We need our own residency programs

Gettin’ there….

Acupuncture especially and our other traditional medical treatments are being used more frequently in modern America. We seem to be very slowly getting integrated into the conventional medical usage (emphasis on the slo-o-o-owly, somewhat like easing one’s body into a cold ocean dip). But still, we’re treated a bit like the proverbial redheaded step-child.

Recently, more than 6,000 Kaiser Permanente Northwest HMO subscribers responded to a questionnaire on medical modalities. Of the respondants, 32% reported using acupuncture for neck and back pain, yet many of them did not tell their M.D.s about it, or even sometimes apply for insurance benefits for which they qualified. So, WHAT is up with that? Why don’t patients report that they seek us out? Can it be our image as “less serious” medical practitioners? Certainly, it’s true that many M.D.s disparage our work; very few of them actually refer to us; and only a microscopic number of M.D.s work together with us in integrated care.

Our training….

Practitioners of traditional East Asian medicine (aka Licensed Acupuncturists, Certified Acupuncturists, Acupuncture Physicians, East Asian Medicine Practitioners) in the U.S. have similar educational backgrounds across the 45 (or so) states that have licensure. We enter graduate degree programs of about 4 years study. These programs are certified by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM),  and include about 1100 hours of AOM didactic classes, 600 hours of Western medicine classes and almost 900 hours of clinical training. Following graduation, we take Board certification examinations in our field, either those that the NCCAOM offer, or state-specific exams. These aren’t optional, but necessary to obtain a license to practice. To maintain our licenses — just like other medical practitioners — we need to regularly take continuing education courses. So, becoming a professional practitioner of East Asian medicine isn’t something that we just decide to do on a sudden whim: we need to invest years of our lives and a good pile of money into the effort. Sounds rather like medical school, don’cha think?

Like us, M.D.s also enter professional graduate programs, and they also take board examinations after graduation. In the U.S., M.D. programs are 4 years of didactic and clinical studies. Our paths diverge AFTER graduation and board examinations, because they then enter postgraduate residency programs. The first year of general residency was formerly known as an internship and in some states is still all that’s required to be a general practitioner. Many graduates choose specialized residency programs of 3-5 years. The resident — although licensed — practices medicine mostly under the supervision of a more experienced doctor. Thanks to TV shows, we all know a lot about the tears, laughs and romances involved in medical residency programs!

A Medscape survey reported on NPR of medical residents found that they work hard and long hours (but not as dangerously long as in the recent past); that they find their attending physicians to have either taken their teaching cues from watching Marine drill sergeants or who genuinely want the residents to become good doctors; and that less than half plan to be primary care doctors — primarily because of money concerns:

On that note, primary care, which pays less than many other specialties, may be unappealing. When asked if potential earnings influence the choice of specialty, the vast majority of residents said it was a significant factor. Only 10 percent said future income potential didn’t factor in at all.

As we all know from television, residency programs are largely situated in public or private hospitals, and in out-patient clinics. We may not all know that they are primarily financed by the government via the Department of Health and Human Services and by Medicare. Residents’ salaries (a modest $45,000/year) and benefits are funded through payments called Direct Medical Education. Medicare also uses taxes for subsidies paid to teaching hospitals tied to admissions of Medicare patients.

Medical residency programs are supposed to include research components, however many programs do not. The Accreditation Council for Graduate Medical Education’s Common Program Requirements for Graduate Medical Education states that the program must contain educational goals, with “competency-based goals and objectives”; and regularly scheduled didactic sessions.

The faculty must establish and maintain an environment of inquiry and scholarship with an active research component. The faculty must regularly participate in organized clinical discussions, rounds, journal clubs, and conferences.

Some members of the faculty should also demonstrate scholarship by one or more of the following: (1) peer-reviewed funding; (2) publication of original research or review articles in peer reviewed journals, or chapters in textbooks; (3) publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings; or, (4) participation in national committees or educational organizations. Faculty should encourage and support residents in scholarly activities.

The curriculum must advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.

Residents should participate in scholarly activity. The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities.

We, on the other hand, don’t really have post-graduate residency programs.

There are professional doctorate programs in play (D.A.O.M.), with strong clinical components. There are also a small number of practitioners who are creating post-graduate clinical apprenticeship programs (mostly in acupuncture), such as the Doane Online Education; the Internship at the Alternative Clinic; and the  Blue Waters Acupuncture Center. The New England School of Acupuncture (NESA) offers an integrative residency program in hospice care of unknown length; and Arya Nielsen started an Acupuncture Fellowship program at Beth Israel in 2008. I believe that the increasing interest in these programs — and consequently increasing number of programs to attract this interest — reflects a growing desire among my colleagues for MORE clinical training!

