Patient Encounter Guidelines

Definition of Patient Encounter (PE)

A patient encounter is defined as a combination of the following, a substantial percentage of which should involve direct, hands-on contact. A patient encounter refers to each encounter: initial or follows up. Schools are encouraged to provide the opportunity for long-term follow up by which students can experience outcomes.

a) Experience history and/or outcomes of patients in order to build an internal database of clinical knowledge and experience. This internal database can be built by a variety of experiences whether it is observation, internship, externship, small group work or apprenticeship (working under and alongside the practitioner in a graduated responsibility model).

b) Carry out procedures such as history taking; prakṛti and vikṛti assessment; pulse, tongue and nail diagnosis; as well as other appropriate methods in order to gain assessment fluency. This cannot be accomplished by passive observation but can be attained in a variety of settings including intern, small group work or apprenticeship (working under and alongside the practitioner in a graduated responsibility model). 

c) Carry out the clinical application of Ayurveda as per category designation. *Refer to the Scope of Practice for the Ayurvedic Profession, Ayurvedic Health Counselor: Educational Outline for Competency, Ayurvedic Practitioner: Educational Outline for Competency and Ayurvedic Doctor: Educational Outline for Competency documents for specific details.

Three Settings for Patient Encounters

1) Observation: Observing the teacher/clinician working with a client in a classroom setting.

2) Student/client encounter with direct supervision of a teacher. This includes working one-on-one or in small groups of two or three.

3) Student/client one-on-one, in a more intimate setting with the student doing complete intake, recommendations, and follow-up; to be supervised directly or via externship.

Patient Encounter Requirements by Category

Ayurvedic Health Counselor

Requires a minimum of 50 patient encounters with at least 25 in the first two settings as indicated above and 25 one-on-one*.

Ayurvedic Practitioner

Requires a minimum of 100 patient encounters over and above the 50 of the AHC category. Twenty-five observation, 25 under direct supervision onsite and 50 completely one-on-one* with direct or indirect supervision.

Ayurvedic Doctor

Requires 250 client encounters that will include the 100 client encounters from the AP category with the additional 150 as mainly one-on-one sessions reviewed by senior faculty or senior Doctor of Ayurveda.

*One-on-one typically means one client, per one student/intern. However, some schools have found that students learn better when working with a client in groups of two or three students, all of whom are fully engaged in all aspects of diagnosis and chikitsa. This is an acceptable substitution for one-on-one encounters, provided students also gain experience working with patients one-on-one before graduating.

Definition of Supervised/Supervision

Each and every patient encounter a student has is supervised by one or more of the methods outlined below. Schools offer a variety of valid methods of supervision, including but not limited to:

a) Supervisor present during consultation

b) Onsite supervisor checks students’ work after student has seen patient

c) Live Internet supervision via a HIPPA-compliant telemedicine platform, e.g. VSee (www.vsee.com)

d) Roundtable discussions

e) Use of approved local mentors

“Six months of supervised clinical practice” should read “Equivalent to six months of supervised clinical practice.” While some school formats would deliver this in a six-month block, others might be interspersing it throughout the training. A student might see only a few patients in six months. Hence, the number of clinical patient encounters is of more importance than the time taken to accrue them.

Recording Patient Encounters

For schools with onsite clinics, students can fill out a form or worksheet that is signed by the clinic for verification. For schools where the students are being mentored from a distance, an online recording system could be used. Some schools may choose to retain the patient encounter forms, while others might record the patient encounters on spreadsheets and return them to the students for their portfolio.

When the student applies for NAMA professional membership, the school informs NAMA that they have completed the required patient encounters, just as the school informs NAMA that they have completed the other educational requirements.

Recommended Roll-out of Increased Patient Encounter Criteria by 2016

Ayurvedic Health Counselor 50 PE

Ayurvedic Practitioner 100 PE

NAMA Responds to Issue of Heavy Metal Toxicity

National Ayurvedic Medical Association (USA)
Ayurvedic Practitioners Association (UK)
Verband Europäischer Ayurveda-Mediziner und -Therapeuten (Germany)

Joint Response to the August 2008 JAMA Article

A study conducted “to determine the prevalence of Ayurvedic medicines available via the Internet containing detectable lead, mercury, or arsenic” has concluded that “one-fifth of both US-manufactured and Indian-manufactured Ayurvedic medicines purchased via the Internet contain detectable lead, mercury, or arsenic.” The article can be found in the August 27 issue of JAMA, the Journal of the American Medical Association (Vol 300, No.8 p915) titled “Lead, Mercury, and Arsenic in US- and Indian-Manufactured Ayurvedic Medicines Sold via the Internet.”

The National Ayurvedic Medical Association (NAMA), Ayurvedic Practitioners Association (APA) and Verband Europäischer Ayurveda-Mediziner und -Therapeuten (VEAT) welcome all efforts to enhance quality and safety of Ayurvedic products but recommend that this study be interpreted with caution. We recognize and support the need for effective quality control in the use of all Ayurvedic products and promote the use of suppliers who use Good Manufacturing Practices. We agree that there is clearly a challenge with heavy metals throughout the food chain as a whole.

