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Center for the Future of Health Professions Feb. 2024 digest

Welcome to the February 2024 op-ed column of the Center for the Future of the Health Professions Digest! We are committed to delivering trustworthy information and research on the healthcare workforce, assisting policymakers and health system stakeholders to plan for a sustainable future. This month, we will review certified registered nurse anesthetists (CRNAs). CRNAs provide anesthesia services for patients across the lifespan at all acuity levels undergoing surgical and diagnostic procedures of varying complexity and have done so for more than 150 years. They provide much-needed healthcare services in this country.

We are pleased to introduce Michael J. Kremer, PhD, CRNA, CHSE, FNAP, FAAN, a professor and interim chair of the Adult Health and Gerontological Nursing Department in the Rush University College of Nursing. He practiced clinically as a CRNA for 35 years in tertiary medical centers in Seattle and Chicago, community hospitals, surgery centers, and office-based practices.

Dr. Kremer completed undergraduate degrees in psychology, nursing, and nurse anesthesia; a master of science degree in nursing leadership; a PhD in nursing science; and postdoctoral studies in psychoneuroimmunology. He has served as a didactic and clinical nurse anesthesia educator and a nurse anesthesia program director at Rush and Rosalind Franklin University. In addition, he was the Rush Center for Clinical Skills and Simulation co-director for 17 years.

Dr. Kremer has held elected and appointed local, state, and national positions. He has served as an on-site reviewer and board member for the Council on Accreditation of Nurse Anesthesia Educational Programs. Dr. Kremer is a peer evaluator for the Higher Learning Commission. He has provided poster and platform presentations at local, regional, national, and international conferences and has authored multiple journal articles and textbook chapters. Dr. Kremer is a fellow in the American Academy of Nursing, the National Academies of Practice, and the Institute of Medicine – Chicago. He is also a Certified Healthcare Simulation Educator (CHSE). 

We invite you to share your thoughts on this month’s digest.

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor and Director

The Center for the Future of the Health Professions

A.T. Still University

Michael J. Kremer, PhD, CRNA, CHSE, FNAP, FAAN

Certified registered nurse anesthetists: Past, present, and future

Certified registered nurse anesthetists (CRNAs) provide anesthesia services for patients across the lifespan at all acuity levels undergoing surgical and diagnostic procedures of varying complexity.

Nurse anesthetists in the United States have provided anesthesia care for over 150 years. Catherine Lawrence was a nurse who administered anesthesia in combat zones during the American Civil War. Agatha Hodgins, founder of the American Association of Nurse Anesthetists (AANA), pioneered techniques in trauma anesthesia care during World War I. Nurse anesthetists were the primary providers of anesthesia care to wounded soldiers on the front lines of these wars and subsequent armed conflicts.1,2 By historical and legal precedents, anesthesia is the practice of nursing provided by CRNAs and is the practice of medicine when provided by physicians.3

The first national certification examination for nurse anesthetists was administered in 1945. By 1952, AANA implemented an accreditation process for nurse anesthesia programs in the U.S. The CRNA credential was developed in 1956. Nurse anesthesia was the first nursing specialty to require continuing education in 1978.4 CRNAs have had direct reimbursement rights under Medicare Part B since 1986.2 In 2001, the Centers for Medicare and Medicaid Services (CMS) altered the federal physician supervision rule for nurse anesthetists, permitting state governors to opt out of this facility reimbursement requirement. Analysis of Medicare data found no evidence that opting out of the physician oversight requirement increased anesthesia morbidity or mortality.4 To date, 24 states and Guam have exercised this opt-out.5

The National Board for Certification and Recertification of Nurse Anesthetists (NBCRNA) reports there are more than 59,000 CRNAs in the U.S.6 AANA member survey data shows that 50,259 CRNAs are members of this organization.7 The gender mix of CRNAs is 47% male and 53% female. Most CRNAs are hospital employees (41%), work for anesthesia groups (25%), or are independent contractors(18%).

Alternatively, a few serve in the military or Veterans Administration (3%). CRNAs have full practice authority in every branch of the military. They are the primary anesthesia providers for deployed U.S. military personnel in all settings, including navy ships and aircraft evacuation teams worldwide. CRNAs are entrepreneurs who own or partner in anesthesia groups and provide anesthesia independently in office-based surgical settings.7

Most CRNAs (87%) are clinical practitioners. CRNAs also serve as clinical administrators (3.6%), business owners/partners (3.3%), nurse anesthesia program administrators (2.1%), and teaching faculty (2.3%).7 In 2023, 8,369 students were enrolled in 133 accredited nurse anesthesia programs, with an additional 15 programs in development.8

There are four CRNA/physician anesthesiologist anesthesia delivery models commonly used in the U.S.: CRNA-only, physician anesthesiologist supervision of CRNAs, physician anesthesiologist direction of CRNAs, and physician anesthesiologist-only. Despite the variety of anesthesia delivery models, CRNAs are not required by deferral or state laws, except in New Jersey, to be supervised, directed by, or even work with a physician anesthesiologist.5

Healthcare systems and facilities have addressed rising costs and flat or declining reimbursement for surgical and diagnostic services, resulting in increased demand for CRNAs, who are paid significantly less than anesthesiologists for many of the same services. In 2023, the mean compensation for CRNAs was $235,000, while the average anesthesiologist salary was $427,800. Since outcomes data are positive for CRNAs, this enhances their participation in emerging quality/value-based reimbursement mechanisms.10

The cost-effectiveness and quality of care provided by CRNAs bode well for the profession’s future. CRNAs provide anesthesia services in hospital operating rooms, labor and delivery suites, and numerous ancillary areas, including cardiac catheterization laboratories, endoscopy suites, and interventional radiology settings. CRNAs may be the sole anesthesia providers in rural and medically underserved areas and downrange military settings. Anesthesia in ambulatory surgery centers and office-based practices may be provided by a CRNA working collaboratively with a surgeon, dentist, or podiatrist.11

The U.S. Bureau of Labor Statistics projects 194,500 average annual openings for registered nurses between 2020 and 2030, with employment expected to grow by 9%. In 2020, the median age of RNs was 52 years, with more than 20% stating their intent to retire from nursing over the next five years.12  This nursing workforce shortage could decrease the supply of eligible applicants for nurse anesthesia programs.

A shortage of anesthesia providers is impacting hospitals, healthcare systems, and patients. An increasing disparity between the number of anesthesia providers and available practice opportunities contributes to this shortage. Other factors related to the attrition of current anesthesia providers include anticipated retirements and burnout. Currently, 31% of CRNAs and 56% of the 42,264 physician anesthesiologists in the U.S. are 55 or older. Almost 30% of currently practicing physician anesthesiologists plan to leave practice by 2033, resulting in a shortage of 12,500 physicians. The demand for qualified anesthesia providers will increase when CRNAs and physician anesthesiologists retire. Burnout is another factor that may contribute to retirements, with 47% of physician anesthesiologists and 56% of CRNAs reporting burnout. CRNA attrition has significant implications for rural counties, where CRNAs represent over 80% of anesthesia providers.13

CRNA employment is forecasted to grow by 11.8% between 2021 and 2031. Since surgical services comprise about 60% of a facility’s revenue, maintaining staffing for surgeons, anesthesia providers, and OR staff is critical. Some healthcare organizations utilize interim directors and locum tenens to fill key roles and supplement existing staff. AI-based technology has been deployed to improve OR utilization, reduce costs, and expand efficiencies. Providing a supportive and flexible work environment can be an effective retention strategy for anesthesia providers. Measures including flexible scheduling, professional development opportunities, and mentorship programs can help organizations surmount the anesthesia provider shortage.13

Based on current and projected demand, CRNAs will continue to be valued and highly recruited healthcare team members. In addition to the salary and autonomy associated with the CRNA role, job satisfaction is high: 95% of CRNAs report that they are satisfied or very satisfied with their career choice.7


  1. American Association of Nurse Anesthesiology, 2023. About us: available at:, accessed 1/21/2024
  2. Bankert M. 1989. Watchful care – A history of America’s nurse anesthetists. New York, NY: Continuum.
  3. Blumenreich G. 1990. Is the administration of anesthesia the practice of medicine? AANA J, 85(4): 261-269.
  4. Dulisse B,, Cromwell J. 2010. No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8); 1469-1475.
  5. American Association of Nurse Anesthesiology. 2023. Fact sheet concerning state opt-outs and November 13, 2001 CMS rule. Rosemont, IL: AANA.
  6. National Board for Certification and Recertification of Nurse Anesthetists. 2023. Promoting patient safety by enhancing provider quality: About the NBCRNA. Available at: About Us | NBCRNA, accessed 1/21/2024.
  7. American Association of Nurse Anesthesiology. 2023 Member Survey Data. Rosemont, IL: AANA.
  8. Gerbasi F. 2023. Program Directors’ Update. Issue 94: 1.
  9. American Association of Nurse Anesthesiology, 2023. Quality reimbursement. Available at:, accessed 1/21/2024.
  10. Merritt Hawkins. 2019. CRNA supply, demand and recruiting trends. Available at:, accessed 1/21/2024.
  11. Liao C, Quraishi J, Jordan L. Geographical imbalance of anesthesia providers and its impact on the uninsured and vulnerable populations. Nursing Economics. 105;33(5): 263-270.
  12. American Nurses Association. Nurses in the workforce. 2023. Available at:, accessed 1/22/2024.
  13. Medicus Healthcare Solutions. The anesthesia provider shortage. 2023. Available at:

Welcome to the January 2024 op-ed column of the Center for the Future of the Health Professions Digest! We are committed to delivering trustworthy information and research on the healthcare workforce, assisting policymakers and health system stakeholders to plan for a sustainable future. This month, our focus is on the crucial role of mentoring in shaping the next generation of clinician scholars. Effective mentoring is key to the success of medical, dental, and health science students, whether they pursue careers as clinicians, basic scientists, or clinical researchers.

