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.

[Benjamin Dierauf]

Hi All,

I wrote for the AAAOM discussion board which I'll post below, but also wanted to provide some perspective with what we're looking at with the FPD. Its not that much different from what schools in CA are required to do now - differences include 3 years of undergrad instead of 2 years, 50 hours of additional clinic (which AIMC Berkeley already does), and much better language articulating the professional competencies that your course/clinic learning objectives should be addressing (they're constantly being improved). For CA approved AOM colleges this is more simply a matter of moving from a bloated MS to a lean and mean FPD, and unless one is an ideologue this shouldn't be too great of a leap for current students.

This whole debate brings up the need for a tiered profession with, at the least, AOM doctors and technicians. There was some legislation a few years ago after the LHC report, but it wasn't well thought out and Schwarzneggar vetoed it. From the discussions I've had with the professional leadership, this much more realistic after we get the entry level doctorate in place, as the profession will have much more control over how it all works out.

From the discussion board at http://forums.aaaomonline.org/forum.asp?FORUM_ID=25:

Hi All,

In regards to the insightful posts of above I’d like to provide the following perspective:

• The discussions I’ve had with school administrators on how to implement the FPD has focused primarily on how to integrate the additional competencies into their current curriculum, as opposed to dramatically increasing hours and raising tuition costs. Although some schools claim they can implement an FPD without any increase in hours, my sense is that there will be a slight increase. However, when this increase is amortized over the tens of thousands of patients that will be cared for by practitioners with increased recognition of red flags/referrals/collaborations, I believe the extra cents from future patients will be well worth their while.

• In regards to Lisa Rohleder’s assertions about the success of AOM graduates in practice, my own research that combines licensing exam passage rates with CA Acu Board mailing list data and the CSOMA/UCLA study, 50-60% of graduates 5-10 years ago are still in practice. As a CA state association board member for 7 years, our understanding was that this weakness came from the lack of learning objectives in AOM education in the areas of practice building and management, information literacy (referrals, collaboration, evidence based medicine, functioning within the healthcare system – insurance, workers’ comp, MediCal), and insufficient clinical practice. These are all being addressed with the FPD. As CA has historically had higher educational standards than the rest of the country and a more successful practitioner population, I assert that the higher standards embraced by the FPD would result in even more successful practitioners.

• The FPD brings additional professional competencies that will help open up jobs in hospitals for acupuncturists. Given the benefits that we all know that AOM can provide the many patients in this venue, it does not seem to be too much of a stretch that 5-10 years down the road AOM graduates will in high demand by hospitals. While we may get there eventually with our current standards, it will take much longer.

• As a participant on the advisory panel to the Little Hoover Commission I can tell you the whole process was a flawed chaotic mess, with the final report being written by insurance reps, MD’s, and acupuncturists not representing any CA professional associations - all of which support a FPD. The LHC report is only advisory and has no legal bearing, serving mainly to provide a snapshot of how the powers that be perceived the AOM profession in the early 2000’s. Five years later much has already changed.

• Physical Therapists, Occupational Therapists, Podiatrists, Chiropractors, Naturopaths all have a FPD. What is their strategic thinking for doing so? What do they have that AOM doesn’t have that makes them more deserving? How does the width and breadth and efficacy of what we treat compare? Within the given structures of our society, why should we not be titled as are others in other doctoring professions?

[Chris Kresser]

Thanks a lot for clarifying some of the issues we've discussed in this thread, Benjamin.

If the FPD can be implemented without significant additional cost and time, and if there is future provision for a tiered professional license (i.e. AOM doctors and "technicians", though I dislike that word and what it implies) then I can't see any reason not to move in that direction.

Whether that actually happens in practice is still a question. I guess we'll just have to wait and see.

[Chris Kresser]

Forgot to ask: how would a FPD affect recent and past MS graduates? Would they be grandfathered in?

[Benjamin Dierauf]

None of this has been determined yet. There are links on the AAAOM Doctoral Survey letter that describe various scenarios that range from straight grandfathering to a specified set of courses covering specific outcomes with challenge exams to a straight transfer credit scenario. For recent AIMC Berkeley grads who have already done most of it, neither of these should be very difficult. Personally i think the easier it is for those with MS to "grandfather", the better.

AOM First Professional Doctorate Q & A: Commonly asked questions regarding the potential transition to a FPD Degree. (PDF)


Physical Therapist Transition to a Professional Entry-Level Doctorate – Contains detailed FAQ’s on issues similar in scope to what AOM practitioners might face that Physical Therapists addressed as they transitioned from a First Degree Masters to Professional Doctorate Degrees. (PDF)

[Shane B.]

Yeah, "technician" really isn't cool.

Are MSWs or Nurse Practitioners merely technicians? Are the people who are L.Ac.s right now (including the majority of our instructors) and those who've been practicing for 30 years or so merely technicians?

What I'd like to see are real alternatives to becoming a Doctor than just more schooling in TCM and I'd like to see them backed by people who currently have some influence in this larger debate. This could be an opportunity for expansion rather than defaulting to the reductionist practice that has sucked most of the joy and diversity out of this tradition of medicine.

Better options:
----mentoring in the style of an advanced or family lineage practitioner (L.Ac. or Doctor, doesn't matter...experience matters)

----completing a training program (classes) in whatever style we choose (Dr. Tan, Worsley 5-element, community acupuncture, Japanese, Korean, Daoist, microsystems, etc).

