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Q7 Pro Argument

About Question #7. Should Licensed Acupuncturists be allowed to have an assistant that may remove needles?

After a thorough analysis the actual question is “Should some Acupuncturists actively suppress the practice and activity of other Acupuncturists?”

Licensing boards in all professions and in all states have one job and one job only and that is to protect the consumer from the licensed professional or an illegally operating unlicensed person. They do not protect or defend the profession over which they preside. It is not the licensing boards responsibility that any given professional is successful or has any particular business model or determine the style of a practice or the specialty of a practice unless there is the possibility of public harm.

Therefore, we must make the inquiry, does one need a 4 year master’s degree to safely remove a needle? Most emphatically the answer is no. In fact, after a thorough search on Pub Med, the Pacific College of Health Sciences library, the NCCAOM Clean Needle Manual, the Essentials of Chinese Medicine, and the Shanghai Text, there is not one mention of an adverse side from a needle removal incident. Nor is there any reference to any technique more complicated than gently pulling the needle out and covering with clean cotton ball in the event of minor bleeding. In the rare event of a broken needle, procedures are reviewed and would require the immediate attention of the attending acupuncturist. But we all know this, right?

We know that Chiropractors, Naturopathic Doctors, and Medical Doctors all have assistants that remove acupuncture needles. The fact is there is zero evidence that simple needle removal has ever caused harm by unlicensed personal.

Given that fact, the State of Arizona Board of Examiners should never have stepped in and regulated this issue. This is a classic example of government overregulating a profession. Now I happen to agree that some minimum training is a great idea, but not a full 4-year degree. The Licensed Acupuncture should be focused on what they do best, diagnosis, prescribing, point selection, and insertion.

If patient safety is not the issue, it clearly is not, the net effect of this restriction is to prevent other Licensed Acupuncturist from operating at their maximum efficiency, whatever that may be.

In plain simple language we have a situation where acupuncturists want to suppress other acupuncturists. Haven’t we had enough suppression from outside our profession? Now we need to damage each other.

I am familiar with most of the other arguments against allowing for a certified acupuncture assistant program, note this is not a license, only a certification.

  1. There is a professional way to have an assistant and an unprofessional way. Patients should always give permission to allow and assistant to remove needles, that should be obvious, if that did not happen that likely was the cause of the alleged complaints. Not any actual harm.
     
  2. There seems to be an odd fear-based focus that some Acupuncture Assistants will secretly start practicing acupuncture and knowingly commit a misdemeanor crime, risk going to jail or some equally unpleasant legal issue, just because they think acupuncture is cool. I think something entirely different is likely to happen, I think many Acupuncture Assistants will fall in love with our medicine and they will go on to acupuncture college get licensed and may contribute greatly to our profession. Which do you think will be more likely? Commit a crime or become a respected professional?
     
  3. Some have suggested that seeing lots of patients, 3-4 per hour, is like an assembly line medicine. Further suggesting that any practitioner seeing that many patients in an hour are greedy “in it for only money”. I guarantee everyone this, if a practitioner is not getting results for their patients, they won’t be in business very long no matter how many patients one sees in an hour. It is up the individual practitioner to set their own pace and acquire the best results possible for their patient. Once again this does not require regulation, this is a free country and with freedom comes responsibility and innovation.
     
    I am left wondering why fellow Acupuncturist want to restrict patient flow, income ability, and ultimately innovation of other Acupuncturists. It makes no sense, but I hear a lot of banter about Acupuncturists making too much money.
     
  4. As we all know Licensed Acupuncturists enjoy the least expensive malpractice insurance of nearly all medical practitioners. This is particularly striking in consideration that we treat a wide variety of medical conditions, but we do so with a high degree of safety. Other medical practices may pay over $2000 to $80,000 a year in malpractice insurance. So, what does malpractice insurance for an assistant actually cost? According to the American Acupuncture Council the cost is zero! That’s right there is no additional cost to have an assistant who removes needles.
     
