What’s the point?

A few weeks back, in my Clinical Seminar (aka “Homeroom”) class, a topic came up that got some people, including myself, a bit roused up.  We were sitting in a small circle and discussing specific patient cases when one student explained a predicament that they were in with one of their patients. The patient repeatedly came back to the clinic to see this particular student but each time they came they requested a certain part of their treatment.  For example, the patient wanted a certain set of ear points that a previous student had once done and in which the patient had received incredible relief from their pain from having done, week after week.  

So, of course, there are a few different potential problems with this situation.  First, the patient is in control, to a certain extent.  They want certain points and they are not willing to have a treatment without having those specific points.  Secondly, the practitioner now seeing the patient is not the practitioner who first administered the “miracle points.”  So, no matter how much the patient is receiving relief from these set of points, the new practitioner is not the one who thought of and started these points.  Thirdly, is the patient having a placebo effect?  Perhaps they received the points one week, they got lucky and had a great pain-free week, and now they attribute that to those certain points.  (But, I do believe that people know if they are still in pain or not and that it is not all in their heads)  And lastly, and what got most people fired up in the group, was the belief that by doing what the patient wanted, week after week, versus doing what you wanted as a highly-educated practitioner, that you were insulting yourself and your education.  You, as a practitioner, are better then that.  You didn’t go to school and pay many thousands to be told how to help someone and then just do it.  Some students felt that if the patient was not willing to accept another treatment, then the practitioner should refer the patient elsewhere, to someone who would be willing to do what the patient asked for.  Also, some students believed that, in the long run, if you do not employ another, possibly more complex, treatment at some point, then you are actually not providing the best service to your patient.  After all, another treatment could cure them of their ailments, or reduce the pain by 90% versus 80%.  

As the students were discussing this issue, there was clearly different views among them.  Some felt that, yes, this was an insult to the practitioner and why, oh why, would you spend so much time and money and then not employ all the theory and skills that you learned?  I was among the group of students that felt that if that was what the patient wanted, and if that was what helped the patient to be in less pain, then why not give them those points? And then throw in a few new ones every now and then? The patient is not coming to see you because you spent lots of time and money on your education, but rather because they really want relief from their pain.  During the discussion, I blurted out, “It’s not about us, it’s about them!” (the patients).

After the class, a few of the students continued the conversation.  One student related an experience where she saw a patient and they complained during the whole treatment because she didn’t do what the other student before her did.  Yes, I could see this being annoying and uncalled for (disrespectful) on the patients part.  And, if they want that practitioner, then go see that certain practitioner.

Where does the line start and end?  How far do we go to compromise what we want to do to give the patient what is actually working for them, even if it requires no thinking on our part?  Is it an insult to the practitioner or is it another instance of acupuncture working in simple yet wondrous ways?  I could even see some practitioners being happy that the patient knows what works and what doesn’t. It makes their job, to relieve suffering, easier.  

Though I am sure others have explored this issue before, I am interested in hearing other thoughts and experiences concerning this. Thanks! 

Cortney Hartman
Author: Cortney Hartman

<p>I am one of the most recent and very-happy-to-be-so acupuncturist additions to Working Class Acupuncture, in Portland Oregon.  I learned about the community acupuncture model from year one of my studies and have been dedicated to it since then.  Not really knowing if and how I would have made it out of school sanely without it, I am so thankful for CAN and the founders, members, and all of the love and knowledge that abounds.  Learning and being challenged constantly, I am often amazed at how the CA model plays out in "real life" and am happy to be a part of the revolution and positive and much needed change in acupuncture and healthcare in the U.S..</p><p> </p>

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  1. Great Discussion!

    I handle this issue in different ways, depending on the energy.  I usually try to figure-out which emotional pattern the patient fits into: why do they want to tell me which points to use?  Is the patient trying to control me in the way they might want to control other aspects of their life?  (Liver points would be helpful.)  Are they afraid of new experiences/treatments?  (Kidney points.)  Anxious?  (Lung points.)  Worried?  (Spleen.)  Fiery?  (Heart.) 

    After identifying which element is contributing to their situation, I look at the points they want.  Are they clinically relevant?  If they aren’t points I would have used, or if they were points that I used on a previous treatment but don’t feel are relevant now, I explain that the acupuncture points chosen depend on the patient’s tongue and pulse diagnosis as well as where a woman is in her menstrual cycle on the day of treatment.  And while those may have been the perfect points for them on a previous day, they’re not clinically indicated today. 

    Furthermore, I add that using the same points over and over again doesn’t always benefit the patient…like if you have a necklace that’s all knotted-up and you’re trying to untangle it, you don’t keep tugging at one section of it endlessly.  You have to keep coming at the knot from different directions until it’s all loosened-up and free. 

    Finally, I treat a few patients who have had breast cancer, and they tell me that they don’t want any needles in their affected arm.  They have fears about infection related to the lymph node removal on that side.  I understand that there’s a big emotional component there, but I work with them.  I usually put ear points in on that side related to the arm points that I’d have liked to use.  I know that the patients won’t relax for their treatment if I insist on putting needles in their affected arm/hand, and they might not come in as often as they should–or even ever again!–if they don’t feel that their fears are respected.  I balance the fact that I can get them to receive frequent acupuncture by modifying my desired treatment protocol to support them in their cancer recovery.

    Hope this helps! 

    Warm Regards,

    Jessica Feltz

    The Turning Point

    http://www.TheTurningPointAcupuncture.com

    Frederick, MD

  2. Nice…

     

    I like Jessica’s way of approaching these situations very much.

