Monthly Archives: June 2013

A Level Playing Field

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This was a comment to It’s Not Fair.  You can see the beginning of the exchange there.  Frank raises some great issues, so I’ve cut and pasted his comment below, along with my responses in italics. I’ll split it into a few posts to keep the length under control.

Frank writes:  Here is why I think we are not on a level playing field:

(I’m not a sports fan,so my analogy is probably off, but there is a difference between a non-level field and not knowing how to put together a team or play the game to your advantage.  My position is that while there are things that put us at a disadvantage we could still develop a winning strategy and a winning team. Underdogs can and do win.)

Exogenous factors  (All have endogenous aspects.)

1) Licensing. Not every state even licenses acupuncture, and of those not all include the scope of practice (herbs,nutrition, tuina) that people are taught in school. As far as I know, every state licenses PT.

If you haven’t seen my post about Scope, please read it. Most of our “leaders” don’t seem to understand the term, and, subsequently, we spend a lot of time and energy fighting unnecessary battles. A technique does not need to be specified in your legislation to be within your scope. Herbs, for example, are unregulated by the FDA and so anyone, including the check-out guy at the 7-11 can sell them.  (Check out the ingredients of Airborne, for example.)

Sometimes I wonder whether licensure has done more harm than good (a discussion alive in the ND community) but, accepting, for the moment, the conventional  wisdom that it is a good thing, shouldn’t we focus on licensure in all 50 states before pushing for Medicare coverage?  Shouldn’t we pay attention to reciprocity, agreeing on a mutually agreeable minimal set of requirements for licensure so that qualified and experienced LAcs in one state are likely to be able to practice in all states? (I’ll be posting more on this, but I find it tragic that within the profession we are setting rules that exclude so many of our colleagues!)

2) Money. PT is a $30 billion industry. A lot of the big clinics are funded with private equity money. They use aggressive Starbucks style positioning and can run clinics at a loss in hopes of pushing other big clinics out of business. Plus, they can fund advertising campaigns that make PT seem like a normative activity, and of course they can generously donate to candidates.

Yes, there are more PT’s and it is an industry. I don’t know enough about the specific business practices to comment, but I do know that many investors in PT practices are MD’s, powerful allies to have.  They also seem to have a strong national association.  Meanwhile we’ve got associations which have been promising they’ve turned the corner for years.  And we’ve spent so much energy fighting with other providers over our fear that they will “steal” our medicine that we’ve made enemies rather than friends (check out Love the Bomb). From what I can tell, there are enough people open to acupuncture that it is normative.  WebMD talks about it on a regular basis. Folks often report the great results they’ve seen when their pets receive treatment, for example. Our problem is that we have been unable to make good use of the positive buzz that is out there.

As for advertising, again, we have the money to do this, we just do it poorly. The AAAOM spent two years coming up with information cards that were intended to carry a positive message about our profession.  Instead, the first line reads — “Many healthcare providers are performing unlicensed therapies similar to acupuncture, but each state licensed acupuncturist has extensive training in an accredited college that ensures their dedication to providing excellent healthcare.”   We can’t even start on a positive note without casting aspersions on professionals who could be allies. This one sentence contains several inaccuracies/inconsistencies:  a) professions are licensed, not therapies, b) hasn’t the profession been arguing (foolishly imo) that these therapies are not similar to acupuncture but are acupuncture,and c)not all licensed acupuncturists graduated from accredited schools — it depends on the state and on whether they attended a US school. I’m no advertising executive, but that isn’t a helpful introductory line.  How many MD’s or PT’s (who could refer to us) would agree to display a card like that in their office?

It doesn’t take necessarily take big bucks to influence legislation — it does take a winning strategy, choosing issues wisely and building alliances whenever possible. We have not done that.

A Rose, Redux!

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Again, there has been an issue with my last post not being sent to subscribers or showing up on the media sites.  Because I want community feedback before posting part 2 I’m hoping this attempt will fly through cyberspace as intended.  Thanks for your patience.

A Rose?

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I would love to leave the TPDN/Dry Needling issue behind. I also believe that if we explore why what we’ve been doing hasn’t been working we’ll end up empowered rather than defeated.

Many colleagues have been referring to this Will Morris article in AT. I hope you’ll bear with more frequent posts over the next few days as we spend some time pondering his points.

A question for the community – is a key factor here the use of an acupuncture needle?

When an MD injects cortisone into a sore spot, is that acupuncture?  Is a vaccination acupuncture? What if a syringe is used to draw fluid out of an area – is that acupuncture?  Is the injection therapy done by some LAcs acupuncture? What about use of a tuning fork or a laser at a point – is that acupuncture?

What about the use of an empty hypodermic needle to stimulate a sore spot?  At what point does the use of a syringe become acupuncture? Or, is the use of the filiform needle the thing that makes a procedure acupuncture?

I’ll see if you have any input before I share my thoughts.

P.S.

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I apologize for two posts in less than 12 hours.  I knew I shouldn’t have been working until 11:00 last night .  I accidentally published a draft of the Mine! post. Subscribers, please visit the site for the correct version of the post.

