Washington, DC

U.S. Office of Personnel Management
Classification Appeal Decision
Under section 5112 of title 5, United States Code

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Damon B. Ford
Acting Classification Appeals and FLSA Claims
Program Manager
Agency Compliance and Evaluation
Merit System Accountability and Compliance

05/07/2020

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Date

As provided in section 511.612 of title 5, Code of Federal Regulations (CFR), this decision constitutes a certificate which is mandatory and binding on all administrative, certifying, payroll, disbursing, and accounting officials of the Government.  The agency is responsible for reviewing its classification decisions for identical, similar, or related positions to ensure consistency with this decision.  There is no right of further appeal.  This decision is subject to discretionary review only under conditions and time limits specified in the Introduction to the Position Classification Standards (Introduction), appendix 4, section G (address provided in appendix 4, section H).

Introduction

The appellant’s position is currently classified as a Health Technician (Acupuncturist), GS-0640-08.  The position is assigned to the Complementary and Integrative Medicine Center (CIMC), Department of Pain Management, Brook Army Medical Center (BAMC), Department of Army (DA) in Fort Sam Houston, Texas.  The appellant believes his position should be classified as an Acupuncturist, GS-0601-12.  We have accepted and decided this appeal under section 5112 of title 5, United States Code (U.S.C.).

Background

In July 2014, the appellant was hired by the DA for the position of Acupuncturist, GS-0601-12.  In October 2014, the U.S. Army Medical Command (MEDCOM) conducted an internal classification review of its Acupuncturist, GS-0601-12 positions.  In August 2015, the Defense Civilian Personnel Advisory Service reclassified DA’s acupuncturist positions to Health Technician (Acupuncturist), GS-0640-08.  Disagreeing with the results, specifically with its classification in a technical rather than a professional series, the appellant subsequently filed this appeal with the U.S. Office of Personnel Management (OPM).  

General Issues

The appellant makes various statements about his agency’s classification review process and evaluation of his position, and compares his position to higher-graded acupuncturist positions at other Federal agencies.  In adjudicating this appeal, our responsibility is to make an independent decision on the proper classification of the appellant’s position.  By law, we must make that decision solely by comparing his current duties and responsibilities to OPM position classification standards (PCS) and guidelines (5 U.S.C. 5106, 5107, and 5112).  Since comparison to standards is the exclusive method for classifying positions, we cannot compare the appellant’s position to others, which may or may not be classified correctly, as a basis for deciding his appeal.  Therefore, we have considered the appellant’s statements only insofar as they are relevant to making that comparison.  Because our decision sets aside any previous agency decisions, the appellant’s concerns regarding his agency’s classification review process and evaluation of his position are not germane to the classification appeals process.

The appellant certifies to the accuracy of his official position description (PD) of record, number FRMC452192.  The appellant’s supervisor initially did not certify to the accuracy of the appellant’s PD.  He stated the PD omits the word ‘Professional,’ and “Professional, however, does exactly describe [the appellant’s] dealings with his patients and fellow staff members.”  However, during the interview with the appellant’s supervisor, he clarified that the PD describes the duties performed by the appellant, but what it does not do is reflect the professional nature of the position.  A position is the duties and responsibilities that make up the work performed by the employee.  Classification appeal regulations permit OPM to investigate or audit a position and decide an appeal based on the actual duties and responsibilities currently assigned by management and performed by the employee.  An OPM appeal decision classifies a real operating position and not simply a PD.  This decision is based on the work currently assigned to and performed by the appellant.

Position information

The BAMC in Fort Sam Houston, Texas, serves as the largest and most robust military healthcare organization within the Department of Defense.  Both inpatient and outpatient services are provided by approximately 8,500 staff members, including active duty military personnel from each of the uniformed services, Federal civilian employees and contractors.  The medical center provides care for up to 483 military and civilian inpatients and for more than 4,000 patients each day during visits to its five separate outpatient clinics including: Westover Medical Home, CPT Jennifer M. Moreno Primary Care Clinic, McWethy Troop Medical Clinic, Taylor Burk Clinic at Camp Bullis, the Schertz Medical Home, and the Corpus Christi Occupational Health Clinic.  BAMC facilities provide comprehensive care for more than 240,000 military beneficiaries living throughout the San Antonio metropolitan area.

The appellant is part of the CIMC at the BAMC.  According to the organizational chart provided by the agency, the CIMC falls under the Department of Pain Management.  The mission of the Department of Pain Management is to provide compassionate comprehensive pain care while advancing medical education and research to optimize readiness and function, and empower patients and their families to maximize their quality of life.  Its vision is to change the culture of pain management by decreasing medication and treatment risk and emphasizing self-management, function, and quality of life.  The appellant’s supervisor, Supervisory Physician (Physical Medicine and Rehabilitation), GP-602-14, also serves as the Chief of the CIMC.  The CIMC staff is composed of a Chiropractor, GS-0601-12, two Chiropractors (contractors), two Chiropractors Assistants (contractors), one Health Technician (Chiropractor), GS-0640-05, two Health Technicians (Medical Massage), GS-0640-06, one Kinesiotherapy Technician (Yoga), GS-0636-06, one Administrative Assistant, GS-0679-06, one Administrative Assistant (contractor), and two Health Technicians (Acupuncturist), GS-0640-08 (the appellant’s position and the other currently vacant). 

