Best Practice for WHO?

 I debated whether to respond to these comments by Peter Deadman about community acupuncture. It seems like most of us in POCA have had this argument over and over. But plenty of students and new practitioners, especially in the UK, are having it for the first time. In hopes of not having to have it a hundred more times, here goes.

Here are his comments:
The hardest thing is to get a rewarding (emotionally and financially) practice. So many new practitioners never get a practice off the ground – at least one that can give them a decent living. In my mind there are two answers. The first is the work being done in the field of community acupuncture … matching patients who simply can’t afford high fees with practitioners happy to work in multibed clinics. The other is the development of the highest level of skill and knowledge allied with a degree of specialisation.I think these two strands can find a way to co-exist.
There is a buzz about multibeds right now, and lots of patients benefit from the affordability, the communal atmosphere and the ability to have more frequent treatments. They are a pragmatic solution to a particular problem. However, I don’t think they represent best practice and I feel very strongly that best practice (which is almost inevitably more time consuming) risks being diminished by the need to offer quick treatment.
In fact I think that lots of practitioners need to raise their game – continuously studying to build on their initial education. How many practitioners for example know the diagnostic tests, natural progression and prognosis of the hundreds of different musculoskeletal disorders the human body can suffer from? This despite the fact that musculoskeletal problems probably form the majority of the cases we treat.
I also feel that acupuncture – having its roots in the Chinese medical tradition – has a lot to offer patients in terms of understanding cause of disease and what are helpful and unhelpful behaviours. The way I was taught, this was part of the job and Chinese medicine has extraordinary wisdom in this respect.
When community acupuncture offers three-minute consultations and tacitly or overtly expects ‘the needles to do all the work’ I think this is a betrayal of acupuncture as medicine. After all, much dismay accompanied the transition from the old-style GP who lived in a community, knew their patients and their lives, relationships, strengths and weaknesses, to the modern rushed GP whose main preoccupation is to find a way to stop their patient talking so as not to exceed the few minutes allotted to each consultation
Yet even they spend considerably longer than three minutes.

So, isn’t it interesting that Mr. Deadman, like any number of acupuncturists and scholars before and since, has no qualms about glancing over the vast historical diversity of acupuncture practice and choosing (coincidentally?) its “best practice” as something which the majority of patients will never be able to afford? There are thousands of ways to practice acupuncture, some of them quick, some of them slow; there is no objective evidence that any of those ways work better clinically than any others,  and yet the best way to do acupuncture, the right way to do acupuncture according to these scholars, is a way which inevitably puts it out of reach for millions of people who could otherwise benefit from it.

    I was thinking about Mr. Deadman’s comments during my first hour in clinic this morning and how “best practices” might apply to the first 6 people I treated. My first patient — let’s call him Joe — is a security guard who has worked the graveyard shift for the last 20 years. He has a variety of health problems related to diabetes. His most acute problem right now is neuropathy in his feet, and it’s acute not just because it hurts, but because he has to take a physical fitness test tomorrow and if he doesn’t pass, he’ll lose his job. There are all sorts of lifestyle changes he’d like to make to address his diabetes, such as exercising more and eating better, but he hasn’t been able to make them because he’s in so much pain that he can barely get through the day (or rather, night) and also, his sleep is wrecked. He’s now in love with acupuncture because, since he started treatment earlier this week, he’s had several pain-free hours in a row and also, he’s sleeping much better. (He slept in the clinic yesterday, with his needles in, for 6 1/2 hours.) I learned all of this in 3 minutes as I was putting in his needles — he could only stay for an hour today so I needed to get them in quickly. He’s counting on this treatment to help him get through the physical fitness test and keep his job. The last thing he told me before he fell asleep was that the relief he’s getting from acupuncture gives him hope that he’ll be able to start an exercise routine.

    He knows the lifestyle changes he needs to make. I know where to put the needles to give him relief. He needs a nap and he needs to keep his job. What good would it do him — or me — to spend any more time talking? I don’t need to palpate, I don’t need to take his pulses in three positions,  I know what to do and I know it will work. It’s been working all week.

    My second patient, let’s call her Lydia, started crying right after she said hello to me. She’s crying because she had an entire day of pain relief for the first time in about five years after her last treatment. Lydia is in her 70s, significantly overweight, with a history of depression and excruciating knee pain. Her doctor sent her to acupuncture 3 weeks ago and we’ve treated her 10 times since then. She told me that both her doctor and her grown children can see the change in her and they’re thrilled. Her mood is much better, and she’s able to do more for herself. “For the first time in years I really have hope.”  Her goal is to start exercising and to reduce her pain medication; she’s started reading books about nutrition. As with Joe, my conversation with her took about 3 minutes, and there’s really nothing more to say. We both just have to keep plugging away, on opposite ends of the needle.