We are thrilled to feature Len Goldstein, DDS, PhD, as our guest writer once again. Dr. Goldstein serves as the Assistant Vice President for Clinical Education Development in the Office of Academic Affairs, primarily based on the Mesa, Arizona, campus. His responsibilities include ensuring that all ATSU clinically based programs offer a sufficient number of high-quality clinical rotations and experiences in core and elective fields, aligning with program accreditation standards and the respective number of students. He collaborates with deans, directors, and ATSU clinical partners, including community health centers (CHCs), to create additional quality clinical opportunities for ATSU students.

Dr. Goldstein’s accomplishments include being awarded fellowship in the International College of Dentists, the Pierre Fauchard Academy, and the American College of Acupuncture. He is a diplomate of the American College of Forensic Dentistry and the American Academy of Pain Management. With more than 60 published scientific articles in peer-reviewed publications, Dr. Goldstein has demonstrated expertise in mentoring students and colleagues engaged in scholarly activity.

We invite you to share your thoughts on this month’s digest with us.

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor and Director

The Center for the Future of the Health Professions

A.T. Still University

Dr. Leonard Goldstein

Mentoring tomorrow’s clinical medicine scholars

My starting point in osteopathic medical education began in early 2003 as director of clinical education at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM). From the beginning, I saw a need to mentor students and assist them with clinical education, especially in publication. Although there was no requirement for medical students to publish, I saw the value in a student being published. By assisting students with writing and publishing, they took a “deeper dive” into the subject matter. This helped them with their residency applications and interviews. While not a requirement, it was better to be published than not published. I made myself available to any and all NYITCOM students, writing and publishing articles with them. The student was always the “first author”.

When I came to A.T. Still University, I continued writing and publishing with students at A.T Still University’s School of Osteopathic Medicine in Arizona (ATSU-SOMA), Arizona School of Dentistry and Oral Health (ATSU-ASDOH), and Arizona School of Health Sciences (ATSU-ASHS).

Before entering medical education, I published numerous articles and participated in clinical research. I had been part of the executive editorial board of Practical Pain Management, a peer-reviewed journal for practitioners who required information regarding pain management. I have published more than 130 manuscripts with students and have currently submitted 21 for publication. Since I am not a physician, an ATSU-SOMA faculty member co-authors any manuscript.

I have found that students see the value in increasing subject knowledge and have a desire to research and publish more. I now have developed a reputation with students in which they seek out opportunities to write with the “team.” Over the years that I have been at ATSU, I have seen many students “match” into outstanding residencies, and I hope my mentorship and their research/publication(s) have assisted in this endeavor. Hopefully many more faculty members in all of our programs will, if they are not already doing so, utilize their own time to mentor our students.

In this era of explosive medical scientific growth, it is important to mentor tomorrow’s medicine scholars with availability, dedication, and creativity. In this same era, substantial impediments prevent gifted medical and other healthcare students (dental, PA, PT, OT, etc.) from developing into independent patient-oriented investigators.1,2

Superior mentoring is a vital ingredient to the success of all medical and healthcare students, including those who become clinicians, basic scientists, and clinical researchers.3

With Step 1 of the United States Medical Licensing Exam(USMLE) and/or the Step 1 Comprehensive Osteopathic Medical Licensing Exam(COMLEX) recently changing to a Pass/Fail format, medical students now, more than ever, are looking for true mentorship to excel in their future in medicine, and equally important, to be competitive with their residency application.

Relationships between medical students and faculty are an effective means of navigating a student’s professional development path,3,4 increasing the success of their future careers,5 and potentially preventing burnout.6,7

Despite the potential benefits, there has been a lack of mentoring relationships between medical students and physicians/faculty.8 An engaged mentor who takes interest in a trainee’s development is critically important to a successful career. Mentoring will typically encompass a number of functions and relationships, including counseling, career guidance, discipline, and teaching. A commonly used definition of mentoring in medicine is from the Standing Committee on Post-Graduate Medical and Dental Education (SCOPME 1988). According to SCOPME, mentors should support the trainee/student to acquire or hone skills and foster career goals.9

Finally, specific to health professions students, is the goal of integrating research skills with clinical knowledge and education; the three pillars of an academic health professional.10

The United States Accreditation Council for Graduate Medical Education (ACGME) has developed a list of core competencies11 that provide a useful guideline for mentors to impart practical skills and a sense of social and ethical responsibility, including:

  • Patient care
  • Medical knowledge
  • Interpersonal and communication skills
  • Professionalism
  • Practice-based learning
  • System-based practice

All of us in health sciences professions should consider becoming a mentor to tomorrow’s clinical medical scholars.

I want to acknowledge James Keane, DO, MEd, ATSU-SOMA associate professor, OMT/OM, a very important mentor who works with me on student publications.


  1. Wyngaarden JB: “The Clinical Investigator as an Endangered Species”; NEJM; 1979; 301: 1254-1259
  2. Heinig SJ, Quon AS, Meyer RE, Korn D: “The Changing Landscape for Clinical Research”; Academ Med; 1999; 74: 726-745
  3. Schrier RW: “Ensuring the Survival of the Clinician—Scientist”; Academ Med; 1997; 72: 589-594
  4. Kalen S, Ponzer S, Seeberger A, “Longitudinal Mentorship to Support the Development of Medical Student’s Future Professional Role: A Qualitative Study”; BMC Med ED; 2015; 15: 97
  5. Morrison IJ, Lorens E, Bandiera G, “Impact of a Formal Mentoring Program on Academic Promotion of Department of Medicine Faculty: A Comparative Study”; Med Teach; 2014; 36(7): 608-614
  6. Fallatah HI, Park YS, Farsi J, : “Mentoring Clinical Year Medical students: Factors Contributing to Effective Mentoring”; J Med Educ Curric Dev; 2018; 5: 2382120518757717
  7. Vogan CL, McKimm J, Silva ALD, : “Twelve Tips for Providing Effective Student Support in Undergraduate Medical Education” Med Teach; 2014; 36(6): 480-485
  8. Buddeberg-Fischer B, Herta KD: “Formal Mentoring Programs For Medical Students and Doctors—A Review of Medline Literature”; Med Teach; 2006; 28(3): 248-257
  9. Bower DJ, : “Support-Challenge-Vision: A Model for Faculty Mentoring”; Med Teach; 20(6): 595-597
  10. Manabe YC, : “Resurrecting the Triple Threat: Academic Social Responsibility in the Context of Global Health Research”; Clinic Infec Diseas; 2009; 48(10: 1420-1422
  11. Stewart MG: “Accredication Council on Graduate Medical Education Core Competencies”; Available from :

We are excited to introduce the December 2023 op-ed column for the Center for the Future of the Health Professions Digest! Our goal is to provide accurate and reliable information and research on the healthcare workforce to help policymakers and health system stakeholders effectively plan for a sustainable future. This month’s column covers the evolution and future of postgraduate physician associate/assistant (PA) training programs. These programs have become a vital component in PA postprofessional education and training. We explore where we currently stand and where we might be heading.

We are excited to feature Dr. Melissa Ricker. Dr. Ricker holds a bachelor of science in human biology from North Carolina State University, a master’s in PA studies from East Carolina University, and a doctor of medical science from A.T. Sill University. She also completed the WakeMed Health and Hospital Surgical Trauma Critical Care PA Fellowship Program.

Currently, Dr. Ricker practices clinically in pulmonary critical care and serves as the PA fellowship director for the enterprise-wide Atrium Health Advanced Practice Provider (APP) fellowship, overseeing tracks in Charlotte, North Carolina, Winston-Salem, North Carolina, and Macon, Georgia. Since taking on the role of PA fellowship director in 2018, she has collaborated closely with co-director Anne Vail, DNP, to maintain the national reputation of being the largest and most clinically diverse APP fellowship in the country.

To ensure these PA fellows are equipped to provide compassionate care to all, recent program enhancements have included a diversity, equity, and inclusion curriculum, a formal leadership program, local and international service opportunities, and education/research collaborations with other allied health residents at Atrium Health.

We invite you to share your thoughts on this month’s digest with us.

Randy Danielsen, PhD, PA-C Emeritus, DFAAPA

Professor and Director

The Center for the Future of the Health Professions

A.T. Still University

Dr. Melissa Ricker

The evolution and future of postgraduate PA training programs: A vital component in PA education and training

With just over 50 years of the physician assistant (PA) profession in the rearview mirror, it is humbling to think how far the profession has come in such a relatively short period. Certainly innovative for its time, the PA curriculum was designed to run over just two years from its inception, intended to build upon an educational and life experience foundation to fulfill a post-war workforce shortage. Initially a primary care focus recognizing the value of the PA profession, didactic and clinical training were eventually broadened, per accreditation standards, to include a minimum of family medicine, emergency medicine, internal medicine, surgery, pediatrics, women’s health, and behavioral health.1 These professionals are prepared to practice clinically after completing a standardized national certification exam. This is the story we, as PAs, all know and tell.

Unknown to many, in a blind spot on that same rearview mirror lies the fact that PA postgraduate education has co-existed for nearly the same duration. Just six years after the PA profession was founded, Montefiore became the first hospital to include PAs as house officers on inpatient surgical services, and their clinical experience was formalized into [the first] 12-month residency in general surgery and surgical specialties.2 Healthcare professionals and institutions saw value in postgraduate education for these PAs decades ago, enhancing specialty education and training while intensively cultivating other professional skills not traditionally taught within this PA education and continuing to invest in them today. In 2023, more than 160 programs across the United States offer advanced specialty training in nearly every specialty of medicine and surgery.3

This raises the question, do postgraduate PA training programs continue to have a place in the future of PA education and training?

