A Thousand Insults and A Lot of Pride
In Pennsylvania, where I live, Chinese medicine ranks second class or even third class to the traditional Western medical model. I take the long view of the class system, however. When you are in second class, you are at least on the train. By contrast, 30 years ago, when I started in this profession, my colleagues and I couldn't even get on board.
Whereas my colleagues in Florida, California, Colorado and New Mexico live with the luxury of primary care status, I have the designation "acupuncturist" on my medical license. Pennsylvania, does not recognize the full scope of Chinese medicine, although it is used by the majority of people worldwide for primary health care. Like many states in the U.S., Pennsylvania only licenses our assessment of patients and use of needles. Thus, a large portion of our treatment protocols, which employ the full spectrum of Chinese medicine are not recognized. Chinese herbal medicine, Chinese physical therapy and exercise techniques, dietary counseling and the use of Western diagnostics such as blood work or imaging are unrecognized and unregulated in Pennsylvania.
Chinese medical practitioners who have primary care status are called "Doctors of Oriental Medicine" or DOMs, and they are recognized by both insurers and patients - many of whom choose Chinese medicine as their preferred option for healthcare. Because of these state-to-state licensing inequalities, our profession, rides in second class.
For example, those of us who national certification in Acupuncture and Chinese Herbology in one state are conferred different authority to order blood work, imaging and other tests, and they also have different ability to bill insurance companies for their work. If they had fully recognized first class status, Doctors of Oriental Medicine (DOM) could easily integrate into Western medicine's healthcare delivery systems. As it stands, second class doctors cannot earn as much, bill as much, or be perceived with sufficient authority to influence policy.
For these reasons, most practitioners of Chinese medicine in the U.S. have to form alliances with Western medical doctors, physical therapists, psychologists, surgeons and hospital administrators so that our patients get what they need. If I think my patients need blood work or imaging, I can call many cooperative Western doctors, share my rationale, and ultimately obtain the information. I have to work harder to get the same results, not unlike the scholarship students at universities who carry a full course load and also work two part-time jobs to afford the privilege of studying at a university. Not unlike scholarship students, our hard work to overcome the additional barriers can erode self-esteem, even though our second class status does not reduce the quality of care.
Western medicine dominates in Philadelphia. Although I have a fulfilling practice of "regulars" who know the value of the care they are receiving, many other patients find themselves caught between advice from their doctors and advice from me. If their doctor is "primary" and my care is considered "alternative" or "complementary," the other opinion often receives more credibility. Here's an example from a very well educated patient, who recently called for treatment of a new injury. A few years ago, this patient came for successful short term treatment of a broken ankle. She sent me an email timed 9:47 PM the night before her 1:00 PM treatment:
"I am really sorry to do this, but i am in a lot of pain with my knee. I thought it was on the mend, but it just keeps getting worse and my internist wants me to see a knee specialist. I have an appointment at a premier orthopedics center downtown. So that is where i am going tomorrow and I think I should hold off on the acupuncture.
I know this is late for canceling and I do apologize. I just fear it isn't smart with the way I feel. Am I wrong?
I will ask the doctor tomorrow, but I have a feeling she will say to wait on the acupuncture.
Previously, the patient told me that she'd had her knee "cleaned out" following a diagnosis of with a partial tear and some deterioration of the medical meniscus. Now, a month post operatively, she was experiencing significant pain and swelling, and she hoped acupuncture could help.
It's interesting to note that "evidence based medicine" often discourages this "cleaning" procedure, since most patients do not improve after surgery. The Western medical model suggests that post operative pain is treated with pain medicine and or physical therapy. Sometimes, further imaging is prescribed to determine what's wrong. Some surgeons admit that the procedure may not help, but they cite the small percent of patients who do improve and present this option to desperate patients.
Western medical options for post operative recovery will not treat the qi and blood stagnation that is causing the post operative knee pain. Thus, the Western doctor's advice directs the patient away from treatment that could serve him or her best, and toward options that lead to further diagnosis or medicine that masks the cause of the pain. Despite the National Institute of Health's (NIH) 1997 endorsement of acupuncture for post-operative pain, most orthopedists do not think of this as an option, much less prescribe this for their patients.
The correct referral, one that would get the best outcome for the patient, would be to send the patient for Chinese medicine post operatively (and possibly physical therapy as well) where we would treat with needles, gua sha and Chinese medicine, not just acupuncture.
So when I was going through my emails at 6:30 A.M. the day of Sally's treatment, I wrote back:
The right time to come for acupuncture is when you are in pain, or to prevent pain, so I would respectfully disagree with your plan of action. Most people who see me for knee pain start by using Chinese medicine prior to considering surgery. Often it is effective. If patients wait to call until a problem is too severe to prevent, we start treatment immediately post-operatively to promote healing and reduce swelling. Often if patients wait until weeks after surgery, the pain may be worse. I prefer the pre or post-operative model since it prevents the future pain, but I'll do either.
