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12 February 2006
Health Care Unprofessionalism
Often, the things I write about surface because of a synchronicity of multiple themes of thought and discussion. This is one of those times. On one email list, I was contributing to a discussion on professionalism, on another talking over the motivations for the California Chiropractic Associations's (CCA) and California Physical Therapy Association's (CPTA)opposition to SB 412. In the background, I was thinking over recent discussions with physics colleagues on the general state of health care and health care expenses in the U.S.
I've blogged and written a column about professionalism in times past. The essence I talked about back then and hold to today is that professionalism stems from altruism and service to the public. To again quote from Justice Sandra Day O'Connor:
"Personal relationships lie at the heart of the work. Even in the face of the vast technological advances of the information age, the human dimension remains constant, and these professional obligations will endure. ... A business can focus only on profits. A profession cannot. It must focus first on the community it is supposed to serve."
What I'd add today to my prior comments is that professionalism also includes a substantial element of reflection both on sessions done and on contributions made. However, simple a task, there is almost always something that could have been done with more awareness or with more smoothness.
In my previous post, I'd mentioned the Ontario model of having an explicit list of reserved acts as a basis for health care licensing. Ontario's Regulated Health Professions Act was used as a case study (#4, p. 59) in recommendations made by the Pew Health Professions Commission on revitalizing health care for the 21st century.
While a primary purpose of the RHPA is to protect the public from practitioners who are unfit or perform poorly, the act also functions to minimize the social costs that result from regulatory-based limitations on (1) consumer choices of providers, (2) innovative use of individual health professionals, and (3) the evolution of professions to meet changing health care needs. The framers of the RHPA hope that the new legislation will afford effective public protection from harm, greater accountability to the public by regulatory bodies, and respect for consumers’ right to choose their health providers from a range of safe options.
Previously in Ontario, a small number of professions held exclusive license to the provision of services that fell within their scopes of practice, while other professions were registered—that is, held exclusive rights to use certain titles. This system, however, could not adequately protect the public and promote cost-effective and efficient use of the health care workforce. Critics of the old system contended that it …gave physicians (and other professions with exclusive licenses) a monopoly that was broader than could be justified by the need for public protection, a monopoly paid for by the public purse in higher fees to physicians and in less efficiently run health care institutions….
So, some hard questioning is due on the professionalism of opposition of SB 412 by the CCA and CPTA. Is such opposition truly in the public interest or merely an example of a couple of professions seeing an opportunity to gain their own selfish advantage? Are we simply seeing yet another example of the lack of team-work in U.S. health care that increases costs and decreases choice?
Why should a clause be so controversial to physical therapists that indicates massage practitioners have a responsibility to assess, within their limits, whether massage is or is not immediately contraindicated and referral needed? Why so particularly, when such a clause is common to many of the laws regulating massage in the various states? Why is a scope of practice that includes passive stretching within the physiological range such a problem for the CCA? Particularly again, when there is ample demonstration that it is current practice, safe, and within the most elementary training? SB 412, after all, is not trying to change current massage practices but simply normalize reasonable and uniform regulation. SB 412 is not responding to harm caused by the profession but by harm caused to the profession. In short, SB 412 is about creating a working business format for an existing scope of professional practice.
It's time that we in the massage profession straighten our own spines and stand fast against this opportunistic nonsense. It is time for the massage profession and our friends in the public to make it clear to those who would oppose us for their own selfish gain that it's time to either work with us for the public good or to bear the public ire. It's high time that we and our friends start writing letters to the editor of our favorite news outlets as well as to our legislators. Let's get the professionalism back into the health care practices and get back to the altruism of the public good. Think teamwork, not turf. Enough unprofessionalism.
07 February 2006
The CCA Follies
Ignoring substantial documentation for current practices, the California Chiropractic Association continues to oppose the use of passive movement and stretching by massage practitioners. The discussion on this is well-captured on today's notice on the CAMBS website. This type of nonproductive turf skirmish motivates why British Columbia and Ontario both have moved to uniform reserved/restricted acts lists to facilitate overlapping scopes of practice and cooperation between synergistic professions. SB 577 already set the precedent for such a list in California.
05 February 2006
In Pixels and in Health
The 21 January issue of Science News had a short article on how computer modeling is pushing the threshold of medical research by allowing a dynamic view of interactions that can't be broken down into parts. A short abstract and links to references are available online. We've considered before how the sensory input of massage is input to the complex interacting system of the human mind-body.
A Time for Solidarity, not Ersatz Cheerleading
A recent piece on California legislation in Massage Today erred both in some details about the bill and, more importantly, on the issue of prior agreements made to obtain wide support by the profession within California. Here's the response that I sent to MT this last week.
Re: California: Time to Unify by Dixie Wall
From the perspective of a person with continuing involvement with California massage legislation, I believe that there are several misconceptions in Dixie Wall's article (February 2006) that require correction.
The current two-year legislative session, beginning in January 2005, began with AMTA-CA, ABMP, and CAMBS (the California Alliance of Massage and Bodywork Schools) already in substantial agreement. Prior to the sunrise hearing in January 2005, the three organizations had agreed upon language developed from the prior bill AB 1388. While the California Joint Legislative Committee on Boards, Commissions, and Consumer Protection agreed that regulation on the state level was warranted to correct problems with diverse and in some instances onerous local regulation, they did not feel a full licensing bill was needed. Thus Senator Liz Figueroa, chair of both the Joint Committee and the Senate Business and Professions Committee, authored SB 412 under a model of private certification with control/review by the Joint Committee. California has previously used this model of regulation for tax preparers and interior designers. SB 412 retained at least two features agreed previously upon by the three massage organizations mentioned above: a two-tier system and exemption from local licensing of individual practitioners. In a series of hearings and negotiations, I believe that the AMTA-CA lobbyist, Mark Rakich, the ABMP lobbyist, Kathryn Scott, and officials of the organizations have been scrupulous in adopting a unified approach. For those interested, hearings before the several committees have been archived as webcasts by the California Channel.
