Full title: “Strengths, Weaknesses, Opportunities and Threats of Traditional Chinese Medicine in California: SWOT Analysis using Qualitative Research”
Traditional Chinese Medicine (TCM) in California (CA) is a profession with capacity for continued growth and diversity of practice, but also faces many challenges. The purpose of this study is to identify significant strengths, weaknesses, opportunities and threats for TCM in CA, and to explore new strategic directions, solutions and priorities for the field. Method: A standardized online questionnaire was designed, and its content validity and reliability were reviewed using a test-retest method. Twelve in-depth interviews with experts were conducted and related literature was reviewed, in addition to the questionnaire. Results: The main strength we found is that TCM practitioners are well-educated (76%); the main weakness is inadequate insurance compensation (74%); the main area of opportunity is growing public awareness about TCM (85%); and the main challenge is lack of public education about the benefits of TCM for patients (73%). Direct-pay and non-direct-pay practitioners hold significantly different beliefs on whether TCM is a low-cost, affordable treatment (p value=0.03). There is also a significant difference in belief regarding TCM business saturation among pioneer and non-pioneer practitioners (p value=0.04). Lastly, there is a significant difference in perception of competition with chiropractors between TCM practitioners treating orthopedic versus non-orthopedic patients (p value= 0.04). Conclusion: TCM as a holistic, comprehensive medicine has many strengths and diversities, and can be applied widely in our public health system while providing patients the freedom to choose their medical providers.
Acupuncture, as a holistic, energy-based approach, can be presented to treat patients on top of the other disease-oriented diagnostic and treatment models in Western medicine. Practitioners of this growing approach need licensure or registration in all but three U.S. states. States set their own standards for licensure, and these standards may vary widely with no consistency in qualification of acupuncture practitioners.1
This study illustrates strengths, weaknesses, opportunities and threats (SWOT) of, for, and to traditional Chinese medicine (TCM) in the state of California and provides suggestions to improve and develop the practice of TCM in the foreseeable future. The TCM profession is suffering from a lack of strategic planning to develop the profession and affect its full integration into the health care system in California. SWOT analysis is needed to illustrate the strategic direction of the acupuncture profession. Other health occupations such as chiropractic, nursing, and allopathic medicine have employed several independent SWOT analyses as a way of engaging in professional self-study. While the California Acupuncture Board has done a SWOT analysis for its strategic planning, an independent SWOT analysis has never been done in this field, so this will be the first independent and academic study designed to define and describe new solutions and priorities to develop the professional practice of TCM in California.2
TCM practice in California encounters a great number of strengths, weaknesses, opportunities, and threats; this practice is growing and requires strategic directions and priorities. Some existing strategic initiatives have been successful, and other national or non-CA state initiatives may be implemented or further developed in California.3 SWOT Analysis of TCM will help the TCM profession to become more visible, widely-used, and safe. It will also move the profession forward in California. Figure 1 shows some of the main stakeholders of the TCM profession in California. Stakeholders may be in the internal environment, the external environment, or both. For example, insurance companies may belong to both internal (acupuncture liability insurance companies) and external environments (health plan providers).
Figure 1. Stakeholders of TCM practice in California: External vs. Internal
This study uses qualitative methods to analyze SWOT as a tool and foundation for strategic planning in the development of the TCM profession in California.
In this study, three different forms were developed:
1) Experts’ interview form: This form was used to collect information, suggestions, and directions from TCM instructors, TCM schools, California Acupuncture Board, the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM), acupuncture associations, policymakers, insurance companies, MDs, chiropractors, physical therapists, and TCM products dealers, manufacturers, and patients. The data collected was used to shape the qualitative study and to develop our TCM professional and patient forms.
2) TCM professional survey: This form was used to collect information from Licensed Acupuncturists from California and other states. The information was gathered through a Survey Monkey questionnaire and qualitatively analyzed. The survey was developed by checking content validity and test-retest reliability in May 2017. Six experts, including four TCM experts with experience in TCM research, one qualitative research specialist, and one senior research coordinator, reviewed content and the face validity of the questionnaire. Test-retest reliability of the questionnaire was examined during a residency weekend on May 19 and May 21, 2017, at Yo San University (YSU). Ten doctoral candidates from Yo San University participated in this single-blind study via a paper-and-pencil survey. The researcher did not know which questionnaire belonged to which participant. Each questionnaire was assigned a code by YSU, and faculty distributed and collected the completed questionnaires to ensure that each May 19 participant received the same questionnaire code on May 21.
3) Data extraction form: Data from different sources such as the California Acupuncture Board, especially Minutes and Webcasts, were reviewed and categorized through a data extraction form.
English is the only language used in all assessment tools.
This study used the minimum number of participants for in-depth interviews as per John W. Creswell, who recommends five to twenty-five interviews,4,5 and Mason, who recommends at least six in-depth interviews for doctoral program research.6
Survey Monkey is the main source of data-gathering in this section. YSU helped to develop and post the survey online. YSU alumni and experts were asked to respond to the online survey. Other universities and associations were also invited to respond.