“Metals,” “heavy metals” and “toxic metals” are all terms used for a group of elements which include lead, mercury, arsenic and others that are known or suspected to cause toxicity in certain forms and at certain doses. The detectable presence of these elements in dietary products and food or water is not the same as toxicity. These elements are present in many of our everyday foods and as shown in this study, Ayurvedic dietary supplements. In the case of foods and herbal products their presence can occur because: 1) they are naturally occurring in the soil, water and air, 2) from pollution as a result of human activity where in both cases theses elements are taken up by the plants, 3) from contamination in the manufacturing process, and 4) these elements are intentionally added. Toxicity is the result of too much of the specific form of metal being ingested over time.

In the U.S, there is no current national law precisely regulating the amount of lead, mercury and arsenic in dietary supplements. There are various opinions on what the maximum safe daily limits for lead, mercury and arsenic in dietary supplements should be. For example, four authorities are, mentioned in the JAMA article and their limits vary considerably. They are: the California Safe Drinking Water and Toxic Enforcement Act (California Proposition 65) that gives a maximum level of 0.5 μg /day for lead as a reproductive toxin; The American National Standards Institute (ANSI)/National Sanitation Foundation (NSF) International Dietary Supplement Standard 173 that gives a maximum level for lead at 20 μg /day, mercury at 20 μg /day and arsenic at 10 μg /day; the US Environmental Protection Agency (USEPA) that gives a maximum level of 21 μg /day for inorganic mercury and 21 μg /day for inorganic arsenic for a 70 kg adult; and The Food and Agricultural Organization / World Health Organization Joint Expert Committee on Food Additives (FAO/WHO) that give total dietary intake maximum levels of 250 μg /day for lead, 50 μg /day for mercury and 150 μg /day for arsenic for a 70 kg adult. In the absence of specific standards it is difficult for the dietary supplement industry and Ayurvedic community to know what limits to meet. NAMA, APA and VEAT welcome government guidelines for the industry. [μg = mcg = micrograms or one millionth of a gram = 0.000001 sometimes referred to as ppm or parts per million -- mg = milligrams or one thousandth of a gram = 0.001]

The JAMA article states that “one-fifth of both US-manufactured and Indian-manufactured Ayurvedic medicines purchased via the Internet contain detectable lead, mercury, or arsenic.” However, as discussed above, the simple presence of any of these elements does not in and of itself translate to toxicity. This “one-fifth” (or 20%) was based simply on whether lead, mercury or arsenic was able to be detected in the product, not the specific forms of these metals that are of concern and without consideration of the resulting daily dose. More importantly, all these products were said to “cause ingestions exceeding at least 1 regulatory standard.” The “regulatory standard” with the lowest levels is California’s Proposition 65, with a maximum level of 0.5 μg /day; the lowest by far of all of the limits cited in the article and one that does not take into consideration naturally occurring lead. It is important to note that California Proposition 65 is not a regulation prohibiting sales of these products, but rather requires a specific warning to the consumer if a product contains these elements above its limits. If a different analysis were done using the daily dose limits of ANSI/NSF, USEPA and FAO/WHO, we would find that the percentage of products containing heavy metals and resulting in daily doses above their recommended amounts is approximately 8% of total products, not the 20% stated in the article.

There is one more important issue to consider. Among the products tested, there were some traditional Ayurvedic products that intentionally contain specially prepared forms of lead, mercury and or arsenic. Although these products have been in use in India for hundreds of years with claims of efficacy and safety, they have not been proven by modern medical science to be either safe or effective. NAMA, APA and VEAT recommend that practitioners and consumers should avoid the use of products in which lead, mercury and or arsenic have been intentionally added until these products are better understood by modern science and medicine, and there are clear guidelines both from within the Ayurvedic community and national laws. Finally, if we were to count only those products that do not have lead, mercury or arsenic intentionally added but would still result in daily doses above the authorities other than California Proposition 65, we find about 5%, not “one fifth” 20%.

In order to adequately and effectively meet the existing challenge of heavy metal contamination in Ayurvedic products, NAMA, APA and VEAT make the following recommendations:

1.  That government and industry establish sound, scientific daily dose limits for lead, mercury and arsenic in all dietary supplements and establish Good Manufacturing Practices that all manufacturers demonstrate compliance through independent third-party testing using validated preparation and testing methodologies, not just for Ayurvedic products and dietary supplements but also for conventional foods.

2. That manufacturers, marketers, practitioners and consumers of herbal products stop importing, manufacturing, distributing, selling, recommending and using any product for which lead, mercury or arsenic have been intentionally added until such time as modern western science and medicine have proven the safety of such products.

3. We support those companies who adhere to the points in these recommendations, Good Manufacturing Practices, quality control and who are members of one or more recognized industry associations that are committed to safety and quality.

4. Until such time as government and industry can agree upon and establish scientifically sound daily dose limits for lead, mercury and arsenic, we recommend that manufacturers and practitioners adhere to any government regulations currently in existence and at a minimum follow the lower of the guidelines established by ANSI/NSF and FAO/WHO which are currently 20 μg /day for lead, 14 μg /day for mercury and 10 μg /day for arsenic. Consumers must make their own decisions on what is safe for them based on sound scientific, medical and expert advice according to their own personal situation.

NAMA-APA-VEAT Joint Response to JAMA Article on Heavy Metals in Ayurvedic Medicines - September 2008