Point-Counterpoint: Should the California Acupuncture Board Raise the Number of Hours Required for Licensure?
By Lloyd Wright, Elizabeth Goldblatt and Thomas Haines, PhD
Do Acupuncturists Need More Education at This Time? No!
By Elizabeth Goldblatt, PhD
The Issue: Raising Eligibility for Licensure by Increasing Hours 36%
Any emerging profession such as Oriental medicine can always be improved by increasing standards, especially as more knowledge, skills and abilities become more available to this society.
However, any adjustment in standards should be based on demonstrated needs. Further, in order to be most effective and economical, such changes should be coordinated with the recently developed ACAOM clinical doctorate.
A consensus of the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), representing 40 accredited and candidate colleges in the U.S., and the California Acupuncture and Oriental Medicine Education Committee (CAOMEC), an organization representing the 25 California-approved colleges, are urging the California Acupuncture Board to reconsider its recent decision to raise the hour eligibility criterion for California licensure. As indicated, any raise in hours must be legally based on demonstrated need. Further, such changes should not unduly affect acupuncture students and professionals across the United States.
The traditional role of a licensing board is to set minimum entry-level standards based on competencies necessary to protect public safety. It is not to set the vision of the field or to mandate mastery. Rather, entry-level is a "do-no-harm" standard and should reflect the number of hours necessary to train an entering practitioner to treat in a competent, safe manner without endangering the public.
In order to raise eligibility standards, a board should demonstrate that the current educational standard is not protecting the public. For example, if there were a number of complaints that practitioners had harmed patients, the board would look at what educational areas are inadequate and how to remedy the situation. However, the safety record of our profession is impeccable. Consumers across the United States, in their increasing use of the services of licensed acupuncturists, demand for third-party payment for LAcs and support for new acupuncture practice acts, have shown their satisfaction with the current educational standards. In fact, the safety record of licensed acupuncturists in California (which already has one of the highest number of hours required for licensure in the U.S.) is no better or worse than other states with lower requirements. This supports the argument that there is clearly no demonstrated need related to safety to raise the number of hours in California.
Although the argument regarding demonstrated need may appear to be a technical, legal argument, it was developed due to the tendency of practitioners in all fields to attempt to raise the hours of new graduates to enter the profession. This is one mechanism to reduce competition. However, raising hours also raises costs to students (and therefore consumers), which is a legislative concern. For this reason, the test of "demonstrated need" arose.
If hours are increased, students will be affected across the U.S., not just California. Eleven of the 25 California-approved colleges are outside the state. Costs to students across the U.S. will increase without any evidence that the current educational curriculum is insufficient. Further, such an increase in hours would result in at least one additional year for many students, substantially increasing their student loans and strongly affecting the economics of their practice when they graduate.
What is Driving This Increase in Hours?
This increase is being driven, for the most part, by some practitioners in California who would not be required to meet the additional hourly requirement. Many practitioners have far fewer hours of training than current graduates. The majority of students, patients and colleges do not support this drastic increase in hours without being convinced there is, in fact, a credible demonstrated need.
One reason given for the increase in hours is that "California wants to set the vision for the profession." However, the vision of all the national organizations that affect change within the profession is to establish a credible academic clinical doctorate. Unfortunately, no matter what the number of increased hours is in California, such hours can only be applied to the current master's programs.
Current practitioners with less than five years of full-time clinical practice who want to get an accredited doctorate degree under the upcoming clinical doctorate program in a California approved college will have to meet the current master's level requirements (3200 hours) prior to entering a doctorate program. For example, practitioners who graduated from a 2400-hour masters program will first have to make up the 800 hour difference to the new 3200 requirement, then complete at least 1200 hours under ACAOM guidelines. Some colleges will require more. This would push doctorate programs for existing practitioners to a significantly longer program length and cost more. This will affect a large number of practitioners, since in many areas of the country colleges are California approved.
Which Entry Level Should the Profession Have?
Since the ACAOM clinical doctorate has not yet been implemented, it is premature to assume the doctorate will become entry-level. Strong elements within the profession, including the Council of Colleges and the National Alliance of AOM, support the master's degree as entry-level and the doctorate as optional at this time. Since the doctorate does not address an increase in the scope of practice, and since there is no evidence of harm at the master's level, the entry level will remain master's for some time. Further, due to increased educational costs of a doctorate program, and an extension of the time before one could enter the profession, there would be an adverse effect limiting access to the profession.
What about Licensing Titles Using "Doctor of Oriental Medicine"?
Since the ACAOM clinical doctorate is an academic clinical doctorate, it would not be appropriate to grandfather current practitioners. Historically, only approved institutions of higher education can award academic degrees, not licensing boards.
