Third Night – Lowering Standards!?

In recent conversations with colleagues I’ve heard a few exclaim “we won’t agree to lower our standards!” and “we aren’t going to go backwards on our education!”

I haven’t heard anyone suggesting that we lower our standards or go backwards, so I was baffled.

Only momentarily, though, because then I remembered -The Acupuncture Revisions Proposal from the POCA Tech BOD to “revise acupuncture education and testing standards so as to benefit current and future (1) acupuncture students, (2) acupuncture schools, (3) acupuncturists, and (4) the general public.”

They make clear that their proposed standards are based around students meeting all of the competencies required for ACAOM accreditation and preparing graduates to be safe and effective practitioners. (The proposal is concise, well-written, and worth reading. Please do.)

Unfortunately, “high standards” in this profession has come to mean number of hours spent in school. So any change in the number of hours is interpreted as a lowering of standards.

I understand how it happened. When we’ve fought for acceptance, we’ve stressed our hours of training to establish our worth. When clients mention that they got acupuncture from their Chiropractor, we talk about how much time we spent in acupuncture school compared to the D.C.’s short courses. Hours of education has been a battle cry in the dry needling fight. (Which has been mostly unpersuasive since the PT’s 1) deal in competencies, and 2) we use different rules when we count our hours and we count theirs.)

Actually, a standard is “a conspicuous object (such as a banner) formerly carried at the top of a pole and used to mark a rallying point especially in battle.” (Merriam-Webster).

So, hours has become our standard. But it’s such a meaningless standard. I’m sure I’m not the only person who’s been to three-day CEU classes that have been a complete waste of time while a one-hour class contains a transformative nugget. I’ve spoken to people who have taught at some acupuncture schools and the picture they paint is not of hour after hour of quality programming.

We’ve got a workforce that needs to grow. And levels of educational debt that are an impediment to professional success. Affording graduate school and repaying loans isn’t going to get easier.

Read the Acupuncture Revisions Proposal with an open mind.

Our banner should be more meaningful than a number.

 

 

Proposal regarding Acupuncture Education

The POCA Tech Board of Directors has been studying what it takes to become an LAc and wondering whether there isn’t a better way. POCA Tech has been approved by ACAOM as a candidate for accreditation, and has graduates who are NCCAOM-credentialed, state-licensed and working in the field. The POCA Tech BOD is in a good position to know what works. Here’s what they propose –

Acupuncture Revisions Proposal

I’ve been around long enough to expect the proposal will be met with some outrage. We’ve been insisting that it is the hours of education we have that set us apart. And that almost 2000 hours of training only scratches the surface of what there is to know about Acupuncture and Asian Medicine.

I’ve also been around long enough to know that 1305 hours of training is enough to produce competent providers. That there are countless CEU programs and additional degree programs to help us deepen our knowledge. And that there is no clear evidence that our more extensive training leads to better outcomes.

People want acupuncture. We need more practitioners to meet the demand. And 100K in debt helps no one. I think the POCA Tech proposal makes a lot of sense. What do you think?

 

 

Happy AOM Day??

“Acupuncture is a safe and cost-effective treatment that could benefit so many. If only the medical establishment could see the benefits of what we do.”

That was our mantra decades ago.

So one might think, now that Acupuncture has become accepted and of increasing interest to the establishment, we’d be happy, thriving, and confident.

But that isn’t the prevailing feeling. We love our work and most of us couldn’t imagine doing anything else. And yet AOM Day 2017 finds us fearful and disheartened.

Many of us carry significant debt and are not earning enough to pay it down in a timely fashion. Many of us are limited in where and how we practice due to varying state rules. The hoped for benefits from insurance reimbursement came with significant administrative burden and limits on what will be covered. Increasingly acupuncture is being provided by non-acupuncturists. Meanwhile, the profession isn’t growing. Based on figures from Acupuncture Today, there are fewer LAcs now (24,612) than there were in November 2013 (24,707).

So it is not surprising that we aren’t hopeful. The public and the medical establishment see the value of acupuncture, but we aren’t thriving.

There are things we control that could change our trajectory.

