Examining the Current State of Acupuncture Research and Education

Abstract

Research data, funding and education have been identified as the main difficulties in Acupuncture research by the World Health Organization and experts in the field. These barriers to the integration of Acupuncture and Herbal Medicine (AHM) in primary care, health coverage and accessibility are interconnected. AHM is a personalized medicine system and research methods applied by biomedical science (BMS) are insufficient in AHM research. This delays AHM integration as policy makers rely on research data for decision making. Changes in AHM education to unify degrees, establish BMS pre-requisites, base the curricula on Classical Chinese Medicine and offer research education, may produce AHM providers who deliver high quality AHM research and benefit all stakeholders. Raising the bar in AHM to offer a sole DAOM and a subsequent clinical and research PhD degree may be the next step in AHM education to improve the overall situation. This literature review explores the current state of AHM research and education to identify opportunities for improvement.

Data Collection Procedures

Only free full articles were used. Searches were performed by hand for English literature.

Database searched: NCBI/Pubmed, Google Scholar, Institutional websites.

Literature reviewed spans the recent 20 years, plus earlier key works.

Types of literature searched include Meta-Analysis, Systematic reviews, RCTs, peer reviewed journals, chief documents, institutional publications and websites.

Selection of relevant articles by keywords addressed in the studies.

Flowchart of selection process.

Introduction

As of 2022 the WHO Global Report on Traditional and Complementary Medicine and WHO Traditional Medicine Strategy 2014–2023 (WHO GRT&TM and TMS) have not been fully implemented and Acupuncture and Herbal Medicine (AHM) is not integral to primary care in the West.^1,2 Statute regulation awaits biomedical science (BMS) to support AHM in primary care and yet BMS has not delivered satisfactory research data. The research methods used do not apply to AHM as an individualized and complex health system which is a barrier to implementation and care. Research in BMS is costly and funding for AHM research is limited although Acupuncture has been widely studied and over 10,000 randomized controlled trials (RCTs) have been published so far.³ Most research has not been conducted by or with AHM providers with a deep understanding of AHM. However, these providers have not received sufficient training in Classical Chinese Medicine (CCM) or research and there is no dedicated career path to become a professional AHM researcher. In return, BMS researchers have none or very little training in AHM.

The curricula in AHM schools are diversified and little of CCM or research is taught, as biomedical classes occupy a large portion of the hours. Degrees are not unified, six different degrees are currently offered at accredited AHM schools. The variety of professional competencies may not be obvious to the public.

The WHO TMS suggests to “develop appropriate research methodologies consistent with T&CM theories and practice…and encourage investment”. The WHO Guidelines for Clinical Research on Acupuncture state:

“The protocol should be deployed by the joint effort of representatives from several disciplines including research subjects (if possible), health workers, acupuncturists and biostatisticians.” (p 16) and “Research education of interested acupuncturists and other health professionals should form an essential first step in developing a research culture within each member state….” (p. 42)

“…to foster cooperation between acupuncturists and other health care providers” (p.56).

Improving AHM education may generate AHM providers who develop AHM specific research questions, appropriate research methods and deliver high quality research data. This may further policy making, AHM integration into primary health care and promote funding. Funding could in return advance AHM CCM education and create AHM research facilities. This may assist in reaching the goals of accessibility in health care.

Statement of the Problem

The key issues of research, funding and education in Acupuncture/TCM research have been identified by experts in the field and there has been ongoing debate on which methods are applicable to generate high quality research data in acupuncture research (AR), which may advance access to AHM care. Issues include: research design and methodology, reporting quality, outcomes analysis, placebo, controls, database registration barriers, diagnose pattern identification, funding, infrastructure, access to technology and statistical software, education, research training, publishing opportunities, bias, attitude in the Biomedical and AHM profession.

Progress has been made in the development of documents and guidelines such as Standards for Reporting Interventions in Controlled Trials of Acupuncture and Consolidated Standards of Reporting Trials (CONSORT). Acupuncture is included in the ICD11 (11th International Statistical Classification of Disease and Related Health Problems).

Collaborative dialogue with other disciplines such as Systems Biology, Epigenetics, Anthropology, Physics, Neuroscience are innovating new research methods. The development of new software and technology expands the possibilities of what is measurable in AHM trials.

But the dichotomy between BMS wanting to explore the mechanism of Acupuncture on a bio-molecular level with a RCT structure, and the evidence of AHM in clinical practice calls for a new definition of evidence for stakeholders to move forward. Mirza et al. reviewed RCTs and found “an average 73% exclusion rate and recruitment of less than 10% of patients with the primary diagnosis.”⁴ Iyioha describes in “Law's dilemma” as “the nexus between statutory legitimacy and scientific validation of health systems” and calls for “a new regulatory model….in support of a pluralistic health care system balancing the imperative of quality assurance with the need to ensure access.”⁵ Baars and Hamre review the factors that promote the integration process of complementary alternative medicine (CAM)⁶ and Vickers poses the question of “how much evidence is enough evidence?”⁷ A new definition of clinical evidence may emerge from inclusion of AHM providers as professional researchers. CCM education as the base of AHM may provide a vast body of knowledge and bring forth clinically valuable research questions.

Significance of the Study

To inform of the current status in AR and education and inspire constructive dialogue.

Limitations

Data was hand gathered. The data from AHM schools and institutional websites is incomplete or may be out-dated. No analytic or statistical software was available. No collaboration with professional researchers and statisticians was available.

