Safety: Dry Needling and Acupuncture

We worry about the public’s well-being.

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

Are we walking our talk?

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

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

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

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

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

Lisa Rohleder writes –

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

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

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

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

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

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

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

Why Should All LAcs Voluntarily Report Adverse Events and Errors?

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

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

 Why Did the POCA Cooperative Create an AERD?

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

Why Voluntary and Anonymous?

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

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

Here’s the place to report adverse events.

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

 

 

Acupuncture Exceptionalism

American Exceptionalism is the idea that The United States of America is inherently different from other nations. That our founding and background gives the US a unique mission to transform the world and a superiority over all of other nations.

I’ve recently noticed that practitioners of Chinese/East Asian Medicine have their own version of this, which I call Acupuncture Exceptionalism.

The attitude of exceptionalism skews the interpretation of events. Our own actions are given the benefit of the doubt and ascribed to the best of intentions. The actions of others are considered with a critical eye.

Some examples of Acupuncture Exceptionalism:

We regularly advise clients regarding vaccinations, pharmaceuticals, procedures, and dietary plans suggested by other health care providers. When other providers advise about acupuncture and herbs we are outraged at their presumption.

We widely share studies and news reporting positive results from acupuncture treatment. Studies and news showing a negative outcome are dismissed because “they aren’t doing it right” or didn’t tell the whole story.

When a patient reports harm from “Western medicine” or a treatment done by a non-LAc we rant about the failings of the system or the provider. When a patient reports harm after a treatment provided by an Acupuncturist we find ways to deny that harm occurred, find another cause for the situation, or place responsibility on the patient.

We encourage patients who have been harmed by dry needling to report it to the authorities, and if they won’t we will. We are shocked and angry when a patient files a formal complaint pertaining to treatment received from an Acupuncturist.

We complain that PT’s are engaging in insurance fraud by using the Manual Therapy code for Dry Needling. We justify the use of pain codes for every client, because, well, everyone has pain and, after all, the system is stacked against us.

We are furious that other professions are using “our” medicine, especially without what we determine to be appropriate training. We add homeopathy to our scope without a second thought.

We support and celebrate a lawsuit filed against a PT Regulatory Board as an appropriate defense of our profession. We are outraged when a counter-suit is filed against our board.

 

An attitude of American Exceptionalism does not increase the standing of the US in the eyes of the world. You can’t learn from mistakes when they are denied or explained away. Hypocrisy and double-standards impress no one.

Likewise, Acupuncture Exceptionalism does a disservice to our medicine and to our future as health care providers. If our medicine is powerful enough to help people, it is powerful enough to cause harm. Denying risk puts our patients and our profession at risk. Dismissing valid concerns about acupuncture and herbs from other professionals prevents us from establishing collaborative and respectful connections. If we want to improve our skills and training and service, we must take a clear-eyed look at where we are succeeding and where we could do better.

I’m confident enough about the benefits and overall safety of this medicine that I’m not afraid of looking inward with a critical eye. Are you?

 

 

NCCAOM Code of Ethics & Grounds for Professional Discipline, Part II

The NCCAOM’s call for comments on the Code of Ethics and Grounds for Professional Discipline ends September 12, 2015 .We owe it to ourselves and our profession to share our thoughts with them.

Here’s what I’ll tell them —

Dear NCCAOM,

Thank you for the opportunity to comment on the Code of Ethics and Grounds for Professional Discipline. My significant concerns with these documents can be traced to three overarching issues —

  1. The NCCAOM credential is required to maintain state licensure for many acupuncturists. You advocate for this arrangement. Yet the current Code of Ethics is more suitable for a voluntary exceptional standard adopted by choice.
  2. States that require NCCAOM credentials have their own regulatory boards, ethical codes, and disciplinary process. The NCCAOM Grounds for Professional Discipline empowers you to pull a practitioner’s credential, removing them from practice, even when a state board would allow continued practice for the same violation. This turns the NCCAOM into de facto regulators and creates double jeopardy for practitioners.
  3. The NCCAOM reserves the right to take disciplinary action against any practitioner who violates the Code of Ethics. The Code covers behaviors ranging from serious threats to the public safety to those in the realm of Public Relations. The NCCAOM should explicitly limit the use of disciplinary action to violations that risk the public safety.

A few specific examples —

  • “Exceeding the scope of practice as defined by law or certification” is grounds for discipline. Scope is defined by the state, and may not be accurately determined by written language in code or regulation. Since state regulatory boards ultimately rule on whether or not a procedure is within scope, and since that board would determine proper discipline for any violation, no action from the NCCAOM is needed. References to scope should be removed from the NCCAOM document.
  • “I will continue to work to promote the highest standards of the profession” is listed in the Code. Must practitioners promote the FPD or DAOM, the addition of herbal exams to licensure requirements, and the expansion of the NCCAOM credential requirement to all states? Who determines the highest standard? This language is coercive at best.
  • The Code of Ethics requires credential holders to report peers who violate the Code. It is untenable to expect Diplomates to report every peer in violation of any aspect of this far-reaching code, and it is unfair to wield the power to hold us responsible for any failure to do so.

