POCAFest Fall 2014 Keynote: Sustainability for the Next Generation

POCAfest Fall 2014 Keynote: Sustainability for the Next Generation

Before I begin, I’d like to continue a tradition started by Lisa Baird and acknowledge that this is the traditional territory of the Santee people, and that we’re visitors here.

Something interesting happened last weekend. A group of people gathered in a classroom at St. Charles parish in Portland, Oregon, and talked about social justice. These weren’t religious leaders, community advocates or local politicians. This was the next generation of community acupuncture: POCA Technical Institute’s first class.

Now, I don’t remember exactly what we talked about on my first day of acupuncture school, but it wasn’t social justice. There was probably some discussion of zang fu theory, the 8 Principles, tonguesand pulses. But expanding healthcare accessibility as a means to fight oppression? I don’t think so. But this is POCA, and we do things a little differently. We’re doing more than training new acupuncturists. We’re building a sustainable new world.

Sustainability – that’s the theme of this POCAfest, and it’s a word that gets used a lot these days. Sustainability is a hot topic, and rightly so. It’s becoming increasingly clear that our planet simply cannot support a post-industrial way of life for 7 billion people. But what does sustainability mean for us, for our patients, our clinics, and our next generation of community acupuncturists? Well, it’s pretty obvious that the acupuncture profession in this country has become unsustainable in its current form. The AAAOM is barely functioning and has only a few hundred professional members. The NCCAOM is focused on maximizing income, for example exploring a certificate in facial rejuvenation. Turf warfare is at an all-time high as state organizations are battling Physical Therapists over dry needling. ACAOM is trying to convince the US Department of Education that proposed gainful employment and income to debt ratio rules shouldn’t apply to acupuncture schools. Schools are churning out more graduates who will never be able to repay their student loans. And that all amounts to decreasing access for patients. We desperately need a new world. We have to build a new world that will last. And that’s what all of us, together, are going to talk about this weekend.

Key Elements of Sustainability

I want to talk first about the two key elements to sustainability. Anytime some expert talks about sustainability, in any context, these themes will inevitably come up. In fact, these two elements are so intertwined, it’s difficult to even talk about them as separate concepts. Everyone agrees: if you want to build something sustainable, you must cooperate and innovate. Ideas born from collaboration take root and grow. Great inventions (at least the ones that aren’t accidents) are almost always made by lots of people making small, incremental improvements. For great ideas to become transformative, people need each other. POCA, of course, is an obvious example of the power of cooperation. Things happen in POCA not just because we’re all stakeholders and expect some benefit, but because we all have the power to make things happen. We can vote; we can share our voice on the forums; we can volunteer on a project or launch a new idea. We can fund new clinics. We can 2help more patients. We can start an affordable school – can you imagine trying to do that by yourself?? All through the power of cooperation.

The second key element of sustainability is innovation. Experts talk about how when you’re designing for sustainability, you have to basically ignore whatever has been done before, because humans tend tobuild things to meet our immediate needs, and not to consider the needs of generations down the line. You can’t just think outside the box; you have to pretend like you’ve never even seen a box. So if youwere to design a human-powered airplane, for example, you couldn’t base your design on existing models of aviation. It would never work. Another example of this type of thinking would be designing an acupuncture clinic for lots of patients, not just wealthy ones. Or building an acupuncture organization where the most important stakeholders, the patients, have a voice. Or building an acupuncture school that prepares students to treat lots of patients and doesn’t saddle them with debt they’ll never be able to repay. Yes, POCA is innovative! And don’t just take my word for it – in case you haven’t heard, people outside the acupuncture world are taking notice of what we’re doing. The International Summit of Cooperatives has even called POCA “innovative.”

When we cooperate and innovate, we hold each other accountable to our values. The things that prevent sustainability: hoarding of resources, competition, individual accumulation of wealth – cooperation and innovation are a natural antidote for these things. Another way to look at it is this: if you’re NOT interested in building something sustainable, by all means, do it by yourself, or just keep doing it the way it’s always been done. You’re guaranteed to achieve your goal of unsustainability.

Now, when I think about everything it takes to build a sustainable acupuncture world, it’s overwhelming. So I’m going to break it down into more easily digestible chunks and talk about sustainability at different levels of the POCA fractal.