Review of the Literature

Research Issues

Design, methodology, reporting, outcomes analysis

Ho et al. conclude that “most systematic reviews on acupuncture effectiveness are of critically low methodological quality.” 93.4% of 106 systematic reviews (SRs) showed low and critically low methodological quality. Exclusion criteria were absent. 0.9% were found to be of high quality. The authors suggest improvement of publishing protocols and competency of reviewers via classes and education to appraise SR critically.⁸

Shuai et al. report design and reporting issues in regards to patient and practitioner criteria, randomization, blinding, controls, and outcome measures. Further insufficient statistical analysis, sample sizes, power calculation, handling of missing data, multiple comparisons, inefficient methods for repeated measurement, cluster data, baseline adjustment, and confounding issues are present. Suggestions are made to develop better design and statistical methods so analysis can show accurate results and improve trial design.⁹

Lao et al. discuss “obstacles inherent in the design and statistical analysis of clinical trials of TCM” and demonstrate by application of statistical methodology to a RCT that models of statistical analysis need to become more sophisticated.¹⁰

Wieland et al. report low qualities of RCTs.¹¹ Manheimer et al. describe most Traditional Chinese Medicine (TCM) reviews as inconclusive (58.57%) with poor methods and heterogeneity.¹² Liu et al. state deficits in reporting of primary outcomes, blinding, and safety. Issues of selective reporting are found to be similar to BMS studies. International requirements at the database are not uniform and methodological data could be missing.¹³ Hammerschlag et al. suggest Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) and CONSORT need to be used more widely and should be translated into Chinese. The quality of reporting in regards to practitioner training, adverse events, randomization, and blinding requires improvement.¹⁴ Deng et al. comment on the need for high quality design and Acupuncturist's administration in trials.¹⁵

Diagnostic pattern identification

Liu et al. found <25% use of TCM differential diagnostics in TCM Herbal trials.¹³

Bias, controls, placebo

Kaptchuk summarizes placebo effects in AR and states that more research is needed to understand placebo, sham and controls to differentiate between intervention and control.¹⁶

Zheng et al. argue that efficacy outcomes of Acupuncture are still controversial due to lack of consensus on placebo control and encourage utilization of a “blank control” including “no treatment controls, waiting list control and treatment as usual” as possible controls.¹⁷

Birch et al. reviewed the history of use of sham Acupuncture in Acupuncture clinical trials and note “non-inertness of sham acupuncture has been known for more than three decades” and “introduces bias against Acupuncture with risk of underestimating its' effectiveness.”¹⁸

Wieland et al. find that Traditional Eastern Asian Medicine (TEAM) reviews receive low priority. TEAM reviewers have difficulties in understanding and assessing a TEAM intervention.¹¹ Manheimer et al. list an average of 1139 person-hours per review with little recognition.¹²

Deng et al. mention Placebo creates bias.¹⁵

Databases

Wieland et al. describe barriers to registration and conduct of Cochrane SRs as poor understanding of the intervention and low priority of Acupuncture/TCM topics as the main challenge; quality and accessibility of randomized trials as a major concern. “Funding for database access, development of information retrieval expertise, translation and other language assistance activities, and training in systematic review methods specific to TEAM (Traditional East Asian Medicine)” are suggested.¹¹

Cogo et al. find little overlap beyond major databases.¹⁹

Suggestions made for research data issues

Improve publishing protocols, the competency of reviewers via classes and education to appraise SR critically (Ho et al.⁸ and Table 1)

Better trial design and statistical methods for accurate results (Shuai et al.⁹)

Statistical analysis needs sophistication (Lao et al.¹⁰)

Blank controls, care as usual, waiting list (Zheng et al.¹⁷)

More placebo research (Kaptchuk¹⁶)

Funding database access, training, education in SR of TEAM (Wieland et al.¹¹)

More research, rigorous RCTs (Manheimer et al.¹²)

More Sham research (Birch et al.¹⁸)

Search multiple databases beyond Medline, Embase, Cochrane, very little overlap controlled trials in CAM (Cogo et al.¹⁹)

The need for international standards in trial registration items (Liu et al.¹³)

Acupuncture trials need large sample size (MacPherson et al.²⁰)

Wider use of STRICTA, CONSORT, reporting (Hammerschlag et al.¹⁴)

Design quality, Acupuncture delivery, minimize placebo and bias (Deng et al.¹⁵)

Multidisciplinary research to advance (Shang²¹)

Table 1.

Research Issues

Design methods reporting	Outcomes analysis	Database	Diagnostic pattern identification	Bias control placebo
Ho et al: 93.4% of 106 systematic reviews critically low quality⁸
Shuai et al.⁹	Shuai et al.⁹			Shuai et al.⁹
Lao et al.¹⁰	Lao et al.¹⁰
				Kaptchuk.¹⁶
				Zheng et al.: no consensus¹⁷
Wieland et al.: low quality randomized controlled trials¹¹		Wieland et al.: barriers to register and conduct¹¹		Wieland et al.: low priority of acupuncture/TCM topics¹¹
Manheimer et al.: poor methods and heterogeneity¹²	Manheimer et al.: most inconclusive 58.57% Cochrane¹²			Manheimer et al.: 1139 person hours/review, little recognition¹²
				Birch et al.: Sham non-inert, false results, bias¹⁸
		Cogo et al.: little overlap beyond 3 major database¹⁹
Liu et al.: blinding, primary outcomes, safety¹³	Liu et al.: selective reporting¹³		Liu et al.: <25% differential diagnosis in TCM Herbal trials¹³
Hammerschlag et al.: reporting, use of STRICTA, CONSORT¹⁴
Deng et al.: Acupuncture administration, design¹⁵				Deng et al.: Placebo effect creates bias¹⁵

Acu, Acupuncture; CONSORT, Consolidated Standards of Reporting Trials; STRICTA, Standards for Reporting Interventions in Clinical Trials of Acupuncture; TCM, Traditional Chinese Medicine.

