Since it was first discussed at length in the March 2001 issue of AT, the question of whether medical doctors and chiropractors have the right to practice acupuncture -- whether or not they have proper training -- has continued to spark debate throughout the acupuncture and Oriental medicine profession.In the past few months, several practitioners have sent faxes, e-mail messages and letters to the editor to Acupuncture Today voicing their opinions on the subject.
As a result, we have decided to share selected letters with our readership to give an idea how practitioners feel about the issue. What follows is a complete list of letters to the editor sent to Acupuncture Today on the matter (as of June 1, 2001).
"I Hope That an Open, Honest and Well-Intentioned Dialogue Continues"
Thank you for opening a dialogue which is in sore need of a beginning - the Point-Counterpoint printed in the March 2001 issue between Dr. John Amaro and Mr. David Molony, LAc.
Mr. Molony makes the valid contention that an acupuncturist should have a certifiably demonstrated minimum proficiency to be allowed to practice acupuncture. This protects the public from untrained practitioners. I believe that any healer whose primary intention is to help suffering humanity would (or should) agree on this point.
The National Board of Chiropractic Examiners provides parts I, II, III and IV of the national board exams which must be successfully passed to obtain licensure. Upon successful completion of these four parts, the person must pass individual state boards for licensure in a given state. I truly believe that any professional health care provider (MD, DO, PT, LAc, etc.) who demonstrates minimal proficiency of the philosophy, science and art of chiropractic by passing these required board exams should be licensed as a doctor of chiropractic. This protects the public from untrained practitioners. I would welcome any practitioner who is able to demonstrate this minimum level of proficiency as a fellow doctor of chiropractic, regardless from whence they achieved their knowledge/training.
If there were a fair, impartial board to test, certify and license any practicing professional health care provider who seeks to include acupuncture in their existing practice, I would happily agree to be tested. If there is not currently such a board, there should be one formed; now would be an excellent time to begin the process. I would suggest a "National Board of Physician Acupuncture Licensing" to test doctors of medicine, chiropractic, osteopathy, etc. Dr. John Amaro currently provides an excellent educational program for practicing doctors (MD, DC, DO, etc.) which includes a rigorous exam and certification, so the program, testing and board (consisting of DCs and MDs) is already in place. The designation earned is FIAMA (Fellow of the International Academy of Medical Acupuncture).
For the benefit of all concerned, I hope and pray that an open, honest and well-intentioned dialogue continues. Perhaps a website could be opened to continue discussion on Mr. Molony and Dr. Amaro's points of disagreement. I believe that each issue will be resolved inevitably at some point in the future. Surely common ground found in a spirit of understanding, compassion and love is preferable to that resolved in a contentious spirit of distrust, fear and hatred.
James J. Derbes, DC
Thank you for some relevant and stimulating content in the March 2001 Acupuncture Today. I'd like to comment on the Amaro-Molony Point-Counterpoint.
I was interested to learn that Dr. Amaro's own clinic would see "an average of 75-125 patients per day, five days a week · with the help of 12 clinical assistants." I would certainly like to know if they were truly just "assistants," or if Dr. Amaro was employing other acupuncturists, because if he was treating these patients himself, in a 10-hour day, he would have about 5-7 minutes to spend per patient. What kind of medicine is that?
Barry Levine, LAc
Standards Should Apply to "All Who Wish to Practice Acupuncture and Herbal Medicine"
I was quite disturbed by the tone of the exchange of viewpoints in the Point-Counterpoint article in the March 2001 issue.
No one may practice medicine, dentistry, nursing or chiropractic without having attended an accredited school, passing the required examinations and becoming licensed to practice in a specific state. The same applies to the practice of acupuncture and Chinese herbal medicine.
All practitioners in these disciplines should be diplomats of an accredited school and should take the national written and practical examinations. This establishes the individual's competency to practice acupuncture and/or herbal medicine no matter what other professional credentials the person may possess.
