《学术英语（医学）》拓展阅读资料：Medical accupuncture the legal Environment as Practiced by the Physician

INTEGRATIVE MEDICINE ELSEVIER Medical Acupuncture: The Legal Environment as Practiced by the Physician Deborah L. Wirsing, BBA, MS, and Sherman L Cohn, BSFS, LLB, LLM Acupuncture has been practiced for 2000 to 5000 years A medical acupuncturist, on the other hand, is generally It is no more experimental as a mode of medical treat defined as the conventional physician, MD or DO, who ment than is the Chinese language as a mode of commu- adopts acupuncture into his or her conventional medical nication. What is experimental is not acupuncture, bu practice Professional training is usually limited to about 200 Westerners'understanding of it and their ability to uti hours and state regulation is highly variable. The American lize it properly Academy of Medical Acupuncture(AAMA)nationally repre U.S. District Court for the Southen District of Texas sents and supports medical acupuncture and its practitioners Andrews v. Ballard, 498 F Supp. 1038 in education, training, and legislation, and in many ways (SD.Tex.1980) promotes solidarity among medical acupuncturists as A cupuncture is a two millennia-old system of health care merging body of health care providers. The AAMA more that involves the insertion of needles into the body at specifically defines medical acupuncture as"acupuncture distinct points that correspond to underlying channels of an performed by a doctor trained and licensed in Western med energetic flow called qi(pronounced"schee"). Underlying icine who also has thorough training in acupuncture as a specialty theory of acupuncture holds that this therapeutic insertion of practice"italics added for emphasis. 2 A more encompassing he needles, sometimes in conjunction with other stimulating definition can be found to describe medical acupuncture as techniques, encourages the flow and rebalancing of this en- acupuncture that has been successfully incorporated into ergy, qi, and thus a subsequent relief of the gamut of ailments medical or allied health practices in Western cour and diseases treated in traditional Chinese medicine for the purposes and focus of this article, only MD and DO In the United States, acupuncture is legally practiced in acupuncturists will be discussed. variety of styles and settings by conventional physicians, al Medical Acupuncture integrates both the conventional un- lied health professionals, and non-physician acupuncturists derstanding of neuromuscular anatomy, pain physiology, Non-physician acupuncturists are trained in Acupuncture and disease states with a classical Chinese ideology of the and Oriental Medicine programs accredited by the national imperceptible flow of vivifying energy that supports life, bal- governing body, the Accreditation Commission for Acu ance, and well-being to the whole person. Both pure forms of puncture and Oriental Medicine(ACAOM), certified through acupuncture, where treatment is based on traditional Chi- a proficiency examination by the National Certification nese concepts, and hybrid forms, in which treatment is ad Commission for Acupuncture and Oriental Medicine ditionally supported by conventional diagnostic tools, exist (NCCAOM), and are licensed for legal practice by states un- in medical acupuncture. Hybrid acupuncture, the most com- der varying requirements. Accredited acupuncture programs mon approach, enables the medical acupuncturist to orga- include both didactic and clinical training over the course of nIze and address patients symptoms such as recurring pain, 3 years, with the completion of at least 1,905 resident hours nausea and malaise which are so elusive in standard medical evaluation and treatment. 2 a growing body of about 6000 practicing physicians, including mainly neurologists, anes- Medical College of Georgia, Augusta, GA thesiologists, pain specialists, and general practitioners con- gEorgetown University Law School, Washington, DC. Note that membership to the AAMA or any professional organization has stitute those physicians practicing medical acupuncture. many advantageous elements of services, information, and prestige that beyond the scope of this paper This paper was initially prepared for Seminar on Alternative and Comple aConventional c include examination of past medical records, ra mentary Medicine Legal Issues(L] 065-05)at Georgetown University ory evaluations, for example, used to confirm or Law School, under the direction of Professor Sherman L Cohn and even iden disorders not readily identified in the traditional djunct Professors Peter C. Cohen, MD, and Jonathan Missner, JD Chinese evaluation. This becomes especially important when consider Address reprint requests to Deborah L. Wirsing, BBA, MS, MCG Box 672 ing malpractice issues of misdiagnosis or the overlooking of a disease 112015thSt,Augusta,Ga30912-0006.e-mail:diawirsing@yahoo.com such as early stages of cancer. 24 1543-1150/05/S-see front matter O 2005 Elsevier Inc. All rights reserved doi:10.1016 J-sigm.2005.03.003

Medical Acupuncture: The Legal Environment as Practiced by the Physician Deborah L. Wirsing, BBA, MS,* and Sherman L. Cohn, BSFS, LLB, LLM† Acupuncture has been practiced for 2000 to 5000 years. It is no more experimental as a mode of medical treat￾ment than is the Chinese language as a mode of commu￾nication. What is experimental is not acupuncture, but Westerners’ understanding of it and their ability to uti￾lize it properly. U.S. District Court for the Southern District of Texas Andrews v. Ballard, 498 F. Supp. 1038 (S.D. Tex. 1980) Acupuncture is a two millennia-old system of health care that involves the insertion of needles into the body at distinct points that correspond to underlying channels of an energetic flow called qi (pronounced “schee”). Underlying theory of acupuncture holds that this therapeutic insertion of the needles, sometimes in conjunction with other stimulating techniques, encourages the flow and rebalancing of this en￾ergy, qi, and thus a subsequent relief of the gamut of ailments and diseases treated in traditional Chinese medicine. In the United States, acupuncture is legally practiced in a variety of styles and settings by conventional physicians, al￾lied health professionals, and non-physician acupuncturists. Non-physician acupuncturists are trained in Acupuncture and Oriental Medicine programs accredited by the national governing body, the Accreditation Commission for Acu￾puncture and Oriental Medicine (ACAOM), certified through a proficiency examination by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM), and are licensed for legal practice by states un￾der varying requirements. Accredited acupuncture programs include both didactic and clinical training over the course of 3 years, with the completion of at least 1,905 resident hours.1 A medical acupuncturist, on the other hand, is generally defined as the conventional physician, MD or DO, who adopts acupuncture into his or her conventional medical practice. Professional training is usually limited to about 200 hours2 and state regulation is highly variable. The American Academy of Medical Acupuncture (AAMA) nationally repre￾sents and supports medical acupuncture and its practitioners in education, training, and legislation, and in many ways promotes solidarity among medical acupuncturists as an emerging body of health care providers. The AAMA more specifically defines medical acupuncture as “acupuncture performed by a doctor trained and licensed in Western med￾icine who also has thorough training in acupuncture as a specialty practice” [italics added for emphasis].2 A more encompassing definition can be found to describe medical acupuncture as “acupuncture that has been successfully incorporated into medical or allied health practices in Western countries,”2 but for the purposes and focus of this article, only MD and DO acupuncturists will be discussed. Medical Acupuncture integrates both the conventional un￾derstanding of neuromuscular anatomy, pain physiology, and disease states with a classical Chinese ideology of the imperceptible flow of vivifying energy that supports life, bal￾ance, and well-being to the whole person. Both pure forms of acupuncture, where treatment is based on traditional Chi￾nese concepts, and hybrid forms, in which treatment is ad￾ditionally supported by conventional diagnostic tools,a exist in medical acupuncture. Hybrid acupuncture, the most com￾mon approach, enables the medical acupuncturist to orga￾nize and address patients’ symptoms such as recurring pain, nausea, and malaise, which are so elusive in standard medical evaluation and treatment.2 A growing body of about 6000 practicing physicians,3 including mainly neurologists, anes￾thesiologists, pain specialists, and general practitioners con￾stitute those physicians practicing medical acupuncture.4 *Medical College of Georgia, Augusta, GA. †Georgetown University Law School, Washington, DC. Note that membership to the AAMA or any professional organization has many advantageous elements of services, information, and prestige that are beyond the scope of this paper. This paper was initially prepared for Seminar on Alternative and Comple￾mentary Medicine Legal Issues (LJ 065-05) at Georgetown University Law School, under the direction of Professor Sherman L. Cohn and Adjunct Professors Peter C. Cohen, MD, and Jonathan Missner, JD. Address reprint requests to Deborah L. Wirsing, BBA, MS, MCG Box 672, 1120 15th St, Augusta, GA 30912-0006. E-mail: diawirsing@yahoo.com a Conventional diagnostics include examination of past medical records, ra￾diographs, and laboratory evaluations, for example, used to confirm or even identify organic disorders not readily identified in the traditional Chinese evaluation. This becomes especially important when consider￾ing malpractice issues of misdiagnosis or the overlooking of a disease, such as early stages of cancer. 24 1543-1150/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.sigm.2005.03.003

