Work in Progress: POCA Tech Needling Policy

I confess, I love blogs. Most social media is not my cup of tea -- bad for my nervous system -- but blogs are the opposite. Both writing and reading them does good things for my brain. Over the past couple of weeks I started noticing that blogging is helping me think through some problems -- most recently, POCA Tech’s policy on extra curricular needling by students.

In theory, that policy should be as simple as it gets: one big DON’T. Oregon law (rule 847-070-0005) states)

...(5) An individual who is a trainee or student of acupuncture may not perform any act that constitutes the practice of medicine or the practice of acupuncture, except under direct supervision of a person approved by the Board to provide clinical training as described in rule 847-070-0017.

Got that? It’s illegal for acupuncture students to needle humans unless they’re in class or in clinic. They are not allowed to practice outside of class. The problem is that many of them, maybe most of them, do. And acupuncture schools know that they do.

I certainly did, circa 1993, so it seems like epic hypocrisy for me to intone DON’T! to POCA Tech students. Or to tell them, I know you will, but don’t get caught, okay? Neither of these responses is safety-positive. I’ve been feeling ridiculous every time I go over the rules with a new cohort of students.

As a result of feeling ridiculous, you know what I didn’t do? Have a thorough discussion with students about safety specifically in relationship to extra curricular needling. (Having them read the Clean Needle Technique manual and get the certification is important, but it’s not enough!)

Back when I was an acupuncture student merrily disregarding the law, four things were true about me:

1. I loved acupuncture,
2. I wanted to help a lot of people,
3. I really, really didn’t understand risk, either generally or in relationship to needling. I’m pretty sure some version of Clean Needle Technique instruction existed even back then so it’s not like I didn’t know that adverse events were possible. I just had no idea how to relate to risk as a reality in my life.
4. I was lucky. Nothing bad happened to me or to anyone else as a result of my extra curricular needling adventures.

If you study the history of acupuncture in the US, you learn that a number of people who became acupuncturists (including some prominent figures) basically taught themselves how to needle, either with minimal instruction from another acupuncturist or from reading books. There seems to be a human impulse, with respect to acupuncture, to want to try it. I think we can assume that impulse is multiplied tenfold in anybody who actually enrolls in an acupuncture school.

I couldn’t think clearly about this problem until I wrote a post about harm reduction. Trying to keep POCA Tech students and their potential patients absolutely safe from the risks of extra curricular needling is probably not a realistic goal; it would be better to aim for safer.

It’s important to acknowledge that as soon as you become an acupuncture student, your family and friends will present you with conditions that they wonder if acupuncture can treat. They might even directly ask you to treat them. You love acupuncture, and you want to help them. It doesn’t do any good to pretend those things aren’t true.

It’s equally important to recognize that there is no medical intervention without risk. It doesn’t matter whether your heart is pure and your intentions are good. Things happen. And while it helps to receive training in how to needle safely, when it comes to acupuncture, things still happen. Adverse events (including perceived adverse events) can happen to anyone, including very experienced acupuncturists with excellent training.

A crucial aspect of becoming a practitioner is learning to navigate the complexities of safety and risk. Declaring a practice legal or illegal is not the same thing as making it safe or unsafe. Regulation and safety are not identical, though many people in the acupuncture profession believe they are. Yes, the point of barring people from certain behaviors or practices is to increase safety, in theory, but harm reduction recognizes it often just doesn’t work that way. Until I started writing here, I didn’t realize how much it was bothering me that POCA Tech students’ very first introduction to the topics of safety and risk was so muddled. If we want to build a culture of safety, that’s not the way to start.

Mostly what acupuncturists need to do in terms of safety is to deliberately and patiently create a container. A big part of the transition from lay person to practitioner is learning how to create the container in which treatments can happen safely, for both the practitioner and their patients. The container is composed of systems, skills, and technical knowledge; it includes the practitioner’s clinical persona, which is distinct from, but overlaps with, their ordinary personality; and it’s held together by various boundaries. Because there are so many components, it takes time to learn how to assemble a strong container. A lot of what an acupuncture school does is to provide a container for students so that they don’t have to do it themselves before they’re ready.