Calling the attempts of legitimate practitioners to adhere to standards of practice and education "turf wars" is only to achieve standards of vulgarity. Since standards have been duly and law set by the NCCAOM, they should be adhered to by all who wish to practice acupuncture and herbal medicine.
Regina Bodenheim, PhD, PT, Dipl.Ac., LAc
"Perhaps Thoughtfulness Will Save the Day, and Our Field Will Be Left the Stronger"
I read the Acupuncture Today Point-Counterpoint article with great interest. As a second-year student at the New England School of Acupuncture, a full-time program that, when completed, will take three years (2,795 hours), I have been struck by the issues raised by the article. Dr. Amaro skillfully related the history of the "weekend" acupuncture education for physicians - as well as its cultural foundations - which I was desperately missing to have anything close to perspective on the matter.
Dr. Amaro's career is exemplary and distinguished, and the history of acupuncture in the United States heavily owes him and his contemporaries a significant debt of gratitude. Of that, there is no doubt.
I too agree that making enemies with a powerful lobby (i.e., the AMA) would be terribly costly. Certainly, too, physicians and chiropractors who use acupuncture see positive, perhaps tremendous results (thus the power of the art!). Thankfully, for the sake of this field, the time demands are extremely costly for physicians to practice acupuncture in great numbers. Add to that an education based on completely unrelated theory and practice, and a strong ingrained skepticism of anything that cannot be broken down to cause and effect, and I don't believe there is an immediate reason for panic - and there fore a reason to create forest fires out of chimney smoke by forcing a so-called "turf war."
What concerns me, however, are two issues: one which Dr. Amaro hit on, the other which did not come up in the article to any great degree.
First, the issue of training. Clearly, with Dr. Amaro's decades of first-hand training crossing multiple continents and many years, he has learned the art and science of this practice. He has fought the earliest fights, and won them, for the highest benefit of our community.
Certainly, though, not all physicians or chiropractors will pursue a continued exploration of the theory and techniques and further develop their skills beyond the minimum requirements, as Dr. Amaro has no doubt done to penetrate the depths of the practice to become a skillful clinician. I know from experience that 200 hours of classroom in any acupuncture subject, be it meridian theory or TCM, is truly an introduction, and hardly substantial education on the matter. I believe I will leave my master's program as the earliest neophyte, even with approximately 15 times the classroom and clinical education of the 200-hour program, and not because of poor teaching or lack of interest and persistence.
So, then, it concerns me that physicians and chiropractors who limit themselves to such a short introductory course, a beginner's education, might present themselves as diplomats of acupuncture. I believe the bar should be raised. Just as the master's program meets high standards to be able to produce safe and skillful practitioners, physicians and chiropractors should meet a requirement of proficiency. I am tempted to say that they should pass the NCCAOM exam, but that's a stretch. Rather, increasing their requirements from 200 hours to 1,000 hours and including a supervised clinical rotation with someone in the field with 10+ years of hands-on experience would be far preferable than outright fighting a turf war of any sort. Our highest concern should be the safety and recovery of the patient. Of that, there should be no dispute.
While I have no acupuncture examples as illustrations, nowhere is this issue more clearly demonstrated than with the issue of guang fang ji (aristolochic acid) and the FDA in relation to Chinese herbology. Here, misuse of the herb by an untrained Belgian physician (fatalities resulting from the inappropriate inclusion of the herb in a diet supplement) is causing ripples throughout the herbalist community here in the States (and perhaps irreparable harm). While it may seem like a turf war, there obviously are legitimate issues looming in the background that require thoughtful attention.
The second issue of concern relates to the issue of acupuncture research. I am concerned about individuals who are not thoroughly trained in traditional theory and technique conducting experiments as if they are qualified practitioners. Without a sound theory of practice, no research about our field has any meaning.
When I read research printed in the trades, rarely is there an indicator of the practitioner's level of experience. And this, I believe, is a terrible Achilles heel. The statistical significance of the study may very well be related to this crucial information. As we know, acupuncture requires skills that take years to fully develop. Wrong point location; inappropriate manipulation; and errors of diagnosis can result from incomplete education. These and other factors can perhaps nullify research results, harming our reputation with an uneducated public.
