Acupuncture without the Acupuncture Profession, Part Two
on lowering expectations
Part One is here. Also, a quick public service announcement: the first 5NP for OR Coalition meeting is TODAY, Monday, October 21st at 5pm PST via Zoom. We’ll be talking about our progress towards 5NP legislation and what everyone can do to support this important effort. Everyone’s welcome! Join the Zoom Meeting here:
https://nayapdx-org.zoom.us/j/85131217016?pwd=xKakejghaIExDE7xyfkFi2g1NZU3rN.1&from=addon
One of the most counterintuitive aspects of doing pain management with people is the way that lowering a patient’s expectations can help bring them relief. I’ve recommended this article before and I can’t resist doing it again: The Heroism of Incremental Care by Atul Gawande. If you’re an acupuncturist you should read it, even though it isn’t about acupuncture specifically. Here’s a passage where he observes a doctor at a center that’s known for getting results with otherwise intractable headaches:
She reviewed the (patient’s) records—all the medications she’d taken, all the tests she’d undergone—and did a brief examination. Then we came to the moment I’d been waiting for, the moment when I would see what made the clinic so effective. Would (she) diagnose a condition that had never been suspected? Would she suggest a treatment I’d never heard of? Would she have some special microvascular procedure she could perform that others couldn’t?
The answer was no...
She started, disappointingly, by lowering expectations. For some ninety-five per cent of patients who see her, including this woman, the diagnosis is chronic migraines. And for chronic migraines, she explained, a complete cure was unlikely. Success meant that the headaches became less frequent and less intense, and that the patients grew more confident in handling them. Even that progress would take time. There is rarely a single, immediate remedy, she said, whether it was a drug or a change in diet or an exercise regimen. Nonetheless, she wanted her patients to trust her. Things would take a while—months, sometimes longer. Success would be incremental.
A lot of what happens at WCA, day in and day out, is exactly like that. When new patients tell us about chronic pain, we tend to say something like, “So, this sounds like a project — we’re really happy to work on it with you, and also we want to let you know that it will probably take time. Every so often there’s a one-treatment acupuncture miracle, but that’s not common; usually it’s a process.” Lowering people’s expectations helps them hang in with treatment long enough to get results — and a much better quality of life. Success is incremental.
Possibly this post is an example of the maxim that when what you’ve got is a hammer, everything looks like a nail — but I really like my particular hammer so here goes: I think we need a conversation about lowering expectations for the acupuncture profession itself.
I understand why other people didn’t respond to the recent Oregon Public Broadcasting articles with the same relief that I did; the picture they paint of the acupuncture profession is pretty disturbing. I felt relieved because most of what was in there was confirmation of what I already knew. (I’ve been disturbed for a long time, lol.) One example is the contrast between what WCA can offer acupuncturists — low paying but steady employment for people who are committed (like Haley at WCA Hillsdale, who was interviewed) and then loan forgiveness after ten years — versus what’s more common, which is irregular gigs, independent contractor status and other forms of self-employment that don’t lead to loan forgiveness.
A quick note for anybody’s who’s never been an independent contractor: It’s very different from being a W-2 employee. You have to take your own taxes out of your paychecks and you generally pay a higher tax rate. You’re not covered by workers’ comp insurance and you can’t claim unemployment. You can’t necessarily count on a regular schedule. There’s much more awareness now of how different “gig work” is from regular employment than there used to be — but most people don’t realize that a lot of acupuncturists are doing gig work.
Most licensed acupuncturists don’t work full time as acupuncturists. Sometimes that’s their preference, of course, but preferences don’t actually matter that much when full time employment for acupuncturists is so hard to come by.
This is another major indication that the 1980s dream of an acupuncture profession that could compete with other professions (like physicians, nurses, and physical therapists) hasn’t panned out. None of those professions are dominated by part-time, independent contractor work; most people who graduate can expect to get a steady job. Whereas most acupuncturists have to make their own jobs, and the steadiness varies tremendously.
Let’s take a look at the US Bureau of Labor Statistics data for occupational employment for acupuncturists. These are W-2 jobs, not self-employment, and ironically, these numbers are based on the assumption that all jobs are full time; they automatically translate hourly wages into 40-hour weeks, so income for acupuncturists looks better than it is. Even so, these numbers are revealing. Remember there are some 33,000 licensed acupuncturists in the US; it turns out only about 28% of them are W-2 employees.
The holy grail for the acupuncture profession, for as long as I’ve been in it, has been jobs in hospitals. Acupuncturists working in hospitals is proof of acupuncture’s legitimacy as a profession and an indication that we’ve “arrived”. Creating educational standards that support the dream of hospital employment is part of what drove the entry-level doctoral degrees.
