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.

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.

Firefighting

More than 42,000 Americans died from opioid overdoses in 2016. In 2009 at least 23.5 million people over the age of 12 needed treatment for illicit drug or alcohol use in the US. That number is growing dramatically.

People are dying.

LAcs are rightfully enthusiastic about the use of acupuncture to treat the physical and emotional pain that can lead to the use of and dependence on addictive medications and drugs. We have been proud of the history of auricular acupuncture helping those who struggle with addiction.

The development of a profession of Licensed Acupuncturists and the spread of acupuncture detox specialists happened comfortably, side-by-side, for a long while. Lincoln Recovery in the Bronx was treating addicts with acupuncture in 1974. In 1975 (More History ) the Traditional Acupuncture Institute was founded in Maryland. The AAAOM was incorporated in 1983, NADA in 1985. In many states, auricular acupuncture programs predated the regulation of acupuncture. Their safety and effectiveness was used promote acupuncture and lobby for Licensure.

In 2005 South Carolina (currently 123 LAcs, 658 deaths in 2016 related to prescription opioids and heroin) passed a licensure law with a dark side. Although 53 Acupuncture Detox Specialists (ADSes) had been working without incident in South Carolina, language was included that required an LAc be on site to supervise ADSes. With zero LAcs at the time the law passed, no ADS could continue to treat. (The force behind the legislation was Acupuncturist and then-president of the AAAOM, Martin Herbkersman, whose brother was and is SC state Representative Bill Herbkersman. Rep. Herbkersman also shut down a 2007 bill that would have removed the direct supervision requirement.)

Programs to provide the NADA protocol to addicts have been limited by the supervision requirement.

People are dying.

Unfortunately, South Carolina is not a fluke. The only voices against New Hampshire HB 575, allowing for the certification of acupuncture detox specialists, were the voices of LAcs. Luckily for New Hampshire (127 LAcs, almost 400 opioid related deaths in 2015, over 2000 opioid-related ED visits), the bill passed.

Connecticut (323 LAcs, 539 overdose deaths in the first six months of 2017) did pass a law expanding use of ADSes, but comments in response to the legislation from LAcs included gems like, “acupuncture should be left to the experts, the licensed acupuncturists” and ADSes “have absolutely no idea what it truly entails to safely provide acupuncture to others whether it be one needle or many.”

People are dying.

Remember, at least 42,000 opioid deaths in 2016. The number of Acupuncturists in the US? About 32,000 at best. Dealing with the epidemic is expensive, funding is limited.

It’s a crisis.

  • If you believe ADSes require in-person supervision, become a supervisor.
  • If you believe only LAcs should provide the NADA protocol, commit to weekly shifts at recovery centers, jails, and other programs, and take responsibility for daily staffing of those programs. Remember, funding will be minimal or nonexistent, and, unreliable.
  • If you believe that everyone deserves the benefits of full body treatment, commit to provide them to everyone – even if they can’t pay, don’t have reliable transportation, and aren’t as tidy as your typical clientele.
  • If you believe ADSes should work only within treatment programs available to those in active addiction, make sure your services are accessible to those struggling to maintain their recovery, whatever their circumstances.

Remember, some of the people most needing treatment won’t have insurance, housing, financial resources, steady employment, or reliable transportation. Where and how will you provide the services you think they should have?

If you don’t want to supervise, don’t want to treat everyone who walks through your door regardless of ability to pay, and don’t want to take regular shifts at treatment facilities, then, please, get out of the way of the people who do. Better yet, support them.

People are dying.

I’ve joined NADA, I’m making plans to receive training, and I’ll keep supporting efforts to increase access to NADA-trained providers in all states.

People are dying.

 

This post is in honor of Dr. Michael O. Smith. May his memory be for a blessing.

Fourth Night – Service

Join your state acupuncture association.

At least once in your professional life, serve on the Board of that association, or, serve on the Board of another professional group, or serve on a committee that serves the profession, or serve in a regulatory position.

If you support other groups, like AWB, SAR, POCA, join them too. But not instead.

Join your state association even if you are thinking “but they haven’t done anything that I agree with” or “they don’t do anything at all” or “they are a bunch of a-holes who actively work against my interests” or, “I already support these other organizations that actually do the stuff I care about.”

Trust me, when I get a newsletter telling me that a top priority for my state association is continuing the fight against dry needling, I struggle to write that membership check. (Because the fight has sucked up our resources and poisoned relations with potential allies and there is no chance we’ll win.)

Why give your hard-earned and too often insufficient money to a group that you believe uses it poorly?