Those of us who completed acupuncture training prior to 1990 (some of our most admired mentors and colleagues) probably got about 1000 hours of formal schooling. If you graduated in 2000 you likely had about 1725 hours of schooling, and if you completed your training after 2011 your program was at least 1905 hours.

You can see, here, how the Virginia regulations have changed over the years. The hourly requirements did not change in response to concerns about practitioner safety or skill, but to keep the regulations compatible with the ACAOM and NCCAOM requirements.

In 1988 tuition at The Traditional Acupuncture Institute (now MUIH) was $11,000 (about $23,000 in today’s dollars). When I started in 1992 it was about $18,540, ($32,616 in today’s dollars). By 2003 tuition had increased to $32,865 ($43,722 in 2017 dollars). And, if I wanted to begin at MUIH today, the program would take almost four years to complete with tuition of $75,924. For a Masters in Oriental Medicine, necessary to practice in Florida, California, and Nevada, I’d pay $99,604.

A student loan of $40,000 at 6.8% interest can be paid off in 10 years at $460/month – considered manageable with an annual salary of about 50K. A $100,000 loan will take over $1150/month and you’d need to make almost 140K/year to manage that.

So it’s not surprising that the profession isn’t growing and that acupuncturists are worried.

Sure, the NCCAOM can embark on a major public education campaign touting our training and credentials.(Well, touting their credential, actually). That’s fine. But with the downward pressure on health care spending in this country, and the impact of debt considerations on professional training, it’s going to take some damn fine PR to make a difference. (Big Pharma & Health Products spent about 245 million on lobbying in 2016.)

A far more direct way to help the profession grow, help future graduates make a living, and make Acupuncturists available to those who want acupuncture would be to address our training. If those who graduated in 1989 were safe with a 1000 hour $18,000 education, why do current students need at least 1905 hours and $75,000? Can we simplify the path and reduce the cost of becoming an Acupuncturist? (Yes, we can!)

If people want acupuncture they will find a way to get it. If we’re not there to provide it, someone else will be. We do have the power to change this, and it won’t take 245 million. In honor of AOM Day 2017, let’s agree that more Acupuncturists and less debt would be a very good thing.

 

 

Continuous Improvement and Feedback

It’s difficult to make things better when you don’t know what’s wrong.

I’m glad when a client lets me know that something isn’t working. It gives me a chance to change things, or help them find something that better meets their needs. Things are better for both of us when we’re honest.

That’s why I’m having trouble moving on from a column that equates discussion about our problems with treason (“giving the other professions … the ammunition they need to diminish acupuncture”) and so many of the responses to the Gainful Employment regulations. (Here’s a selection — ACAOM gainful employment word, Acupuncture school response, and the ASA’s response.)

The cost of an acupuncture education, how that cost compares to future income, and the likelihood of that income being sufficient to pay off loans in a timely fashion while also sustaining oneself, are critical issues for the profession. Welcoming feedback from those who have “been there and done that” is necessary to guide improvement.

The Gainful Employment rules require transparency and accountability from for-profit career colleges. The regulations don’t close schools. They may, in time, keep students from receiving federal Title IV student aid to attend programs that don’t meet the accountability standards.

Although the impacted schools insist that the education they provide is a good value, they are correct to fear that, absent federal guarantees, students will have trouble coming up with enough money to attend.

Ideally, their concern would translate into concerted efforts to gather data about their graduates’ experiences and provide it to prospective students. They’d focus on what could be done to reduce expenses for students, and develop programs to ease those first few years post-graduation when they acknowledge income may be low. They’d make sure that all prospective students had an understanding of the economic realities of life as an LAc before collecting that first tuition payment.

Instead, when I read the responses from our schools and organizations, I hear, mainly, this isn’t fair, it’s not our fault, and it shouldn’t apply to us.

They argue that the responsibility is on prospective practitioners to educate themselves about the field and educational options, but also say that the data available doesn’t reflect the true picture. (And they fail to mention that before the Gainful Employment rules required it, they paid little to no attention to what happened to their students post-graduation.)

Try comparing the earnings of graduates from various programs, or finding out the percentage of graduates still in the field 5 years later. That data doesn’t exist. How will prospective students get a fair picture if practitioners who are share their struggles are told to keep quiet and say only nice things? If the concern is that some of the things being said are inaccurate or overly negative, take the opportunity to provide correct information and the other side of the story.

