The following letters were written in response to Dr. John Amaro's article "The Bottom Line," which appeared in the March issue. While they were originally slated to appear in the May issue, they were pulled from the issue due to space restrictions, and instead posted on AcupunctureToday.com for review.These letters will also appear in the June issue of Acupuncture Today.
Dr. Amaro's reply follows the last letter.
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My belief on the issue of medical/chiropractic practitioners being able to practice acupuncture with 100-300 hours of training is that it is not in the best interests of the public or the profession of acupuncture. As an acupuncture student in New York, I have written letters to help prevent the passing of any future legislation allowing it for the following reasons:
1. The 100-300 hours of training allowed involves basic knowledge of theory, no requirements in testing, and brief, untested clinical hours. Practitioners just have to show up for class and in the end are deemed able to practice acupuncture.
2. The general public, in going to these medical/chiropractic practitioners for acupuncture, is not aware of their abbreviated training in most cases. They do not have any knowledge, nor are they duly informed, of the differences between these practitioners (100-300 hours) and a typical acupuncturist having undergone 3-4 years of study (2,200+ hours of didactic, plus clinic hours) as well as exams for licensure.
3. Acupuncture is not a "modality" (akin to trigger point release). It is a complete system of healing. An acupuncturist must call upon his or her knowledge of theory and clinical experience to be able to cater a full treatment to the individual based on an Oriental medicine perspective, integrating Western medical diagnosis as a guide, not as a basis for formulating treatment.
4. The assertion that medical/chiropractic practitioners have been granted diplomas allowing them to practice acupuncture for years is not a reason to keep allowing them to do so. More and more insurance companies are covering acupuncture treatments in their policies, and I believe this is the reason for the great surge in health care practitioners wanting to classify acupuncture as a modality and add it to their practice. In New York, the going rate of reimbursement is around $75 per treatment, regardless of the length of the session, and acupuncture cannot be so easily classified and broken down into timing and treatment requirements (yet). This is a great impetus indeed for those who would desire to utilize acupuncture as a "modality" to add another billed service. In the past, this was not necessarily the case. Rarely was acupuncture covered by insurance, so the basis for wanting to practice it would not have been made with the assurance of insurance reimbursement.
5. Allowing further legislation for medical/chiropractic practitioners to practice with abbreviated training will open up the floodgates for other health care providers to want to also do so regardless of their scope of practice. At present, podiatrists are aggressively pursuing this goal, and to say that just needling points on the feet (within their scope of practice) does not affect and treat other parts of the body is in contradiction to basic acupuncture theory, in which points on the feet and ankles are used frequently to affect all areas of the body and in the treatment of a multitude of disorders, not just foot pain or associated conditions. The NCCAOM is also at present considering expansion of eligibility with abbreviated training not limited to chiropractors, dentists, naturopaths, nurse practitioners, occupational therapists, pharmacists, podiatrists, medical doctors, osteopaths, physician assistants and physical therapists. Along with this, they are considering changes to formal education requirements in the same way for Chinese herbology.
This approach is extremely detrimental to the public, who will only become more confused when, for example, podiatrists become able to treat headaches and urogenital disorders with acupuncture, and physical therapists become able to treat gynecological disorders.
Not one of these professions allows abbreviated training that leads to diplomas in their field, and for good reason. Each system has a specified route of training and testing to assure that standards within their field are met. I cannot, for instance, after graduating from my 2,600+ hour Oriental medicine program (I am already a massage therapist), take a couple of bioscience courses and a 100-300 hour course, and be awarded a certificate or diploma in any of the aforementioned fields. Acupuncture and herbology deserve the same standards to be upheld.
Dr. Amaro's assertion that by allowing further and expanded legislation on this issue would allow closer relationships between acupuncturists and other practitioners, thus leading to referrals, has no basis. What would induce other practitioners, afforded the ability to bill insurance providers for acupuncture sessions, to refer them to a fully trained and licensed acupuncturist?
When asked if they have ever tried acupuncture, most of my clients have responded that their medical/chiropractic practitioner will advise them, if their limited treatments induced no beneficial results, that acupuncture just wasn't right for them, or that it didn't work for their condition(s). In addition to the obvious disregard of acupuncture as a system of healing presented by offering certificates to those with extremely limited training, what impression is this making on individuals who experience a treatment by a practitioner who has limited training and uses acupuncture as a "modality" adjunct to their practice? The individual, without any knowledge to the contrary and regardless of the results of treatment, can be led to believe - and often does - that this is indicative of what the entire field of acupuncture can offer.
