Dear NCCAOM

Dear Ms. Ward-Cook, NCCAOM Board of Directors, and NCCAOM staff:

The selection of Chief Executive Officer is a critical time for an organization. Continuity might be the primary goal when a business is thriving. When things haven’t been going well, the best choice might be someone with a fresh perspective and a willingness to shake things up.

As you know, the number of people entering the profession has dropped significantly. Without a change, the growing demand for acupuncture will increasingly be met by people who are not Licensed Acupuncturists. The profession we have worked so hard to build is at risk of becoming little more than a footnote, even while acupuncture itself becomes widely accepted. We must face this issue head on. Every decision made by our organizations must consider which choice supports growth of the profession, and which will contribute to our demise.

With such a small profession anything that divides us, or limits opportunities, is problematic. So is anything that inflates the cost of our education or entry to the profession. These all increase the odds that an interested person will choose another profession, or, having entered the profession, will struggle to succeed.

Over the years, the NCCAOM has made a number of decisions that have, in fact, divided us, limited us, and complicated educational choices and entry to the profession.

I hereby request you select a CEO committed to change, so that the NCCAOM can be an organization that unites, and that removes any barriers for entry to the profession that are not necessary for the protection of the public.

Your new Chief Executive Officer should –

  • Understand that it is in our best interest that everyone who passes the NCCAOM exams finds it easy and inexpensive to obtain and maintain their NCBA (Diplomate) status. In the absence of any findings of unsafe practice, active status should renew automatically, and at a minimal cost. With such a small number of practitioners, we can’t afford to exclude any competent and safe practitioners from employment or licensure. As it is, significant numbers of Licensed Acupuncturists are excluded from job opportunities even after passing the NCCAOM exams. The current system of CEU verification is complicated, and has no measurable impact on practitioner quality.
  • Develop exams that test only what is necessary for safe practice, focusing on crucial tasks and red flags. No particular lineage has been shown to be safer or more effective than any other. Testing requiring knowledge of one specific lineage adds to the cost of an education, complicates school choice, divides the profession, and increases NCCAOM expenses, all without benefit to the public. Since knowledge of a particular lineage is not required for competence, a Job Task Analysis focused on knowledge of a lineage is flawed and must be redesigned.
  • Fight any attempt to exclude any Licensed Acupuncturist from practicing to the limits of their knowledge and experience. The NCCAOM should never support efforts to limit, for example, the use of herbs to any subset of acupuncturists. They should be clear – the herb credential is optional, and acupuncturists without that credential should not be disadvantaged compared to all other individuals in a jurisdiction. Using resources gathered from Diplomates to support efforts to limit their practice feeds resentment and division. The addition of requirements for the herbal credential limits opportunities for practitioners, increases barriers to practice, and increases educational costs.
  • Ensure that the NCCAOM changes policies or procedures only after extensive consultation with all potentially affected parties, allowing us to minimize and mitigate harm. Changes that lead to additional costs or stress to students, schools, and licensing boards work against success and growth.
  • Prioritize execution. User friendly and functional portals are important. So is accurate information. Errors (such as incorrectly reporting licensure requirements) can have a huge impact on educational choices and employment decisions. For practitioners who have a choice, a frustrating hour spent fighting with the recredentialing process can be a deciding factor in whether or not they maintain active status.
  • Keep the focus on the core of the NCCAOM’s mission – ensuring the safety of the public through credentialing Acupuncturists. Lobbying costs money. Taking a position on a matter of politics leads to division and disappointment. The NCCAOM needs to minimize expenses for Diplomates, not use our money to fund activities that we may not support.
  • Leave education to the schools. When the NCCAOM develops educational programs, such as content for the CHCS COQ, it increases concern that the NCCAOM could one day move to make this certificate mandatory due to self-interest. Likewise, the approval system for CEU’s adds to the cost of classes and complicates maintaining certification. This system has no discernible benefit to the public, and stands in marked contrast to the practice of many other credentialing bodies.

I’ve held NCCAOM certification for the past 25 years. I have spent decades as a Board member – of my State Association, State Regulatory Advisory Board, and even the AAAOM. I know that many of my colleagues are quick to demand action, resistant to reconsidering their positions on issues, and eager to place blame. I know it’s frustrating to work hard to give people what they want, only to be criticized for your efforts.

I write now as a Licensed Acupuncturist, and do not speak for any other group or organization.

The existence of a national credential was a great help during our efforts to establish licensure in Virginia in the early 90’s. Over the years I have defended the organization countless times. But when I last renewed my board certification I had to grit my teeth.

As it stands, I’m no longer clear that the NCCAOM is a net benefit for the profession. I don’t trust you to look out for my best interests, even though I’ve been a Diplomate for all these years.