As one technical clarification, CAMBS is not “an informal organization of schools”, but a member organization specific to massage schools that has been acting as a school advocate since 1997. Many smaller vocational schools in California had been severely impacted in the early 1990's by state regulation adopted to curtail abuse of financial aid by a few large vocational schools. The regulation did not originally discriminate between schools not using financial aid and those that did. It also did not originally discriminate between training leading to placement as employees and training often leading to self-employment. As noted in the 'about' section of their web page, CAMBS grew out of efforts at correcting inequities of regulation and examination of curricula.
As another technical correction, the exam connected with the 500 hour massage therapist tier is a sufficient requirement, not a mandatory requirement. The proper phrase is “500 hours or passage of an approved exam”.
After SB 412 proved to have sufficient unified backing to clear the state Senate and the Assembly Business and Professions committee, other entities began to take a more serious interest. There have been a number of areas in which the bill has had to be defended or modified. Physical therapists objected to open access for massage professionals. The chiropractic association had a number of objections, including wanting to limit movement of a joint to the active range of motion. This would have virtually eliminated passive stretching from the scope of practice. Drawing on the texts and input of a number of colleagues, I was personally involved in the response to this issue.
CAPPS a general organization of vocation schools, including career colleges with massage programs, objected to the 250 hour tier. The lower tier, however, provides an important economic niche for those not wishing or able to accumulate loans, those making career transitions while meeting multiple responsibilities, and for many of the over 200 state-approved schools. Despite the serious of these issues, however, the main impediment to continued movement of the bill has come from the League of California Cities.
After SB 412 passed the assembly B&P committee, the Cities decided that they either needed time to review and negotiate the exemption language or that they would have to oppose the bill. To my knowledge, the Cities have not agreed upon specific language as of the end of January 2006. Perhaps they also suffer from some disunity. A brief summary of League of Cities on the bill is at <http://www.imakenews.com/priorityfocus/e_article000422838.cfm>. It is extremely unlikely that a bill opposed by the League of Cities would become law and it is equally unlikely that a bill not providing a exemption would be supported by the massage profession.
Unlike other states that have initiated state massage regulation, California already has a large number of practitioners and schools and well-developed business models. Any bill with wide support will need to respect our existing economic niches. Despite our unique diversity, the massage profession in California came into the 2005-2006 legislative session in relatively wide unity. Contrary to Ms. Walls statement, it is not time for us to unify but time to demonstrate to the legislature our solidarity and support for the agreements we have already forged. The business of advocating for a bill is neither a quick matter nor one without effort and need for defense. Ms. Wall's ersatz cheerleaderism (*) is a disservice to the many who have spent long hours to support a bill for all of us.
(*) Cheerleading is an athletic endeavor potentially leading to injuries. Massage may be useful as part of maintenance and rehabilitation.
29 January 2006
Conversation
Last Tuesday, Teresa Nead, Ramona Moody, and James Mally of CAMBS and I had a conference call with Robin Hartley, Senator Figueroa's current staff point person for SB 412. Senator Figueroa and her staff are still sorting out input and language from different parties, so the bill won't be scheduled for hearing in the immediate future. That also means there's still time to use the physical mail to send in some more letters in support of the 250 hour tier. See below for details on mail Senator Figueroa. Take the CAMBS link for more on the conversation.
Synergies
Got up to a wonderful staff party at the McKinnon Institute tonight. Such parties are one of the few times that, as instructors, we are co-located and have the time to chat. Paula and I also used the opportunity to try a few dance moves to the blues playing of school co-owner Carl Johns and his band. Carl was playing the sax tonight, but he's often been doing wood flute at school events. I got to verify that I still know how to lead a dip or a drop after not plying such dance moves for a while. Good music provokes movement. The evening also provided an opportunity to chat with sports & deep tissue teachers Jason and Rob about a few changes in the order in different body areas are covered in the progress of techniques.
Earlier this week, I had one of those moments of confirmation from an unexpected source when a new book I'd ordered arrived. Opening up the book, right in the beginning I encountered:
“The ease with which we recognize a face, understand spoken words, read handwritten characters, identify our car keys in our pocket by feel, and decide whether an apple is ripe by its smell belies the astoundingly complex processes that underlie these acts of pattern recognition. Pattern recognition—the act of taking in raw data and making an action based on the ‘category’ of the pattern—has been crucial for our survival, and over the past tens of millions of years we have evolved highly sophisticated neural and cognitive systems for such tasks.” — Richard O. Duda, Peter E. Hart, David G. Stork, Pattern Classification, 2nd ed., Wiley Interscience, ISBN 0-471-05669-3, p. 1.