Figure 2. Assessment tools for stakeholders in two environments
In this study, 86 responses were received through the standardized online survey, and 10 in-depth interviews were performed. Of the online survey respondents, 86% were California licensed acupuncturists, 58.1% were female, and 90.7% were over 36 years old. About 78% of respondents were white, and 10.5% were Asian. Some 31% of survey respondents have practiced acupuncture for 1-5 years, and 33.7% have practiced 6-10 years. Only 40.7% of survey respondents were certified by the NCCAOM. 90% of respondents were paid by direct-pay, while 13% were paid by Medi-Cal or other health insurance. 100% of participants in this survey reported using full body acupuncture, 91% using ear acupuncture, and 70% using scalp acupuncture.100% of participants in this survey treat pain management cases, 94% orthopedic cases, and 94% sleep problem cases. In this survey, 90% of participants practice TCM, 31% practice Master Tung’s, 21% practice the Richard Tan method, 19% practice Japanese medicine, and 10% practice Korean medicine.
In response to questions regarding the strengths of TCM practice in CA, 76% of participants mentioned well-educated TCM practitioners; 71% the safety of TCM and 63%, the efficacy; 59% diversity of treatment modalities; 50% high satisfaction with treatment received; 38% the non-invasive methods used; 31% low cost/affordability; and 13% had other comments.
In regards to weaknesses of TCM practice in CA, 74% of participants expressed concerns about inadequate insurance compensation; 62% a lack of understanding about TCM; 56% insurance compensations requiring too much paperwork; 53% market saturation with other acupuncturists; 42% TCM terminology confusing patients; 40% a lack of trust or belief in acupuncture; 37% a lack of TCM practitioner education; 35% a lack of evidence-based research about acupuncture; 20% a fragmentation of TCM practice; 13% poor regulations; and 26% had other concerns.
When asked about TCM opportunities in CA, 85% of online participants noted growing public awareness about TCM; 77% the opportunity to coordinate with other medical and complementary medicine practices; 71% increasing insurance coverage; 53% growth in hospital-based practice; 45% the opportunity for delivery care for businesses; and 10% had other comments.
Considering challenges and threats to TCM practice in CA, 73% of participants noted the lack of public education about the benefits of TCM for patients; 50% competition with physical therapists; 44% competition with physicians, nurses, etc.; 42% competition with chiropractors; 35% competition with other holistic medicine, such as homeopathic medicine, yoga, massage therapy, etc.; and 31% had other concerns.
According to our data analysis, adding different acupuncture styles to TCM has a significant effect on the belief that TCM is a fragmented practice (p value=0.05). Direct-pay and non-direct-pay practitioners hold significantly different beliefs on whether TCM is a low-cost or affordable treatment (p value=0.03). There is also a significant difference in belief regarding TCM business saturation among pioneer and non-pioneer practitioners (p value=0.04). Lastly, there is a significant difference in perception of competition with chiropractors between TCM practitioners treating orthopedic versus non-orthopedic patients (p value= 0.04).
In our interviews with experts, the main issues highlighted were the lack of leadership, poor education, lax school entry requirements, weak professional associations, fragmentation in the field, low insurance compensations, and lack of communication among practitioners. TCM universities use different titles for their master programs, which may confuse patients and the health care community (Table 1). In the author’s opinion, the strategic priorities of the TCM profession in California should be to encourage licensed acupuncturists to join professional associations and to increase public awareness and media exposure about the benefits of using TCM modalities. The main strategic direction of TCM practice in California should be engaging strong lobbyists and developing a joint strategic plan to fill out the leadership gap in the profession.
Table 1. Master Degree Titles in Accredited California Acupuncture Schools
|No||Master Degree Title||Abbreviation||No. of Schools||Examples|
|1||Master of Science in Oriental Medicine||MSOM||11||Dongguk, AIMC|
|2||Master of Science in Traditional Chinese Medicine||MSTCM||8|
|3||Master of Science in Acupuncture and Oriental Medicine||MSAOM||4|
|4||Master in Acupuncture and Oriental Medicine||MAOM||2||Southern California|
|5||Master of Acupuncture and Oriental Medicine||MAcOM||2||AOMA|
|6||Master of Traditional Chinese Medicine||MTCM||2||Five Branches (San Jose, Santa Cruz)|
|7||Master of Science in Oriental Medicine and Acupuncture||MSOMA||1||Southern California University School of Oriental Medicine & Acupuncture|
|8||Master of Oriental Medicine||MOM||1||University of South Los Angeles|
|19||Master of Traditional Oriental Medicine||MTOM||1||Emperor’s College of Traditional Oriental Medicine|
|10||Master of Acupuncture and Traditional Chinese Medicine||MATCM||1||Yo San University of Traditional Chinese Medicine|
This study shows that fragmentation of the TCM profession is one of the main challenges it faces in California. In other words, the utilization of Chinese, Korean, Japanese and other Asian medicine techniques, and the methodological disagreements that are based in the nuances of these differing techniques lead the profession to be internally fragmented, thereby enabling outside medical practitioners to argue that the profession is not standardized. The terminology of TCM is not easy to understand for many patients. As such, TCM practitioners should use layman’s terms to communicate with their patients. Failure to clearly communicate is still one of the biggest challenges of the profession, as some TCM practitioners’ English proficiency may not be adequate to educate their patients properly.
