Eight mini-Posts for Eight Nights! First Night – Acupuncturists, Weigh In!

The NCCAOM is looking for feedback on a possible Safe Compounding and Dispensing certificate program. I don’t work with herbs so I’m not considered a stakeholder, but please reply if you are eligible. My questions/concerns —

  1. Will the certificate be available to anyone or just those with an NCCAOM herbal credential? Practitioners often delegate herbal preparation to office staff, so staff might benefit the most from the training. Additionally, some excellent and well-trained practitioners aren’t able to sit the NCCAOM herbal exam due to the nature of their herbal education. Could they still obtain this certificate?
  2. Will this certificate result in restrictions on the practices of those without it? The NCCAOM has previously developed credentials promoted as optional, which have, in short order, become requirements.

There are many areas of practice in where some of us could use more knowledge and training. It’s nice to have a way to show that you’ve got some special training or skills. At the same time, we’ve got enough battles with other professions and within the profession, and too often new credentials lead to new fault lines and new tensions.

Share your thoughts with the NCCAOM if you’re a stakeholder. Let’s help them serve our needs and understand our concerns.

 

 

 

 

Copyright —

© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2019. Unauthorized use and/or duplication of this material without express written permission from Elaine Wolf Komarow is prohibited. Excerpts and links are encouraged, provided that full and clear credit is given with specific direction to the original content.

22 thoughts on “Eight mini-Posts for Eight Nights! First Night – Acupuncturists, Weigh In!

  1. Henry —

    Regarding assurances to the FDA – let’s not forget that what LAcs do with herbs had little to do with banning Ma Huang. I’m not sure it relates to this certification, but all of the efforts to add herbal credentialing requirements to professional licensure seem to ignore that most of the herbs sold in the US aren’t sold by LAcs. Of course we need to be educated and know what we are doing if we are going to use them, but too often we’ve taken actions that have excluded LAcs from using herbs or being licensed at all, while every other person in a state can sell and recommend herbs with no training or education at all. Unless we want to take on regulating the use of herbs and supplements in general (and most of us think that would be a bad idea) I’m not sure we do ourselves any favors by putting more and more restrictions on LAcs while it’s the wild west for everyone else. We seem to have little faith in our colleagues – not trusting them to know their limits.

      • I’m not sure your summary is accurate. In any case, there is going to be a public comment period before there is any change (for whatever that is worth these days), but the industry itself doesn’t seem to be too worried. This is from the NPR report —

        “Mark Land, president of the American Association of Homeopathic Pharmacists, said in an email that the group “shares the FDA’s commitment to protecting public health,” and noted the action “would not materially affect the vast majority of homeopathic drug products available in the United States.”

        “As always, AAHP is committed to ensuring that consumers have access to natural, safe, homeopathic medicines in the United States and throughout the world,” Land said.

        During a briefing for reporters about the proposed new policy, FDA officials stressed that the agency had no intention of requiring most homeopathic products that are on the market to undergo formal FDA review, however, or to remove most homeopathic products. So people who believe such products help them will still have access to many of them, the officials said.”

  2. I’ll also say that not only would the profession and the NCCAOM benefit from a strong professional organization counterweight, they also need to accept and own the extent to which their exams shape the profession. They will often say they base the exams on what practitioners do based on their JA surveys, and so the emphasis on TCM only reflects what is practiced. But TCM is what people learn because they must learn it to pass the exams. Schools that don’t cover it are putting a significant burden on their students. So, most (all?) schools include enough to get people through the exams. Which means they can’t spend all that much time on Tan or Tung or 5 E or scalp acupuncture or any of the other things that won’t get you through the exam if you don’t also know TCM.

    I understand the challenges of correcting that situation, but they need to acknowledge that the exam is driving practice traditions in the US, and not vice versa.

    • I like that: “the exam is driving practice traditions in the US.”

      It is a bit of a chicken and egg problem, but there is no denying this basic self-reinforcing mechanism.

      I did want to address something you said in a post below, which was to refer to TCM as a “lineage.” (“I also think that because the NCCAOM exam is so focused on TCM it’s had its downsides – promoting the teaching of one lineage at the expense of others.”)

      I would say that it is accurate to describe Worsley five-element or Master Tung acupuncture as a lineage, but TCM was developed to be a new amalgam of available textual and oral traditions that could be taught in a university setting. It is kind of a “non-lineage,” and there is really nothing that approaches it as a discrete body of knowledge that covers the basis of the majority of clinical and theoretical approaches used throughout the history of medicine in East-Asia.