For why that's a moment of synergy for me, look at what I wrote a couple of months back at the end of my December 2005 column: Massage Mechanisms
“Someday, we might be able to model the complexity of neurological-chemical-emotional-sensory interactions to determine patterns of sensory input that are most effective at inducing positive change. We still are far away in the infancy of such concepts. The best tool we have to bring to bear today is the equal complexity of the observational instrument known as the human practitioner. The human ability to learn from practice and observation and then to react in real-time to sensory input remains unmatched. We are slow at consciously processing input, but rapid at "unconsciously" matching patterns. There is great value in being able to initiate a simple touch, judge the response and adjust our input toward assisting the client's system toward a better place. We've known this intuitively for a good while. We are just beginning to develop the scientific finesse to explain it.”
So in response to those individuals who disdain intuition, here's the reframe. “Responding to my innate sensory pattern matching abilities, my hands naturally started to …”. I also noticed that my column for February is up on Massage Today, "Interconnecting Science, Massage and Medicine".
22 January 2006
The Clash between Doers and Definers
Driving home on Thursday (19th), I caught part of the public radio MarketPlace special on China. Toward the end of the program, they were commenting on interior areas of China like Chongqing still being open to spontaneous innovative ideas — places you could get people interested in development ideas that they had never encountered and that you were creating as you progressed. The contrast was being made against places like Shanghai, a city that a few years ago was wide open but is now overtaken by more middle managers. It sounded to me like one more example of the ongoing clash between those who are nonlinear and those who are linear. In this case, the nonlinears were moving west into the interior of China to escape being stifled by increasingly linear constraints.
I've long viewed much of the massage education ‘wars’ as the cultural war between the linear/verbal/linguistic and those of use who are more nonlinear/spatial/visual/kinesthetic. There's a cartoon that captures the intuitive essence of this conflict. Here's more on visual thinkers and picture thinking.
The linear types don't have the sense (i.e. don't ‘grok’) the worth of learning incrementally (just-in-time-learning). They seem to particularly miss the need and the value of the approach of creating benefit by jumping into the middle of an activity at first chance. For those of use who are more spatial and learn in the act of doing, the limiting factor is not what we know in advance but our ability to discover and organize simultaneously — to recreate ourselves and our context on the fly.
We spatial/kinesthetic types also seem much more prone to be plying multiple professions and multiple life tasks simultaneously. A recent discussion on the body-tech email list, high-lighted the linear/nonlinear differences. The list itself is a tribute to the number of us who have a hand in massage and a past or continuance in technology. That we often don't have a single defining profession is important to how we view the world and what we seek from it. For the record, I also think most of us don't read technical manuals from cover to cover but skip around trying stuff until we have a feel for it.
My friend and colleague, Robert Flammia, is partial to stating that the AMTA legislative pushers don't represent those who follow Ida Rolf's maxim of “just do the work”. There's at least once sense in which Robert's admonition is straight to the target; there's a difference between those who do the work for the innate sense of human contact and the benefits it brings, and those who are looking for massage to convey to them some greater sense of identity. As near as I can figure, the verbal-linguistic types feel a need to define their identity by imposing nonfunctional structure on what they do. It's like watching a car ad and realizing that 90 percent of what's being sold is an identity transplant rather than a means of transportation So Robert's right, there's a crowd for whom defining the work has more weight to it than just doing the work.
The scary part is that these linear types seem to have a penchant for wanting to involve the rest of us in their identity crises rather than setting up their hurdles on a voluntary basis. So, if you're feeling a bit on the nonlinear side and want to keep entry-level requirements at a relatively functional compromise in California's SB 412, remember to email Senator Figueroa (and staff) urging her to keep the 250 hour tier as a permanent level. Let the verbal-linguistic-linear types keep their ever-raising pursuits voluntary. The rest of us have work to do (in more than one area). By our works shall you know us and by our works shall we know ourselves.
MMAP References
The majority of the time I've managed to spend on the Massage Medical Applications Projects (MMAP) [remember, nonlinear multi-tasker] lately has been in collecting and organizing references. All of these have abstracts with them, and many link to the article online. Linking may or may not imply access to the entire text, depending on the journal and publisher. That's one reason I've stuck to articles with abstracts. The other reason has more to do with what I believe an author should provide. There's still more to do, but the links are beginning to collect at the bottom of the database page.
08 January 2006
Support your local Massage School
Over the last month, I've been urging you to write Senator Figueroa and her staff in support of the 250 hour entry tier currently present in SB 412. I'm still urging that; the email links, contact information, and a PDF envelope file are just below. What I'm writing about today are more of the reasons that I believe you should take time from your life and world to do that writing. Time's short.
Several of my colleagues who oppose state regulation on principle are fond of saying that both the push for regulation and the push for higher hours for entry to practice comes from the massage schools. On first glance it does seem that massage schools would benefit, but it's not that simple. Let me explain, as succinctly as I can, why your choice to write or not to write will shape the future of massage in California.
There is an organization, the California Association of Private Postsecondary Schools (CAPPS), that has lobbied at each legislative hearing for a minimum entry of 500 hours. What may not be immediately obvious, is that this is not an association of massage schools. It's an association of many types of postsecondary schools. Most CAPPS members that teach massage courses are career colleges. These trade schools, in general, offer programs of 600 hours or more, because 600 hours and accreditation are the minimum requirements for federal financial aid under Title IV. These trade schools can be expected to be adept at this loan-funded financial niche — it's their business. CAPPS and its trade school members wouldn't shed many tears (except the 250 hour tier) if the majority of independent massage schools ceased to exist. A 500 hour minimum is also somewhat of a red herring. It's not particularly attractive to offer an expensive program just under the minimum for financial aid. It's easy to see why CAPPS supports what it does. Trade schools are the supermarkets of the vocational education business, being no better or worse than other supermarkets. There is another school organization, specific to massage, that has worked to see that all state-approved massage school in California are kept informed. That organization is the California Alliance of Massage & Bodywork Schools (CAMBS).
