Entry-level doctorate in OM is the wrong choice

[Chris Kresser]

I recently received an email from AIMC asking me to complete an AAAOM survey on whether an entry-level doctorate would be a positive step forward for the AOM profession. Several potential benefits were mentioned, from increased employment opportunities in hospitals to enhanced recognition and acceptance of the AOM profession by the general public and medical establishment.

I am strongly opposed to the idea of an entry-level doctoral program for our profession. We're experiencing a crisis in health care in this country. Millions of Americans don't have access to timely and effective health care. 15% of Americans don't have any form of health insurance. Yet the U.S. spends more than any other country in the world on health care - 16% of its Gross Domestic Product (GDP), or an average of $7,026 per person per year. In nine years health care spending will be one-fifth of the economy. Per-person spending will nearly double.

But what do we have to show for it? The U.S. is not healthier for the money. Despite our vast resources, the U.S. ranks 34th in life expectancy (behind Boznia-Herzegovina and Jordan) and has a higher infant-mortality rate (tied with Slovakia and Poland) than many other industrialized nations. A survey by the Commonwealth Club indicated that half of Americans did not receive any preventative care in 2005, and that 100,000 deaths between 2002-2003 could have been prevented by timely access to health care.

Acupuncture and Oriental Medicine have the potential to provide affordable and effective health care to a large majority of the population. I say "potential" because the current model of how acupuncture & OM are practiced in this country make it accessible to a very small percentage of people. It has been estimated that less than 20% of the population can afford to pay for acupuncture on a regular basis. This is significant because both the classical literature and the modern scientific evidence supporting the efficacy of acupuncture clearly indicate that it must be administered at least once a week, and preferably more often, to be consistently effective. At an average cost of $75+ per treatment, acupuncture is simply not affordable for the vast majority of Americans.

An entry level doctorate will only make this worse. As the cost of education and licensing rises, so too will the the average cost of treatment. But can the market support such an increase? There are already serious doubts that the current "boutique" model of acupuncture, in which patients are treated individually in "spa-like" settings, is sustainable. A recent OCOM study revealed that the average annual income for its graduates in full-time acupuncture practice is $75k. That sounds good until you realize that this figure is for gross income, not net. Remove 50% for overhead and another 30% for self-employment taxes, and you have an average take home income of about $26,000. Another study by the AAOM showed even worse results for the acupuncture profession. 43% of respondents brought in less than $40K, gross. That means 43% are making less than $20K, which means a lot of acupuncturists are earning wages below the poverty level. And we haven't even mentioned the ugliest statistic at all: between 50-70% of acupuncturists (depending upon which study you look at) are not practicing at all five years after graduation.

Clearly neither the majority of patients nor the majority of acupuncturists are benefiting from the current "boutique acupuncture" (BA) system. Adding an entry-level doctorate program, which will escalate the costs of education, increase the already considerable average debt of OM school graduates, and increase the average treatment cost as a result, will only make the situation worse.

What we need instead is to reduce the number of hours required to receive a license to practice acupuncture, and reduce the cost of education. This would make acupuncture more affordable. Affordable acupuncture provides not only a social benefit in the form of making effective health care accessible to a greater percentage of the population, but also a stronger and more stable business model for the practitioner because they have a larger pool of potential patients to draw from.

These benefits have already been realized in the relatively new but rapidly growing model of Community Acupuncture (CA), developed by Lisa Rohleder and pioneered in her clinic Working Class Acupuncture in Portland, OR. The low-cost, high-volume CA model makes acupuncture affordable for more than 80% of the population, with sliding scale payments ranging from $15-40 - about the same cost as an insurance co-pay. And because patients can often afford to come more than once a week at this rate, CA practitioners report that they are getting much better results than they were when they saw patients once a week or even less frequently in their conventional BA practices.

At first glance it may seem that the practitioner could hardly make a living by charging $15-40 per treatment. However, because patients are treated in armchairs with distal points below the elbows and knees in a common room, and diagnosis relies heavily on tongue, pulse and a brief conversation with the patient, it becomes possible for each practitioner to treat up to six patients per hour. At an average payment of approximately $20/patient, that represents income of $120/hour (gross, of course) per practitioner. Indeed, in its fourth year of operation Working Class Acupuncture has gross revenues of over $300,000. Also consider that with hundreds of patients per week instead of 20-30 (Working Class Acupuncture currently has 450 patients/week, and other established CA clinics have 200+), there are exponentially more people that are marketing your services to their friends, family and colleagues. And whereas the loss of a few patients in a standard practice could represent a large fraction of your income, a CA practitioner would hardly even notice if a a few patients stopped coming.