So, can we trust someone trained with only 200 hours to be our ambassador when making the claim that acupuncture can or cannot benefit individuals with diabetes, arthritis, and other Western or Eastern-defined diseases? What tremendous harm could a bad outcome by a poorly trained practitioner cause at this fragile moment in American acupuncture history! Perhaps worse, an unsubstantiated positive result that brings a throng of high hopes ultimately to be crushed.
Perhaps we acupuncturists, regardless of title and educational pedigree, should include the experiential qualifications of those inserting needles or supervising practitioners in all of our future studies, so as to provide some anchor of legitimacy to our work, and to help us differentiate quality research from what could amount to the mechanistic hokum of poorly trained individuals.
Thanks to Dr. Amaro for taking on this issue with wisdom and aplomb. Perhaps thoughtfulness will save the day, and our field will be left the stronger.
Student, New England School of Acupuncture
Turf, Politics and Power
I'd like to respond to the articles written in the point-counterpoint column recently regarding the right of medical and chiropractic physicians to practice acupuncture. I am amazed at the smoke being blown around this issue by both of the respondents. I was very impressed with John Amaro's article. However, I think John has missed part of the issue that is fundamental to this argument. That issue would be brought to light if we asked John to comment on the right of acupuncturists to use chiropractic techniques in their acupuncture practice. I am sure he would provide a very convincing argument that acupuncturists should not be allowed to use chiropractic techniques without graduating from chiropractic college.
I think we would all agree that physicians, acupuncturists and physical therapists could easily incorporate chiropractic adjustment techniques into their practices, and with very little risk to the patient. However, we are all aware that these techniques are part of the turf that the chiropractic community is guarding jealously. I see no reason to expect that acupuncture techniques should not be guarded to the same degree by the acupuncture community. I am sure, as John states, there was a time in the early '70s that acupuncture techniques were being utilized by anyone interested in using them. The world has changed, however. And now, 30 years later, the acupuncture community is attempting to establish a political power and a turf over which it may rule. This is a very reasonable expectation, and one that every profession needs to make manifest in order to exist.
The whole discussion of education in this debate is nothing more than smoke being blown around to confuse the real issues. Education, in a large part, is nothing other than paying one's dues in order to achieve legitimacy. A significant part of what we learn in school does not have any direct clinical significance. But it is a necessary part of our establishing legitimacy in the professional world.
I would readily concede that three years of schooling is not necessary in order to practice acupuncture in a very clinically effective manner. I have heard Mark Seem state during a seminar that it is well within reason to train someone in six months to be a clinically effective acupuncturist. I agree. I could teach someone in a few months to do what I do in my clinic, and depending on their aptitude, they could learn in a very short time to be an effective clinical practitioner.
I have had quite a lot of chiropractic treatment by a variety of chiropractors, and I work with a chiropractor one day a week. I feel like I have a pretty good idea of how some of the most common chiropractic techniques are performed, and there is not a doubt in my mind that I could learn to do what a chiropractor does clinically in a very short period of time. A chiropractor does not need 150 hours of anatomy; 175 hours of biochemistry; 120 hours of microbiology; 305 hours of physiology; or 205 hours of pathology to perform a chiropractic, just like I don't need them to do acupuncture.
The issue is indeed about turf. It is also about politics and power. Just because a technique is clinically effective and can be easily utilized does not mean that it should be within the scope of practice of every health care practitioner. Physical therapists do not do chiropractic. Physicians do not do chiropractic. Podiatrists do not do chiropractic. Each of these professions has their own turf and hopefully refers out to the appropriate specialist when necessary.
Establishing rigorous educational standards is necessary in all professions in order to create legitimacy and respect. The acupuncture community has focused intensely over the past few years on these issues. There has been an attempt to establish a legitimacy both in the professional health care world and in the political arena.
We need to also be aware that politics in America is generally very biased. Usually, the political party that has the most money gets their way. This is a cause of fear in the hearts of many acupuncturists, because the American medical acupuncturists associations and chiropractic communities have far more financial resources at their disposal than the acupuncture community does.