There are currently over 200 state-approved massage schools in California. The majority of these are Mom and Pop businesses. They were started by people with a passion for massage, the ability to communicate with others, and the desire to share the practice of massage as a life path. In turn, these schools add to the income and professional development of a substantial number of massage practitioners who are also part-time teachers . One such school, the McKinnon Institute, has allowed me to leverage my time, limited by another full-time profession of physics, to contribute to the professional growth of many more people than I could have hoped to have reached in individual practice. It is largely in gratitude for what that opportunity has added to my life that I write what I do. These individual massage schools, because they have a flow of students as their base support, also are able to teach massage to those who seek to learn for life enrichment or to further their skills as family care-givers. The schools, their owners, and their teachers are part of and support the communities around them.
If, as seems likely, SB 412 passes, the 250 hour tier will be the life-blood of the independent massage schools — if it continues to exist . Most of these schools rely on pay-as-you-go students — students making career transitions, of limited economic resources, or simply not able or not willing to incur more debt. Students who wish to study massage from schools and teachers devoted to massage. Students who need early entry to practice so that they can test the waters, make ends meet, and fund further learning. Many of the schools have small physical facilities that aren't going to support a transition to the larger classes and administrative staff required to make accreditation and financial aid feasible. These are not schools that are going to push for a minimum entry of 500 hours, for that will almost certainly result in their destruction. People with years, heart, and soul devoted to a profession and a business don't go out of their way to commit business suicide.
Statistics on California entry to practice tell me that most of you practicing out there came to practice by programs of 250 hours or less. Those same programs, if you value their continued existence, need your help. Within the next few weeks, the language of the next revision of SB 412 will likely be set in place. The teaching of massage in California has a substantial and special history. If you value that experience and history, take the time to write Senator Figueroa. Tell your story. Please. It's your world, your time, your choice.
Senator Figueroa's mail address is just below. Again, here's a PDF file for an envelope to her. Her capitol office phone is (916) 651-4010. Here's a link to email her (with a copy to staff). Ask her to support a permanent 250 hour entry tier.
The Honorable Liz Figueroa
State Capitol, Room 4601
Sacramento, CA 95814
Re: SB 412
31 December 2005
Closing Matters for 2005
Paul has posted a reply from Beverly May on his SVS blog, along with his own following comments. I totally agree with him that the 500 hour tier is literally only a guarantee of hours, not a measure of any manner of organized content leading to defined outcomes of practice. It also is not a measure of experience. That doesn't mean that there aren't 500 hour programs that do provide more and should be commended for it, just that this isn't general enough for including the tier in regulation to be more than a desire for a marketing distinction. Such distinctions, however, should be the matter of entirely private and voluntary certifications independent of state regulation. That said, I wouldn't oppose a bill simply because it carries a marketing title, unless that tier starts carrying more weight than it merits and begins to influence entry requirements.
This is a good segue into another matter of the difference between purely private certification and state regulation —delegation of authority. Atkinson & Atkinson, the law firm retained by the Federation of State Massage Therapy Boards (FSMTB), has written an extensive memo on delegation of authority. This will be linked to the FSMTB website as they go through their next web update cycle. The memo is a powerful document that marks a reference point in the maturing of the massage progression to clearly demark different kinds of roles for different types of legal entities. For the record, the private organization that would be created under SB 412 would be a 501c(3) organization under review by the Joint Committee on Boards, Commissions, and Consumer Protection (JCBCCP). The January 2005 issue of Massage Magazine also contains a summary of the legal issues on page 66. The MM summary includes comments from Bob Fellmeth, head of the Center for Public Interest Law (CPIL), supporting the conclusions in the Atkinson & Atkinson memo.
I managed a bit more on the Massage Medical Applications Project (MMAP). It's not yet linked to anything else , it requires a relatively recent web-browser to view nicely, and it's an all or nothing view, but the unedited results of my searching PubMed for massage articles are available as a styled XML file. This file contains the references and abstracts for 375 articles with massage in the title and is about one MB in length. Recent versions of IE, Mozilla, and Firefox (and likely other recent browsers) can use the linked stylesheet to transform the XML (text with defining tags) into HTML for viewing.
My thanks to those of you who have contacted legislators, attended hearings, and spread information outward to your own circles of colleagues and friends. Those such as myself can help to keep you informed, but what we know and say is effective only to the extent that individuals like yourselves are willing to lend your voices. Political pressure is ultimately about individuals writing letters or picking up the phone. However well or poorly your practice might be going today, however swamped you might be with what else you juggle in life, your voice counts if you can spare even a moment to express it. Many people speaking from the heart, however simply, speak with a loud voice.
Happy New Year to All! May the new year bring you growth and fulfillment and the warmth and comfort of family, friends, and community.
29 December 2005
Another Hard-Hitting Piece on the SVS
Paul's done another thought provoking SVS piece on opposing the very presence of the 500 hour tier. As it stands, I agree with Paul's take that the 500 hour tier provides little of benefit to the consumer of massage and that it is basically a marketing distinction. As long as it didn't endanger the actual entry tier at 250 hours, allowing the 500 hour tier was simply a way to gain greater feasibility. As it seems that it will endanger the lower tier, it's time to call the 500 hour tier what it is — a piece of cargo-cult marketing. While the benefits are an illusion of smoke and mirrors, as Paul points out, the harmful effects to those of limited time and means are real.