For new graduate PAs entering the workforce, the job market can be challenging. According to the Physician Assistant Education Association’s June 2023 End of Program PA Student Survey, only 35.0% of graduating PA students reported accepting or receiving at least one job offer.4 Landing that job took an impressive number of applications, an average of 9.9. However, even more impressive, those reporting no job or offer reported submitting an average of 13.3 job applications.4 For those for whom clinical work experience or specialty training is an employment barrier, seeking an optional PA fellowship may be a solution to secure long-term employment. A certificate of completion is often awarded following the successful completion of a PA fellowship program and is used to demonstrate increased competence and confidence. In a 2020 national survey of postgraduate physician assistant fellowship and residency programs, 96% of the respondents were employed within two months and 78% reported the demand was “high” for their employment, often presented with “multiple offers”.5 Following the hiring trends of new PA graduates and institutional tendency to hire a PA without experience will be vital to potential increased adoption and growth of the postgraduate training of PA new graduates.

Adding to the marketability of a PA completing a fellowship, PA fellowships seek collaboration with Doctor of Medical Science (DMSc) programs to add to their value, combining the efforts of academic clinical coursework and the structured clinical fellowship experiences. PA fellows enroll in a clinical fellowship and time de-escalated academic doctorate program to apply academic concepts, research methods, and educational and leadership learnings deeply. Graduates receive both a fellowship certificate of completion and a doctorate. While no published work exists on the impact on their employability, one can hypothesize that the increased academic skill only boosts their marketability and value to any hiring institution.

That said, these programs are not solely beneficial for the PA fellow, they are often very beneficial for the sponsoring organization. After all, with the affordability of healthcare becoming more at the forefront of our training and clinical decision-making, hospital operational leaders are choosing to invest in PA fellowship programs because of the financial and nonfinancial return on investment. The opportunity to select highly motivated PA candidates, enroll them into a year-long program at a reduced stipend, invest in their clinical and leadership growth, introduce them to key system leaders, and promote engagement in scholarly work all collectively facilitate this introduction into a multifaceted and fulfilling career as a PA. In the same 2020 postgraduate survey previously mentioned, 83% of participating programs endorsed a local retention strategy to retain trained talent, with 55% intentionally cultivating graduates to serve in local [leadership] roles post-training.5 Additional retrospective added value was the interprofessional collaboration these programs fostered (93%). And, 76% reported they felt their fellowship programs helped improve the overall system autonomy of their APPs.5 As financial value becomes more transparent to the public, this will likely influence further institutional investment into PA fellowship programs.

Lastly, without a doubt the pandemic challenged the medical community, and PAs were not immune to the hardships. Our professional flexibility afforded many PA transitions into new or virtual roles, often with limited mentorship or training. APP fellowship curriculum remains dynamic as healthcare delivery evolves and institutional changes occur. PA fellowship programs can more readily and intentionally provide training for PAs entering these specialties. Mentorship is also a pivotal root of the program (lasting often after fellowship) that can influence future career trajectories, development, and advancement. Examples include training those in behavioral health and specialty medical tracks telehealth, preparing new leaders as their institutions develop their APP leadership structures, and opening/closing fellowship tracks that may align with future institutional growth or consolidation.

When we look in this rearview mirror in another 50 years we envision a future where postgraduate training for PAs is readily visible, highly esteemed within the field, and characterized by rigorous academic and clinical standards. This training will foster intentional collaboration across disciplines and serve as a valuable optional pathway for PAs to enhance their expertise and confidence in both academic and clinical settings.



The Center for the Future of the Health Professions is publishing another monthly op-ed column. These columns provide strong, well-informed opinions on matters that impact the future of the health professions. As mentioned previously, the center was established to offer accurate, reliable, and comprehensive data and research on the healthcare workforce to support effective planning for a sustainable future and optimal use of available resources for state, local, and national policymakers, as well as health system stakeholders.

This month’s column will serve as a follow-up to last year’s article, “Further Confessions of a Recovering Sage-on-the-Stage Performer,” by Norman Gevitz, PhD, professor of history and sociology of health professions and senior vice president-academic affairs at A.T. Still University. This addition, “Sage on the Stage – Part 3 – A Return to the Classroom,” further explores Dr. Gevitz’s humorous presentation on his return to teaching as he shares his experiences in an entertaining manner. We eagerly await your response.

Randy Danielsen, PhD, PA-C Emeritus, DFAAPA

Professor and Director

The Center for the Future of the Health Professions

A.T. Still University

Sage on the Stage – Part 3 – A Return to the Classroom

When I was hired to be the new senior vice president-academic affairs at A.T. Still University in 2013, I believed my time in the classroom was done. The new position was, and is, labor intensive; you’re directly responsible for, and have oversight of, all the schools/colleges and degree and certificate programs at our University, including its programmatic and institutional accreditation. As I hope I have conveyed in my previous two contributions* to this series, I loved teaching, whether as a “sage on the stage” and, subsequently, as someone who created an interactive dynamic where students essentially taught themselves by discussing cases in the classroom, using basic concepts presented to them. So, when I accepted the position as senior vice president-academic affairs, it was with great anticipation of looking forward to the challenge, yet with regret that a significant ongoing joy of mine – teaching – would not be a part of my new responsibilities.

Nevertheless, nine years into my position at ATSU, I was asked by one of our colleges – the School of Osteopathic Medicine in Arizona (SOMA) if I would consider getting “back in the saddle.” The professor who taught medical ethics had just retired, and they could not find someone within their faculty to teach the subject. I consulted with the President, who raised appropriate concerns, which I addressed, and told SOMA I would agree. I would teach four two hour blocks – to two sections of students – 16 classroom hours. Not a heavy load, I thought. I have been teaching medical ethics for more than 25 years. I could do this.

The biggest surprise for me was the amount of literature I had to review. Ten years is a long time to be away from the printed materials that constitute the corpus of learning in a field – including medical ethics. While the basic concepts of medical ethics were still operative, new applications of these concepts have changed as medicine has been transformed, as well as the related field of medical jurisprudence. This was most apparent in women’s reproductive rights, given the recent Supreme Court decision in Dobbs. Much of what medical ethicists taught and what students were tested on in national board examinations related to reproductive ethics has now been made uncertain and questionable.

Also, though I only wrote a few exam questions, the time I needed to develop board-quality test items was considerable. In my early years of teaching medical ethics, I asked short essay questions, which is a reasonable assessment, but they do not prepare students for the multiple choice vignette-based questions that COMLEX or USMLE ask. In reviewing sample test questions in the written literature and viewing online tutorials, I was struck by how nuanced many of these test questions were, whereby more than one of the choices had merit. It was more a matter of choosing the “most” correct answer based on the precise language in the stem. As a result, I worked on mirroring this approach in many of the questions I constructed.

However, as to the teaching itself, it was a joy. I had truly missed my time in the classroom with health science students ­– in this case, osteopathic medical students. I followed the classroom interactive style outlined in my first two contributions to this periodical. I wrote the clinical vignettes – approximately eight of them – for each session, had the students discuss the vignettes in small groups five or six at a table, and then asked for volunteers to address the ethical questions posed within the vignette. The discussions that ensued in the larger group were lively, and at the end of these sessions, students appeared to grasp how to work through complex ethical issues in medicine.

The student feedback at the end of these sessions was positive. They enjoyed the interactive nature of these encounters, and frankly, after every session, I felt pumped up. It is truly exhausting to spend four hours in a classroom. However, as any professor who enjoys teaching will likely admit, it feels exhilarating when you believe a teaching experience has gone well. Furthermore, as for me, since SOMA has yet to find a permanent replacement to teach medical ethics, I am happily doing this once again.

*Read Dr. Gevitz’s previous column’s here:

  1. Confessions of a recovering sage-on-the-stage performer
  2. Further confessions of a recovering sage-on-the-stage performer

We are delighted to present the Center for the Future of the Health Professions Digest’s op-ed column for October 2023. We’re committed to supplying trustworthy and precise data and research on the healthcare labor force, with the aim of assisting policymakers and stakeholders within the health system to efficiently plan for a robust future.

In this edition, we’re excited to spotlight Ellen Gohlke’s article, “The Evolution of the Dental Hygiene Profession.” Ellen holds a bachelor’s degree in dental hygiene from Marquette University in Milwaukee, Wisconsin, and is pursuing her master of health science degree from A.T. Still University’s College of Graduate Health Studies (ATSU-CGHS).

Ellen holds many roles and is a full-time clinical hygiene instructor at the Arizona School of Dentistry and Oral Health’s Center for Advanced Oral Health. Here, she mentors students as well as AEGD residents tasked with treating individuals needing special care or managing medical complexities. Additionally, she dedicates part of her time as an adjunct hygiene instructor at Rio Salado College of Dental Hygiene in Tempe, Arizona.

Ellen’s practical experience in dental hygiene extends beyond her academic surroundings, having practiced in Wisconsin and Lausanne, Switzerland, upon graduating from Marquette. She has gained exposure in various dental specialties, including periodontics, pediatric, and general dentistry. In 2019, Ellen was presented with a fellowship in special care dental hygiene (FSCDH).

Passionate about social care, Ellen commits her time to serve underserved communities, focusing primarily on individuals with intellectual, developmental, and chronic medical conditions.

We welcome your reflections and insights on this month’s digest. Share your thoughts with us!

