33 thoughts on “Late July Acupuncture News”

1. Here’s a blog post about the new school opening in Oregon, which also contains some great info about the cost of an acupuncture education (up until POCA Tech joins the party) and what loan payments will look like if you are earning the median income in the field. (Short answer, not good.)
   https://www.pocacoop.com/prick-prod-provoke/post/poca-tech-some-math-required

2. Elaine: Once again, thank-you for keeping on top of what is going on in our field and for taking the time to disseminate that info.

   As to the way the income data was presented in NCCAOM’s survey – it would be far more informative to include the mean (average) than the median. The median is the midpoint between the highest and lowest income – not very useful, because it does not reflect where the majority of incomes lie. The mean would take that into account. The graphs are helpful in reflecting that info though, and it clearly shows that many acupuncturists who participated in the survey have very low incomes. I agree with those of you who are concerned that some of the data was not included in the study – without explanation of why that was a valid thing to do.

   Then the question is – do these data (from a relatively small sampling of the entire acupuncturist population) accurately reflect the whole? Maybe, maybe not….. It also does not show how we fared relative to previous years, which I think would lead to more questioning about where we are headed.

   It might also be useful to ask why so many acupuncturists are working part-time (less than 30 hours) – is it by choice, or does it reflect outside factors – changes in the economy, changes in expectations of the public (regarding insurance coverage), need for better education of the public about the unique role of acupuncture as a healing modality? Do we need to become better marketers (something a degree in from acupuncture school has not prepared us for)?

   In the 10 plus years I have been practicing, things have changed quite a lot – and we need to change with the times if we want to be successful – individually and as a group. Blaming other professions for encroaching on our turf is not the solution. If, as some of you have stated, many schools have turned out less-than-adequately trained graduates, that is truly a shame for our profession as a whole. How can we collectively improve the level of excellence in our profession? By requiring a minimum of OM degree? Even this does not guarantee a higher caliber graduate – it may just prompt schools to include a broader curriculum, but what we really need is to ensure a deepening of the skill-sets they already teach. Adding herbal skills to the mix may be useful in practice because it gives the practitioner more tools, but it does not guarantee higher competency in either acupuncture or herbal medicine.

   We may need some sort of national standard, but which group would do a good job of defining what that minimum standard should be and how would that be implemented to ensure the competency of new graduates as well as on-going competence in practice?

   • Hey, Pat, thanks for joining the conversation!

     If you look through the NCCAOM report, they did include a section on why people were working part time. I think just shy of 40% reported that it was a choice. So, that is significant.

     One important thing would be to look at whether respondent’s acupuncture careers are meeting their expectations. If people went in with eyes wide open — I want to work part time and set my own schedule and am fine with making 40K without benefits for example, then, cool, we don’t have a problem. But by all indications that is not what people expect — and they are not told to expect it. They are told it is a growing field with opportunities in many settings and that acceptance is growing…. These things are true, but misleading in many ways.

     We don’t even know how many are in the profession, but assuming the frequently cited 22K, I think we’ve got a 5% response rate. I don’t know how that’s seen in survey circles — but we have no idea how representative it is. What I REALLY want to know is how many degrees the ACAOM schools have given out in the last 20 years. That would be really eye-opening.

     We would all benefit from a good look at what the schools need to be doing better. I think they are the place where things could change, and the people who continue to sell a dream without any concern about the many who make the investment, but get nowhere.

3. “Tilting at windmills”…really? Let me just say that I am very aware of the kinds of changes that need to be made in the Delaware Law. It has been my part time job during, and since, the time it was authored. Let me just say this and I promise it will be the last contribution make to this discussion. No matter how perfectly you articulate each section, each sentence in the law it will not survive the legislative process in tact. That is because there are always stakeholders with competing interests at the table. In our case we were trying to swim waters infested with physicians, chiropractors, massage therapists, health-food shop owners, nutritionists, a representative of the NCCAOM, and a self -appointed leader of practitioners in the state who herself clearly had an unexpressed agenda that happened to match that of the NCCAOM. All through this process I had to fend off all sorts of attempts to rewrite paragraphs in the law that I can only characterize as idiotic. This law is very bad, but would have been much worse had I not been part of the process. Once the legislators bought into the delusion that only OM certification could protect the public (sold to them by the NCCAOM) it was all over.

   When the time came to rewrite the regulations things got even worse. Good portions of these were simply cut and pasted from other bodies of regulation around the country. The sections on PDA’s are particularly laughable given that they permit licensees to generate credits from organizations that no longer exist.

