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.

[Chris Kresser]

BTW, when I said this:

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.

I was referring to Dawna's earlier comment about wishing there was more of a guarantee of making a good living after graduating from school. It's true that there is never any guarantee, but if you go to nursing school and you do reasonably well, there's a decent chance you'll get hired and make $45+/hour right away. My point in the statement above is that there aren't many opportunities like that for acupuncturists right now, and that it's unlikely that we'll be integrated into the health care system to the degree that nurses are anytime soon.

[Dawna]

Hey Chris!

You asked for a discussion from your fellow classmates, I am only giving you just that. I don't care if you are "invested" in agreeing with me either. :-)

Question- What makes you think that if the program is shortened, the price of schooling will suddenly come down? As we all know, tuition keeps going up and up. Even if the program did get shortened, there is a potential for a tuition hike that could make the cost of a shorter program the same as it is now.

You used the example of how schooling is done in the field of pshycology. Look at how its done in more simular professions like chiropractic and physical therapy. Two professions in the "holistic health" field that are both doctorate degrees. Chiropractic school is the same as acupuncture school. 3 1/4 years. Yet when they are done, they get doctorate degrees. Why is this? I don't know about the physical therapy profession, but they now get doctorate degrees too.

[Chris Kresser]

Question- What makes you think that if the program is shortened, the price of schooling will suddenly come down? As we all know, tuition keeps going up and up. Even if the program did get shortened, there is a potential for a tuition hike that could make the cost of a shorter program the same as it is now.

If tuition rates rise and the hours are reduced, school would still be cheaper than it would be if tuition rates rise and the hours stay the same or are increased. Also, as I pointed out above, fewer hours would mean a shorter time in school and less $$ taken out as loans to support living expenses. Overall I think it's safe to say that shorter hours would mean less expensive.

The reason we don't get an entry-level doctrine is probably due to the fact that the acupuncture lobby isn't as strong as the chiropractic or PT lobbies. Perhaps Sara or someone else could shed some light on this - I don't really know.

Anyways, I think we've all made our arguments. I'm for something like a two-tiered program, with a basic MS/license for those who want to be able to get a good foundation and practice in something like the CA model, and a longer doctorate program for those who see the benefit of that.

I don't necessarily want acupuncture to go in the direction of the chiropractic or PT model, as I think they have the same limitations that acupuncture does currently. Namely, they are not generally accessible to a large percentage of the population.

[Mandy Rosenberg]

I know I'm coming into this conversation a little late but here goes...

It's interesting to think about the amount of time we are putting into this program, the path of life and healing we are choosing, and what that should me in terms of our status as practitioners. I have never cared about a title by my name or really about a piece of paper that "grants" me some sort of elevated status. Having a masters degree or a doctorate really doesn't mean much of anything to me. What matters is educating myself to be the most effective and tuned in healer and human I can be in this world.
This doesn't mean that I don't understand why Dawna feels the way she does, we put in a lot of time and money and it's only fair to feel like you come out of it at the same level as any other practitioner (doctor, chiro, etc.) doing the same amount of school work. That does deserve societal respect.
I think the most positive step forward for the AOM profession at this point would be to take that energy and focus on streamlining our program to make us stronger healers and business people versus trying to elevate our status. I don't know if that means reducing the required number of hours necessarily, but maybe streamlining the curriculum and eliminating classes that don't benefit our practice. It's like Chris said, he learned more in his two day seminar than most of the time he has spent in school so far. Doesn't anyone see a problem there?
Maybe this is a different issue....
I feel that instead of worrying about making our program longer and more prestigious we should be focusing on strengthening it. I'm not sure what I think about the two tiered program, that seems like it might dilute training and set up exclusivity in the field. I like the fact that we all get the same training yet we come out of school with many different ideas as to how to implement this type of healing in the world.
I do think it's important for the AOM profession to have a stronger political base, but what's really important to look at is how the healthcare system needs to change, is changing, and where we fit into that. I think affordability and accessibility is an extremely important way to help the field grow and gain more respect. There will always be a place for private practice to thrive... CA is not the only way to go, but it's a good place to start to open that up to more and more potential patients.
School is already outrageously expensive and we have those 50 CEUs we have to do every two years. It seems like the continuing education you get after school (while you are actually practicing, and can put what you learn into effect) is more important (and gives more opportunity to learn things we don't have access to in school) than extending our program as it stands now.
There's my two cents for now...

[Dawna]

Chris I think you are referring to Richard Tan's seminar that you recently took. Are you aware that we do learn his methods here at AIMC? We learn them mostly in orthopedics 2 during our 8th trimester. We also get a taste of his style in ortho 1, but mainly we learn his methods in ortho 2. And the best part of all is we get to practice his methods and the many other methods we learn in clinic.

[Chris Kresser]

Dawna,

My guess is that you were exposed to Dr. Tan's Balance Method for treating pain that occurs in a fixed location or on a particular channel. We were actually first introduced to this in Hideko's Acupuncture Therapy II class (don't know if you had that one or if it's new?), and that's what got me interested in learning more of Dr. Tan's method.

It turns out that Dr. Tan is teaching an entirely different approach to acupuncture than the "zang fu" method that we learn in school. Dr. Tan's method focuses on balancing meridians, which apparently is the way acupuncture was traditionally practiced for thousands of years prior to the development of TCM in the 1950s. It is based in one of the oldest Chinese medical texts, the Nan Jing.

I should clarify what I mean when I say "Dr. Tan's method", because he didn't develop it himself. What he did do is organize classical techniques into a cohesive, systematic method that can be applied to not only pain (as it is most often taught and referred to) but also internal disorders of all types. It's a complete system in its own right.