Working part-time, having employment structures that don’t accurately reflect all money earned as taxable income, and a lag in the time it takes to reach full earning potential are not unique to acupuncture school graduates.

Low student loan default rates aren’t evidence that all is well. Default carries significant and long-term harms and, luckily, acupuncturists are responsible enough to make payments and take advantage of options to defer or reduce payments when necessary. Of greater significance – do we earn enough to pay off our loans in a timely fashion while also supporting ourselves? Can we save for retirement and purchase disability and health insurance? Will we ever be able to buy a home, or build up a cushion in case of hard times? The overall financial health of the average graduate should be the focus of attention. The highly successful grads are the exception, not the rule.

I’m not surprised that the schools are fighting to avoid consequences for the struggles of their graduates. I am surprised that other organizations and voices are supporting their evasions.

There are more than sixty Acupuncture and Oriental Medicine Programs in the US. What’s a bigger threat to our future – that a few might close or that a significant number of graduates, burdened by debt, leave the profession before they can get established? How about the impact of student loan debt on the affordability of our services? Is that important?

Understanding and acknowledging our problems is the first step in making things better. We need more data and discussion, not less. More transparency and accountability, not less. A greater emphasis on making things better, not making excuses for why they aren’t. It’s time for us to own our challenges, not blame and deflect. Let’s get honest.

 

 

Ethical Questions

Our future requires a willingness to explore beyond our quick conclusions of what is “right” and what is “wrong.” How do we proceed when two “rights” are in conflict with each other, or when a good end might depend upon a questionable means (or vice versa)?

Providing safe, effective, and accessible treatment to everyone who wants/needs treatment while also supporting ourselves and our families requires us to face various ethical quandaries. Many ethics classes are short on teaching principles to guide ethical decision-making and are long on lists of rules like “don’t have sex with your patients.”

Marilyn Allen’s recent column on ethics demands our attention. She’s had a significant role in shaping the acupuncture profession, and she teaches ethics. She has power.

The column focused on a discussion about “gainful employment” that has since been removed from the AAAOM practitioner forum.

The forum included colleagues sharing concerns about their debt, and upset at schools that exaggerated the future acupuncture job market while glossing over the skills and financial backing needed for success.

Ms. Allen (who has given considerable funding to the AAAOM over the years) is angry that this discussion was permitted. She insists that it is in the best interest of the profession, and our future colleagues, to keep concerns to ourselves. Even a shared conversation in a practitioner forum is too risky. We “should have shown support for the schools,” she writes.

Ms. Allen proposes the Rotary’s Four-Way test in her column. It’s not my preferred guideline for ethical decision-making, but since she refers to it I’ll use it —

 

1) Is it true? Many graduates of acupuncture schools do struggle to pay off debt. Schools did use misleading data in promotional materials, leading to unrealistic career expectations. The proposed Gainful Employment regulations did raise concerns about acupuncture programs. The forum topic is no longer present to allow for a complete fact check, but my assessment is that much of the content was true.

2) Is it fair to all concerned? What do we mean by “fair.” Who is “all concerned?” And what is “it?” I could write a post on each question. When a topic is being explored by many people, in many settings, does each contribution need to reflect the views and feelings of each stakeholder? Is it unfair to share our personal experiences and opinions about a system in which we have little power and bear the consequences? Is it fair for a membership association to solicit the opinions of its members? My assessment – it was fair for the AAAOM to provide a forum and for practitioners to use it.

3) Will it build goodwill and better friendships? Humans do better when we know we are not alone. Sharing our concerns and our experiences is a way to build community and friendships, which support us in our sometimes isolated professional life. Knowing that other regulated fields share these concerns can also help build goodwill and understanding. If we feel that a friend (or, in this case, a system) is taking advantage of us, does it strengthen the friendship and build goodwill if we speak up, or stay quiet and suffer? Yes, the discussion had the potential to build friendships and goodwill. Ms. Allen’s column, by advocating denial and repression, does not.

