Opening Talk at the Big Damn Clinic Workshop

(But first: for those of you who couldn't make it this weekend, we are doing our best to put all of the materials for the workshop up online. Wade, our fabulous website-whisperer, has created a new category in the Mighty CA Wiki for the BDC. Check it out! There's a lot there.)

For WCA, we always start our workshops by saying, we only teach what we absolutely know from experience. We try to only talk about things we have learned in real life in the clinic, and not extrapolate too far from them — because as many of you are aware, one of the big problems with the acupuncture profession is that people are constantly making stuff up and talking with great authority about things they know nothing about. (I'm not going to mention any names *cough* Peter Deadman *cough*) This workshop is going to be even more like that than usual — in fact, we're going to be sharing stuff with you that we haven't finished working out for ourselves. You're going to see all the gaps and loose ends and flaws, as well as the things that run smoothly. Because as far as we can tell, that's what a Big Damn Clinic is — a Big Damn Work in Progress.

There are a lot of different aspects to making a community acupuncture clinic, and the
part that happens in the treatment room — the strictly clinical aspect — was the part that we
figured out first, and in some ways, it was the easiest. There are all these other processes and
systems that have to be in place in order for what happens in the treatment room to be
sustainable. But important as they are, we kind of patched those together in a haphazard fashion around what happens in the treatment room. It’s only now, six years or so since we started doing workshops about community acupuncture, that we are trying to give all the other parts of the clinic the same level of attention that we’ve been giving to the acupuncture part. Which makes sense; even with the shared brain trust that is POCA, most of us who have started these businesses have been acupuncturists, just trying to make a living, not managers or systems designers or even, primarily, entrepreneurs. We don't really know what we're doing; we're just learning as we go.

What’s interesting, now that we are focusing on it, is how many similarities there are
between having a Big Damn Clinic and practicing acupuncture as a community punk. And that’s a good thing, because it suggests that the model has a lot of integrity; it’s a whole, and all of its aspects look like each other, like a nice symmetrical faceted diamond. It doesn’t look radically different from the front than it does from the back. Also, it’s transparent.

So what are those similarities? We’ll be talking about them throughout the weekend. It’s
good to know that if you have gotten the hang of punking in your community acupuncture
practice, you can get the hang of a Big Damn Clinic.

One of the first and most obvious ones is that just like community acupunks can't obsess
about creating the perfect individual treatment, people who have a BDC can't obsess about
making every aspect of their clinic perfect. In fact, having a Big Damn Clinic is in part about
letting go of getting everything right and just doing the best you can on a lot of different fronts.
Just as community acupuncture focuses on the process of healing, on letting things unfold over a series of treatments, a Big Damn Clinic takes the long view. Its development is organic. It's OKto try something and see what happens; if it doesn't work, you just try something else.Having a tolerance for creative chaos is very, very important.

One of the big reasons that acupuncture is important and needed in Western society is
that it’s not dualistic in the way that so much of our culture and our medicine is. We can talk
about yin and yang, certainly, but yin and yang are not simply opposites. They’re the shady side of the hill and the sunny side of the hill, right? Just one hill, not cut in half or separated. In
Western society we love to chop things up, especially in Western medicine. Acupuncture doesn’t do that, and that’s one reason we need it so badly.

One of the things that you learn pretty quickly when you are working in a community
acupuncture clinic, whether you are a punk in the treatment room or a receptionist at the front
desk, is that a lot of dualisms go right out the window. Health and illness are not these separate, distinct states — you can see that in the people who come in to the clinic. Most people are on a continuum somewhere, making the best of it. You can also see that the mind and the body are not at all separate either. People’s mental states have enormous influence on their physical state, and vice versa. And of course, a lot of how the clinic is set up is to make the haves and the havenots less separate from each other. So instead of a lot of nice, neat, abstract categories, in a community acupuncture clinic, what you get is a lot of messy human life. (It’s great.)

I think that lack of dualism is a large part of why so many people feel that our clinic
spaces are healing to them. Things that were cut apart get to grow back together, in peace. And everything doesn't have to be perfect before you can relax. You get to just relax anyway.