  5. HIPPA and OSHA compliance is a requirement of all employees in any business and is a must as part of any training for a certified acupuncture assistant and a good reason to have a certified education program detailed and standardized. In addition, this creates the opportunity to relate best practice standards of patient care from the start of a visit to the end, thus professionalizing our practice even more.
     
  6. There had been the suggestion that “most” Licensed Acupuncturist oppose having an assistant that can remove needles. This is pure guesswork and hopeful speculation on the part a few acupuncturists who object to this proposal. The fact is we don’t how many Licensed Acupuncturists and future Licensed Acupuncturists would like to have a practice busy enough to hire an assistant. That is part of why we are doing this survey.
     

In conclusion, it is quite clear there is no threat to public safety. All other arguments against an acupuncture assistant program are either self-serving or fear based on some delusion that having an assistant will somehow destroy the profession. Meanwhile, other acupuncture providers have no such problem in their respective profession in having an assistant remove needles and have not self-destructed.

Many Acupuncturists use or would like to be able to utilize an acupuncture assistant. Part of the reason for this survey is to discover how many of us use or at some point would like to hire an assistant to improve patient care and clinic efficacy and in order to help more people. There is no reason we as a profession should not embrace freedom of choice and allow improvement in patient care and clinic efficacy.

I urge everyone to vote yes on this survey to add to our scope of practice a Certified Acupuncture Assistant with needle removal training and authorization.

We have a bright future let us all embrace it with a warm and open heart.

Sincerely,

Lloyd G. Wright, LAc, DNBAO
AMAAZ Board Member and Practitioner of 36 years

RNA Statement for AMAAZ

SB1255 defines Acupuncture as the insertion *and the removal of needles, done only by a licensed acupuncturist”. Only individuals licensed by this Board exempt pursuant to A.R.S. § 32-3921(B) are authorized to remove needles from patients being treated with acupuncture. Any unlicensed persons removing needles without a license, certificate, or statutory exemption may be subject to legal action pursuant to A.R.S. § 32-3953 and any licensed acupuncturist directing or supervising an unlicensed person in the removal of needles may also be subject to discipline by the Board for unprofessional conduct.” https://acupunctureboard.az.gov/statutes-rules/legislation

It resulted after the Arizona Acupuncture Board was receiving inquiries and complaints from the public within the last few years related to unlicensed persons removing needles from patients in some clinics in Arizona. Those patients wanted to know if it was legal, also commenting that they do not welcome anyone other than their practitioner to remove their needles. Some said it felt like they were being cheated because someone else was ending their treatment. One of the public members of the Acupuncture Board stated that she as a consumer/patient also felt the same way. Also, in other various practitioner’s conversations with the public, they (public) had the same sentiments and indicated that it also seems like an invasion of the patient’s privacy.

The issue is not just the physical act of removing a needle but also the patient’s uncomfortable sense of disregard for the patient’s treatment experience and treatment results.

In April 2019, The State Board released its Substantive Policy Statement of Definition of Acupuncture” in A.R.S. § 32-3901(1) (SB1255)

Many state licensees agree with and fully support SB1255 and its Definition of Acupuncture, as it clearly helps enforce Arizona Acupuncture laws, protects patient care and privacy, and public safety. And it especially avoids confusing or annoying patients that someone other than their acupuncturist is removing their needles. It also eliminates legal problems that could arise for the Licensed Acupuncturist who would be responsible for that “needle removing” assistant.

This year, a few practitioner members of Asian Medicine Acupuncturists of Arizona (AMAAZ), upon reading SB1255 which states the revised definition of the Practice of Acupuncture, determined a disagreement with that revision in SB1255, and have set action to create license or certification for non- Licensed Acupuncturists to be able to remove needles from patients, and to be referred to as “acupuncture assistants”

Opposing considerations to creating a legal title of “acupuncture assistant” that is allowed to remove patient’s needles:

1. The “needle removal assistant” will reduce the quality of patient care because we will negate that each licensed practitioner is responsible for their patients from beginning to the end of treatment.