One might expect, that a higher tier would guarantee training and proficiency in the more clinical aspects of massage, but that guarantee is lacking pretty much across the board of U.S. massage regulation. The result has been the upstart establishment of two separate organizations attempting to create a training patch and wrestle what they term 'medical massage' away from the rest of the profession. Here's one piece from the AMMA in support of this statement and here's another from the USMMA. Both organizations are basically responding to a situation in which the 500 hour 'standard' lacks well-defined outcomes. I differ from Paul somewhat. I don't blame this situation on lack of research but on lack of focus.
Years ago, a major organization in the profession left the road of looking at rigorous needs and benefits from requirements into the alluring shortcut of simply pushing hours. While this has been successful as a legislative agenda, I believe it has side-tracked the profession from the educational rigor needed to motivate our true potential. We now have a generation of therapists who believe that 'high standards' are about hours in the classroom rather than about content, capabilities, and outcomes. My own MMAP is about bringing the power to define away from the meetings of private organization boards and back to the open review of the professional community itself. So, my hat's off to Paul for turning over the rock to look at what squirms in the muck underneath. We should do better and can do better than what's currently being pushed as a (defective) standard.
Please take the time to jot out even a short note or email to Senator Figueroa. She's a good legislator, but she needs to hear good input from California's many individual practitioners. Her contact information is in my last post just below.
25 December 2005
Holidays, MMAP and SB 412
Our
hopes that you are having a holiday season filled with warmth and togetherness
and, if not for any reason, that the coming year holds bright promise and
happy surprises for you and yours.
Having been working on the viewer for
the Massage Medical Applications Project (MMAP)
over the last several days, I've felt like the shoemaker
aided by the elves. Progress to an initial working outline viewer has
been greatly aided by work that others have done on markup languages for
graphs and manipulation of outlines, such as GraphML.
Although I'm not directly using OPML,
what Dave Winer (Scripting News)
has done with that has also provided a substantial conceptual backdrop.
These have been indirect 'Christmas presents' getting me back more quickly
to the data itself. Hopefully the MMAP effort (along with the new FSMTB)
will start providing a basis to move toward a more outcome-oriented (rather
than agenda-oriented) basis for curricula.
I've felt for a long time that claims of 'high standards' needed a knowledge
benchmark against which they could be measured as to needs and outcomes.
Having set the groundwork over a series of columns and white papers, I've
now started a move in creating such.
Please also continue to send Senator Figueroa holiday email and paper mail supporting the 250 hour tier in SB 412. Senator Figueroa's mail address is just below. Again, here's a PDF file for an envelope to her. Her capitol office phone is (916) 651-4010. Here's a link to email her (with a copy to staff). See my prior December posts for more on the letter writing. Many thanks and my best for the holidays and New Year.
The Honorable Liz Figueroa
State Capitol, Room 4601
Sacramento, CA 95814
Re: SB 412
18 December 2005
Simi Valley Sophist
In his 16 December posting of the Simi Valley Sophist, Paul has done a good overview of the legitimate practice regulated as illegitimate quandary. See Massage Therapist, Masseuse, or Whore--Take Your Pick.
Massage Medical Applications Project (MMAP)
I finally got tired enough of the "Medical Massage" verbiage that I decided to take my Massage Today columns from October and December a good pace further. The webpage for the Massage Medical Applications Project is so new that, if it were a bird, it's feathers would still be wet from the eggshell. That said, it's a start at looking in detail at the diversity of applications and knowledge connections that are out there in the field. I've already had several people contribute to the content, making this already into a community project.
15 December 2005
A Specific Example on Why SB 412's 250-hour Tier is Important
A north Olympic peninsula (WA) local paper has a really good example of just how much strain people go through in trying to better their lives. What's exasperating, is that there are more efficient and economical means to progress people into practice. A lot of the stress comes from disallowing incremental training and early entry to practice.
A couple of hundred dollars separated Stephanie Robson from a career in massage therapy that she had spent countless hours pursuing. In juggling a full-time school schedule and tight budget as a single mother of three, Robson, 30, of Forks was tapped out when it came time to pay for her state board exam to practice massage therapy. … Robson graduated in June from the massage therapy program at Peninsula College in Port Angeles. She had spent nine months commuting between Forks and Port Angeles five days a week, leaving at noon and returning home at about 10 p.m.
While it's great that there was a fund that came along to help with a $250 exam fee, that doesn't alleviate the stress on family those nine months cost. It's an extremely pertinent question to ask how much of that education really was necessary just to begin practice and how much could have been done, apart from licensing laws, in later increments. How much of that initial training had clearly defined outcomes that would be carried into immediate practice and how much was simply an arbitrary hurdle? Arbitrary requirements have social costs!
Get those letters supporting the 250 hour tier out to Senator Figueroa and her staff (see PDF envelope and mailto link in prior post). Just think of the letters as Christmas (or other approriate winter holiday) Cards to those working hard to find meaningful work. Also think of them as Christmas cards to those who will ultimately benefit from their touch and care. I've collected a number of links to my various background documents.
The world waits for those who will show us how this new world of meaningful work will come about. But until it does, let us support those who are feeling displaced or disillusioned. More importantly, let us not lose our sense of purpose and calling in our work.