Funding Issues

National Center for Complementary and Integrative Health budget, education, research training

Pritzker and Hui identify three major hurdles in TCM research, one of them obtaining financial support and the small size of the National Institutes of Health (NIH) budget for CAM and Integrative Medicine (IM) research (Table 2).²² Khalsa and Pearson point out that National Center for Complementary and Integrative Health (NCCIH) awards are not permanent and CAM schools have no research training.²³ Menard et al. recommend to NCCIH that Complementary and Integrated Health (CIH) professionals need research training.²⁴ Mills et al. list Whole Systems Research (WSR) is not funded by NIH.²⁵

Table 2.

Funding Issues

Education, research training	Career development	Infrastructure, technology, software	Publishing
Pritzker and Hui: small NIH budget for CAM research²²		Pritzker and Hui: Small NIH budget for CAM research²²	Pritzker and Hui: Few opportunities²²
Khalsa and Pearson: NIH awards not permanent, CAM schools no research training²³	Khalsa and Pearson: NIH awards not permanent²³	Khalsa and Pearson: CAM schools not affiliated²³
Menard et al.: CIH professions research training²⁴	Menard et al.²⁴	Menard et al.²⁴
Mills et al.: Whole Systems Research not funded by NIH²⁵

CAM, complementary alternative medicine; CIH, Complementary and Integrated Health.

Career development

Khalsa and Pearson show NIH awards for career development are not permanent.²³ Menard et al. recommend funding to promote CIH practitioners.²⁴

Infrastructure, technology, software

Prtizger and Hui state a small NIH budget for CAM research.²² Khalsa and Pearson find CAM schools are not affiliated with research facilities.²³ Menard et al. recommend funding for CIH research infrastructure and partnerships.²⁴

Publishing

Pritzker and Hui show few publishing opportunities for TCM in mainstream medical research journals.²²

Suggestions made for funding issues

NIH to promote CIH professions education, infrastructure, partnerships (Menard et al.²⁴)

NIH to emphasize funding of WSR (Mills et al.²⁵)

Education Issues

For Acupuncturists to be an integral part of AR, research education needs to be included and expanded in AHM schools' curricula. Many schools have recently added some research hours in their programs as prescribed by Accreditation Commission for Acupuncture and Herbal Medicine (ACAHM). There is no obvious career path for Acupuncturists to become a professional researcher and only few schools are associated with a research facility. No data is available on the number of AHM professionals in AHM research.

CIH schools, curriculum

Lam et al. suggest an international TCM curriculum with a joint degree in Western Medicine.²⁶

Gray et al. reveal the absence of a strategy for research education and a lack of international standards.²⁷ Wong et al. state the cross-training of TCM and Western Medicine doctors in China.²⁸ Zhang et al. also note cross-training of TCM and Western Medicine doctors in China.²⁹ Lam et al. suggest mental health training for TCM clinicians.²⁶

CIH institutes, research facilities

Gray et al. find only a few active CIH research facilities.²⁷ Zhang et al. note the importance of the School-Hospital-Axis.²⁹ Khalsa and Pearson present the financial awards for research training opportunities from the NIH. However, these awards are not permanent.²³

CIH researchers

Bradley et al. refer to the (previous) grants T90 research training for CIH clinicians and R90 for CIH training for Western Medical practitioners.³⁰ These grants have largely expired and there is no data on the number of AHM providers accepted to participate.

CIH brain drain, career paths

Menard et al. mention brain-drain in CIH.²⁴ Chung et al. describe poor career perspectives and career paths, low salaries and few employment opportunities.³¹

Attitude, bias, collaboration

Bradley et al. describe an inter-professional clinical research training and reference WHO best practices of interprofessional education.³⁰

Suggestions made for education issues

NIH to expand R25 grants to CIH institutes, practitioners (Menard et al.²⁴)

Joint efforts are needed from the government, TCM industry and NGOs (Lam et al.²⁶)

More research on CIH education, create agenda and strategy (Gray et al.²⁷)

Complex systems research in educational curriculum, networking (Ahn et al.³²)

Interprofessional training in CIH research and BMS (Bradley et al.³⁰)

Interdisciplinary medical education (Wong et al.²⁸)

Current CIH education for MDs comprises of:

2 × 45 min. Valentini et al.,³³ 45 hours online class, Kligler et al.,³⁴ a 30-hour class (Amri³⁵)

Research training is needed in TCM schools (Maiers et al.³⁶)

Dual training as a base for IM development (Zhang et al.²⁹)

TCM schools need to seek research grants, evidence-informed practice (EIP) faculty training (Anderson et al.³⁷)

TCM colleges need to be recognized internationally as Medical colleges (Zhang and Tang³⁸)

Funding of graduate, postgraduate education and career development (Chung et al.³¹)

Western Mental Health training for TCM clinicians (Lam et al.²⁶)

Missing data: there is no data available on NIH grants distribution to AHM clinicians. There is no data on distribution of Eastern Medicine, Acupuncture, Asian Herbology, Asian Bodywork (TuiNa) clinicians with research degrees, active in research or having a research career. More research is needed in this area. Most suggestions for improvement were made in the area of education (Tables 3 and 4).

Table 3.