In the meantime, this morning I had a chance to review yesterday’s Health & Science section in The Washington Post and came across this article on myofascial pain.  I suppose I could get my knickers in a twist that the author finds relief from dry needling done by an MD, maybe even posting a comment about how she was putting life and limb in danger by seeing someone other than an LAc for this procedure.  Instead, I’m happy that she got relief. And, to be honest, I’m doubtful that my acupuncture training and experience taught me what I would have needed to know to give this particular patient that relief she’s found.

Mine!

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The AAAOM Position Statement on TPDN, or, Mine!

Who is on the Blue Ribbon Panel?  I can’t find a list of participants anywhere.  Are they independent experts on the regulatory process or medical terminology?  Are a variety of professions represented? Who selected them?  Is there any reason regulatory agencies should care what this mysterious Blue Ribbon panel thinks?

Does the AAAOM believe that acupuncture regulatory boards should be able to expand determine the limits of our scope of practice and make decisions about necessary training?  Are we hypocrites with double standards, demanding a degree of control over the practices of others that we find intolerable?

The AAAOM refers to a malpractice company’s refusal to cover PT’s doing TPDN as proof of an “actual risk of endangerment.” Shall LAcs be prohibited from using acupuncture to induce labor or turn a breech baby because malpractice companies don’t cover those procedures?

Regardless of our shouts of Mine! Dry Needling has been determined to be within the scope of practice of PT’s in the majority of states.  I suppose we can keep beating this dying horse, chasing this ship that has sailed, but there are better uses of our limited resources.

Coming soon – a sad story of how a state acupuncture board is limiting opportunities for LAcs and increasing the likelihood that residents will receive acupuncture from non-LAcs.

It’s Not Fair!!!

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A Virginia colleague asked – “How is it that Chiropractors can do acupuncture and LAcs cannot do manipulations?”

Exploring why things are the way they are (here in Virginia, anyway) might help us move beyond the usual “we’re getting the short end of the stick again” attitude and could teach useful lessons about how the system works.

1)     How is it that DC’s can do acupuncture?

DCs, MDs, and DOs were doing acupuncture in Virginia, without incident, prior to licensure for LAcs. You can imagine the strong opposition that would have arisen from that powerful lobby if, despite our position that acupuncture was safe and effective, we now attempted to pass legislation that would have removed this technique from their scope. The role of regulation is to protect the public from danger, not ensure that people are limited to the “best” care. When the Dieticians introduce licensure legislation in Virginia (not yet successfully) – the Advisory Board on Acupuncture indicates that support of the Acupuncture community depends upon the LAcs retaining the ability to make dietary recommendations. The Dieticians might think our training in this area is grossly insufficient, but we can show a history of safe practice, and the state has no compelling reason to choose a winner and loser among professions in this case.

2)     Why can’t LAcs do manipulations?

The Virginia legislation specifically rules out PT, Chiropractic, and Osteopathic manipulations.  Since acupuncture training does not typically include Osteopathic, Chiropractic or PT adjustments, and since our exams don’t test knowledge of these techniques, it would have been difficult to counter the arguments of the existing providers that this should be excluded from our scope.  When the ND’s introduce legislation for licensure (so far unsuccessfully and not fully supported even within the ND community) the Advisory Board on Acupuncture always reports that support is dependent on language that would specifically exclude acupuncture from the ND scope.

If a Licensed Acupuncturist could show evidence of education in Tui Na manipulation techniques, included the technique in their informed consent, and was careful with insurance coding it would probably be acceptable.  A few years ago I would have suggested that a formal request be made to the Advisory Board to explore whether Tui Na manipulations were within scope. The board could have explored the issue and developed recommendations regarding education and documentation that would have put practitioners on solid ground.  However, our profession’s recent behavior regarding the PT Board’s similar discussions on TPDN have given our fellow health care providers many arguments they might be itching to throw back in our direction. You might want to check out Scope and Dry Needling for more background. This is probably not the best timing for requesting a formal ruling.

 

AAAOM Call for Comments

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Not sure who out there gets communications from the AAAOM, or who pays attention to the communications they do get.  Despite the low of level of support the organization has from acupuncturists (the last I heard was that the organization has about 500 professional members, which would be less than 3% of the profession), it has an outsized impact on the profession’s reputation, our relationship with other providers, and public policy itself.  Therefore, it would be foolish to ignore their call for comments.  First I’ll address the introductory email, which is concerning in and of itself.  Comments on the position statement itself will follow soon.  Here is the email, with my comments inserted.

“Dear AAAOM Members and Colleagues:
We would like to hear from you, our membership, via this “Call for Comments” surrounding the term “trigger point dry needling (TPDN).” Please take a few moments to review this AAAOM position paper, “AAAOM Position Statement on Trigger Point Dry Needling and Intramuscular Manual Therapy.”