The point is that CA solves two problems at once. It offers affordable and effective health care to a large percentage of the population, while providing a stable and rewarding livelihood for the CA clinic owner(s) and employees. But in order for this model to become even more viable, the cost of acupuncture education must be reduced.

In sum, the entry-level doctorate is precisely the opposite direction we should be moving in. We need to make acupuncture cheaper and more accessible to a larger number of patients. We need to create stronger and more viable business models for practitioners. And we need to reduce - not increase - the time and cost required to get a license to make those goals possible.

For thousands of years, and in most of Asia still today, acupuncture has been a "medicine for the people". In the U.S., it is in danger of becoming a luxury of the elite. An entry-level doctorate will only accelerate this disturbing trend.

[Daniel Fonte]

Chris,

You bring up some interesting points. I have over thirty years experience with insurance companies in an automotive setting. It was extremely challenging to negotiate with them in order to receive a fair price for my services. This forced me as a business person to hone my skills of negotiation, understand my business costs, write an effective damage quote upfront, and become familiar with the insurance companies requirements to contain costs. In this way I was able to run several highly profitable shops. On top of this, there was an extremely effective professional association that protected the rights of shop owners. It advocated uniform billing, a bill of rights for consumers, a code of ethics for insurance companies, and published a monthly paper so shops could see what struggles shops were having with insurance companies around the country and be aware of similar tactics in their state. Insurance companies are not exempt for anti-trust laws and this is an effective tool if a pattern of non payment arose.



I believe that our need as acupuncturists is to become better business people. Similar stats exist for new business ventures in all fields. Some of the biggest factors of business failure are under capitalization, poor management skills, poor business planning, and poor marketing. As a business one size does not fit and this will fall true with acupuncture. We need patients to support our business’s and we need to be very competitive and creative to capture them.



I believe we need a strong professional association advocating for our rights as business people. We need to not fall into the trap that md’s and dentists are currently experiencing. In order to maintain a practice they must conform to insurance discounts, do the billing for them, administrate their bills according to their agreements, and allow to be put on the insurance list of preferred providers. Modeling a business on being a preferred provider, restricts the business from capturing new clients, I can’t go to you if you aren’t on my insurance list. We need to face the fact that insurance reimbursements are going to part of our business billing. A strong professional association will advocate for our rights to government regulators and insurance companies.



As doctors we will gain clout as a professional group. Doctors of chiropractic had fierce opposition from the AMA. If it wasn’t for their strong lobbying association they would be in worse shape then they are.



Finally in regards to the cost of our education, potential doctorate program and startup costs for our practice, it’s cheap. Open a restaurant, retail store, flower shop and I bet 150,000 is a bargain. Plus we get it at 5-6% and never get turned down for a gov’t loan. With a strong advocating body we could have some of these loans forgiven by working with the segments of society shunned by traditional healthcare. I would gladly do a doctors without borders to satisfy some of my loans.



I think these ideas will benefit us.

Peace,

Daniel



"I can be here now and somewhere else later"--

Daniel Fonte

[Chris Kresser]

Dan the man,

Thanks for such a thorough response. I can tell you've thought about some of these issues a lot, and it was very informative to hear about your experience with insurance companies over the years.

I definitely agree that the lack of business experience is a big problem for many people entering this profession. Acupuncturists (and those in the healing professions in general) often open a practice believing that their desire to help others and their training in their chosen modality will be enough. It usually isn't. Opening a practice is starting a business, and running a successful business requires completely different skills from simply being a good acupuncturist.

But this isn't the whole story, because there are several examples of acupuncturists who had a conventional practice that switched over to a community model and became much more successful. Opening a community clinic is just as much of a business endeavor as running a private practice. In fact, it is probably more ambitious because community clinics often have larger facilities and more complex legal and administrative organization, including employees on payroll with benefits, etc.