----continuing training in another branch of Chinese medicine (there are 8 branches and beyond herbs and needling, they are largely ignored) such as Daoist nutrition, feng shui, tai chi, Qi gong, Chinese astrology, meditation, studies of the classical texts, and advanced tui na massage

---and last but not least, ****paid**** internships (AKA residencies) through schools or established clinics. [Merely doling out a couple of scholarships here and there isn't going to do anything for the vast majority of student practitioners.]

[Deborah Corrente]

Shane,

Dr. Leon Hammer will have an interesting Doctorate program unlike others that will not include research as I hear other programs will have.

You can get more info. at dragonrises.edu

Just another avenue to explore.

[Benjamin Dierauf]

"Acupuncture Technician" is a term being thrown around by some of the CAN people. In California "Licensed Acupuncturists" are anything but - we have a full scope of practice that includes herbs, supplements, nutrition, therapeutic exercise, lifestyle counseling, bodywork, etc., we are regarded by law as primary health care providers and as Primary Treating Physicians in the Workers' Comp code. There are lots of aspects of this that need to be more fully developed, however, such as increased insurance reimbursement for the modalities we employ, herbs that we give our patients - this is what your professional associations are working on - as well as upgrading your license title/degree title to better match what we do. What do you think it should be?

Your schooling is supposed to provide entry level competencies and get you passed the CALE, which is based primarily on TCM and Western medicine. We also provide some Japanese and Master Tong acupuncture. There is a whole universe beyond school where you can learn all kinds of fascinating and relevant topics - our CEU courses provide a taste of that.

And residencies/clerkships - you're right, those are the next development for AOM education. Unfortunately ACAOM doesn't have those as part of the FPD - yet!

[Chris Kresser]

Benjamin,

You mentioned earlier that you thought the FPD would increase employment opportunities in hospital settings. It seems to me that there are more obstacles to be overcome there than simply giving ourselves a new title. Chiropractors and naturopaths aren't allowed anywhere near hospitals despite the fact that they've had a professional doctorate for many years. Physical and occupational therapists are more closely integrated with the allopathic medical system, but this was true long before they had their doctorate.

My sense is that the level of integration of a particular modality/profession with the Western medical establishment has a lot more to do with how doctors perceive that particular modality than it does with its professional license.

PTs, OTs, and podiatrists are all coming from the same Western perspective on health and disease that doctors come from. Not true with acupuncturists. So we have that challenge to overcome above and beyond what the other professional specialties have already had to deal with.

Of course what acupuncture does have going for it is that it works, and it's safe. New studies continue verify this. Perhaps the efficacy of acupuncture will be enough to justify its use in hospitals, and perhaps not. With some exceptions, my experience with the Western medical community in general is that if they don't understand how something works, they write it off as "placebo" (as if that isn't worth considering) or dismiss it as chance.

There's another issue, which is the desirability of being integrated into a so-called "health care" system that is so badly broken it may be beyond repair. But I'll save that one for another day. :)

[Benjamin Dierauf]

You're correct - the change in title won't increase our employability, but changes in learning competencies will, as we'll have graduates that can explain how the medicine works in biomedical terms, describe the studies that prove its efficacy, be able to communicate in biomedical language what is going on with our patients, chart progress properly, etc.

The system is broken and will hopefully be repaired/replaced by an Obama adminstration, and we need to be able to demonstrate that we can work together with other providers if we want to be a part of what comes along.

The bottom line is that these new competencies are going to become a part of the MS regardless of whether a FPD gets approved or not. I'd rather have the FPD than continue with a bloated MS.

[Dawna]

Thanks Benjamin for jumping into the discussion. Students are often left in the dark when it comes to these kinds of issues. Im glad we now have some clarification on the subject.

It seems that there will be an increase in classes regardless of the title change. If this is the case, we might as well get the title change too. I like the idea of being able to speak about Chinese medicine in biomedical terms. We have to be able to communicate with western doctors and after taking all the IM classes at AIMC, I don't completely feel that I am qualified to do so. Improvement in this area is a must!

Do you have an estimation of when this change might occur? 2 years? 5 years? 10 years? Just curious!

[Benjamin Dierauf]

From a regulatory standpoint, these changes will probably become required for students starting in 2-5 years. We have already started most of these here at AIMC Berkeley and will continue to tweak things and make improvements. For example we are considering carving out 1 unit from the Anatomy & Phys series and having a class that just focuses on learning the scientific perspective on how AOM works.

[Suzanne Friedman]

I'd like to share my two cents as someone who has a "boutique" practice where I try to cultivate a peaceful, spa-like setting. This approach works very well for how I practice Chinese medicine. (I practice a pre-TCM and occasionally Daoist shamanistic style of medicine; I am not a technician). I tried practicing community acupuncture style, and it did not work for me. My interactions with patients were significantly impacted by the presence of others in the room. While a group setting works well for some, it does not work well for others. This leads me to my point: there are many paths up the mountain. Find the one that works for you and do that!

While I am not wedded to titles, I agree with Benjamin regarding the doctorate. We are already practicing primary care medicine, and why get a bloated master's when you can get a streamlined doctorate? (This is more of a rhetorical question-- please don't tell me!)

No matter what you learn in school, you will learn so much more once you are out. School makes you a safe entry-level practitioner. Mindful practice in the clinic makes you the practitioner you are destined to become. How you practice is determined only by you, so treat yourself with respect and that's exactly what you'll get.