As many of you may already know, physical therapy (PT) boards have begun using TPDN terms for the purpose of expanding the PT scope of practice. [How does the AAAOM know the purpose for the choice of the term?  Perhaps the purpose was to help patients distinguish between the release of a trigger point and the practice of a complete medicine? Does the AAAOM believe professions should not be able to expand their scope?] By doing so, this therefore precludes the necessary and adequate education and safety standards already set by state legislatures for the practice of acupuncture. [Education and safety standards are primarily set by regulators, not legislators, and the rules typically apply to classes of professionals, not techniques.  Do we use the term Tui Na to preclude ourselves from massage standards? PT Boards have set standards for the use of TPDN by their licensees.]

At present, 43 states and the District of Columbia have statutorily defined acupuncture along with the educational and certification standards that qualify an individual for licensure. In addition, the current medical literature remains consistent with regards to the definitions of acupuncture as a procedure and practice provided by state practice acts. [I don’t know why the first sentence is significant and I don’t know what the second sentence means.]

The comments you submit via our Membership Feedback Form will be presented to the AAAOM’s Inter-Professional Standards Committee for review, enabling us to take action on your behalf. [Is there a deadline?  Who is on the committee? Can you share what actions are being considered by the AAAOM?]

Additionally, if you have patients who have been hurt by acupuncture performed by someone who doesn’t have a license a license to practice acupuncture, please direct them to the Food and Drug Administration (FDA) Adverse Event Form. These submissions are very important for our work and request that our members advise those patients who submit the FDA form to alert the AAAOM of their actions by clicking here. [Please, AAAOM, explain your strategy.  The FDA does not regulate practitioners, it regulates devices. Reporting adverse events might put our access to acupuncture needles at risk but would not impact state determinations of scope of practice or educational requirements.  If public safety is our concern, why request reporting only when non-LAcs are involved? Isn’t it important to report all adverse events?]

The views and comments we have received thus far on the TPDN issue have proven very helpful, thereby allowing us to fulfill our mission and advocate on behalf of your profession. Thank you for your interest and for taking the time to submit your thoughts on this extremely important issue.”

I’ll share my thoughts on the Position Statement soon.   In the meantime, AAAOM, I request you be clear about the percentage of the profession you represent when speaking on “our” behalf.

Culture and Access…. and, a loss.

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A colleague recently posted a question related to a book of acupuncture case studies from China — “I was wondering if anyone could provide some insight into why the book lists only a handful of points used in their treatments and why the practitioners I’ve seen from China use many many more?  Does anyone have the back story of this book? …. 

 They also consider one course of treatment: 10-15 treatment daily with 2-3 days off. 

 In one of the cases they listed 30 daily treatments until some improvement was noticed…i find that amazing!  Here in the US if there’s no change in 5-8 treatments they’re done.   

 Thanks in advance for any insight….”

An expanded and edited version of my reply —

I believe the 5-8 treatment paradigm is relatively recent, somewhat local, and at least somewhat related to matters of time and money. Treatments multiple times/week for several weeks at the start of treatment is not unusual in China or the Asian community in the U.S.

Regarding factors other than time and money — because 5 Element acupuncture typically focuses on constitutional issues the idea of allowing time for the treatment to “ripple” through the system makes sense. Also, a 5 E appointment can be similar in structure to a therapy appointment, with time spent talking about feelings and emotions, for example. The population our U.S. predecessors were working with was familiar with that structure, so it made sense to present acupuncture in a similar way.

Still, issues of access shouldn’t be ignored – 30 visits at $80.00 is $2,400, so if someone has no experience with this medicine (or even if they do) that’s a big commitment, and more than many people can afford.  (Even if the cost is shared between a client and a third party payer, the same bottom line will be a factor.) Any study exploring the cost effectiveness of acupuncture is obviously impacted by the number of treatments given and the cost of each treatment — it is easier to show cost effectiveness after ten treatments than after thirty.

One of the things I like about my sliding scale is that if people do need to come more frequently, or come weekly on an ongoing basis, it is easier for them to do so.  Many practitioners who have gone from conventional private practice to community acupuncture find that more people come more frequently in the early weeks of treatment and report that patients make faster and more consistent progress.

Another consideration is the “time cost.” Many of my patients couldn’t manage to get to my office 2-3 times a week even if they wanted to and could afford to. I have limited evening hours and no weekend hours, traffic in this area is horrible, and most clients are already over-committed and over-scheduled. A clinic close to a metro station with drop-in hours and/or lots of early mornings or late evenings would make it possible for more clients to get treatment more frequently.

As for the number of points used – I have not yet seen studies comparing treatment protocols.  Miriam Lee wrote that a very limited number of points could help in most cases.  As more insurance companies start covering acupuncture it will be interesting to see if the data shows that more units of acupuncture per visit equals better results.

I’m not an acupuncture historian or scholar — just sharing my thoughts.  We should consider how much of how we practice is determined by the culture of our schools and communities. The results of greater data collection and the emphasis on EBM (evidence based medicine) could rock our world.

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And, a loss in the community —

I just saw the very sad news that Al Stone died.  I never met him, but I did have the privilege of working with him a bit over the years, and that was always a pleasure.  Al developed acupuncture.com back in the early days of the internet (and later sold it) and was also the creator of gancao.net.  It is a big loss to the community that he’s gone.

Thankful that he was.