The appellant works under the Traditional Chinese Medicine (TCM) paradigm that views the body as an intricate system of organs connected by pathways known as channels or meridians.  Acupuncture describes a family of procedures aiming to correct imbalances in the flow of energy (Qi) by stimulation of anatomical locations (acupuncture points) on or under the skin by a variety of techniques.  The appellant describes acupuncture points as places to stimulate nerves, muscles and connective tissue that when treated release endorphins relieving pain and reducing inflammation.  The appellant is the only licensed non-physician acupuncturist in the BAMC treating referred patients with complex, chronic or acute pain problems through the application of acupuncture and other Chinese medicine modalities such as electro-acupuncture, cupping, skin scrapping and others.  Referred patients include those suffering from pain resulting from a wide range of health conditions (e.g., neurological, musculoskeletal, orthopedic, gastrointestinal), pain related disorders (e.g., post-traumatic stress disorder or complex regional pain syndrome), and/or from symptoms or side effects such as those resulting from cancer treatments and burn injuries.  He is responsible for conducting an assessment of the patient using various TCM diagnosis techniques such as physical observations (e.g., pulse, appearance of the tongue, facial complexion), inquiries concerning matters such as diet/appetite, sleep, elimination and others, and reviews of patients’ past and present health, and medical and social (e.g., work and exercise schedules) histories to determine which modalities and acupuncture points to employ and develop a treatment plan for each patient.  He also provides lifestyle counseling on issues such as sleeping habits, stress management, and other matters related to acupuncture care.  He modifies treatment approaches within the scope of the established treatment plan focused on minimizing and/or managing pain, to reflect the patient’s changing needs.  He is also responsible for evaluating the patient’s progress and response to treatment regimen.   

The appellant provides input into the management of patients with pain by charting and documenting information relating to patient acupuncture care in recording systems such as the Armed Forces Health Longitudinal Technology Application (AHLTA), the military’s electronic health record system.  He also provides training relating to acupuncture care to healthcare professionals (e.g., physicians, physician assistants, psychologists), and participates in weekly teleconferences of the Army Pain Extension for Community Healthcare Outcomes (ECHO), a tele-mentoring initiative and collaborative training, sharing knowledge and expertise relating to acupuncture care with providers in dispersed locations.  We describe the appellant’s responsibilities in more detail later in the decision.

In reaching our classification decision, we have carefully reviewed all information provided by the appellant and his agency, including his official PD, which we find sufficient for purposes of classification and incorporate by reference into this decision.  In addition, to help decide the appeal we conducted separate telephone interviews with the appellant and his supervisor. 

Series, title, and standard determination

The agency classified the appellant’s position to the Health Aid and Technician Series, GS-0640, with the title Health Technician (Acupuncturist), and evaluated it by applying the PCS for the Medical Instrument Technician Series, GS-0649, and the Factor Evaluation System (FES) Primary Standard.  The appellant disagrees with his agency’s title, series, and standard determination.  He believes his work warrants classification to the Medical and Healthcare Series, GS-0601, which is evaluated by the grading criteria in the Job Family Position Classification Standard (JFS) for Professional Work in the Medical and Healthcare Group, 0600.

The Medical and Healthcare Series, GS-0601, covers two-grade interval positions managing, supervising, leading, and/or performing professional healthcare or medical related work.  This series is applicable when the work of the position requires knowledge and skills in two or more professional series within the Medical and Healthcare Group, 0600, and no one discipline is paramount; or is consistent with other professional medical/healthcare work, public health and research work in this occupational group, but is not covered by an established series in this JFS. 

The Health Aid Technician Series, GS-0640, covers one-grade interval positions involving nonprofessional work of a technical, specialized, or support nature in the field of health or medicine when the work is of such generalized, specialized, or miscellaneous nature that there is no other appropriate series.  Such work is either (1) characteristic of two or more specialized nonprofessional series in Medical, Hospital, Dental, and Public Health Group, GS-0600, where no one type of work controls the qualification requirements, or (2) sufficiently new, unique, or miscellaneous that it is not specifically included in a specialized nonprofessional series in the Group.

Classification guidance in the Introduction and The Classifier’s Handbook describes distinctions between professional and nonprofessional series.  Professional work requires knowledge in a field of science or learning characteristically acquired through education or training equivalent to a bachelor’s or higher degree (i.e., positive education requirement) with major study in or pertinent to the specialized field, as distinguished from general education.  Work is professional when it requires the exercise of discretion, judgment, and personal responsibility for the application of an organized body of knowledge that is constantly studied to make new discoveries and interpretations, and to improve data, materials, and methods, e.g., mathematics or engineering. Professional work involves creativity, analysis, evaluation, and interpretation.  It involves applying basic or natural law, principles, or theory; evaluating the research of others; and assessing the need for and validity of proposed changes and improvements in procedures and methods.  Professional responsibility involves the ability to reason from existing knowledge to unexplored areas; to adapt methods to circumstances that deviate from the standards; and to stay abreast of and evaluate technical subjects, analyses, and proposals in professional literature. Professional occupational series follow a two-grade interval pattern and are identified as professional in the series definition.

Technical work is typically associated with and supportive of a professional or administrative field.  It involves extensive practical knowledge, gained through experience and/or specific training less than that represented by college education.  Work in these occupations may involve substantial elements of the work of the professional or administrative field, but requires less than full knowledge of the field involved.  Technical employees carry out tasks, methods, procedures, and/or computations that are laid out either in published or oral instructions and covered by established precedents or guidelines.  Depending upon the level of difficulty of the work, these procedures often require a high degree of technical skill, care and precision.  Some technical work may appear similar to that performed by employees doing beginning professional or administrative work in the same general occupational field.  Technical work, however, typically follows a one-grade interval pattern and does not require the application of knowledge and skills equivalent to those required for two-grade interval work. 

