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Introduction

In recent months, several main acupuncture schools in the USA have closed [1–4]. This followed a decrease in the number of both acupuncturists (8.87%) and active accredited schools (9.68%) in 2023 [5]. In previous years, between 1998 and 2018, the number of acupuncturists in the USA had increased exponentially (254%) [6], and growth was observed over the period 2004–2015 (52.09%) and 2009–2015 (23.30%) [7]. The number of masters’ programs in the USA decreased from 62 in 2015 to 50 in 2023 [5,7]. Albeit scarce, data for the UK shows that in the period from 1995 to 2009, the number of university accredited complementary medicine degrees (BSc, BA, MSc, and MA) increased from 4 to 44 [8]. The number of undergraduate acupuncture courses peaked at 14 in 2010, 8 of which were delivered at universities and 6 were offered at private acupuncture schools with university accreditation [9]. Whilst 8 of those courses were still being offered in 2014, 3 were no longer recruiting new students for the following academic year [8]. The reasons are numerous and complex and include both general trends in healthcare and shortcomings in acupuncture education.

1. Increasing research education

Research education can enhance a student’s understanding of acupuncture and Traditional Chinese Medicine (TCM) by stimulating critical thinking. Students of TCM learn how to assess the quality of studies, interpret results, and how to apply relevant findings to the clinic. In the USA and Canada, TCM students have endorsed the view that research is relevant not only for clinical practice but also for mainstreaming of the profession [10–12]. However, a substantial gap in acupuncture research education persists. This is perpetuated by a lack of education on the interpretation and application of research [13]. In a commendable initiative in the USA in 2008 which aimed to close this gap, grants were awarded to acupuncture schools to enhance research education [14]. This enterprise enabled the training of students, faculty members, and alumni in the foundations of clinical research design and implementation [15]. The goal was to stimulate interest in both participating in research and receiving in depth research training [15]. Analysis of the outcome of this initiative suggested that whilst interest in research was high among 1^st-year undergraduate students it was not sustained [12]. These findings on attitudes and interests towards research in acupuncture and Traditional, Complementary and Integrative medicine students become particularly relevant when the course structure is examined in terms of research modules, when they are introduced, and when specialization occurs in the curriculum.

A comparison of acupuncture and TCM education between China and other countries (Australia, Canada, Italy, UK, and USA) showed that whilst programs in the USA emphasize clinical practice, students in China complete a research module in their 1^st year, even before being introduced to clinical practice in following years [16]. In the UK, degree programs include research education, in view of equipping students with empowering knowledge on how to identify, understand, and interpret the vast and valuable evidence base for acupuncture [16]. Countries where universities offer postgraduate research degrees e.g., Australia, allow students to perform laboratory studies or clinical trials on acupuncture and Chinese herbal medicine [16]. Therefore, it seems important to consider that along with the type of research training offered to students, the timing of such engagement is also of crucial relevance.

2. Fostering inter-professional collaboration

Besides students and practitioners of acupuncture and TCM extending education to other healthcare professionals regarding evidence-informed acupuncture in the clinical setting, this could also lead to an increase in knowledge and understanding of its efficacy [17]. Thus, potentially increasing provision and furthering integrative medicine and collaborative practice. This is particularly relevant since despite the increase in acupuncture research and clinical guidelines advocating for its use, and along with its popularity amongst the general public, acupuncture’s integration into healthcare systems still remains low [18]. A few, though encouraging, examples of collaborative and integrative use of acupuncture in healthcare settings have exposed a considerable gap between evidence-based recommendations for acupuncture and its implementation [19]. Education and dissemination of acupuncture research are the foundation of bridging the implementation gap [19], and given how the use of a scientific evidence approach can facilitate communication within healthcare professionals, confidence in acupuncture will grow [20].

