Defining a Primary Care Provider

Over the past decade, I have encouraged an open dialogue as to whether or not DOMs (doctors of Oriental medicine) and LAcs (licensed acupuncturists) should be able to act as a PCP (primary care provider). Due to a number of factors, that dialogue was never openly presented to our profession, but now, the PCP dialogue is finally gaining momentum.

For a meaningful and constructive dialogue to occur, we must first define our terms. In New Mexico, DOMs are defined as PCPs by state law in the Acupuncture and Oriental Medicine Practice Act. The act includes the following definitions:

"Doctor of Oriental medicine" means a person licensed as a physician to practice acupuncture and Oriental medicine with the ability to practice independently, serve as a primary care provider and as necessary collaborate with other health care providers.

"Primary care provider" means a health care professional acting within the scope of his license who provides the first level of basic or general health care for a person's health needs, including diagnostic and treatment services.

I wrote the above definitions, which became law several years ago. Although the term "primary care provider" is used freely by consumers, health care providers, third-party payers and lawmakers in New Mexico (as throughout the country), the above definition is the only one that exists in New Mexico law. Since that definition became law, I have had discussions with others in our profession (and other professions). I have also reviewed the definition of PCP in other states. I think the above definition can be improved and propose the following description.

"Primary care provider" means:

1. a health care provider;
2. legally recognized to practice in a jurisdiction;
3. acting within the scope of his/her license/legal authorization;
4. who provides the first level of basic or general health care for a person's health needs;
5. including diagnostic and treatment services;
6. initiates referrals to other health care professionals when appropriate; and
7. maintains the continuity of care.

The language used for components 1-6 above is simple and clear. For the seventh component, I have seen two other options used that express the same basic concept. They are:

A. assumes responsibility and accountability for the continuity of care; or
B. provides a continuing professional relationship with the patient.

Certainly, in many states, DOMs/LAcs are providing health care consistent with the above definition. In addition to the above components of a PCP's definition, other responsibilities should be discussed. Questions will arise about the following concepts:

Must a PCP, by definition, perform an allopathic, biomedical, conventional diagnosis?

Clearly, what we are referring to as the allopathic, biomedical, conventional diagnosis is the current "language" of health care in America and throughout most of the world. In reality, the level at which any PCP must perform such a diagnosis has yet to be determined. Most assume that a doctor of medicine or osteopathy whose specialty is family practice, internal medicine or pediatrics is the only health care provider qualified to be a PCP. In some areas, a doctor of medicine or osteopathy whose specialty is gynecology may also be considered a PCP. In other areas, however, nurse practitioners are being employed as PCPs. Nurse practitioners have less allopathic, biomedical, conventional diagnostic education than allopaths or osteopaths. Let's examine the assumption.

I believe most common-sense people would agree that the biomedical sciences have contributed greatly to health care. I also think we can all agree that a PCP should possess, to a reasonable extent, the ability to utilize the basic, proven, biomedical diagnostic tools such as laboratory testing and imaging, with the understanding that a specialist radiologist would perform the diagnostic interpretation of the imaging ordered by the PCP, and a reputable laboratory would perform the specimen diagnostic analysis. It seems appropriate that a PCP would be educated at least to the level of a nurse practitioner in performing a biomedical diagnosis.

The allopathic and conventional components of the diagnosis need to be identified. It is important to realize that allopathy is a cognitive map; it is an approach or belief system. It is the most common approach to health care in this country. There is no proven evidence that it is the best approach. It is generally more focused on disease management rather than health care. It is a relatively immature approach; that is, most of allopathy has evolved over the last century. Other valid approaches to healthcare in America include naturopathy, chiropractic and Oriental medicine. Oriental medicine, by comparison, is a more mature approach that has evolved over a few thousand years.

We often fail to realize that there is as much unproven belief in the conventional allopathic system as there is in any of the other systems. For example, the 1992 British Medical Journal editorial, "Where is the Wisdom? The Poverty of Medical Evidence?", quotes an expert who has researched and penetrated the myth of allopathic healthcare during the past few decades. David Eddy, MD, a former cardiothoracic surgeon in Stanford, California and professor of health policy and management at Duke University, acknowledged that only about 15% of medical interventions are supported by valid scientific evidence. One reason for this was that "only 1% of articles in medical journals are scientifically sound"; another reason was that "many treatments have never been assessed at all." (More on this article can be found in the March 1992 edition of The Chiropractic Report.) Granted, Dr. Eddy's conclusions are almost a decade old, and conventional medical practice has evolved since then. However, my point is that we must trust and evaluate our assumptions about what is effective healthcare.

Naturopaths are highly educated to perform a complete biomedical diagnosis. Although they are aware of the allopathic approach, naturopaths do not use the allopathic model when determining the diagnosis or treatment plan. A well-trained chiropractor does the same. Certainly, a well-trained DOM or LAc would also do the same. It is important to remember that in many states, DOMs and LAcs are able to practice independently and make a diagnosis. Currently, DOMs and LAcs are educated to perform (or at least understand) a limited biomedical diagnosis. For most of them, additional education would be necessary to improve their skills if they are to act as competent primary care providers.

That additional education may be very easily completed by a DOM or LAc. For example, New Mexico has a program created by DOMs and chiropractors that educates health care providers to be primary care providers focused on integrative medicine. The program involves training for one weekend a month over two years. In addition, according to an article in the August 2000 issue of Managed Healthcare ("Weaving Wellness into Mainstream Medicine: Innovative Use of Chiropractors as PCPs Places the Emphasis Squarely on Health, Not Treatment"), under a healthcare plan in the Chicago area, chiropractors with additional training are being used as PCPs - with great success.

My personal experience, after more than two decades of providing primary care as described above using the Oriental medical model, is that I frequently see patients whose condition has not been resolved or improved by their allopath or osteopath. In some cases, they have not been accurately diagnosed. In the majority of cases, I have been able to provide these patients with better healthcare than they received in the allopathic conventional model.

What I do is no different than what a few thousand DOMs and LAcs already do every day in America. Quite simply, we are providing better healthcare, in a more cost-effective manner, than any other healthcare provider in the country. There may be great advantages to the American healthcare consumer if DOMs and LAcs were providing the primary care services, and if we referred to allopaths and other providers for specialty care.

In the second part of this series, we will look at the definition of a primary care provider in terms of diagnostic and treatment procedures, prescription rights, immunizations, the "gatekeeper" structure, and hospital privileges.