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Yemeng Chen, New York College of Traditional Chinese Medicine
Abstract: This article is a comprehensive introduction to the gen- eral situation of education and practice of acupuncture and Chinese herbal medicine in the United States. Education system which has been established for Acupuncture and Chinese herbal medicine in the United States and its admission requirements, curriculum, and professional competencies have been formulated. The National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM) Examination is one of the main require- ments for receiving an acupuncture license in all states (except California). The article introduces what is required for examination eligibility, its format, modules, and content, as well as contin- uing education requirements for NCCAOM diplomates. At the same time, it introduces the status quo of acupuncture legislation in the United States, the scope of practice, and the requirements and procedures for license application.Acupuncture in the United States has been been adopted as a native part of the healthcare system, and it is likely that the acupuncture development will enter a new stage.
KEYWORDS: United States; Acupuncture; Chinese herbal medicine; Education; NCCAOM Exam; Acupuncture License. After more than half a century of development, acupuncture has become an integral part of the American healthcare system. Today, integrative medicine is a major trend, and the concept of “patient-centered care” has been adopted in medical practice. In the crisis caused by opioid drug abuse, the promotion of nonpharmacological pain management has reached a consensus among legislatures, government agencies, and medical research institutions. Acupuncture has played an important role on this initiative (1) . Outside of mainland China, the United States is con- sidered as the largest, most systematic, and most influential in its education and practice of acupuncture and Chinese herbal medicine (2) . This article is an overview of this development.
1. Education of Acupuncture & Chinese Herbal Medicine in the United States
Acupuncture education in the United States began in the early 1970s and the New England School of Acupuncture was established in 1976, which was the first acupuncture school officially approved by the government in US history (3). As acupuncture has gradually gained legislative status in various states, acupuncture schools have been booming, and have developed distinct characteristics due to different traditions. At present, there are 52 acupuncture schools or colleges (departments) accredited by the Accreditation Commission for Acupuncture and Herbal Medicine (ACAHM), which is also recognized by the US Department of Education.
1.1 Admission requirements. At present, the entry-level of education in acupuncture and Chinese herbal medicine in the United States is a master’s degree program. The admission requirement is completion of at least 2 years of undergraduate study (60 credits) in American accredited colleges or universities, while professional doctoral programs require at least 3 years of undergraduate study (90 credits). Credits for undergraduate study received in a foreign country must be evaluated by a recognized educational evaluation service. International students whose native language is not English must also demonstrate his/her proficiency in English level, either holding a four-year U.S. high school diploma, or having two years of undergraduate study at an accredited college or university in the U.S. (or foreign countries in an English-language instruction), or having TOEFL score of 61 or IELTS score of 6, or achieving Level 6 of the China English Language Standard Test.
1.2 Curriculum. There are three educational levels of acupuncture and Chinese herbal medicine in the United States.
The Master’s degree in Acupuncture is the current professional entry-level, at least 3 academic years in length. Curriculum includes East Asian medical theory, diagnosis and treatment techniques in acupuncture and related studies, biomedical clinical sciences, professional development including counseling, communication, ethics, and practice management, and clinical training. The ACAHM’s minimum standards for entry-level education must be at least 105 credits (1905 hours), of which clinical training should be at least 22 credits (660 hours). The 4-year Master of Acupuncture with a Chinese herbal medicine specialization (or Master of Acupuncture with Chinese herbal medicine) program covers both acupuncture and Chinese herbal medicine, which should be a total of no less than 146 credits (2625 hours) with instruction in integrated acupuncture and herbal clinical training. After graduating from a master’s degree in acupuncture, students who want to study Chinese herbal medicine can enroll in a Certificate in Chinese Herbal Medicine program which is a minimum of 41 credits of instruction. The actual number of instruction hours or credits in each college is much higher than those minimum standards.
The Professional Entry Level Doctorate (D.AC.) is a 4-year program. Doctoral education as a professional entry standard is the trend of acupuncture and Chinese herbal medicine education in the United States. It is estimated that it will take 5-10 years to be fully implemented.
The Advanced Practice Doctoral (DAOM) program is a 2-year postmaster clinical doctoral education, which is mainly focused on specialties like pain management, gynecology, or oncology, which varies from school to school.