Sustainability on an Individual Level

First of all, we have to think about sustainability on an individual level. Sustainability is all about cooperation, but without passionate, fulfilled, healthy individuals, there is no movement. Individual sustainability is the foundation of everything. Is the work we’re doing sustainable for years to come? I’m not talking about the big picture work here, not yet. I’m talking about the day-to-day work of being a punk. Can someone starting out as a community acupuncturist reasonably expect to do this job for the next 30 years? Do you make enough money to meet your needs? Do you get enough time away from work? Can you keep up with the physical demands of your job? Is your job fulfilling? Is it fun? Why do we do what we do?

One thing that has helped make this work sustainable for me is the simple practice of compassion and kindness towards myself. For me, that means embracing my mistakes instead of beating myself up over them. It means every now and then, sleeping in, and enjoying it. It means not taking criticism as an indictment of my character (still working on that one, for sure). It means not worrying about trying to live up to other people’s expectations of me. Are there ways you can be kinder to yourself?

Something else we can do is be aware of the messages we’re getting. Those of us who are punks have probably all had the experience of the Dreaded Empty Schedule. You know how it is; you’re trucking along, treating lots of folks, and then BAM! A bunch of empty slots in the schedule stare at you like giant black holes of failure. When this happens to me, it’s a sign that what I’m doing is not sustainable. I’m too stressed, too preoccupied, and my back is hurting too much. I actually look at it as the clinic’s way of taking care of me. Like, she’s too dumb to see what’s going on so let’s just do something about it.

Another thing that happens when my job gets to be too much is I have The Dream. I bet some of you have it too. You know the dream – the one where patients just keep coming in, and they’ve taken up every chair and now they’re sitting in circles on the floor, and you can’t remember anyone’s name and you can’t keep track of who came in when, and the internet is down and you can’t check the schedule, and none of your needle stations are stocked, and people JUST KEEP COMING IN and they won’t stop. Anybody else have that dream? When I have The Dream, it’s a sure sign that the way I’m doing things has to change. But I think the single most important thing we can do to ensure sustainability for ourselves as individuals is to work together. We need each other, and not just for big projects like building an acupuncture school. We need someone to call when we’ve had a rough day; we need advice on the forums; we need shoulders to cry on and necks to hug. We need POCA. Social isolation puts people at a greater risk fornumerous health problems, including depression and anxiety, heart disease, Type 2 diabetes, obesity, and ultimately a shorter lifespan. So you might think you can do it all by yourself, but you shouldn’t. Community acupuncture is not a hero’s journey.

Sustainability at the Clinic Level

The next level of sustainability we have to examine is the clinic level. One thing that the POCA annual survey tells us is that clinics become more stable with time. If you missed Skip’s analysis on “Stability Trumps Cleverness” I encourage you to dig deep into the forums and read it. The gist is that followingthe basic CA model ensures years of growth, regardless of clinic size, location, number of employees, or really any other variables. So even if you make lots of mistakes, which we all do, your clinic is still on the long path of sustainability.

Nobel laureate Muhummad Yunus defines a social business as a cause-driven business in which any profits are re-invested back into the business to address a social need, and not paid out to investors. Muhammad Yunus knows a lot about social business. He founded the Grameen Bank in Bangladesh and pioneered the concept of microcredit. His first loan was to a group of families for just $27. He says social businesses like ours have a special responsibility to be sustainable. Communities need stable clinics.

In his book Building Social Business, Yunus shares some lessons in sustainability that we can learn from. First, he says a social business must be at least as well-managed as any profit-maximizing business.There simply isn’t enough financial cushion for costly mistakes. Events such as a harsh winter, an overly ambitious growth plan, or a sudden illness can be devastating for clinics. Second, Yunus says to be flexible – don’t be afraid to adjust your business plan, but never lose sight of your central goal. An example of this would be clinics that have switched from the sliding scale payment model to the low flatrate model. Whatever their reasons, it’s a way that clinics can be flexible in how they uphold their core mission. Third, Yunus says to immerse yourself in the culture of the people you intend to serve. This is why Working Class Acupuncture drew in patients from the start: Lisa and Skip opened a clinic just a few blocks from their house, because they wanted to take care of their neighbors. They weren’t being charitable; they were being practical. The fourth lesson Yunus shares is that you should accept help from allies wherever you may find them. You never know who will become a champion for your clinic. Within our clinic’s first few months of opening I was treating what I considered to be a disproportionately high percentage of hula-hooping enthusiasts. (As a side note, I think this is a rite of passage for clinics: you’ll inevitably end up attracting some sub-culture of patients you never could have anticipated. Working Class had their biker gang; I had my hoopers.) Anyway, there were swarms of hoopers coming in because they were all training for an upcoming half-marathon. And yes, they hula-hooped the entire 13.1 miles. The woman who ran the hooping studio was really excited about our clinic and basically demanded that they all get acupuncture. Her enthusiasm and influence meant rapid growth for our new clinic. Years later, she was instrumental in our decision to relocate the clinic to a bigger and better location. You just never know who is going to shape your business in unbelievable ways. Accept their help. The final lesson Yunus shares is to question your assumptions. You should periodically look back at the assumptions you’ve made, the alternatives you’ve ruled out, the choices you felt you had to make, and consider whether they are still valid. It may open up new opportunities you never dreamed existed. Clinics who have converted to non-profit status – that’s questioning assumptions.