   Authoring laws and regulations is a very messy and highly politicized process. We are, after all, making sausage. Writing policy may be cleaner but it will not assure that those who go into the fray will not be bloodied.

   I will give you credit for what you know, but please do not talk with me as if I am naive and uninformed. Don’t insult me. I am not an idealist and am quite capable of making my own decisions about what I need to do next. That said I do believe that finding out what we all agree on is important. We must think, we must listen, we must learn, we must reflect, and we must put personal ambition aside. Enough said. I have a hundred more things I must do today.

   • I want to thank everyone who has been participating and wish I had more time to more thoroughly explore these issues at this moment. It seems as though we’re a bit far afield from Late July News at this point. These issues could well stand to be explored in a separate post, which I will do.

     The comments do point to a number of the underlying issues we face — chief among them the lack of opportunity for these issues to be explored in community dialogue, the wide divisions between those who believe integration into the mainstream will save the profession/medicine and those who think that integration would destroy it, quickly dismissing the views/experience/wisdom of others as being based on misinformation or ignorance (or an insistence among some that what they believe is true regardless of reality), and relying far too much on “well, what will you do to change it,” especially when that comes without prior knowledge of what the other speaker has been doing for the past 10, 20, 30 years.

     The profession has spent many hundreds of thousands of dollars over the past few years on lobbyists and legal battles and has devoted no resources to taking a step back and really looking at where we could go, where we want to go, and the most efficient way to get there. And has been quick to shut down those who press us to take a good hard look at whether what we are doing is working. From the accusations of “devaluing the medicine” directed to the Community Acupuncture movement to the “why don’t you go work for the Physical Therapists” directed at me when I try to explore the political implications of our actions, it is no wonder that so many of my caring colleagues have run far away from getting involved.

   • Thicker skin comes with sharing opinions. This is not personal.

     On the mean versus the mode (not sure who wrote this)… the mode is preferable when there are many many data points. The mode is the largest, i.e., most frequently appearing, set of data points in the distribution. The mean is often the least preferred choice because it does not account for the impact of outliers. The mode is the midpoint between the highest and lowest value and is therefore the best measure of central tendency when there are significant outliers.

     Acupuncture is a profession built upon the presence of outliers; i.e., those LAcs earning more than $100K. Question 23 shows a bimodal distribution for LAc income (recognizing this is not a randomized stratified sample and is therefore cannot be claimed as representative of any group other than those responding). 60% earn between $5K and $65K. This group needs finer parsing. However, the real news is that ~13% earn more than $100K. This is the group that bumps up the mean.Of course, dropping out “all values below $5K and above $450K” is not a balanced edit. Which group do we imagine was larger? Why not simply show the distribution so we can do our own analysis? This is obfuscation.

     • I am quite curious, for those high earners, how many are working with “medical extenders” and how much of the income comes for seeing patients. The question simply asks, “What was your gross personal income before taxes?” Perhaps the high earners are also running acupuncture schools.

       • Agreed with your interest in getting more detail on high earners. I would like to see the data arrayed for that 60% at and below $65K. Did you get my point about the bimodal distribution? Blue sky statements about opportunities for LAcs are always based on this subset of working LAcs.

         I would like to see a workforce survey that meets essential criteria for BLS. NCCAOM recently submitted their “submission” to BLS/SOC making claims about their methods and their history collecting accurate data that BLS requires. Not at all! As though they had never read the BLS/SOC guidelines. AAAOM and NGAOM sent critiques twice before the NCCAOM Research Committee understood what was required. Here are the guidelines for how to collect data and what should be collected. http://www.bls.gov/oes/current/methods_statement.htm

         A survey of the AOM workforce has never been conducted. Surprising? I have a publication from 2010 on the subject. I wrote it in 2008. Acu journals were not interested. I found a CAM journal that published two articles at once. The other is about mainstreaming acupuncture (apologies for what might appear to be self promotion – the mainstreaming article is far more popular than the workforce pub).

         This is a good time to see how poorly NCCAOM does its job. Their “submission” and the 2014 JA reveal a lot about their “expertise”and their ability to lead the profession.

         • Yup, I get what you mean about the bimodal distribution.

