The Risks and Challenges Facing the Acupuncture Profession in the United States

Abstract

Introduction:

Acupuncture has gained recognition in modern health care for its effectiveness in managing chronic pain, reducing stress, and enhancing well-being.

Discussion:

Despite this, the acupuncture profession in the United States faces significant challenges, including the disconnect between education and job markets, the encroachment of other health professionals such as physical therapists, preference for medical doctors over licensed acupuncturists in medical establishments, and inconsistent entry standards that affect care quality. Fragmented regulations and public misconceptions further undermine the profession’s credibility.

Conclusion:

To ensure its future, a unified professional body, standardized education, and collaborative efforts among stakeholders are essential to promote rigorous standards and enhance public trust in acupuncture.

INTRODUCTION

Acupuncture, a practice rooted in ancient traditional Chinese medicine and referred to in the United States as acupuncture and Oriental medicine (AOM), has been used for thousands of years to treat various ailments by stimulating specific points or areas on the body. This practice, which involves inserting fine needles into the skin and other soft tissues, aims to balance the body’s energy flow and promote healing. In recent decades, acupuncture has gained recognition in modern health care for its potential to alleviate pain, reduce stress and anxiety, enhance fertility and reproductive health, improve digestive and respiratory health, support rehabilitation, boost the immune system, manage menstrual and menopausal symptoms, support addiction treatment, alleviate the adverse effects of chemotherapy, and enhance overall well-being, etc.^1–12 As a result, it is increasingly being integrated into mainstream medical practices, often as a complementary or integrative therapy alongside conventional treatment.¹³

As of January 1, 2023, there were 34,524 licensed acupuncturists (the term “acupuncturists’ will be used thereafter) in the United States. There were also 56 active, accredited AOM schools, offering a total of 147 programs: 121 at the entry level required for licensing, 12 at the advanced level for practicing acupuncturists, and 14 certification programs. Specifically, these programs included 50 master’s degrees in acupuncture, 40 master’s degrees in Oriental medicine, 31 entry-level doctorates (10 in acupuncture and 21 in acupuncture combined with Chinese herbal medicine [CHM]), and 12 advanced-level doctorates in AOM. The certification programs comprised one in East Asian Medical Bodywork and 13 in CHM. Additionally, 48 jurisdictions (out of 51) had acupuncture practice laws in place.¹⁴

Despite its growing acceptance, the acupuncture profession in the United States still faces significant challenges that extend beyond clinical safety concerns. These challenges include the disconnect between education and job markets, the recognition of medical doctors over professional acupuncturists for providing acupuncture services within medical establishments, the encroachment of physical therapists and other health professionals into the field, regulatory challenges, weak public perception of acupuncture, fragmented profession, and the impact of low entry standards on the profession. These issues pose risks to the professional identity, credibility, and sustainability of acupuncture as a specialized practice. Addressing these risks is crucial to ensuring the continued growth and legitimacy of the acupuncture profession in the evolving landscape of American health care.

DISCONNECT BETWEEN EDUCATION AND JOB MARKETS

Mainstream health care in the United States has increasingly adopted evidence-based medicine (EBM) practices, integrating acupuncture due to its demonstrated benefits in rigorous scientific research and clinical trials. However, professional acupuncture training programs continue to predominantly use the classical paradigm, i.e., mainly using traditional Chinese medicine “languages,” which the policymakers, patients, and other medical professionals may have difficult to understand, relying heavily on classical literature-based texts, practitioner experience, and a case-based approach, although some biomedical courses also have been taught in recent years. Most acupuncturists do not have residency training in hospital settings, such as medical doctors. This makes a large number of acupuncturists unfamiliar with the practice style in hospitals or medical clinics. This dichotomy has created a significant rupture between acupuncture education and the job market, posing several risks for the profession.

The primary risk is the growing disconnect between what is taught in acupuncture schools and what is expected in the mainstream health care job market. As health care providers increasingly demand evidence-based practices, acupuncturists trained in classical methods may find themselves ill-equipped to meet these expectations. Employers in integrative health settings may prefer or require practitioners who can demonstrate their skills and knowledge through the lens of modern scientific validation and communicate themselves using biomedical language, leading to decreased employability for traditionally trained acupuncturists. This misalignment can limit acupuncturists’ opportunities in hospitals, clinics, and interdisciplinary practices that adhere to EBM standards.

