June 2006

The LAC Study Group
This article provides information derived from the findings of The Licensed Acupuncture Collaborative (LAC) Study conducted in California during 2002-2003. The research was conducted by the LAC Study Group which comprises a team of investigators from UCLA, San Francisco State University, and the California Health Institute. The group also included advisors and other contributors from the acupuncturist community, including members of the California State Oriental Medical Association (CSOMA). Investigator, advisor, and other contributor information are provided below.

Investigator Information
Tony Kuo, MD, MSHS, Principal Investigator is Clinical Faculty in the Department of Family Medicine, David Geffen School of Medicine at UCLA. Adam Burke, PhD, MPH, LAc is Associate Professor and Co-Director of the Institute for Holistic Healing Studies in the Department of Health Education, San Francisco State University. He was previously a member of the Executive Committee and the Chair of Research at CSOMA (2001-2003). Ian Coulter, PhD is Professor at the UCLA School of Dentistry. He is also Senior Health Policy Researcher at RAND Health, RAND Corporation, and the Director of Integrative Medicine & Clinical Research at the Samueli Institute. Kevin McNamee is Director of the California Health Institute in Woodland Hills, California. He is licensed both in chiropractic and acupuncture. Lillian Gelberg, MD, MSPH is Professor and Vice Chair for Academic Affairs in the Department of Family Medicine, David Geffen School of Medicine at UCLA. Steven Asch, MD, MPH is Associate Professor of Medicine in the West Los Angeles Veterans Affairs (VA) Medical Center. Lisa Rubenstein, MD, MSPH is the Director of the VA/UCLA/UCSD/RAND Center of Excellence for the Study of Healthcare Provider Behavior, located in the VA Greater Los Angeles Medical Center in Sepulveda, California.

Advisor and Other Contributor Information
Rebekah Christensen is the Executive Director of the American Association of Oriental Medicine (AAOM). Yolanda Marin-Sandoval was CSOMA’s Interim Executive Director from 2004-2005. Howard Kong, LAc was the President of CSOMA from 2003-2005. Lam Kong, OMD, LAc is an experienced and highly respected acupuncturist in California.

Please address all correspondences to:
Tony Kuo, MD, MSHS
Department of Family Medicine
David Geffen School of Medicine at UCLA
10880 Wilshire Blvd., Suite 1800
Los Angeles, CA 90024-4142
Tel: (310) 794-3219

INTRODUCTION

Although the training component of the Licensed Acupuncture Collaborative Study (The LAC Study) has culminated in several publications^20,21,25 and reports to various state and national agencies, including the Little Hoover Commission25, the LAC Study Group has yet to release the written comments of several acupuncturists who participated in the mailed survey. This paper presents some of these comments. In the following section, we provide a summative review of how several California acupuncturists viewed the quality of their training in traditional Chinese Medicine (TCM). It is our hope that by publishing these qualitative statements the reader will gain a better appreciation for the diverse opinions on training quality and practice that currently exist among members of the acupuncturist community.^{15,16,26,30,33,35,37} The poignant perspectives presented by these survey participants provide a useful snapshot of the general attitudes and beliefs of licensed acupuncturists in California.⁵

This article begins with a general description of the TCM profession, the TCM training curriculum, and The LAC Study. It concludes by summarizing the various comments in their original transcribed format. We leave to the reader the interpretation of these provider comments.

Why California is an Important Case Study
Use of provider-based therapies in complementary and alternative medicine (CAM) has expanded in the United States during the past two decades.^{2-4,6-13,17-19,22-24,27,29,32,36,38} The profession of TCM, for example, has been rapidly growing in California.^2,6,34 As of 2002, there were approximately 5,500 licensed acupuncturists with mailing addresses in the state.^2,34 By July 2003, this number had exceeded 7,000-plus.³⁴ During the past several years, at least 600 individuals have passed the state licensing examination annually.²⁸ As a result, California now accounts for more than one-third (> 38%) of the total U.S. acupuncturist workforce, estimated to be about 20,750 (i.e., total licenses issued in the U.S. in 2004).³⁴ Because of this unprecedented growth, training standards and qualifications of these healthcare providers as they relate to consumer safety have become increasingly important to both TCM educators and state licensing agencies.²⁶

The current TCM curriculum in California
State-approved training programs currently require students to complete a minimum of 3,000 hours to graduate.^1,10,14,31 The curriculum typically extends over a period of four academic years. It must include 400 hours in the basic sciences; 30 hours in the history of medicine and medical terminology; 128 hours in clinical medicine and Western health sciences, including instruction in cardiopulmonary resuscitation (CPR); 30 hours in professional ethics; over 600 hours in Chinese Medicine principles, theories and treatment; 300 hours in traditional herbology, and more than 800 hours in clinical instruction and supervised practice (see Title 16, California Code of Regulations, Article 3.5 at www.acupuncture.ca.gov/ law_reg/regs.htm).