I would like to be able to defend you again. I’d like to know that you had my back. That my fees weren’t being used exclude me from practice. That lapsed status wasn’t keeping colleagues out of the profession. That your exam didn’t require people to learn a lot of information they’ll never need to practice safely. That my fees weren’t being used to fund futile turf wars. That the information you provided could be trusted. That your systems worked. And that when concerns were brought to your attention you didn’t deny or evade or misrepresent what happened.

It’s time for a CEO who understands the changing landscape, and understands that without a change in direction there will be no profession left to protect. For the sake of the profession, and the future of all of us associated with it, I hope that you choose wisely.

 

Sincerely,

Elaine Wolf Komarow, LAc, Dipl.Ac. (NCCAOM)

 

 

Dry Needling – Winning, and Losing.

The Battle of Cold Harbor, in May – June 1864, was one of the last victories for the Confederates in the Civil War. (Or, as it was referred to in the South, the War for Southern Independence.) The victory did not change the outcome of the war.

In January, a state judge ruled that Dry Needling is not within scope for Physical Therapists in Florida. This ruling was proclaimed a great victory and widely celebrated on Facebook and here, in Acupuncture Today.

FSOMA won in Florida, because, as appears in the ruling, “A simple reading of the physical therapy scope of practice statute, section 486.021(11), in light of the definition of “acupuncture” in section 457.102(1), makes plain that dry needling is not within the statutory scope of practice for PTs in the State of Florida. The Board had no basis for moving forward with the Proposed Rule.”

FSOMA did not win because the FDA limits the use of filiform needles to LAcs, there aren’t standards for the practice of dry needling, the physical therapists aren’t adequately trained, dry needling would harm patients, dry needling is “cultural misappropriation,” or any of the other many arguments made in Florida and elsewhere.

This ruling sets no precedent for any other state because it is based on the definition of Acupuncture and the scope of PT practice as found in Florida law. If state level rulings did set a precedent in other jurisdictions, FSOMA would likely have lost. We’ve lost in more states than we’ve won.

Of course, you wouldn’t know any of this from that Acupuncture Today article, or all those celebratory posts on Facebook.

Meanwhile, we’ve lost a significant and costly battle. One which should never have been fought. This loss hasn’t yet made the news.

The North Carolina Physical Therapy Association recently announced a settlement agreement, in which the North Carolina Acupuncture Licensing Board would pay the NCPTA a six-figure settlement and agree that all current and future members would stop sending cease-and-desist letters to physical therapists who offer dry needling, and would honor the North Carolina Supreme Court’s decision that dry needling is within the scope of practice of physical therapy.

This loss should surprise no one. The NCALB incurred significant legal debt persisting in a battle that no one outside of the profession thought they could win. And they attracted negative attention from lawmakers in the process. Why, oh why, did they do this?

I’ve stopped hoping that yet another blog post will change our behavior. Will a six-figure settlement? How will the NCALB continue to function without resources?

Even the few battles we’ve won could later be lost. Scopes of health professions can change via legislation. Physical Therapists outnumber us in every state. The trend is away from scope “monopolies” – understandable when we need to improve access to services and reduce health care spending. (Consider the history of scope and Advanced Practice Nurses, Optometrists, Social Workers, and Dental Therapists.)

Both the Acupuncturists and the Physical Therapists might refer to this multi-year hostility as The War of Defending the Profession, or The War of Protecting our Patients. Undoubtedly, each side has been motivated by the belief that they were doing what was right. But, war is costly. And, as the smaller and poorer profession, we have suffered greatly for our few victories.

In the past few years we’ve done a good job increasing the demand or and interest in acupuncture. But the number of people entering the acupuncture profession is dropping. In the vast majority of the country we don’t have enough practitioners to meet the need. Meanwhile, qualified and experienced practitioners can’t practice because of regulatory loopholes that seem to benefit only the NCCAOM. The NCCAOM is looking for a new Executive Director, and it’s critical that we be involved in the selection process. Acupuncturists can’t pay off their student loans while others argue for additional educational requirements. Our schools are closing. We’re increasingly participating in the insurance system, increasingly concerned that the system doesn’t support our work, and increasingly, getting into insurance-related legal trouble.

It’s past time to give up the war. There is no one person who can proclaim the end to hostilities. General Lee could only surrender the Army of Northern Virginia on April 9, 1965 1865.* Other Generals continued to fight. I’m sure some state association somewhere will continue to beat the drums of war, insisting that we fight on. What a shame.

We have far better things we could be doing with our time and our money. Let’s.

(Yes, I’m so tired of writing about dry needling I studied up on some Civil War history to spice things up.)

* When I first published this I goofed and wrote 1965. When it was pointed out (thanks astute reader!) I quickly corrected it. But I’ve been thinking. The consequences of the Civil War are still very much with us. Freedom Summer was in 1963, for example. When I see suppliers marketing that they don’t sell needles to PT’s, and LAcs boycotting suppliers who don’t make that promise, well, it’s heartbreaking. The sooner we reconcile the better. And, yup, some LAcs see me as a Profession Traitor for saying this.

