At my school, and I believe elsewhere in the US, we are required to take the Clean Needle Technique (CNT) exam before doing acupuncture in the clinic as primaries. My exam is coming this weekend in Portland and boy am I excited. (Yes, that’s sarcasm). To tell you the honest truth, I haven’t thought too much about it – positive or negative. The basic procedure is like this – well in advance of the exam nearest you, you submit a sizable chunk of change (135 dollars right now) and an application. Some time later you receive word that you’re accepted or not. You’re then required to buy a copy of the CNT manual (another 20 bucks plus shipping if your school doesn’t carry it) and assemble a “clean needling” kit consisting of various items. You’re meant to study and practice before the exam, and then give up an entire day where you will apparently be lectured to about blood borne pathogens, the importance of controlling your workspace and using the tube insertion method of needling.
The idea, I think, is to ensure the general public that acupuncturists know about blood-borne pathogens and are doing their best to minimize the risk to patients. I don’t think this is a bad thing. The public, especially the American public, is germ phobic to an extreme. Letting them know that we’re doing our utmost to ensure their safety can only be helpful for the profession. Right? That could be the end of the conversation, but many folks have raised questions about the exam and the whole practice of “clean needling.” I’d like to graze over a few here in hopes of starting a conversation and maybe quieting some of the questions in my own mind.
The “course” and exam
The Clean Needle Technique “course” and exam are administered by the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) based in Maryland. One of the major gripes I hear about the CNT course revolves around this organization. The question embedded in most of the complaints I have heard is whether or not this group is exploiting students for a profit motive. The assumption is that the group does nothing more than CNT, that CNT is not necessary or even useful and that the group charges unnecessarily for the service. As determined from their website, CCAOM’s primary aim is to improve the consistency and quality of Chinese medicine education in the US through the establishment of applicable standards for acupuncture and Asian medicine schools. They created a separate commission for the accreditation of Chinese medicine schools, now known as the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). They also have committees on a variety of topics not related to CNT and their newsletter suggests that they are still intimately involved in the continuing development of acupuncture and Asian medicine educational standards. For this reason, I do not support the assertion that CCAOM exists solely for the purpose of administering the CNT exam.
Regarding the profit motive… I have no idea how much profit the CCAOM makes from the CNT exam nor do I know what they would do with such a profit. I am always willing to give people the benefit of the doubt with regards to this issue. I know how much work goes into running an organization like this, and I’m disinclined to believe that they are profiting significantly from this practice. However, the regulations around the CNT Manual are absurd. Every person is required to buy their own manual ahead of time, photocopies and reuse of others’ manuals are prohibited. The manual is republished semi-frequently, so even if you had a friend’s – you may not be able to use it. While I understand the need to have an updated book because of the changing understanding of blood borne pathogens, I cannot think of a viable reason to require every student to spend 20 dollars on the manual. Allow photocopies and sharing of manuals – it’s the right thing to do.
There have been questions raised about the efficacy of the CCAOM in administering the exam from the perspective of enhancing patient safety. You can read a recent article in the Chinese Medicine Times about this issue titled OSHA Compliance: How Clean Needle Technique Falls Short in the US. Personally, I feel that the article goes too far in the WRONG direction – which I will discuss in the next section of this post. But the thought that the CNT exam doesn’t even do what it is intended to do very well is disturbing. That’s a lot of money to not even get the job done.
The practice
It is part of the Oregon Acupuncture Association’s code of ethics states that it is a legal requirement to follow Clean Needle technique to practice acupuncture in Oregon. I have not been able to locate that section in the Oregon statues that govern licensure, but several agencies refer to the requirement and I believe it may be a requirement in some way in the national board examinations. It would be interesting to know whether it is an actual legal requirement, and if not, why not.
The question is this – has there ever been any evidence that blood borne pathogens are transmitted by modern acupuncture needles? It seems certain that the risk would be much higher if you were reusing needles or using needles between patients. Few people do this – and it doesn’t seem like a 135 dollar course and exam would be necessary to teach us not to reuse needles. Assuming you are using disposable needles and using them only once – what is the risk? Several articles, such as this one in the Medical Acupuncture Journal indicate that the evidence is quite scarce that acupuncture poses a serious risk of transmitting blood borne pathogens even in highly risky situations. I personally know of no situation in which acupuncture caused any problems, blood borne pathogen or otherwise. In China, it is my understanding that very few if any people practice Clean Needle Technique and I am not aware of any outcry around the propagation of disease by acupuncturists. It seems exceedingly unlikely that the risk is significant. So why the obsession?
