More on Replicability
This post is partly for Eric, who wondered if he was being held to a higher standard than other toaster applicants, and also for everyone else who is thinking about the questions posed by the Toaster Tour. I am already beginning to suspect that many of the people we would like to interview may intentionally or unintentionally misunderstand what we are asking, especially when it comes to the criteria of Replicability, so I’d like to be a little bit clearer.
Earlier this year, I was on the other side of the interview process with none other than John Weeks of The Integrator Blog. (Look for that interview to be published later this summer.) One issue he was acutely interested in was how many other community acupuncture clinics were anywhere close to replicating WCA’s patient numbers. I reported that several were breathing down our necks (Manchester, Tucson, Berkeley, I’m looking at you!). John looked relieved, and then explained why he was asking, with a story about how mainstream medical doctors initially dismissed popular interest in integrative medicine. They attributed the success of the Lifestyle Heart Trial to “the Ornish effect.” Meaning, they didn’t believe that Dean Ornish’s principles and systems for reversing heart disease were actually successful by themselves, or likely to be widely adopted on their own merits; they thought it was all about Dean Ornish’s extraordinary personality and charisma, and if you factored those things out, everyone could just forget about lifestyle therapy for heart disease. Because somebody with a lot of drive and personal charisma can usually accomplish whatever they want to. It doesn’t matter really what it is; what matters is how badly they want it.
Early on in WCA’s evolution, we heard a lot about that. People didn’t call it the Ornish effect, they just suggested that what we were doing was only successful because of us. It wasn’t our systems, it was our personalities. (Those of you who know Skip and I really well, will you please stop slapping your knees and hooting. I can hear you through cyberspace and it’s distracting, OK?) They also suggested that community acupuncture would never work outside of quirky, laid-back Portland Oregon. It’s been easy to disprove the naysayers on both counts; nonetheless, there’s something really important here about the idea of the charismatic, driven, successful super-practitioner — and its implications for the profession and the creation of jobs.
It took me a while to understand that the acupuncture profession is so enamored of this idea that almost nobody questions it. That idea is so pervasive and compelling, so glamourous (in the archaic sense of “delusively alluring”), that it facilitates many of the other illusions of the profession. When you’re focused on what wonders a really amazing individual can accomplish, it’s much harder to think clearly about the less glamourous and much more important SYSTEMS that provide a stable and lasting foundation for a business, a profession, or a community. A lot of people still don’t understand that what we’re trying to do with community acupuncture is to dispel the glamour of the individual practitioner, for a number of compelling reasons that I won’t get into here. What I mainly want to say is:
One exceptional individual is not enough to create a replicable job. Even if he has, apparently, replicated it once. Because a replicable job is actually not about the individual who created it, it’s ultimately more about the unglamourous arithmetic — the income stream that supports the job. To the degree that the income stream is dependent on any extraordinary attributes of an individual, the job is probably unstable and not really replicable.
So if, back in the day, WCA had only been able to hire Moses (our first acupunk employee) because all of the patients who paid his salary were just overflow patients from me and Skip, or were attracted to the clinic only by our reputation, Moses’ job would not have been replicable. It would have been just a reflection of our glamour. (Ellen, no guffawing, please.) These days, of course, WCA is full of patients who don’t care which acupuncturist they see, and who have absolutely no idea who owns the clinic. Every so often I get a patient who asks me if I’m new there, and how I’m liking my job. I love that. And Moses’ job has been replicated into John’s and Cortney’s and Joseph’s and Gabe’s jobs. Maybe more importantly, Moses’ job has been replicated in other parts of the country by people who really didn’t know me or Moses all that well. All of the community acupuncture jobs are in a sense replications of Moses’ job, and until a bunch of them happened, it was not necessarily clear that I deserved a toaster, either.
So Eric, I swear I’m not being any harder on you than I am on us. You are clearly an extraordinarily resourceful, determined, motivated, and probably very charismatic person, and in this game of job creation, that kind of counts against you. It’s almost like trying to prove a theory with the scientific method: your theory isn’t valid unless somebody WHO ISN’T YOU can get the same results with your methods. It’s not 100% certain that you have created a replicable job until someone who isn’t you has used your methods and also created a replicable job; or until the replication process is entirely dependent on systems and not personalities.
