Heading for the Cliff

On October 26, the NCCAOM and the ASA (that would be the certifying body and the national professional organization for acupuncturists) held a joint town hall in which the state of the acupuncture profession came up as a topic. And that state is best described as, well, apocalyptic. The presenters announced candidly that this year is the 40th anniversary of the NCCAOM and there could very well not be a 45th.

Way back in the spring of 2010 I wrote a series of blog posts titled “NCCAOM and the Terrible, Horrible, No Good, Very Bad Numbers” about economic data for the acupuncture profession, how hard it was to get that data, and how bleak it looked. I’m permitting myself exactly one “I told you so” and this is it. The point is, the apocalypse was predictable from the data.

For over a decade, all signs have pointed to the acupuncture profession being on a road (by choice) that leads to the edge of a cliff. That cliff can be defined as the point at which the cost of an acupuncture education is so clearly not a good investment that people stop entering the profession and thus stop funding its infrastructure (particularly the NCCAOM, which is one of the main gatekeepers for entry into the profession and so depends on, you know, people wanting to enter the profession). Back in 2010, factors like Gainful Employment regulations and the pandemic were of course not apparent, and they probably have something to do with the cliff coming up faster than expected, but let’s be honest, they didn’t create the cliff itself, or the highway to the edge, or (most importantly) the profession’s resolve to go there.

Nobody really listened to me before about all this and I don’t expect anybody to listen now, either, but I feel like I have to say, just once -- there is still another way forward and it might not be too late to take it. And even if it is too late to avoid the cliff, there are ways to make the coming free fall experience less awful, and now’s the time to talk about them. There’s even the possibility of life on the other side. And those things are what I’m going to be working on, FYI, regardless of what anybody else does or doesn’t do (so get in touch if you’re interested).

Before we get into that, though, let’s be clear about what the real danger is. It’s not that other professions, and yes even laypeople with the appropriate training and scope, could be able to practice acupuncture in some form alongside acupuncturists. No, the real danger is that our own infrastructure, particularly the NCCAOM, goes bankrupt and nothing replaces it, in part due to our own failure to plan. No infrastructure means that it’s no longer possible to become an acupuncturist (legally, anyway). The acupuncture profession pushed for laws that require NCCAOM certification to get an acupuncture license in most states, so what happens when there is no NCCAOM anymore -- maybe five years from now? (That’s not a lot of time.)

The danger is not that nurses might be able to practice acupuncture as part of their scope, it’s that nobody can practice acupuncture without first becoming a nurse -- or a physician or a physical therapist or some other profession, and thus access to acupuncture becomes even more restricted than it is now. The danger is that acupuncture as a freestanding, independent occupation disappears entirely because its scaffolding collapses.

I think it’s still possible to avoid that worst case scenario. But it would require not just planning but making some hard, pragmatic decisions, which is not something the acupuncture profession likes to do. It would also require the humility to admit that the profession made some fundamental errors about things like supply, demand, and acupuncturists’ place in society. (Also not a favorite.) A lot of people would have to rethink their assumptions about how acupuncture works and why people want to receive it and practice it (more about those in a moment) so, you know, it’s a long shot. But I’ve been an acupuncturist for more than half my life and even with all of the difficulties involved, it’s been a very good thing for me. I’m glad I had acupuncture as an option for my vocation, and I’d like for other people have it as an option too.

Over the course of my career I’ve seen it become -- thanks to the acupuncture profession’s assumptions about acupuncture -- more and more difficult, expensive, time consuming and generally onerous to become an acupuncturist. And there’s a high risk of not being able to make a living at the end of the process. So we shouldn’t be surprised there are no longer enough people who want to take that risk and thus continue to fund the bureaucratic infrastructure that makes it difficult, expensive, time consuming and onerous. But we could change our approach, along with those assumptions. Let’s make a list of the assumptions that got us to the cliff:

1. That there’s a right way and a wrong way to do acupuncture and the right way is represented by Traditional Chinese Medicine, so we need to certify acupuncturists in TCM in order to make sure they know how to do acupuncture the right way.

Any serious study of the history of acupuncture dismantles this idea pretty quickly. What we call Traditional Chinese Medicine dates to 1957. There has never been one right way to practice acupuncture, there have always been multiple ways that are effective and appropriate, depending on the needs of the patients and the needs of the practitioners. There’s no research that validates TCM acupuncture over any other style or vice versa. Acupuncture is diverse, heterogeneous, and flexible -- just like humans. Different humans benefit from different kinds of acupuncture. There’s no right way to practice acupuncture -- and that’s a good thing.

1a) But what about safety? Don’t we need to certify people to protect public safety in the practice of acupuncture? I thought you’d never ask! Acupuncture safety is my favorite subject, how much time do you have and where would you like to start? How about here? Or here? And of course I would love to share my thoughts on appropriate certification methods if anyone is interested! As the director of an acupuncture school I’ve had many opportunities to ponder how to train people to practice acupuncture safely. (Spoiler alert: acupuncture safety does not equal TCM.)

2. That the acupuncture profession should look like the profession created by biomedical physicians. That the ultimate goal is for acupuncturists to work in hospitals.

