public about other kinds of public health issues, in particular the way the NCI provides additional information, the way information has been provided to the public about HIV and other health concerns.

          I just want to emphasize this again, that this is an area in which we can use our imagination and that we really may be able to make a significant contribution to improving public health, particularly through techniques of self-awareness and self-care, but not just limited to those approaches.

          When it came to issues of advertising, marketing, and labeling, there was a strong consensus that we both concur with the FTC, with the location of responsibility for assessing claims, that that be in the FTC, that we support the FTC in its efforts, that there is a sense from those of us who have been involved in those efforts that they are responsible, that they do make use of information and insights provided by CAM professionals, and that the main difficulty is taking a look at the vast number of sites that are providing fraudulent information or may be providing fraudulent information.

          As Bill pointed out, this issue is not just limited to CAM, but this goes across the board in the provision of health information.  Again, I think this may be an area that, as time goes on, we may want to make a statement about it, a general statement, and then we may want to make some more specific statements about the kinds of standards that we would recommend as an independent body to the FTC.

          Also, there is a sense of the need for interaction between the federal source of information and sources of information at the state and local level, and that this may be a very good area of coordination, not only in terms of providing information about practices, but also about providing information about the recourse that consumers can have, both to find out who is available, what kinds of practitioners are available to help them, and also should there be, if you will, adverse events with these practitioners, ways to report these events to a responsible body.

          Anything else?  Are we okay?

          [No response.]

          DR. GORDON:  Wonderful.  Thank you, thank all of our facilitators, as well as the staff.

          [Applause.]

          DR. GORDON:  We have some changes in tomorrow's schedule.  The main one is, we will be beginning at 4:30 a.m. instead of 8:00

          [Laughter.]

          DR. GORDON:  We will be beginning at 8:00 tomorrow.  What we have done, in order to allow more time for discussion of the Interim Report, is to make a few changes, taking off a few minutes here and a few minutes there in some of the other discussions.

          This is the schedule.  We will be starting at 8:00.  Again, I really appreciate the attention that everyone has paid to the material that has been handed out.  Tomorrow, again we will be going over just the way we did today with the facilitators, going through the material, and looking toward the big picture and looking toward issues where we have consensus, as well as those we need to address further.

          Then, we will have over two hours to take a look and to talk about and to address both the style and the recommendations of the Interim Report.  So, please take a close look at that, so we will all be ready to discuss that one tomorrow afternoon.  At the end of the day tomorrow, we will have time for public comment.

          Thank you, everybody.  See you tomorrow morning.

          [Whereupon, at 6:30 p.m, the meeting was recessed to reconvene the following day, Tuesday July 3, at 8:00 a.m.]

                         + + +

                     CERTIFICATION

This is to certify that the attached proceedings

BEFORE THE:   White House Commission on Complementary

                      and Alternative Medicine

HELD:         July 2-3, 2001

DEBORAH TALLMAN, Court Reporter