Why CAN Exists

When you get down to it, the reason is quite simple: CAN is in the business of retraining graduates of Chinese medical schools so that they are more likely to make a living as independent practitioners. In essence, CAN is an aftermarket provider.

The rest of this blog explains the above paragraph. 

The non-western medical acupuncture world (meaning, I’m not including MD’s who practice acupuncture here) is divided up into two parts, two parallel but separate professions: you have the practitioner profession and you have the education profession. The two professions overlap, with some folks with feet in both professions, but the huge majority of people in the acu-world do not overlap. They are in one profession or the other. 

Importantly the two professions have different goals and to the degree that this isn’t recognized is a good measure of the level of confusion about what direction the field should take to sustain itself, live, thrive, and grow. 

The practitioner profession is most concerned about finding patients who will pay for its services. Payment might be via insurance or out-of-pocket or (very occasionally) grants and it’s how to maximize this cash flow that is Priorities #1, 2, and 3 for these folks. Priorities #4, 5, and 6 deal with removing obstacles for this cash: difficult state and federal regulations, insurance company requirements and the like.

By contrast the educator profession is primarily concerned about maintaining and growing the number of students in their institutions. The more students the better. Not enough students means a closed school.For this profession the issues of accreditation (national and nowadays regional), research grants, federal student loan and (holy grail) student grant availability are the major issues.

Hopefully you are starting to see where the different goals of these two professions both complement and conflict with each other. Ideally the education profession graduates professionals who move into successful careers as practitioners of all types: private practice mainly, but also in hospital/HMO settings, and even future educators. Unfortunately that is not what is happening as most graduates leave the field within five years of graduation because lack of ability to make a living and even for those who stay in the field the average net salaries are only somewhere in the range of $20-30,000/year. This is not a field where you can expect to make the Big Bucks even if “successful”, i.e. able to stay in practice of some sort.

So CAN was born and grows as a result of this inadequacies of the education profession and it does it in a specific way. One of the glaring holes in basically all Chinese Medicine schools is that they fail to address the true needs of the private practice practitioners which is what the huge majority of their graduates become. The schools train their graduates to treat only the upper middle and wealthy classes but the fact is, the huge majority of people in the USA belong to neither of those classes. To put numbers to it, the schools train their students to only target about 15-18% of the households in the country. So even if you exclude people too poor to pay anything (another 15-20%) there is still 60-70% of the population that the schools do not train their graduates for. CAN was born to retrain graduates (and students who find CAN while still in school) to meet the needs of that 60-70% of the population and this make it easier for practitioners to make a living. 

Now there is no one thing that needs to be said to retrain practitioners to make a living while treating this 60-70% (216 million people) of the population. However you can group all the “things” together by saying that retraining consists of meeting the different needs that this 60-70% has that separates them from the upper 10-16% and the lower 15-20% of the population. These “thing” speak to two similar sounding but very different terms: Cultural Education and Cultural Competency.

Cultural Education is a term traditionally used by some early practitioners here in the US and also by the education profession. It refers to understanding the roots of Chinese medicine: the ancient theories, how these theories developed in (mainly) China, and Chinese language. The general idea is that the more we understand where and how the medicine we are learning came from, the better practitioners we might be. 

Cultural Competency is a term that is borrowed from outside the field all together: it comes from diversity training. Cultural Competency deals with better understanding who you are dealing with, or as practitioners, who we are treating. Cultural Competency recognizes that the US is a polyglot of cultures, classes, and races, each with different values and beliefs, and it would be wise if, when you interacted with people of a different group than yours, that you take their beliefs into consideration as opposed to preaching a foreign (to them) belief system. 

Now I ask you, do you see the ultimately very different effects of Cultural Education and Cultural Competency?  Almost solely, the acu-schools teach the former while CAN emphasizes the latter. Why is this? The following is my educated guess, told very succinctly.

For almost all intents and purposes, the ideas and uses of acupuncture and  Oriental herbal medicine in this country have been confined to Asian communities until say the 60’s and 70’s. (There are definite exceptions to this but they are exceptions that prove the rule.) So you can say that the whole Oriental medicine practice template was a foreign concept to the white, black, and Latino populations that make up the large majority of the US. Now traditionally (and I mean All of History when I say traditionally) when a culture/civilization adopt new ideas or materials from a different culture/civilization, the people who do that first adopting are the rich people. Why? Because they are rich and so are much more likely to have free time to look beyond their day to day existence. As an example the people on either end of the ancient Silk Road through Asia who benefited were the people who wore silk and could pay for it: rich people. The same is true for ideas like the importation of Buddhism into China or the Plantation system into the New World. They first were adopted by some of the rich folk before gradually assimilating into the rest of the population.

