The debate over whether to raise entry-level education hours in California spawned two pieces of legislation, SB 1951 and AB1943, which, in turn, brought several questions regarding the acupuncture profession before an independent commission known as the Little Hoover Commission (LHC).
"provide recommendations for reviewing the competence of licensed acupuncturists who are not subject to the 3,000 hour minimum curriculum requirement, and shall provide recommendations for training, testing, or continuing education that would be required for these individuals to meet the standards for continued licensure."
Up to this point, those advocating raising entry-level training in California have given mixed responses to the LHC regarding this issue. The following is a review of the responses the LHC has received thus far.
The California Acupuncture Board (CAB) was asked the following question by the LHC; their response follows.
LHC: What changes in continuing education requirements does the Board recommend for currently licensed practitioners who have completed less than 3,000 hours of education? Does the Board recommend different levels of continuing education requirements, or retesting of competency for practitioners licensed with differential education levels?
CAB: In recent years, most California-approved acupuncture schools have added classes well beyond the 2,348 hours required by law. In 2000, the average number of hours offered by the 22 approved schools was 2,928. Depending on where they obtained their schooling, recent graduates have completed anywhere from 2,623 to 3,350 hours. The Board also recognizes the significant educational value for years of practice after an acupuncture license is obtained. Therefore, the Board does not recommend changes to CE requirements for currently licensed practitioners or retesting practitioners licensed with different education levels.
In essence, the CAB is stating they believe all current licensed acupuncturists should be grandfathered into any new standard that is passed. In the following recommendation, given by Fred Lerner, DC, Chair of the National Board of Acupuncture Orthopedics, during the LHC Acupuncture Advisory Committee meeting on Sept. 24, 2003, in response to whether existing licensees should "upgrade," Dr. Lerner stated:
A. There is no doubt that, if the students are going to the 4,000-hour level, and that level becomes a clinical doctorate as in all other primary health care professions (OMD), the rest of the profession should not be simply "grandfathered." In discussions last year regarding AB 1943 and SB 1951, the Department of Consumer Affairs made it very clear that they would not accept a straight grandfathering of existing licensees, and I agree.
B. Recommendation: Require 400 hours over 10 years of continuing education in courses approved by the CAB. The CAB should approve CE courses which are relevant to fulfilling the "upgrade" needs, such as drug-herb interactions, neuromusculoskeletal evaluations, diagnostic tests (laboratory, diagnostic imaging, etc.). Some of these courses are 300-hour courses which lead to Board certification (e.g., NBAO), and it would be relevant to allow attendees to apply those 300 hours over one year. Other licensees may elect to take 40 hours per year, or some combination that allows completion of these hours over the 10-year period.
Dr. Lerner's recommendations are at odds with those of the CAB and point out that the Department of Consumer Affairs (under which the CAB operates) is opposed to grandfathering. A third recommendation on this issue was presented to the LCH at its Oct, 22, 2003 Acupuncture Advisory Committee meeting, within a document making six recommendations and eventually signed by 23 individuals, many of whom represent California acupuncture organizations and schools. That recommendation states:
"Licensees not meeting the doctoral level requirement (4,000 hours) must obtain additional continuing education or credentialed experience in the subjects of herb-drug interaction, physical examination, ordering and utilizing lab test and diagnostic imaging, identifying patients' conditions by an appropriate ICD-9 description, or providing evidence of sufficient prior education on those subjects. The details of specific hours, coursework, competency exams, and credentialing should be based upon discussions and recommendations of a special task force convened by the Board."
This recommendation is also at odds with the CAB's recommendation of grandfathering, but while it designates the specific subjects this group feels current California licensed acupuncturists "must" obtain additional continuing education or credentialed experience in, they suggest leaving details such as the number of hours of additional training up to the CAB and a special task force to be convened by the Board at some later date.
Neither Dr. Lerner's recommendations nor those of the 23 signors of the six-point recommendation document give any rationale for what their recommendations were based upon, and neither addresses the question raised in AB 1943 which asks for recommendations for those not trained under the 3,000 hour standard.