4) Will it be beneficial to all concerned? My list of people who would benefit from the conversation, even if it escaped the private forum: current debt holders who feel alone and unheard, schools who care whether graduates are satisfied, potential students who may not have fully explored the economics of entering their dream career, and taxpayers who may not want to subsidize ineffective programs. The discussion isn’t beneficial for the schools that want to keep raking in loan money while avoiding responsibility. Should we be censored for their benefit?

Ms. Allen writes “It is sad when you read an article about the profession that contains negativity coming from inside the profession. Essentially, this is giving the other professions (those looking to treat acupuncture patients) the ammunition they need to diminish acupuncture and attain their own goals.

I say, it’s sad when those with the power to change things for the better instead advocate for a flawed status quo. It’s a danger sign when secrecy is demanded for the good of the group. The Catholic Church and the Penn State Football program are examples of the moral failure that comes with that argument.

Thank goodness we’re dealing with finances and not child abuse. Nonetheless, shutting down conversation and preaching secrecy is neither ethical nor effective. If Ms. Allen wants to uphold acupuncture as the place “where hope and healing meet” then we need to delve into our challenges, not hide them.

 

 

Acupuncture Education 2015 – The State of the Profession

If we want people who want acupuncture to receive it from an Acupuncturist, acupuncture education deserves our attention.

There aren’t good statistics on how many Acupuncturists or acupuncture students there are in the US. But those handy maps printed in Acupuncture Today can give us some idea. The December 2013 issue (with an article on AT’s unprecedented growth) showed 24,342 Acupuncturist and 3,124 student issues mailed. In December 2015 – 24,231 Acupuncturist and 2,624 student issues mailed. That’s not growth. The 2014 NCCAOM Annual Report (the most recent available) also reveals – we are not a growing profession.

There is a lot of churn in Acupuncture education — schools close, schools open, programs merge, new degree programs are established. New Gainful employment rules adopted in late 2014 may well contribute to that churn. They require for-profit schools (about 50% of acupuncture programs) to provide at least some debt and jobs data to prospective students.

Small class sizes can skew the data. Still, check out these reports (selected because they came up first in Google): Emperors, ACAOM (the school not the agency), Arizona School of AOM, Midwest, AIAM, and Colorado School of TCM.

Only two schools reported job placement, at 50% and 67%. Median loan amount (omitting a 1.5 million figure given by Midwest that must be a mistake) ranged from 17K to 72K. A real eye opener was the percentage of students completing the program in the expected time frame. The average across all 6 programs was 55%. Omit the 100% reported by Arizona, currently on probation with ACAOM (the agency), and it’s 46%.

It’s not encouraging. Add student uncertainty that the degree they obtain will enable them to practice and it is no surprise our profession isn’t growing.

Imagine if we could tell prospective practitioners –  “A Master’s Degree in Acupuncture from any ACAOM accredited program will fulfill the educational requirements to practice in any state.”

I may not love the ACAOM standards but I’ll accept them to help the profession. Is there a downside to offset the upside?

NGAOM you have a stated goal of establishing uniform standards, yet are fighting to keep California schools out of the ACAOM system. Please explain.

We had some significant losses in Acupuncture education in 2015.

Spring brought news that Dianne Connolly and Bob and Susan Duggan would no longer teach or be part of the program at MUIH (which Bob and Dianne founded in 1974 as The Maryland College of Chinese Acupuncture). Bob and Dianne are part of the foundation of this medicine in the US. They profoundly influenced my acupuncture journey and it is a significant loss that they won’t be part of every MUIH student’s education. I am glad they are continuing to teach and share their wisdom in other settings.

Bob Duggan played an integral role in establishing acupuncture standards, credentials, agencies, and commissions. His goal in so doing was to enable this safe and effective medicine to be legally available to more people. He shared in a personal communication his ambivalence at how things turned out – that though his work enabled so many people to be healers and to be healed, “If I had real courage I’d have gone to jail and insisted this was the people’s medicine and we shouldn’t allow it to be professionalized.”

