Pain Management 2: Professionals and Branding

I know — you guys are starting to wonder if I really have a job, because all I seem to do is blog. I can't stop. Can acupuncture help with that? No, seriously, I seem to be doing a series of posts on pain management.  #3 is in the works.

And speaking of my job, one of our current projects at WCA is tracking how we spend all of our non-acupuncture time. After 8+ years, it seems like we should know everything that goes into running the clinic, but somehow, we're not completely sure; the tasks keep multiplying, and so do we. What exactly are we all doing, and what does it cost WCA? We really would like to know. So let me tell you about how Moses and I together spent about an hour and a half of staff time last week, costing WCA about $40 (give or take taxes, FICA, and workers' comp); whom I would like to bill for that time and why; and what I think it all means for the Revolution.

It started Wednesday morning when I opened my email. (I think I spend about 3-5 hours a week on email, including the time it takes to motivate myself to respond to emails or apologize for not motivating myself sooner.) There was one titled, “community acupuncture questions”, and I winced, expecting that it was from an acupuncturist, and that it was yet another version of the classic, “Hey, I love your business model! Would you please explain the details of how it works. Thanks so much!” But it wasn't. It was actually a lot more wince-inducing than that. It sounded something like this:

Hello,

I went to get acupuncture in another community clinic, not yours. The practitioner told me that about 10% of the population doesn't respond to acupuncture. He said he had many years of experience and that I should experience pain relief as he was putting in the needles and manipulating them. He kept asking me if my pain was going away. The feeling of the needle manipulation was electric and painful in itself. I felt somewhat sedated but I didn't experience enough change in my pain for his liking. He told me I was not a candidate for acupuncture and that I should get on methadone. I am writing to you because this experience made me feel very discouraged. I am already feeling kind of shaky due to my problems with chronic pain and I would really like to know if you think this is an accurate assessment after just one treatment. This is not what I was expecting from community acupuncture and can you please give me a second opinion.

Thank you,

****

My reply sounded something like this:

Dear ****,

first, I'm sorry to hear that you are in pain, and that you did not have a good experience with acupuncture. Obviously chronic pain can be very complex to treat, and I don't know all of the issues that you are dealing with, but I'll give you my perspective based on what you wrote.

There are a lot of different ways to practice acupuncture, a lot of different perspectives. It sounds like the acupuncturist you saw takes almost exactly the opposite approach to ours. I've been an acupuncturist for 16 years and I can only tell you what my experience has been; I can't say for sure what the Truth-with-a-capital-T is about how acupuncture works and doesn't work, and for who. There do seem to be some people who don't respond well to acupuncture, but I wouldn't say 10% — maybe 2%? In any case, from my perspective, ESPECIALLY if you are talking about chronic pain,  you need to do a series of acupuncture treatments before you can say for sure whether or not acupuncture is going to benefit someone. We usually call 10 treatments “a series”. I've had patients who showed no response to acupuncture for 3, 5, even 9 treatments, and then all of a sudden, at some magic nth treatment, they got substantial and lasting relief. Also, I've treated a lot of patients who know from experience that acupuncture doesn't seem to kick in immediately for them; they feel the benefits of the treatment a few hours or even a few days later. They know this about themselves so they know what to expect.

So what we would do with someone in your situation is to recommend that you get 10 treatments in a row, as close together as possible. At the 10 treatment mark, we would want to have a conversation with you about how you're feeling about the acupuncture, how much improvement you're seeing, whether you want to continue, etc. It's often not a black and white issue, especially when you're dealing with chronic pain, whether acupuncture works/doesn't work.  Often it works to some degree; it helps people manage their pain, and/or sleep better, and/or have more energy, and/or lift their mood, even if it doesn't get rid of their pain entirely — and so then those people might decide that they want to use acupuncture as one of a number of strategies to deal with their pain. One of the funny things about acupuncture is that it often helps people with issues other than the issue that they came in for — issues that they might not even have told their acupuncturist about — and then we are ALL pleasantly surprised. So we would never tell someone that they weren't a good candidate for acupuncture. We would want you to try it out and then make that decision for yourself.

