Dollars and Sense: Information for Prospective Acupuncture and Oriental Medicine Students By Shauna

I’ve been thinking for a while about writing an open, honest account of my investment in acupuncture school for the benefit of prospective students. I acknowledge that this is just one person’s experience. Through my connections with other acupuncture and Oriental medicine (AOM) students and alumni, I’ve come to understand that my journey is not outside the norm of what to expect or how to navigate the decision making process.

It’s useful to know that I consider myself to fall somewhere in the range of the average population. What does that mean to me? Well, for starters, I knew I would need to finance my entire acupuncture education on student loans. The thought of incurring this amount of debt was a more than a bit scary to me. The trend in rising tuition costs would not allow me to work for a few years and save enough money to pay outright for the going education. Like the majority of other AOM students, I didn’t have a trust fund, wealthy parents or a partner who could pay for my tuition and related school costs while keeping a roof over our heads, food in our stomachs and health insurance. In high school, I worked to save some money for college. In college, I worked to make my rent, cover my car payments & insurance and buy groceries. During my AOM graduate studies, I once again knew that I would need to work to make up the difference between student loans and living expenses. I think most prospective acupuncture students find this situation to be a familiar scenario.

The view from outside of the classroom was much different from the experience on the inside. If you are in the process of considering a career in the AOM field and are currently a prospective acupuncture student, I hope you will find at least one worthwhile piece of information from my experience.

What’s the Return on Investment: The Search for Credible, Factual Statistics

I remember how challenging it was to find credible statistical data on acupuncture as a career. I consider myself a pretty sensible person, so I thought it was reasonable to find out what salary range I could expect as an acupuncturist in order to determine if the cost of the education could reasonably be repaid. Long story short, I had a difficult time finding anything unbiased and useful to help me with my decision making process. Knowing what I know now, it’s important to understand that most acupuncturists don’t earn a salary. Most people in this field are self-employed. Information is all over the board. If you dig deeper, more often than not, you will find that the sample size that supplied the data is relatively small and therefore, unreliable to base a major financial decision upon. Available data does not provide anywhere close to the necessary information prospective students need to weigh the costs of this education with the ability to repay student loans all while making a decent living. Not an extravagant living, just a respectable living while responsibly paying back the student loan debt.

Here’s a great example currently available on one AOM school’s website: “According to a recent salary survey available at, $43,000 to $60,000 per year is the average salary of a licensed acupuncturist, depending on the length of time they have been in business. Anecdotally there are those that earn considerably more than that.”

If you go to you will find that only 7 responses have been received as of May 2010. The average listed ‘salary’ is $30,710. There are two problems here that allow for a huge misrepresentation of the profession 1) only 7 responses contribute to this data and 2) most acupuncturists don’t earn a salary because they are self-employed or independent contractors. There are many more examples just like this on other AOM schools’ websites and in their marketing catalogs. How can any school justify presenting this misleading information to prospective students?

The good news for prospective students is that the NCCAOM recently released the results of the Nationwide Job Task Analysis for the AOM Profession So even though the news in the analysis isn’t good, you have a bit more information to base your decision on today than in the past. I strongly suggest anyone considering this career path to sit down and read the report. Key points to take under consideration are that 90% of the respondents in this survey are self employed, 91% see less than 10 new patients per week, 46.5% see 11 to 30 returning patients per week, and 70% gross less than $60,000 per year. Remember, you don’t take home and live on that gross pay. So cut that $60,000 in half after taxes, business expenses, etc. and you will probably be taking home right around $30,000 per year if you are grossing at the top of the range of this respondent group. If you aren’t at the top, you can expect to be living on even less than $30,000 per year. Unfortunately, there are no results for the number of years in practice to allow for a comparative change over time, if there even is a change over time.

My AOM School Experience:

With the information that I gathered in 2003 and 2004, what did I decided to do? I decided to attend a school in the Pacific Northwest. I completed a four year master of acupuncture and Oriental medicine (MAcOM) degree program in four calendar years. I entered school in September of 2005 and graduated in September of 2009. You might be wondering, why not complete the four year academic program in three calendar years as it is promoted by many schools? Actually, I did start my studies on the three calendar year program. I chose to take this route in order to experience the academic demands firsthand. I wanted to make an informed decision about continuing at this pace or transitioning to the four year timeline. I also knew that I could switch to the four year program at any time, but not the other way around. Needless to say, it didn’t take long for me to realize the four year program would work better for me and I made the switch. Simply put, here’s what factored into my decision 1) class, study and work time was pushing me to exist in a 50-60 ‘work’ week 2) time management was no longer the issue, sleep deprivation was 3) my quality of life was becoming unbalanced & frankly unhealthy, but most important contributing factor was that 4) I knew that I could not look a patient in the eye and ask them to find 30 minutes in their day for self care, when I was struggling to do it myself. It’s ironic how the entire program is set up. To remain competitive, new requirements and hours continue to be added to the curriculum without any recognized regard for the expansion of the calendar time. Care for students’ health doesn’t really seem to matter.

When I started my program in the fall of 2005, the entire 36-month program tuition was listed as $47,875. This figure does not include books, supplies, Clean Needle Technique (CNT) certification, the NCCAOM board application and exams, state licensing. This list of items is in addition to tuition costs and the responsibility of the student to cover. I added $10,000 to the tuition to cover the cost of the additional education expenses and rounded up to $60,000 just for good measure. Based on the credit load and classroom/clinic hours listed in the school catalog, I anticipated working 15-20 hours per week to pay for my living expenses. During my decision making process, I regularly consulted school and financial aid administrators to see if my plan was reasonable. I never received any words of concern ‘although each student’s financial needs are different’ it seemed reasonable in their opinion. Additionally, I repeatedly heard that the US will need 15,000 new acupuncturists in the next 10 years, insurance will start covering acupuncture and hospitals will soon be hiring staff acupuncturists. The profession painted itself a nice picture and I, the prospective student at the time, felt reassured.

Here are the numbers that I used to calculate my debt decision being fully aware that during the first couple of years in practice I would likely fall on the lower end of the pay scale:

  • Loan Balance: $60,000.00
  • Loan Interest Rate: 3.00%
  • Loan Term: 10 years
  • Monthly Loan Payment: $579.36
  • Total Interest Paid: $9,523.83

Once you plug all the numbers into the calculator, you get this message “It is estimated that you will need an annual salary of at least $69,523.20 to be able to afford to repay this loan. This estimate assumes that 10% of your gross monthly income will be devoted to repaying your student loans. This corresponds to a debt-to-income ratio of 0.9. If you use 15% of your gross monthly income to repay the loan, you will need an annual salary of only $46,348.80, but you may experience some financial difficulty.”

In 2003 and 2004, student loan interest rates were at an all time low of 2% to 4%. This added to my reassurance that this was an acceptable risk for such a rapidly growing professional field of medicine. Or so I thought. Near the end of the first year, my school administrators delivered the news that tuition rates were increasing only weeks before we needed to sign off on our next year’s financial aid offers. This became an unwelcome and poorly communicated annual event. By July 2006, student loan interest rates had jumped up to a fixed 6.8%. Yes, fixed and quite a historical change. My budget was quickly being blown out of the water. This education was becoming very expensive, very fast. My logical side was telling me to get out, but I didn’t listen. I After all, I was only $18,500 in debt after one year in. I learned more than I bargained for about AOM, the education and the state of the profession while I was a student.

The Acupuncture Mortgage:

Are you thinking of going to school to become an acupuncturist (because when you say you are anything else, most people don’t know what you do.)? If you walked into a bank and asked them for a $100,000 loan on a self-employed living income of $30,000 or less with no collateral, you’d likely get turned down. The bank would probably consider the risk too high to fund. However, in the education market there is something I refer to as the ‘acupuncture mortgage’. Almost anyone can get one as long as they qualify for student loans and meet some basic pre-requisite requirements.

Let me put the acupuncture mortgage into perspective. Students in my graduating class have an average student loan debt of $88,000. That’s the average for my entire class, not the average per student who needed to take out loans. A few classmates were fortunate enough to avoid federal loans to complete their degree. Understanding this, you know that the average debt per student who actually needed to take out loans is much higher than $88,000. By subtracting each of my classmates who paid for their education costs out of pocket, this quickly pushes the school reported average to a much higher personal student average. This explains why I know more classmates who have over $100,000 in student loan debt from attending acupuncture school than I don’t.

Many changes took place at AOM schools between the 1990’s and 2000’s. At my school, tuition changed from an average of $7,000 annually with evening only classes to an average of $15,000 annually with 5, 6 and even 7 days of instruction per week. This curriculum format makes it very difficult to hold a job and expect to be a reliable employee. The school I attended cared very little about outside factors involved in students’ lives when it came to scheduling concerns. In 2010, the tuition exceeds $21,000 annually and the entire three year program tuition is estimated to cost $63,480. This easily translates to over $70,000 in education costs alone. If you complete the four year program in four calendar years, expect your tab to exceed $80,000. Don’t forget to add in your living expenses. If you are considering going to an AOM school, you might want to take a look at my 2005-09 AOM graduate school budget to see if it makes financial sense to you. Keep in mind the recent NCCAOM study finds that 90% of the respondents are self employed and 70% gross less than $60,000 per year.

Please check-out this worksheet for a year-by-year breakdown of expenses, loans, and work income.

