Category Archives: hwds

A Rose?

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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!

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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!!!

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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

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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!”

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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.

Imagine, or, How I Learned to Stop Worrying and Love the Bomb.

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Trigger Point Dry Needling — develop a way to harvest Liver Yang rising, bring the topic up in a crowd of acupuncturists, and reduce our dependence on fossil fuels. I’ll save my full critique of our current response for another day. Today I will paint a picture of what could have been, and could still be, if we were to respond to this issue with healthy Wood.

Imagine, if the community’s response to the topic of dry needling went like this —

  1. Similar to Mark Seems’ response, described in his 1993 book A New American Acupuncture, we recognized that the independent identification of types of physical dysfunction by different modalities can provide fruitful opportunities for integrated medicine.
  2. We made sure that all acupuncture students and practitioners had the opportunity to develop expertise in the needle techniques, point identification, and point selection that is necessary to effectively release stagnation at A Shi points.
  3. Our discussions with Physical Therapists and other professionals were respectful, making clear that we understood their interest in serving their clients. (Just as ours is when we explore our own scope of practice, right?)
  4. We had, in advance of hearings and public statements, carefully explored the consequences of insisting that this technique be described as acupuncture. Might it be easier for the public to understand differences in techniques and training if PT’s and others were encouraged to use distinct terminology? Could our insistence that it be called acupuncture actually set the stage for the slippery slope that we fear?
  5. We honestly and forthrightly identified the amount and type of training we considered sufficient to use this technique.  (For instance, if we practice in a state that allows medical extenders, and if we had a spouse who was also a PT assisting in our office, what would be need to teach them before we felt they could use this technique?  How long would it take?)
  6. We were consistent in our arguments — for instance, expressing concern over the pain this technique can cause, while later suggesting that we could accept a situation in which the PT’s used a syringe to stimulate the point is not consistent.  Likewise, arguing that we already do this technique undercuts the discomfort argument.  Another example — we have often argued that patients should have the right to choose their providers, yet here we have argued that patients must be protected from the risk of a poor choice.
  7. We proactively educated the public about our training and experience.  (No need to denigrate the training of others in the process.)
  8. We explored employment opportunities at PT offices — illustrating how the hiring of LAcs would enable the PT to avoid altering their practice flow or having to deal with related insurance and paperwork hassles.  This would provide employment opportunities for acupuncturists and give clients convenient access to TPDN and full acupuncture treatments.
  9. All providers of TPDN knew the location of LAcs in the area and referral relationships were encouraged as appropriate.
  10. We offered appropriate training to PT’s, DC’s, and others interested and legally able to use this technique in our jurisdiction, building relationships of mutual respect while addressing our concerns about existing training, and, adding a source of revenue for our schools and teachers.
  11. We educated ourselves about the regulatory process, making sure that every LAc understands that our regulatory boards regulate people (LAcs) not techniques, and not the activities of other professions.

This list could be longer, but I bet you get the point.  Without resorting to the old canard about the Chinese character for crisis, I will say that this whole TPDN “situation” had (and in some cases still has) the potential to be a huge opportunity for us.  Instead, it continues to suck up a lot of time and energy and burn rather than build bridges.  What a shame.  We have indeed turned potential opportunity into a dangerous crisis.

A House Built on Shifting Sand

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About eighteen years ago, as we were advocating for a practice act in Virginia, a big upset was that MD’s, DC’s, and DO’s (and podiatrists within their scope) could practice acupuncture with only 200 hours of training.  Time and again, acupuncturists complained (and continue to complain) about this — after all they say (and we said to the legislators and staff at the Department of Health Professions) acupuncture is far more than sticking a needle in the body.  Acupuncture is a complete system of healing, a theory, a philosophy, a paradigm, a system of diagnosis.  A doctor may be able to safely stick a needle in a point (though these are, after all, very special needles, nothing like a crude hypodermic), but they aren’t doing “acupuncture.”  Mention MD’s and DC’s “with limited training” doing acupuncture to most LAcs today and you’ll get anger and complaints.

What gets LAcs (or OMDs or CAcs) even more incensed today — Physical Therapists (or DC’s) sticking a needle in a point and saying it isn’t acupuncture.  After all, we say to the regulatory boards (and even more loudly to each other), they’re sticking an acupuncture needle in a point.  We don’t care whether the PT is thinking only that a trigger point causing pain could be released by this needle.  Or that they know nothing of the theory of Chinese medicine.  All we know is that if they are sticking a needle in a point they are doing acupuncture, they darn well better not call it anything else, and they ought not be allowed to do it.

I’ll save the in-depth conversations about TPDN, scope of practice (it doesn’t mean what you think it means), and coalition building for other days.  For today, I just want to ask that our profession show some consistency.  Consider the implications of insisting that acupuncture is defined as a needle in a point, or the implications of insisting it is far more than that, and especially consider the implications of changing the definition to suit a short term need.  Consider the implications on what you do in your treatment room, as well as the impact on our battles with other professions, our interactions with regulators, our involvement with third-party payer systems, and perhaps most importantly, on how we build our brand.  Above all, remember that like a house built on shifting sands, a profession built on shifting definitions is unlikely to stand the test of time.