I hope that helps. Please write back if you have any questions.

take care, 

Lisa

I didn't hear anything back, but then the next day, Moses and I were working the Thursday evening shift together and in the middle of it I noticed that he had sort of disappeared. It wasn't a big deal because we weren't super busy, but Moses never disappears on shift so I wondered what was up. I went out to the waiting room and noticed he was on the phone, kind of pacing back and forth and looking very focused; it sounded like he was talking to a patient about something to do with pain. OK, I thought, went back to the treatment room, pulled a few people's needles, and came back out to check the schedule. Moses was still on the phone, fifteen minutes later. Then we had a little rush of people coming in, and at some point I noticed Moses was back, but we didn't get to talk about it until later, when I asked what the phone call was all about.

“It was a really strange one,” he said. “A patient with a bad acupuncture experience in another clinic. Another community clinic. Some of her friends told her that she should try acupuncture because she's in a lot of pain and she sounds like she's kind of anxious. But it wasn't what she was expecting. It was really bright and kind of loud and the practitioner did a lot of needle manipulation, and then the big thing was, at the end he told her that acupuncture wouldn't help her, she should give up and just get on meds. She was really upset. She wanted to know if that was how community acupuncture was supposed to be.”

“Was her name ****?” I demanded.

“No, it was #####,” he said. “Why?”

“You have to read this email, ” I said, dragging him back to the computer and pulling it up. “Do you think it's the same person?”

He read it. “No, it doesn't sound like the same person. But it sure sounds like the exact same experience.”

We talked about it a while longer. Given that these two patients are local; given that it sounds like they were referred by WCA patients to a community acupuncture clinic closer to them; and given the description by both of them of the practitioner as somebody with 10+ years of experience, I became pretty sure that I knew who they were talking about. There just aren't that many of us who fit all of those categories.

I also became pretty sure that there would be no point at all in calling this person up and saying what I wanted to say, which was, “Dude! Please! If you don't want to treat these people, you don't have to! But how about we just send you a stack of our business cards and you give them out to the patients that you seem to think are too much trouble. That would seriously save WCA time and money. If this happens one more time, I am — for real — going to send you a bill for the staff time we are spending on talking these folks down. Because this is not in our budget.”

There is no point in saying this, because this particular acupuncturist would be one of the first to remind everyone that I have no right to tell him what to do; that I did not invent community acupuncture; and that he was already doing public health acupuncture — WHICH *IS* COMMUNITY ACUPUNCTURE, REMEMBER??!! — when I was a dewy 23 year old student observer. Because he remembers me from then, and who do I think I am anyway. His clinic is proudly not on CAN's LOC, and never will be. So yeah, never mind.

But that doesn't change the fact that this series of interactions point to a bunch of issues that are really important to talk about — at least for us CANners. We know there is a lot more to creating a true community acupuncture clinic than lowering your prices and providing acupuncture in a group setting, but what that “lot” really is can be hard to define. Part of it has to do with how we as acupuncturists identify as professionals; and part of it has to do with the collective branding exercise we are all participating in, whether we mean to or not. 

Because we CANners treat so many patients who otherwise wouldn't get acupuncture; because we are so evangelical about community acupuncture; and because we rely so much on word of mouth amongst all our patients, including connections that link clinics not just across town but now across oceans, we are collectively defining what acupuncture is, what it does, for whom it does it, and who we are, who do it. That's branding. And that “we” includes patients. Our tens of thousands, or maybe hundreds of thousands, of patients are now completely and inextricably involved in the process of branding acupuncture. I LOVE that. Some other acupuncturists, including some who think of themselves as community acupuncturists, are probably not going to love it so much.

Moses and I spent about $40 worth of WCA staff time dealing with a conflict arising from the differences between how our patients had branded acupuncture and how another acupuncturist had branded acupuncture.  The conflict has to do with who is in charge of the process of someone getting acupuncture. The other acupuncturist thinks that he is, because he is the one with the professional identity, the degree, and the many (MANY!) years of experience. Moses and I and pretty much all of WCA's patients think that the patient is in charge of the process of getting acupuncture. Because…it's hard to answer that because to me it seems so obvious. Because acupuncture doesn't do anything that the patient's body doesn't want to do anyway? Because it's not rocket science? Because the success of the treatment depends more than anything else on the patient's willingness to show up? Because we're all a bunch of radicals hellbent on degrading the medicine and devaluing the profession?