10 December 2005
It's Time to Put Pen to Paper on California's SB 412
On Thursday December 1, representatives from the California Alliance of Massage & Bodywork Schools (CAMBS), met with Bob Benson, the president of Associated Bodywork & Massage Professionals (ABMP) and the ABMP lobbyist at the lobbyist's office in Sacramento. In the previous two-days, Bob Benson, had had similar meetings with a core of ABMP members who had been politically active. The topic at hand was language proposed for the next revision of SB 412, the bill that proposes to create a private 501c(3) organization under legislative review to certify massage practitioners/therapists in California. There's more history on SB 412 in my previous post.
In the fall of this year, after passing through the Assembly Business & Professions Committee, SB 412 was placed on hold at the request of the League of California Cities. The League, belatedly realizing the SB 412 might go somewhere, felt that they either needed time to assess the bill and negotiate specific language on exemptions from local regulation, or that they would have to oppose the bill. The hold, turned SB 412 into a two-year bill. There's a League perspective in one of their bill reports. It will become active again with the start of 2006, facing the Assembly Appropriations Committee as its next hurdle. In the meantime, those in the profession have an opportunity to voice an opinion.
While both Physical Therapist and Chiropractic organizations have so far opposed the bill, SB 412 does not change the scope of massage from current practice. Documentation supporting current practice has been written and conveyed to appropriate parties. A summary about half the size of my full-out document was used by the ABMP lobbyist for conveying the concepts. Some statements clarifying current practices have been included in the proposed language. The upshot is that good-faith changes and documentation have been created and that the bill will be advanced against the opposition of the PTs and Chiropractic association. What is also true, however, is that Liz Figueroa and her chief consultant Bill Gage have their own opinions on wording. Liz Figueroa is author of SB 412 and chair of both the Joint Committee on Boards, Commissions, and Consumer Protection and the Senate Committee on Business Professions and Econonic Development. She is also running in 2006 for Lieutenant Governor.
Given all of the above, the arising issue of concern to CAMBS, ABMP, and myself are grandfathering and the retention of the 250 hour entry tier. There is more on the issues on the CAMBS website and history and current needs on ABMP's updates. Note that ABMP has included an informal draft of currently proposed wording. Please look at their list of information for 12/06/05.
The 250 hour tier is something that I strongly believe should be permanently retained. I encourage you to write Senator Figueroa expressing your support for this tier. If being able to start practice with early entry while continuing additional training was important to you, please add your own personal stories. My own letter to Senator Figuero follows below. The position letter from CAMBS is linked to the top of their home page. A white paper on this tier versus 'standards' (or lack of them) is link from my letter below.
Senator Figueroa's mail address is at the top of my letter, just below. Here's a PDF file for an envelope to her. Her capitol office phone is (916) 651-4010. Here's a link to email her (with a copy to staff).
Again, many thanks for what help you can give. … Keith
The Honorable Liz Figueroa
State Capitol, Room 4601
Sacramento, CA 95814
Re: SB 412
Dear Senator Figueroa,
While I am a massage educator and often work with ABMP and CAMBS on education issues, I am also, a constituent of yours in Pleasanton a trained and practicing scientist, and the father of two boys. It is from these multiple perspectives that I’m writing asking you to permanently keep the 250 hour tier within the certification process proposed in SB 412.
As a scientist, I have consistently been appalled that those who speak loudest about ‘high standards’ for massage create educational requirements without well-defined outcomes into practice. They are pushing the appearance of a standard without the substance of specific goals and measurable. A far more well-known physicist than myself accurately defined this approach when he coined the term “Cargo Cult Science”. That physicist was Richard Feynman. I’ve expanded on what I believe is a congruent use of Feynman’s characterization as it applies to massage regulation in my short attached white paper, “Will California Join the ‘Cargo Cult’ Habit of Massage Regulation?” I will let that paper speak to the technical side of massage standards.
As a father of two sons, I have more to say. Both of my sons, one nearly ten, and one thirteen, are what is often called ‘twice-gifted’. What this implies is that they possess great talents and gifts but also that they face great challenges. My younger son is energetic, comes with a heart-melting enthusiasm and smile, understands mathematics years beyond his age, composes classical music, bows the violin with a natural ease …and is diagnosed as autistic. He has perfect pitch, yet cannot handle the noise and commotions of large crowds. He can compose in the style of Chopin or Bach, yet has trouble with what many would consider simple social situations. We don’t go out to movies as a family because he needs the freedom to move a lot when watching a movie. My older son, when eight, could mold a piece of clay to look so much like a frog you would expect it to hop away. He has a natural seeing ability and coordination to draw and sketch. He has inherited my sense of word-play and appreciation of subtle humor, and follows after me in playing the trumpet. Yet he has been dogged by anxiety most of his life, was diagnosed last year as bipolar, and has been on a progression of more serious medications than I can think of without wanting to cry for him. He can sketch something meeting the needs of a class assignment, yet often crumples the paper too frustrated with his inability to create to the standard he can visualize. Having lost my own father in a plane crash when I was four, having been raised by a mother who was caring and creative but made stability a rare luxury, I would make my son’s paths easier, yet too often even that is beyond my reach. What I can do, however, is use the skills of hand and word that I have to be a care-giver and advocate for my sons. I can also use my skills for others, who have the dexterity of hand and heart to contribute through the practice of massage, but may lack the verbal dexterity to fend off the dismissive words of others.