In adjudicating this appeal, we must determine whether the appellant’s work is covered by a two­ grade interval professional or one-grade interval technical series.  Thus, we considered whether the appellant’s position requires professional knowledge such as that of a physician, nurse, engineer, or biologist.  As previously described the “positive education requirement” is common to nearly all professional occupational series.  The bachelor’s degree is often the first degree received on the traditional academic career, requiring completion of at least four years of academic work, and as a prerequisite for a one- or two-year master’s degree program.  In contrast, what is called the Master of Science in Acupuncture (MSA) degree is the entry-level or first degree awarded within the acupuncture field.  Similarly, the Master of Science in Oriental Medicine (MSOM) is the first-degree awarded for study in acupuncture and Chinese herbal medicine.  The Accreditation Commission of Acupuncture and Oriental Medicine (ACAOM) is the national accrediting agency recognized by the U.S. Department of Education that accredits and establishes standards for master’s level programs in acupuncture, requiring such programs to be at least three academic years in length (30 instructional weeks) and follow at least two years of accredited postsecondary education.  The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is the national organization that validates entry-level competency in the practice of Acupuncture and Oriental medicine through certification examinations.  Many States use NCCAOM certification or a passing score on its examinations as documentation of competency for licensure as an acupuncturist.

The appellant states he earned a Master of Science in Traditional Oriental Medicine (MSTOM) after completing a four-year program at the Pacific College of Oriental Medicine (PCOM) in San Diego, California.  He also states he earned a Doctorate of Acupuncture and Chinese Medicine (DACM) from the same school.[1]  Further, during the audit interview the appellant explained that he attained the designation of Diplomate of Oriental Medicine (Dipl.O.M), through a limited-time reciprocal route for California licensed acupuncturists, which exempted him from having to take and pass NCCAOM examinations typically required to achieve this designation.  Published OPM guidance maintains that experience and training requirements of a position, rather than the incumbent’s personal qualifications, govern its classification.  Thus, the level of knowledge reflected by the appellant’s degrees and certification is creditable only to the extent that the position demands them.

In evaluating the education and training requirements of the appellant’s position, we considered the prerequisites for licensure as an acupuncturist.  The licensure requirements of the State where the appellant acquired his license include qualifying for and passing California's written examination.  The examination tests the competency of entry-level acupuncturists.  There are three ways in which an individual may qualify to take the acupuncture examination: (1) Complete the necessary curriculum requirements at an Acupuncture Board-approved training program; (2) Complete a tutorial program approved by the Acupuncture Board.  A tutorial program is similar to an apprenticeship, where an individual learns acupuncture under the supervision and guidance of a qualified acupuncturist and supplements theoretical training with courses taken from either a Board-approved school or an accredited university/college; (3) Complete a foreign education training program which is equivalent to the curriculum required at an Acupuncture Board approved school.  In addition, the appellant’s State’s Acupuncture Board requires acupuncturists renew their licenses and complete 50 hours of board-approved continuing education courses every two years.

Each state regulatory board sets its own rules regarding the licensing requirements for acupuncturists, including whether an NCCAOM examination or certification is required. To illustrate the range of requirements for the licensing of acupuncturists: formal schooling in Texas requires 60 semesters hours of college education and 1,800 hours of training (450 hours of the required 1,800 hours in herbal training) from an accredited acupuncture school; in Connecticut, 60 semester hours of postsecondary education and 1,905 hours of acupuncture training (660 of the required 1,905 hours in clinical training) from an accredited acupuncture program, and successful completion of all portions of the NCCAOM acupuncture examination; in Wisconsin to include two consecutive years of full-time education and clinical work in Oriental diagnostic and therapeutic theories and practices at a school accredited by the NCCAOM; and in California individuals must complete training through an approved training program that offers curriculum that includes at least 3,000 hours of which at least 2,050 hours are didactic and laboratory training, and at least 950 hours are supervised clinical instruction, or a tutorial program in the practice of acupuncture consisting of a minimum of 3,798 hours of theoretical and clinical training, and pass the California written examination administered by its Acupuncture Board.  Furthermore, California does not recognize out-of-state licensing nor does it accept for licensure those individuals who take and pass the national examination administered by the NCCAOM.  Therefore, licensees from other states or those individuals who have passed NCCAOM’s examination may not practice until they have qualified for, taken and passed the California examination.  

Similar to the varying licensure requirements of each State, admission requirements also fluctuate depending on the acupuncture training program.  An ACAOM accredited program may apply stringent admission conditions; for example, requiring applicants to have attained a bachelor’s degree prior to enrollment in the program.  Other programs, like the appellant’s, require applicants have at least an associate degree or equivalent defined as at least 60 semester credits/90 quarter credits of education from an accredited institution.  In general, acupuncturists in the United States are required to complete a three- or four-year training program when the State requires licensure.  The licensure requirements, admission requirements for enrollment in a training program, and length of program curriculum fluctuate significantly by State and school.  We conclude the lack of standardization shows the acupuncture field is currently not considered a broadly recognized profession in the United States for purposes of classification.  The recognition of acupuncture as a profession would be marked by the standardization of essential requirements governing the profession such as licensure and admission requirements and length of program curriculum.  In his request to OPM, the appellant disagrees the acupuncture field is not considered a broadly recognized profession.  To support his assertion he states that “many federal agencies have classified acupuncturists as professionals.”  However, as previously indicated OPM cannot compare the appellant’s position to others, which may or may not be classified correctly, as a basis for deciding this appeal.  Thus, the appellant’s assertion that other agencies “have classified acupuncturists as professionals” has no bearing on the series determination of the appealed position. 

