Re-Focus: ACMAC Conference Presentation
Hi everyone, thank you for inviting me to your virtual conference. I will miss the part where we all go out to the pub afterwards.
I remember sometime in March 2020, someone wrote in an online forum, so does COVID mean the end of community acupuncture? And I think that honestly, to one degree or another, most of the community acupuncturists I knew were wondering that.
My clinic, Working Class Acupuncture, will be 20 years old in March 2022. When we shut down in March 2020, we had never before been closed for more than a week at a time, and that week was the Great Portland Snowpocalypse of 2008 (which I also feared would be the end of us). So when the lockdown happened and we were closed for four months, it felt very strange. Before COVID, Working Class Acupuncture was providing about 60,000 treatments a year in four locations across Portland, and early spring is always our busy time. In March we were just ramping up. So to shift from accelerating to a sudden hard stop, from very high volume to nothing at all -- it was shocking.
That weird, uncertain pause that lockdown created -- it reminded me of other kinds of uncertainty.
First, it made me think of the spring of 2002, when my brand new clinic was empty a lot of the time and I had no clue whether my bright idea about providing affordable acupuncture to my working class neighborhood would actually succeed. Starting in spring 2002, and really going through the next ten years or so, I was often convinced that the clinic -- even as it steadily got busier -- was going to run out of money. I would look at our finances and think, okay, right this minute we have enough money for what we need but NEXT month? I think we’re going to run out of money next month. And then once next month arrived, it was the same story. And it kept going like that. (Right around the time I started my clinic, someone opened a barbecue restaurant down the street and they hung a wooden sign that said, “free barbecue tomorrow” -- and of course tomorrow never arrived. It was like that.) Eventually I just forgot to worry about next month, basically, and got used to just muddling along, having things work out well enough to keep going. Month after month of survival, even if we were just barely making it, added up over time to real stability.
By the time lockdown happened, WCA was in much much better financial shape; I hadn’t worried for a long time about how we’d make payroll -- we even had savings. So there we were in lockdown, and all of our staff were applying for unemployment benefits, and I looked at the clinic’s bank account and thought, huh, we’re okay right now -- but we’re going to run out of money next month. It was like someone had hit “rewind”, right back to the early years. Oh, hello, I know what it’s like to live like this -- I remember how to do it, it’s maybe not my first choice but it’s definitely a skillset I’m glad I have. I remember how to get through one day or one week or one month at a time.
And that made me think about what it’s like to treat a lot of the patients who come to our clinic, the ones who are dealing with a serious diagnosis ( maybe they’re doing a course of chemotherapy) or dealing with a chronic condition (especially chronic pain), or they’re going through a divorce, or they’ve lost someone close to them and it’s just very hard to get through the day, let alone a week, let alone a month.
As community acupuncturists, a lot of what we do is accompaniment -- walking with our patients down whatever road they’re on. And a lot of people are navigating experiences that they just have to take one bit at a time, because they can’t see very far ahead. We believe that healing is accessible to people no matter what road they’re walking, and acupuncture more often than not is effective at lightening the load of pain, stress, and anxiety. We are glad to treat conditions that we can’t “cure” if it helps our patients have a better quality of life.
One of the beautiful things about not charging very much for treatment is that people can afford to come in repeatedly, even multiple times a week, as well as regularly, for years. They use acupuncture on their own terms, in ways that fit into their lives. They use it to manage conditions that can’t be cured; they use it because it offers them consistent relief, even when other parts of their lives are uncertain, difficult, and precarious -- and as a result they develop a relationship with the clinic that can last for decades. As community acupuncturists, we get to keep people company, both during some of their most challenging experiences and over long periods of time -- it’s an honor, to be able to accompany them.
I thought about that during lockdown. And I observed that outside of a pandemic, I’d never before been so successful at staying in the present moment. During lockdown, nobody knew what was going to happen, and it was useless to speculate; there was literally nothing to do about any of it except stay home and wait. So I was just hanging out in the present, the uncertain present, and it was kind of amazing, actually, to be suspended like that. I thought about all the people we treat who do that all the time, who don’t have any choice about being anywhere BUT the present, regardless of COVID.
As you might know, we started our own acupuncture school in 2014 and we focus on training students in community acupuncture exclusively. And it’s a super interesting process, figuring out how to make a layperson into a skilled acupuncturist. The main reason we made a school is because there were community clinics all over the US that were having similar problems hiring acupuncturists. So we were very concerned about graduating practitioners who could do a good job immediately -- we were really tired of having to try to re-train acupuncturists who went to other schools, we needed them to be well trained before they started working.
Seven years later, I believe that the most important skill for an acupuncturist is focus.
Giving a good treatment, whether in a community clinic or in any other setting, is largely a matter of focus. Our tools, our needles, are literally very small, you have to look hard to be able to see them (a fact that you’re reminded of whenever you drop one on the floor). Just finding the points in order to needle them -- that requires a lot of focus too. And then there are all the other skills of a good acupuncturist: paying close attention to a patient’s body language, knowing when to turn the intensity of your needling down or up, making sure the needles are neither too deep nor so shallow they’ll fall out, looking for the subtle signs of pain relief in someone’s face or movements in order to know if your treatment is working. Not to mention, in a community setting, keeping an eye on all the other patients in the room.
