Four Stages and the Acupocalypse, Pt 1

Published in on Feb 13, 2023

Okay, so remember a few posts ago, I mentioned "The Four Stages of Professional Careers" an old academic article that transformed the way I look at my problems?

Back in 1977, management researchers Gene Dalton, Paul Thompson, and Raymond Price presented a model for leadership development based on their interviews with hundreds of “knowledge workers” like scientists, engineers and accountants. They believed that people who thrived in their careers had the ability to grow -- through making psychological adjustments as well as adapting their relationships and activities so that they could take on new roles. People who didn’t thrive had a tendency to get stuck, and the big question was, how to get them unstuck?

The acupuncture profession is sadly stuck. I think the four stages model offers a useful perspective on what it would take to get it unstuck. (Spoiler alert: it wouldn’t be easy.)

The four stages of leadership development according to Dalton, Thompson and Price are:

Stage 1: Dependence on others -- being led. Central activities: learning, helping, following directions. “Apprentice”

Stage 2: Independence-- personal leadership. Central activity: independent contributor. “Colleague”

Stage 3: Assuming responsibility for others -- local leadership. Central activities: Interfacing, training, contributing through others. “Mentor”

Stage 4: Exercising power. Central activity: shaping the direction of the organization. Leading through vision -- organizational leadership. “Sponsor”

A crucial point about Dalton et al’s research is that they conducted it mostly in a corporate context. (In my experience, most leadership development books come out of corporate contexts, and a lot of what’s left comes from the military.) The professionals they studied were working in big, complex organizations. I’ve never actually worked in a big, complex organization myself so I found it illuminating, especially as I tried to understand what it might mean if it was translated into a small business context. And because acupuncturists are collectively so bad at organizations, the four stages article helped me see things I’ve been missing for the whole twenty nine years that I’ve been in the acupuncture profession.

Okay, let’s start with Stage 1!

Stage 1 is where we all are when we’re learning something new. We need someone else to direct us and provide a container for our activities. A lot of acupuncturists really like Stage 1. It’s what most acupuncture schools offer: the opportunity to learn, the opportunity to help, the security of feeling like there’s a right and a wrong way to do everything, plus someone to guide you. In Stage 1, you don’t have to create your own structure, you just have to fit into someone else’s. There’s relatively little need to manage risk or uncertainty.

In Dalton et al’s model, the four stages can be developmental, but they’re not necessarily. You don’t automatically progress from one to the next without focused effort. Many people in big corporations stay at Stage 1 for their entire careers, no matter how much they “advance” in terms of their job title. The stages aren’t about status or compensation; they’re about mindset, relationships and specific tasks. A person at Stage 1 doesn’t look beyond their own job and needs to be told what to do by someone else, whether they’re working in the mailroom or they’re directing a department. A person at this level focuses on performing detailed and/or routine tasks; they may show some directed creativity.

As a person progresses through the stages, they need to strengthen certain behaviors and attitudes. Moving out of dependence on others requires developing the ability to tolerate risk, to take responsibility, to initiate communication with other people, to manage uncertainty, and to contend with your own doubt and negativity. (Hey, look, those things happen to be recurring themes of this blog! What a coincidence.) From a safety perspective, a person at Stage 1 is able to practice a checklist approach to safety, to obey a set of do’s and don’ts, but they’re not able to create safety. A person at Stage 1 can only ask other people, “How are you going to keep me safe?”

You know what else someone can’t do at Stage 1, if they’re an acupuncturist? Build a patient base. Even though treating individual patients is about helping them, building a patient base requires more engagement, more creativity, and more personal initiative than simply being responsive and following directions. There’s a certain passivity at Stage 1 that’s developmental for someone who’s learning a new skill, but it doesn’t match up with the responsibility required to hold space for a diverse group of patients. Nobody can tell you from the outside how to invest enough of yourself into your practice to build a patient base that’s big enough for you to make your living. You have to figure that out from the inside and then motivate yourself to do it, including managing your own doubts and fears. It’s a unique, intensely personal process and most new acupuncturists are unprepared to tackle it.