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor and Director

The Center for the Future of the Health Professions

A.T. Still University

Ellen Gohlke

The evolution of the dental hygiene profession

The dental hygiene profession was first established in 1913 by Alfred Fones, a dentist who realized the importance of having clean, healthy teeth.1 He believed it was essential to train female dental assistants to teach patients oral hygiene. He also believed women were less expensive to train and better at cleaning than men. His focus in dentistry was not on treatment, but more on prevention. Dr. Fones’ dedication to improving patients’ oral hygiene through prevention and education led him to establish the first dental hygiene school in Bridgeport, Connecticut, in 1913. Subsequently, he trained the first dental hygienist, Irene Newman, to work in his practice. Most dental hygienists are familiar with Fones since the “Fones toothbrushing technique” is still taught to dental hygiene students. In 1914, Fones initiated a five-year demonstration project in public schools that documented the success of a dental hygienist in providing education for dental disease prevention.2

In the early 1900s, a dental hygiene program began in the United States, requiring a year of training.3 Today, the country has more than 300 dental hygiene programs, most of which are housed in community colleges.4 People entering the dental hygiene profession can pursue a two-year associate degree, a four-year bachelor of science degree, or a master’s degree in dental hygiene. Dental hygienists must take national and regional license exams to enter practice. Degree completion programs allow dental hygienists with a two-year degree to complete their baccalaureate degree and there are no doctoral programs in dental hygiene in the United States. Dental hygienists pursuing leadership positions in universities, hospitals, federal agencies, and healthcare organizations will seek doctoral degrees in other disciplines.5

Dental hygiene is one of the fastest-growing healthcare occupations today. According to the American Dental Education Association, the dental hygiene workforce is estimated to increase by 20% in 2026.6 There are several reasons why the dental hygiene profession continues to grow in this country. The work schedule flexibility, the ability to improve a patient’s oral health, the potential to earn a good income, and the opportunity to get an advanced degree in dental hygiene are common reasons why people choose this healthcare profession. Many dental hygiene programs have a waiting list for acceptance and enrollment.

Since the pandemic, I have noticed a greater demand for dental hygienists. I still receive phone calls, text messages, or emails from dental colleagues asking if I know a dental hygienist interested in a job. However, the profession has faced some challenges, with more hygienists leaving the profession since the COVID-19 outbreak. Many licensed professionals retired during the pandemic for safety reasons, while others stopped working due to high childcare costs and other practice-related concerns.7 Nevertheless, dissatisfaction with salary and feeling unappreciated in the workplace are the main reasons why dental hygienists stop practicing. As a result, in March of 2022 the American Dental Association’s Health Policy Institute reported over 90% of dentists faced difficulties finding hygienists to hire. Despite dental hygienists leaving or retiring, the number of students entering programs continues to increase.

Dental therapy is a new occupation with a different scope of practice than dental hygiene and requires additional education and training. This occupation is distinct from dental hygiene. Dental therapists primarily work in underserved regions and provide essential restorative dentistry services and preventive care. The number of dental therapy programs continues to grow in the United States. Dental therapy first began in New Zealand in the 1920s.However, it was not until 2005 that the first dental therapist in the United States treated people in a rural Alaskan community.9 The need to provide dental care to people in underserved areas prompted native tribes to seek help for these impoverished areas. Even though most dental therapists in the United States have a dental hygiene degree, programs exist that train dental health aide therapists to provide dental care to rural tribal communities. Dental therapists practice under the supervision of dentists but may treat patients in settings other than dental offices in 13 states across the country. Licensed dental hygienists interested in dental therapy must complete an additional three-year program followed by a credentialing exam in Arizona.

Dental hygienists play an active role in teledentistry, which is especially helpful in providing patient care to those in rural and other underserved areas.10 Training and regulations for dental hygienists related to teledentistry continue to be developed and differ by state. Patients in remote areas of the country will benefit if teledentistry is allowed under the dental hygiene scope of practice by state dental practice acts. A.T. Still University’s Arizona School of Dentistry & Oral Health includes teledentistry coursework in its curriculum and employs dental hygienists who provide teledentistry services in collaboration with dental faculty to reach several communities of vulnerable patient populations. This model can help people across the country with little or no access to oral healthcare resources.

Dental hygienists may be employed in various settings, including skilled nursing facilities, community health clinics, and hospitals. There are also dental hygienist models who are employed within medical practices, most notably in pediatric medical offices.2 There is a growing recognition among medical professionals about the importance of good oral health as it relates to overall health. The link between poor oral health, particularly poor oral hygiene and periodontal disease, and systemic diseases such as diabetes, heart disease, and respiratory disease is well known. Good oral health is medically necessary for many patients who are critically ill, such as those undergoing cancer treatment or organ transplantation, to ensure successful health outcomes.

Graduating from a dental hygiene program years ago usually meant working in a private dental practice setting. Historically, very few dental hygienists taught in educational institutions and public health facilities. Whole-body healthcare was not the focus when I graduated in the 1980s. As a dental hygiene educator, I recognize that the dental hygiene profession advances by training and preparing future oral healthcare providers to treat the entire body, not just the mouth. The dental students and dental hygiene students I mentor who rotate through our Special Care Clinic at ASDOH realize the importance of treating the whole person. Most patients we treat have physical disabilities, intellectual disabilities, and medical comorbidities. Students and dental residents are taught new skill sets and tools to treat these complex populations.

ATSU focuses on pursuing knowledge, the whole body, and patient-centered care. My journey in dental hygiene has changed me into a healthcare provider who treats the entire individual as I educate lifelong learners on the importance of comprehensive healthcare while serving people from disadvantaged, diverse backgrounds. In the Advanced Care Clinic at ASDOH, I am fortunate to work with students, residents, and faculty as we meet the educational, healthcare, and societal needs of these communities in our state. As our population ages and grows, integrating dental and medical healthcare services for patients is essential. According to an article in the Journal of Dental Education, dental hygienists practicing in solo offices will decline by 2040 as the number of hygienists transition to organizations where medical and dental care are combined.11 In the future, dental hygienists will work with other healthcare disciplines while treating patients’ dental care needs.


  1. The History of Dental Hygiene and a Look Toward the Future. Access. 2014;28(2):27-29. Accessed August 26, 2023.
  2. Bowen DM. History of dental hygiene research. J Dent Hyg. 2013 Jan; Supple 1:5-22.
  3. Watson, R. (2023), President’s Message. International Journal of Dental Hygiene. Accepted Author Manuscript.
  4. Dental Hygiene by the Numbers. American Dental Education Association. 2023
  5. Gurenlian JR, Rogo EJ, Spolarich AE. The Doctoral Degree in Dental Hygiene: Creating New Oral Healthcare Paradigms. J Evid Based Dent Pract. 2016;16 Suppl:144-149. doi:10.1016/j.jebdp.2016.01.011
  6. American Dental Education Association. Why Be a Dental Hygienist? 2015-2023.
  7. Harrison B. HPI Dental Office Employment Declined in March. ADA News. Accessed April 10, 2022.
  8. Dental Therapy in Arizona. Arizona Oral Health Coalition. Published 2023.
  9. Holland M, Kottek A, Werts M, Mertz E. Expanding Dental Therapy Education Programs. Dimensions of Dental Hygiene. Accessed November 25, 2020.
  10. Atchison KA, Fellows JL, Inge RE, Valachovic RW. The Changing Face of Dentistry: Perspectives on Trends in Practice Structure and Organization. JDR Clinical & Translational Research. 2022;7(1_suppl):25S-30S. doi:10.1177/23800844221116836
  11. Fried, J.L., Maxey, H.L., Battani, K., Gurenlian, J.R., Byrd, T.O. and Brunick, A. (2017), Preparing the Future Dental Hygiene Workforce: Knowledge, Skills, and Reform. Journal of Dental Education, 81: eS45-eS52.

The Center for the Future of the Health Professions introduces its September 2023 op-ed column! Our mission is to provide accurate and reliable data and research on the healthcare workforce to assist policymakers and health system stakeholders in effectively planning for a sustainable future.

We are thrilled to have Sarah Chagnon, a dental therapist and president of the American Dental Therapy Association, as our guest author. Sarah has served her community at the Swinomish Dental Clinic in Washington state for 4.5 years. She is dedicated to promoting dental therapy and ensuring everyone has access to dental care. Sarah believes in empowering patients by providing them with the knowledge and resources they need to make informed decisions about their oral health, as she understands oral health is integral to overall well-being.

We encourage you to share your thoughts on this month’s digest with us.

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor & Director

The Center for the Future of the Health Professions

A.T. Still University

Sarah Chagnon

The dental therapy profession is gaining traction in the U.S.

The dental therapy profession started in New Zealand more than a century ago and has expanded worldwide. In fact, dental therapists (DTs) practice in more than 70 countries.1 Dental therapy has gained traction in the United States over the last 20 years, with six states currently licensing DTs and eight states that have passed legislation to codify the profession.

Now, you might be wondering what a dental therapist is. DTs are highly trained mid-level oral health practitioners and are often described as being comparable to PAs. Their scope of practice can vary slightly from state to state. Typically, they provide the most common straightforward and simple dental procedures and are frequently described as restorative experts. DTs also heavily concentrate and participate in health promotion and disease prevention programs.

DTs can benefit the oral health team in the United States because we live in a time where our society faces a continuing shortage of dentists. The U.S. Health Resource and Service Administration estimated the shortfall will grow to 15,600 fewer dentists than needed by 2025 and nearly 60 million people will forgo regular care as a result.1 Dental problems can lead to serious health risks if left untreated. DTs can provide an alternative for those who may not have access to a dentist or who cannot afford it. Their scope of practice consists of preventive procedures such as cleanings, sealants, and fluoride varnish applications, and oral evaluative procedures such as diagnosing and treatment planning. Routine restorative procedures include fillings and stainless-steel crowns on baby teeth, pulp capping, and simple extractions. This helps relieve some of the burden from the dentist’s schedule and ultimately helps the clinic run efficiently and effectively.