A recent report showed that only 10.1% of acupuncturists work as employees or contractors in medical clinics, hospitals, or integrative settings, while 61.7% practice independently and 23.9% work in group settings. More than 55% of acupuncturists worked fewer than 32 h per week.¹⁵ During and after the COVID-19 pandemic, the percentage of acupuncturists working in medical clinics, hospitals, or integrative settings decreased significantly, falling even lower than the pre-pandemic level.¹⁴

The integration of acupuncture into mainstream health care is also contingent upon its practitioners being able to operate within the EBM framework. The continued reliance on classical paradigms in acupuncture education poses risks to the profession in the United States. If acupuncture training programs do not evolve, acupuncturists may find themselves isolated from collaborative health care environments where EBM is the norm. This isolation can restrict the profession’s growth and integration, reducing opportunities for acupuncturists to work alongside other health care providers and contribute to comprehensive patient care plans. Additionally, health care policies increasingly emphasize evidence-based standards. Acupuncture schools that do not incorporate these standards may face challenges in placing their graduates.

To address these risks, acupuncture training programs must adapt by incorporating EBM principles into their curricula. This adaptation includes integrating current research findings, teaching students how to critically evaluate evidence, and emphasizing the importance of using the best evidence in clinical decision-making. Additionally, fostering collaborations with research institutions and engaging in ongoing professional development can help bridge the gap between classical training and modern health care demands. To remain relevant and integrated within the evolving landscape of mainstream health care, acupuncture training programs must embrace EBM, ensuring that future practitioners are well-prepared to meet the expectations of employers, regulatory bodies, health policy carriers, and patients. And, schools should consider working with hospitals and establishing acupuncture residency programs.

COMPETITION FROM OTHER HEALTH PROFESSIONALS

In recent years, physical therapists and other health care professionals have begun to incorporate acupuncture techniques, usually adopting other names such as “dry needling,” into their practices. This trend is partly driven by the growing body of evidence supporting the efficacy of acupuncture for pain management and musculoskeletal conditions. “Dry needling,” which involves inserting needles into trigger points to relieve muscle tension and pain, is often viewed as a subset of acupuncture.^16–18 However, it is typically performed with less training and using a “different” theoretical framework (such as using a myofascial language) than traditional acupuncture.^18,19 This integration by non-acupuncturists raises concerns about the appropriate use and understanding of acupuncture techniques. The phenomenon of “poaching” occurs when physical therapists and other health care professionals adopt acupuncture techniques, encroaching on the traditional scope of practice for acupuncturists. This encroachment undermines the specialized role that acupuncturists play in health care. Acupuncturists undergo rigorous training and certification processes that are not matched by the relatively short courses taken by physical therapists for “dry needling.” As a result, the unique expertise and depth of knowledge that acupuncturists bring to patient care are not fully appreciated or utilized, leading to a devaluation of the acupuncture profession. When health care professionals without comprehensive training in acupuncture begin to practice needling techniques, there is a risk of diluting the quality and standards of acupuncture. Traditional acupuncture is rooted in a complex understanding of the body’s energy distribution and anatomy and requires a holistic approach to diagnosis and treatment. Physical therapists and other non-acupuncturists may lack this deep understanding, potentially leading to less effective or inappropriate treatments. This dilution of education standards and bypassing of the acupuncture practicing law and regulations can compromise patient safety and efficacy, further challenging the integrity of acupuncture as a distinct and valuable medical practice.

The integration of acupuncture techniques by other health professionals can significantly impact the perception and credibility of the acupuncture profession. When physical therapists and other practitioners perform needling without the extensive training that acupuncturists receive, it can create confusion about what constitutes legitimate acupuncture practice. This confusion may lead the public and health care policymakers to question the necessity of specialized training and licensure for acupuncturists. Consequently, the profession’s credibility is at risk, as the unique skills and knowledge of acupuncturists are not fully recognized or valued. This erosion of professional identity poses a significant threat to the future of the acupuncture field, making it crucial for acupuncturists to advocate for their profession and highlight the importance of comprehensive training and standards in acupuncture practice.

RECOGNITION BY MAINSTREAM MEDICINE

In the United States, 33 states allow physicians to provide acupuncture without requiring any additional training. Eleven states and the District of Columbia require 200–300 h of training, and three states require physicians to obtain a separate acupuncture license. Three states have no regulatory agency governing acupuncture. Forty states require non-health care professionals to complete an accredited program of more than 1900 h and pass an examination. Twenty-three states have an Acupuncture Detoxification Specialist designation, allowing individuals without a clinical professional license to provide auricular acupuncture for substance use disorder treatment after completing a 70-h training course.^19–21

Acupuncture has progressively gained recognition within mainstream medicine, particularly in the new century.^22,23 Numerous studies and clinical trials have demonstrated its effectiveness in managing chronic pain, reducing stress, and improving overall wellness. This scientific validation has led to its incorporation into various health care settings, including hospitals, pain management clinics, and integrative health centers. Many health insurance plans now cover acupuncture treatments, reflecting its acceptance as a legitimate therapeutic option. Despite this progress, the pathway to full integration remains fraught with challenges, particularly concerning who is deemed qualified to perform acupuncture.