In these cases it wasn't additional business experience that contributed to greater success. It was a dramatic increase in the pool of potential new patients and in retention of existing patients enabled by the low-cost, high volume model. The community model also tends to ramp up much more quickly than the conventional model, which means the business owner doesn't have to raise as much start-up and operating capital and they reach break-even much sooner. This makes everybody - especially the lender - happy.

You are no doubt aware that we're just getting started with a very nasty economic downturn that is likely to last for several years. Unemployment is projected to rise to more than 12% next year, and that's using the government's manipulated data. Most people have health insurance through their jobs. More people without jobs means more people without health insurance, and more people who can't afford to see an acupuncturist for $85 every week. So even if we ignore the social and political issues I raised in my original post, it's likely that the community model will be more viable for the majority of acupuncturists.

I'm not saying that it won't be possible for some acupuncturists to be successful using the conventional model. I'm just arguing that they will be the exception to the rule, as they are even now, and that it will become even more difficult as the economy continues to tank and even relatively affluent folks feel the pinch. As such it's likely that type of acupuncture will become even more relegated to the upper-middle and upper classes than it already is.

Which brings us back to the question of how to provide acupuncture for those who cannot normally afford it. I realize that not everyone is looking at these issues from a social justice perspective. But I want to make an important distinction here: community acupuncture is not charity. It's what Muhammad Yunus calls a "social business", which is an organization dedicated to helping people while still turning a profit. Most middle and working class people do not want and won't accept charity, because of their values and work ethic. What they do want is an affordable and effective means of health care they can access without losing their dignity or self-respect.

In a recent email conversation with Mandy about this, she said she thought the doctorate was mostly about money, politics and esteem. I agree with her. I just can't see how the doctoral program will help expand the use of acupuncture and OM in the populations that need it most. It seems to me that it will instead push the profession further in the direction of exclusivity and elitism.

Benjamin replied to my email about this and we're going to get together and discuss it. I'm interested to hear his perspective as someone who's been involved in the profession and active politically within it for a long time. I'd also love to hear where you all land on this issue and what your reasons are.

Chris

[Daniel Fonte]

Chris,
Lawyers perform pro-bono work as a way of contributing to the overall health of a community. If everyone deserves their day in court, so too does everyone deserve good health. Social business is the key here, we see it with donation based yoga. A true acupuncturists will construct a business model on a dual system of retail/wholesale and serve the community. Integral Counseling Center has a sliding scale therapy program that works well. With these business models already in place we can see that they are a viable way to make money, serve the community, and keep some for ourselves. It is a free market and there will acupuncturists that will serve the elite and those that will be socially conscious. The pie is big enough for all of us to share. Everyone can afford something, we just have to, as acupuncturist decide how we want to be paid.

For us to not want to engage in politics is irresponsible. We must protect our profession as we are a state regulated business. We can model our businesses as social businesses while at the same time keeping the the government and regulatory agencies at bay. They mess with midwives enough and we could fall victim to these same naysayers. Remember we are still seen as practitioners of voodoo science.

Society always views doctors in a different light. It is how we have to work within the system. In order to gain recognition we need to play the game per the rules of the game. Being called doctor instills centuries of respect, similar to when we see a priest in their collar, a cop in their uniform, a judge in their robes, and a surgeon in scrubs. We recognize the ethos in each profession, these myths. With out these ethos we are all just a homogeneous group.We can't negotiate with the regulatory bodies if we are nothing special. Being a doctor of OM changes how we would be treated.

Always,

Daniel

[Chris Kresser]

Daniel,

I'm not knocking pro-bono work or suggesting that everyone embrace the CA model. I meant to use it as an example of a direction I believe our profession could move in to serve the greatest number of people. As you pointed out, there are many means to the same end and CA is not the only way to make acupuncture accessible.

I don't agree with you about the necessity or benefit of the doctoral certification. Or, perhaps more accurately I should say that the cost of such a certification may be too great. But I've already made my arguments on this, so we'll just have to agree to disagree.

Thanks for the dialogue,
Chris

[Sara Szmodis]

Chris,

I talk to acupuncturists every day. It's what I do. All of them are fully licensed. Most practice in California. Only a fraction of them practice in the community model. Most practice either part or full time in a more one-on-one model. The grand majority, even in these tough times, have active practices. Many have more patients than they know what to do with.