In general, I don't read online reviews of WCA — because I know that I and everyone else who works there is truly doing their best, working flat out to take care of our patients, and at some point you just have to hope people like you, even when you're not perfect and there isn't that much you can change. But through a series of unrelated-to-work circumstances I ended up on Yelp and read a review of WCA that both cracked me up and provided a perfect example of patients getting involved in branding. Check out the review dated 8/26/2010. What I love most about it is that this patient essentially rewrote our welcome letter for us. She explained, better than a lot of acupuncturists could, how community acupuncture works. She felt empowered to do this; she felt that she got what was going on so thoroughly that she could explain it to anyone who wanted to know. That, right there, tells me a lot about our brand, a lot that makes me really happy.

But I can only assume that the two unhappy patients who contacted me and Moses had been referred to the other acupuncturist by patients who were saying pretty much what that Yelp review was saying. Community acupuncture is great because it makes you feel better. It's affordable. You're in charge of your experience. Relax, it's no big deal. Notice how little our reviewer said about the practitioners and how much she said about what community acupuncture feels like to her. No wonder those patients wanted a reality check, after having a community acupuncturist suddenly turn into a gatekeeper.

Bottom line? If you think that you are in charge of the patient's experience of acupuncture; that you can define what it means for acupuncture to work for someone; or that you think the center of your clinic is YOU, you are headed for a branding conflict with the thousands of us who think otherwise. You're not tapped into what is actually fueling the Revolution. You might want to brace yourself for confused, unhappy patients; also, itemized bills for WCA's time. (Kidding! I'm kidding!)

Our entire economic model rests, basically, on patients receiving acupuncture on their own terms, unmediated by anything, including our opinions as acupuncturists about how they are using what we offer. Our marketing depends on patients being able to explain community acupuncture to other patients. This has interesting implications for CAN's relationship to efforts such as Steven Stumpf's to integrate acupuncture with mainstream medicine, to put it side by side with other therapies and modalities. I can't think of any other medical modality in which the practitioners really want the patients to decide for themselves not only whether it's working and how much of it they want, but to determine their entire relationship to the modality. (Not to mention, to continue receiving the modality after all their complaints are resolved, just because they like how it feels.) What would happen to our collective branding, and to our economic sustainability, if we diverged from this foundation? I'm thinking that it wouldn't be good.

When I say community acupuncture is unmediated, I really mean unmediated. Going to work for me mostly means showing up with a group of people who are creating an experience for themselves individually and for each other collectively. I'm part of it, not in charge of it. I have no idea how they define it for themselves, and I don't define it for them. Does that make me a professional? Or just part of a starfish

lisafer
Author: lisafer

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The theme for this conference is “Breaking Barriers”. You know, there are so many barriers to break in acupuncture that it was really hard to choose which ones to talk about for this speech. But since I’ve spent so much time talking about classism as a barrier, I thought it might be fun to shift gears a little and talk about numbers.

Responses

  1. Patient centered practice

    Just got back from posting on the AAAOM google group fighting with folks who think they are fighting for the salvation of the profession evidenced by their desire to use the title doctor or physician because they think they deserve that right by legislation. See. I am long winded. I think I have written it here before but just in case, this will be brief. The Family Physicians are the largest branch in mainstream medicine. They are the largest group of MDs at ~100,000. They are also the most progressive. They are primary care providers and the keepers of the Hippocratic flame. They are most likely to know something about and approve of acupuncture, yoga/meditation, mind-body-stress-reduction, etc. IMO this group by and large is not interested in learning acupuncture because it is not a revenue stream for them. They have that already by being a part of the mainstream (albeit medicine is hurting bad and undergoing profound change). They are often referred to as the gatekeepers. They have championed two “reforms” that are central to how they practice: (1) the medical home, and (2) patient-centered medicine. As the medical home family docs plan to coordinate all care for their patients. This means they will make all referrals to specialists and manage the health of each patient in their practice for which they will receive a capitated fee. Being fam docs they will happily refer to acupuncturists. Patient-centered medicine means they will work with the patient to determine care. If the patient asks for needling or prayer or massage or a PT instead of a DC they will not talk them out of it. I posted an article on my blog by a forward thinking family practice group in Seattle who call themselves Q-liance. They stopped billing insurance companies 12 years ago. They work on a cash basis and consider the quality of their work life, the patients they treat, and providers they work with to be top priority for working at all. They made this choice in the late 1990s before healthcare reform. I can send the article to you if you like. Just ask.