In Western medicine, there’s often a sense that the goal is to triumph over illness. To
diagnose it and to beat it and to win. But so often in community acupuncture, we are treating
people who are not going to triumph over whatever they have going on. Whether it’s a chronic
condition, or it’s age, or it’s stress, or just some difficult aspect of life, there isn’t going to be any clear-cut victorious moment where you get to pop a bottle of champagne and say, Yay, we won! It’s not like that. In fact, even if you do “beat” one condition, then another one pops up, or
somehow, the guy’s left knee still hurts for no reason you can figure out, or just when his
shoulder pain was finally going away, he gets into ANOTHER bike accident and breaks his arm. A lot of what we do is to help people accept and work with whatever it is: stress, pain, disability, limitations, illness, terminal illness, loss. We encourage and support and accompany people in working with whatever it is that their lives have given them to work with. We try to get out of the way and let them connect with their own inner resources, their own source of healing — which doesn’t mean that everything gets fixed.

Probably the main thing we are doing in community acupuncture is trying to give
ordinary people a better quality of life. That’s not a dualistic undertaking, it’s not a win-lose kind
of scenario. It’s creative and it’s hopeful and it emphasizes working with what you’ve got. And of course, it helps immensely that acupuncture itself almost always gives people more energy,
better sleep, a lift in their mood, a reduction in their stress. Those are humble benefits but they
are very important.

Making a Big Damn Clinic is exactly like that.

It’s not about winning at capitalism. It’s not about some single triumphant dot-com
moment where your stock goes public and you make a fortune. It’s not about being a paragon of small-business success, or even feeling like you’ve got everything figured out and you finally
know what you’re doing now! That doesn’t actually happen, or at least it hasn’t happened to us. Making a Big Damn Clinic is basically about giving yourself and the people who work with you a better quality of life, in the midst of all the hard stuff. It’s a hopeful, creative thing to do.

But none of the business experts are going to give you a gold star for doing it because the
benefits are so humble — not victory, just a better quality of life. Just like community
acupuncture is a good way for patients to work with what they’ve got and to manage their pain, a BDC is a good way to work with what you’ve got and to manage some of the pain of making your living as an acupuncturist and a small business person.

What do I mean by pain? Well…

1) There's the economic insecurity of being a solo owner with a service based business,
where you don't get paid unless the service is being provided. If you are a solo practitioner, you get paid as long as you don't stop. And if you do stop, for a vacation or for maternity leave or for any of life's unforeseen developments, when you come back you might not get paid then either, because you have to rebuild your business. If you had to stop for long enough, you might have to rebuild it back up from nothing; there is no security. A BDC can provide some measure of security, in the form of other people providing the service while you are away, so at least you have something to come back to.

2) There's the fragility and the responsibility of being the brand. A business based on a
solo practitioner depends entirely on that practitioner and, for better or worse, mirrors that
practitioner's individual personality. The person is the brand, and if something happens to that
person, the business dissolves overnight. It can be difficult or impossible to sell or otherwise
transfer the business to someone else if, as is often the case, nobody can quite do what the owner did. No matter how many people depend on the business or on the service, only one person really matters, in the end. There is no value outside of the individual. That's a lot of pressure, when it's you. When you create a BDC, you create a more stable brand that is not dependent on you or any one person. You create something that might be able to outlive you, and keep on helping the people you care about long after you are gone.

3) There's the pain of building a business that most likely, you can't sell. No matter how
much work you put into it. With a solo practice, if there is any value outside of the individual, it
still may be difficult or impossible to get that value back out of the business. Acupuncture
practices are difficult to sell, in part because new acupuncturists are burdened with
unreasonable levels of educational debt. If a sale is to happen, it generally depends on owner
financing, and so if the owner is to get paid, the next owner needs to be at least as successful as the last owner, in order to finance the payments through the operation of the business. In
reality, though, the next owner needs to be even more successful than the last one, because the need to pay out the value of the business adds an additional level of financial demand. The
failure rate for acupuncturists is so high that this represents quite a gamble. A BDC can either
support the new owner to succeed, or can itself be the exit strategy. (More on that towards the
end of the workshop.)

4) There's the pain of having to do everything yourself. Long before the exit strategy
matters, it can be hard to be successful as a solo practitioner. Running a business demands a
wide range of skills and talents that any single individual is unlikely to possess. One person's
inability to be good at everything takes its toll over time – and can be expensive as well. A BDC is a collective of people with various talents and skills that complement each other, and that is an invaluable business asset.

5) There's loneliness — that's very painful, and very common for acupuncturists. Being
alone in a business can be exhausting, especially having to make all the decisions alone. The
weight of total responsibility on top of the weight of isolation can be too much for solo
practitioners to carry. Everyone needs backup. When you build a BDC, you build backup for
yourself and everyone else who works there. It’s a big relief.