The coming of Chinese Medicine to the US in the last 40-50 years is following a similar pattern. The richer parts of the US have adopted it first. (Not all of them of course.) Now part of this adopting is done because it is different: Exotic. Alternative. There’s a quest for some people to delve into this new exotic thing and that is ultimately the purpose of Cultural Education. At best it’s a drive to understand a different way of thinking by people who have the time to do so; at worst it’s just treating this different civilization as an exotic decoration, otherwise known as cultural appropriation. You always see both impulses. Either way though, the people who do this in the US are intentionally separating themselves from the dominant culture that exists here.

This can have economic consequences. Two of them in fact. One is that the educational profession is defined as different than the established western medical institutions so the schools can exist separately. They can have their own systems of accreditation and such without being immediately absorbed into the much larger mainstream medical fields in this country. An exception to this is that MD’s and sometimes Chiropractors and ND’s can practice Oriental Medicine without needing to go through the stand alone schools of which the rest of us must partake. And with that defining of how people can become practitioners, come the Turf Wars in every state. These Turf Wars are very important to the education profession in order for them to survive.

The other economic consequence is that what is taught in the schools focuses on Cultural Education,  which means that little time is spent on Cultural Competency training. In other words, most of the time and money is spent on where the medicine came from and little on where the medicine is going to. This is okay if we are trying to confine our patient base to the upper middle classes/ rich classes as a bunch of those people like that sort of thing. (And those are the classes where many of the early non-Asian leaders in our field came from.) But this Cultural Education emphasis limits the types of patients that we can treat and make a living, because it and its derivative beliefs is frequently a big turn off for the rest of the population.

For instance focusing your practice on the richest 15% of the population makes you put an emphasis on the things those people value. The first is appearing like they are and valuing what they value: wealthy, professional, exotic, served by others. You see this in the advertisements in the profession where either spa treatments or faux-MD’s with stethoscopes wrapped around their necks while wearing white lab coats are emphasized. Neither of these two advertising strategies resonates much with the 60-70% of the population (more since you can add the poorest people so call it 80-90% of the population) and so they don’t go get treated. Of course charging $60-$250 a treatment for the multiple treatments necessary to help the patient also drives away most of the population. They might know their medical condition is serious, but they have to weigh such things as paying the mortgage or rent and buying food. Necessities are more important and get their money first. (As we all should know, acupuncture insurance is not available to the large majority of the population which again emphasizes the rich/poor divide in our profession.)

To sum up, the schools emphasize Cultural Education at the expense of Cultural Competency which forces their students away from treating most of the US after they graduate. The students graduate field with exotic knowledge which only makes them connect with only the richest portion of our country. No wonder most of the graduating students get out of the profession within five years.

So CAN looks to promote Cultural Competency, which in context means how to make a living by treating the rest of the US. We emphasize Class because that is the first barrier that practitioners must face. There are other barriers: race, language (usually Spanish, not Chinese), religious being the three biggest. The better a practitioner deals with these barriers the more likely they will get more patients. This means a de-emphasis of the Cultural Education that the practitioners are exposed to in school and beyond. Practitioners can be scholars but they are not missionaries–if they want a viable practice.

From the reason for CAN’s existence comes the Community Acupuncture (CA) model. To better deal with class diversity, prices must be brought down to levels that are manageable to the average person-if not further. From that it is given that the practitioner needs more volume (more patients) to make ends meet. It’s a physically  easier to treat more patients at once in a big room than it is in a bunch of small individual rooms. One thing leads to the next, just like in the business model the schools teach. It is possible to have a Hybrid model of the two systems though as far as we can tell, that can be harder to pull off. Practitioners are trying however and possibly some practitioner may find a new way to treat that makes economic sense. Until then CAN promotes just the basic CA model, as that seems to work pretty well from our experience, and because the CA model is still unknown to most of the professional population — because the schools don’t teach Cultural Competency and its implications. 