1.3 Professional Competencies. Professional training not only requires the above-mentioned minimum number of hours of instruction, but graduates must also meet the corresponding competencies required by the college’s educational goals, especially clinical competencies. The professional competence formulated by ACAHM includes three aspects, Patient Care (foundational knowledge, critical thinking professional judgment, history taking and physical examination, East Asian Medicine-based diagnosis, case management, East Asian Medi- cine-based treatment, emergency management, and advanced diagnostic studies), System-Based Medicine (education and communication, patient care system, collaborative care) and Professional Development (education and communication, formulating and implementing plans for individual professional development, incorporating scholarship, research and evidence-based medicine/ evidence-based practice into patient care). Each of these competencies includes different domains and specific sub-items. Among them, “case management” is a new concept. In this do- main, students must demonstrate the ability such as awareness of and familiarity with culture competency (understanding the cultural background of different ethnic groups and LGBTQ+ community), communicating with other healthcare providers to determine an appropriate plan of care, providing a report of findings and health care plan to the patient, creating reports and professional correspondence relevant to the care of patients, identifying a range of referral resources and the modalities they employ, and using information systems in case management. It shows that the clinical competencies in training are of great importance to integrative medicine, safety, and regulatory compliance.
2. National Board Exam for Acupuncture & Chinese Herbal Medicine
The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is responsible for the national board exam for Acupuncture and Chinese herbal medicine. Except California, all states which have legalized acupuncture use NCCAOM exams as an important aspect of the credential review in the process of applying for an acupuncture license.
2.1 Eligibility and Exam Format. Graduates from regular acupuncture schools accredited by ACAHM are eligible to participate in the exams. Graduates from TCM colleges in mainland China can first contact NCCAOM and have their transcripts evaluated by its designated educational evaluation agency. Generally, the credits of graduates from the Department of Acupuncture and Moxibustion or Department of Chinese Medicine in TCM universities in China basically meet the professional entry-level standards recognized by ACAHM, or they may only need to make up some credits such as ethics and clinical consultation.
Exams are taken online. When an NCCAOM Authorization to Test Letter is received, applicants can directly contact the nearest Pearson VUE Testing Center to schedule an examination time. Different modules can be scheduled at different times.
2.2 Examination modules and contents. The NCCAOM Examination has four modules, each having 100 multiple-choice questions with a 2.5-hour time limit. The exams are administered in computer-adaptive format, that is, they adjust the difficulty of the next exam questions in real-time according to the performance on the answers given so far. The Foundation of Oriental Medicine module covers the contents of clinical examination methods, assessment, analysis, and differential diagnosis based upon acupuncture and Chinese medicine theory, and treatment principles and strategy. The Acupuncture with Point Location module tests safety and professional responsibilities, treatment plan, treatment techniques, and acupuncture point location. The Biomedicine module covers the clinical application of biomedical sciences(e.g., anatomy, physiology, pathology, pathophysiology), pharmacology, and nutrients and supplements, patient history and physical examination, clinical assessment process, and safety and professional responsibilities. The Chinese Herbology module includes content on the safety and quality of Chinese herbs, treatment planning and strategy, and patient management. If you pass the first three exams, you will be awarded a Diplomate of Acupuncture; if you pass all four exams, you will be awarded a Diplomate of Oriental Medicine. Before taking the examinations, a Clean Needle Technique (CNT) Certificate is required.
The exam has a clear content outline and a detailed bibliography. The Acupuncture with Point Location Content Outlines has an appendix of 27 extra points. The Biomedicine Content Outline has three appendices including pharmaceuticals, nutrients and supplements, and medical conditions. The Chinese Herbology Content Outline listed 272 Chinese individual herbs and 162 Chinese herbal formulas.
2.3 Continuing education requirements for NCCAOM Diplomates. All NCCAOM diplomates should renew their certificates every four years and provide 60 points for Professional Development Activities (PDA). They can update and enrich relevant knowledge in the core categories of Oriental Medicine Foundation Theory, Acupuncture, Chinese Herbology and Biomedicine/Western Medicine by attending lectures. When it is time to renew, it is specified to attend a practice safety lecture (2 points) and professional ethics lecture (2 points) during the 4-year time period and a current Cardiopulmonary Resuscitation (CPR) Certificate (4 points) among 60 PDAs.
3. Acupuncturist Practice and License in the United States
3.1 Overview of Acupuncture Legislation in the United States. In 1973, the legal practice of acupuncture and Chinese herbal medicine were successfully legislated in Nevada, which opened a new chapter for its professional development in the United States. Afterward, the Practice Acts for acupuncture have gradually passed in various states. This kind of grassroots lobbying and legislative campaign was very difficult but successful. So far, acupuncture has legal status in 47 states plus Washington, D.C., only South Dakota, Oklahoma, and Alabama do not have legislation in place.
