Talking about our Education

“We have over (2000 hours, 4000 hours, 3 years, 4 years) of education and they want to do acupuncture with (a weekend, less than ten, 200 hours) of training!The public is in danger.”

“The (PT’s, Chiropractors, MD’s) doing acupuncture are significantly undertrained! If they want to do acupuncture they need to go to acupuncture school, or at least take (400, 500,1000) hours of training.”

It’s a no brainer, right? But ….

1) We are comparing our total professional education to additional post-professional-degree hours.

An MSAOM curriculum includes: Biochemistry, Introduction to Organic Chemistry, Anatomy and Physiology, Microbiology, Introduction to Western Pathology, and a Survey of Western Clinic Sciences (3 semesters). M.D.’s have already covered these classes in their education.

2) Does the aspect of “our” medicine they want to use require a full TCM education?

Is Tai Qi, Qi Gong, Introduction to Botany, 40 credits of herbal medicine, a semester of auricular acupuncture and 3 semesters of point location needed for a PT to safely use a needle to release a trigger point? (If you insist they learn all of that, won’t they then argue that they can also do auricular acupuncture and distal points?)

3) How well-educated are most acupuncture school graduates? How worthwhile was most of their time spent in school?

ACAOM standards were based on the programs that existed at the time credentials were being established. They were not based on a careful analysis of what was needed to train safe, effective, successful practitioners. Acupuncture related Facebook groups include posts asking about using moxa to turn breech babies, how to treat TMJ (no pulse, tongue, or presentation information provided), and recommendations for treating people undergoing chemotherapy. With our thousands of hours of training, shouldn’t we know the answers to these questions? (Or have a better source than Facebook for answers?)

4) Is there a correlation between the length of a program and the quality of the graduates? Were the early U.S. practitioners (many of whom had less than 1300 hours of training) harming the public?

It is an article of faith in the acupuncture community — our training of X hours is necessary for safety, and anything less is an affront and a danger. Yet a colleague recently wrote “I am at a medical acupuncture conference. Exceeding my expectation. The presenters know their stuff. Lots of depth…. I am going to find out about their training. Maybe they are a special group….what i am seeing here meets any high standards TCM conference…. Very surprised.”

The more (as defined by us) = better has done us no favors. The numbers we fight for are arbitrary. The argument is easily refuted by other providers. Adopting it within our profession has increased the business strangling debt-burden new grads carry. And created internal divisions which only further harm our growth. (How long before a state (or the NCCAOM) demands the FPD to become an LAc?)

Please, let’s let the knee-jerk “less is dangerous, more is better” argument go.

Copyright —

© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2018. Unauthorized use and/or duplication of this material without express written permission from Elaine Wolf Komarow is prohibited. Excerpts and links are encouraged, provided that full and clear credit is given with specific direction to the original content.

17 thoughts on “Talking about our Education

  1. The Education of the Acupuncturist and the Formation of Cartels

    How much education and training is necessary to do safe and effective acupuncture? I believe that this may a very important discussion, and long overdue, for a number of reasons. But I am not sure that the reasons it is important are self-evident. Very often in our communications with the public, or in the context of lobbying for legislation we act as if it is self-evident that more hours of education, or attending ‘the best schools’ will mean that we will be more effective as practitioners and the safety of the acupuncture as a procedure will be improved. But how much education is enough? Which are the best schools and how do we know? For one thing, framing the question in this way can easily lead us down the wrong path. I would like to take a look at the question from another point of view. My preference would be that we as practitioners take some time to reflect on what is truly in our best collective interests. By collective interests I mean both the interests of practitioners and the public we claim to be protecting.

    As practitioners, do want to become, or think that we are, superior clinicians—better than any of our colleagues or ‘competitors’—with more and better ‘credentials’—capable of treating any disease—of eradicating any condition we are presented with quickly, safely, and effectively? Can we achieve that for all by requiring that all of our colleagues and potential competitors (physicians, chiropractors, physical therapists, detoxification specialists, or the Community Acupuncture Clinic down the street to name only a few) meet our version of “higher standards”? Should we all become politically active, lobbying for laws and regulations that will, we would like to claim, assure that the public is getting only the very best outcomes? And of course I this process of lobbying let’s be certain to make sure no one else can offer acupuncture services in our jurisdiction. Perhaps we would like our schools to do a better job of training current and future practitioners. Should we prescribe or dictate curricula that meet our presumed rigorous standards and exclude, through laws and regulations, all practitioners and institutions that do not, or cannot, meet the challenge of our image of competency. If that is what we are after how would we conclusively demonstrate any of our claims? How would or should we measure or quantify this presumed superior competency?