3. Closing the dissemination gap and bridging clinical practice and research

Increasing student awareness of effective dissemination of research findings in acupuncture and TCM clinical applications is an empowering communication tool. Non-profit organizations such as Evidence Based Acupuncture [21] and the Society for Acupuncture Research [22] highlight innovative research topics such as artificial intelligence and digital health [23,24] in special interest groups [25] and online journal clubs [21]. One such initiative focuses on Practice-Based Research [25], with the goal of optimizing data collection from acupuncture and TCM clinics, including teaching clinics. Acupuncture schools can educate students on evidence-based practice whilst simultaneously contributing towards the body of research and research-informed practice by publishing case reports originating from teaching clinics.

Case reports serve as an essential bridge between theoretical knowledge and practical application. In acupuncture education, students often learn complex theories and principles that can be challenging to apply in real-world settings. Well-written case reports demonstrate how these theories translate into practice, provide examples of how diagnostic principles are applied, reason why specific acupuncture points or techniques were applied, and how treatments were adjusted based on patient response [26].

4. Applications in acupuncture education and professional development

Case reports can be used in a variety of ways to enhance acupuncture education. They can form the basis for discussions, be incorporated into clinical training to promote thorough observation and critical thinking, and serve as a tool in continued education (including PhD, and MSc courses).

Preparing cases of significance for a case report, collating data, describing diagnostic methods, and discussing key observations introduces students to basic research skills and helps them communicate effectively on acupuncture treatments, and publication facilitates access for other healthcare professionals [27,28] (it is important to differentiate between “case histories” - often gathered in the short-term, taught as a technique-based training program in acupuncture schools - and properly structured “case reports” which are articles published in a journal for medical, scientific, and educational purposes. These terms are often used interchangeably. Here we refer to a “case report” as used across medical, and complementary medicine fields, which has clear guidelines [27,28], and requires a high level of academic rigor and data collection).

5. Case reports in acupuncture education, research, and practice

Case reports have long been a cornerstone of medical communication, serving multiple purposes from documenting new or rare conditions to reporting adverse events [27]. In the field of acupuncture and TCM, case reports take on additional significance due to their historical importance and capacity to allow an accurate diagnosis for the multifactorial nature of holistic health interventions [28]. One of the primary educational benefits of case reports lies in their capacity to sharpen clinical reasoning and diagnostic skills. By documenting the detailed process of patient assessments, treatment planning, and outcome evaluations, case reports provide a valuable tool for student practitioners to learn from real-world clinical scenarios. This process encourages them to meticulously observe and record patient symptoms, critically analyze the effectiveness of interventions, and reflect on their decision-making process throughout the course of treatment [26]. Whilst randomized controlled trials are considered the gold standard in medical research, case reports build the foundation for practice-based research in acupuncture. They introduce students to systematic documentation and reporting, encourage critical evaluation of treatment outcomes, and familiarize them with research methodologies and reporting standards such as the internationally recognized CAse REport (CARE) guidelines and the specialized CHM (Chinese Herbal Medicine)-CARE guidelines, which are guidelines for writing case reports that ensure accuracy, transparency, and usefulness [27,28].

6. Secondary analyses – tools to bridge theory and practice

When combined with other pragmatic data sets, such as those from clinical registries, secondary analysis can also provide a research model that more closely reflects actual practice than randomized controlled trials. Due to the inherent limitations of individual data sources including generalizability and selection bias [29], secondary analyses of combined case reports and clinical registry data offer a promising approach to mitigate these potential pitfalls. By aggregating data from multiple sources, researchers can increase the sample size and produce a large amount of clinical data (at a relatively low cost) [30–32]. This approach works for traditional medicine best when data are standardized across sources such as when International Classification of Primary Care-2 codes for health complaints and International Classification of Diseases-11 codes for diagnoses are used [33,34], and this facilitates a more reliable and valid comparison.

