Hope Is a Risk: Leadership and Pain Management
Apologies for the long lapse in posting. For most of 2022 Jersey and I have been occupied with another kind of writing -- POCA Tech’s Self Study Report for our upcoming accreditation review next spring. The final product was 115 pages, much of it bureaucratese, but one of its themes is going to show up as a theme in future posts here. And that’s leadership development, which is now a focus at POCA Tech.
What do leadership and leadership development have to do with safety?
I hope we’ve established that you can’t have safety without organization. Well, you can’t have organization without leadership. And since leadership is such a fraught, mystifying and complex topic, it requires a lot of unpacking. Many people don’t want to be leaders, for good reason, or if they ARE willing they don’t know where to start -- which means you need leadership development. There’s really no way around it. You can’t do healthcare without a focus on safety, you can’t have safety without organization, you can’t have organization without leadership...and you can’t have leadership without leadership development. So here we are!
Leadership is the art of making things happen, with and for other people. The need for leadership skills shows up everywhere in an acupuncturist’s practice and that’s what we need to talk about at POCA Tech. Let’s start, actually, with something not directly related to safety (but like everything else, it connects eventually) -- and that’s pain management. It occurred to me recently that when I’m effective as a leader, I’m usually doing many of the same things I learned to do in order to be effective at pain management.
We love to talk about fractals at POCA Tech. Community acupuncture is a fractal and cooperative leadership shows up over and over: what you need to do with your patients in clinic looks a lot like what you need to do to interact with coworkers and/or volunteers, and that in turn looks a lot like what you need to do to manage your business. And the repeating pattern of cooperative leadership shows up most clearly in the very first conversation you have with a new patient: the intake.
Most acupuncturists are treating pain, most of the time. Community acupuncture clinics in particular attract people who are at the end of their rope with pain, especially chronic pain. So almost every new patient intake represents the possibility of beginning the process of pain management with someone. And pain management is a cooperative undertaking between the patient and you, the acupuncturist -- but it also requires you to practice leadership skills.
The first step, right after you say “hello”, is some version of asking the person, “so what can I do for you?” When they answer, they’re sharing a problem with you. Your first task is to set a tone in the conversation that feels like you’re confronting the problem together. You’re not trying to take over the problem and solve it FOR them, because you can’t. You’re setting the stage so that you can work on the problem together, as collaborators. This doesn’t require a lot of verbiage; it’s largely a matter of your attitude which should be, in a word, cooperative, but also clear and assertive because you’re getting ready to bring your resources to bear on this situation, and your new patient should be able to feel that energy from you.
Even when there aren’t many words in the conversation, you will very likely get at least a glimpse of multiple levels of your patient’s problem. If they say, “My doctor suggested I try acupuncture because nothing seems to be helping my knee pain, and I’d like to avoid surgery”, right there you get a glimpse of weeks or more likely months of appointments, consultations, and frustration. They’ve been trying to solve their problem but they’re not getting anywhere. When you ask about how intense the pain is on a scale of 1 to 10, they might say something like, “If I’m sitting it’s not too bad but bending is awful, like an 8/10 when I’m trying to garden” -- and then you get a glimpse of activities becoming restricted, pleasures being subtracted from daily life. This person’s problem isn’t just their knees, it’s their quality of life. And so you should absorb that information with focused, one-pointed attention and some gravity too. This is serious.
The book Reframing Organizations: Artistry, Choice and Leadership is a foundational text of leadership development. The authors make a point early on of saying that a leader’s primary job is to grasp what’s going on in their organization (so that they can respond appropriately), and when leaders fail, it’s usually because they got it wrong. The main thing a leader needs to do is have a clue and the worst thing a leader can do is to be clueless.
The new patient intake is where you clue in to your patient’s problem and you show them, in a low-key way, that you have a clue -- by treating them as if their problem is real and it really matters to you. Unfortunately, a lot of healthcare providers are clueless about how to approach pain, and it’s highly likely that at least one provider has demonstrated that they don’t believe the patient about the pain or they don’t take it seriously.
The next step in the conversation is for you to give a brief overview of what you (and your clinic) can offer in response to their problem. This is where you describe what a course of treatment might look like, and you begin to set clear and realistic expectations for incremental improvement. You need to be as transparent as possible without overloading them with details. You’re setting the stage for the person to be able to make a good decision for themselves about whether to use acupuncture, with you, to address their problem.
