As California Goes, So Goes The Nation!

Today is my first clinic’s 15th birthday. Happy Birthday OAP!  I’ve been an acupuncturist, running an acupuncture business, and hiring acupuncturists in California since 2008. Note to self:: think twice about opening a small, women-owned business in the midst of a global financial crisis with a business partner who will be out on maternity leave before your clinic has its first birthday.  Actually, then, and especially now, I wouldn’t have it any other way. 

It’s been a tough few years for acupuncture businesses (well, most businesses really) so it wasn’t that much of a surprise when 2022 was by far our most challenging year in terms of HR and hiring ever, even dating back to when we were truly terrible at it. It more than edged out 2020, a year in which we lost about half of our staff. So, that’s saying something. Turns out that “something” may not be probably isn’t what I thought it was. I think my current business partner and I agree (we agree on most things) that hiring and HR issues are our least favorite parts of the job. That stuff is really tough, even in the best times. But if we want to continue being people that run three high volume/low cost clinic locations it is also one of the most vital parts of the job. 

As last year (thankfully?) came to a close we reflected on what was causing our difficulties, why were we having such a hard time getting and keeping a solid staff?  What were we doing wrong? Ultimately we chalked it up to “COVID Chaos”. Over the last (almost) three years we’ve declared that a lot of things must be caused by COVID Chaos. We even have documents, meeting agenda titles, and clinic policies where that moniker wormed its way in, because it fit.  Before COVID we had gotten pretty good at identifying the variables that impacted our successes, our obstacles, and our failures (Yes, we have those too. And failures are definitely something we should all talk about more.)  Anyway, in the olden days we could usually see pretty clearly what was working for us and what wasn’t, and with the variables recognized, we either fortified the good stuff or took corrective action in the areas needing help. In the realm of COVID Chaos though, the variables have become harder and harder to identify. What even are they? The new pattern is that there really aren’t many patterns anymore.

I had a hunch that our schools’ being under enrolled might have something to do with our hiring woes, but getting actual enrollment numbers from schools is next to impossible. Probably just Covid Chaos, anyway. Our two Oakland clinics are in very close proximity to four acupuncture schools, well actually three now, since ACTCM is closing. Tuck this sad news away, it’ll come up again in a bit. Our third clinic is only 90 miles away from the Bay Area, in Sacramento, so over the years we’ve been pretty lucky to have a steady stream of newly licensed, recent grads, who are hungry for work. We were spoiled out here, and we knew it.  Hiring in more remote areas of California, or even larger cities in other states, that don’t have any schools in the region has always been tough. Keep reading, it’s about to get tougher, for all of us.

Anyway, on my hunt for variables, because it’s hard to find solutions when you don’t know what the problems are, I came across this: CALE Statistics!  CALE is the California Acupuncture Licensing Exam for any of you out-of-staters who don’t run around with the name of that beast on the tip of your tongue, or haunting you in your dreams. Sidebar: I still have a recurring dream where I’m in my seat at the convention center in Sacramento. I’m ready, but I lost all of my pencils, and my booklet only has ½ of the questions in it, but I’m definitely not allowed to get up and talk to anybody about it. So, I sit there. For however long the dream lasts, I just sit there, panicking.

For decades CALE has been held up as the gold standard for acupuncture licensing tests. It’s said to be harder and more rigorous than its counterpart, the NCCAOM exams. That’s the National Certification Commission for Acupuncture and Oriental Medicine for any of you lucky enough to have zero experience with the tests used as the gateway to getting licensed as an acupuncturist in the US.  Interestingly, at least to me, neither of these exams have been proven to have any real bearing on whether or not the individuals taking them will go on to become competent and capable practitioners.  People who pass with flying colors go on to lose their license or leave the profession, or anything else weird you can imagine in between those two extremes. People who fail, sometimes repeatedly, may be the same people who got the very best treatment results in student clinic, and they may have a background in business, but they are just really bad at taking tests. Lots of gateways we come across out there have gatekeepers, and in the acupuncture world these two tests are our big, burly bouncers. The numbers here show that, at least in The Golden State, the bouncers don’t always like to let very many people through. And the numbers seem to show that if you’ve tried to get through the gate before but were turned back (you failed your first attempt at the exam) your chances of getting through on future attempts really aren’t all that good. 