I became a licensed acupuncturist in 1994 and the whole time I’ve been in the profession, its obsession has been to get hospital jobs for acupuncturists. What has thirty years (give or take) of sustained focus on that goal gotten us? According to the U.S. Bureau of Labor Statistics, as of 2021 there are, nationally, a whopping 200 acupuncturists employed in hospitals, with another 170 in outpatient care centers if you want to be generous. Out of maybe 30,000 licensed acupuncturists and (per the American Hospital Association), some 6100 hospitals. While we’re at it, the BLS says that only 7250 acupuncturists have jobs, period -- the rest are self-employed. No wonder prospective acupuncture students are not excited to take out $100K or more in student loans in order to launch themselves into the risky, demanding world of self-employment.

That’s the world where I live and a major lesson you learn if you want to live there successfully is that sometimes the things you want just don’t work out, and when they don’t you have to let them go and move on. Recognize that you tried -- and now it’s time to try something else. Goals that aren’t achievable can be exchanged for goals that are. The humility to admit you’ve made mistakes about supply and demand is a survival skill. See above: acupuncture is diverse, heterogeneous and flexible, maybe we should be too.

3. That the practice of acupuncture should be exclusive.

This is maybe the most destructive assumption, that the value of acupuncture lies in its restrictions. We don’t want just anyone to be able to practice acupuncture, or to receive acupuncture because that would “devalue” it. Another thing I’ve observed by making my living for the last 28 years, working in a high volume acupuncture clinic in a city theoretically saturated with other acupuncturists, is that the more people get acupuncture, the more people get acupuncture. I’d stake my job on the corollary that the more people who provide acupuncture, the more people provide acupuncture. If more people were getting acupuncture from all kinds of providers, there would be much more demand for, and more opportunities for, licensed acupuncturists. It’s not a zero sum game.

The ASA’s and the NCCAOM’s last ditch attempt to avoid the cliff is to get acupuncturists included in Medicare. I don’t think that’s a solution, because there simply aren’t enough acupuncturists to meet the demand that inclusion in Medicare would create...because we’ve made it too difficult, expensive, time consuming and generally onerous, not to mention risky, to become an acupuncturist. Lobbying for inclusion in Medicare is most likely to drive up the demand for acupuncture to be provided by other, more populated, professions like nurses. Inclusion in Medicare won’t magically cause people to enter the profession if they still end up $100K+ in debt and facing the prospect of self employment (funded by Medicare reimbursements that even physicians claim are too low to make a living).

Because you know what else it’s hard to do? Create actual jobs for acupuncturists, as I know from experience and as the BLS data demonstrates. Inclusion in Medicare will not magically create jobs for acupuncturists. Just like the profession has made it hard to become an acupuncturist, the very same infrastructure has made it hard to hire them (particularly the NCCAOM).

The way to avoid the cliff is to do what it takes to make going to acupuncture school a good investment of prospective students’ money, time and resources, taking into account the risks of self employment and what graduates can actually expect to earn based on the data that we have. Which means make it easier, shorter, and less expensive. If other professions want to practice acupuncture, make it easier for them too and offer them appropriate training. Let go of demanding that everyone who practices acupuncture be an enlightened scholar-physician with physician-level socioeconomic status. Embrace diversity. Focus on survival -- which means more people getting acupuncture and more people providing acupuncture, all kinds of acupuncture and all kinds of people, some of them L.Acs, some of them Doctors of Acupuncture, and some of them...not. Allow people to use acupuncture in ways that we may not think are ideal. This approach could be a good thing for acupuncture itself, and people who want to devote themselves to the practice of acupuncture, and people who benefit from receiving it. And it’s the only thing likely to create enough cash flow to fund the infrastructure for a freestanding acupuncture profession.

Some concrete steps in that direction:

1. Create an entry level degree that’s the length of a normal Master’s degree: 18 months to 2 years, that acupuncture schools could offer at a lower cost, that would appeal to more prospective students, including other professionals. It’s entirely possible to train safe, competent, entry level practitioners in that amount of time, especially if you don’t have to teach them TCM.

Yes, I am aware that some state acupuncture laws require more hours than this for a license and will have to be changed, and changing state laws is an awful process. If the NCCAOM folds, though, we’re going to have to deal with all the state laws that require it as a condition for licensure -- so we are now facing the prospect of legislative change no matter what, if we want to preserve the possibility of acupuncture as a freestanding occupation.

2. Revise the certification exams to actually focus on acupuncture safety, red flag conditions to refer out, etc, as opposed to TCM. This is also entirely possible. The certification exams we have are based on a deeply flawed Job Task Analysis -- and it could be fixed. I know because I participated in an alternate Job Task Analysis for acupuncture. JTAs and test development are a lot of work but they’re not rocket science.

If we’re not willing to do those things (and let’s be realistic, we’re probably not) we need to begin preparing for a future without the NCCAOM -- because the representatives of NCCAOM themselves have warned us. One thing I’ve learned from starting an acupuncture school from scratch is that certain things just can’t happen quickly, and the more lead time you have, the better. Five years is not much time at all. If the acupuncture profession can’t or won’t take a different road than the one that goes off the cliff, I guess we’re all going over the edge together.

So can we at least start talking about what that free fall experience will mean, in concrete terms, for those of us who still want to provide acupuncture, train acupuncturists, and hire acupuncturist employees? My email is lisar@pocatech.org, serious inquiries only please.