Extra curricular needling happens outside of the pre-made container of a clinic and a school, and it happens inside the container of the student's personal relationships. The container of personal relationships might be able to accommodate acupuncture treatments, but it wasn’t built for that purpose, unlike a clinic or a classroom. Even experienced, licensed practitioners can find it challenging to deal with issues related to boundaries, communication, and expectations with the people that they treat. Students practicing extra curricular needling are equally likely to encounter these same challenging issues, but outside of the protective container of the clinic.

I wish I had known this when I was a student. I also wish I had known that it was possible, through no fault of my own, to have a patient skewer their tendon with an acupuncture needle and have to go to urgent care to get it removed. Or to have a patient become convinced that the needles I put in had somehow shattered during treatment and so they needed to dig out the fragments with their fingernails. I wish I had known that a non-zero percentage of patients will feel that acupuncture made them worse -- no matter how talented and well-trained their acupuncturist is. As a student practicing extra curricular needling, I wouldn’t been prepared to deal with any of those scenarios. I would have panicked, and if I had gotten in trouble, I would probably never have become an acupuncturist at all.

So what are we going to do differently, going forward?

POCA Tech is a school for adults; furthermore, we’re a school for adults with the purpose of facilitating entry into a highly regulated profession. Laws and regulations are an unavoidable feature of life for licensed acupuncturists (by definition). It’s our responsibility to introduce our adult students to this reality right away, and clearly inform them of the potential legal risks of unsupervised extracurricular needling.

It’s also our responsibility to try to provide as much supervised needling practice as students need in order to feel comfortable entering clinical internship, and so we have to maintain open communication about that -- including establishing that it’s okay to bring up this entire topic. If a student has chosen to practice extra curricular needling because they’re not getting enough practice in class, that’s vital information for the school to have, but we won’t get it if the shadow of punishment is hanging over over the entire conversation.

Without the feedback loop of the AERD, we can’t make good decisions about risk, and so we also need to introduce the topic of the AERD and how to use it, at the same time we introduce needling itself.

As noted earlier, a defining aspect of safety is communication and organization. Creating safety includes having policies that make sense and communicating honestly about them, including rethinking them as needed. This is obviously more work than just telling people DON’T, but I’m convinced it’s worth it. Right now our new draft policy (see below) is making the rounds of our sociocratic governance.

Trying to be a good example here. Let’s make more safety!

Proposed Revision to Extra Curricular Needling Policy

According to Oregon law (rule 847-070-0005, see https://secure.sos.state.or.us/oard/displayDivisionRules.action?selectedDivision=3898)

...(5) An individual who is a trainee or student of acupuncture may not perform any act that constitutes the practice of medicine or the practice of acupuncture, except under direct supervision of a person approved by the Board to provide clinical training as described in rule 847-070-0017.

It is POCA Tech’s policy to:

1. clearly inform students in their first module that unsupervised needling of humans and animals is against the law;

2. clarify that unsupervised needling of humans and animals could result in the student’s inability to get an acupuncture license in the future;

3. clarify that needling practice outside of supervision is necessary for developing appropriate motor skills and must be restricted to fruit (oranges, grapefruit) or intramuscular injection practicing models.

4. emphasize that at any time, students may request additional supervised needling practice if they feel they need more, and faculty will always do their best to provide it.

It is also POCA Tech’s policy to emphasize safety in our acupuncture training program, specifically according to a trauma informed care and harm reduction model. We recognize that there is a risk that students will engage in unsupervised needling outside of these bounds and that all needling carries safety risks.

As sociologist Zeynep Tufekci writes: Harm reduction is the recognition that...(r)isk can never be completely eliminated; life requires more than futile attempts to bring risk down to zero. Pretending we can will away complexities and trade-offs with absolutism is counterproductive. Consider abstinence-only education: Not letting teenagers know about ways to have safer sex results in more of them having sex with no protections...The better approach is encouraging risk reduction and layered mitigation—emphasizing that every little bit helps—while also recognizing that a risk-free life is neither possible nor desirable.

In order to mitigate the safety risks of unsupervised needling, it is POCA Tech’s policy to provide as much information as possible regarding safety practices and to encourage all students, under all circumstances, to report needling safety issues to our Adverse Events Reporting Database (https://acupunctureconsumersafety.net/)