  1. Membership organizations are designed to represent the needs and desires of their membership. To think “I’ll join when they stop doing stupid stuff I hate” is asking them to put the preferences of non-members over members, and that’s unreasonable.
  2. Health care is regulated by the states, and the state association has some degree of power (it varies from state to state) over regulations, legislation, and appointments. It’s good to have a say in how they’ll use that power.
  3. The policies of our best hope for a productive, consensus-building, national organization meant to serve all LAcs, the ASA, are determined by a Council, the membership of which is determined by state associations.
  4. There aren’t that many of us. Even if state associations have 25% of their state’s practitioners as members (optimistic – though maybe our lower percentage is related to misperceptions in how many LAcs practice in the state) that’s still a small number. It’s hard to do much if your organization is supported by and represents fifty people.

You should serve on a Board at least once because –

  1. The experience of: working to give people what they want, balancing the demands of those who want very different things, explaining that there is no shortage of good ideas just resources, explaining (again) why the association can’t provide a health insurance plan, giving people what they’ve asked for only to find out they weren’t really going to take advantage of it (you all said you wanted inexpensive monthly CEU classes, but only two of you came) – is educational. It builds compassion and understanding for those who serve.
  2. It will teach you a lot about regulation, legislation, and how some of what people insist we could do if we just FOUGHT, is not actually doable, even when everyone involved fights their hardest.
  3. Numbers again. A fifty person organization, with a five person board, and three committees of three people means about a third of the members have to be serving at any given time.
  4. People usually become willing to make the sacrifice of serving when they get worked up about something. They feel strongly about a particular issue. It’s good to have balance so one strong leader doesn’t shut out other voices.

Now, for my friends who are serving –

  1. Thank You!
  2. Working for consensus is good. Compromise is good. Listen to the concerns of all of your colleagues and don’t automatically respond with the party line. Be thoughtful.
  3. We’d have an easier time getting people to serve if Board members didn’t end up burdened with tons of administrative work. $$ for political action is important, but let’s not neglect the benefits of $ for organizational support.
  4. Criticism is not the same as negativity. Some positions and actions are deserving of criticism. If we don’t dismiss it, we can learn.

 

And, for all of us — let’s not take our differences personally.

 

(It’s not dark yet. I made it.)

 

(Note to self, 8 posts in 8 days requires advance planning. Not a good spur of the moment project.)

 

 

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.

 

 

Second Night – Census Time!

How many Acupuncturists are there?

As we strive to increase opportunities for acupuncturists, we should know if we have the workforce to fill the demand we’re trying create. If we don’t have the workforce available, others will step up to fill the need. That may still be a win for the population able to receive acupuncture from other providers, but it won’t be the win the profession has been working for.

The new Standard Occupational Code with the BLS may, eventually, give us a good sense of our numbers. In the meantime, different sources give wildly different numbers of our strength. The NCCAOM, relying on state figures and their active Diplomate data gives a count of under 20K. Others who have gathered date from all of the states (no easy task) have been presenting a figure of almost 35K (Fan AY, Faggert S. Number of Licensed Acupuncturists and Educational Institutions in the United States in Early of 2015. J Integrat Med. 2017 September; Epub ahead of print. doi:10.1016/S2095-4964(17)60371-6).

I’ve historically used the numbers provided by Acupuncture Today. They’ve had the resources to purchase mailing lists and the financial incentive, at least in the days of paper publications, not to send multiple copies to the same practitioner, even if they were licensed in multiple states. I’m not sure their numbers are as accurate in the days of their digital edition, but they are currently showing about 28K LAcs.

In my experience a significant number of practitioners are licensed in multiple states, and a not insignificant number keep an active license when they are rarely or never treating. When getting a license is complicated and expensive, we don’t let them go lightly. For instance, if there were actually 25,000 practitioners, and 20% are licensed in two states, 5% in 3, and 2% in 4, there would be 34,000 state issued licenses.

(To put the numbers in perspective, there are 456,389 primary care physicians in the US. And a lot of patient care is still provided by nurses, PA’s, and other providers.)

Whether there are 20,000 of us or 34,000, it’s a small number to serve the population we hope to serve. And if we’ve got inaccurate numbers we may be writing checks with our ego that our bodies can’t cash.

The Hanukkah story celebrates a miracle – one night’s worth of oil lasted for eight nights. Maybe we’ll have a workforce miracle too. But it would be better if we knew how much “oil” we were starting with. And if we used that information when deciding where to focus our limited resources.

 

 

Dry Needling Updates for LAcs

Not again! Yes, again.

[If nothing else, read: NC AG Opinion, NC Order and Opinion, Henry v NCALB, and TX AG Opinion. If you have an opinion on dry needling, and you want it to be an informed opinion, these documents are necessary reading.]

