Stop Fighting The Last War. Start Owning the New Reality.

WARNING! This is a long post. A loooooog post. Hold-your-arms-out-wide-long. Its long because it attempts to put together thoughts that various other people have been writing on this group blog and in part because, well, I have diarrhea of the fingers. So get comfy and make sure you have the time. I suggest some cookies and milk...

There’s an old adage that says generals fight the last war, meaning that generals (and everyone else) tend to get stuck in the past, not realizing that time keeps changing the world under their feet. As a result poor decisions, missteps and confusion are the order of the day. This is particularly true of the world of Acupuncture these days. Why? How? To answer those questions we must step into Mr. Peabody’s time machine. Sherman! Set the dial to the seventies....

The seventies. Hair was long but not yet big. Liberalism hit its high water mark with President Jerry Ford (!). Only surfers wore long shorts and St. Mary (Tyler Moore) preached the optimistic gospel that, “You’re gonna make it after all!” We believed. In this time of disco-very, a weird variant of medicine entered our consciousness from China: Acupuncture. For most of us it was just another tidbit from the Evening News with Walter Cronkite (aka The Most Trusted Man In America) but for a select few it was intriguing; exciting even and they took action to find out more about it. Many of them took the journey to China to learn while others learned the art from folks (Asians) here who had been practicing it all along,

Naturally when a new development in medicine happens along people wonder if its actually effective and such was the case with acupuncture. This encouraged people with an intellectual bent to lead the charge of acceptance for this highly unorthodox medicine and thus the First War, the war of survival for acupuncture began. This war lasted until the nineties when peace broke out, though as we will see it was only a cease fire. What were the main concerns of this war? 1) Legalizing it and 2) professionalizing it. Many old-timer acupuncturists today remember practicing beneath the legal radar; remember their colleagues getting arrested for practicing medicine without a license. Perhaps the most celebrated case involved Miriam Lee, whose arrest lead to legalization in California.

Soon after the war began however a new and unexpected front opened. Acupuncturists even back then had a clue that there were many variants of acupuncture and the rest of the Oriental Medicine regime; that other countries besides China had been practicing the science since forever. This was known but at this point in time, (Watergate reference!) the main flavor was what came from mainland China: TCM. At first just discovering variants was merely an exercise in map making: getting the lay of the land so to speak. But by the late seventies, one J.R. Worsley, an acupuncturist from England, arrived throwing bombs. He attacked TCM as superficial, not getting to the underlying cause of illness in a person. Naturally this caused a response from the TCM folks, and to a lesser extent from practitioners who were studying other variants. This front became bitter in part because there was nothing that anyone could point to that said their side was the better. So this front was waged with rhetoric only. Its important to note that because while rhetoric was also used extensively on the legalization front it wasn’t rhetoric that won the day; it wasn't the crucial weapon because, again there was no hard evidence that everyone could agree upon that said acupuncture was valid. Nothing concrete that everyone could agree upon. No, the legalization front was won by patients voting with their feet: they walked into clinics and payed to get treated. Money talks.

Hopefully you can see how the two fronts of the war dovetailed quite neatly. Both sharpened the swords of their champions, pushing the formation of institutions and societies. Those acupuncturists who were most interested in organizing came to the forefront. As Lao Tzipher put it:

“As with nearly every strand of the counterculture in those years, two distinct types emerged. On the one hand, there were the ideological enthusiasts. They were excited and content to learn and practice their new art as individuals, moving quietly among like-minded folk, providing their services with little concern about their reward or economic future. On the other hand, there were the organizers. They were the acupuncture equivalent of the political organizers of the radical underground. They sought to find ways to organize the “acupuncture movement” into structures that would ensure its political and economic success. The group was small, discreet, and close-knit. It included acupuncturists, non-acupuncturists, and young attorneys. Some of the most influential figures were both lawyers and acupuncturists.

These early organizers cast their eyes in two different directions. Some of them, closer in spirit perhaps to the individualist practitioners, sought to create institutions to protect their own perspectives and attitudes about acupuncture and Oriental medicine. They founded schools to teach the art as they had learned it. Many of these schools persist today, and represent some of the most identifiable institutions in the profession. Those who were successful became very influential and quite wealthy. Owning a successful school is a sound economic platform. Others, of course, failed and lost everything. The second group sought to organize the institutions of the profession. Because the group was small, they were able to craft a single strategy for institutionalizing the profession which guaranteed a source of revenue to each component part, and could lead to the professionalization and regularization of the profession, with an eye to its economic and political success.”

