Monday, 29 July, 2013
“The mid- level physician believes this knowledge to be something attainable. The lower physician believes this to be something easily acquired. It is the superior physician (alone) that understands the true difficulties of (its study).”
Lingshu, Chapter 11
Many different forms and versions of acupuncture are now available from many different healthcare providers. Some basic distinctions are important to make. Just in the small community I live and work in, you can get acupuncture from a physiotherapist, chiropractor, addictions counsellor, naturopath, holistic nurse or someone who goes by the professional label of ‘acupuncturist’ (as is the case with me). Is it all the same? Most certainly not. This is a very complex topic I could write dozens of pages on (and I am always available to discuss it further with anyone). But for this blog, let’s keep it simple to help you, as a patient, gain practical clarity on a confusing matter.
The most important distinction to make here is between three levels of acupuncture practice . . .
acupuncture as a technique,
acupuncture as a modality and
acupuncture as a profession.
These three categories of acupuncture are distinguished from each other primarily on the basis of the depth, breadth and scope of practice. If there is one thing to take away from reading this blog, it’s understanding that distinction . . . technique, modality, profession.
You probably already understand that there are big differences in the depth, breadth and scope of practice between opticians, optometrists and ophthalmologists or between paralegals and lawyers or between paramedics and physicians or between bookkeepers, accountants, financial advisors, auditors and tax preparers. The same kind of distinctions apply between these different levels of acupuncture practice.
A. Acupuncture as a Technique.
When acupuncture is practiced as a technique, it is being used in a very narrow sense to serve a very specific therapeutic goal. A good example of this is the Ear Acupuncture (Auricular) protocol that many Addictions Counsellors use to support their overall goal of addictions treatment. Established in 1985 as the NADA (National Acupuncture Detox Association) protocol, this involves the placement of needles in specific points in the ear. The NADA protocol is a proven therapeutic contribution to the addictions treatment process.
Training is minimal and the professionals involved are first and foremost, in the business of providing addictions counseling and treatment. They are enlisting a single, specific one-size-fits-all acupuncture technique with proven power to help with withdrawal and recovery from addictions. They are not acupuncturists and the therapeutic scope of their acupuncture is limited to this single application. NADA certified practitioners have 30 hours of class training and 40 hours of clinical supervision in this protocol before they are certified.
From my perspective, this level of practice should never be referred to as acupuncture. It should simply be referred to as the Ear Needle Treatment for Addictions.
B. Acupuncture as a Modality.
When acupuncture is being practiced as a modality, the therapeutic scope is expanded beyond the very specific focus of acupuncture as a technique. It is, however, acupuncture usually provided by professionals who are, first and foremost, practicing healthcare under a primary banner other than acupuncture. Most typically, this scenario is found amongst physiotherapists and chiropractors. It can also include medical doctors, nurses, osteopaths and naturopaths (the latter being quite different in Canada and the United States). In Canada, the core curriculum involved in this level of training totals somewhere between 100 and 300 hours.
Acupuncture practiced as a modality is often given labels such as ‘medical acupuncture’, ‘contemporary acupuncture’, ‘evidence-based acupuncture’, ‘neuro-anatomical acupuncture’, ‘dry needling’, ‘trigger point therapy’. Some of these are very controversial terms as they lead to unwarranted presumptions about the service you are receiving. A full discussion on this would require that we delve deeply into things like what medicine is, how medicine works, the history of medicine, what science is, how science works, the history of science, how evidence is gathered, what constitutes evidence, and what is the nature of innovation. But from my perspective, labels like ‘medical acupuncture’, ‘contemporary acupuncture’, and ‘evidence-based acupuncture’ are unwarranted, frankly dishonest and lack an appropriate level of humility. Some modality level labels are, however, very legitimate. For example, ‘Trigger Point Therapy’ is a well developed stand-alone, therapy in its own right that makes no claims beyond it’s scope.
Acupuncture practiced as a modality is in need of a name that reflects honestly and appropriately the fact that it is applied narrowly and mostly locally (as opposed to systemically) to musculoskeletal problems (shoulder pain, hip pain, knee pain, back pain, etc). The best name I can think of is ‘Adjunctive Musculoskeletal Acupuncture’. It makes no claims to be something it is not.
