Heading for the Cliff, Part Two
On January 18, the NCCAOM and the ASA presented a follow up webinar on the state of the acupuncture profession-- so I thought I’d do a follow up blog post as well. The recording of the meeting is available at: https://vimeo.com/790959699?embedded=true&source=video_title&owner=7308889
The presentation is concise and to the point and I recommend listening to it. Also, that photo of tombstones in a cemetery is a memorable touch.
But my favorite slide, actually, was this one:
After the presentation, I found myself thinking about myths. (I love words and etymology, dictionaries and lexicons, I’m a nerd -- please be patient, we’ll get back to the future of the acupuncture profession in a minute.) Merriam Webster defines myth as:
a: a usually traditional story of ostensibly historical events that serves to unfold part of the world view of a people or explain a practice, belief, or natural phenomenon
b: parable, allegory
a: a popular belief or tradition that has grown up around something or someone
especially : one embodying the ideals and institutions of a society or segment of society
seduced by the American myth of individualism —Orde Coombs
b: an unfounded or false notion
the myth of racial superiority
3: a person or thing having only an imaginary or unverifiable existence
The unicorn is a myth.
I studied mythology in college, or myth under the first heading. Myths aren’t the same as fairy tales or folktales or any other story; they’re powerful and generative in a distinct way. Myths can make things happen, for better or worse. I think the acupuncture profession in the US possesses, and is possessed by, one of these: the myth of the scholar-physician with a hospital job. You know, the fortunate L.Ac who’s steeped in Taoist arts and ALSO has a parking space with their name on it at the local hospital, where they get to practice “the whole system of acupuncture medicine” in exactly the way that they want to practice it, within their preferred hours. The L.Ac who has abundant time for tea drinking and peaceful contemplation, who has a perfect work-life balance, and simultaneously is in great demand in busy biomedical settings. The serene, well-paid, white-coat-clad authority on American Chinese Medicine, who floats benevolently above the fray of a broken healthcare system on the wings of their doctoral degree.
If you read Tyler Phan Ph.D’s work (and if you haven’t, please do, right away, here’s a summary for your convenience: https://acusafetynerd.com/assets/content/documents/Acu-in-the-US.pdf) you can see how this myth, enacted by the graduate students of the “UCLA Cohort” laid the foundation for the infrastructure of the acupuncture profession. This was the vision that animated their activities (most notably AB 1500, the first acupuncture bill in the US, that stated that the practice of acupuncture was limited to unlicensed persons under the supervision of a licensed physician or surgeon in an approved medical school for the sole purpose of scientific research, in other words, only the UCLA Cohort themselves -- that’s the law that Miriam Lee was breaking when she got arrested.)
What’s interesting to me is how the scholar-physician with the hospital job functions as a myth not only in the sense of unfolding a world view and embodying an ideal -- but also as a myth in the same way that a unicorn’s a myth. That’s what the Bureau of Labor Statistics data says -- also, all other occupational data about acupuncturists, it all says the same thing, that well paid scholar-physicians with hospital jobs for the most part have “only an imaginary or unverifiable existence”.
After my last blog post on this topic, I was contacted by an acupuncturist who’s been based in a hospital for almost seven years, who owes 216K in student loan debt, whose salary doesn’t match their debt and shows no signs of ever matching it, despite treating more patients than many acupuncturists are willing to treat. This person applied for Defense to Repayment on the grounds that their acupuncture school misled them about potential earnings. I was also contacted by another acupuncturist who described trying to apply for acupuncturist jobs in the VA system, only to find that those positions were filled by chiropractors, because the VA prefers to hire chiropractors.
IF legislation can be passed (and that’s a big if, no offense to the NCCAOM’s well-spoken lobbyists) so that Medicare will pay for acupuncture performed by L.Acs, it doesn’t mean jobs will be magically created as a result. And even if they are, it doesn’t guarantee that they’ll be compensated at a level that will match acupuncturists’ student loan burden, OR that those jobs will even be filled by L.Acs. No matter how we argue, appease, litigate or legislate, the healthcare system as a whole isn’t obligated to transform the myth of the scholar-physician with the hospital job into economic reality for us. We can’t make anybody believe in our myth, and the rest of the healthcare system certainly doesn’t.