We recognize the appellant’s position requires acupuncture-specific training or education to understand TCM theory, philosophy and the meridian system; how to apply this knowledge to patients by recognizing symptoms and behaviors using diagnosis techniques involving physical observation (looking), examination (touching), listening, and inquiry (asking); and how to plan treatment based on TCM diagnosis.  In reviewing the curriculum of the appellant’s and other training programs, we noted the specificity of the course descriptions and objectives.  The training programs, geared to provide practical, extensive training on the application of acupuncture treatments in a controlled environment, are characteristic of technical schools providing employment-preparation skills to train a workforce like licensed practical nurses and radiology technicians.  Sixty semester credits of college course work typically satisfy the associate degree requirements of junior and community colleges.  Such training is typical of the occupational theory requirements for technical rather than baccalaureate programs.

We examined the appellant’s assignments along those dimensions most closely aligning to those of a professional.  The objective of the appellant’s acupuncturist position is to treat patients with complex, acute or chronic pain by the application of acupuncture and other modalities to help minimize pain and maintain focus on maximizing function and quality of life.  The patient’s primary care provider, however, generally makes all clinical decisions related to the patient’s medical care, including referring the patient to the Interdisciplinary Pain Management Center (IPMC) for pain management specialty referrals and consultation services.  IPMC staff is comprised of interdisciplinary personnel (e.g., Physicians, Physical Medicine Rehabilitation Specialists, Clinical Pharmacists) involved in interventional pain management who in turn refer patients who may benefit from an integrative treatment modality such as acupuncture, chiropractic treatment, medical massage, and/or movement therapy to the CIMC.  Once referred to the CIMC, the appellant works collaboratively with physical therapists, chiropractors and his supervisor (physician) to discuss all referrals and conduct a review of the patient’s medical records and outcomes in order to confirm if the referral is viable and develop an integrative treatment plan having the best potential for a positive result.

The appellant works with a high degree of freedom when making technical decisions such as the selection of acupuncture points for treatment based on physical observations, inquiry and other diagnosis techniques.  He is knowledgeable of and skilled in a variety of acupuncture modalities such as electro-acupuncture, cupping, skin scrapping and others.  He applies acupuncture and introduces other modalities in combination with acupuncture, as necessary (e.g., acupuncture and electro-acupuncture or both).  The appellant rotates between two treatment rooms with one bed in each room and treats an average of 10-12 patients per day.  As described by the appellant, patient treatments can take anywhere from 75-90 minutes and he can treat a patient for a maximum of 12 sessions.  The appellant’s supervisor stated there is no set number of sessions a patient may receive treatment, thus if the appellant determines it necessary, a patient could receive more than 12 treatments. 

We find the appellant’s position does not involve two-grade interval professional work, thus does not meet the series definition and nature of work for positions classified in the Medical and Healthcare Series, GS-0601.  While some of his tasks require a high degree of technical skill, for example when inserting, manipulating, and maintaining needles in the skin using different depths and angles, they do not require the extent and depth of scientific theory and knowledge found in GS-0601 positions.  Professional healthcare work requires applying a range and depth of knowledge acquired specifically through an intensive learning regimen of the phenomena, theories, and concepts of a scientific body of medical knowledge.  Instead, the appellant’s work applies knowledge of acupuncture and other TCM modalities and corresponding holistic principles acquired through training and practical experience of accepted acupuncture processes methods to identify acupuncture points corresponding to the patient’s source of pain.  His work does not require applying originality and imagination, evaluating the research of others, or having to reason from existing knowledge to unexplored areas.  For example, when monitoring patients’ responses to acupuncture and recognizing unanticipated reactions from the norm, he is not expected to analyze the results to determine the causes or possible significance of such reactions beyond the immediate situation.  His work does not require him to adapt methods to circumstances that deviate from the standards, rather he may only deviate from established standards within the scope of his practice and as allowed by BAMC policies.  For instance, while he may suggest for a patient with cardiovascular problems to take regular sauna baths to improve cardiovascular function (as shown by a complementary therapy study) he must direct the patient to first discuss the option with a cardiologist.  Furthermore, while the appellant stays abreast of existing and new practical acupuncture and oriental medicine methods and applications through training (i.e., CEU) and personal research (e.g., research relating to treatments for hearing loss/tinnitus and pain management to help fund a study), he does not evaluate technical subjects, analyses, and proposals in professional literature. 

The appellant states that he is recognized as subject-matter expert in acupuncture “functioning as a ‘recognized technical authority in his particular discipline.’”  We note this term is taken from the Level 1-8 description of the JFS for Professional Work in the Medical and Healthcare Group, 0600, for positions in the GS-0601 series.  This term is given within the context of an employee with agency-level policy/program development responsibilities.  Thus, while the appellant is regarded as a subject-matter expert in acupuncture and may be consulted by medical providers, the purpose of his consult is to acquaint or provide training to professionals new to the field with acupuncture knowledges, approaches and techniques.  He does not serve as an agency expert because policy and programmatic responsibilities are vested at the MEDCOM or at higher echelons in his agency.  Instead, his work is limited to drafting standard operating procedures relating to acupuncture care to be used at his local level (i.e., CIMC and/or IPMC) and his work does not affect MEDCOM’s public policies or programs as would be expected from GS-601 positions.  Thus, we conclude his position does not apply the discretion, judgement, and personal responsibility in the broad application of knowledge as expected of professional work. 

Since the appellant performs nonprofessional technical work, we determined his position is properly classified to the Health Aid and Technician Series, GS-0640.  Titles are not prescribed for positions in the GS-0640 series but Health Technician is the suggested title for positions at grades GS-4 and above.  The Health Aid and Technician Series, GS-0640, does not contain grade-level criteria.  The Introduction directs if there are no specific grade-level criteria for the work, an appropriate general classification guide or criteria in a standard or standards for related kinds of work should be applied.  The standard selected for cross-series comparison should cover work as similar as possible to the work being evaluated with respect to the following: the kind of work processes, functions, or subject-matter of work performed; the qualifications required to do the work; the level of difficulty and responsibility; and the combination of classification factors with the greatest influence on the grade level.

