Full title: “TCM Integrative Medicine Residency Program at Highland Hospital”
Abstract
In response to the opioid crisis, the Joint Commission mandated that all U.S. hospitals provide non-pharmacological alternatives to manage pain beginning January 1, 2018. Many physicians see the need for an alternative to opioids, and recognize the value of integrating complementary medicine into standardized care to decrease patient reliance on pain medications. In response to the opioid crisis, the Traditional Chinese Medicine (TCM) Residency program at Highland Hospital was ready to care for the under-served populations of Oakland, CA. The residency program aims to train acupuncturists alongside western medical students in the operation and management of patient care in a hospital setting. The graduates attain the professional, cognitive, and technical skills necessary to provide patients with compassionate care. Hospitals are recognizing the need for acupuncture in pain management therapy; as such, it is important that acupuncturists are properly prepared, and trained side-by-side with western practitioners in order to enhance patient outcomes at these institutions.
Introduction
In western medicine, medical students begin their training at the undergraduate level, completing a four-year bachelor’s degree before moving on to four-years of medical school. Their education is divided between classroom-based instruction in the sciences and clinical rotations in various disciplines. The student must then pass the United States Medical Licensing Examination (USMLE) during (Steps 1 and 2) and after (Step 3) medical school. During their final year of medical school, students start narrowing down their specialty of interest and apply for residency programs throughout the country. Residency training may take 3-7 years.
Residents are given guidance to develop their careers by the attending medical doctors. This is made possible by having residents rotate through intensive care, coronary care, emergency medicine, general medicine wards, subspecialty wards, and urgent care. The residents work in teams with physicians, students, pharmacists, social workers, advanced providers, and case managers for the management of patient care.
Traditional Chinese medicine (TCM) students are offered two entry level degree options – either a four-year master’s degree (MATCM) or a 5-year first professional doctorate (DAc). They are not required to have a bachelor’s degree, but are allowed to enter the master’s program with the completion of at least two (2) years of undergraduate-level education (60 semester credits or 90 quarter credits); and the doctorate with at least three (3) years of undergraduate-level education (defined as 90 semester credits or 135 quarter credits). A small percentage of students then move on to the advanced practice degree or doctor of acupuncture and oriental medicine (DAOM) which requires 2 more years of advanced study and clinical training. There are no formal residency programs, though some TCM schools have externship programs at various out-patient clinics and hospitals.
Many hospitals in Asian countries have adopted TCM into their standard of care. In addition, there are hospitals that offer only TCM services. Students in mainland China start their training with a 5-year bachelor’s degree in TCM, then move into a 3-year master’s program before they can sit for the national exam. Clinical residency programs are the norm, and prepare Chinese medicine practitioners to work alongside medical doctors (MDs) and other healthcare professionals, supporting the integration of acupuncture and standard western care, and allowing the two systems to reach their full potential.
Alameda Health System – Highland Hospital
Highland Hospital in Oakland, California is a public hospital with a mission to care for the region’s underserved population. Since August 2017, it has been designated a Level I adult trauma center and operates as one of the busiest emergency departments in the country. Through its affiliation with the University of California San Francisco (UCSF), the medical residency program at Highland is one of the most competitive and sought out programs in the country.
TCM Residency Program
Highland Hospital is the first hospital in the United States to provide a TCM residency program.1 To be qualified for the residency training, an acupuncturist must have a doctoral degree or be enrolled in a doctorate program. The goal of this residency program is to provide Chinese medicine doctors the opportunity to enrich their understanding of western medicine. The students are then able to integrate what they know about Chinese medicine with what they have learned about western medicine.
All providers in the division of Integrative Medicine work towards the goal of making acupuncture a mainstream treatment option for pain, offered by hospital-trained acupuncturists. The division believes that acupuncturists need to know western medical terminology, and be familiar with hospital environments and operations in order to be respected by western doctors.1 This is why the TCM residents’ training encompasses a similar residency program to that of traditional western medical students.
At the end of each term, the TCM residents prepare a presentation on a patient case seen at the hospital, which is then presented to both TCM and western medical residents. In addition to the presentation, TCM residents must pass an exam based on the lessons of both TCM and biomedicine. The TCM residents also join a research project and publish in a journal before completing the residency.
Clinical Rotations
The TCM and western medical residents train side-by-side and learn about clinical care management for various conditions. TCM residents attend rounds with the western medical students and residents within the Department of Internal Medicine (e.g., Cardiology, Neurology, Gastroenterology, Oncology, etc.) to manage patient care in the Emergency Department (ED), Intensive Care Unit (ICU), oncology infusion clinic, and birthing center. Attending rounds provides TCM residents the opportunity to be immersed in hospital protocols, and allows them to identify patients who may benefit from acupuncture. Observing the relief patients feel post-acupuncture, clinical medical residents begin consulting with TCM residents about how acupuncture therapy functions.