2. The “needle removal assistant” could inadvertently harm a patient, as they have no training in the theories of intended needle technique effect which also includes needle removal.

3. There is a small number of practitioners who think there should be certification for “assistants”, but the vast majority of practitioners have no interest and no need for assistants. Most practitioners would not even be able to employ them because of professional liability factors.

4. Many practitioners feel that “needle removing assistants” should not be created and thus get involved in patient’s treatments (i.e. performing cupping, moxa, or removing needles) as it can easily open the door for those “assistants” to experiment and test their skills outside of the acupuncture clinic, and having something go wrong, thus further damaging the image of the profession, as the media/public will only hear the word “acupuncture”.

5. The model of having assistants removing the needles has been implemented by practices that work as a ‘factory’ similar to western medicine clinics, meaning, offices where the provider is seeing a large number of patients for a few minutes in one hour, just to be able to bill the insurance companies for profit. It is a money vs real patient care issue. Acupuncture patients will become just another number like in western medical clinics.

6. A Certified “needle removing” assistant program will create a huge loophole and unfair regard for Acupuncture interns who are eager and who can assist L.Ac’s as part of their education. The same applies to new licensees who are just starting out and who can assist other established practitioners while they are trying to build their own practices and who could even eventually work out of that same office.

7. Any practitioner has the legal freedom to hire assistants to help in their clinics, but not for “removing needles” from patients.

8. As we all know that malpractice insurance is not cheap. Paying extra insurance fees for coverage of a ” needle removing assistant” is not possible for a majority of licensees. And because of the potential public safety risk, how would that affect lawyer’s fees if need be? Most practitioners are self-employed and there is no need to create unfair competitive advantages between large and small practices. And for the sake of billing insurance into all kinds of billable modalities, it will continue to allow other professions with far more financial and political clout and with little or no training to usurp and continue to dismantle this traditional Asian medicine/our profession for their own business profits, while we stand on the sidelines smiling and thinking we’re winning.

9. There may be an OSHA violation, exposure to infectious disease or personal injury claim if the assistant gets stuck with a needle. How will you handle that and what medical liability insurance coverage would an AA need or additional liability insurance for the licensed acupuncturist for such an occurrence?

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Other important things to consider in the creation of a certified position that will allow an ‘Acupuncture Assistant’ (AA) to independently engage in various medical modalities, specifically needle removal, in addition to any other non-medical duties they may have under the supervision of a licensed acupuncturist:

1. Can we ensure safety, quality, and continuity of treatment for patients? What kind of training would be needed/created? What kind of wages would be sustainable for certified assistants? Is there any existing data from controlled studies or carefully gathered anecdotal information on practitioners who already use AA’s vs. those who do not? Should research be done prior to attempting to reverse an established law (designed to protect the public) that does not present a problem for the vast majority of licensed practitioners in the state.

2. Currently there appears to be more practitioners that feel “needle removing” should be done by only the licensed acupuncturist. This is also the position malpractice insurances currently take. There is also concern that the more AAs are involved in medical procedures such as cupping, gua sha as well as needle removal, etc., it would be harder to control the quality of care, potentially damaging the reputation of our profession and potency of our medicine. If everyone can do these things, then why are we particularly special? Why does it take someone with a graduate degree or clinical doctorate and loads of debt to perform tasks that someone can do with little or no training??

3. At present the major malpractice insurance companies for acupuncturists are clear, only a licensed acupuncturist may insert and remove needles at this time. If that were to change, it will most likely mean an increase in malpractice insurance costs across the board. How will coverage work if we have people working for us doing even minimally invasive medical procedures? Would L.Ac’s pay for the AAs malpractice insurance or would they have to carry their own? It is also important to consider that this will lead to more litigious interaction between the acupuncturist and their patients, and legal fees could be overwhelming. Most practitioners are self-employed and may not have the kind of capital required to deal with the increase in legal challenges along with the increase in malpractice rates.

