Purpose vs. Idealism
on cash flow in the acupocalypse
On the heels of the last couple of acupocalypse posts, I’ve had enough people ask: But what do you think we should do? What would you do? — that it seemed like a good idea to write a post about it.
First, though, I want to revive something I wrote a few years ago because it’s got some necessary context about how I do anything. Here goes:
Awhile back, I was talking with Gail Roudebush (who edits the Praxis workbooks and who’s been involved with WCA and its projects for 15+ years now) when she said something great. We were talking about how WCA has a difficult relationship with people who think of themselves as idealists; sometimes it seems like we attract them over and over even though we always end up disappointing them and they always end up frustrating us. It’s like moths to a flame, if the flame were tired and exasperated and wishing the moths would do something more useful with themselves.
Gail said, “Well, that’s because idealism is different than purpose. What WCA has is purpose.”
And I said, “AAHHH!” because that was the exact distinction that I needed to hear.
Merriam Webster defines idealism as “the practice of forming ideals or living under their influence” and ideal as “existing as a mental image or in fancy or imagination only; broadly: lacking practicality; relating to or constituting mental images, ideas, or conceptions”. Meanwhile purpose is “the feeling of being determined to do or achieve something”. WCA’s purpose is to offer as much acupuncture as it possibly can to ordinary people so that they can use it on their own terms, in whatever way works best for them. And while WCA’s purpose might be appealing to people who orient themselves towards ideals, it actually has very little to do with idealism itself.
All of WCA’s operations are based on our observations over the last two decades about how acupuncture actually works in our community, as opposed to how anybody thinks it SHOULD work, and our observations about how people actually behave in relationship to acupuncture, instead of how they SHOULD behave. Hence our mission of offering people as much acupuncture as they want, so that they can use it in support of whatever goals they have. We’re not trying to micromanage how they use it; we’re not trying to get anybody to believe in anything. We’re only creating a resource.
This practical, adaptive approach has made WCA resilient.
For us, the distinction between idealism and purpose has to do with being aware that there are plenty of people out there, legions even, who want to tell our patients what they should do and how they should manage their health — there is no scarcity of lifestyle advice! However there are relatively few people who are willing to buckle down and create actual resources for patients like ours.
I don’t think anybody needs more shoulds. However, there are a lot of people (particularly low income people), who could really benefit from having more options. Especially when it comes to managing chronic pain and chronic conditions. Ironically, some of the acupunks, students, and prospective students who appear most passionate about community acupuncture and other health equity topics in the abstract are also the least able or willing to do the on-the-ground labor to make it possible for people like our patients to receive acupuncture.
Access to acupuncture doesn’t magically happen as a result of anyone passionately believing that it should happen; somebody has to suck it up and DO something. In the society that we live in, that means somebody has to make a social container for affordable acupuncture, which requires contact with some very non-ideal elements such as small business — and other people. We live in capitalism, with other flawed, suffering humans. There is no charitable funding source, nor any kind of universal healthcare, that will pay for unlimited acupuncture treatments for people of ordinary incomes with chronic problems like headaches, back pain, anxiety, stress, and depression. Of course it would be better if there were, but in the meantime, there are a lot of people in immediate need; people are literally dying as a result of un-managed pain.
WCA decided, a long time ago, not to wait for help from the powers that be, because we were pretty sure it wasn’t coming.
And indeed, it has yet to show up! Meanwhile we keep treating people, year in and year out, 55,000 low-cost treatments per year. And so that’s the approach that our school teaches: get your act together so that you can treat people in the world we live in now, don’t wait for it to become more ideal. (See also: control what you can control, and talk is cheap.)
A common feature of the idealism that we’ve encountered is the expectation and the demand that other people should change in order to meet an ideal of how things should be. Understandable — but also, unlikely. Purpose involves taking responsibility for what we want to accomplish, and putting all our attention on that, as opposed to spending any energy on what other people are or are not doing.
In a best case scenario, idealism represents latent energy that can be converted into purpose. However, this almost always requires the idealist to lower their expectations, in the exact same way that people being treated for chronic pain have to lower their expectations for relief — in both cases, to be able to persevere in a context of slow, incremental progress.
Hope is a discipline and survival is a triumph — that’s the reality that many, many community acupuncture patients are living, especially those with chronic pain. We aim to follow their example.
When I think about what to do about the acupocalypse, I consider the distinction between idealism and purpose. Also, I remind myself that low-income people with chronic conditions are my personal North Star; what I want is what’s good for them. They’re where I come from, they’re who I work for, and as long as I’m focused on their needs, I don’t get lost. I navigate my entire professional life by that star. (Otherwise who knows where I might end up — making sketchy franchises with venture capital, writing acupocalypse outrage porn? )
It’s worth noting that WCA didn’t want its own acupuncture school because we had a vision of an ideal form of acupuncture education. Quite the opposite; we recognized that with the limited resources we had, whatever we’d make wouldn’t be ideal at all. We expected it’d be full of flaws and problems, and oh, we weren’t wrong. Still, we wanted a school because we desperately needed acupuncturists who could work in our clinics. We needed practitioners who could provide patient-centered, trauma-informed care to low-income people with chronic conditions. Which is something many acupuncturists absolutely do not want to do.