His latest book "Acupuncture 1-2-3" explains the method. The first step is to diagnose the sick meridian. This is not like zang-fu diagnosis where we identify an organ disease pattern (i.e. SP qi deficiency), but instead locating the dysfunction or pain on a specific meridian or meridians. Step 2 is determining which meridian to use to "balance" the sick meridian. The 6 Systems are used to do this. Finally, Step 3 is to choose the points. This is where his method goes very deep. You probably learned the Mirror and Imaging formats in orthopedics, which are good for pain conditions. But there are also a variety of point selection methods used when the condition is internal, such as Global Balance (with particular 6-channel patterns), 5-element Ba Gua (for internal disorders with a clear excess or deficiency), Seasonal Ba Gua (for internal disorders with a clear temporal or seasonal influence) and the 12 Magical Points (for complex, difficult to diagnose and treat disorders like CFIDS and FMS). There is also Ba Zi, which is based on Chinese Astrology but I haven't learned that one yet.

My point is that Dr. Tan's method is vastly more sophisticated and diverse than what we are exposed to in school. That doesn't mean I think school should necessarily teach us his method, but it's an example of where we can sometimes learn more at a faster rate outside of the formal school program. That's true for me, at least - your mileage may vary.

Chris

[Kim Peirano]

I honestly don't think the doctorate is a BAD idea per se. Granted, everything Chris says above, could come completely true and it yes, could be a terrible idea. But I don't think the PhD is the cause of the problem.

First of all, we are in a Masters based program now, everyone who has gradated has attained a Masters. This prblem with people receiving preventative care, exists now, it isn't a fear for the future if we get PhDs, it is the reality of now. So, getting a doctorate may have the ability to make the availability of affordable preventative medicine even more scarce, but what are we doing now to make it more prevalent? Are the majority of people going into acupuncture school even interested in providing low cost or free clinics after their years of schooling? It seems to me that the people who dream of providing that type of care, and opening those practices, aren't necessarily concerned with the outweighing the costs of schooling, because helping that demographic of people is what they had set out to do. So we have to think, if we want more of those types of practitioners, not what will sway them away, but what will entice them to join our community of healers? What will make people change their visions of the "boutique" acupuncture clinic to that of a community clinic? I think the desire of people to even want to have that type of practice is the major issue. Not the potential PhD level of the program.

And with everything the PhD could possibly hinder, it can bring that much more to our careers. With more opportunity to practice in hospitals because of those little letters at the end of our name, we can then help more people. And be able to help those people with the backing of an entire hospital, not just out of our own pockets. With more "respect" of the general medical community we will receive more referrals, and a better reputation as a medicine, not just an "alternative therapy."

I don't think that alienating ourselves, to believe or push extremes on people is any way to gain respect, patients or cohesiveness among our community. We have to understand that as much as it would be nice to have the same space in the US as acupuncturists do in Asia, we do not, and it is America, not Asia. Things are different, and it will take a different approach to get to the level where acupuncture is accepted by most Western Doctors, not just some. If getting a PhD helps us get to that point, then we should get PhD's. The people who want to open low cost clinics will still open their low cost clinics. And we will be able to finally make some head way in exposing ourselves and the benefits of our medicine to help make it a more respectable and accepted practice.

If we want more available acupuncture for people, then we really need to find a way to make people want to have that type of practice. With more patients, and more respect among the general medical community it could make it easier for us to treat people in a hospital setting, which in many cases could be low cost to patients, especially if covered by insurance.

I just think that having a doctorate can really make a statement for our medicine. And getting one, or not getting one, or shortening programs is not necessarily going to make anyone want to open a free clinic anymore or less than they already do. Maybe it would be nice to shorten the program, but the risk of getting even more incompetent people in school and through programs could only further perpetuate the idea that acupuncture is a scam, and that is definitely not a step forward, for anyone.

[Chris Kresser]

Kim,

Nice to hear from you and thanks for weighing in.

Just to clarify, I'm not referring to opening a free clinic as a charity for people who can't afford acupuncture. I'm actually talking about an entirely different business model (community acupuncture, or CA for short) that has the potential to benefit both patients and practitioners.

I know of several acupuncturists that had "boutique-style" practices and were struggling financially. They didn't have enough patients, and the ones they did have didn't come frequently enough. Then they switched over to a CA model and not only were they able to treat a much larger cross-section of people, but they were making more money and their businesses were thriving. So this isn't only about altruism, although of course that's part of the equation. It's about building a more successful and financially rewarding practice too.

This is the concept of a "social business", i.e. one that gives back to the community while creating jobs and making a profit.

Chris

[Kim Peirano]

Hmmm.... well I still hold true to what I wrote earlier. Except that I think Sara and Daniel make excellent points. There are plenty of successful acupuncturists around, and that everyone creates the type of practice that they wish to have, and Daniels comment that better practice building classes or preparation can help tremendously. Now I'm wondering what this situation has to do with receiving or not receiving a Doctorate degree. It just seems that the two are only loosely correlated and that there may be other more pressing issues surrounding it than community acupuncture and practice building.

[Chris Kresser]

Yeah, we've gotten a bit off on a tangent. But not completely. My major objection to the entry-level doctorate is that I was under the impression that it would raise tuition costs and lengthen the program.

Now I hear that it's possible that the cost and hours won't go up. If that's true, then great. But I'm skeptical...

[Shane B.]

Yes, skeptical...

[Amy Shouse]

"Maybe it would be nice to shorten the program, but the risk of getting even more incompetent people in school and through programs could only further perpetuate the idea that acupuncture is a scam, and that is definitely not a step forward, for anyone."

EXCELLENT point Kim.