The use of concurrent triangulation mixed method design allows for corroboration of findings from different data sources and analytical methods, and enhances the reliability and validity of results [35,36]. This approach is particularly valuable in acupuncture and TCM research where interventions often involve multiple components and nonlinear changes that may not be apparent in simpler study designs [37–39]. By combining data from a broader context (for example including private medicine with public health medicine data) provided by clinical registry data, detailed information from case reports can provide enough data for quantitative and qualitative analyses to balance generalizability with in-depth understanding [40–42]. This synthesis of data sources and research methods can, more specifically, help identify diagnostic patterns, treatments, outcomes, and inform the design of future clinical trials [43,44].

Conclusion

Degree-level education goes beyond mere technical proficiency, and it is crucial to equip students with the research skills and analytical thinking necessary to engage meaningfully with clinical data. We suggest that research and analytical skills be fostered in students so that meaningful case reports can be produced. For established practitioners, engaging in writing up case reports can be a powerful professional development tool. By regularly documenting and analyzing their clinical experiences through publishing case reports, practitioners can refine their practical skills, and be up-to-date with their research-based knowledge [31]. Educating and immersing acupuncturists in evidence informed practice and in the practice of informed research [45] is essential to ensure they become not only proficient in their clinical skills but are also capable of contributing to the broader field of acupuncture research through well-constructed, scientifically valuable case reports. After all, the way to construct a strong pyramid of evidence starts by ensuring that its base is solid and robust.

Article information

Author Contributions

Conceptualization: SG and SJA. Methodology: HL, RNS, and KL. Formal investigation: SG, SJA, and KL. Project administration: SG. Writing original draft: SG, SJA, HL, RNS, and KL. Writing – review and editing: SG, SJA, HL, RNS, and KL. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

None.

Ethical Statement

This research did not involve any human or animal experiments.