Okay, so having retraced my steps to the edge of the acupocalypse, what would I do next, if I could? I don’t have an image in my mind of what the acupuncture professional landscape should look like. Frankly I’m not convinced acupuncture ever should’ve been a profession in the first place, but here we are.1 The idea of the acupuncture profession is, well, an idea; it’s kind of abstract to me. What’s not abstract is that WCA’s clinics are full of people who need acupuncture (and so are other community clinics, all over the country). I want them to continue to get it. Other professions will never provide acupuncture at the volume and consistency that our patients need.
What’s the most direct path to patients continuing to get community acupuncture? That’s the path I’m looking for. I want to continue to train future L.Acs. So:
I’d immediately survey the forty-some acupuncture schools to find out, who has a plan to survive without federal student aid? Is it a realistic plan? In other words, estimate how many other survivors there might be. Then I’d count new schools that are in the pipeline, that are starting up without student loans (meaning they presumably can run without them).
Having made a headcount of schools that are likely to survive, I’d try to forecast cash flow for ACAHM and NCBAHM, which are written into most state laws. (Also I’d ask the California Acupuncture Board how they plan to respond when all the California schools fail the earnings test and lose their federal financial aid.)
I’d find out more about the requirements for ACAHM and NCBAHM to operate as nationally recognized bodies and figure out if it’s possible to meet those requirements on a shoestring budget. What I really want to know is: Are we losing our national infrastructure because we can’t fund it? If so, how soon?
There isn’t much planning to be done until we have an answer, or at least an informed estimate, for those questions. Because when you’re acting from purpose rather than idealism, you figure out how to pay for things. You don’t treat cash flow as an afterthought — or as an annoying, mundane obstacle to the pristine ideal in your mind.
Low-income people always think about what things cost and how to pay for them, because they have to! Meanwhile a lot of acupuncturists — including people in positions of power — tend to treat those questions as inconvenient and rude. That’s how we got into this fix, by not paying attention to what things cost (and who’s really paying for them). Now we have to collectively figure out how to fund both education and infrastructure for L.Acs. Nobody’s going to do it for us. The acupocalypse is a money problem.
Spoiler alert: whatever we can actually afford isn’t going to look like what we’ve been accustomed to. And it probably won’t look like anybody’s ideals.
I often think about a conversation I had with Dilip Babu, one of ORCCA’s Board members, about the state of healthcare in this country (he’s an MD) and how we’re trying to make a little alternate universe. “Of course WCA isn’t perfect,” I said. “Of course,” he replied, “but the thing about WCA is, it exists. People can come up with 500 different perfect versions of it, ways that it should be better or do more, but those versions of it don’t exist. This one does. Under the circumstances, it’s kind of a miracle.”
That same principle is likely to apply to everything about acupuncture education and infrastructure on the other side of the acupocalypse.
Something I’ve heard from a lot of different people — and, for the record, something that I agree with — is that the crisis of the acupocalypse also represents the opportunity to address the problems that got us here. But I worry about idealism in this context, particularly when it comes to acupuncture education.
People are going to come up with 500 different perfect versions of acupuncture education — but how is the cash flow going to work, exactly? I’ve heard acupuncturists waxing poetic about the possibility of education that is BOTH more rigorous and more affordable, which always makes me want to ask: You realize that whatever you’re imagining, students are going to have to pay for, right? Every requirement you tack on to a program costs something.
Same-same for infrastructure. I’ve heard people speculate that if acupuncture’s current accrediting body, ACAHM, doesn’t survive the acupocalypse, that would be a good thing. I want to state unequivocally that it would not be a good thing for our little school or for WCA. We can’t just jump to a different accreditor. We have dozens of hacks built into our systems to meet ACAHM’s requirements, painstakingly constructed over the last decade; it would be a big deal for us to figure out a whole new set of hacks for a different accreditor’s requirements. And we can’t take for granted that we’d succeed, because we run on a shoestring and another accreditor might not accept that. There’s an ideal version of ORCCA that can both contain costs for students and qualify for all possible accreditors, but it’s not the version of ORCCA that actually exists. This version needs ACAHM.
One of my objections to idealism is that sometimes it takes a lot for granted. Particularly, the existence of imperfect things that real people depend on. But on the other hand, there’s research to show that purpose keeps people alive; purpose is literally life-giving. Going into the acupocalypse, I think we need less idealism and more purpose.
Next up: acupuncture apprenticeships.
See also,