This blog post originated from comments on More on Replicability. Eric asked a number of good questions and in the process of preparing meaningful answers to his questions, this post grew into a blog of its own. (I have noted the ‘question’ and ‘response’ for ease of following this conversation.)
Eric – thank you for taking the time to read the article published in the American Acupuncturist vol. 56. I’d like to address a few items that may help you understand the magnitude of collecting this data, analyzing and reporting it in a coherent manner, as well as the challenges of actually getting the article in print. As addressed in the Survey Methods section of our article, a number of investigators helped with the data collection. Since you are specifically curious about the CAN data, I will mainly address the items I am familiar with through discussions with my co-authors. The CAN data was collected for each of the 3 previous calendar years (2008, 2009 and 2010). As noted in the article, CAN surveys had to be recoded using methods that are conservative and commonly accepted in order to provide reasonable comparisons and identify trends in the data. The surveys were designed and administered by CAN board members that volunteer to undertake this effort. Authors of this article entered into a voluntary collaboration with the CAN, Balance Method (BM) and newly graduated (G09) investigators in an effort to uncover some of the factors that may influence economic success and business models used. In the spirit of full disclosure, I am the only author who also designed and administered a survey (the G09 survey to graduates that were 12 months post graduation).
The summary we present is the first of its kind. It’s important to note that there has never been a Bureau of Labor and Statistics (BLS) workforce survey of acupuncturists. Technically, we don’t ‘exist’ as a profession in their eyes. Acupuncturists get lumped in with all kinds of healthcare professionals, but acupuncture itself is not identified as an independent profession according to the BLS. The data we present is remarkably consistent with the only existing data summarized in the Stump et al. Workforce paper. (Stumpf S, Hardy, ML, Kendall, D, Carr, CR. Unveiling the United States Acupuncture Workforce. Complementary Health Practice Review 15(1) 31-39.). Now that you have little extra background, below are my responses to your specific questions.
Question: Page 32 in the comparative chart: It records CAN practitioners as making a mean monthly income as being $5,277. The median income is stated as being $4,796. If one does the math, 311 txs per month @ $21 per tx = $6,531 mean average income. While 209 txs a month @ $20 per tx = $4,180 median average.
Response: The data displayed in Table 2 cannot be over simplified by the math you have used above. The mean and median gross monthly income, fees and patient visits is a result of the data analysis from all 3 years of CAN surveys. In the Survey Methods section we address this issue and state “For purposes of analysis, responses to the three CAN surveys were collapsed.” We had to apply commonly accepted data analysis methods to make sense of it. We had to start somewhere. The bottom line is the gross picture is not in the small details.
Question: Multiply these by twelve months = $63,324 mean and $57,552 median yearly average income.
Response: I found your calculation error. If you could simplify everything down to what is displayed in Table 2, your multiplication should read $78,372 and $50,160 respectively. It is important to note that the numbers discussed in our summary are gross annual income not net income.
Question: Meanwhile, on page 33 the article states, “CAN averaged $78,523 annual income.” While the chart below this records that average to be $74,832. The math seems fuzzy, at best.
Response: I cannot speak to this directly. Possible transposed numbers between the paragraph and Figure 1? Keep in mind, this is the average gross annual income as reported by CAN clinics (not individual practitioners) from the collapsed data of all three CAN surveys. It continues to be true that many CAN clinics are run by 1 owner acupuncturist with or without reception staff. It might be useful for you to look at some of the summarized data from the 2010 CAN survey posted on this blog in April 2011. While this survey alone doesn’t detail all the data from 2008, 2009 & 2010, you should be able to see some tends in the shared results that help to explain the information in our article. Note the surge in clinic openings over the past 2-3 years and, although not a direct correlation, the large number of CAN clinic responses reporting gross annual incomes under $69,999. In 2010, 33 CAN clinics reported gross income between $70,000 and $479,999 (broken down into $20,000 increments).
Question: Then if you consider that all of the CAN propaganda (meant in the educational material definition, not the extremist dogma definition) that I have seen states that CAN clinic opportunities offer practitioners a working class wage that averages $35,000 a year.