Even more alarming than the pass rates for CALE though, are the stats on just how many people have been taking this beast over the last several years. TL;DR, Not Nearly Enough!  

From these numbers it looks like the number of test takers has been in a pretty steady decline since about 2017. This is very valuable information because it means we can’t blame the low numbers of test takers on COVID Chaos. This was a preexisting condition! If we take the math backwards then a clearer picture of what must be going on in the schools starts to emerge, even if we can’t get ahold of their real enrollment numbers. Fewer test takers has to mean fewer grads. Sure, some grads from California schools leave the state after they finish school; that was their plan all along. Some wait to take the test until years after they graduate for whatever reason(s). But correcting for that smallish percentage of people who are either waiting, or never planned, to take the California Exam does not explain what I found. 

Y’all, the numbers are BAD. Really bad. This may explain why ACTCM, one of the oldest TCM schools in the country and another gold standard from the Golden State, is closing its renowned and revered doors.  Fewer and fewer people are choosing to go to acupuncture school.  It definitely helps to explain why there has been such a drastic change to the quantity of our job applicants. That steady stream of those hungry new licensees is drying up right before our eyes and we actually have numbers to back this theory up. Sorry Jeff, it looks like the tough stuff is only going to get harder for us. 

Let’s look at this another way. In the five year period (2013-2017) 4920 people took CALE. In the subsequent five years (2018-2022) approximately 2367 people took it. This is adjusted since the second batch of 2022 test statistics have not been released yet.  In the first half of last year only 198 people took the exam. I estimated that another 250 took it in the second half of the year, leaving 2022’s estimated total potentially just shy of 450 test takers. I will definitely update when those new numbers are released, but unless they are way outside the current pattern this is still a 50+% decline over the last five years. I miss reliable patterns but this is not how I wanted them to re-enter my life. 

In 2002, the busiest year for CALE in the last 22 years, a whopping 1259 people attempted to tame the beast. Sadly 616 of those folks were taking it for (at least) the second time. Many have made 5, 6, even 7 (or more?) attempts before the gatekeeper finally let them through. But it’s starting to look like even that is changing. The numbers here, and here, show that lots of people who fail at their first attempt are just giving up now, moving on. You would expect the total number of retakes to also drop when overall numbers are dropping but these recent numbers for the folks making multiple attempts are tanking even faster. These poor grads are taking their big debt, their little diploma, and just cutting their losses. This is super sad for them but it’s also really sad for California employers. I bet some of those folks could have turned into fantastic punks for us, or for any other clinic with jobs to fill. 

I’m assuming that because the California Acupuncture Board (CAB) operates from within our state’s Department of Consumer Affairs that there is some requirement for them to release testing statistics and other data. Yay, transparency! Seriously, it’s hard to come by in the acupuncture world. I have not been able to find similar statistics for the NCCAOM exams (for even one year, much less 22). Update as of 2/11: I found them! Spoiler Alert: The numbers aren’t quite as alarming as CALE’s but they still suggest cause for concern.  More on this in the next post.

Recent rumblings and grumblings indicate that schools nationwide are feeling the same squeeze we are feeling here. ACTCM may be one of the biggest names to bow out of the game but schools are closing nationwide, at an alarming rate. Southwest Acupuncture College, who had campuses in two different states, is also hanging it up. 

Given all of this, there really isn’t anything to indicate that NCCAOM’s testing statistics (and the revenue streams tied to them) would trend in a wildly different direction. As California goes, so goes the nation, right?  So, if we want to keep living the dream out here in acu-land it’s probably time to get up, grab some pencils, get the full book of questions, and run! Well actually, I think we may need to swim sideways. I hear that’s the best way out of a rip current and this one seems to be pulling us toward the cliff.  Whenever I have that dream, at the end, I always wonder why I just sat there.  

