Please support discrimination?!?

Another entry in our Hypocrites with Double Standards (HWDS) files?

I’ve been reading about the importance of Section 2706 of the Affordable Care Act for our profession. It wouldn’t be right for insurance companies to cover acupuncture only if performed by an MD, right? The concerns within our community, according to the press, are that the section might be undermined by the actions of the AMA (this makes us angry!) or not strongly enforced.

Okay, non-discrimination good.

Wait a second — AOMSM, the Massachusetts acupuncture association, is pushing legislation that discriminates.  Section 7 of S1107 and H2021 reads “The use of needles on trigger points, Ashi points, and/or for intramuscular needling for the treatment of myofascial pain will be considered the practice of acupuncture” (does it matter what type of needles?) and Section 8 reads “Only licensed acupuncturists or medical doctors shall be reimbursed for acupuncture services.” Is anyone surprised that “political agents for PTs in MA have taken measures to prevent “An Act Relative to the Practice of Acupuncture” from advancing”?

So — discrimination is good if it works in my favor, bad if it works against me?  How does this reflect on our profession and the future of integrated health? Not well, in my opinion.  What do you think?

Dry Needling, Herbs, and Scope — How to Regulate a Profession

A regulatory Board is contacted.  Your licensees are doing X, that isn’t (or, is that?) in your scope.

Ask a PT Board about Dry Needling and the answer usually goes something like this — We trust our licensees. Many learn this technique and it helps their clients. We find room in our regulation to include this in our scope.  We have a few concerns and suggest that those who want to utilize this technique have some additional training and take additional precautions. Our existing system for addressing unsafe practice is sufficient to address risk to the public.

Ask an Acupuncture Board or organization about herbs and the answer usually goes like this. We are being threatened again!  We’d better legislate, and fast! Help! Thanks NCCAOM and schools. We are so grateful for your efforts to ensure that any acupuncturist who wants to utilize this dangerous aspect of our medicine add your $20,000 education and your formal $800.00 seal of approval to their already extensive education and credentials. In fact, in the name of raising standards we should require that from all LAcs. It might prevent some of our most qualified practitioners from practice, but, hey, it is a step toward getting the respect we deserve.

Is something wrong with this picture?

It’s a radical idea, but how about we respect ourselves. Let’s recognize the safety of our medicine and the depth of our education.  Let’s trust our colleagues’ professional judgement and open doors rather than close them and let’s stop deferring to those who profit from our love of this medicine.

For additional reading, check out an example.  In this case, I agree with Dr. Morris when he wrote,

To avoid conflicts of interest, no individual who stands to profit from seminars should determine competencies and educational standards, nor should they testify in legislature on behalf of the common good.

(Of course, he was talking about the PT’s when he wrote it, so maybe in this case he doesn’t agree with himself.)

You have until Monday, 9/30, to comment on the NCCAOM’s “proposals.” Does the current CEU arrangement put the public at risk? Are the states incapable of effective regulation?

One more thing — during the great FPD debate, many expressed concern that once the degree was available the NCCAOM could, by fiat, require it for entry level practice. We were assured that would be impossible. Informed by history, it seems very possible indeed.

Making a Difference, in ten steps.

  1. Write a letter to the Delaware Acupuncture Advisory Council, and mail it by this Friday, August 23rd. Here is a new, improved template!  Do this now! (Please cc Gayle MacAfee at the board and send a copy to de@theacupunctureobserver.com. Thanks!)
  2. Share this post on facebook.
  3. Tune in. Subscribing to this blog is a good start but I can’t keep track of everything. Check in at websites for the AAAOM, NCCAOM, ACAOM, your state association, POCA, etc.  A few current issues (which I’ll be posting more about soon) — AAAOM is calling for public comment by August 31st on draft legislation, NCCAOM wants public comment on proposed changes by September 30th, ASVA (Acupuncture Society of Virginia) is having a town hall October 19th to discuss possible changes to scope, and the IHPC wants us to stay involved regarding implementation of section 2706 of the Affordable Care Act. Any one of these issues could impact your ability to practice.
  4. Question Authority. Is X really the biggest problem facing the profession? Is the public better off in a state that requires the OM certification rather than the AC certification? Is an independent board better for acupuncturists? Will an FPD degree lead to greater respect? Does scope mean what you think?
  5. Know the system. For example, boards can only regulate their own licensees. And the executive branch doesn’t determine what Medicare covers, regardless of how many signatures are on a petition.
  6. Avoid us/them thinking. In Our Worst Enemy I wrote about the practitioners in focused on increasing standards as a “them.” That was a mistake.
  7. Remember, we are all in this together. What happens in another state or a change that seems to impact only new students or new licensees might end up affecting you in unforeseen ways.
  8. Assume good intentions. Assuming bad intentions (the PT’s want to do dry needling to make money, for example) doesn’t lead to productive dialogue.
  9. Be consistent. Do we support the right of people to choose their healthcare provider? Are herbs safe? Is acupuncture safe? When we change our answers to these questions based on the circumstances we create a negative impression.
  10. Learn from history. Has participation in  health insurance been good or bad for healthcare? For providers? Has a standardized system of Chinese Medicine led to greater effectiveness?