I’m reiterating this because I know a lot of people are going to try to dodge the criteria of Real, Relevant and Replicable in their interview answers. I chose those criteria not because I wanted to be difficult, but because one more time, I am just trying to talk about the hard numbers. Focusing on individuals — including, focusing on the responsibility of individuals to create work for themselves through self-employment and independent contractor positions and whatnot — obscures the big picture that we really need to look at here. The degree to which acupuncturists need to be amazing and extraordinary in order to make a living is actually the degree to which the profession is failing. It’s also the degree to which our leaders are failing to lead.
I’m not saying that people shouldn’t work hard. Ask any of WCA’s employees, we’re all about hard work. But that’s different. You can and should be able to work hard for a stable income without being a star. It’s on a different scale, but it reminds me a little bit of some conversations I had when I tutored some kids from a very low income neighborhood. If you asked them what they wanted to do when they grew up, a bunch of them would say that they wanted to be pro basketball players, or rich and famous musicians. Of course that was totally unrealistic; one kid in ten thousand has that kind of talent and drive. The degree to which superstars were their only models for adult success was the degree to which those kids were oppressed and deprived. Not enough people from their neighborhood grew up to get good, solid, unglamourous jobs as accountants or nurses or mid-level managers. For a variety of reasons, the economic foundations of their neighborhood had been destroyed, and what society offered them instead was a lot of illusions. I think the acupuncture world never had any economic foundations to begin with, and compared with those kids, most of us L.Acs have enormous amounts of privilege. But still. In our situation, it’s our schools themselves that are telling us that if only we had our act together, we could be a pro basketball star and we wouldn’t have any problems with those pesky student loans. That’s the solution — for ALL of us to be pro basketball stars, even though the evidence shows that’s impossible. That’s not a grown-up solution, and the essence of the Toaster Tour is that we’re asking the profession’s leaders to act like grown-ups. Keeping a whole bunch of people focused on the illusion of superstardom is a good way to keep them from demanding some basic economic dignities. Such as real, replicable jobs.
Employees and Employers
Lisa – thinking of
your post here reminded me that there is another facet to the production of
real replicable jobs that I know you are aware of and has been discussed deep
in the Forum’s threads but really needs to be front and center in this
discussion. That is the skill-set needed to be an employer. You talked about
all the jobs created in the CA model were really replicating Moses’ job but in
order for Moses to he hired it took you and Skip developing the understanding
of how to be employers. What you yourself do in the clinic providing treatments
may not be distinguishable from your hired acupunks and that is due to the
success of the CA model to be replicable from a clinical perspective but you,
as the employer, also need to have a whole other skill-set in creating and
managing the hiring of others.
In my current efforts (inspired by you – Lisa) to help
support successful solo-private practice, I let people know I have no
experience hiring other acupuncturists to work for me. I am trying to teach
what I know and what I know is solo private practice. For many years, I have
had the potential to grow my practice into one that could hire other
acupuncturist but I have not taken that direction because I don’t have any
skill in being an employer. It scares the hell out of me. I suspect there are
others (not a lot but some) out there in a similar situation that could grow
their practices to the point that they could bring-in others to work for them
but don’t know how and find the risks of doing so to not be worth it.
I tried at one point to bring someone into my practice and
realized that I did not have the knowledge I felt I needed to make that
significant change to my otherwise almost auto-pilot practice. As the sole
bread winner for my family, I did not feel I was in a position to learn on the
job what it takes to be an employer of another practitioner. The prospect that
this could turn-out badly and cost me money my family could not afford to lose
stopped me from taking that risk. So, if we are going to get serious about the
subject of creating jobs, we need to realize that it is not just about a reproducible
practice model but also about the need to develop resources for potential employers
to become actual employers. What you do in you clinic providing treatments may
be indistinguishable from what your hired acupunks do, but behind the scenes
you have developed employer skills that the other punks don’t have to contend
with. If I could get training on the special skills needed to take the plunge
on being an employer, I might have gotten one of those super cool toasters.
Very good point
Lisa and I made some awful mistakes the first year or two we tried being employers. (I cringe to think of them.) Moses was not our first try at all. And I see various other community clinics trying to be employers and making mistakes too. Some, like Lisa and I, do learn from our mistakes-and keep making new ones. Oy.
But the bigger point is very important. In our profession, we are not trained to be either employers or employees. Now there are a lot of tangents to that statement and I won’t cover most of them here, but I do want to make a couple of points.
