We have met the Enemy

It’s not paranoia if they are really out to get you.

Our siege mentality is understandable. Doc Hay was charged with practicing medicine without a license in the early 1900’s, as was Miriam Lee in 1974. In some places we’re still seeking legal recognition of our right to practice. It’s not unusual to read that acupuncture is quackery.

So it’s not terribly surprising when multiple participants in an official government meeting announce that your practice is a danger to the public and that the NCCAOM Acupuncture credential is insufficient. It’s not the first time we’ve heard that it would be better for the public if we were excluded.

But it’s different when the people saying these things are Acupuncturists.

It’s shocking. And upsetting. And bad for the profession.

We complain about PT’s, Medical Acupuncturists, insurance companies and even the perceived disrespect of some of our clients. But those groups aren’t building coalitions to restrict our ability to practice, or to put hurdles in the path of new practitioners. I can imagine the outrage and the calls to action if they did.

Instead, it’s Acupuncturists who are on the record (warning audio autoplay) slandering colleagues and attempting to slow growth of the profession.

Our safety record and our well-established and generally respected educational and credentialing systems don’t seem to matter. Nor are these Acupuncturists concerned about our small numbers or student debt.

Why is this happening? One school that is concerned about student debt, accessibility, and the growth of the profession, asked ACAOM and NCCAOM to reconsider the hourly requirements for acupuncture education and sitting the credentialing exams. There was no move to lower standards (read more here) or change competencies, only to use the same hourly requirements that served our teachers and most experienced practitioners so well.

ACAOM hasn’t responded to the proposal, and NCCAOM did not respond favorably (NCCAOM Response Ltr to POCA Board 11-9-17 Final with signatures.doc). But members of Utah’s Acupuncture Advisory Board and the Utah Association of Acupuncture and Oriental Medicine were so upset by POCA Tech’s request that they launched a preemptive strike, moving to require the NCCAOM herb credential of all practitioners, whether or not they want to use herbs.

Listen, and ask yourself – how does this help our future?

By the way –

The participants’ claim that this is a clarification of existing law is “alternative fact.” The evidence shows that the Utah action is in direct response to the POCA Tech proposal, and the representative of the Department of Professional Licensing makes clear that existing law would not support this action.

In a prior meeting a board member insisted that there is no need to require specific education or curriculum for practitioners who use injection therapy, since acupuncturists know their limits. The same board member argues here that all practitioners need to obtain the herb credential. (The board member performs injection therapy.)

The exemption of those already licensed works to undermine opposition to changes like this. Don’t be fooled – increasing debt for the next generation of practitioners isn’t good for our future, even if it doesn’t impact your ability to practice.

The Advisory Board and the Utah Association, with the help of the NCCAOM, promoted the Board’s proposed changes. The letter (UtahNCCAOMletter) they distributed is inaccurate. For example, a growing number of states are not requiring the herbal exam of all practitioners, and acupuncture and Chinese Medicine have not always been inextricably linked.

A letter written by a professional association, signed by the Chair of the Advisory Board, and distributed and supported by the NCCAOM (which would benefit financially from the change) raises significant ethical and good governance concerns.

The NCCAOM’s message in the February meeting – that they defer to the will of the profession – is a questionable position for a credentialing agency. It also differs from their position in cases where the will of the profession was for changes not in NCCAOM’s interests, such as a state removing the requirement to maintain active Diplomate status.

There’s good news – the Utah Advisory Board can’t add a requirement for the herbal credential via regulation.

There’s bad news – the parties involved seem eager to pursue legislation to make this change.

There’s terrible news – the enemy is us. It isn’t the PT’s, MD’s, or insurance companies undermining Acupuncturists. It’s Acupuncturists.

 

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.

23 thoughts on “We have met the Enemy

  1. Hello Elaine,

    Thank you for this discussion topic. I also appreciate the comments made by Anthony, and by Steven Stumpf. The way that I connect the psychology of a “siege mentality” with the real data concerning abysmal earnings of acupuncture school “graduates” is through labels like “cult” and “pyramid scheme.”