    If we take a sober look at actual data, it turns out that we may be deluding ourselves if we believe that our own arguments actually merit serious consideration. As I was thinking about how to respond to the question of possible links between education, training, certification and competency I thought a little about the state of the ‘science’ reflected in the peer reviewed literature connected with Chinese Medicine. At this point, the only thing that seems certain is that we are in no position to dictate terms to anyone. And if we act, as we apparently are doing, as if we are at war with other licensed occupations, and sadly, even our colleagues, what will the outcome be?
    We cannot, and never will, win the science ‘war’. At this point I would have to say it is rather clear that the skeptics occupy the high ground. The peer reviewed literature on the efficacy of acupuncture (and much of Chinese herbal medicine for that matter) is lukewarm, at very best, in its support. I prefer systematic reviews to individual studies because individual studies all too often do not survive tests of statistical significance or scientific validity. I could cite a number of articles published in refereed biomedical journals that document this and if you have not read (Colquhoun & Novella, 2013), this might be a good place to begin. The conclusions drawn by the authors, all of which are rather well supported considering their rather thorough survey of the literature, are rather dire. I cite a few paragraphs from the article not because I consider them the last word on the subject but to illustrate the precarious nature of our position.

    On the first page of the article we read:

    “Curiously, given that its alleged principles are as bizarre as those on any other sort of prescientific medicine, acupuncture seemed to gain somewhat more plausibility than other forms of alternative medicine. As a result, more research has been done on acupuncture than on just about any other fringe practice.
    The outcome of this research, we propose, is that the benefits of acupuncture are likely nonexistent, or at best are too small and too transient to be of any clinical significance. It seems that acupuncture is little or no more than a theatrical placebo. The evidence for this conclusion will now be discussed.”

    And later in the same article:

    “Since it has proved impossible to find consistent evidence after more than 3000 trials, it is time to give up. It seems very unlikely that the money that it would cost to do another 3000 trials would be well-spent.”

    A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias. Furthermore, demonstrated that exploitation of “undisclosed flexibility in data collection and analysis” can produce statistically positive results even from a completely nonexistent effect. They say this is “. . . not driven by a willingness to deceive but by the self-serving interpretation of ambiguity, which enables us to convince ourselves that whichever decisions produced the most publishable outcome must have also been the most appropriate.”

    With acupuncture, in particular, there is documented profound bias among proponents (Vickers, Goyal, Harland, & Rees, 1998). Existing studies are also contaminated by variables other than acupuncture, such as the frequent inclusion of “electroacupuncture” which is essentially transdermal electrical nerve stimulation masquerading as acupuncture.

    The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research.

    The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

    The interests of medicine would be best-served if we emulated the Chinese Emperor Dao Guang and issued an edict stating that acupuncture and moxibustion should no longer be used in clinical practice.”

    As I said earlier; while this may not be the last word on the subject, it does suggest that the ‘science’ does not actually support whatever claims we might make about the likelihood that ‘higher standards’ (whatever they may be) will lead to greater clinical efficacy and better outcomes—thus ‘protecting’ the public from charlatans and incompetents.

    And isn’t ‘protection of the public’ the rationale we cite when we lobby for laws, write regulations, and accept or reject practitioners in the states in which our boards operate? For many years now, those who have actually looked carefully at the costs and benefits of occupational licensing are onto the “public protection” argument. One of the most succinct summaries of the adverse effects of occupational licensing was made in an article entitled The Myth of Professional Licensing authored over three decades ago (Gross, 1978). To wit, from the abstract of the article:

    “The public and most professionals believe that occupational licensing protects service consumers against charlatans and incompetents. The present review of historical, economic, and sociological research indicates a specious association between licensing and the competence of practitioners. Rather, it is suggested that the evidence reveals licensing to be a mystifying arrangement that promises protection of the public but that actually institutionalizes a lack of accountability to the public. The collusion between the state and the professions, which may be justified in altruistic terms, appears not to merit public confidence. It is concluded that acknowledging the failure of licensing is preparatory to defining the problem of how to protect the public.”