THE LAC STUDY

From November 2002 to February 2003, we conducted a mailed survey of a representative sample of licensed acupuncturists in California, collecting data on respondent characteristics such as provider demographics, provider training, self-reported practices, and clientele information.^20,21 The study design (see Table 1) was implemented with the support of the California State Oriental Medical Association (CSOMA), one of the largest professional associations dedicated to advancing the TCM profession in the state.

Participants
We used the 2002 public records from the California Acupuncture Board (CAB) to randomly select 400 practitioners from a pool of 4,914 eligible individuals. These selected acupuncturists were invited to participate if they met the following inclusion criteria: 1) age 18 and over, 2) licensed to practice acupuncture in the state, 3) primary address in California, and 4) not licensed as a physician in the U.S. (MD or DO).

Survey Instrument
Based on an iterative process with input from key stakeholders, a self-administered, 29-question dual language questionnaire in English and Chinese was developed for use in the LAC Study. The questionnaire was piloted among 44 practitioners prior to field implementation. The final version comprised 5 sections, one of which, “Your Training” asked acupuncturists about their TCM college training, their educational activities after TCM college, and their perceived needs for further training in select content areas. This 64-item section evaluated 57 content areas comprising five domains of TCM student development: 1) knowledge of herbal medicine and pharmacology; 2) history-taking and physical exam skills; 3) technical skills in acupuncture (needling) and other TCM modalities; 4) skills for integrated practice and working with physicians; and 5) practice management.

TABLE 1: Study Overview

• As of 2002, there were approximately 5,459 licensed acupuncturists with California addresses. Based on study inclusion criteria, 4,914 of these practitioners were eligible to participate in the study; 545 were not.
• A random sampling was conducted of these eligible acupuncturists in the state (the probability of selection was about 1 in 12 practitioners).
• Survey mailings were conducted from November 2002 to February 2003.
• 400 surveys were mailed initially, accompanied by a letter of support from CSOMA. This was followed by postcards and phone call reminders at 2 and 4 weeks, respectively. At approximately 6 to 8 weeks after the first mailing, additional questionnaires were mailed a second time to those who had not responded. A $10 incentive was included with the second mailing. Those who did not respond 4 weeks after the second mailing were considered non-responders.
• The estimated number of practitioners not in active practice was approximately 15% of the total survey sample (n = 60).
• The response rate after adjusting for undeliverable mail and for those who were not in active practice was approximately 84% (n = 276); the initial unadjusted response rate was approximately 69%.

Written comments from participants
All study participants who completed the mailed survey were asked to comment on their TCM practice and training on the final page of the survey instrument. General information from those acupuncturists who provided comments and feedback about their training is given below. One hundred twenty-two (122) of the 276 survey participants (44% of the total sample) provided written comments as part of their response to the survey. The reported statistics only apply to those who provided comments and should not be generalized to the overall total sample of acupuncturists in the study. Aggregate data on these participant demographics are reported in Table 2. The next section summarizes some of these hand-written comments.

Table 2: Demographics of acupuncturists who provided written comments
as part of their response to the survey(n=122)

SAMPLE WRITTEN COMMENTS ABOUT TCM TRAINING

#1
“Note: many practitioners have multiple disciplines and didactic backgrounds with grounding in Western medicine, and individuals like myself, [has] a good discipline in almost all of the alternative arts.”

#2
“In the question which asks if I feel I need more training in those areas, I have answered instead whether I wanted more training. I am always looking to better myself and increase my skills. So I believe I haven’t answered it correctly. In many cases, I may not necessarily need more training but would like more to be the best that I could be – my ideal…”

#3
“I feel that I could have gotten better use with [and training on] raw herbs during school.”