This is the crux of the issue. The best interests of the public are best served by fully trained and licensed acupuncturists that can offer the full breadth and depth of Oriental medicine as a whole, not just partitions of treatment. We must uphold the standards and requirements of training and licensure, not discard them for the asking.
Rita Valentino, acupuncture student
New York, New York
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Dr. John Amaro's letter opens with a generalization about an "increasingly growing resentment between acupuncturists" and allopathic physicians and chiropractors, although he does not stipulate who the resentful parties are. It is significant to note that he does not mention the very strong feelings that are held by chiropractors, who have taken fully accredited programs in acupuncture, toward those who promote and sell abbreviated workshops in acupuncture. There are many chiropractors and acupuncturists who have taken the fully accredited programs, and believe, rightfully so, that the chiropractors who have taken these abbreviated workshops are being deceived into thinking they are getting adequate training. Certainly, there is a measure of gullibility if a provider actually thinks that he or she could be qualified in acupuncture, or any other complete medical system, after 100 or 200 hours of training.
So, this is not a situation of "resentment" between acupuncturists and chiropractors, but in fact, it is a situation where competently and fully trained practitioners (acupuncturists and chiropractors alike) have very good reasons to have strong doubts about the ethics of offering weekend programs under the guise that the programs are supposedly adequate. Rather than "resentment," as regards the sentiment of fully trained practitioners toward these abbreviated programs and those that promote them, the words "unethical" and "unprincipled" are certainly more appropriate.
Nevertheless, it is important to focus on the distinction between the practice of Oriental medicine and that of acupuncture, as does Dr. Amaro. In short, this distinction has been made much of, and forms the basis for Dr. Amaro's argument that chiropractors and other practitioners of contemporary medicine should be allowed to utilize a limited subset of the practice of Oriental medicine; that is, the practice of acupuncture as a technique, in order to supplement their practices and, in addition, to potentially become allies of Oriental medicine practitioners.
There are a number of things wrong with this argument.
First, the allocation of the practice of acupuncture to a technique within Oriental medicine is a contested concept, with proponents and detractors taking both sides. Indeed, the theoretical foundations of acupuncture are identical to those of the expanded practice of Oriental medicine. The Council of Colleges of Acupuncture and Oriental Medicine is already working diligently on a degree at the doctoral level to continue the study of acupuncture as a solitary practice well beyond even 3,000 hours of study. In Japan, the practice of acupuncture is the practice of Oriental medicine, and the training for acupuncturists is at least as rigorous as the training for any other branch of medical practice. In China, attempts to reduce the practice of acupuncture to a therapeutic technique have resulted in utter failures. Acupuncture, practiced without the benefit of the theoretical principles which underlie it, and the logic which informs its treatment plans, is at best minimal and perhaps detrimental in terms of patient use. Some argue that it creates a clear case of endangerment.
Second, the fully expanded practice of Oriental medicine adds to the study and practice of acupuncture the use of the vast field of traditional Chinese herbal medicine. The use of herbal medicine for the treatment of disease is based upon the same underlying theoretical framework as the practice of all aspects of Oriental medicine; therefore, the study of acupuncture and Chinese herbal medicine combine synergistically to form the unitary practice of Oriental medicine. This term is now widely accepted throughout the world, and the degree in Oriental medicine is now the accepted degree in the United States, Korea, Taiwan and numerous other venues. But the separation of any of these therapeutic interventions from the body of knowledge that underlies them is anathema to the proper and responsible practice of this medicine, or indeed, any medicine.
Third, the promotion of adopting of a sterile group of interventions and practices by other professions is not acceptable to most medical fields. Why, then, should it be acceptable to Oriental medicine? For a comparative example, we could extract adjustment techniques from the study of chiropractic. It is foolish to assume that 100 or 150 hours is not sufficient for any reasonably skilled medical professional in any other field to learn to perform chiropractic adjustment by rote. Would the field of chiropractic then suggest that licensed acupuncturists throughout the country study adjustment technique for 100 hours, then practice as much of that medicine as they felt they could comfortably deliver? All on the premise and promise that we would then be good friends? I doubt it.