North Carolina has been a major DN battlefield. It’s been a rallying cry for strong action elsewhere. How’s it going?

Not well.

Some history –

In 2011, the North Carolina Acupuncture Licensing Board (NCALB) requested an opinion from the NC Attorney General regarding the North Carolina Board of Physical Therapy Examiners’ (NCPTE) decision that Dry Needling was within the PT scope of practice. The AG opinion was that the NCPTE could make this determination if it conducted appropriate rule-making.

Subsequent to that decision, but before the NCPTE concluded the rule-making process, the NCALB sent “cease-and-desist” letters to PT’s practicing dry needling, accusing them of illegal activity. And, in 2015, the NCALB filed a complaint, demanding a ruling that DN was the unlawful practice of acupuncture, and insisting that the PT Board inform its licensees that DN was not within the scope of practice of PT’s.

Given the AG opinion it’s no surprise that the NCPTE (and individual PT’s who had received the cease-and-desist letters) weren’t ready to roll over for the NCALB.

On August 2nd, the Court issued this NC Order and Opinion affirming the NCPTE’s decision that dry needling is within scope for PT’s, and that it is distinct from acupuncture.

(Again, please read the documents. They are critical to understanding why our arguments aren’t leading to more wins.)

In January the court ruled that Henry v NCALB could proceed. This is not good news for the NCALB and its members, who may be found (subsequent to the NC Board of Dental Examiners Supreme Court ruling) guilty of antitrust violations.

My top takeaways —

  • Don’t request an AG opinion if you won’t accept the answer. (A colleague recently wrote that he’s gearing up to “CRUSH dry needling” in Texas. Here’s the Texas AG opinion.)
  • If it’s determined that a PT Board has the power to pursue rulemaking on dry needling, we should make a good faith effort to offer respectful input. We should focus on minimizing risk to the public, while accepting that we don’t get to call the shots. Obstructing the regulatory process or making unrealistic demands puts the public at greater risk. (Also, we should make well-informed arguments. Insisting that dry needling is outside of PT scope after it’s been ruled otherwise, for example, doesn’t help our case.)
  • Don’t use dud ammunition. NCASI and others still argue, for example, that it’s illegal for anyone other than acupuncturists to possess acupuncture needles. The court wrote (highlighting mine)

¶¶ 16–20.) In particular, the Acupuncture Board contends that the needles used in dry needling “must carry a specific FDA warning as required under 21 CFR §880.109(b)(1), stating ‘Caution: Federal law restricts this device to sale by or on the order of a [qualified practitioner of acupuncture licensed by the law of the State in which he practices to use or order the use of the device.]’” (Petition ¶ 19) (brackets
and emphasis in original).
50. The Petition takes glaring liberties with the cited regulation, however. The full text of the regulation requires medical devices, such as the solid filament needles at issue here, to include a label bearing: The symbol statement “RX only” or “℞ only” or the statement “Caution: Federal law restricts this device to sale by or on the order of a ____”, the blank to be filled with the word “physician”, “dentist”, “veterinarian”, or with the descriptive designation of any other practitioner licensed by the law of the State in which the practitioner practices to use or order the use of the device[.]
21 C.F.R. § 801.109(b)(1). As such, the cited regulation does not support the Acupuncture Board’s argument that the needles used in dry needling are “medical devices” only for use by acupuncturists.

  • Our professions’ news sources are full of misleading, inaccurate, and incomplete information. This AT article, this NGAOM post, and this blog post, are inaccurate – repeating the false needle argument, misstating the finding of the NC rules review commission, and/or misrepresenting what the NCPTE told licensees. We need to do better.
  • Long-term, there may be a few states where PT’s are not permitted to do dry needling, just as there are a few states still not open to LAcs. There is already PT DN in most states. Making the argument that dry needling is acupuncture, as the NCCAOM did in their recent statement, is a terrible mistake. Do we want the PT next door to advertise “now offering acupuncture”? Our statements encourage them to do so. We need to adjust to the current reality.

In 2013 I wrote Imagine, or, How I Learned to Stop Worrying and Love the Bomb. I can still only imagine where we’d be if we had spent the last four years doing those 11 things, instead of what we’ve done (and continue to do). Let’s stop doing what we’ve done. We can get something better if we understand what’s gotten us here.

 

 

 

Professional Harmony, Professional Growth

Acupuncturists know that good health isn’t acquired by attacking invaders. Instead, we advocate living in balance with our environment to develop a strong, self-reliant, vessel. We are healthy when our system excludes threats without our even being aware of them.

As individuals, most of us practice (most of the time) what we preach. We strive for balance.

