Dear Zhang Zhong Jing

I have to say that I was very surprised to discover that you had risen from the dead in order to wade into the FPD debate. Obviously I have great respect for your work. So please forgive me for saying that the following letter, which you posted on the Internet, does not quite measure up to your previous achievements as a writer. Your arguments in support of the FPD are about what I would expect from someone who has been dead for a couple of millennia: 

Dear ACAOM Commissioners,

I’m writing to express my support for continuing the discussion on developing a First Professional Doctorate. I believe that the FPD is critical to the future growth and strategic positioning of the AOM profession for the following reasons:

1. The additional biomedical learning competencies would better position graduates to get jobs in integrative clinics and hospitals, providing more access to AOM care for patients who really need it.
2. In our culture the doctorate title provides a higher level of respectability to the AOM profession from both patients and other health care providers.
3. The FPD would help protect and better support our scope of practice in state legislative and regulatory bodies.
4. Besides opening the possibility for more jobs in the health care sector, a FPD opens access to seats at the table of policy-making bodies that make decisions on how our medicine fits into the health care system.
5. Future students would have a choice in whether to pursue the current three academic year acupuncture Masters, four academic year OM Masters or a four academic year FPD.
6. Future students that would otherwise be attracted to pursue a DC/ND/MD might choose an AOM career instead.

I also support the development of a transitional FPD for currently licensed AOM professionals and students that takes into account such factors as the program from which they graduated, their professional experience, and post-graduate learning endeavors. A transitional FPD should be affordable, accessible (with distance learning options), and include challenge exams as part of the process.

According to the recent AAAOM profession on the FPD, 65-70% of those who expressed an opinion were supportive of the FPD in Acupuncture-Oriental Medicine (http://acupuncturetoday.com/mpacms/at/article.php?id=32093). This clearly demonstrates enough support to continue the discussion about developing the FPD, and I strongly encourage ACAOM to do so.

Sincerely,

Zhang Zhong Jing

I think the problem here is that, quite understandably, you don't get what's going on with the FPD debate.  Having been incorporeal for so long, your perspective will naturally be a little different from those of us who are involved in this issue on the ground, us flesh and blood mortals who need to make a living and pay our bills. You're beyond all that and have been for a long time. So I hope you won't mind if I try to catch you up a little. 

The medicine which you love has been having a hard time here in twenty-first century America, particularly around the issue of professionalization.  This article provides an excellent summary of our struggles in the recent (to you, at least) past. But things have been changing even since that article was written. That's one of the challenges of our time: things change fast. We're arguably in the midst of several social and economic upheavals that profoundly affect the prospects for acupuncture in America.

We don't know much about your life. I hear you may have held "an official position", which I'm guessing means that you had a job. I don't know hard it was for you to get that job or keep it, or whether you had any anxiety about supporting yourself or your family, if you had a family. So I don't know how this will sound to you, but I need to speak to you very bluntly about jobs, money, and acupuncture in the present time, because that's the area where your FPD arguments really fall apart.

Everything in our society is shaped by the way it is paid for. This might have been true in your day as well, I don't know. To understand how something works, you have to look at its funding stream. A very eminent acupuncturist of our time, Dr. Michael Smith of NADA, commented that it has been hard for America to understand acupuncture, but it's easy for America to understand schools. And so, as people (and by this I mostly mean white people in this context) became interested in establishing acupuncture among other (mostly white) people, they concentrated on making schools. They concentrated on making schools to teach acupuncture more than they concentrated on the actual mechanics of how practitioners could PROVIDE acupuncture.

Because it is easy for America to understand schools, soon after the acupuncture schools began to be established, an easy funding stream was found for them in the form of federal student loans. Now, I'm sure you didn't have those back in your time. Basically what it means is that people who want to become acupuncturists can borrow money in order to go to acupuncture school, with the expectation that once they become acupuncturists and are working, it will be no problem for them to pay it back. But there is a problem, of course, and it's that the mechanics of how practitioners were to provide acupuncture in American society remained shaky and unformed, particularly the economic aspects -- even as the schools became more and more organized. I know this because I was there for much of this organizing process. When I went to acupuncture school, my class was only the second class to receive a Master's degree or to be able to take out federal loans. Everyone was excited about this development, but in hindsight it is obvious that no one had the faintest idea about how those of us who got those degrees were going to make a living.