           The NCCAOM should not be leading the profession. The NCCAOM should not need to lead the profession. They are a credentialing agency with their own agenda. Until we can develop a voice for the working professionals, we’re at the mercy of the schools and agencies that make money off continuing to do what they’ve been doing — , founding schools, churning out grads (the more degrees the better) and administering tests.

         • In 100% agreement with you Joe. Call me.

4. Excellent article on the relationships between licensing and occupations and workforce modulation.

   “in the states where the occupations were unlicensed, there was a 20% faster growth rate than in states that did license these occupations”

   This sums up the status of acu schools. The more they proliferate the lower the quality. The “good” schools are disinclined to eliminate or call attention to the obvious visa scammers and tuition mills because that might cast a slight shine on their own performance outcomes. 40% of Calif licensing exam test takers are repeaters (only 10% for NCCAOM). Conclusion? Many schools admit too many students for the tuition which students are convinced to apply for by the schools.

5. Good posts on questions about LAc workforce information. NCCAOM releases information selectively. The 2008 JTA reported “70.1% earn $60,000 or less.” In 2010 NCCAOM released a second report stating “the average income for an AOM practitioner working full-time is roughly $60,000 per year…overall average income is much less when the number of part-time practitioners is included in the analysis of income level.” (Acupuncture Today, September, 2010). 58% of their sample worked part time (less than 30 hrs/week). Dropping respondents out of the sample requires explanation. Dropping as many as 300 from a 1500 sample definitely will affect the mean and the median. The 2014 JTA claims a majority of respondents work f/t (30 hrs plus). I have to review the 2014 JTA once more. The NCCAOM recently sent a “submission” to the SOCPC (BLS office that creates job codes – LAcs do not have one) that was significantly massaged following input from AAAOM and the NGAOM. The tone was reduced from “capable and authoritative leadership” to a more appropriate “doing the best we can.” NCCAOM should not be conducting national surveys.

   Regarding the NCCAOM exams…these are utilized state-by-state on the basis of convenience. That is why the credentials differ so widely state-to-state. Each state regulates its professions. That is the outcome of a Supreme Court from the 19th century (?). The key to national standards is a functioning federation of regulatory boards that effect uniform laws. Acupuncture, along with other health professions (but not the big ones), is not yet there. The California battle presently taking place has tremendous implications for the the nature of national standards. NCCAOM and ACAOM are not the bearers of national standards. Both groups work hard to conceal information from the practitioners.

   The LAc dropout rate is widely known but never documented. How can a “national” standard bearer ignore this issue? Student loan debt and schools that operate as tuition mills is in the crosshairs of the USDE Gainful Employment Guidelines. ACAOM sent a letter to USDE asking for AOM schools to be exempted.

   There is too much distortion in this profession. I have several publications under my name that can be accessed through pubmed or google scholar. EXPLORE journal has accepted a new pub titled “Acupuncture Practice Acts: A Profession’s Growing Pains.” The focus is on the tremendous variation in scopes of practice and other statutory features.

   I am sitting on quite a bit of workforce information. The NCCAOM is sitting on more! I am interested in a working group that coalesces what is known about the LAc practice/workforce based on published outcomes.

   • Your desire for a working group mirrors my wish that any of organizations/agencies — state, national, whatever — would focus on strategic planning and policy. Rather than taking a good look at where we are, where we could go, what we would gain or lose from choosing one direction over another, we, instead, continue to battle other health professionals over turf. And, while we may win a battle here or there,we are not going to win that war. But the average practitioner will continue to complain about the PT offering pain relief next door while accepting that they have to go to Facebook to find out how to bill insurance or turn a breech baby and that what they were told about the opportunities in the field were mostly fiction.

     • I belong to the NGAOM. We have a strategic plan to move LAcs into the mainstream; not everyone, just those who like the idea. We have a diverse membership that does not agree on everything. Turf battles over needling is an example. Many members actively support opposing encroachment. I choose to put my time and efforts into mainstreaming acupuncture. I believe that work will lead to jobs. Very few LAcs get involved in policy matters. We have to choose between goals. The workforce data are pretty strong. LAcs are not earning a living wage when private prx is the only choice.

       • It will be interesting to see how practitioners do as they move into the mainstream models advocated by NGAOM. I’m not sure it will be better, but time will tell. IMO, the biggest issues are that few grads come out with few business skills. As long as they have come out with the common attitude that “if people want acupuncture they will find a way to pay for it” they aren’t going to succeed in any model.

         And, LAcs do get involved in policy matters, just not consciously. When they attack PT’s doing dry needling, or allow a state level change requiring the OM, they are getting involved.