Medical establishments such as Medicare, Medicaid, and veterans’ hospitals still tend to prefer medical doctors and conventional health care professionals without much acupuncture training to perform acupuncture, which presents several risks to the acupuncture profession. When conventional medical professionals are preferred over professional acupuncturists for performing acupuncture, it can undermine the credibility of the profession. Acupuncturists undergo extensive specialized training in acupuncture medicine, often amounting to 3 or more years of focused education.

In contrast, other health professionals, including medical doctors with their extensive medical training, might only receive a brief introduction to acupuncture as part of their broader medical training. This disparity in expertise can lead to a public perception that acupuncturists are less competent or trustworthy, despite their more comprehensive education in the field. The medical establishments’ preference for medical doctors to perform acupuncture also affects the professional identity of acupuncturists. It can marginalize their role and diminish their unique contributions to health care. Furthermore, it impacts the job market, reducing opportunities for acupuncturists to practice and grow their careers. As established health care institutions opt for other health professionals to provide acupuncture services, acupuncturists may find it increasingly difficult to secure positions, leading to economic and professional instability. Acupuncturists are trained extensively in the theoretical and practical aspects of acupuncture, including the holistic principles of Eastern medicine. This training ensures a high standard of care and adherence to authentic acupuncture techniques. In contrast, other health professionals, with their limited training in acupuncture, may not fully grasp these principles, potentially leading to a more mechanistic and less effective application of acupuncture. This inclination could dilute the traditional practice of acupuncture, resulting in treatments that are less effective and possibly less safe, ultimately undermining the integrity of this ancient healing art.

During and after the COVID-19 pandemic, insurance companies have tended to decrease acupuncture reimbursements, either by lowering the fee schedule through various methods or by delaying payments, likely due to the significant expenses incurred from COVID-19 treatments. This has significantly impacted the cash flow of acupuncturists, leading many to leave the practice.¹⁴

LOW ENTRY STANDARDS

To become a licensed acupuncturist in the United States, individuals must meet specific educational and clinical training requirements. These typically include completing a master’s degree or doctoral program in AOM from an accredited institution. Programs often involve extensive coursework in acupuncture theory, acupuncture techniques, biomedical sciences, and clinical practice. Additionally, acupuncturists must pass national certification exams, such as those administered by the National Certification Commission for Acupuncture and Oriental Medicine (Dr. Fan notes: the State of California has its own AOM tests instead). However, the standards and requirements for licensure can vary significantly by state, leading to differing levels of rigor and preparation among practitioners. Another issue with low entry standards is related to the admission requirements for acupuncture programs. While all accredited or pre-accredited programs by the Accreditation Commission for Acupuncture and Oriental Medicine, now the Accreditation Commission for Acupuncture and Herbal Medicine (ACAHM), mandate at least 2 years of college education, the quality of students who meet this requirement and the requirements for the 60 credits in terms of subjects and GPAs varies significantly.²⁴ This variation results in a lack of consistent rigor in their acupuncture (or AOM) education once they are accepted.

The variability in educational and training standards for entering the acupuncture profession poses significant risks. In some states, the requirements for becoming an acupuncturist are less stringent, such as no biomedicine required, allowing individuals with minimal training to practice. This inconsistency can lead to disparities in the competency and expertise of practitioners. While some acupuncturists may have undergone extensive education and rigorous clinical training, others may have received only basic instruction. This variation undermines the uniformity of the profession and can confuse patients about the qualifications of their acupuncturists. The differences in education and training among acupuncturists can result in inconsistencies in the quality of care provided.¹⁹ Practitioners with limited training may lack a comprehensive understanding of acupuncture principles and techniques, let alone EBM principles, which can result in suboptimal treatment outcomes. Inconsistent care quality can diminish patient trust and satisfaction, impacting the overall reputation of the acupuncture profession. Furthermore, inadequate training increases the risk of incorrect diagnoses, ineffective treatments, and potential harm to patients, which can have serious implications for public health and safety.