Just be clear that when you are receiving acupuncture as a modality, you are in the care of a physiotherapist or a chiropractor (or some other health care professional) who is primarily looking at you through their main lens and applying specific and limited acupuncture approaches to support their main therapy.
An important side-issue that I must point out here is that 100 to 300 hours of training is NOT guaranteed for modality-level practitioners. This is because there is no universal regulatory or even profession-wide self-enforced requirement that practitioners in this category even complete the entire program before practicing acupuncture. So they are often practicing with only components of their particular full training program completed (can be and often is as little as a single weekend of 16 hours training or perhaps a few weekends or a few dozen hours). Imagine a law school or medical school or engineering school that lets people practice when they have completed as little as 15% of their training? In Canada, two major sources of training in this category are the Acupuncture Foundation of Canada Institute and McMaster University.
C. Acupuncture as a Profession.
When acupuncture is being practiced as a profession, it is being practiced by someone who has been through 3 to 5 years of schooling dedicated to acupuncture alone and who practices acupuncture first and foremost. At this level, an entire complex system is being used as it was both originally synthesised in the Chinese Han Dynasty and as it has been subjected to twenty centuries of subsequent clinical development. The channels and frameworks of acupuncture represent an entire system integrating anatomy and physiology, the material and the non-material, the body and the mind. The numerous physiological and anatomical frameworks a professional acupuncturist uses to understand and serve your healthcare needs include what are known as the 6 Stages model, the 5 Phase model, the 4 Stages model, and the 3 Burners model. They include a multi-level channel system framework from superficial Sinew Vessels through the Connecting (Luo) Vessels, the Primary Channels, the Divergent Channels, the Extraordinary Vessels and finally, the Organs themselves.
(Note: These frameworks are all centuries old and quite ‘foreign’ to modern-day frameworks of anatomy and physiology. For some, that is ground enough to dismiss them as lacking any validity. For those who have taken time – ten years and more in daily clinical practice – it is abundantly clear through repeated experience and evidence that these frameworks have tremendous validity. That is a separate discussion.)
Acupuncture when understood and practiced at this level involves a set of principles incorporating a comprehensive model of health, how illness arises (pathogenesis or aetiology), and how illness progresses.
Acupuncture practiced at this level includes numerous frameworks for diagnosis and assessment including palpation, asking questions, observing, listening, pulse taking, tongue inspection, and full medical and personal history gathering.
Acupuncture, practiced at this level, does not only involve the use of needles (in fact there is no such word as ‘acupuncture’ in Chinese!). It includes moxibustion (the application of directed heat at acupuncture points through the burning of herbs), cupping, dermal abrasion, blood letting, and massage, as well as lifestyle and dietary advice.
Acupuncture practiced at this level also includes a philosophical and cosmological understanding that positions humans in dynamic relationship between the Earth (and all of its influences, including the seasons) and the Cosmos and Universe (and it’s larger implications and influences).
And finally, acupuncture practiced at this level by serious practitioners, involves a developmental path that should begin on graduation from school with complex algorithmic thinking and eventually merge into what is known as physician-level thinking where clinical integration through experience and study leads to a practice based primarily in an understanding of the principles involved.
In short, acupuncture practiced at the professional level does not view you as a simple symptom – elbow pain or neck pain – it views you as an entire complex system in relationship to your entire life and the world around you. Those practicing at this level provide treatment from a sophisticated holistic, integrated whole system perspective.
D. A Wrinkle in the Picture
The three categories I have presented above are simple, straightforward and clear. And they reflect the basic distinctions you should be making when you seek care. And these three categories translate into the real world with a lot of truth. But of course, the real world is also more complicated. There are many exceptions. For example, there are professional-level acupuncturists who are also trained in the NADA auricular protocol and like to use it a lot. There are physiotherapists and physicians who have gone beyond the modality-level training of their colleagues and pursued a comprehensive professional-level acupuncture training. And to be honest, the state of professional-level acupuncture training is not uniform and there are those in practice carrying that banner who might be performing more at a modality-level. There is even an acupuncture tradition originating from the Chinese revolution, called ‘barefoot doctor acupuncture’ which has migrated West, morphed into many different versions and is essentially at the modality level of practice.