It seems to me that it would be smarter and easier for students to make Clean Needle Technique a mandated portion of their acupuncture curriculum (perhaps a couple weeks of the first class) and have a few salient questions concerning it on the national board exam. I cannot at this time think of a substantial reason to support the course and exam as it now stands. I would be delighted to hear any opinions to the contrary with supporting evidence. Have any of you practitioners been involved in any efforts to change or get rid of the requirement?
Eric
{ 16 comments… read them below or add one }
When I took the NCCAOM exam there were some questions back from the clean needle technique class.
As for the applicability.. hmm… a friend practiced in England for awhile. They have an examination. She demonstrated clean needle technique and they laughed and asked why she swabbed the areas with rubbing alcohol. Their point was that unless the patient is filthy you aren’t doing anything–and that little swab isn’t going to help anything if the patient is that filthy. It also doesn’t create a sterile field.
At the time I took the CNT we were not taught about treating immunocompromised patients with anything but rubbing alcohol but I do keep some betadine for my chemo patients or for anyone who admits to HIV just to create a more sterile field.
We were not required to needle with tubes at the time I went through–nor were tubes emphasized. I think we were taught both. Most people went to tubes because it takes less energy to use them. I am sad to hear that the style of teaching may have had to change. There are a lot of good reasons to freehand.
Hey Bonnie,
Thanks for the great reply. I agree that it’s pointless. I was trying to be judicious. :D I would love for anyone to produce any study showing that the Clean Needle method is less disease producing than any other method. If it isn’t, we should drop it.
Regarding freehanding. I agree that this is the best method and it is the one most of our teachers teach. It seems clear to me that while a Clean Needle technique exam is required for national licensure and stated as legally required in some States for continued practice there is no way to enforce it, and in fact, no easily recongizable statutes that would even cover such a thing. That being said – I think it’s important to learn how to minimize infection (especially with “high risk” patients) and then needle in the way that gives the greatest therapeutic benefit. In most cases, IMHO, this is freehanding.
Eric
Hello Eric,
I’ve never really given the exam much thought in this context, but I definitely want to endorse freehand needling (with a heartfelt thank you to Dr. Robert Johns). I believe strongly that it is virtually impossible to develop a high degree of skill in needling if one never learns how to needle without the tube. I’d also like to add that nowadays people think simply jolting someone off the table is obtaining Qi. So when I treat students they are often often surprised to learn that the movement of Qi can be felt in a gentle, harmonious manner. Great post!
Yah, we had to do CNT first semester and weren’t really taught much in the way of freehand technique. Our CNT teacher-now the clinic director-made a point of showing us a freehand method but it was pretty clear that she was teaching it because she felt it was important and that it wouldn’t be showing up in official curriculum. Our dean of WM told us that alcohol doesn’t do much other than glue the creepy crawlies to the contact surface. Personally, I plan on licking all my needles before and after insertion.
we were taught tube, and free hand
though we used tube more often than not in clinic situations.
as to thisobsession with swabbing, im not a fence sitter at all, we were taught swabbing, and i’ll keep them there like tissues and wet ones for the odd excess heat bleeder, you’ll get the odd drop. but nothing to get hysterical over
i think it is the general media beat up, and the mass phobia generated by it.
havent heard of a case and ive looked.
trying to hunt down stats on herbal purity in packaged formulations; now there are some blank walls….but thats for another time
Cm
Journeymans
Sorry I haven’t replied to these comments. We’re in midterms and everything is just so BUSY! I’ll batch reply.
Cm : Yeah – I think it’s probably ok to keep around, but I can really tell the difference when I’m needled with a tube vs freehand. But it’s my thought that you can develop skill with a tube – but I’ll have to agree with Abdallah above that you should probably learn freehand first to get a better sense of the needles and their interaction with the patient’s Qi.
Michael: I’ve heard the licking method is very popular in… um… somewhere, I’m sure. :D
Abdallah: I totally agree. I guess I don’t have much to add to your excellent comment. I feel blessed to be at a school where so many professors want to impart information about their freehand techniques to us.
Thanks to everyone for your great comments!
Eric
I know I know very little, but maybe you can answer this question. The clean needle technique, is there any other technique? I would assume that acupuncturists always use clean needles. It sounds like common sense or am I missing something?
Kate,
“Clean Needle Technique” as I am describing it is the name of a very specific protocol, course and exam mandated for national certification in Chinese medicine/acupuncture. The vast majority of acupuncturists, maybe even all (in the US) use disposable needles for a single use. So, yes, they are clean.
The question is whether we need to follow the REST of the protocol, particularly given the cleanliness of our needles and the fact that the majority of healthcare practitioners wash their hands religiously.
Thanks for your comment!
