Uncertainty and the Acupocalypse

Having an acupuncture school, especially in the era of gainful employment, means always having to ask, is an acupuncture education a good investment of a student’s resources? Who should spend their precious time, energy, attention and money on becoming an acupuncturist? Who does our program work out well for, versus who’s likely to regret it afterwards? I’m thinking a lot lately about how someone’s relationship to uncertainty can have a profound effect on their relationship to practicing acupuncture, to owning or managing a small business, and to their success or lack thereof with both.

Most people find uncertainty challenging, and plenty of people flat-out hate it. They don’t want to learn to manage it, thank you very much, and they can get very angry at the suggestion. Isn't that somebody else's job? Acupuncture, however, is full of uncertainty. Sometimes people are drawn to acupuncture’s other good qualities without realizing that uncertainty is part of the package.

Remember how, according to Tyler Phan, the best metaphor for the medicine of acupuncture is the kids’ toy Slime? It behaves like a solid and a liquid at the same time. It oozes, it’s viscous. It’s hard to wrap your mind around its contours because they’re always changing. If you put it on a flat surface, it spreads out; if you put it into a container, it takes the shape of the container. Otherwise it doesn’t really have a shape. One of its most significant characteristics is how it sticks to things and how things stick to it, how it adheres and is adhered to. Its nature is to be shapeless, sticky, malleable -- and fun to play with. Acupuncture is a blob...and blobs make people nervous.

Here’s my first pass at a list at how uncertainty shows up for acupuncturists (and acupuncture students):

1. The first question that people unfamiliar with acupuncture tend to ask is, “does it work?”

A recent article asked, What is the certainty or quality of evidence in recent systematic reviews for use of acupuncture in adult health conditions? It identified 434 systematic reviews published since 2013; of these, 127 assessed the certainty or quality of evidence of their conclusions. Overall, 82 systematic reviews regarding 56 health conditions were mapped, and most reviews concluded the certainty of evidence was low or very low. Despite acupuncture having been the subject of hundreds of randomized clinical trials and systematic reviews for dozens of adult health conditions, there were few conclusions that had greater than low certainty of evidence.

If you need an abundance of research evidence to provide certainty that acupuncture works for any given condition, you are out of luck.

A subset of this question is, will acupuncture work for any specific patient? The answer to that one can be long.

2. What are acupuncture points?

Merriam-Webster defines acupuncture as the “practice of inserting fine needles through the skin at specific points especially to cure disease or relieve pain” and acupuncture points as “specific locations on the body that in the practice of acupuncture and acupressure are stimulated (as by the insertion of a thin needle or by the application of pressure) to produce beneficial health effects (such as the relief of pain or promotion of healing)”. So an acupuncture point is where you put a needle, and acupuncture itself is the process of putting needles in particular points. Wait, which points? You know, the ones where you put the needles.

And if you’re thinking, but that’s just what a modern American dictionary says, surely if you dive deeply into the history of the practice and theory of acupuncture, you will get a much clearer and more precise understanding of what acupuncture REALLY is --

Nope. You won’t. What you’ll get is endless iterations of “acupuncture is because of acupuncture points and acupuncture points are because of acupuncture” -- those same turtles all the way down. And the deeper you dive, the fewer answers there are, and the more questions you end up with -- including really troubling ones like, do acupuncture points even matter? Or is it actually more about channels and zones?

3. Is acupuncture a growing profession?

A few days ago, alumni of one of the oldest acupuncture schools in the US, Maryland University of Integrative Health (formerly Tai Sophia, formerly TAI, the first school accredited by ACAHM in 1985), received an email from the president:

"In June of last year, we made a difficult decision to pause new student intakes in the acupuncture and herbal medicine (AHM) programs due to the declining and very low enrollment numbers. We indicated that we would evaluate the situation and make a decision by summer of 2023 whether to resume new student intakes beginning in fall 2024.

Over the last year we have conducted a comprehensive assessment of the situation. We gathered information and looked at trends in the field, information on other acupuncture schools, received input and suggestions on how to increase enrollment from students, faculty, and staff, received information from the national study conducted by the Council of Colleges of Acupuncture and Herbal Medicine (CCAHM) and aggregate enrollment trends provided by the Accreditation Commission for Acupuncture and Herbal Medicine (ACAHM), reviewed the operating expenses and margins of AHM programs, assessed overall trends in MUIH’s total university enrollment, and reviewed trends in higher education enrollment in general. Based on this assessment we do not believe we would be successful in dramatically changing the trajectory of enrollment in the AHM programs. As a result, we will no longer be admitting new students into the programs and will focus on teaching our current students and the completion of their programs. This action has been approved by our Board of Trustees..

This decision is dictated by the circumstances and the changing market forces related to higher education and is not a reflection of the quality of our programs or the great work our AHM faculty and staff have done over the years... Undeniably, our roots are in teaching and graduating acupuncturists and it is emotional and unfortunate that we will be winding down the program."

This language is remarkably similar to the announcement of the closing of ACTCM about a year ago. When the school evaluated the sustainability of their acupuncture programs, based on everything they can see about the field, they couldn’t find any way to reverse the declining trajectory of enrollments. And so they couldn’t see a way forward.

A lot of my complaints about the acupuncture profession, particularly those aspects that contribute to its unfriendliness toward community acupuncture, represent ways that people try to minimize or avoid the uncertainty of acupuncture itself. There’s a right way to do acupuncture and community acupuncturists are doing it wrong. Acupuncture is destined to become part of mainstream healthcare on acupuncturists’ own terms. If you say the words “evidence-based” enough times in a row, respectability and compensation will surely follow. Acupuncture safety is never an issue for licensed acupuncturists with a few thousand hours of education.

I predict that a lot of people who got involved with acupuncture because they were counting on it becoming less uncertain rather than more uncertain are about to become un-involved, over the next decade or so. Which means that anybody who’s planning to stick with it (no pun intended) needs to work on their relationship to uncertainty. That gets us back to leadership skills and why we need more of those -- leadership is all about making commitments in the face of uncertainty.