The Last Acupuncture Observer Post?

The planet is burning, the country is splitting apart.

I can imagine the despair of the climate scientists. They sounded the alarm when there was time to change course. But those in power prioritized their own short term interests. The rest of us were powerless to make the big changes. And we remain mostly unwilling to suffer the discomfort that smaller (though still helpful) changes require. We take long hot showers, drive big cars, take cruises, crank the air-conditioning on hot days, and lament the loss of the natural world we know. Being really good at recycling isn’t enough.

In the grand scheme of things, the loss of a Profession isn’t as serious as the loss of cool summer evenings and Orangutans and New Orleans. The knowledge and wisdom of this medicine preceded Licensed Acupuncturists and will live on without us.

I’m no Greta Thunberg. But I will sound the alarm again, and hope that the Profession I love will change course before it’s too late.

  • We have created a growing demand for acupuncture. Patients want it, insurance companies want to include it in their offerings, governments – federal 1,state and local, want to provide it to their citizens. There are lots of jobs, and lots of practices available.
  • There are many Acupuncturists who are leaving the field.
  • There are many areas with no Acupuncturists at all.
  • Enrollment in entry-level Acupuncture programs is down more than 20% in the last five years.

It’s an odd combination. High demand, unfilled jobs, LAcs leaving the profession, and fewer people entering the profession.

Representatives from ACAOM and the NCCAOM, asked about the drop in school enrollment at the ASA conference2, chalked it up to “the economy” and the “overall drop in people attending graduate school” and the change in “employment goals” for “the current generation.” And, “as we have more jobs more people will see it as a viable profession.” In short, ¯\_(ツ)_/¯

They aren’t being honest – maybe not with themselves, certainly not with us.

It’s simple. The investment required to become an LAc, and the education and training students receive, is disconnected from the job skills, jobs, and compensation available to most acupuncture school graduates.

People are spending four plus years in school, graduating with significant student debt, offered jobs that don’t match that investment, and without resources to start or purchase a practice. In some states even four years of education isn’t enough. Florida just added a requirement for training in injection therapy for licensure.

Meanwhile, most entry-level acupuncture jobs don’t require injection therapy or herbal skills. (Not necessary for Modern Acupuncture or most Community Acupuncture jobs, for example).

In order to pass Board exams, extensive study of TCM is needed, even though that system is not required to practice safely and competently, which is what licensing exams are supposed to test.3 The NCCAOM acknowledges the problem, but hasn’t offered a solution.

Existing LAcs spend a lot of time bitter that things aren’t better. Many believe that if only “the profession” fought harder they’d get the higher pay and monopoly on techniques they believe they deserve.

Now is the time to speak clearly.

  • The vast majority of LAcs will never be paid physician level salaries. We can spend more time in school, we can get more titles, we can all refuse to work for reimbursements we consider insufficient, and, still, average net incomes of even 80K are a long way off.
  • We cannot, in general, prevent others from using techniques we consider to be “ours.” 4
  • The higher the demand for acupuncture and the higher our expectations for compensation, the more quickly the system will shift to having non-LAcs provide acupuncture.
  • There is a bipartisan consensus that restrictive Occupational Licensing harms the economy.
  • We are vastly outnumbered by most of the professions we view as competition.
  • If you think that we haven’t been able to “protect the profession” because we haven’t fought hard enough you have not been involved and have no grounds on which to judge.

There are things we can do, powerful things within our control, that could help us survive. We must –