Through cooperating and innovating, we’ve learned a lot about how to build sustainable clinics. Now, eight years after the first CA-101 workshop in Portland, we continue to experiment and push boundaries. After all, innovation is one of the cornerstones of sustainability. Some innovations work great, and a lot fail miserably. But you always learn something regardless of the results.

Satellites: A Lesson in Unsustainability

So now…a lesson in unsustainability, which is not actually a word, but I’m going to use it anyway. Like many clinics, we’ve had the desire to expand our reach but not enough punks for multiple locations. Solast year, we experimented with doing offsite, pop-up clinics – what I call “satellites.” It seemed like a good way to increase access that required very few startup resources. We did one satellite in a corporate setting with a local IT company, and another within a popular primary and urgent care walk-in clinic. The formula was the same for both: a few zero-gravity chairs in a multipurpose room, scheduling through our website, same prices as our home clinic – basically just a mini-version of our clinic. At both satellites we started with one shift per week and planned to expand as necessary. So what happened? At both locations, a lot of buzz and busy shifts during the initial weeks, followed by months of slow, slow shifts. And not just slow: money-losing slow; morale-crushing slow. One patient per hour or less slow.Flyers, promos, and hair-pulling didn’t help. We finally realized the satellites weren’t ever going to be sustainable, and we made the difficult decision to cut them.

We learned some valuable lessons in sustainability from the experiment. One is that when you do a mini-version of a clinic, you might to end up with a mini-version of a patient base, which is not a good thing. Our corporate setting satellite was at a company that had about 800 employees, which sounded like a lot at first. But over time it felt like we had set up a clinic in a town with a population of 800 people, and no one from outside of the town could come see us. Clinics need a large and diverse community from which to draw patients. Try to have as few possible limitations on who can come to your clinic. Another lesson is that marketing should be close to effortless. As the numbers declined at our satellites I naturally ramped up our marketing efforts. Pretty soon, I was spending a ton of time and energy trying to get a handful of people into our satellites, and doing practically nothing to bring in the hundreds of patients to our home clinic every week. Sure, there will be periods of intense marketing energy, like when you’re planning a free day, or running a promotion, or trying to fill up a new shift you just opened. But for regular, day-to-day clinic life, patients should be the ones doing most of the marketing. Another thing we learned was that little tweaks to the formula make a big impact. Because of space restrictions at the satellites, patients were resting for 30 minutes at most. We also had very limited hours; each satellite was open only a few hours per week. These strict limitations meant that patients had very little control over their acupuncture experience. Turns out, they don’t like that. Finally, the biggest lesson we learned is that without a community, community acupuncture simply does not work. At the satellites, there was no receptionist to chat with, no waiting area to relax in and drink tea, no POCA map, no community bulletin board. The magic was gone. It wasn’t a third place.

I share all this not to say that satellite clinics or other experiments can’t work. I think they can; but we still have some work to do in figuring out how. My mistake was focusing so much on expansion that I lost sight of sustainability. But we have to remember that innovation drives sustainability, so clinics, keep trying your crazy ideas. You might stumble upon some groundbreaking new opportunity, or you might end up frustrated, in tears, but that’s okay. POCA is here for you. Failure helps us be more sustainable too.

Sustainability for POCA and the Next Generation

We’ve talked about sustainability for us as individuals, and for our clinics, so now our beloved fractal grows and I am going to talk about the macro level – sustainability for POCA, and for the next generation. Like a lot of people here, I didn’t really know what I was getting myself into when I joined the Community Acupuncture movement. I thought I was joining because I needed help starting a clinic, which was true. But a lot has changed in the 5 years since I first paid my membership dues to the Community Acupuncture Network. CAN is now POCA; it’s stronger and more inclusive. It’s almost like POCA has its own gravitational pull. I’ve changed a lot too. When I first signed up I was doing so as a consumer: CAN had something I wanted, which was information and support. It was like a big encyclopedia. My relationship with POCA is much more complex. Now I consider myself a steward of POCA. Because POCA belongs to all of us, we‘re all responsible for it. It’s a shared resource like clean water. When you sign up for POCA you sign on to be a part of something bigger than yourself, and not just be a part of it, take care of it.