Education Issues

CIH schools, curriculum	CIH institutes, research facilities	CIH researchers	CIH brain-drain, career paths	Collaboration, attitude, bias
			Menard et al.: braindrain in CIH²⁴
Lam et al.: International curriculum, joint degree Western Medicine²⁶
Gray et al.: No strategy in research and education/international standards²⁷	Gray et al.: Few active²⁷
		Bradley et al.: T90 CIH Doctoral, R() CIH West. Med.³⁰		Bradley et al.: BRIDG interprofessional clinical research training³⁰
Wong et al.: China cross training²⁸
Zhang et al.: China dual training²⁹	Zhang et al.: School-Hospital-Research axis²⁹
			Chung et al.: Employment, salary³¹

Table 4.

Total of Recommendations from All Three Areas Reviewed (Research Data, Funding, Education)

Suggestions	Research data studies	Funding issues studies	Education issues studies	Total
Funding	1	1	2	4
Career	0	1	1	2
Education/training	7	2	5	14
Access	1	1		2
Partnerships	1		1	2
Multidisciplinary	1		1	2
International Recognition			1	1
Research methods	4	4	0	8
More research	3	1	0	4

Educational hours in TCM schools curricula

There are currently 50 TCM schools accredited by ACAHM in the United States (Table 5). The information was hand gathered by reading through each school's website and school catalog, when available. Not every school has made a school catalog available for the public on their website, some of them only allow for viewing of catalog pages but not for downloading a catalog. Some schools send a catalog on demand after gathering personal information for their mailing list, text and phone calls to solicit prospective students. Often educational hours are listed as credit hours or units, a conversion key into clock hours is not always declared.

Table 5.

Education Hours in Traditional Chinese Medicine School Curricula

ACAHM accredited TCM school	Type program: DAOM	DAc	DAcCH	Master. AcCH	Master Ac	Cert. CH	Date first accredited	Total hours didactic	Total hours clinical	Total hours Research education
Academy of Chinese Culture and Health Sciences, CA	X						02/19/2021	600	650	120
				X			11/9/1992	1935	970	45
Academy for Five Element Acupuncture, FL				X			05/04/1998	2566	1005	Elective
						X	04/09/2021	522	265	Elective
Acupuncture and Massage College, FL				X			11/12/2000	2852	158	15
Acupuncture and Integrative Medicine College, CA			X				08/07/2021	2265	1071	4.5 units
				X			05/04/1998	2093	990	2 units
Alhambra Medical University, CA				X			02/12/2014	2160	960	30
American Academy of Health and Wellness, MN	X						08/15/2020	540	660	60
				X			11/11/2001	2280	900	0
					X		04/08/2019	1650	780	0
American College of Acupuncture and Oriental Medicine, TX			X				08/15/2020	No data	No data	No data
				X			05/13/1996
American Institute of Alternative Medicine, OH				X			08/10/2007	1435	690	30
AOMA Graduate School of Integrative Medicine, TX	X						08/17/2019	540	660	14
			X				02/19/2022	2286	1308	Elective 12
				X			11/18/1996	1998	1008	0
						X	05/18/2020	558	216	0
Arizona School of Acupuncture and Oriental Medicine, AZ				X			11/16/2003	1974	1172	0
					X		11/16/2003	1598	1028	0
Atlantic Institute of Oriental Medicine, FL	X						02/24/2018	575	660	24
				X			05/02/1999			15
Bastyr University, WA	X						08/10/2007	699	504	33
		X					02/19/2022	1472	1004	33
				X			11/14/1994	1810	1092	32
					X		11/14/1994	1285	828	0
						X	05/18/2020	605	220	0
California Institute of Integral Studies, CA	X since 2019 teach out						02/10/2012	N/A	N/A	N/A
			X				11/12/2018	2370	1020	No data
				X			11/11/1991	2160	960	No data
California University- Silicon Valley, CA				X			08/07/2021	2145	960	15
Chicago College of Oriental Medicine, IL				X			Pre-accredited 08/15/2020	2093	870	15
					X		Pre-accredited 08/15/2020	1808	870	15
Colorado School of Traditional Chinese Medicine, CO				X			05/05/2002	2220	825	0
					X		05/05/2002	1815	555	0
Daoist Traditions College of Chinese Medical Arts, NC			X				08/17/2019	175	130	30
				X			08/09/2008	2205	740	30
						X	08/17/2019	510	210	0
Dongguk University Los Angeles, CA			X				02/19/2022	2430	1000	30
				X			05/12/1994	2130	960	30
Dragon Rises College of Oriental Medicine, FL				X			05/02/2004	2355	870	0
Eastern School of Acupuncture and Traditional Medicine, NJ					X		05/04/2003	1840	861	30
						X	05/18/2020	600	270	0
East West College of Natural Medicine, FL				X			11/15/1999	2148	900	0
Emperor's College of Traditional Oriental Medicine, CA	X						08/16/2013	600	650	48
				X			05/09/1989	No data	970	No data
Five Branches University, CA	X						08/18/2012	594	686	64
			X				08/11/2018	2445	990	45
		X					08/11/2018	180	135	68
				X			05/13/1996	2445	990	45
					X		05/13/1996	1838	810	45
Florida College of Integrative Medicine, FL				X			11/17/1997	2128	900	0
Institute of Clinical Acupuncture and Oriental Medicine, HI				X			11/17/2002	2160	1080	0
Institute of Taoist Education and Acupuncture, CO					X		08/06/2006	No data	No data	No data
Jung Tao School of Classical Chinese Medicine, NC					X		10/07/2005	1373	810	0
Maryland Institute of Integrative Health, MD			X				02/19/2022	3189	528	3″ units
		X					02/19/2022	2382	423	3″ units
				X			08/13/2016	2660	408	3″ units
					X		05/06/1985	2082	303	3′ units
						X	05/18/2020	No data	No data	No data
MCPHS University, MA				X			02/26/1988	2553	400	5′ units
					X		02/26/1988	1743	409	5′ units
						X	05/18/2020	540	225	0
Middle Way Acupuncture Institute, WA					X		02/27/2016	1269	660	30
Midwest College of Oriental Medicine, WI				X			11/08/1993	1980	918	0
					X		11/08/1993	1488	660	0
National University of Health Sciences, IL				X			02/26/2011	2123	1200	60
					X		02/26/2011	1620	840	60
National University of Natural Medicine, OR			X				08/17/2019	2742	1068	24
				X			05/07/2000	2250	1056	24
					X		10/15/2019	No data	No data	No data
New York College of Health Professions, NY				X			11/18/1996	No data	No data	No data
					X		11/18/1996	No data	No data	No data
New York College of Traditional Chinese Medicine, NY				X			05/05/2002	2295	900	0
					X		05/05/2002	1755	720	0
						X	05/18/2020	540	360	0
Northwestern Health Sciences University, MN			X				02/19/2022	2427	1050	No data
				X			05/02/1999	1677	893	No data
					X		05/02/1999	No data	No data	No data
Oregon College of Oriental Medicine, OR	X						08/10/2007	2444	1224	48
				X			05/09/1989	2096	1131	48
					X		06/19/2018	1511	693	0
Pacific College of Health and Science, CA			X				02/16/2019	No data	No data	No data
		X					02/16/2019	No data	No data	No data
				X			11/12/1990	No data	No data	No data
					X		11/12/1990	No data	No data	No data
						X	02/16/2019	No data	No data	No data
Phoenix Institute of Herbal Medicine and Acupuncture, AZ				X			05/07/2005	2340	1268	75
					X		05/07/2005	1935	1058	75
POCA Technical Institute, OR					X		08/11/2018	1319	770	no data
Seattle Institute of East Asian Medicine, WA			X				08/11/2018	2543	1335	12
				X			05/04/1998	2243	1185	0
					X		no data	No data	No data	No data
South Baylo University, CA	X						02/16/2013	600	660	40
				X			06/14/1993	2180	960	30
Southern California University of Health Sciences, CA			X				02/24/2018	2520	1080	60
				X			10/23/2005	2310	1020	30
Texas Health and Science University, TX				X			11/18/1996	1725	1020	30
University of Bridgeport, CT			X				02/24/2018	2556	1400	No data
				X			02/27/2016	2178	1190	18
					X		08/10/2007	1815	830	18
University of East-West Medicine, CA				X			05/07/2005	2130	960	15
Virginia University of Integrative Medicine, VA	X						02/22/2020	600	660	48
			X				02/19/2021	2282	1110	54
		X					02/19/2021	1752	810	54
				X			02/11/2015	2000	990	30
					X		02/11/2015	1470	690	30
						X	02/22/2020	560	255	0
Wongu University of Oriental Medicine, NV				X			08/17/2019	2500	1000	30
Won Institute of Graduate Studies, PA					X		02/12/2010	No data	No data	No data
						X	05/18/2020	No data	No data	No data
Yo San University of Traditional Chinese Medicine, CA	X						08/15/2013	570	650	75
				X			05/03/1993	2385	990	15