   • Thank you for this post Dr. Stumpf. I was not aware of your website and will return to it with great interest. I am delighted that you have made this contribution to the discussion. I wanted to comment on one sentence in your post though.

     “Regarding the NCCAOM exams…these are utilized state-by-state on the basis of convenience. That is why the credentials differ so widely state-to-state. Each state regulates its professions. ”

     Yes, each state regulates occupations but there is a great deal of evidence that regulation (or in fact lawmaking) is not done on behalf of the “public” but rather on behalf of the occupation regulated. I do not think that this is a trivial point.

     Yes the NCCAOM examinations are a ‘convenience’ for lawmakers and regulators but there is no compelling evidence that they assure competency or public safety. In Delaware OM certification was accepted by practitioners in the state although they knew full well that institution of this law would greatly reduce competition, by greatly reducing the pool of potential applicants for a Delaware license. They knew because I told them it would and presented data in support of my arguments. During the debate I challenged the NCCAOM rep to produce data (or even a rationally based statement) in support of any counter arguments. She did not because she could not. Even worse the majority of practitioners to be grandfathered in would not meet the standards they were willing to impose on everyone else. One individual to be grandfathered in had not written any NCCAOM examinations, attended a school of acupuncture or Oriental Medicine, or participated in a formally organized apprenticeship program. The law started out as a simple acupuncture law but at the very last committee meeting, before it was to be released to legislature, we were told it would be an OM bill or the highway.

     I believe that had acupuncturists been willing to walk away from the table at this juncture it would have been possible to change the outcome. So when we look at the issue of ‘convenience’ here it might be important to note that choosing one set of requirements (I refuse to call them standards) over another is a convenient way for the group to be licensed to reduce competition by supporting them. Furthermore physicians and chiropractors were given the authority to practice Oriental Medicine although no training requirements were specified in this law (and are still not specified in their regulations). And of course our certification agencies, schools, accreditation agencies, and exam administrators are all beneficiaries of these policies.

     It is also important to note that there have already been successful legal challenges to the terms of this law and there will be more unless the law is changed. So while I agree that, in principle the NCCAOM exam may have been perceived as a ‘convenience’ by some, it has turned out to be a massive inconvenience for practitioners, the state itself (because taxpayer money must be put to legal defense of the law), and potential clients of acupuncturists. I am aware of cases in which physicians and chiropractors in Delaware have wanted to hire practitioners to work in their clinics but have been unable to do so because of the shortage of practitioners in the state. While these arrangements may be of limited value to experienced acupuncturists that can be very good for practitioners moving here from out of state wishing to get a foothold in a new place. I happen to believe that unjustifiable restrictions on labor mobility are a massive inconvenience.

     All that aside–you raise some exceedingly important points and ask many of the same questions I have been asking for decades now.

     • Mr. Wiper – Thanks for the comments. I use the phrase “standard of convenience” to challenge the NCCAOM claim that its exams are a “standard of Excellence.” Evidence showing the NCCAOM exam reflects excellence is on point. In fact, the only other AOM exam is the California licensing exam – CALE. The two exams differ because licensing and certification exam serve two distinct functions. Cert exam like NCCAOM purportedly address “excellence” while a licensing exam assures “minimum competency.”

       California is home to ~40% of all LAcs. The next largest state has ~10%. In Calif we are contending with NCCAOM referring to Calif as the ONLY state that does not use the NCCAOM exam. Seeing as we have the greatest number of LAcs and schools, and that the CALE covers the material in one exam that NCCAOM does in 4 modules, and the CALE costs one third to take, we have some good reasons.

       Delaware has fewer than 100 LAcs and is regulated under the Bd of Med, correct? Approx one quarter of states with a practice act have fewer than 100 LAcs. There is a place for an org like NCCAOM. However, it is not NCCAOM as presently operated.

       Convenience is a fiscal and practical choice for the majority of states that have less than 300 LAcs. NCCAOM is there to accommodate.

       • It is true that it is convenient for states to rely on the NCCAOM credentialing process — but there it is no more convenient or fiscally prudent for the state to demand the OM credential over the AC credential.

         I have no problem with California continuing to administer the cheaper CALE exam as an option — however, for those who have already earned the NCCAOM credential it is neither cheaper not more convenient to require the CALE in addition. The only justification would be whether those holding the CALE have a better safety record than those with the NCCAOM credential. There is zero evidence of that being the case.

