An Exploration of Mainstreaming Acupuncture by Employing Evidence-Based Medicine Teaching in Acupuncture Education—A Needs Assessment Study - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Med Acupunct . 2025 Apr 17;37(2):155–165. doi: 10.1089/acu.2024.0042 Search in PMC Search in PubMed View in NLM Catalog Add to search An Exploration of Mainstreaming Acupuncture by Employing Evidence-Based Medicine Teaching in Acupuncture Education—A Needs Assessment Study Dongcheng Li Dongcheng Li , AP, EdD 1 Global TCM, Davie, Florida, USA. Find articles by Dongcheng Li 1, ✉ , Karen Karp Karen Karp , EdD 2 School of Education, Johns Hopkins University, Baltimore, Maryland, USA. Find articles by Karen Karp 2 Author information Article notes Copyright and License information 1 Global TCM, Davie, Florida, USA. 2 School of Education, Johns Hopkins University, Baltimore, Maryland, USA. ✉ Address correspondence to: Dongcheng Li, AP, EdD, Global TCM, 9235 Lagoon Place, #410, Davie, FL 33324, USA [email protected] Collection date 2025 Apr. Copyright 2025, Mary Ann Liebert, Inc., publishers PMC Copyright notice PMCID: PMC12038308 PMID: 40308736 Abstract Background: There is often a disconnect between standard medical treatment in the United States and complementary therapies such as acupuncture. While acupuncture has gained public attention, its integration into mainstream U.S. healthcare remains limited. Physicians rarely refer patients to acupuncture, and the profession is not well integrated into the American healthcare system. Despite the increasing number of licensed non-physician acupuncturists and accredited acupuncture programs, practitioners in private outpatient settings face significant challenges when attempting to integrate into inpatient hospital environments. Objective: This study aims to identify the opportunities and barriers to mainstreaming acupuncture in the U.S. healthcare system by conducting a needs assessment among both licensed non-physician acupuncturists and mainstream medical practitioners. Methods: A mixed-methods design was employed, incorporating both quantitative and qualitative data collection and analysis. Licensed acupuncturists and mainstream medical professionals participated in surveys and interviews to assess the factors influencing acupuncture’s integration into mainstream medicine. Results: Findings from the needs assessment highlighted several barriers to acupuncture integration. Key challenges included inconsistencies in professional competence among acupuncture practitioners, particularly in terms of knowledge, skills, and abilities, as well as a lack of awareness among mainstream medical professionals regarding reliable, evidence-based acupuncture treatments. Conclusion: The results underscore the need for standardization in acupuncture education and greater awareness of its evidence-based benefits among mainstream medical professionals. Addressing these barriers may facilitate acupuncture’s integration into the U.S. healthcare system and improve interdisciplinary collaboration in patient care. Keywords: mainstreaming acupuncture, mixed-methods, health beliefs and attitudes, safety concerns, health cost, surveys, semi-structured interviews Over the last decade, acupuncture has received remarkable attention and use. 1 , 2 According to the National Center for Complementary and Integrative Health, millions of Americans use acupuncture each year. 3 Meanwhile, examples of well-studied acupuncture therapy in systematic reviews have shown potential benefits for different types of pain and other health conditions. 4–6 However, acupuncture use is not a mainstream medical treatment in the United States. 1 Kielczynska et al. argued that despite the evidence of acupuncture’s effectiveness, the U.S. mainstream medical system does not include acupuncture as a mainstream option. 7 As a profession, acupuncture remains outside the mainstream medicine in the United States. To ascertain the opportunities and barriers to mainstreaming acupuncture in the current context, this needs assessment employed a mixed-methods approach. PURPOSE The needs assessment aimed to understand the perception and attitude toward acupuncture and its placement within mainstream medicine as well as potential barriers and opportunities to integrating acupuncture into medical mainstream medicine. The proposed research questions (RQs) for this study included the following: 1. What are the perceptions and attitudes toward acupuncture and its placement within mainstream medicine from the perspective of licensed (nonphysician) acupuncturists and mainstream medical practitioners? 2. What are the opportunities and barriers to integrating acupuncture into medical mainstream medicine from the perspective of licensed (nonphysician) acupuncturists and mainstream medical practitioners? METHODOLOGY The behavioral model of health care utilization was the theoretical perspective to frame the methods used in this needs assessment. This model was used to investigate the factors that lead to the use of health services including acupuncture care. 8 , 9 According to the model, three component factors that include predisposing, enabling, and need contribute to the selection of health service type. 10 Predisposing factors include an individual’s demographics. Examples of enabling factors are where they are living, whether they have health insurance, and where they were born. The need factors include an individual’s demand for acupuncture therapy, depending on his or her health conditions. 