Eleven schools offer an accredited Doctorate of Acupuncture and Oriental Medicine (DAOM) which is currently the highest accredited degree offered in the United States (Table 6). Forty-four of them offer an accredited Master's degree of Acupuncture and Chinese herbology/Master of Oriental Medicine, which formerly was the standard degree. Five schools offer a Doctorate in Acupuncture, 15schools offer a Doctorate in Acupuncture and Chinese herbology, 26 schools offer a Master of Acupuncture, 11 schools offer a Certificate in Chinese herbology.

Table 6.

Total of Degrees Offered at the Accredited Acupuncture and Herbal Medicine Schools in the United States

DAOM	DAc	DAcCH	MAcCH	MAc	CertCH
11	5	15	44	26	11

Doctorate of Acupuncture and Oriental Medicine

Two of the schools listed the program hours as including Master program hours and it was unclear how many hours comprised the DAOM program alone. One school is teaching out the program and has no information available.

Doctorate, Acupuncture

Two of the schools gave the program hours separate from Master's program hours. One school did not give any data.

Doctorate, Acupuncture and Chinese Herbology

One school listed separate hours. Twelve schools listed total hours including the Master's degree coursework. Five schools did not list research hours and were counted as Zero hours. Two schools did not provide any information.

Master, Acupuncture and Chinese Herbology/Master Oriental Medicine

Five schools gave no or incomplete data. Three schools gave units for research hours without a ratio to clock hours. These units were counted as if they were clock hours in the table.

Master of Acupuncture

Seven schools gave no data. Two schools gave units of research hours without conversion into clock hours and were counted as hours.

Certificate of Chinese Herbology

Two schools gave no data. All schools had zero research hours.

Of 49 schools with available data (Table 7):

Table 7.

Average of Educational Hours by Program

Program	Average didactic	Average clinical	Average research
DAOM	570.89	642.22	54.00
Doctorate Acupuncture	375.00	392.50	71.50
Doctorate Acupuncture and Chinese Herbology	2504.42	1080.00	18.75
Master Acupuncture And Chinese Herbology/Master Oriental Medicine	2177.36	960.49	18.38
Master Acupuncture	1642.84	746.05	16.37
Certificate Chinese Herbology	549.44	247.89	0

12 schools (24.49%) either are or have access to a research facility.

8 schools (16.33%) listed affiliation with one or more Universities.

10 schools (20.41%) listed affiliation with one or more hospitals.