4. It should also be noted that these AA’s might well be hired by other licensed professionals outside our profession, what’s to stop them from doing that? Would we limit where these certified assistants go and who they work for? Or will PT’s, RN’s and others, simply hire an AA or will they send PTAs, COTA’s LPN’s etc. to get our AA training? And certainly perhaps they will create their own comparable AA, in the same sense that they did a pretty good job with creating “dry needling” and “biomedical acupuncture”

PIHMA Comments on Acupuncture Assistants

As stewards of acupuncture and herbal medicine education and those bound to look out for the future of practitioners in this profession, the Asian medicine colleges look very closely at the job trends that will sustain this medicine going forward. We are concerned about opposition to the role of the Acupuncture Assistant in removing needles.

The acupuncture assistant role and function has existed for centuries when used to treat large numbers of people, and more recently has been gaining in popularity across the country as practitioners see its benefit in providing better patient care in an increasingly competitive marketplace. It has only recently been limited by legislation in Arizona through an unintended consequence of efforts to clarify and tighten up the definition. We are concerned about the impact that the recent change will have on Acupuncturists in the field already using Assistants and about the ability of future practitioners in this medicine to choose a model of practice that suits them and their needs to be successful in life and in the community.

While the changes this year limiting the use of assistants were well-intentioned, it is problematic for the following reasons, and unintended or unanticipated consequences:

1) Restraint of Trade/Limiting Practice: This recent legislative change prevents delegating removal of needles by Licensed Acupuncturists, some of whom have already been delegating this procedure in Arizona with great success and for quite some time.

There is much value in the attention (and intention) given to the process of insertion and removal of needles by a skilled Acupuncturist, and indeed it is one of the aspects of needling that defines our profession and sets it apart from others. Yet, there are also many styles and individual approaches a Licensed Acupuncturist may choose in creating their practice, all with their own value and benefit. One such style is the choice to see multiple patients, either in different rooms or in a group setting. This style, while still providing comfort, healing and positive outcomes, is often made possible by delegating limited simple functions to an Assistant, leaving the highly trained Licensed Acupuncturist more energy to focus on high-level, critical thinking functions.

With Licensed Acupuncturists being limited to being able to see only 1-2 patients at a time due to a prohibition of assistance, they are prevented from choosing a method of practicing the medicine that not only harms their earnings and the growth of their practice, but also limits the number of lives they can positively impact. This is especially frustrating and disheartening when acupuncturists in other states or other medical providers in Arizona (MD, DO, ND, DC, PT) are licensed to needle and delegate removal, thus allowing them to fill the need for treating more of the public. This inability to compete on a level playing field leaves our profession at a distinct disadvantage. Moreover, hospitals and corporations which have the resources for greater outreach are unable to meet a broader public need, and will end up turning to other professions which do not have this legislative limitation to do the needling.

2)  Harm to the Public: When Licensed Acupuncturists have to deal with other emergencies or issues, the patient is then at risk from needles being left in too long or from other procedures because the practitioner cannot be everywhere at all times. A skilled and trained Acupuncture Assistant can be of great service and support for the weary or busy Acupuncturist. Any concerns about needle removal safety or injury can be addressed with specific requirements for standardized training, testing and clinical practice, focusing on clean needle technique in removal, OSHA management, and side effects like unusual bleeding or dizziness, which is handled in conjunction with the Licensed Acupuncturist. This certification or licensure would also provide assurance to the public that the Assistant has been competently trained. Just as it is illegal for acupuncture students to needle outside of an approved educational program, so would it be illegal for an assistant to remove needles without supervision by the Acupuncturist. Thus, the public would be protected by our state laws.

Finally while some think that it should be an Acupuncture Intern performing this function, it should be noted that Interns are limited in the time they may spend with a single professional due to the requirement for different leveling and experience of training. Professional Licensed Acupuncturists and regular patients would be better served having a regular, consistent employee that would only need to be trained once and who could form longer lasting relationships with the patients, as well as gain experience useful to the Acupuncturist. Thus safety, quality and continuity of care is ensured.