Medical acupunc Physicians incorporate acupuncture into their medical prac- integrated in some medical programs, such as at Georgetown tice in a variety of ways. Some complement their conven- Harvard, and John Hopkins Universities, and "rapidly taking tional regimen of drugs and standard procedures with acu- a legitimate place as a valuable therapeutic technique. "1, 2 puncture to augment treatment or palliate adverse side Most states now license acupuncturists to practice under effects. Yet others completely transition to the sole practice of varying degrees of autonomy, and the medical acupuncturist acupuncture treatment, referring to other practitioners when may feel the impact of the changing environment of acupunc necessary,4, 5such as to an oncologist or surgeon for chemo- ture as demand for and understanding of acupuncture con therapy or mastectomy. In the United States, acupuncture is tinues to promote acupuncture into a more sophisticated and most utilized by physicians in the management of musculo- robust system of health care skeletal pain, but due to its high adaptability for treatment of both premorbid and disease states, medical acupuncture is The Legal Environment ding on the individual patient, as well as the particular of Medical Acupuncture A Matter of power nd or Historical Background State Regul A single definition of acupuncture as it is practiced in the United of Medical Acupuncture States does not exist in the legal literature supporting and/or restricting the practice. States vary widely in their regulatory role The incorporation of acupuncture into the Western medical ractio ting beganin mid-16th century Europe with various texts and ture outside of biomedical licensing (MD or DO), to practically United States, physicians were some of the first to formally im- ordaining acupuncture as the practice of medicine. The former plement acupuncture in their practices in the 18th and early while the latter is most clearly delineated in the statutes of New 9th centuries, utilizing the European Chinese medicine texts or Mexico or Florida, where the"acupuncture physician"practices accompanying Chinese herbalists practicing the art . 7 Perhaps cupuncture as a form of "primary health care"for the diagnosis the first well-known text dealing with medical acupuncture is and treatment of disease. 8 Sir William Osler's The Principles and Practice of Medicine,written So far, all states, with one exception, have included acupunc- in 1913, in which acupuncture is clearly indicated for the man- ture within the scope of practice of other health care providers, agement of lower back pain. ' The first licensed acupuncturist on though this body varies in membership across the states, from record was actually the Chinese Ah Fong Chuck, who, in 1901, only the allopathic and osteopathic doctors in most states,to won a medical license through legal action in Idaho. Acupunc ture, though, was generally not recognized as a legal practice of podiatrists, homeopaths, naturopaths, optometrists, and veteri- practice acts appearing in such states as Nevada, Maryland, and marians"in Connecticut 8 Currently, 36 states include acupunc- ture in the scope of a physicians medical or osteopathic license. 8 Oregon in 1973. 8 Recent developments in the environment of The remaining 14 states either require a minimum training of acupuncture, as one of the oldest and most widely used medical about 200 hours on average, clinical expenence, or registration procedurest--from the reclassification of the acupuncture nee- with the state medical board. Thus, the practice of acupuncture dle to a Class Il standard medical device. 9, b to the 1997 NIH by physicians is sanctioned by most state medical boards with consensus statement declaring acupuncture as"widely prac- out any kind of training or proof of experience, whereas in other ticed"and effective in a vast array of medical diseases and symp- states including Hawaii, Pennsylvania, and Rhode Island,sur- toms-has captured the attention of both the scientific comm nities skeptical and embracing of the practice, and the federal Pnsingly stringent requirements exist in initial training,clinical government concerned with patient protection, further re- experience, and registration in order to practice acupuncture &,d search, and regulation of acupuncture. 10. By examining the various licensing statutes across state Today, European medical schools formally teach acupunc one can see that the practice of acupuncture is progressively ture where it is applied in almost all fields of medicine, icine to varying degrees Not surprising, gleaned from this to States with training requirements for physicians wanting to practice acu bIn March 1996. the FDA reclassified the act puncture also include District of Columbia(250 hours), Georgia (300 experimental device to the Class ll standard medical device appropriate hours depending on time entry), Louisiana(6 months), Maryland (300 in standard practice by physicians and general non-physician acupunc- ours), New Jersey (300 hours), New York (300 hours), and virgin ture use. This reclassification a result of increased availability of (200 hours). (See ref. 8, p 12 on Hawaii,s regulations. li][r] Pennsylva- data supporting needle ia State Board of Medicine requires that all physicians must have 200 Results of the NIH consensus, include the awarding of sizable federal grants hours of Category I Continuing Education credits in acupuncture and b or acupuncture and. a federal mandate created the NCCAM to investi- gistered with the board in order to practice acupuncture. Rhode lsland gate complementary and alternative healing modalities under statute contains exemption language for physicians, but the Board of scientific study, to train CAM researchers, and produce authe Medical Licensure and Discipline requires that physicians complete 300 information on CAM to both the public and professional communi hours of acupuncture education that includes a clinical practicum

Physicians incorporate acupuncture into their medical prac￾tice in a variety of ways. Some complement their conven￾tional regimen of drugs and standard procedures with acu￾puncture to augment treatment or palliate adverse side￾effects. Yet others completely transition to the sole practice of acupuncture treatment, referring to other practitioners when necessary,4,5 such as to an oncologist or surgeon for chemo￾therapy or mastectomy. In the United States, acupuncture is most utilized by physicians in the management of musculo￾skeletal pain,2 but due to its high adaptability for treatment of both premorbid and disease states, medical acupuncture is used in preventative, primary, and complementary care, de￾pending on the individual patient, as well as the particular orientation of the provider.2 Historical Background of Medical Acupuncture The incorporation of acupuncture into the Western medical setting began in mid-16th century Europe with varioustexts and treatises published and used by European physicians.6 In the United States, physicians were some of the first to formally im￾plement acupuncture in their practices in the 18th and early 19th centuries, utilizingthe European Chinese medicinetexts or accompanying Chinese herbalists practicing the art.6,7 Perhaps the first well-known text dealing with medical acupuncture is SirWilliam Osler’s The Principles and Practice of Medicine, written in 1913, in which acupuncture is clearly indicated for the man￾agement of lower back pain.7 The first licensed acupuncturist on record was actually the Chinese Ah Fong Chuck, who, in 1901, won a medical license through legal action in Idaho.6 Acupunc￾ture, though, was generally not recognized as a legal practice of health care until the early 1970s, with some of the first licensing practice acts appearing in such states as Nevada, Maryland, and Oregon in 1973.8 Recent developments in the environment of acupuncture, as one of the oldest and most widely used medical procedures4—from the reclassification of the acupuncture nee￾dle to a Class II standard medical device,9,b to the 1997 NIH consensus statement declaring acupuncture as “widely prac￾ticed” and effective in a vast array of medical diseases and symp￾toms—has captured the attention of both the scientific commu￾nities skeptical and embracing of the practice, and the federal government concerned with patient protection, further re￾search, and regulation of acupuncture.10,c Today, European medical schools formally teach acupunc￾ture where it is applied in almost all fields of medicine, whereas in the United States, acupuncture is beginning to be integrated in some medical programs, such as at Georgetown, Harvard, and John Hopkins Universities, and “rapidly taking a legitimate place as a valuable therapeutic technique.”11,12 Most states now license acupuncturists to practice under varying degrees of autonomy, and the medical acupuncturist may feel the impact of the changing environment of acupunc￾ture as demand for and understanding of acupuncture con￾tinues to promote acupuncture into a more sophisticated and robust system of health care. The Legal Environment of Medical Acupuncture A Matter of Power and Opinion: State Regulation A single definition of acupuncture as it is practiced in the United States does not exist in the legal literature supporting and/or restricting the practice. States vary widely in their regulatory role in acupuncture practice from complete disregard of acupunc￾ture outside of biomedical licensing (MD or DO), to practically ordaining acupuncture as the practice of medicine. The former case is demonstrated by states such as Delaware and Alabama, while the latter is most clearly delineated in the statutes of New Mexico or Florida, where the “acupuncture physician” practices acupuncture as a form of “primary health care” for the diagnosis and treatment of disease.8 So far, all states, with one exception, have included acupunc￾ture within the scope of practice of other health care providers, though this body varies in membership across the states, from only the allopathic and osteopathic doctors in most states, to “medical doctors, chiropractors, dentists, physical therapists, podiatrists, homeopaths, naturopaths, optometrists, and veteri￾narians” in Connecticut.8 Currently, 36 states include acupunc￾ture in the scope of a physician’s medical or osteopathic license.8 The remaining 14 states either require a minimum training of about 200 hours on average, clinical experience, or registration