I maxed out the possible subsidized and unsubsidized student loans offered to me in order to stay afloat. In my third year, I needed to save any extra funds to make sure I could avoid taking out any of the dreaded private Grad Plus loans in my fourth year. The budget should be a good starting point for prospective students to measure their financial decisions regarding AOM school costs. Figure out how much you need to live on annually. Add an extra $1,000 per year for unexpected and unforeseen costs. Plug in your annual tuition. Ask the school for the average annual tuition increases for the past five years, do the math and add that number to your expected tuition. Decide if you’ll be able to work during school. How much do expect to earn? Will you need to extend your time in school? If so, will it cost you more in total tuition? Once you have the all the numbers, go to and enter your anticipated loan debt into the calculator. You may get a message like this: “Wow! You’re borrowing a lot of money to pay for your college education. Maybe you should think about attending a less expensive college? A good rule of thumb is that your total education debt should be less than your expected starting salary. If you borrow more than twice your expected starting salary you will find it extremely difficult to repay the debt. Live like a student while you are in school so you don’t have to live like a student after you graduate.” Please take a long look at what this education costs, how you will finance it, your repayment terms along with your ability to earn a decent living. There is more information out there today than there was 6-10 years ago. Do your homework before you start into any AOM program. The acupuncture mortgage can last a lifetime, especially with all the repayment terms offered now.

My Perspective Now:

Let me just start by saying that I truly love this medicine and what it can do. I’ve witnessed some amazing transitions and changes in patients’ lives. However, I wouldn’t suggest jumping on the bandwagon unless you clearly know the financial path you are on. With the rising tuition costs, unless you are prepared, it could financially ruin your future. Don’t count on any loan forgiveness programs to save you as they are not a guarantee. So, knowing what I know now, what would I change? Lots of things. Here’s a list of questions prospective AOM students may want to consider during the decision making process.

Think as long term as possible if this is your chosen career path. Find out what prerequisites you need to complete. Also find out what other classes will transfer into the curriculum prior to your enrollment. Can you take many non-AOM specific classes at a local community college? Did you already take them in your undergraduate studies? Transfer in as much as possible if it will lighten your AOM academic load in order to work and keep some balance in your personal life.

Is tuition based on credit load or programmatic standing? I’d suggest finding a school that charges per credit so you aren’t paying for classes you don’t need to, don’t want to, or aren’t allowed access to take.

What is the five year trend on tuition increases? Ask for specifics so you can plan your budget appropriately.

Are the credits you complete at an AOM school transferrable to other non-AOM schools? Find out exactly what ACAOM accreditation means? Very few school are regionally accredited and this could be very important if you want to transfer to another healthcare profession or decide to supplement your license with another degree.

How often are classes offered? If only once per year, what happens if you need to drop or fail a class? Will you be forced to add another year to your education? Lots of life happens in while you are in school. How flexible is the curriculum at the school you are considering?

How many hours can a student expect to be at school? Ask for the past two years of quarter/semester academic schedules to see how the curriculum actually lays out. Hours vs credits don’t seem to fall into line like most other institutions of higher education. How will the way the classes are offered impact your personal, family or work responsibilities?

Since the NCCAOM study finds that 90% of acupuncturist are self employed, ask to see the full series of business class syllabi. How well will the classes prepare you for the real world? Does the information discuss the different practice models available today. Will you need to take outside classes to get the practical information you need to actually run a business? Consider starting a relationship with a SCORE chapter to get some general small business advice.

What specific job opportunities are available for graduates? Ask for at least twenty alumni contacts so you can contact ten of them yourself. Ask for contact information for alumni who have left the profession to get both sides of the coin. If the school claims that information isn’t tracked, ask why not.

Does the school have an annual job fair? Most institutions of higher learning do. For the cost of this education, it is not out of the question to anticipate this.

Request to be placed with a student for a day so you can get a feel for the experience. Ideally, you want to shadow an intern or a student further along in the program. Try to avoid only talking with first year students if you want to gain a realistic perspective of the overall program.

What percentage of their operating budget comes from student tuition? What scholarships does the school offer? Do the alumni make significant financial contributions to the school after graduation? If not, ask why not.

After graduation, another very important decision that you might want to consider is how are you going to live while you are passing your boards, waiting for your license and getting your practice up and running. Do you have another job, spouse, or family financial support to carry you? What if you can’t meet the minimum student loan payments early in your professional career? Are you going to forebear your student loans (many, many people do) for the first year or more?

In the end, there’s way more to consider about a career in the field of acupuncture and Oriental medicine than what schools you would like to attend and if you’ll be a good practitioner. I truly believe prospective students understand this and are starving for some information that will allow them to adequately weigh their financial options. Mixed in with rising costs of tuition, newly available professional data and student loan repayment options, I hope prospective students will find at least one worthwhile piece of information from my experience as they are considering what it really means to have an acupuncture mortgage of their very own.

Author: POCAGuestBlog

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  1. FINALLY!!!!!!!

    Someone else has put this information out there!!!!! I knew there were others in the same boat, but finally, this dirty little secret about AOM education is getting out.

    Awhile ago, I was asked by one of the state organizations why I don’t participate in them. One major issue is this: The state orgs and the alphabet orgs can legislate all they want for the profession. However, they know next to nothing about the practitioners in the profession aside from current (or estimated numbers) and nothing else.

  2. Thank you so much Jessica and Shauna for this


    I have a patient that is currently considering acupuncture school and this will be SO helpful.



  3. Transparency is sorely needed

    Shauna – What a sorry and familiar story. Thank you for telling one person’s story about AOM student debt. I know there are many other stories like yours in AOM. Finding workforce information is almost impossible. Your initial search was bound to come up sort. And many schools do their best to paint a blue sky picture about your prospects. I have written a paper titled “Unveiling the US Acupuncture Workforce.” It is not yet accepted for publication. My co-authors and I have been putting it together for more than 2 years. We have had a very difficult time getting it published. The paper has been turned down by 3 different well known acupuncture journals. I know I sound like the TV “entrepreneur” Kevin Trudeau but the information is stuff “they don’t want you to know.” Here is an excerpt.

    “The growth of acupuncture is most commonly measured by the well documented demand as a treatment modality and the rapid increase in the number of licensees. However, these data are confounded by an apparent stagnation in work opportunities and income. Prospects for employment beyond independent practice are almost non-existent. As many as half of all licensees, upon graduation and licensure, may be unable to support themselves working in their chosen profession. Unlike complementary and alternative health professions chiropractic and massage, acupuncture is conspicuously absent from the Bureau of Labor and Statistics occupations manual. Only a handful of studies are available that together provide an inexact picture of the workforce.”

    The two most useful acu surveys that contain some workforce data were completed by the Calif Acu Board (2008) and NCCAOM (survey from 2008, published in 2010). The CAB did not collect income data but they did collect work hours like NCCAOM (same results). Along with the discouraging NCCAOM finding you cited about 70% earning less than $60K it was also reported on average, AOM graduates borrowed $55,948 to finance training of which $45,891 was still owed when they completed the survey.

    For the record there are only 7 studies I could find that address in part the acupuncture workforce. Aside from two NCCAOM studies none have been sponsored by one of the alphabet leadership groups. I find this incredible. It begs the question – are workforce data not reported by accident, as if an oversight? Or does the professional leadership – the schools, the accreditation body, the professional groups – prefer to ignore the questions?

    When will AAAOM or ACAOM or NCCAOM sponsor a comprehensive and useful workforce survey; a practice common in nearly every other healthcare profession? The NCCAOM stated in its report it intends to file annual workforce data that will eventually provide the Bureau of Labor Statistics the data required for acupuncture to be listed alongside chiropractic, physical therapy, massage therapy and nursing as a recognized profession. I can tell you as a statistician and workforce researcher that the quality of data reported in the NCCAOM report is insufficient to make the grade. Keep in mind that the aim of these two “best” workforce reports were not workforce surveys. The 10 to 20 workforce questions were a subset of what was a much larger exam validation survey.

    Here is the good news. IMO the current healthcare reform will create opportunities for LAcs to work in mainstream medicine as an acupuncturist AND in a new role that will be titled something like “care coordinator.” I don’t want to depress everyone who reads this BUT there are proposals and demonstration projects already implemented that extend the training of MAs to fill these roles. If an MA can fill this role so can an LAc. What are the chances the AAAOM will lead the way in finding a way to allow LAcs to get a piece of this pie? What is the likelihood any AOM school will prepare students to actually land a job in healthcare?

  4. No prospective student or current student. should in anyway

    Believe this good news:

    “Here is the good news. IMO the current healthcare reform will create
    opportunities for LAcs to work in mainstream medicine as an
    acupuncturist AND in a new role that will be titled something like “care
    coordinator.” I don’t want to depress everyone who reads this BUT there
    are proposals and demonstration projects already implemented that
    extend the training of MAs to fill these roles. If an MA can fill this
    role so can an LAc. What are the chances the AAAOM will lead the way in
    finding a way to allow LAcs to get a piece of this pie? What is the
    likelihood any AOM school will prepare students to actually land a job
    in healthcare?”

    I have been an acupuncturist for nearly 12 years now and I have been friends with and girlfriend of acupuncturists for 10 years before the 12 years and I can tell you those demonstration projects that extend the training of MAs to fill these rolls don’t really exist except from moment to moment.

    Really and truly the only way to make a living as an acupuncturist with very RARE and notable exceptions is to own your own business.  You HAVE to know that very few other methods of employment are reliable in the long term.  Even in community acupuncture we are looking for new hires but if we hire 10 new community acupuncturists in the entire country in 2010 I would be surprised (though pleasantly to be sure). 