  • Streamline our schooling. The focus must be on competencies, not hours. Safe and competent practitioners can be trained in far less than 2000 hours. We know, because we used to do it all of the time.5
  • Minimize the expense of the necessary training. Much could be accomplished through distance education. Bring back apprenticeships which served us well for many generations (we can call them clinical internships, if we’re afraid of what the mainstream will think). Employers can provide additional post-graduate training in specific techniques and modalities.
  • Demand that the NCCAOM develop licensure exams that test minimal standards for safe and competent practice, not specific knowledge irrelevant to practice.6 The NCCAOM bears the responsibility of designing a JTA that supports the development of an appropriate exam. Particular settings or styles that want to do additional testing can chose to do so. Schools bear responsibility for assessing  knowledge of their particular traditions/lineages.
  • Protect licensure for everyone who has sufficient training in acupuncture, which includes teaching that all health providers have a duty to limit their practice to their own training and experience. Requiring all Acupuncturists to have additional training in herbs, or any other specific, optional, modality shall not be a requirement for licensure.
  • Understand that our success as a profession depends upon our having sufficient LAcs to provide treatment in a timely and affordable fashion in most communities in the US, not on whether the Cleveland Clinic has a few OMD’s on staff. We must provide resources to help and support those willing to practice in underserved areas.7
  • Drop the expectation that “the system” will pay us what we think we deserve. Everyone wants to pay less for health care – people, insurance companies, governments.

We must reclaim Acupuncture as a simple, straightforward interaction between a practitioner and a patient, and recreate the accessible path to licensure we once had. Otherwise, we are creating a future with fewer Acupuncturists, who may manage to pay for their extensive education and keep up with demand only by handing off patient care to minimally-trained assistants working for low wages.

Individual acupuncturists and our professional organizations must acknowledge that we have a problem. It may be a little uncomfortable, but we have the power to make changes that will, at least, delay the day when an Acupuncturist in the US is as rare as the critically endangered Sumatran Orangutan.8 It’s not too late.

 

Notes:

1) Please read this, and comment, on the CMS proposal! Deadline August 15!

2) The ASA did a great job with their first conference. Excellent speakers, well-organized, great facility. Very impressive right out of the starting gate.

3) “The sole purpose of a licensing examination is to identify persons who possess the minimum knowledge and experience necessary to perform tasks on the job safely and competently–not to select the “top” candidates or ensure the success of licensed persons. Therefore, licensing examinations are very different from academic or employment examinations. Academic examinations assess how well a person can define and comprehend terms and concepts. Employment examinations can rank order candidates who possess the qualifications for the job.” (from https://www.clearhq.org/resources/Licensure_examinations.htm)

4) Vermont recently deregulated auriculotherapy. Here’s an opinion from Washington state regarding Nurses and Acupuncture.

5) Other Professions have altered training and education in order to address worker shortages and minimize debt (which also encourages increased diversity). Acupuncturists in Nevada were finally able to bring their licensing requirements closer to what we find in other states.

6) My individual conversations with NCCAOM reps at the ASA conference didn’t move beyond quick chats in passing. I’ve got some hope that they’ll work to improve the recertification process. I’m less hopeful that there will be progress in the other areas in which I’ve expressed concerns. Meanwhile, a big congratulations to Mina Larson on her appointment as the next NCCAOM CEO. I know that she understands the challenges facing the profession.

7) Dealing with the shortage of rural providers.

8) Current population of the Sumatran Orangutan estimated at 14,613.

 

 

 

Copyright —

© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2019. 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.

31 thoughts on “The Last Acupuncture Observer Post?

  1. This is bad news: The acupuncturists report to the Supervisory Chiropractor.

    “The VA Saint Louis Health Care System has 2 full time openings for Acupuncturists. These positions are located in the Whole Health Program at the John Cochran Division. The acupuncturists report to the Supervisory Chiropractor.”

    Please call: John Cochran Division
    915 North Grand Blvd.
    St. Louis, MO 63106
    314-652-4100 | 800-228-5459 Directions
    Or Please call Whole Health at 314-289-6583.
    https://www.glassdoor.com/job-listing/whole-health-licensed-acupuncturist-us-department-of-veterans-affairs-JV_IC1131270_KO0,35_KE36,69.htm?jl=3324590181&ctt=1566736530499&srs=EI_JOBS

    Let them know this is unacceptable. Chiropractors and Acupuncturists don’t have the same scope of practice. Chiropractors cannot be supervised Acupuncturists.

    This is where our focus ought to be instead of complaining about other issues.