    A number of legal scholars, sociologists, and experts in administrative law have taken the argument even further. It is not just that occupational licensing schemes fail to protect the public from incompetence and charlatanism-they actually establish anti-competitive environments operating more like cartels than institutions with a legitimate public function. The late Walter Gellhorn (father of administrative law and the ombudsman movement) notes that “only the credulous can conclude that licensure is in the main intended to protect the public rather than those who have been licensed or, perhaps in some instances, those who do the licensing” (Gellhorn, 1976 p. 25). A recent comprehensive study on occupational licensing in the United States published by The Institute for Justice finds the following:

    “The contexts [of occupational licensing] within states, of course, are not so radically different as to warrant such inconsistent and often overly burdensome licensing schemes. It is far more likely that the irrationalities endemic in occupational licensure stem from the personal interests of those already practicing the occupations.

    More than 200 years ago, Adam Smith observed that trades conspire to reduce the availability of skilled craftsmen in order to raise wages (Smith, 2013), and modern public choice theory (Becker, 1983) and social science research (Abbott, 1988) demonstrate little has changed since that time. Occupational practitioners, often through professional associations, use the power of concentrated interests to lobby state legislators for protection from competition though licensing laws. Such anti-competitive motives are typically masked by appeals to protecting public health and safety, no matter how facially absurd (Institute for Justice, 2012 p. 29).”

    This has certainly been the case in Delaware, a situation with which I am intimately familiar. After two weeks of tough negotiation about the terms of this acupuncture law the requirement that all acupuncturists in Delaware be certified in herbal medicine was imposed on all of us. This inclusion was supported by a representative of the NCCAOM, a representative of the medical board, the self-appointed ‘leader’ of the acupuncture community in the state, and ultimately the majority of practitioners in the state (a number of whom were not even NCCAOM certified in acupuncture). Data demonstrating the folly of this imposition was presented to everyone at the time, but to no avail.

    Since this law was passed there have been a few successful challenges and I anticipate many more unless the law is changed. A chiropractic physician Douglas Robert Briggs was denied an acupuncture license by the Board of Medical Licensure and discipline. After taking his case to the Superior Court of Delaware he received his license. The presiding judge wrote, citing prior cases:
    “when the Court cannot determine, from the ultimate findings and the record, whether the [Board] proceeded upon a correct theory of law, or whether its findings are based upon competent evidence,” further findings are needed and remand is required (1) .

    Neither the Board nor the Advisory Council contested the judge’s decision because in truth they could really provide no good reason for denying Briggs his license. If they persisted in the denial in all likelihood they would have to explain to the judge why one member of the Advisory Council who currently presides over meetings was issued a license despite the fact that he had neither attended an acupuncture school, participated in a formally organized apprenticeship program, nor written the NCCAOM examinations in either acupuncture or herbal medicine.

    More recently two very experienced practitioners from Maryland were also denied licenses but received them after engaging an attorney to write a letter to the Board of Medical Licensure and Discipline on their behalf. This letter is quite lengthy but the attorney summarizes his arguments quite succinctly in the final paragraph:

    “The March 13, 2014 Orders of the Council denying the acupuncture license applications of Ms. XXXXXX and Ms. YYYYYY prolong acupuncture underservice in Delaware, and keep it among the worst served states in the nation. The Orders keep out exceptionally qualified acupuncturists praised by the Council’s Chair: “[T]hese people are wonderful. I think you guys are really great. “The Council denied their licenses to practice acupuncture because they did not have a diplomate in Chinese herbs, even though any non-acupuncturist can prescribe, formulate and dispense Chinese herbs in Delaware without a license. The Council’s Orders are based on errors of law, are arbitrary and inconsistent with the Council’s own precedent, and violate the Privileges and Immunities Clause of the United States Constitution. Accordingly, the March 13 Orders of the Council should be reversed, and the acupuncture license applications of Ms. XXXXXX and Ms. YYYYYY should be granted (names not revealed to protect the confidentiality of the persons involved.”