with the state medical board.8 Thus, the practice of acupuncture by physicians is sanctioned by most state medical boards with￾out any kind of training or proof of experience, whereas in other states including Hawaii, Pennsylvania, and Rhode Island, sur￾prisingly stringent requirements exist in initial training, clinical experience, and registration in order to practice acupuncture.8,d By examining the various licensing statutes across states, one can see that the practice of acupuncture is progressively becoming acceptable apart from the scope of practice of med￾icine to varying degrees. Not surprising, gleaned from this bIn March 1996, the FDA reclassified the acupuncture needle from a Class III experimental device to the Class II standard medical device appropriate in standard practice by physicians and general non-physician acupunc￾ture use. This reclassification came as a result of increased availability of data supporting needle use. c Results of the NIH consensus, include the awarding of sizable federal grants for acupuncture and...a federal mandate created the NCCAM to investi￾gate complementary and alternative healing modalities under rigorous scientific study, to train CAM researchers, and produce authoritative information on CAM to both the public and professional community. dStates with training requirements for physicians wanting to practice acu￾puncture also include District of Columbia (250 hours), Georgia (300 hours depending on time entry), Louisiana (6 months), Maryland (300 hours), New Jersey (300 hours), New York (300 hours), and Virginia (200 hours). (See ref. 8, p 12 on Hawaii’s regulations.) [i][r] Pennsylva￾nia State Board of Medicine requires that all physicians must have 200 hours of Category I Continuing Education credits in acupuncture and be registered with the board in order to practice acupuncture. Rhode Island statute contains exemption language for physicians, but the Board of Medical Licensure and Discipline requires that physicians complete 300 hours of acupuncture education that includes a clinical practicum. Medical acupuncture 25

and S L. Cohn examination is the basic fact that enough variability exists A. Acupuncture is within the scope of medical practice,ie among state laws dealing with acupuncture to confuse and physicians(MD and DO)are exempt from acupuncture possibly inhibit the advancement of acupuncture as integra- acts set forth. No demonstration of training required tive in medicine. But despite the political reputations of va B. Acupuncture is within the scope of practice of physi ious states or trends of acceptance of nonconventional mo- cians(MD and DO)and demonstration of minimum dalities of medicine, as acupuncture becomes more training required professionally and politically accepted, the reshaping of state C. Acupuncture is within the scope of practice under a laws is inevitable in order to deal with such issues as an different title made explicitly separate from the li ing demand for quality care by patients as part of the censed acupuncturist right to healthcare(ie, right to privacy, access to care)and for D. Physicians may not practice acupuncture if the statu more comprehensive reimbursement. Such a reformulation tory requirements for acupuncture licensure are not has already been seen in Texas through Andrews v. Ballard, where the restriction of acupuncture to the practice of med- icine was deemed unconstitutional for denying access to care The final category is particular to Hawaii, where the State in the form of acupuncture under the right to privacy. 13 Thus, Board of Medical Examiners declares, "medical doctors,os- acupuncture in Texas, although still within the scope of prac teopaths, and physician's assistants who desire to practice e for conventional physicians, is a licensed practice for the acupuncture must be licensed under the laws governing non-physician acupuncturist as of 1993.8 acupuncture." 8.I Thus, only a trained, licensed acupuncturist A spectrum can be created demonstrating the status of may practice acupuncture in the Hawaii, and the medical acupuncture practice in the United States, from placing acu- acupuncturist is held under the same educational standards puncture solely in the hands of licensed physicians (Ala- as nemetes will follow suit on this stringent regulation of non-physician acupuncturist. Though it is doubtful states), on the one end, to titling acupuncturist as"Doctors acupuncture in the near future, Hawaii,s acupuncture statute of primary care, as seen in Florida, New Mexico, and Nevada exemplifies the extreme to which states can regulate the prac the first state to design acupuncture statutes in 1973.8% e In tice of complementary and alternative medicine by physi- puncture, though, a similar spectrum can be formulated. The acupuncture has so long been commonly embodied which regards to the impact state regulations have on medical acu- cians,distinct from conventional medical practice, in which general consensus among 36 states is that acupuncture is What is more likely is that states will eventually become more like the few that presently require some minimal within the scope of practice of medicine, and statutes regu- amount of training of about 200 hours, such as Maryland, lating the training or expertise of physicians practicing acu- New jersey, New York, Virginia, and the District of Colum- puncture are not mentioned or are explicitly stated as non- applicable or exempting. Another ll states require some bia. Thus, although acupuncture will remain within the minimal training, from a vague "adequate training"to up to cope of practice of medicine, some training may be re 300 hours in Georgia, Maryland, New Jersey, and Rhode quired. 8 Thus, in states like New York, a physician only needs Island. 8 The remainder states are either undecided/undeter- to complete the first year of the curriculum at Tri-State Col- lege of Acupuncture in New York City, for example, to obtain puncture altogether, unless licensed as an acupuncturist by more than enough "credit hours to be qualified to practice statute.8 Needless to say, the perception of acupuncture has vember 26, 2003), and completion of this first year in most come a long way in the legal arena, from an outright violation accredited acupuncture schools would fulfill the majority of of the medical practice acts, as demonstrated in Amber v. New state training requirement of usually 200-300 hours. 8 York, to a valid, licensed healing art that insurance companies From the perspective of the patient, might this not be an are beginning to reimburse as an entry point into our health advancement in quality assurance, where all acupuncturists The following is a list of the various categories of legal are assured to have equal and adequate training as set forth by accrediting and credentialing bodies such as the ACAOM and acupuncture practice in relation to medical acupuncturists, the NCCAOM? If patients are truly at the center of policy from least regulated to most restricted construction in medical law. a more coherent set of standards for acupuncture and medical acupuncture practice will en- consistent quality of care and confidence in the In Florida. the title of th sion in general and acupuncture is defined as"a form of primary health care"incor rating"adjunctive therapies and diagnostic techniques. "Nevada, the title of"Doctor"is allowed by statute by the licensed acupuncturist who practices under the title"Doctor of Oriental Medicine"by statute.New acupuncture statute is als Mexico also awards the title"Doctor of Oriental Medicine"or DOM potential to be interpreted as less stringent by the Montana Attomey despite the fact that there are currently no recognized programs at the eneral. (See "Acupuncture and Oriental Medicine Laws, "ref. 8, p 58 doctoral level in acupuncture and Oriental medicine. Statutory defini- " How states determine the number of hours required for medical acupun on of acupuncture includes oriental techniques, "both traditional and turist to practice is both unknown to the author and beyond the scope of modem, for the diagnosis, prevention, correction of any disease the paper. Most likely, states base hour requirements on the or pain..”( see ref.8,pp22-24,59-61,67-69) length of the first year of accredited acupuncture schools

examination is the basic fact that enough variability exists among state laws dealing with acupuncture to confuse and possibly inhibit the advancement of acupuncture as integra￾tive in medicine. But despite the political reputations of var￾ious states or trends of acceptance of nonconventional mo￾dalities of medicine, as acupuncture becomes more professionally and politically accepted, the reshaping of state laws is inevitable in order to deal with such issues as an increasing demand for quality care by patients as part of the right to healthcare (ie, right to privacy, access to care) and for more comprehensive reimbursement. Such a reformulation has already been seen in Texas through Andrews v. Ballard, where the restriction of acupuncture to the practice of med￾icine was deemed unconstitutional for denying access to care in the form of acupuncture under the right to privacy.13 Thus, acupuncture in Texas, although still within the scope of prac￾tice for conventional physicians, is a licensed practice for the non-physician acupuncturist as of 1993.8 A spectrum can be created demonstrating the status of acupuncture practice in the United States, from placing acu￾puncture solely in the hands of licensed physicians (Ala￾bama, Delaware, Kentucky, and Nebraska, among other states8), on the one end, to titling acupuncturist as “Doctors” of primary care, as seen in Florida, New Mexico, and Nevada, the first state to design acupuncture statutes in 1973.8,e In regards to the impact state regulations have on medical acu￾puncture, though, a similar spectrum can be formulated. The general consensus among 36 states is that acupuncture is within the scope of practice of medicine, and statutes regu￾lating the training or expertise of physicians practicing acu￾puncture are not mentioned or are explicitly stated as non￾applicable or exempting. Another 11 states require some minimal training, from a vague “adequate training” to up