Andreas Sandner-Kiesling, MD1,
David E. Molony, L.Ac., Dipl. Ac., Dipl. C.H. (NCCAOM)2,
Susan B. Goldstone, L.Ac., Dipl. Ac., MSOM, MA3
1 Dept. of Anesthesia, Wake Forest University School of Medicine, Winston-Salem, NC
2 Executive Director, AAOM, Catasauqua, PA
3 NCALB Member, Past President of the North Carolina Acupuncture Association, Winston-Salem, NC
This review contrasts the provision of acupuncture in the United States versus the practice in Europe (focusing on Germany and Austria). A brief history of acupuncture is provided along with current practice trends. Information regarding educational preparation, licensing and provider groups is highlighted. Efforts of practitioners on both continents to seek acceptance and integration of acupuncture in their national health care systems are outlined. The article concludes with a review of research studies being funded in the United States to determine the efficacy of acupuncture as a viable treatment modality.
Acupuncture history in Europe
Acupuncture and Oriental Medicine comprise a system of health care, which originated in China more than 3,000 years ago. It was introduced to neighboring countries in Asia in the 6th Century, being readily accepted, and by the early 16th Century it had reached Europe. The source of acupuncture information was transmitted to Europe in the 17th through the 19th centuries via Latin translations by Portuguese, French, Dutch, and Danish missionaries, traders, and physicians travelling and working in China and Japan. There was a flurry of primitive acupuncture experimentation by physicians in France, England, Germany, Italy, Sweden, and the United States in the first decades of the 19th century, which did not renew itself in Europe until a century later and in the United States until the 1970’s. The most influential impact on the development of 20th century European acupuncture was the work of George Soulie de Morant, a scholar-diplomat engaged in the French diplomatic service in China between 1901 and 1917. Soulie de Morant published articles and French translations of Chinese and Japanese texts to French physicians. He systematically introduced acupuncture theory from the classical texts to the French and European medical community. The commonly used terms “meridian” and “energy” both originated in his texts as translations for the two fundamental tenets of acupuncture: anatomy and physiology. At about the same time, the German University Professor Dr. Franz Hübotter, who had spent quite some time in China, published a voluminous work on Chinese medicine. Unfortunately, his work did not become well known to the public, because there were no German acupuncturists or practitioners of Traditional Chinese Medicine to utilize his very detailed knowledge. Thus, his work attracted scholars of Chinese studies and historians of medicine. With a background of Chinese studies, he translated the above mentioned terms as “vessels” and “pneuma” .
In the 20th century France and throughout much of Europe since the 1950’s, clinical acupuncture has codeveloped with biomedical science. Europe has thus served as another influence for acupuncture approaches that integrate into the practice of conventional Western medicine . In the 1950’s, the German medical doctor (MD) Georg Bachmann, himself a student of French acupuncture, brought acupuncture to Germany. One of his students, University Professor Dr. Johannes Bischko, a surgeon from the Viennese School of Medicine, began to reestablish acupuncture as medical treatment in Austria. With his experiments and scientific explanations for the effects of acupuncture on the human body, the acceptance and the curiosity into this Traditional Chinese treatment increased among his medical colleagues. Since the early 1970’s the demand for acupuncture educational programs has increased.
Education in Europe
In Europe a wide spectrum of Traditional Chinese Medicine is offered today including different kinds of Acupuncture, Herbal Medicine, Tuina, Qi Gong, Tai Ji Quan, Acupoint Meridian Massage, Acupressure, and more. The acupuncture training is offered only (e.g. in Austria) or mainly (e.g. in Germany) for physicians. Great Britain and the Netherlands tend to offer longer acupuncture curricula like in the United States. In Europe usually a standard of at least 120 theoretical and 25 practical hours is required for physicians, held on weekends or more seldom in weekly lecture blocks. After passing one written, oral and practical exam the first Diploma in Acupuncture and Auriculotherapy is earned. The Physicians’ Associations and Chambers of most European countries accept these diplomas, which allow offering acupuncture to patients and earning money as an acupuncturist. In Austria, three acupuncture associations this way accredit approximately 1500 out of 5000 acupuncturists. In contrast to Austria, in Germany the Physicians’ Associations so far have not accredited acupuncture so any MD, who wanted to, could offer acupuncture. Since the 1980’s, insurance companies began to reimburse acupuncture, mainly due to public pressure. After an inflationary increase in acupuncturists (1998: approximately 30,000 MD’s practicing acupuncture; the two biggest German medical associations of acupuncture – the DÄGfA , the German Medical Association of Acupuncture, and the DAA, the German Academy of Acupuncture and Auriculotherapy – have approximately 23,000 members) a restriction to practice and a higher educational level was needed. Since the fall of 1999, the Health Insurances require a MD’s diploma after 140 hours of theoretical and practical education. Probably, a longer education of 350 hours (Diploma B) in acupuncture will be required in Germany in the year 2001, but that is still shorter than for most other postgraduate education, e.g. psychotherapy.