While the community model is certainly one way to be prosperous, it is not the only way. Quite frankly, I find it misleading and wrong-headed to intimate that a successful practice outside of the community model is the exception rather than the rule. As one of our teachers likes to say, there's room enough for all of us. I hope that patients who don't dig what I do will go to you or Daniel or someone else who suits them and that patients who aren't suited by others will come to me.

As regards first professional doctorate issues, I'm not sure that a title will simply cure all of our professional ills. As Daniel points out, teaching acupuncturists to be better business people may do more than any title--that and knocking off the petty infighting that keeps us from as powerful a lobby as the chiros or MDs have.

Cheers,
Sara

[Chris Kresser]

Sara,

Thanks for your reply. It's great to hear about your experience talking with acupuncturists day in and day out.

I'm not sure it's fair to claim I'm being misleading or wrong-headed when I write that most acupuncturists don't have thriving practices. After all, I'm not making this stuff up - I'm just going by statistics and surveys that have been released by organizations like AAAOM. It sounds like their numbers don't jibe with your anecdotal experience, so I'm curious about that discrepancy. Perhaps acupuncturists in California are more successful than the national average? Also, if you're aware of other surveys or studies that demonstrated higher success rates than those I quoted in my original post, I'd love to see them.

Trust me, I was pretty shocked when I first read those statistics. The reports really caused me to wonder why so many acupuncturists would be struggling. My first thought was along the lines of what Daniel suggested, i.e. that many acupuncturists are sorely lacking in business and marketing skills and that could at least partially explain the low median incomes. There's no doubt this is true. But I also believe there's more to it than that.

In any event, I didn't mean to suggest that the CA model is the only viable model, or that everyone should pursue it. I brought it up because it represents an entirely different perspective, attitude and approach to the practice of acupuncture that, to me at least, is fundamentally at odds with further increases in the cost and time involved in obtaining a license.

I agree with your statement that "there's room enough for all of us", but I'd have to amend it with "if we respond to the needs of our patients and communities". I don't believe the market is anywhere near saturation for acupuncture in general. But I do think that certain places are nearing saturation for $85+/hour acupuncture, simply because there is only a limited number of people that can afford that price. As a case in point, almost all of my friends and classmates at school cannot. (I often wonder about the ethics of offering a service that I myself and almost everyone I know and care about cannot afford. But that is a different discussion.)

I think the reason the CA model has become popular of late is that it is a response to a genuine need for more affordable acupuncture. Nothing more, nothing less. Some will be drawn to that model and some will not. But where this relates to the doctoral program is that it would be a shame for those who know they are going to practice CA to be required to go through even more schooling in order to get a license. Having higher debts and more hoops to jump through would impede their ability to keep the fees low and make their services accessible.

Thanks for sharing your thoughts!
Chris

[Dawna]

Hey Chris!

I would love to hear how your meeting with Benjamin goes about this. As you know, I really want to open a community clinic. I am one of the many people who have never been able to afford $70+ for acupuncture. Actually, I don't know many people who can afford that price. I understand the very real need for affordable acupuncture.

But, I also believe that there is a real need for our profession to take the next step, get organized, and become "doctors." We spend 3 1/2 years in a masters program. Please tell me what other master's program is this long!?! I agree with Daniel on this, having the title will make us more respected in the health community and in the state. I don't know why having the "doctor" title will "push the profession further in the direction of exclusivity and elitism." Poor people see doctors too. They just don't see doctors who charge a high price for their services. You can be a Doctor of Oriental Medicine and still have a community clinic.

I hear you say this will cost us (students) more in the end. When speaking with an administrator the other day, I was told it would be around the same price for the program change. If you have info on this, please post it. Or if someone else who knows a little more about this subject is reading this post, please clear the air for us and let us know what you know.

It also sounds to me like you are saying that if an acupuncturist wants to run a CA clinic, then it is a waste of time for them to go to school more. I simply couldn't disagree with you more. The more time I spend learning, the more valuable my education becomes to me. I wouldn't trade it in for anything. I just wish it wasn't so expensive or that I was guaranteed to make good $$$ once I am done with school.

Sara- thanks for your response. Its comforting to hear that there are plenty of acupuncturists out there supporting themselves and making a good living.

Cheers!

[Chris Kresser]

Hi Dawna,

Yep, our Master's program is much longer than any other I'm aware of. But whereas you suggest we keep it the same length or extend it and come out with a higher degree, I suggest we shorten it and keep our degree the same.