    My next two patients, Jennifer and Cindy,  both have allergies that make them miserable. The lovely Willamette Valley in which we all live is one of the worst places in the world for spring allergies. My car had what appeared to be a quarter-inch of yellow pollen on the windshield this morning. I have a protocol for allergies and I know it works, not only because my patients tell me that it does, but because I receive it myself. Jennifer tells me she’s gotten off Zyrtec and she’s very happy about it. What is there to talk about? They both are very clear about their treatment plans: come in at least once a week until the pollen count goes down.

    My fifth patient, Daniel, is a new patient so I have, in theory, a luxurious 20 minutes to talk to him and treat him. Except that I don’t, because he’s late and he hasn’t filled out his paperwork. In the 7 minutes I end up with, I learn that he has had a lot of acupuncture because he has had HIV for almost 20 years. He’s here because his partner of 30 years died of cancer in March. This set a series of events in motion: he can no longer go to the public health clinic where he’s been getting acupuncture because his partner left him just enough money to make him ineligible, but not enough money to afford a conventional acupuncturist; the HIV medications he’d been taking for years mysteriously made his liver, in his words, “ suddenly just go flat” so he had to stop taking them; and he completely lost his appetite. The chief complaint he wrote on the intake is “grief”. His doctor, like Lydia’s, really wants him to get acupuncture, and in fact sent him directly to us. Daniel says he mostly just wants to stop thinking. “OK,” I say, “ how about we also work on supporting your liver and getting your appetite back?” “Great”, he says. “I used to get acupuncture three times a week at the other clinic, I was thinking I’d like to do the same here.” Sure, I say, let’s start with that. Daniel also tells me that he always knows when his body’s done with the treatment and he prefers to have the needles in about 45 minutes. Better and better, I tell him, we like for all of our patients to tell us when they’re done instead of the other way around. He’s so thin that he has no problem rolling his pants all the way up to the top of his thigh so that I can needle Tung points on his Liver meridian.  Daniel falls asleep immediately after I put in a cautious (for me) 15 needles.  Again, there’s not much to say, and the treatment’s pretty obvious. In our 7 minute conversation, Daniel told me that he knows he needs to eat, and in fact, he knows what he should be eating; the problem is wanting to eat.

    So I’m on time for my sixth patient, which is good, because my sixth patient is actually two patients in one slot: Juan and Rigoberto, the teenage Ramirez brothers. Three weeks ago Juan, who is 16, came in with his father, Juan Sr. Though Juan Jr.’s English was much better than his father’s, Juan Sr. did all the talking while Juan Jr. hung his head: Juan Jr. has terrible headaches every day, his father said. He is depressed and angry, having a hard time in school. Juan Sr. also has headaches; his wife Elena has headaches and a swollen leg. The whole family is very stressed because they own a taqueria and business has not been good lately. On the first visit, I told Juan Sr. frankly that Juan Jr. would probably need a series of treatments, and his face fell. They couldn’t afford it, he said. I took a deep breath, looked into the eyes of my fellow small-business owner and fellow parent, and said, How about $25 for 10 treatments? He brightened — they could afford that. I explained to him how to buy a punch card for Juan Jr. The next thing I knew, Juan Sr. had bought punch cards for everyone in the family, including Rigoberto, who was the only one who doesn’t have headaches. Rigoberto just has stress because he is in an accelerated college program, he is only 18, and of course he has to work in the taqueria. We see quite a lot of the Ramirez family. They bring us burritos. The best part of treating them, though, is not the burritos (which are delicious), it’s the change in Juan Jr. He no longer has headaches every day, he smiles at me, he actually volunteers some information about his stress level. (Way down, he said.) Treating all of the Ramirez family members is quick and mostly not very verbal: Juan Sr. and Elena don’t speak much English, and Juan Jr. and Rigoberto are teenage boys, they don’t really talk to adults in any language. But they all love acupuncture.  And they’re all getting better, sometimes dramatically. Elena’s leg isn’t swollen anymore, and she’s delighted.

    Why not define “best practice” as that which produces the best results for the most people? Or at least acknowledge that how you define “best practice” is profoundly influenced by your personal class lens and the class of the patients you want to treat?  To do so, of course, would require admitting that for acupuncture to work, people have to be able to receive it.  Expensive, time consuming ways of delivering acupuncture, regardless of the skill and knowledge associated with them, are utterly worthless to people who aren’t going to receive them because of outright cost or any of the other subtle class barriers that the acupuncture profession has put up around itself.

