17 Foundational Beliefs of The Acupuncture Observer

Embracing the season of gratitude and thanks, it’s time for The Acupuncture Observer to take a step back and share some of her foundational beliefs about the medicine, the profession, and life.

  1. Acupuncture/OM works. The unique situation of the patient and the unique skills of the provider influence effectiveness. No single tradition provides all of the answers or benefits.
  2. Acupuncture/OM has fewer negative side effects and risks than conventional treatment for many conditions.
  3. Access is a necessary precursor to effective treatment.
  4. Effective treatment will increase wellbeing and could decrease health care costs.
  5. Every means to increase access carries trade-offs. Those trade-offs must be understood as we determine our path forward. We should learn from the experiences of other professions.
  6. Understanding and explaining the mechanism of acupuncture from the knowledge base of modern biology and physiology is useful and interesting, but is not necessary for acceptance by the medical establishment.
  7. The current “science-based” understanding of health is known to be limited. Insisting that Acupuncture/OM be taught, thought of, or explored only in the language of modern medicine/science is unscientific and risks centuries of experience and wisdom.
  8. Consumers should have significant freedom of choice in health care. Understandable and clear information about potential benefits and risks, as well as an exploration of the costs (financial and otherwise) is necessary for good decision-making.
  9. Self-serving thinking leads to hypocrisy. Special attention is needed when an argument for patient protection creates an economic benefit for particular providers.
  10. Simple, easily learned treatments can be effective and safe.
  11. There is the potential for growth and success within the acupuncture/OM profession.
  12. Many acupuncture programs do not provide sufficient or accurate information about post-graduation life and do a poor job of teaching business skills. This can be changed easily and inexpensively.
  13. The financial and karmic ROI (Return on Investment) of positively promoting our profession is superior to that of engaging in political/regulatory battles with others.
  14. The future of the medicine and of the profession are interconnected but not identical.
  15. Thoughtful and respectful analysis can identify areas of common ground.
  16. Focusing on areas of common ground decreases factionalism, and builds unity, understanding, and participation.
  17. The profession lacks venues for respectful dialogue on these issues. As a result, many scholars and potential leaders within the profession avoid involvement.

Do we agree on some of these? Can respectful dialogue increase the areas of agreement? What if we read the Tao Te Ching, the I Ching, and The Art of War first? What if we go deeper than our Wei level response to some of these issues? I believe it is possible that we’ll be able to find a new path forward, one we can walk together, with our hair flowing free. After all, I’m an acupuncturist.

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.

(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.

Positive Developments for the U.S. Acupuncture Profession

Volume 1, No. 1 of Meridians: The Journal of Acupuncture and Oriental Medicine hit my mailbox last week.  It’s difficult to keep up with my “reading pile,” but knowing that Jennifer Stone and Lynn Eder were involved was a great incentive.

Though my time at the AAAOM was “nasty, brutish, and short” I did meet some great people there. Jennifer, who was editor-in-chief of The American Acupuncturist, and associate editor Lynn were among them.  Their work was top-notch and when I saw that they were part of the exodus from the AAAOM I feared their skills would be lost to the profession. Luckily, the new endeavor is off to a great start.

My favorite section was “Clinical Pearls”, focusing on Frozen Shoulder this issue. (Submissions on How to Treat Blocked Menses (Secondary Amenorrhea) will be accepted until November 15.)  I was so glad to see a focus on acupuncture treatments rather than herbal remedies. The growing (damaging and disturbing) trend in the profession to restrict practice to those with full herbal credentials demands frequent reminders that needling points is an incredibly effective stand-alone treatment. Thanks, Dylan Jawahir, Clinical Pearls Editor.

I also appreciated Jennifer Stone’s piece on postherpetic neuralgia. I’ll give the protocol a try the next time I’m confronted with a case that does not respond to my usual treatment choices. Again, simple needling can have great results.

My state association membership includes online access to MeridiansJAOM, which is a great perk. Still, ongoing survival of the journal will depend on subscribers and I hope that many of us will step up, subscribe, and support its advertisers. Subscription rates are very reasonable.