The PCS for the Medical Instrument Technician Series, GS-0649 Series, is adequate for extrapolating to and evaluating the appellant’s acupuncture work.  Positions in the Medical Instrument Technician Series, GS-0649, perform, like the appellant, diagnostic examinations or medical treatment procedures as part of the diagnostic or treatment plan for patients.  The work involves operating or monitoring diagnostic and therapeutic medical instruments and equipment associated with cardiac catheterization, pulmonary examinations and evaluations, heart bypass surgery, etc.  Similar to the appellant’s position, positions in the Medical Instrument Technician Series, GS-0649, require knowledge of the capabilities and operating characteristics of one or more kinds of instruments and a practical knowledge of human anatomy and physiology.  Work in the Medical Instrument Technician Series, GS-0649, also requires a practical understanding of medical data generated by patient/equipment connections.  So although instruments used by positions in the Medical Instrument Technician Series, GS-0649, are different from the appellant’s own work tools and equipment (e.g., acupuncture needles and cupping sets), the GS-0649 PCS as a whole gives full weight and consideration to the purpose of his work (to perform diagnostic examinations and medical treatment procedures) and the nature of his work (e.g., when providing acupuncture treatment, he must recognize a patient’s unanticipated reactions to make necessary adjustments).

Grade determination

The GS-0649 JFS is written in the FES format, under which factor levels and accompanying point values are assigned for each of the nine factors.  Under the FES, each factor-level description demonstrates the minimum characteristics needed to receive credit for the described level.  If a position fails to meet the criteria in a factor-level description in any significant aspect, it must be credited at a lower level unless an equally important aspect that meets a higher level balances the deficiency.  Conversely, the position may exceed those criteria in some aspects and still not be credited at a higher level.  If a position factor is evaluated at above the highest factor level published in the classification standard, the factor is evaluated by reference to the Primary Standard, the FES’s “standard-for-standards” in Appendix 3 of the Introduction.

Factor 1, Knowledge Required by the Position

This factor measures the nature and extent of information or facts the employee must understand to do acceptable work (e.g., steps, procedures, practices, rules, policies, regulations, and principles) and the nature and extent of the skills needed to apply the knowledge.

At Level 1-5, the highest level for this factor described in the PCS, work requires knowledge and skill as described at Level 1-4 on page 10 of the GS-0649 PCS (e.g., practical knowledge of instruments used in the specialization to make adaptations and adjustments and interpret test results based on previous experience and observation) in addition knowledge of the instruments and complex procedures of the specialization to perform special complicated examinations or treatments for which there are no standard instructions and procedures.  At level 1-5, work also requires knowledge of anatomy and physiology including an in depth understanding of the major systems and internal organs to interpret requests and to recognize the need for additional tests or a different position; knowledge of a variety of related acute disorders and diseases, their effects on the organs, and methods of treatment; and knowledge of pharmacology including the classification and administration of drugs, patient responses, and common dosages.  At Level 1-5, work requires skill to apply such knowledge to perform relatively new diagnostic procedures involving very fine distinctions or many delicate and exacting steps, the instruments are complex, and the setting and measurements are fine.  At Level 1-5, the work also requires skill to change and adapt parts of the instrument to meet especially difficult situations; knowledge of and skill to start emergency cardiac arrest procedures and monitor vital signs during examinations; and skill to prepare and analyze quality control of test results.

A work illustration in the GS-0649 PCS at Level 1-5 describes a position where the work involves performing diagnostic ultrasound examinations and echocardiographs.  The employee locates and records internal elements of the body (for example, organs, tissues, skeletal members), displays their position and function, and identifies any anomalies indicative of disease, injury, or other medically significant condition, from ultrasound imaging and simultaneous recordings of the doppler.  The employee also incorporates the causes and results of a variety of symptoms and conditions into a plan of ultrasonic diagnostic examination.  The employee changes and develops sounding techniques to accommodate such variables as limited patient mobility, variation in physical condition or dimension of patient, presence of prosthesis or foreign objects and ultrasonic response of different body parts.  The employee also produces diagnostic quality images and doppler frequency shift recordings using the M-mode, two-dimensional and doppler ultrasound.

The appellant’s position meets but does not exceed Level 1-5.  In addition to the knowledges and skills required at Level 1-4, the appellant’s position requires using knowledge comparable to Level 1-5 in using acupuncture equipment, devices, and procedures to perform specialized treatments for which there are no standard instructions and procedures.  For example, to perform electro-acupuncture, needles are inserted at specific points on the body and are then attached, using small clips, to a device that generates continuous electric pulses.  The appellant uses the device to adjust the frequency and intensity of the impulses being delivered based on the acupuncture points being treated.  He also performs patient assessments using specialized diagnosis techniques such as those involving tongue and pulse evaluations to develop a customized treatment plan for each patient.  Furthermore, treatment plans may require the appellant to apply more than one modality and corresponding equipment or tools (e.g., needles, cupping sets, heat lamps, alpha stims) depending on the patient’s needs. 

Like Level 1-5, the appellant’s acupuncture work also requires knowledge of anatomy and physiology to understand which meridians (pathways of energy) in the body correspond to certain internal organs or body parts.  He applies this knowledge when assessing patients for acupuncture treatment helping him recognize the need for a different type of integrative treatment for a patient (e.g., physical or movement therapy), or the use of an alpha-stim to help with conditions associated with pain such as anxiety and insomnia.  Also, like Level 1-5, the appellant’s acupuncture work requires knowledge of anatomy, biology, the pathology of diseases used when reviewing physicians’ referrals, and patient health and medical records including surgical history, prescribed medications, X-ray and other test results.  The information he reviews when coupled with the results of his acupuncture patient assessments allows the appellant to understand a patient’s needs and develop a treatment plan.