Actually, there are acupuncture residency programs in the U.S. . . . but they exist as part of family medicine residency programs for M.D.s, such as this “longitudinal acupuncture residency program” that Maine Dartmouth offers, one of several specializations within the residency program, which will finish with a medical acupuncture certification.

So I want to see postgraduate clinical residency programs started in our field. I think they should be equivalent to Western medicine residency programs, because I think that they are a good basic structure, for both offering newly educated practitioners the chance to start practicing with oversight, and also the chance to start learning to specialize. I want more parity in our field. I also want us to progress in providing more published clinical research, and I very much want to see this rather marvelous medicine being utilized in the public health care sector! My ideas evolved a lot from my years of experience with the Kang Wen Clinic. (Don’t look for it in Seattle — sadly, it ain’t there anymore.) My goals:

1. to create a clinical residency program where residents are able to observe experienced practitioners and to themselves gain more experience by treating MANY patients, using the full range of our tools as needed: acupuncture, moxibustion, cupping, gua-sha, tui-na, herbal medicine, movement therapies and lifestyle advice.

2. to provide teaching moments for young practitioners, via Grand Rounds sessions and educational courses.

3. to create opportunities for clinical research studies in our medicine, and which could help to break us out of the “pain management only” perception.

4. to provide affordable care — our care — for poor communities, because it’s not really medicine if it’s only available to a few.

I am imagining a 1-2 year residency program. The 1st year resident’s emphasis is on experience: she or he will be in observation shifts with attending practitioners, as well as herself/himself treat many patients under supervision. She or he will have regular Grand Rounds sessions with supervisors, as well as classes and workshops on techniques, theory and specializations.

The 2nd year resident continues to treat patients with less supervision, and is also responsible for designing a clinical research program, recruiting patients and writing up the subsequent research for publication. And there’s really so much to research — even just following up on published journal articles to add more data to their arguments, like acupuncture benefits for skin conditions; or Chinese herbal medicine being helpful for IBS; or shi chang pu for age-related neurodegeneration; or acupuncture and gastrointestinal function; or any of hundreds of other articles.

Just like other medical residency programs, I believe that this program needs to offer low-cost, subsidized care in order to bring in large numbers of patients. I estimate that to generate statistically significant patient numbers, the facility needs to support a capacity of at least 18-24 patients in 8 hour days for a minumum of 4 days/week. Again, I’m getting my ideas on patient volume from the physical arrangement we used at Kang Wen (and which other clinics use): a large room with treatment tables separated by curtains or screens, that can support at least 3 simultaneous practitioners, seeing patients every hour.

How to fund it? There’s the tough nut to crack, as neither the HHS nor Medicare has yet to begin throwing money in our direction. Not through patient revenue, because the attraction for poor patients will be the LOW COST TREATMENTS, so institutional funding is necessary. Such as: grants (specialty programs such as for migrant workers, HIV/AIDS patients, pediatrics, geriatrics, etc. might qualify for niche funding); donations from the rich and from our industry suppliers; alliances with AOM schools (because this same site can also provide externship training opportunities for their students), and partnerships with our professional organizations; crowdfunding; revenue from resident’s education workshops being offered to the larger professional community as CEUs; and there are always bake sales.

We need these programs everywhere. I just want to start one somewhere. I really think this is could be how we work towards raising our profession’s visibility and usage. And hey, maybe we could eventually spawn not just better practitioners but our own TV shows!

SOME ADDITIONAL THOUGHTS:

Firstly, I appreciate the feedback that I’ve already gotten — thanks! I want to clarify that I am thinking of a clinical residency program as essentially a continuation or a 2nd chapter of our education, which is something that more and more of us are seeking out. It’s a big effort preparing students to become medical practitioners: we all learn a lot in school (and sometimes feel as though our heads might burst), and we all feel a little bit un-prepared when we graduate. “Medical school” isn’t enough to create a Western medicine doctor without the extra time to practice medicine under supervision that a residency provides — and, as we are becoming more and more a part of the medical landscape, we are facing the same challenge. I think the phrase is called “practicing medicine” for a reason —  it is a continuous learning event.

I also want to clarify that I’ve written a lot about the education system of M.D.s and East Asian traditional medicine practitioners as seen in the U.S., because this is what I am most familiar. I imagine that there is a lot overlap with other national experiences.