Understanding the Challenges of U.S. Acupuncture Practice (Pt. 3)

The Chronosystem: History of Western Medicine & Acupuncture in the U.S.

The chronosystem, within which the macrosystem is nested, includes the history of the acupuncture profession in the U.S. and reflects the change over time of the environment surrounding acupuncture. To understand more about acupuncture and mainstream medicine, a brief history of Western medicine is necessary.

Historically, Western medicine practitioners did not have consistent regulation, and the profession comprised all kinds of competitive practitioners, which made the profession stay in a divided status until the Medical Act passed in 1858.¹

Before 1858, Western medicine practitioners consisted of all kinds of learned persons, and they competed with other types of therapists for patients. The Medical Act of 1858 made physicians stand out from their competitors, such as homeopaths and herbalists, which established a coherent and united medical profession.¹

The acupuncture profession faced similar challenges as the Western medical profession had in the early 1900s. However, Western medicine achieved advancement due to the implementation of professionalization within their system. As a result, Western medicine eventually became the dominant mainstream medicine.²

Since the early 1900s, acupuncture did not receive attention from the U.S. public until the 1970s, when James Reston published a story in The New York Times about acupuncture, which had relieved his pain after an emergency appendectomy.³

Over the past four decades, the acupuncture profession has achieved specific milestones of professional development. These milestones include the creation of national agencies, such as the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) between 1980 and 1982, the American Association of Acupuncture and Oriental Medicine (AAAOM) in 1981, the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) in 1982, and the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in 1982.

In 1996, the Food and Drug Administration (FDA) classified acupuncture needles as Class II medical devices.⁴ Moreover, the National Institutes of Health (NIH) continues to fund ongoing research to evaluate acupuncture’s effectiveness.⁵

According to the National Health Interview Survey (NHIS), the number of acupuncture adult users increased by 8.01 million from 2002 to 2012.⁶ And in 2018, the Bureau of Labor and Statistics (BLS) started to list acupuncture as a profession.

All these data seem to demonstrate that acupuncture has received national recognition, but the acupuncture profession continues to remain outside of mainstream medicine.

The Macrosystem: Cultural Differences, Ideologies and Safety Concerns

The macrosystem, within which the exosystem is nested, includes broad cultural influences or ideologies that have long-ranging consequences for the focal individual.⁷ For instance, the widespread societal recognition of the opioid crisis places emphasis on complementary health approaches to pain as the opioid epidemic rages.⁸ This section mainly focuses on society’s health beliefs from cultural influences and patient safety concerns.

1. Cultural Differences

Many factors can influence people’s views on health and illness including their cultural background. Pachter described an example of Puerto Rican parents who preferred folk healers instead of physicians treating their child’s illness, which illustrated health care is a culturally sensitive system.⁹ This system can be affected by “ethnic values, cultural orientation, religious beliefs, and linguistic considerations” (p. 692). Different ethnic groups may have different beliefs about medicine.

Another example of the influence of cultural factors is evident in a study conducted by Horne, et al. (2004).¹⁰ This study indicated that students who were from Asia held more positive views toward traditional medicine than Western medicine as compared to students who were from a European background.

The study identified significant differences between Asian-origin and European-origin undergraduate students in beliefs about the general harms and benefits of medicine, which suggests a strong association between cultural background and beliefs about traditional vs. Western medicine.¹⁰

Similarly, a cross-sectional designed study conducted by Li, et al., evaluated 249 Chinese immigrants in the San Francisco Bay Area on their perceived drug susceptibility concerning antihypertensive medication adherence.¹¹ This study revealed that different levels of perceived benefit of Chinese herbs vs. Western medications could be predictors for medication nonadherence.

Another study was conducted by Tang, et al., regarding participation in breast self-examination (BSE) and cervical cancer screening among young Asian and Caucasian women in the U.S.¹² This study found that Caucasian women participate in the examinations more frequently than Asians, possibly indicating that different cultural backgrounds influence attitudes and beliefs in choosing these two medical screening options.