Emergency Department (ED)
TCM residents participate in the signoffs in the ED. A signoff is the time when outgoing practitioners provide shift reports and transfer care to the incoming practitioners. Medical doctors may refer patients to the Integrative Medicine team for acupuncture during the signoffs. This is also an opportunity for the acupuncturists to assess which patients may benefit from acupuncture. The ED is constantly discharging and admitting patients. The acupuncturists keep track of current and new patients as they arrive with various complaints. If there is a patient an acupuncturist believes will benefit from acupuncture, a medical doctor must first be consulted. Should the doctor agree that acupuncture may be beneficial, the acupuncturist must confirm if the patient consents to treatment.
Department of Internal Medicine
The TCM residents have the opportunity to participate in rounds with every sub-division within the Department of Internal Medicine. When rounds begin, the western medical students present the patient cases to the team, consisting of the attending physician, residents, and medical students. The acupuncturist will participate in the discussion between the attending physician and western medical students to determine the management of patient care. Often, the medical doctors will question the TCM residents about how acupuncture may help the patient’s symptoms and conditions.
Each sub-division provides TCM residents with unique and focused training. For instance, the Division of Cardiology exposes them to interpretations of electrocardiograms (EKG/ECG), angiograms, and ultrasound images of the heart. The Division of Neurology teaches them how to evaluate headaches and conduct proper neuro exams to assess patients who may have suffered from strokes or have unexplained nerve pain. Gastrointestinal (GI) rounds teach the management and treatment of conditions like gastroesophageal reflux disorder (GERD), and inflammatory bowel disease (IBD), and provide the opportunity to observe endoscopy and colonoscopy exams.
During rounds, the TCM residents are provided the opportunity to practice TCM diagnostic techniques. With the permission of the doctor and patient, an acupuncturist can take the pulse, look at the tongue, and question the patient. This usually piques the interest of the medical doctors and acts as an icebreaker for discussing TCM theory and diagnosis.
Doctors recognize the need for acupuncture in the hospital. During rounds, the western medical residents and doctors witness patients’ relief after acupuncture. This aids in raising awareness for the acupuncture profession within the hospital. The majority of the physicians at Highland Hospital now advocate acupuncture for pain and other conditions.
TCM Treatments
Highland Hospital prescribes the practice of acupuncture to assist in opioid withdrawal and pain management. Other referred conditions may include, but are not limited to, nausea, anxiety, paresthesia, stroke recovery, and chemotherapy side effects. When a physician believes a patient may benefit from acupuncture, the Division of Integrative Medicine is consulted. Treatments are limited to acupuncture, acupressure, and massage. There is currently no electric stimulation (e-stim), cupping, moxibustion, or herbal medicine practiced in the residency program.
When the consult is received, the acupuncturist will obtain a Consent to Treatment from the patient. After receiving consent, the patient’s chart must be reviewed in detail prior to treatment. An intake and review of systems (ROS) is performed for the patient’s chief complaint(s), followed by a TCM diagnosis based on the pulse, tongue, and presentation. The charting is done through electronic medical records (EMR/EHR) and on paper using both TCM and biomedical terminology. An Integrative Medicine supervisor observes and approves every acupuncture treatment provided by acupuncture residents and signs off on every chart at the end of treatment.
My Experience
After graduating from pharmacy school, it was my belief that there must be other treatment options aside from pharmaceuticals. Originally planning to apply to medical school, I instead became fascinated by the practice of acupuncture and committed to a doctoral program in San Francisco at the American College of Traditional Chinese Medicine (ACTCM) at the California Institute of Integral Studies (CIIS).
During my doctoral studies, I desired to expand my clinical experience beyond the college’s community clinic to an integrative setting. I was given the opportunity to become the first acupuncture intern at the University of California San Francisco (UCSF) Osher Center for Integrative Medicine. After interning for one year with UCSF, and before graduating and obtaining my license to practice acupuncture, I decided to apply for the Highland Hospital TCM Residency Program.
Once accepted into the residency program, I started off as an observer for one term. As an observer, I was able to attend rounds with medical students and learn how hospitals operate. It gave me the opportunity to familiarize myself with the practices in each of the sub-specialties within the Internal Medicine Department. At the end of my observation term, I gave a presentation comparing TCM and biomedical approaches in the treatment of cardiovascular accidents (CVA).
Upon completion as an observer for one term, I began my residency training with Highland Hospital. My first medical rounds as an acupuncturist were with Dr. Herbert Schub and the Division of Pulmonology. During this time, I was able to see and interact with patients diagnosed with tuberculosis (TB) and sarcoidosis. Working with the medical students, we would decide upon a treatment plan and approach to care for each patient. Many of the patients with TB had a pulse that was slightly rapid, weak, deep, and thready, especially in the lung cun position. A majority of the patients had a tongue that was red in color with scanty coating.