Building a co-op is a lot like building a clinic; it takes a lot of people and skills, and much of it is learn as you go. In my early days of clinic ownership, I had to force myself to envision seeing 100 patients a week 6– I really could not even wrap my head around the idea of being that busy. Now, as a Clinic Success mentor, I encourage new clinic owners to take a long-range view from the beginning. One question I like to ask is, “Whatever task you’re doing or system you’ve implemented – will this work when you’re doing100 treatments every week? Or what about when you have multiple punks, all doing 100 treatments per week?” And just like we have to take a long-range view for our clinics, we have to adopt a long-range view for POCA too. So I’ll ask the same question. Currently POCA has 1,742 members: 1,091 patients, 633 acupuncturists and students, 9 organizations and 178 clinics. Imagine POCA with a membership five or ten times that. What will POCA be like when we have 1,000 clinics, or 10,000 members?

One thing I like to imagine is the day when everything I need as a business owner is available from POCA and POCA members. A POCA insurance company will meet all my insurance needs; I’ll get great rates on credit card processing from a POCA merchant services member, and I’ll deposit my money into a POCA member-owned credit union. My employees will get direct deposit and their 401(k) plan from POCA payroll. My accountant, a POCA member of course, will work with other local POCA clinics and know our unique needs inside and out. Won’t that be great? I’ll have so many wonderful POCA products at my disposal. But I can’t just wait for that day in eager anticipation. As a steward of POCA, it’s my responsibility to help make that happen. It’s all of our responsibilities.

POCA has a long history of sharing. But beyond just sharing among ourselves, we should think about sharing outside the acupuncture world. What we have is pretty great. For years, it seems like a lot of acupuncturists who were trained in the West have always tried to be like someone else: doctors, health experts, life coaches, gurus, whatever. Community punks came along and changed all that. We are who we are; we do acupuncture and nothing else; we like it that way, and we see no reason to change. So imagine, instead of us trying to be like doctors or other health professionals, what if they started trying to be like us? What if primary care doctors or nurse practitioners or physician assistants started opening up independent, low-cost clinics in their communities where patients could go for basic medical care without needing to prove their worthiness, wade through endless bureaucracy, wait forever for an appointment or pay some unaffordable price? We could be blazing the path of a true healthcare revolution – one that’s actually patient-centered and not profit-driven.

Sustainable healthcare is needed today more than ever before. And one of the reasons community acupuncture works so well is because we have a broad vision of healthcare accessibility for all, but we aim to realize that vision in a very specific way. We focus on what we’re good at. We don’t have to reform the entire healthcare system. We just have to reform what’s around us, and we never know what effects that might have.

We all have the power to be revolutionary. When people work together to tackle a social problem in their own community, the ripple effect can be massive. Let me give you an example. In 1969 there was a group of people in Oakland, California who saw that a lot of children in their neighborhood were going hungry. So they decided to start serving free breakfast every day at St. Augustine’s church to any child who needed it. Within a year, they had replicated their breakfast program in cities across the country, feeding 10,000 children every day before they went to school, for free. Who was this group of people? The Black Panthers. Interestingly, the federal government had started a similar pilot program three years earlier, but the Panthers basically shamed the government into making the program permanent, which they did in 1975. Today, the Federal School Breakfast Program feeds 16 million children a day. Muhammad Yunus tells us to work on a small scale to impact our immediate surroundings. The Black Panthers did exactly that –they wanted to feed the children in their communities and nourish the next generation. And now, as a result, millions of kids don’t have to start their day hungry. We have that kind of power too. Don’t ever think that what you’re doing in your clinic, in your community, within this cooperative, isn’t making a huge impact.

And while we’re talking about our power to be revolutionary, I’d like to circle back around to where Istarted: POCA Tech. Without POCA Tech, this world we want isn’t going to happen. So when I think about what sustainability truly means to me, as a punk, a clinic owner, a patient, a steward of POCA, I find this definition from the World Bank to be fitting: The World Bank defines sustainability as “the requirement of our generation to manage the resource base such that the average quality of life that we ensure ourselves can potentially be shared by all future generations.” POCA Tech is our Next Generation: of acupuncturists, of patients, of POCA stewards. So it’s our responsibility to manage theresource base so that they can thrive. And we have a vast resource base. We have money. And while other acupuncture organizations might spend their money on something like hiring a Washington lobbyist, we put ours directly into clinics so that more patients have access. That’s innovative. We have our massive amount of social capital and goodwill. How many people here have spent any amount of time volunteering for POCA or POCA Tech, maybe going to a circle meeting, or working on a project, or helping out at a local clinic? Raise your hands. That’s cooperation. I wonder how many people would raise their hands if the same question were asked at any other gathering of acupuncturists.