    Difficult interactions are really opportunities to see into the nature of a person’s ‘imbalance’ (and ours too) – they may very well push our buttons as practitioners – but also may give us a chance to observe behaviors through the prism of our medicine, 5-Phases or otherwise. 

    It’s often hard to take a step back while in the thick of this, but I find it does get easier with time and focus.

     

     

  3. I see something different here

    The practice of Acupuncture to the Acupuncturist is an act of self-discovery.  By working for the improved health of others you are discovering yourself. At first (like where you and your fellow students are) that self-discovery is fairly gross.  You get patients who make you question just what your core beliefs are in how to interact with your patients. They question your point selection, your needling technique, the way you speak: everything will get called into question- repeatedly.  In my opinion its how you answer those questions (what you believe) that brings understanding to you.

     

    Its easy for others not involved in the interaction you describe to talk out of their heads about what should happen and what they would do but honestly everyone would react in a slightly different way. I hope you can see that there is no one right answer to how to handle that interaction.  Just looking at your next to the last paragraph and the issue of “respect”- for some of your fellow students it is about respect: thats where they are in their lives right now. They want to se themselves as Acupuncturists with this special knowledge and want to be treated with respect.  Hopefully they will get to the bottom of why they want that so badly. I sense for you that is not an issue.  Each to his own.  You have your own issues.  In this instance how you interact with your fellow students, and what feelings are brought up is what is most important to understand.

     

    One thing’s for sure: for you and your fellow interns, how you deal with what your school is of huge importance.  Your school is like one big patient and all of you have to deal with the ideas that the school is trying to get you to believe.  Do you adopt the school’s beliefs or not?

     

    The important thing here is the process.  Regardless of the issues that you, the Acupuncturist sees, the more receptive you are in dealing with the issues, the better you get at understanding yourself. That leads to, among other things, being a better practitioner. The difficult in doing this is that we tend to feel all sorts of things about any intense interaction and in reaction we look at some things and not others.  Doing that long enough tends to limit one’s abilities in dealing with new situations.  I find that particularly true with being an acupunk.  It can be hard to stay open to the subtle things going on in a treatment.

     

    Practicing Acupuncture is awfully hard when you get down to it. Sure is fun though.

  4. In addition to what has been

    In addition to what has been said before, all of which I agree with, think about the restaurant metaphor in a recent blog.  If I go to my favorite restaurant, I bring certain expectations with me.  There are favorite dishes I don’t mind having every time I go there.

    Lots of people are like me.  One of the principles in The E-Myth states that in any business, the entrepreneur should seek to make the experience consistent every time a customer comes through the doors.  The author used the metaphor of the barber who cuts his hair.  So, we can think about human nature from that perspective.

    When I feel the need to change up the treatment, and the patient asks about it, I’ll say that there are many different strategies in acupuncture and they all work.  Also, once the body has made a shift, it won’t respond exactly the same way twice.  And, occasionally it is necessary to change the treatment to avoid irritating the same point locations.

    Marty

  5. point requests

    i like it when patients tell which points they like or find really helpful. i just don’t make any big deal out of it, and if the points seems appropriate, i will do at least some of them. i might tell them gently that we need some other ones today of they have a cold or something like that, but if i can, i throw in what they asked for, at least partially. it’s thier body and they are tuning in and discovering things and i like that. i think it’s pretty cool that people get attached to acupuncture points and it seems to me like an important part of their process of building their personal relationship with the acupuncture itself. i also find that as our trust builds they have no need to request points because there is a lot more ease in the interaction and they relax and let me take care of them. cool topic!

    -tatyana

  6. thank you…

    …all, for offering some great insight. (you all are so gosh-darn smart). thanks!

  7. not sure if i have ever treated the same person twice

    planets are moving

    seasons are changing

    cells are a-jigglin’ 

     

    breathe in breathe out 

     

    excellent reflections 

  8. also an opportunity to educate

    Just one other point I thought I might add to this discussion is that often patients that come back requesting “the exact same treatment as last treatment” haven’t yet reached an understanding of how acupuncture works. We sometimes get patients who come back asking us to ‘do what we did last time so I feel ____ way again”. Generally it’s with patients that don’t yet understand that acupuncture treatmentis unique in that:

    -points may change from treatment to treatment because YOU have changed- as healing progresses, the treatment often needs to be adjusted to reflect the changes occurring

    -healing is a process and takes time- just because results are not as dramatic every time does not mean treatment is not working. even negative results may be a positive sign of progress.

    -there is no single one best way to approach a problem

    As patients learn more about how acupuncture works, they tend to be more accepting of the treatment. I think we are all familiar with the resistance that we are sometimes met with from new patients. They WANT to believe and they WANT treatment, but they may have a skepticism that can only be dealt with through education, experiencing results, and building trust. I remember being this way when I started learning about acupuncture!

  9. I’m not an acupuncturist. I’m a nurse practitioner.

    In a situation like yours I remind myself that the patient is always in control. My role is to educate and work very hard to convince the patient to follow through with what I believe is the best course of action. This is true for every part of my practice, diet, activity, stress management, medications, referrals to specialty care and performing procedures in the clinic. The patient is Always in control.

    It sounds like your patient needed more education over time. What harm could come from following the patient’s desire in order to develop trust and a better rapport with them in the future?

    We are all managing relationships. Try to meet your patients where they are, with compassion. Only good can come of it.