1) There is very little incentive for acupuncturists to employ other acupuncturists. And by incentive I mean money as in there’s no money. It’s not like hiring another Punk makes more money roll into the clinic. In fact, the employer has to nurse the employee along for a good year before they are at a good level of being cost effective for the clinic. But even at that level the margin of profitability remains thin.
WCA is thinking hard of opening a third clinic. But for Lisa and I, the owners, we are not projecting increased profits if we do. What we hope is that the clinic pays for itself, just like the first two clinics, and makes maybe 1% profit. It will probably make less than 1% profit-if everything works out in the next five years.
So why open a third clinic? Good question. Being larger makes us more stable. We no longer have weeks where the cash flow varies wildly so to a large extent we don’t have that anxiety that most one person shops have. Other than that we like making jobs, and that is not a quality we share with most people. Call us crazy.
2) So I think the idea of acupuncturists making jobs for other acupuncturists is not a long-term viable strategy for our profession. That leaves other people/companies employing acupuncturists and that ain’t happening either. I think at this point it is fair to say that there’s no company that employees dozens or hundreds of acupuncturists. There’s no HMO out there that sees gold in our profession. Given that they’ve had 20, 30, 40 years to look at us, it’s fair to say that that won’t change anytime soon.
I’ve heard it said by some FPD proponents that if we just had Doctorates, companies would hire us, but those folks have nothing to back up their claims. And even their claims are pitiful and along the lines of maybe a local hospital would definitely hire an acupuncturist if only they had a Doctorate. So they are talking one job. Whoo-hoo.
So basically I see that our profession hasn’t caught on in the general medical profession. Until it does, there will be few jobs that we create ourselves. And it is hard for us to create jobs as there is little incentive and a lot of disincentive. That people like you are staying away from creating jobs, then that’s just telling.
.
some 5e perspective on the super-star pitch from the schools..
They do the same thing but with a twist. They acknowledge that it is difficult to make it as an acupuncturist but claim their students are immune because they learn the True Medicine. Other schools that bill themselves at being “Classical” do the same thing. Their argument is that acupuncture went wrong in this country because the Wrong Style has been dominate.
They all teach the same practice model though! In addition, schools that bill themselves as 5E or Classical tend to be more expensive.
They are probably right that a claim to mystical secret knowledge helps a BA practice. I think the benefits probably end there though.
Every Little Bit Counts
When you consider the NCCAOM’s JTA showed that only around
10% of practitioners were grossing over $120k a year, that means that only a
small percentage find themselves in the situation I have been in; having the
potential to grow my practice to the point I could hire another practitioner or
two. But even though this is a small percentage of overall practitioners, every
little bit counts. If there are 10,000 actively practicing out there and 10% of
those were at a point that they could expand their practices and bring-in
another practitioner if they only knew how to make this work that would be
1,000 potential new positions. Expanding a successful solo practice can be done
in a way that financially benefits all but it takes knowledge that does not
come automatically with a successful solo practice and involves risks.
I know I am much more the exception than the rule but had my
motivation been to make as much money as possible, I would have undertaken the
task of learning how to expand my practice. Once I got to the point that I was
comfortable enough in my practice to support my family, I decided to not build up from there so I could pursue other projects while keeping the
stress level down. I only started to look seriously at expanding recently now
that retirement is not such a distant prospect (there is a lesson here kids – it sneaks-up on you). I don’t want to just keep practicing
and then retire without taking the time to bring-in someone my patients and I
am comfortable with taking over.
So, even though it would not be big numbers, cultivating resources
to help the small percentage of busy practitioners to learn how to expand and
hire others would be helpful. For now, my focus will remain on helping others,
especially students, learn how to make solo practice work.
And lastly Skip, come on now: Fess-up. Your interest in possibly
expanding is not just about a broader base for stability or even hiring more
punks – it’s also because you guys want to help more people who are suffering
and need help. I see that as a big motivator behind CAN and many CA clinics and
that’s why I am so grateful and supportive of your work. The clinic model and
things like being diligent about the numbers and reproducibility are all just
the means to an end. The end is helping those who need help in a sustainable
way. Once upon a time, many of the leaders of the acu-establishment were
motivated by the same thing (except they didn’t give reproducability much thought). I miss those long-gone days. – Matt Bauer
everyone’s a star!
This is a perfect example of the difference between the liberal and radical perspective when looking at a problem. Liberal thinking tends to focus on the individual, while radicals look at systems.
The problem: not enough folks getting acupuncture, not enough acupuncturists making a living. The liberal train of thought emphasizes the notion that it’s up to individual skill and development. The radical notion insists that we focus on the concrete conditions of economics and structures to create lasting change.