I have just one gentle request for Jennifer — can we have a more eye-friendly font? The footnotes were almost impossible for me, and even the main text required good lighting and rested eyes.

Another bit of good news last week — the launch of the Acupuncture Now Foundation. I’m often frustrated that so much of our profession’s energy and money goes to fighting with other professions, increasing our own licensure and educational requirements, and fighting to participate in a broken medical system. Meanwhile, helping the public understand the benefits of our medicine doesn’t seem to be a priority for many of our professional organizations.

Just as Matt Bauer’s Making Acupuncture Pay book and website have helped new practitioners by filling the gaps left by many of our acupuncture schools, the Acupuncture Now Foundation promises to do the public outreach work often given short shrift by our organizations. I hope that Matt gets the support he needs to finally do the work that has been his vision for years. He’ll need our help if this project is going to reach its potential. Sign up to receive updates on the ANF home page.

What’s your Acupuncture Degree Worth?

Answer: Less than it used to be.

(Please, sign the petition.)

If you earned an MAc and Dipl. Ac (NCCAOM) twenty years ago, you thought you had it made. You could get a license in almost all states with licensure. The schools and the NCCAOM touted the caliber of the education and credentials. You knew you had plenty to learn about this medicine, but you could practice safely.

In the gainful employment letter ACAOM points to the (supposed) earnings of those long-ago grads to minimize the financial struggles of recent grads.

But in 1995 the NCCAOM added the Herbal exam, and later the OM. Some states now require those additional credentials of all practitioners. ACAOM has increased hourly requirements for school accreditation several times. And the NCCAOM has put additional limits on who can take their exams.

Some of our most esteemed teachers do not meet the current requirements for sitting the exams. Many practitioners are trapped, unable to relocate.

By increasing the range of degrees and credentials available before our “brand” was established and our profession was strong, the alphabets increased division and confusion. No wonder the public can’t figure out how an LAc’s education compares to that of other providers.

And here comes the First Professional Doctorate. With this new degree, my alma mater announces,

“[graduates] will be recognized as doctors, both professionally and publicly, and will have increased credibility and standing.”

If graduates with an FPD have increased credibility and standing, what has happened to the credibility and standing of graduates of Masters programs?

According to ACAOM’s gainful employment letter, licensure requirements just happen, and practice success is a simple matter of practitioner choice.

Really, though, the “alphabets” have played a significant role in the expansion of requirements and credential creep, and most of the schools do little to teach students how to make wise business choices.

If, as ACAOM wrote, the graduates of twenty years ago do so well, why have entry level requirements been increased so much? Why are grads struggling to pay off existing loans encouraged to return to school to maintain their credibility? Will the NCCAOM require an FPD to sit their exams? Will the alphabets encourage states to require it for licensure?

ACAOM/NCCAOM/CCAOM/AAAOM — if you represent us, defend the value of our degrees and credentials. Your “options” too often become a requirements.

Colleagues, did the gainful employment letter represent your views? If not, sign the petition. 129 people have, which means ACAOM etc. can still claim to represent 32,871 of us.

For additional information and analysis about educational costs and value, check out this from The New York Times and two posts from Dr. Phil Garrison

 

 

Loans for Acupuncture School

It’s been too long. September brought a rush of obligations. And my post of X things (X to be replaced with a number when the list was completed) wrong with the Gainful Employment letter made it to 25 things by the time I got to the bottom of page 2 (of 7).

The gist of ACAOM’s Gainful Employment letter — It’s not our fault. The cost of the education and the inability of many of our graduates to pay off their loans in a timely fashion has nothing to do with ACAOM, the schools, or CCAOM. It’s the fault of the system and the poor choices of our grads.

If you believe the schools and professional organizations should spend less time denying responsibility and more time taking responsibility, let them know by signing this petition.