Does it Tingle?

Acupuncturists believe we’re the best-trained, most-qualified, most-effective providers of acupuncture. Many of us believe that our personal style of practice is superior to other styles and traditions.

And, we panic when faced with competition.

News of non-acupuncturists using filiform needles, a low-cost clinic opening in the area, or, a splashy franchise, are met with a combination of outrage and disdain, and fear that our practice, our clinic, the profession, won’t survive.

It’s an interesting juxtaposition. We’re the best, and, if the public has options we’re doomed.

There are reasons for concern. We’re burdened with debt. There’s consumer confusion. Reimbursement rates are falling, and, yes, competition is growing.

Efforts to increase educational hours, require additional training and certifications, add new titles and degrees, increase involvement of third party payers, and to “protect our turf,” have too often contributed to those problems rather than being the promised solutions.

We haven’t, with few exceptions, explored why clients would chose someone else’s services. Or considered how we might respond to client needs in mutually beneficial ways.

One notable exception — in 2002 Lisa Rohleder and Skip Van Meter founded a clinic to make it easier for more people to get more treatment, while also providing a stable income for practitioners. Lisa wrote a series of columns for Acupuncture Today to share her system with the profession as a whole. (These columns are excellent reading for all practitioners, whether or not sliding scale/community acupuncture is of any interest. Visit POCA for more information.)

After her sixth column, the Executive Editor of Acupuncture Today wrote to Lisa – “we are concerned about continuing your column under its current “theme”, for lack of a better word. While the concept of social entrepreneurship, particularly the “pay according to what you can afford” aspect, is admirable, it has dangerous potential from the perspective of professional advancement.”

Crazy, right?

Contrast that with AT’s love for Modern Acupuncture. Marilyn Allen, AT’s editor-in-chief has a new mantra – “Modern Acupuncture will save the profession.” She exhorts us to appreciate their “different” marketing, which, after all, has been designed by a top advertising firm to appeal to the “target demographic” (people with money). She even says we we should join the NCCAOM in promoting their advertising campaign.

I dislike MA’s marketing campaign, and I won’t promote their advertising. I’m sad that instead of, for example, exploring barriers to practice in underserved areas, we’ve got powerful voices touting acupuncture for hipsters. And I’m angry that Marilyn Allen and AT rave about MA but saw danger in “pay what you can afford.”

Meanwhile, rather than dwell on my judgements about how others practice, I choose to learn from my competition. Are they filling an unmet need? Is my pricing, location, schedule, office procedures, or technique keeping me from being more successful? How can I better serve my clients?

My patients don’t owe me anything. It’s their right to decide whether I serve their needs. If I don’t, I hope they will find someone who does. I wouldn’t be happy if there were serious competition down the street, but I’d try to learn from the experience.

We don’t have evidence that patient outcomes or satisfaction depends how long the practitioner went to school, the style of treatment, the treatment setting, or the practitioners titles or certifications. Different patients have different preferences and priorities.

There are many reasons to think the new acupuncture franchises won’t save the profession. Running the numbers raises doubts. Reports from early employees have been less than glowing.

So, I’m not counting on Modern Acupuncture to save us. Nor do I fear they’ll destroy the medicine. (It’s survived quite a lot over the millenia). My concerns for the future of the profession have nothing to do with competition, whether from LAcs or others.

My concern is that we don’t seem very interested in what our potential clients tell us they want. My concern is that we chase after the respect and acknowledgement of the establishment, even as the cracks in that establishment and the unhappiness of the participants grows. My concern is that some of the most powerful voices in the profession seem so clueless about what it’s really like to be a working LAc, and how their plans and policies so often hinder rather than help.

I don’t know whether that tingle I’ve been hearing about is the precursor to a pleasant thrill or shingles. I’ll focus my efforts on taking good care of my clients, supporting increased access to acupuncture for those who want it, and hoping that those with power use it for good. I hope you’ll do the same.

Safety: Dry Needling and Acupuncture

We worry about the public’s well-being.

The excellent safety record of Licensed Acupuncturists is part of our “brand” and has been a focus in the fight against the use of filiform needles by those without our extensive training.

Are we walking our talk?

At a recent professional gathering a representative of a malpractice insurance company recited a terrifying list of problems that turned into insurance claims against acupuncturists: a double pneumothorax, infections from needles manufactured in unsterile conditions, broken bones from tui na, burns from heat lamps. The message – Buy Malpractice Insurance!

On Facebook, Acupuncturists regularly look for support after a patient reports a post-treatment issue.The equivocations quickly pour in: Is that really where you needled? Are they on medication? It’s a healing reaction. Did you have them sign a waiver? There is such a thing as a spontaneous pneumothorax….