    • Hmmm, so you are suggesting that we tell a potential employer looking to hire an LAc that their job posting is “unacceptable”? I disagree. What does scope of practice have to do with it? Don’t get me wrong, I understand that LAcs are used to being independent practitioners, and that we feel insulted when it’s suggested that anyone, especially someone that we view as “less than” might have some say over our work. And, yes, in their response to the CMS proposal the ASA did address this issue. But, as the gentleman from the VA indicated during his presentation at the ASA conference (this is not at all a direct quote but my best recollection of the gist of his remarks), if you are working at the VA you’re going to be part of a team, there are going to be people in charge, and that’s the way it works in that setting. Get over yourselves.”

      If you don’t want to do the job advertised, don’t apply. If you want to engage in useful discourse about lines of authority in integrative medicine settings, or in working for a branch of the federal government, have at it. But some bold pronouncement that we find their job description unacceptable, or that we’re too damn special to work within the system, that does us no favors imo. And too bombard those offering the job with letters about the position we think they should be advertising — I don’t think that would serve us well.

      You know who is used to working under supervision? PT’s. Perhaps if we make ourselves incredibly unappealing as hires, we’ll get employers to look elsewhere to fill their needling needs?

      Also — do you have direct feedback from LAcs working in similar positions? How are they finding the set-up. Are your concerns based on the experiences of those already in the system? Or just an emotional response?

  2. Elaine, stop waiting for the NCCAOM to create a more efficient, safety based, affordable exam – just do it! The profession desperately needs another exam. I believe if someone would just start one with those goals in mind, they would do incredibly well. The NCCAOM has shown their true colors in leaving out half the profession in their federal lobbying pushes to require the purchase of their “diplomate” product to work for the VA and now Medicare/Medicaid. Thank you for your honesty and forward thinking in a profession that is in desperate need of both.

    • You are very welcome, Jessica. It’s not so much a matter of waiting for the NCCAOM. I don’t have high hopes that they’ll ever make the changes needed. But it would require far more than just designing a new exam. At the moment, many states require the NCCAOM exam by name. So, there would need to be development of an exam (which is not cheap) and then an effort to make legislative and regulatory changes across the country. If there were significant agreement within the profession that this is something that should happen, that would ease the path. But, there isn’t that sort of agreement. There are plenty of powerful voices within the profession who would fight tooth and nail to maintain the primacy of the NCCAOM exam.

      The whole profession is starved for resources to support the profession, so any big, costly, fight like this could in some ways be the nail in the coffin. Or — like the Moose scene in Into the Wild. Did you see that movie? (I don’t want to spoil it.)

      I couldn’t take on an effort like this on my own. If enough people and enough schools and enough organizations were ready to walk away from the NCCAOM and their sometimes extortionist policies (like their growing insistence that any LAc that hasn’t maintained active NCCAOM status should not be allowed to practice), and devote themselves to an alternative, perhaps we could get somewhere.

  3. Acupuncture is a medical field. As any specialty, it is constantly changing. A good medical acupuncturist, Yes this is the real term. I’ve seen that allopathics are trying to hijack the name. Acupuncture is a vast field compromising: Japanese, Korean, Western medical, and Chinese. I encourage the readers to read George SOULIÉ DE MORANT
    PRECIS DE LA VRAIE ACUPONCTURE CHINOISE. If they can read French or get the translation. Soulie mentioned trigger points or dry needle, not by name but he described them. He mentioned Dr. Berlioz and Dr. Jules Cloquet in 1825 used needle to cure, but the procedure was extremely painful.
    For those who speak French, “docteur Berlioz, de Tours (père du musicien) et le docteur Jules Cloquet, professeur à la Faculté de Paris, entreprirent, vers 1825, de traiter des malades à coups d’aiguille. Mais, dans leur ignorance, ce n’était pas l’acuponcture chinoise qu’ils appliquaient, car ils enfonçaient de très longues aiguilles jusque dans les organes et les laissaient en place pendant vingt et trente heures. L’étude de leurs expériences est pourtant instructive. Mais la cruauté du traitement, malgré des succès intéressants, mit vite fin à la grande vogue que le docteur Cloquet connut pendant plusieurs années.” pg7

    Soulie although controversial as I mentioned acupuncture vs acupuncture where the needle is place in the muscle, but not in the specific point.