The Challenge

POCA has moved way past the point of simply trying to survive. A few years ago we were being called, in all caps, “LOUDMOUTHED, UNDEREDUCATED, OVEROPINIONATED, MISINFORMED LOW-LEVEL PRACTITIONERS,” and now we’re being called innovative. A few years ago, I heard Lisa talk about how the fact that CA was even a thing at all was basically a miracle. It was a miracle that WCA started in this big, cheap space with this great landlord; it was a miracle that other people were able to replicate their model; it was a miracle that a group of acupuncturists were able to organize enough to the point of doing something actually useful. And I’m not one to discount the power of divine intervention, but I think we’ve moved past the stage of miracles. It’s in our hands now. Community Acupuncture exists now because so many of us and our patients desperately need it to exist. The only way we continue to thrive, to push boundaries and increase access, is to cooperate and innovate.

One of my favorite things about any POCAfest is the time between breakout sessions and scheduled activities. I think of these as the interstitial spaces. This is when some of the best conversations happen. There is always plenty to talk about, and I’m going to give you a few more topics. One. How can you ensure sustainability for yourself as an individual? Can you keep doing your job for another 20 years? Two. Is your clinic sustainable? If not, what needs to change? How can you expand access and maintain stability? Three. What do we want community acupuncture to be like twenty or fifty years from today? What do we want POCA to look like when we have a thousand clinics and ten thousand members? Not what could be; what do we want to be. We’re the stewards of POCA after all. What world do we want to create?

Sustainability, ultimately, is a choice. It’s the choice to work together, to pioneer and share and learn from one another, to build something that will outlive us, versus trying to survive a harsh world alone. I think that poet W.H. Auden explained the choice in the simplest, most beautiful terms when he said, “We must love another or die.”


I’d like to close with a quick lesson in US History. Does anyone remember learning about the Gilded Age? This was a period during the late nineteenth century when industrialization drove rapid economic growth. This was a time of railroads, steel mills, and robber barons. Massive corporate wealth was created. But underneath it all was vast corruption and a long list of social problems. Mark Twain named this period the Gilded Age to describe the thin layer of shiny veneer barely disguising what was underneath, which wasn’t pretty. People eventually had enough and the Gilded Age gave way to a new movement to eliminate government corruption and establish a more direct democracy: The Progressive Era. Women were given the right to vote during the Progressive Era; antitrust laws were created, and waste and inefficiency were curtailed.

 I think it’s safe to say the acupuncture profession in this country has been in its own Gilded Age: beautifully appointed schools funded by unfettered tuition costs thanks to Title IV funds, promises of universal acceptance and insurance reimbursement just around the corner, virtually nonexistent workforce data, more education, more degrees, more certifications, more costs, with no tangible benefits. All borne on the backs of students, who then can’t afford to treat anyone. It’s time for the Gilded Age to end. It’s up to us to peel back the shiny veneer. It’s time to rein in the excesses and give more people a voice. It’s time for POCA to usher in the new Progressive Era.

Author: alexa

Hey y'all!  I opened my CA clinic here in beautiful Music City, USA, in January 2010.  I love hanging out with other community acupuncturists, so come visit!

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  1. This was Alexa putting our dreams and hopes into a clear concise and inspiring message. As people devote time to service and correcting the wrongs in society in order to bring compassion into our daily existence, there are crucial moments when one of our peers comes forth and contributes by helping us to better see what our collective consciousness actually looks like while inspiring us to go even higher in our service which is why we are even here….to be of service to each other!

  2. I was honored to hear this speech live! Just tremendous, Alexa was able to captivate even the skeptic and excite the unexcitable and make everyone a believer in not only CA but in the coop too! LOVE LOVE!!!!

  3. I have to admit, I was bummed when I first heard Lisa wouldn’t be doing the keynote for our POCA Fest. When I heard Alexa was doing it I knew it would be really good, but wow! Your keynote speech was incredible Alexa, and I can’t wait to see what else you will produce in the years to come!