to 300 hours in Georgia, Maryland, New Jersey, and Rhode Island.8 The remainder states are either undecided/undeter￾mined, or otherwise restrictive of physician practice of acu￾puncture altogether, unless licensed as an acupuncturist by statute.8 Needless to say, the perception of acupuncture has come a long way in the legal arena, from an outright violation of the medical practice acts, as demonstrated in Amber v. New York, to a valid, licensed healing art that insurance companies are beginning to reimburse as an entry point into our health care system. The following is a list of the various categories of legal acupuncture practice in relation to medical acupuncturists, from least regulated to most restricted: A. Acupuncture is within the scope of medical practice, ie, physicians (MD and DO) are exempt from acupuncture acts set forth. No demonstration of training required. B. Acupuncture is within the scope of practice of physi￾cians (MD and DO) and demonstration of minimum training required. C. Acupuncture is within the scope of practice under a different title made explicitly separate from the li￾censed acupuncturist. D. Physicians may not practice acupuncture if the statu￾tory requirements for acupuncture licensure are not met. The final category is particular to Hawaii, where the State Board of Medical Examiners declares, “medical doctors, os￾teopaths, and physician’s assistants who desire to practice acupuncture must be licensed under the laws governing acupuncture.”8,f Thus, only a trained, licensed acupuncturist may practice acupuncture in the Hawaii, and the medical acupuncturist is held under the same educational standards as the non-physician acupuncturist. Though it is doubtful that other states will follow suit on this stringent regulation of acupuncture in the near future, Hawaii’s acupuncture statute exemplifies the extreme to which states can regulate the prac￾tice of complementary and alternative medicine by physi￾cians, distinct from conventional medical practice, in which acupuncture has so long been commonly embodied. What is more likely is that states will eventually become more like the few that presently require some minimal amount of training of about 200 hours,2 such as Maryland, New Jersey, New York, Virginia, and the District of Colum￾bia. Thus, although acupuncture will remain within the scope of practice of medicine, some training may be re￾quired.g Thus, in states like New York, a physician only needs to complete the first year of the curriculum at Tri-State Col￾lege of Acupuncture in New York City, for example, to obtain “more than enough” credit hours to be qualified to practice within the state (Tri-State College telephone interview, No￾vember 26, 2003), and completion of this first year in most accredited acupuncture schools would fulfill the majority of state training requirement of usually 200-300 hours.8 From the perspective of the patient, might this not be an advancement in quality assurance, where all acupuncturists are assured to have equal and adequate training as set forth by accrediting and credentialing bodies such as the ACAOM and the NCCAOM? If patients are truly at the center of policy construction in medical law, a more coherent set of standards for acupuncture and medical acupuncture practice will en￾sure consistent quality of care and confidence in the profes￾sion in general. e In Florida, the title of the licensed acupuncturist is “Acupuncture Physician” and acupuncture is defined as “a form of primary health care” incorpo￾rating “adjunctive therapies and diagnostic techniques.” Nevada, the title of “Doctor” is allowed by statute by the licensed acupuncturist who practices under the title “Doctor of Oriental Medicine” by statute. New Mexico also awards the title “Doctor of Oriental Medicine” or DOM, despite the fact that there are currently no recognized programs at the doctoral level in acupuncture and Oriental medicine. Statutory defini￾tion of acupuncture includes oriental techniques, “both traditional and modern, for the diagnosis, prevention, cure or correction of any disease or pain...” (see ref. 8, pp 22-24, 59-61, 67-69). f Montana acupuncture statute is also constructed similarly, though it has the potential to be interpreted as less stringent by the Montana Attorney General. (See “Acupuncture and Oriental Medicine Laws,” ref. 8, p 58.) gHow states determine the number of hours required for medical acupunc￾turist to practice is both unknown to the author and beyond the scope of the paper. Most likely, states base hour requirements on the average hour length of the first year of accredited acupuncture schools. 26 D.L. Wirsing and S.L. Cohn

Medical acupunc Title Restrictions doctor, physician, or Dr. if a doctoral degree is awarded from a An interesting development in state restrictions on physicians e cognized college or university. 8J practicing acupuncture is how the medical acupuncturists may As more universities and colleges of acupuncture and ori- identify themselves and their practice(as described in category ental medicine develop and subsequently offer doctoral level C"above). Montana is a prime example of this position where programs, a growing body of acupuncture"doctors"may title'acupuncturist'or any similar title unless the person is li- physician of allopathic or osteopathic medicine and the acu- censed under the provisions of this acupuncture statute chap- puncture doctor. It is even debatable whether the standards ter. In Rhode Island, where the title"Doctor of Acupunctur states set for licensure of acupuncturists and the practicing has been awarded to the licensed acupuncturist since 1978, the titles thus granted will change as the ACAOM begins cians to practice"Medical Acupuncture as defined by regula. replace the masters level training in acupuncture, but it may tions, "but they shall not be considered equivalent to licensed be"currently premature for states licensing boards to con- acupuncturists. Rhode Island requires that patients receive ider basing licensure on graduation from a doctoral pro- complete disclosure as to the medical acupuncturist,'s training, gram, "according to the ACAOM. 4, I5J Thus, as the prime route to formal education, as accredited by the ACAOM which must consist of at least 300 hours from a recognized through the U.S. Department of Education, 15,k clinically school and a supervised clinical practicum in order to legally practice.Finally, in New Mexico, acupuncture is considered to practicing graduates of such doctoral programs will be in fact be within the scope of physician practice, but, unless fully li- doctors or " DOMs"performing, in many(perhaps most) censed under the state requirements, physicians are prohibited states,acupuncture and Oriental Medicine for the diagnosis, from using the title"acupuncturist"or any related terms, and treatment, and prevention of disease. even from describing their services as such. New Mexico statute Medical Malpractice: Is this an Issue? declares, "lother physicians] shall not hold themselves out to the public or any private group or business by any title or descrip- Although there have yet to be court cases dealing with mal- tion of services which includes the term acupuncture or acu- practice in medical acupuncture, there are various issues that puncturist unless they are licensed under the Acupuncture Prac- tice Act. B,h Conversely, many states, such as California and ments particular to the conventional phy Washington, are in a mediating position, where the titles"Dr. acupuncture. It will be interesting to see how courts will "OMD, "or "Physician"may be used only when further identifi- handle the issues of standard of care, expert/professional testi cation is explicitly given as to the nature of practice.8 causative injury, and other elements related to malpr Thus, despite the long-standing rule of the American Med- tice specific to acupuncture Shall acupuncture be considered as part of the standard of care as medical communities em- al Association, legal restrictions against"holding oneself out as a medical doctor" through the use of titles may be weak brace it as a legitimate practice, or will there be a separate ening, as some states begin allowing the usage of titles that standard of care dealing with acupuncture? Who would be directly confer to the acupuncturist the role of a healer in the he expert witness or authority for medical acupuncturists? realm of medicine, and more importantly relay to the lay application of medical malpractice specifically to comple patient that the acupuncture"physician"is a valid and per- mentary and integrative medicine in general. 16 Legal writer Michael Cohen, director of Harvard Medical School's Legal As acupuncture continues to be integrated and accepted as a medically valid treatment, it is likely that states will have to respond to the evolving educational mandates set forth by the sTates include Arkansas (DOM if licensed), Hawai (DAC, Doctor, or Dr. formal regulating bodies of acupuncture training and certific Massachusetts(PhD/OMD), New Jersey(OMD or PhD), New York(Do tion On the forefront of developments in acupuncture curricu- tor), Nevada, Utah(Doctor of Acupuncture or Oriental Medicine Doc- lum is the introduction of educational standards for a doctoral tor), and West Virginia, with subtle variability in exact titles permitted. It level degree program in Acupuncture and Oriental Medicine, is worthy to note, though, that some states have other statutes that hibit the use of titles according to certain applications, like education. through which the graduate is awarded a title of "Doctor of What more, the ACAOM has proposed to eventually require all ACAOM Oriental Medicine. "4 This may pose interesting questions on accredited acupuncture training grams to transition to the doctoral how states should regulate the usage of the title"Dr. "in practice. creditation of Masters degree programs in acupuncture after a 10-year transition period, in effect eliminating the ac Although there are currently no schools offering such a degree How this will the title of " Doctor"is already a statutory title in some states, such affect physicians access to training in acupuncture may be negligible but alarming nevertheless. as New Mexico and Rhode Island, in which DOM (in the former) cUrrently, an entry-level doctoral education program in Oriental Medicine or DAc(in the latter)are the only title awarded to licensed and/or Acupuncture is not offcially offered, though the ACAOM has puncturists.Other states permit the usage of titles relating to adopted guidelines for such a program in 2000, which shall consist of 4,000 hours of didactic and clinical training. Although there is much development in acupuncture and Oriental ironically, physicians are otherwise free to practice within their scope of medicine education amongst the professional organizations, acupuncture colleges like Tri-State College of Acupuncture can be ractice, and appropriate training is only recom pected to offer a doctoral program in acupuncture in the near future