My top 7 issues with the letter:

  • The authors absolve the schools of responsibility for the success or failure of their graduates. Where is their evidence that “the primary determinant for success in earnings is dependent upon the students who make their own personal choices….”  And doesn’t an effective education include helping students make choices that lead to success?
  • The organizations claim to represent the entire profession without justification.
  • With the exception of CCAOM, the participating organizations are operating far outside their missions. For example, NCCAOM’s job is to provide a means of credentialing practitioners to protect the public. Why are they weighing in on student loans?
  • The authors conflate the impact of the proposed gainful employment rules with the impact of student debt on establishing a practice. It is student debt that limits practice choices, not plans that would prevent excessive debt for ineffectual schools.
  • While the authors blithely refer to the “realistic” time frame to establish a health care practice, materials provided to prospective acupuncture students are silent on such matters.
  • Putting schools in charge of the metrics (like graduation rates) that determine loan availability is a classic fox guarding the hen-house scenario.
  • The salary figures reported in the letter are questionable at best and mostly irrelevant. Even if it were true that the median salary of practitioners with 20+ years of experience is $122,500, which is doubtful, an acupuncture education 20+ years ago was far less expensive and shorter. (Perhaps the lack of federally guaranteed student loans had something to do with that?) Graduates who could not establish a successful practice are not around twenty years later. What are grads supposed to do about their loans for the first twenty years of their professional life?

It’s requiring a good deal of self-restraint not to continue with my list, but enumerating the failings of ACAOM’s letter doesn’t create momentum for positive change. A petition signed by some of those 30,000 people the organizations claim to represent might create momentum. It isn’t easy to determine how best to lower costs and increase practitioner support. It will require careful analysis and consultation with experts. But if the powers don’t care enough to ask the questions, we’ll never approach the answers. Sign the petition.

(Before you say it isn’t possible, here is a school that has designed an affordable acupuncture program with a focus on creating successful practitioners.)

Who Speaks for You?

ACAOM’s letter to the Department of Education regarding the proposed gainful employment rules begins —

On behalf of the Commissioners of the Accreditation Commission for Acupuncture & Oriental Medicine (ACAOM), and in partnership with the Council of Colleges of Acupuncture & Oriental Medicine (CCAOM), the National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM) and the American Association of Acupuncture & Oriental Medicine (AAAOM), we write to offer comments…. Collectively, we represent over 33,000 students and graduate acupuncturists in the United States, and 56 colleges of Acupuncture & Oriental Medicine.

Are there 33,000 students and graduate acupuncturists? Where did they get that number? Do they represent me? Reading the rest of the ACAOM gainful employment letter confirmed it – their letter doesn’t reflect my position on the proposed rules, or on the state of the profession.

ACAOM‘s existence depends on the schools and a steady flow of students, CCAOM represents the schools, and the NCCAOM‘s income depends primarily upon new graduates taking credentialing exams.  Once these groups get their money the future of acupuncture school grads is of little consequence to them.

Of course they would make the case for maintaining the status quo, but they should not be telling the DOE that they represent me.

I’ve just sent this email to the ED of ACAOM (mark.mckenzie@acaom.org) with CC’s to the leaders of NCCAOM, CCAOM, and AAAOM (kwardcook@thenccaom.org; executivedirector@ccaom.comcastbiz.net; DonLeelac@gmail.com), and to ashley.higgins@ed.gov (of the DOE) and bduran@mpamedia.com (of Acupuncture Today) —

 

ACAOM’s May 23rd letter to the DOE regarding the proposed gainful employment rules includes this phrase —

“Collectively, we represent over 33,000 students and graduate acupuncturists in the United States.”

Neither ACAOM nor any of the other organizations mentioned represents me.

The only organization listed that even pretends to serve graduate acupuncturists is the AAAOM. Their professional and student membership is a thousand or so, optimistically, and they were not in partnership with you for this letter.

I am not surprised that organizations that profit off students and new graduates would write a self-serving letter avoiding responsibility for the number of acupuncturists struggling to pay off huge educational debt.

I am not even surprised that you would claim to represent me. But I am angry that you did so.

Unless you can provide documentation that you do represent 33,000 students and graduate acupuncturists please retract your statement to the Department of Education and make clear that you are speaking on behalf of your organization, which depends on schools and a steady flow of students to survive.