10 Data from this study were used to understand the underlying factors and causes of the problem of practice (POP). Research Design This study employed a mixed - methods design to examine the perceptions and attitudes of licensed (nonphysician) acupuncturists and mainstream medical practitioners toward acupuncture. Quantitative surveys captured these perceptions, while qualitative interviews offered deeper insights into the reasons for differing viewpoints. The acupuncturist group was engaged through a state oriental medical association in a southeastern coastal state, representing 2,677 licensed members with standardized training and qualifications, lending credibility to their Perspectives on professional integration. Mainstream medical practitioners were recruited from two sources: a county medical association in the southeastern U.S. with 1,200 physicians and a department of anesthesiology and critical care medicine within a Northeastern University-based School of Medicine, which included 215 faculty members. A convenience sample of 150 participants from each group was targeted, with eligibility restricted to licensed or board-certified professionals to ensure rigor. Data collection involved a 10-min survey and optional semi-structured interviews for participants who opted in. The surveys were tailored to the unique professional contexts of each group, but 23 core questions were shared to enable meaningful comparisons. Instruments for this needs assessment addressed key themes, including health beliefs and attitudes, safety concerns, and health care costs. Table 1 illustrates how each data collection method helped to inform the RQs for this study. Table 1. Instrument and Research Question Alignment Research question 1 What are the perceptions and attitudes towards acupuncture from the perspective of licensed (nonphysician) acupuncturists and mainstream medical doctors Research question 2 What are the opportunities and barriers to integrating acupuncture into medical mainstream medicine from the perspective of licensed (nonphysician) acupuncturists and mainstream medical doctors? Survey X X Semi-structured interview X X Open in a new tab Survey The survey was adapted from the Complementary Alternative Medicine Health Belief Questionnaire and supplemented with validated questions from Chan et al. and Lie and Boker. 11–15 Two customized versions were created: one for licensed (nonphysician) acupuncturists (33 questions) and another for mainstream medical practitioners (31 questions). Both versions shared 23 core items, with additional questions tailored to each group’s specific context. The surveys covered demographics, beliefs about acupuncture, safety concerns, and health costs, using a 5-point Likert scale to measure responses. Negatively worded questions were included to help identify potential barriers to integrating acupuncture into mainstream medicine. 11 , 15 To ensure clarity and reliability, the instruments underwent expert review by senior professionals and were pretested, achieving a Cronbach’s alpha coefficient of 0.75, indicating acceptable reliability. 15 The data collected informed the perceptions and attitudes of both populations toward acupuncture and its potential mainstream integration. Insights gained from the survey also addressed RQ2, focusing on barriers to mainstreaming acupuncture. Limitations related to sample size and response rates are acknowledged in the article. This methodology effectively captured nuanced Perspectives while emphasizing areas for further exploration. 11 , 15 , 16 The subscales, definitions, and sample questions for three populations are as follows (see Table 2 ). Table 2. The Subscales, Definitions, and Sample Questions Subscale Description Example from the questionnaire Health beliefs and attitudes The perceptions of patients on health and decision-making about their own health according to agency for health care research and quality. Licensed (nonphysician) acupuncturists: “I suggest the patients should receive western medical treatment when undergoing acupuncture treatment.” Mainstream medical practitioners: “I suggest the patients should not receive acupuncture therapy when undergoing western medical treatment.” Safety concerns The apprehension of patients regarding acupuncture treatment that may cause physical or mental harm. Licensed (nonphysician) acupuncturists: “Acupuncture has fewer side-effects as compared with western medicine.” Mainstream medical practitioners: “With improper needle application, acupuncture can induce severe aftereffects.” Health cost The expense of health care, including out-of-pocket, reimbursement, and insurance coverage. Licensed (nonphysician) acupuncturists: “I would like acupuncture treatment to be covered by insurance.” Mainstream medical practitioners: “I would like acupuncture treatment to be covered by insurance.” Open in a new tab To recruit participants for the study, the researcher sought permission from association coordinators via email, providing details about the study’s purpose, data collection methods, and estimated time commitment (see Supplementary Appendix A2 for the email protocol). Following approval from the coordinators and the Johns Hopkins University IRB, a Qualtrics survey link was disseminated to potential participants (see Supplementary Appendix A3 for the email with link to survey). Informed consent was embedded at the beginning of the survey (see Supplementary Appendix A4 for informed consent protocol). The surveys were initially distributed on August 15, 2018, with a completion deadline of August 28, 2018. Due to low response rates, the survey period was extended to September 18, 2018, and later to October 28, 2018. Ultimately, the licensed (nonphysician) acupuncturist group yielded 146 valid responses from 2,677 members, while the mainstream medical practitioners’ group produced 36 valid responses, including participants recruited from a university School of Medicine. Survey data were imported into SPSS for descriptive statistical analysis after an initial review using Qualtrics