    One thing I notice about PocaTech is that they suggest how low new graduate earnings may be in their tuition discussion. Deceptive schools are linking to the BLS figure misleadingly presenting PA earnings as acupuncturist earnings.

    Consider the totalist nature of an acupuncture school, and the cosmology of Chinese medicine, the thought reform involved in approaching anything and everything – from another perspective, and the resocialization of people immersed both in terms of emotional and economic investment. Compare this to the absolute absurdity of the gainful employment statistics showing graduate earnings below high school graduates, numbers that I think might be compared, with say, felons.

    One may begin to understand that the society of acupuncture in the United States has skipped becoming a recognized and well-regulated profession and become an embarassingly amateur and predatory economic process. I see the development of marketing more than medicine in acupuncture businesses. It is like the worst of chiropractic with Chinese medicine characteristics. Good practitioners fail while pushy marketers of unnecessary suppliments stay in business.
    Those gainful employment fail schools would be shutting down if not for a current department of education that is very protective of fraud.

    The enemy is not acupuncturists or Chinese medicine, the enemy is an economically predatory model that benefits ACAOM and their schools while sticking future acupuncturists with the debt and Stockholm syndrome. This model does not incentivize professionalism, but profit for those associated with the schools. This is why the entrance requirements are a joke. “Write us an essay about how much you really want to be the next victim of an expensive scam.” Like all for-profit school systems, as detailed by the Harkin report, this model also incentivizes consumer abuse and fraud. First professional doctorate degree!

    Considering that schools and their clinics are economic competitors with their graduates, this suggests that a profession without practitioner growth would also be the natural outcome. Anthony is correct that acupuncture is not a profession in the sense of a truly regulated field like nursing. It is important to note that regulatory inaction is just as necessary as greed for fraud to flourish.

    The siege mentality is just the constant state of boundary control that is felt and practiced in all coercive groups. The stability of the insular group is protected by antagonistic attitudes about outsiders. Ask a 2nd year acupuncture student what they think about “western medicine.”

    Follow the student loan money. Recognize the fraud. Please and thank you.

    Let me suggest what is a sort of corollary to your statement: Just because you’re not paranoid, doesn’t mean they’re not out to get you.

    Cheers,

    Benjamin Merrill

    • Thanks for sharing. I even laughed through the tears a few times. I’m not sure ACAOM deserves the blame, though. I’ve been pleased to see them move to a competencies model (yes, there’s lots more discussion to be had about determining competency in this field) and I hope they will give fair consideration to POCA Techs’ request that they do away with the arbitrary number of hours requirements for programs. Meanwhile, the NCCAOM has been happy to promote requirements for additional examinations – something with a clear economic benefit to the NCCAOM but with no known benefit to the public. In fact, some of our regulatory boards have been quite active — but the only believable motivation for their actions has been to establish a monopoly — but eliminating competition from other professions or from new practitioners entering the area.

      • Acupuncture will follow the same developmental path as every healthcare profession has followed. Merrill has described what has proven to be commonplace in the professional histories of chiro, medicine, osteopathy, nursing: shabby principles, scamming the public and the wannabes, setting up visa and diploma mills.

        In the early 20th century the struggling AMA hired Abraham Flexner to “survey” the existing array of medical schools. The outcomes included (1) shutting down many proprietary and predatory schools that were degree mills, (2) establishing standard uniform KSAs and a standard curriculum based on KSAs. This greatly improved the professional stature of medicine.

        Trying to fault NCCAOM misrepresents the reality of what is NCCAOM and how it functions; in fact, it shows how unaware you are about how any certification body functions. No state other than CA has enough licensees to economically support development of a licensing exam. Therefore, all states other than CA use NCCAOM. The number of exams required for any state is NOT determined by NCCAOM. That is determined by the state acu board.