3.2 Scope of Acupuncture Practice. In the United States, special attention should be paid to the scope of practice of acupuncture licenses in each state(5) . The definition of acupuncture profession with practice scope of acupuncturists varies from state to state, while it includes Chinese herbal medicine in California, Florida, and New Mexico, and it also includes injection therapy in Florida and Colorado. According to the definition of the profession of acupuncture in New York State Law, it is the treatment, by means of mechanical, thermal or electrical stimulation, effected by the insertion of needles or by the application of heat, pressure or electrical stimulation, at a point or combination of points on the surface of the body predetermined on the basis of the theory of the physiological interrelationship of body organs with an associated point or combination of points for disease, disorders and dysfunctions of the body for the purpose of achieving a therapeutic or prophylactic effect. The law also described that the profession of acupuncture includes the recommendation of dietary supplements (like herbal remedies) and natural products. (6)
3.3 Requirements and procedures for license application. Those who hold a diploma from a regular acupuncture college and obtain an NCCAOM Diplomate of Acupuncture (or Oriental Medicine) are eligible to apply for an acupuncture license in various states which have an acupuncture practice act. California only accepts individuals who graduated from colleges recognized by the California Acupuncture Board and passed the California Acupuncture Licensing Exam. In the states that have licensure there are governmental agencies that administrate acupuncture licenses. Log on the website of the corresponding acupuncture board of the state government to learn about the requirements and application procedures for acupuncture licenses. The state acupuncture board usually contacts the college or university directly to verify 60 credits of pre-professional study and professional acupuncture study. NCCAOM test results will also be delivered directly by NCCAOM to the state board. Some states have other regulations. For example, non-Florida acupuncture school graduates who apply for a license in Florida must also complete additional training which includes 15 hours supervised instruction in universal precautions applicable to needling techniques, 20 hours on the laws and rules of practice in Florida, and 60 hours for an injection therapy course.
Conclusion