If you’re an acupuncturist at Stage 1 and somehow find an actual job, it’s unlikely you’ll be able to keep it unless you develop the non-Stage-1 skills to build your own patient base within the structure that your employer provides. (Modern Acupuncture found out the hard way that there's no automatic stream of patients who will book appointments with uninvested acupuncturist employees.) Stage 1 acupuncturists who can’t figure out how to accomplish this task end up losing money for their employers. Since their employers are usually NOT big corporations who don’t need to watch their cash flow like a hawk, acupuncturist employees who don’t attract and retain patients typically don’t stay employees for long.

And you know what really can’t happen at Stage 1? Entrepreneurship. Someone who needs other people to tell them what to do, who needs a structure that other people provide, is not a candidate for starting and running their own business.

From my perspective, the problem for the acupuncture profession is that the basic template for an acupuncture school requires everyone to treat students like Stage 1 people -- which in many ways of course they are. However, apart from acupuncture school itself, the acupuncture profession has very little to offer Stage 1 people. It’s not full of big corporations with middle managers ready and waiting to create structure for Stage 1 people to do their work. Most acupuncturists are going to have to manage themselves and create their own structures if they want to work.

So if you encourage students to believe that being a successful acupuncturist is all about learning and following directions and getting it “right” the way you can get the answers right on multiple choice tests, you’re setting them up for failure -- because all the data about acupuncture employment suggests that there are vanishingly few spaces where L.Acs can just learn, follow directions, and then collect a paycheck. The reality of making a living as an acupuncturist demands the ability to perform tasks that are more complex, with infinitely less structure and supervision, than students typically encounter in acupuncture school.

Also, people who are in Stage 1 need someone else to create opportunities for them because they don’t know how to create opportunities for themselves -- Stage 1 isn’t about that. (We’ll dig into this issue more at Stages 2 and 3.) But a huge problem for the acupuncture profession is that very few acupuncturists are interested in creating opportunities for other people. They might be interested in making use of opportunities that other people create for them, but extending themselves (and possibly inconveniencing themselves) on behalf of another acupuncturist? Not so much.

And unfortunately, as the case of Modern Acupuncture demonstrates, if people do create opportunities for acupuncturists they expect to make money as a result. And since there isn’t much money to be made providing acupuncture, alas, when creating opportunities doesn’t produce a return on investment, those opportunities tend to disappear fast. Also, if you want to make a profit off of employing acupuncturists, there’s no way you’re going to pay them enough to match their crushing student loan burden. So it’s rare for the math to actually work when it comes to creating jobs for acupuncturists -- as the BLS data shows so starkly. Inclusion in Medicare won’t magically fix that. There are no external fixes for the acupuncture profession’s problems.

Stage 1 acupuncturists are out of luck. There’s almost nowhere for them to go. So for POCA Tech, the take home message is that if we do nothing else for our students, we need to point the way out of Stage 1 into at least Stage 2. Most people were not expecting to have to grow in this way when they signed up for acupuncture school, especially if acupuncture was marketed to them as a career where they can do whatever they want because it’s so flexible and they’ll never have to worry about work-life balance because acupuncture is all ABOUT balance! And harmony! And unicorns, otherwise known as scholar-physicians with hospital jobs!

Too often people go to acupuncture school looking for a magical solution to real world problems. Training acupuncturists as if they’ll be able to make a living without getting past Stage 1 is an example of the acupuncture profession as a whole expecting magical solutions -- which sets us up to continually invest our energy in more magical solutions like entry level doctoral degrees and Medicare inclusion. Unlike Dalton, Price and Thompson, we don’t work in a big corporate context. Nobody’s going to make structures for us that we can just plug into and take for granted.

Next up: Stage 2 and the Acupocalypse.