    Above all else, if you choose this profession, you will need to focus your attention on developing your entrepreneurial spirit.  Maybe the statistics are unreliable but what I know to be true is not.  And break from the current acupuncture school model and DEMAND that your business development class speak to the 75% of the U.S. population not even referred to in the current business models being taught in schools.  It is a travesty that will, even more than the ridiculous costs of school, kill this profession.

  5. Along these lines:
    “Here is

    Along these lines:
    “Here is the good news. IMO the current healthcare reform will create opportunities for LAcs to work in mainstream medicine as an acupuncturist AND in a new role that will be titled something like “care coordinator.” I don’t want to depress everyone who reads this BUT there are proposals and demonstration projects already implemented that extend the training of MAs to fill these roles. If an MA can fill this role so can an LAc. What are the chances the AAAOM will lead the way in finding a way to allow LAcs to get a piece of this pie? What is the likelihood any AOM school will prepare students to actually land a job in healthcare?”…

    As noted in Shauna’s blog, if AOM schools are not regionally accredited, and their credits/units are not accepted by “regular” universities or even Vocational Tech schools, why would acupuncturists be accepted into this type of program? I have looked into many ways of using my acupuncture education to bootstrap into other educational programs and the truth is that many AOM schools will not even accept your transfer credits, much less any reputable institution or licensing body other than Acupuncture boards.

    I would be surprised if this avenue of employment was open to licensed acupuncturists.

  6. Edit:

    I finally figured-out how to add a link to the fabulous worksheet which Shauna created, based on her experiences as an acupuncture student.  Check it out from above (under the “Acupuncture Mortgage” section) or take a peek here.

  7. Just to add to the weight of

    Just to add to the weight of Shauna’s comments, her experience almost completely parallels mine (I was in school from 1996-2000). The only work I was able to find during that time was part-time $10/hr working for the school I was attending. This in no way offset my student loans and did not provide much toward living expenses.

    The point she makes regarding the inhumane scheduling and study requirements seems to be almost universal amongst AOM schools as well. Even those schools which claim to be more spiritual (i.e., “require” you to do daily meditation at the beginning of class, or “require” you to take tai qi or qi gong classes every quarter or trimester), are not sincerely interested in improving the students’ health as much as they are interested in appearing to do so. Many students completing AOM 4-year programs are a health train wreck themselves by the time they get licensed. How, then can they even begin to see to the needs of others.

    If I had not been subsidized during and after school by my relationship partner, I could not have gone to school and worked in my chosen profession for the 8 years after school.

    And if I had not found the Community Acupuncture Network and business model, I would probably be doing something else by now in order to pay back my school loans.
    Mary Margaret Dobson

  8. the reason I think this is true,

    “Many students completing AOM 4-year programs are a health train wreck
    themselves by the time they get licensed.”

    Has not as much to do with the academic requirements which are not particularly brain expanding but with glib fact that most students look at the end of school and don’t see much out there in the future.  How emotionally daunting it must be to look into your dim future of huge loans and unemployable skills.

    M.D. training is extremely expensive and academically challenging but they at least have some kind of light at the end of their tunnel.  At this point in the medical hx of the west it seems that the light is getting kind of dim, but there nonetheless.  Nothing of the kind can be spoken of acupuncture school.

  9. And Shauna,

    It looks like your math skills will take you farther into the future than your acupuncture training.  I don’t know if you are in our membership, but you should be, all the math whizzes cum acupuncturists seem to be having quite a successful professional life in community acupuncture.  They don’t deal in mathmatical vagaries like the acupuncture schools do.

  10. Good point, Tess, I remember

    Good point, Tess, I remember after graduation and before taking exams, when someone asked me what my plans were I honestly answered, “I don’t know yet”.

    Basically I waited around until someone had vacant treatment rooms to rent out…I had no plan, no expectation, no clue. I suppose that could stress a person out….

  11. Thank You!

    Thank you so much Jessica for this insightful and well-thought out article.

    I am a prospective student in hopes of applying for school in 2011. I have flown across the country to visit the top schools I am interested in applying and have asked the really hard questions no one seems to want to talk about — the business and money aspect of the industry.

    Your article has answered some of my questions and concerns and has also added more questions to my list.

    I am so grateful to the acupuncture community but I truly feel too many people feel awkward or uncomfortable talking about money when it involves peoples’ health and wellness. At the end of the day, this amazing form of healing is a business and if people can’t figure out how to make money than there will be no way of treating people.

    Thank you! Thank you! Thank you!

  12. Please don’ take this the wrong way…

    Dr. Stumpf

    I wholeheartedly agree with the lack of transparency regarding AOM training, professional prospects, and the observed unwillingness of AOM programs and the alphabet organizations to address who they serve; the future and current practitioners. I am also not surprised that AOM publications would not publish the data you and your colleagues have collated, assessed, and analyzed.

    One thing I am curious to know is if you have sought remuneration for your proposed article from the AOM journals. That said, I highly doubt they would publish it if you asked for none. The issues you have raised must be addressed and accountability must be taken by the orgs and the schools.

    Perhaps the avenues for publishing are inappropriate. Perhaps another avenue, such as an education journal or perhaps a general publication (such as the NYT) would be better avenues. Considering the overall economic crisis and the financial meltdown, the risks for student loan defaults from AOM programs seems to be very high. I have been unable to locate default stats for AOM graduates. However, the chiropractic profession can be used as a template to predict student loan defaults (DCs have the highest HEAL loan defaults by a very wide margin. This is important to note because The number of DCs is very low in comparison to other medical/health professions such as MDs, PTs, DDS, etc.)

    I think it would be wholly appropriate for theDOE, legislators, and the general public to know this information as they are stakeholders as well.

  13. Great article

    I appreciate your well thought out article. I graduated in 1999 and was completely unprepared for practice.

    It is a crime that acupuncture schools have you waste time doing things like Tui Na and Tai Qi when they will not help you. To be well rounded, the curriculum should include business classes every semester. You should not get out of school, completely shell shocked and have to go back to your old job.

    I managed to make it because I hired a management consulting company. The simple things they taught me could easily have been taught in school.

    We have the most amazing medicine. The problem is, most people do not know that. It is a tough road. I still would not wish I had not gone to school. Acupuncture has changed my life and literally SAVED the lives of my parents when they had life threatening illnesses.

    You will struggle the first year or two to find your way. The economic analysis is a fair one though. My first degree is in business, but even with that, I was not prepared for private practice in Acupuncture. I am very grateful for Community Acupuncture. I think it will change the face of acupuncture in this country.

  14. Sliding Scale $15,000 -35,000

    In my opinion, we will see either spiking interest rates or hyperinflation, or both, within 1 year. Our state and national organizations, and the schools as far as I can tell, are still operating under the mentality that economically, we are just hitting a bump in the road and will eventually go back to normal. Mathematically, it is impossible. The only way to generate economic value is by extraction and production, and as individuals and collectively, there are just not enough resources on the planet to grow out of our debt. Even if by some miracle the currency isn’t debased, a student entering any type of school today can look forward to rising interest rates. Paying off $100k at 6% is nearly impossible, at 16% it is unimaginable. The long term value of community acupuncture is in my opinion, developing the infrastructure of community as we adjust to a new pared-down reality. A devolution to a Mad Max scenario overnight is not likely, but I do think there will be a sharp drop downward in lifestyles. I don’t expect many acupuncture schools to survive the next 5 years. Hospital jobs, expanded insurance coverage, and I’m sorry, the FPD, are pipe dreams. I expect we will eventually return to a master-apprentice system. I could be wrong but all trends are leading in this direction, so unless there is some unseen deus-ex-machina waiting to rescue our system, these things seem likely to happen. I have not posted anything about this because I haven’t wanted to be alarmist, but it seems now like things are coming to a head and changes are imminent, this thread is as good as any. Don’t get me wrong, I’m not hoarding gold or food supplies, but I am adjusting my plans for the future and rethinking what will be important. Anybody else get this feeling?

  15. Thank you

    It is great to see something like this spelled out, in black and white.  It seems to me that the community acupuncture centers have a unique opportunity to have apprentices learning on the job.  I can only imagine how much more grounded I would be in what I know had I been seeing the effects of acupuncture on real live people from day one.  That and not having a pile of debt hanging over my head would constitute a very different point from which to enter the field as a licensed acupuncturist. 

  16. Thank you Shauna and all who commented

    I sent a prospective OM student to this post this very morning as we were to have a phone call to discuss her plans to attend acu-school.

    Timely for us and well-written.

  17. MAs and acu workforce trends

    Dear Tess – Nice post. I am sure you are correct about the fact there are very few MAs currently working in this extended role. I had never heard of this practice until I read the article in the May Health Affairs journal which only concerns the coming healthcare reform. The article is”Transforming The Role Of Medical Assistants In Chronic Disease Management” and the first author is Karen Nelson (knelson@ who is chief executive officer and medical director of UNITE Health Center in New York City. You will have to go to a med school library to access the article online. Maybe you can email Ms. Nelson and ask for the manuscript. Unfortunately the article does not say how many MAs were trained to become “health coaches”. Ask her how many MAs have completed the training.

    My point is that healthcare reform will create new primary care positions which, if they can be filled by MAs, they can be filled by LAcs. LAcs need options other than solo practice to earn a living. You are also correct that the sole practitioner model is really is the only available work choice for LAcs. While owning your own business may be appealing working on your own as a healthcare provider is generally considered ill advised. Of course, the bigger problem is that one cannot take enough business coursework to get referrals. These simply have to come from other providers which means mainstream medicine where all the patients are. To imagine otherwise is naive. You should build wooden homes in the Sahara. The CAB and NCCAOM both conducted marginal workforce surveys at the beginning and at the end of the 2000 decade. The little workforce data produced by both surveys shows opportunities for LAcs to work somewhere other than a solo practice has actually diminished. You might think of this as the tightening noose. Why does the CAN model work? It makes treatment affordable on a cash basis. Studies consistently show that if individuals are fiscally able to pay on their own for healthcare they will do so. Stick with CAM. Get ready to work in the mainstream.