There is also a fear that should physicians and chiropractors (with only a few hours of training) become certified to perform acupuncture and at the same time be reimbursable, while a licensed acupuncturist with far more expertise and training cannot get reimbursed, that acupuncture as a profession will cease to exist.
Another issue I would like to mention is greed. The motive behind many chiropractors, podiatrists and physicians wanting to become acupuncturists is simply that acupuncture offers a safe, effective and billable service that can be quickly and easily performed in an office with no additional overhead or equipment. This is a troubling issue for those of us attempting to practice acupuncture with integrity. Imagine the temptation, for a chiropractor who doesn't have a very busy practice, to take a "quickie" course and then be able to stick a couple of needles in and charge an extra $80 every time he or she sees a patient. If John thinks this is something that isn't happening now or wouldn't explode, should chiropractors or physicians be certified easily, he is deluding himself.
I also must say that I take exception to the implication John makes that Mark Seem is being hypocritical when he states that Joseph Helms' medical acupuncture training is excellent while at another time referring to it as inferior. These statements are not necessarily contradictory. Medical acupuncture is inferior to the type of acupuncture described in the Ling Shu, the same way that cracking a knuckle may be considered inferior to a comprehensive chiropractic adjustment. Saying that it is inferior is a statement of relativity, not necessarily a judgement of value.
Learning a relatively simple, albeit effective, technique is indeed inferior to learning a complete system of Taoist alchemy, philosophy and medical theory that underlies that simple technique. John has obviously spent the time and energy to study acupuncture and Chinese medicine far in excess of what would be required of him to practice legally. This is admirable. We would certainly like that all practitioners who chose to become acupuncturists are also dedicated and sincere. A measure of these characteristics is the educational commitment to which they are willing to engage. An acupuncturist in the 21st century should also be expected to dedicated, serious, purposeful and willing to pay their dues in order to practice and be accepted as an acupuncturist. Those of us who have spent years studying feel slighted by others who want to call themselves acupuncturists without spending a fraction of the time and effort that we have. We have every right to have and protect our acupuncture turf.
Daniel Zal, LAc
Albany, New York
Turf: Them's Fightin' Words
It seems Dr. Amaro is in a fighting mood. That makes sense, since chiropractors have had to truly struggle throughout difficult times to establish political power and professional credibility in the light of allopathic attacks. But is his call to arms appropriate? Is his threat of professional isolation and defeat for acupuncturists real, appropriate or moral?
I would say it is real. The acupuncture community would be isolated without allies in the chiropractic and allopathic communities. We would rely on the support of the citizenry, as did the chiropractors of the 1940s and 1950s. But what is the nature of this threat? Why is it being presented? What acupuncturists like David Molony, others and myself are asking is to follow the rules as set up by the profession. Surely chiropractors can trace their lineage to allopathic and osteopathic sources as does Amaro with acupuncture, but did this promote MDs to do chiropractic without the appropriate training? No! The professions split into DOs and DCs, and they elaborated on the educational training needed to meet basic standards. What is wrong with acupuncturists establishing their own standards and asking others to follow it? Furthermore, what is wrong with the concept of establishing acupuncture as part of the field of Chinese medicine? It seems to me that chiropractic has many similar historic parallels that Dr. Amaro is conveniently ignoring.
Dr. Amaro spends a lot of time in the historic development of acupuncture but fails to understand that it was the acupuncture vanguard that opened the way for a "profession." It was this vanguard that helped to promote students, who had no ties to other professions, to fight for separate legislation for acupuncture (albeit often with the help of MDs and DCs). Furthermore, the acupuncture school often stood in the way of "independence" because of its financial interest in training anyone who walked in the door. The rank and file practitioner recognized this conflict and acted. The rank and file practitioner, along with the Chinese community, made the legal changes necessary for professional independence. What is important to recognize is that professional support is different than vanguard activity and perspective.