Acupuncture is an emerging profession with potential in the US healthcare system. The Department of Labor has promulgated a new occupational code 29- 1291.00 for acupuncture, and it is expected that there will still be an average growth of 4-7% in the next few years (7) . Through the efforts of several generations, the acupuncture profession now has a well-established system of entry-level standards, college accreditation, curriculum and professional competencies, board exam system, and license administration that reflect a true adoption of the acupuncture profession in the United States. With the continuous expansion of integrated medicine, the further implementation of non-pharmacological pain management, and more acceptance of acupuncture in the insurance industry, the professional development of acupuncture will enter a new stage.
References
1.Chen Y. Acupuncture: An Important Modality in Non-Pharmacological Pain Management. J Complement Med Alt Healthcare. 2018; 5(1):555653. DOI: 10. 19080/JCMAH.2018.05.555653.
2. Boli Zhang Editor-in-Chief. Overview of World Chinese Medicine Education. China Press of Traditional Chinese Medicine, Beijing. 2019, pp.83-88. (In Chinese)
3. Yemeng Chen. A Perspective of Acupuncture Education in the United States. J Complement Med Alt Healthcare. 2019; 9(5): 555773. DOI: 10. 19080/JCMAH.2019.09.555773
4.Directory of Accredited/Pre-accredited Programs and Institutions. https://acahm.org/directory-menu/directory/[Accessed on February 8, 2023]
5. A look at American Chinese medicine education and Chinese medicine practitioners practicing in the United States—Interview with Yemeng Chen, President of the New York College of Traditional Chinese Medi- cine. Kailin Zhou, Qing Wu, et al. Guiding Journal of Traditional Chinese Medicine. 25(15):1-3, 2019 (In Chinese)
6.New York State Education Law, Article 160, Acupuncture. https:// www.op.nysed.gov/professions/acupuncture/laws-rules-regulations/ article-160[Accessed on February 8, 2023]
7.Acupuncturists (29- 1291.00). O*Net OnLine. https:// www.onetonline.org/link/summary/29-1291.00?redir=29-1199.01
(Accessed on February 10, 2023)
美國中醫針灸教育與執業概述
陳業孟(美國紐約中醫學院)
摘要： 本文全面介紹美國中醫針灸教育與執業概況。美國中醫針灸教育已成體系，其入學條件、課程設置、專業能力標準均已健全；全美中醫針灸資格考試是各州(除加州)審核針灸執照的主要條件之一，本文具體介紹了考試資格與形式、考試模塊與內容，以 及證書持有者繼續教育要求；同時介紹美國針灸立法現狀、執業範圍與執照申請要求與步驟。針灸在美國本土化已經形成，可預見針灸專業的發展將進入一個新的階段。
關鍵詞：美國；針灸；中醫藥學；
教育；資格考試； 針灸執照
歷經半個多世紀的發展，針灸已成為美國醫療健康體系中不可或缺的組成部分。如今，整合醫學成為大趨勢，“以病人為中心”的概念深入醫療實踐，在鴉片類藥物濫用造成的危機中，推廣非藥物疼痛管理已成立法機構、政府部門、醫療研究單位的共識，而針灸扮演了重要角色 (1) ，美國中醫針灸教育與執業在中國 大陸以外地區最具規模、最具體系、最具影響 (2) ，本文對此作一概述。
1. 美國中醫針灸教育
美國針灸教育肇始於上世紀70年代初，新英格蘭針灸學校成立於1976年，是美國歷史上第一家政府正式批准的針灸學校 (3) 。隨著針灸在各州逐漸獲得立法地位，針灸學校猶如雨後春筍不斷增加，由於傳統不一，具有明顯的多元特色。目前獲得“針灸與草藥醫學院校認證委員會(ACAHM)認證、也即聯邦教育部認可的中醫針灸院校(系)有52所 (4)。
1.1入學條件：目前全美中醫針灸教育以碩士學位為准入水準，其錄取標準為在美國高等院校完成至少2年的 本科教育( 60學分)，而專業博士課程則需要至少3 年的本科教育(90學分)。如在外國接受的本科教育，其學分必須由公認的教育證書評估服務機構評。 母語非英語的國際學生還必須證明其英語水平，或持有美國四年高中畢業證書、或在美國(或英語教學 體系的外國)獲得正式認證的大學中有兩年本科學習經歷、或托福考試61分、或雅思考試6分、或中 國英語語言標準考試6級等。