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The Worsley front in the war basically served to push the TCM-orientated organizers all the harder in the race to become the Standard in American acupuncture. This front reached a cease fire when TCM became the standard for the national test (which was and is administered by one of the organizations created in the early years.) But as we know, money greases many wheels, and the underlying reasons for this cease fire was money: the profession was becoming a success and with legalization in state after state more and more people were attending acupuncture schools and setting up private practices. Both TCM and Worsley styles prospered. That the general public didn’t care about the variants made it easier for the practitioners of the variants to make peace. A rising tide lifted all boats at that time. By the early nineties it seemed that the profession was maturing and growth, with the help of the insurance industry paying for more and more treatments as well as the ability to get student loans to pay for education, was assured. Little did we know that we were not even hitting adolescence but the 5-7 year old transition into the concrete operational stage of maturity. That is to say we aren't grown-up yet.

Its funny in a gruesome way to look back at that orthodox view these days. What happened? Acupuncture become a viable form of practice but the organizations formed did not secure the peace. The organizations assumed a static world (as organizations do) but the world is never a static place. Time marched on and created a crisis in the acupuncture world, a crisis that we are in the middle of today. What crisis? Actually there are two crises. The first is that most acupuncturists can’t make a living. The second is that student debt loads are getting so onerous that prospective students are starting to think twice before enrolling. With the crisis a Second War has started but, as the title of this post states, the Generals (the organizers) of the last war still think they are in the last war and are using the same weapons to fight, causing the inevitable confusions and miscalculations. But what is the present war about? In a word: survival. What are the details and how did it start? Like the last war, there are two fronts:

The second front (I’ll get tot he first front presently!) had its origins in the peace settlement. I’ve written about this front before, calling it then The Second Wave. Here’s what I wrote about the Second Wave for those who aren’t CAN members:

“Basically what happened was this: By establishing acupuncture as a normal profession in this country the First Wave (the organizers of Lao Tsipher) also subjected acupuncture to the basic economic forces that dominate the country. That meant that acupuncture became another capitalistic enterprise just like every other profession. Two crises came from this but the First Wavers only noticed one crisis (since it fit their model of growing and establishing the profession for the first time) and its the second crisis that is bringing about the Second Wave in the profession.

The first crisis the First Wave noticed was that other medical professions wanted a piece of the acupuncture cash cow. MD's, Chiropractors, and Naturopaths all wanted to be able to practice acupuncture too and have set up programs to train themselves that are much shorter than what the acupuncture schools required of their students. As a response the First Wavers did two things: 1) Engage in turf battles over Scope of Practice with the other health care professions and 2) Up the requirements at their schools including pushing for state acceptance of their granting of first Masters degrees and lately Doctoral degrees. In doing this second thing they hoped that acupuncturists would attain status at least as much as Chiropractors and Naturopaths and hopefully MD's and DO's. The turf battles are ongoing today; they are just a natural state in the medical profession and have been since way before acupuncture came onto the scene. They aren't going to end in any foreseeable future.

The increase in schooling however, which again is an effort for acupuncturists to be recognized on the same level as other medical professionals, hastened the second crisis of unsupportable debt load. Increased schooling for the students has led to increased student debt which at this point in time is now often topping $100K for some schools' graduates. Unlike the pioneer First Wavers who had no debt new acupuncturists now have so much debt that servicing it must become their prime consideration upon graduation. Its these new acupuncturists (since the mid-90's) who are now the Second Wave of the profession. They have a very different environment to work in than the First Wavers did when they started and so their concerns are different. Establishing the profession is no longer then main priority. Making a living is. The question now is if its really possible for most new acupuncturists to make that living since entry into the profession comes now at such a high price.

The bottom line at present is that the acupuncture institutions that exist today run on student credit. How long will that credit line exist? There is evidence that it may be ending soon.

For several years now there have been rumors that more than 50% of acupuncture school graduates fail in the business within five years of graduation. Sometimes the figure is much more than 50%. Sometimes the figure is 80%. No one really knows and that in itself is chilling to students or prospective students thinking about the debt load that is now necessary to take on in order to go to school.

- One publicized direct consequence of that is that this year (2006) the Santa Barbara school closed it's doors. In doing so they said that applications to schools nationwide are down. There are rumors now that one of the San Francisco areas schools is about to close. They are rumors because all colleges, not just acupuncture colleges, don't like to talk publicly about their finances.

