Monthly Archives: March 2013

So You Want to be an LAc

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Dear A,

I don’t know whether I am a leader. I do know that there is a big difference between being a leader and being a cheerleader. I care too much about my profession and the medicine of acupuncture to blindly cheer it on. I speak up because I care.

I assumed when you asked me about a career in acupuncture that you wanted the honest feedback of one who has seen it from the inside. The field does have challenges: the education is expensive; the schools do not do an equally good job of teaching the medicine or preparing graduates for business success; there is no reliable way to know which programs are doing a good job; rules and regulations vary so that your education may only provide you limited opportunity; you will likely begin practice as a self-employed individual starting a business from the ground up, and so on. I did not say it was the most expensive or most difficult profession, and, as I did say, I love acupuncture and am happy to be an acupuncturist. It was not my intention to “actively discourage” you, but to help you enter with eyes wide open.

My concerns about Medicare are varied, but overwhelmed acupuncturists is not one of them.  In the 2010 AA letter you found I was pointing out that the cost savings of Medicare inclusion being promoted by the profession could not be realized through the efforts of LAc’s alone. There were not enough acupuncturists, especially LAc’s interested in participating in Medicare, and those individuals were not geographically distributed such that they could create the savings being touted.  For much of the profession the thought of non-LAcs doing acupuncture is Anathema and interfering with the ability of other health care professionals to use our techniques continues to be a major focus of political involvement and spending. It is reasonable to point out to the profession that the Medicare push may undermine efforts to maintain a monopoly of the medicine. Your accusation that I am personally driven by a fear of competition could not be further from the truth. I have repeatedly urged my colleagues to drop their monopolistic mind-set and focus on self-improvement and promotion.

I am sorry that my response upset you.

You Keep Using That Word. I Do Not Think It Means What You Think It Means.

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Scope of Practice. We use the phrase often. However, the term does not, as Inigo Montoyo would say, mean what you think it means.

When a jurisdiction determines that a particular profession should be licensed, it defines a range of activities that it considers to be a part of that profession.That is what we think of as the scope of practice.

For a super-great exploration of scope of practice I strongly, strongly, urge you to read this and this.  Based on these sources, my own experience on a regulatory board, and additional reading and experience —

  1. Scope does not give a profession a monopoly or a copyright. Scopes overlap. Convincing the public that TPDN is acupuncture will not prevent PT’s and other professionals from adding the technique to their scope.
  2. Something does not have to be formally listed within a profession’s scope to be legally used by licensees. It is not necessary to legislatively add Tui Na or herbs to a scope for it to be permissible for qualified practitioners to use those modalities, as long as their scope does not expressly forbid it.
  3. Adding a technique to a formal scope can increase the educational and testing burden on all licensees, not just those who intend to use the technique.  The acupuncturist who has no intention of incorporating herbs into his or her practice, but who can’t obtain a license without also spending years and tens of thousands of dollars studying and obtaining herbal certification is an acupuncturist whose livelihood is unnecessarily threatened with no benefit to the public.

Our superficial understanding of scope of practice leads us into battles that we will ultimately lose, limits our opportunities, and distracts us from efforts that could better serve the profession and the public.  What a shame.

Legislation: Know Before You Go

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Yesterday I received a survey from ASVA (The Acupuncture Society of Virginia). My excitement at being asked for my opinion quickly turned to surprise as I read the questions. Several deserve a post of their own. (The discussion is pertinent for other states as well.) Today I’ll look at “Should ASVA organize a grassroots campaign and fundraising to support the election of legislators that would be favorable to licensed acupuncturists in Virginia?” Perhaps it seems like a no-brainer to you — of course! Why not?

Here are my questions:

  1. What makes a legislator favorable to licensed acupuncturists?  If they think acupuncture is great and should be covered by insurance, but feel strongly that MD’s and DC’s should continue to provide acupuncture with short training, is that favorable?
  2. If our positions are unlikely to be amenable to MD’s, PT’s and DC’s, will any legislator go for support from the 400 Virginia LAcs without regard for the 34,000 MD’s, 7000 PT’s, and 1600 DC’s?
  3. Does their position on other issues matter?
  4. There are 100 Delegates and 40 Senators in Virginia – in how many races will we get involved?
  5. There are few open seats in any election year.  Do we support a challenger knowing that incumbents usually win and may bear grudges?  (In 2011 two Delegate races were won by challengers.) Does an incumbent need our support?
  6. In those two races each candidate spent about $500,000 on the race.  What is our best estimate of the amount we could raise and is it enough to have an impact?

What could we do that would be far easier? As individual practitioners we could know and support our state legislators and local candidates and be sure that they know us.  Make a few $20.00 donations over the course of a campaign to your local legislators (unless they are really awful, in which case support the challenger). Attend your Senator’s or Delegate’s Town Halls during the session and their Meet and Greets during the campaigns.  If you think they are decent, work for their campaign. Do what you can to educate them about our issues while making sure they know who you are and what you do. This is best to do when the legislature is not in session, as they have more time then. (Of course, if you ask them one week to get rid of the form that recommends a visit to a physician for patients because, after all, acupuncture is safe, and ask them the next week to make sure PT’s can’t do acupuncture because, after all, it puts the public at risk, it may confuse them.)

Making a difference in state politics doesn’t require a big campaign and, in Virginia and many other states, the acupuncture community is probably too small to be a special interest to be reckoned with any time soon. As individuals, though, we excel at building relationships. Build connections on a personal level and create legislators who are favorable to acupuncture — it’s the easier way.

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

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

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

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

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

Lighthearted?

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Take a look at this fun video that pertains to a serious (and not fun) issue for the profession.  (The specific circumstance is in Great Britain.)