In the short run it is easier to ignore the big issues, to figure you’ll be okay, or to decide you can’t really make a difference. Staying involved takes time and energy you’d rather use to see clients or spend time with your family or learn that new technique. Do it anyway. Tune in, question, participate. The future you save may be your own.

To Wit, Hypocrites with Double Standards?

This will be it (I hope) regarding dry needling for a while.  Just these last few points which are pertinent to other discussions.

Will Morris concluded his AT article with this  — “To wit: let us pursue a collaborative process of developing inter-professional competencies. Remove biomedicine and herbal medicine courses from the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) standards. Then, take what is left over in acupuncture programs as the starting place for a dialogue for portable competencies….To avoid conflicts of interest, no individual who stands to profit from seminars should determine competencies and educational standards, nor should they testify in legislature on behalf of the common good.”

My comments  –

1)    Collaborative processes don’t start with a one-sided statement of the starting point.

2)      Why stop with removing only biomedicine and herbal medicine from the ACAOM standards?  An incomplete list of things I was taught in my ACAOM accredited program that seem unnecessary for the education of a licensed PT who wants to use an acupuncture needle to stimulate a trigger point: tai chi, qi gong, pulse diagnosis, tongue diagnosis, point location, point indications, the officials, the five elements, business development, TCM principles, and the Classics. I have yet to find a colleague who could come up with more than 40 hours of content – Day 1: contraindications, risk factors, areas in the vicinity of forbidden points, reasons to refer.  Day 2: Clean needle technique, Day 3-5: Needle technique, practice and a review of reasons to refer. Seems like anything more and we are encouraging these practitioners to move beyond trigger point release.

4)      As a member of a regulatory board, I believe it is important to hear from educators when exploring issues of scope, or really, any issue. On the other hand, when NCCAOM sent two representatives to a Virginia board meeting to explain why requiring licensees to maintain current NCCAOM Diplomate status was critical to protect the public I did feel it was self-serving. So, to those making this argument, will you agree to it across the board? If there is any exploration about licensure requirements for LAcs will the schools, NCCAOM, ACAOM, and any other organization that “stands to profit” keep silent on behalf of the common good?  Some may say this violates the First Amendment, but as long as everyone agrees to abide by this limitation, I’m willing to give it a try.

A Rose, Redux!

Again, there has been an issue with my last post not being sent to subscribers or showing up on the media sites.  Because I want community feedback before posting part 2 I’m hoping this attempt will fly through cyberspace as intended.  Thanks for your patience.

A Rose?

I would love to leave the TPDN/Dry Needling issue behind. I also believe that if we explore why what we’ve been doing hasn’t been working we’ll end up empowered rather than defeated.

Many colleagues have been referring to this Will Morris article in AT. I hope you’ll bear with more frequent posts over the next few days as we spend some time pondering his points.

A question for the community – is a key factor here the use of an acupuncture needle?

When an MD injects cortisone into a sore spot, is that acupuncture?  Is a vaccination acupuncture? What if a syringe is used to draw fluid out of an area – is that acupuncture?  Is the injection therapy done by some LAcs acupuncture? What about use of a tuning fork or a laser at a point – is that acupuncture?

What about the use of an empty hypodermic needle to stimulate a sore spot?  At what point does the use of a syringe become acupuncture? Or, is the use of the filiform needle the thing that makes a procedure acupuncture?

I’ll see if you have any input before I share my thoughts.

Mine!

The AAAOM Position Statement on TPDN, or, Mine!

Who is on the Blue Ribbon Panel?  I can’t find a list of participants anywhere.  Are they independent experts on the regulatory process or medical terminology?  Are a variety of professions represented? Who selected them?  Is there any reason regulatory agencies should care what this mysterious Blue Ribbon panel thinks?