Dentists who utilize DTs can rest assured their patients are receiving the most up-to-date preventive and restorative care. They can then focus on complex treatments, such as root canals, crowns, implants, dentures/partials, specialties, etc. DTs help fill the gap in access to care and are cost-effective. Adding this team member can offer more flexible patient scheduling, eliminate patient wait times, increase revenue, ensure clinics operate at their total capacity, allow every provider to work at their full scope of practice, contribute and improve the overall clinical workflow, and provide new workforce opportunities.

The Commission on Dental Accreditation (CODA) serves the public and dental professions by developing and implementing accreditation standards that promote and monitor the continuous quality and improvement of dental education programs. This means the training meets the same standards as a dentist’s. Depending on the educational route, DT students complete three academic years of full-time instruction, including a clinical preceptorship experience.2

There are only five dental therapy educational programs in the United States: Iḷisaġvik College (CODA-accredited) in Alaska, Skagit Valley College (CODA-accredited) in Washington, the University of Minnesota (CODA-accredited), Minnesota State University, and Metro State University, also in Minnesota.

Dental therapy has faced many barriers since its introduction to the United States. Recognition and awareness have been a slow process, as only a few states have approved practice rights. In fact, DTs were initially only allowed to offer their services to tribal clinics, which led to the next barrier: workforce mobility. Because few states employ DTs and their scope varies by state, DTs cannot move anywhere and be ensured employment. Many states are interested in implementing this profession, but the legislation process is a long journey. In some states, lobbyists and dentists have resisted (though it’s important to note not all dentists feel this way). Adding a new role can be overwhelming and daunting since a dental clinic’s workflow has been the same for decades. The resistance could also stem from the fact that dentists simply don’t understand a DT’s scope of practice and/or how to implement a DT into their clinics.

Dentists have also expressed concern about the amount of training DTs receive. While DTs do receive a shorter education, they learn approximately 100 out of the 500+ procedures dentists learn in their four years of training. In addition, there is a high demand for DTs, but not enough DTs to fill these positions because there are not enough educational programs offering this degree.

Despite the hardships, thousands of case studies indicate this profession’s success in the short time its been around. According to the 2018 Journal of Public Health Dentistry, in Alaska, children and adults had lower rates of tooth extractions and more preventive care in communities served routinely by DTs than in communities with no care by midlevel providers.3  According to the report “Provider and Patient Satisfaction With the Dental Therapy Workforce at Apple Tree Dental,” respondents acknowledged having a dental therapist on staff allowed patients to have more needs met in one visit and improved patients’ sense of having a regular dental provider.4  A study conducted in rural Minnesota towns found having a dental therapist as part of their oral health team improved dentists’ ability to spend more time performing procedures requiring their expertise, resulting in increased revenue. Satisfaction ratings for the therapist’s chairside manner and technical skills were similar to those given to clinic dentists and dental hygienists.5


  1. Potter, W. (2021). The Rise of the Dental Therapy Movement in Tribal Nations and the US [Review of The Rise of the Dental Therapy Movement in Tribal Nations and the US]. Lessons from the W.K. Kellogg Foundation.
  2. Licari, F. W., & Evans, C. A. (2014). Recommended standards for dental therapy education programs in the United States: a summary of critical issues. Journal of Public Health Dentistry, 74(3), 257–260.
  3. 2022 Provider and Patient Satisfaction With the Dental Therapy Workforce at Apple Tree Dental. (n.d.). Retrieved from
  4. In Alaska, Dental Therapists Seen as Helping to Improve Oral Health. (2019, November 21). Retrieved from
  5. Dental Therapy Increases Access in Rural Minnesota. (2017, May 31). Wilder Foundation. Retrieved from

Welcome back!

ATSU campuses are abuzz with new and returning students ready to complete another exciting academic season. Unusually hot weather in Missouri and Arizona made the first several weeks challenging for all. Thanks for hanging in there!

Summer commencements honored a record number of graduates with 911 students receiving diplomas across six ceremonies. Thank you to everyone who supported our graduates, faculty, staff, and commencement activities. We are also looking forward to September graduations for physician assistant programs in California and Arizona.

Thank you, Board of Trustees members, Danielle Barnett-Trapp, DO, ’11; Bertha Thomas; Jonathan Cleaver, DO, FAOCD, FAAD, FASMS, ’08; and Kim Perry, DO, MBA, MHCM, FACEP, FACOEP, ’91, for participating in commencement and white coat ceremonies.

California dreaming

On Friday, Sept. 8, 2023, ATSU will celebrate College for Healthy Communities’ physician assistant program’s inaugural commencement.

Thank you, Drs. Ted Wendel, Eric Sauers, and Dan McDermott, and faculty and staff, for all of your hard work and perseverance. Also, thank you to the pioneering inaugural class for battling through COVID, curriculum updates, and new campus snafus.

California’s Central Coast community continues to play a vital role in the success of our students and campus. We are thankful for their support.

2023-2024 strategic plan focus areas

  1. Incorporating ATSU’s core professional attributes (CPAs) and osteopathic philosophy into students’ education and experiences

ATSU students and graduates possess a unique set of knowledge, capabilities, and skills to succeed in today’s and tomorrow’s challenging world. ATSU’s CPAs cover five domains critical to graduates entering healthcare.

Knowledge regarding the philosophy of osteopathic medicine also provides graduates an advantage in providing, guiding, and leading healthcare delivery. Today, more than ever, understanding the interconnectedness of our bodies’ systems is essential in delivering whole person healthcare. 

  1. Exploring artificial/augmented intelligence’s emerging role in healthcare and education

Three ATSU AI projects are underway to improve student, faculty, and staff experiences. Funds have also been allocated to provide pilot research grants for interested faculty and staff.

  • Ivy.AI chatbots to assist students, faculty, and staff. 
  • Google Bard to assist with generating text, language translation, and answering questions. 
  • Anthology CRM for crafting messages and promoting engagement. 

  1. Student recruitment and retention

Colleges and universities are facing future headwinds with fewer high school graduates, the public’s questioning of higher education’s value proposition, and rising costs.

Focusing on student retention is paramount to a successful health science university. College deans and Student Affairs are working closely together to assure ATSU students receive the support necessary for success.

  1. Cultural proficiency

Essential to becoming the best healthcare professional, student, faculty, or staff member requires understanding and practicing cultural proficiency. Appreciating the unique perspectives we all bring to healthcare and education makes ATSU a great place to learn and work.

Understanding recent conversations around the U.S. Supreme Court’s decision regarding admissions and race is helpful. Please visit this link to learn more.

Reaccreditation news

The A.T. Still University-College of Graduate Health Studies’ (ATSU-CGHS) Master of Public Health – Dental program successfully met all metrics required for reaccreditation. After an April 3, 2023, site visit on the Mesa, Arizona, campus, the program was notified it met all standards and complied with all commission policies. Congratulations to Jeff Chaffin, DDS, MPH, MBA, MHA, assistant professor and program director; Mary-Katherine McNatt, DrPH, MPH, MCHES, CPH, COI, professor and chair; and team on this accomplishment.

ATSU commencement ceremonies

Arizona School of Dentistry & Oral Health (ATSU-ASDOH)

Friday, May 12
Mesa, Arizona
76 graduates
Commencement speaker: Wayne Cottam, DMD, MS, vice dean, associate professor, ATSU-ASDOH

Missouri School of Dentistry & Oral Health (ATSU-MOSDOH)

Friday, May 19
Kirksville, Missouri
57 graduates
Commencement speaker: Dennis A. Mitchell, DDS, MPH, vice provost for faculty advancement, Columbia University

Kirksville College of Osteopathic Medicine (ATSU-KCOM)

Saturday, May 20
Kirksville, Missouri
166 graduates
Commencement speaker: Robert A. Cain, DO, FACOI, FAODME, president and CEO, American Association of Colleges of Osteopathic Medicine

College of Graduate Health Studies (ATSU-CGHS)

Friday, May 26
Mesa, Arizona
217 graduates
Commencement speaker: Daryl Nelson, MS, ATC, director of team growth and development, Las Vegas Raiders

School of Osteopathic Medicine in Arizona (ATSU-SOMA)

Friday, May 26
Mesa, Arizona
138 graduates
Commencement speaker: Faith L. Polkey, MD, MPH, CPE, CEO, Beaufort-Jasper-Hampton Comprehensive Health Services Inc.

Arizona School of Health Sciences (ATSU-ASHS)

Friday, June 2
Mesa, Arizona
257 graduates
Commencement speaker: Victoria Garcia Wilburn, DHSc, OTR, FAOTA, assistant professor of occupational therapy, Indiana University-Purdue University Indianapolis

Upcoming ATSU commencement ceremonies

College for Healthy Communities (ATSU-CHC)
Friday, Sept. 8
Santa Maria, California

ATSU-ASHS Physician Assistant
Friday, Sept. 22
Mesa, Arizona

ATSU white coat ceremonies

ATSU-ASHS Physical Therapy

Class of 2024
Thursday, June 1
Mesa, Arizona


Class of 2027
Friday, July 14
Mesa, Arizona


Class of 2027
Friday, July 14
Mesa, Arizona

ATSU-ASHS Physician Assistant

Class of 2025
Friday, July 14
Mesa, Arizona


Class of 2027
Friday, July 14
Kirksville, Missouri


Class of 2027
Saturday, July 15
Kirksville, Missouri

ATSU-CHC Central Coast Physician Assistant

Class of 2024
Friday, Aug. 18
Santa Maria, California

Faculty and staff updates (as of July 31)

Recent promotions: Please view the list of employee promotions (PDF).
Accomplishment kudos: Please view the list of accomplishment kudos (PDF).
Anniversary milestones: Please view the list of employee anniversaries (PDF).

