Acupuncture as Work
In a recent New York Times article, this description of three different kinds of work popped out for me: “There is a job, which pays the bills and lets you live your life; a career, where you feel a sense of satisfaction from the work, but it doesn’t own you; and a calling, where you are willing to sacrifice other areas of your life for your work because this is your identity.”
One of the causes of the acupocalypse is how many acupuncturists and prospective acupuncture students aren’t clear on those distinctions, and particularly, those distinctions in relationship to small business.
As a result of running an acupuncture school and also trying to employ acupuncturists, I’ve met a lot of people who went into acupuncture expecting to find either a job or a career, only to end up disappointed. I have to disagree a little with the definition of “calling” in the NYT article, because while acupuncture has definitely been a calling for me (though I prefer “vocation” -- you know, I’m Catholic) it’s not my identity and I don’t want it to be. However, my experience with acupuncture was that it wasn’t a job or a career even if I had been looking for that. Acupuncture work didn’t actually allow me to live my life in the way that a “normal” job would and it did own my time, my energy, and my attention in a way that’s really different from a “normal” career.
Practicing acupuncture in a way that allowed me to make my living was more like raising a child than anything else. And this isn’t because I’m a community acupuncturist instead of a private room acupuncturist, it’s because I was running a small business, period. Successful acupuncturists, no matter how they practice, demonstrate similar levels of commitment and investment. So I think the crucial point is about what you expect to get out of your acupuncture work versus what you expect to put into it. (Yourself!) For both jobs and careers, you can get money and a certain kind of stability out of them without first pouring in your heart’s blood. Acupuncture work, not so much.
We could debate all day about why that is and whether inclusion in Medicare would actually change it. For whatever reason, though, the reality is that acupuncture work in this country right now and for the last forty years has been, at its core, about small business. And an immutable law of small business is that you have to love it for it to exist.
Just like a child, you may not always feel warm and fuzzy about your small business or even like it at any given moment -- but its survival depends on your willingness to pour your energy, your attention, your time and your resources into it. You can’t ask it what it’s giving you back because for a long time the answer will be too depressing. You can only ask yourself whether this test of your love and your stamina is a good way to spend your time. You have to put in so much more than you take out in order to take out anything of substance that the act of putting in had better be valuable and rewarding in its own right -- or it just won’t be worth it. For me it was worth it. Ultimately I got out way more than I put in to my acupuncture practice but that’s not true for everyone so be careful, YMMV.
Having a small business also requires personal risk and vulnerability in ways that having a job or a career just doesn’t. More about that here. And the overarching problem, as far as I can tell, is that the acupuncture profession doesn’t respect small business.
Many of the acupuncturists who are angry about the push for Medicare inclusion are complaining, rightly, that the impact of Medicare on small business doesn’t seem to be part of the conversation. The NCCAOM and the ASA are arguing that the acupuncture profession’s survival depends on Medicare inclusion while not recognizing that most working acupuncturists are laboring away at their own small businesses and the intersection of small business with huge government bureaucracy rarely turns out well. They have a right to be wary.
One of the first things we do at POCA Tech these days is to talk about small business, specifically its parameters, because almost everybody is confused about that. Did you know that the practical definition of a small business according to the US Census is a business that has less than $5 million in annual revenue? That means that the vast majority of organizations in the acupuncture profession -- everything except the biggest schools and the biggest needle companies, and there aren’t many of those -- is operating at a small business scale. In 2021 the NCCAOM’s gross revenues were about $4 million. And many acupuncturists aren’t just operating small businesses, they’re operating microbusinesses.
For small businesses and microbusinesses, survival is a triumph. It can’t be taken for granted.
A good way to ensure that a small business will struggle (let alone a microbusiness) is to over-regulate it. A good way to sink a small business is to burden it with massive loan debt before it even opens. But the acupuncture profession keeps doing both those things to its practitioners because it doesn’t recognize that there just isn’t much money in the business of acupuncture in this country. Acupuncture work happens at a small business scale. There shouldn't be any shame in that, but there seems to be.