#4
“I value ongoing education; I like to learn. I also value any help that I can get in running my practice/business.”

#5
“I think the biggest weakness in my training was in business skills. It’s hard to be a successful practitioner when you don’t know how to stay in business. I don’t want a lot of Western training; [when it comes to Western medicine] I’d rather leave it to the Western doctors.”

#6
“My sister is a MD. She was ‘groomed’ by her university to be a MD. Her experience [in medical school]…changed her from an ER nurse to a doctor – she is not the same person! Granted our situation in life is different, there is no ‘machinery’ for us to segue way into, no lottery, internship or job waiting after our schooling (many acupuncturists lose their confidence when confronted with the ‘real world’). We need to be entrepreneurs. Our schooling is ‘softer’ and we’re in a ‘softer’ profession, and in a way, that is good, we can spend more time with each patient and be an ‘ear’ when frequently the Western doctors don’t have the time. Also, we are less likely to do harm and OM therapies have less risk. BUT, I think we need to be ‘groomed’ to be able to interface with Western professionals – doctors, chiropractors and lawyers. Not to mention our patients who don’t take us as seriously as ‘real doctors’. Recommended training areas to address:

• Communication skills – speaking, writing, and to whom (patient, doctor, lawyer, public). These skills are necessary because there are so many teachers and students in our profession who speaks English as a second language (ESL).
• Billing and report writing.
• Office management.
• More training in critical thinking [skills].
• What to expect in deposition or in court. How to respond (if at all) to attorney letters. Fees for copying records, court appearance fees, deposition fees, liens.”

#7
“My education in […TCM college] was adequate to begin a career in acupuncture and herbs, and to do no harm. I have more quarrel with the way in which the information was delivered (in 3-hour chunks) which made it difficult to absorb rather than focusing on the quality of the information itself. Also, I marked that I felt I needed to know more about almost everything because I believe that learning in this profession is endless, but not because we need to have more information crammed into us before we begin our career. Finally, while I believe we should interface with Western doctors and be conversant regarding their tests and in their ‘lingo’, I am completely against “Western medicine-izing” Chinese Medicine.”

#8
“In many cases I said that I ‘need’ more training in some areas. I have to learn and like to learn what’s new; i.e. tongue [exam]/pulse [analysis]/herbs, etc. I do feel lacking in Western medical exams.”

#9
“I appreciate partaking in this comprehensive survey. Regarding continuing education, I have marked ‘NO’ in many boxes. I feel my current training is adequate. However, I would still take courses on many of these subjects if the instructor and course materials were compelling. There is always room for improvement! I intend to always continue studying. I also feel educating patients, the public, and other medical providers about the practice and benefits of TCM are very important. Also, communication between various modalities [or professions] is very important. I am encouraged by the move toward integrative medicine and try to utilize it in my practice as much as possible.”

#10
“Need more knowledge about Western Medicine.”

#11
“Schools need to spend more time for on-the-job training and teaching actual patient treatment procedures instead of learning theories and arts of healing. I think most acupuncturists need more education about insurance, practice, giving patients health advice, and physical examination.”

#12
“Many things I took upon myself to learn in more detail for the clinic. I am also a QME, so I have a better idea of how to write reports for insurance purposes. I also learned more orthopedic testing through my study as a QME.”

#13
“…I felt that my education was adequate [generally] but was lacking in the areas of office/business management, practical application of CM theories, and in Western medicine. I’ve learned a lot on my own by studying each new problem that my patients bring to me. I feel I’m a good practitioner but marked ‘YES’ in all of the items under the ‘Do I need/want more education?’ section because I think we can all learn more; not because I don’t know enough to be good and effective. If I don’t know something, I will look it up. I hope this helps in some way.”

#14
“I’ve been in practice for a long time so I am relatively comfortable with the way I practice. But it would have been helpful to learn more about Western diagnosis/tests and practice management. We can never have enough training in Chinese Medicine. It’s a lifetime study.”

#15
“My concern in answering this questionnaire is that I rate much of my initial training fairly low especially as in regards to Western skills. I don’t think more didactic training at the Master’s level is the answer. We need residency training with stipends in TCM, and integrative care. We need hands on work.”