Ideas and concerns?

Please submit your ideas to Each email will receive a personal response from me. Ideas are only shared with the sender’s permission.

If you see something you are worried about, please contact the anonymous Fraud Hotline to report situations or behavior that compromises ATSU’s integrity. The hotline is available 24/7 at 1.855.FRAUD.HL (1.855.372.8345) or Reference code “ATSU” when making a report.

In closing

Thank you for taking a few minutes to catch up on ATSU activities. For daily updates, please visit ATSU News.

May your 2023-2024 academic year be one of professional and personal successes. 

Yours in service,

Craig M. Phelps, DO, ’84

A.T. Still University of Health Sciences
800 W. Jefferson St., Kirksville, MO 63501 | 660.626.2121
5850 E. Still Circle, Mesa, AZ 85206 | 480.219.6000
1075 E. Betteravia Rd., Ste. 201, Santa Maria, CA | 805.621.7648
Office of the President |
ATSU Communication & Marketing |

A.T. Still University of Health Sciences serves as a learning-centered university dedicated to preparing highly competent professionals through innovative academic programs with a commitment to continue its osteopathic heritage and focus on whole person healthcare, scholarship, community health, interprofessional education, diversity, and underserved populations.

The Center for the Future of the Health Professions will post its fifth monthly op-ed column for 2023. Our columns represent strong, informed, focused opinions on issues affecting the health professions’ future. As mentioned, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce to effectively plan for a sustainable future and make the best use of available resources.

This month we feature a discussion on using standardized patients in health professions education. Standardized patients (SPs) are used in healthcare professions education to simulate a realistic patient experience. SPs can help students learn how to effectively interact with patients, practice communication skills, and gain clinical experience. SPs also help to ensure that all students have the same learning experience and that their assessments are fair. Additionally, SPs provide a safe and controlled environment where students can practice their skills and develop confidence. Finally, students are better equipped to handle real-life patient interactions by interacting with SPs.

This month’s column will turn to our own Mandy Weaver as she interviews her husband, George Cohen, an SP for over two years, in a Q&A entitled “Confessions of a retired standardized patient.” George was a community leader and a senior partner with CPA firms. The majority of his clients were physicians and other health care professionals.

We look forward to your comments on this month’s digest.

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor & Director

The Center for the Future of the Health Professions

A.T. Still University

George Cohen

Confessions of a retired standardized patient

Howard Barrows, MD, was the first to use standardized patients (SPs) in 1963. He initially referred to those SPs as “programmed patients.” They have been called by several names since, and the more generic term is “simulated individuals,” especially in nonmedical fields, such as education, spiritual care, law, police training, and many others. Since Dr. Barrows trained those first SPs, human simulation has become an integral part of medical education worldwide.1

A.T. Still University’s Kirksville College of Osteopathic Medicine (ATSU-KCOM) in Kirksville, Missouri, has documentation of SP cases as early as 1995, according to Lisa Archer, director of simulation and performance assessment. Lorree Ratto, PhD, associate professor at A.T. Still University’s School of Osteopathic Medicine in Arizona (ATSU-SOMA) began the SP program officially for SOMA’s inaugural class of 2011.  

ATSU’s Arizona-based Interprofessional and Culturally Proficient Standardized Patient Experience Center opened in 2019. Lisa McNeil is the center’s manager. The facility is open to ATSU’s medical, dental, physician assistant, physical therapy, and occupational therapy students. One technological tool utilized by the center is the GERonTologic suit, which simulates the effects of aging, teaching students empathy for older adult patients.2

This article features an interview between ATSU’s Center for the Future of the Health Professions program administrator Mandy Weaver and her husband, George Cohen, CPA, who was an SP for over two years. He also participated in the SP programs at Arizona College of Osteopathic Medicine – Midwestern University and Southwest College of Naturopathic Medicine. Cohen is a recognized community leader and ambassador for the osteopathic medical profession in Arizona.

What drew you to the SP program?

Cohen: I was a budding actor after retiring from a successful professional accounting career. Soon after my retirement, I talked to someone who was an SP who told me about the ATSU program. I thought, “What better way is there to hone my skills for acting?” Working with students was also appealing.

Were there other actors in the program?

Cohen: There were many actors and other people looking to make a few extra bucks. So, it was a cross-section of individuals. Kudos to the program faculty and staff for getting a diverse population with whom the students can learn.

Were you familiar with medical education?

Cohen: I really wasn’t familiar despite having a career surrounded by physicians and having a spouse who was deeply involved in the medical profession as the executive director of the Arizona Osteopathic Medical Association. So, I wasn’t aware of the educational rigors a budding physician would be going through, particularly in year one.

Were there any surprises about medical education?

Cohen: I was pleased and pleasantly surprised to see how much attention and effort is given to teaching the students empathy. When I grew up, most physicians were very stiff and clinical. Having a physician who has a more caring attitude and takes an interest is much more reassuring to their patient.

Were there any surprises with the students?

Cohen: I was surprised by the diversity of the students. There were older students who had some type of medical background, such as PAs and EMTs. There were also “legacy” students whose parents or other family members were physicians. In addition, there were international students from other cultures with more poverty and different healthcare systems than U.S. students have experienced.

What was the interaction between the students and faculty and staff?

Cohen: The interaction was incredible and a confidence-building relationship. The faculty and staff were genuinely interested in the students. A special thanks to the ATSU team Lisa McNeil and Dr. Lorree Ratto.

Did you have a script?

Cohen: Everything was scripted, and you had to stick to the script – no improvising. The scripts indicate the age and symptoms of the patient and social determinants, such as a homeless single mother. The students took the history and examined the SPs. My favorite symptom was kidney stones because the SPs were told that if the student touches the kidney, it is ok to scream and reach for the roof. Pretending to pass out was also a valuable acting experience.

Did they ask their patients about their current environment?

Cohen: Yes, such as:        

  • Are you depressed?
  • Do you interact with other people?
  • Can you walk to a pharmacy to get meds? Do you know the meds you are using?
  • Are you eating every day?

I understand that the SPs also evaluate the students from a patient’s perspective.

Cohen: There was a checklist that included:

  • Washing their hands when they entered the exam room.
  • Knocking on the exam room door before entering.
  • Helping the patient get on and off the exam table.
  • Being kind and courteous.
  • Facing the patient and making eye contact when talking to them.
  • Taking a thorough history.
  • Asking for social determinants information.

Note: An instructor can watch the exchange between the SP and the student from a nearby video monitor room. Later, the student and the instructor can view the video and discuss ways to improve exam skills.

What is the benefit of the SP program to the students?

Interacting with a human being is much better than a simulated encounter. You are eye to eye. That is a good life lesson when they learn how to communicate and listen.

What impact did you have on the students and what impact did they have on you?

The impact they had on me was to elevate my medical education and be aware of things going on in my body. I learned that medicine, in general, requires educated guesswork. My expectation that healthcare professionals can just solve things is unrealistic. I must take responsibility for myself in terms of being aware of issues and being able to communicate those issues. I need to take better care of myself.

The ATSU SP program is incredibly well run; I am sure it is a role model for other schools. I really hope that I made a difference in the student’s education. It was a wonderful experience.


  2. June 18, 2019

The Center for the Future of the Health Professions will post its fourth monthly op-ed column for 2023. Our columns represent strong, informed, focused opinions on issues affecting the health professions’ future. As mentioned, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce to effectively plan for a sustainable future and make the best use of available resources.

This month we feature a discussion on the future of the optometric profession by Dr. Taylor McMullen. Dr. McMullen is an optometrist working in the private practice modality. He received his undergraduate training from the Indiana University of Pennsylvania and earned a Bachelor of Science degree in natural sciences and mathematics in 2003. While an undergraduate, he spent a semester studying abroad at the University of Valladolid in Valladolid, Spain. He continued his education and earned a Bachelor of Science in vision sciences and a Doctor of Optometry in 2007 from the Pennsylvania College of Optometry. He founded Salt River Eye Care, PLLC, in 2012 and enjoyed seeing patients there. In addition to primary eye care, Dr. McMullen has extensive training in the diagnosis and treatment of ocular disease, as well as the management of ocular complications of systemic disease. He is active in his community and a member of the Arizona Optometric Association Board of Directors.

According to the U.S. Bureau of Labor Statistics, optometrists diagnose and treat visual problems and manage diseases, injuries, and other disorders of the eyes and work in standalone optometry offices. Optometrists may also work in doctors’ offices and optical goods stores. Some are self-employed. Most work full-time, and some work evenings and weekends to accommodate patients’ needs. Optometrists typically need a Doctor of Optometry (OD) degree and a license to practice in a particular state. OD programs take four years to complete, and most students have a bachelor’s degree before entering such a program. Employment of optometrists is projected to grow 10 percent from 2021 to 2031, faster than the average for all occupations.

About 1,700 openings for optometrists are projected each year, on average, over the decade. Many of those openings are expected to result from the need to replace workers who transfer to different occupations or retire and exit the labor force.

We look forward to your comments on this month’s digest.

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor & Director

The Center for the Future of the Health Professions

A.T. Still University

Dr. Taylor McMullen

The future of optometry through the lens of its past

Though not officially recognized in the United States until 1901,1 optometry can trace its roots back to 1263 when Roger Bacon, in his study of optics, described lenses as “useful to old persons and those with weak eyes.2 “Useful” is a great way to describe optometry. Throughout the last 122 years, this profession has sought to be useful to people.

