The Practice of Acupuncture: Who Are the Providers and What Do They Do?

I agree that there should be more communication on both sides. In my practice there are several reasons I rarely have positive contact with their doctor.

As the authors pointed out most of the complaints were for chronic conditions. By the time most people have tried acupuncture they feel either that their doctor has given up, they can't deal with the medications,and/or they are trying every type of alternative treatment they have ever heard of. If you only knew how many times patients refer to their doctors as "an idiot".

Until recently in California, acupuncturists were considered to be primary care physicians for Worker's Compensation. I would regularly send my patients to orthopedic specialists. Once referred I would have to get the treatment plan from the adjuster and what the patient remembered since neither leaving a message with the receptionist or written requests were honored. One doctor actually scheduled an operation and physical therapy without ever contacting me. In a discussion with my own doctor he considers me to be an educated consumer. Attitudes on both sides need to change.

The authors were also correct in pointing out that acupuncturists tend to single person offices. Paperwork is despised even more than in a western office. California has the majority of acupuncturists in the United States and the requirements for licensing are stricter than the Nationals. Other than the small sampling this was an objective study, maybe in the future acupuncturists will be included in the design.

Competing interests:   None declared

Sherman and colleagues have produced a thoughtful analysis of the training and practice of acupuncturists in the Massachusetts and Washington area. As reflected in table 2 of the article, the reasons for visits to Acupuncturists, are very similar to those seen for PCP’s. Moreover, a growing body of evidence suggests increasing indications for CAM treatments. It is therefore projected that more patients will be treated by both mainstream medicine and CAM, either concomitantly or sequentially. In this reality, a relationship between PCP’s and CAM providers is mandatory, for the benefit and safety of the patients. Only 10% of patients were referred to acupuncture by their physician. However, physician referral increased the chance for physician - acupuncturist communication/collaboration four- fold (50% Vs 12%). This is quite similar to the communication/collaboration rates between specialists and PCP’s following PCP referral (39% to 88%)[Donaldson MS, ed, Yorkdy KD, ed, Lohr KN, ed, Vanselow NA, ed. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press; 1996]. The study by Sherman and colleagues did not inform us the level of physician communication/collaboration following an acupuncturist’s referral to physician. In addition, their study did not elaborate as to why acupuncturists initiated discussion with the patient’s physician in only 12% of their patients. Williams et al [Williams TF, White KL, Fleming WL, et al. The referral process in medical care and the university clinic's role. J Med Educ. 1961;36:899-907] proposed 3 coordination events involved in the referral process: (1) the referring physician communicates reasons for the referral and relevant patient information to the specialist, (2) the specialist completes the referral by communicating findings to the referring physician, and (3) the referring physician, specialist, and patient negotiate continuing care arrangements. We argue that one of the reasons acupuncturists seldom initiate communication with PCPs is the lack (or perception of one) of common professional language for adequate communication. This lack in doctor-CAM provider communication is common in both sides and contributes for the notable communication gap between patients, physicians and CAM practitioners. Bridging this gap is one of the main objectives of the Complementary and Traditional Medicine Unit, which is an integral part of the Department of Family Medicine, The Bruce Rappaport Faculty of Medicine, The Technion, Haifa, Israel. For the last 6 years we teach introductory courses in CAM for family medicine residents and specialists as well as nurses and CAM practitioners. These courses emphasize the common themes shared by the philosophy of family medicine and CAM: A patient-centered approach based on a bio-psycho-social-spiritual context and obligation for evidence-based medicine. Teaching communication skills and practicing doctor-CAM practitioner consultations is a major theme in these courses. In the last 4 years we instruct a yearly mandatory 100-hour course designed for 4-th year CAM students in the largest CAM College in Israel. The course titled "Fundamentals in Integrative medicine" is aimed at providing the basic communication skills needed for collaboration with conventional practitioners, as well as with CAM providers from other disciplines. Writing educated referral letters to their patient's primary care physicians is one of the major assignments expected from the students. Our experience confirms that better doctor-CAM practitioner communication is indeed feasible and rewarding for the healing triad of patients, physicians and practitioners.

Elad Schiff MD, Dipl. Ac. (NCCAOM). Internal Medicine, Bnai Zion Medical Center, Haifa, Israel. e-mail: eschiff@bezeqint.net

Eran Ben-Arye M.D. The Complementary and Traditional Medicine Unit, Department of Family Medicine, The Bruce Rappaport Faculty of Medicine, The Technion, Israel Institute of Technology, Haifa, Israel and Clalit Health Services, Haifa and Western Galilee district, Israel e-mail: eranben@netvision.net.il

Competing interests:   None declared