6) There's the pain of running into limits. A solo practitioner can only work so many
hours in a week, which limits the all important factor of patient convenience. People want
acupuncture when they want it, and they're happiest if they can get it on short notice. A BDC
can offer much more convenience, by being open more hours, by offering more appointments
per hour for walk-ins and other surprises, and by providing more varied personalities for all
your varied patients to attach to. Not everyone is going to like you, but maybe they'll like
somebody who works with you. All of this contributes to a reputation for being accessible, and
uultimately, to more stable revenues.
7) There's the pain of having to be everything to everyone. A business' value increases
over time in part through the social capital that it accumulates, especially in the form of
relationships within the community. Even the most gregarious individual can only form so
many relationships. A BDC, however, can form a huge web of relationships, all of which
contribute to promoting and stabilizing the business. A BDC is simply a better match than an
individual for treating a whole community.

Just like pain management for patients doesn't mean you can make all the pain go away,
having a BDC doesn't mean that you get rid of all uncertainty and all struggle. The holy grail of
success in community acupuncture, from our perspective, is a huge, stable patient base — plus
really good systems. That is as much security as you are going to get in the world of community acupuncture. A Big Damn Clinic is the key to that kind of security — and the cool thing is, it’s a shared security. It’s an interdependent security; it’s not a survivalist version of security, building a bunker and hoarding supplies and keeping the world out. A Big Damn Clinic is security that’s made out of relationships and flow. It’s dynamic — OK, what that means is, it’s messy as all hell sometimes — but damn, it’s fun.

And the really good news is, a Big Damn Clinic is ultimately a mindset. Just like punking
in the clinic is a mindset as opposed to a technique. A BDC is not about having a lot of money — we can attest to that! — or even having a huge building. It’s about creating structures and
relationships. Just like an awful lot of being a punk in a community clinic is about having a
treatment room that does the work for you — a space that “holds the space” for people to heal in, as opposed to you as an individual having to hold the space — a BDC is about making a structure that holds the space for a lot of people to participate in. So that the work doesn’t ever fall solely on any one individual. Just like boutiquers have a hard time understanding how much work our treatment rooms do, until you have the right structures in place, it can be hard to imagine how much a BDC can run itself. But if you can work as a punk in a community treatment room — if you can make that mental shift — you can make another one, and you can build a BDC.

In some ways, making a BDC requires going into start-up mode all over again. Putting
the structures in place requires a serious investment of time and attention. There are 2 main
things that WCA has been working on for at least a year, and they're taking up all our energy.
One is bureaucratization, and the other is learning how to be one clinic in 3 places. Our long
term goal is collective management and collective ownership in some form, so that WCA can
outlive the people who started it. We've discovered that bureaucratization and becoming one
clinic in 3 places are steps on the way. Bureaucratization, to us, means that roles and job
descriptions within WCA are defined enough that different people could step into them.
Becoming one clinic in 3 places…we're still in the early stages of figuring that out, as you'll see.

But the process has some interesting implications for other clinics that might want to combine
operations or merge in some way. It's all pretty fascinating, but it's very demanding as well. It
takes a lot of focus, and of course, we all still have the jobs we had before we decided to tackle this project. So we're working a lot. But we really believe that it's worth the trouble.
One of the other big problems with the acupuncture profession is that an awful lot of it is,
unfortunately, sort of socially stunted. People have a hard time working together. Many, many
acupuncturists are facing a very lonely, hardscrabble, deprived professional existence — as John Weeks said, once you graduate from acupuncture school, it's a lot like being pushed out on to an ice floe. And so a lot of acupuncture practices are tiny, fragile, and very temporary; just one person trying to survive as an individual. A BDC is the opposite of that. Ultimately, a BDC is about what all the rest of POCA is about: developing more sophisticated, rich, and satisfying social structures.

I think we all know that acupuncture has an immense amount to offer Western society.
We have a gift. But in order to give it, acupuncture has to reach out socially in all kinds of ways
that it hasn't yet been able to. POCA represents a lot of progress, because it holds out the vision of acupuncturists cooperating with patients and cooperating with each other. There's more to life than just surviving as an individual. Acupuncture in the West has to develop more complex, mature, organized ways of being in society, if we are going to reach more people and be really useful. A BDC represents one of those ways of being. It's a collective way of being, and we find it very satisfying, even when it seems like tons of work. We hope that you all get a lot out of this weekend.

Author: lisafer