Yes. Malpractice insurance is a good idea. And sometimes post-treatment issues aren’t treatment related. But the lack of concern about the problems, and the lack of interest in how they might be avoided, calls into question our supposed devotion to public safety. Not only are we advised to never admit responsibility to our patients, we’re encouraged to never admit it to ourselves.

In 1999 The Institute of Medicine released a report, To Err is Human: Building a Safer Health System.

“The committee’s approach was to emphasize that “error” that resulted in patient harm was not a property of health care professionals’ competence, good intentions, or hard work. Rather, the safety of care—defined as “freedom from accidental injury” (p. 16)—is a property of a system of care, whether a hospital, primary care clinic, nursing home, retail pharmacy, or home care, in which specific attention is given to ensuring that well-designed processes of care prevent, recognize, and quickly recover from errors so that patients are not harmed.”

Lisa Rohleder writes –

“It’s impossible to effectively promote safety when we don’t know where WE are going wrong. An important part of developing a culture of safety is to establish, as much as possible, a compassionate, neutral, and curious attitude toward safety errors and adverse events. Nobody wants to make an error (either large or small) or have a patient suffer an adverse event — and yet anybody who practices acupuncture for long enough will experience those things. Acupuncture is a practice that involves humans on both ends of the needle, which means sometimes, unfortunately, things will go wrong.”

“Acupuncture legislation and regulation are not the same as creating a culture of safety. Training cannot ensure that the people who receive it will never play a role in an adverse event. A culture of safety requires an active, ongoing, self-reflective, cooperative process.”

An adverse event does not necessarily mean that a mistake was made. It means that something didn’t turn out as we would have liked. It can happen when a practitioner does everything right. The more we know about what happened, the more we can confront and minimize the risks involved in treatment.

But we can’t know what happened without collecting the data. And we can’t collect the data if 1) there is no mechanism to report adverse events and 2) people are afraid to share about and discuss adverse events.

Until recently, no acupuncture organizations have been interested in collecting such data. Alarmingly, in the name of acupuncture safety, one shadowy acupuncture group has created what it calls an Adverse Event Reporting system for the sole purpose of weaponizing reports of adverse events related to dry needling. The data are not anonymous. (The board of the group collecting the data is.) The goal is not to improve the safety of a practice, but to attack competitors. It makes it more difficult to develop a culture of safety.

Finally, we have the opportunity to participate in a voluntary and anonymous database for reporting adverse events in acupuncture, developed with the goal of promoting safety.

Some questions and answers from POCA’s materials about the AERD they created –

Why Should All LAcs Voluntarily Report Adverse Events and Errors?

POCA created this AERD for ourselves but it is designed to be used by anyone who provides acupuncture services and anyone who is a consumer of acupuncture services. We are hoping that many L.Acs will participate, and that other acupuncture school clinics will want to join us in collecting safety data.

Using a voluntary and anonymous AERD is a way for the acupuncture profession to encourage a culture of safety. AERDs are standard in other healthcare professions and it is notable that the acupuncture profession has not had one; that’s a problem that needs to be fixed, especially in light of acupuncturists’ practicing in integrative medical settings.

 Why Did the POCA Cooperative Create an AERD?

POCA loves data, and collecting our own safety data has been a topic of discussion in the co-op for years. Having POCA Tech as a resource to manage an Adverse Events Reporting Database, along with getting support from Dr. Suzanne Morrissey (medical anthropologist and professor of anthropology at Whitman College), allowed us to make an AERD a reality.

Why Voluntary and Anonymous?

Research suggests that it’s possible to collect better safety data, and thus do a better job of improving safety practices, when reporting adverse events and errors is voluntary and anonymous. Nonconfidential and mandatory reporting systems may discourage practitioners from disclosing adverse events and errors.

The goal is to focus on safety practices and systems, not on errors made by individuals.

Here’s the place to report adverse events.

Additionally, membership in POCA provides many excellent perks, whether you provide community acupuncture or not. I encourage you to check it out. Thank you, POCA, for establishing the AERD, and Lisa Rohleder, for starting this discussion. This post borrows heavily from her writing. Any errors, however, are mine alone.

 

 

Insurance, Again. The s**t got real.

Photos of an acupuncturist in a prison jumpsuit, bond reduced to $455,000, facing charges of racketeering, insurance fraud, engaging in an organized scheme to defraud, patient brokering, and unlawfully waiving copays and deductibles. It’s bad for the profession.

It’s worse when the acupuncturist taught insurance billing seminars.

Whether or not she is ultimately found innocent, I’m sure none of us want to be in her shoes. Let’s learn what we can from the case, and from the discussions about it happening on social media and elsewhere.