2015 closed with another loss, the death of Dr. Richard Teh-Fu Tan. Dr. Tan was an excellent teacher, deeply committed to teaching. Directly, and through his students, he eased the suffering of countless patients. Dr. Tan made no secret of his doubts about the caliber of acupuncture education most of his students received in their degree programs. Many seminar attendees reported learning more about effective acupuncture in four days with Dr. Tan than in four years of acupuncture school.

Attention must be paid.

 

 

 

 

 

 

9 Reasons why Acupuncture Regulations There Matter Here!

Changes in acupuncture regulation in any state matter to each of us individually, and to the profession as a whole.

Here are 9 reasons why —

  • We don’t know what the future holds. Unexpected moves happen.
  • You may need to hire practitioners or sell your practice. Can interested parties easily move to your state?
  • Your patients might move and want a practitioner just like you. Will one be available?
  • Growth in the profession is not keeping up with demand. Regulatory uncertainty diminishes the appeal of the profession.
  • High educational and credentialing costs interfere with business growth. If the requirements vary from state to state, the impact is multiplied. (See this report on Occupational Licensing.)
  • Regulatory differences lead to divisions within the profession. With fewer than 25k acupuncturists in the US unity is critical.
  • What happens in one state impacts every state. States look at what has happened elsewhere when considering regulatory changes.
  • Changes in one state can lead to changes for everyone. When CA increased required educational hours every school and ACAOM soon changed as well.
  • Different regulations, training requirements, and titles make it difficult to educate the public about our qualifications, draw contrasts with other professionals, or advocate for our profession as a whole.

Staying informed is not easy. Neither is getting involved. We are all busy, we don’t always know how to assess the pros and cons of a possible change, and things can get heated and unpleasant when there are differences of opinion.

And, the future of our profession and our businesses is greatly impacted by regulatory changes – even those happening across the country.

Please, stay involved.

Forgive two posts in quick succession, but regulatory changes are on the way. You’ll hear from me again soon.

(Note — I advocate for standardizing and simplifying the regulatory process for acupuncture licensure. I am not advocating for standardizing the medicine itself. Our diversity is powerful indeed.)

FPD/DAOM required, Schools, ANF, Dry Needling — and more Acupuncture News….

New news:

Word is that the Nevada acupuncture board is poised to require an FPD (or is it a DAOM?) for licensure, even though citizens there are already under-served. I’m trying to get more information. Stay tuned for updates. State actions that limit our profession tend to stay under the radar until it is too late.

The acupuncture school landscape is changing. Last week brought news that Bob Duggan and Dianne Connelly will no longer be part of MUIH faculty or staff. For those who have been paying attention as The Traditional Acupuncture Institute morphed into MUIH, it shouldn’t have been a surprise. But it is sad. While TAI had its good and its bad, many who attended did so because of Bob and Dianne’s contributions. The announcement was quickly followed by a letter, in perfect TAI-speak, that, for the sake of the students, we shouldn’t get caught up in stories about this. As in, don’t even ponder what it is we aren’t telling you.

This week also included the news that NESA is merging with MCPHS, and ACTCM is merging with CIIS.  (Thanks, Integrator Blog.) Is the age of the stand-alone acupuncture school coming to an end?

Have you heard of The Acupuncture Now Foundation? They aren’t a membership organization, and they don’t want to get involved in acupuncture-politics. They just want to educate the public about our training, our skills, and the great results from our medicine. Please, support ANF! Marketing the medicine shouldn’t have to be an individual effort.

Older News:

Developments in dry needling, with the hope that we might learn from history:

  • Louisiana joined other states with an AG opinion that dry needling is within scope for PT’s and DC’s. Other AG opinions can be seen here.
  • Tennessee’s Governor signed Legislation formally adding dry needling to scope for PT’s, joining Utah and Arizona which saw similar legislation in 2014.
  • The Maryland Acupuncture Society came out in strength behind HB 979 and SB 0580 that would have set limits for dry needling by PT’s and DC’s. The bills went nowhere, perhaps a blessing in disguise as “success” would have opened a can of worms.  (The bills did not define dry needling, MAS support put the acupuncture community’s stamp of approval on a 200 hour standard for acupuncture training that had been previously unacceptable, and the wording opened the door for PT’s with 200 hours of training to argue that they were now, indeed, doing acupuncture.)