3 schools (6.12%) listed affiliation with a PhD program abroad.

To date there is no accredited PhD program in the United States.

Accreditation Commission for Acupuncture and Herbal Medicine

Standard 7 “ Program of Study, Criterion 7.02 Minimum Program Length, Credits and Hours” by clock hours (Table 8):

Table 8.

Affiliations of Accredited Traditional Chinese Medicine Schools

ACAHM accredited TCM school	Research facility^a	University	Hospital	PhD abroad
Academy of Chinese Culture and Health Sciences, CA				X
Academy for Five Element Acupuncture, FL
Acupuncture and Massage College, FL
Acupuncture and Integrative Medicine College, CA		X	X
Alhambra Medical University, CA
American Academy of Health and Wellness, MN
American College of Acupuncture and Oriental Medicine, TX	X	X	X
American Institute of Alternative Medicine, OH
AOMA Graduate School of Integrative Medicine, TX
Arizona School of Acupuncture and Oriental Medicine, AZ
Atlantic Institute of Oriental Medicine, FL				X
Bastyr University, WA	X
California Institute of Integral Studies, CA	X
California University- Silicon Valley, CA
Chicago College of Oriental Medicine, IL
Colorado School of Traditional Chinese Medicine, CO
Daoist Traditions College of Chinese Medical Arts, NC
Dongguk University Los Angeles, CA		X
Dragon Rises College of Oriental Medicine, FL
Eastern School of Acupuncture and Traditional Medicine, NJ
East West College of Natural Medicine, FL
Emperor's College of Traditional Oriental Medicine, CA
Five Branches University, CA		X		X
Florida College of Integrative Medicine, FL
Institute of Clinical Acupuncture and Oriental Medicine, HI			X
Institute of Taoist Education and Acupuncture, CO
Jung Tao School of Classical Chinese Medicine, NC
Maryland Institute of Integrative Health, MD		X	X
MCPHS University, MA	X
Middle Way Acupuncture Institute, WA
Midwest College of Oriental Medicine, WI
National University of Health Sciences, IL	X
National University of Natural Medicine, OR	X
New York College of Health Professions, NY
New York College of Traditional Chinese Medicine, NY	X		X
Northwestern Health Sciences University, MN		X	X
Oregon College of Oriental Medicine, OR	X
Pacific College of Health and Science, CA	X		X
Phoenix Institute of Herbal Medicine & Acupuncture, AZ	X		X
POCA Technical Institute, OR
Seattle Institute of East Asian Medicine, WA	X
South Baylo University, CA
Texas Health and Science University, TX
University of Bridgeport, CT	X
University of East-West Medicine, CA		X
Virginia University of Integrative Medicine, VA
Wongu University of Oriental Medicine, NV			X
Won Institute of Graduate Studies, PA		X
Yo San University of Traditional Chinese Medicine, CA			X

Schools with affiliations to or being a research facility.

Prerequisite to enter the Master's study is 60 semester units/90 quarter units of general education with a GPA of 2.5 or higher

Master's Program in Acupuncture (Acu): 1245 didactic/660 clinical, 1905 total

Master's Acupuncture with Chinese herbal medicine (CHM) specialization:

1755 didactic/870 clinical, 2625 total

CHM certificate: 510 didactic/210 clinical, 721 total

Professional Doctoral Acupuncture: 1245 didactic/790 clinical, 2035 total

Professional Doctoral Acupuncture with CHM: 1755 didactic/1000 clinical, 2755 total

Advanced Practice Doctoral DAOM program: 550 didactic/650 clinical, 1200 total (Fig. 1).

Figure 1.

Accreditation Commission for Acupuncture and Herbal Medicine minimum hours required by program.

The Master's program in Acupuncture with CHM and the end degree DAOM together comprise 2305 didactic/1520 clinical, total 3825 hours. This was the original subsequent route of education from a Master's to a DAOM degree.

The AHM schools provide the obligatory educational hours but there is no standard of curricula and professional degrees. For example in the profession of Chiropractor, Doctor of Chiropractic, is the only and terminal degree. This is transparent to the public and regulatory agencies, unifies the profession and facilitates legislative actions. The AHM profession and other stakeholders may benefit from consolidating the number of degrees offered into one terminal degree such as the DAOM degree, which would include the current Master's degree, and a subsequent clinical and research Phd degree, which may promote AHM to become a highly competent and recognized profession. Specialization in diversity of schools of thought and practice of CCM could follow after the DAOM degree to ensure a base standard curriculum to build on.

Literature Examining AHM Schools

Wayne et al. “surveyed the students of two accredited TCM schools in the United States to explore the attitudes and interests towards research. Both schools had received NIH funding to train faculty and students in basic research competencies and induce collaboration with external research facilities. Results showed the students were highly interested in research at the beginning of the curriculum. As clinical hours are introduced later in the program the interest in research declined, possibly due to time constraints. Overall students state the importance of research for stakeholders and policy makers but not as highly relevant to their clinical practice as current research methods do not reflect principles and clinical practice of TCM. Limited research training during CAM education is noted as a significant barrier for CAM clinicians to engage in research.”³⁹

Anderson et al. “surveyed faculty of an accredited TCM school in the United States to assess research literacy and EIP interest. Responses indicated high interest and support for research. 95% stated TCM clinicians and professors trained in research could make substantial contributions to research. Obstacles were concerns regarding current research paradigms not relating to TCM practice and the co-option and assimilation through biomedical science.”³⁷

Anderson et al. describe “the training of faculty and development of a Evidence-Informed Practice (EIP) curriculum at the previously surveyed accredited TCM school in the United States. The faculty trained successfully developed and implemented EIP training into the school's curriculum.” Current research standards were identified as an obstacle as they “do not provide a valid treatment approach that acupuncturists can relate to….”⁴⁰