    He also mentioned the pancreas. I thought the pancreas was not mentioned in TCM, however in his book I mentioned above mentioned it with the spleen.

    Please read the book.

  4. Is this really your last post ever (closing the website) or the last post for the year?

    • I don’t know.

      What I do know is that it’s gotten very painful to write what is basically “the same” two or three posts repeatedly, while trying not to let resignation or anger creep in. Or figuring out some new way to present things that might actually change hearts and minds. The truth is, there will probably be more posts. At some point, something will happen and the motivation to reach out will override the burn out.

      In the mean time, I suspect there will be some posts that link to the articles and papers that inform my points and conclusions. I already post these to FB, but I know not all of us are on FB. And, I’m always open to guest posts if some of you have something to say.

      Thanks for asking.

  5. I love this blog post, and I thank you for speaking so many important truths about our profession. I really am tired of the world view of the acupuncture regulating associations, which act as though their job is to keep our numbers small, our members in debt and our licenses useless outside our particular state. There is more than enough pain and suffering to go around. We need more Lic Acs with less debt and more flexibility. Learning safety basics in school makes sense — we have a lifetime to learn the rest.

  6. I can’t thank you enough for sharing this. Everything you say is SO true. It is getting to the stage that students are now questioning their path in this field, even though it’s something they passionately want to do. The finances now make it almost untenable to do an entry level Masters program, and yet financial burdens on schools make it hard to keep tutition lower. We need to re-think what we’re doing in this profession – which is to serve the public and help sick people!

  7. I think I have said this before in response to your post, yet I think it is worth saying again: BRAVO! Thank you for saying the things that are real, that are honest. These things can feel hard to acknowledge, yet they are vastly important for those who truly and deeply care about our patients, about access to acupuncture, about the future of the profession, and in impacting our communities in a positive way.

    • Thank you! It’s been hard that so many seem to dismiss my heartfelt requests that we think deeply about how we can help ourselves and others as detrimental to the profession and the public.

  8. Acupuncture isn’t going anywhere. The acupuncture profession, however, is facing an existential crisis. The average L.ac. takes it as an article of faith that anybody doing acupuncture with less than a full acupuncture school education is going to be ineffective at best and dangerous at worst. That is the argument made over and over (and over) against dry needling. Absent any statistical evidence to prove that an L.ac. gets better results than a PT, it is just an opinion, and not a persuasive one. In fact, let me go full on into apostasy and suggest it is possible PT’s get better results. It’s hard to make a compelling argument that the best choice for anybody who wants to practice acupuncture is acupuncture school. Why limit your treatment and employment choices, when you could go to PT or chiro or nursing school and have a much wider scope and better employment options. I think this explains our dwindling enrollment as much as anything. Now I know, some will claim that missing out on TCM theory will render you inadequate as an acupuncturist. But for anyone who has a genuine interest in filling that gap, there is now a seemingly unlimited array of online, high quality CEU’s to choose from. The ability to learn TCM or East Asian medicine is not confined to the acupuncture school any longer.

    • I asked some of the SAR folks, after a presentation at the ASA conference, whether there is any study that compared various “styles” of acupuncture. Was there evidence that the TCM that is tested by the NCCAOM exams, for example, yields better results than any of the other styles. Nope, no studies showing that. And, I’ll apostasize (?) right there with you. I do have some concerns unskilled DN by PT’s is causing patient harm, I’m also concerned that a lot of LAcs are insisting that what they do is so much better than dry needling, with no basis for that claim. Or that, they are doing dry needling, when they have no training in that particular technique.