Among certain social classes in America, money is kind of an unseemly, awkward topic. It's not polite to bring it up. I come from a social class in which talking about money is natural and expected, because we have so little of it, relatively speaking. We have to talk about it; we don't have a choice. When I first started bringing up the details about the economics of acupuncture in America -- were practitioners really making a living? who could afford to pay for acupuncture at the going rate? -- many of my fellow practitioners treated me as if I had violated a taboo, as if I had taken all my clothes off in public.  There was a definite if unspoken message that I was doing something sort of disgusting by trying to provide acupuncture cheaply to my friends and neighbors. (Even that word, "cheap", is loaded in our culture). Anyway, I got the message that I was both dirty and out of line, and I learned that there was no possibility of having these conversations politely. Which turned out to be all right in the end, because some of the economic structures of the acupuncture profession, as it has evolved in America, are so ugly that being polite about them is no longer appropriate.

So let's talk about your arguments.

1. Adding more biomedicine into the curriculum will make it easier for graduates to get jobs in hospitals. Oh Zhang Zhong Jing, you're centuries and centuries old, how can you be so naive? Do you not understand that the healthcare system in America, especially as represented by hospitals, is a for-profit system? Remember what I said about the shape of anything here is determined by its funding? There is no profit in acupuncture. Even though it works at least as well as many drugs, it can't be patented. Funding for hospital jobs is inextricably tied up with the funding streams of the pharmaceutical companies, the insurance companies, and all the other for-profit companes that make up American healthcare. Acupuncture doesn't make anybody's shareholders any money. Sure, there may be a handful of jobs for acupuncturists in hospitals who want an integrative "flavor", but we're not talking about more than a handful. And if you really want to bring up this discussion, you need to stay current with John Weeks' blog. You might be especially interested in all the posts that talk about how many integrative medicine initiatives fail because their funding streams collapse.

2. In our culture the doctor title provides a higher level of respectability from patients and other health care providers. OK, I can see how even if you were floating incorporeally around the Internet, and you found Linda Barnes' article, you might believe, as many acupuncturists believe, that doctors are the gatekeepers, and if doctors respect us, we will be able to participate in taking care of patients within the health system. That isn't true anymore. Doctors aren't the gatekeepers of healthcare in America, insurance companies are the gatekeepers. And what happens in healthcare is no longer about who gets respect, but about what makes a profit. Having a title does not help us to create a funding stream for our work; titles and funding are no longer inherently connected. Ask all of the folks with doctoral degrees who are vainly trying to get their "evidence based medicine" into actual practice.

Also, while you might be hoping to magically conjure power and authority by means of using a name, names don't work that way in our current economic reality. Not even yours. Ahem.

3. Scope of practice, regulatory bodies, etc. You're showing your age here again, Zhang Zhong Jing. The acupuncture profession fought the battle of independent licensing a long time ago (mostly, though not everywhere) and won -- but stands to lose the war over, well, our long-term existence. In this day and age, it's not about legislation, it's about economics. For the majority of licensed acupuncturists in America, their scope of practice, however well defended and supported by titles, is like a beautiful fantasy, because they have no actual patients to practice ON. Our own lack of an economic foundation for our profession is our problem, not what other people will let us do.

4. FPD opens policy doors, how our medicine will fit into the healthcare system, etc. Maybe you can't believe this, because it's pretty hard even for us to believe, but America is rapidly going broke trying to pay for health care.  In this climate, nobody is going to be adding new modalities. I know, I know, we could save them money -- but the ones who are in true control of the system, who are making money, don't care. And the ones who aren't in control see acupuncture as a luxury, as fluff, as something exotic for rich people to pamper themselves with -- maybe because, I don't know, American acupuncturists themselves have been busy marketing it that way? And even if we got a seat at that table, as one of my colleagues pointed out recently, it's a filthy table. It's actually killing people.

5. Future students would have a choice. They have a choice now. If they want a doctorate, they can get a DAOM. Making the doctorate entry-level is what makes those of us opposed to it so very suspicious.

6. Future students that otherwise might pursue a DC/ND/MD would go into our field instead. I'm going to combine my response to this with your paragraph about supporting a transitional FPD, because they reflect the same issue.