Lim et al. describe the status of Acupuncture in China. Higher education in TCM is offered by 46 tertiary Chinese Medicine (CM) Universities, 10 Western medical and 6 non-medical Universities. A Bachelor's degree is earned in five years, the Master's degree in additional three years, and a Phd in another three years. A combined Bachelor's and Master's degree can be earned in seven years. BMS and research training are included. After studies, one year of clinical supervision is required to apply for examination for licensure. Challenges to international research collaborations are identified as the differences of research trends and priorities in the East and West. Western BMS is searching for evidence of the efficacy of TCM using Sham or Placebo controls. Research in the East prioritizes the underlying mechanisms and clinical practice effectiveness and techniques.⁴¹

Givati and Berlinsky analyze over 20 years of Acupuncture education in the United Kingdom titled “The Disenchantment of Traditional Acupuncturists in Higher Education.”⁴² This study describes the “rise and decline of Acupuncture training programs in higher education,…efforts to obtain legitimate academic status within a system that is dominated by biomedicine….the gap between institutional demands to standardize and formalize…biomedical adjustments of their programs, while maintaining authenticity..”. It further touches on the underlying matter of colonialism in regards to BMS and CAM therapies, the “persistent and organized scrutiny” Acupuncture is under, and the political rulings affecting the practice of Acupuncture in the United Kingdom. Acupuncture was to “remain self-regulated,which meant that almost anyone can practice Acupuncture regardless of the level of training or qualification.” From 2011–2020 “several Acupuncture programs in Higher Education closed, leaving only four active undergraduate programs of which one stopped recruiting new students.” The “…gap…has not been narrowed by merely the inclusion of biomedical teaching modules within Acupuncture programs.” Student numbers have dropped, “ongoing hostility and marginality…eventually eroded Acupuncture educators….” At the same time Acupuncture educators “demonstrated academic and professional credibility” and “positioned themselves as professional academics within higher education institutions….”⁴²

Barnes surveys the professional development of Acupuncture and AHM education finding the “growing resemblance to biomedical training”, the TCM (post 1950s) “Americanizing of Chinese Medicine,” tension within the profession, the response from BMS to Acupuncture, and how Acupuncture “has survived by submitting to the authority of biomedicine.” “TCM continues to be the dominant system represented” in AHM education for licensing purposes but some schools value CCM knowledge and “different schools of practice persist.” “Biomedicine, when faced with a paradigm that does not fit its understanding of how things work, has tended to look for whatever pieces of that paradigm can be fitted into its own model and to reject the rest. Either that, or it has found ways to absorb ostensibly contradictory language into its own explanatory system.” “The biomedical community reacted by pursuing two measures. The first involved asserting control over acupuncture's knowledge base through the demand for research and clinical trials; the second entailed regulating….” “ The challenge was to prove that biomedical measures and paradigms could, in fact, explain what was going on.” “It requires the reduction to a single etiological factor and corresponding single intervention, the very premise of RCT is incompatible with Chinese medicine theories and practices.” “…it is more likely that the call for evidence-based outcome studies will reinforce the trend in biomedical circles to conceptualize acupuncture only in the narrowest of terms.” as for example the analgesic aspect of acupuncture has been assimilated and applied in BMS. “Still failing to recognize or understand the paradigms upon which the modality is based, a reductionist version of Chinese medicine was now recognized by hospital and medical school administrations to be a potential source of patient satisfaction and of income.” “The insurance companies, therefore, often paid nothing but created the illusion of openness to complementary and alternative medicine for which the patient still paid out of pocket on top of paying for health insurance. Such policies, it should be noted, continue to restrict use to a largely middle- and upper middle-class patient population…”. “Thus the efforts of the PRC (People's Republic of China) to integrate TCM into state-run services mean something quite different from the attempts of American practitioners to make a place for themselves in the health care marketplace.…”⁴³

Classical Chinese Medicine

CCM is the original body of AHM which was omitted in the 1950s when TCM was made the new standard. The educational curricula are lacking studies of CCM, research education, career and research opportunities alike. TCM is taught at Acupuncture schools today and is the current regulatory standard. Neither the history of CM, the classical foundations nor the difference between the modern hybrid and the original medicine are mandatory in AHM curricula. Rhonda Chang's work shows “how this has affected AHM education, practice and research alike as the effects of omitting crucial information has led to incoherence and failure and how the assimilation and adaptation of CCM by BMS has allowed for confusion.” Chang explains the “clinical, theoretical and historical difference and disconnections” between Yi (original medicine) and CM (present, TCM). “Since the 1950s the Yi theoretical base and principles of practice have been omitted and replaced with BMS concepts. This has created a schism in the recently created TCM theory and practice.” This new model of CM has been conflicted from the beginning by not not standing on the original foundation, a mixture of modalities being neither one nor the other.⁴⁴

Regulatory statutes require health professionals to have basic training in BMS. If BMS were a prerequisite to enter AHM education, the curricula could focus on AHM in its entire body including the original classical foundations. Research education hours could also be increased and a research track could initiate a career in research for interested AHM providers.

Science is examining the post 1950's TCM, which is only partially science based and lacking a full original CM foundation. It is not surprising that research outcomes are not satisfactory and waste in research is generated. With a deep understanding of the classical foundations, meaningful research questions and research methods may develop as AHM professionals distinguish the original from modern versions of CM.

This may clarify which areas of AHM are suitable for which type of research, while also restoring the original medicine in clinical practice.