When thinking of optometry, it is natural to think of eyeglasses and perhaps maladies like conjunctivitis or glaucoma. Before optometry existed, eyeglasses and disease were the domain of two different groups: opticians and oculists. While opticians were responsible for creating and fitting eyeglasses, oculists were concerned with diseases of the eyes.3,4 When fitting eyeglasses, the first step is refraction. Refraction is the process used to determine an optical prescription and the gateway to assessing the health of an eye. A healthy eye should achieve 20/20 vision. If an eye is incapable of 20/20 vision after careful refraction, then there must be another cause for the decreased acuity.5 The person performing the refraction is first to know if something is out of the ordinary; thus, optometry combines physics and physiology.     

In 1901, Minnesota became the first state to pass legislation regarding optometry. This first law established the minimum educational requirements for the practice of optometry. Other states followed, and universities soon offered optometry programs with standardized curricula.6 However, the definition would have to expand only a short time after optometry was defined. An important step forward in scope expansion came during and after World Wars I and II. There were not enough enlisted ophthalmologists to treat the needs of soldiers and veterans. Optometrists began using diagnostic and therapeutic drugs under the supervision of physicians even though this was not allowed by legislation in any state. After leaving the service, these optometrists lobbied for the ability to continue practicing at that level.7 Thanks to their successful efforts in scope expansion, optometrists are now regarded as primary eye care practitioners. Indeed, “optometry delivers more than two-thirds of the primary eye healthcare in America, with doctors practicing in more than 10,176 communities.”8 Now training includes using diagnostic drugs to dilate pupils to obtain a better view of internal ocular structures. Training also involves using therapeutic drugs to treat conditions, including the many causes of conjunctivitis, inflammation like uveitis, and diseases like glaucoma. Filling a gap in access to healthcare is the primary driving force for optometric scope expansion. Medical school enrollment has increased, but residency slots have not increased at the same rate.9

As our population grows, so does the demand for refractive and medical eye exams. As a point of reference, let’s look at the time frame of 2015 to 2025. In that period, refractive eye exams are projected to increase by 3.2%, whereas medical exams are projected to increase by 31.5%.10 A 31.5% increase equals 16.3 million annual medical exams.10 Compare these figures to the number of full-time-equivalent optometrists and ophthalmologists joining the workforce. One calculation projects that the number of eye care providers in the U.S. will increase by 34 ophthalmologists per year while the number of optometrists will increase by 1,800.10 As things are currently in eye care, we face a real shortage of medical eye care providers. The easiest and least costly way to counter this is by expanding the scope of practice for optometrists because “99% of the U.S. population has access to a doctor of optometry.”8

Optometry education is standardized in the U.S., but the scope of practice for optometry is regulated at the state level. This means that many states need to allow optometrists to practice at the level they are trained to. Some of the minor in-office procedures that optometrists can perform are laser procedures and the removal of noncancerous eyelid lesions. These few items would decrease the patient load for surgeons, but optometrists are only legislated to practice at this level in a few states.11, 12

The patient need will ultimately determine the growth of optometry. Even with pandemic-related setbacks, increased access to healthcare and improved healthcare outcomes have been made in many states.13 The future of optometry lies in the hands of the people who, working tirelessly, seek to bring high-quality eye care to the people living in all 50 states.


1. Kekevian B. Senior. Legalizing Optometry.

2. James RR. THE FATHER OF BRITISH OPTICS: ROGER BACON, c. 1214-1294. Br J Ophthalmol. 1928;12(1):1-14. doi:10.1136/bjo.12.1.1

3. Prentice CF. Legalized Optometry and the Memoirs of Its Founder. Casperin Fletcher Press; 1926. Accessed January 7, 2023.

4. John F. Amos O.D. A Summary of the Life of “The Father of Optometry,” Charles Prentice. Hindsight: Journal of Optometry History. 2022;53(1 & 2). doi:

5. 20/20 Vision | Cleveland Clinic. Cleveland Clinic. Published 2020.

6. Taron A. A Fight for the Right to Learn. Accessed January 7, 2023.

7. McAlister WH, Weaver JL, Davis JD, Newsom JA. Military Optometry from World War I to the Present. Hindsight: Journal of Optometry History. 2021;52(1):4-8. doi:

8. The scope of success. Accessed March 11, 2023.

9. Boyle P. Medical school enrollments grow, but residency slots haven’t kept pace. AAMC. Published September 3, 2020.

10. Edlow R.C. The Future of Optometry in America. Modern Optometry.

11. Cooper SL. 1971 – 2011: Forty-year history of scope expansion into medical eye care. Optometry. 2012;83(2):64-73. Published 2012 Feb 15.

12. Kekevian B. Expanding Scope of Practice: Lessons and Leverage. Accessed March 11, 2023.

13. Spiegle L. Scoping Out Optometry’s Next Era. Accessed April 12, 2023.

The Center for the Future of the Health Professions will post its third monthly op-ed column for 2023. Our columns represent strong, informed, focused opinions on issues affecting the health professions’ future. As mentioned, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce to effectively plan for a sustainable future and make the best use of available resources.

This month we feature a discussion on the future of the acupuncture profession by Catherine Niemiec, JD, LAc. Niemiec obtained her juris doctorate in law from the University of California College of the Law, San Francisco, after receiving her undergraduate training from the University of Arizona (political science major and biology/chemistry minor). After practicing law, she became the director of a national bar review company. While working as a litigator in the San Francisco Bay area, Niemiec was introduced to acupuncture medicine to address repeated bouts of bronchitis. After a Chinese herbal tea cleared her symptoms within minutes, she was inspired to study medicine and became an herbalist. Returning home to Arizona, she helped draft legislation establishing the Acupuncture Board of Examiners and established the first medical school of acupuncture in Arizona. The Phoenix Institute of Herbal Medicine & Acupuncture (PIHMA) is now in its 28th year, offering four-year master’s and doctorate degrees in acupuncture and herbal medicine. With more than 400 graduates working in private practice, integrative clinics, and hospitals, PIHMA spreads this highly effective, safe, and cost-effective medicine through its alums and onsite community clinic. For more information, visit

We look forward to your comments on this month’s digest.

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor & Director

The Center for the Future of the Health Professions

A.T. Still University

Catherine Niemiec, JD, LAc

The future of the acupuncture profession

What is acupuncture medicine?

Acupuncture medicine, also known as Asian or Oriental medicine (AOM) or traditional Chinese medicine (TCM), is also known by the various Asian nationalities or approaches, e.g., Chinese, Korean, Japanese, 5-Element, and French Energetics. This traditional medicine is a highly effective, affordable, low-risk treatment option for many health issues and chronic conditions. It is one of the most requested complementary and alternative medicine choices in the U.S. today. Used by most of the world’s population, it is highly efficacious, providing solutions and relief for various health conditions. The World Health Organization cites more than 43 conditions successfully treated by acupuncture. While some insurance companies cover acupuncture treatments, most are paid out of pocket. In the U.S., nearly 40,000 licensed practitioners and 56 colleges teach this medicine. The future of the acupuncture profession depends upon its continued and greater acceptance into mainstream healthcare. However, it has existed outside of this system and has been used by the general public for several decades.

As stated by the Council of Colleges of Acupuncture & Herbal Medicine, acupuncture medicine (AM) is an ancient and empirical system of medicine based on the concept of Qi, pronounced “chee”, meaning energy/life force and its flow through the body along channels or meridians. This invisible energy guides the flow of blood, fluid, and energy to all parts of the body. Any imbalance or deficiency of this energy, fluid, or heat can cause disease and aging. Specifically, acupuncture refers to the stimulation of specific points on the body, called acupoints, by inserting very fine, sterile, stainless steel needles to elicit a predictable physiological response. This stimulus may also be administered to the points using mild electrical stimulation (with or without needles), pressure techniques with the hands (acupressure), or the application of heat or energy using other methods such as laser, fire cupping, electrical, or mechanical. Applying pressure or needling to these points stimulates the nervous system to release certain chemicals in the muscles, spinal cord, and brain. These chemicals either change the body’s experience of symptoms, especially pain, or trigger the release of additional hormones that influence the body’s internal regulating system.

There have been many attempts to define a common physiological mechanism that explains the location and healing attributes of these points. The ancient theory of “channels,” where flows an unseen energy called the “qi,” has been called pseudoscience by many. Despite thousands of years of usage and effectiveness, this medicine continues to be challenged in finding its fully accepted place in conventional medicine. Acupuncture channels are utilized in acupuncture education and actual practice as a way to group points in terms of location and function and for ease of learning and utilization. It is a metaphorical way of describing a very scientific system of energy flow. This approach has endured for centuries as a way of understanding, explaining, and healing using a simple and effective way of moving and rebalancing energy. Understanding and mastering this approach has allowed for this medicine to be used and delivered throughout the world beyond the practice of conventional medicine. It has allowed many to use it as a form of health maintenance and prevention, as well as anti-aging and recovery from illness or injury.

The need to put AM into the conventional western medical framework is vital for the future so that this medicine can take its proper place and work with other health professions and professionals in a way that comprehensively addresses the needs of patients and the public. Thus, research helps improve credibility and foster the growth of integrative medicine hospitals and practices. Since the mid-20th century, several studies have demonstrated the mechanism of acupuncture from various perspectives. For example, during an acupuncture session, the practitioner and subjects should attain the “de qi sensation, an alternative way to describe the needle sensation.1,2 Some studies have shown that the central nervous system plays a crucial role in the outcome of acupuncture.3-5 Like common studies on the function of the brain, neuroimaging technologies, such as positron emission tomography,6 functional magnetic resonance imaging,7,8 as well as electroencephalography,9 and magnetoencephalography10 have also been employed to map the effects. In addition, some studies have attempted to define the location of acupoints according to the interstitial connective tissue with ultrasound.11

In contrast, others link acupuncture to the release of neurotransmitters, neuromodulators, and cellular signaling molecules in the peripheral and central nervous systems.12 Ultimately, there is no single answer to explain why or how acupuncture works. The exact mechanism is multifactorial, involving a number of different paradigms depending on anatomical location and the specific effect acupuncture tries to induce in each case.