(Here are additional stories about the case: Indian River Meeting MinutesMarch 2017August 24, IRC MemoFlorida CFO, September 13)

My takeaways –

  • There are wonderful, respected, kind, people who engage in criminal activity. Encomiums about the accused show us humans aren’t one-dimensional, but are irrelevant to guilt or innocence.
  • Insurance billing is no game, despite books, seminars, and conversations presenting it as one.
  • As a profession (the community acupuncture folks being the main exception), we haven’t accepted the conflict between wanting people to get as many acupuncture treatments as we think appropriate/they desire, earning what we “deserve”, practicing in our preferred style, and the overall health care economy. We grabbed insurance as the savior. It isn’t.
  • It is easy to rationalize wrongdoing. Practitioners justify creative billing to help their clients or counteract an unfair system. That’s bad for our profession, personally risky, and, because “insurance money” comes from people buying insurance, ultimately costly to anyone buying insurance.  If a plan doesn’t cover acupuncture for depression, explaining that to your clients, and giving them a discount if you’d like, is honest. Believing that the insurance company is forcing you to figure out a way to “treat them for pain so it gets covered” is dishonest.
  • If you want to advocate for better coverage, be prepared with data to show the economic benefits. Do you want your premiums to cover other non-medically necessary choices? Who should decide?
  • We need to be honest when discussing the efficacy and cost of acupuncture. Many practice websites, and much of our lobbying for increased coverage, refer to a course of treatment of eight to twelve visits. If an average of almost forty treatments/year, as in this case, is appropriate “for today’s complex patients” (as many commenters stated) we need to own that. If it varies based on condition (of course it does), let’s make sure we let patients and insurance companies know. If you are treating for a complex condition, but code for a simple one to facilitate reimbursement, you’re skewing the data about acupuncture efficacy.
  • There are lots of acupuncturists eager to give definitive answers to questions outside their area of expertise. Having a successful insurance-based business does not make one an expert on insurance law.
  • Our burdensome systems for approving CEU/PDA classes don’t provide quality control.
  • Having demanded entry to the system, we owe it to ourselves (as consumers and providers) to speak up when we see wrongdoing. We need to acknowledge that our colleagues who review charts and advise insurance companies are necessary if we are going to be part of the system. It’s a bad sign when those within the profession who work to protect the consumer are dismissed as the enemy. The insurance companies will find problems even without our participation.
  • Context is important when determining legality. Patterns of individually legal actions (in this case, waiving co-pays was permissible) can add up to illegal activity.

Here’s more on Health Care Fraud – from an investigator.

Being a health care provider is serious business. Participating in the insurance system is serious business. Let’s be careful out there.

 

 

 

The NCCAOM Replies

In early August I received a comment from Mina Larson of the NCCAOM in response to A Feature or a Bug. I approved it, replied, and now, with a bit more time, will give it a closer look.

I always encourage those who disagree with my posts to share their thoughts in the comments. I moderate to limit rudeness, screeds, and ad hominem attacks, not viewpoints. I’ll run guest posts, though I admit I’m more enthusiastic when the guest is a voice that doesn’t already have access to various other megaphones.

As I wrote in About Me,

” I continue to do my best to serve the profession and the public by encouraging a deeper exploration of the professional choices we are making. This blog is an effort to provide a forum for the dialogue necessary for our success.

All of my writing for The Acupuncture Observer reflects my own opinion.  I do not speak for any organization or board and am not representing any group here. I apologize in advance for any mistakes. Please let me know of any errors so that they can be corrected.”

Now, Mina’s comment (in italics), and my responses:

Elaine, it is very disappointing and alarming that you do not share with your group the many times I have communicated with you, informed you and updated you on updates on and rationale for proposed and new policy decisions – even our decision to not move forward proposed policies when we received input from our Diplomates (you were one of them) regarding a PDA and eligibility proposed policies a few years back. You also conveniently forgot to mention the fact that we delayed our linear testing (that we have to do to stay complaint with adaptive testing) and pre-grad elimination (also to stay compliant [sic] for our accreditation) based on stakeholder input. Please see NCCAOM Student Webinar: http://www.nccaom.org/nccaom-webinars-posted/student-webinars/

 

Mina, I have been unclear on whether all of our discussions are “on the record.” In several cases I have not shared our communications as I was unsure what was official NCCAOM policy. I’ll do better in this regard in the future. In many cases our discussions have not changed my assessment of the situation. Some of our talks were a factor in my feeling that the NCCAOM talks out of both sides of their mouth. I did not “forget to mention” to the times the NCCAOM has changed or delayed changes in response to input, I specifically refer to it. I even include a link to the announcement of the delay in linear testing, as well as an additional post (June 5th) reporting on some changes.

You continue to also bring up the NCCAOM testimony in Utah, in which I have provided information about our Chinese Herbology exam and requirements upon request by the Utah Advisory Board of Acupuncture. We testify at state hearings upon request from state regulatory boards and state associations to provide information about our standards and our exams. That is what credentialing organizations do! The herbal exam is one of our requirements for OM Certification and if you listen to the testimony at the Utah hearing, we provided information. We did not “side” with any group during that meeting. I had several meetings with groups opposed to and for the CH exam. We do not “pick and chose” what hearings we should go to – we are there to provide information about our standards and exams and to support our Diplomates in that state. How do you think there are now 47 states that have a practice act for acupuncture? We have been involved with helping a majority of these states to develop a practice act. How convenient you leave this info out.