So, keeping everything I have written in mind, ask yourself when you seek care . . . where does the care I am receiving fit into this big picture? The important thing is that YOU are honest with yourself about who you are seeking treatment from and THEY are honest with you about their training, their strengths and their limitations.
E. Recipes, Algorithms and Physician-Level Thinking.
Let’s go a little deeper into what lies beneath this technique-modality-profession continuum.
A recipe as I use it here is essentially a one-size-fits-all prescription – usually for a particular symptom.
Examples of recipes:
“if the patient has an addiction problem, use these five points in the ear every other day
“for headaches, use this acupuncture point”.
I often hear these kinds of statements from patients, “My friend told me to press this point for headaches”. There is no diagnostic skill involved (except knowing that a ‘headache’ is pain in the head and not somewhere else!). All that exists at the recipe level is the ability to apply a particular therapeutic intervention to all cases of a particular presentation in clinic.
An algorithm begins to introduce choice and differentiation, so it adds complexity beyond the recipe level. However it is still mostly spelled out for the practitioner and there is no or not much immersion in principles to the degree the practitioner can respond uniquely to all the exceptions and complexities that often and typically turn up in clinic. A simple algorithm might go something like,
“if the knee pain is medial, use these 5 points,
if the knee pain is lateral, use these 5 points”.
Obviously, algorithms can be very simple or get more and more complex and ultimately start to become quite responsive to the full range of likely presentations. For example, you could have an algorithm that goes something like,
“if the patient has menstrual pain, heavy bleeding with clots, premenstrual headaches, premenstrual breast tenderness, visual floaters, a choppy pulse, and a purple tongue with dark sublingual veins, use these points. But if they have menstrual pain, heavy bleeding with no clots, premenstrual headaches, premenstrual breast tenderness, a normal coloured tongue and normal sublingual veins, use these points instead”.
More complexity is being included, but still within an algorithmic decision-making framework. Algorithmic thinking can get quite complex. And it can be quite a clinical achievement to provide acupuncture at a high level of algorithmic thinking.
But, there is still further one can go, to a deeper form of practice. This is where the bird truly leaves the nest, so to speak. This is where the crutches of protocols and algorithms are dispensed with and a full understanding of principles and processes are fully integrated into the practitioners experience and understanding. This is physician-level thinking. Chinese Medicine provides such a rich and complete medical model that it is possible for a practitioner to fully attain this level of clinical development. To be honest, not many fully do, for many reasons (actually, Doctors of Modern Medicine today are often not working at this level either. The so-called ‘evidence-based’ medical paradigm combined with a litigious and bureaucratically rigid context is forcing more and more of what doctors do, out of physician-level thinking and into provision of protocols and algorithms.). But many professional-level acupuncturists do reach some degree of attainment of physician-level clinical capacity.
It is important not to confuse this level of practice with ‘intuition’. That is an often-heard confusion. They can appear the same. And at times, they certainly can merge. But they are not the same. Intuition can completely bypass any knowledge, understanding or experience with principles and processes. Physician-level thinking requires a deeply understood and experienced relationship with the principles and processes of Chinese Medicine.
F. A Final Note
The issues I raise here, as they exist in the real world, are very thickly intertwined with confounding relationships to ego, professional turf, business expediency, technical confusion, historical confusion, professional politics, compromised regulatory agendas and more. At times, professional and regulatory wars are fought over and between these differences. It can be very difficult to have an honest and well-informed discussion about these distinctions with your healthcare provider. A few of the points I have made above are clearly my opinion, and that should be obvious. But the fundamental distinctions regarding
depth, breadth and scope of practice between
technique, modality and profession and between
recipe, protocol, algorithm, physician-level thinking and intuition
are very real. They stand on their own, independent of anyone’s opinion.