Data Availability

References

• [1] American College of Traditional Chinese Medicine [Internet]. American College of Traditional Chinese Medicine: 2024 [cited 2024 Sep 14]. Available from: https://www.actcm.edu
• [2] Camhi T [Internet]. With deep debt and low-paying jobs, Portland alternative medicine graduates say their degrees will never pay off: OPB: 2024 [cited 2024 Sep 12]. Available from: https://www.opb.org/article/2024/08/29/portland-oregon-college-of-oriental-medicine-debt-alternative-degree-acupuncture/
• [3] Ferguson P [Internet]. AOMA: a time to reflect: Acupuncture Today: 2024 [updated Jun 2024; cited 2024 Sep 11]. Available from: https://acupuncturetoday.com/article/39258-aoma-a-time-to-reflect
• [4] Medicine ACfAaH [Internet]. Previously accredited/pre-accredited programs and institutions: 2024 [cited 2024 Sep 14]. Available from: https://www.acahm.org/directory-menu/previously-accredited-pre-accredited-programs-and-institutions/
• [5] Fan AY, He DG, Sangraula A, Faggert Alemi S, Matecki A. Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2023, during the late stage of the COVID-19 pandemic. J Integr Med 2024;22(4):379−84.ArticlePubMed
• [6] Fan AY, Stumpf SH, Faggert Alemi S, Matecki A. Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2018. Complement Ther Med 2018;41:295−301.ArticlePubMed
• [7] Fan AY, Faggert S. Distribution of licensed acupuncturists and educational institutions in the United States in early 2015. J Integr Med 2018;16(1):1−5.ArticlePubMed
• [8] Givati A, Hatton K. Traditional acupuncturists and higher education in Britain: the dual, paradoxical impact of biomedical alignment on the holistic view. Soc Sci Med 2015;131:173−80.ArticlePubMed
• [9] Givati A, Berlinsky S. The ‘disenchantment’ of traditional acupuncturists in higher education. Health (London) 2023;27(1):20−40.ArticlePubMedPMCPDF
• [10] Anderson BJ, Kligler B, Cohen HW, Marantz PR. Survey of Chinese medicine students to determine research and evidence-based medicine perspectives at pacific college of oriental medicine. Explore (NY) 2016;12(5):366−74.ArticlePubMedPMC
• [11] Ijaz N. Research-related attitudes among Chinese medicine students at a Canadian college: a mixed-methods study. Integr Med Res 2019;8(4):264−70.ArticlePubMedPMC
• [12] Wayne PM, Hammerschlag R, Savetsky-German J, Chapman TF. Attitudes and interests toward research among students at two colleges of acupuncture and Oriental medicine. Explore (NY) 2010;6(1):22−8.ArticlePubMedPMC
• [13] Allen SJ, Conboy L, Wasserman TL, Graca S, Mager A, Howlett B, et al. 2021 American society of acupuncturists survey on acupuncturists’ backgrounds, interests, and attitudes toward conducting research. Med Acupunct 2024;36(4):215−26.ArticlePubMed
• [14] Kreitzer MJ, Sierpina VS. NCCAM awards grants to CAM institutions to enhance research education. Explore (NY) 2008;4(1):74−6.ArticlePubMed
• [15] Wayne PM, Buring JE, Davis RB, Andrews SM, John MS, Kerr CE, et al. Increasing research capacity at the New England School of Acupuncture through faculty and student research training initiatives. Altern Ther Health Med 2008;14(2):52−8.PubMed
• [16] Xue P, Zhan T, Yang G, Farella GM, Robinson N, Weihong Yang A, et al. Comparison of Chinese medicine higher education programs in China and five Western countries. J Trad Chine Med Sci 2015;2(4):227−34.Article
• [17] Dilts JJ, Esparham AE, Boorigie ME, Connelly M, Bickel J. Development and assessment of an abbreviated acupuncture curriculum for pediatricians. Acad Pediatr 2022;22(1):160−5.ArticlePubMed
• [18] Koppelman MH. Acupuncture: effective and recommended but more implementation needed chinese medicine and culture. 2024;7(1):86−93.Article
• [19] Graca S, Huemer M, de Valois B, Vang B, McClure L. “Are we there yet?” – green shoots of progress in acupuncture implementation in healthcare. Eur J Integr Med. 2024, 69:p 102371. Article
• [20] Mallory MJ, Do A, Bublitz SE, Veleber SJ, Bauer BA, Bhagra A. Puncturing the myths of acupuncture. J Integr Med 2016;14(5):311−4.ArticlePubMed
• [21] Acupuncture EB [Internet]. Evidence based acupuncture: 2024 [cited 2024 Sep 13]. Available from: https://www.evidencebasedacupuncture.org
• [22] Research SfA [Internet]. Society for acupuncture research: 2024 [cited 2024 Sep 13]. Available from: https://www.acupunctureresearch.org
• [23] Citkovitz C, Graca S, Anderson B, Conboy LA, Gold MA, Hirsch E, et al. Acupuncture practice-based research in the age of artificial intelligence: developments as of May, 2024. J Integr Complement Med 2024;30(8):712−5.ArticlePubMed