    While the question of the legality of the Council’s actions is interesting, even more so is the invocation of the Fourth Amendment of the United States Constitution in support of his argument. Is it time to change the Delaware acupuncture law? I think so. And perhaps while we are at it we should rethink all the actions taken by state boards everywhere to deprive perfectly qualified practitioners of their right to work at the time and in the place of their choosing.

    In many states we are seeing signs of the frustration legislators are having with the behavior of licensing boards. In 2012 the Michigan Office of Regulatory Reinvention released a report recommending the elimination of 18 occupations and 9 boards. Take note that Acupuncture was one of the occupations that the study and report recommended could be totally deregulated. From the LARA webpage:

    “The Advisory Rules Committee was very deliberate in weighing the public health and safety implications of deregulation,” said Roger Newton, Founder, President, and CEO of Esperion Therapeutics, Inc. in Plymouth. MI. “I think these recommendations create a more business-friendly environment and eliminate unnecessary government oversight that does not provide any value to the citizens of Michigan.”

    Implementation of these recommendations would reduce the impact of government regulations on businesses and professionals. They will also reduce both the size of government and the cost of licensing the large number of currently regulated occupations.

    “The Advisory Rules Committee was very serious in its considerations about whether certain occupational licensing regulation provides consumer protection.” Rose Baran, Assistant Professor at Ferris State University. “We found a number of occupational regulations that simply did not provide enough benefit to justify devoting taxpayer dollars for administration of these programs.”
    The ORR’s recommendations continue to protect the public from unscrupulous business and health service providers, while streamlining government processes related to regulating occupations. In addition, these recommendations will increase competition in the affected occupations, thereby lowering costs for consumers. The recommendations encourage business growth and job creation by removing barriers to entry and allowing employers to hire qualified employees without government dictating the employee’s qualifications.

    “A comprehensive review of our occupational licensing system was long overdue,” said Russ Harding, Senior Fellow in Environmental and Regulatory Policy, Mackinac Center for Public Policy. “This report sends a strong signal to businesses across the nation that Michigan is serious about regulatory reinvention. These recommendations demonstrate that Michigan is focused on creating an environment where job creation flourishes. The Legislature should take a hard look at these proposed reforms. (2)”

    Returning to the question of other professions integrating acupuncture into their practices(3)–MDs, chiropractors, and physical therapists are very well organized, well educated, outnumber acupuncturists, and are very good at what they do. Even if we could justify our claims of being superior acupuncture clinicians, and we cannot in my opinion, we must recognize that, in time, there is no way that we can prevent what some may regard as ‘encroachment’ on what we take to be our domain. Many battles have already been lost and if there is a ‘war’ with them we will lose that too. What we should be doing is focusing on our own situation. That is what I really would like to do.

    We have no business prescribing ‘standards of competency’ for other occupations, especially when we have utterly failed to demonstrate our own presumed clinical superiority. Chiropractors and physicians have their own programs for certifying adequate competency to integrate acupuncture services into their practices . Can we really claim that the public will be imperiled if we do not fight these trends? But even more importantly, do we have any business using state laws, regulations, and the authority of our boards to tell other acupuncturists, many of whom may be our friends and colleagues, what they must do or know to preserve their quite legitimate right to work in the place and at the time of their choosing?

    References

    Abbott, A. D. (1988). The system of professions: An essay on the division of expert labor. Chicago: University of Chicago Press.

    Becker, G. S. (1983). A Theory of Competition Among Pressure Groups for Political Influence. The Quarterly Journal of Economics, 98(3), 371. doi:10.2307/1886017

    Colquhoun, D., & Novella, S. P. (2013). Acupuncture Is Theatrical Placebo. Anesthesia & Analgesia, 116(6), 1360–1363. doi:10.1213/ANE.0b013e31828f2d5e

    Gross, S. J. (1978). The myth of professional licensing. American Psychologist, 33(11), 1009–1016. doi:10.1037/0003-066X.33.11.1009

    Institute for Justice. (2012). License to work: A national study of burdens from occupational licensing. License to work : a national study of burdens from occupational licensing

    Smith, A. (2013). The wealth of nations (a modern library e-book). New York: Modern Library. Retrieved from http://rbdigital.oneclickdigital.com

    Vickers, A., Goyal, N., Harland, R., & Rees, R. (1998). Do certain countries produce only positive results? A systematic review of controlled trials. Controlled clinical trials, 19(2), 159–166.

