I’m a big fan of The Fat Nutritionist, and it was her blog post “if only poor people understood nutrition!” that introduced me to Ellyn Satter and her Hierarchy of Food Needs, which makes brilliant sense to me (both as a practitioner and as a parent who had to think about feeding kids). I don’t know why it’s taken me so many intervening years, not to mention having to start an acupuncture school, but I finally connected the dots. I realized that the concept of a hierarchy of needs explains every single argument I’ve ever had with the acupuncture profession, and much of what we’ve struggled to teach students at POCA Tech.
As Ellyn Satter explains, the basic concept of the hierarchy is that needs at each level must be satisfied before those at the next higher level can be addressed. If you don’t meet the needs at the foundation, you can’t move up. So without further ado, I’d like to present Rohleder’s Hierarchy of Acupuncture Needs (because obviously, I’m very attached to it, and one way or another, it’s apparently all I can talk about). Thanks to Gail and Wade for the very fancy graphics!
From the foundation up, here are the levels and what I think they mean for the relevance of acupuncture in 21st century North America. Do we really want a lot of people to get acupuncture in a meaningful way? Then this is what we need to think about, in order of priority.
First do no harm. Acupuncture that is likely to leave a patient with more physical problems than they came in with is not acupuncture that works, and not the kind of acupuncture we want to be doing.
This level includes the need for sterile needles, safe needling depths, red-flag referrals, and good needling technique that minimizes pain. I think it should also include adverse events reporting, collecting safety data, and engaging a feedback loop that comes from using an adverse events reporting database. Because acupuncture is basically a much safer practice than many other medical interventions, the acupuncture profession as a whole has gotten by with paying less attention to adverse events than is warranted — but we should fix that, in part because by definition (OK, by my definition) it’s such a foundational issue.
Also worth remembering because it’s foundational: acupuncture is much, much safer than pain medication or surgery and can potentially save lives by providing an alternative to dangerous forms of pain management, like opioids. For some people, getting acupuncture is of life and death importance, and this is a major reason why we care about it.
Acupuncture that people can’t afford to try is acupuncture that doesn’t work. Full stop.
While the most basic need of physical safety for acupuncture is relatively easy to meet, this next level makes up for it by being excruciatingly difficult. This level encompasses not only affordability for patients, but having an economic delivery mechanism for acupuncture that exists, as opposed to not existing. This level means acupuncturists who are in business, as opposed to not in business. This level means small businesses surviving more than a couple of years. It means practitioners not entering practice with student loan debt that they’ll never repay.
All sorts of beautiful dreams crash and burn at this level. The mobile acupuncture clinic in the Airstream trailer, the community acupuncture clinic that only serves people that its owner personally approves of, the acupuncture clinic near the beach with the flexible, ever-changing hours built around its owner’s surfing schedule…the list goes on. It's easy to imagine acupuncture practice scenarios that you want, and much harder to establish them in reality. Hospital-based integrative medicine centers that go out of business because they can’t make their revenue streams work, no matter how shiny and impressive they are, fail at this level.
This level is where the POCA Cooperative lives. It’s the co-op’s reason for being: to provide collaborative, self-organized support for acupuncturists being in business and delivering acupuncture in forms that patients can afford to access. And the co-op came into being in part because almost nobody else in the acupuncture profession wants to hang out down here (or even acknowledge that “down here” exists, even though it keeps undermining the rest of the pyramid).
Acupuncture that people can’t get, because there’s no economically viable place to get it, is acupuncture that doesn’t work.
If people don’t feel safe in the clinic environment — including in relationship to their practitioner — they won’t get acupuncture, and (say it with me now) acupuncture that people don’t get is acupuncture that doesn’t work.
Social safety is always relative because humans are so diverse. We can’t guarantee social safety for anyone, let alone everyone, but we can work to make our practices socially safer. This level encompasses trauma-informed care and “low barrier” environments that are nonjudgemental and welcoming. It means not pushing people to change their diets or quit smoking as a condition of getting acupuncture, and honoring people’s autonomy. It means practitioners who can take care of their own needs and boundaries. It’s also a challenging level, but not nearly as hard as the prior one. You can’t practice social safety if you’ve got no workplace in which to practice it.
From the GERAC studies, and also from our own years of clinical experience, we know that when it comes to acupuncture, dose matters. Acupuncture that people can’t get enough of is acupuncture that doesn’t work, or doesn’t work the way we want it to.
It doesn’t matter what kind of acupuncture it is if the dose isn’t sufficient.
People need reliable access to acupuncture in order to fulfill a course of treatment. Social safety and economic access are the foundation for this level (because people won’t get enough acupuncture if they don’t feel safe and can’t afford it) but it also requires practitioners who can competently give treatment plans (because they understand dose) and support patients to fulfill them.
The GERAC studies also show that sham acupuncture works. In the real world, however, practitioners need a theoretical framework that makes sense to them. Once the needs for physical safety, economic access and stability, and relative social safety are met, and once it’s possible to provide a sufficient dose of treatment, we can begin to consider what kind of acupuncture we’d like to do.
The beautiful thing about acupuncture is that it’s so old and so diverse that the list of options is vast. Dr. Tan? Master Tung? Japanese? TCM? Knock yourselves out, acupuncturists, you could spend the rest of your lives exploring the options. Just don’t forget that the most theoretically elegant treatment delivered only once –because you didn’t take care of the prior levels in the hierarchy of needs — will almost certainly be less clinically effective than, say, Miriam Lee 10 delivered twice a week for five weeks at a cost the patient can afford, in a setting where they can relax, with a treatment plan that they know how to follow.
Seriously, never forget that.
Unfortunately a lot of the acupuncture profession is obsessed with the theory level, to the exclusion of everything else.
This level might overlap with Acupuncture Theory so much that they shouldn’t be separated, but I’m not completely sure about that yet. I think culture encompasses issues like practitioner clothing: wearing a white coat vs a t-shirt with a POCA logo vs a uniform with a Modern Acupuncture logo. It’s not that culture’s not important — in some ways it overlaps with issues of social safety — but in terms of what it has to do with the efficacy of acupuncture from a patient perspective, it’s not on the same level as affordability or dosage. It’s something we can think about when we’ve taken care of the preceding levels.
Unfortunately a lot of the acupuncture profession is also obsessed with this level, to the exclusion of everything else. This is where issues of social status live. Do other medical professionals respect us? takes on great urgency. Some acupuncturists will claim that culture has everything to do with economic access/stability, but POCA knows that’s not true. Status doesn't have to take priority over economics. There are so many people who are sick and in pain and traumatized, there will never be enough of us to treat them, no matter how much other professions “infringe on our turf” or “steal our patients”. No matter who respects us or doesn't respect us, there are more people who need us than we can take care of. If we do the work of creating economically accessible and stable settings for people to get acupuncture, people will use them.
So yeah, this is maybe just one more way of me saying that the acupuncture profession’s priorities are literally upside down. But also I think it’s helpful, in a practical way, in determining an order of operations for people who are serious about making acupuncture available to people who need it. This pyramid is probably going to be the basis for a bunch of new POCA Tech materials ( because even POCA Tech students don’t necessarily understand this right away), and also probably some more blog posts. Please stay tuned.