Cultural differences can also be reflected in the different viewpoints of both medical systems. In a study conducted by Bertrand regarding how registered nurses decided the options for patients during their triage process, the results reflected that nurses were influenced differently in their thinking and assessments due to different medical culture training.¹³

This study showed that most nurses who received Western medicine cultural training would only assign patients to receive Western medicine due to their prior training. However, some nurses who had both TCM and Western medicine training would recommend TCM options for their relatives.

Another example, from a study by Austin, et al., demonstrated that acupuncture received particular attention and extensive use from U.S. Pacific states because many Asian immigrants who share a common cultural background reside in these states and prefer to use traditional Chinese medicine for illness.¹⁴

However, the study also highlighted that immigrants are assimilated by the local culture over time, and then adopt the Western medicine.¹⁴ Therefore, a cultural factor may exist, particularly for those who decide to use acupuncture.

The advancement of mainstream medicine relies on the development of modern diagnosis technology and treatment modalities, as well as a scientific methodology.¹⁵ Kaptchuk and Miller stated, “Mainstream medicine undoubtedly draws upon the insights gathered from careful clinical observation, medical knowledge is considered most reliable when it is produced under controlled experimental conditions, allows for mathematical representation, and uses explicitly formulated methodological procedures” (p. 286).¹⁵

Western medicine’s studies and protocols prefer to choose replicable empirical research methods; in acupuncture research, there is a tendency to share anecdotal evidence, which is not trusted by Western medicine.¹⁵

Furthermore, “bias and extraneous factors (such as spontaneous remission, natural history, or placebo effects) constantly threaten genuine knowledge claims about treatment efficacy in mainstream medicine” (p. 286). According to Starr, medical mainstream authority is highly related to the belief in modern cultures and advances in science.¹⁶

On the contrary, alternative medicine is a subject of the combination of the study of nature, intellectual achievement, and system of faith.¹⁷ Whether patients believe in science becomes a predictor of their preference between alternative medicine and medical science. Therefore, different viewpoints by TCM and Western or mainstream medicine reflect on the cultural or ideological difference in nature, which might be one of the underlying factors that influence acupuncture’s integration into mainstream medicine in the U.S.

2. Safety Concerns

Currently, mainstream medicine does not include CAM, which might be due to most of the essential questions regarding CAM therapies that cannot be verified by scientific experiments such as randomized, controlled trials that mainstream medicine advocates.¹⁸ Lin, et al.., further argue that the value of CAM therapies includes not only their effects, but also their relative safety.¹⁸

However, there is a lack of evidence to demonstrate that CAM therapies are risk-free. A survey of physician attitudes on CAM by Wahner-Roedler, et al., indicated 70% of 660 physicians perceived that CAM therapies may bring risk to patients.¹⁹

A survey of 6,348 patients conducted by MacPherson, et al., revealed that the most common adverse events for acupuncture therapy patients were tiredness and exhaustion, pain at the site of needling, and headache.²⁰ In another study, Chan, et al., stated that the perception of acupuncture treatment among nonusers reflected concerns about insufficient clinical evidence, high risk and different levels of acupuncturists.²¹

Therefore, to some degree, there exists possible safety concerns by the mainstream medical system. The factor of safety concerns in this section is influenced and nested in the factor of cultural difference.^22-24

Meanwhile, patient safety concerns that might be related to their cultural difference would affect their decision to see a Western medicine doctor vs. a CAM professional.^10,23 For example, Western medical doctors with more safety concerns about CAM could remind their patients to use CAM therapy with caution.¹⁹

Similarly, CAM professionals with more safety concerns about Western treatment or medicine, such as side effects of chemotherapy for cancer patients, would likely suggest their patients receive CAM therapy instead of Western medical treatment.²⁵ Therefore, safety concerns might be associated with cultural differences and further impact health decision-making.¹⁰

Editor’s Note: This eight-part monthly series began in the June issue. Part 4 (September issue) examines the exosystem, which includes health policy and acupuncture regulations.