In short, the study and practice of acupuncture is a part of, and not separable from, the study and practice of Oriental medicine. The basic theoretical and practical education for acupuncture is the same basic education as is required for the study of acupuncture and the practice of herbal medicine, or Oriental medicine in its totality. Any attempt to argue that a minimal study of technique by other professions not schooled in the thought and diagnostic work required of the practitioner in any branch of Oriental medicine is arrogant and flawed in its entirety.
Finally, even though Dr. Amaro tries to imply a similarity between "medical" (allopathic) providers and chiropractors, it is well-known that MDs have open and unlimited scopes of practice, and chiropractors do not. The inappropriateness of alluding to similarities between the scopes of practice of MDs and DCs in the same breath is also illustrated by the World Health Organization's (WHO) published guidelines on acupuncture training, in which chiropractors are not given the same recommendations for training as MDs. The WHO guidelines recommend a full 2,500 hours of training for chiropractors, not abbreviated training. Although certain states do allow chiropractors to practice acupuncture with inadequate training, most states have held practitioners to higher and more responsible standards. The attorney general of the state of Hawaii's opinion should be of particular interest, as it even eliminates the status of MDs with limited training. I have copied the first page summary of his opinion below.
State of Hawaii
The Honorable Mark E. Recktenwald
Dear Mr. Recktenwald:
RE: Medical acupuncture as it relates to the scope of practice and acupuncture
By memorandum dated July 9, 2003, you asked for legal advice as to whether medical acupuncture is sufficiently distinct from traditional acupuncture so as to fall outside the scope of the practice of acupuncture and whether physicians licensed by the Board of Medical Examiners (BME) may practice medical acupuncture without having to also be licensed by the Board of Acupuncture (BOA).
The short answers to these questions are: (1) medical acupuncture is not sufficiently distinct from traditional acupuncture so as to fall outside the scope of the practice of acupuncture and (2) physicians licensed by the BME cannot practice medical acupuncture absent licensure by the BOA.
We of the American Association of Oriental Medicine (AAOM) urge the chiropractic community to join with us in demanding more rigorous standards of practice for all our medicines and more responsible adherence to the educational standards established by our respective professions. Surely there is enough pressure on chiropractic from other branches of medicine, including physiatry and osteopathy, to keep them and us focused on the core nature of our educational qualifications. It is a shame that we cannot all respect the expertise, skills and knowledge that belong to each other's respective fields of study and then work together productively, without feeling that we need to appropriate some of these practices without sufficient training.
Gene Bruno, LAc, OMD
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Dr. Amaro's official response is as follows:
Thank you for allowing me to respond to the extremely negative letters to the editor concerning my recent article "The Bottom Line" which appeared in the March 2004 issue. Acupuncture Today is to be commended for living up to its mission statement of being "committed to bringing an open forum to the acupuncture profession." To respect the diversity, techniques, styles and philosophies of the acupuncture community as a whole is tantamount. Recognizing the vast variety of cultures and styles of acupuncture being practiced in America and around the world is of extreme importance.
After reading the letters of response to my article, I re-read "The Bottom Line" four or five times to glean why these respondents were so adamant, especially since my intention was to offer a very significant solution to what is obviously a very significant problem. I specifically brought to the attention of the reader that there seems to be a disproportionate number of academic hours of education between those studying "Oriental medicine" and medical and chiropractic physicians who learn "medical/clinical meridian acupuncture." This has prompted a vehement response from some in the Oriental medicine community. It was my intention to offer a potential understanding and possible solution to what has obviously developed into a significant turf war over who owns the right to practice acupuncture.
Please understand I am both a traditional and contemporary-trained Oriental medicine and acupuncture practitioner, having graduated from the Chinese Medical Institute in Kowloon, China in 1976. My formal studies, however, go back to 1967. I am both a diplomate of the National Certification Commission of Acupuncture and Oriental Medicine (NCCAOM) and a licensed acupuncturist (LAc) in Arizona, in addition to my DC license and degree. I was appointed by the governor of Arizona to serve on the first Arizona Acupuncture Board of Examiners, which I successfully and honorably served for three years during its establishment.