  18. why AOM credits do not transfer

    Before I get to the subject of this reply let me clarify that I am not suggesting LAcs should become MAs. I am suggesting that LAcs may be better qualified to function as a health coach or a “care coordinator”; both are roles that will be looking for qualified providers in the next few years and over the next couple decades. I actually support creating a new training program for LAcs to get them trained in primary care so they can work in a range of roles in community clinics, including as acupuncturists. But they need to “speak doctor” first. I have written about such a program on my website. Look for the Aug 20 2008 post “PAs and LAcs: is there a model here?”

    AOM school credits do not transfer for several reasons. The training produces a terminal degree. Whether it is MTOM or MAOM or OMD for that matter, whatever, it is the terminus for the training. End of the line. The degree is not an academic degree. The schools are not academic centers. The schools generally offer one program only…AOM. If a school offers multiple degrees then it MUST be regionally accredited. There are very few AOM schools that have regional accreditation. Probably less than 10. Maybe only a handful. Maybe only 2! the standards for regional accreditation are much stricter than for specialty accreditation such as ACAOM. You may find it interesting to learn that, IMO, the toughest hurdle for most AOM schools to overcome in a regional accreditation would be the financial requirements, e.g., debt to assets ratio, cash reserves, etc.

    Much is made about ACAOM being approved by the Dept of Ed as though it is on par with all DOE approved accreditation bodies. This is simply a misrepresentation of things. In fact, ACAOM is not be the most authoritative body with program oversight in the world of AOM education. I would argue the California Acu Board is more powerful since it actually has regulatory power, meaning it can actually specify what must be taught by every school it approves in order for their graduates to sit for the licensing exam. ACAOM has “standards” but they can only refuse to recognize schools that do not stick to them. The CAB can actually put a school out of business.

    There is an unprecedented opportunity for LAcs to forge their own path into employment. New jobs are going to be created in the medical mainstream as MDs give up lots of “ordinary” patient care. Forging a path for LAcs must be bootstrapped. Nobody is going to say “hey maybe we could use LAcs for these new roles!” For once it could actually happen. But you gotta speak doctor.

  19. where are the data and who cares anyway

    Dear Guest – thanks for the reply post. For “default stats” on LAcs you need look no further than the ASAP blog in which the energetic Ms. Wolfson is also involved.!/topic.php?uid=114018918610527&topic=15

    You should also look at the CAB and NCCAOM surveys which are not really about workforce. Each survey had an earlier version at the beginning of the decade. The surveys are both validations of their exams. All four included a subset off “demographic” items.

    California Acupuncture Board Occupational Analysis: Acupuncturist. Office of Examination Resources of the California Department of Consumer Affairs.

    Ward-Cook K, Hahn T. 2008 Job Task Analysis: A Report to the Acupuncture and Oriental Medicine (AOM) Community. NCCAOM 2010.

    I have not asked to be paid to publish either article. These are scholarly articles and payment is a conflict of interest. If I did write a popular media version I could be paid. First, I wold have to publish the scholarly pieces. In either case pop writing is not my immediate goal. I put together programs. projects. I see a huge job need, tremendous injustice and a lot of wasted time and money. Put them together and there is an opportunity to help healthcare providers work in their field, increase access to care, and fill a monster gap in the number of providers needed to take basic care of people. I do not think I am a dreamer. Maybe it is easier for me to see since I am not an LAc and I am a strategist.

  20. maybe


    I’m not much of an economist, but I’m wondering if there are other forms of value besides extraction and production? Where do things like community acupuncture, tree planting, environmental restoration, arts, human services, etc. fit into this equation? There was an issue of YES magazine devoted to the green economy recently. If we are limited to extraction and production (and if production is narrowly defined), then what hope is there?

    Not to deny the possibility of Mad Maxor scenarios…and perhaps we are already there in some parts of the world. But as for “the big one”…it’s sort of like predicting the next big earthquake to hit the west coast…could be tomorrow…or a few centuries…a lot of pain and suffering likely, unless we figure out a way to make altruism and earth stewardship universally popular overnight – in a manner of speaking.

  21. The Story of Stuff

    I recommend/deeply wish that everybody would read this.  My dear friend Annie Leonard has spent her entire adult life as an activist studying and working with the global extraction/production/garbage trail.  The online viral video is easy and fun to watch, but her new book by the same name goes into fabulous detail about the different ways we can envision things changing and what people are doing to rethink the Big Picture.


    thanks for a great thread.


    Julia in Berkeley

  22. story of stuff

    This video is classic. I second your recommendation Juli and please thank Annie next time you see her. By the way, a patient may drop in…she’s going to be visiting someone in South Bay area for a few weeks and I gave her a few cards to Eastside clinics.

  23. awesome!

    you are friends with annie leonard? i have LOVED the story of stuff since i first saw if a few years ago, sent it to everyone i know. it is brilliant. please thank her for me, for putting so much of her life into this project!



    Good health is not a measure of adapting to a sick society.

    When the power of love outshines the love of power, the world will know peace.

  24. smiling…

    I’ll send her both of your thanks! She is a ROCK STAR.  Her daughter and my youngest son have been in the same small class since they were in Kindergarten and I have all of the love notes they’ve sent to each other over the years.  Now that they are in 5th grade, they barely talk to each other in front of others, of course, but when they were younger, Annie’s daughter would often stay at our house while Annie was traveling the globe doing her research. 


    I can’t wait to see what her next project will be.


    But do read the book.  Even though I thought I knew lots of it before reading it, I was still totally blown away, and it absolutely changed my perspective about many, many things.


    If only I could get her to slow down long enough to poke her regularly. 


    Julia in Berkeley

  25. Exaclty, we can do better……..

    at taking care of each other as an entire profession and this begins with prospective and current students. I had classmates that were scheduled (aka had no other choice) from 8 am-7 pm with only 15 minute breaks speckled through their day.  Employees aren’t legally allowed to work like this, so how does this fly at some AOM schools?

  26. do not get that woman to slow down…

    the work she does is eye opening and transformative…she needs to help us all re-think our garbage.

  27. AOM cost of eduction

    Thank you for writing Shauna.  I too have been considering writing about my school financial experience.  There is really no way to plan one’s costs by the information available to prospective students, and when I spoke of this to my school administrators, they were not terribly responsive.

    The real issue, is how to convey this to our profession such that schools and regulators really consider options for correcting this situation. In addition, one the job front, how do we help successful acupuncturist with the notion of expanding their practices and hiring new graduates.  How do we best connect with our local physicians, hospitals, and other allopathic colleagues that acupuncture should be included in their practices and venues.  

    In the United States, our culture is so oriented to ‘the individual’ that it is difficult to make headway on forming comunities that will function together to turn problems into opportunities.  CAN at least is in the forfront of this effort!


  28. Correction

    The blog that Steve is referencing is Keith Zabik’s “Survey Says” post, and it is hosted here on CAN.  The Facebook group is just our attempt at grouping together some of the CAN blogs which are more industry-related.

  29. no gold to hoard here…

    Is the feeling you’re getting that we’re beginning to witness all of industrial civilization collapse?  Cause that’s the feeling I’ve been having for some time now.

  30. The way to do would be…

    The way to correct the situation would be to speak to DOE regulaotrs and possibly legislators about the expense, lack of opportunity, the fact that the “profession” doesn’t self-regulate via income and employment tracking of graduates. We should firmly recommend that AOM schools, becuase of this, be removed from Title IV financial aid programs.

    Want to be radical and revolutionize the field? Then this would be it

  31. There are myriad forms of

    There are myriad forms of human value. But in economic terms, adding value only means making an object more expensive in real dollar terms than before. Furniture is more expensive than trees. Services can be exchanged for value, I can trade a haircut for acupuncture, but at the end of the trade, if no product remains, there is no value added. I know these things are valuable and enriching, but I am talking about economic terms. I agree this is a crass way to talk about the earth but it is what it is. I don’t consider this to be like predicting an earthquake, because no one can know all the data about the earth’s tectonic activity. But we do know a LOT about the human population’s financial activity, and the consensus is that our current activity will not be supported much longer. By much longer, I’m talking several years or less. You and I will live to see it. If you are asking me where do things like environmental restoration,arts, human services, and tree planting fit in, it is obvious that things are not well funded, and as a society are not valued in dollar terms. They may be valued in people’s hearts, but not in dollars, they can’t be monetized easily. That is the problem with the green economy, at the end it also relies on production and extraction. Our money system requires infinite expansion and we are running out of room to expand, that is why it is breaking down. This is a poisonous system, but I hope that if we understand it, as it breaks down, we can be ready with alternatives and not make the same mistakes. (Yes Whitsitt, I am talking about industrial and financial collapse!)

  32. You may find it interesting to learn that, IMO, the toughest hurdle for
    most AOM schools to overcome in a regional accreditation would be the
    financial requirements, e.g., debt to assets ratio, cash reserves, etc

    well, yeah — none of their alumni make enough money to actually support the schools, and they probably resent them too much to even consider it.