visualization tools. The survey consisted of 64 items, with 23 overlapping core questions focusing on beliefs, safety concerns, and health costs. Semi-structured interviews provided additional qualitative data. These interviews, guided by questions developed from the POP and literature review, underwent pilot testing for clarity and accuracy with both acupuncturists and mainstream practitioners (see Supplementary Appendix A5 for interview questions). Participants who opted into interviews after completing the survey were contacted for 10–15 min Zoom sessions. The researcher conducted interviews with five licensed (nonphysician) acupuncturists and three mainstream medical practitioners to explore perceptions, attitudes, integration, and cost-related themes. Data Analysis Data from the survey were analyzed using SPSS for descriptive statistical analysis, summarizing participant responses and identifying trends in attitudes and beliefs regarding health beliefs, safety concerns, and health costs. Descriptive statistics, including means and standard deviations, provided an overview of the findings. For the qualitative data obtained through semi-structured interviews, thematic coding was employed, combining a priori codes derived from the literature and RQs with emergent codes that surfaced during transcript analysis. Guided by Saldaña’s Coding Manual for Qualitative Researchers (2009), the researcher validated the coding process through member checks with participants and peer debriefing with the research team, ensuring the accuracy and credibility of the thematic structure. 17 FINDINGS AND DISCUSSION The needs assessment was conducted across three professional settings: a State Oriental Medical Association, a County Medical Association, and a Department of Anesthesiology and Critical Care Medicine at a university School of Medicine. A total of 146 licensed (nonphysician) acupuncturists from the State Oriental Medical Association and 36 mainstream medical practitioners from the County Medical Association and the university’s department participated in the survey. In addition, interviews were conducted with five licensed (nonphysician) acupuncturists from solo practices and three mainstream medical practitioners from university- and hospital-based settings. Both groups demonstrated positive beliefs about acupuncture, low safety concerns, and support for insurance coverage. Survey questions for the two groups addressed perceptions, safety concerns, and health costs but were tailored differently for each group. Therefore, only shared questions were compared: four on belief and attitude (questions 16, 20, 22, and 23), eight on safety concerns (questions 24–31), and two on health costs (questions 32 and 33) from the acupuncturist questionnaire (see Supplementary Appendix A1 ). Negatively worded questions, such as questions 16, 20, 22, 23, and 25–32, were reverse-scored in SPSS for analysis. Given the limited number of health cost questions, only descriptive statistics were reported, while SPSS was used to compare mean differences in belief and safety concern subscales between the two groups. The findings focus on the descriptive statistics and their interpretation for each cohort. FINDINGS Findings from the surveys and semi-structured interviews are shared below. Major themes that emerged from the analyses included health beliefs and attitudes, safety concerns, and health costs. Online Surveys Health belief and attitude Prior to comparing differences in both groups’ mean scores, the skewness and kurtosis, as well as Shapiro–Wilk’s W test, were conducted to determine if the assumption of normality had been met. Analysis of the difference between the two groups revealed that the data was normally distributed across both licensed (nonphysician) acupuncturists and mainstream medical practitioners’ groups ( w = 0.99, df = 181; skewness = 0.11, kurtosis = −0.19, p > 0.05). The online survey measuring the belief of licensed (nonphysician) acupuncturists ( n = 145) and mainstream medical practitioners ( n = 36) towards acupuncture revealed that both the group of mainstream medical practitioners ( M = 12.14, standard deviation [SD] = 3.31) and the group of licensed (nonphysician) acupuncturists ( M = 11.37, SD = 2.57) present a positive belief about acupuncture use. The mean scores for both groups, as shown in Table 3 , are relatively close ( M = 11.37 for licensed acupuncturists and M = 12.14 for mainstream medical practitioners), indicating that both groups exhibit a positive attitude toward acupuncture. Despite the slightly higher mean score among mainstream medical practitioners, the independent sample t- test revealed no statistically significant difference between the two groups ( t = 1.52, p > 0.05). This means that while there may be minor differences in belief, the overall perception of acupuncture as a valid therapeutic option is similarly positive among both acupuncturists and mainstream medical practitioners. The descriptive statistics for these shared four questions of perception and belief subscale toward acupuncture survey are displayed in Table 3 . Table 3. Results of Independent Sample t-Test and Descriptive Statistics for Belief and Attitude Toward Acupuncture by Groups Groups 95% CI for mean difference Licensed (nonphysician) acupuncturists Mainstream medical practitioners M SD n M SD n t df p Belief and attitude toward acupuncture 11.57 2.57 145 12.14 3.31 36 −0.23, 1.77 1.52 179 0.20 Open in a new tab SD, standard deviation; CI, confidence interval. Safety concern The online survey measuring the safety concern of licensed (nonphysician) acupuncturists ( n = 146) and mainstream medical practitioners ( n = 36) revealed that both groups of mainstream medical practitioners ( M = 23.42, SD = 3.80) and licensed (nonphysician) acupuncturists ( M = 20.00, SD = 3.99) think acupuncture use is safe. The skewness and kurtosis, as well as Shapiro–Wilk’s W test, were conducted to reveal that the data was normally distributed across both licensed (nonphysician) acupuncturists and mainstream medical practitioners’ group ( w = 0.99, df = 182; skewness = 0.17, kurtosis = −0.09, p > 0.05). Comparisons between the two groups using the independent sample t- test indicated that there was no significant difference ( t = 4.64, p > 0.05) in the scores for licensed (nonphysician) acupuncturists ( M = 20.00, SD = 3.99) and mainstream medical practitioners ( M = 23.42, SD = 3.80) in belief and attitude toward acupuncture. The descriptive statistics for the shared eight questions about safety concerns toward the acupuncture survey are displayed in Table 4 . Table 4. Results of Independent Sample t-Test and Descriptive Statistics for Safety Concern Toward Acupuncture by Groups Groups 95% CI for mean difference Licensed (nonphysician) acupuncturists Mainstream medical practitioners M SD n M SD n t df p Safety concern toward acupuncture 20.00 3.99 146 23.42 3.80 36 1.97, 4.87 4.64 180 0.61 Open in a new tab Health cost In licensed (nonphysician) acupuncturists group online survey, 87% of licensed (nonphysician) acupuncturists ( n = 146) disagree or strongly disagree that acupuncture treatment costs more than western medicine and 74% of licensed (nonphysician) acupuncturists ( n = 146) agree or strongly agree that insurance should cover acupuncture. In the mainstream medical practitioners’ online survey, 52.8% of the mainstream medical doctors ( n = 36) disagree or strongly disagree that acupuncture treatment costs more than mainstream medicine and 61.1% of the mainstream medical doctors ( n = 36) agree or strongly agree that insurance should cover acupuncture. The descriptive statistics for the two questions about acupuncture treatment costs are displayed in Table 5 . Table 5. Results of Descriptive Statistics for Health Cost toward Acupuncture by Groups Strongly disagree (%) Disagree (%) Undecided (%) Agree (%) Strongly agree (%) Licensed (nonphysician) acupuncturists ( n = 146) Acupuncture treatment costs more than western medicine. 59.6 27.4 8.9 2.7 1.4 I would like acupuncture treatment to be covered by insurance. 4.8 5.5 15.8 23.3 50.7 Mainstream medical practitioners ( n = 36) Acupuncture treatment costs more than western medicine. 11.1 41.7 38.9 8.3 0 I would like acupuncture treatment to be covered by insurance. 0 5.6 33.3 16.7 44.4 Open in a new tab Regarding the participants’ attitudes on whether acupuncture should be included in mainstream medicine, 75.9% of licensed (nonphysician) acupuncturists ( n = 145) agree and strongly agree versus 55.6% of mainstream medical practitioners ( n = 36) agree and strongly agree. The descriptive statistics are displayed in Table 6 . Table 6. Attitudes About the Inclusion of Acupuncture in Mainstream Medicine Strongly disagree (%) Disagree (%) Undecided (%) Agree (%) Strongly agree (%) Acupuncture should be included in mainstream medicine (mainstream medical practitioners, n = 36) 8.3 0 36.1 30.6 25.0 Acupuncture should be included in mainstream medicine (licensed [nonphysician] acupuncturists, n = 145*) 8.3 1.4 14.5 16.6 59.3 Open in a new tab Note: * one participant did not answer this question. Regarding what evidence is needed for acupuncture therapy to be included in mainstream medicine, mainstream medical practitioners ( n = 36) think evidence-based practice (75%) is the primary evidence, followed by consistent professional competencies (16.7%) and other (8.3%). In the licensed (nonphysician) acupuncturists group ( n = 145), five evidence include evidence-based practice (33.8%), other (31.1%), consistent professional competencies (16.6%), adequate biomedical training (9.0%), and consistent practice acts (7.6%). The descriptive statistics are displayed in Table 7 . Table 7. Evidence for Acupuncture to Be Included in Mainstream Medicine Mainstream medical practitioners ( n = 36) Licensed (nonphysician) acupuncturists ( n = 145 * ) N Percentage (%) N Percentage (%) Evidence-based practice 27 75.0 49 33.8 Consistent professional competencies 6 16.7 24 16.6 Consistent practice acts 0 0 11 7.6 Adequate biomedical training 0 0 13 9.0 Other 3 8.3 48 31.1 Open in a new tab Note: * one participant did not answer this question. Semi-structured interviews Semi-structured interviews produced rich data for qualitative analysis. A qualitative data analysis computer software called NVivo was used to analyze the transcript of the interview. The participant responses were exported to NVivo. Saldaňa’s Coding Manual for Qualitative Researchers was used to guide the process of data coding and analysis. 18 Descriptive coding was employed to summarize the primary topics and ideas that arose in the reflections. Initially, 10 a priori codes were produced. These a priori codes had descriptive names such as belief, safety, effectiveness, awareness, evidence-based medicine (EBM), cost, insurance coverage, professional competency, integration, and credentials. The codes reflected perception and attitude, as well as safety concerns, cost, and barriers. After reviewing the interviewee’s interview transcript, 16 emergent codes were produced such as adjunct, low risk, replicated, randomized controlled trial, research outcomes, convincing evidence of efficacy, cost-effective, vagueness, inconsistent, bad impression, dress, weak lobby, weak influence, ineffective representation, sub-professional training, and communication. A total of 26 codes were distributed among seven categories. The categories were as follows: Societal views Safety concerns Evidence-based medicine Acupuncture awareness Professional representation Acupuncture education Health cost The first category (Societal views) is attributed to perception and belief toward acupuncture, which is one of the possible factors discussed in Li’s article. 