• [24] Witt CM, Balneaves LG, Carlson LE, Cohen M, Deng G, Fouladbakhsh JM, et al. Education competencies for integrative oncology-results of a systematic review and an international and interprofessional consensus procedure. J Cancer Educ 2022;37(3):499−507.ArticlePubMedPMCPDF
• [25] Research SfA [Internet]. SAR special interest groups: 2024 [cited 2024 Sep 15]. Available from: https://www.acupunctureresearch.org/special-interest-groups
• [26] Florek AG, Dellavalle RP. Case reports in medical education: a platform for training medical students, residents, and fellows in scientific writing and critical thinking. J Med Case Rep 2016;10:86. ArticlePubMedPMC
• [27] Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D, et al. The CARE guidelines: consensus-based clinical case reporting guideline development. Headache 2013;53(10):1541−7.ArticlePubMed
• [28] Linder B, Yang G-Y, Lumiere K, Taylor-Swanson L, Graca S, Armour M. Collaborative design of a Chinese herbal medicine case report guideline (CHM-CARE). Eur J Integr Med 2024;68:102364. Article
• [29] MacPherson H, Hammerschlag R, Lewith GT, Schnyer RN. Acupuncture research: strategies for establishing an evidence base. Churchill Livingstone, Elsevier, 2007.
• [30] Langevin HM, Wayne PM, Macpherson H, Schnyer R, Milley RM, Napadow V, et al. Paradoxes in acupuncture research: strategies for moving forward. Evid Based Complement Alternat Med 2011;2011:180805. ArticlePubMedPMCPDF
• [31] MacPherson H, Hammerschlag R, Coeytaux RR, Davis RT, Harris RE, Kong JT, et al. Unanticipated insights into biomedicine from the study of acupuncture. J Altern Complement Med 2016;22(2):101−7.ArticlePubMedPMC
• [32] Nissen T, Wynn R. The clinical case report: a review of its merits and limitations. BMC Res Notes 2014;7:264. ArticlePubMedPMCPDF
• [33] Organization WH [Internet]. International classification of primary care: 2024 [cited 2024 Sep 12]. Available from: https://www.who.int/standards/classifications/other-classifications/international-classification-of-primary-care
• [34] Organization WH [Internet]. ICD-11 implementation: frequently asked questions: 2024 [cited 2024 Sep 12]. Available from: https://www.who.int/standards/classifications/frequently-asked-questions/icd-11-implementation
• [35] Creswell JW, Plano Clark VL, Gutmann ML, Hanson WE. Advance mixed methods research designs. Edited by Tashakkori A, Teddlie C: Handbook of mixed methods in social & behavioral research. Thousand Oaks (CA), SAGE Publications, Inc, 2003, pp 209−40.
• [36] Tashakkori A, Teddlie C. Mixed methods research. Edited by Denzin NK, Lincoln YS: The SAGE handbook of qualitative research. 4(1): Thousand Oaks (CA), SAGE Publications, Inc, 2011, pp 285−300.
• [37] MacPherson H, Schroer S. Acupuncture as a complex intervention for depression: a consensus method to develop a standardised treatment protocol for a randomised controlled trial. Complement Ther Med 2007;15(2):92−100.ArticlePubMed
• [38] Paterson C, Baarts C, Launso L, Verhoef MJ. Evaluating complex health interventions: a critical analysis of the ‘outcomes’ concept. BMC Complement Altern Med 2009;9:18. ArticlePubMedPMCPDF
• [39] Paterson C, Britten N. Acupuncture as a complex intervention: a holistic model. J Altern Complement Med 2004;10(5):791−801.ArticlePubMed
• [40] Lowe N, Permyakova N, Dutton R. A clinical audit of patient outcomes in real-world acupuncture practice. Acupunct Med 2024;42(4):209−15.ArticlePubMedPDF
• [41] Lowe N, Permyakova N, Dutton R. A clinical audit in a UK-based acupuncture private practice: assessing patient demographics, outcomes and experience. Acupunct Med 2024;42(3):166−72.ArticlePubMedPDF
• [42] Sayre JW, Toklu HZ, Ye F, Mazza J, Yale S. Case reports, case series - from clinical practice to evidence-based medicine in graduate medical education. Cureus 2017;9(8):e1546. ArticlePubMedPMC
• [43] Hunziker S, Blankenagel M. Multiple case research design. Research design in business and management. Wiesbaden (Germany), Springer, Gabler, 2021, pp 171−86.Article
• [44] Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med 2018;23(2):60−3.ArticlePubMedPMC
• [45] Graca S, Citkovitz C. From bench to bedside and back again: developments in the evidence-informed practice (and practice-informed research) of acupuncture. J Integr Complement Med 2022;28(8):613−7.ArticlePubMed

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