Eric
CNT is just the tip of the legal and ethical iceberg that is the environment you will operate in as a medical professional. If you think blood borne pathogen standards are not something you have to worry about you are mistaken. As an example, what happens when an employee of yours makes a Workers Comp claim for a needle stick? Guess how fast OSHA will be visiting your office and how much money that it will cost you when they find you are not in minimum compliance. As a professional provider you will be legally responsible for compliance in all these areas like it or not. If you want to educate yourself to a level that will generally exceed what your school will provide then I suggest reading Quality in Complementary and Alternative Medicine by Kailin. You’ll be far better prepared to operate in the medical environment as it exists now and if you find yourself in an employee in a hospital environment far less likely to get your hands slapped by the safety officer. By the way I have no vested interest in the aforementioned text. I do have and interest in seeing you and your student colleagues be successful and safe providers. Good luck with your studies.
Well, before I address the CNT topic, one quick comment. I am a practitioner of an eclectic American style based mainly on Japanese acupuncture techniques. I don’t agree with the assessment that using a tube will not allow one to develop skills. Though it is true that some degree of accuracy with regard to the point might be lost – thought doesn’t have to be -, I find a high degree of accuracy when employing another Japanese technique: that of holding the needling shaft with the left hand, called oshide. This is the sensing hand, the hand that can feel very clearly what is happening under the skin and at the appropriate depth, while the right hand, sashide, manipulates the needle.
It is this practice of grasping the needle while manipulating which CNT proscribes, and which is a great loss to our community. The Chinese used to do it also – it says so in the commentary in one of the classics – don’t have the time to look it up now – that the right hand manipulates while the left hand is used to sense the movements of Qi. The Japanese have used this techniques for a few hundred years, and if you’ve been to Japan you know that overall they are just as germ-phobic as we are. Still, when you speak with acupuncturists over there, they laugh and shrug. Most will swab the point as a concession to public perception; at the Tokyo Therapeutic Institue, I saw students wearing finger cots during palpation and insertion (but still using those gloved fingers to grasp the needle); but all in all, I think the evidence that disease is transmitted by an acupuncture needle is scant.
I had one famous acupuncturist in Tokyo tell me they ran experiements in their clinic which took sterile needles, inserted and removed them, then placed them in what were effectively petrie dishes for months, then examined under a microscope. He smiled as he told me nothing grew there.
Rachel,
Thanks so much for your insightful comment. I think you’re right in that you can develop those techniques even with tubes, perhaps it is just easier? I think I like learning w/o tubes to begin and developing skill with the tube as time goes on.
I’m interested in this technique you refer to – oshide, I’ll have to study more about it… can you point me in the direction of some articles?
Hi Eric,
Thank you for raising the issue and asking about the CNT and its potential “scam” designation.
You should have taken your CNT exam way back in October of 2007, and I trust you “scraped by” with a passing score (Ha!).
In the beginning, there was no CNT.
Then, in 1984, NCCA (that was their name then) held its first exams and CNT was one of the components. I was there and passed the written and the practical (CNT). I didn’t have to “scrape by” because both exams were really quite straightforward, easy and realistically basic and reasonable.
After that, I soared within the profession and went on to become an exalted examiner for NCCA’s Point Location module and CNT exam.
Then (circa 1992-93) the political “special interest groups” in our profession decided to remove CNT from the NCCA and give it to the Council of Colleges (of Acupuncture). This was in lieu of the other option that was being presented: That the SCHOOLS would host the CNT exams. I never understood why this was done and why a Council of schools should administer an exam and why it was removed from NCCA (an official testing agency), and no one in political prominence at that time was able to explain it to me.
Today, the Council, the NCCA (now called NCCAOM), and NACSCAOM (the accrediting association – now simply called ACAOM), plus the approved/accredited schools, all appear to be happily intertwined in a group understanding that places CNT with the Council and God help you if you don’t comply – because you’ll never get through school or get licensed. This is unlikely to change anytime soon.
With the profession being driven mainly by the SCHOOLS, most of which are private, profit-making businesses (and don’t kid yourself that most of the non-profit variety aren’t just covers for big salaries), who are the members of the COUNCIL, I have seen what I consider to be self-serving, unrealistic expansions in the entry-level, educational and licensing/certification requirements over a 30-year timespan. Here is a very brief summary:
1. There was never any reason to increase the curriculae of the SCHOOLS beyond 2300 hours or so. Oriental Medicine is a complete system that fits entirely and nicely in a box of that many hours. The requirements were increased at the insistence of the SCHOOLS that just wanted more dollars per student. Any fanfare about more study, more hours, more books, more research is just gas-passing in order for authors to promote new books and SCHOOLS to sell them along with their inflated courses of study. Recent surveys show that no more than 28% of graduates end up practicing acupuncture full-time, and the SCHOOLS never tell that to applicants!