As for y’all’s personalities, Skip makes for a fine drinking buddy (and he holds up well to teasing), and you’ve got that tendency to just get all wiggly-eyed and crazy on a moments notice. Maybe that’s not glamorous, and I don’t know how well those traits lend to being employers, but you’ve both got your charms.
thanks, Matt
For the kind words and the comments. What you and Skip said above is basically an extended promotion of POCA:
1) One of the main goals of POCA is to make it much easier for clinics to employ people: both acupuncturists and front desk staff. When clinics join POCA as members, they receive a packet of basic employer materials (hey, who out there knows what an I-9 is and where to put it?) and also access to support forums especially for employers. We are also looking at contracting with a human resources specialist to be available on those forums for a set amount of time per month to answer technical questions — we have somebody who wants to do it and who is very qualified, it all depends on how many clinics sign up as POCA members.
2) At a certain level of arithmetic, it *doesn’t* make sense for acupuncturists to be employers — if they are only thinking in the short term, and if they are not thinking about what it will take to stabilize and build the profession as a whole. If they are only thinking about themselves and what benefits them right at that moment – of course that is the tone of the profession pretty much as a whole.
As you point out, Matt, if you are thinking about how you are going to not work every minute of the day in your own practice until you drop dead of old age, you need to think about employees. If you care about what happens to your patients in the event that you aren’t there, it’s good to think about employees. One of the effects of the skyrocketing student loan debt for new grads is to make it very, very difficult for the few successful practitioners out there to SELL their practices if they want to retire. Because who is going to come up with the capital that represents a fair price? If they already have 150K of debt before they even start their careers? I am truly mystified by long-term practitioners who think the schools are somehow on our side; their economic interests and ours are obviously divergent at that level. They are making it harder and harder for us to have an exit strategy.
3) POCA is a multi-stakeholder cooperative, which means its purpose is transformational rather than transactional. Unless the acupuncture profession gets out of its utterly selfish and short-sighted economic thinking, we have no future. The point and the function of POCA is to give people a framework to build a truly sustainable economic foundation for everybody — patients, employers, employees — everybody who cares about acupuncture being available.
aw, shucks
Coming from you, “wiggly eyed and crazy” is a true compliment.
Suddenly I’m thirsty.
Suddenly I’m thirsty.
Not about individuals but systems
I am preping for the workshop this weekend by reading through everything again. I think the best part about the community acupuncture model is that it actively shifts the focus away from star acupuncturists to replicable systems. Not about talking for hours but about simple treatments. And that’s why I love the model so much. I read the Noodles book and had an ahah moment. Like this is IT. This is what I’ve been looking for. Something so I can do acupuncture WITHOUT it being about ME. And that’s such a relief! Just being an acupuncturist without having to be their counselor and nutritionist and therapist and EVERYTHING ELSE.
A job at a hospital in AK
Hey Lisa,
I jumped online to see what was happening at the hospital that I was working at in Alaska a few years back and found this very curious thing… a job advertisement …curiouser and curiouser..
Anyhow if any one is interested in applying for a real job ..that I know has been replicated for at least the last 11 years …check out the Southcentral Foundation websites career page.
Close your eyes….click those ruby slippers together….
Diane
Kaiser
I know that Kaiser hospitals employ some acupuncturists, but I am not sure of the details of those jobs.
There is one local Kaiser acupunk that we know only through phone contact, because he calls us every few months and secretly asks for some of our biz cards to be sent to his home address (so that Kaiser will not know), so he can refer us the folks that Kaiser is no longer letting him treat, but who still need more treatment.
I sadly do not have his email address but will try to get in touch some other way and see if he might want to participate in the tour. Not sure if he would respond, but we’ll see.
~tatyana
Sarana Community Acupuncture
Albany, CA
de-rail
Just had our ‘ployees sign I9s this week. Filed them separate from the rest of their personal files — just in case Homeland Security or INS goes fishing.
David L f’ing Ac (my earned title)
our profession hasn’t caught on in the general medical professio
My uncle, a dentist, sent me this:
“I had a patient this morning whose daughter
is an M.D. and runs a pain clinic here in Mason (Ohio). Interestingly,
the daughter is also a licensed acupuncture practioner, but I don’t
think she does much of that now (probably because insurance companies
don’t pay?). ”
Details are lacking, speculation is rampant… we don’t know if she is a medical acupuncturist and an MD, or if she is a licensed acupuncturist and an MD. What is asserted is that she doesn’t do acupuncture despite seeming to have the ability to do so and despite running a pain clinic. The speculation is that it is because of insurance not paying (or not paying enough)?