I support rigorous professional ethics and respect the NCCAOM’s intent to establish high standards for the benefit of our patients and our profession. However, your role for the profession is to validate entry-level competency. Much of the current Code of Ethics and Grounds for Professional Discipline goes far beyond this role. Continued overreach into areas best left to regulators and voluntary affiliations puts at risk the NCCAOM’s position as a credentialing organization.

Thank you for your consideration of these comments,

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

Those of you who would like more background on the role of the NCCAOM in our profession should look at Part I of this post.  I encourage those who are interested in another viewpoint of the NCCAOM and its impact on the profession to review these comments and consider signing this petition.

An Acupuncturist Looks for Balance

How do I help the greatest number of people?

The wisdom of Acupuncture/East Asian Medicine has improved my health and the health of my clients for more than two decades. Throughout that time I’ve worked with professional regulation, legislation, and our organizations, with the goal of increasing public access to the full benefits of this medicine.

My involvement in the political sphere of our profession has taken significant qi that I could have used to study the medicine, improve my technical skills, and increase my own well being.  Most days at my clinic include at least one moment when I know that with deeper study I could have provided better care.

This fall I felt that I should choose, Practitioner or Advocate? My clients weren’t getting my best. Could I find a way to support myself through advocacy and leave my practice? Would I be happier if I focused on the intellectual challenge of working toward a widely shared vision of success for the profession, and developing a path to that success? Or should I leave the advocacy work and focus on my patients? In the clinic the appreciation doesn’t carry a side order of harassment and ill will. When I treat I see the positive impact of acupuncture and Asian medicine every day.

It’s winter. I’ve been taking a break. I can’t quite follow the Nei Ching and sleep until the sun rises, but I’ve stepped back. I’ve read the communications from ACAOM and the AAAOM (and this, and this (apologies for it being post-deadline, it was hidden), followed the complaints about health insurance (what it costs, what it covers, what it pays, the work involved in getting those payments), wondered about our dry needling strategy, and pondered whether blogging about these things is “worth” the qi.

It’s still winter….

 

 

 

 

17 Foundational Beliefs of The Acupuncture Observer

Embracing the season of gratitude and thanks, it’s time for The Acupuncture Observer to take a step back and share some of her foundational beliefs about the medicine, the profession, and life.

  1. Acupuncture/OM works. The unique situation of the patient and the unique skills of the provider influence effectiveness. No single tradition provides all of the answers or benefits.
  2. Acupuncture/OM has fewer negative side effects and risks than conventional treatment for many conditions.
  3. Access is a necessary precursor to effective treatment.
  4. Effective treatment will increase wellbeing and could decrease health care costs.
  5. Every means to increase access carries trade-offs. Those trade-offs must be understood as we determine our path forward. We should learn from the experiences of other professions.
  6. Understanding and explaining the mechanism of acupuncture from the knowledge base of modern biology and physiology is useful and interesting, but is not necessary for acceptance by the medical establishment.
  7. The current “science-based” understanding of health is known to be limited. Insisting that Acupuncture/OM be taught, thought of, or explored only in the language of modern medicine/science is unscientific and risks centuries of experience and wisdom.
  8. Consumers should have significant freedom of choice in health care. Understandable and clear information about potential benefits and risks, as well as an exploration of the costs (financial and otherwise) is necessary for good decision-making.
  9. Self-serving thinking leads to hypocrisy. Special attention is needed when an argument for patient protection creates an economic benefit for particular providers.
  10. Simple, easily learned treatments can be effective and safe.
  11. There is the potential for growth and success within the acupuncture/OM profession.
  12. Many acupuncture programs do not provide sufficient or accurate information about post-graduation life and do a poor job of teaching business skills. This can be changed easily and inexpensively.
  13. The financial and karmic ROI (Return on Investment) of positively promoting our profession is superior to that of engaging in political/regulatory battles with others.
  14. The future of the medicine and of the profession are interconnected but not identical.
  15. Thoughtful and respectful analysis can identify areas of common ground.
  16. Focusing on areas of common ground decreases factionalism, and builds unity, understanding, and participation.
  17. The profession lacks venues for respectful dialogue on these issues. As a result, many scholars and potential leaders within the profession avoid involvement.