Speaking for myself,

Elaine Wolf Komarow, LAc

In coming weeks I’ll explore more of the distortions and spin in the ACAOM letter. But for now I hope you agree that standing by while these organizations claim to speak for us is a mistake.

Borrow my text or use your own, but, let ACAOM and the other alphabets know they don’t represent you — and make sure the Department of Education knows that too.

Acupuncture Careers

ACAOM gainful employment — This deserves its own post.  I don’t have the head-space to write such a post at the moment.  I don’t even have the time to fully read and digest this document.  The little bit I can digest is making me sick to my stomach. I’m betting some of my readers would like to dig into this. I’d love to hear what you think.

NCCAOM/Dry Needling/A Young Profession

A survey about the possibility of a new NCCAOM certificate in Facial Rejuvenation showed up a few days ago. The online conversations were a reminder that many of us are confused about the NCCAOM — what their role is, what we want their role to be , what their role “should” be.  The topic deserves its own post, but, in short, the NCCAOM is a credentialing agency. They design, administer, and maintain the process by which most of us are able to be licensed.  There are loads of consequences of their power within our profession, especially because we have not had, for some time, a truly effective or well-functioning national professional association.

There were many complaints that the NCCAOM hadn’t done more to “stop dry needling.” That, combined with yesterday’s urgent petition regarding legislation on the Governor’s desk in Delaware, made we think I’ve got to try, one more time, to explain where we are with the issue and why what we’ve been doing won’t work. My post to my alumni group is out of context, but I hope still worth sharing (somewhat edited for clarity) —

Since Dry Needling is the issue that keeps coming up as a major focus for the profession, I wanted to give a little more info about the “court rulings” in our favor.

The one that received the most notice and attention was the case in Oregon regarding Chiropractors and Dry Needling.  The outcome of the case was widely misrepresented within the acupuncture community. Various stories indicated that the courts said that dry needling was acupuncture or that it had been determined that the training programs were insufficient.  This was not the case.  You can read a fuller explanation of the outcome of the case here – http://theacupunctureobserver.com/a-practical-next-step/. The gist of the ruling is that dry needling does not meet the implied definition of physiotherapy within the Oregon code.

Other states have also had rulings (usually informal) from the Attorneys General stating that dry needling is not within PT scope.  These rulings have typically been much celebrated within the acupuncture community, but we haven’t been hearing what happens next.  For instance, some time ago Utah was celebrating such a ruling.  Since that time, legislation added dry needling to the scope of physical therapists.  Similar legislation passed in Arizona.  When the AG recently ruled that dry needling was not within PT scope in Tennessee, the ruling included phrasing that basically said, PT’s will need to address this legislatively, as was done in Utah.  (You can get the link to the ruling here — http://theacupunctureobserver.com/late-july-acupuncture-news/).  Illinois is another state where the AG’s latest opinion agreed with the argument that dry needling was not within PT scope, but where the PT groups are already preparing legislation for the next session.

There will probably be states where the acupuncture community is large enough and well-connected enough (and Maryland might well be one) where similar legislation would not be successful, but if you look at the numbers in most states, the PT’s (who also often have business connections with the medical establishment) are likely to prevail.

Today I received a notice of a petition regarding DE HB 359, adding dry needling to the scope of PT’s in Delaware.  HB 359 passed by overwhelming majorities in the House and Senate and needs only the Governor’s signature.  Among the “gems” in the petition – “Accordingly, HB 359 will potentially place the general public in significant danger of injury and harm due to unsafe and unqualified needle practices.”  There are about 800 PT’s in DE, and even more PT Assistants.  There are 45 LAcs.  The odds of the Governor exercising his veto are slim, the odds of pissing off 800 PT’s?  Pretty good, considering we’ve just stated they are putting the public in significant danger.  Interestingly, one of the authors of this petition is the same person who pushed for the requirement of the NCCAOM OM credential in DE, putting practice off limits to about 70% of US acupuncturists.  Isn’t it ironic that the profession’s self-imposed restrictions on licensure in Delaware have left the LAcs scrambling to block action by an overwhelmingly larger group?