  33. Point on!

    I remember sitting back and observing this while I was a student…..where were the alumni funds?  Why wasn’t the support there in financial contributions from their graduates?  My thoughts continue to be 1) grads are not making enough money to contribute and/or 2) they observed the respective institution’s spending and didn’t feel comfortable with their allocation/distribution choices.

  34. Thanks Allyndreth!

    You spent lots of time and energy as a student trying to break down ‘old school’ barriers, thinking outside the box, articulating concerns and opportunities.

  35. Yes, acupuncture schools suck…

    But this is a problem with all of higher education.  How many Sociology majors get a job within their field immediately after graduating?  How many families can afford to send their kids to college without massive scholarships and loans?

    We need reform on a much bigger scale.

  36. Besides that, where is the

    Besides that, where is the job placement, support of alumni projects, ANY show of appreciation for alumni achievements, even support on the school website for alumni organizations and rooms available for alumni meetings?

    If the school doesn’t support the alumni efforts, the alumni no longer see themselves as associated with the school.

  37. Sociology vs. Acupuncture

    Perhaps you may be missing the point with regards to the comparison. Sociology has a much broader application as it may apply across various sectors: International relations, federal, state, municipal agencies, healthcare, law/criminal justice, commerce, education. It is a science, therefore it uses theoretical frameworks and scientific methods to test hypotheses with empircal data via systematic observation, in-depth interviews and ethnography, conversational analysis, content analysis of both written and visual documents, survey research, and statistical analysis ( Therefore, the opportunities for study and employment may have a much broader application. There is also the academic aspect as well. First is it an academic degree (meaning it involves research, analysis, and discourse)? Or is it a professional degree? It can be both. Unfortunately, Acupuncture/AOM is not. It is a trade degree that uses a theoretical framework that may be perceived as mystical, not to mention, there are many questions regarding the translation of texts and various terminology such as “qi” and “jing mai/jing luo.” There are writings and research that indicate these terms were mistranslated, thereby disrupting (and possibly obliterating) the theoretical basis for AOM.

    You are correct that reform should be made on a much greater scale. But I ask you this: What can someone do with their sociology degree if they are unable to “work in their field” versus what can an acupuncturist who only fulfilled the 60 semester hours of prereqs (meaning, NO Bachelor’s degree) and came out with such a highly specialized “Masters?”

    I will tell you this: When I worked in the strategy and technology field, we did hire many people with various academic backgrounds: Cultural ethnographers, sociologists, psychologists–these people had strengths in terms of research and statistics that could be utilized for psychographic analysis of data for marketing, had the strength to understand the cognitive dynamics of human/computer interaction.

    What praytell, could an acupuncturist do with just the AA and a diploma mill Master’s if unable to work as a practitioner? Uh, Starbuck’s anyone? Trader Joe’s? Whole Foods?

    What I am trying to illustrate is the huge difference between having an actual degree in the liberal arts and sciences versus a diploma in a highly-specialized and possibly esoteric area where there is at least 50% of unemployment/underemployment, and what, at least an average of 60k in student loans, and the majority, as Lisa has painfully illustrated, that make barely 30k with little other opportunity. At least someone with a Sociology degree could return to school and obtain a Master’s in education and possibly teach. However, yes, perhaps Sociology isn’t a practical academic endeavor, but is AOM?

    From what I gather about the post-secondary system of education in Europe, there are Universities and there are Polytechnics. The Universities are purely academic–generally upper class, etc, while Polytechnics are practical academics–similar to MIT or IIT. Then there are trade guilds where people learn via apprenticeship. Somewhat of a multi-tiered education system that has its roots in classism. Whether this is good or bad is up for debate. However, polytechnic system ideally prepares students for professional-level careers–so there aren’t too many Literature majors serving you coffee at the corner cafe. Of course, education is different in Europe than it is here, and whether the polytechnic system’s aims of practical, applied education for professional/trade work is still successful is up for debate.

    Anyhow, getting back to AOM, it is clear, as Steve Stumpf has illustrated, the alphabet organizations seem to have no interest in knowing whether or not the practitioners in the AOM trade are successful. Their aim seems to be more about promotion of the theoretical framework as an “alternative” to biomedical medicine. This is woefully misguided. The focus should be more on how it fits within the context of biomedicine.

    first and foremost, the alphabet orgs and state orgs must all go. Second, all of the AOM schools must close. Third, AOM should, or must be part of a post-graduate/post-doc program for current practitioners of biomedicine–those would be Master’s level PA’s, Nurse Practitioners, DPTs, DO’s, and MD’s. That is how it will best be served in this country, and this is how it will survive.

    Another option would be to utilize the above model, as well as lowering the number of hours for a single-line practitioner (LAc)–somewhere in the ballpark of 1300hrs, may be sufficient to teach the framework for acupuncture, safe needle technique, and treatment strategy…perhaps along the lines of CAN–jingei pulses, and possibly balance method via Dr Tan, Master Tung, scalp acupuncture, korean 4 needle, along with what stumpf has proposed by utilizing the LAcs with basic training via clerkship in primary care for safety net clinics.

    I can see both models working concurrently. However, the current model as it now stands, will most likely be obsolete in 5-10 years. The regulators may get wise and remove AOM schools from title IV financial aid (if that is possible–perhaps we can start petitioning them to do so?)

  38. time to get the ball rolling!

    Department of Education, Office of the Inspector General, Audit to
    Determine if Cohort Default Rates Provide Sufficient Information on Defaults in the Title IV Loan Programs, ED-OIG/A03-
    C0017 (December 2003) and General Accounting Office, Student Loans: Default Rates Need to Be Computed More
    Appropriately, GAO/HEHS-99-135 (July 1999)

  39. I wrote that too quickly and

    I wrote that too quickly and expected you all to have ESP to understand where I’m coming from.I’m as upset as anyone about the state of the acupuncture profession and the fact that there are few ways to make a living in this field.  I am also saddled with loans from acupuncture school, so I certainly get the pain of the “acupuncture mortgage”.My point is that this is an issue that goes beyond acupuncture culture and into mainstream Western culture.  Acupuncture schools are our particular bad guy, but they are just following the lead of the rest of higher education.  Keep raising fees, keep raising tuition, force students further into debt and know you can get away with it because higher education is valued in our culture and the students keep coming.  It’s out of control.*If there were a movement out there to make higher education more sustainable, they would be our natural allies, but I haven’t found one.  And I’m not sure that stripping acupuncture schools of the ability to qualify for federal aid is the answer.  Wouldn’t that just make acupuncture school even less accessible to people of limited means?  Yes, we wouldn’t graduate with acupuncture debt (because we wouldn’t go in the first place!), but isn’t that our choice to make?And, if all the acupuncture schools somehow folded overnight, where would that leave us?  The state regulations would still exist, and in Mass., at least, the state regulations require an advanced degree.  In fact, the Mass. regs have gotten even more strict over the years.  So maybe that’s the place to start, with convincing the folks doing the regulating that acupuncture can be safe and effective without all the over-training.*I don’t want to waste air space arguing about the difference between a liberal arts degree and a technical degree.  Yes, of course there are differences but there are also lots of similarities, and that wasn’t really the point of my comment.

  40. the future of acupuncture

    This reply may have some info for Emily but it is inspired b the guest commenter. AOM programs refer to themselves as schools, colleges, universities, etc. They are more like trade tech schools. For the most part, at least in California, they do a very poor job of preparing graduates to work in their chosen field. All you have to do is look at the pass rates for each program on the Calif Acu Board website. I compiled the pass rates for the Calif Acu Licensing Exam (CALE) over the previous 3 years; ~59% over all programs. Compare that to pass rates for other professions where LAcs should be inlcuded as peers – PTs, PAs, NPs. Each profession passes their licensing exam at 85% and higher. I am simplifying the exam issue but it does draw a line in the sand. IMO The AOM programs are a big part of the problem. The inability of half the licensees to support themselves (and 40% of graduates to pass the CALE) is all the evidence needed to see something is very wrong with the current approach to training. Remove CAB approval for every school that does not meet the 60% threshold of graduates passing the CALE. That is how you close educationally bankrupt programs. Acupuncture belongs in mainstream medicine. LAc training should take place in community colleges, Cal State campuses and even strong tech trade schools like Phoenix, Devry or ITT. Standards for accreditation are vastly superior and more respectable than ACAOM. So let’s train LAcs to work in mainstream settings. A Master degree is appropriate. Mock it up like a PT, PA or MSN. Include needling therapy. Make TCM courses elective. Be able to work alongside other mid-level providers. And do acupuncture in a community clinic. Set up your private practice after a five years working alongside mainstream providers who will become your best referral source. And structure the payment scale like CAN. Large brains not required to see what is working and what is not. I realize my comments focus on Calif but the ideas should apply all over.

  41. barefoot medicine

    Steve,I respect your opinion, you have obviously given it a lot of thought. I am less convinced that handing acupuncture over to a broken (IMHO) Western medical system would be a good idea.

    Take PTs, for example. The trend is now for physical therapists to get PhDs as an entry level degree. This is complete over-kill and lends itself to the rising cost of health care. PTs have already appropriated the traditional Chinese technique of gua sha– something that can be done with a cheap ceramic spoon (mine was less than $1)– and turned it into the trademarked Graston Technique, which costs thousands of dollars for training and special equipment.

    My goal is to make acupuncture as accessible as possible. While I see that integrating acupuncture into mainstream medicine might make it more visible, I can also see a potential for it to go horribly wrong.

  42. CALE

    i agree that the schools in California do not do a good job, but part of the probelm with poor CALE passing rate is the test itself. there should not be a serparate test and license for California. that exam makes no sense, literally. i think taxpayers $$ can be way better spent in California than administering CAB on a shoestring, without enough funding to hire people who really know what they are doing and without any idea about what is important to test in order to license someone to practice in the real world.