You’re not trying to sell them on anything or pressure them in any way (see also: trauma informed care). You respect their autonomy and their knowledge of their own lives. Is a course of acupuncture worth trying for them, right now? You’re looking for clear and informed consent.
If their answer is yes, the patient is agreeing to allow you to lead them, to be their guide, through a course of treatment. You’re embarking on the process together. You can’t take them anywhere they don’t want to go -- because the determining factor in whether acupuncture works is whether or not they show up. (You’re not in control of the moment they pick up their keys and leave their house -- you’re not there for that moment at all.) In your own mind, you have to be very clear about the division of responsibility. They’re responsible for showing up and allowing you to lead them through a course of treatment. You’re responsible for doing the leading. You’re holding the container for their process.
One of the most important aspects of leadership in a pain management context (and also in many other contexts) is managing negativity and all its subcategories: discouragement, hopelessness, despondency and gloom. There’s a great article by Atul Gawande about pain management titled “The Heroism of Incremental Care” and if you haven’t read it, you should. It’s about how pain management can be miraculous -- but it’s a gradual miracle that requires patience, discipline and staying the course.
Successfully managing pain requires not fighting pain, because fighting pain involves focusing on pain, and focusing on pain makes pain worse. Resisting pain amplifies pain. Successfully managing pain, as a practitioner, means helping people focus instead on incrementally reducing their pain and incrementally increasing their quality of life. But the focus has to be on living life, not on fighting pain. And this requires leadership skills, because for most humans, the default setting is to fight pain.
The new patient intake represents the beginning of you and your patient going down a different road, together, away from fighting pain -- but you have to be clear where the two of you are going and that part of your leadership role is to help them stay on the path when they get discouraged. You’re not leading them towards a fantasy world where they won’t have to deal with pain ever again. You’re leading them towards a world in which their pain is manageable and they can get on with their lives. But at some point, they’re likely to get discouraged, lose perspective, and wonder if they should give up. That’s the point at which your skills in managing negativity -- theirs and potentially yours -- become important.
In my experience, there’s just no way around it: pain management requires faith, hope and love. Not as aspiration or decoration, but as decisions and commitments. You have to cultivate faith, hope and love for your patient, for yourself, and for acupuncture in order to help both of you stay on the path of incremental improvement. Faith, hope and love mean that you keep moving forward with your efforts no matter how bleak things look from where you’re starting.
I recommend Rebecca Solnit’s book Hope in the Dark, and even though it was written about politics I think her descriptions of hope apply to pain management too:
“Hope is not a lottery ticket you can sit on the sofa and clutch, feeling lucky. It is an axe you break down doors with in an emergency...Hope locates itself in the premises that we don’t know what will happen and that in the spaciousness of uncertainty is room to act. When you recognize uncertainty, you recognize that you may be able to influence the outcomes–you alone or you in concert with a few dozen or several million others. Hope is an embrace of the unknown and unknowable, an alternative to the certainty of both optimists and pessimists. Optimists think it will all be fine without our involvement; pessimists take the opposite position; both excuse themselves from acting. It’s the belief that what we do matters even though how and when it may matter, who and what is may impact, are not things we can know beforehand. We may not, in fact, know them afterward either, but they matter all the same, and history is full of people whose influence was most powerful after they were gone.”
Managing negativity requires tolerating uncertainty. Hope is a risk. Maybe acupuncture won’t work for your patient, no matter how many treatments you give them. But if your patient is dealing with chronic pain, you won’t know how much of an impact acupuncture can make without giving them a lot of treatments -- maybe dozens or hundreds. Hanging in there long enough for results to appear requires faith, hope and love. And if it turns out that you and your patient arrive together at the conclusion that acupuncture isn’t working and they need to try something else, well, faith hope and love will help you let them go, will help them move on, and help you move on to the next person you might be able to help.
This perspective has served me well over several decades as an L.Ac. in high volume practice. It’s kept me on the path, accompanying all kinds of different people through all kinds of problems. Next up: applying these lessons to the current state of the acupuncture profession. For those of us who are neither giving up nor opting for fantasy solutions, this is the perspective we’re going to need.