Had LAcs been more willing to work with the PT’s from the start, I suspect that in many jurisdictions we’d have come out ahead.  We’d have built relationships and understanding and had some influence, perhaps, on how this modality is practiced.  By sending PT’s to the legislative fix (that’s what “we” said right from the beginning – if they want to do this they should do it legislatively) we’ve taken ourselves out of the process.  As they succeed with changing the law we’ve lost any influence on the procedure.

Of course, trying to work together might not have changed anything.  Professions (including our own) are universally unhappy about outsiders coming in to tell them what they should do and how they should do it.

I will add three things in response to the previous post.  1) While I appreciate the frustration felt by LAcs when dry needling and acupuncture are spoken about as being equivalent, hasn’t it been our insistence that dry needling IS acupuncture that led to this? Wouldn’t we be better served by clarifying the distinction between the two? (Of course, that would undermine our argument that we have a right to regulate the procedure.)  2) There are many cases of patients not wanting to report harm suffered at the hands of providers.  This happens among acupuncture patients too. Even LAcs can cause a pneumothorax.  3) The cease and desist orders can’t help but remind me of the stories from decades ago of acupuncturists being threatened with arrest for practicing medicine without a license.

It hasn’t taken long for us to go from being the scrappy upstarts just wanting to help people with a simple technique, and frustrated by the establishment that was trying to shut us down, to acting like the establishment.  We’ve got our ever-increasing credentials, and maybe specialties soon, and are increasingly able to participate in the bureaucratic system of figuring out which set of codes gets us a reimbursement we can live with. Now, in Maryland, LAcs can interfere with a citizen’s ability to choose what treatments they get from which providers, and can throw their weight around in the provider community.

PT’s will outnumber us for a long time to come.  It’s a shame we’ve pissed in that particular well.

 

Late July Acupuncture News

CCAOM has released two new position papers regarding Clean Needle Technique. (No mention on the AAAOM or CCAOM sites about this important news.)  We practitioners are responsible for knowing the latest standards for safe practice, so here are the new position papers on the use of gloves and skin preparation for your convenience.

 

NCCAOM has finally released the report on 2013 Demographics from the JTA survey. 52K as the median pre-tax income is not good news, especially since most of us get no benefits (no paid sick leave, no paid vacation, no disability or health insurance, no retirement savings plan). (Then again, many of us seem to be working part-time, often by choice. So maybe the figure isn’t so crazy?)  Math lovers among my readers — feel free to share what additional number-crunching reveals. I’m not a numbers person, but I’m pretty certain that the average income will be below the median income figure.

67% of respondents hold only the NCCAOM AC credential.  If this accurately reflects the overall credential distribution within the profession the states requiring the OM credentials are off-limits to 2/3 of practitioners. That can’t be a good thing. (I’m still waiting for someone to explain the public health issues that led to the upcoming change in FL. And I sure wish FSOMA and the Florida Board would do a better job of spreading word of that change.)  Do those with the OM credential have a higher median income to offset the additional education and credentialing costs? The NCCAOM should collect that data next time.

The NCCAOM survey is designed to gather information from acupuncture practitioners so there is no data on how many acupuncture school grads have left the profession. I hope the CCAOM will soon require schools to track those numbers.

 

The California Board came in for some media scrutiny recently.  If the extra attention helps eliminate some of the extra hoops (which equal extra costs) necessary to practice in California, it will be a silver lining. I hear there might be some trouble on the New Mexico board as well (no details, though). Have independent boards been a winner for the profession?

 

It wouldn’t be an update without a little Dry Needling talk. The vocal segment of our community obsessed with the practice hasn’t been crowing about the Tennessee AG Dry Needling ruling that IMT/TPDN is not within the current scope of Physical Therapy. (Thanks National Policy Group for keeping us informed!) No doubt the concluding paragraphs referring to a legislative fix, as happened in Utah, tempers the celebration. And while I’m on the subject, here is a legal analysis of the faulty argument that the use of acupuncture needles by non-acupuncturists is illegal.  Can we please stop saying that now?

I suppose this is enough to keep everyone busy for a while….