  43. Phoenix, Devry, ITT?

    Wow, I agree with a lot of what you say, Steve, but you’ve lost me with this one.  From the ridiculous to the sublime.  Even more than many acupuncture schools these “institutions” will do or say anything to get a tuition payment.  Phoenix in particular has gotten a lot of negative attention recently for misleading students and shady financial practices.  Phoenix came very close to convincing my sister-in-law that the DOE would pay the entire cost of her training in Medical Billing and Coding (which would cost 3 times what the same training would cost at the local community college).  Changes do need to be made in the educational system for acupuncture, but let’s not throw the baby out with the bathwater.

  44. I guess the question would be…

    While I don’t doubt the viability, of what you are proposing, the question is why “mock it up ‘like a PA, NP, or DPT'”? I guess, I’m not sure how what that would look like: A&P, Pathophys, pharm, biobehavioral basis for disease, Research methods/Evidenced Based Practice, Issues in bioethics, Care across the lifespan, psychosocial behavioral dynamics, Acupoint practicums, Acupoint treatment methodology? Clinical practicums? (some of this is based on on some of the coursework for an APN program, with some things geared for AM).

    There may be some inherent problems: There may not be enough EBP for AM (“Acupuncture Medicine). What is the care framework for AM? Is it on the based on the medical model, the rehabilitative model, or the nursing model? If it’s mocked up “like a PA, NP, or DPT,” why not have be a PA, NP, or DPT, and then have AM added as an adjuvant, post-masters. Alongside of this, there could be a 2 yr LPAc program that could be provided at Junior Colleges (conceptually similar to an LPN), with clerkships in safety net clinics. This may be much faster way to implement.

    Perhaps it would be necessary to determine how a “single-line” practitioner (an acupuncturist) could really function and have demonstrable proof that it can be duplicable and replicable across the public health safety net spectrum. Test pilots may be good, but it could take years (perhaps decades?) for this to be implemented.

    Just some random thoughts.

    Having a TCM background myself, I have often vacillated between maintaining the “integrity” of “the medicine” versus finding a way to make it fit within the cultural context of healthcare delivery in the U.S. Yes, it may very well be collapsing, however, does that imply that AOM will supplant it? We may all very well know the answer to that one. Could it mean that the current system may be “too large to fail” and that it must be transformed in order to be more effective? That may be more likely. AM can have a part in that. What this means is that it may be necessary for all of us to figure out how best to make that happen. What did Mao do with AOM? It was almost obliterated in the early part of the 20th century. The lack of physicians and the need for care forced the communist government to find ways of making it work. Essentially, the “best practices” of AOM were kept, while other aspects were thrown out, hence the difference between “Traditional Chinese Medicine” and “Classical Chinese Medicine”. The former is what was codified and integrated into China’s healthcare system by the Maoist government–pulling all the “best parts” from the historical literature. the latter was essentially more of a lineage-base, with more fragmentation and possible focus on certain aspects of certain bodies of work on AOM. Of course I am way over generalizing.

    That said, this is not China. Medicine is practiced and delivered differently due to the different cultural context. It is nearly impossible to force the TCM paradigm down the throats of EBP. We’ve all read the allegory about Zu San Li, that the emperor, after being needled at this point, was able to walk three leg miles. I do not mean to offend anyone, but this, metaphor is very similar to Jesus turning water into wine. Is that evidence or is that faith?

    Then there are these articles in uh *** cough*** cough*** AT

    and this

    as well as this

    These all raise interesting points about Qi, Jing-mai/jing-luo, their mistranslation and their possible implications for AM in countries outside of China. If the basic framework that we were all taught was mistranslated (and there are some Professors from various AOM universities in Chine that do believe so), then the framework from which we may all be practicing could very well be flawed.

  45. Guasha, Graston, Ultrasound

    I used to crack comments with patients that I’m doing “Chinese Ultrasound” when I did gua sha. PTs, for entry into the profession is DPT, not PhD. Yes, NPs will ultimately be DNPs–whatever. They have to serve a residency, and they have to do research…a bit more than what an MSN-NP would do, but at least there are jobs for DPTs and DNPs upon completion. They can also be clinical preceptors, clinical professors, and possible adjunct didactic professors, not sure about tenure track–I believe it is (and should be) the domain of the PhD.

    I guess we all have to be open for it to succeed and also fail. The question, regarding the integration issue, is does to current non-integration model work? Has it ever? Could it be forseen that it will work?

  46. This is a massively complex issue

    I think there is a great deal of merit in the core of what you’re saying, Steve. My concerns rest in the fact that it will only work to the degree that the mainstream system fixes itself and its current enormous problems in the process. It isn’t just about getting acupuncture in. We’ve talked about this already elsewhere, but I don’t trust the mainstream system all that much more than I trust the existing acupuncture institutions. Community colleges are logical places to do this kind of training, and the idea of five years of “residency/apprenticeship” before starting your own clinic is a SORELY needed structural piece. 

    As to the California acupuncture test, I have some questions there, too. I would be very interested to see the statistics on the pass rate for folks taking it the second time. It’s been common knowledge among everyone I’ve ever talked to about it, since before I got out of school that you have to take it the first time to find out where all the ridiculous landmines are, none of which have to do with your actual grasp of the material of the medicine, and THEN you go back and pass it. 

  47. I’d be happy

    to see more acupuncture being done in hospitals, but it seems like in general doing something in a hospital setting makes it more expensive.  Also, not everyone who could benefit from acupuncture wants to go to the hospital to get it. 

  48. Guest,

    please continue this line of thought! And everyone else please chime in. We have to grapple with this issue in our own ranks before we have even a chance of getting taken seriously anywhere else. We haven’t even got a very clear grasp of our own “tradition” yet, and we’re trying to sell it to everyone else. The process of regarding Chinese medicine as a monolithic whole, while there are clear historical reasons for it, has left us stuck in trying to move with the changing of the greater medical system. A deep examination of the diversity of the tradition in China, complete with all the inevitable mistranslations and misunderstandings, as well as a revisioning of how those various of those components fit, is crucial if this process is going to go on with any integrity. 

  49. *Sigh*

    I have zero interest in talking about “integrity” in “the medicine.”  I couldn’t care less about what “lineage” a treatment came from or how “traditional” or “authentic” it is.What I DO care about is helping people.  And adding acupuncture into the managed care bureaucracy would not be very helpful.On the other hand, community acupuncture IS helpful– for thousands of people.  So, while I agree that acupuncture education needs to be overhauled, I think CAN has already done a great job finding a practice model that works.

  50. CALE

    Frankly I considered the CALE to be NOT so difficult as I thought it would be, and I took it in a year when it had just been overhauled (because of yet another cheating incident) and no one knew what would be on it. I don’t think I’m any smarter than the majority of people taking the exam in any given year, and I KNOW I overstudied by far.

    It was my opinion at the time that a few good Study Technique classes and more attention paid to Test-taking techniques would have produced a better result.

    That being said, it is, as Tatyana suggested, ridiculous that CA would have their own exam. The original premise for it seems not to be valid any more, if it ever was, and the expense to the state cannot be justified. But since CA has their own engineering exams and other professional exams, it seems unlikely that it will be changed.

    I agree with Steve in that I believe I was given more of a Vocational Tech education. It was not a classical education by anyone’s standards, and it was not so much a clinical education as the school would like you to think. Since I was looking for a practical application-type education the Vo-Tech model was okay with me, but I would have liked more clinical application, and it sort of pissed me off that everyone was fooling themselves that they were doing cutting edge work when a lot of what we learned wasn’t particularly effective.

    But I still wouldn’t like it to be done by ITT, DeVry or Phoenix or whoever, since their graduates are often similarly ripped off and cast adrift.

    And Brent, the second-time pass rate on CALE are published after every exam is complete – although if they aren’t good it can be hard to find the small print.

    Sorry if this was rambling, just had a few points to throw in the mix and didn’t want to take up more than one message.