As a profession, though, we’ve chased the equivalents of miracle cures, mega-antibiotics, and the promises of “experts.” Like our clients who seek well-being that way, we are tired and struggle to maintain our tenuous health.

What if practitioners, schools, organizations, regulators, and credentialing agencies saved the energy and money that went to filing lawsuits against PT’s, (and having to defend ourselves when we are sued in return), establishing new degrees, and changing state regulations to require more training and exams? What if, instead, they identified the minimal standard necessary to practice safely and effectively and committed to work, state by state, to establish that standard as sufficient for licensure? What if we took as a guiding principle and goal that an acupuncture license in one state, and a history of safe practice, should be sufficient for licensure in any state?

Other professions are doing this. PT’s, Nurses, and MD’s are all working to make it easier for practitioners to relocate. Even lawyers can be “waived” into a state based on prior experience. These professionals don’t have to start school wondering whether their degree will be sufficient. A family move doesn’t mean giving up a career.

Acupuncture school is a risky investment, especially when requirements for licensure vary widely and change regularly.

Unlike our other battles, moving toward standardization (of licensure NOT lineage), doesn’t require convincing any judge or insurance company of our position or value. We hold the power to create a system that supports acupuncture professionals and serves the public.

It shouldn’t be difficult. It will be. We are better at vehemently disagreeing and walking away than we are at overcoming differences and finding compromise.

Both herbal credentialing and the FPD degrees were enacted despite concerns we now know were prescient.The ACAOM-sponsored DELPHI process (to establish degree titles), an after-the fact attempt to address some of those concerns, is moving forward, but not without challenges.

We lack an organization for regulators. This increases the tendency for states go their own way, and will make coming together even more difficult. Too often regulators have focused on their personal visions for the profession rather than serving the public. Many of them also sit on the boards of, or work for, acupuncture schools, raising the potential for conflicts of interest.

We could overcome these challenges. We could focus on the benefits and commit to sticking together. We could ensure the public can access Acupuncturists when they want acupuncture. We’ve spent enough on the antibiotics of legal action and the miracle cures of being Doctors and pursuing third-party payment. Now we need to focus on establishing common ground and common requirements, building our strength and our stamina. That would be a huge step toward good health for the profession.

 

 

Acupuncture News

We lack a national news source for the profession and so we are often in the dark about the forces shaping our future.

Here is some state-level news with national implications —

California: 

In January 2016 the NGAOM joined with CAOMA and nearly advanced AB758. This would have overturned last year’s legislation which moved California to the industry standard of ACAOM school accreditation rather than depending on the troubled CAB.

Connecticut:

The NGAOM successfully fought for legislation mandating Malpractice Insurance for all LAcs. Practitioners in CT report this was done without consultation with the state association. Malpractice insurance is a significant expense, and a needless one for licensees not in active practice.This new requirement doesn’t seem to benefit anyone other than insurance companies and the NGAOM (which gains members through discounted coverage) despite the NGAOM’s pro arguments.

Delaware:

Regular readers know that the DE Acupuncture Advisory Council has generally refused to use their waiver power to license practitioners lacking the full NCCAOM herbal credential. The BOM knows that depriving the public of qualified practitioners is not a public service and is proceeding with draft legislation (text not yet available) that would establish tiered licensure. While it’s not the best solution, it’s an improvement. New Council members are taking their seats in the next few months. Let’s hope we can all work together to grow the profession in Delaware.

Nevada:

The Nevada Board continues to push for an increase in educational requirements far beyond the Masters level. Having again ignored the advice of Nevada’s Deputy Attorney General they are now moving to hire their own counsel, perhaps explaining why Nevada’s fees are the highest in the country.

 

Acupuncture Today didn’t just miss these important news items, history shows AT is willing to selectively hide some developments within the profession.

After a series of well-received columns in 2007 author Lisa Rohleder received a letter from Executive Editor Crownfield — “After several conversations with my publisher and others, 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.” Yes, AT considered affordable acupuncture dangerous. (The ideas did have potential. The ideas Lisa presented developed into POCA. POCA has established a school, helped clinics provide millions of treatments, helped practitioners establish successful businesses, and provided free CEU’s and many other benefits, to members.)

The Acupuncture Observer may change a bit over the next few months. But until the profession develops a reliable source for news delivered in a timely fashion, TAO will do what it can to keep you in the know. Let’s keep each other informed. Are you aware of news of importance to Acupuncturists? Is there regulation that could keep Acupuncturists from practicing in your state? Is a group pushing for change that seems detrimental to the practice environment?  Email editor@theacupunctureobserver.com with your news. Let me know if you’d like to write a guest post. And subscribe to TAO (box on the upper right of the home page, your address will not be shared or sold) for news updates.