Having served on that board, I approved close to 200 acupuncture and Oriental medicine practitioners who came from very diverse backgrounds. Some were TCM trained; some were not. All of those approved, however, after review of their credentials, were deemed to be competent and qualified regardless of their different schools, countries of origin, or cultural heritage. There were Five Element practitioners, meridian medical/clinical acupuncture practitioners, and of course, those who were TCM trained. There was never a thought process amongst the board that "this person could join the club because they were TCM trained and this person would be refused licensure because they were not."
It became very apparent that the individuals responding to my article through the letters to the editor, as well as the president of the American Association of Oriental Medicine (AAOM), who represents an entire national organization, do not endorse, recognize or accept any style or cultural form of acupuncture other than traditional Chinese medicine (TCM). I find this exceptionally disturbing. It is obvious that acupuncture is practiced around the world in a variety of forms to include meridian acupuncture, and TCM is only one of those specific types of acupuncture. To deny this fact would be "unethical" and "unprincipled," to use the words of the president of the AAOM in his letter.
The National Institutes of Health (NIH) states in its Consensus Statement: "Competing theoretical orientations (e.g., Chinese, Japanese, French) currently exist that might predict divergent therapeutic approaches (i.e., the use of different acupuncture points)."
Medical/clinical meridian acupuncture is practiced by a vast number of practitioners throughout every European and Scandinavian nation; North America; South America; the Middle East; Africa; the former Soviet nations; Indonesia; Taiwan; Korea; Japan; and Australia. These practices utilize acupuncture in conjunction with Western medical practices as a part of their armamentarium to assist the patient's clinical response. As a matter of fact, to quote directly from the AAOM's Web site: "Americans from all walks of life now look upon acupuncture as a form of treatment which can be used in conjunction with Western medical practice."
The NIH Consensus Statement also clearly states: "Acupuncture describes a family of procedures involving stimulation of anatomical locations on the skin by a variety of techniques. There are a variety of approaches to diagnosis and treatment in American acupuncture that incorporate medical traditions from China, Japan, Korea, and other countries," and that "Acupuncture has been used by millions of American patients and performed by thousands of physicians, dentists, acupuncturists, and other practitioners for relief or prevention of pain and for a variety of health conditions."
Dr. Bruno's letter specifically states: "In short, the study and practice of acupuncture is a part of, and not separable from the study and practice of Oriental medicine. The basic theoretical and practical education for acupuncture is the same basic education as is required for the study of acupuncture and practice of herbal medicine, or Oriental medicine in its totality. Any attempt to argue that a minimal study of technique by other professions not schooled in the thought and diagnostic work required of the practitioner in any branch of Oriental medicine is arrogant and flawed in its entirety."
The National Center for Complementary and Alternative Medicine (NCCAM) defines traditional Chinese medicine as "an ancient system of medicine and health care that is based on the concept of balanced qi or vital energy, that flows throughout the body. Among the components of traditional Chinese medicine are herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, acupressure and remedial massage." According to Dr. Bruno's definition of acupuncture, which he states cannot be separable from the study of Oriental medicine, this would mean that every medical, chiropractic, naturopathic or ancillary practitioner, regardless of background, who practices massage, nutritional therapy, or prescribes exercise, would fall directly under OM, and these practitioners are unworthy to practice unless they have taken the full course of study of Oriental medicine only because those procedures are a part of the study of Oriental medicine. Shall we discuss "arrogance" and "flaws"?
One young lady who identified herself as an acupuncture student took exception to the fact that there are professionals who are learning meridian medical/clinical acupuncture and are doing so in 100-300 hours, whereas she elected to study an Oriental medicine program, which will amount to 2,600 hours. There are those who wonder how someone can honestly feel qualified to practice the extreme complications, diversities and overwhelming amount of academia of TCM in just 2,600 hours. As Dr. Bruno so aptly put it, "The Council of Colleges of Acupuncture and Oriental Medicine is already working diligently on a degree at the doctoral level...well beyond even 3,000 hours of study." I agree completely. If one is going to study and become proficient in the complexities of Oriental medicine, didactic and clinical hours should at least approximate that of every other healing arts professional in the nation - which, I might add, is over 4,500 hours. She also said, "My belief on the issue of medical/chiropractic practitioners being able to practice acupuncture with 100-300 hours of training is that it is not in the best interests of the public or the profession of acupuncture. As an acupuncture student in New York, I have written letters to help prevent the passing of any future legislation allowing it..." Something tells me every chiropractic and medical practitioner of meridian medical/clinical acupuncture in the country will find this mentality extremely disturbing. When I stated in my article that "there seems to be an increasingly growing resentment between acupuncturists and medical/chiropractic physicians who are also engaged in the practice of acupuncture," it was this person's mentality that I referred to. This person will do what she can to censor and eliminate a procedure out of an established profession, denying patients the right to be treated by their choice of practitioner only because she has elected to study another form of acupuncture and apparently fears the possible competition. This mentality is totally inexcusable!