Acupuncture history and background in the United States
In the United States Benjamin Franklin started to work with acupuncture in the middle of the 17th century. Since the appearance of one article about Acupuncture Treatment of postappendectomy pain and its success in Beijing, China, written in the New York Times in 1971 by the journalist J. Reston, and the visit of President Richard Nixon in China in 1972, there has been widespread enthusiasm for acupuncture. Before that time, acupuncture had been practiced only in Asian communities, discreetly and primarily by and for Asians. In the past two decades, acupuncture has grown in popularity in American medical and scientific communities. In 1993, the U.S. Food and Drug Administration (FDA) estimated that Americans made 9-12 million visits per year to acupuncture practitioners and spent as much as 500 million US Dollars (USD) on acupuncture treatments . At the same time Dr. Eisenberg, a Harvard researcher and MD, published the results of his survey that revealed Americans spent a conservatively estimated 14.6 billion USD on visits for alternative medical treatments like acupuncture, osteopathy, or massage therapy in 1990. Two thirds of that amount was not covered by insurance . Then, in 1998, Eisenberg released another survey, showing that spending on alternative therapies increased 45.2% between 1990 and 1997, to 21.2 billion USD, with at least 12.2 billion paid out-of-pocket. He estimated that people paid 629 million visits to alternative practitioners in 1997, more than the total number of visits to U.S. primary-care physicians that year. He concluded that the use and the expenditures of alternative medicine increased substantially between 1990 and 1997, attributable primarily to an increase in proportion of the population seeking alternative therapies, rather than increased visits per patient .
The introduction of acupuncture as a choice of treatment modalities readily available to the public is in its early stages. Battered by tight-fisted managed care companies and increased competition, more and more physicians are being lured by alternative health treatments – which patients usually pay for out of their own pockets, in cash. It remains difficult to find acceptance for acupuncture or Traditional Chinese Medicine at medical universities. Of 117 American medical schools, 64% teach alternative medicine, either as stand-alone electives or as a part of required courses. Some of the country’s most prestigious educational institutions such as Harvard, Stanford, Columbia, and Duke have developed alternative medicine centers at their teaching hospitals . In 1995, an estimated 10,000 nationally certified acupuncturists were practicing in the United States. More than 1,000 new practitioners are certified each year. By the year 2000, that number is expected to double. Currently, an estimated one-third of certified acupuncturists in the United States are MD’s . About half of all acupuncturists can be found in California. The high population of individuals with Chinese heritage may explain the wide spread number of acupuncturists and acupuncture schools in that state.
Education and accreditation of acupuncture in the United States
Since the 1970’s, guidelines for education, practice, and regulation in acupuncture have been established and implemented. State, regional, and international societies have evolved to represent the interests of affinity groups of practitioners. In 1989, the World Health Organization (WHO) convened a Scientific Group of more than 50 international experts, which developed a series of statements and guidelines on acupuncture relating the basic training, safety in clinical practice, indications and contraindications, and clinical research for physician and nonphysician providers. The training guidelines reflect the minimum hours expected in most member nations and are consistent with regulations enacted in the United States: 2500 hours for nonphysician acupuncturists and 200 hours for physicians. The basic curriculum is founded on the classical tradition of acupuncture requiring a firm knowledge of the acupuncture points and channels and the traditional models of diagnosis and treatment. A basic knowledge of Western biomedical science is also encouraged in the curriculum . It is the responsibility of the accrediting bodies for each profession to establish those guidelines for either group.