Does the AAAOM believe that acupuncture regulatory boards should be able to expand determine the limits of our scope of practice and make decisions about necessary training?  Are we hypocrites with double standards, demanding a degree of control over the practices of others that we find intolerable?

The AAAOM refers to a malpractice company’s refusal to cover PT’s doing TPDN as proof of an “actual risk of endangerment.” Shall LAcs be prohibited from using acupuncture to induce labor or turn a breech baby because malpractice companies don’t cover those procedures?

Regardless of our shouts of Mine! Dry Needling has been determined to be within the scope of practice of PT’s in the majority of states.  I suppose we can keep beating this dying horse, chasing this ship that has sailed, but there are better uses of our limited resources.

Coming soon – a sad story of how a state acupuncture board is limiting opportunities for LAcs and increasing the likelihood that residents will receive acupuncture from non-LAcs.

It’s Not Fair!!!

A Virginia colleague asked – “How is it that Chiropractors can do acupuncture and LAcs cannot do manipulations?”

Exploring why things are the way they are (here in Virginia, anyway) might help us move beyond the usual “we’re getting the short end of the stick again” attitude and could teach useful lessons about how the system works.

1)     How is it that DC’s can do acupuncture?

DCs, MDs, and DOs were doing acupuncture in Virginia, without incident, prior to licensure for LAcs. You can imagine the strong opposition that would have arisen from that powerful lobby if, despite our position that acupuncture was safe and effective, we now attempted to pass legislation that would have removed this technique from their scope. The role of regulation is to protect the public from danger, not ensure that people are limited to the “best” care. When the Dieticians introduce licensure legislation in Virginia (not yet successfully) – the Advisory Board on Acupuncture indicates that support of the Acupuncture community depends upon the LAcs retaining the ability to make dietary recommendations. The Dieticians might think our training in this area is grossly insufficient, but we can show a history of safe practice, and the state has no compelling reason to choose a winner and loser among professions in this case.

2)     Why can’t LAcs do manipulations?

The Virginia legislation specifically rules out PT, Chiropractic, and Osteopathic manipulations.  Since acupuncture training does not typically include Osteopathic, Chiropractic or PT adjustments, and since our exams don’t test knowledge of these techniques, it would have been difficult to counter the arguments of the existing providers that this should be excluded from our scope.  When the ND’s introduce legislation for licensure (so far unsuccessfully and not fully supported even within the ND community) the Advisory Board on Acupuncture always reports that support is dependent on language that would specifically exclude acupuncture from the ND scope.

If a Licensed Acupuncturist could show evidence of education in Tui Na manipulation techniques, included the technique in their informed consent, and was careful with insurance coding it would probably be acceptable.  A few years ago I would have suggested that a formal request be made to the Advisory Board to explore whether Tui Na manipulations were within scope. The board could have explored the issue and developed recommendations regarding education and documentation that would have put practitioners on solid ground.  However, our profession’s recent behavior regarding the PT Board’s similar discussions on TPDN have given our fellow health care providers many arguments they might be itching to throw back in our direction. You might want to check out Scope and Dry Needling for more background. This is probably not the best timing for requesting a formal ruling.

 

AAAOM Call for Comments

Not sure who out there gets communications from the AAAOM, or who pays attention to the communications they do get.  Despite the low of level of support the organization has from acupuncturists (the last I heard was that the organization has about 500 professional members, which would be less than 3% of the profession), it has an outsized impact on the profession’s reputation, our relationship with other providers, and public policy itself.  Therefore, it would be foolish to ignore their call for comments.  First I’ll address the introductory email, which is concerning in and of itself.  Comments on the position statement itself will follow soon.  Here is the email, with my comments inserted.

“Dear AAAOM Members and Colleagues:
We would like to hear from you, our membership, via this “Call for Comments” surrounding the term “trigger point dry needling (TPDN).” Please take a few moments to review this AAAOM position paper, “AAAOM Position Statement on Trigger Point Dry Needling and Intramuscular Manual Therapy.”