         Additional exams or extra levels of credentialing have not been shown to benefit anyone other than the schools and the exam givers.

         • You are making the argument for licensing vs credentialing. What is the point of having 4 modules as does NCCAOM? There are very good reasons for Calif to have its own exam: Calif law requires 3,000 hrs training (ACAOM = 2850) and 23 specific content areas with hourly specs (ACAOM defers to states). These are highest “standards.” There are NO national standards (also known as KSAs).

           Additional levels of credentialing is often motivated by $$. Perhaps it is not so widely recognized that NCCAOM has the deepest pockets of any acu org not including ASH.

           IMO the issue is not really the exams. It is the schools. There are 50+ AOM schools for 30,000 LAcs. There are 16 DC schools for 80,000 DCs. 40% of CALE test takers are repeaters. That tells me there are too many students not qualified to be in school. Unless the schools are not really in the acupuncture training business. http://www.mercurynews.com/ci_21222408/sunnyvale-university-ceo-indicted-visa-fraud-charges

       • I use the phrase “standard of convenience” to challenge the NCCAOM claim that its exams are a “standard of Excellence.”

         It is, of course, absolutely correct to point this out. The NCCAOM examination is little more than the product of a political process. Exam content is determined, ultimately, by their periodic JTA’s and so-called “item writing workshops”. The JTA surveys are periodically sent to practitioners who frequently have little actual experience and, when asked what it takes to perform acupuncture competently, safely, and effectively can only parrot what they were told in their schools and colleges (or gleaned from cramming for the NCCAOM examinations). There is no real meaningful oversight of this process. Anyone who has participated in this survey can see that it is engineered to drive a particular set of answers which are then used to rationalize the processes of curriculum development and accreditation. The process is circular. If you ask persons practicing acupuncture what it takes to practice acupuncture safely and effectively, what answers can they give but those they were given in school, especially if no questions probe the extent to which some practitioners may dissent from the status quo? In my own case I think a discussion of the relevance of the NCCAOM examination to clinical practice is long overdue, and I have been practicing for 34 years.

         You are spot on about the California examination. A single licensing examination given in a single module may just as effectively assure ‘competency’. I do have trouble though, with the idea that either certification examinations or licensing examinations assure competency. There is no credible evidence that they do. The quality of your training (be it by apprenticeship or in schools) is what assures this.

         Perhaps it would be appropriate to examine applicants on clean needle technique, since an argument could be made that this might the public. But I would argue though that any school that graduates students without assuring they have a grasp of this, or how to avoid puncturing lungs, should be shut down. I suppose an argument could be made that applicants might also be required to pass a test on the applicable regulations and rules for practice in that jurisdiction.

         What would I like to see? I believe in the replacement of occupational licensing with simple registration based on assured competency. Graduation from an accredited program should suffice. Once you create a board you introduce the possibility of massive conflict of interest. The American Academy of Medical Acupuncture will also certify applicants from an apprenticeship program. The NCCAOM also currently permits apprenticeships to serve as a basis for writing the certification examination. I have guided two apprentices through this process who will make excellent practitioners. They were permitted to write the four modules based on this apprenticeship and certified after taking the Clean Needle Technique module. I assure you that I made them work harder than any school makes anyone work. I did not accept any money for training them. That is a long story that would lead us into a philosophical debate. It is fair to say that the NCCAOM made more than I did on my apprentices.

         It is also important to point out that while the NCCAOM examination is indeed touted as a certification examination it has become the basis of licensing in several states. I do not know the exact number but I would guess it has become the basis of licensing in most states. In that respect debating whether the NCCAOM examination is a licensing exam or a certification exam is moot. And finally I would like to hear someone make a well supported argument that anyone who has practiced legally without complaint or incident in any other state should be permitted to register to practice anywhere else.

         On the question of the number of practitioners in Delaware–45 have been issued licenses but I am quite certain that fewer than half ever practice here.

         best wishes,

         Joseph

         • A correction which should be obvious from the context but:

           “And finally I would like to hear someone make a well supported argument that anyone who has practiced legally without complaint or incident in any other state should be permitted to register to practice anywhere else.”

           should read:

           And finally I would like to hear someone make a well supported argument that anyone who has practiced legally without complaint or incident in any state should not be permitted to register to practice anywhere else.