Low entry standards and the resulting inconsistencies in practitioner competence from training can have profound implications for the credibility of the acupuncture profession. When patients encounter varying levels of care quality, they may question the legitimacy and reliability of acupuncture as a serious therapeutic option. This skepticism can erode public trust and reduce the willingness of individuals to seek acupuncture treatment, even when it may be beneficial. Additionally, health care providers and policymakers may view acupuncture with increased scrutiny, questioning its value and the need for rigorous professional standards. To protect the integrity and future of the acupuncture profession, it is essential to advocate for higher and more consistent entry standards, ensuring that all practitioners are well-trained and capable of providing high-quality care.

LEGISLATIVE AND REGULATORY CHALLENGES

The regulatory environment for acupuncture in the United States is complex and multifaceted, governed by a mix of federal and state-level regulations. While the federal-level regulation provides general guidelines and indirectly oversees the accreditation of educational institutions through agencies such as ACAHM, the licensure and practice of acupuncture are regulated at the state level. This decentralized approach means that each state has its own set of laws, requirements, and regulatory bodies responsible for overseeing the practice of acupuncture. These regulations can cover various aspects, including educational prerequisites, certification exams, scope of practice, and continuing education requirements. The state-by-state variation in licensure and practice requirements for acupuncturists creates a patchwork regulatory landscape. In some states, acupuncturists must complete extensive educational programs and pass rigorous certification exams to obtain a license. These states may also have strict guidelines regarding the scope of practice and mandatory continuing education. In contrast, other states may have more lenient requirements, allowing individuals with less comprehensive training to practice. Some states may not even regulate acupuncture at all, leaving practitioners to operate without formal oversight. This inconsistency can lead to significant disparities in the quality and standardization of acupuncture services across the country.

The lack of uniformity in acupuncture regulation presents significant barriers to establishing a unified professional standard. Without a consistent set of national guidelines, it is challenging to ensure that all practitioners meet the same level of competency and adhere to best practices. This fragmentation can hinder efforts to promote high standards of education, training, and practice, ultimately affecting the quality of care that patients receive. Furthermore, it complicates the process of interstate practice for acupuncturists, who may face different requirements and regulations as they move from one state to another. The disparate regulatory environment also poses challenges for advocating for the acupuncture profession at the national level and makes it difficult to present a consolidated front. Addressing these challenges is crucial for enhancing the credibility, standardization, and integration of acupuncture into the broader health care system. The gainful employment rule imposes strict accountability measures on for-profit educational institutions, including acupuncture colleges, by tying federal student aid eligibility to graduates’ ability to repay loans. About half of the acupuncture colleges are for-profit, making them particularly vulnerable. If their graduates struggle to meet the required debt-to-income ratios, these institutions could face reduced enrollment, financial instability, and even program closures.

Despite for-profit acupuncture colleges having some of the lowest student loan default rates, the instability of the gainful employment policy, driven by its partisan nature, has led to serious consequences, impacting the development of a new generation of skilled acupuncture practitioners.²⁵

PUBLIC PERCEPTION AND EDUCATION

Public understanding of acupuncture varies widely, with many people holding both accurate knowledge and significant misconceptions. Some view acupuncture as a legitimate and effective form of therapy for pain management, stress reduction, and other health issues, supported by a growing body of scientific research. However, others perceive it as a fringe or alternative practice with questionable efficacy. Common misconceptions include beliefs that acupuncture is purely a placebo, inherently painful, or not scientifically validated. Additionally, there is often confusion about the training and qualifications of professional acupuncturists versus other practitioners who may use needling techniques.²⁶

Misinformation and lack of public education about acupuncture can significantly impact patient willingness to seek treatment. If potential patients are misinformed about the safety, efficacy, or purpose of acupuncture, they may be reluctant to try it, even when it could be beneficial for their conditions. Misconceptions about the qualifications and expertise of acupuncturists can also deter individuals from seeking treatment. This hesitancy can limit the patient base for acupuncturists and restrict the profession’s growth, ultimately depriving individuals of a valuable therapeutic option.

The public’s difficulty in distinguishing between professional acupuncturists and other practitioners who perform needling, such as physical therapists or chiropractors, poses another significant risk. Professional acupuncturists undergo extensive training and certification to ensure they provide safe and effective care. In contrast, other practitioners may incorporate needling techniques with much less training, leading to variations in treatment quality and safety. This confusion can dilute the perceived value and credibility of professional acupuncturists, making it harder for patients to make informed choices about their health care. Moreover, it undermines the professional identity of acupuncturists, as their specialized skills and knowledge are not fully recognized or appreciated.

Addressing the risks associated with misinformation and lack of public education is crucial for improving patient willingness to seek acupuncture treatment and for clearly distinguishing professional acupuncturists from other practitioners. Enhancing public understanding through education and outreach can help build trust in the acupuncture profession and ensure that individuals receive the highest quality of care.