        Not every state has a stand alone acu board. I you want to appreciate the complications you need to do the research…or read something more global on how various health professions have developed.

        NCCAOM and ACAOM may seem like easy targets. Each is a 501(c)6 so you can pull their 990s and see how “wealthy” each is (spoiler alert: not very). Unfortunately, there is no info available about the big player in “acupuncture today.” This is a big part of the problem. The schools are pischers. The worst will go out of business. The remainder will survive long as there are supporters of the FPD and teaching TCM in terms of magic and folklore. Kendall, Kavoussi, Schnorrenberger, Ullet and Unschuld present the “unpopular” POV. Happy Easter.

        • Steve —

          I’m approving your post because I generally approve anything that isn’t spam or completely obnoxious/without any merit. However, you’ve got a bad case of correctile dysfunction when you state I am unaware of how certification bodies function. Furthermore, I’ve not suggested getting rid of the NCCAOM. I do have an issue with much of what they do, including lobbying states (at the behest of some practitioners in a state) to increase the educational and testing requirements by promoting the herbal exam and questionable reasoning as to what is included in their exams.

          As far as money, NCCAOM may not have much, but as far as acupuncture related groups go they have plenty. And through their control of the exam they have a great deal of control over the profession.

          In any case, I have also supported the use of the NCCAOM exam many times on this blog, and the post on which you are commenting is not focused on the NCCAOM and makes little (no?) reference to ACAOM.

          • I realize how difficult it is for you to overcome your valuesitis. You describe NCCAOM as profit driven. You can do some homework and see how little profit they have. If they are profit driven they are not doing a very good job. Try here http://foundationcenter.org/find-funding/990-finder

            Feel free to delete any of my comments. I am writing for you readers.

          • Here’s an example of the way the NCCAOM influences the profession that works against your desired outcome — although ACAOM does not require schools to teach TCM, it is impossible to pass the NCCAOM exam without learning TCM. Therefore, schools include it in the curriculum. The NCCAOM justifies their focus on TCM through their JTA, which surveys the practitioners in the field, who, with few exceptions, had to pass the exam and therefore learned TCM and so, no surprise, tend to use that material in their practices. That makes it difficult for the “science-focused” education that some see as preferable to make inroads in our training or schools.

            I know how much money NCCAOM has. I have done the research. I haven’t said I think their only motivation is profit, but they will continue to fight for their continued existence, which depends upon making their exam the entry point to the profession.

          • ACAOM is a school accreditation body. NCCAOM prepares certification exams. It is not unusual for an accreditation body to dictate curriculum typically thru adherence to KSAs – Knowledge, Skills and Abilities. But KSAs are not singular. There are different KSAs for different purposes. The development of “aspirational” KSAs which are about “excellence” is a step towards establishing standards in a profession. This is neither the job of ACAOM or NCCAOM. It is the job of the professional org(s). We have a serious problem far as that goes.

            Professional KSAs (which should drive curriculum) are different from licensing KSAs which aim for “minimum competence.” The difference is important. NCCAOM KSAs are about “minimum competence” which is the standard for licensing. If neither ACAOM or NCCAOM works toward the development of “excellence” in training then who does? The profession and professionals. In this regard EWK is correct: “we are (and continue to be) the enemy.” Identity crisis. Every healthcare profession has gone through this.

            Ulett, Unschuld, Kendall, Kavoussi. It is up to practitioners to define their profession. See Flexner, Stillwell Jr…

            Elaine – who do you think is the big dog running the dog pound in “acupuncture today?” Why not run a column on that.

          • Steve —

            Last I checked, you also write for a blog. If you feel I am missing some big story about “acupuncture today” I encourage you to write it. I also hope you are aware of the many negative impacts of the Flexner report.