References

1. Turner BS. Foreword: The End (s) of Scientific Medicine? In: Tovey P, et al. (Eds.). The Mainstreaming of Complementary and Alternative Medicine: Studies in Social Context. London: Routledge, 2004, pp. xiii-x.
2. Willis E. Medical Dominance. Sydney: Allen & Unwin, 1989.
3. Fan AY, Faggert S. Dr. Gene Bruno: The beginning of the acupuncture profession in the United States (1969-1979) - acupuncture, medical acupuncture and animal acupuncture. J Integ Med, 2015;13:281-288.
4. Sec. 880.5580 Acupuncture Needle. U.S. Food and Drug Administration, Dec. 6 , 1996.
5. Acupuncture: In Depth. National Center for Complementary and Integrative Health, Sept. 24, 2017.
6. Statistics from the National Health Interview Survey. National Center for Complementary and Integrative Health, March 14, 2018.
7. Neal JW, Neal ZP. Nested or networked? Future directions for ecological systems theory. Soc Devel, 2013;22:722-737.
8. Abbasi J. As opioid epidemic rages, complementary health approaches to pain gain traction. JAMA, 2016;316:2343-2344.
9. Pachter LM. Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery. JAMA, 1994;271(9):690-694.
10. Horne R, Graupner L, Frost S, et al. Medicine in a multi-cultural society: the effect of cultural background on beliefs about medications. Soc Sci & Med, 2004;59:1307-1313.
11. Li WW, Stewart AL, Stotts N, Froelicher ES. Cultural factors associated with antihypertensive medication adherence in Chinese immigrants. J Cardiovasc Nurs, 2006;21(5):354-362.
12. Tang TS, Solomon LJ, Yeh CJ, Worden JK. The role of cultural variables in breast self-examination and cervical cancer screening behavior in young Asian women living in the United States. J Behav Med, 1999;22(5):419-436.
13. Bertrand SW. Registered nurses integrate traditional Chinese medicine into the triage process. Qualitat Health Res, 2012;22(2):263-273.
14. Austin S, Ramamonjiarivelo Z, Qu H, Ellis-Griffith G. Acupuncture use in the United States: who, where, why, and at what price? Health Market Quart, 2015;32:113-128.
15. Kaptchuk TJ, Miller FG. What is the best and most ethical model for the relationship between mainstream and alternative medicine: opposition, integration, or pluralism? Academic Med, 2005;80(3):286-290.
16. Starr P. The Social Transformation of American Medicine. New York: Basic, 1982.
17. Dworkin RW. Science, faith, and alternative medicine. Policy Review, 2001;108:3.
18. Lin YC, Lee AC, Kemper KJ, Berde CB. Use of complementary and alternative medicine in pediatric pain management service: a survey. Pain Med, 2005;6:452-458.
19. Wahner-Roedler DL, Vincent A, Elkin PL, et al. Physicians’ attitudes toward complementary and alternative medicine and their knowledge of specific therapies: a survey at an academic medical center. Evid-Based Compl Alt Med, 2006;3:495-501.
20. Macpherson H, Scullion A, Thomas KJ, Walters S. Patient reports of adverse events associated with acupuncture treatment: a prospective national survey. BMJ Quality & Safety, 2004;13:349-355.
21. Chan K, Siu JYM, Fung TK. Perception of acupuncture among users and nonusers: a qualitative study. Health Market Quart, 2016;33:78-93.
22. Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res, 1999;47:555-567.
23. Lam TP. Strengths and weaknesses of traditional Chinese medicine and western medicine in the eyes of some Hong Kong Chinese. J Epidemiol Community Health, 2001;55:762-765.
24. Pachter LM, Weller SC, Baer RD, et al. Variation in asthma beliefs and practices among mainland Puerto Ricans, Mexican-Americans, Mexicans, and Guatemalans. J Asthma, 2002;39:119-134.
25. Akpunar D, Bebis H, Yavan T. Use of complementary and alternative medicine in patients with gynecologic cancer: a systematic review. Asian Pac J Cancer Prev, 2015;16:7847-52.