How does this relate to the day’s hot topic, the FPD, and why does CAN oppose it? Two reasons:

1) The FPD will provide more Western medical training and-this is simple-practitioners don’t need it. They don’t need it to attract patients as patients come by word of mouth from friends and relations. They also don’t need it because many MDs will refer even if they have no idea on how acupuncture works because they hear from their patients that it does help them. I am talking pragmatic here, and patients and especially MDs don’t want to hear about theories; they want to hear about results. Since acupuncture, especially, is a benign tool, as long as patients and other medical providers hear of the upside to the medicine (it makes people feel better) then they will refer more people. We already have more than enough training (Chinese and Western) to do our jobs (thank you schools). We don’t need more. We could use less.

2)  In the long run, we believe the FPD, if adopted as the basic entry level degree in the profession, will serve to reduce the number of practitioners in the country. There’s two parts to this objection so let me tease out each part.

–  The FPD will not be more than a very minor “other” degree, meaning a non-important part of the education profession like the DAOM today unless it becomes the sole avenue to becoming licensed. We understand that that is not directly what is being asked in this initiative to get it established, but, obviously to us, the schools will want to push for such eventually. Yeah, I know that there is nothing now that says that the FPD will be the only entry level degree but as a practitioner who’s used to cutting through the crap to see what is really going on, that’s what will eventually happen because otherwise students will just go for the current Master’s which would be cheaper. We don’t think the FPD should increase requirements and student debt which would make it harder to establish a practice and looking at other professions (Physical Therapists, and Chiropractors) who went through the same practice to no benefit of the practitioners, we see no evidence that the FPD would help practitioners.

– With the increased educational requirements of the FPD the debt load (mentioned just above) of students will go up. Already the debt load is approaching an average of $100,000 per student; the FPD will drive it higher. As that huge debt load is becoming more known to prospective students more of them are saying, “no” to a career in the field. Right now at most schools enrollment is down. That might be expected in a recession but normally school enrollment goes up in a recession as people look for training in a different career. That’s not happening with our schools. In the long run we strongly feel that enrollment will go down further if the FPD becomes the only way of entry into the profession. It will even be a deterrent to Chinese nationals, already trained in the PRC from coming over as most of them would have to go back to school to get up to Doctorate level.

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What practitioners need to thrive and what the schools think they need to thrive are at odds. As it stands, practitioners are marginalized both within the field by the schools and in the general medical community in the US.  The schools are so far not responsive to the concerns of the practitioners, leaving the likes of CAN and various continuing education providers like Richard Tan to fill the gaps. In most education fields, the schools eventually react and direct their resources towards better training as this NY Times article states. But with our profession being so marginal still we fear that the schools will react too late: killing the profession at worst and at best adapting very slowly, causing both the numbers of practitioners and the number of schools to decline, thus crippling the profession as an independent entity from western medicine. Already there are way too few practitioners who can fill the true needs of the general population of the US. Aftermarket entities such as CAN cannot correct the problems the schools are already making and would make worse with the FPD. Thus we are against the FPD and want a true conversation about how to increase practitioner numbers and practitioner profits so the profession becomes a viable one.

Skip
Author: Skip

Skip is Lead Acupuncturist and Co-Founder of <a href="https://www.workingclassacupuncture.org/" target="_blank">Working Class Acupuncture</a> in Portland, Oregon. With the earlier part of his life spent acquiring knowledge about geology, urban planning and teaching high school, he has now been an acupuncturist for 19 years, using about a 1,750,000 needles poking his patients. He likes all things soccer, has three fabulous sons, the best wife in the world, and a great dog and two cool cats.

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Conference Keynote: Breaking the Ceiling

The theme for this conference is “Breaking Barriers”. You know, there are so many barriers to break in acupuncture that it was really hard to choose which ones to talk about for this speech. But since I’ve spent so much time talking about classism as a barrier, I thought it might be fun to shift gears a little and talk about numbers.

Responses

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  1. what was I going to say

    Skip,

    I’ve missed hearing your voice on CAN. I like how you always seem to cut through the BS…which is to say…I agree with your point of view. 

    Cultural history  vs. cultural competency is a key distinction to make in how we are trained as acupuncturists in America. I’m a little embarrassed to recall how starry eyed I was back in my early days fresh out of the acu-mill, spouting my knowledge of the former to my patients, with precious little awareness of the latter.  Oh the things I said! Oh the patients who didn’t come back!