Dr. Bruno proudly quoted the only state in the union - Hawaii - that does not allow medical practitioners to use acupuncture. He failed to mention the other 49 that do allow it as part of their scope of practice. Concerning the chiropractic profession, toward which some in the Oriental medicine community have taken a personal vendetta of practicing meridian Euro/Asian medical/clinical acupuncture, allow me to share some very significant information.
The National Board of Chiropractic Examiners, in its most recent survey analysis and summary of the practice of chiropractic in the United States, showed specifically that 13.6 percent of the practicing DCs in the nation utilize needle acupuncture as a routine procedure in their clinical practice. The College of Acupuncture of the American Chiropractic Association estimates this figure to be 18 percent. This amounts to approximately 8,500 to 11,000 chiropractic practitioners who utilize needle acupuncture daily. In addition, the latest survey specifically shows that 58.2 percent of the profession, or 35,743 chiropractors, utilize the principle of meridian acupuncture thru non-invasive meridian therapy in their daily practice. Please note, this is not Oriental medicine nor is it called traditional Chinese medicine. It is clearly meridian therapy, which bases itself on the principle of meridian acupuncture but utilizes non-needle forms of stimulation.
When I wrote "The Bottom Line," which I highly recommend everyone re-read, my intentions were completely constructive. It is very obvious to me there is a severe animosity towards medical and chiropractic physicians practicing acupuncture by many in the Oriental medicine community, and it further appears the problem revolves around the use and title of the word acupuncture. This is precisely why I stated, "The acupuncturists should hold themselves out to be the uncontested authority in 'Oriental Medicine.'" The word "acupuncture" is firmly established within the medical, chiropractic and naturopathic professions as well as the public's perception of what is acupuncture.
To quote the AAOM Web site again: "In recognition that acupuncture was just one part of the entire scope of Oriental medicine, the AAOM has streamlined its name to be the American Association of Oriental Medicine (AAOM). Our members are regarded as the highest qualified practitioners of Oriental medicine in the United States." This is precisely the point. Let the public know the practice of Oriental medicine is a specialty in its own. Now I realize that to be a member of the AAOM and to be "regarded as the highest qualified practitioners of Oriental medicine in the United States," all one needs to do is join. I will not be as catty as the student who specifically stated of those practitioners taking the 100-300 hour programs, "Practitioners just have to show up for class and in the end are deemed able to practice acupuncture." Again, this mentality is totally inexcusable!
Dr. Bruno states emphatically, "It is significant to note that he (Amaro) does not mention the very strong feelings that are held by chiropractors, who have taken fully accredited programs in acupuncture, toward those who promote and sell abbreviated workshops in acupuncture...Certainly there is a measure of gullibility if a provider actually thinks that he or she could be qualified in acupuncture, or any other complete medical system, after 100 or 200 hours of training." Again, remember that we are not referring to the complexities and cultural approaches of Oriental medicine, but a complete and distinct style of meridian acupuncture with rules and laws complementary to TCM but a treatment approach based on Five Elements and the meridian system. Yes, it respects the factors of TCM, but it is not learned or practiced in the same way. It is a totally different system. Regardless of the AAOM's stance, all acupuncture is not TCM-based. This is not my opinion; it is an empirical fact of life. Incidentally, as to the argument of "How would the chiropractic profession like it if we were to take 200 hours of manipulation and receive a certificate in chiropractic" - please remember, we in acupuncture have an incredible form of manipulative therapy known as tui na. Why not develop it? Again, this is a bad argument.