Like I said, I don't know how to say this politely, Zhang Zhong Jing, but your perspective on our field is that of someone who clearly doesn't have to make a living in practice. I recently heard a quote from a practitioner that goes like this: "I have been practicing for four years now, and much of the feedback I get from fellow graduates is that they cannot make a living in this field...and some it seems go back to teaching or working at our school when it appears they cannot make their own practice fly." This was in the context of a survey that showed the average income of practitioners in that area coming in at $20,000 dollars a year, and no one identified whether that was gross or net. If you were ever in business for yourself, Zhang Zhong Jing, you would know why that difference really, really mattered.

DCs and NDs have much the same problem as we do; competing with their fields doesn't solve our problem. The problem is that all alternative medicine education, whether chiropractic, naturopathic, or acupuncture, bears a painful -- though I'm sure unintentional -- resemblance to a Ponzi scheme. I hope they didn't have those in ancient China. By which I mean alternative medicine education requires a steady stream of people who don't understand what is really going on to keep giving it their money. When they discover that their diploma, whether it be an ND, DC, or M.Ac.OM, plus $4, will buy them a cup of coffee at Starbucks -- and that's it -- one of their only viable options, besides leaving the field altogether, is to try to get back in the business of educating other people. Alternative medical education is mostly financially viable because it perpetuates itself, not because it helps people create a livelihood. I know this is a terrible thing to say.  Actually, I would like to be proven wrong. However, since statistics on practitioner success seem difficult or impossible for anyone to gather, no one even wants to have this discussion with me. As usual. I don't think you are intentionally trying to hurt anyone, ZZJ, as you advocate for more education. I just think, because you do not have to support yourself the way we do, you have absolutely no idea how hard it is, or how the process of acupuncture education sets people up to fail. So you would have no way of knowing how badly we as a field need to deal with the underlying issues of creating viable economic structures for acupuncture delivery. And how jumping towards an FPD will only make an already bad situation so much worse.

One last thing. Developing the FPD standards requires consensus in the acupuncture profession. Being from a hierarchical society, you might not understand the definition of consensus.  It doesn't mean a majority, and it doesn't mean that you can spin your presentation to make it look like people who don't agree with you don't exist. Now, I know you're new to this scene, but you really might want to think twice before trying to personally represent the disembodied essence (though you ARE disembodied, I realize that) of the acupuncture profession. Because if that's who you are, you and I have a lot of talking to do. And while you might not be accustomed to having women and peasants talk back to authority, you're going to have to get used to it. Because, like I said, things are different now.

Lisa

This story was posted on December 1 2009 by Lisafer.
Tags: humor

Comments

  • December 1 2009 at 3:05 PM
    LarryG writes:

    here is a link

    to the ancient doctors ghostly musings on the AIMC website.

      0 likes
  • December 1 2009 at 4:14 PM
    peoples writes:

    Lisa, you are far more

    Lisa, you are far more articulate than I can ever be.  I hope that our alphabet organizations are actually reading what you putting in front of them.

    This is my short choppy letter to the NCCAOM.  I applaud you for not paying them off. Currently I am a member. 

    If anyone else is writing in to them, AT, and any other acupuncture organization, please share and please share any responses.

    Thanks, Elizabeth

    Dear Executive Office on NCCAOM,
     
    I am a new practioner and a new member of NCCAOM.  This is the only acupuncture association that I am a currently a member of.  I have just read an article in Acupuncture Today about a survey conducted by the AAAOM regarding the First Professional Doctorate.  904 members of AAAOM have been surveyed.  Acupuncture Today is distorting this information to make it sound like a majority is speaking up for the whole profession.  904 individuals is not a majority. I am opposed to major decisions, such as the FPD, being made on such a small figure.
     
    I am a licensed practioner.  I want my opinions to be taken into consideration.  I want more practioners to have an opportunity to state how they feel in this important matter. I want NCCAOM to conduct a survey and to make it accessible by emailing it to practioners or mailing it to us.  I want to know that the money have to pay to you goes towards looking out for my best interest as a practioner. You can do this by getting involved in the FPD discussion creating a forum for NCCAOM members to put forward our opinions.
     
     
    Sincerely, Elizabeth Ropp, L. Ac. DOM

      0 likes
  • December 1 2009 at 6:29 PM
    emily writes:

    Exactly.