I tell you these things, so that you can understand that, through my sons and through the writings of those such as educational psychologist Howard Gardner and pediatrician Mel Levine (author of All Kinds of Minds), I hold deep regard for the struggles people encounter and the contributions to life and community that they are often also capable of making. I took my first massage class in 1980, while still a graduate student. I obtained my first formal 100 hour certificate in 1985. I taught my first massage class for the Mckinnon Institute in 1992, and wrote my first column for Massage Today in 2001. My training has home in the increments of week and two-week ‘vacations’ to take workshops, in one three-day ‘weekend’ per month spread over nearly a year (200 hours), and in the hours of self-study approaching midnight and prior to the dawn. If there at been a 500 hour minimum in place when I started, I wouldn’t have started at all. I also know that this continues to be true for others out there —parents trying to find meaningful careers, burned out tech people looking to find another side of life, and those who have to judge the value gained for every expended dollar. I know the truth of this reality because I have walked this path myself.
It is for these reasons that I ask you to keep a door open for those who may have limits to funds or time; for those who care and can work with their hands, yet struggle terribly with memorization and the academic world. Both Justice Sandra Day O’Connor and Roscoe Pound, Dean of the Harvard Law School from 1916-1936, noted that the essence of professionalism lies in altruism. Many who struggle know the meaning of this long before massage school. I fully understand that SB 412 is a voluntary certification, but I also know that, when all the interactions with local regulation settle down, it will carry far more weight in setting or foreclosing a path than does a typical title act. Having presented at the January sunrise hearing before the Joint committee and followed the committee hearings via live web-based audio and post-hearing video, I appreciate the effort and balance you have given to massage. Ultimately, requirements without clear need and specific goals are simply discrimination against those who can contribute but don't quite match an arbitrary social norm. Are we willing to say that we, as a diverse state and culture, have nothing to gain from what they could contribute? I ask that you consider this carefully.
Sincerely,
Keith Eric Grant, PhD
Father, Physicist, and Massage Instructor
10 October 2005
California SB 412: Recent History
After a good while simmering like a batch of candy, the California legislative process is reaching “the soft ball” stage and the temperature on the thermometer may start rising rapidly. There are things to look at closely and carefully on the California legislative front. Today's post provides a quick status summary. Within the next several days, I'll post about the issues threatening our norms of practice.
After hearing the massage regulation sunrise testimony last January 6th, the California Joint Committee on Boards, Commissions, and Consumer Protection determined, in a public meeting on April 12th, that the current system of local regulation was an inequitable business burden for a legitimate practice. The implication was that more direct state intervention was warranted to correct the market flaws of local regulation, even though such regulation was granted to the local agencies by the state. Regulation was both nonuniform, limiting mobility, and local agencies were poorly differentiating legitimate practices from less savory claims of doing massage.
Following the Joint Committees determination, Liz Figueroa, Chair of both the Joint Committee and the Senate Committee on Business, Professions, and Economic Development, authored SB 412. SB 412, if enacted, would establish a private, non-profit organization under Joint Committee Review to certify massage professionals in the two tiers of Massage Practitioner and Massage Therapist. The two tiers would require 250 and 500 hours of training, respectfully. Other than the title and training requirements, current wording in SB 412 does not otherwise differentiate the two tiers. This configuration of two tiers, otherwise undifferentiated, has resulted from extensive negotiation between organizations (ABMP, CAMBS, AMTA-CA) within the profession and is crucial to maintaining support. A recent poll of schools by ABMP adds additional support to that statement.
To tamper with this is to fall off the plateau of mutual support into opposition and fragmentation. We've been there before. Back in November 2003, the potential that the scope of practice for the 250 hour tier would be restricted in AB 1388 was a predominate factor in a storm of opposition letters to the Assembly Business and Professions Committee. Judith McKinnon and I had hand-delivered a position paper on One-Scope of Practice to the Assembly B&P committee at that time. Off the plateau is not a productive place to go again; this issue is fundamental to trust within the profession.
Fulfilling its underlying motivation, SB 412 would require that those certified under its auspices be exempt from local massage practitioner licensing. There would also be a requirement that individual practices run by certified massage professionals or multiple person businesses employing only those certified be zoned as other professional practices are zoned. At this point, SB 412 has been approved by the Senate and the Assembly Business and Professions Committee and the Senate Appropriations Committee. It was held for changes before having a hearing in the Assembly Finance Committee. With that hold, SB 412 has become a two-year bill. The negotiations behind the hold and how you can help will be the subject of a very near future post on scope and tiers .
The various hearings the bill has already had are available for viewing via webcast from the California Channel. The January hearing is in “Real Player ” format and the hearings in April onward are in “Windows Media-Player” format. For the April 12th Joint Committee hearing, the massage part happens about 50% of the way through (at about 22:15 to 27:40 minutes). For the April 25th Senate Business and Professions Committee hearing, the massage part is from 5:12-5:29 in terms of hours and minutes into the hearing. There are additional votes at 6:42 and 6:55 to bring things to the final 4 to 1 to move the bill out of committee. The hearing started at 1:30 pm, so by there is some accumulating giddiness by the time massage comes up more than 5 hours later. The Senate Appropriations Committee hearing was on Monday May 9th. The parts on SB 412 are from 18:54 to 23:50 and from 01:29:20 to 01:29:52, times measured from the start of the hearing. This hearing was strict about sticking to financial matters. The Assembly B&P hearing was on June 28th. SB 412 squeaked out of this committee by one vote late in the hearing. ABMP has up more history on hearings and wording.
