Reposted: Acupuncture Today and the Terrible, Horrible, No Good, Very Bad Numbers

Although I have a whole bunch of other things I really ought to be doing (more on that later), there's this article in last month's AT that I can't seem to stop thinking about. So in honor of my two-year anniversary of being fired as a columnist of AT (thanks for the reminder, Keith! I opened a new box of wine to celebrate!), I'm going to offer you all a little commentary, punctuated by some basic arithmetic. Please, everybody, check my math — are these numbers really saying what I think they're saying?

The article starts out exuberantly:AOM soaring dramatically! Use jumps 50%! An estimated 3.1 million Americans used acupuncture and oriental medicine in 2007, a 50% increase since 2002, according to a study released by the federal government. (NCCAM, that is, a division of the National Institutes of Health.) Over 3 million!  Sounds good, right?

Well, for about a minute or so, until you remember that the total American population in 2007 was in the neighborhood of 300 million people. (It's now about 306 million people.) If 3.1 million people used acupuncture in 2007, that's equal to about 1% of the population. Another way of stating that? 99% of Americans didn't get acupuncture in 2007.

If you think about it some more, it gets a lot worse. 3.1 million Americans used acupuncture — how many acupuncture treatments do you think that adds up to? I have no idea…but it shows that we're not talking about treatments, but individual patients, right? How many individual patients do you think it takes to make up an acupuncture practice? A practice that isn't a hobby, a practice that doesn't require the acupuncturist to have a day job?

For each of the past two weeks, WCA saw 50 new patients. We had our usual 420-ish total patient visits, but how many unique individuals, besides those 50 new folks, are we seeing? And what would this suggest about acupuncture practices in general?  Who knows? First, WCA is a behemoth among acupuncture clinics, and second, we have some patients whom we've been seeing for years and years and years. Relative to other acupuncture practices, our overall visit numbers are much higher, and our individual patient numbers are probably a lot lower, because we have so many “regulars”. So let's look at a more typical practice. I have a friend, a community acupuncturist who opened her practice a couple of years ago, who sees around 50 patients per week, and I know, because she told me, that most weeks she has about 4 new patients per week. So in the course of a year, she sees 200 individual NEW patients a year. I'm guessing that, to keep up her totals of 50 visits per week, she probably has a total individual patient count of somewhere between 1000 and 2000 unique people per year: that includes all her regulars, all the “tourists”, all the folks who come in twice for a sprained ankle, all the folks who come in during the spring when their allergies get bad and then don't come back again until next spring — you get the idea. It's hard to figure out how many individuals we're talking about in a year when we are counting the weekly visits. But we can estimate.

How many unique individuals do you think we are talking about for a boutique/conventional practice? If a BA practitioner wants to support herself, she probably is going to need more than the 1,000-2,000 individuals per year that my CA friend needs, right? If she's taking insurance, we know that insurance only pays for a limited number of visits, and it never pays for prevention. And we all know from experience that fewer people stick with long-term treatment in a BA practice. So you are necessarily talking about a wider pool of people. How many? I'd estimate 2,000 individuals per year at the low end.

OK, let's do the math. In 2007 there were something like 20,000 licensed acupuncturists in the U.S. Maybe it was a little less or a little more, but 20,000 is a nice round number and it's in the ball park. For the sake of those nice round numbers, let's assume that every one of those 3.1 million people got their acupuncture from a licensed acupuncturist, as opposed to an MD or a chiropractor  — which we know is highly unlikely, but let's just give our little profession the benefit of the doubt here. So 3.1 million patients divided by 20,000 licensed acupuncturists is…

155 individual patients per acupuncturist.

The first time I did that, I thought I must have screwed up the zeroes somehow, so I did it again. I did it in reverse. That can't be right…but if it IS right, what does it mean?

Let's be really, really conservative, and say that an acupuncturist of any variety who wants to have any kind of a steady income needs about 1,000 individual patients to show up at her practice at some point in the course of a year. We know that's too low a number, but let's use it anyway to compensate for all those acupuncturists who say they're not practicing because they don't want to right now, just had a baby, are going to China to study, whatever; let's pick a low average because we know a lot of acupuncturists are not busy “by choice”. So 1,000 times 20,000 — if that were happening, the federal government should have found that 20 million people got acupuncture in the course of 2007. But no, they found out that it was only about 3 million. That is a whole lot less than 20 million. In fact, 3.1 million is  only 15.5% of 20 million.

Just for fun, let's take 15.5% of 20,000. That comes out to 3100. 

