Acupuncture and Closure: Turf Wars
Not a fan of turf battles, I support the notion of "portable competencies", which are skills that may be applied by different professions. That ported competency, however, must be equitable, safe and effective.
As an example of equity, acupuncturists could perform chiropractic adjustment given a chiropractor who does acupuncture. The catch is quality. It is safe to assume poor quality services with low levels of education. The question: where are the bounds of safety, quality and efficacy given a ported competency?
It makes no difference if a legislator uses acupuncture. It is likely that someone important to them will during the course of their life. And – that beloved should be confident of the best possible care.
Safety and efficacy should be determined through co-operative inquiry in a large group process where important stakeholders participate to define the necessary educational, testing and certification processes.
Turf issues are often foisted upon policy makers as a concern for not confusing the public. Such arguments are often patronizing, and provide poor masks for the protection of monopolies.
Acupuncturists must now face the problem of other professions attempting to co-opt acupuncture by reframing acupuncture as dry needling, percutaneous electrical nerve stimulation (PENS) or trigger point therapies. As Shakespeare's Juliet suggested, "What's in a name? That which we call a rose by any other name would smell as sweet." The insertion of a needle into the skin --- no matter the purpose, cognitive framework upon which it is exacted, or best wishes of practitioners and policy makers --- is acupuncture!
Economic impact of a work is at the heart of the matter. These efforts of turf battle are bound within a social power structure, which can be called "closure." Here we explore Weber's notion of Closure Theory, which describes a process of domination whereby one group monopolizes advantages in their own interest. This is accomplished by closing off opportunities to another group of outsiders beneath it, which it defines as inferior and ineligible.
Closure can be accomplished when the state, through legislators, maintains economic interest in a profession. These interested and benefitted parties then play a role in a profession's rise to dominance and power through the definition of licensing and educational requirements. Such goals are often achieved through ideas such as public safety – a necessary component of licensure – but, an idea, which is also used to sustain closure.
We have seen the effects of closure on natural products based care. In the post – Flexner era, schools of homeopathic and natural products bias were crushed, even though they were often safer and more effective than the surgical and chemical based forms of care at that time.1 We are finally seeing a return after some 83 years with Eisenberg's report on use of CAM practices in 1993.2 Further, the impact of closure can affect the availability of Chinese medicine to patients and ultimately, whether we can lower 'cost of care' to the culture at large. Practitioners of acupuncture and Oriental medicine are often a last stop resort.
Weber identifies 4 types of closure. 1) Exclusion exercises hierarchical dominance of inferior social groups by closing off access to opportunities and resources. This occurs through the creation of specific skill sets and entry credentials that protect and secure a privileged access to the market. 2) Demarcation and interdisciplinary control occurs when members of a discipline monitor and regulate closely related occupations defining and controlling boundaries between them. 3) Exclusion suppresses vertically while demarcation does so horizontally. 4) Inclusion refers to subordinate's attempts to access the advantages of higher-level groups. The privileged elite dismisses it as usurpation.3, 4
Closure contributes to a sociopolitical and economic environment that isolates and disconnects people. Thus, the issue of closure presents a larger concern than advantages for a given profession.5 Closure limits access to care and creates economic privilege. How is this to be balanced with quality, safety and the best possibilities for a social system? These are the questions we must solve.
Scope of practice refers to procedures. Any agency ruling upon scope, without clearly designated processes for establishing standards of education, operates in the interest of the guild and not the public.
Agencies are obligated to protect public safety. They should consider independent risk analyses that include available data on adverse events related to a given procedure. Risk is greater than individual physical harm caused by undertrained providers of acupuncture. There is risk of economic harm caused by poor results from undertrained providers. Lastly, there is potential harm caused at the level of public policy. Take for instance the lawmaker who may have a poor conception of the value of acupuncture based upon poor outcomes, personal experience and public perception of low levels of education.
To date, no state agency tasked with oversight of Chiropractic, Physical Therapy or Nursing has established guidelines for its approval of entry-level education and certification agencies for acupuncture. Those responsible for public safety should require an external qualifying agency for the procedures it authorizes. It should be an agency with a track record such as the National Commission for Certifying Agencies (NCCA). This would at least ensure that valid process for determining competencies and assessing them were achieved.
Further, no allied health care agency has performed appropriate risk analyses, published appropriate guidelines for qualifying certification agencies, nor have they demonstrated systems for oversight of physical therapists practicing acupuncture. The state acupuncture boards have. They are the only agencies identified in legal code with the authority, budget and capacity to ensure public safety in the practice of acupuncture.
The complexity of the problem is tied to the identity of a profession: AOM. We do acupuncture, but it is more than that. There is the entire fabric of being as a community and a profession.
Acupuncture, myofascial work, chiropractic manipulation and physical agents such as ultrasound and infrared therapies all have billable codes. In a world of equitable and truly portable competencies, there is a path for gaining rights and privileges commensurate with having gained the competency that allows for performing a procedure. Further, all procedures are placed upon the table and the requisite competencies are determined. Once this takes place, then the establishment of programs with corresponding assessments of outcomes is possible.
One option is an interdisciplinary process whereby the competencies that are to be shared between disciplines are defined and the criteria by which those competencies are accomplished are mutually agreed upon between the disciplines.
This should be inclusive of all procedures performed using physical agents, manual therapeutics and the full range of evaluation and management codes.
- Morris WR. Flexner to Eisenberg: The Turning of a Nation. Acupuncture Today. 2011;12(11).
- Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional Medicine in the United States -- Prevalence, Costs, and Patterns of Use. N Engl J Med. 1993;328(4):246-52.
- Parkin F. Strategies of social closure in class structure. London: Tavistock; 1974.
- Hollenberg D. Uncharted ground: Patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings. Social Science & Medicine. 2006;62(3):731-44.
- Morris W. Scope and Standards for Acupuncture: Dry Needling? 2011;12(5).