I took this email as an invitation to tell my uncle about the community acupuncture model. I also expressed my opinion that I hoped people who could help people in pain would do so whether or not it was reimbursed by insurance.
Just an anecdote, but seemed relevant.
Article
Hi Lisafer,
I recieved the new issue of the American Acupuncturist recently and read with interest the article titled: The U.S. Acupuncture Workforce: The Economics of Practice by
Steven H. Stumpf, EdD; Clifford R. Carr, EdD; Shauna McCuaig,
MAcOM, LAc; Simon J. Shapiro, DO, DAOM, LAc
You can find it at the address below:
https://www.aaaomonline.org/resource/resmgr/americanacupuncturist/aa_summer11_v56_web.pdf
I am very curious what you think about this article. It states some data that I find curious. If you find the time, check it out and then shout out about it.
Eric
Workforce Data
Hi Eric –
Shauna here, one of the researchers and authors of the workforce article. I’m equally curious to know what items you find curious. I am inquiring in the most constructive way possible. Now that the issue has gone public, I’d love to start the conversation here. I will be writing a blog posted devoted to this topic and find your input beneficial.
Curious Data
Hi Shauna,
Thanks for your inquiry. My specific questions come from page 32 and 33 (https://www.aaaomonline.org/resource/resmgr/americanacupuncturist/aa_summer11_v56_web.pdf0).
P 32 in the comparative chart:
It records CAN practitioners as making a mean monthly income as being $5,277. The median income is stated as being $4,796. If one does the math, 311 txs per month @ $21 per tx = $6531 mean average income. While 209 txs a month @ $20 a tx = 4,180 median average. Multiply these by twelve months = $63,324 mean and $57,552 median yearly average income.
Meanwhile, on page 33 the article states, “CAN averaged $78,523 annual income.” While the chart below this records that average to be $74,832.
The math seems fuzzy, at best.
Then if you consider that all of the CAN propaganda (meant in the educational material definition, not the extremist dogma definition) that I have seen states that CAN clinic opportunities offer practitioners a working class wage that averages $35,000 a year. Working class practitioners that treat working class people, right? Lisafer and Jessica, please correct me if I am off base.
I could maybe see where a CAN clinic with two practitioners would report gross $75,000 a year. That would be about $37,500 a year each.
So, if my facts are straight, you doubled the average yearly income for a sole practitioner, painting a more rosy picture utilizing practitioners and a practice model that doesn’t even attempt to portray things as rosy as your study documents.
I asked the owners of our local CAN clinic, Kelly and Melissa (sorry to drag your names into this fracas, my friends and colleagues) of WE The People Acupuncture in Santa Fe, NM what they thought of this stat and the response I got is: maybe just one, or maybe 3 owners in the network is making this kind of money (paraphrased). Please, Kelly, tell me if I misparaphrased you.
Believe me, I’m not trying to pick a fight. I just want the facts. Sadly, there is little good data. I appreciate you working in this direction, but I cannot wrap my mind around your numbers. Could you please explain to me how this critique is unfounded?
Curiously,
Eric
BTW
By the way, how do people get their responses to come out in nice paragraphs? My responses always get lumped into one big paragraph, while I notice this is not the case for everyone.
ERB
Fuzzy Math
Sorry, I guess my own math is fuzzy. One of the reasons I went to acupuncture school in the first place, instead of majoring in physics.
See if you can find my mathematical error. Then you may proceed with your critique 🙂
Eric
i love it too
when Skip lets me dress him up in glitter eyeshadow and throw him on the airplane.
when you are posting
at the bottom of the box, right above Preview Comment, hit Input Format and then select Full HTML. That should work.
I haven’t read the article
I haven’t read the article but Eric asked me if CAN practitioners averaged an income of $78,523 a year. A glance at the CAN Survey shows that we obviously don’t. I don’t think that’s ever been our goal.
Kelly
Waiting
Thanks, Kelly. I and others eagerly await Shauna’s response.
Eric
Still haven’t read the article but
Eric, are you thinking gross or net? I assumed when you asked me you meant net.
Kelly
Eric….
your reply is here. Thanks again for starting the conversation!