Poor people sometimes don't see doctors, actually. Some don't have health insurance, or some have health insurance with a high deductible that they can't afford. Others feel intimidated or put off by the white coat. But I certainly agree that you can be a doctor of OM and still have a community clinic. The question is, why should you have to be? If you are spending 10-15 minutes with a patient and doing acupuncture only, rather than acting as that person's "physician", why is it necessary to go to school for four years?

I value my education as much as anyone I know, but the truth is that there are many ways to educate oneself. A formal school program is only one of those ways, and in my personal experience, it's one of the most costly and least efficient ways of learning. For example, I recently took a two-day acupuncture workshop outside of school. I feel like I learned more practical acupuncture skills in those two days than I learned in two years at school. As acupuncturists we are (hopefully) committing ourselves to a lifetime of learning. In fact, we are legally required to continue our education when we finish school in order to retain our license. So I do not see "education" and "school" as being synonymous.

You might be right that the entry-level doctorate wouldn't cost us any more. I don't think there's a consensus on that yet. If the number of hours is extended, it seems inevitable that it would cost more even if the tuition stays the same, simply because most students use loans to support their living expenses and the longer they stay in school the more loans they will need to take out.

The thing about professional programs is that they are expensive. Wishing that they weren't isn't going to change that, unless we get some major new federal or state funding to offset the cost of our education. California is nearly bankrupt and the federal government isn't far behind, and there is no political will for this at all, so I don't see it happening anytime soon. Nor is it likely that we'll be guaranteed a good living once we're done with school in the foreseeable future. The only way we could get close to that is being "hired" by HMOs or hospitals like doctors or nurses are now, and there are no signs that we're anywhere near that happening.

So it seems to me we need to deal with the reality of our situation, which is this: the median income for an acupuncturist is not commensurate with the cost and length of the licensing program. I'm opposed to the doctoral program because I don't think it will do much to remedy this problem. I think our profession should be channeling our energy into other activities, such as strengthening our lobby (as Daniel and Sara mentioned), training graduates to be sharper businesspeople and reducing the cost of education.

[Dawna]

Poor people do see doctors. We/they go to community clinics where we have to wait and wait and wait for 6 hours in an uncomfortable chair in a cold waiting room, before seeing a doctor who will probably just look at you for 2 minutes before prescribing some nargly antibiotic with side effects like tendon rupture and arthritis to treat your runny nose. But, we do see them when we feel we need to. We just go to the ones that charge the least amount of money.

As far as shortening the program, I am entering my 10th trimester so it doesn't really apply to me. By the time I graduate in April, I will have spent 3 1/4 years (summers included) in school. This is much closer to the doctorate degree then to a master's degree. I don't think its wrong of me to want the title. School is extremely time consuming and stressful. I and many of our classmates have put in a lot of energy and effort into learning to be the best health care professionals we can be. I haven't heard one student say acupuncture school was a breeze. To me, knowing that all my hard work and effort will be paid off with a doctorate degree makes me feel more assured.

I personally do not think the program should be shortened. If you would have asked me 2 years ago, I would have said, "hell yes, make the program shorter." But not now, not after I have been working in clinic treating people. Patients are complex and I really value my time learning in the clinic.

Thats just my 0.02!

[Chris Kresser]

Dawna,

It's clear we don't see eye to eye on this, and that's fine. I'm not invested in you agreeing with me.

I do want to reiterate a couple of things I mentioned in my last post, though. There are really only three ways I can think of that poor people could afford acupuncture. One is the CA model. Two is pro-bono or reduced rate services specifically for poor people (i.e. free clinics, charity, etc.). Three is if acupuncture is completely integrated into the health care system so that a poor person could see a doctor under their insurance program and pay a $20 co-pay. (Of course this doesn't help the 15% of the population with no health insurance, but we'll leave that aside for the moment).

In my opinion the CA model is the most sustainable and realistic of the three. Charity work is necessary and laudable, but without ongoing grant money or outside funding it can't support the practitioners who do it, so it will never be able to reach more than a fraction of the underserved populations. The chance of acupuncturists being fully integrated into the insurance system in the near future is extremely remote. Chiropractors haven't been even after decades of lobbying by an organization much stronger than ours. I'd also argue that working inside of the insurance system would be a nightmare for most acupuncturists, and would very likely threaten the very things that make our medicine unique. That's not something I wish for.