My next medical rounds were with Dr. Sophie Barbant and Dr. Marina Trilesskaya in the Division of Cardiology. This was one of the most difficult of all the rounds because of my lack of education interpreting EKGs and ultrasound images. However, this round was also the most rewarding because of the number of patients successfully treated for unexplained chest pain with acupuncture. I was able to see the patients’ high blood pressure and heart rates drop as they received acupuncture without medication. The medical residents I worked with were all astounded to see how effective and quickly acupuncture and acupressure worked.
The Division of Neurology was accepting and open to acupuncture treatments for stroke recovery, headaches, and nerve pain. A large number of patients in the neurology department complained of unexplained numbness, tingling, and shooting pains. Instead of prescribing nerve pain medications such as selective-serotonin reuptake inhibitors (SSRIs) or Gabapentin, the neuro department often utilizes acupuncture for the management of pain and numbness. It is interesting to see how some patterns of numbness follow a TCM meridian/channel. I found the neurologists were always open to hearing the TCM theory behind channels to explain the numbness and tingling.
My favorite medical round was with the gastroenterology department and working with Dr. Taft Bhuket. In TCM we learn a lot about the stomach, large intestine, small intestine, and spleen. Being able to see how the anatomy of the digestive tract looks via endoscopy and/or colonoscopy was a valuable experience. To see Heat in the Large Intestine or Stomach Heat TCM diagnoses helped me better understand the presentation of these conditions. The gastrointestinal (GI) team consults the Integrative Medicine team (acupuncture) for nausea, vomiting, and abdominal pains. I had the privilege to teach the GI team how to apply acupressure to Pericardium 6 for the management of nausea. The medical doctors now educate patients on how to apply pressure to this point when they are feeling nauseous. Dr. Bhuket enjoyed hearing the theories of TCM and provided the opportunity for me to explain to the medical students why certain acupuncture points are good for various digestive complaints.
Overall, the experience I obtained from the TCM residency program prepared me to work successfully alongside medical doctors in a hospital setting. As an acupuncturist, working alongside doctors in the emergency department is thrilling. Because of this residency, I feel prepared and confident to go to any hospital environment, and able to work as an acupuncturist within any department. Our supervisors at Highland provide in-patient acupuncture care within the ICU and in an out-patient clinic as well. The practice of acupuncture continues to grow in hospital settings, and it is our job as acupuncturists to adapt to these changes and to be ready when called upon.
Conclusion
Acupuncture is being adopted by hospitals to enhance and improve patient care. Most hospitals are hiring acupuncturists as an out-patient service. Hopefully, it will not be long before acupuncture will find its way into emergency departments and in-patient care at every U.S. hospital. Highland Hospital is the first and only hospital in the country offering a TCM residency program to train acupuncturists for this transition.
The residency is nearly identical to the medical students’ training, and allows acupuncturists to integrate with western medicine. Medical doctors do not receive in-depth education about acupuncture, what it is, and how it benefits patient care; however, acupuncture residents are trained to explain TCM to doctors and other health care professionals. This brings awareness to doctors and medical students about the effectiveness of acupuncture as a non-invasive, non-pharmacological approach for patient care management.
Beginning Spring of 2020, Highland Hospital’s TCM Residency program will be moving to Sutter Health Alta Bates Summit Medical Center located in the East Bay of the San Francisco Bay Area. This will provide acupuncturists experience working in a multiple campus sited hospital with some of the most brilliant minded doctors in the country. The program’s curriculum and training remain the same as before. This competitive residency program will continue to provide acupuncturists a unique opportunity working alongside western medical practitioners.
The future for the acupuncture profession is bright. Effective January 1, 2018, the Joint Commission has mandated all hospitals have alternative non-pharmacological options for pain management. The 11th revision of the World Health Organization’s (WHO) International Statistical Classification of Diseases (ICD) will include TCM diagnosis on January 1, 2022.2 The WHO stated its inclusion of a TCM chapter was to provide doctors the opportunity to diagnose patients using both TCM and western medicine codes.3 This is important for acupuncturists because it will raise awareness for the practice internationally. This awareness will be helpful in bringing forth established TCM centers around the world.3 Currently, there is a growing demand for acupuncturists in out-patient clinics at hospitals. And these out-patient clinics are looking to expand services to in-patient care. The Highland Hospital TCM residency program is the first step toward training acupuncturists to be confident and comfortable when providing patient treatments in hospital settings.
References
- Old Practices Now New Traditional Chinese Medicine Residency Program at Highland Hospital. Alameda Health System. June 2018. http://www.alamedahealthsystem.org/old-practices-now-new-traditional-chinese-medicine-residency-program-highland-hospital/. Accessed July 21, 2019.
- Rosenberg, Natalya PhD, RN. Approved: New and Revised Pain Assessment and Management Standards. The Joint Commission Perspectives. 38(7):17-18.
- Break the Tradition: The World Health Organization. Nature. 570, 5(June 6, 2019):183-192. doi:10.1038/d41586-019-01726-1
