Not a Weapon

When we launched our AERD in 2018, some acupuncturists argued that we didn’t need it because the acupuncture profession already had the National Center for Acupuncture Safety and Integrity and its “Dry Needling Adverse Event Tracking System (DNAETS) Map”. (2023 Edit: this organization's website is no longer functional.)

There’s an important distinction to make here: NCASI isn’t trying to collect safety data from acupuncturists in order to improve our own safety practices. It’s trying to collect safety data for the purpose of engaging in turf wars with other professions. Its target is adverse events in the practice of physical therapists performing dry needling (which is by definition unsafe according to NCASI, because it’s needling done by people who aren’t acupuncturists).

The acupuncture profession promotes some peculiar, inconsistent, self-serving arguments about whether acupuncture is or is not defined by inserting a needle into a point in the body. Elaine Wolf Komarow said it better than I could here. But the purpose of this post isn’t to address dry needling and its adverse events (we’ll get to those later) but to begin to talk about why safety isn’t a weapon and shouldn’t be used that way.

Researchers who study adverse events reporting as a safety practice agree that it works best when the process of reporting is voluntary, anonymous, and can’t be linked to any kind of negative consequence. The prospect of being punished makes people clam up, about errors and events that aren’t errors but might be cast as such. You can’t build a culture of safety in an atmosphere of fear and condemnation, because nobody will want to talk, compare notes, collaborate, or do any work that requires any degree of trust. For an AERD to do its job, sharing information about safety should feel as neutral and routine as possible, no big deal. Just another pro-social behavior like, say, recycling.

Part of a culture of safety is the sense that we don’t have to hide our mistakes, and in fact we don’t want to; what we want to do is learn from them, together. We expect that everybody will make mistakes and so our mistakes represent a kind of collective project we’re always tinkering around with (and nerding out on). Nobody’s going to use anybody else’s mistakes against them, because we’re busy trying to use our mistakes FOR each other.

I’m going to suggest that this would be a good thing for the acupuncture profession, to be busier learning from our own mistakes than weaponizing physical therapists’ mistakes against them.

One of the challenges of building safety that’s active, participatory, cooperative, and relational is that it overlaps with things that acupuncturists find it difficult to pay attention to, because they’re not exciting. Physical therapists stealing our medicine -- now that’s exciting, especially if you like drama in which you’re the victim. But being organized, having meetings, writing documents, working diligently at safety communication and safety decision-making -- not so much.

This contrast reminds me of Ursula Le Guin’s beautiful essay, “The Carrier Bag Theory of Fiction” (please read it, it’s amazing) which addresses why we think stories have to have heroes and weapons and why we believe “the proper shape of the narrative is that of the arrow or spear, starting here and going straight there and THOK! hitting its mark (which drops dead).” She writes, “I differ with all of this. I would go so far as to say that the natural, proper, fitting shape of the novel might be that of a sack, a bag. A book holds words. Words hold things. They bear meanings. A novel is a medicine bundle, holding things in a particular, powerful relation to one another and to us.”

A culture of safety holds things in right relationship to each other. A culture of safety is a container and so it can’t be aimed at anyone. It’s a bag, not a spear.

In fact, let’s call it “the Carrier Bag Theory of Safety”: safety is process, not product, and also not a weapon wielded by a hero against a villain. Often, safety done successfully looks like nothing much is happening. It looks like people quietly getting what they need and then going about their lives. You can’t even see it unless you’re looking for it.

One of the lessons I learned from dealing with trauma is that valuable aspects of healing are gentle, repetitive, and honestly sort of boring. I couldn’t heal in certain ways until I felt safe enough, and feeling safe enough also required being kind of bored, at least in comparison to what life had felt like before. Healing demands energy and intention; there are parts you just can’t do when things are blowing up all around you. Surviving bad things can sometimes involve exciting, heart-racing, heroic moments, but I’m not sure that healing from them ever does.

Safety in biomedical settings often requires steering patients through a terrifying gauntlet of potentially life-threatening adverse events and errors like hospital-acquired infections, side effects of chemotherapy, and drug interactions. Acupuncturists are lucky that safety issues for us are nowhere near as dramatic. But just because cultivating safety in acupuncture practice doesn’t involve heroics doesn’t mean it isn’t important, both to us and to our patients.

Mostly what acupuncturists need to do in terms of safety is to deliberately and patiently create a container. But in order to focus on making the bag, first you’ve got to put down the spear.