Although a few states have succeeded in granting licensure titles of "doctor," this will be increasingly difficult once an accredited doctorate program is in place. The Council of Colleges, the California AOM Educational Committee and the Accreditation Commission will continue to inform legislatures regarding appropriate educational standards, scopes of practice and licensure titles and will also educate those states that do use the professional title of "doctor" and request them to change their licensure titles.
In conclusion, the current public hearings utilized by ACAOM to address educational standards allow input from professional groups, educational institutions, certification organizations and the public (consumers and students) to be systematically evaluated and incorporated in an organized change process, especially when core competencies are at issue. The California Acupuncture Board has not undergone the comprehensive processes necessary to adequately identify proper curriculum changes. Without a higher level of accountability, the credibility of raising its standards has been compromised. Therefore, the CCAOM and the CAOMEC are urging California Acupuncture Board members to reconsider their decision to increase the hourly eligibility criterion for California licensure by 36% until such time that any increase is based on a demonstrated need for additional competencies that are required to assure the safe practice of acupuncture.
Do We Really Need All That Education?Yes!
By Lloyd G. Wright, LAc, DNBAO, QME
The short answer is yes, but the long answers come from why, how, and when. On August 22, 1999, the California Acupuncture Board passed a motion to raise the required hours of education for licensure of acupuncturists in the state of California to 3200. The concept has been an ongoing discussion on the board since 1993. While the discussion has often been set aside to in order to deal with more pressing matters, the issue has been under consideration for quite some time.
The motion has been met with opposition from some schools and their representative body, the Council of Colleges of Acupuncture and Oriental Medicine. Before we assess the arguments presented to the Acupuncture Board on each side of this issue, it is important to understand the mandate of the board. The California Acupuncture Board, like all state boards under the Department of Consumer Affairs, is established by the state legislature to protect the public from incompetent and unethical practitioners. The relevant concept with regard to educational levels is that the Acupuncture Board must establish an educational level that provides consumers with practitioners that are safe and effective. At the same time, the board should not raise standards without good cause. To do so may artificially prevent good practitioners from completing the educational process due to excessive and unnecessary education.
Let us consider some of the arguments favoring increased standards:
A 4000-hour doctorate program is consistent with the level of education required of other primary health care providers of equal (or even less) responsibility, e.g. medical doctors, doctors of chiropractic, podiatrists, optometrists, psychologists and doctors of osteopathy. Even some secondary health care providers such as physical therapists and registered nurses have four years of education beyond a bachelor's degree. It is reasonable to assume that the state legislature agrees with the state boards who oversee these other professions that 4000 hours represents minimal competency training.
It is difficult to believe that a licensed acupuncturist, with all of the responsibilities of a primary health care provider such as a chiropractor, achieves a level of minimal competency at 2350 hours, while minimum competency training for a doctor of chiropractic requires 4000 hours of training. I am personally hard pressed to believe that traditional Oriental medicine (TOM)is either simpler or has less depth than the field of chiropractic. In fact, traditional Oriental medicine treats a full range of illnesses, including musculoskeletal and internal medicine issues, and has a broader scope of practice than chiropractic.
The California legislature has continuously cited inadequate education as a reason licensed acupuncturists may not participate fully and equally with other primary health care providers in the workers' compensation system. We are very close to equal status, but I would hate for the profession to lose privileges for not stepping up to the plate and accepting the responsibility that goes along with the ability to treat independently. Evidence of this is cited in the March 13, 1997 draft report by the California Senate Office of Research, which concluded that acupuncturists need to "á gain greater patient assessment and diagnostic skills."
The range and depth of traditional Oriental medicine is now recognized as considerably more broad and deep than was commonly perceived in the 1980s. Numerous classical textbooks have been translated and are now available for study.
According to the World Health Organization's recent guidelines on basic training and safety in acupuncture, a minimum of 2500 hours is considered the minimal standard for the study of acupuncture alone. Of those 500 hours are recommended for the study of Western medicine just to practice independently, with no mention of becoming a primary care provider. This would certainly suggest that the competent study of traditional Oriental medicine, including modalities such as herbal medicine, tui na, diet, exercise form, and lifestyle counseling, is much more than the current 2350 hours and probably much more than the recommended 3200 hours currently under consideration.
Every professional acupuncture association in California, most associations in other states, and the national association, the American Association of Oriental Medicine, are in full support of increasing the number of hours of education to 4000 hours, primarily to improve patient care and increase effectiveness of treatment. Many schools also support an increase, including South Balyo University, Emperor's College and China International Medical University.