      • I certainly don’t want any PT’s to cause harm. But despite the fact that L.ac. frequently characterize them as untrained, unlicensed, only in it for the money, etc. they have just as strong a motivation as us to be safe. Additionally, the entire field of PT is much more data and evidence driven than ours, and I’m confident that most of the PT’s who dry needle will seek to improve over time, and will incorporate better techniques. The effort by some of us to denigrate and misrepresent another profession is always something that I felt ashamed of, and I’m not surprised it hasn’t been fruitful.

        • Yes, of course. The PT’s are professionals and have every reason to be vigilant and careful as they set their own policies, procedures, and regulations. I have always felt that a more collaborative process would have actually led to more careful policies on the part of the PT’s. I think coming at them with the attitude that they are incapable of self-regulation, and that they must agree to our demands, has created a very understandable push back.

    • Jeez, where have you been my whole professional life! Thanks to Elaine and all who chime in here in support of sustaining the vital energy of our medicine. It’s such an incredible medicine, I am always surprised by how little faith our profession has in our medicine, or the understanding that we don’t “own” it, it has a life of its own, and a movement.

      • Every time I read “They’re stealing our medicine” I cringe. It’s a gross idea when you think about it.

  9. Just a quick comment on the CMS National Coverage Analysis: They’re looking for additional information pertaining to chronic low back pain in seniors (65+) and are allowing NIH to fund studies specific to supporting this cause.

    Here’s an excerpt from an email I sent to the NCCAOM advocacy committee:

    I think the key takeaway is summarized as follows (Cut and Pasted from the CMS website):

    Public comments that cite the published clinical evidence are most helpful. Public comments that give information on unpublished evidence such as the results of individual practitioners or patients are less rigorous and therefore less useful for making a coverage determination. Public comments that are part of letter writing campaigns by groups or individuals who espouse a single point of view through identical or nearly identically worded emails or documents are not useful. Multiple iterations such as these will be considered as a single comment.

    We (IHPC, ACA, SAR, NCCAOM) already offered some RCTs in addition to what they’ve already gathered during the first comment period. We may be able to offer some studies that have been published in NON-INDEXED journals such as early copies of Meridians, and other peer reviewed publications that don’t offer public access unless you have a subscription may be useful. (I already reached out to the SAR folks regarding this when CMS made the request a month or two ago.)

    Obviously a letter writing campaign is not appropriate, however, a call to those who have access to obscure studies of CLB in senior patient populations would be encouraged.

    If I were to say something like, “As an acupuncturist with 65 years experience, I can say without hesitation that I have a 99% response rate in patients over 65 years old suffering from chronic low back pain,” it would provide no value added to them.

    I hope that helps.

    • Thanks, Bill. I’m curious – is the idea that comments/input like those you suggest would lead CMS to make a coverage decision without any further study? My impression is that they’ve already reviewed the published evidence, are proposing to fund some additional studies to gather more info., and that our comments at this point would “ideally” be 1) yes, we think more studies are good and 2) it would be appropriate to include LAcs in this study with recognition of our independent role in health care, and that respect the credentials of all LAcs.

      I didn’t get the impression that CMS would be likely to bypass this step, regardless of how much evidence we provide. Do you think otherwise?

      • My understanding is rather than an “Either/Or” it can be a “Both/And” situation.

        They certainly have dog-eared money for further research, but if we can provide solid evidence from more obscure journals, they may change their decision. Just between you and me, it may also be a stalling tactic. These involved studies take close to a year to get up and running, then data analysis and writing a report for another year.

        • Well, between you and me, I’m not sure Acupuncturists would benefit from a decision sooner rather than later. We don’t have anywhere close to the number of practitioners we’d need if Medicare did cover acupuncture. How will we meet the demand. Are we ready with Medicare compliant EHR systems? Seems like we need to do a whole heck of a lot of preparation – we’ll need a few years to be ready.

          • That is ABSOLUTE TRUTH.