The online survey shows that many TCM practitioners are using methods and modalities that are not part of the curriculum of TCM schools, such as Master Tung or Richard Tan’s methods. To develop the current standard of practice to an expanded range of modalities, revising the elective curriculum of TCM schools based on the needs of practitioners is recommended.
Insurance compensation is one of the biggest challenges to acupuncture practitioners; as Medicare has no acupuncture coverage, many elderly patients cannot afford access to the treatments they need. Medicare is a national insurance program, and the California government has no power to include acupuncture coverage in Medicare; however, the California Acupuncture Board, NCCAOM, and lobbyists should work with national authorities to provide the benefit to patients. In this regard, the Acupuncture for Heroes and Seniors Act of 2015, presented to Congress by Rep. Judy Chu, would be a great step.7 This act was reintroduced in February of 2019 as H.R. 1183, the Acupuncture for Heroes and Seniors Act of 2019.
There are more routes that the acupuncture community should follow to promote their profession. For example, many hospitals, including Kaiser Permanente in southern California, and US army medical facilities fail to provide acupuncture coverage to their patients. These institutions should be approached and educated on the opportunities that will grow with the additional offering of acupuncture services in their facilities.
It is understood that there are many challenges in the field of acupuncture. However, in spite of those challenges, the profession is growing in size and acceptance. Success stories of effective acupuncture treatments for different diseases lead to more patient visits, and the growing number of referrals by physicians and other health practitioners indicates that the acupuncture profession has a bright future (Figure 3).
Figure3. Implications of this study to theory and practice
Unfortunately, many experienced and knowledgeable experts in this field could not be reached due to the study’s short time frame or were reluctant to express challenging opinions.
The researcher also contacted many TCM schools and alumni to share the link to the online survey, or asked participants in continuing education classes to participate in the survey, yet these communications were unsuccessful in many cases. Schools and alumni appeared to be only sporadically encouraging when asked to disseminate the survey to stakeholders.
The connection between TCM and Western medicine is poorly defined, insurance reimbursement remains inadequate, and educational deficiencies need to be addressed. Increased public awareness and media exposure are considered priorities towards expanding recognition in the United States. Acupuncture associations should be strengthened, and more active members and lobbyists are needed to promote the profession. TCM professionals should develop a joint strategic plan with all stakeholders and improve leadership and communication to create a stronger TCM practitioner network. (Figure 4)
Figure 4. Conclusion and recommendations of SWOT analysis of TCM in California
Dr. Farshid Towfighi Namin graduated from Tehran Medical University, Iran. He worked many years in the field of emergency medicine. After immigrating to the USA, he obtained both his Master’s and Doctorate of Acupuncture and Oriental Medicine. Dr. Farshid is a licensed acupuncturist in California. He serves as Associate Academic Dean at Yo San University, Los Angeles.
- The National Institutes of Health (NIH), (1997). The National Institutes of Health (NIH), Consensus Development Program: Acupuncture. Retrieved August 8, 2017, from https://consensus.nih.gov/1997/1997acupuncture107html
- California Acupuncture Board. (2013). Retrieved August 8, 2017, from http://www.acupuncture.ca.gov/pubs_forms/strategic_plan.pdf
- California Acupuncture Board. (2018). Retrieved January 4, 2018, from http://www.acupuncture.ca.gov/about_us/board_meetings.shtml
- Creswell, J. W. (2012). Qualitative Inquiry and Research Design | SAGE Publications Inc. Retrieved January 12, 2017, from https://us.sagepub.com/en-us/nam/qualitative-inquiry-and-research-design/book235677
- Baker, S. E., & Edwards, R. (2012). How many qualitative interviews is enough (Working Paper). NCRM. Retrieved August 8, 2017, from http://eprints.ncrm.ac.uk/2273/
- Mason, M. (2010). Sample Size and Saturation in PhD Studies Using Qualitative Interviews. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 11(3). Retrieved August 8, 2017, from http://www.qualitative-research.net/index.php/fqs/article/view/1428
- Chu, J. (2015, November 23). Actions – H.R.3849 – 114th Congress (2015-2016): Acupuncture for Heroes and Seniors Act of 2015 [legislation]. Retrieved November 11, 2016, from https://www.congress.gov/bill/114th-congress/house-bill/3849/actions