Title Restrictions An interesting development in state restrictions on physicians practicing acupuncture is how the medical acupuncturists may identify themselves and their practice (as described in category “C” above). Montana is a prime example of this position where “A person may not purport to practice acupuncture or use the title ‘acupuncturist’ or any similar title unless the person is li￾censed under the provisions of this [acupuncture statute] chap￾ter.”8 In Rhode Island, where the title “Doctor of Acupuncture” has been awarded to the licensed acupuncturist since 1978, the state Board of Medical Licensure and Discipline allows physi￾cians to practice “Medical Acupuncture as defined by regula￾tions,” but they shall not be considered equivalent to licensed acupuncturists.8 Rhode Island requires that patients receive complete disclosure as to the medical acupuncturist’s training, which must consist of at least 300 hours from a recognized school and a supervised clinical practicum in order to legally practice.8 Finally, in New Mexico, acupuncture is considered to be within the scope of physician practice, but, unless fully li￾censed under the state requirements, physicians are prohibited from using the title “acupuncturist” or any related terms, and even from describing their services as such. New Mexico statute declares, “[other physicians] shall not hold themselves out to the public or any private group or business by any title or descrip￾tion of services which includes the term acupuncture or acu￾puncturist unlessthey are licensed underthe Acupuncture Prac￾tice Act.”8,h Conversely, many states, such as California and Washington, are in a mediating position, where the titles “Dr.,” “OMD,” or “Physician” may be used only when further identifi- cation is explicitly given as to the nature of practice.8 Thus, despite the long-standing rule of the American Med￾ical Association, legal restrictions against “holding oneself out as a medical doctor” through the use of titles may be weak￾ening, as some states begin allowing the usage of titles that directly confer to the acupuncturist the role of a healer in the realm of medicine, and more importantly relay to the lay patient that the acupuncture “physician”8 is a valid and per￾haps insurable mode of medical treatment. As acupuncture continues to be integrated and accepted as a medically valid treatment, it is likely that states will have to respond to the evolving educational mandates set forth by the formal regulating bodies of acupuncture training and certifica￾tion. On the forefront of developments in acupuncture curricu￾lum is the introduction of educational standards for a doctoral level degree program in Acupuncture and Oriental Medicine, through which the graduate is awarded a title of “Doctor of Oriental Medicine.”14 This may pose interesting questions on how states should regulate the usage of the title “Dr.” in practice. Althoughthere are currently no schools offering such a degree,14 thetitle of “Doctor” is already a statutorytitle in some states, such as New Mexico and Rhode Island, in whichDOM(inthe former) or DAc (in the latter) are the only title awarded to licensed acu￾puncturists.8 Other states permit the usage of titles relating to doctor, physician, or Dr. if a doctoral degree is awarded from a recognized college or university.8,i As more universities and colleges of acupuncture and ori￾ental medicine develop and subsequently offer doctoral level programs, a growing body of acupuncture “doctors” may challenge the distinguishing line between the conventional physician of allopathic or osteopathic medicine and the acu￾puncture doctor. It is even debatable whether the standards states set for licensure of acupuncturists and the practicing titles thus granted will change as the ACAOM begins to ac￾credit enough programs at the doctoral level as to eventually replace the masters level training in acupuncture, but it may be “currently premature for states licensing boards to con￾sider basing licensure on graduation from a doctoral pro￾gram,” according to the ACAOM.14,15,j Thus, as the prime route to formal education, as accredited by the ACAOM through the U.S. Department of Education,15,k clinically practicing graduates of such doctoral programs will be in fact doctors or “DOMs” performing, in many (perhaps most) states, acupuncture and Oriental Medicine for the diagnosis, treatment, and prevention of disease. Medical Malpractice: Is This an Issue? Although there have yet to be court cases dealing with mal￾practice in medical acupuncture, there are various issues that need to be addressed in future policy and malpractice ele￾ments particular to the conventional physician practicing acupuncture. It will be interesting to see how courts will handle the issues of standard of care, expert/professional testi￾mony, causative injury, and other elements related to malprac￾tice specific to acupuncture. Shall acupuncture be considered as part of the standard of care as medical communities em￾brace it as a legitimate practice, or will there be a separate standard of care dealing with acupuncture? Who would be the expert witness or authority for medical acupuncturists? For now, there is little authoritative literature describing the application of medical malpractice specifically to comple￾mentary and integrative medicine in general.16 Legal writer Michael Cohen, director of Harvard Medical School’s Legal hIronically, physicians are otherwise free to practice within their scope of practice, and appropriate training is only recommended. i States include Arkansas (DOM if licensed), Hawaii (DAc, Doctor, or Dr.), Massachusetts (PhD/OMD), New Jersey (OMD or PhD), New York (Doc￾tor), Nevada, Utah (Doctor of Acupuncture or Oriental Medicine Doc￾tor), and West Virginia, with subtle variability in exact titles permitted. It is worthy to note, though, that some states have other statutes that prohibit the use of titles according to certain applications, like education. j What more, the ACAOM has proposed to eventually require all ACAOM￾accredited acupuncture training programs to transition to the doctoral program after a 10-year transition period, in effect eliminating the ac￾creditation of Masters degree programs in acupuncture. How this will affect physician’s access to training in acupuncture may be negligible but alarming nevertheless. kCurrently, an entry-level doctoral education program in Oriental Medicine and/or Acupuncture is not officially offered, though the ACAOM has adopted guidelines for such a program in 2000, which shall consist of 4,000 hours of didactic and clinical training. Although there is much ongoing debate over this new development in acupuncture and Oriental Medicine education amongst the various professional organizations, acupuncture colleges like Tri-State College of Acupuncture can be ex￾pected to offer a doctoral program in acupuncture in the near future. Medical acupuncture 27

and S L. Cohn Programs for the Division for Research and Education in ical procedures and other CAM treatments, medical acu- mplementary and Integrative Medical Therapies, writes, puncture has the potential to be considered malpractice pe "Whether using Western diagnostic tests or evaluating the se, since the practice is still, by definition, considered outside flow of chi, the physician would be held to the standard of of the standard of care by most courts, relying on the con- care of conventional medicine for related diagnoses and treat- ventional medical community, which often dictates what ments. "16 Likewise, the American Academy for Medical Acu- stance courts will take in medical malpractice. 16 Overall puncture has clearly declared that members are strictly held though, this position is very unlikely since all courts(with to the standard of medical care of their license as a physician few exceptions) now have medical board statements allowing in practice and in referral as part of the Code of Ethics. 7 Dr. the practice of acupuncture as the scope of practice of med- Rotchford of the AAMA writes on the double liability medical icine And"while most complementary and alternative ther- acupuncturists face, between"the legal obligation to provide apies will remain outside of standard care, "6 acupuncture is the standard of care pursuant to a licensed physician"and quickly being integrated into the medical mainstream with the extra liability of providing a surgical procedure based on the rapid growth of medical acupuncturists in hospitals and a poorly understood/accepted physiology "5 But, he further third-party reimbursement programs, more refined and de points out, "The likelihood of being sued for a complication finitive studies that are federally funded, and more educa of acupuncture is nonetheless small. The major liability for a tional initiatives for acupuncture theory in medical school physician remains a missed diagnosis or a delay in providing curricula 2all of which seem to make acupuncture conven- standard therapy, which are also listed by the Federation of tional medicine, by the classic definition of the Eisenberg State Medical Boards in their statement on Complementary study20 so commonly referenced in both legal and biomedical and Alternative Medicine(CAM)use in medical practice. 18 literature. 