The current requirements for licensure in California in the area of Western biomedical training are inadequate. A survey of the number of hours of basic Western medical sciences -- not specialized diagnostic procedures -- found that naturopathic physicians are trained 1685 hours in basic Western biomedical sciences; medical doctors are trained 1279 hours; chiropractors, 2614 hours; and licensed acupuncturists, 360 hours. In China, as much as one-third of the education for traditionally trained practitioners is in the Western biomedical sciences. Many acupuncture colleges already exceed the state requirements in this area. Licensed acupuncturists need these skills to protect their patients by knowing how to establish a working diagnosis and when to refer and to communicate with Western trained practitioners.
Let's take a quick look at some of the arguments against raising the hours of required education.
1. Some practitioners may have a vested interest in limiting the number of practitioners and colleges. It is not the role of the Acupuncture Board to limit the number of colleges or practitioners.
I believe this incredible assertion is at best rumor and at worst the opinion of a few individuals. I have personally never heard such opinion discussed in my professional circles, and I have never seen any support for such an opinion formally or informally on the part of any professional association. I would oppose this as a reason to raise educational standards because it places the practitioner's own self-interest above the profession, the consumer and students.
The assumption that higher standards of education prevent or restrict the number of new practitioners entering a given field is false. In fact, other primary health care providers (medical doctors, chiropractors, dentists and psychologists) are not in short supply, yet they all have 4000 hours clinical doctorate programs in place. Their schools have not closed because the curriculum is 4000 hours. It is my understanding from leaders in the insurance industry that California actually has over 5000 chiropractors in excess of the population's needs based on current utilization models. I would invite any proponent of this assumption to demonstrate a lack of chiropractors, medical doctors, psychologists or any other primary health care provider that can be attributed to the fact that the educational requirement is a 4000-hour clinical doctorate. The evidence appears to support quite the contrary, chiefly that a 4000-hour doctorate program encourages more students to apply and actually increases the availability of practitioners in a given profession.
2. The safety record of acupuncture and Oriental medicine is excellent and requires no further instruction to be practiced safely.
The issue of safety and effectiveness is not well tracked by any practice, as most malpractice claims are settled out of court and are not public information. Alhough I have heard informally of several such cases that never came to the attention of the board during my tenure, I would agree that acupuncture and traditional Oriental medicine have excellent safety records.
Although the first issue to consider is physical safety, the principal of do no harm, there are other types of harm to consider. I recall reviewing the chart of an acupuncturist who took over 30 treatments to resolve a simple acute low back strain. If a patient or insurance company pays an additional $300 (or $500 or $1000) to treat or resolve an injury or illness because an acupuncturist was not fully trained, the damage has been done. Perhaps some people believe it is all right for a patient to waste $200 or $400 on an acupuncture series that was not preformed competently. I disagree. This damage is very likely to go unnoticed in the system except by the field practitioner who sees the type of results that current training has allowed him or her to produce. The feedback from the profession at large is quite clear on this matter; it appears some schools have largely ignored this feedback.
It is also worth noting that the master's degree became the current standard without the need to show that patients were being injured or dying. Today, no one argues that the current standard is too high.
3. A gentler increase to 2800 hours would be much more helpful at this time. When the 4000-hour doctorate program becomes available, the doctorate program offered by a school must be 1200 hours more than that school's masters degree program. By creating a 3200-hour masters program, we have an extraordinarily long master's degree that will force the doctorate to be a minimum of 4400 hours for all California schools.
In my opinion, this argument may have some merit. It becomes problematic because clearly a large number of field practitioners believe that a clinical doctorate should be the minimal entry-level standard. We are now faced with even further delays of up to two years or more before the proposed doctorate program even becomes available. The California Acupuncture Board apparently chose to take the middle ground and increase the hours to 3200. I believe this particular point may merit further discussion and perhaps negotiation between the perspectives of the board, the professional associations and the schools. Perhaps the Council of Colleges would be willing to support the implementation of a full 4000-hour clinical doctorate as the entry-level requirement sometime in the near future, and the Acupuncture Board may be happy with raising the immediate standard to 2800 hours, thus simplifying the administration and accreditation process on behalf of the schools. I encourage dialogue in this area.
In conclusion, we see there are differing points of view on each side of the argument. After spending five years as a member of the California Acupuncture Board and giving considerable thought to the arguments on both sides, I fully support an increase in required hours of education to be licensed as an acupuncturist. I believe this because I am acutely aware of the level of responsibility required of a primary health care provider. I am also certain that having status as a primary health care provider has been and will continue to be an important position in our health care system which will allow patients to access the services of acupuncturists and gain the benefits of traditional Oriental medicine. I, like many of my colleagues, have gone to great efforts to fill in the gaps in education that are the legacy of the past 20 years of acupuncture education in America. It is my sincere wish that we all work together in harmony to bring the best benefits of this wonderful medicine to the Western world.