I included a link to the entire testimony in the post about Utah. In that post, I include a link to a letter (UtahNCCAOMletter), distributed under the NCCAOM’s auspices and letterhead, showing that the NCCAOM supported the position of the state association and regulatory board to require the herbal testing. Although, in discussion, you told me that the letter was a mistake, the NCCAOM has not done anything to correct record. If the profession is confused about the NCCAOM’s position, that is on the NCCAOM. You and I went through that post word for word. In the end, the only place you could quibble with my writing was that my statement that the NCCAOM was unwilling to reconsider the hourly requirements for sitting the test did not include your position that that change was not within the NCCAOM’s purview.

In the interest of space, every post leaves out all sorts of history. Overall, I have often expressed my appreciation for the hard work of the NCCAOM.

Yet some people want to blame the NCCAOM for any problems with the profession. They want to point out that we moved to DC from Florida, but leave out the fact that not one dollar was spent on “moving employees”. Any employee who moved to the DC area from Florida, paid their own expenses. It is very disturbing to see people making false assumptions and publish information that is not validated. We did not invest, lease or buy headquarters, in fact, we are sharing our space with other associations in DC so that we can give those funds back to our Diplomates through our advocacy and PR work for promoting them and our profession.

I can’t be held responsible for what “some people” think. I have often defended the NCCAOM. I have not concerned myself for one second about where you are moving and how much it is costing. It’s an insignificant issue in my book. The NCCAOM has a MONTHLY column in Acupuncture Today, and the ability to mail or email every single Diplomate in the US. If you can’t make your case to “some people” I hardly think I’m responsible.

Now the gossip continues by assumptions that we go out and testify on selected issues, when what we do and have always done is testify and provide support to state associations who need our help or regulatory boards who request our input on NCCAOM standards. How come you do not speak of the many times we have traveled to states to provide information to advance the profession and our work with the Bureau of Labor Statistics and the VA? You and others on this blog choose to ignore the information on our website and focus on assumptions.

I have often reported on the work of the NCCAOM in various states. Your work is widely reported in AT and in your news alerts. There is no need for me to cover it extensively, though I do cover it. I link to the NCCAOM website and publications regularly.

You seem to leave those details out! How come you publish our 990s but forget to reveal that Kory, I and other NCCAOM dedicated employees work around the clock to help our Diplomates? You even have my cell phone number and I have taken your calls weekends, nights, holiday, but you are on a mission to discredit the NCCAOM because there needs to be someone to blame for issues in the profession. Anyone can also take a look at our annual report on our website with our financial statements. In fact, if you were to look at the data from the last couple of years, you will see a deficit as we have invested to give back to the profession. If you want evidence, just contact associations in Kansas, Wyoming and others who received practice acts last year as well as associations like FSOMA whom we have helped over the years, just to name a few.

I don’t leave those details out. I am glad for your hard work, and have said so many times. I appreciate your willingness to communicate. The 990’s and annual report stand for themselves.

In is also interesting that you have also left out the PR and advocacy work that the NCCAOM has accomplished (please go to http://www.nccaom.org for this information) to advance the profession. I have learned in my 15 years of serving this profession, there are some amazing people that make a difference by collaboration, selflessness and hard work and some who will continue to point fingers, have agendas, and cause needless disruption at a time when we need to unify to strengthen our medicine and the profession.

I haven’t left any of this out. I agree that there are many people working hard to strengthen the profession. I too, have worked selflessly on boards, with associations, to increase collaboration and unity. My goal is never “needless disruption” and I am sad that you seem to believe that is what I am doing.

Many of us have worked to build a better profession. And, honestly, much has been done that has not served us well. We have created fault lines, left qualified practitioners with limited options (requiring the herbal exam of all practitioners is one example), and selected winners and losers among the varied lineages behind this medicine. My efforts have always been to help us learn from our past and from the experiences of other professions, so that we protect the public without unnecessarily limiting freedom to practice and without putting additional burdens on professionals who are struggling for success.

It’s too bad that within this medicine, which looks for balance and harmony, we have so much trouble negotiating our differences.

A Feature or a Bug?

Quote

When a trusted business or organization screws up, it’s good to give them the benefit of the doubt. We all make mistakes.

I have trusted the NCCAOM. They were important to our acceptance as a legitimate profession. In 2014 I encouraged people to support a transition to their exams in California, hopeful that one national standard of entry would further the growth of the profession.

But I’ve noticed a pattern – the NCCAOM makes a big announcement and seems unprepared for the response. They scramble to address the upset, explaining why we don’t understand their good intentions or their difficult position.