19,2 Ironically, these same dangers were given by the Texas state Granted, as Cohen states, "Few, if any, sources of legal medical board in Andrews v. Ballard, in regards to non-phy uthority describe the applications of medical malpractice sician acupuncturists; though, in this case, the courts decided rules to the physicians integration of complementary and against the medical board, saying that restricting acupunc alternative medicine, "l and with the majority decision that ture to "those least schooled in the art"italics added for em- acupuncture is within the scope of practice for medical doc- phasis, ie, the physicians, was not a solution to the risks tors and osteopathic physicians, acupuncture spans into the carried in acupuncture treatment. 9 category of medical standard of care. But, overall, malpractice So, is malpractice really a substantive issue of concern for the for the medical acupuncturist should not pose a great threat medical acupuncturist? Considering that adverse side effects of so long as the physician practices with due care and common acupuncture are relatively rare, risks of malpractice are relatively sense in patient treatment as the"best legal protection low. Founding member of the AAMA Dr Joseph Helms writes, A more interesting development may appear once acu- "It is difficult to introduce new and lasting problems with acu- puncture is deemed to surpass the standard care for some puncture treatment, even if the treatment is not designed skill onditions that have, for the standard options, more fully as an experienced provider would desire. "2 A range of ad expensive, invasive, or risky procedures such as surgery, like verse side effects have been cited in relation to acupuncture, in chronic back pain or osteoarthritis. In these situations, in such as fatigue, depression, and other transient psychophysics which both the National Institutes of health and world logical states, syncopy, retained needle, cardiac tamponade, an Health Organization have indicated the effectiveness of organ punctures, like pneumothorax, pneumoperitoneum, he- puncture, the medical acupuncturist (or the medical doctor mothorax, and penetration of the kidney, bladder, and spinal in the future), who does not make available the option for medulla, though all are very rare. Perhaps more commonly, acupuncture in the treatment of these conditions could be liable for malpractice under the principle of lack of informed and bleeding at the insertion point are less severe and temporary consent, where using a fairly ineffective surgery could be undesired consequences of acupuncture treatment, some of equated with an "obsolete technology"that falls below the which are viewed by the Chinese as positive indicators of acu- puncture effectiveness medicine and conventional medicine, would be quite"radi In practice, then, malpractice concerns for the medical cal and controversial, "writes Cohen, "that a physician could acupuncturist will more likely deal with the standard of care liable in malpractice for failing to provide complementary inherent as a physician, rather than those issues related to the and alternative treatments. 0 practice of acupuncture itself, since most side-effects or com- plications, edema or bleeding at insertion point, are too tran- Addressing Variability Among sient to meet the malpractice elements of deviation from the standard of care and patient injury. Furthermore, the more Medical Acupuncturists: Self- serious adverse effects worthy for legal suit, such as serious regulation Through the infection or punctured organs, are unlikely results of acu- American Academy for Medical puncture by professionally trained medical physicians wit Acupunct expertise in anatomy and sterilization techniques Rs Although acupuncture carries a relatively low level of Medical acupuncturists are self-regulated by the professional .16 especially when compared to many conventional med- organization of the American Academy for Medical Acupunc

Programs for the Division for Research and Education in Complementary and Integrative Medical Therapies, writes, “Whether using Western diagnostic tests or evaluating the flow of chi, the physician would be held to the standard of care of conventional medicine for related diagnoses and treat￾ments.”16 Likewise, the American Academy for Medical Acu￾puncture has clearly declared that members are strictly held to the standard of medical care of their license as a physician in practice and in referral as part of the Code of Ethics.17 Dr. Rotchford of the AAMA writes on the double liability medical acupuncturists face, between “the legal obligation to provide the standard of care pursuant to a licensed physician” and “the extra liability of providing a surgical procedure based on a poorly understood/accepted physiology.”5 But, he further points out, “The likelihood of being sued for a complication of acupuncture is nonetheless small. The major liability for a physician remains a missed diagnosis or a delay in providing standard therapy,” which are also listed by the Federation of State Medical Boards in their statement on Complementary and Alternative Medicine (CAM) use in medical practice.18 Ironically, these same dangers were given by the Texas state medical board in Andrews v. Ballard, in regards to non-phy￾sician acupuncturists; though, in this case, the courts decided against the medical board, saying that restricting acupunc￾ture to “those least schooled in the art” [italics added for em￾phasis], ie, the physicians, was not a solution to the risks carried in acupuncture treatment.19 So, is malpractice really a substantive issue of concern for the medical acupuncturist? Considering that adverse side effects of acupuncture are relatively rare, risks of malpractice are relatively low. Founding member of the AAMA Dr. Joseph Helms writes, “It is difficult to introduce new and lasting problems with acu￾puncture treatment, even if the treatment is not designed skill￾fully as an experienced provider would desire.”2 A range of ad￾verse side effects have been cited in relation to acupuncture, such as fatigue, depression, and other transient psychophysio￾logical states, syncopy, retained needle, cardiac tamponade, and organ punctures, like pneumothorax, pneumoperitoneum, he￾mothorax, and penetration of the kidney, bladder, and spinal medulla, though all are very rare.2 Perhaps more commonly, contact dermatitis, inflammation, pain upon insertion of needle, and bleeding at the insertion point are less severe and temporary undesired consequences of acupuncture treatment, some of which are viewed by the Chinese as positive indicators of acu￾puncture effectiveness.2 In practice, then, malpractice concerns for the medical acupuncturist will more likely deal with the standard of care inherent as a physician, rather than those issues related to the practice of acupuncture itself, since most side-effects or com￾plications, edema or bleeding at insertion point, are too tran￾sient to meet the malpractice elements of deviation from the standard of care and patient injury. Furthermore, the more serious adverse effects worthy for legal suit, such as serious infection or punctured organs, are unlikely results of acu￾puncture by professionally trained medical physicians with expertise in anatomy and sterilization techniques. Although acupuncture carries a relatively low level of risk,16 especially when compared to many conventional med￾ical procedures and other CAM treatments, medical acu￾puncture has the potential to be considered malpractice per se, since the practice is still, by definition, considered outside of the standard of care by most courts, relying on the con￾ventional medical community, which often dictates what stance courts will take in medical malpractice.16 Overall, though, this position is very unlikely since all courts (with a few exceptions) now have medical board statements allowing the practice of acupuncture as the scope of practice of med￾icine. And “while most complementary and alternative ther￾apies will remain outside of standard care,”16 acupuncture is quickly being integrated into the medical mainstream with the rapid growth of medical acupuncturists in hospitals and third-party reimbursement programs, more refined and de- finitive studies that are federally funded, and more educa￾tional initiatives for acupuncture theory in medical school curricula12—all of which seem to make acupuncture conven￾tional medicine, by the classic definition of the Eisenberg study20 so commonly referenced in both legal and biomedical literature.19,21-27 Granted, as Cohen states, “Few, if any, sources of legal authority describe the applications of medical malpractice rules to the physicians’ integration of complementary and alternative medicine,”16 and with the majority decision that acupuncture is within the scope of practice for medical doc￾tors and osteopathic physicians, acupuncture spans into the category of medical standard of care. But, overall, malpractice for the medical acupuncturist should not pose a great threat, so long as the physician practices with due care and common sense in patient treatment as the “best legal protection.”16 A more interesting development may appear once acu￾puncture is deemed to surpass the standard care for some chronic conditions that have, for the standard options, more expensive, invasive, or risky procedures such as surgery, like in chronic back pain or osteoarthritis. In these situations, in which both the National Institutes of Health and World Health Organization have indicated the effectiveness of acu￾puncture,10 the medical acupuncturist (or the medical doctor in the future), who does not make available the option for acupuncture in the treatment of these conditions could be liable for malpractice under the principle of lack of informed consent, where using a fairly ineffective surgery could be equated with an “obsolete technology” that falls below the standard of care.16 This interesting reversal of integrative medicine and conventional medicine, would be quite “radi￾cal and controversial,” writes Cohen, “that a physician could be liable in malpractice for failing to provide complementary and alternative treatments.”16 Addressing Variability Among Medical Acupuncturists: Self￾regulation Through the American Academy for Medical Acupuncture Medical acupuncturists are self-regulated by the professional organization of the American Academy for Medical Acupunc- 28 D.L. Wirsing and S.L. Cohn