3100 is a generous estimate of how many of those 20,000 acupuncturists are actually working.  If you estimate individual patients per acupuncturist at the higher range of 2,000 per acupuncturist per year and do the same math, we're looking at 1500 acupuncturists or so who are actually working — in the whole entire US.

That suggests a failure rate of at least 85%, probably higher.

So what that “soaring” AOM use of 3.1 million patients in 2007 really means is that the acupuncture profession is screwed even worse than I thought it was…and wait…this is 2007 we're talking about, back before the recession kicked in.

Last year, I had a very short, very unpleasant tenure as the president of the Oregon Acupuncture Association (it was even more unpleasant for the Association than it was for me). I took that job mostly in the hopes that I could do a survey of L.Acs in Oregon to find out how many of them actually working, and how many patients they were seeing. The survey didn't happen, for a whole bunch of reasons, but I did get to look at a lot of mailing lists for L.Acs, and I got to know a bunch of people, and I think I got a pretty good sense of the lay of the land. When I think about it now, I'm pretty sure that of the 800 or so licensed acupuncturists in Oregon, I can only come up with a list of about 20 or so that I know are busy — by which I  mean busy seeing patients, not dependent on a spouse, not employed by a school. Let's say my list is way too short and multiply it by five — and remember too that most of those 800 acupuncturists are actually in Portland, because most of the people in Oregon are also in Portland, so I might actually know what I'm talking about here. 100 acupuncturists working. 15.5% of 800 is 124, so yeah, similar numbers. And Oregon is one of the states that has a relatively high number of acupuncturists.

OK, and now I have to ask — why is that terrible, horrible, no good, very bad 3.1 million number splashed triumphantly on the front page of AT as if it were good news? Why is there not public consternation throughout our profession about what it really means? I've wanted forever to do a survey of acupuncturists, but the government saved me the trouble: counting patients is a much better way to figure out what's really going on. But why am I the one, yet again, who is doing the math here? Isn't there somebody more qualified who should be analyzing these numbers? Why am I the one bringing this up?  Because our profession cares so little about patients, we don't even know how many of them we need, that's why.

Another thing that these numbers mean, all you new acupuncturists who are nervous about the market being “saturated” (like it is in  Portland, right?): it's not. Not at all. The truth is more complex and problematic than that. It makes me think of that G.K. Chesterton quote: Christianity has not been tried and found wanting; it has been found difficult and not tried. The market for acupuncture has not been tried and found wanting; it has been found difficult and abandoned by acupuncturists, en masse. That's what those numbers really mean. 3.1 million patients, somewhere in the neighborhood of 1500 to 3,000 practicing acupuncturists, after 20 years or so of the acu-establishment's efforts to mainstream acupuncture in America, that's it? On a fundamental level, our profession is not trying. So take heart, new CAN acupunks: you are doing something that almost nobody has tried yet, something so different that it is going to take the market a while to understand what you are offering. What we're doing isn't difficult because we're doomed, it's difficult because we're new. And ultimately it will work because we are trying.

But while we're on the subject of doomed, let's revisit conventional acupuncture.  CANners, I'd like  you to tell me: how many acupuncturists do you know, really know, in your home state who are busy? If you started your practices recently and can still count your patient files (unlike at WCA,  where we need a forklift to deal with our files), how many individual patients do you think you will treat in a year? Is the picture as bleak for acupuncture as I think it is? And extrapolating from these terrible, horrible, no good, very bad numbers, and factoring in the recession, how long do you think it will be before community acupuncture clinics are providing the majority of acupuncture treatments in America? How long before we are the majority of acupuncturists? How do you feel about the large responsibility that is coming your way? ( I think we're doing pretty good in terms of fulfilling our responsibilities so far — and hell, at least we're trying, not just to reach patients but to help acupuncturists.)

Thanks for following me through the Arithmetic of Doom there, thanks for listening yet again. Hopefully now I can stop obsessing about that article and those numbers and get back to my ever-extending to-do list, because in other news, we just signed a lease for our second location. WCA Jr., opening spring 2009. Detailed blog posts coming soon — and yes, it will be fully staffed by monkeys.

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Conference Keynote: Breaking the Ceiling

The theme for this conference is “Breaking Barriers”. You know, there are so many barriers to break in acupuncture that it was really hard to choose which ones to talk about for this speech. But since I’ve spent so much time talking about classism as a barrier, I thought it might be fun to shift gears a little and talk about numbers.


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