Order of Operations and the Acupocalypse

A Doctor of Acupuncture wrote:

"I liked your article. I see the acupuncture world lacking a major understanding about running a business. I also see for me it's hard to make a living without taking insurance, particularly the VA. Medicare is dysfunctional until LAc's can bill. For the profession to thrive it needs to be able to earn a living and then form a powerful lobbying ability to protect it. If we as acupuncturists don't define acupuncture someone else will - ie like the P.T.s - they have a strong lobbying ability and are thriving. I love tradition, I love the history, but I believe it needs to fit in modern times as much as modern medicine I believe is dysfunctional we need to find a way to fit in, establish an income to thrive and establish efficacy to justify its use.

I welcome any feedback. What solutions or articles suggesting solutions could you suggest I read?"

Thank you for your question. I think the way you framed it, “for the profession to thrive it needs to be able to earn a living” is important.

In my world, the concept of “order of operations” has turned out to be crucial. I’m pretty sure that concept originates in math, the idea that in order to solve an equation, it matters what you do first, second, third, etc. In community acupuncture, in acupuncture safety, and in running a small business, I’ve found that order of operations often represents the difference between being effective in solving a problem, versus unproductively spinning my wheels. You have to know where to start.

I agree that economic sustainability comes first in the order of operations when you’re thinking about how acupuncture fits into people’s lives in the present, as opposed to the past.

If you’ll indulge the math metaphor for a minute, I think there are at least two (possibly more) equations here. One is, how can we save the acupuncture profession? And a related but fundamentally different question is, how can we preserve the existence of L.Acs (or, how can we make it possible for people to legally practice acupuncture without first joining some OTHER profession like physical therapy?)

You asked about the acupuncture profession so let’s start there. If you haven’t read Tyler Phan’s dissertation, or the slideshow remix version, I think you should. Because what we refer to as “the acupuncture profession” was put together very quickly in the 1980s by a relatively small group of people, and to understand its problems, I think you need to look at its history.

And now I’m going to throw another metaphor into the mix, which is building. (Sorry about that, I love metaphors so I can’t help mixing them.) My own trajectory in the acupuncture profession has involved a lot of building. When I opened my clinic in 2002 it was your basic acupuncture micro business (just me and my twenty or so patients); then for a while it was an LLC; then it became a professional corporation when I wanted to hire other people; and finally it settled on being a 501c3 nonprofit (for lots of reasons, one of which was being able to offer loan forgiveness to acupuncturists.) By then it was three clinics, not one. In addition, I helped build another 501c6 nonprofit, another 501c3 nonprofit (an acupuncture school), and a multi stakeholder cooperative. One of the things I learned along the way is that when you’re building an organization from scratch, you have to make a lot of educated guesses about how it will run. Once it’s actually up and running, you’re likely to find out that it doesn’t work exactly the way you hoped it would, because there were things you couldn’t know when you were in the building phase. So then you need to go back and try to fix it, which is unfortunate because building organizations has a lot in common with pouring cement.

As far as I can tell, the acupuncture profession’s structures and organizations were built in the 1980s before there was an economic foundation for them. It appears that the people who built them believed that if they copied the structures that physicians built, then physician level status and physician level compensation would magically follow for acupuncturists, thus giving birth to a new profession. And you know what, this is the opposite of what I’ve learned about building organizations, which is that you have to start with understanding the economic foundation and anticipating the cash flow; only then can you build structures that are solid and sustainable.

A striking thing about the acupuncture profession, the whole time I’ve been in it (29 years and counting) is how averse it’s been to collecting data about its own economic status. Fundamental things like, how many acupuncturists are actually practicing, and how much are they earning? I’ve been a data nerd about this stuff for a long time but it’s been almost impossible until now to get a conversation started, which I think is important to note. The nuts and bolts of cash flow is not something the acupuncture profession likes to pay attention to -- or as you said in your email, “I see the acupuncture world lacking a major understanding about running a business”.

I suspect the BLS data about how very few jobs there are for acupuncturists represented a shock for some of the acupuncture profession’s leadership. Also, I think the data is even worse than it appears because of this footnote: “Annual wages have been calculated by multiplying the hourly mean wage by a "year-round, full-time" hours figure of 2,080 hours”. As we know, many acupuncturists work part time whether they want to or not, but the BLS doesn’t take that into account, it assumes everyone is working full time -- because in other industries, they are. So actually, acupuncturists are probably working less and earning less than the BLS data says they are.

The people who built the acupuncture profession in the 1980s didn’t think about how acupuncture practices would run as businesses, because they didn’t know. They were not, for the most part, practicing acupuncturists. And the profession they built did in fact drive any number of practicing acupuncturists underground. Racism, specifically Orientalism, is in play and I don’t want to argue about that here but it’s absurd to ignore its role in building something so economically unsustainable. If the people who built the acupuncture profession had paid more attention to the communities where Chinese medicine was already being used and how it operated there, they would have gained some vital information about how patients used Chinese medicine and how they paid for it (Miriam Lee could have provided plenty of data, all by herself!) -- as opposed to assuming that patients would use and pay for acupuncture the way they use and pay for an MD’s services.

