"It's Best If Everyone Keeps Their Clothes On"

I had a good conversation with a class of second year POCA Tech interns about boundaries in the clinic, in which the topic of patients taking off their clothes came up.

As it tends to do -- the sentence “It’s best if everyone keeps their clothes on” didn’t appear in our clinic’s new patient paperwork by accident. *

Early on in my community practice (circa 2003, long before those words landed in the Informed Consent), I was showing a new patient -- a nice lady in her eighties -- into the treatment room, giving her a short whispered spiel about how the clinic works. I looked away from her for a moment as I gestured around the room, and when I looked back she was standing in her underwear, having whipped off her skirt and her pantyhose in a matter of seconds, waiting for me to stop talking so we could get down to business. She had sciatica, her leg hurt, she expected me to needle her leg and she wasn’t fooling around. Fortunately all the other patients were sound asleep. I got her into a chair as quickly as I could and threw a blanket over her lap (at which point I explained the concept of distal needling).

Moral of the story: situations involving older ladies with no false modesty can get away from you fast.

The POCA Tech interns reported that they had had a couple of patients, young men who didn’t speak much English, who had taken off their shirts because they were being treated for shoulder pain and they assumed the interns would need access to their shoulders. The result was shirtless young men sitting around the treatment room, which is not the look we’re going for. I suggested a two part solution: first, if the shirt was already off, pick it up, smile gently at the patient and carefully drape it over his bare torso, possibly following it up with a blanket. (We don’t want anyone getting cold!) Second, once you know a patient is prone to taking their clothes off, make sure you intervene the next time right when they’re starting the process, if necessary miming universal gestures for “thank you but I don’t need you to do that, please stop”. Most of the time, this takes care of the problem and they won’t do it again. (Of course, if your intervention is met by a sultry smirk and prolonged eye contact while the patient continues to slowly undo their buttons, you have a different problem.)

It occurred to me that the process of cheerfully draping a shirt or a blanket over someone who has mistakenly but well-meaningly divested themselves of their clothing is what setting boundaries in the clinic in general should feel like: neutral, impersonal, and friendly.

A community acupuncturist’s job requires establishing and re-establishing boundaries, in a variety of ways (verbally, non-verbally, in writing, purely by example) with large numbers of people. In order for the job to be sustainable and not emotionally exhausting, the majority of boundary negotiations can’t feel dramatic and/or personal and/or laden with anger or shame. The majority of boundary negotiations need to feel like no big deal, and at least some should involve humor.

If that’s not the case, the acupuncturist has work to do -- possibly on the clinic space, the clinic systems, or themselves. Or maybe all three. That’s okay! Most of us have to learn about boundaries on the job, based on things going awry. A key to being a successful community acupuncturist is managing one’s energy, which includes knowing which tasks should take a lot of energy and which ones shouldn’t, and also experimenting with various hacks to make repetitive tasks less demanding. Setting boundaries in the clinic should eventually be easy. If it isn’t, figure out why; it’ll be worth the effort.

• Here’s the whole paragraph from WCA’s Informed Consent: I understand that community acupuncturists usually only need to needle areas below the elbows and knees, regardless of the conditions being treated. I also understand that I don’t need to remove major articles of clothing such as shirts or pants for treatment, and that doing so isn’t a good idea because it could be disturbing to other patients in the room. It’s best if everyone keeps their clothes on! If needed, the acupuncturists may ask me to roll up my sleeves or my pant legs.