As many of you may already know, physical therapy (PT) boards have begun using TPDN terms for the purpose of expanding the PT scope of practice. [How does the AAAOM know the purpose for the choice of the term?  Perhaps the purpose was to help patients distinguish between the release of a trigger point and the practice of a complete medicine? Does the AAAOM believe professions should not be able to expand their scope?] By doing so, this therefore precludes the necessary and adequate education and safety standards already set by state legislatures for the practice of acupuncture. [Education and safety standards are primarily set by regulators, not legislators, and the rules typically apply to classes of professionals, not techniques.  Do we use the term Tui Na to preclude ourselves from massage standards? PT Boards have set standards for the use of TPDN by their licensees.]

At present, 43 states and the District of Columbia have statutorily defined acupuncture along with the educational and certification standards that qualify an individual for licensure. In addition, the current medical literature remains consistent with regards to the definitions of acupuncture as a procedure and practice provided by state practice acts. [I don’t know why the first sentence is significant and I don’t know what the second sentence means.]

The comments you submit via our Membership Feedback Form will be presented to the AAAOM’s Inter-Professional Standards Committee for review, enabling us to take action on your behalf. [Is there a deadline?  Who is on the committee? Can you share what actions are being considered by the AAAOM?]

Additionally, if you have patients who have been hurt by acupuncture performed by someone who doesn’t have a license a license to practice acupuncture, please direct them to the Food and Drug Administration (FDA) Adverse Event Form. These submissions are very important for our work and request that our members advise those patients who submit the FDA form to alert the AAAOM of their actions by clicking here. [Please, AAAOM, explain your strategy.  The FDA does not regulate practitioners, it regulates devices. Reporting adverse events might put our access to acupuncture needles at risk but would not impact state determinations of scope of practice or educational requirements.  If public safety is our concern, why request reporting only when non-LAcs are involved? Isn’t it important to report all adverse events?]

The views and comments we have received thus far on the TPDN issue have proven very helpful, thereby allowing us to fulfill our mission and advocate on behalf of your profession. Thank you for your interest and for taking the time to submit your thoughts on this extremely important issue.”

I’ll share my thoughts on the Position Statement soon.   In the meantime, AAAOM, I request you be clear about the percentage of the profession you represent when speaking on “our” behalf.

“Jerk MD!”

Have you ever found yourself thinking that a client’s physician has missed something important?  Have you ever attempted to communicate to the physician, either directly or via the mutual client, that you believe there is something that deserves further attention?  Have you ever had the response reveal that the physician gives no value to your observations and thinks you are unqualified to have any thoughts about a patient’s medical condition?

Most of us who have been in practice a while have had a few such experiences (though we likely have had positive interactions with MD’s too). It is maddening! One would expect that a healthcare provider would welcome any input that could provide new insight to benefit a client. It is a shame, and a risk to quality healthcare, when arrogance or ignorance or a bad attitude interferes with a respectful consideration of another professional’s input.  It’s easy to see why a colleague used “Jerk MD” as the subject line of a post about a dismissive MD.

What response would we like in such a situation? — Thank you for sharing your concerns, I’d like to hear your observations? Even better would be a conversation, with each of us sharing our thinking. Perhaps an ongoing referral relationship of mutual respect could develop, serving our clients and our own professional development.

In a recent conversation with a fellow acupuncturist about non-LAcs doing acupuncture (or, using acupuncture needles, depending on our definitions), my colleague was outraged that a PT had suggested to a mutual client “mention to your acupuncturist that I think your Kidneys need special attention.”   The sputtering — “how can that PT, with a 30 hour course, presume to think they might know something I don’t already know.” I’ve had similar conversations with colleagues in the past and I can relate. I’ve had clients come to me with similar news — oh, my DC said he thinks the problem is my Liver meridian — and my initial internal response has been a dismissive tossing away of the input along with the thought that there is nothing about acupuncture and Chinese Medicine that a 200-hour acupuncture wanna-be could tell me.

We, in effect, become the “Jerk MD” in these interactions. The input from another provider, who no doubt wants only the best for the client, is disregarded, and our self-serving sense of superiority is stroked. We indulge our arrogance.

Let’s be the change we would like to see in the world. Let’s welcome input from others who are caring for our clients. Let’s be willing to have a dialogue about what they are observing and consider whether it might be helpful to us, regardless of our judgments about their training. Let’s share what we know that makes us think they might be off-base or on the right track. Perhaps an ongoing referral relationship of mutual respect could develop, serving our clients and our own professional development! And let’s be sympathetic to the MD who might think we, with our limited training in western medicine (most of us), are presumptuous if we have thoughts about a western diagnosis. We know what it feels like to have someone with less training offering us their assessment.