As more scientific evidence reveals the effectiveness of Chinese medicine, particularly on chronic diseases, and as the public's demand of natural medicine increases, more hospitals and clinics in the United States are exploring the possibility of integrating complementary/alternative medicine and Western medicine in a conventional setting.
I have been employed as an acupuncturist at a university hospital for one-and-one-half years. My students in the acupuncture school where I teach, and my colleagues in and outside of the school often ask me the same question: "What are the differences between working in a hospital and a private practice?" Personally speaking, there are six discernible differences, in the areas of patient sources; referrals; reserved resources; teamwork; continuing educational opportunities; and the scope of Chinese medical practices used.
Different Sources of Patients
Patients in the hospital are complex with regards to the types of conditions seen and the type and number of medications used. It is not uncommon for outpatients to be diagnosed with five or six conditions, and to regularly visit a rheumatologist, gynecologist, cardiologist, internist and/or oncologist in addition to their primary care physician.
For example, take the case of a 31-year-old woman with fibromyalgia; lupus; obesity; a pituitary gland tumor; and osteoarthritis. She complained of muscle pain all over her body; chronic fatigue; weight gain; knee pain; hot flashes; amenorrhea; and other disorders. She also suffered from constipation; nausea; edema; a metallic taste in her mouth; oral sores; sleep disturbances; and hallucinations. Some of her symptoms were associated closely with the adverse effects of pharmaceuticals.
When a patient like this comes to see me, his or her chief complaint on that particular visit determines my treatment plan. Because the patient has so much going on, each visit presents a different crisis, and I can only deal with the acute condition(s) needing attention at that time. Treating the "root" of the disease, according to traditional Chinese medical theory, becomes out of the question. By focusing only on the patient's immediate concerns, the patient's overall improvement will be limited. For instance, fibromyalgia is a chronic disease considered a mixture of deficiency and stagnation related to the Spleen, Kidney and Heart. I have treated a few cases of fibromyalgia successfully with Chinese herbal medicine, acupuncture and dietary adjustments, and although it takes six months to a year to achieve results, progress is usually steady. The treatment plan is to tonify the deficient organs and clear blockages in the appropriate meridians.
Based on my experience, patients using TCM for treatment need fewer pharmaceuticals and improve more quickly with less adverse side-effects and herb/drug interactions. On the other hand, because patients with multiple disorders struggle with the progression of diseases and drug side-effects, alternative medicine becomes their last resort. They expect to find quick relief, or even a "magic cure."
This is true of the patient mentioned above. She has made some progress with acupuncture and does not want to lose hope; in turn, I do not want to disappoint her. In the end, though, I am frustrated because I cannot get to the root of the problem.
Medication is another challenge. Patients are commonly on many pharmaceuticals, such as anticoagulants and antiplatelets, which can interact with herbs. Some patients take up to 15 prescription drugs daily. These medications are modified periodically by the attending physicians because of side-effects or changes in a patient's condition. Medication changes have a great impact on a patient's physical and mental status. In turn, this can alter the patient's chief complaint when he or she visits me, which shifts the focus of my treatment plan. As a result, the most important question I must ask is the status of the patient's medication use.
Patients taking several drugs are usually suffering from chronic diseases, multiple disorders, severe pain and/or tumors. Among my patients, the drugs most commonly used include narcotics; antihypertensives; anticoagulants/antiplatelets; anti-infective agents; and/or anticancer agents. Some patients also self-administer herbal remedies. Sometimes, these patients use Chinese herbs properly; however, herb-drug interaction is a concern. When prescribing herbs, I have to be conservative. Sometimes, there is no data to support how a Chinese formula (either classical or custom-written) may interact with pharmaceuticals. In these cases, I record in my chart that there is no known drug-herb interaction. Research into herb-drug interactions has focused solely on the components of individual herbs, but when herbs are used together, there is a synergistic effect. It is not as simple as adding one herb's effects to another.
A relatively high percentage of patients in my clinic take coumadin or aspirin (anticoagulant and antiplatelet agents), and are at high risk of bruising or bleeding, particularly after an acupuncture needle is removed. Therefore, in my initial intake, I ask the patient whether he or she is taking these types of medications. As a safety precaution, I must look over a patient's medication records prior to exam and treatment to prevent any possible bleeding.
Although the majority of hospital care takes place on an inpatient basis, these patients represent only a minority of my case load. The majority of inpatients that come to see me come from two primary channels: 1) referrals from an attending physician or 2) requests for acupuncture from an inpatient or family member on the patient's behalf, which is then approved by the physician.