    • I’m having a bit more time to read through these comments and wanted to add a few thoughts —
      1) In the specific case I was writing about here, the problem really was other Acupuncturists. It wasn’t schools that were pushing for a change in credentialing.
      2) Despite everything, I do believe the profession has become relatively well-respected among a surprising number of MD’s. Generally, when my profession comes up in discussions with other medical professionals, there is genuine interest, enthusiasm, and, relatively often, a number of new patients that come my way.

  2. Wow! 10 years ago, I exited this expensive trade (it is not a profession for various reasons) and you people don’t have stuff together and are still battling over POCA, dry needling, medical acupuncture? And those running the orgs/sitting on state boards are still trying to restrict practice trained practitioners?

    Shame on you all! It seems as if Acupuncture and East Asian Medicine is now circling the drain. People who ask me about wanting to study acupuncture and tell them not to unless you can pay for your education out of pocket and have 5 years worth of income to survive the lean years while you try to establish yourself. (Or have an affluent spouse who is willing to support your hobby). I have not checked attrition rates, but I can tell you that only a handful from my class are still practicing, the rest have either left the trade behind or are just dabblers. So I tell people who are interested in it to not waste their time and money.

    Has there been any growth in the number of AOM practitioners in the past 10 years or has the number stayed the same?

    This really is shameful, but not surprising.

    • I’m not sure we all should be shamed, as some of us are working very hard to address the issues you mention. In any case — it’s hard to have an answer on growth of the profession and attrition. No one is tracking attrition. Some are trying, but it’s no easy task. The numbers of practitioners appear to be growing, but, again, there is not much info in how much of the increase in # of licenses actually translates to an increase in the number of practitioners.

      The problems are real.

      • Yes, unfortunately for acupuncturists, the problems are real and don’t really seem to be resolving any time soon. When the schools mention “more and more hospitals are using acupuncture” I wonder which ones, where, and has this been through shrewd marketing that Benjamin alludes to or actual acceptance of the little research that is out there, which I will get to in a moment. Going along the lines of acupuncture in hospitals, why not have MDs, APNs, and PAs trained in medical acupuncture? It is more cost effective to have providers with multiple skill sets as opposed to a provider with only one skill set. We can debate herbs, tui na, cupping, etc., but here’s the thing: Massage therapists to massage cupping, Naturopaths utilize herbs, supplements, homeopathy (which, multiple studies conclude that it does not work beyond placebo–and many acus expand into these areas to as added revenue streams). Is is really cost-effective for a hospital to employ a provider with a single skill set?

        Getting back to research, Anesthesia and Analgesia did a lit review of meta analyses, they conclude that after more than 3000 studies of various quality (none were high quality), the results were inconsistent. The studies that were well controlled demonstrated that acupuncture was no better than placebo. (see https://journals.lww.com/anesthesia-analgesia/Fulltext/2013/06000/Acupuncture_Is_Theatrical_Placebo.25.aspx ). I’m sure there are those that will state the authors were “biased against” acupuncture, or the studies were flawed due to improper point selection because TCM pattern discrimination/differential Dx was not appropriately implemented. Come on, providers can’t always agree on pulse and tongue Dx. Unfortunately, in pubmed database, no principal investigator in acupuncture studies was a DAOM (and probably never will be because they are not properly trained to perform research or even understand an analysis because they’re too busy trying to stay afloat to pay acupuncture mortgage). Based on Calquhoun and Novella’s assessment, I don’t it would ever be appropriate for any acupuncture/AOM/AEAM practitioner to be able to participate in loan repayment assistance programs. But then again, it would seem most acupuncturists/AOM/AEAM practitioners would not want to participate in medicare/medicaid (which is/should be are requirement for participation in loan repayment assistance programs such as practicing in medically underserved areas.