2. There was never any reason to take CNT away from NCCA, except that it (NCCA) was an independent licensing agency and the SCHOOLS wanted to (indirectly) retain control. Today, NCCA requires that candidates go through the COUNCIL’s CNT course. I know of no other profession that is so anal as to not simply make a practical technique (in this case, the CNT course) part of the curriculum within the SCHOOLS.
3. In its own arena, the NCCA has gone on to become NCCAOM, the puppet of the COUNCIL and the ACAOM accrediting commission, that has recently raised its prices for ALL of its services to an unreasonable level. They are also engaging in unfair restraint of trade in relation to their (rubber-stamping procedure at inflated prices) policies, procedures and tactics (especially tactics!) related to Continuing Education.
4. In (my) final analysis, I find the profession of Oriental Medicine to be: (a) effective, interesting and amazing; (b) not very productive as a vocation unless one is among the 28% that make a go of it; (c) horribly prejudiced towards early pioneers who are now shut out of licensing in most states and even the NCCAOM exams unless they return to school and pay big bucks to catch up; (d) terribly fragmented due to the racial prejudicial backgrounds, (big) egos, and technical preferences involved in the various State and National Associations (Chiropractors, MD’s, Dentists, etc. do not suffer from this type of disastrous splintering; and (e) controlled by SCHOOLS that are surely accruing a big batch of negative karma.
5. I love Oriental Medicine – I hate what has been done to the profession.
Is the CNT a “scam”? – In some respects – Yes, absolutely! The information is necessary, although sometimes a bit silly (alcohol), but the administration is pompous and self-serving.
Thank you for asking the original question and allowing me to set down my thoughts right here – A project I had already decided to pursue wherein I will eventually name names, cite dates, and provide an exposé of the immoral (and sometimes just plain stupid) actions of many of our “highest and most esteemed” leaders.
Sincerely, Shiva Nataraj, O.M.D., L.Ac.
Hi Eric,
In relation to my previous comments on CNT, I just read (today!) the following in the California Journal of Oriental Medicine, Vol 19, No 1, Spring/Summer 2008:
Hand Hygiene
“Hand hygiene is a particularly important measure in protecting from biological hazards. Here we have a potential conflict over which standards to follow. The 5th edition of the Clean Needle Technique Manual for Acupuncturists defines a double-soaping protocol for hand washing, and a protocol of using alcohol swabs for antisepsis of the fingers. Neither is concordant with current Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene. Since 2003, OSHA has accepted CDC’s guidelines for the use of alcohol-based hand rubs. The acupuncture profession has neither updated its national standards in the interim, nor established why its standards are preferable. The CDC guidelines for use of alcohol-based hand rubs mark a significant advance in hand hygiene…This example highlights the acupuncture profession’s urgent need to develop continuous and transparent mechanisms for reviewing, updating and communicating standards, and mechanisms for more rigorous review of standards.”
I am also reminded of ACAOM’s blind-eye (in late 1993) turned towards the OSHA Bloodborn Pathogen Act of 1991. They were accrediting schools without even checking to see if the institution was in compliance with OSHA.
I fail to see why the leading agencies of our profession are simply unable to keep current with anything. I suspect there is an element of naive, unprofessional ignorance in those who yearn to be leaders of the profession. And worse yet, any attempts to question their incompetence WILL result in subtle penalties and black-balling. I know. I have seen it happen on numerous occasions, and I have had it done to me.
Shiva Nataraj, O.M.D., L.Ac.
Very interesting! Any recommendations as to what one might do to combat this?
Eric
I read an article said ,Acupuncture needles won’t cause any infactions, because the needle gague is too small to cause inforction, in contrast, It will produce the antibody to fight the infaction.
However, I forgot where I read this article. It is from NHI or WOH? who will know this , please tell me.
Jianwei
There is exactly one reason for the national CNT exam: STANDARDIZATION. Who wants standardization? State licensing boards, hospitals, malpractice insurers, medical insurance companies, and more. All of these must assure your needling safety and do not know your particular school or instructors. As we all know, all schools are not equal in quality of instruction. Say two acupuncturists apply for a job in a hospital, where infection control is a major concern. When the interviewer asks about infection control training, one applicant assures the interviewer that he is trained by the “Yellow Emperor’s Ball of Qi College,” and one assures him that he is nationally certified in CNT. Which applicant do you think the hospital administrator might prefer? Medical insurance companies also want standardization of certification for those who participate as providers, as do malpractice insurers. Certification on the school level can never substitute for national certification, and for our profession to grow and take a place in the medical community, we must have standardization in infection control and safety.