      I do not mean that it is above reproach or criticism, but there is currently nothing that could replace it as the basis for a relatively unified curriculum for the study of East-Asian medicine.

      This makes the question of how to adapt NCCAOM certification exams much more challenging, because once you leave the TCM sphere there are soooooo many directions you could go in!

      Just some thoughts!

      • I suppose my question is whether we need to have a “relatively unified curriculum.” It’s my understanding that, at least so far, there isn’t any evidence that one style or tradition of acupuncture has profoundly better results than any other. (Though a big problem with that statement is how we measure results and the extent to which our desire to participate in Western-style research leads to a western-style assessment of results, so that reduction on a pain scale is considered success, whereas I’ve still got pain but I reconciled with my sister and my kids and I’m so much happier doesn’t matter.) (And it would make sense if different styles of acupuncture were more or less successful depending on conditions treated. What’s good for stroke recovery might be very different than what’s best for depression.)

        I think the POCA Tech proposal in which the NCCAOM exams became focused on safety and ethics would be ideal. And that could be combined with different modules for different traditions.)

        The “Medical Acupuncturists” who take 200 hours courses seem to have great success. That’s important data, even if I don’t know exactly what to do with it.

        • If the certification exams focused only on safety and ethics that would be a huge change. I haven’t considered the implications of such a change.

          Do you know if any other healthcare professions do this? My impression is that all board exams test professional knowledge, as well as safety and ethics.

          • 1) I don’t know if I’d say ONLY, but primarily.
            2) I suppose one question is how other professions separate professional knowledge from safety. And whether the same factors apply to acupuncture. In most professions, we can talk about specific harms that come from “wrong” treatments. Does that apply to acupuncture? As long as we identify red flags (safety) can we say that wrong treatment has specific and defined harms? And, if we can, isn’t that due to faulty diagnosis which is hard to pick up on a multiple choice exam in the absence of a patient?

            We made a lot of very understandable choices in order to gain acceptance as a profession — establish formal programs, specify hours, establish accreditation and credentialing. They all made sense at the time. Have they now become impediments to the profession? Can they be altered in ways to help the profession grow without creating risk for the public?

  3. I think there might be some misunderstanding about NCCAOM’s role here — they can create a new type of certification, but they cannot require that anyone takes it.

    This can only be done state by state in the practice act for the profession.

    • I think everyone (in this discussion anyway) understands that. History has shown, however, that once it is out there, some states will adopt it as a requirement. And there have even been cases in the past (I don’t think it would happen again) where NCCAOM representatives have “testified” to state boards why a particular “optional” requirement should be required.

      • Yea, I might have been misunderstanding the comments below, but to clarify:

        Cera Mae wrote: “This certification is another barrier for practitioners.”

        I would want to point out the the NCCAOM just offers this certification. If a particular state adopts it, then it becomes both a barrier and protection for practitioners (as is the case with all regulation). Another incentive to get involved in your state association!

        John Pirog wrote: “[…] we don’t need to be certified to do something we should already be trained to do, and if training is inadequate, then it’s up to ACAOM, not NCCAOM to make changes.”

        If the first part of this sentence was accurate, then why would NCCAOM certification exist at all? Why even have acupuncture certification? The answer is that we need certification to demonstrate to state regulatory agencies that we have not just been deemed competent by the school that we graduated from (clear conflict of interest), but also by an independent certifying body.

        The second part is also problematic. The NCCAOM certification does not in itself imply that training is inadequate. It is in response to a (perceived) need for independent certification for this particular aspect of our training and practice.

        ACAOM certainly has a large role here in determining and enforcing the curriculum standards for accredited programs, but for the reasons pointed out above, neither they or the individual schools should be involved in certification.

        Elaine, about your comment about NCCAOM testifying in favor of certain certifications, I haven’t heard about this and cannot really comment. The last time I talked with them they emphasized how hands-off they had to be.

        But if I can offer an analogy for this new proposed certification: If I take CEU classes so I can offer a new modality to my patients, and then encourage my patients to take advantage of it by explaining the benefits, I’m both helping them get healthier and helping myself financially.