The AAAOM website has been updated with board bios and a revamped committee list, but still no answers for any of my sixteen questions for the AAAOM.

ACAOM responded to the petition in response to their Gainful Employment letter in the ACAOM Fall Newsletter.  The good news — they heard us. The bad news, they continue to believe that significant student debt is helpful for those who want to serve low-income communities.

There you have it, at least some of the news you aren’t seeing in Acupuncture Today.

 

More on Acupuncture Education

The for-profit schools don’t want to take responsibility for the circumstances of their graduates. And they won’t let the new gainful employment regulations go into effect without a fight.  Within days of the posting they filed suit to block the regulations. They did the same thing when similar regulations were announced in 2012, so I expect the DOE wrote the new regulations carefully to withstand an expected legal challenge.

However, with a pro-business and anti-regulation majority in the House and Senate as a result of last week’s election, even regulations found to be legal might not be enforced.  If the funds to track compliance aren’t in the budget, for instance, enforcement can’t happen.

Of course, if the schools and alphabets were committed to doing the right thing — producing the best possible graduates at the lowest possible cost to the students, regulations wouldn’t be needed, and wouldn’t threaten the schools even if they were adopted. I don’t expect that commitment from large businesses like Corinthian. I wish I could expect it from acupuncture schools. But most acupuncture schools seem to have little interest in what happens to their grads, and continue to present an unrealistic picture of life after graduation to potential students.

We’ve gotten to the point where even prominent conservatives acknowledge that the current system is a “bad deal for students and parents” and at least some are advocating for change. And it’s true that regulations, however carefully written, often have unintended negative consequences. All too often the well-off and powerful find ways to exploit loopholes and other tricks to avoid regulation, while smaller businesses find themselves significantly disadvantaged. (Consider what happened with the organic label.)

If the schools were on the hook for the money students borrowed no doubt things would be a lot different — from materials provided to prospective students, to the admissions process, to the education provided, to alumni support.

I don’t expect that will happen. And with the change in the political picture here in the US, who knows what will happen with the gainful employment regulations. For now, all acupuncturists can help the market work by helping prospective acupuncturists look past the pitch. Anyone entering the profession should do so with eyes wide open.

(Read this for more on how the November elections will impact the future of acupuncture and complementary medicine in the US.)

Gainful Employment and Strategic Errors

The Gainful Employment final regulations have been announced. Forgive my commenting prior to a complete and thorough analysis of the 941 page document. (You can see some analysis here.) The gist is that for-profit schools (which includes half of US acupuncture programs) will soon have to show that graduates’ student loan payments are manageable with the profession’s available employment (not taking IBR into account). If they can’t, federally guaranteed student loans will no longer be available.

Why should taxpayers continue to provide loans for educations that history shows aren’t worth the investment? Imagine tuition rates and post-graduate employment assistance if the schools provided and guaranteed loans, and took the hit if they weren’t paid back in a timely fashion.

It is no surprise that for-profit schools are displeased about the impending end of the gravy train. Many for-profit schools, and their related organizations, did everything they could to block the regulations. And, just under the wire, the acu-educational establishment contributed comments (see ACAOM gainful employment word).

(The more expensive FPD, and pressure away from “acupuncture-only” degrees now carry a significant downside for the schools.)

Did ACAOM think their letter might exempt them from the rules or impact the final regulations? It seems unlikely that this little community would shift the tide. It was an unforced error for ACAOM to write a letter that reveals such little concern for graduates and such a strong desire to dodge responsibility. (Some of the more significant issues in ACAOM’s letter are discussed here.)

But our own strategic errors have allowed ACAOM and other other alphabets to disregard our well-being.

The petition that asked the alphabets to stop denying their role in our circumstances received 227 signatures. Petitions to stop dry needling often receive thousands of signatures. Which is more likely to limit professional success — a school that leaves students with extensive debt, poor business skills, and no job placement or alumni support, or a little competition? If we can’t survive the competition from those “untrained” professionals our education is surely lacking.

The Feds and the taxpayers pay a price when schools sell an education for far more than it is worth. We graduates pay a far more personal price. It’s too late for us, but at least the Feds are willing to look out for the interests of those who will follow in our footsteps.