As for what you expect from the orthopedic doctors , I seriously doubt they know when to refer or which condition is appropriate for referral to Chinese medicine. The problem with the health care system at this point is that it is not integrated, and patients will make the choices they make based on habit - following what they have done in the past and what they know, rather than what would be most effective.
The doctors are usually not helpful when advising patients about acupuncture or Chinese medicine. Despite the fact the NIH (National Institutes of Health) recommended acupuncture for post operative orthopedic surgery in 1997, most doctors do not know the science, and are afraid to recommend something they don't know. As such, patients go to western specialists (who will prescribe tests or drugs) and often miss what they need: a natural form of healing that is less invasive and often more effective for pain and recovery.
That being said, I wouldn't disagree with your getting more imaging so we can see what's going on, but I wouldn't cancel the appointment that could start the cure.
As you probably know, I have a 24 hour cancellation policy that is necessary to keep a practice working well.
Please let me know what you'll do later today.
I'm sorry the pain is worse, Sally, and also sorry that you are in a decision dilemma. I hope the comments helps you sort out the right solution.
Nancy Post, Ph.D.
Later that day, Sally arrived after seeing the orthopedist. She seemed buoyant and cheerful. "You'll be thrilled at what the orthopedist told me," Sally said with enthusiasm. "She said that she didn't believe in acupuncture, but it worked on her horse, so it must be alright! Isn't that great!?"
I assumed that Sally's initial comments were fueled by the fear she felt as her knee worsened and ignorance of Western versus Chinese medical approaches to pain and inflammation – even though she had previously recovered well using Chinese medicine for an orthopedic injury! Fear drove her into an expensive orthopedics practice when her knee first hurt. Fear fueled her resistance to self-care that could have prevented the injury. Fear and ignorance drive up the cost of healthcare in this country.
By anticipating that I would be "thrilled" at her physician's reluctant acceptance of acupuncture, she assumed that I, too, am afraid and need approval from her doctor, ie., the Western medical establishment. I am not afraid. I simply want to do the best work possible for my patients.
Should I be insulted, or treat her pain and fear? I chose the latter.
Her positive experience with Chinese medicine for a prior injury brought her back to me with her current knee problem. But her apprehension almost led to a cancellation based on a contrary opinion from her primary physician.
When she finally arrived, we treated her both for anxiety and pain. After two treatments, she was able to walk without discomfort, while enjoying a much calmer mood. After three treatments, she is pain free and is reclaiming mobility. A lot of pride on my part.
Now, let's count the insults:
- Last-minute cancellations in order to see another practitioner devalues both one's time and reputation;
- The patient's belief that another practitioners "approval" is necessary is invalidating;
- The implication that Western medicine is more valid than Chinese medicine (despite compelling World Health Organization data);
- The fact that the patient had what was probably a medically unnecessary procedure and still went to that practitioner for an opinion… what does this say really? Are we so habituated to giving away our authority that we can't stop ourselves? Is this addiction to an external medical authority so pervasive that even a well educated patient goes back to the same source to get a "fix" of authority even if it doesn't heal her? ;
- Is it insulting that we have to treat both fear and pain induced by a failed medical procedure? Are we cleaning up the messes caused by the plethora of unnecessary procedures that can hurt patients? Is it insulting that so many of these procedures happen and that our healthcare insurance costs rise as a result?;
- I thought it ironic that I knew more of the current Western science about the procedure than the doctor did. Or at least I was more willing to share the research with the patient. Two years ago, I asked an academic clinician, a Professor of Orthopedics at a major university medical center about "cleaning out the knee." The man was scornful. "There's no evidence for it and patients convince their doctors to do it, even though it is not usually successful." He then gave me the studies. Is it insulting that scientific evidence is ignored by practitioners who purport to be experts?
Where is our professional pride?
Like Jackie Robinson's early days in professional baseball, Chinese medicine is the minority in most states in the U.S. We are the minor league , generally operating small clinical practices while the majors run billion-dollar healthcare systems that offer only Western style medicine.
There are biases against us that are mostly based in ignorance and fear. Increasingly, the science fully supports our work the same way Robinson's statistics were infallible. Like Robinson, we practitioners of Chinese medicine must gracefully endure the insults while keeping our performance high. Robinson had sponsors who came from the white, moneyed, majority and similarly, we need insiders in the Western medical community to share their power. The patients will benefit. The clinical results will be better.
When Robinson started his career, he traveled in third-class, too. By the end, throngs of supporters met him at any train station. I think we should anticipate this success and take pride in the face of insult.