    Endnotes
    (1) http://courts.delaware.gov/opinions/download.aspx?ID=160180

    (2) http://www.michigan.gov/lara/0,4601,7-154–275935–,00.html

    (3) Standards for physicians have been developed by the American Academy of Medical Acupuncture and standards for chiropractic physicians, by the American Board of Chiropractic Acupuncture. As of the date of this paper physical therapists are beginning to develop standards of training for the performance of dry-needling. It is only a matter of time before they will have fully evolved training and certification programs. The American Physical Therapy Association webpage on dry needling already includes its own position paper, educational resources and a few favorable state attorney general opinions on the question of whether or not the technique falls with the scope of physical therapy practice.

    • Error Correction: The Privileges and Immunities Clause (aka the Comity Clause) is not in the Fourth Amendment to the US Constitution, rather it is from Article IV, Section 2, Clause 1 of the U.S. Constitution. I apologize for any confusion this may have caused.
      http://www.law.cornell.edu/wex/comity

      It would have been exceedingly interesting to see what the implications might have been if the State of Delaware had persisted in their denial of the licenses of Briggs and the two practitioners from Maryland. It also would be exceedingly interesting to get an estimate of the costs to the state of the two legal challenges to this law. Ultimately these costs will be passed on to the citizens of Delaware. And of course there is the issue of how much it would cost of the legal challenges to the individuals involved. Nothing is clearer at this point than the need to rethink this law and laws like this in every jurisdiction.

      • Thanks for the correction.

        The reports I heard of events at the BOM meeting made it sound like the Board members were well aware of the problems with the law and the way it has been applied. If practitioners in Delaware were able to unite behind legislative changes to make acupuncture more available to the citizens and open business opportunities to a greater population of qualified practitioners (by removing the OM requirement) I think it could be quickly passed. However, it would seem that among the small number of DE practitioners there are several who would go to the mat to maintain the restrictive language.

    • Joseph, thank you for your well-reasoned arguments and accompanying citations. This is the kind of clarity and discourse that I would like to see driving our profession forward. The truth may well take people to some uncomfortable places emotionally but we’re not going to get anywhere without acknowledging it.

      • Thank you for the kind words Frank. It is, of course, impossible to predict how ideas like these might be received. But you are absolutely correct. Unless we begin by acknowledging a few basic truths we will keep pushing the same very large boulder up the hill. And we all know what happened to Sisyphus. I do hope that someday soon we will all begin having a dialogue about what is really in our best collective interests. To do that of course we will all have to put our personal ambitions aside. I don’t believe we have much time left to change our course.

        • At this very time there is yet another thread over on Acupuncturists on Facebook about how to distinguish what “we” do from what other acupuncture-needle-wielding practitioners do. Sure enough, we’ve got all the usual responses — our 4000 hours of training vs. their 100, our treating the underlying causes vs. their superficial treatments (one must ignore all the other threads that begin how do I treat (insert western diagnosis), and our excellent safety record vs. all the problems they cause (with no supporting data but many authoritative statements). It is so predictable!

  2. I think it is of paramount importance to look at existing standards. Sometimes less is more.

    • It would have been so fantastic if, before embarking on the great FPD escapade we had done just that. We could build programs from the ground up — what do we need to teach for folks to be able to practice at the basic level, what do we need for the next step, what do we need to be a “Doctor” of this medicine. However, who is going to push for that? The existing schools have already developed around the existing standards, so they don’t want anything to change. They’ll push for the FPD because that is a new product to sell. Also, the legislation in many states specifically mentions the current ACAOM hours and existing standards. It wouldn’t be all that difficult to change that, if we had a united profession with a functional national level organization with the resources to support that sort of change and the desire to do that sort of work. But, we don’t yet have that.

      • This might have been better placed as a guest post, but for now it will be interesting to see the responses here. You make many good points. I do believe acupuncture is an effective modality. And my own experience is that not all practitioners are equally adept. That being said, it has become clear to me that most of our credentialing, accreditation, and regulatory processes don’t have all that much to do with protecting the public and do have a lot to do with what we believe we deserve or are owed by the system.