With the rumor of fewer applications to schools going around questions must be asked about the schools themselves. Are the classes they are offering essential or not for a new practitioner? This question takes on significance in light of debt loads. Many schools are now requiring 3 1/2 years full-time, minimum, to earn a Masters. Many programs are longer. This is longer than what many of the same schools required when they first began awarding Masters degrees. All graduate educational institutions must balance length of programs requirements with economic realities of their students. For instance there is a trend in Business schools towards shorter MBA programs. Justifying Medical programs' longer lengths because they are different since the students are being taught to deal with potentially life or death situations, is not looking at the issue fully since graduates will only get the chance to deal with potential life and death situations if they can afford to stay in practice.

To this must be questioned the usefulness of the Doctoral programs and the effort the schools that offer a Doctoral are putting into their program. There have been calls by some educators in the profession to make the Doctoral the entry-level degree. Can new students possibly handle much more debt and still operate a private practice?

The NCCAOM, recently moved from expensive headquarters in Washington D.C. to Jacksonville, also has potential problems on its hands besides just administering the exams correctly. A decade ago it started a new exam in herbal studies and part of the hype around it was the contention that states would soon be requiring that exam for licensure. That's not happened and thus the long term revenue stream there should be questioned since there is no reason to take it and pay $800 or so. Also continuing to pay them for rectification has come under question by some since the benefits of doing so are not great: mainly it helps acupuncturists move to a new state but doesn't at all help in maintaining one's license in most states.

This is the environment that is spawning the Second Wave in the acupuncture field. So far however the Second Wave of acupuncturists are just starting to respond in any way other than their feet. So far the main response is the high attrition rate that is rumored to exist.

This is where CAN fits in. CAN is trying to build a viable business model for most of the acupuncturists these days with their high debt loads. However the Second Wave will have to go further: So far the institutions that the First Wavers created don't appreciate how different things are now. The institutions they set up, including the schools, aren't yet responsive to the Second Wave's needs. In fact those institutions are largely parasitic on the new acupuncturists. It will be up to the Second Wave to modify or create new institutions in order to allow the profession to survive as an independent entity. As the only organization thus far created by the Second Wave, CAN is and will be at the forefront of this effort.”

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Establishing viable business models- even one- is what this second war is about.

How the First Wave Generals fighting to preserve the status quo of the organizations formed from the first war are fighting is interesting and leads to the second front. (Remember this war has two fronts). As said (way) above the first war also had a second front, that of which style of acupuncture was the deepest and which was superficial, just treating symptoms. As part of the end of the first war, the various factions of acupuncturists agreed not to keep fighting about which style was the best, mainly because every style was making money. (Like most cease fires, this one was and is not wholly successful. Various brush fires break out. Most of the brush fires are however easily contained. But some were not and while this cease fire was set there were challenges and from a completely different direction. Miriam Lee inadvertently (I think) fired the first salvo when she wrote her, Insights Of A Senior Acupuncturist, which you can buy from Amazon here. I highly recommend it:

http://www.amazon.com/s/ref=nb_ss_gw/002-9232160-1192844?initialSearch=1...

For those who have read this book, can you see the subversive nature of this book? How it could be interpreted as undercutting the increasingly scholastic bent of the acupuncture colleges and intellectuals in the field? How various teaxchers at the colleges would put it down as the product of cookbook acupuncture? By itself it wasn’t enough to change the course of study at the schools, most of whom keep adding classes to this day in order to try to get more information in their students.

But what happened after Miriam Lee’s book came out in 1992 was the rise of probably the most influential educator in the field today, Richard Tan. The first interesting thing about Richard Tan is that he doesn’t teach at an acupuncture college. Instead he works the CEU circuit (set up by the Organizers) like its going out of style. Unlike many CEU lecturers he doesn’t tour just to supplement the income from his latest book. Instead he actually teaches and what he teaches takes Miriam Lee’s Insights to another level. To quote Diana DiGioia in a comment in the Think Pink! blog post,

“On the subject of acupuncture, Dr. Tan presents the idea that the whole concept of symptomatic acupuncture treatment is plain nuts. Any time you treat a part, you treat the whole. The part that is in pain or distress is the body calling out to you with a convenient avenue through which to treat the whole.”

Acupuncture colleges are of two minds about Richard Tan. On the one hand, he’s a successful lecturer, students love him and his treatments get results more directly than what is taught in the schools. The schools like that. They like to be associated with an acupuncturist who gives their students hope.

