Regulation in other states
* understand the evolution of different systems of medicine such as Kampo and Tibetan medicine that developed from Chinese culture, and the philosophical basis of these systems.
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1980: Definition of acupuncture expanded to include additional TOM modalities, including herbal medicine, in CA (electroacupuncture, cupping and moxibustion, oriental massage, breathing techniques, exercise or nutrition, “drugless substances and herbs as dietary supplements)
According to one acupuncturist active in promoting the professionalization of AOM, on of the major barriers to the development of acupuncture are professional acupuncturists themselves. He informed me of three major professional AOM organizations, which are differentiated along ethnic/national lines: Chinese acupuncturists, Korean Acupuncturists, and “American” acupuncturists. The third group tends to attract second generation Chinese American acupuncturists, as well as first generation immigrants from non-Asian countries who have become acupuncturists (e.g., from my study alone = Israel, Brazil and the UK).
§205.254. RENEWAL OF EXPIRED LICENSE BY OUT-OF-STATE PRACTITIONER.
§205.253. PROCEDURE FOR RENEWAL.
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The committee is composed of 11 members: 5 acupuncturists with at least five years of acupuncture experience and not licensed as physicians, 2 licensed physicians with two years of acupuncture experience, and 4 public members. The Governor appoints the seven practitioner and two public members who are subject to Senate confirmation, and the Senate Rules Committee and the Assembly Speaker each appoint one of the two remaining public members. Committee members are appointed to a term of three years. Currently there is one physician board member vacancy which has persisted for a number of years - apparently indicating a difficulty in finding a satisfactory candidate with the requisite acupuncture experience to serve on the board.
§205.252. NOTICE OF LICENSE EXPIRATION.
Before acupuncture became regulated in California acupuncturists could be arrested and prosecuted for engaging in the unlicensed practice of medicine. As a result, acupuncturists and their patients organized and sought regulation to make the practice of acupuncture by acupuncturists legal.

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TCM has four main components: acupuncture, herbal medicine, tui na, and qi gong. Herbal medicines are generally delivered in compound formulas specially formulated for a clinical syndrome or constellation of symptoms. Tui na is the ancient Chinese massage used for lymphatic drainage and muscle rejuvenation. Qi gong is the practice of energy movement in the body through physical movement.
My dissertation is about the relationship between acupuncturists and their patients during the treatment session. I conducted in depth open ended interviews with 12 acupuncturists (8 of whom became full participants in the study). I have also had informal conversations with many acupuncturists, at least three of which have influenced my thinking about this topic. The initial purpose of the interviews was for me to establish rapport with the acupuncturists and learn about things that might influence their participation in the interactions that I video taped. In the interviews I asked about how they decided to become acupuncturists, their educational history and experiences, what it is like to be an acupuncturist in the US, how they run their practice, their relationships with their patients, and how they see acupuncture/AOM fitting into American health care. The parts of the interviews that seem to be most relevant to this paper is the part where they talk about their education, but some issues surrounding licensing and practice my be relevant, too.
Exemptions: Physicians licensed by the Medical Board of California are authorized to practice acupuncture within their scope of licensed medical practice, with or without acupuncture training. Podiatrists licensed by the California Board of Podiatric Medicine and dentists licensed by the Board of Dental Examiners may also practice acupuncture as part of their respective licensed practices - if they have completed a course of instruction in acupuncture approved by their respective licensing boards. Further, the Acupuncture Act does not prohibit non-licensed persons from performing or prescribing oriental massage, breathing techniques, exercises, or nutrition to promote health so long as those activities are not performed or prescribed in connection with the practice of acupuncture.
Improvements noted by the Committee over the past few years have included: (1) Adoption of a Strategic Plan with goals and performance objectives; (2) Performance of an occupational analysis for the licensing examination in 1996; (3) Establishing a system to perform random audits for continuing education compliance; (4) Making changes in the administration of its practical examination in response to numerous complaints, and contracting with a new examination contractor to revise and administer that examination; (5) Anticipated elimination of one portion of the clinical examination (clean needle technique) as no longer necessary beginning next year; (6) Proposing, through regulation, the upgrading of the Tutorial Program to make it more equivalent to the current formal educational requirement for acupuncture school training.
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Acupuncture is a component of the health care system of China that can be traced back for at least 2,500 years. The general theory of acupuncture is based on the premise that there are patterns of energy flow (qi) through the body that are essential for health. Disruptions of this flow are believed to be responsible for disease. Acupuncture is used to correct imbalances of qi flow at identifiable anatomical locations on and just below the skin, the acupuncture points, by the stimulation of a variety of techniques. The most studied mechanism of stimulation of acupuncture points employs penetration of the skin by thin, solid, specially tipped, metallic needles, which are manipulated manually or by electrical current. There are a variety of approaches to diagnosis and treatment in American acupuncture that incorporate medical traditions from China, Japan, Korea, Tibet, Vietnam, and France.
Kampo continues to be practiced extensively in Japan, as well as in America and other countries. Tibetan medicine has considerably less adherents than either TCM or Kampo. However there is increasing interest in certain herbal formulas for the management of cancer.
(b) In establishing standards for the entrance requirements and course of instruction of an acupuncture school, the acupuncture board may consider the standards set by the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine.