#16
“While there is a great discrepancy in educational background among California acupuncturists, it seems that the new 45 hour CEUs per year proposal won’t adequately address the problem. For one, it is excessive for those with adequate education, and secondly, it does not directly address the deficiencies of those with an inadequate education. Remedial exams with re-licensure seem a more targeted solution.”

#17
“More training from the beginning on how to practice acupuncture in America is a good idea! TCM when applied early in an illness [and for health promotion] is most effective. Unfortunately, treating last resort medical rejects/failures is both difficult and discouraging.”

#18
“While my OM education was good overall, I feel that it seriously fell short on providing training in musculoskeletal problems and orthopedics. This is 80% of what I see. Education spent too much time on internal disease processes that we never see or see only in China. Schools must provide solid training in orthopedics and must do a better job in Western medical training!”

#19
“Keeping in mind, when I went to school, they only introduced herbal training in the last (third) year which consisted of a couple of intense weekend seminars. Now is totally different. Also, Western medicine was not taught which is different then before but nonetheless is very important to know.”

#20

• "I would have liked receiving more training in filling out health insurance forms and how to set up and run a practice.
• Also it would be useful to find out how to establish referral networks and how better to communicate with Western practitioners.
• I would like to see more business opportunities for acupuncturists in a Western medical setting (i.e. hospital, etc.).”

#21
“I thirst for more knowledge to help me use the full potential of TCM, especially the herbal aspect. I felt that my education was totally lacking.”

#22
“In the U.S., most licensed acupuncturists are not well trained. Their fund of knowledge is deficient. I hope Traditional Chinese Medicine (TCM) colleges would improve the quality of TCM education; especially that now, integration of care has become popular. Research will be necessary to advance integrative care and our profession.” [In Chinese; translated to English 7/29/03]

#23
“…Overall, I think my education was strong. But they can improve on teaching more Western clinical practices such as orthopedics and neurological testing/exams…in the clinic instead of just in the classroom. My skills as an acupuncturist/herbalist are strong, but that does not mean it’s easy to bring in new clients. I would like to have more referrals from MD’s and other specialists.”

#24
“I believe it is as important to learn the classics of acupuncture techniques and Chinese Medicine as it is to broaden our awareness of Western medicine. Learning from the current discussions in China about their research is another important aspect. I was trained in massage before I got my acupuncture training and so that made it easier to understand general human anatomy not only intellectually but also through practical experience. This understanding helps in the techniques of needling (acupuncture). As for Chinese Medicine, a balanced approach to training is essential.”

#25
“From discussions with my colleagues, I believe that many TCM practitioners do not have enough formal training and therefore often has a difficult time finding a job and attracting clients. Moreover, they have a difficult time taking a good medical history from a patient. Also many TCM practitioners who are without formal training have a hard time starting a practice. More training such as an internship is needed to create more opportunities in the future for TCM practitioners. In retrospect after training, I believe that our fund of knowledge as acupuncturists is limited and that our TCM training did not prepare us for ‘real world’ practice. My experiences suggest that California’s TCM colleges don’t have good standards for training and varies from college to college. If there is an opportunity, curriculum and quality of teaching should be standardized and improved. TCM profession lacks unity and current education and practice standards are not clear. Under these circumstances, it is very difficult to start a solo practice.” [In Chinese; translated to English 7/29/03]

#26
“Today’s demands on California licensed acupuncturists are different from 10 years ago. Patients and other providers (MD’s, DO’s, DC’s) expect us to operate as members of the health care team; primary care has a lot of responsibilities.”

#27
#27 “I feel that the field of TCM needs to introduce an internship and residency program equivalent to Western MDs. There are many practical areas of training, which are overlooked in school. It is difficult to gain this knowledge once out of school because most of us practice alone. CEU’s are helpful but still not enough to bridge the gap. Of course until we can make equivalent salaries to MDs most of us will not be able to afford the additional training.”

#28
“As both a practitioner and teacher of CM and the Chinese Healing Arts I would like to suggest the following based on meetings with practitioners from all over the USA and abroad over the years:

• broaden our profession’s skills/effectiveness in treating pain
• emphasize Qi Gong cultivation for both the practitioner and the patient
• encourage training to include other branches of OM besides acupuncture and herbs, e.g. bodywork, Qi Gong, etc.
• include other systems of classical-ancient medicine besides TCM
• help to keep the Roots/Essence of our medicine alive and well, especially its spiritual and wisdom traditions which elevated it to both art and science…for all to enjoy!”