Medical acupunc ture. The AAMA was initially founded in 1987 by graduates for full membership. Presently no states require such certifi- of UCLA's"Medical Acupuncture for Physicians" training cation, but perhaps the passage of this examination could bo program and now embraces all styles of acupuncture prac- employed as a standard requirement for acupuncture prac tice, 5-element theory, Korean constitutional, Japanese me- tice by physicians in the future. In many cases, membership ridian therapy, electro-acupuncture, etc, under the one dis- eligibility to the AAMa has developed into standard phys tinguishing factor of medical licensure. 16 Standards set forth cian credentialing for physicians in hospital settings, liability for membership are based on the World Federation of Acu- insurance, and reimbursement coverage. It is therefore fore puncture-Moxibustion Societies guidelines for training, 7 seeable that the size and influence of the AAMA will only and the organization itself is presently the sole national pro- continue to influence both the medical and legal environ fessional society in the United States for physician-only acu- ments of medical acupuncture, as more and more regulation puncturists integrates the viewpoints of this professional association, the Statistics from the AAMA reveal an accelerating acceptance general scientifc community, and the tient of acupuncture into the conventional medical communities of allopathic and osteopathic physicians. Beginning with less Conclusion than 50 members in 1987. the AAMA has more than 1800 members with membership doubling every 2 to 3 years. 5A Medical acupuncturists have a definitive role in health care 1997 survey of AAMA members revealed that most were today, utilizing a technique that is a highly adaptable, rela non-specialists in private practice that incorporate acupunc- tively safe, and proven effective Medical acupuncture has the ture into their practice mainly for pain management. 28 1 benefits of integrating both the rigors of biomedical research When asked, physicians claimed that they chose acupunc- and expertise with an ancient knowledge of the bodys un- ture because it is efficacious as a treatment. an alternative in derlying energetic systems to address a more holistic realm of cases of inadequacy of standard medical approach, and because patient care that is becoming more important in health care it offers a"multi-dimensional approach to healthcare. 28 today. Although regulation of non-physician acupuncturists The establishment of a professional organization helps to remains clearly defined and comprehensive in terms of train assuage some of the controversy over the validity of physi ing and licensure, the legal environment of medical acupunc- their medical licen- ture has yet to be formulated beyond being within the scope cians practicing acupuncture as part of their medical licer sure. Competency of medical acupuncturists can at least be of practice of medicine. The main trend within state laws assured through the membership standards of the organiza- governing the medical acupuncturist is one of high variability tion, especially in states lacking any kind of regulation on the and inconsistency across states. Whether a result of the nov- be an active MD or Do licensed to practice in the U.S. or ir cture, or lack of incentive to construct more congruous laws, this confusing network of training requirements and anada;the physician must have completed at least 220 title restrictions only seems to inhibit the acceptance and hours of formal acupuncture training or an apprenticeship refinement of acupuncture by both the medical field and the approved by the Membership Committee; and the physician tific research and more rigorous training requirements across general public. Addressing acupuncture with further scien- must have at least 2 years of clinical experience in acupunc ture. 5, m Additional strata of membership to the AAMA all practicing acupuncturists could unify western biomedi exist for non-practicing physicians, international affliates, cine and traditional Chinese concepts as a more complete and even medical students and residents, demonstrating the and effective system of American health care. Hopefully diverse, growing interest and support of medical acupunc though, increased regulation and quality control of medica acupuncturists does not become so stringent as to limit the ture in the scientific communities, as well as the desire for role physicians have in the deveopment of acupuncture in more formal/authoritative information on acupuncture. nA proficiency examination has also been developed by the Western medicine. Partly because of the relaxed regulatory AAMA as part of a two-part board certification examination, nature of laws regulating physicians in acupuncture, medical but it is unclear whether passing the examination is required acupuncture has yielded innovative applications of acupunc ture in biomedicine. seeding further research and enhanced in the United States is still in this study, a as mailed to 715 members of the AAMA and 312 relatively new field, and thus the legal framework supporting the healing art is rudimentary and anticipatory at best. Con- 12 respondents between the ages of 35-54 years old in private and structing a legal and scientific foundation from which medi- specialty practices. cal acupuncture can be further integrated into physician his 220 hour requirement can be compared to the 300 hours that most practice as not only a complementing but enhancing element states(Georgia, Maryland, New Jersey, New York, and Rhode Island) of patient care is the mission of future policy makers, profes that require training for physicians in order to practice acupuncture Acupuncture programs, on the other hand, must be 3 years in length, sional organizations, and the biomedical community consisting of 1725 hours to be accredited and therefore recognized by References nNote that membership to the AAMA or any professional organization has 1. Accreditation Commission for Acupuncture and Oriental Medicine: many advantageous elements of services, information, and prestige that AccreditationHandbookPartOne,2005.Availableat:http://www. beyond the scope of this paper acaom.org/handbook. htm

ture. The AAMA was initially founded in 1987 by graduates of UCLA’s “Medical Acupuncture for Physicians” training program and now embraces all styles of acupuncture prac￾tice, 5-element theory, Korean constitutional, Japanese me￾ridian therapy, electro-acupuncture, etc, under the one dis￾tinguishing factor of medical licensure.16 Standards set forth for membership are based on the World Federation of Acu￾puncture–Moxibustion Societies guidelines for training,17 and the organization itself is presently the sole national pro￾fessional society in the United States for physician-only acu￾puncturists. Statistics from the AAMA reveal an accelerating acceptance of acupuncture into the conventional medical communities of allopathic and osteopathic physicians. Beginning with less than 50 members in 1987, the AAMA has more than 1800 members with membership doubling every 2 to 3 years.5 A 1997 survey of AAMA members revealed that most were non-specialists in private practice that incorporate acupunc￾ture into their practice mainly for pain management.28,l When asked, physicians claimed that they chose acupunc￾ture because it is efficacious as a treatment, an alternative in cases of inadequacy of standard medical approach, and because it offers a “multi-dimensional approach to healthcare.”28 The establishment of a professional organization helps to assuage some of the controversy over the validity of physi￾cians practicing acupuncture as part of their medical licen￾sure. Competency of medical acupuncturists can at least be assured through the membership standards of the organiza￾tion, especially in states lacking any kind of regulation on the extent of training or experience of the medical practitioner. Full membership requires three elements: the physician must be an active MD or DO licensed to practice in the U.S. or Canada; the physician must have completed at least 220 hours of formal acupuncture training or an apprenticeship approved by the Membership Committee; and the physician must have at least 2 years of clinical experience in acupunc￾ture.11,15,m Additional strata of membership to the AAMA exist for non-practicing physicians, international affiliates, and even medical students and residents, demonstrating the diverse, growing interest and support of medical acupunc￾ture in the scientific communities, as well as the desire for more formal/authoritative information on acupuncture.11,n A proficiency examination has also been developed by the AAMA as part of a two-part board certification examination,2 but it is unclear whether passing the examination is required for full membership. Presently no states require such certifi- cation, but perhaps the passage of this examination could be employed as a standard requirement for acupuncture prac￾tice by physicians in the future. In many cases, membership eligibility to the AAMA has developed into standard physi￾cian credentialing for physicians in hospital settings, liability insurance, and reimbursement coverage.2 It is therefore fore￾seeable that the size and influence of the AAMA will only continue to influence both the medical and legal environ￾ments of medical acupuncture, as more and more regulation integrates the viewpoints of this professional association, the general scientific community, and the patient. Conclusion Medical acupuncturists have a definitive role in health care today, utilizing a technique that is a highly adaptable, rela￾tively safe, and proven effective. Medical acupuncture has the benefits of integrating both the rigors of biomedical research and expertise with an ancient knowledge of the body’s un￾derlying energetic systems to address a more holistic realm of patient care that is becoming more important in health care today. Although regulation of non-physician acupuncturists remains clearly defined and comprehensive in terms of train￾ing and licensure, the legal