    On a side note, I’ve been hearing the pro-FPD leaders lately saying that actually, it wouldn’t involve more education, just a restructuring of the current 3 years. Obviously you aren’t buying it. And in any case, more western medicine misses the point of how acupuncture can become a viable form of healthcare – for patients and practitioners – in America.

    It’s possible I had something more to say, but my brain is tired and I just finished seeing 15 or so patients for the day…something I have you and Lisa to thank for. (I think I’ve learned a little about keeping my mouth shut with eastern esoterica and just put in dem needles).

  2. Thanks, Skip

    This is helpful to me to see the current FPD chaos in a more managable light.

     And in fact, keeping the number of practitioners at a relatively low number may be precisely what some supporters of the (likely) entry-level doctorate are hoping for – or at least see as a positive development.

    To wit: From the developing Pro’s & Con’s list mentioned in the AOM Community Forum, this item is listed in the possible benefits of the first professional doctorate…

     “Decrease overall competition for patients/consumers amongst current practitioners by limiting the overall influx of students, and subsequently practitioners, in the field.”

    This of course crawls in the opposite direction most Community Acupuncturists fly, that is working toward bringing acupuncture to more people.  

     

  3. The FPD draft standards

    The FPD draft standards suggest minimum standards and minimum level hours for training. There is no maximum in the document. If a school wishes to go to four years or more hours, it can. Tri-state already says on their website they are planning the fourth, or doctoral year. Plans to go to four years, wordy paradoxes of 4 academic years equaling 3 calendar years, some AOM educators having publicly stated their belief that more education = better entry level practitioners, … all of this adds of to longer and longer, and more expensive programs for the future, with, theoretically more loans available to fuel the longer programs.

  4. Right

    I think the closest that we could get to reality of what  trial FPD program might look like is what Mark Seem has proposed that Tri State would do. That’s fairly concrete. Of course it could be longer as Baten Switch says above and I would presume it would get longer in time.

     

    Happy New Year to you Jordan! 

  5. Exactly.  

    There’s been a strong current among some in the acu-world for at least 20 years that there were too many practitioners. This of course is due to the standard practice model only catering to rich people and there are often not enough rich people in any given community to support ever increasing numbers. The lack of vision on the part of the pro-FPDers is breathtaking.

  6. After market retraining

    I sure needed it, Dr. Tan and CAN provided it, it is the main reason I am marking my 15th year of making my living as an acupuncturist.  Thank you Skip, CAN, and all of you.

  7. Thank you Skip

    Its been four months now with a license and I am treating fifty plus a week. Not because I have a doctorate, but because I offer affordable acupuncture with no bells or whistles. Currently alot of my patients are health care providers themselves- nurses, LMTs, psychotherapists,DCs. They all respect me for who I am, an acupuncturist. They all love CA.

    If I had to spend another year in school just for a hyped up title, I might not have made it. And if they are thinking of dropping eastern theory classes to replace it with western theory then future grads will just be filled with even more jumbled information not practical to such a practical medicine.

    Not to mention I had lunch with an N.D. the other day. BECAUSE she has a doctor title it is illegal for her to practice her medicine here. For some reason the board of medical examiners don’t like alternative medicines meddling with there ego status.

  8. This was a beautiful reboot

    This was a beautiful reboot for my attitude in the new year.  You lay out the situation in clear terms that I can understand and agree with, and attempt to pass on to others.  Thank you for the clear thinking.

    MM 

  9. thanks, Skip

    This was very clarifying and helpful.  You always have a fresh angle on things; I really appreciate it.

  10. Thank you!

    I’ve been having this discussion with some other people about education in general and how little advanced degrees really prepare people for the real world. Why do these interns I have have Masters degrees in Business yet don’t know how to use Excel or basic database programs.

    It is this same disconnect in acupuncture schools. Maybe instead of promoting the FPD schools can just profit off some post-graduate practice building and management courses :p. (Finding a good location, Negotiating rent, Licensing, Permitting, Articles of Organization, setting up bookkeeping and accounting systems, marketing, surviving a hard month, budgeting, building systems)

    -Jade 

    Jade Community Acupuncture, Winona, MN

    acupuncturewinona.com