#29
“Needless to state that TCM colleges were not teaching Western medicine. Hopefully, this has improved! Without my previous training and many years of experience as a…[allied health professional], OM practice in the real world would have been difficult.”

#30
“Our education has a long way to go. The most important areas are: recognizing emergency situation that requires immediate Western health care; formulas; and basic acupuncture framework. There was no theoretical framework taught with acupuncture, just cookbook techniques. We were exposed to the presence of other methods on our own; we learned no real method for choosing points to do.”

#31
“Formal training in acupuncture/Chinese Medicine – that is important. Acupuncture institution in the U.S. needs more training (1-2 years more) in many areas.”

#32
“I find that my training in TCM diagnosis was very good, but applying that to a clinical setting was not. I have been able to make a living only because I managed an acupuncture office while in school and learned these skills. School did not prepare me for the real world.”

#33
“U.S. TCM colleges have low standards for training students. Standards should be higher and similar to the higher standards found in China’s TCM colleges. Curriculum should include:

• TCM peer consensus on diagnosis and treatment for various health conditions.
• Examination system needs to have higher standards and focus more on practical clinic skills that will help practitioners establish a successful practice in the real world.”

#34
“I’ve been practicing acupuncture in a private clinic for 4 years. I’ve also attended many ‘re-education’ courses. I think licensed acupuncturists will benefit from education in:

• report writing (general health, history of present illness, worker’s compensation)
• marketing methods
• communicating with Western medical doctors...”

#35
“I was highly disappointed with my education and training in Chinese Medicine. My school enforced classes that were a waste of time and money. I took a formula writing class and the teacher never taught us how to write a formula. It was mandatory that we take classes on subjects that will never enhance CM skills, while vital information like running a practice was never taught. There were never enough supervisors during internship and most of the ones that we did have barely spoke English. I’m sorry to sound so negative. However, if I had the chance to do it all over again, I would choose another profession.”

#36
“The more Western medical knowledge and diagnostic skills we have the better, but Chinese Medicine is not Western medicine and that should be clear to us and to the patients. There should be more information available regarding pediatrics in our education.”

#37
“I would support a state approved OMD [Oriental Medicine Doctorate] program for senior acupuncturists, especially if it included a specialty program and internship abroad in China, Korea or Japan.”

#38
“My suggestion is: an acupuncture school needs to extend their training hours for their students.”

#39
“I think studying Chinese Medicine is a lifetime learning process. You need to review and constantly learn new things. You need to be modest and know your limitations. You need a good attitude and work hard to learn new knowledge. In the U.S., TCM training should include internship experience at a larger scale (e.g., in a hospital). Otherwise, without such an experience, it is difficult to succeed as a practitioner in the U.S.

Licensed acupuncturists should work together and ask the government to help establish a hospital system that allows TCM trainees to do internships prior to going out into the real world and practice.” [In Chinese; translated to English 7/29/03]

Abbreviations:

CEU = Continuing Education Unit(s)
DC = Doctor of Chiropractic
DO = Doctor of Osteopathic Medicine
ER = Emergency Room/Emergency Department
MD = Doctor of Medicine (Western physician)
ND = Doctor of Naturopathic Medicine
NP = Nurse Practitioner
OM/CM = Oriental Medicine/Chinese Medicine (also called Traditional Chinese Medicine)
OMD = Doctor of Oriental Medicine or Traditional Chinese Medicine
PA = Physician Assistant
PharmD = Doctor of Pharmacy
PhD = Doctor of Philosophy (in a particular field of study)
QME = Qualified Medical Evaluator (e.g., Worker’s Compensation)
RN = Registered Nurse
RPT/PT = Registered Physical Therapist
TCM = Traditional Chinese Medicine
Western Medicine = Refers to allopathic or osteopathic medicine

All efforts were made during the transcription process to preserve the intent and content of all comments, including translations. However, select edits were carried out for the purpose of correcting grammar, translating comments from Chinese to English, and for protecting respondent confidentiality (i.e., all information that could inadvertently or potentially reveal the identity of a respondent were removed). Comments in Chinese, for example, may have lost some of its original content and meaning when they were translated to English.

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