    I’m not attacking the kind of acupuncture practice that Mr. Deadman is promoting; I’m just saying it has no value to the people I want to treat, to all the Joes and Lydias and Daniels and Juans Jr. and Sr. Certain practices may have value to people who have more resources than my patients, but I’m sorry, I’m not going to accept those practices as “best” when they are no good at all to the people I saw this morning. Wouldn’t that be kind of like saying that Joe, Lydia, Daniel and the Ramirez family don’t really count, that their needs don’t deserve to be considered?  I would have no issue with Mr. Deadman’s comments if he framed them in a less classist way: if he simply specified, for example, that he is discussing “best practice” for a set of patients who have abundant disposable income, plenty of time to spend in one-on-one consultations with a practitioner, and no cultural or class barriers to the way that acupuncture is conventionally practiced in the West. If acupuncturists who want to treat those people in that way accept it as best practice for their limited circumstances, that’s fine with me, I have no problem co-existing politely with that strand.

    I’ll even acknowledge that there are situations for some practitioners and some patients where it could be useful to know the diagnostic tests, natural progression and prognosis of the hundreds of different musculoskeletal disorders the human body can suffer from. There are situations for some practitioners and some patients in some socio-economic environments where I’m sure it’s helpful to do back points, and maybe even to give lifestyle advice. Mr. Deadman thinks that lots of practitioners need to raise their game – continuously studying to build on their initial education. But no matter how much you raise your game as a private-room acupuncturist, you are never going to be able to get the results I get with the Ramirez family. All the back points and all the continuous studying in the world will not get you Lydia crying with hope. Because you are never going to be able to treat these people at all unless you can treat six people an hour and let the needles do the work.

     I do have a  big problem co-existing politely with a strand that tells me that I diminish the profession by treating Joe, Lydia, Jennifer, Cindy, Daniel, and the Ramirez brothers all in the same room, in the same hour, in a way that gets good clinical results, that works for them and works for me.  Statements like this don’t make me feel like coexisting politely, either: When community acupuncture offers three-minute consultations and tacitly or overtly expects ‘the needles to do all the work’ I think this is a betrayal of acupuncture as medicine. If you put it like that,  OK, I’ll gladly betray acupuncture as a medicine.  If I have to choose between being loyal to that and being loyal to my patients, the Ramirez family is going to win every time.  Also, doesn’t it occur to the critics of community acupuncture that statements like that are insulting to our patients? If their relief, their hope, their clinical improvements require their practitioners to betray acupuncture as a medicine — what does that mean about them? Is acupuncture not medicine when it works for people who are poor?

    Recently one of my colleagues told me that the most important thing the community acupuncture movement gave him was permission. Permission to take care of the people in his community, permission to trust that he knew enough to try to help, permission to ignore what he learned in school if it came between him and real people in pain. So much about the practice of community acupuncture is so obvious, why did it take until 2002 for a Western acupuncturist to start doing it in a concentrated, conscious, replicable way? Because there was no permission to throw out the “best practices” in situations where they’re not in fact “best”, where they’re not even useful or good.

    Believe it or not, community acupuncturists are as earnest and committed as acupuncturists who work with wealthier patients. Shocking, I know. We too want to give our best to our patients: to make sure they can get enough acupuncture as is indicated to be clinically successful, and to deliver it in a culturally respectful way. If we really believed that “best practices” in acupuncture were all the things that our patients could never afford to pay us to do, we wouldn’t be working at all. That’s where the need for permission comes in, and the need to publicly respond to comments like Mr. Deadman’s. Because those comments will, unfortunately, keep some acupuncturists from doing tangible good for all of the Joes and Lydias and Daniels out there, all in the name of being better acupuncturists.

    It would be quite funny, if it weren’t so sad, that those comments start with the acknowledgment that it’s very hard for most acupuncturists to have emotionally and financially rewarding practices. (Are best  practices still best if most people can’t make a living when they’re doing them?) Community acupuncturists might struggle with the financial rewards — because no small business is easy — but the emotional rewards are overflowing, oceanic. As Michelle Faucher wrote: If you stick to the standard CA model and work hard, you will have made yourself one of the sweetest, most rewarding jobs imaginable. You will be surrounded by people who are suffering – but working on it – and you get to be a witness and even a partner in that every day. It is humbling and awe-inspiring and sweetly funny in different ways every day.  There isn’t a “buzz about multibeds” because community acupuncture is a new style of acupuncture, interchangeable with any other kind, on the same level as developing particular skills or specializations. There’s a buzz about multibeds because our newfound connection with our patients is electric and liberating. That's the essence of POCA, actually. There’s a buzz because thousands of people are falling in love with acupuncture — and some of them are practitioners who never knew before how useful they could be.

    Everybody in POCA already has too much work to do, but I’d like to propose adding something else to our list. We need to define “best practices” for community acupuncture. We need to include within our best practices the ability to address isolation and the other social forces that cause disease.  We need to validate our ability to treat whole families, and the ability to offer acupuncture across language barriers. We need to articulate the difference between practices that only benefit individuals in a consumer transaction, and practices which benefit whole communities — or a whole cooperative.  After a certain point, we shouldn’t be defending ourselves against charges of betraying and diminishing the medicine.  We should be defining the terms in the first place.
 

Author: lisafer