The AM field

Nevertheless, despite this, the field of acupuncture and AOM has grown widely and rapidly ever since James Weston, a reporter for The New York Times, wrote about his emergency appendicitis surgery when reporting on President Nixon’s trip in China in the 1970s. Reston’s surgery in China was performed without anesthesia and only used acupuncture needles for pain and sedation. His subsequent article spawned a rapid growth of interest in Asian medicine. Training and schools started with the first on the East Coast, expanding over the years to more than 50 colleges in the U.S. Acupuncturists are now licensed or regulated in all 50 states.

Training and knowledge

Acupuncturists receive more than 3,000 hours of training with at least 1,400 hours specifically in acupuncture theory, practicum, and 800 hours of supervised clinical training in this Asian medical theory and pathology. Theory and practicum include knowledge of more than 365 points, training in angle and depth of insertion, and many indications and contraindications. Herbal medicine training is more than 500 hours, with the classification of herbs and formulas according to the energetics, matched to the specific energetics of a patient’s patterns of disharmony. It is the original “personalized” medicine. The training also includes more than 700 hours of western biomedicine and pharmacology. The Accreditation Commission for Acupuncture & Herbal (formerly Oriental) Medicine oversees the standards for colleges which offer these four-year master’s and entry-level Doctorate degrees in acupuncture or acupuncture and herbal medicine. This is the minimum requirement for state licensing, along with successfully passing an extensive certification exam by the National Commission for Certification in Acupuncture & Oriental Medicine. In addition, there is post-graduate doctorate training (DAOM).

The practice of acupuncture by other health professions may impact the future of AM. While there are other health professions (MD, DO, DC, ND, PT) that incorporate a weekend to 200 hours of acupuncture needling training, which can be very effective, the practice of this medicine requires a deeper, more comprehensive, and extensive training to accomplish all that this medicine has to offer. (For a comparison of training and skills, see Know Your Acupuncturist.) Notably, acupuncturists must take nearly 1,000 hours of supervised clinical training, practice, and needling technique before independently practicing on patients, as several hundred hours are required to conduct this invasive surgical needle technique safely, effectively, and comfortably. Nonetheless, these other health professions have Medicare and insurance coverage, which is not yet fully available to acupuncturists. This has impacted access to comprehensively trained acupuncturists who can offer even more to the public.

Another factor in the future of acupuncture is the growing realization that AM provides a viable solution for those areas where conventional medicine is challenged. A 2012 study of acupuncture published in Archives of Internal Medicine showed that acupuncture outperformed sham treatments and standard care for osteoarthritis, migraines, and chronic back, neck, and shoulder pain. This study was conducted by researchers at Memorial Sloan-Kettering Cancer Center and 30-40 other people worldwide over six years for a meta-analysis of 29 randomized high-quality studies. One meta-analysis of almost 18,000 patients across 29 randomized controlled trials found that true acupuncture was significantly more effective than the absence of the service or sham acupuncture (placebo) controls.13 More specifically, the Acupuncture Evidence Project has tabulated research studies that have found evidence of acupuncture’s positive or potentially positive effects on different conditions, covering 46 different symptoms.14 Recognizing the potential of acupuncture as a pain management modality, the American College of Physicians (ACP) published guidelines in 2017 strongly recommending acupuncture as an effective treatment for chronic and acute lower back pain, often leading to opioid prescriptions among sufferers.15 The ACP also promotes payment reforms by public and private insurers to cover these services.

Thus, acupuncture can replace an initial opioid prescription when faced with acute or chronic pain concerns. In fact, beyond simply treating pain, the mechanisms of acupuncture produce and release endogenous opioids in the body, acting as a natural analgesic without prescribing opioid drugs.15 Additionally, acupuncture activates opioid receptors in the brain, thus allowing lower doses of opioid medication to be more effective when used with acupuncture treatments. Acupuncture provides the same analgesic effects as opioid medications, reducing the harmful potential for abuse or addiction. Significantly, studies on acupuncture as an opioid complement can reduce opioid-like medications consumption by more than 60% in post-surgical environments.16, 17

The Joint Commission, which accredits all hospitals, released its standards in 2018, stating that hospitals should prioritize modalities such as acupuncture before prescribing opioids. Further, the Veteran’s Administration and the Department of Defense incorporated acupuncture for pain and other health issues for years and continued to do so. Acupuncture also addresses symptoms post-addiction or abuse, reducing or alleviating opioid withdrawal symptoms.18 The National Acupuncture Detoxification Association cites more than 1,000 programs across the U.S. and Canada that use acupuncture to overcome addiction. As the number of opioid addicts in the U.S. continues to rise, acupuncture can and should be more widely used to achieve drug independence.19

The World Health Organization has recently published ICD-11 classifications and terminologies for traditional medicine codes globally based on the work of the International Classification of Traditional Medicine project experts from China, Japan, Korea, Australia, U.S., U.K., Netherlands, and other countries. These ICD-11 codes will facilitate research and reimbursement.


The future growth of AM is strong and steady. This medicine has grown to regulation in every state due to word of mouth from satisfied patients paying out of pocket, up to now, when medical referral, insurance reimbursement, and hiring of acupuncturists regularly occur. Research continues to prove and support its efficacy, safety, and benefits for the public. Combining all the aspects and greater scope of acupuncture treatments by comprehensively trained acupuncturists with the strengths of conventional western medicine will save healthcare costs in the long run and create a healthier, happier public. The growth of AM is both necessary and beneficial. Desired by the public and saving costs for insurers, hospitals, and employers, it is worth promoting its growth and supporting its preservation.


1. Jung WM, Shim W, Lee T, et al. More than DeQi: Spatial Patterns of Acupuncture-Induced Bodily Sensations. Front Neurosci. 2016;10:462.

2. Zhou W, Benharash P. Significance of “Deqi” response in acupuncture treatment: myth or reality. J Acupunct Meridian Stud. 2014;7:186–9.

3. Hui KK, Liu J, Makris N, et al. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum Brain Mapp. 2000;9:13–25.

4. Lundeberg T, Lund I, Näslund J. Acupuncture–self-appraisal and the reward system. Acupunct Med. 2007;25:87–99.

5. Fang J, Jin Z, Wang Y, et al. The salient characteristics of the central effects of acupuncture needling: limbic-paralimbic-neocortical network modulation. Hum Brain Mapp. 2009;30:1196–206.

6. Huang Y, Tang C, Wang S, et al. Acupuncture regulates the glucose metabolism in cerebral functional regions in chronic stage ischemic stroke patients–a PET-CT cerebral functional imaging study. BMC Neurosci. 2012;13:75.

7. Wang Y, Qin Y, Li H, et al. The Modulation of Reward and Habit Systems by Acupuncture in Adolescents with Internet Addiction. Neural Plast. 2020.

8. Cai RL, Shen GM, Wang H, Guan YY. Brain functional connectivity network studies of acupuncture: a systematic review on resting-state fMRI. J Integr Med. 2018;16:26–33.

9. Yang X, Yu H, Zhang T, et al. The effects of Jin’s three-needle acupuncture therapy on EEG alpha rhythm of stroke patients. Top Stroke Rehabil. 2019;1-5.

10. Dhond RP, Witzel T, Hämäläinen M, Kettner N, Napadow V. Spatiotemporal mapping the neural correlates of acupuncture with MEG. J Altern Complement Med. 2008;14:679–88.

11. Langevin HM, Yandow JA. Relationship of acupuncture points and meridians to connective tissue planes. Anat Rec. 2002;269(6):257-265. doi:10.1002/ar.10185

12. Li Y, Wu F, Cheng K, Shen XY, Lao LX. Zhen Ci Yan Jiu. 2018;43(8):467-475. doi:10.13702/j.1000-0607.180196

13. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-Analysis. Archives of Internal Medicine. 2012; 172(9): 1444-53.

14. McDonald J, Janz S. The Acupuncture Evidence Project: A Comprehensive Literature Review. Australian Acupuncture & Chinese Medicine Association Ltd, Dec. 19, 2016.

15. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and

Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine, 2017 April 4; 1667(7): 514-530.

16. Zhang, R, Lao L, Ren K, Berman BM. Mechanisms of Acupuncture-Electroacupuncture on Persistent Pain. Anesthesiology, 2014; 120(2): 482-503., and Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The Effect of High and Low Frequency Electroacupuncture in Pain after Lower Abdominal Surgery. Pain

17. Wang B, Tang J, White PF, Naruse R, Sloninsky A, Kariger R, et al. Effect of the Intensity of Transcutaneous Acupoint Electrical Stimulation on the Postoperative Analgesic

Requirement. Anesthesia and Analgesia, 1997; 85(2): 406-13.

18. Wen H, Cheung SYC. Treatment of Drug Addiction by Acupuncture and Electrical Stimulation. Asian Journal of Medicine, 1973; 9:139-141.

19. National Acupuncture Detoxification Association. “About NADA.”

See also:

Learn about AM

Acupuncture: What You Need To Know

Acupuncture and Herbal Medicine News and Resource Center

Society for Acupuncture Research – Every month, an average of 100 acupuncture-related articles are published in more than 50 journals. PubMed lists more than 1,000 randomized controlled trials assessing efficacy or effectiveness of acupuncture.