        • Yes placement as a guest post might have been more appropriate but I wasn’t sure that you permitted guest posts. But thank you for permitting me to post this. I realize that this is a post that may upset many. One thing I very much respect about you Elaine is that, even where we might disagree, (and I don’t think we disagree about much) you always respond intelligently and respectfully. Thanks again.

          • I haven’t had any guest posts yet, but I’m willing to change that.

            You are very welcome. I look forward to the time when more of us within the profession will explore these issues thoughtfully. Far too often (always?) the message from those who are in power is that hew to the party line or you’re a traitor.

  3. You bring up many good points about the significant differences between MD, DPT and TCM education then ask “how well educated are TCM graduates.” “Educated” is the operative word. Here are some further distinctions between allopathic and PT education vs TCM training:
    Those wanting to be MDs must take a pre-med curriculum. Those wanting to be a DPT must also take pre-med coursework. MD and DPT schools are highly competitive: a 3.5 GPA is the baseline GPA for med school and applicants must take MCAT. DPTs must also have a solid GPA plus take the GRE. This also goes without saying that the undergraduate schools attended by MSs and DPTs are also competitive.

    TCM requirements?
    Well, the CCAOM has set the standard at at least 60 hrs of college credit. Individual programs may vary, but the standard set is some college, not a bachelors degree. No exam is required for entry, just the ability to demonstrate that one can pay for their TCM training or are eligible to receive financial aid (ie. loans).

    The majority of TCM schools are for profit and do not receive direct grants from state or federal government (unlike all public and some private regionally-accredited colleges and universities) so their operating costs are covered primarily by tuition, not to mention that I haven’t heard of any TCM program that has a list of alumni or other philanthropic donors, although many many MD and DPT programs do. Therefore, it can be surmised that TCM programs cannot afford to be choosy when it comes to accepting students.

    I’ll leave the “how well educated are TCM practitioners” answer up for grabs, but based on the academic standards, my money (and experience) says not very.

    • Great points.

      I’ve noticed that most recent grads talk about their superior skills and training only when asked about other professionals using acupuncture needles. Chat with most new practitioners privately and you’re likely to hear that they aren’t feeling very confident about their skills (no surprise given the low number of clinical hours in most acupuncture programs) and have little knowledge about what’s involved in setting up a private practice (what sort of insurance do I need, how do I get rid of my sharps, does my office need to be ADA compliant, how do I set fees, etc.).

      • Additionally, if we look at acceptance rates, i doubt there are many acupuncture/TCM programs that would actually reject an applicant provided the basic admission requirements were fulfilled.
        A very cursory look at https://services.aamc.org/30/msar/home indicates that roughly 25% of med school applicants get accepted. I think the arguments regarding training hours are pretty moot. One has to be quite smart to get accepted into medical school…again, based on my experience, not so much with acupuncture school.

        • It is also significant that it seems that almost everyone who starts an acupuncture program manages to complete a program as long as they keep finding a way to pay the tuition. That’s how it seems anyway — data from the schools would be helpful here. I suppose that could mean that the schools provide great support to struggling students and that they do a good job with admissions — but I’m pretty sure that’s not the whole story.

          All that being said, I don’t think we need to arbitrarily make it more difficult to gain access to schools or complete programs. I do think we need to stop our arrogant self-regard and our knee-jerk disdain for others who would like to use an acupuncture needle. It seems to me that there is a basic level of knowledge that could enable people to practice safely and provide benefit to most clients.

  4. Elaine, thanks for allowing me to take a good, hard look at the training debate along with my morning tea. Since there are several DO’s practicing acupuncture in our town, I’ve found it safest to take the middle ground in my conversations with the public. Meanwhile, I try to keep my eyes and mind open. I am over being pissed off. Who cares? People just want to be helped out of their suffering.

    • You are very welcome.

      I’d be all for taking a look at our training — what do we really need to be safe, effective, successful, and what don’t we need. And what do other professionals already know, and what else do they need to know. I rarely see that looked at in a clear-eyed, evidence-based way, though.

      Just saw that PCOM will be school number 2 (I think) to add the FPD. Soon there will be even more confusion out there about our training.

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