Yes, I do receive hate mail from DCs who have gone to the sanctum sanctorum and taken the "accredited program." They write to tell me that any form of acupuncture other than TCM is not valid; only theirs is. That suggest I "turn from the dark side" and join them for enlightenment, and hat the so-called "abbreviated program" has no merit. The chant is TCM, TCM. Please bear in mind, I have never received a letter from a DC in the U.S. who is critical of the meridian medical/clinical Euro/Asian style of acupuncture that was from a state in which acupuncture was a part of their scope of practice. I find that very significant. I wonder how many DCs in New York, New Jersey, Washington, Oregon, California and a few others would truly feel compelled to attend an Oriental medicine school if their state included acupuncture within its scope.
Currently in 30 states (and growing), DCs may practice needle acupuncture by licensure or by scope of practice inclusion. The remaining states allow for electronic or laser stimulation of the body utilizing the principle of acupuncture through meridian therapy. As stated earlier, 49 states allow for the practice of acupuncture by the allopathic physician. As a reminder to the Oriental medicine profession, there are approximately 11,000 DCs practicing acupuncture, and over 35,000 utilizing the principles of acupuncture through meridian therapy. When one adds the approximately 17,000 medical, osteopathic, naturopathic, podiatric and dental practitioners practicing medical acupuncture, this should certainly be a wake-up call to the acupuncture profession that perhaps developing the reputation as "Oriental medicine" authorities may be a very viable solution.
So, what's "the bottom line?" As I suggested in my article, those medical and chiropractic physicians utilizing acupuncture who have an academic or clinical interest in exploring the full range of Oriental Medicine in their busy practices are few in number. I specifically stated the acupuncturists today should make the stand that they are the experts in "Oriental medicine," recognizing that the word and practice of acupuncture is being used by a variety of professions. Oriental medicine practitioners can stand out from other practitioners who perform just the principles of acupuncture. It would make them so much different than the other practitioners using acupuncture, and they would become authorities in a complete system of healing (Oriental medicine), which would include acupuncture, tui na, herbal medicine, nutrition, restorative physical exercises and meditation as suggested by the National Center for Complementary and Alternative Medicine.
If I had one thing to change about the chiropractic profession, I would divide it into two separate and completely distinct professions. I would recognize chiropractors who limit themselves to adjustment of the spine and the correction of subluxation and who are philosophically and professionally completely different from chiropractors who utilize the full range of therapeutic applications to include nutritional therapy, physiotherapy, rehabilitation procedures, acupuncture, meridian therapy and more. They are both chiropractors and practice chiropractic; however, they are completely different in their mission and philosophy. The public is not confused as to competence; in fact, they are both very competent - they just practice two different approaches to chiropractic. I would let the subluxation-based DCs be "chiropractors," which is what they want, and allow the fully trained, therapeutic-based DCs to be "Doctors of Chiropractic (Medicine)," and perhaps change their title to DCM. There would be a definite distinction drawn. The public who wish to seek out the doctor of chiropractic (medicine) would then recognize the difference in name alone from the Chiropractor, even though ultimately, when it comes to adjustment of the spine, it would be the same procedure, but with a different philosophical and academic approach.
There are many parallels the acupuncture and Oriental medicine profession could explore via the above comment. Should the Oriental medicine profession find this suggestion worthwhile, I would be happy to volunteer my time and insight into its exploration and possible development.
I urge the acupuncture profession as a whole to re-read "The Bottom Line" from the March issue, and instead of reading it as someone who was being critical, look upon it as being constructive, and perhaps entertain the message I tried to convey. The acupuncture profession must recognize the fact that in the United States alone, there are close to 30,000 medical/chiropractic physicians utilizing acupuncture as a part of their scope of practice. This is regardless of any argument as to their competence due to the fact they are practicing a form of acupuncture, which is totally accepted around the world, but only differs from what is being taught in Oriental medicine schools.
It is totally unreasonable to think those in the medical/chiropractic community are going to give up their scope of practice and license to include acupuncture in their practice regardless of accusations of incompetence and foot stomping by the OM profession. All of the insults, name-calling and arguments in the world are not going to change the practice. All it will do is polarize the professions, which should be working together as opposed to fighting. Again, I will repeat from "The Bottom Line": "We can all co-exist and thrive together as professions as long as we are able to put aside the animosities, which have inundated our professions from the beginning...It is my wish for 2004 that the professions may move forward with peace, harmony and mutual respect for each other."
John A. Amaro DC, LAc, Dipl. Ac.(NCCAOM)
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