19 The second category (Safety concerns) is attributed to the factor of safety concerns. The rest of the categories are connected with the mesosystem and microsystem discussed in Li’s article. 19 These topics emerged during the participants' semi-structured interviews and were categorized separately to enhance reflection and analysis of their meaning. Societal views The social views category that includes the perception and attitudes from both licensed (nonphysician) acupuncturists and mainstream medical practitioners has four codes, which contain belief, effectiveness, integration, and adjunct. This perception is aligned with the online survey about the belief in acupuncture, which presents a positive attitude toward the use of acupuncture. The sample responses under these codes were included in the interview. For instance, one mainstream medical practitioner demonstrated her attitude toward acupuncture by stating, “I think acupuncture is a great additive. You know of course I practice medicine differently. But I think if you combine these two that you got something very successful. Ok, I wish it was more mainstream.” Another mainstream medical practitioner expressed her positive attitude toward acupuncture by saying, “I think to some extent that acupuncture help the patient.” Similarly, licensed (nonphysician) acupuncturists also showed a positive attitude toward acupuncture. For example, one acupuncturist stated, “you know the most I think acupuncture is very effective. I think Western medicine is also effective.” Safety concerns The category of safety concern generated two codes, which includes safety and low risk. This perception is aligned with the online survey about the safety of acupuncture, which presents results that reveal the safety of acupuncture use. The safe and low risk were the codes that generated the most references within the category of safety concern, with statements such as: one mainstream medical practitioner stated, “I would say acupuncture is a very safe procedure.” Licensed (nonphysician) acupuncturists thought acupuncture was safer than mainstream medicine. However, safety depends on the medical condition. For instance, one acupuncturist highlighted, “I think acupuncture is safer and mainly for the chronic condition.” Another acupuncturist pointed out, “I mean both are all safe. Acupuncture depends on the severity of the condition.” EBM EBM as a category encompasses five codes, which includes EBM, replicated, randomized controlled trials, research outcomes, and convincing evidence of efficacy. Two codes that include EBM and convincing evidence of efficacy generated the most references. A comment supporting this evidence came from an acupuncturist, “The evidence that’s needed for acupuncture is the same evidence they use for all procedural evidence.” Another acupuncturist also expressed the importance of evidence by saying, “what would prevent acupuncture from being covered by insurance is if there’s demonstrated efficacy.” Similarly, mainstream medical practitioners emphasized the value of evidence. For instance, one mainstream medical practitioner pointed out, “The main difference between mainstream medicine and acupuncture is the scientific evidence and pathophysiology mechanisms. The mainstream medicine is evidence-based medicine.” Another mainstream medical practitioner expressed his concern about the evidence for acupuncture by saying, “I’m just unaware of any evidence for acupuncture. It does not say evidence doesn’t exist. I am just not aware of it.” Acupuncture awareness The category of acupuncture awareness generated the code of awareness. The code that generated the most references within the category of acupuncture awareness from mainstream medical practitioners’ interviews, with statements such as: “Very little knowledge about acupuncture.” “I don’t know anything about acupuncture.” “I’m not familiar with acupuncture.” “I’m just unaware of any evidence for acupuncture. It does not say evidence doesn’t exist. I’m just not aware of it.” Professional representation Professional representation merited five codes with a few references each. These five codes are bad impression, unprofessional dress, weak lobby, weak influence, and ineffective representation. One participant referred to the current status of professional representation by stating: “acupuncture profession has not acted enough to become properly represented. They have not formed a strong enough union they have not influence.” Furthermore, a participant emphasized the importance of strong professional representation as well as its influence by stating: “Licensed (nonphysician) acupuncturists do not have enough influence with the insurance companies and with the legislators and look at the chiropractic associations and medical association and even other professional association. Their associations have done great job for lobby things. Lobby things are right for the protection of any profession. However, acupuncture profession didn’t do a good job and we have a weak lobby.” Acupuncture education Acupuncture education as a category encompasses six codes, each with a few references from the interviews. These six codes are professional competency, credentials, vagueness, inconsistency, sub-professional training, and communication. The sample responses under these codes were included in the interview. For instance, one acupuncturist suggested, “I think we should have included biomedical science into our schools to prepare more acupuncture physicians to get closer to the biomedical science.” Another acupuncturist highlighted, “So, I think that vagueness between the style and the way that