(Further Note: Concerns about an “Assistant pretending to be an Acupuncturist” thus creating harm to the public, is already addressed by the Board which handles the current variety of general public who misrepresent themselves as licensed acupuncturists. In the case of an Acupuncture Assistant, there is a mandatory Licensed Acupuncturist is overseeing them and their behavior, thus thwarting much of this concern.)

3)  Patient Choice and Comfort: Recognizing that not all Acupuncturists will choose to employ an Assistant who can help remove needles, and that patients often choose a practitioner that best suits them, it is apparent that patient comfort is relative to consumer choice. Patients should be able to choose the type of practitioner and treatment experience that suits them. Some patients will prefer a treatment model that includes more individually focused time, while others will opt for less interventional healing.

In addressing the concern that a patient might feel uncomfortable or annoyed by the Acupuncturist who delegates to an Assistant, everything depends on how the Licensed Acupuncturist informs and manages customer expectations and service. If the Acupuncturist introduces and explains the role of the Assistant, and that Assistant carries the core values of the practitioner and the medicine, then the patient will feel comfortable and engaged with the Assistant. If the Acupuncturist fails to do this, then it is possible the patient will feel neglected or short-changed. We see the importance of this process in our teaching clinic where the Clinic Supervisor, who is responsible for the patient from beginning to end, delegates interview and initial diagnosis, needling and removal to the Intern who is then responsible for the customer experience. The patient accepts and expects the procedures by the Intern and enjoys the interaction. The success of this delegation is dependent upon making it clear that the Assistant is part of the process and that the patient is always in good hands. We also see this in the Supervisor Acupuncturist /Auricular Acupuncturist relationship modeled in the successful treatments performed by acu-detox technicians that perform NADA/auricular treatments.

Ultimately, the consumer has the freedom to choose, and will choose where to take their business based on the experience, relationship and outcomes. In terms of liability, our Acupuncture Insurer has stated they will cover the Assistant based on state law inclusion, thus addressing any professional liability concern. Moreover, our insurer has indicated this coverage would be minimal, especially since removal is not as risky as the needling process. Acupuncturists enjoy some of the lowest rates among healthcare providers since needling is one of the safest medical procedures.

4) Discrimination and Diversity, Parity and Equal Access: Our practitioners and students WANT to have the option to hire an Assistant to help in these areas. Having legislation for an Assistant does not mean all Acupuncturists are required to hire or use an Assistant; it simply allows those who wish to hire one to be able to do so. By denying this option, we are forcing all practitioners to use only one style of practice, one manner of treating patients, and one pathway to personal success when in fact there are many styles. This is a form of discrimination against other styles and practitioners, and prevents the diversity that is needed for Licensed Acupuncturists to work in a variety of settings.

We should not be preventing other practitioners from working in the style that best suits them, or from creating a thriving practice, or from healing as many people as they can. By withholding this option from our profession, we are also discriminating against our own profession in favor of other medical professions (MD, DC, ND, DO, PT) who do have assistants and who can delegate needle removal. We need to be able to compete on a level playing field.

Parity and equal access are important. When all the other leaders in medicine have assistants and we cannot or do not, there is no parity and we lower ourselves below other healthcare providers. For the public to have access to our medicine, it depends on our ability to reach out to them. An assistant can help make that possible, allowing practitioners to focus on the patient in other ways, avoid errors and get the support they need.

5)  Removal of needles is already being delegated in our profession in Arizona: Currently, the Arizona Acupuncture Board of Examiners allows both needling and removal of needles to be delegated to Auricular Acupuncturists who work under supervision of a Licensed Acupuncturist. These auricular “assistants” must have at least 70 hours of classroom training in needling, removal and clean needle technique, testing, and supervised clinical practice of many patients. Then they apply for licensure (along with a background check) to the State Board which licenses these individuals to work in detox settings treating many patients at a time with needles and removing them. Surely we can create similar standards for a an Acupuncture Assistant that can include removal needles in a way that will protect the public.