As a TCM physician with extensive hospital training in China, I am familiar with inpatient care. Personally, I believe the reasons patients need acupuncture are very similar in the U.S. and China. The difference is that inpatients in the U.S. have much less access to acupuncturists while inpatients, and acupuncturists trained in the U.S. have less access to treating patients on an inpatient basis. Acupuncturists in the U.S. treat a smaller variety of diseases and illnesses in the hospital, and physicians and acupuncturists communicate much less. This is understandable when comparing the history of medicine in China vs. the U.S. China used its traditional medicine exclusively from 200 A.D. until the introduction of biomedicine in the 16 th century. Since then, Western medicine has steadily integrated with TCM, and has served as a parallel medical system. Additionally, doctors of TCM in China are trained in the hospital, work mainly in hospitals, and use Western diagnostic procedures. This difference makes the integration of the two systems very simple. I am confident that in the next five years, patients will have improved access to acupuncture on an inpatient basis, and there will be an increase in communication with physicians. As a result of the increasing use of TCM, mainstream clinicians will become more open to complementary and alternative medicine.
Solid Backup and Support
There is a tremendous amount of support I can depend on while working in the mainstream environment. If I have questions about the indications of prescriptions; interpretations of advanced diagnostic results; medical procedures; or even questions as simple as the spelling of a prescription, I may ask any doctor, nurse or medical assistant in the area. In addition, the hospital has an intranet that includes access to the pharmacy, ICD-9 manuals and radiology. There are references books such as the Natural Medicine Database, the Merck Manual, the Physicians Desk Reference, and others at my workstation. They are great resources and provide incredible aid. Furthermore, computerized medical records and on-screen radiological images allow all clinicians to share medical information anywhere and anytime in the hospital. Clinicians can review a patient's clinical activities in the hospital simultaneously.
Referrals
Different situations cause physicians to refer their patients to the integrative medicine clinics. For instance, some doctors simply believe or are interested in CAM; others suggest the patient try an alternative modality after unsuccessful treatment with conventional medicine; and some physicians respect their patients' requests. In the third situation, the referral occurs with a patient who has a severe condition, or if someone has had experience with CAM and is insistent on pursuing CAM in the hospital setting. Although more physicians are interested in CAM and the physician referral rate is increasing gradually, the majority of patients self-refer to complementary and alternative medicine. In spite of this gradual increase, only a small percentage of referrals has been from doctors. In my opinion, however, there is a higher ratio of physicians referring to acupuncturists in the hospital than a private practice. On the other hand, patients in hospitals have more complex conditions, and often need to be referred back to the primary care physician or some other specialist for further examination or diagnosis. Practicing in a hospital provides an easy route of referral for the physician and myself, because I know how to move patients to the next level of care, and whom they should visit next.
Teamwork
The integrative medical model varies from hospital to hospital. It is certainly an advantage to work with a group of professionals that specializes in different aspects of medicine. As an acupuncturist, I currently work with people who specialize in psychology; nutrition; pharmacology; biofeedback; massage therapy; and internal medicine. There is a medical doctor who acts as a medical director and is responsible for new patient assessment in addition to the supervision of daily medical practice. Interdisciplinary care team members regularly discuss complicated cases, share successes, and search for the best care for patients utilizing each person's expertise.
Continuing Education
My hospital requires every employee to participate in continuing educational training online every year. The content and quality of questions depends on each person's job description. There are general questions for everyone that pertain to issues like fire safety, biochemical disasters, child abuse and HIPAA. Clinicians are responsible for more questions than other workers. This training is mandatory, and must be passed and completed by a certain date. The process is overseen by the human resources department. The purpose of this training is to keep staff attentive to issues that are particularly sensitive and/or unique to the health care environment. The questionnaires are time-consuming and sometimes to difficult on top of the regular workload, but in my opinion, the benefits are worth it.
Differences From Private Practice
Working in a hospital has some shortcomings compared to private practice. For example, some techniques such as moxibustion and fire-cupping therapy are forbidden because of fire safety concerns. Point injection and lab requests also are not allowed because of certain regulations regarding the scope of practice for acupuncturists. In a private practice, each practitioner can organize his or her clinical notes. In the hospital, there are many more rules regarding documentation of treatment. The patient's chief complaint; progress; medication; drug allergies; past medical history; past surgical history; family medical history; social history; vital signs; treatment plan; acupuncture procedure; and all herbal prescriptions, must be documented thoroughly. Furthermore, a Chinese medicine practitioner must provide an explanation of herbal functions; length of use; dosage; and potential herb-drug interactions. Another shortcoming in working in a hospital is the lack of flexibility in working hours. Working hours are decided by the hospital, not the acupuncturist.
I am fortunate to have had the opportunity to practice Chinese medicine in a hospital setting since 1998. I am more familiar with American health care delivery in both family practices and hospital settings. I also have learned the day-to-day routines of conventional medicine. I have learned to incorporate TCM, a relatively new medicine to the U.S., yet an ancient medicine in its own right, into the conservative modern medical system. If I had only practiced in China, I would never have encountered the issues surrounding the combination of TCM and conventional medicine. I have learned a great deal from this experience.