         • Licensing is based on minimum competency, testing to assure the public all licensees have the same basic knowledge. Certification is for showing exceptional knowledge. Nearly every state other than CA uses the NCCAOM exam (number of modules or which ones usually not specified) exam as a criterion for licensure. Every state board reserves the right to grant licensure. This is true for every health profession. 29 of 45 states with an acu law (incl DC) have reciprocity with other states although with varying conditions. If you read some of the differences in laws you might also reconsider reciprocity as a good idea.

           Acupuncture is a young profession in terms of its development. Still needs KSAs developed by the licensees which will lead to uniform practice acts. NCCAOM and ACAOM cannot sustain their present political positions.

         • “Licensing is based on minimum competency, testing to assure the public all licensees have the same basic knowledge. Certification is for showing exceptional knowledge.”

           Thank you for reminding us all of the basic theoretical distinction between licensing and certification. However I don’t think it is relevant to this discussion. The question is whether either licensing or certification actually assures that the public will be protected from charlatans and incompetents. The “protection of the public” argument is frequently (actually almost invariably) made to state legislatures when they are approach legislature to lobby for “the right to practice” and title protection. In truth this might the only legitimate argument that could be made in support of licensure. If you believe that I am arguing for reciprocity you misinterpret me. I am arguing that no legitimate valid argument can be made for excluding any practitioner who has practiced legally and without incident or complaint in another jurisdiction from setting up shop in another state. But perhaps you could cite passages from some of the defective laws you mention and document that these deficiencies have resulted in actual statistically significant harm to the public. In any event I do not have to “reconsider” whether or not reciprocity is a good idea because in fact, I consider it also irrelevant to this discussion.
           In our own state a Superior Court a Superior Court judge remanded the denial of a license back to the medical board (Briggs v. Delaware) for not giving adequate reason for the denial (the question was whether the applicant had to meet all of the conditions stipulated in the law to receive a license). The State chose not to contest the remand, not wishing to contest the validity of the law. In another case in Delaware an attorney representing two rejected applicants made several arguments against the denial of their licenses citing that the law, among other things, may violate the Privileges and Immunities clause of Article IV of the US Constitution. They received their licenses before the case went to court.
           And while “every state board reserves the right to grant licensure”, it is prudent to remember that every board member serves at the pleasure of the Governor, who, in turn, serves at the pleasure of the people. And furthermore boards themselves would not exist without the laws that create them and define their responsibilities. Whether or not these boards are good ideas is a question that is being looked at more closely. I am sure you are aware that in a number of states (Michigan is most relevant here) there have been movements emanating from within government to abolish unnecessary occupational licensing. Acupuncture was one of the 18 occupations and 9 Boards targeted for elimination and deregulation in Michigan after a lengthy study determined that this could be accomplished without harm but rather with benefit to the public. I am skeptical of the idea that KSAs will ever be developed by acupuncture licensees because as I see it, it will be impossible to get everyone to even sit at the same table. Be that as it may, I think it is important to take from this discussion the important things we are in agreement about.

         • Let’s not forget about this —

           http://www.scotusblog.com/case-files/cases/north-carolina-board-of-dental-examiners-v-federal-trade-commission/

         • OK Joseph. You’re aggravated. You should join up with others who share your views and form an agenda with realistic goals to effect change. I admit I am not persuaded by arguments that belong in courts of law. I am not much interested in philosophy or being “right.” I put a lot of value in being informed and understanding how things work. I try to use data to inform myself and others who share my goals. Together we try to make persuasive arguments.

           My points about licensing vs certification are essential to framing arguments about why Calif should operate independently (one shared goal) and why NCCAOM is NOT a leader in this profession (another goal). Your opinion is fine but not nearly enough to move this profession in a new and improved direction. If we are going to continue we have to agree moving the profession in a new direction, i.e., towards the mainstream, is a shared goal. I work with enough people now to pursue this goal. I am not recruiting. Acupuncture is a health profession that is outside the mainstream, marginalized; widely ignored by other health professionals and payors. We need a strategy that addresses the small details to change our circumstances. That strategy includes KSAs. Honestly, I do not think you are informed about the role they play in establishing standards. This is a history lesson that has played out in many health professions, recent and ancient (at least 150 years ancient).

           Important things we are in agreement about? 1. NCCAOM disguises and conceals data. Now what do we do? 2. Importance of data that are collected according to standard and defensible sampling methods AND that reflect real world concerns in acupuncture; not just the marketing interests of NCCAOM and CCAOM. And your next step is?