    “However, since statistics on practitioner success seem difficult or impossible for anyone to gather, no one even wants to have this discussion with me.”

    Exactly.  Shouldn’t gathering that data be the first step before we even talk about an FPD? It would be very interesting to see if those practitioners with DAOMs are making a better living than those of us who “only” have MAOMs.

      0 likes
  • December 1 2009 at 10:44 PM
    keithananda writes:

    So far there has still been

    So far there has still been no compelling reason given to transition the entry level degree to an FPD. 

    Regardless of a potential tiered system or any current/future DAOM programs, the fact remains that the current Master’s curriculum has not been shown to be deficient for students to learn the skills of AOM to practice these skills competently as entry level practitioners upon graduation.

     

      0 likes
  • December 2 2009 at 2:55 AM
    Guest writes:

    Hey Elizabeth,
    It doesn’t

    Hey Elizabeth,

    It doesn’t seem like you know very much about the NCCAOM. (That statement wasn’t meant to be a dig against you.) If you did, you would know that the NCCAOM’s main concern is how much money that it can make off students and practitioners. To put it more bluntly, the NCCAOM is at the very top of the Ponzi scheme. The FPD would be a new revenue stream for the NCCAOM.

    Clay

      0 likes
  • December 2 2009 at 12:41 PM
    Moses.C writes:

    such a cool employer…

    Thank you Lisa for your continued fire and clarity! This particular blog is such a great summary of how the proposed FPD just makes no sense for patients. There is not yet a clear indication that the already available optional doctorate is more effective in producing better patient care and or more revenue than the requisite masters degree in acu. Thanks for the big picture perspective.

      0 likes
  • December 2 2009 at 1:44 PM
    ellengrover writes:

    compartmentalization is the principal mechanism of evil

    ZZJ’s letter is just all about what the FPD would do for the practitioners.  Or rather, what he thinks it would do for practitioners.  Let’s imagine, for a second, it was even right, even at all, and that the FPD would do all of these great things for the students and practitioners.  WHAT ABOUT THE PATIENTS?  What about the people we are supposed to be wanting and trying to help?  How is the FPD going to benefit the patients?  Duh, it’s not.  I am going to risk sounding hateful and venomous and go ahead just call me immature to boot, but who’s being a little selfish here?  You want to solve problems in the profession?  Go ahead, try to implement an FPD and say that you have the profession’s best interests at heart.  Just make sure you don’t think about the vast majority of the people who actually need acupuncture.  Just think about yourself, and the people who will want to give you money once you have that title after your name.  Forget about the fact that the people who can only afford to pay $15 a treatment really, really don’t give a fuck whether you even have a lousy master’s degree.  Really, forget about them.  Let them suffer.  The way you can so easily ignore them is by the process of compartmentalization, and it’s time to realize that actually, acupuncture and ethics aren’t two separate things. 

      0 likes
  • December 2 2009 at 3:19 PM
    River Jordan writes:

    NCCAOM’s ethics

    I posted a while back that when I graduated from acu-school, NCCAOM had an ethics statement which included a strong statement along the lines of being conscious of the need to offer access to the medicine for everyone, ‘poverty care’ or something they called it. A few years later, I noticed that all references to that sentiment had been removed from their ethics statement. Now their ethics appears to be more about having a spotless white coat, etc.

      0 likes
  • December 2 2009 at 5:43 PM
    crismonteiro writes:

    At least Zhang Zhong Jing has the sense

    not to include the magical spell of primary care in his letter, which some of you might not know, has the power to turn an ancient Chinese healer into the into a bio-medical super-hero!   Swooosh…. (duck!)