Back in 2010, the drama in the acupuncture profession was all about the creation of the entry level professional doctorate (the FPD). I confess, I was involved in that drama, and for years afterwards I felt kind of bad about the episode where a board member of the Community Acupuncture Network showed up at the ACAOM offices in Maryland and slammed a pile of anti-FPD petitions onto an unhappy staff member’s desk. Or maybe threw them on the floor? I can’t remember, but there were indignant emails about harassment and trespassing and it’s true, CAN was notorious for its shenanigans. But after this last town hall I’m looking back and thinking, okay, if you consider where the profession is now (an ASA slideshow featuring a photo of tombstones in a cemetery?), we weren’t actually overreacting. Yes, we had bad manners, but no one can say that we didn’t try everything to draw official attention to the problem.
One of the things I remember from the FPD battle was how an entry level doctoral degree was portrayed by certain people as the inevitable new baseline for the profession. It was destiny! The Master’s degree was going away, they said, and the sooner the better. Soon there would be no more schools offering a lowly Master’s degree, especially an acupuncture-only Master’s degree. The irony is not only that right now, there are more schools offering a three-year, acupuncture only Master’s degree than there were in 2010 (including my alma mater which never had one before 2015 or so) -- the irony is that the same people are now talking about ALL the acupuncture schools closing because prospective students are increasingly aware that a doctoral degree is a bad investment.
That thing we had to do twelve years ago -- create a longer, more expensive, fancy-pants entry level degree for acupuncturists (because the myth of the scholar-physician with the hospital job demanded it) -- is now the very reason we have to get Medicare inclusion or we’re headed for the cemetery. Twelve years ago, the argument was that more economic opportunities for acupuncturists would magically be created by this new doctoral degree because it would make us look more respectable. Now the argument is that more economic opportunities for acupuncturists will magically be created by Medicare inclusion because THAT will make us look more respectable (and also, we have no choice because of the costs of those doctoral degrees).
To sum up, there’s a good chance that acupuncture as a free-standing occupation (the L.Ac) will die, in order that the myth of the scholar-physician with the hospital job might live. That was my big take away from the January 18th town hall: the acupuncture profession has no desire to avoid the cliff. It’s not just that the profession can’t get itself together to turn around in time, it doesn’t want to. It might even enjoy throwing itself off the cliff as a kind of ritual sacrifice. Nothing matters more to the acupuncture profession than the image of the scholar-physician with the hospital job, and so to prove our abject devotion to it, we’ll keep doing exactly what we’ve been doing until all the infrastructure that makes it possible to be an L.Ac runs out of money.
The acupuncture profession won’t save itself. So anyone who finds that whole ritual sacrifice thing unappealing, anyone who cares about a future for L.Acs apart from the myth, is going to have to make other plans. No help is coming from the powers that be. That’s important information to have and I appreciate it. I feel like I know a lot more than I did in October.
Really, though, this whole discussion only matters if you care about the future of acupuncture as an independent occupation and let’s be honest, the majority of acupuncturists don’t care about that at all (especially if it’s separated from the myth). My experience is that most acupuncturists don’t care about anything that doesn’t directly and personally benefit them within, say, the next ten minutes. They are incredibly unlikely to do anything for the sake of the next generation, particularly anything personally inconvenient. In the town hall it sounded like the Medicare inclusion plan depended in part on acupuncturists caring about the next generation enough to act in a thoughtful, unified, coordinated effort, and so -- I mean this sincerely -- good luck with that.
If the professional infrastructure of acupuncture as we know it now collapses in the near future (note to self, figure out when to stop writing “if” and start writing “when” at the beginning of sentences like that), most L.Acs won’t be personally affected. When/if there’s no NCCAOM, it will be inconvenient to move between states, but for the acupuncturists who stay put, I’m sure they’ll be some kind of grandfathering provision as the state L.Ac licensing structures slowly wither away from lack of revenue. You (probably) won’t lose your existing acupuncture practice as a result of the coming acu-pocalypse (to use Whitney Thorniley's excellent term) though you might have some bureaucratic headaches.
This is only a problem for those people who, for whatever reason, need there to be a way for laypersons to legally become acupuncturists without also becoming nurses or PTs (or whatever other licensed occupation that can refrain from throwing itself off cliffs), OR who need acupuncture itself to be accessible outside of “the pharmaceutical/insurance healthcare -industrial complex” (as a friend recently put it).
Unfortunately, that describes a lot of patients.
It describes almost all of the patients that my clinic treats, so I’ll be making plans for life after the acu-pocalypse*. I’m invested in the future of my clinic and I’ve never believed in the myth of the scholar physician with a hospital job. If you too have an investment in something (and I don't mean an ideological investment) that requires acupuncture as a free standing occupation to have a future (beyond your personal license if you have one), we should probably talk. My email is email@example.com, looks like I’m starting a mailing list, serious inquiries only please.
- Thanks Whitney!