        Although NCCAOM is a non-profit, the incentive to develop and offer new “products” is still there, and we should see each new certification as a product that they are offering. But are we judging them the same way we might judge ourselves? Or judging them the way we expect patients to judge us? The profit motive is never completely not there, but I see a knee-jerk anti-authority reaction among so many people in the profession (usually based on a misunderstanding of NCCAOM’s actual role), that I think the emphasis on their profit (or other) motive(s) is usually overstated.

        I’m interested in your thoughts!

        • My first thought is that I wish I hadn’t deleted my almost completed reply!

          My second thought is, Yea! Another Obie LAc (’86, Anthro). There are A LOT of us.

          My third thought is wondering whether you currently serve on an NCCAOM Board or Committee, not to critique, but to get a sense of your background and experience.

          I shouldn’t have spoken for others when saying what “everyone” knows. Elsewhere in the thread I’d clarified to another person that this was an optional credential, but others may not have seen that. Certainly I am aware that it is proposed as an optional credential.

          I agree that people should join their state associations – I just wrote a post on that! But joining a state association is not the same as having the association agree with you on every issue. Additionally, it’s a Regulatory Board that would likely make the final decision about whether a credential is required, and in some places state associations have little influence in that process. I believe FL’s relatively recent requirement for the herbal credential was driven by the Regulatory Board, not the state association. Also, I believe the NCCAOM mentioned that the certification would be of interest to malpractice insurers, and those groups could make a unilateral decision to require such a credential for certain coverage.

          I wasn’t suggesting that everyone should protest this proposal. I agree (and wrote) that it’s nice to have extra training and to have a way to confirm that you do have that training. I agree that having an independent group to assess whether a new graduate is ready to practice safely and ethically is a good thing, and that it many ways the NCCAOM has been very helpful to the growth of the profession. I also think that because the NCCAOM exam is so focused on TCM it’s had its downsides – promoting the teaching of one lineage at the expense of others. Also, I don’t think a written exam is the best way to assess competence. I may be able to tell you what a wiry pulse means, but can I identify one? And do I need to be able to if I am doing Tan style treatments? Also, by making decisions about who can even sit their exams they have a lot of control over the profession. Some other professions have multiple credentialing organizations, which may be preferable.

          I can’t speak for John or others. I do wonder whether existing herbal programs and the existing exam test for this knowledge and if not why not? It seems it should be part of any accredited herbal program.

          The history of the licensing law in Delaware is the most infamous case of the NCCAM participating in a legislative process so that a credential originally introduced as optional became required. Here’s one of my posts about that — https://theacupunctureobserver.com/history/an-example/ I believe the fall-out from that renewed their commitment to being hands off. Though I also recall how they showed up in force when some of us in Virginia were exploring doing away with the requirement that practitioners maintain active Diplomate status.

          I agree that many in the profession misunderstand the role of an accrediting agency (that also appears elsewhere in this comment thread and many other places on the blog) and that many have a knee-jerk negative reaction. I wish that wasn’t so. I do my best to help others have a better understanding of the NCCAOM’s role.

          I don’t have a knee-jerk negative or positive reaction. I am wary. I’ve seen lots of “good ideas” become burdens or have problematic fallout. I know that the NCCAOM is (one of?) the wealthiest acupuncture related groups. They’ve got a lot of power and can overwhelm the efforts of others. Especially since the organization intended to represent LAcs haven’t been strong historically. I have a like/dislike relationship with the NCCAOM. They did a lot to help us gain acceptance, and they have a significant amount of power over how we enter the profession. I think caution is wise and responding to their request for input, which is what I was encouraging, is a good idea.

          • Thanks, I appreciate your thoughts. And yes, Obie grad (’00, horn performance!), and where are the others hiding? Besides Misha Cohen? 🙂

            I’m not associated with NCCAOM in any way. I’ve worked with them in my roles on the board of the Michigan AOM association, and as a state delegate to ASA. These encounters all post-date Delaware.

            Just to continue the conversation where you left off, I think that NCCAOM does a great job, and also that, like any strong organization, they would benefit from a counterweight. In this case it should be a professional member-based organization. ASA is on a good trajectory and seems poised to offer that.

            I haven’t finished the survey yet, as I haven’t gotten past the question that requires reading the AHPA white paper yet!