  51. the PC LAc education, for profit JCs, CALE

    Nice work everyone. We have a conversation. We have roles – a skeptic, several disillusioned folks, a couple of looky loos, and a couple of strong opinions about what is possible. I am asking to be stereotyped myself so I will say I am a health professions educator with more than 30 years experience. As Granpappy Amos would say no brag just fact. I want to respond to a few of the themes and comments. My intention is to keep the conversation rolling, diminish hopelessness and disillusionment, and help find a way out and into the mainstream for the benefits of the workers (LAcs), the patients, and the graduates who find themselves stuck. First let me say again the CAN model is the only one I see that can work for LAcs given the current state of things in healthcare and AOM. The financial models being proposed under the “reinvention of primary care” are not inventive – grants, extend Medicare benefits, P4P. The CAN model is simple, independent and outside the danger zone. I find it completely logical that the acu leadership rejects this model. I have written about the PC LAc model on my blog – My new publicaiton in Complementary Health Practice Review called “Mainstreaming Acupuncture: Barriers and Solutions” describes the ed program. It has been accepted. I have proofed the galleys. Couple of weeks? We hope. You will recognize a lot of the content. When I say mockup a PA or NP program I am referring to teaching the basic coursework listed in other posts on this string. The current breakdown of “Western” to “TCM” hours in the current CAB lineup for program approval (so grads can sit for CALE) is 30% to 70%. I say flip it. That would be for the 3 year Master degree program. For the 1 year PC LAc program I have described, the LAc would be immersed in about 32 weeks working in a safety-net/community clinic the same way PAs and NPs and MDs for that matter are trained (longer than 32 weeks for these guys of course but then LAcs are not going to replace them; they will supplement them, that is the point of healthcare reform – all mid levels move up). What about the Devry/ITT/Phoenix stuff? OK. Maybe I wanted to open some minds about how one supplants the standing cohort of AOM programs. A Cal State campus would be great. They already have mid-level healthcare programs. Already pitched there. Won’t have it. A few good reasons, mostly budget. A private school would work better but they see clearly that the AOM profession is marginal both in terms of student base and earning power. Why bother when they can train PAs or RNs or even LVNs who actually get jobs. But it could work in the right private school. Take a look at the only PA program in the state placed in a private JC. It is a certificate program. No degree granted. Why is CALE a good if imperfect thing…first the CAB is not funded by state $$. It is funded by licensees who pay to register for the test, pay to take it and pay to stay licensed. So not to worry about how state $$ is being spent. It is you guys who are paying for the CAB. Next, ACAOM ed requirements are less than what is required by the Calif Acu Act. In other words, AOM ed is non-standard. Won’t find that in too many other healthcare professions with a national certification exam. Who writes the CALE questions? Subject Matter Experts or SMEs. I attended a recent CAB meeting where the new board members grilled a rep from the Office of Examination Services (OES) which constructs all licensing exams administered by the state. When the OES rep described the SME as someone with a license the board members looked at him and did the “Dude Where’s My Car” routine at the fast food joint…”and then?” there is no “and then.” You have a license you are an SME. The OES gives you a workshop on how to write tests items (measurement speak for questions) and get to work. Better we should ask what are the domains of knowledge and how do they reflect the ed regulations written by the CAB? You guessed it – 70% TCM and 30% “western.” As someone with 4 or 5 courses in measurement I could go on but Emily is probably already sick of this discussion. I spent the previous couple years attending every CAB meeting. I have now stopped that. Calif is an important state because 40% of all LAcs live and try to work here. The greatest number of Asian LAcs live and work here. The greatest number of AOM programs are located in the state, most in SoCal. I used to think if we could turn the tide here we could turn it all over. Now I think if we can turn the tide in just one state that might be enough because the tide is finally with us. Healthcare is changing. I have tried to describe the coming changes in the most basic terms – scope of practice, jobs, patient access to care. CAN is good for many but not for everyone. I believe there are enough LAcs that would like to work in medicine that would support a PC LAc program.

  52. lineage is interesting…but not useful for what is needed now

    I find the lineage info interesting however I am not qualified to discuss it. I have read sections of Deke Kendall’s and spoken with him about his main theses for hours. I have read Unschuld, Ullett, Barnes, Kavoussi and Scheid. IMO these should be mandatory reading for every AOM student because these authors elevate the entire subject lineage. However, it is more esoteric than practical and only supports the reason to focus on how to get LAcs properly trained to practice medicine. I like Tom Martin’s writing on the particulars of TCM scholarship and its vanities. One of my co-authors also finds it irksome when TCM is discussed as “the medicine.” It is all so silly…and distracting. The Martin refernce is worth checking out.

  53. LOL, Steve

    I do see the merit in focusing on one or two states at a time, and trying to build momentum from there.  My thought is that it would be better to focus on states with the least stringent acupuncture regulations (I haven’t fully researched this, but it looks like WY, SD, MI, OK might be good places to start) and try to build something from the ground up.

    Are you a CAN member (you don’t have to be a LAc to join)?  That would give you access to the forums and there have already been many discussions about how to reform acupuncture education that might be useful for you.

  54. yes…i agree…

    nothing gets my eyes rolling faster than when “practitioners” use “the medicine” or “this medicine.”

    Perhaps a way to make it viable for a University, would be to have it not as a degree, but as post-master’s or post-docs. Yes, that would shut out training of LAcs, but create expansion into clinical areas where it may not occur. It would also provide the NPs, PAs, DPTs, MDs, DOs with a greater grasp. Look at it this way, in a busy clinic, what NP, PA, DPT, MD, DO is really going to have to want to take the time to needle a patient when they’re 45 minutes behind, haven’t had lunch, and have had numerous “emergent” add ons.

    As far as hospitals go, I don’t remember where I saw it (and am a little too lazy to do a CINAHL, EmBase, Cochrane, or Pubmed search at the moment), but i do recall some article–maybe it was one of those “beat your acupuncture chest” type fluff piece publications–that discussed how acupuncture, when used post-operatively, reduces the need for narcotics. the implication was that this would “lower costs.”

    We all know hospitals have no interest in lowering costs. However, the above implication is incorrect. Just what hospital would hire a staff LAc to do post-op acupuncture? Would this be a billed service, or an optional, support care plan component to manage pain? If it is the latter, then RN’s can be taught how to needle safely, some simple protocols, and confer with the MD, DO, PA, NP, or DPT who had a 1300hr post-doc in Acupuncture Medicine.

    In all honesty, Stumpf does raise a touchy point with licensure. In IL, the license is $500. There is no state board licensure exam, it’s only the NCCAOM exam. Those sitting on the the State acupuncture board are/were mostly AOM school administrators. I’m currently preparing for my NCLEX-RN, the state license is, get this $88. The exam was, are y’all sitting? $200. I will eventually also be taking national NP boards in a few yrs as well as applying for APN and controlled substances licensure. I do have to maintain three licenses (RN, APN, Controlled Substances) as required by the APN act of IL. All three combined are less than the Acupuncture license in IL, and of course I would have to maintain my Acu License if I wanted to adjunctively practice it. Why am I saying this? Because, as a “lowly” (as has been described by some “holier than thou” acupuncturists) RN (in an acclerated RN-preparation through to APN program), I’m interviewing for staff positions that range between $55-60k as base. This does not include shift-differenctials (anywhere between $1.25/hr-3.50/hr for eves, nights, weekend, weekend nights, holidays). There is PTO, hospitals will pay for CEUs, vacation, health insurance, tuition assistance/reiumbursement. As an APN, salaries approaching 6 figures are not uncommon (unlike acupuncturists). So when I say post-master’s/post doctoral training in AM as an adjuvant, that really means adjuvant, and could utilize a 1500hr trained Licensed Practical Acupuncturist (possibly offered through a junior college) to do most of the work–and poof, refering only to the PCP on as need basis (sort of like how a PA operates, but different). But, as stumpf says, there has to be a need. Apparently there isn’t. What was that statistic being touted by PIHMA as “more and more” people are seeking it out? 3.1 million? Ok so that translates into what less than 1% of the U.S. population? I think Lisa has illustrated that before.

    To Bottley, or anyone else for that matter. My prior discussions regarding mistranslation of texts and the implications on the theoretical basis of TCM outside of China would make for a fascinating PhD dissertation. I have always told people, don’t bother with those correspondance PhDs from Chinese AOM colleges that you can get in 2-3 yrs. They would be better served getting a PhD in Medical Anthropology specializing in TCM and design your curricula past the initial course work and get the support (including financial) from the University endowment and other grants. Hey, why not. I understand the need for that type of discourse, it has merit and value, however, it doesn’t necessarily change the employment landscape, but is a factor in the overall landscape.

  55. I agree with you Steven

    I am one of those that’s perfectly happy in a CA setting and doing detox
    work, etc. I would be interested in doing more training on the
    integrative side, but my “acupuncture mortgage” is already far too high
    to accumulate more. I think Emily and maybe some others interpreted my
    comments as yet another attempt to speak in favor of the mythical construct called “the medicine”
    because I talked about integrity, and I think your post above talks a
    lot more about the territory I’m interested in. I’m sick to death of the fake lineage crap and the bogus reverence, and I could care less about
    the preciousness and arrogance of the TCM dillettantes. I am a die hard
    heretical pragmatist and I believe the best way to honor our professional ancestors is to roll up our sleeves and make sure we help as many people as is humanly possible, as much as is possible, however we can do it. The movement of techniques currently claimed by
    TCM into other areas of medicine is already well under way, as you point
    out in this and the entry on the other thread. It’s going to happen one way or another. When I talk about
    integrity, I’m not trying to be difficult or obstructionist. I’m really
    talking about maintaining the integrity of the techniques at their
    highest level AS THEY ARE INCORPORATED so they keep their ability  to work as well as they’re capable of
    working. Part of what motivates me as a CA practitioner and a CAN person is the process of distilling the simple stuff to find ways to make it work at the highest possible level of effectiveness for patients. One of the very best things about CA for me is the freedom it gives me to chase and research solutions over enough time with patients to help them at levels I never knew were possible before. CA will continue to be what it is, and thank the powers for that. What I hope we’ll be vigilant about is the tendency, as
    our specific modalities and thought systems get brought into the much larger and more institutionally powerful structures of mainstream medicine that they won’t get diluted and dumbed down by commercial imperatives and institutional control structures masquerading as “best practices”. Well constructed studies will do part, but not nearly all of that. Studies can be a double edged sword when dealing in this realm of medicine, and we have much work to do to learn how to “study” this stuff without chopping chunks off it in the process. We have to do it, but we have to remember how much of what “works” for patients is also very, very hard to quantify, and I hope we’ll work to find ways to deal with that aspect of things as we go on as well. I agree that there is a lot of interesting stuff about our history, etc. that would make for a great medical anthropology dissertation, but I’m not talking about an antiquarian pursuit here. I’m referring to the tendency of large systems to homogenize some of the best and most useful stuff right out of components they assimilate. Steven, you’ve already had my Borg comments elsewhere. I actually think the models that are being talked about are how it’s going to happen. But I think we can do a lot to help that happen more effectively by being clear on what is and isn’t important to hold on to as the movements happen.