ACUPUNCTURE SCHOOLS.
§205.208. TEMPORARY LICENSE.
(2) provide supervised patient treatment for at least two terms of the resident course of instruction;
(b) The acupuncture board shall consider the approval of a course conducted by:
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In 1972, the California Board of Medical Examiners (now called the Medical Board of California) began regulating the practice of acupuncture under provisions which authorized the practice of acupuncture under the supervision of a licensed physicians as part of acupuncture research in medical schools. Subsequently, that regulation was amended to allow acupuncture research to be conducted under the auspices of medical schools rather than just in medical schools.
1989: Immigration Nursing Relief Act
(c) In addition to the other requirements of this section, an acupuncture school or degree program is subject to approval by the Texas Higher Education Coordinating Board unless the school or program qualifies for an exemption under Section 61.303, Education Code.
Relevant legislative and diplomatic history (not a complete list)
(2) the qualifications needed to be considered a preferred provider of continuing education; and
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(a) The acupuncture board by rule may require a license holder to complete a certain number of hours of continuing education courses approved by the acupuncture board to renew a license.
* appreciate modern applications, develop an understanding of the safety of TCM procedures, and understand 5-10 common clinical situations where TCM may be used as a primary modality.

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Traditional Chinese Medicine (TCM) is a comprehensive system of medical thought, pathophysiological concepts, and therapeutic interventions that developed out of the matrix of Chinese civilization over a period spanning more than four thousand years. The primary modality of TCM is the use of an extensive pharmacopoeia of over 6,000 herbal and other natural products for the prevention and treatment of disease and the promotion of health. TCM, as practiced in America, is largely the product of a synthesis of herbal prescribing methodologies derived from post-cultural revolution China, Japan, Korea, and Vietnam.
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1999: Federal Acupuncture Coverage Act of 1999 provides for coverage of acupuncturist services under Medicare and Federal Employees Health Benefits Programs
SUGGEsted course Format
§205.251. ANNUAL RENEWAL REQUIRED.
(a) The medical board may renew without reexamination the license of a person who was licensed to practice acupuncture in this state, moved to another state, and is currently licensed and has been in practice in the other state for the two years preceding application.
There appears to be a relationship between changing immigration policy and the development of the professional practice of acupuncture and oriental medicine in the United States. A timeline of the major immigration policy changes from 1965 to the present (see below) parallels in suggestive ways significant changes in the development of acupuncture and oriental medicine in the US. These changes appear to be strongly related to the increasing number of acupuncturists from China coming to the US to practice and teach. Increasing interest of Americans (especially those of nonAsian ancestry) in using and practicing acupunture and oriental medicine, beginning in the 1970s, created demand for acupunture and oriental medicine practitioners and schools. Some of the areas of professional AOM practice affected by increased migration of skilled acpuncturists are education, certification and licensing, medical and professional ideologies and identities, and the development of professional associations.