          • I don’t have my working list of Obie LAcs here – but here’s a list of 16 – or 19 if you include me, you, and Misha. —

            Richard Mandell (Global Acupuncture Product)
            Laura Hawley
            Bob Weisbord
            Dawn Weisbord
            Micheal Ishii
            Mariko Wirth
            Laura Christensen
            Erico Schleicher
            Mitchell Bebel Stargrove
            Anna Panettiere
            Nyssa Tang
            Kate Chilson
            Hency McCann
            Julienne Battalia
            Judith Boice
            Elizabeth Carpenter

            Once upon a time I told the alumni magazine they should do a story about us….

        • Henry Buchtel, we needed certification because it was the only we we could get licensing back in the 80’s and 90’s. Multiple choice examinations are a pro-forma necessity that do little to assure the public of safety. And that’s what this proposed certification will almost certainly lead to — add another multiple choice examination to a profession that is swimming in them. You imply that the schools have a conflict of interest in graduating their students. Fair enough. But the whole purpose of accreditation is to ensure that in spite of this conflict the standards are met. Herbal pharmacy competencies have been a part of herbal training from day one. So what is the basis for this “perceived” need for a whole separate certification? Is there some kind of data that shows that herbal diplomates don’t know what they’re doing in their own pharmacies — in spite of their training and in spite of NCCAOM’s tests?

          • Hi John Pirog, I don’t disagree with your criticism of multiple-choice certification exams. When I’m thinking about the survey, I’m separating the questions of: 1) how effective would this certification be at preventing harm stemming from poor compounding/dispensing practices; and 2) how effective would this certification be at assuring the FDA and state regulators that the AOM field is doing a good enough job of self-regulating and does not need additional layers of government oversight.

            At this point I’m mainly interested in understanding the second question, and haven’t given the first one too much thought.

            I’m not aware of any data showing that there is a definite need for this certification. I’m not actually aware of any solid data about this topic at all, so there is probably a need that is not being filled here.

            Unfortunately the FDA didn’t need much data to ban mahuang. All they needed was a case that received enough public interest. And that is really where my vague sense of support for this certification is coming from.

            Hope that clarifies my interest in this issue!

  4. I agree, John, and wrote a similar comment. People who are learning raw herbs should already be learning how to safely compound. Curriculum and training is overseen by ACAOM. Additionally, full herb pharmacies are becoming less popular among practitioners and the majority are using patents. This certification is another barrier for practitioners.

  5. The survey asked for comments on the adequacy of the white paper and on the need for pharmacy certification. My answer to the later was swift and merciless — we don’t need to be certified to do something we should already be trained to do, and if training is inadequate, then it’s up to ACAOM, not NCCAOM to make changes.

    My opinion on the white paper itself is more nuanced. Overall, it was fairly thorough and practical. It was missing some critical TCM-specific safety issues, however, such as pregnancy warnings on labels; procedures for avoiding mix-ups when compounding toxic herbs; and proper identification and confirmation throughout the storage and compounding process. If it redresses these deficiencies it could be a good guideline in training and practice.

  6. I think it’s a load of sh**. Just another license that needs to bought. Really?? We are worried about this? How about worrying about terrible reimbursement rates from insurance, more and more pressure to take insurance and the reality of making a good living in this profession? Nope, let’s chase our tails. ?

    • Well —
      1) I hope you will weigh in, since they are looking for feedback at this point.
      2) They aren’t talking about a required license at this point, though I do share your concerns that some board somewhere could decide it should be required.
      3) The NCCAOM isn’t the group that can do much about reimbursement rates. And the pressure to take insurance was completely driven by practitioners who thought it would solve all of our problems, and who also insisted that it wouldn’t impact anyone who decided not to participate. (Which of course was ridiculous.)

      I do get your frustrations and I share many of them. I also understand that not all of us received training in compounding and manufacturing and I like the idea that those who want more training could get it and could have something to show for that additional training. But, yes, given our history, any new credential makes me nervous. I’ll be writing more about that later this week.

      Thanks for weighing in and I hope you’ll let the NCCAOM know what you think.

      • I did reply to the survey and gave them my ten cents. I do use a company for compounding which elevates me of the worry about clean room, dispersing…etc.

        I guess I’m more frustrated with how poorly the whole acupuncture industry is run.

        I had to explain to a new client the difference between a chiropractor doing “acupuncture” and how I do acupuncture. To me – patient education is so much more important than a compounding Pharamacy. Sorry can’t help it – ???? – lots of eye rolling.

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