  2. for starters

    This sounds like a personal self-esteem issue for these practitioners, this “failing” after just one treatment, and giving up.

    And this is doing the patient no favors. The patient who may have been suffering for decades with pain only gets one shot at acupuncture…a method that works more the more its used?

    These people are coming in, often desperate, in many cases complaining that they’ve given up on every other possible form of relief, and turning to acupuncture as a last resort. 

    Do these practitioners even think acupuncture has the potential to change pain? And quality of life? And perspective/relationship to imbalances? 

     

  3. That practitioner sounds like a pretty jaded

    human.  As a seasoned practitioner they should know that treating folks with chronic pain can be challenging.  They have tried everything, they are tired of their pain, tired because of their pain and tired that there seems to be no hope for them.  So they want help but are not always easy to treat.   One treatment?  Seriously, that is deranged.  It takes a while to figure out how to approach different people who suffer pain.  Some do not handle so many needles well.  Some need short treatment times.  Some need longer treatment times.  Some just need to seriously take a nap with needles.

    I hope you do talk more about chronic pain, I think about it often.  The last issue of Buddha Dharma mag has a very useful article about chronic pain, it’s relationship to meditation practice and the science of it.  If you like I could send it to you.  I’ve been test driving it on my chronic pain folks and they like it (though the information is frankly more educational for me than for them).

     

     

  4. This practitioner…

    I know who Lisa is talking about here, but honestly, when it comes to his name I’m drawing a blank. He is a really odd duck. We have known this dude for a looong time, since we were students (he was two years ahead of me in school). The first word that Lisa uses to describe him is Crusty.

    I think of him as a cautionary tale because he’s a person who takes to extremes what are initially really good impulses that we all share.  He has no interest in being a high-end boutiquer, he worked in public health for as long as that train was viable, he did a lot of reaching out to very marginal communities here in Portland. All his life has been in devoted to public service.

    His heart is in the right place but he has absolutely no vision or something.  In terms of how he needles, I would call him a Tandinista except he’s waaaaaaay beyond Richard Tan. He rolls his eyes at Miriam Lee (so simplistic) and views himself on the cutting edge of all things Tung. He’s a True Believer. 

    So he takes the form of that lineage but can’t figure out, or disregards the heart, so his style is hard and unfeeling. He winds up saying shit to patients like Lisa describes above. 

    But in the end he is just an extreme version of all of us Punks. And in the end we all have to be careful about  becoming such a person. Which is the subject of the next CAN @ 4 thread, inside the forums, up in one hour.  Cool

  5. so macho!

    I wonder if the machismo is covering over the bleeding heart…

    I am one of those people for whom acupuncture (for acute pain) kicks in about two or three hours later…and I only recently figured that out.  I can’t imagine why one would expect chronic pain to be gone immediately.  

    I often think Dr. Tan’s “where the pain now?” thing is 90% performance, designed partly to give the acupuncturist more information, but also (perhaps mostly) to give the patient enough confidence in the potential of acupuncture that they come back for a *course of treatment.*  There’s more than a bit of the old revival tent in that performance – nothing wrong with a little of that, per se, I do it myself sometimes – except that it requires something of a reciprocal performance from the patient.  Not everyone is instantly ready to take acupuncture (or her acupuncturist) into her heart as her personal savior, in front of everyone – certainly not on the first visit.  [obviously that is not the goal, I’m just playing out the analogy…]

  6. Betcha wish

    Community Acupuncture was a protected/regulated title now, eh? It would defeat the purpose of inclusiveness that’s at the heart of WCA and CAN, but you’d spend a lot less time on defence.

    There’s something about those crusty old practitioners who’ve spent decades in practice, many often having spent time in jail for practicing back in the day; the pioneers. Their public worship the ground they walk on solely because of their longevity and that cavalier attitude that carried them through those dark days, and sadly remains unchanged. Some of them grew with the times, but so many remain in denial; better to reign in hell than serve in heaven, n’est pas?

    Sad to think that very attitude will remain until they retire, which considering the ego involved will only be when they die. Best of luck with your crusty old acu-saint, the two ladies (mother & daughter) in my neck of the woods have turned so many people permanently off of acupuncture that I’ve spent hours of my life trying to convince people to give it another shot.