To get back to the building metaphor, you could say that the acupuncture profession was built with inaccurate blueprints. Since the people who built it wanted to replicate both the structures and the material successes that physicians had, anything about acupuncture or Chinese medicine itself that didn’t fit that paradigm, they tried to ignore or cover up. For example, the innate diversity of acupuncture practice and theory. There’s much more agreement among physicians about the right way to practice medicine than there is among acupuncturists in how to practice acupuncture. Tyler Phan calls this “horizontal epistemology”.

Something Michael Smith said to me a long time ago was that in the US, people understand schools, but they don’t understand acupuncture itself. (He was practicing acupuncture before there was an acupuncture profession in the US.) In allocating their energy, the people who built the acupuncture profession focused on education in part because it was clear how to make money by providing education, while it wasn’t clear to them how to make money providing acupuncture and they probably didn’t even know where to start with that problem. When acupuncture schools were able to qualify for federal student loan funding, that’s when “the acupuncture profession” was able to -- seemingly -- scale itself up. Most acupuncture schools were built in the 1990s, on a paradigm conceived in the 1980s, and nobody has tried to adjust that paradigm since. And what was scaled up was mainly the schooling (more schools, more students, more money flowing through the student loan channels) and not the actual delivery of acupuncture to patients. Tyler Phan describes the whole enterprise as “a house of cards”.

So I think, when we talk about “the acupuncture profession”, he’s exactly right -- we’re talking about a house that was built too fast and with huge gaps. Construction was shoddy and too much money went into shiny features that would give it curb appeal at the expense of the important things. From certain angles, and in the right light, this house that was built without a foundation looked okay enough that people kept being willing to walk through the door. But time has passed and the things that were never right about it, the places where the builders cut corners and hid problems, have become impossible to hide and now people are starting to avoid it. People on the inside who can look at the plumbing, the wiring and the HVAC (like the head of the NCCAOM, for instance) are dropping ominous hints that the house is falling apart. What it needs is a team of structural engineers, but nobody who has real responsibility for it wants to deal with what structural engineers would find. The BLS data was like a really terrible home inspection report.

Focusing on other professions “defining acupuncture” is a way of continuing to focus on the part of the profession that acupuncturists like thinking about -- the status part, the shiny curb appeal -- as opposed to the overwhelming structural problems. You asked for other recommended reading, so I’m going to point you toward Elaine Wolf Komarow’s blog The Acupuncture Observer. Start anywhere and read it all.

Getting back to the idea of order of operations, nobody has really tried to solve the equation of how to make jobs for acupuncturists. It hasn’t been a priority, unlike fighting other professions over encroachment. I know that’s the idea behind the push for Medicare inclusion, but as someone who has both worked for non-acupuncture organizations that hire acupuncturists and who has tried to create jobs for acupuncturists myself, I’m really dubious that it’s a simple legislative fix. As my friend Whitney put it, it’s not like there are a bunch of hospital administrators sitting at their keyboards compulsively refreshing the legislative status of Medicare inclusion for acupuncturists so that they can hurry up and post thousands of job announcements. I mean, if it is that simple I’ll be happy to be wrong, but it’s more likely that it’s another case of the acupuncture profession lacking understanding about how business is done. I don’t think trying to plug acupuncturists into Medicare is the right first step in the order of operations to actually solve this difficult, complex equation.

You wanted to focus on solutions, which makes sense. The problem we have is that what the acupuncture profession sees as solutions to the equation of “how to save the acupuncture profession” has significant overlap with things that make it hard to earn a living as an L.Ac, period. Pushing for an entry level doctorate to compete with other professions that offer doctorates has driven up the cost of education and made an acupuncture degree a $250,000 investment that doesn’t pay off. Fighting other professions sucks up resources (time, energy, attention) that otherwise could be devoted to supporting acupuncturists as small business owners. What actually might prevent L.Acs from becoming extinct -- a shorter, less expensive entry level path and a different kind of credentialing exam -- are the very things the acupuncture profession won’t even entertain because they represent “going backwards” for the profession’s image.

You’re asking, how do we fix this house that was built without a foundation? And I think the answer is, you can’t, because where would you even start? All signs suggest that it’s a decaying money pit and I think we actually passed the point of no return some time ago. What we could still do is to save the L.Ac, using the lessons we learned about what didn’t work over the last forty years. We could start with focusing on the economic sustainability of acupuncture practices (pro tip: that is NOT the same as “what other professions are doing with acupuncture needles”) and from there determine what acupuncture education should look like. But we’d have to be willing to use more common sense in our order of operations.