PROFESSIONAL UNITY AND ADVOCACY

The acupuncture profession has suffered from fragmentation due to numerous competing organizations representing it, especially in the larger states. This has weakened their collective power in legislative efforts and diminished their ability to defend against encroachment from other professions. A unified professional body for acupuncturists is crucial for the growth, recognition, and regulation of the profession. Such a body can provide a cohesive platform for establishing and maintaining high standards of education, practice, and ethics. A unified professional body can effectively advocate for the interests of acupuncturists, promoting public awareness and acceptance of acupuncture as a legitimate and valuable medical practice.

Fragmented professional organizations can lead to a disjointed approach to policy and advocacy. When multiple organizations represent acupuncturists, each with its own priorities and agendas, it becomes challenging to present a unified stance on critical issues. This lack of cohesion can weaken the profession’s influence in legislative and regulatory discussions, making it harder to achieve favorable outcomes. Disparate voices can also confuse policymakers and the public, diluting the impact of advocacy efforts and hindering progress in areas such as insurance coverage, research funding, and professional recognition, as well as legislation. Fragmentation within the acupuncture profession can also impede the establishment and maintenance of high professional standards. Different organizations may have varying criteria for education, certification, and practice, leading to inconsistencies in the quality of care provided by practitioners. This variability can undermine the credibility of the profession, as patients and health care providers may encounter acupuncturists with differing levels of competence and expertise.

To address the challenges posed by fragmentation, the acupuncture profession must adopt strategies to strengthen unity and enhance advocacy efforts. Establishing a centralized professional association that includes all (or at least, the majority of) acupuncturists can provide a unified platform for the profession. This association should encompass regional and specialty organizations to ensure comprehensive representation. By consolidating resources and efforts, the association can present a cohesive voice in policy discussions, lobbying for legislation and regulations that benefit the profession as a whole. A unified professional body can effectively collaborate with accrediting agencies and educational institutions to ensure that all acupuncturists receive rigorous training and a consistent message. A unified professional body can spearhead public education and outreach initiatives to enhance the visibility and credibility of acupuncture. By promoting accurate information about the benefits and safety of acupuncture, the association can build public trust and encourage more individuals to seek treatment. Outreach efforts can also highlight the specialized training and expertise of acupuncturists, distinguishing them from other practitioners who use needling techniques. Fostering collaboration with other health care professionals and organizations can strengthen the position of acupuncturists within the broader medical community. Joint initiatives, research projects, and interdisciplinary conferences can showcase the value of acupuncture and promote integrative health care approaches. These collaborations can also help acupuncturists gain recognition and respect from their peers, enhancing the profession’s overall standing.²⁷ Professional unity and advocacy are vital for the advancement and recognition of the acupuncture profession. By forming a unified professional body, engaging in public education, and collaborating with other health care professionals, acupuncturists can overcome the risks associated with fragmentation and build a strong, cohesive profession.

CONCLUSION

The acupuncture profession in the United States faces several risks that threaten its viability and credibility. These risks include the preference for other health professionals within medical establishments, the disconnect between education and job markets, medical doctors performing acupuncture over professional acupuncturists, the encroachment of physical therapists and other health professionals into the acupuncture field, low entry standards leading to inconsistencies in the quality of education and care, and a fragmented regulatory environment that complicates the establishment of unified professional standards. Additionally, public misconceptions and a lack of sufficient public education about acupuncture further undermine the profession, while fragmented professional organizations struggle to present a cohesive voice in policy and advocacy efforts.

Recognizing and addressing these risks is crucial to ensure the future viability and credibility of the acupuncture profession. Unified efforts to establish and enforce high education and certification standards, advocate for consistent regulations across states, and enhance public understanding of acupuncture’s benefits are essential steps. Strengthening professional unity through a centralized association and promoting collaboration with other health care professionals can also bolster the profession’s standing and influence.

A call to action is necessary for all stakeholders, including acupuncturists, educators, regulatory bodies, and health care organizations, to work together in addressing these challenges and risks. By promoting the benefits of professional acupuncture practice and advocating for the profession’s integrity and standards, they can help secure a strong, respected place for acupuncture within the broader health care landscape.

AUTHORS’ CONTRIBUTIONS

C.G.: Conceptualization, methodology, formal analysis, investigation, resources, data curation, writing—original draft, writing—review and editing; A.Y.F.: Conceptualization, methodology, formal analysis, investigation, resources, data curation, writing—review and editing.

AUTHOR DISCLOSURE STATEMENT

No competing financial interests exist.

FUNDING INFORMATION

No funding was received for this research.