Forgive me if I take a detour for a minute and talk about one of the more fascinating recent developments in the acupuncture industry, and that’s Modern Acupuncture’s attempt to scale up acupuncture into big business. Okay, I found it particularly fascinating because they were specifically trying to scale up the community acupuncture model and the whole thing felt surreal to me. I was pretty sure it wasn’t going to work for a number of reasons, but the most obvious problem had to do with what the founders of Modern Acupuncture expected to get out of the community acupuncture model versus what they were putting into it. They left out the heart’s blood part.
They believed that on some level the community acupuncture model could work like a vending machine -- that if you just set it up right, in a nice enough neighborhood, it would generate enough money to pay investors and owners who didn’t work in the business themselves. They were counting on acupuncturist employees who weren’t necessarily personally invested being able to build and maintain large patient bases in exchange for a paycheck. They thought the clinics could grow without actual love. (Not to say that some owner/operators didn’t put their own heart's blood into their clinics, I talked to some who did. But that was about who those people are as humans, not about the business model of Modern Acupuncture.)
By the time Modern Acupuncture arrived on the scene (anybody remember “Let’s Tingle”? Even though acupuncturists were screaming bloody murder about that slogan the whole thing feels oddly nostalgic to me now) I had watched a lot of acupuncturists struggle with implementing the community acupuncture model in one way or another. I’d never seen anybody turn it into a vending machine, not for lack of trying. Despite big infusions of venture capital, in 2023 all signs suggest that Modern Acupuncture isn’t long for this world. COVID accelerated what was going to happen anyway -- the people who invested in franchises realizing they’re not going to get their money back. Because there’s just not that much money to be made doing acupuncture, and any money that you do make requires putting in love first.
Anyway, it seems to me that the NCCAOM and the ASA are making the same mistake that Modern Acupuncture made. They think that somehow external infusions of money (via Medicare inclusion instead of venture capital) will be effective at magically scaling up acupuncture and balancing out the costs the profession has imposed on practitioners. It's as if there's some shame in admitting that acupuncture is fundamentally about small business.
As long as I’ve been in the acupuncture profession I’ve listened to people complain that acupuncture organizations are underfunded and disorganized -- that’s how we ended up with the NCCAOM as our defacto leader. Some of that has to do with acupuncturists’ generally dysfunctional relationship with organizations but some of it has to do with the fact that small business is tough and let’s say it again, there just isn’t much money in the business of acupuncture. A lot of acupuncture practices don’t survive, and most of the ones that do have owners who are entirely focused on keeping their own small businesses afloat and don’t have any time, energy or resources left over for anything else. It’s rare for an acupuncture organization to have paid full time staff the way the NCCAOM does; most are run by volunteers.
So the infrastructure of the acupuncture profession depends more on the NCCAOM than it does on the ASA, and that’s unfortunate for many reasons. Not least is that it means that the acupuncture profession has allowed the burden of funding its infrastructure to rest on people entering the profession as opposed to the people making a living in it.
As the costs for entry have gotten higher and higher, the burden of risk also rests disproportionately on those same people -- the ones entering the profession instead of the ones already in it. And now we’ve gotten ourselves into the position where, quite reasonably, they’re refusing to take on that kind of risk. It’s unfortunate that many acupuncture schools market “a career in acupuncture” when what’s actually waiting for acupuncture students on the other side of graduation is the terrifying opportunity to love a small business into existence.
Infrastructure is built by humans (but not your mom), it doesn’t fall from the sky, and so I believe it’s possible to build infrastructure for acupuncture work that respects its small business scale. And indeed if /when or when/if our current infrastructure collapses, our choice will be to rebuild it at a sustainable scale or allow the L.Ac to become extinct. The thing is, though, the immutable law applies: if we want our infrastructure to exist, we’re going to have to love it.