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Responses

  1. Thank you for writing this, Whitney. It’s as excellent as it is sobering. I starting looking through blog posts from 10 years ago, specifically one titled “We’ve reached peak acupuncture.” I couldn’t find that one specifically. But so many posts on this blog from a decade ago pointed to where we are now. And it’s not a satisfying feeling. It’s just frustrating.

    1. Thank you! And a big thanks to you, Roppy, for paying attention to (and working on) this stuff for so long. I’ve been meaning to comb back through the old blogs and bring some of the relevant ones back to the surface. We’ve been writing about and talking about the writing on the wall for a long time now. Yep, there’s little satisfaction in maybe having been on point all those years ago. Frustrating for sure. Thanks for hangin’ in and hangin’ on with us.

  2. Bay Area CA starting Punk wage: $20-$25/hr
    Post-secondary education required: 7-8 years, BS & MS.
    Licensure: In CA: over $500 for testing, $500 for licensure, + ongoing continuing education
    Diplomate: $500 per NCCAOM exam
    CA Bay Area minimum wage in 2023: $16-18/hr
    Return on investment: ___?

  3. Thanks for this interesting bit of research Whitney, seems to confirm what the NCCAOM/ASA is finally admitting about the profession. The shiny image of being a lab-coated Chinese medicine doctor proffered in Acupuncture Today could only obscure people’s vision for so long, and seemingly the gainful employment and other acu-skool financial woes that have forced several to close or be subsumed into a larger entity have acted as corrective lenses for prospective students of acupuncture. That doesn’t help our situations in trying to hire; it’s been abysmal trying to hire here.

    An interesting tidbit from lil Rhody- the exam requirement for licensure was recently struck from the statute governing social workers. The board manager for several licensed professionals mentioned this to me when we were discussing the recent addition of language to the acupuncture statute that names the examination board (you guessed it). She was happy that language had been added that says an entity approved by the DOH can also provide the exam. Or in the instance that the old entity goes away, and there is no new entity, the DOH can grant a license by endorsement.

    At least currently, the lawmakers in RI agree that graduating from an approved program indicates a level of competency sufficient to justify giving someone a social work license. I don’t know what the legislative argument was like over this change (I’ll ask around) but I can imagine there were those in the profession supporting this change, saying things like: “There’s a need for more [insert professional] and the added costs of repeatedly taking an exam have the unintended consequences of increasing cost of services, and decreasing number or providers; thus limiting access.” And likely there were those screaming how “unsafe” and “detrimental” it would be [to the professionals] to allow people to practice without this gold standard of test taking.

    In this NPR article about the Association of Social Work Boar’d’s examination bias, someone interviewed from a state social work association put it this way: “It’s not like we having been taking tests for years,” and “We have to pass this test, but it’s not necessarily an indication of your practice skill.” This is the argument that could be made when/if NCCAOM/CALE collapse. It would be a slog getting laws passed in every state. The optimist in me hopes that with every new ear acupuncture law passed in the next few years (at least the ones that are passed as exceptions to the acupuncture statute) language that accounts for succession in a post-NCCAOM/CALE world can be added. I imagine that in other states, like in RI, it’s possible for professional licensing boards to grant licenses by endorsement by providing evidence to an applicant’s experience and education. Qualifying exams are only one facet of measuring competence presumably adopted for convenience.

    1. Thank you for sharing. I have been studying for the CALE with TCM review for 9 months now and feel like it’s not enough to get me through my exam studies. Do you mind sharing which review course you went through to pass?