Consistent with Level 1-5, the appellant’s position requires knowledge of a variety of related acute disorders and diseases such as neurological and stress disorders, musculoskeletal disorders, respiratory and circulatory disorders, their effects on the organs, and methods of treatment.  Comparable to the Level 1-5, the level of skill and exacting adjustments described parallel the appellant’s acupuncture work.  His work requires skill to perform diagnostic or treatment procedures involving very fine distinctions or many delicate and exacting steps when inserting thin metal needles and manipulating and/or retaining at precise depths and angles into specific acupuncture points in a patient’s body, or when selecting appropriate densities and frequencies when applying electrical stimulation to needles.  Also, comparable to the work illustration at Level 1-5, the appellant applies sounding techniques to accommodate to variables such as the use of electrical stimulation near or around the presence of a pacemaker. 

This factor is evaluated at Level 1-5 and 750 points are assigned

Factor 2, Supervisory Controls

This factor covers the nature and extent of direct and indirect controls exercised by the supervisor, the employee’s responsibility, and the degree to which work is reviewed by the supervisor.

At Level 2-3, the highest level for this factor described in the PCS, the supervisor defines goals, priorities and deadlines of the work.  When working as a member of a team, physicians accept the technician's knowledge of complex procedures.  Instructions include what is to be done, medical conditions expected, and what equipment is available for particular special procedures.  The supervisor helps the employee with unusual situations which have no clear precedents.  The technician plans and carries out procedures, handling problems and deviations in the work assignment in line with previous training and accepted practices.  The technician uses judgment and initiative that include selecting appropriate instruments and methods, recognizing conditions that cause erroneous results, and troubleshooting complex instruments.  At this level, the technician may participate with physicians in planning procedures.  The technician rarely consults the supervisor for technical advice and independently makes recommendations about procedures or changes to procedures in some situations.  The supervisor checks completed work for results achieved and for conformance to hospital policy and overall adequacy of results produced.

The appellant’s position meets but does not exceed Level 2-3.  Comparable to this level, the appellant’s supervisor defines goals, priorities and deadlines as described in the appellant’s performance standards.  Like at Level 2-3, as the only licensed non-physician acupuncturist performing the full scope of acupuncture services for referred patients, the appellant’s knowledge of specialized acupuncture procedures is accepted by the staff of the IPMC and CIMC, including physicians.  Similar to this level, the appellant follows established BAMC operating procedures and instructions of practice to independently plan, and carry out treatment activities.  Further, as previously described, the appellant’s work flow and referrals are clearly established.  A patient’s primary physician makes the initial referral for the patient to be seen by the IPMC, which in turns assesses whether an integrative modality is an alternative for a patient’s pain management regimen.  If so, the patient is referred for assessment to the CIMC team for further assessment and treatment.  Treating patients outside of this flow requires specific approval from the CIMC Chief.  As expected at Level 2-3, the appellant works with substantial independence and carries out acupuncture procedures, handling problems and deviations in the work assignment in accordance with accepted acupuncture practices.  Consistent with Level 2-3, as an experienced acupuncturist he uses judgment and initiative including selecting the appropriate acupuncture techniques and recognizing conditions or incidents that could adversely affect the patient.  For instance, the appellant must recognize when a patient has a pacemaker and the contraindications for applying electro-acupuncture.  

Characteristic of Level 2-3, the appellant works collaboratively as part of a multidisciplinary team to evaluate patients and determine viable integrative medicine treatment options (e.g., acupuncture, yoga and/or physical therapy).  Like this level, when treating patients the appellant rarely consults with his supervisor for technical advice and independently makes decisions as to what acupuncture modality to apply based on the patient’s progress or changing conditions.  However, and as confirmed by the appellant’s supervisor, in the case of unusual, unique or complex situations which have no clear precedents, he may seek guidance from his supervisor, a trained physician in acupuncture with over 20 years of experience.  Also characteristic of this level, the appellant’s supervisor does not review the acupuncture techniques as they are being employed by the appellant to the patient, but reviews patient treatment charts completed by the appellant for results achieved and conformance to BAMC policies and procedures. 

This factor is evaluated at Level 2-3 and 275 points are assigned.

Factor 3, Guidelines

This factor considers the nature of guidelines and the judgment needed to apply them.

At Level 3-3, the highest level for this factor described in the PCS, guidelines are available but are not completely applicable to work.  The technician must frequently make searches in textbooks, journals, and technical manuals for application to individual cases.  Decision criteria do not cover every situation (for example, confirming unusual test results; using an altered technique; assessing and correcting unexpected reactions or errors; or the complexity of patients’ illness and physical condition).  At this level, the technician uses judgment to adapt and change procedures, and adopts or develops new procedures or techniques for individual problems.  The technician also uses initiative to learn new developments in the field and to recommend changes to improve service, correct deficiencies, and improve reliability of test and treatment results.  The procedures and techniques adapted or developed by the technician form the basis for hospital standardization.

The appellant’s position meets but does not exceed Level 3-3.  The guidelines available to the appellant include Federal and State regulations (e.g., for clean needle techniques), BAMC policies and directives (e.g., hospital medical emergency policies), CIMC procedures and work directions, IPMC referrals and precedent studies.  Like Level 3-3, while these guidelines are available, they are not completely applicable to the appellant’s work because they lack specificity relating to the application of acupuncture and other Chinese medicine modalities.  Thus, similar to Level 3-3, if necessary, the appellant searches textbooks, trade publications, case studies and other technical manuals for guidance on established and developed acupuncture techniques for application to his patients.  Similar to Level 3-3, he uses judgment to adapt and change treatment procedures and modalities to adjust for the patient’s illness, injuries, or physical disabilities, frequently assessing and modifying treatment based on unexpected reactions.  Comparable to this level, the appellant’s work requires using judgment and personal initiative to learn new developments in the field and to improve service by drafting standard operating procedures relating to acupuncture care (e.g., contraindications regarding the use of electrical stimulation around a pacemaker).  