each acupuncturist doesn’t make things objective as Western medicine. There are so many different styles and there's different ways. You know the different ways of practicing acupuncture. And I think that makes acupuncture vague.” Then, this acupuncturist further concluded, “acupuncture is very flexible and inconsistent. It’s not like Western medicine.” Regarding the communication between licensed (nonphysician) acupuncturists and mainstream practitioners, one acupuncturist pointed out, “I think with more evidence-based treatment practices has results. Yeah. The mainstream practitioners are going to realize that this can really help them that we licensed (nonphysician) acupuncturists can help together. It doesn’t have to be me or them it could be more collaboratives going on. I think that communication is the key between licensed (nonphysician) acupuncturists and mainstream medical practitioners.” Health cost Health cost as a category encompasses three codes, with a few references. These three codes are cost, cost-effective, and insurance coverage. The responses from the interview are aligned with the online survey about the health cost. The sample responses under these two codes are included in the statements. For example, one acupuncturist stated, “It’s also inexpensive. It lowers the price compared to the medical treatment and lowers the chance of medical caused complications and health problems.” Further, this acupuncturist pointed out, “They would see how it actually saves them hospital visits; it saves them time from work; it saves them you know anxiety because now they don’t have the added financial piece.” Regarding insurance coverage, one acupuncturist highlighted its importance as well as the concern by saying, “So, insurance to cover definitely is a very important factor. You know it’s hard to get even preventive things covered these days.” DISCUSSION The results of the needs analysis not only revealed the perceptions and attitudes toward acupuncture of licensed (nonphysician) acupuncturists and mainstream medical practitioners from university-based and hospital-based settings (RQ1) but also informed opportunities and barriers to integrating acupuncture into mainstream medicine (RQ2). Utilizing a mixed-methods approach helps to understand RQ1 and RQ2 by integrating quantitative data (5-point Likert scale scores on the survey) with qualitative data (transcripts of interviewees) and further provides a more complete and synergistic data collection as well as data analysis than either method would alone. The following section addresses emergent themes and how those themes informed possible interventions. Health Belief and Attitude (RQ1) As previously stated, data from the two online surveys revealed both licensed (nonphysician) acupuncturists and mainstream medical practitioners present a positive belief about acupuncture use. Semi-structured interviews from mainstream medical practitioners ( n = 3) expressed they believe that acupuncture can help patients’ health. Two of the medical doctors thought acupuncture had potential benefits and less risk than mainstream medicine although they did not have previous acupuncture treatment experience. A medical doctor shared her positive personal experience with acupuncture, highlighting its role in aiding her post-surgery recovery while managing an allergic reaction to sutures. When asking the placement of acupuncture within the mainstream, all three medical doctors thought acupuncture was a positive addition to mainstream medicine. One medical doctor stated: “I think it’s a great addition. You know, of course, I practice medicine differently. But I think if you combine these two then you got something very successful. Ok, I wish it was more mainstream.” Comparing the view of acupuncture as an additive therapy by mainstream practitioners, licensed (nonphysician) acupuncturists ( n = 5) believe mainstream medicine is necessary for healthcare, especially for diagnosis and emergencies. For example, one acupuncturist stated: “Definitely, emergencies like a car accident broken bone things where they may need advanced diagnostics. They say they have a lymphoma or something that looks questionable. I think that for lifesaving and emergencies definitely need surgery. Western is the best choice for people’s life.” When asking the main difference between acupuncture and mainstream medicine, licensed (nonphysician) acupuncturists ( n = 5) seem to understand mainstream medicine more than mainstream medical practitioners ( n = 3) understand acupuncture. For example, one acupuncturist stated: “Acupuncture is a macro view of health and health-related problems and Western medicine is a micro view of health and health-related problems.” Another acupuncturist stated: “I think the main difference is how we look at the body anatomy physiology wise the way that western looks at the body is there’s something wrong. Here’s the prescription and this is how we fix it. Acupuncture looks at the person as a whole as their body as their mind. Not just a symptom. We’re treating that patient a day at a time. The way that there are patterns present. So, it’s a completely different point of view on the body.” In terms of the question above, two medical doctors could not give a clear answer because they had known little about acupuncture, but they expressed the role of evidence in distinguishing acupuncture and Western medicine. For example, one medical doctor stated, “I think the main difference is it’s going to be the scientific evidence and pathophysiology mechanisms. The mainstream medicine is evidence-based medicine.” The other medical doctor stated: “Difficult question for me to answer because I don’t know anything about acupuncture, and don’t understand the basics of what it is or anything about the evidence