  4. Thank You for writing this, Whitney! Very sobering indeed, but are acupuncturists really that surprised? Disgusted should be the right word. And a call to a protest thru mass emailing, mass phone calling, mass online petitions sent to the governors, senators, schools, state insurance commissions, etc. I have written about my complaints years ago after I was first licensed at one of the POCA forums just before Modern Acupuncture got started. I clearly remember being warned that Modern Acupuncture owners were part of the forum. More about Modern Acupuncture later. I was one of those people who took the CALE 5 times. These schools surely do not want students retaking the exam since it messes up their pass rate & makes them look bad. There is a BIG BACK story to why I took the CALE 5 times other than I was a poor student. First, the school I went to did not really prepare you for taking the CALE. The review course that they were pushing at the time wasn’t the correct class to take. Little did I know that till later. In the first review class, the instructor openly stated to everyone that “they” were extremely partial to males. I am implicating myself right there since I am giving away who that person is. Makes you feel like total crap if you happen to be any other gender than a Caucasian, straight male. Second, my “partner” for group study “fired” me, so I was basically on my own. Turns out this person “fired” other people, but the instructor said that there was nothing to be done about that. My “ex-partner” was clearly having issues since he was openly perspiring in class & had frequent outbursts during the middle of winter. The instructor did not intervene whatsoever. So I ended up flunking the 1st exam. People in my class just could not understand why I should be so extremely upset. Nevermind the cost of this school that I had racked up-at that time, it was $65,500 per year. What I did not know was the fact that the State of California had changed the testing company. The exam that this company used was very poorly translated. Even the Valedictorian at my school flunked the exam. Across the state, a ton of people flunked the exam. When the Valedictorian from my school flunked, the school decided to investigate. But they did not inform me of these things at all. Guess I was not considered worthy of being informed. The only way I found out was by taking the test multiple times & I started to complain to different students, etc. By complaining to different students, I found out that some passed only by 2 points. They passed, so who really cares anyway, right? I could not agree more. In addition, since I took the test multiple times, I realized that many people from my school flunked multiple times which included the Valedictorian. I clearly remember seeing those people, most of whom did not want to look me in the eye or even be seen hanging around me. A few people did, which is one of the main reasons that I finally passed. Going out to eat after the exam, I was informed by another test taker of a different review class. I had never heard of it but made the decision to take it if I didn’t pass this time, which was #4. Of course, I ended up taking the different review class & that is the reason I passed the CALE. I should have taken that review class the first time around. I clearly remember almost losing it in the post office when I got my results, since people were openly looking at me like I was losing my mind. No small wonder that people don’t want to take that exam again. The state of California goes out of its way to discourage everybody from taking that exam!!!!! One time there was a girl chomping on Corn Nuts & doing yoga postures in the aisle right next to me. It was just disgusting!! The proctors did not do anything to stop her. Each time I took that exam, I wrote complaint after complaint when the exam was finished.
    The public does not really care what is happening to medical care & that includes acupuncture. They do not realize what acupuncturists are paid by the insurance companies, the cost of the education, or of setting up a business. Acupuncturists are struggling & many wonder why they are staying in a business that does not pay even the cost of doing business much less making a decent living. Modern Acupuncture cannot be doing that well if they are now doing IV Therapy along with acupuncture. IV Therapy is a passing fancy for the wealthy & people who can afford to pay for such things. Not everyone who runs a Modern Acupuncture clinic has experience with acupuncture or IV Therapy. I just better keep anymore comments on Modern Acupuncture to myself. I am saddened that ACTCM is closing, but I am not surprised. Allopathic medicine has been in turmoil for years with the numbers for licensed doctors & nurses dropping like mad. The public has been deliberately mislead regarding that for a long time. Small wonder that it is happening in acupuncture. I truly believe in the power of acupuncture, but truth be told, unless I win the lotto, I will never break even just for the cost of my schooling much less make a living at it.

    1. I find it hard to believe that you will not break even. Because, even looking on indeed today, there are so many jobs, that pay at least 70 k a year. And working as a massage therapist for 16 plus years, and barely able to make it after doing 2-6 massages in a day, to me that kind of salary, with full benefits, is something I was never even once offered as a massage therapist, working so much harder. I am on your side though, that school is too expensive. Many of my friends that graduated before me, and passed the Nccaom before me, were supported fully by their parents and did not have to work. Unfortunately, sadly, this American dream is for the rich, and the ones that have to work their way through school, they struggle, and suffer more than most would ever care to know. I feel it is because the rich don’t want the poor to get educated, they want them to work for them and do the grunt work…while they and their family get educated. Also schools tend to cater to the rich. The teachers, don’t care if you have to work while the other students don’t, and they make nearly impossible demands, on people who work and study. I saw so many people who looked like they were dying by the end of acupuncture school. I’m sure it’s the same for medical school, and nursing, or far worse. And the weed out classes, weed out the poor.