I used to think it was a bug. They just weren’t as competent as I’d thought. And Acupuncturists mostly don’t understand their role and are quick to react.

But now I think it’s a feature.

We don’t understand their role because they talk out of both sides of their mouth – they say or do contradictory things depending on their immediate desire.

In the “NCCAOM Questions and Clarifications” document (released in draft format), their response to the reaction to the changes in testing policies, the NCCAOM writes:

“There are some policies where we may ask our stakeholders’ opinions and use that to determine policy.  There are many other policies where this is not appropriate because of the requirements of our accrediting body, fiduciary responsibilities (the fiscal health of NCCAOM), or impacts to public safety need to drive our policy decisions.  NCCAOM is not a membership organization, it is a credentialing organization. Examples of this include: the elimination of the apprenticeship-only route, elimination of the pre-graduation route, and the revisions to the NCCAOM® Code of Ethics and the Grounds for Professional Discipline. These are examples that our policies are driven by our NCCA accreditation standards.”

But the NCCAOM did ask for input on the Code of Ethics and Professional Discipline, and their revised code reflected that input.

And the NCCAOM did step back from some of their announced changes in response to concerns from stakeholders. Clearly they had some flexibility, and could have done this prior to their announcement.

And in 2016 the NCCAOM shared –  “Breaking News! New Membership Organization Announcement!” describing their “Academy of Diplomates.” The Academy Board is a subset of the NCCAOM Board, your NCCAOM recertification fees support this organization, and links on the Academy website take you back to the NCCAOM. No wonder we’re confused.

In “Questions and Clarifications” we read – “It is no secret that the number of students taking the exams, annually, has dropped dramatically over the past decade.” Their upbeat NCCAOM Spring 2018 newsletter doesn’t mention it, nor has it been a topic in their frequent Acupuncture Today articles. Study their annual reports and you can uncover the truth, but that isn’t the news they’ve been sharing.

Fewer people taking the tests means fewer new practitioners. Shouldn’t the profession give scrupulous consideration to any policy or regulatory changes that make it harder to enter the field?

The NCCAOM’s current honesty regarding their financial concerns is appreciated. It also demands that we reconsider their previous denials that money drives their policy positions. Their support of efforts to require the herb exam of all practitioners (UtahNCCAOMletter), and their complicated PDA system, make sense from a financial perspective, not from a safety one.

The NCCAOM denies that their exams shape our education. They say schools should not teach to the test. They also advertise, “It is recommended that ACAOM Approved Schools Faculty members sign up for [the NCCAOM] practice tests to familiarize themselves with the process.”

They dismiss concerns that a new voluntary certificate program could become mandatory. They simultaneously support efforts to make the voluntary herb testing mandatory.

Underneath it all is the refrain, the “NCCAOM’s number one priority and mission is to protect the public.” This is as it should be. But one insurer recently reported receiving 1-3 reports of harm per week, including reports of pneumothorax, burns, and infections. In a profession of, at best, 30,000 practitioners, shared between multiple insurers, that’s alarming. Is there evidence that patients in Maryland or West Virginia, where there is no NCCAOM testing requirement, are more likely to suffer harm?

With great power comes great responsibility. The NCCAOM denies their power and their responsibility, but they are the gatekeeper to the profession. They have us by the short hairs. Their denials aren’t believable.

I’ve given them the benefit of the doubt for years. I’ve explained away their errors as bugs and defended their good intentions. It’s painful to acknowledge that I no longer trust the NCCAOM.

They need to get a lot more honest and a lot more competent quickly, or we need to get serious about finding an alternative.

 

 

 

Third Night – Lowering Standards!?

In recent conversations with colleagues I’ve heard a few exclaim “we won’t agree to lower our standards!” and “we aren’t going to go backwards on our education!”

I haven’t heard anyone suggesting that we lower our standards or go backwards, so I was baffled.

Only momentarily, though, because then I remembered -The Acupuncture Revisions Proposal from the POCA Tech BOD to “revise acupuncture education and testing standards so as to benefit current and future (1) acupuncture students, (2) acupuncture schools, (3) acupuncturists, and (4) the general public.”

They make clear that their proposed standards are based around students meeting all of the competencies required for ACAOM accreditation and preparing graduates to be safe and effective practitioners. (The proposal is concise, well-written, and worth reading. Please do.)

Unfortunately, “high standards” in this profession has come to mean number of hours spent in school. So any change in the number of hours is interpreted as a lowering of standards.

I understand how it happened. When we’ve fought for acceptance, we’ve stressed our hours of training to establish our worth. When clients mention that they got acupuncture from their Chiropractor, we talk about how much time we spent in acupuncture school compared to the D.C.’s short courses. Hours of education has been a battle cry in the dry needling fight. (Which has been mostly unpersuasive since the PT’s 1) deal in competencies, and 2) we use different rules when we count our hours and we count theirs.)

