A Steady Increase in Educational Requirements
Little Hover Commission 2004
Regulation of Acupuncture: A Complementary Therapy Framework
Between 1976 and 1978, when acupuncturists were first certified in California, approximately 900 practitioners with between two to five years of experience were "grandfathered" into licensure.63 Those with five years of experience (or three years if affiliated with approved medical school programs) were "grandfathered-in" without education or examination requirements. Those who could prove two years of experience were still required to take an examination, but did not need to present proof of education.64 From 1976 to 1984, board regulations required new practitioners who did not have two to five years of experience to have 1,350 hours of training.
In 1985, six years after the legislative decision to allow patients to have direct access to acupuncturists, the board increased the education hours from 1,350 to 2,348 hours, a 74 percent increase.
Over the last several years, the acupuncture profession and the Acupuncture Board have advocated for further increasing the educational requirements. Those efforts included an attempt to raise the educational requirement to 3,200 hours through the regulatory process, which was rejected by officials at the Department of Consumer Affairs.
In a statement to the Commission, the former director of the Department of Consumer Affairs said:
There is often an initial impulse to assume that more education, more training hours, improve the performance of licensed professionals. But our job at the Department of Consumer Affairs was to ensure that proposed increases in license requirements were directly related to the scope of the profession as defined in law; and equally important - objectively warranted in order to ensure the safety of consumers, and not designed to, or have the effect of, inappropriately restricting access to practice. The proposed acupuncture regulations to increase education requirements did not meet any of these tests.65
The board subsequently formed a Competencies and Outcomes Task Force, which identified a range of hours needed to teach necessary elements, and ultimately recommended 3,000 hours in training. Legislation was passed in 2002 - AB 1943 (Chu) - which raised the standard to 3,000 hours, a 28 percent increase, effective January 1, 2005. Still, the board and the profession have advocated for even higher minimum educational standards of 4,000 hours.
The 3,000-hour standard was not prompted by a new increase in the scope of practice. Rather, the argument for increasing education levels is based substantially on the 1979 change in law enabling consumers to be treated by acupuncturists without having been diagnosed and referred by medical doctors.
The board's proposed regulations reflect the recommendations of the task force. Some of the requirements appear to respond to patient safety concerns associated with direct access. For example, the proposed regulations would add 40 hours in public health, including eight hours of first-aid and cardiopulmonary resuscitation from the American Heart Association, American Red Cross, or other board-approved organization.
But the board also includes 350 hours of "basic sciences" to be taught at an acupuncture school approved by the board. The subjects include biology, chemistry, physics, biophysics, psychology and counseling skills, anatomy, physiology and pathology.
In addition, the new regulations would add 240 hours of "clinical medicine, patient assessment and diagnosis," which would include the International Classification of Diseases (ICD), which is used in Western medicine. This new section would require students to learn "procedures for ordering diagnostic imaging, radiological, and laboratory tests and incorporating the resulting data and results."66
As described in the scope of practice discussion, attorneys for the Department of Consumer Affairs have long asserted that acupuncturists do not have the authority to provide Western diagnosis, and the Legislature declined to even add the word diagnosis to the scope of practice. So at the least, the new curriculum will substantially increase minimum training requirements in areas of practice where the legal authority to provide that service is unclear.67
According to a UCSF analysis, the acupuncture curriculum is far more detailed and prescriptive than the educational requirements for other health professions. The regulations also would incorporate a task force recommendation that students be taught the practice of "bleeding," which is not listed in the approved scope of practice.68
The Acupuncture Board, in the proposed regulations, makes the following arguments for raising the standard to 3,000 hours:69
- "California Business and Professions Code Section 4926 states that individuals practicing acupuncture be subject to regulation and control as a primary health care profession…. The board's main objective is to require an adequate level of education, which is more consistent with standard health care, providing the applicant with the knowledge, skills and abilities to perform as a primary health care professional. A licensed acupuncturist is a first-contact health care professional who possesses the skill necessary to provide comprehensive and routine care (preventive, diagnostic, palliative, therapeutic, curative, counseling and rehabilitative) for individuals with common health problems and chronic illnesses that can be managed on an outpatient basis, and who can differentiate health conditions that are amenable to their management from those conditions that require referral or co-management." The board cites a 1997 analysis by the Senate Office of Research stating that acupuncture education is not comparable to other health professionals in the workers' compensation system.
- "All primary health care providers, medical doctors, doctors of osteopathic, doctors of chiropractic, doctors of podiatry, and naturopathic doctors have a core medical curriculum leading to a basic medical understanding. All medical practitioners should have an overview of the strengths and weaknesses of other modalities in order to know when to refer and who best to communicate to those providers."
- The World Health Organization in 1999 recommended 2,000 hours of acupuncture training. This is in addition to the WHO recommendation of 500 hours of "Modern Western Medicine Theory and Clinical" training to provide acupuncturists with the "ability to decide whether a patient may safely and suitably be treated with acupuncture, or should be referred to a health professional or facility."70 Unlike California, the World Health Organization does not include herbs in acupuncture practice.
- In 1996, the board surveyed 1,000 practitioners with less than six years of experience. The board's assessment of the results was that the majority felt they needed more education in herbs, and many felt they needed more education in all areas of practice. Also, a variety of surveys have been conducted that indicate graduating students feel unprepared, particularly in communicating with Western medical professionals and in business aspects of solo practice.71
Typically, efforts to increase educational standards also would be supported by evidence that the existing standards are inadequate to ensure patient safety. However there is no evidence that the standards set in 1985 are jeopardizing patient safety.