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(1) maintain a resident course of instruction equivalent to not less than six terms of four months each for a total of not less than 1,800 instructional hours;
The development and popularization of traditional Chinese medicine (TCM), especially the TCM technique of acupuncture, in the US, occurred in the wake of the1965 immigration legislation and the 1979 normalization of diplomatic relations between the US and China, the former of which brought renewed and more varied flows of new immigrants from China to the US, and the latter which opened the door to increased travel by Americans to China, for tourism, education, and trade. (In this paper, TCM and AOM will be used interchangeably).
(c) After guidelines are established under Subsection (a-1), the acupuncture board shall delegate to medical board employees the authority to approve course applications for courses that clearly meet the guidelines. Medical board employees shall refer any courses that are not clearly within the guidelines to the acupuncture board for review and approval.
A Summary of Some other points that might be addressed
(2) a reputable school, state, or professional organization.
1965: Immigration Act of 1965
The AC has an annual budget of approximately $1.2 million and a staff of 7 full-time and 3 part-time positions including an exempt appointed Executive Officer, 4 analysts, 2 office technicians/assistants, 2 interpreters, and temporary help.
1979: The US and PRC establish formal diplomatic relations; PRC given a separate annual immigration quota (from Taiwan and HK).

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§205.255. CONTINUING EDUCATION.
* describe the twelve main meridians of acupuncture and six commonly used acupuncture points, such as hegu (LI4); shusanli (ST36); sanyinjiao (SP6).
History, Philosophy, and Methods
Traditional methodology involves the use of acupuncture to regulate the state of yin and yang, promote the free flow of qi, and balance the function of the meridians. Herbal prescribing follows well-defined clinical guidelines based upon traditional pharmacology and established methods, such as the “eight methods,” that include treatment for restoration of qi and the treatment of disease, and which emphasize therapeutic benefits and minimize side effects and interactions.
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(b) The person must pay to the medical board a fee in an amount equal to two times the required renewal fee for the license.
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(a) The acupuncture board may, through the executive director, issue a temporary license to practice acupuncture to an applicant who:
Committee Composition
(3) pays the appropriate fee;
Kampo is the practice of traditional Chinese herbal medicine adopted by the Japanese that underwent changes in therapeutic orientation from the original Chinese methodology including the development of standardized herbal extracts. Kampo medications have been approved for national health insurance coverage in Japan since 1970. Kampo was the official system of medicine in Japan until 1868, when modern Western medicine was introduced by the Dutch to Japan and popularized. Over half of Japanese clinicians used Kampo-formulas in their daily practice either alone or in combination with modern drugs (Terasawa, 1993). There are over 150 formulations available for use and modern clinical research study.

1999: winning NIH approval (?)

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As currently practiced, TCM includes internal medicine, gynecology, pediatrics, traumatology, and disorders of the eyes, ears, nose, and throat. Acupuncture modalities include moxibustion, microsystems like auricular and hand acupuncture, scalp acupuncture, electro-acupuncture, and point injection therapies. In addition, TCM includes manipulation techniques (tui na), dietary regimes, therapeutic exercises, and herbal pharmacology. The history of TCM is extensive, extending back at least 2,500 years with the writing of the Yellow Emperor’s Classic of Internal Medicine.
* describe ten of the most frequently used Chinese herbs, such as ginseng (Panax ginseng) and astragalus (Astragalus membranaceus).
* understand the clinical usefulness of TCM as supported by evidenced-based and basic research.
A majority of medical schools in the U.S. have begun introductory coursework on CAM using different approaches. Most focus on a few topics or modalities of CAM that are easy to teach or provide an epidemiologic overview. Formats include pre-orientation workshops, lunch-time lecture series, longitudinal evening or weekend workshops with faculty, student interest groups with faculty sponsors, guest speaker series, and /or medical center-sponsored CME courses open to medical students. Many of these have evolved to a more formal integration of CAM topics into the existing medical curriculum, either using longitudinal courses or electives. Schools are encouraged to design innovative approaches to introducing the CAM modalities they choose, with encouragement to provide balance in education by selecting modalities from each of the 10 core CAM categories.
(a) The medical board by rule shall provide for the annual renewal of a license to practice acupuncture.
Immigrant practitioners adapt their practice styles to the US context. Many adopt holistic jargon.
Acupuncture schools serve as immigration gatekeepers. They recruit practitioners from China to teach in their schools. Many of these teachers choose to remain and settle in the US. Acupuncture education was different before there were so many immigrant Chinese teachers. In general, the education was considered to be of lower quality. Among the acupuncturists I interviewed, travel and study in Asia seemed especially important for the earlier generation. In addition to the problem of qualified teachers there was the problem of teaching materials. The export of teaching materials from China to the US and the growth of the AOM related publishing industry has been important for improving AOM education. Along with teaching and instructional materials, there has had to be an increasing supply of medicinal supplies. Most controversial of these has been herbal products. An innovation of providing traditional formulas in powdered form in capsules increased the market for Chinese herbs in the US. SUGGESTED LEARNING OBJECTIVES