Actually, a standard is “a conspicuous object (such as a banner) formerly carried at the top of a pole and used to mark a rallying point especially in battle.” (Merriam-Webster).

So, hours has become our standard. But it’s such a meaningless standard. I’m sure I’m not the only person who’s been to three-day CEU classes that have been a complete waste of time while a one-hour class contains a transformative nugget. I’ve spoken to people who have taught at some acupuncture schools and the picture they paint is not of hour after hour of quality programming.

We’ve got a workforce that needs to grow. And levels of educational debt that are an impediment to professional success. Affording graduate school and repaying loans isn’t going to get easier.

Read the Acupuncture Revisions Proposal with an open mind.

Our banner should be more meaningful than a number.

 

 

Proposal regarding Acupuncture Education

The POCA Tech Board of Directors has been studying what it takes to become an LAc and wondering whether there isn’t a better way. POCA Tech has been approved by ACAOM as a candidate for accreditation, and has graduates who are NCCAOM-credentialed, state-licensed and working in the field. The POCA Tech BOD is in a good position to know what works. Here’s what they propose –

Acupuncture Revisions Proposal

I’ve been around long enough to expect the proposal will be met with some outrage. We’ve been insisting that it is the hours of education we have that set us apart. And that almost 2000 hours of training only scratches the surface of what there is to know about Acupuncture and Asian Medicine.

I’ve also been around long enough to know that 1305 hours of training is enough to produce competent providers. That there are countless CEU programs and additional degree programs to help us deepen our knowledge. And that there is no clear evidence that our more extensive training leads to better outcomes.

People want acupuncture. We need more practitioners to meet the demand. And 100K in debt helps no one. I think the POCA Tech proposal makes a lot of sense. What do you think?

 

 

Happy AOM Day??

“Acupuncture is a safe and cost-effective treatment that could benefit so many. If only the medical establishment could see the benefits of what we do.”

That was our mantra decades ago.

So one might think, now that Acupuncture has become accepted and of increasing interest to the establishment, we’d be happy, thriving, and confident.

But that isn’t the prevailing feeling. We love our work and most of us couldn’t imagine doing anything else. And yet AOM Day 2017 finds us fearful and disheartened.

Many of us carry significant debt and are not earning enough to pay it down in a timely fashion. Many of us are limited in where and how we practice due to varying state rules. The hoped for benefits from insurance reimbursement came with significant administrative burden and limits on what will be covered. Increasingly acupuncture is being provided by non-acupuncturists. Meanwhile, the profession isn’t growing. Based on figures from Acupuncture Today, there are fewer LAcs now (24,612) than there were in November 2013 (24,707).

So it is not surprising that we aren’t hopeful. The public and the medical establishment see the value of acupuncture, but we aren’t thriving.

There are things we control that could change our trajectory.

Those of us who completed acupuncture training prior to 1990 (some of our most admired mentors and colleagues) probably got about 1000 hours of formal schooling. If you graduated in 2000 you likely had about 1725 hours of schooling, and if you completed your training after 2011 your program was at least 1905 hours.

You can see, here, how the Virginia regulations have changed over the years. The hourly requirements did not change in response to concerns about practitioner safety or skill, but to keep the regulations compatible with the ACAOM and NCCAOM requirements.

In 1988 tuition at The Traditional Acupuncture Institute (now MUIH) was $11,000 (about $23,000 in today’s dollars). When I started in 1992 it was about $18,540, ($32,616 in today’s dollars). By 2003 tuition had increased to $32,865 ($43,722 in 2017 dollars). And, if I wanted to begin at MUIH today, the program would take almost four years to complete with tuition of $75,924. For a Masters in Oriental Medicine, necessary to practice in Florida, California, and Nevada, I’d pay $99,604.

A student loan of $40,000 at 6.8% interest can be paid off in 10 years at $460/month – considered manageable with an annual salary of about 50K. A $100,000 loan will take over $1150/month and you’d need to make almost 140K/year to manage that.

So it’s not surprising that the profession isn’t growing and that acupuncturists are worried.

Sure, the NCCAOM can embark on a major public education campaign touting our training and credentials.(Well, touting their credential, actually). That’s fine. But with the downward pressure on health care spending in this country, and the impact of debt considerations on professional training, it’s going to take some damn fine PR to make a difference. (Big Pharma & Health Products spent about 245 million on lobbying in 2016.)

A far more direct way to help the profession grow, help future graduates make a living, and make Acupuncturists available to those who want acupuncture would be to address our training. If those who graduated in 1989 were safe with a 1000 hour $18,000 education, why do current students need at least 1905 hours and $75,000? Can we simplify the path and reduce the cost of becoming an Acupuncturist? (Yes, we can!)

If people want acupuncture they will find a way to get it. If we’re not there to provide it, someone else will be. We do have the power to change this, and it won’t take 245 million. In honor of AOM Day 2017, let’s agree that more Acupuncturists and less debt would be a very good thing.