In the United States, physician as well as nonphysician practitioners perform acupuncture showing a dichotomy in its medical value system. In 37 American states and the Canadian District of Columbia, the practice of acupuncture is included in the scope of a physician’s medical or osteopathic license, and no regulations or restrictions are imposed on medical practitioners. This means they are allowed to perform acupuncture with no additional training. The 15 other states require physicians practicing acupuncture either to demonstrate evidence of participation in training programs of 200 to 300 hours or simply to register with the board of medicine with evidence of formal training. From these loose regulations of physician practitioners, it is clear that the degree of acupuncture training and experience among physicians varies from state to state and individual to individual. Compared to the expected 2500 hours of education for nonphysician acupuncturists it sounds for this group demeaning that 200 hours or no education for physicians is enough to offer Oriental Medicine.
The AAMA with approximately 1,800 members represents the education, legislation, and professional interests of physicians trained in acupuncture. Full membership in the AAMA requires 220 hours of formal training (including 150 hours of video education) and 2 years of clinical experience not stating if this means full or part time. These standards follow the physician-training guidelines established in the constitution of the World Federation of Acupuncture-Moxibustion Societies, an international society guided by the World Health Organization. The AAMA has established a proficiency examination as the first of a two-part board certification examination. Membership eligibility in the AAMA has become the standard of physician credential for state registration, hospital privileges, liability insurance, and third party reimbursement .
The practice of nonphysicians is regulated in at least 33 states, and another dozen states have statutes pending. The educational prerequisites and training requirements vary widely from state to state. More than 50 schools of acupuncture exist in the United States. Till today the ACAOM (Accreditation Commission of Acupuncture and Oriental Medicine) accredited approximately 30 colleges. To start an education in Acupuncture and Oriental Medicine an individual must be at least 21 years of age and a baccalaureate degree from a college or university (BA/Bachelor of Arts, BS/Bachelor of Science, Ph.D./Doctor of Philosophy) is required. The training consists of approximately 2200-2800 hours and is completed within 2-5 years depending on part time or full time studies. The total costs of completing the full-time program are usually about 24,000 USD (16,000-43,000 USD). The training consists of Acupuncture, Moxibustion, Biomedical or Western Sciences (Anatomy, Physiology, and Nutrition), Chinese Herbology, Acupuncture Clinic and Adjunctive Courses like Tuina, Shiatsu, Medical Qi Gong, Oriental Nutrition, Magnet Therapy, Electrotherapy, Business and Ethics. Some schools offer additional education in countries such as Vietnam, China, Korea, or Japan. There are various titles and degrees offered in the United States. Depending on the accreditation of the school by the ACAOM the training ends with a Master’s Degree (MAC/Master of Acupuncture, MTOM/Master of Traditional Oriental Medicine, MSOM/Master of Science in Oriental Medicine) or a Diploma (Dipl. Ac./Diploma of Acupuncture) after a NCCAOM (National Commission for the Certification of Acupuncture and Oriental Medicine) competency or state licensing exam. The NCCAOM was organized in 1984 to establish nationally recognized standards of excellence in the practice of acupuncture. It’s exam includes acupuncture, herbal, point location, and clean needle technique sections . All states except California and Nevada that license nonphysician acupuncturists recognize the national examination developed by the NCCAOM. Procedures for licensure in each state begin upon completion of the educational and examination requirements. A licensed acupuncturist (L.Ac.) is not a degree, but a title granted by the individual states. So for instance in North Carolina, the law states that the use of the title acupuncturist can only be used by licensed acupuncturists, not by MD’s, Doctor of Osteopathy (DO) or Doctor of Chiropractic (DC). The licensed New Mexico acupuncturist is granted the title “Doctor of Oriental Medicine”/DOM and enjoys many privileges available to the allopathic physician, such as the ability to order X-rays, CT scans, and various other diagnostic tests for their patients. Rhode Island issues a Doctor of Acupuncture (DA) to its licensees. Some states like Florida consider licensed acupuncturists as Acupuncture Physicians. The abbreviated education programs typically offered to MD’s, DO’s, DC’s, or drug detox technicians are not accredited by the ACAOM. There are two main national societies (the American Association of Acupuncture and Oriental Medicine/AAOM in Catasauqua, PA, and the National Acupuncture and Oriental Medicine Alliance in Olalla, WA, each approximately 1300 members), together with many regional, state, and local organizations that represent the interests of the licensed acupuncturist communities.