Tibetan Medicine is a distinct practice of medicine derived largely from Ayurvedic medicine, but with considerable influence from Chinese medicine, and some Unani (Greco-persian) with a primary philosophical basis in Buddhism as practiced in Tibet, Nepal, Bhutan, Sikkim, and the western regions of China.
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199(3): Establishment of the NIH center for the study of alternative medicine
(a) A person who is otherwise eligible to renew a license may renew an unexpired license by paying the required renewal fee to the medical board before the expiration date of the license. A person whose license has expired may not engage in activities that require a license until the license has been renewed under this section or Section 205.254.

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According to the AC, relying on information from the National Acupuncture Foundation, 44 states currently regulate the practice of acupuncture in some fashion: 26 license, one certifies, and two register acupuncturists; and 16 specify that only physicians, osteopaths, chiropractors and or podiatrists may practice acupuncture. In some of the states, the authority to practice is restricted to acupuncture only, while other states permit an expanded scope of practice or the use of other practice titles such as doctor of acupuncture (New Mexico) or acupuncturist physician (Florida). 6 states do not appear to regulate the practice of acupuncture.
Because true integration of complementary medicines can be achieved only when coursework is incorporated into the existing curriculum, AMSA suggests that schools work toward building lectures, handouts, slides, and cases that can be introduced in existing core courses. This approach allows the students to actively compare other medical systems with allopathic and osteopathic medicine and will reinforce basic science and modern clinical practice. It will also allow exposure to all students, not only those already interested in CAM. Experiential activities such as field trips, demonstrations, and lab exercises are encouraged and can be appropriately introduced to complement didactic instruction.
Immigration from China in general has increased since 1965. A question that remains to be answered is whether immigrant acupuncturists have tended to enter the US via special categories for skilled migrants or via the general pool or through family reunification. At present, I have interview evidence that the supply of acupuncturists from China has increased significantly, beginning in the late 1980s and increasing throughout the 1990s (see illus case # ___ below). I also know that acupuncture colleges have been a “pull” factor in recruiting acupuncturists from China to teach at their schools (see e.g. illustrative case #___ below).
OF THE ACUPUNCTURE COMMITTEE
TCM thrived in the Western US in the late 19th and early 20th centuries, but none of these early TCM doctors remained in independent practice by the middle of the 20th century. TCM was affected by the same social processes that marginalized other nonbiomedical healing practices in the US in the early 20th century. Restrictions of movement of people and goods between the US and China in the middle of the century further contributed to the decline of professional TCM in the US. The late 20th century witnessed a renewed and widespread interest in TCM in the US. This could not have taken place without an increase in the number of Americans going to China to receive TCM treatment and study TCM, the increasing availability of TCM herbal medicines and other products in forms accessible to a broad US user population, a growing Chinese immigrant consumer population, and especially an increasing number of highly trained practitioners coming to the US to practice and teach.
Upon completion of the TCM/acupuncture/kampo/Tibetan medicine learning components of the curriculum, medical students should be able to:
Initial observations and analysis