        So yes, problems indeed. They still haven’t figured out their own nomenclature: Acupuncturist vs TCM vs AOM, vs AEAM; not to mention the various schools of thought vying for relevance: TCM vs 5 element vs Classical Chinese Medicine, etc, etc, etc; Degree status: MSOM, MAOM, FPD (still?, really?), DAOM–and the title chasing/title envy implied with the doctorate (yes, I receive direct mail from one school that states “we would love to call you ‘Doctor'”–how much more Freudian can they be?). Quick note about education, keep in mind most of the schools are for-profit, nationally accredited institutions. Not to mention the various state boards that try to limit the number of providers through various tactics. Lastly, I do not know where they are getting this crap, but 95% of the acus I know still in practice still believe vaccines cause autism (so yeah, go work in a hospital spouting that, and you’ll see how fast they escort you out the door). I think everyone involved should be ashamed. Of course, there are those such as yourself and POCA who are trying to change that. However, the trade is slowly dying, the growth is nominal at best, utilization is in the single digit percentage across the country.

        • Anthony (thanks for your post) lists quite a few of the issues that keep acupuncture from finding a role in the mainstream. Consider AOM research. Medical Acupuncture – editor Niemtzow MD PhD MPH – published an article in 2016 [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926228/] written by leading AOM researchers who found that “Evidence for nonpharmacologic treatments, such as acupuncture, are needed.” I asked a neutral educational researcher to evaluate. He has no dog in this hunt.

          “They messed up the the design re outcomes, the sample size which needs to be at least 3 times larger if not 5 times, which outcomes were of interest. “Did you see how they brought up the “if” question as a primary outcome in the design section. That should have been the primary outcome. They should have looked at any acupuncture v. usual care and possibly vs. the most used other treatment, and looked at maybe 5 outcomes at the most. Once they realized that the HIT wasn’t significant — but it was for AA — they started doing post hocs like crazy. There literally is no outcome in this study you can hang your hat on because of the small sample size, lack of Bonferroni correction in calculating it, and poor design. This was a shotgun blast at a small target.”

          Good luck finding his evaluation in the AOM “press.”

          On the other hand “naysayers” get little recognition in the world of defenders of the faith. “Should doctors recommend acupuncture for pain? YES or NO.” Even handed, yes? https://www.bmj.com/content/360/bmj.k970

          Jonas is an insider as was Kaptchuk who appears to have left acupuncture research behind for placebo effects. That is interesting in itself.

          Final thoughts from Anthony’s post: The DAOM? Everybody wants to be a doctor incl LAcs, PTs, etc. Such is the nature of healthcare today. Scopes of practice for many midelevels (dental hygienists, optometrists) are expanding while the pool of MDs continues to shrink. LAcs will be midlevels once the profession develops KSAs that drive curriculum. This requires a unified profession.

          “keep in mind most of the schools are for-profit, nationally accredited institutions.” Not exactly. Approx 60% are for profit. The problem is there are ~60 schools for less than 30,000 LAcs. Compare that to DC, PA, DO and OT.

          “Not to mention the various state boards that try to limit the number of providers through various tactics.” Many states that do not have an Acupuncture Board. Those states place acu under the board for other providers. This is an example of how poorly organized and represented we are. In this respect EWK is spot on; we are our worst enemy. We do not understand the health professions battlefield.

          The good news is acupuncture’s process of step and stumble is precisely what every other health profession has gone through. Try this one for perspective (I hope EWK allows this to get through! Maybe some people on this blog will read all three links. https://www.ncbi.nlm.nih.gov/pubmed/25847764

        • It may be surprising, but there are indeed hospitals that are seeking out the services of acupuncturists, and I expect this will become more common as the easy “solution” of prescribing opioids becomes increasingly difficult. And several states do have pilot programs to make acupuncture available to Medicaid recipients. Though I agree that finding acupuncturists to participate is likely to be a problem.

          I agree that we’ve got a nomenclature problem. Groups have been working toward a resolution, but, of course, finding an agreement has been difficult.