         • Well, I knew it, somewhere in there we are in agreement about a couple of things and I suppose that is a good thing. I am not sure that making declarations about what we are or are not sufficiently informed about can move this discussion forward. Let me just say that I definitely know more than you give me credit for. My next step? I want to work toward replacing the law in Delaware with one that both protects the public and the interests of practitioners. It is a small thing but one that I think is achievable. I expect an uphill battle though.

           The ‘mainstreaming’ of acupuncture will also be an uphill battle especially given the scientific consensus, reflected in a number of systematic reviews published in peer reviewed biomedical journals, that acupuncture has failed to demonstrate efficacy. Please read Acupuncture is a Theatrical Placebo by Colquhoun & Novella (Anesthesia & Analgesia, 116(6): 1360-1363) and tell me how we will be able to persuade anyone that any of our arguments regarding certification or licensing should be taken seriously. And this is only one of many recently published review articles that take acupuncture researcher to task for shoddy workmanship. Better yet, if you think he is wrong yet go the blog of David Colquhoun (http://www.dcscience.net/) and take the issue up with him. He loves to field questions and criticisms. That will be an interesting exchange I am sure. So there you have it, we have accredited schools, certification and licensing agencies, laws and regulations, and state licensing boards yet despite all this oversight there is no credible evidence that what we do is effective. Do you really think that under the circumstances investing energy in developing KSAs is what we need to be doing? However, I will acknowledge though that all too often political action, which appears to me to be your primary activity trumps reason, evidence, and common sense. No offense intended–it is just an observation based on experience. I wish you the best of luck. KSAs could, I suppose, if it were possible to develop them, be a useful tool that could potentially be used to reform our laws, regulations, and systems of training certification, and licensing. Do I know enough about their history? I do not. I promise to read up on them. But I do know how boards do their work and how stakeholders write laws and regulations, and I am impressed only by how much they seem to get away with. One more issue, I am not interested in “being right” (if that is what you believe about me), but I am interested in the “right thing” being done. Laws and regulations that shut out perfectly qualified practitioners without good reason, do not pass the “smell test” with me.

         • Are you all familiar with this study? http://www.hhh.umn.edu/people/mkleiner/pdf/Final.occ.licensing.JOLE.pdf

           Paul Ryan may well try to put more focus on this issue.

         • Changing the law in Delaware is probably a good idea. You could pick five of the 45 state laws (incl DC) out of a hat and get five that need revision. Practical idea… with 45 LAcs in Delaware isn’t it better to put your energy and effort into establishing some kind of defensible national standard that can impact all laws? Maybe not.

           I am interested in political action. The evidence base for acupuncture essentially shows acu is good as placebo. Most folks do not understand that placebo is an effect, just not attributable; i.e., better than “sham.” However, I only see the evidence base as a card to play when writing a treatment protocol for a payor. The card to play in acu politics is workforce. Thanks for the Colquhon citation. I will read it. Here is a 2013 vol of Med Acu on mechanisms of action http://online.liebertpub.com/toc/acu/25/2

           Vickers 2014 published the most recent meta analysis of acu effects. Very brief. Helpful. You can find it online.

           You summed the situation up succinctly, Joe: “we have accredited schools, certification and licensing agencies, laws and regulations, and state licensing boards.” And? This is where the struggle begins, not ends. Many schools are tuition mills. The USDE is going to close many. OIT would be better if our state boards took action. There are only 16 Acu Boards. Acu is regulated mostly by Med Boards, some but not all with acu advisory committees. There’s a mission: how to provide the various advisory committees with the arguments they need to strengthen practice while protecting the public. KSAs play here. No KSAs, no standards. NCCAOM says it has KSAs. But developing KSAs is not their realm. Development of KSAs belongs to the licensees.

           You are tilting at windmills. You need a project. Find the sections in the DE law that you wish to change. I would suggest beginning with the scope of practice and the definition of practice. IMO Hawaii has the best of both in the nation even though it mentions energetics (some do not). HI also mentions functional medicine. This is where acu belongs for those who want to join the mainstream.

         • My sense is growing that the independent Acupuncture Boards have been relatively detrimental to the profession. There are exceptions, of course, but too often there seems to be a limited understanding of what a regulatory board should be doing. How are things for practitioners in Nevada? If it weren’t for Medical Board oversight in DE there would be fewer LAcs, not more.