Career Pathways in Research for Acupuncturists

National Center for Complementary and Integrative Health. NCCIH Strategic Plan FY 2021–2025: Mapping the Pathway to Research on Whole Person Health states “At the individual level, NCCIH supports multiple interdisciplinary opportunities for training of clinician-scientists. For example, NCCIH has partnered with the National Center for Advancing Translational Sciences (NCATS) to provide a research career development pathway for complementary and integrative health clinician-scientists to join careers…” NCCIH Strategic Plan FY 2021–2025

OBJECTIVE 4: Enhance the Complementary and Integrative Health Research Workforce.“development cohorts of other types of clinician-scientists” (p38/39) Yet there are no obvious links for Acupuncturists on the NCCIH's or the National Center for Advancing Translational Sciences's websites to find individual training and funding opportunities.

Further Barriers

As the majority of AHM providers are in private practice (NCCAOM website, accessed December 18, 2022) and not associated with an institution, access to free full text research articles is limited. This is a barrier to enhance clinical practice or to conduct research as a sole AHM provider.

The career outlook for AHM providers with large amounts of student loans is not very encouraging. The cost of AHM education is high and Federal Student Loans in this field are not eligible for loan forgiveness work programs.

The DAOM degree designates providers in some states as primary physicians yet with limited ability to for example order medical tests and laboratory work. Insurance coverage is an ongoing issue and out-of-pocket pay is an obstacle to patient access. The economic burden to become a AHM provider, the non-unified profession, the effort to study BMS and AHM to practice TCM, which is lacking the classical foundation, the lack of career paths, except in private practice, are factors which hinder brilliant research to come from AHM schools, graduates, and their, if existent, affiliated research facilities.

Cultural appropriation, colonialism

Political climate has made the term “Chinese Medicine” and recently “Oriental Medicine” become assimilated into the vagueness of “Acupuncture and Herbal Medicine” which may be a case of cultural and heritage appropriation. Debate on CM history, oral traditions and colonialism are currently not part of AHM school's curricula.

Naming

Frequent name changes within the profession are confusing to the public and may suggest instability and further fragmentation.

Benchmarks for the Training of Acupuncture

The WHO 2020 Benchmarks for the Training of Acupuncture⁴⁵ outlines training content for people without a medical background, with a traditional medical background, and with a conventional medical background:

Basic training: 1168 didactic/400 clinical, total 1568 hours.

Advanced: 1968 didactic/500 clinical, total 2468.

The WHO suggests 200 hours basic training for BMS physicians which consists of an introduction to TCM, 201 (of 409 official) Acupuncture points, application in BMS, safety guidelines and treatment techniques. WHO 2020 Benchmarks for the Training of TuiNa (TuiNa is part of AHM training)⁴⁵ outlines training content for people without a medical background, with a traditional medical background, with a conventional medical background (Fig. 2).

Figure 2.

WHO benchmark outlines acupuncture and TuiNa by hours. Basic level hours: 1104 didactic/400 clinical, 1504 total. Advanced level hours: 1854 didactic/500 clinical, total 2354. There is to date no WHO Benchmark for Chinese Herbal Medicine Training.

AHM Education for Biomedical Physicians

Educational hours in AHM for biomedical Physicians range overall from 90 minutes to 30 hours.

The American Academy of Medical Acupuncture offers basic training in Acupuncture of 150 to up to 300 hours maximum for BMS physicians of which three times 3.5 days are in person.

This is a stark contrast to the BMS and AHM hours required for AHM practitioners.

Summary of Findings and Discussion

The reviewed studies relating to research issues, funding issues and education issues demonstrate the need for improvement, especially in AHM education. BMS is to date not satisfied with the results of its AHM research and AHM is not incorporated into primary care in the West. The reasons may be:

BMS has no or little background in AHM to select applicable research methods and questions

AHM providers have little or no research training

AHM schools are based on TCM with little or no CCM education.

AHM degrees and curricula are currently fractured: there are no BMS pre-medical entry requirements. There is no dual-training as for example in China and the educational requirements in the West are less.

No clinical professional experience is needed to enroll in a AHM Master's or Doctoral program. An AHM student may continue directly from a Master's to a DAOM or Doctoral degree without clinical professional experience,which may be an obstacle to higher level discussions within a Doctoral program. CCM and research education hours in AHM schools are few.

If the portion of BMS taught in AHM schools were a pre-medical entry requirement, for example, a Bachelor's of Science or a medical profession, the curricula could be reserved for CCM and research education instead. A Master's degree within the DAOM (which might soon again be renamed) as only degree may provide coherence and transparency to the public and facilitate patient access to AHM in primary care. Yet to ultimately raise the bar in AHM education a single, direct DAOM degree, followed by a PhD clinical and research degree would bring AHM up to par nationally and internationally. This would further stabilize the profession, eliminate the concern of being co-opted by BMS or encroached on by other professions aiming to use Acupuncture in their scope, and allow for studies of diverse CCM traditions after a solid educational foundation.

Funding may promote the collaboration between AHM schools, hospitals, research facilities, and create career pathways for AHM professionals, becoming the clinical and research experts in their own field. This may facilitate implementation of the WHO TM strategy and ensure patient access.

There is no AHM university teaching and research hospital in the West. A change in AHM curricula, based on CCM with an additional research track, unified degrees such as a DAOM and PhD, may be an attainable next step to improve the current state of AHM research and AHM education and to improve outcomes in and access to patient care. As AHM continues to evolve as a profession in the West, choices can be made to create a complete and emancipated body of medicine and to shape its future accordingly and independently from previous assumptions and limitations. More research on AHM education is needed.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.▪

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