I'm certainly not telling you that you "shouldn't" want the title of doctor, or that you are "wrong" for wanting it. But I am suggesting the possibility that it's more about esteem than actually improving our ability to care for patients or make a good living. Having the title of doctor isn't going to magically make us more effective acupuncturists or help us start and run a successful business. Just ask any psychologists who have recently graduated with their PhD or PsyD. They still have to go through all of the steps that psychologists with their MA or MSW go through. The degree itself is no guarantee of success.

I know that shortening the program doesn't apply to you. But this thread was started in response to a proposed change that will affect future students. We may be affected by these changes too, if we are grandfathered in to the doctorate after we graduate, but for the most part I'm thinking of future students when I write this. I'm quite certain I'll be finished with school as well before any of the changes suggested are implemented.

If the school program isn't shortened, it won't become less expensive. That's just economic reality at this point. And if it doesn't become less expensive, we're going to be in the same position we are in now: students graduating with $50-$100k+ in loans who are almost forced to charge $85/hour (even if they don't want to) in order to make ends meet. This doesn't strike me as a desirable situation.

[Sara Szmodis]

Hi Chris:

While the statistics and surveys paint a somewhat bleak picture for acupuncturists, I will say that, as you probably already know, statistics and surveys are only as valuable as the integrity with which they were conducted. I don't know the sample sizes, etc. of any of these things so it is difficult to say how accurate any of it is or is not. I will say that I believe that every acupuncturist has the exact practice that they want--whether they like that or not. If you want a large, highly successful practice, you can have that. If you want part-time work while pursuing other interests, you can also have that. In my opinion, your practice is more dependent on you than anything else.

You said:
Nor is it likely that we'll be guaranteed a good living once we're done with school in the foreseeable future. The only way we could get close to that is being "hired" by HMOs or hospitals like doctors or nurses are now, and there are no signs that we're anywhere near that happening.

Other professionals aren't guaranteed a good living either, necessarily. None of it is guaranteed. Again, it's all dependent on us. And dependent on what you envision as a "good living." Again, I point out that thinking that there's no way to support ourselves and the only way to do so is to be hired by a hospital is just destructive to the profession as a whole. There are many, many happy, successful acupuncturists out there. Also, there are already many large hospital systems partnering with acupuncturists to provided complementary treatment, including one of the largest in California. These partnerships are not simply in California, either. Colorado, Florida, Pennsylvania, and Missouri all have such partnerships actively working.

As for schooling, while you may find it to be unnecessary, I think that as Dawna points out, patients are complicated. The time spent crafting ways to encounter that is valuable and necessary, as is the continued education we do beyond this immediate program. Shortening the program isn't the answer, creating appropriate designations for the time we put into the program is.

[Chris Kresser]

Sara,

You raise a good point about the statistical methods of the surveys. The sample sizes were probably quite small, and the survey response rate was about 70% I think in both cases. That's about the same as the completion rate for most medical studies, so it's a fair number. But it's true that a scientific study is only a "map" of the territory, and not the territory itself. And it's a biased map at that.

I completely agree that "your practice is more dependent upon you" than anything else. I also said in my original post that there are now and always will be successful acupuncturists practicing the conventional way. I'm talking more about the "averages" than I am about specific practitioners.

And yes, I agree that no one is guaranteed a good living regardless of what degree they have. That's exactly my point! A doctoral degree for acupuncturists isn't going to change that.

I don't think I ever said school is unnecessary. I said that I think the program should be overhauled and made shorter and less expensive so that those who don't want to go the conventional route don't have to be saddled with triple-digit loans. Perhaps a two-tiered system would serve this purpose, i.e. a "basic" program for those who imagine going into CA or a similar model, and an extended program (doctorate?) for those who want the additional experience and credibility that affords.

In fact that's exactly how it works in the field of psychology. One can get an MA or MSW in two years and go out and be a practicing psychotherapist (after their internship). If they want additional training, or the opportunity to work in a hospital or medical setting, then they opt for the PhD or PsyD program. They spend more time and money on school at that point, but they may be able to command a higher salary/income as well.

I think a similar system could work very well for acupuncturists.