Understanding ACAOM Draft Doctoral Standards

For the past six years, the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) has engaged in a comprehensive process to assess the likelihood that the AOM profession might eventually migrate to a first doctorate for entry into the profession. During this time, AOM colleges, the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) and AOM practitioners have provided input and taken different positions on the development of first-professional doctoral standards for entry into the profession.

One thing ACAOM has underscored at every public hearing on this issue is that it is not up to ACAOM to determine when (or if ever) the AOM profession ought to change from the current master's entry-level standards to an entry-level doctoral set of standards. This will only come about, as ACAOM Chairman Dr. Howard Simmons clarified repeatedly, if appropriate nationally recognized accreditation standards are established for a first-professional doctorate.

A critical mass of AOM colleges then would have to successfully run such doctoral programs and gain accreditation for them. Once there are graduates from some of these programs and if there has been consensus along the way from all stakeholders, ACAOM would be in a position to apply to the Department of Education for an expansion of scope to incorporate accreditation of first-professional doctoral programs into its activities, thus gaining access to Title IV funds for such programs.

At that time, which could easily be several years after the draft standards are adopted, the likelihood that the AOM profession would embrace a shift in entry level to the first-professional doctorate would be very high. This is what happened in physical therapy and occupational therapy, which will each soon stop offering master's level education in favor of an entry-level doctorate.

Another thing that is critical to understand is that during any such transitional period, already-licensed acupuncturists will be protected in their licensure and will not be forced to go back to school to gain the new degree.

The AOM Entry-Level Cat is Out of the Bag

Regardless of what positions or actions are taken by individual AOM colleges, the CCAOM and the ACAOM, the fact is that the ACAOM Doctoral Task Force has now identified a set of core competencies it believes must be integrated into current entry-level in order to establish appropriate standards for first-professional doctoral education in the field of AOM. These core competencies have been integrated into medical education for medical doctors, nurses and physicians' assistants. These core competencies were integrated during the process of developing first-professional doctorates in physical therapy and occupational therapy by redefining the entry level to include the competencies whether a master's or doctoral degree was attained.

A careful comparison of the current master's-degree entry-level standards and the draft first-professional doctoral standards, which have been developed over the past six years with AOM community-wide input, is very instructive. In the six-year development of these draft first-professional doctoral standards, it was determined that the AOM competencies had been well-developed in the master's standards and merely needed to be framed in competency- and outcome-based terms. AOM professional practice had thus come of age, and the master's AOM competencies were determined to be adequate to a first-professional doctoral level of practice.

What is different between the entry-level standards and the first-professional doctoral standards is that the master's standards focus on the professional competencies for safe and effective private practice, while the draft first-professional doctoral standards include those competencies, but then add other competencies designed to enable graduates to also practice in other health care systems like hospital-based practices and integrative multidisciplinary settings.

Additionally, in contrast to the master's standards, the draft first-professional doctorate set of standards frames all of the standards in terms of required institutional, program and student learning outcomes. Rather than focusing on acquisition of knowledge, the draft standards focus on the development of professional competencies, attitudes and values, in addition to knowledge.

Biomedical Competencies: The Big Difference

For two decades, critics of the entry-level master's standards have argued for more rigorous biomedical knowledge and skills for entry-level practice in North America. While this was reduced in many debates to the ability to perform biomedical differential diagnosis, the larger debate recognized that in those states where AOM practice arguably occupies a primary care status, it was logical to require stricter biomedical knowledge and skills sets to support a primary care scope of practice.

In the draft first-professional doctoral standards, something more rigorous and relevant to actual AOM practice is included in the definition of independent AOM practice competencies, namely the ability to:

• engage in critical thinking that will facilitate good judgment because it relies on criteria and evidence, is self-correcting and is sensitive to context to improve patient care; and
• identify needs and locate sources of information to support clinical decision-making to improve patient outcomes, which is referred to as "information literacy."

Another major difference between the current master's entry-level standards and the draft first-professional doctoral standards is in the area of biomedical clinical sciences and biomedical diagnostic skills. It is here, in addition to the integration of critical thinking and clinical decision-making based on information and evidence throughout an entry-level AOM education, that the first-professional doctoral standards represent an enormous shift in thinking about AOM entry-level skills. This shift takes classroom theory in biomedical clinical sciences and places this theory and knowledge in the context of clinical skills that AOM interns must be able to practice for improved patient care.

In the first-professional doctoral standards, diagnosis is defined as "The process used to identify the disease entity and individualizing factors of disease," with five specific competencies:

• Collect and organize relevant data to facilitate the development of a diagnosis.
• Access relevant resources such as research literature and clinical experience in arriving at a diagnosis (representing AOM evidence-based practice).
• Formulate an Oriental medical diagnosis pursuant to AOM principles and theory.
• Identify and describe the biomedical pathophysiological process responsible for the patient's clinical presentation.
• Explain the subjective and objective findings that warrant consultation with, and referral to, other health care providers.

Finally, while the master's entry-level standards delineate only a few very basic diagnostic skills that require minimal biomedical knowledge, the draft first-professional doctoral standards state that independent AOM providers are "expected to be able to review, understand and communicate about diagnostic studies," demonstrating an ability to:

• describe the relevant laws and regulations, including scope and practice, that may govern or limit conducting diagnostic studies;
• explain the clinical indications, risks, and benefits for diagnostic procedures;
• outline the principles and applications of equipment utilized for diagnostic imaging, laboratory and other relevant diagnostic tools;
• assess diagnostic reports, including the range of values that distinguish normal from abnormal findings, as relevant to patient care and communicate with other health care providers;
• incorporate findings from diagnostic studies with objective and subjective findings from the assessment of the patient; and
• communicate effectively with other health care providers regarding the results of diagnostic studies.

While some critics of the draft standards might wish the competency to order diagnostic tests were listed, nothing in these standards would preclude an AOM college from teaching

students how to do this in a state where AOM providers have primary care scope of practice and can order and even perform diagnostic tests. The standards merely stipulate that an independent AOM provider practice within their legal scope of practice when "conducting diagnostic studies." State laws would also require this.

In the new systems-based medicine domain (again, totally absent from the current master's entry-level standards) independent AOM providers will be expected to do the following:

• communicate with other health care providers from a knowledge of these other disciplines, in language understandable to other health care providers;
• discuss biological and physiological theories of the mechanisms of AOM; articulate expected AOM clinical outcomes from a biomedical perspective; and
• access relevant and appropriate information to educate health care colleagues (informatics and critical thinking).

AOM Comes of Age

Taken together, the increase in rigor and relevance of the biomedical knowledge of the disease process, and the integration of competencies in both information literacy and AOM evidence-based practice, represent a tremendous increased level of professional competence. This augmented set of competencies and professional practice expectations places independent AOM practice on the same footing as all other doctoring health care professions such as medicine, osteopathy, naturopathy, chiropractic, and physical and occupational therapy.

What Next?

The AOM professional and educational communities have worked tirelessly on the careful review and development of first-professional doctoral standards, and continue to do so while protecting all currently licensed practitioners and students. It is not easy to reach consensus on any new set of standards where some compromise from all sides is inevitable. It is easy to recognize that the profession is ready for credible first-professional doctoral standards. All that is needed is a little prod from AOM practitioners to offer sufficient evidence of consensus to ACAOM for renewal of its review and finalization of standards for a first-professional doctorate in acupuncture and in Oriental medicine.