Federation of State Massage Therapy Boards
There is now a fledgling national Federation of State Massage Therapy Boards (FSMTB). There was a preliminary organizational meeting for FSMTB in Denver in May followed by a full meeting 20-21 September in Albuquerque. The concept behind FSMTB is that it provides a channel of communication between the individual state agencies regulating massage and that it provides a basis for creating a licensing examination with a direct line of public accountability.
The time and place for the September meeting were were chosen to coordinate with the AMTA national convention and to make the FSMTB process as inclusive as possible. ABMP had provided seed funding for both the meetings, but control was rapidly turned over at the May meeting to an interim board of representatives from the state boards. Coordinating with the AMTA meeting was seen as encouraging as wide as possible participation. Interim board president Rick Rosen (now executive director) and vice-president Patty Glenn (now president) gave a presentation to the AMTA board on Monday 19 September. At the September FSMTB meeting, John Page and Garnet Adair, from NCBTMB, were welcome observers. There was also an AMTA representative at the meeting, although I can't recall her name. I do recall a number of serious and productive private discussions I had with John Page. He had earlier posted to the Body_Work email list on being the 'first' actual NCBTMB employee and on being committed to changing their corporate culture to be customer oriented. From my conversations with him, I believe that is a true, serious and welcome intent.
The FSMTB has some serious considerations ahead on how to define minimum competencies and how to "insure provision" of a licensing exam. The FSTMB is using the legal counsel of Dale Atkinson, JD of Atkinson & Atkinson. Atkinson has had experience with a number of board associations and is involved with FARB, the Federation of Associations of Regulatory Boards . In his presentation at the September meeting, Atkinson noted that there is a legal exposure involved in state boards delegating authority to private agencies. The legal issues raised by Atkinson, strongly suggest that the provision of a licensing exam needs to be under the publicly directed auspices provided by a federation such as FSMTB. That provision doesn't preclude the NCBTMB or any other test provider in being a contractor to the FSMTB. That kind of relationship was also discussed in a model social workers bill that Atkinson was involved with (see the comments in sections 213 and 307). A crucial legal point is that state agencies are either public agencies in themselves or delegates of the state under direct individual state supervision. The FSMTB, while a nonprofit 501(c)3, is governed by delegates from the states and thus has a direct line of public accountability and a mandate to act in the public benefit.
The FSMTB, under its now adopted by-laws is assuming a responsibility of coordinating public accountability for supervising the public purpose and content of an exam. This responsibility is clearly set out in the court decision of California Liquor Dealers v. Midcal Aluminum, 445 U.S. 97 (1980):
A state can delegate some of its actions to a private organization while maintaining the umbrella of state action immunity only if the purpose is “one clearly articulated and affirmatively expressed as state policy” and under the requirement that the policy be “actively supervised' by the State itself”.
At the FSMTB meeting, the legal counsel. Dale Atkinson, made a presentation in which he noted the legal exposure a state board can occur in delegating authority to a private agency. I read the above quote to Mr. Atkinson, asking his opinion on it. His reply was that this was a concise and accurate summary of the issue. The quote was from a more extensive document on motivations for a new exam that I put together for the initial FSMTB meeting last May.
Given the complexity of the above, the AMTA national board demonstrated a remarkable trivialization of the issues in sending an email to AMTA members on 22 September, only a day after the FSMTB first adopted by-laws, urging a letter campaign to pressure the FSMTB simply to "cooperate fully" with the NCBTMB. A mass email campaign goes substantially beyond adopting a national board position urging the FSMTB to fully consider potential for working with the NCBTMB. In encouraging the tail to wag the dog, the AMTA board spent remarkably little time reflecting in depth on either the issues or the likely reaction to jamming FSMTB board member's inboxes.
In the computer world, trying to overload the capacity of a system to handle input is known as a denial of service attack. Hackers do this by placing Trojan Horse robot software ('bots') on innocent user's computers and then having them all send data to a single site on command. AMTA has seemingly attempted this using human 'bots'. If it were my inbox, I wouldn't be amused and it wouldn't be my thumb that would be pointing upward.
If anything, this AMTA spamming of FSMTB board members underscores the need for the FSMTB as an organization to help coordinate regulation as an action in the public interest rather than as a way of leveraging an agenda. I was glad to find out that the new FSTMB president and executive director were able to attend the 2005 meeting of CLEAR (Council for Licensure, Enforcement, and Regulation). Both FARB and CLEAR have experience with the public benefit purpose of regulation. Drawing on such experience helps to clarify the important division in purpose between regulatory boards and organizations advocating for a profession. CLEAR provides a resource brief making the distinction for licensing exams.
MPS Entries for July 2004 through September 2005 Archived
My MPS entries for July 2004 through September 2004 have been moved into their own archive file. There's also a link to the old index page from the archive index page on the navigation bar to your left.
If you came here via a link or search to the old index entries, there may be a date hash of the form "#yymmdd" following the "index.html" at the end of the URL in your browser's address bar. When you get to the archived file, go to that date to see the entry you were seeking. You can even copy the "#yymmdd" hash here, and paste it on the new page, then hit the enter key to go there. Here's a JavaScript based link that does all of that for you.
It is through each of our individual efforts that together we work to keep or get our profession and practices independent of unnecessary and/or onerous regulation. It is the responsibility of the state to protect the public from harm. It is the job of the profession itself, independent of the state, to develop norms of practice for particular client populations and contexts.
Liberty means responsibility. That is why most men dread it. — George Bernard Shaw, Man and Superman, "Maxims: Liberty and Equality", 1905