  56. Speaking of Phoenix, ITT, and the cost of education

    From today’s Washington Post
    Sen. Tom Harkin, chairman of the Health, Education, Labor and Pensions Committee, said he plans to hold a series of hearings to examine the surge in federally funded grants and loans flowing to for-profit colleges in the United States.

    The committee will probe the “rapid growth of federal investment” in the sector and “the corresponding opportunities and risks for students and taxpayers,” Harkin, an Iowa Democrat, said in an announcement Thursday on his Web site.

    Apollo Group Inc.’s University of Phoenix, ITT Educational Services Inc., Career Education Corp. and other for-profit educators are under increasing federal scrutiny over their recruitment practices and level of student loan defaults. President Obama‘s administration is proposing tougher regulation of the companies because of concern that recruiters are signing up unqualified students and leaving them with loans they may be unable to repay. For-profit colleges receive more than $20 billion a year in federal student grants and loans, Harkin said in his statement. The hearings are scheduled to begin June 24.

    “We need to ensure for-profit colleges are working well to meet the needs of students and not just shareholders,” Harkin said in the statement. “We owe it to students and taxpayers to make sure these dollars are being well-spent.”

    The number of students attending for-profit colleges in the United States rose to 1.8 million in 2008, up from 550,000 in 1998, according to Harkin’s statement. One in five students who left a for-profit college in 2007 defaulted on the loan within three years, Harkin said, citing Department of Education statistics.

    For-profit companies cater to lower-income and minority students, who are often unable to attend traditional schools, according to Harris Miller, president of the Washington-based Career College Association, which represents more than 1,400 for-profit colleges. Higher default rates at the for-profit colleges reflect graduates’ socioeconomic backgrounds rather than the quality of their educations, according to Miller.

    The for-profit colleges are lobbying against the Education Department’s proposed regulations, which are expected to be issued for public comment as soon as next week. They would cut federal aid to for-profit colleges whose graduates’ starting salaries make it difficult to repay their loans as well as tighten rules against tying recruiters’ pay to the number of students they enroll.

    ‘) ;
    // –>


    — Bloomberg News


  57. Medical Acupuncturist point of view

    I’m an MD who has realized how effective and powerful acupuncture can be for my patients. Have started an integrative clinic with an acupuncture instructor at a local TCM school and very much enjoy working with the students who are a delight to get to know.

    I am terrified however of how much debt these young people are taking on. Student loans are rarely able to be discharged through bankruptcy. That is, you can lose your practice, home and vehicles but will still owe every penny of your loan plus interest for the rest of your days.

    I once attended a student recruitment seminar put on by the school. Been in solo medical practice for almost 20 years so feel comfortable with the economics of healthcare. Didn’t have to think too hard to realize the school is a for-profit corporation; it was obvious to me from the start the speaker was being paid on commission. He painted such an unrealistically glowing picture of how much money there is to be made in TCM I felt nauseated. The audience unfortunately swallowed it whole.

    The greatest limitation on the future of TCM is how financially crippled students are upon graduation. This desperation I believe causes them to charge unrealistically low prices in an effort to get patients into their practices which only compounds their cash flow problems.

    I constantly encourage the students to plan for how to transition from school to becoming a successful practitioner. A few of these people appreciate it but the students I have now are clearly not interested in taking part in this discussion.

    Sometimes it feels like watching a person being hit by a speeding car in slow motion…

  58. Thank you Medical Acupuncturist for sharing your observations!

    You hit the nail on the head with your observations of the TCM school you are involved with.  It is not an isolated experience and I appreciate your willingness to share it.   

    The inspiration for my article was to put something out there for prospective students to consider as they are in the AOM school decision making process.  My intention is not to discourage students who truly want to pursue this as a future career, but instead to take a hard look at what they are entering into.  Consider all options and that includes the financial implications.

    In regards to patient care, there are many business model options out there today for prospective and current AOM students to explore.  The community model is one of many.  Whatever model a new graduate decides to pursue, it must have a population base to sustain it along with a community that needs and finds value in it in their own unique way.  My school business classes tended to pass over the wide range of economic realities of patients in America today, simply discounting it as patients’ not valuing their own health or acupuncturists’ services. 

    Thanks again for your comments.

  59. Acupuncture mortgage…

    Thanks Shauna! I love your term “acupuncture Mortgage”! I too had a very similar experience and have a very sizable “Acupuncture Mortgage”. I found the same lack of reliable information when I was researching schools and the profession. However, I too kept hearing “that the US will need 15,000 new acupuncturists in the next 10 years, insurance will start covering acupuncture and hospitals will soon be hiring staff acupuncturists”. So, even with the lack of information about AOM and it’s future, I decided to take the gamble on AOM as a career.

    I too, needed to take the maximum loan amounts – I do like to eat and have a roof over my head. I am also still paying off my undergraduate loans. Combined with my “acupuncture mortgage”, my student loan debt is well over 100k (80% of that is from acupuncture school, with the higher interest rate). According to the student loan repayment calculator, my minimum annual salary to make the standard payments needs to be $192,247.00. WOW! If I choose to do the extended repayment, then I only need to make $115,948.00. Hmm, well, that’s a lot of acupuncture patients! It kinda makes me sick to my stomach… and I’m not banking on loan forgiveness.

    I have recently changed my practice model to the “community acupuncture” model, in order to make it affordable for the average person in my community. If I average $20 a patient, I will need to treat over 5,800 patients a year, in order to pay my student loans on the extended payment plan. The patient breaks down to look like this:

    484 per month
    121 per week
    18 per day
    2-3 per hour (8 hour day)

    I suppose it could be feasible? Now keep in mind, like most acupuncturists, I am self employed. There are overhead expenses to take into consideration in addition to basic living expenses. Remember, I do like to eat and have a roof over my head! So, I probably need to at least double those numbers. You may be asking “why don’t you charge more? You would only need 1,932 patients a year, 161 a month, 40 a week, and 6 a day? That seems pretty feasible if you do your math as presented in AOM schools and under the assumption that patients will just magically flock to the office. Given the lack of really good and useful business classes at my school, I found it necessary to take classes in addition to my ‘required’ classes to gain the skills I needed. Combined with this kind of debt, it is a bit daunting to be a new practitioner, self employed, in a bad economy, trying to build a practice and expect patients to consistently pay $60 or more out of pocket weekly for acupuncture.

    The school I attended keeps upping the number of enrollment hours and requirements while trying to cram in as many students as possible (trying to up the admittance numbers too). If the so called “jobs” aren’t really there, in hospitals and such, and 90% or more acupuncturists are self employed, why the need for so many acupuncturists? It seems greedy and unethical on the schools’ part, but that’s a whole different discussion…

    In spite of all of that, I do love our medicine and am so happy when I am treating patients and helping them to be well. All I can do is hope for the best.

    Prospective students really need to think about what it means for them to have an “acupuncture mortgage” and should not jump right into school. They should make sure they really want to pursue acupuncture as a career.

  60. Bottom line is you have to work hard…no work around

    GREAT article about your experience getting your acupuncture degree! Loved it…and is true to what i’ve been noticing too…

    And I would like to add some input to my experience as well as to not have the above happen…

    1) You’re going to have to work your ass off. For my first 1.5 years of Acup school I was working 4 days a week (Saturdays, Sundays, Thurs, Fridays). It’s not easy and it’s what you have to do to keep costs down.

    2) You’re going to lose sleep. With a family as well…a lot of the time I was up til 3am doing homework and studying. To be honest, it you have kids, it was like the first 8 months after giving birth where you’re not getting any sleep. That’s what the first 2 years will be like.

    3) You’re going to be out of balance and be a living pattern of disharmony for 3 years. Just the facts unless your independently wealthy. Honestly, what this teaches is something great as most of our patients live this way for fun. So in the midst of this chaos how can you find your center and live the best?

    4) Read as much about business as yoiu do acupucnture. Period. should be your favorite site. (you don’t have to…but in the end you will have to).

    5) Get a mentor in business. They’re FREE!! SCORE is the group that has retired business owners help you and mentor you. What is your business plan?

    6) For ever hour you study your texts… 15 mins should be devoted in getting business, planning talks, meeting people…

    7) People mistake excelling in one’s craft for having happy thriving business and money flowing in. Being the BEST at what one does has no baring on the income you will generate. Take a look at or and read how these guys start their businesses. It’s usually not the guy who’s creating the stuff…it’s the marketing guy. Being a business person and constantly recruiting and getting business does make you the money. 30-50% of your time needs to be in marketing. Minimum of 2-3 days a week in the beginning.

    8) Do some research on startups. And see how much energy is involved in building a new business. Most of my family owns their own business and I will tell you it’s not 9-5. It more like 7am-7pm. Holidays and weekends. AND after they “work like no other” they get the rewards of that hard work. Some people don’t want to work past 7pm or hate to go in on weekends. When can patients show up? after work and on weekends…especially in busy metropolitan areas.

    I hate to sound harsh but this image of everything going to fall into place naturally, at least from what i’ve seen, is an illusion. YES the universe will help you but youi have got to get out there and let the universe work through you. Self employed is much harder then getting your 9-5. 9-5 means that someone else above you is having to do all the above burden of making sure there are customers to pay us.

    Good luck and focus on how to achive what you want and not on all the whys of why it’s not happenings. Make it happen! If this is your calling people will see that and come to you… But the people have to see you!