1.2 課程設置：全美中醫針灸教育有以下三大層次。針灸碩士是目前專業准入水平，學制3年，課程包括中醫基礎、針灸理論與治療、臨床生物醫學、專業發展(包括臨床諮詢、與病人交流溝通技巧、倫理學和開業管理等課程)、以及臨床實習。根據ACAHM專業准入最低標準，課程至少105學分(1905小時)，其中臨床實習至少22學分(660小時)。 4年制針灸碩士(中醫藥學專長)或稱針灸與中醫藥學碩士課程包括針灸與中藥，總學時數不少於146學分(即2625小時)，臨床實習也必須綜合針灸與中藥治療。針灸碩士畢業後再學中藥可參加中醫藥學證書課程，至少41學分。各學校實際課時數遠遠高於這個最低標準。專業博士(D.AC.)的學制為4年，專業准入博士化教育是全美中醫針灸教育趨勢，全面實施博士化 教育估計需5- 10時間。臨床專科博士(DAOM) 是2年制碩士後臨床專科博士教育，或以痛症為主、或以婦科為主、或以腫瘤學為主，各學校不一。
1.3專業能力：專業培養不僅有上述學時數要求，畢業生還必須達到學校總體教育目的所要求的相應能力，尤其是臨床能力。
ACAHM制定的專業能力包括三大方面，病患醫療 (基礎知識、批判性思維與專業判斷、病史採集與 檢查、中醫診斷、病案管理、中醫治療、應急處理 和現代診斷研究)、系統醫學 (教育與交流、醫療體系運作、醫療協作)以及專業發展 (教育與交流、規劃與實施個人專業發展計劃、將學術、研究 和循證醫學實踐納入病患醫療)，三大方面能力每一項均有具體子條目。其中“病案管理”是新概念，如展示病案管理中 的文化能力(了解不同族裔、特殊社群的文化背景)；與其他醫療保健專業人員交流以確定適當的治療計劃；向患者提供檢查結果和醫療計劃的報告； 創建與患者治療相關的報告和專業信函；確認一系列轉診資源以及他們的專業與採用的治療手段；在病案管理中使用信息系統等。由此可見，臨床能力培養重 視整合醫學、安全性與規章制度的合規。
2. 美國中醫針灸資格考試
全國針灸與東方醫學證書委員會(NCCAOM)負責全 國中醫針灸資格考試，除加利福尼亞州，各州均以此資格證書作為申請針灸執照的條件。
2.1考試資格與形式：獲得ACAHM認證的正規針灸院校畢業生都有資格參加。如果中國大陸中醫院校畢業生，可以先聯絡NCCAOM ，並在其指定的學歷評估機 構評估成績單。一般國內中醫藥大學針推系、醫學系畢業生的學分基本滿足ACAHM認定專業准入標準，或僅需補修倫理學、臨床諮詢等學分即可。考試在線上進行。當收到考試批准信函後，聯繫就近的專業考試中心預訂考試時間，幾個模塊可以安排在不同時間應試。
2.2考試模塊與內容：全美中醫針灸資格考試設有四個模塊，每個模塊100道多選題，在2.5小時內完成，考題採用計算機適應性測試形式，即根據答題的表現及時調整接下來考題的難度。 中醫基础考試包括臨床診斷方法、根據中醫理論進行評估分析和辨證、治則與治法。 針灸及腧穴定位考試包括安全和職業責任、治 療計劃、治療技術、穴位定位。 生物醫學考试涵蓋生物醫學科學的臨床應用(包括解剖學、生理學、病理學、病理生理學等)、 藥理學、營養素和保健品知識、病史和體格檢查、臨床評估程序、診所安全和職業責任。 中藥考试包括中藥安全與質量、治療計劃和策略、病人管理。如果通過前三項，可獲頒針灸資格 證書；如果通過全部四項考試，可獲頒東方醫學資格證書。參加考試前需提供潔針技術證書。
考試有明確大綱，詳列參考書目。針灸及腧穴定位考綱列27個經外奇穴，生物醫學考綱有藥物、營養素和保健品、臨床病症等三個附錄，中藥考綱載有272 味中藥與162個方劑名錄2.3證書持有者繼續教育要求： 所有中醫針灸資格證書持有者，四年要更新一次證書，提供60個專業發展活動點數，可以通過聽取講座來更新、充實有關中醫、針灸、中藥以及生物醫學知識，但四年中必須參加一次執業安全講座(2分)與專業 倫理講座(2分)，並遞交仍在有效期的心肺復甦證書(4分)。
3.美國針灸師執業與執照
3.1美國針灸立法概況： 1973年針灸與中草藥在內華達州成功立法，為中醫針灸在美國的專 業發展開啟了新篇章。隨後星火燎原，針灸立 法在各州逐漸展開，這種草根性遊說立法運動 非常艱難也很成功，到目前為止針灸已在全美 47個州與華盛頓特區具有立法地位，僅南達科 塔州、俄克拉荷馬州、阿拉巴馬州尚未立法。
3.2針灸執業範圍：在美國執業，尤其要注意各個州針灸執照的執業範圍 (5) 。各州對針灸專業的定義與針灸師執業範圍不盡相同，而加利福尼亞州、佛羅里達州、新墨西哥州等明確 包括中藥，而佛羅里達州、科羅拉多州還包括穴位注射。根據紐約州“針灸專業”的法律定 義，針灸是根據身體器官與相關穴位或穴組相互生理關係的理論，在體表選用的穴位或穴組 採用針刺進行機械、熱或電刺激或通過施加熱、壓力或電刺激而對身體各種疾病、失調與 功能障礙達到治療或預防效果的一種手段；法 律還規定針灸專業包括食品輔助劑(草藥)和 天然產品的推薦 (6) 。
3.3執照申請要求與步驟： 持正規針灸院校畢業文憑並獲得全國針灸資格證書(或東方醫學 資格證書) 有資格申請各州針灸執照，當然加利福尼亞州只接受加州針灸局認可的院校畢業生以及加州針灸執照考試通過者。針灸立法的州都會有管理針灸執照與執業的機構，進入所在州政府針灸管理部門網站了解針灸執照的要求與申請步驟。州政府部門審核專業學習前的 60學分以及中醫針灸專業學習的成績單都會與 這些院校直接聯繫確認， NCCAOM考試成績也是由證書委員會直接送達。一些州還有其他規定，如非佛羅里達州針灸院校畢業生到佛州申請執照，還必須完成15小時針刺作業時預防感染措施的監督指導、20小時佛州法律法規培 訓、60小時穴位注射課程。
结语
針灸是美國健保體系中新興發展、具有潛力的專業，勞工部已頒布新的針灸職業代碼(29- 1291.00)，並預計今後數年仍有平均4-7%增長 (7) 。經過數代人的努力，針灸專業准入標 準、院校認證、教育體系、考試制度與執照管理均已規范成熟，針灸在美國本土化已經形 成。隨著整合醫學的不斷深化、非藥物疼痛管理的進一步落實，保險業對針灸的更大規模容 納，針灸專業發展將進入一個新的階段。
參考文獻
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5. 管窺美國中醫教育與中醫師在美執業 —採訪 美國紐約中醫學院院長陳業孟. 周開林、吴 青等。中醫藥導報， 25 (15)： 1-3，2019
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