Response: I do not know all the compensation details for each independently owned CAN clinic. I can only speak about my current employment at Working Class Acupuncture in Portland, Oregon. Lisa is as transparent as she can be while breaking things down in The 4 R’s post https://www.communityacupuncturenetwork.org/blog/jobs-post-1-4-rs. You would need to contact every CAN clinic to uncover this data before coming to any conclusions about your question above.
Question: Working class practitioners that treat working class people, right? Lisafer and Jessica, please correct me if I am off base.
Response: CAN clinics treat all kinds of people. Since CAN clinics do not ever ask for income verification, I cannot speak to this detail with 100% accuracy. What I do know as a practitioner in a CAN clinic is what my patients tell me directly. It usually involves some part of the phrase “I could not afford to get acupuncture……” or “I could not continue my acupuncture care……if this clinic didn’t exist”. The patients I provide care for are teachers, lawyers, bartenders, nurses, cashiers, chiropractors, home makers, HR managers, students, janitors, massage therapists, etc. There is no direct correlation that can made about their working class status or not from our summary.
Question: I could maybe see where a CAN clinic with two practitioners would report gross $75,000 a year. That would be about $37,500 a year each.
Response: If a clinic has a gross annual income of $75,000 and two practitioners work there, they are definitely not each taking home $37,500 per year. Remember the surveys are reporting gross annual income not net annual income for CAN clinics. Taxes, rent, insurance, licenses, CEU credits, business expenses, payroll dollars (if practitioners are even compensated in that manner), etc all must come out of that $75,000 pool. If a clinic is operating with two practitioners each taking home $37,500 per year, that clinic needs to be grossing around $150,000 per year.
Question: So, if my facts are straight, you doubled the average yearly income for a sole practitioner, painting a more rosy picture utilizing practitioners and a practice model that doesn’t even attempt to portray things as rosy as your study documents.
Response: The suggestion that our article is “painting a rosy picture” is odd given that all the results still pretty much suck (I could use other words but pretty much want to get right to the point). For a large percentage of acupuncturists earning a living is hardly rosy. This is why we included the student loan data for the G09 group as earning a living with such disproportionate income to debt ratio is one more factor that may influence economic success. Review the NCCAOM 2008 JTA one more time if you need another source of suckiness. The rosiest picture that our summary may paint is that average gross annual income of all reporting CAN clinics is comparable to the BM folks.
Question: I asked the owners of our local CAN clinic, Kelly and Melissa (sorry to drag your names into this fracas, my friends and colleagues) of WE The People Acupuncture in Santa Fe, NM what they thought of this stat and the response I got is: maybe just one, or maybe 3 owners in the network is making this kind of money (paraphrased). Please, Kelly, tell me if I misparaphrased you. Believe me, I’m not trying to pick a fight. I just want the facts. Sadly, there is little good data.
Response: I completely understand that you want the facts, good data and information about the profession that we belong to. Sadly our “leadership” organizations (NCCAOM, CCAOM, ACAOM, AAAOM, etc) that have paid staff aren’t really of much help in regards to workforce data collection, reporting and transparency. How can we even begin to tackle the issue of jobs (not ‘opportunities’, not ‘self-employment’) for acupuncturists when we don’t even investigate and uncover the real state of our profession? More work is desperately needed in this area. We already know there is a tendency within the profession to paint a rosy economic picture. It’s time for our profession to see if the reality of a ‘career’ in acupuncture matches the myth.
Question: I appreciate you working in this direction, but I cannot wrap my mind around your numbers. Could you please explain to me how this critique is unfounded? Curiously, Eric
Response: Thank you again Eric for your time and questions. It’s time to uncover the details and pay it forward to the current and prospective students who are coming up behind us before we fade away as profession and abandon our patients because the “acupuncture midlife crisis” got the best of us. Remember, we could always use additional curious acupuncturists. Don’t be afraid to let us know if you would like to help us continue this work.