     

      0 likes
  • December 2 2009 at 5:44 PM
    crismonteiro writes:

    what I learned about ethics in acu-school

    ethics in acupuncture education= don’t have sex with your patients

      0 likes
  • December 3 2009 at 7:35 PM
    Guest writes:

    Letter of Zhang Zhong Jing

    Thank you Zhang Zhong Jing for your clear and useful comments, and Lisa for yours. From my point of view, both comments have validity. Certainly, as Zhang Zhong Jing highlights, we want our education to make us the bet possible practitioners. The better we are, the more we can help patients, and the more our practices will grow. Having the title Doctor does not guarantee anything, but id does reflect that we want to practice our medicine at the highest levels possible.
    Lisa, you bring up the pioneering stage of our profession. For better or for worse, the insurance system does not remunerate us fairly and graduates have to work very hard to make a good living. Where I live (Santa Cruz) practitioners trained in China do better in their practices mostly because of their superior knowledge and skills. The goal of the educational program at Five Branches University, our local school, is to train us to that same level, so we also can do well in our practices.
    I personally support having the title Doctoral rather than Master’s because I consider the knowledge and skills we learn in acupuncture and herbal medicine at least at the same level as that of chiropractors and naturopaths. I can not agree with Lisa that they should be called Doctors and not us. Lisa - we can practice at the same level as them—really.
    Our profession has been very reasonable to keep the FPD at 4 years (rather than increase to 5 years) so that we don’t add an extra financial burden to students.
    Ron

    Ron

      0 likes
  • December 3 2009 at 9:17 PM
    Nora writes:

    Hey Ron

    I’m curious if the folks trained in China might (also?) have better skills because they saw more patients in their training?

      0 likes
  • December 3 2009 at 9:29 PM
    Jessica Feltz writes:

    Amount of time

    that I’ve spent discussing our acu-education with fellow acupuncturists in the last month: +100 hours.

    Amount of time that I’ve spent discussing my acu-education with thousands of patients over the past two years: 1/2 hour.

    Acupuncturists seem to be far more concered with our level of education than the patients we are serving. 

      0 likes
  • December 3 2009 at 9:41 PM
    Whitsitt writes:

    You hint at the problem with

    You hint at the problem with this line of thought (more education = better practitioners) when you state “having the title Doctor does not guarantee anything.”

    More education means more debt.  It also means more burned out students entering a field with few jobs after using up all their qi and blood grinding away in schools to pass tests that have little bearing on the real world practice of acupuncture.

    So much of what our schools already teach is completely irrelevant to the actual practice of acupuncture.  Loading up more of this would just make things worse.

    Finally, I’d rather keep practicing this medicine at the lowest possible levels.  Things are more real down here with the people.  To each their own, but if you want to be called “doctor”, go to medical school.

      0 likes
  • December 3 2009 at 10:02 PM
    Nora writes:

    OMG

    So true.  I bet between all of us talking and writing about this in the last month, we’ve spent enough hours to fill a DAOM!

      0 likes
  • December 3 2009 at 11:39 PM
    LarryG writes:

    back this statement up

    “Where I live (Santa Cruz) practitioners trained in China do better in
    their practices mostly because of their superior knowledge and skills.”

    please provide the details of the study that supports this claim.

    also: 

    “Having the title Doctor does not guarantee anything, but id does
    reflect that we want to practice our medicine at the highest levels
    possible.”
     

    your use of the word “we” here.  it’s forced.  don’t force you and i or the rest of CANners together with the word “we” as if each of us share similar wants, values, ideas, desires, patient population, etc.   


    “the insurance system does not remunerate us fairly and graduates have to work very hard to make a good living.”

    you’re whining.  insurance is a for-profit biz designed to enrich shareholders, not be fair to you, me or anyone else. besides, most people have to work very hard to make a good living, whether they are plumbers, pilots, or physicians.  you seem to imply that the fpd will raise reimbursement rates for practitioners who can then stop working “very hard” to make a living. i hope you don’t sell this to your students.  it’s crap.

     ”...they should be called Doctors and not us.”

    more whining.  and stop with the forced coupling with the word “us”.  there is no “us”. 

    “Our profession has been very reasonable to keep the FPD at 4 years
    (rather than increase to 5 years) so that we don’t add an extra
    financial burden to students.”

    i’m curious.  would you share your current debt to the US gov’t in the form of student loans?  I’m in for 75K, graduated in 2007.  I net 42K a year, full time acupunk, sole earner with a family of 4.  How about you?  

    that’s why there is no “we” or “us”.

     

      0 likes
  • December 4 2009 at 7:59 AM
    Jessica Feltz writes:

    ~lol~

    And for that, dammit, we DESERVE a DAOM!