           The actions of many LAcs might be doing more to keep us out of the mainstream more than our education, credentialing, etc. Look at our responses to the PT’s and MD’s who are actually believers in the power of the needle — do we have outreach? do we build relationships. No, we attack, and write about how they are putting people at harm, can’t possibly know what they are doing, etc. This is no way to make friends and influence people.

         • As Juila Child always said “…independent Acupuncture Boards have been relatively detrimental to the profession” The proof is in the pudding. Professions follow a well worn path when it comes to establishment. One of the first steps is to create 4 interlocking orgs: one that represents and speaks for the professionals/licensees; one that accredits the schools; one that manages the testing; and one that represents the schools. In acupuncture these are the persons that take responsibility for leading the profession to where it is today. From that POV things are always getting better. Except the data consistently show far too many LAcs are unable to earn a living, too many schools fail to train, and the “leadership” orgs turn a blind eye.

           Mark Seem, acu historian, wrote in 2011 (paraphrased here) that the process of establishing acupuncture was directed by the organization representing training programs (that would be CCAOM). A compromise was sought between factions who differed on whether biomedicine or Traditional Chinese Medicine should be the underlying basis of acupuncture training. This long-standing factionalism produced compromised outcomes that failed to unify support or direction. [Seem M. (2011). AOM Education & Practice in the 21st Century: A Bold Step Forward. Acupuncture Today.]

           Divisiveness within the profession is toxic and serves no purpose except to divide and conquer. I always wonder what is the treasure worth so much in-fighting given the current state of things.

           Here is a thought. My guesstimate is that fewer than 10% of all LAcs are involved in any of these orgs. Leadership has usually been like musical chairs. This changed with the March 2013 battle between CSA and AAAOM which was resurrected this year with the Acu Today attack on the AAAOM board and President. All for naught.

         • The Acupuncture Today stories on the AAAOM was among the more useful things that publication has done. While I am sorry that not more has happened in response, I think the expose was not for naught. One reason so few LAcs are involved — the kind of crap that was going on at the AAAOM. There were good people attempting to serve — and many left saying never again.

6. A few remarks on the most recent 2013 NCCAOM JTA Demographics survey:

   On the Demographics survey:
   Right you are again Elaine–it is almost certain that the $52,000 figure cited as the median income of acupuncturists gives a distorted picture of how well acupuncturists are doing (and it isn’t very well). The presentation of the data raises a number of questions for me:
   1. The mode (most commonly reported income) for the survey is between $5000 and $25,000 (234). This is considerably less than the $52,000 reported as the ‘median’ income of practitioners.

   2. The survey is distorted in other ways too. In reporting incomes the NCCAOM removed all values under $5,000, giving an N (population on which the analysis was performed) of 1112 (see question 23). This seems quite significant, given that the N for most other questions typically runs close between 1400 and 1500. It is quite possible that the largest category of respondents and therefore the mode for the survey is less than $5000 and this could represent 200-400 respondents). Without some explanation and clarification we really don’t know what this income distribution indicates. But I think it is fair to say that we still do not know how acupuncturists as a whole are actually doing (this is me being diplomatic).

   3. On the issue of the distribution of credentials I think it would have been very interesting to drop some of the states (like Texas) that require herb certification in order to practice acupuncture from the survey and present figure that gives us a sense of how many practitioners have voluntarily sought herb certification (when not compelled by occupational licensing laws). I believe that considerably more than 67% of acupuncturists would hold acupuncture only certification if not required by their state legislatures. When I was working to oppose the Delaware law as it was being written the figure only 17% of acupuncturists held OM certification. This figure was based on numbers generated from the NCCAOM database and their most current surveys. Furthermore it excluded, from this total, a very significant number of practitioners in states that did not require NCCAOM certification even in acupuncture in order to practice. At that time Maryland was one of those states. Now the numbers are shifting. And this, of course, is why that the hand of the NCCAOM has been so visible in lobbying efforts connected with the push for new OM laws (requiring herb certification) in newly licensed states like Delaware and in efforts for changes to established acupuncture laws in states like New York.

   • Thanks for making these points. I know there is a lot more to be gleaned from the data.

     At some point in elementary school my daughter learned to make box and whisker plots and one of those might be very helpful in looking at the income data. I’ll have to see whether I can come up with the right incentive ….

     As to point 3, I know that most current students are being told that they should go ahead and get their herb credential as “that is the direction things are going” and “you will need it some day.” Then, of course, once most practitioners get it they will be all too happy to require it of everyone.

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