This factor is evaluated at Level 3-3 and 275 points are assigned. 

Factor 4, Complexity

This factor covers the nature, number, variety, and intricacy of tasks, steps, processes, or methods in the work performed; the difficulty in identifying what needs to be done; and the difficulty and originality involved in performing the work.

At Level 4-3, the work includes a variety of duties involving performance of different specialized diagnostic and treatment procedures, methods, and techniques.  Decisions about what needs to be done depend on instruments, examination and treatment procedures, and other variables.  The work typically requires interpreting a variety of conditions and elements such as patient condition, medication, or instrument performance to be sure of test results.  For example, the technician may change settings based on a sudden onset of physical signs or symptoms of distress by the patient.  The chosen course of action is selected from several alternatives; for example, when procedures do not give acceptable results the technician selects a different procedure.  The technician must identify and analyze factors related to the equipment operation and patient responses to discern their interrelationships.  At this level, emergency situations require precise timing and coordination of action with others while making quick and accurate adjustments to the instrument in response to physician orders or patient condition.

At Level 4-4, the work typically involves full responsibility for the technical aspects of the specialization and includes a wide variety of duties involving diverse and complex technical problems (for example, testing, refining, and implementing new procedures and developing procedural instructions to ensure proper performance of procedures).  Decisions involve complicating factors which hinder use of standard procedures and normal alternatives.  Such factors include changing technology, inadequate information about the use and capabilities of new instruments, seriousness of the illness and mental and physical capacity of the patient, requests for changed procedures, test alternatives, or special studies to meet specific clinical situations and research requirements.  At this level, the work performed by the technician requires variations of technical factors to accommodate the patient’s condition; extending standard test methods; changing conventional methods to produce acceptable results; developing new or revised procedures using standard techniques; or refining existing procedures.

The appellant’s position meets Level 4-3.  Like this level, the appellant’s work involves using different TCM diagnosis techniques and treatment methods and procedures when performing his work.  Similar to Level 4-3, decisions on what needs to be done are affected by many variables such as the variety of body systems examined, changes in health condition of the patient showing improvement or plateaued improvement in pain and function.  For instance, if a patient is responding and benefit of continued therapy is anticipated, the appellant may increase overall number of visits for that patient.  Consistent with Level 4-3, he chooses a course of action during treatment from several alternatives.  For example, when procedures do not give acceptable results, the appellant selects a different procedure to accommodate the patient’s changing needs, such as adding electrical stimulation to the acupuncture, recommending the use of a different integrative treatment (e.g., yoga), or providing stress management counseling.

Comparable to Level 4-3, the appellant identifies and analyzes factors related to patient responses to discern their interrelationship with the pain being experienced to develop a treatment plan.  He does this by conducting patient assessments and consulting with patients on matters such as nutrition, sleep, stress, etc., and by reviewing physician referral notes, patient’s health and medical histories (including prescribed drug therapies) and other medical records and imaging such as X-rays.  Additionally, as expected at this level, emergency situations require precise timing and coordination of action with others so as to not cause an adverse effect on the patient’s condition in accordance with BAMC policies.  Similar to Level 4-3, the work also requires precise timing and coordination when making quick and accurate adjustments to needles, electrical frequencies, and other instruments or tools such as heat lamps in response to a patient’s reactions.

The appellant’s position does not meet Level 4-4.  Although the appellant has full responsibility for the technical aspects of acupuncture, unlike Level 4-4 his position does not entail the diversity and complexity of technical problems equivalent to testing, refining, and implementing new procedures and developing procedural instructions to ensure the proper performance of procedures described at this level.  In contrast to Level 4-4, his decisions do not involve complicating factors that hinder use of standard procedures and normal alternatives such as: changing technology; inadequate information about the use and capabilities of new instruments; requests for changed procedures, test alternatives, or special studies to meet specific clinical situations and research requirements.  Instead, upon careful assessment of the patient’s medical history and consultation, the appellant develops a treatment plan and makes necessary adjustments based on the patient’s emotional health, functional limitations and other factors.  Unlike this level, he is not responsible for extending standard test methods or changing conventional methods to produce acceptable results.  Instead, the appellant follows established criteria, standard practices, procedures and commonly used approaches and alternatives of the acupuncture and oriental medicine field.

This factor is evaluated at Level 4-3 and 150 points are assigned. 

Factor 5, Scope and Effect

This factor covers the relationship between the nature of the work (i.e., purpose, breadth, and depth of the assignment) and the effect of work products or services both inside and outside the organization.

At Level 5-3, the highest level for this factor described in the PCS, work involves performance of a variety of specialized diagnostic and treatment procedures.  Positions at this level provide diagnostic and treatment services during regular and recurring critical care situations.  The work has a significant impact on the well-being of the patient.

At Level 5-3 in the Primary Standard, the work involves treating a variety of conventional problems, questions, or situations in conformance with established criteria.  The work product or service affects the design or operation of systems, programs, or equipment; the adequacy of such activities as field investigations, testing operations, or research conclusions; or the social, physical, and economic well-being of people.