I offered my own thoughts on this question at the Sept. 24, 2003 Acupuncture Advisory Committee meeting. I suggested the LHC consider some form of a multiple (tiered) licensing system that would allow for a 4,000-hour doctoral-level practitioner with a "Dr." title and expanded scope of practice, while allowing current LAcs to practice with their current titles and scope of practice without the need for mandatory further education. I made this recommendation after becoming very concerned that the push to increase entry-level training, with no clear plan for what to do with the training of current licensed acupuncturists might lead the LHC to recommend substantial additional training for current California LAcs. I became especially concerned over this possibility during the first Acupuncture Advisory Committee meeting. At that meeting, one of the supporters of the 4,000-hour standard was sharing his view that California licensed acupuncturists are less competent and pose more of a risk to the public than statistics indicate when the chair of the LHC interrupted him and asked, "So what should we do - suspend everyone's license until they can get caught up in their competencies?"
It is my personal belief that California licensed acupuncturists are competent and should not be forced to undergo additional education to remain in practice, although it is not my intention to argue that point in this article or to lobby the idea of a multi-licensing system. The main reason I wrote this article is to inform California licensed acupuncturists that, by mandate of AB 1943, their competence is under scrutiny and that recommendations about the need for further training and testing will be given to the legislature by the LHC by the end of this summer. I encourage California acupuncturists who have concerns or opinions about mandated additional education to write and share their views with the California Acupuncture Board, their acupuncture association, the Little Hoover Commission, and Acupuncture Today.
I also wanted to bring up the point that when we as a profession consider the issue of raising entry-level education standards, we must also consider what such action will mean for current practitioners. If the profession decides to raise the bar for all new entrants, regulators will naturally want to know what current practitioners will need to do to catch up, just as the California Legislature is asking in AB 1943. Up to this point, virtually all of the discussion on this issue has focused on the relative merits of raising entry-level education, and no serious discussion or research has taken place regarding how much, if any, additional education current practitioners would then have to take to keep practicing.
The Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) thought about asking this question in its recent survey when it asked those involved in the acupuncture profession their thoughts on raising entry-level standards. According to Dort Bigg, ACAOM's executive director, the commission eventually decided against adding these questions, as it is the state licensing boards (and not ACAOM) that have jurisdiction over existing practitioners. To the best of my knowledge, none of the professional associations or state acupuncture boards have conducted any surveys of the profession on this issue.
As the question of raising entry-level education of acupuncturists/OM practitioners continues to be debated in California and across the nation, I urge all involved to remember that, as far as regulators are concerned, this is a two-part question: what standards can we establish for those entering the profession, and what do we then do about current practitioners? Not having reasoned, well-researched answers to this second question is creating difficulties for the Little Hoover Commission and will present similar problems for any state regulators who consider making the jump to doctoral entry-level standards.
My own recommendations, along with those of Dr. Lerner and the California Acupuncture Board, can be found on the Little Hoover Commission's Web site (www.lhc.ca.gov/lhc.html). Click on "Acupuncture Regulation" under the "Current Projects" heading, then click the "Agenda with Presentation" tab for the Sept. 24 Advisory Committee meeting (mine and Dr. Lerner's presentations) and the Sept. 25 "Public Hearing Agenda & Written Testimony" tab (CAB testimony). The six-point recommendations were published in CSOMA's winter 2004 journal under the heading "Consensus Document Regarding the Future," which is also available online to CSOMA members via www.csomaonline.org.
The following addresses may also be of interest:
The California Acupuncture Board
Ms. Marilyn Nielsen, Executive Officer
444 N. 3rd Street, Suite 260
Sacramento, CA 95814
Fax: (916) 445-3015The Little Hoover Commission
Acupuncture Regulation Project
925 L Street, Suite 805
Sacramento, CA 95814
Fax: (916) 322-7709
Click here for previous articles by Matthew Bauer, LAc.