But if effective treatments can be that quick and effective, then why are the colleges teaching so many courses, requiring students to get into so much debt? Why are colleges saying that you need to talk so long with each patient? In addition, Mr. Tan has also thanks the colleges for being what they are (very unclear) so that there is a need for someone like him to go around and teach students and new practitioners how to treat their patients. So in the back of people’s minds there is the wonder about what the colleges are doing and should they continue to act like they do.

So in the present day there are two trends, CAN, and what Richard Tan symbolizes, that together call into question much of what the establishment espouses. Naturally there is a backlash, and thus we have the second war. Now here is where the title of this thread comes into play:

CAN undermines the established private practice model by calling it classist/elitist on the one hand and just plain bad business on the other. It says that effective treatments can be done quickly, once you retrain yourself from what your college probably taught you, at least several treatments an hour. Thus you can lower your prices so that a much greater percentage of the population can afford to come- and to come frequently much like how acupuncture was practiced traditionally in the Orient.

The establishment attacks this line by repeating how they attacked in the Worsley/TCM wars: that CA is superficial. That it doesn’t get to the heart of the matter with a patient. That they reach a deeper level in their treatments and therefore while they are copasetic with CA as a business model per se their more labor intensive and expensive model must remain the gold standard. They say practitioners must be allowed to practice as they want, while teaching only one business model. It gets so tiring listening to this broken record from practitioners and institutions...

See where this is going? CAN laughs at this old argument pointing not only at traditional models in the east but also at Richard Tan, noting his practice method looks at that whole superficial/deep argument as one for the birds, that their business model is just fine at treating the whole person effectively, and that what is taught in the schools mainly benefits the schools at the expense- literally in the form of student debt- of the students and practitioners. The very idea that one acupuncture treatment method is deeper or better than another is silly as it can't be proven at present because we lack the verifiable platform to make such a conclusion. As a group we all practice idiosyncratically. That that argument keeps getting dragged out like a 50 year old moth-eaten raccoon coat proves how intellectually immature the profession is. Rhetoric ain't truth even if it says it is.

That’s where we are today. I can’t wait to see what happens next. The first war ended when legalization in most states happened and because it seemed (via student loans and insurance reimbursements) that a lot of money was coming into the profession. But the insurance thing isn’t panning out and with student debt rising to unacceptable levels because the length of the programs keep increasing, fewer potential students are applying to the colleges every year and most practitioners go out of business within five years of graduating.

Its not hard to imagine the collapse of the organizations as they are constructed these days if these organizations don’t change their orientation from looking for maximum profits for themselves. To do that though they have to stop using the weapons of the first war, that of faux intellectualism, and honestly assess what they are doing. How likely is that? I have no idea as it looks to me that many older acupuncturists are being caught living complacent lives. In reading what these folks are saying (folks? As Nora says, these folks are disproportionally guys, quite unlike the profession as a whole) I get the sense that they are sound asleep and they resent waking up. Cranky even. Reviewing one’s complacent life is never easy.

Ultimately what needs to be understood by everyone in the field is that acupuncture and Oriental Medicine is a social profession. Its spirituality applied to the human condition, much like all medicine is. That’s not what many people think today. The First Wave organizers think of acupuncture as a science and an art. The reality is that it is not only these things but a whole lot more because it deals with the human condition. That means it deals with human interactions which brings in the fields of economics and politics.

As Lao Tzipher notes above, many of the early acupuncturists were ideological enthusiasts. That understanding has faded over the years in the profession but the reality that acupuncture is a political and economic statement is still true. Trying to keep the war strictly in the intellectual/scientific mode strangles the profession as we are seeing because it removes the practitioner’s relationship with their patients and substitutes airy even spacey statements of the nature of the medicine. It removes the fact that every patient/practitioner contact involves money and also an unstated argument on how the world works. When we start to understand that we will take another step closer to 1) maturity in our profession as lakshmita notes in her blog post and 2) Personal Responsibility as Jenn notes in her blog. As Matt Gulbransen says in a comment to the Another Person’s View, “In ANY form of health care, the measure of success is not your skill, but how your patients feel at the end of the treatment.” If we truly look at that comment then we have to reorganize how we are organized as a profession. That’s what CAN wants to foster.

So far our profession has been remarkably selfish, like a little child. It talks about how deeply it sees the world but has a hard time saying things that can be backed up, also much like a little child. Eventually (I hope) we will get to the stage of using our acupuncture skills to reach abstract understanding of ourselves and our patients. But we need to get concrete first. Concrete in having sustainable business practices.