  3. “it appears that the trend for increasing educational hours occurred because of the concurrent increase of available Title IV federal student loan funding.” No shit. Many statements here worthy of consideration. The curriculum is bloated. Needling therapy is the principal modality. TCM is not acupuncture. ACAOM is controlled by AOM schools. However, NCCAOM is by far the most progressive among AOM cornerstones. The professional route should follow nursing. There are multiple entry points from LVN to RN to BSN. A nurse who wishes to “specialize” can get a certification in that special field. These are times when the profession might grow up – as it downsizes – to fit in the healthcare mainstream. One of the obstacles will be the difficulty building alliances among AOM groups who might work together. Can AO and POCA do that?

    • What do you mean when you say “NCCAOM is by far the most progressive among AOM cornerstones”?

      By AO do you mean The Acupuncture Observer?

      I’m not sure why we need to follow the professional route of other professions when we had a simple route that was working. Reverting back to the lower hours of the past, keep the competencies – we have a great safety record. That’s true in the states that don’t require the NCCAOM. And it’s true of the practitioners who had shorter programs.

      • Why follow professional routes of other professions? EVERY respected, respectable and reimbursable health profession has followed a similar path. I do not recall whether AO (your blog) supports reimbursement by Medicare or jobs for LAcs in the VA.

        The educational position by POCA contrasts with previous prickly isolationist positions. Not clear whether they are asking for support.

        Safety is one of the best reasons to recommend needling. I support the emphasis on safety. This is the primary role of govt regulatory bodies.

        NCCAOM is involved in a CA legislative action that will impact AOM ed and testing in our state; working closely with groups like CAOMA and NGAOM which have been played against each other in recent years. You might reach out to NCCAOM for info.

        A good place to start with the development of health professions is “Social Transformation of American Medicine” by Paul Starr. I have also published on these ideas apply to the AOM profession.

        Times change.

        • I support opening as many practice environments for acupuncturists as possible.

          I think health care spending in this country is out of control so I’m not sure the solution for every problem is do what everyone else did (regarding educational paths).

          I haven’t found POCA to be prickly isolationalists as much as having little time for professional games that actually get in the way of getting more acupuncture to more people.

          I’ve been in touch with the NCCAOM and regular readers of my blog know I’ve been supportive when they do things I can support. For instance I wrote in favor of their involvement in CA.

          • Educational levels unrelated to excessive spending which is a function of overused procedures. One part of the opportunity for LAcs is low cost low tech needling for reimbursable diagnoses…esp for pain control. On going along same route as others have…not a question of choice: observation of predictable path with predictable steps.

  4. Hi Elaine. I was not aware that this legislative effort was happening in UTah. It sounds like a turf battle. Thanks for keeping us posted….any recommendations or action steps to take?

    • You are very welcome, and thank you for asking!

      The hearing at which the Utah Advisory Board was told they could not accomplish this change via regulation was two weeks ago. It is too late to introduce a Bill for this legislative session. At the end of the meeting the Advisory Board and the Utah Association discussed preparing legislation for the next session and the NCCAOM offered to help.

      Ideally, those groups would get the message as soon as possible that this legislation – or even legislation which sets up a tiered system – is not in the interests of the profession. One difficulty in figuring out the action steps is that one would think a state association would be eager to stop something like this. In this case, the state association is actually promoting this change.

      Because POCA and POCA Tech were the direct targets of this action, I think supporting those groups is a great way to protect access to acupuncture and acupuncturists. Here’s a way to support POCA Tech — https://www.pocatech.org/how-donate/

      And here’s the link to join POCA (which also includes free CEU’s) — https://www.pocacoop.com/membership/join-punk

      I think it is also important to let the NCCAOM know that their assistance in efforts to discriminate against their Acupuncture-only Diplomates are concerning (to say the least)! If they are as committed to a strong profession and addressing the problem of student debt as they claim to be, they wouldn’t participate in efforts to further divide the profession.

      Oh — one thing that didn’t make it into the Post — there are fewer than 200 LAcs in Utah. An Acupuncturist on the Board said she thought that was plenty – after all, her practice wasn’t as busy as she wanted it to be. There are about 3 million people in Utah. It’s a big state.

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