The appellant’s position meets Level 5-3.  Like this level, the appellant provides a variety of specialized TCM diagnostic and treatment procedures to patients suffering from pain.  Also like Level 5-3, the acupuncture treatments he administers become a part of the patient’s pain management regimen and may have significant impact on the well-being of the patient by reducing pain levels, increasing function, and improving quality of life.  However, although the appellant administers acupuncture treatment to patients with multiple or a severe conditions, his work does not involve providing diagnostic and treatment services in critical care situations as intended at Level 5-3.  However, as described in the Army Comprehensive Pain Management Campaign Plan dated November 2014 (provided by the appellant), the IPMC is comprised of interdisciplinary personnel in order to provide a “holistic approach to pain management” with both conventional pain management and integrative medicine modalities, thus stressing the patient’s overall well-being.  Further, the plan states the IPMC team “will recommend multimodal pain management treatment plan that may incorporate integrative treatment modalities, such as acupuncture (medical or licensed), chiropractor, medical massage, and movement therapy.”  Therefore, the appellant’s acupuncture treatments are regarded as an integrative treatment modality and used as an alternative method for pain management, thus would be precluded in a critical setting as expected at this level. 

To provide a more reliable, fair, and comprehensive means of evaluation, we compared the scope and effect of his position with Level 5-3 of the Primary Standard to ensure the overall intent of the factor level is met.  Level 5-3 in the Primary Standard describes work similar to the appellant’s position involving treating a variety of conventional problems, questions, or situations in conformance with established criteria.  The appellant’s work also compares favorably to Level 5-3 of the Primary Standard in describing work products or services affecting the social and physical well-being of people.  By coordinated application of the PCS and Primary Standard, we conclude the scope and effect of the appellant’s position meets the intent of Level 5-3.    

This factor is evaluated at Level 5-3 and 150 points are assigned.

Factors 6 and 7, Personal Contacts and Purpose of Contacts

Personal contacts include face-to-face and telephone contacts with people not in the supervisory chain.  Levels are based on what is required to make the initial contact, the difficulty in communicating with those contacted, and the setting in which the contact takes place.  The factors are interdependent so the same contacts selected for crediting Factor 6 must be used to evaluate Factor 7.

Personal Contacts

At Level 2, the highest level in the PCS, contacts are with employees within the hospital, but outside the immediate work unit, patients, their families, physicians, nurses, or other professional and technical personnel.

The appellant’s contacts meet but do not exceed Level 2.  Like this level, the appellant’s contacts are with military and civilians, their family members, physicians, nurses, and other professional and technical staff assigned to the IPMC, the CIMC, and the BAMC. 

Purpose of Contacts

At Level b, the highest level in the PCS, the purpose of contacts is to coordinate work efforts and resolve technical problems.

The position meets but does not exceed Level b.  The purpose of the appellant’s patient contacts is for obtaining health and lifestyle information to assess and provide acupuncture treatment, education and follow-up.  Furthermore, as his patients are referred through the IPMC and as part of the CIMC team, the appellant works collaboratively with professional and technical staff to provide input into the management of patients with pain.  

The combined factors are evaluated at Level 2b and 75 points are assigned.

Factor 8, Physical Demands

This factor covers the requirements and physical demands placed on the employee by the work assigned.  This includes physical characteristics and abilities, as well as the extent of physical exertion involved in the work.

At Level 8-2, the highest level for this factor described in the PCS, the work requires regular and recurring physical exertion.  It may involve walking, frequent bending, reaching and stretching to set up and take apart equipment; lifting and positioning patients; and carrying pushing, or pulling moderately heavy objects.  Duties may require above average dexterity. 

The position meets but does not exceed Level 8-2.  Similar to this level, the appellant’s work requires regular and recurring physical exertion involving walking, standing, and frequent bending and lifting when positioning patients (i.e., straight leg raises).  His acupuncture duties also require above average dexterity and precision to insert needles in precise locations and exact depths, and when applying electric currents to needles. 

This factor is evaluated at Level 8-2 and 20 points are assigned.

Factor 9, Work Environment

This factor considers the risks and discomforts in the employee’s physical surroundings.  Any safety regulations related to the work assigned are also considered.

At Level 9-2, the highest level for this factor described in the PCS, technicians perform work in a setting involving regular and recurring exposure to infectious and contagious diseases, odors and other risks which require special health and safety precautions such as wearing protection clothing such as gloves, masks, or lead aprons.

The position meets but does not exceed Level 9-2.  Like this level, the appellant performs work in a clinical setting involving regular and recurring exposure to infectious and contagious diseases (e.g., hepatitis), odors, and other risks (e.g., sharp needles, bodily fluids).  These exposures require special health and safety precautions such as wearing protective clothing, using clean needle techniques, and following safety and infection control guidelines and procedures. 

This factor is evaluated at Level 9-2 and 20 points are assigned. 

Summary
Factors	Level	Points
1. Knowledge required by the position	1-5	750
2. Supervisory controls	2-3	275
3. Guidelines	3-3	275
4. Complexity	4-3	150
5. Scope and effect	5-3	150
6. & 7. Personal contacts/Purpose of contacts	2b	75
8. Physical demands	8-2	20
9. Work environment	9-2	20
Total		1,715

A total of 1,715 points falls within the GS-8 range (1,605 to 1,850) on the grade conversion table provided in the PCS.

Decision

The appellant’s position is properly classified as GS-0640-08.  Position title is at the agency’s discretion.

[1] The appellant did not provide the requirements to attain the DACM.  However, published information in the PCOM website states that “For previous graduates of master’s level degrees or equivalent, Pacific College has designed an online pathway for PCOM MSAc and MSTOM alumni to upgrade to the doctorate.  PCOM master’s alumni largely meet the requirements for the doctorate; the upgrade program adds crucial skills and knowledge for acupuncturists working in today’s team-based medical model.”  The website also notes that because the doctoral degrees achieve all the competencies of the master’s degrees, doctoral graduates (if they did not previously acquire the MSTOM) will simultaneously earn both degrees.

 

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