And so even though we’re in the middle of a POCA Tech module, I’m writing this post because as far as I’m concerned it’s Christmas morning for me and all the other data nerds out there. You know what’s in those articles, my friends? An estimate of how many visits to complementary and alternative medicine therapists that people in the US made in the years 2002 and 2008 as well as the total amount they spent on those visits. And you know how the researchers got these numbers? They did a survey (between 29K and 37K individuals, so like this survey, not a small sample) and then they followed up by calling providers and insurance companies to verify visits and amounts. Yeah. This data looks like it’s the really good stuff.*
These authors also believe that use of alternative therapies has fallen off since the recession and stagnated in general over the last decade or so. To get specific, though, you know how many TOTAL acupuncture treatments they think happened in the US?
In 2002: 6.4 million.
In 2008: 5.4 million.
So if you believe these folks that acupuncture use has stagnated (and what evidence do we have to the contrary?), and if you adjust for population increase, we can estimate acupuncture treatments in the US in 2014 to be around 5.6 million. (I’m really hoping the authors will do a follow-up at some point.) 5.6 million total. Let that sink in for a minute.
What we don’t know is how many of those acupuncture treatments were performed by MDs, DCs, NADA acudetox specialists, and of course those dirty low-down dry-needlers the PTs. (Are they really stealing our medicine if we were barely using it in the first place?) Even so, it looks like the treatments that POCA can actually count are close to 20% of the total.
If you include all the treatments that don’t get counted in our survey — the community clinics that wouldn’t qualify for POCA and all the community treatments given in hybrid clinics — what percentage of the total treatments given by L.Acs are now given in community settings? 30%? 40%? More?
Nobody’s got any data that says otherwise. And if the total numbers really are that low, it’s too bad we’re the only ones making a serious effort to count — because counting is probably quite doable.
You guys, I have this theory: the acupuncture profession as we know it in the US today is a product of social and economic conditions that are gone, never to return. A whole lot has changed and you could argue (I’m going to argue, is anyone surprised?) that the profession’s foundations are liquefying beneath it, just like infill liquefies during an earthquake. Basically there’s been an earthquake over the last decade or so; we just haven’t registered it yet. Let’s start making a list of the social and economic conditions that have changed:
1. The acupuncture profession as we know it exists because of the easy availability of federal student loan money, particularly for for-profit schools. It’s a lot of work to start up an acupuncture school, but it used to be that once you did, at least you didn’t have to worry about where tuition was going to come from: people could just borrow it, no matter how much it was, no matter what they could expect to earn after graduation. That created the situation that we’ve all been complaining about, where the profession is dominated by schools and regulatory agencies because there’s been a pipeline of money for education and regulation while there’s been no pipeline for the actual practice of acupuncture. There’s the appearance of growth because the schools keep pumping out new grads, which masks the 50%-80% 5 year attrition rate.
But that pipeline has a big kink in it now, thanks to the Gainful Employment Regulations and a growing awareness among prospective students that education is not automatically a good investment anymore. So it’s going to be interesting to see if the schools and regulatory agencies continue to ignore the concerns of working practitioners.
In Oregon there were fewer licensed acupuncturists in 2014 than there were in 2013 — as far as I’m aware, that’s a first.
2. The acupuncture profession as we know it was created for an economy that no longer exists. I’m the first person to get annoyed when somebody implies that community acupuncture is trendy like Occupy is trendy; my family has been poor forever, that’s kind of the point of this whole exercise for me. However, it’s one thing to be poor in an economy where social mobility is possible, if difficult; it’s another thing altogether to face the level of income inequality that exists in the US now. The acupuncture profession as we know it was formed at a time when a new profession could easily ignore people who don’t have money, just like the schools and regulatory agencies could easily ignore working practitioners. Now there are so many people with so little disposable income that you can’t really ignore them if you want to be economically viable in any collective way. There’s also a glaring overlap between “people who don’t have disposable income” and “working practitioners”.
3. The acupuncture profession as we know it developed in an environment that didn’t include the Internet. The more I think about this, the more important it seems. The dominant paradigm in the profession since I got out of school (and before that) has been this idea of Chinese medicine as “a complete system of medicine” of which acupuncture was only one small, possibly low-class component. Why would anybody want to do “just” acupuncture? All the other components were more important, especially herbs, lifestyle coaching, nutritional advice, and a general perspective on Chinese philosophy. You know the thing about those other components, though? Now anybody can get them off the Internet. And the process is infinitely cheaper and more convenient. You don’t need an acupuncturist for any of them. The only thing you still can’t get off the Internet is an acupuncture treatment itself.
Sure, you can’t get a customized herbal formula either, but how many people use those anyway? I would LOVE to see the breakdown about how much money gets spent specifically on Chinese herbs in the US. Does it justify all those state laws requiring acupuncturists to know how to prescribe them? In my experience, there are way more acupuncturists trying to make their practices economically viable by selling nutraceutical supplements (that you can buy off the Internet) than there are acupuncturists who are making money off of having a full herbal pharmacy (raw or granular).
Possibly the more important issue for the acupuncture profession and the Internet, though, is that the Internet makes it harder to keep secrets, not only the premise of “secret knowledge” (if it exists, you can read about it — a corollary to Rule 34: if it exists, there is porn of it) but big, crucial secrets like the huge disparity between what it costs to become an acupuncturist and what working acupuncturists can actually expect to earn. See #1. I hear a lot of acupuncture schools are seeing declining enrollments.
4. The acupuncture profession as we know it got where it is by continually promising that a mainstream embrace of acupuncture was just around the corner, and by enough people continually believing it that they thought it was OK that the schools and the regulatory agencies dominated the profession. All those hoops we had to jump through, all the increasing costs of education and regulation, those were all going to pay off sometime soon, just as soon as the mainstream gathered us in, which was inevitable because acupuncture use was “soaring dramatically”, right? Right?
Now there is now too much damn data that shows acupuncture utilization has stalled out. Any mainstream embrace of acupuncture, if it comes at all, is only going to benefit a handful of acupuncturists. Hospitals are not going to hire acupuncturists en masse tomorrow, or next year, or in five years. The hoops benefit nobody but the hoopmakers. The acupuncture profession is like a production of Waiting for Godot where the actors are continually jumping through hoops; basically we’re doing theater of the absurd. Also, there are signs that economic forces are eventually going to affect the healthcare mainstream, so even if they did embrace us, it might not matter in the long run; see also, “Nobody saved Blockbuster.”
So in a sense, it’s not surprising that community acupuncture is quietly taking up more and more of what market there is for acupuncture. All of the forces that are shaking the foundations of the acupuncture profession are forces that POCA is thoroughly adapted to. In fact, we’re old friends. We’ve been surviving the new reality for years and now we’re at home in it. Welcome to our world, acupuncture profession; it’s going to be interesting to see how you manage here.
* Anybody else see Only Lovers Left Alive? Anybody besides all of the people whose arms I twisted? Some great thoughts about survival there.