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(3) maintain a course of instruction in anatomy-histology, bacteriology, physiology, symptomatology, pathology, meridian and point locations, hygiene, and public health; and
The Immigration Act of 1965 “profoundly affected the composition and the size of Chinese communities. The Chinese population increased dramatically: from 236,084 in 1960 to 1,079,400 in 1985. Today, the Chinese are the largest Asian group in the United States” (Kwong 1992 (1987):22). It is possible that the expansion of TCM will turn out to be seen to be in part an unintended consequence of the changing organization of immigration, such that immigration legislation intended to increase the supply of professionals to support the status quo (e.g., mainstream medical institutions and industries) also increases the supply/power of groups who offer a challenge or alternative to that status quo. [An important question here would be what types of visas the acupuncturists have entered with.] Another view might look at the ways this professional migration brings in new ideas, creativity, and helps fuel experimentation and innovation.
Some results of this growth are increasing professionalization (and resistance to professionalization), competition, differentiation, changing entry standards.
Definitions
(b) A temporary license is valid for 100 days after the date issued and may be extended only for another 30 days after the date the initial temporary license expires.
(1) a knowledgeable health care provider; or
(3) course content requirements.
(a) A reputable acupuncture school, in addition to meeting standards set by the acupuncture board, must:
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§205.207. RECIPROCAL LICENSE.
(5) meets all the qualifications for a license under this chapter but is waiting for the next scheduled meeting of the medical board for the license to be issued.
BACKGROUND AND DESCRIPTION OF THE COMMITTEE
(2) has passed a national or other examination recognized by the acupuncture board relating to the practice of acupuncture;
1976: Gov. Jerry Brown signed legislation approving a licensing exam for acupuncturists in CA
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(4) if licensed in another state, is in good standing as an acupuncturist; and
The Acupuncture Licensure Act (Business and Professions Code Sections 4925 - 4979) and its related administrative regulations (Title 16, California Code of Regulations, Sections 1399.400 et seq.) regulates both the practice of acupuncture and the use of professional titles by its practitioners. The AC licenses and regulates acupuncturists, establishes standards for and approves acupuncture training programs and schools, and establishes requirements and approves acupuncture tutorial programs. As part of its licensing function the AC also administers its own two part licensing examination, the California Acupuncture Licensing Examination (the CALE), composed of a written examination and a practical examination.
The scope of practice of acupuncture is defined in B&P Code Section 4937 to include acupuncture, prescribing and use of oriental massage, acupressure, breathing techniques, exercise, or nutrition, including the incorporation of drugless substances and herbs as dietary supplements to promote health. “Acupuncture” is defined by B&P Code Section 4927 as the stimulation of a certain point or points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions, including pain control, for the treatment of certain diseases or dysfunctions of the body and includes the techniques of electroacupuncture, cupping and moxibustion.
SUBCHAPTER F. LICENSE RENEWAL
History of acupuncture regulation and the Acupuncture Committee
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(1) submits an application on a form prescribed by the acupuncture board;
Committee regulation of the practice and practitioners
AC program improvement efforts
There is struggle over credentialing. Some Americans complain that the licensing exam is controlled by acupuncturists from China and that they favor ethnic Chinese. Some acupuncturists want to raise the entry standards to the profession, others don’t.
Data and Methods

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1979: Acupuncture becomes “primary care” in CA
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(a-1) The acupuncture board shall establish written guidelines for granting continuing education credit that specify:
(d) In reviewing an acupuncture school or degree program as required by Subsection (c), the Texas Higher Education Coordinating Board shall seek input from the acupuncture board regarding the standards to be used for assessing whether a school or degree program adequately prepares an individual for the practice of acupuncture.
1990: Immigration Act of 1990
All of these systems are based upon phenomenology, cosmology, the observation of natural events including the course and outcome of disease, which is considered caused by internal imbalances for emotional states, external factors such as trauma and environmental factors, and other pathological factors. Ultimately, health and disease, according to Chinese medicine, is dependent on the regulation of the two complementary yet opposing forces of yin and yang, the underlying principles that manifest in everything from plant growth, effects of herbal remedies, differentiation of the sexes, as well as health, disease, and healing. In addition, besides observational anatomy, Chinese medicine proposes that there are currents of energy in the body, called meridians that are modulated by the effects of yin and yang, and influenced by environmental and emotional events.
An understanding of this context, I believe, helps to explain the ways that the acupuncturists I spoke with, interviewed, and videotaped as part of my dissertation research (which focuses on the communication and relationship-building between acupuncturists and patients) presented themselves during interviews and present themselves to patients during consultation and treatment visits. It may also help to explain developments on the “mezzo” levels of professional AOM associations and organizations, and state and local AOM-related legislation.
Faculty and community lecturers should be familiar with the topic from a traditional and clinical perspective, not merely an academic exposure. Emphasis on accurate portrayal of the CAM modality from professionals is essential to accurate teaching. The resources within this module should serve that goal and assist educators in providing timely, relevant, and professionally reviewed materials to medical students.

US acupuncture colleges recruit acupuncturists from China to teach the upper division courses in their curricula and supervise the students clinical internships. The availability of teachers from China has improved the quality of acupuncture education, improving the reputations of the schools, and attracting increasing numbers of new students. Many of the teachers from China eventually settle in the US and open private practices. Acupuncturists from China who enter the country via other channels set up practice here, too, after passing the necessary licensing exams. Thus, immigrant acupuncturists both increase the number and skill level US native acupuncturists and compete with them for patients.