Acupuncture and the Health Care System of the United States
More than 1 million Americans currently receive acupuncture treatment each year. The number of patients seeking acupuncture treatment in the US is increasing substantially. Because many individuals seek health care treatment from both an acupuncturist and physician, the National Institutes of Health (NIH) recommends that communication between these providers should be improved and coordinated. There is evidence that some patients have limited access to acupuncture services because of inability to pay. The NIH recommends, too, that insurance companies decrease or remove financial barriers to access depending on their willingness to provide coverage for appropriate acupuncture services . An increasing number of insurance companies are either considering this possibility or now provide coverage for acupuncture services. For instance, the insurance company Blue Cross/Blue Shield covers acupuncture treatment in several states. Medicaid, a state health insurance plan, covers acupuncture treatment for substance abuse in several states. . Reflecting public demand, an estimated 70 to 80 percent of the nation’s insurers covered some acupuncture treatments in 1996. The cost per treatment typically ranges between 30 and 100 USD but it may be more. MD’s performing medical acupuncture may charge more than nonphysician practitioners .
Research in the United States
After reviewing the existing body of knowledge, the FDA removed acupuncture needles from the category of “experimental medical devices’ in 1996 and now regulates them just as it does for other devices, such as surgical scalpels and hypodermic syringes, under good manufacturing practices and single-use standards of sterility. The FDA requires manufacturers of acupuncture needles to label them for single use only .
Over the years, the NIH has funded a variety of research projects on acupuncture with more than 1 Million USD that have been awarded by its National Center of Complementary and Alternative Medicine (NCCAM), National Institute on Alcohol Abuse and Alcoholism, National Institute of Neurological Disorders and Stroke, and National Institute on Drug Abuse. It included studies on the mechanism by which acupuncture may produce its effects, as well as clinical trials and other studies . Originally founded in 1992 as the Office of Alternative Medicine, the NCCAM facilitates the research and evaluation of unconventional medical practices and disseminates this information to the public. The NCCAM, reestablished in 1998, supports 13 Centers, where researchers conduct studies on complementary and alternative medicine for specific health conditions and diseases .
We thank Pamela A. Wilson, MS, TRS/CTRS, Recreation Therapist and Co-Chair of the Integrative Medicine Workgroup at Wake Forest University School of Medicine for reviewing this manuscript, sharing her knowledge, and adding a lot of positive input.
- Hübotter F, Die chinesische Medizin zu Beginn des XX. Jahrhunderts und ihr historischer Entwicklungsgang. Verlag der Asia Major. Leipzig, 1929
- Helms JM, Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, California, Medical Acupuncture Publishers, 1995
- Lytle CD, An Overview of Acupuncture. United States Department of Health and Human Services, Health Sciences Branch, Division of Life Sciences, Office of Science and Technology, Center of devices and Radiological Health, Food and Drug Administration. Washington, DC, 1993
- Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL, Unconventional Medicine in the United States. NEJM 1993; 328(4): 246-52
- Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, van Rompay M, Kessler RC, Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998; 280(18): 1569-75
- Wetzel MS, Eisenberg DM, Kaptchuk TJ, Courses involving Complementary and Alternative Medicine at US Medical Schools. JAMA 1998; 280(9): 784-7
- Culliton RD, Current Utilization of Acupuncture by United States Patients. National Institutes of Health Consensus Development Conference on Acupuncture, Program & Abstracts, National Institutes of Health, Bethesda, MD, 1997, Nov 3-5
- Guidelines on basic training and safety in acupuncture. World Health Organization, 1999
- Helms JM, An Overview of Medical Acupuncture. American Academy of Medical Acupuncture, 1998, http://medicalacupuncture.org/helmsarticle.htm
- Acupuncture, NIH Consensus Statement. 1997, Nov 3-5; 15(5): 1-34 (also presented in JAMA 1998; 280(17): 1518-24)
- Educational Options in Oriental Medicine, 5th edition. American Association of Oriental Medicine, 1999
- National Institute of Health, Frequently Asked Questions About Acupuncture. Bethesda, MD: National Institute of Health, 1997
- U.S. Food and Drug Administration, Acupuncture Needles No Longer Investigational. FDA Consumer Magazine, 1996, Jun, 30(5)
- NCCAM, Acupuncture Information and Resource Package. National Institute of Health, National Center for Complementary and Alternative Medicine Clearinghouse, http://www.medicalacupuncture.org/nccaminfo.htm