Dr. Amaro is clear to explain that the chiropractic colleges had conducted the first studies on acupuncture. This can be paralleled to the work and research that allopathic and osteopathic schools had done before chiropractic colleges were "accepted." He goes on to explain that the "first practitioners and students of acupuncture in the United States" were DCs and MDs. Historically Dr. Amaro is correct, as is the fact that chiropractic grew out of medicine and osteopathy. Is this an argument for osteopaths to absorb the chiropractic field, or for osteopathy to "claim" ownership of chiropractic? Maybe, with Dr. Amaro's logic.
Dr. Amaro wants to claim ownership by historic association. I contend that he should look at the historic roots of his "primary" field of practice, chiropractic, to understand that historical relatedness does not preclude the apparent need for autonomy in any given field of study or practice. After all, dialectics can work both ways. I can understand the interest in acupuncture and Chinese medicine by the chiropractic field, since it truly holds a holistic view of the human condition. Personally, I think this is the most important reason for the practitioners of any given field to make clear the distinction between acupuncture as a physical therapy and acupuncture as practiced in the scope of Chinese medical and philosophical theory. It should be noted at this point that TCM is a politicized version of a traditional form of medicine the Chinese practiced. TCM was an attempts to base Chinese medicine in the scientific process. This was the beginning of compartmentalizing and Westernizing a health care practice that was based in a cosmic, "holistic" algorithm.
I find it very interesting that Dr. Amaro is more interested in creating historic links to acupuncture in the U.S. rather than addressing the issue of educational competence. This seems to be the real issue that the "100-hour brigade" is avoiding. We are not here to argue who is responsible for the existence or acceptance of acupuncture in the U.S. It is the Chinese culture that has preserved it for eons, and it was the Chinese people that forced Mao to accept more traditional applications of Chinese medicine since they were unwilling to give up their traditional medicine for Western medicine. Mao realized this, as well as the practical and effective use of traditional Chinese medicine.
I see Dr. Amaro, Dr. Helms, and others as advocates of the dedicated practice of Chinese medicine. This may be the reason Dr. Seem quotes Dr. Helms. It is not in the interest of the community to attack MDs or DCs just because they hold that title, which Dr. Amaro seems to suggest in his aggressive tone. He fails to glean the essence of the acupuncture community that is asking for other professionals to aspire to the educational goals all professionals aspire to - basic competence training. When Dr. Amaro writes, he seems to be building a fortress around the professions he allies with. It is not the acupuncture Oriental medical community; it is the established professions of medicine and chiropractic he allies with, and that is his true tone.
I commend Dr. Amaro for his support of the Idaho acupuncture community. That is another reason why the acupuncture community would support and note the value of Dr. Amaro's efforts. But because Dr. Amaro feels it important to support "us," does it than make us obliged to exclude comment on our goals and aspirations for our chosen profession?
I do agree with Dr. Amaro's observations that educators don't necessarily act altruistically. I do not see Dr. Seem as a representative of the acupuncture community, though. He and other educators have a serious conflict of interest which has been addressed by others in the struggle for legislative changes. In New York, where Dr. Seem is based, legislative victory was accomplished by breaking ties with the educators. It was the practicing acupuncturists who were able to understand their own interests and strategize to make legislative changes possible. To his credit, Dr. Seem recognized this at the time. It would be a shame for Dr. Amaro not to see the difference. It would also be a shame for him to miss the parallel between acupuncture and chiropractic as independent fields of study.
It further confuses me when Dr. Amaro agrees with Mr. Molony and others that Chinese medicine deserves more educational emphasis and refuses to understand that is exactly what the acupuncture community is saying. "Traditional Chinese medicine is a very complete system of healing that goes well beyond simple acupuncture administration. How can Dr. Amaro and the "100-hour brigade" explain that? What is at issue here is turf, not educational standards, and Dr. Amaro is on the side of those fighting for turf. I find that unfortunate for the practice of acupuncture and Chinese medicine in America.
Hari Khalsa, LAc
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Click here for previous articles by John Amaro, LAc, DC, Dipl. Ac.(NCCAOM), Dipl.Med.Ac.(IAMA).