6)  Standards for Acupuncture Assistants already exist in other states: Other states already license Assistants and it is growing, as reported in Acupuncture Today. Actively prohibiting Assistants in Arizona puts our community behind other states and at a disadvantage. By setting good training standards for these assistants, we can still retain our integrity as the highest trained professionals in this medicine. We can set our own standards for an Assistant’s scope of practice, as well as the ability to perform a multitude of other functions supporting the Acupuncturist. Such training can include safe needle removal and OSHA safety. And finally we can look to the other medical providers’ practice statutes (MD, DO, DC, ND, PT) who have developed proven standards for having an assistant, many of whom can do injections or remove needles, but also make the lives of their practitioners much easier.

7)  We need to reach more people with our medicine. Everyone benefits when we heal more people. Currently we only reach a small percentage of the population. If our practitioners can take care of more people, then we all benefit as more people learn about and are drawn to our medicine. Those engaged in this expanded style of practice can help increase the awareness of Asian medicine and create customers for us all. For those who are fearful of others expanding their practices to the detriment of other practitioners, this is particularly reassuring, as truly the success of others can translate to success for all. Those who are concerned that Acupuncturists who want to employ assistants are being selfish and working just for the money by billing the insurance companies, or that the practitioner should simply not be that busy, are devaluing our fellow practitioners and the medicine. Instead, we can learn from the success of these practitioners. One of the best stories I heard was from a graduate who treated one to two patients at a time. When she learned how to treat more people, not only did her income increase dramatically, but she also had much more energy and was happier. And she created many happy patients, all without insurance billing. Thus, there are a variety of approaches to reach the public and we all benefit from this diversity.

8)  Our practitioners want it and the longevity of our medicine depends on it. Our graduates and other Licensed Acupuncturists have been asking for help in their practices, and many need and want an assistant. We teach our graduates to effectively treat patients, singularly and in a multi-patient setting. These graduates want to be able to choose the practice model and lifestyle that they want. Providing excellent and safe care to more than a couple of patients at a time is possible, and a qualified and trained assistant can help. Our graduates are reaching out to us to change the law to make it possible, and we must respond. Our job as a college is to help our students succeed in the world, and we are dedicated to helping them do so. They are the future, and we need them to succeed long after we have all retired.

9)  Unintended consequences: While the original intent of the removal legislation was to ensure public safety, it was not anticipated that we would be harming an Acupuncturist’s practice. With few to no injuries from needle removal by assistants, we have created overly broad legislation that negatively impacts members of our profession. We can repair this by creating an Acupuncture Assistant category, similar to what other professions have. It is clear that public safety can be met by using the same or similar standards already in use for Auricular Acupuncturists in needle removal, plus additional training for other areas of the body.

10) Strength in Diversification: Longevity and sustainability of a medicine can be well-supported through diversification and by building a field of many different and interactive roles within a field of medicine. Western conventional medicine has doctors, physician’s assistants, nurses, nurse assistants, physical therapists, nutritionists, pharmacists, exercise trainers, counselors/therapists, and more. They all work together using the concepts of western medicine. Acupuncture & Asian Medicine can similarly create and build a field of different and related practitioners (and even Asian medicine hospitals someday) based on the concepts of Asian medicine? Having an assistant to help busy Licensed Acupuncturists is a start and helps create sustainability for the future of our medicine.

In conclusion, creating a role for an Acupuncture Assistant is about creating greater access to our medicine, parity among healthcare providers, preventing discrimination within our ranks, creating diversity in our medicine, growing our profession, and healing more people. It is a win-win for all to create legislation which can be tailored and written to ensure public safety, while helping our practitioners have more options to earn an excellent living or practice in they way they choose. We need to allow ourselves to have this worthwhile option like other healthcare providers do, because we have much work to do in healing others with our most amazing medicine.

-Catherine Niemiec, JD, L.Ac
President, Phoenix Institute of Herbal Medicine & Acupuncture (PIHMA), College & Clinic