      0 likes
  • December 13 2009 at 9:17 PM
    tessmcginn writes:

    this thread is probably past its prime

    but you just wrote something Whitsitt that I’ve been thinking about.  I’ve been thinking about this FPD thing from many different angles trying to find holes in my beliefs and arguments.  And finally you have said (at least at the very right moment that aligned me with your comment) the thing that has been begging to be said for quite some time.  

    “If you want to be called ‘doctor’ go to medical school.”

    By God it just can’t be anymore expensive than being an acupuncturist, you get to walk the doctor walk and talk the doctor talk.  You can wear the white lab coat with the long sleeves!  If people want so much to “integrate” than go to medical school. After medical school, you can take the 500 hour course at Harvard or UCLA and become an acupuncturist.  If you want to do research, go into herbs though because no one is going to give you any funding for acupuncture…BIG PHARMA who funds the lion’s share of medical research in this country (with the name of a University slapped on the front) has ZERO interest in acupuncture because acupuncture can be used by all…it’s not proprietary.

    And we do not argue enough about the realities of primary care doctors.  They are leaving the profession in droves and some of them are becoming acupuncturists because their patients keep asking about it.  Only their patients are in for a rude awakening because guess what?  Most insurance coverages for average work-a-day people do not cover acupuncture.  It’s out-of-pocket expenses.  So they go for awhile and then stop.

    I see this a lot and I am going to see it a lot more.  A few of the “shopper” type patients feel more secure with the doctor but most don’t give a rats as long as the acupunk is duly licensed and other people dare to come to the office, they are happy to pay their $15.  

    Those who argue in defense of FPD and the importance of adequate recognition through curriculum development, and streamlining the process and enhancing our skills in biomedicine are usually people who do not have much of an aptitude or willingness to train in that way.  

    They do however think that since it is “the wave of the future” will heave it onto the rest of us.  But there is no plan for the future.  

    Many Chinese doctors trained in TCM are doing well in Santa Cruz because they are willing to work hard and they stayed in one place.  The acupuncturists I know in Santa Cruz who do well and aren’t Chinese do so because they work hard and are confident in their practice.  Many Chinese doctors in the larger cities who are doing well often charge less than U&C market rates for acupuncturists at large in the US.  And as someone in one of the above comments astutely noted that anecdotal evidence is not proof.

    And speaking of proof -while I’m on this lovely rant on this rainy Sunday evening- evidenced based medicine is making huge strides…look at at the controversy about mammograms.  That mammograms are overused has been known for many years but the impetus to do “something” rather than “nothing” has largely driven its success though its efficacy is highly questionable.  This of courses fits with lots of different tools of biomedicine.

    So where does that leave Chinese Medicine?  Lots of studies, not much believable to BIG PHARMA or BIG INSURANCE.  At this juncture, your biomedicine training wannabes will need to think big thoughts to escape this fact.  NO reliable studies, no third party reimbursement.

    You have no idea how much better off we are with no insurance coverage.  If you think we’d be better off, start billing away.  All those nice little teaching classes they offer through the acupuncture associations will not prepare you for the nightmare of billing.  I used to bill 3rd party reimbursements for a chiropractor so I have first hand knowledge.  I was good at it, but I started to be a person I didn’t like much.  It’s a good job for some, but when it’s you and you think you want to be a healer, good training in patience and greed, anger and ignorance I guess.  And many, many medical practices have joined with larger groups because billing for insurance is a money loser unless you have a volume practice.  “oh that word again, VOLUME.”  We put that word to good use in community acupuncture.  Only a few non CA practitioners can say the same and most make their BIG money writing books or getting other acupuncturists to listen to them in weekend seminars.  I bet Richard Tan would tell you that.  

    One acupuncturist I know used to have a 90 patient per week practice at somewhere around $70 per treatment and he netted only about $70,000 per year.  While that is indeed respectable income, it will not make you rich.  He certainly didn’t get rich.

    As Lisa et al says so often I’m surprised her skin is not permanently blue, acupuncturists cannot be in it for the money.  If you are, most likely you will fail.  

    And the sad and bitter truth is that most Medical doctors are not making much more than my busy acupuncture friend.  The average salary for a pediatrician is about $75,000 per year.  Specialists can make much more but even that is winding down slowly but surely as insurance companies are capping payments.

    It borders on insanity to think our profession is anywhere near being accepted by the medical establishment.  And if you do, like Whitsitt said, “go to medical school.” 

     

     

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