behind it, or you know what people are to treat or cure.” The statement by medical doctors not only reveals the importance of evidence in understanding acupuncture but also reflects the lack of acupuncture awareness in the mainstream medical practitioners’ community. This lack of acupuncture awareness might be related to the shortage of acupuncture education within mainstream medical programs. In the online survey, 36.1% of mainstream medical practitioners ( n = 36) neither choose to agree nor disagree regarding whether acupuncture should be included in mainstream medicine. The percentage of 36.1% is relatively high, and it might be related to the finding that many mainstream medical practitioners stated they did not have background knowledge of acupuncture. In our interview, two of three mainstream medicine practitioners stated that they did not have acupuncture treatment experience ever in their life, which might explain the high percentage of mainstream medical practitioners in the online survey neither choose to agree nor disagree regarding whether acupuncture should be included in mainstream medicine because they did not have knowledge of acupuncture. Opportunities and Barriers (RQ2) As alluded to earlier, barriers to mainstreaming acupuncture are two-fold: external and internal. External barriers consist of issues with evidence for efficacy and insufficient awareness of mainstream professionals. 7 , 11 , 12 Internal barriers consist of issues such as inconsistent professional competencies, varied training of acupuncture professionals, and ineffective representation of the profession. 20 Data from the needs assessment revealed that lack of evidence related to acupuncture efficacy remained a key impediment to mainstreaming acupuncture. Research indicates that evidence-based practice is a key factor in integrating acupuncture into mainstream medicine. 12 , 14 , 21 , 22 Data from the online survey indicated that 33.8% of licensed (nonphysician) acupuncturists ( n = 146) and 75% of mainstream medical practitioners ( n = 36) believe that evidence-based practice is the primary evidence for acupuncture therapy to be included in mainstream medicine. Regarding what evidence is needed before acupuncture therapy would be considered for integration into mainstream medicine, the semi-structured interview revealed that all three mainstream medical practitioners and all five licensed (nonphysician) acupuncturists emphasized the necessity of evidence for acupuncture efficacy and safety. For example, a medical doctor stated: “I think it really depends on the convincing evidence of safety and efficacy.” Furthermore, one medical doctor first affirmed that insurance coverage is a very important factor for acupuncture being included in mainstream medicine and then she emphasized the importance of evidence. She stated: “I think insurance coverage definitely is a very important factor. So, some insurance company think you should be the evidence-based medicine. You know, you’ll have to be approved.” Another medical doctor also highlighted: “I think what would prevent acupuncture from being covered is if there’s no demonstrated efficacy.” Therefore, evidence-based practice may be the ultimate decisive factor for integrating acupuncture into mainstream medicine. The need for more evidence may bring the opportunity of adding evidence-based research to acupuncture education and practice to increase the chances of mainstreaming acupuncture. Data from the needs assessment revealed that the factor of insufficient acupuncture awareness exists within mainstream medical professionals. The responses from the semi-structured interview for mainstream medical practitioners ( n = 3) reflect the lack of awareness of mainstream professionals may be one of the barriers to mainstreaming acupuncture. For example, several mainstream medical practitioners expressed their knowledge of acupuncture by saying the following statements, “I don’t know anything about acupuncture.” “I am not familiar with it,” and “I’m agnostic; I don’t know much about it.” When asking their attitude toward acupuncture, one medical doctor stated, “We have zero exposure to acupuncture in my training either in medical school residency or fellowship.” Ghassemi argued that the students of medical sciences have recently voiced their interest in evidence-based complementary and alternative medicine (CAM). 23 A survey of 233 physicians in the Mayo Clinic indicated that 62% of physicians expressed difficulty in finding reliable information about CAM treatment or techniques, and 70% of respondents believed that the Mayo Clinic should offer proven CAM therapies to patients. 7 The study by Kielczynska et al. reflects that there is a possible need for increasing acupuncture awareness within mainstream medicine. 7 This need may bring the opportunity of incorporating acupuncture courses combined with the evidence-based research discussed above in medical schools’ curriculum, which can be one of the potential interventions of mainstreaming acupuncture. Data from the needs assessment revealed that inconsistent professional competencies, varied training of acupuncture professionals, and ineffective representation of the profession may be the internal factors that acupuncture remains outside mainstream medicine. These three factors were mentioned in the semi-structured interview from the licensed (nonphysician) acupuncturists ( n = 5) group. Data from the online survey indicated that 16.7% of mainstream medical practitioners ( n = 36) and 16.6% of licensed (nonphysician) acupuncturists ( n = 146) believe consistent professional competency is a factor for acupuncture to be included in mainstream medicine. Furthermore, adequate biomedical training supported by 9.0% of licensed (nonphysician) acupuncturists ( n = 146) was a factor that can contribute to mainstreaming acupuncture. In the semi-structured interview, one licensed (nonphysician) acupuncturist stated: “I think acupuncturists should know a little bit more about biomedicine because they are in that setting. They should know, and they should be able to communicate with other doctors and other medical staff. In that way because that’s the way that they understand things, so I think they should probably be a little bit more emphasis on biomedicine.” Another acupuncturist stated: “I think we should have included biomedical science into our schools to prepare more acupuncture physicians to get closer to the biomedical science.” Therefore, increasing biomedical training in current acupuncture education might be one intervention for mainstreaming acupuncture. Regarding acupuncture training, the varied training makes the profession appear inconsistent and lacks standardization. One acupuncturist stated in the semi-structured interview: “There are so many different styles and there are different ways of practicing acupuncture. And I think that’s what makes things vague.” “I feel like the vagueness of acupuncture. Everyone has a different style. Mainstream medicine is very objective. You know their diagnosis and the treatment is very regulated.” In terms of ineffective representation of the profession, the weak lobby and weak professional organization were two aspects that licensed (nonphysician) acupuncturists believe makes the acupuncture profession remain outside mainstream medicine. A comment supporting this weak lobby and profession came from one acupuncturist, “Two things. One is a very weak lobby. The acupuncture perfection seems not do a very good job. The lobby fight for our profession. Look at the chiropractic associations and medical associations and even other professional associations. They’ve done a much better job than us.” Another acupuncturist also highlighted: “I think that it’s because of not having enough lobbyists and not have enough people doing what you’re doing right now bringing acupuncture out to the mainstream, educating the people that is worth it.” Therefore, consistent training and strong acupuncture association might be necessary for acupuncture to integrate into mainstream medicine. LIMITATIONS This study encountered several limitations that may affect the generalizability of the results. First, the sample size for the semi-structured interviews was exceedingly small, with only five licensed nonphysician acupuncturists and three mainstream medical practitioners (from university-based and hospital-based settings). These small sample sizes limit the ability to generalize the findings to the broader population of nonphysician licensed acupuncturists and medical practitioners, both in different regions of the United States and across different medical specialties. In addition, the survey sample also reflects responses from a limited geographical area and a mixed pool of opathic (MDs) and osteopathic (DOs) physicians, adding another layer of variability, potentially missing variations in attitudes and beliefs that may exist in other parts of the country. Another limitation is the age of the data. The data were collected in 2018, and since then, significant changes in the health care landscape, including attitudes toward acupuncture and the integration of acupuncture into mainstream medicine, may have occurred. This time gap should be acknowledged when interpreting the findings, as these changes may influence the relevance and applicability of the results to the present context. Further studies with larger and more diverse samples are recommended to validate these findings and provide a more comprehensive understanding of the integration of acupuncture into mainstream medicine. CONCLUSION The needs assessment revealed the attitude and perception of licensed (nonphysician) acupuncturists and mainstream medical practitioners as well as opportunities and barriers to mainstreaming acupuncture. The emergence of evidence-based practice suggested that licensed (nonphysician) acupuncturists and mainstream medical practitioners relied on the research evidence for guidance on how to integrate the acupuncture profession into mainstream medicine. Therefore, the next step in addressing the POP—acupuncture profession remains outside mainstream medicine—was to consider potential interventions that 1) improve acupuncture professional competencies by teaching EBM at acupuncture colleges; and 2) enhance mainstream medical practitioners’ awareness of reliable evidence-based acupuncture treatment through effective communication with acupuncture professionals who are equipped with EBM knowledge in acupuncture. AUTHORS’ CONTRIBUTIONS D.L.: Conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft, and project administration. K.K.: Writing—review and editing, supervision. Each author played a key role in their respective areas, and all authors reviewed and approved the final article. AUTHOR DISCLOSURE STATEMENT No competing financial interests exist. FUNDING INFORMATION No funding was received for this article. 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Supplementary Materials Supplementary Appendix A1 acu.2024.0042_supplementaryappendixa1.docx (25.7KB, docx) Supplementary Appendix A2 acu.2024.0042_supplementaryappendixa2.docx (17.6KB, docx) Supplementary Appendix A3 acu.2024.0042_supplementaryappendixa3.docx (16.8KB, docx) Supplementary Appendix A4 acu.2024.0042_supplementaryappendixa4.docx (16.4KB, docx) Supplementary Appendix A5 acu.2024.0042_supplementaryappendixa5.docx (18KB, docx) Articles from Medical Acupuncture are provided here courtesy of SAGE Publications ACTIONS View on publisher site PDF (547.3 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top