environment of medical acupunc￾ture has yet to be formulated beyond being within the scope of practice of medicine. The main trend within state laws governing the medical acupuncturist is one of high variability and inconsistency across states. Whether a result of the nov￾elty and uncertainty towards the discipline of medical acu￾puncture, or lack of incentive to construct more congruous laws, this confusing network of training requirements and title restrictions only seems to inhibit the acceptance and refinement of acupuncture by both the medical field and the general public. Addressing acupuncture with further scien￾tific research and more rigorous training requirements across all practicing acupuncturists could unify western biomedi￾cine and traditional Chinese concepts as a more complete and effective system of American health care. Hopefully, though, increased regulation and quality control of medical acupuncturists does not become so stringent as to limit the role physicians have in the development of acupuncture in Western medicine. Partly because of the relaxed regulatory nature of laws regulating physicians in acupuncture, medical acupuncture has yielded innovative applications of acupunc￾ture in biomedicine, seeding further research and enhanced patient care. But acupuncture in the United States is still a relatively new field, and thus the legal framework supporting the healing art is rudimentary and anticipatory at best. Con￾structing a legal and scientific foundation from which medi￾cal acupuncture can be further integrated into physician practice as not only a complementing but enhancing element of patient care is the mission of future policy makers, profes￾sional organizations, and the biomedical community. References 1. Accreditation Commission for Acupuncture and Oriental Medicine: Accreditation Handbook, Part One, 2005. Available at: http://www. acaom.org/handbook.htm l In this study, a survey was mailed to 715 members of the AAMA and 312 responded for the analysis of the data. Results showed that there were 312 respondents between the ages of 35-54 years old in private and specialty practices. mThis 220 hour requirement can be compared to the 300 hours that most states (Georgia, Maryland, New Jersey, New York, and Rhode Island) that require training for physicians in order to practice acupuncture. Acupuncture programs, on the other hand, must be 3 years in length, consisting of 1725 hours to be accredited and therefore recognized by most states. nNote that membership to the AAMA or any professional organization has many advantageous elements of services, information, and prestige that are beyond the scope of this paper. Medical acupuncture 29

D L. Wirsing and SL cohn 2. Helms JM: Medical acupuncture, in Jonas WB, Levin JS(eds): Essentials the Accreditation Commission for Acupuncture and Oriental Medicine. of Complementary and Altemative Medicine. Baltimore, MD, Lippin- No.16,2003.Availableathttp://www.acaom.org/newsletter.asp ott, williams, and wilkins, 1999, pp 340-3 16. Cohen MH: Beyond Complementary Medicine: Legal and Ethical Per 3. Wisneski L: Medical Acupuncture: Clinical Overview. Lecture at spectives on Health Care and Human Evolution. Ann Arbor, MI, Uni- eorgetown University School of Medicine, September 30, 2003 Ii versity of Michigan Press, 2003 cording and notes on file with the author 17. American Academy of Medical Acupuncture: About the AAMA [on- 4. Acupuncture Information and Resources: Finding a Licensed Practitio- line].Availableathttp://www.medicalacupuncture.org/aama_marf/ ner.Availableat:Mhttp://www.thebody.com/nccam/acupuncture/ aama. html cupuncture. html*findpract 18. Federation of State Medical Boards of the United States, Inc: Model 5. Rotchford JK: Incorporating medical acupuncture into a standard med- Guidelines for the Use of Complementary and Altemative Therapi ical practice. American Academy of Medical Acupuncture. Available MedicalPractice[online].Availableat:http://www.camlawblog http://www.medicalacupuncture.org/acu_info/articles/incorporating com/professional-discipline-45-federation-of-state-medical-board delines html html 6. Ergil KV: Chinese medicine, in Micozzi MS(ed): Fundamentals of 19. Cohen MH: Complementary and Alternative Medicine: Legal Bound aries and Regulatory Perspectives. Baltimore, MD, John Hopkins Uni Complementary and Alternative Medicine (ed 2). New York, NY, 20. Eisenberg DM, Davis RB, Ettner SL, et al: Trends in alternative medicine 7. Ergil KV: Acupuncture: History, theory, and practice, in Wisneski use in the United States, 1990-1997: Results of a follow-up national (ed): The Physician's Integrative Medicine Companion. Newton, MA, survey.JAMA280:1569-1575,1998 ntegrative Medicine Communications, 2000, pp 18-28 Astin JA: Why patients use altemative medicine. JAMA 279: 1548 8. Mitchell BB: Acupu and Oriental Medicine Laws. Washington, DC, National Acupuncture Foundation, 2001 22. Josefek K]: Altemative medicine s roadmap to mainstream. Am J Lay 9. U.S. Food and Drug Administration Updates, June 1996. Available at: Med26:295-310,2000 http://www.fda.gov/fdac/departs/596upd.html 23. De Smet PA: Herbal remedies. N Engl J Med 347: 2046-2056, 2002 10. NIH Consensus Statement 107, 15(5)(November 3.5, 1997). Available 24. Barrett S: The Alternative Medical Practice Act: Does it adequately http://consensus.nihgov/cons/107/107introhtm rotect the right of physicians to use complementary and alternative 11. American Academy of Medical Acupuncture [online]. Available at medicine? St Johns Law Rev 77: 75-122, 2003 http://www.medicalacupuncture.org/aama_marf/aama_membership 25. Van Hemel P: A way out of the maze: Federal agency preemption of state licensing and regulation of complementary and alternative medi ne practitioners. Am J Law Med 27, 2001 2.Wetzel MS, Eisenberg DM, Kaptchuk T]: Courses involving comple- 26. Studdert DM, Eisenberg DM, Miller FH, et al: Medical malpractice AMA280:1619-1615,1998 84787,1998 13. Andrews v. Ballard, 498 F. Supp. 1038(SD. Tex plementary and Altenative Medi cine Policy [online 14.AcaoM:QuestionsAskedbyLicensingBoards.Availableathttp:// fr2. html 28. Diehl DL, Kaplan G, Coulter I, et al: Use of acupuncture by american 15. Acupuncture and Oriental Medicine Accreditation: The Newsletter of ysicians. J Altern Complement Med 3: 119-126, 1997

2. Helms JM: Medical acupuncture, in Jonas WB, Levin JS (eds): Essentials of Complementary and Alternative Medicine. Baltimore, MD, Lippin￾cott, Williams, and Wilkins, 1999, pp 340-354 3. Wisneski L: Medical Acupuncture: Clinical Overview. Lecture at Georgetown University School of Medicine, September 30, 2003 [re￾cording and notes on file with the author] 4. Acupuncture Information and Resources: Finding a Licensed Practitio￾ner. Available at: Mhttp://www.thebody.com/nccam/acupuncture/ acupuncture1.html#findpract. 5. Rotchford JK: Incorporating medical acupuncture into a standard med￾ical practice. American Academy of Medical Acupuncture. Available at: http://www.medicalacupuncture.org/acu_info/articles/incorporating. html 6. Ergil KV: Chinese medicine, in Micozzi MS (ed): Fundamentals of Complementary and Alternative Medicine (ed 2). New York, NY, Churchill Livingstone, 2001, pp 303-344 7. Ergil KV: Acupuncture: History, theory, and practice, in Wisneski LA (ed): The Physician’s Integrative Medicine Companion. Newton, MA, Integrative Medicine Communications, 2000, pp 18-28 8. Mitchell BB: Acupuncture and Oriental Medicine Laws. Washington, DC, National Acupuncture Foundation, 2001 9. U.S. Food and Drug Administration Updates, June 1996. Available at: http://www.fda.gov/fdac/departs/596upd.html. 10. NIH Consensus Statement 107, 15(5) (November 3-5, 1997). Available at: http://consensus.nih.gov/cons/107/107 intro.htm. 11. American Academy of Medical Acupuncture [online]. Available at: http://www.medicalacupuncture.org/aama_marf/aama_membership. html. 12. Wetzel MS, Eisenberg DM, Kaptchuk TJ: Courses involving comple￾mentary and alternative medicine at US medical schools. JAMA 280: 784-787, 1998 13. Andrews v. Ballard, 498 F. Supp. 1038 (S.D. Tex. 1980) 14. ACAOM: Questions Asked by Licensing Boards. Available at: http:// www.acaom.org/faq q7.htm#q3. 15. Acupuncture and Oriental Medicine Accreditation: The Newsletter of the Accreditation Commission for Acupuncture and Oriental Medicine. No. 16, 2003. Available at: http://www.acaom.org/newsletter.asp 16. Cohen MH: Beyond Complementary Medicine: Legal and Ethical Per￾spectives on Health Care and Human Evolution. Ann Arbor, MI, Uni￾versity of Michigan Press, 2003 17. American Academy of Medical Acupuncture: About the AAMA [on￾line]. Available at: http://www.medicalacupuncture.org/aama_marf/ aama.html. 18. Federation of State Medical Boards of the United States, Inc: Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice [online]. Available at: http://www.camlawblog. com/professional-discipline-45-federation-of-state-medical-board￾guidelines.html. 19. Cohen MH: Complementary and Alternative Medicine: Legal Bound￾aries and Regulatory Perspectives. Baltimore, MD, John Hopkins Uni￾versity Press, 1998 20. Eisenberg DM, Davis RB, Ettner SL, et al: Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 280:1569-1575, 1998 21. Astin JA: Why patients use alternative medicine. JAMA 279:1548- 1553, 1998 22. Josefek KJ: Alternative medicine’s roadmap to mainstream. Am J Law Med 26:295-310, 2000 23. De Smet PA: Herbal remedies. N Engl J Med 347:2046-2056, 2002 24. Barrett JS: The Alternative Medical Practice Act: Does it adequately protect the right of physicians to use complementary and alternative medicine? St Johns Law Rev 77:75-122, 2003 25. Van Hemel PJ: A way out of the maze: Federal agency preemption of state licensing and regulation of complementary and alternative medi￾cine practitioners. Am J Law Med 27, 2001 26. Studdert DM, Eisenberg DM, Miller FH, et al: Medical malpractice implications of alternative medicine. JAMA 280:1619-1615, 1998 27. White House Commission on Complementary and Alternative Medi￾cine Policy [online]. Available at: http://www.whccamp.hhs.gov/ fr2.html. 28. Diehl DL, Kaplan G, Coulter I, et al: Use of acupuncture by American physicians. J Altern Complement Med 3:119-126, 1997 30 D.L. Wirsing and S.L. Cohn