            We have all of 35 acupuncturists in West VA. We can’t possibly meet the demand, much less in places like North and South Dakota, etc. It wouldn’t surprise me if 90% of all private practices use a paper health record system. I know I do…

          • And quite a few of those licensed in WV don’t actually practice in WV.

            And not all EHR systems are even Medicare compliant.

            It would be good for patients if Medicare covered acupuncture, imo. And, it would mark the middle of the end of the profession — because the people who want it are not going to wait around for four-six years for people to decide to go to acupuncture school and get licensed (and 4-6 years would only give us another 5,000 practitioners, if we were lucky.) If CMS covers it, expect a rush of MD’s and Nurses to start offering it, and PT’s to get included….

          • Valid points. We’ll get bulldozed while PTs, MDs and RNs start getting short-cut certs to provide our services.

  10. Thank you, Elaine, for laying it out succinctly. Rural health care is a serious challenge, and could always be used to our advantage when attempting to influence policy. That’s how my NADA bill passed unanimously in Texas, rural legislators, who have power when it comes to health care. If only we had a patient advocate group centered around acupuncture, besides POCA and NADA.

    • Thank you! I’m hoping others agree. I spent a chunk of time yesterday in a back and forth on FB with a practitioner who insists that once we are all “Doctors” we’ll get those big bucks we deserve. I kept asking for some evidence, some parallel, to support the argument. But all I got was Magical Thinking.

      • Again, hit the nail on the head. I couldn’t have said it better myself!

        The questions are: why can’t we move in this direction as a profession? How did we get so tied up in trying to be perceived like “real doctors”? And why can’t we see the insanity in continuing to pursue the path we currently appear to be on?

        • It’s a good question. And I suppose the answers overlap with some of the reasons why we aren’t doing anything about climate change! The professional level organizations (state associations, ASA, AAAOM back in the day) respond to what their members want. Their active members are a small percentage of the profession, and folks that may not have any basis for their strongly held beliefs. The groups that have a bit more independence from the profession may actually benefit from some of the Magical Thinking – it doesn’t hurt their bottom line, it may even help it. Or, they may, to some degree appropriately, hey, it’s our job to do what the profession thinks we should do, not set policy. Certainly the move towards the degree formerly known as the First Professional Doctorate didn’t originate with ACAOM. A group of practitioners decided it was the solution, and moved forward based on their firmly held beliefs.

          You were part of the FB discussion — people believe that more education = higher pay – in the absence of any evidence in support (and even when there is evidence that they’re wrong) – and if those people have power in associations, on regulatory boards, etc, they set policy.

          It’s uncomfortable to change our beliefs. It’s uncomfortable to shake things up. It’s easier to check out.

          • Yes, I was part of the discussion – though I’m pretty sure we were arguing the same thing, just coming from different directions.

            I suppose this is where I get hung up “in the absence of any evidence in support (and even when there is evidence that their wrong)”. Which leads us back to your “Magical Thinking” position, because it takes a degree of magical thinking to assume your plan of action is somehow not going to be affected by contrary evidence.

            I think this may be my “Et tu Brute?” moment. I’m just glad there are other folks who see the problem(s) and are willing to speak up. Having been on the receiving end of a few dog-piles, it’s refreshing to know there are others out there….

          • Oh, yes, we were in agreement.

            I should say, on behalf of others, it was a tangent from a request for comments on the CMS proposal to study acupuncture for low back pain. (The ASA materials on this are good, and I encourage everyone to read and submit comments.) And one person insisted that once we’re all Doctors we’ll get the respect and compensation we deserve/want.

            And, yes, I always wonder, hey, are my positions based in experience or my own beliefs. What I can say is that the PT’s recently all became “Doctors” and I couldn’t find any evidence – I looked – that their reimbursements have gone up. And, the folks in CA who have all the additional training, and just had their reimbursements cut a lot by ASH.

            I completely agree with your position that we have good arguments to make about acupuncture’s relatively low cost compared to other treatments. And – what’s more cost effective that acupuncture at $100/treatment? Acupuncture at $55/treatment.

            I was very happy you were in on the discussion!

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