for acupuncture students, alumni, faculty & friends — sponsored by AIMC Berkeley
Entry-level doctorate in OM is the wrong choice
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.
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.
Tags: accessible, acupuncture, affordable, aom, community, doctorate, entry-level, phd
Replies to This Discussion
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Permalink Reply by Chris Kresser on -
Yeah, I've been throwing that word around without defining what I mean. It's often used in the community acupuncture world to describe the way acupuncture is generally practiced in upscale cities and towns in the U.S.. Getting an acupuncture treatment at these places can be like going to a spa, so sometimes they're also referred to as "spa-style" treatments. You know, elegant space, plush furnishings, beautifully decorated, etc.
Where it's relevant to this discussion is that it's a type of treatment that is only affordable (or even appealing) to a small percentage of the population. I'm not implying that there's anything wrong with it - just that it's out of reach for most people.
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Permalink Reply by Dawna on -
Chris- yes, Dr Tan's Balancing method is taught to us in ortho 2. We learn Acupuncture 1, 2, 3. It is more deeper then what Hideko teaches us in acu therapy 3 (or whatever class it was that she taught).
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Permalink Reply by Chris Kresser on
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Dawna,
Did they teach you Dr. Tan's methods for balancing internal disorders? That's pretty cool if they did in an orthopedics class!
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Permalink Reply by Chris Kresser on
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Shane,
Thanks for your response and good to hear your thoughts on this.
I can certainly understand why you the way you do about the CA crowd. There's a lot of righteousness in that bunch. I've also been put off by the attitude of some folks in that community, and I have said as much on the CAN forums.
In the end, though, I'm not interested in CA to be part of the "CA community". I'm interested in it because I think it's a model that works for both practitioners and patients. I'm also drawn to it because there's an opportunity to build genuine community around the clinic from day one: everything from friends and family donating armchairs and items for decor to patients helping with the books to pot-lucks and art openings.
I should also mention that as much as I do like the CA model, I'm not 100% committed to it. If I think of something that is a better fit for what I want to accomplish, then I'd have no trouble doing that (whatever it might be). The CA model is just one of many means to an end, as you pointed out.
If you knew me better you'd probably know I'm not a fist-raised radical. :) I completely agree that communication, cooperation and respect are far more powerful vehicles for change than conflict and opposition.
Finally, just curious: what's your plan? Are you studying five-element/Worsley style?
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Permalink Reply by Chris Kresser on
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Shane,
I'd be interested in knowing who you're studying western herbs with in the East Bay. I've been studying western herbs on my own, with Jeremy Ross's book "Combining Western Herbs and Chinese Medicine". Do you know it? It's excellent.
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Permalink Reply by Daniel Fonte on -
Ladies and gentlemen
Tonight in the center ring....
Whew classmates et al, I am so glad to read all the emotional,sensible,experience and personal accounts around this issue. There are many sides to this issue and several seem to really stand out.
Expense
Time
Achievement
It seems if it won't take more time,perhaps by modifying our present curriculum, then ending up as doctor is an option. If we have to add more time onto what we already have to get through, then entry level doctorate has no interest.
Same reasoning on the expense side.
Achieving a doctorate is perceived as only an esteem booster, without assisting in a better pay scale.What are we doing then? As acupuncturist we deal with all issues of whole health from the simplest to the gravest. People are entrusting our ability to diagnose and treat disease. We write prescriptions,administer treatments, and refer out to other medical professionals with our patient notes accompanying the patient. We do what doctors do, that is the adjective that fits.We are doctors.
The other issues on the business model and type of acupuncturists we want to evolve into are separate issues.
Perhaps, if a curriculum can be established that takes no more time, no more expense, is geared towards teaching medicine and not towards passing a state test, then the title doctor would not be so contested. So before any of our professional organizations puts the idea of doctorate on the table they should overhaul the present system and come back to us with real facts about the time and expense required to achieve this goal.
I wouldn't have come to this conclusion if it hadn't been discussed here. Thanks for the education .
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Permalink Reply by Chris Kresser on
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Yes, thanks to everyone for a great discussion. Clearly there are a lot of variables to consider and many ways to look at this.
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Permalink Reply by Donna Chang on -
Wow, great discussion.
If a Doctorate degree requires minimal increase in classes (considering how lengthy the AIMC program is) or tuition, then I am all for it. But I don't think I would want an entry-level doctorate that requires more standardized classes (in the herbalized acupuncture tradition) than what we already have. I do think that a lot more education is needed outside school to be good healers. But the focus (whether it be 5-element, japanese acu., qigong, etc.) should be left to the individual.
Re: Community Acupuncture
I have respect for what they do, (except being so self-righteous). But I don't think anything NOT CA is automatically shi-shi.
Here are a coupla more ways I can think of to make one-on-one acupuncture (what CAers call "boutique" style) more affordable:
1) Strive to be the best chinese medicine practitioner you can be. More effective tx=less sessions=less cost to patients.
2 Make self-care education for patients an integral component. If you teach them to do qigong, mindfulness exercises, moxa, have healthier lifestyle, it would have a greater effect than acupuncture alone. I think the greatest tragedy nowadays in healthcare is not only that health insurance is unaffordable to many people, but that most people don't have idea how to be healthy. Most people's idea of "home remedies" involves Tylenol or other OTC drugs, and they have always rely on medical practitioners to "fix" their problems. Sadly, I have seen this same attitude in both patients+practitioners in acupuncture clinics.
3) Use herbs. That's like patients continuing treatments themselves at home.
Of course I can go on and on about why a lot of Chinese medicine treatments these days are not as effective as it can be. But when done well, even one-on-one treatment can be very cost-effective.
Cheers,
Donna
P.S. Chris, from what you said about Dr. Tan's acupuncture, you may enjoy this book: Applied Channel Theory in Chinese Medicine by Wang Ju-Yi. Also, I believe channel palpation/ diagnosis is taught in the Japanese Acupuncture Therapy classes.
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Permalink Reply by Benjamin Dierauf on -
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?
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Permalink Reply by Chris Kresser on
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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.
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Permalink Reply by Chris Kresser on
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Forgot to ask: how would a FPD affect recent and past MS graduates? Would they be grandfathered in?
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Permalink Reply by Benjamin Dierauf on
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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)
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