Do we agree on some of these? Can respectful dialogue increase the areas of agreement? What if we read the Tao Te Ching, the I Ching, and The Art of War first? What if we go deeper than our Wei level response to some of these issues? I believe it is possible that we’ll be able to find a new path forward, one we can walk together, with our hair flowing free. After all, I’m an acupuncturist.

Assistance for the Working Acupuncturist

I went down the Facebook rabbit-hole, and while I was there I learned a few things.

For instance, “just a quick look” and “I’ll just scan my notifications” can quickly lead to a month without a blog post. I will not let that happen again.

Also, based on posts about HIPAA, insurance billing, choosing office space, maintaining records, etc., we have  a lot of questions and we are looking for answers. It’s great that we’ve got communities of colleagues to ask. It is also inefficient, and sometimes downright dangerous that our colleagues are often the only source of answers.

Looking at HIPAA and ADA for example, we see that some professions (but not acupuncturists) have access to lots of resources from their national associations.

  • a search of the AAAOM site gets one, not very useful hit, regarding HIPAA-related responsibilities.
  • Here’s information from the APTA (American Physical Therapy Association) site on HIPAA.
  • Here are the search results for HIPAA over at the American Chiropractic Association.
  • I can find no information on the AAAOM site about acupuncture offices and ADA compliance.
  • APTA provides these useful links about ADA compliance.
  • The American Psychological Association has great information about ADA compliance.

While acupuncture organizations are working on national legislation, increasing insurance coverage for acupuncture, adding an entry level degree, and fighting with other professions to limit the use of the acupuncture needle, we search for authoritative assistance on current practice issues in vain. (Luckily, the links above are pertinent to our practices.)

To make matters worse, sometimes it seems that we prefer ignorance. In my time on Facebook I was reprimanded for self-promotion when I shared useful links to this blog, and I was threatened with banishment from Acupuncturists on Facebook because I “acted like [I] know it all.” (I don’t know it all. I do know a few things.)

When many of us don’t understand or comply with our obligations under the ADA and HIPAA, are we ready to be a part of the Medicare system or have acupuncture be an EHB? Isn’t accurate information about ADA compliance an important part of our stated goal of having acupuncture accessible to all? It’s past time for our schools and organizations to make sure we have the skills, knowledge, resources and information to be successful practitioners now. The FPD, Medicare inclusion, higher standards, and expanding our scope/suing our competitors should wait.

Petitions, Medicare, and Licensure

Notable news items in the acu-world this week:

1)  We finally got a response to the petition to the White House to add acupuncturists to the list of Medicare providers. My regular readers already knew that a petition to the White House is not going to create the legislative and administrative changes that would be required.  (Newbies, you can use the tag cloud to find previous posts on the petition and Medicare.)  The response has (no surprise) created the usual teeth-gnashing, with acupuncturists (who seem not to have read the response) lamenting that Obama doesn’t like acupuncture, that it’s all about money and power, that we’re doomed,…. The conversation also shows that even among those most strongly advocating for becoming part of the system, there is still significant ignorance about what would be needed to succeed and the consequences for the profession of “success”.  Also not surprising — no response from the AAAOM or NCCAOM who helped distribute the petition — even though they should have known enough to predict the response and had a year to prepare.

2)  The latest Acupuncture Today newsletter included an article on the six states in “licensure limbo.”  I suspect that overzealous regulation on our part (for example, Delaware and Florida requiring extensive herbal credential requirements for acupuncture licensure) contributes to the lack of enthusiasm for a practice act among practitioners.  I also believe that the acupuncture community’s aggressive and disrespectful response to PT Dry Needling and to MD’s and DC’s who do acupuncture is a significant factor in the unwillingness of those communities to support a practice act in those states.  Actions have consequences.

3)  A new “threat” on the horizon — some LAcs on Facebook are up in arms about Tattoo artists who are doing “dry tattooing” for skin rejuvenation.  You know the drill — how dare they, we have so much training, we need to gather the troops to fend off this encroachment. My points — tattoo artists can use needles, they can do cosmetic work (tattooing eyebrows for people with alopecia and tattooing nipples for people who have had breast reconstruction, for example) and they could tattoo someone’s face completely blue if the client wanted it.  Facial rejuvenation acupuncture is typically not taught in acupuncture school. Is there any reason (other than arrogant self-importance) why we believe we should have control over this technique?

I’m still adjusting to the addition of Facebook into my life. I haven’t figured out how to stay informed and involved there without taking the energy and the dialogue away from The Acupuncture Observer.  For those of you on Facebook, like the Observer page and you’ll get breaking news updates between blog posts.

Also, for those of you interested in learning more about navigating the political/regulatory system I’ll be doing a breakout session at POCAfest,  on March 15th in Tucson.  I’d also be happy to come to your state association meeting, conference, or other event. Knowledge is power.

Culture and Access…. and, a loss.

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.