So I think it’s notable that after forty-some years of seeking the holy grail, and a decade of offering doctoral degrees, hardly any acupuncturists are actually working in hospitals. 150 of them in 2023, to be exact, with another 210 in outpatient care centers, representing about 1% of 33,000 L.Acs.
Here’s a thought: if it’s so hard for acupuncture to turn into full-time work, maybe we should adjust our expectations. Maybe the template for acupuncture as an occupation shouldn’t be physicians, even though that’s what the founders wanted.
What if it were artists?
Because that’s what our occupational employment looks like, at least to me.1 Most people who do art, like acupuncture, are doing it part-time. The people who do it full-time are either lucky and well-connected, or remarkably entrepreneurial, or passionately motivated and in a position to be very frugal (that’s those of us who work full-time at WCA and POCA Tech). People go to art school because they love art; they don’t go with the expectation that after graduation, all of them will find a well-paid, secure position as artist-in-residence at a hospital. Artists don’t expect to become full-time professional artists just by virtue of an academic credential.
On this theme, POCA Tech has a zine that we put together for prospective students called The Art of Community Acupuncture:
We ask everybody who enrolls to read it before the first day of class.
What could acupuncture in the US look like if we weren’t trying to force it into the container of a profession that competes with physicians, nurses, and physical therapists? If we lowered our expectations of upper middle class professional income and high status hospital jobs? I’m typing this on my laptop, on the couch in my study next to my snoring dog, but I can hear the gasps and the sputtering quite clearly! Somebody’s yelling already: Acupuncture without expectations of physician-level status and reimbursement??? It’s not even worth doing!
I disagree. I think acupuncture’s worth doing, regardless. And I’m pretty confident that WCA’s patients would back me up on that.
This is probably a good time to re-read what Tyler Phan Ph.D has to say about how acupuncture became professionalized in the first place:
The primary modality of (the original Chinese doctors in the US) was herbs, not needles. And their work was never professionalized… these practitioners didn’t have the capacity to professionalize because they were just trying to survive. Professionalization of acupuncture didn’t come into being until white people of the 1960s counterculture got interested. They chose to focus on the needle. White people + needles = professionalization.
So if acupuncture wasn’t professionalized when it first came to the US, and it hasn’t successfully professionalized after 40-some years of trying, what if we just…stopped trying? What if we started to imagine how acupuncture could be regulated, and how acupuncturists could be educated, outside of the acupuncture profession we’ve got now?
In an earlier post, I wrote about one of our organizational partners, the Native American Youth and Family Center, and how helpful it was for me to volunteer for one of NAYA’s economic development projects in the Cully neighborhood. I don’t think I mentioned that one of NAYA’s goals is not just to support small businesses in Cully, but to promote Native artists. In general, hanging around an organization that’s genuinely trying to uplift small businesses, microenterprises, and artists has been both a hopeful tonic and a reality check for me. I’ve gotten all kinds of perspective and encouragement from NAYA that I never got from any part of the acupuncture profession. Particularly around the idea of community prosperity as opposed to individual prosperity.
The OPB articles made it clear that what acupuncturists in the US are lacking is community prosperity. Plenty of people have gotten long, expensive degrees; plenty of turf wars have been fought. Certainly a few acupuncturists have jobs in hospitals (though I’ve gotten emails from some of them saying that they can’t pay their student loans either) and certainly some small percentage of acupuncturists are making good money. But the community itself isn’t prosperous — it’s precarious.
I don’t expect to convince anybody who’s thoroughly invested in the 1980s vision for the acupuncture profession (which appears to be all of its leadership). At this point my expectations are low: I think the acupuncture profession as we know it will go bankrupt, it’s just a matter of when. But for those of us who are invested in acupuncture itself, I think it’s worth starting to imagine a more sustainable, more collaborative future — one that’s focused on community prosperity.
Another important aspect of pain management is supporting people in achieving realistic goals. Sometimes you have to gently suggest to the person with arthritis in their hands, who’s frustrated about the state of their garden, that planting a hundred tulip bulbs in a weekend maybe shouldn’t be at the top of their goal list? Would they be willing instead to aim for ten minutes of weeding every other day and see how that goes? I think there are some attainable, meaningful goals for acupuncturists to pursue that would improve our collective quality of life — but having a profession that competes with other professions just isn’t one of them.
Like, literally! Look at the occupational employment statistics for artists, they look a lot like ours. As opposed to physicians, which…don’t.