Essentially, in order to give a good treatment, you have to pay close, close attention to a lot of minute details (and your fine motor coordination has to be excellent as well!). You can’t be a good acupuncturist if you’re distracted or careless. In the treatment room, you have to really concentrate. You have to control your attention. Acupuncture itself is a concentrated, minimalist, elegant kind of healing -- you could say it’s a way of focusing.
On another level, a lot of what good practitioners do in order to support their patients in a healing process is to help them focus as well. With chronic pain and chronic conditions, healing is very often incremental. And understandably, people get tired and discouraged when they’re living with pain. We spend a lot of time talking to our students about the details of how to support patients by helping them focus on positive changes, even when -- especially when -- they’re small and they might get overlooked.
Things like making sure to document pain scales, so that you can remind someone that when they started treatment they reported their pain was 8 on a scale of 10, and this week, even though they’re feeling discouraged, they told you it was 6 out of 10. Or making sure to explain to people that often, when you’re working on managing chronic pain, the first signs of improvement don’t necessarily feel like less pain -- they show up as better sleep or more energy or a better mood, so if we see any of those signs, that’s progress. Things like helping patients notice when they’re starting to do things again that they hadn’t been doing, like weeding their garden or playing with their grandchild or cooking a meal from scratch -- even though they’re still feeling pain, they’re able to do things they couldn’t do before. That means the treatment is working -- maybe slowly, but it’s working.
There’s a vicious cycle with chronic pain where the pain narrows people’s lives, takes away their opportunities to do small, pleasurable, fulfilling things, and the fewer pleasurable things you have to focus on, the more you feel the pain and the more space the pain takes up. People can literally lose their lives to that particular vicious cycle, because when there’s nothing but pain, life isn’t worth living anymore and people behave accordingly. The only good news -- and it is good news -- is that the reverse is true, there’s a virtuous cycle that works similarly. An effective way to manage chronic pain is to make space for small, pleasurable, fulfilling things, and the more space those activities take up, the less space there is for the pain. Getting acupuncture can be one of those small, pleasurable, fulfilling things -- an opportunity to relax and be in a healing space with other people -- at the same time as the needles are working on the pain itself.
Pain isolates people, and the more isolated you are, the more intensely you feel your pain. It can be crucial to have someone who’s accompanying you, witnessing you, encouraging you to focus on maintaining space for small, pleasurable, fulfilling activities. That’s an important thing we want our students to be able to do for their future patients. That witnessing, that encouragement, is an important form of pain management. And just like the process of needling, it requires a very specific, sustained kind of focus. You have to not only keep your focus on incremental positive changes, but find ways to help your patient focus on them too.
There’s a beautiful article by Dr. Atul Gawande titled, “The Heroism of Incremental Care” that I think all community acupuncturists should read. He writes about observing a clinician working with someone on managing their migraines, and he notes that the first thing the clinician does is to lower the patient’s expectations. When we’re in pain, we all want to get better fast, we want the pain to just go away -- but one of the most critical aspects of a successful clinical outcome is realistic expectations. Because having high expectations, unreasonable expectations, can make it impossible to sustain an incremental process of improvement.
I think that’s an important reminder for all of us in the process of picking up the pieces after 19 months of COVID. Because in some ways, COVID is like chronic pain; we all hoped it would be over quickly, and we’ve had our hopes dashed over and over in the same way that our patients do when they’re dealing with their pain and yet another prescription, yet another surgery, doesn’t turn out the way they’d hoped. It takes courage to pick up the pieces and keep going.
For me, community acupuncture is all one thing, one integrated whole, which is a big reason why it’s been so healing for me, personally, to practice. The skills of focus, of learning how to manage my attention, that I had to learn in order to be with patients in the treatment room are pretty much the exact same skills I’ve needed to get my clinic through COVID. I know I have a choice about what I focus on, and I have to take responsibility for how I direct my attention.
As a practitioner treating a patient with chronic pain, it’s tempting to put my attention on all the ways I wish the treatment would work faster or how inadequate I feel in the face of pain that has the potential to ruin someone’s life. It’s tempting to focus on everything I can’t do for my patient or how terrible it is that the rest of the healthcare system has failed them or just how unfair life is, in general.
But that’s not my job. If I want to spend my own time spiraling down into misery about how awful everything is, that’s certainly my choice, but I can’t do it at work. When I’m at work I have to focus on controlling what I can control, even if it’s tiny, and on signs of hope, even if they’re only flickers. I have to turn all my attention toward the possibility of a positive future for my patient. That’s the only way to stay with them in an incremental process of improvement, and sometimes even play the role of the anchor that draws THEIR attention back to those tiny positive changes, the glimmers of a hopeful future.
Similarly, all the times during the lockdown when it looked like we really were going to run out of money, I had a choice about where I directed my attention. I could get indignant about how much uncertainty I had to live with, as someone who’s responsible for a small business in a low income neighborhood; I could put all my energy into resisting what was happening, raging at the pandemic and at the politicians’ blunders in handling it. OR I could tune all that out and focus on how to get the clinic through one day, one week, one month at a time. In a sense, I had to lower my expectations. And it was good to do that.
It really worked. WCA never did run out of money and we still have savings. We re-opened in July 2020 and we’ve gotten through ever since. We’re not yet back to where we were in terms of patient volume before the pandemic, but we’re doing 100 treatments a day or so and in other ways, we’re in much better shape now than we were in January 2020. We tightened up a lot of our systems; lockdown gave us the opportunity to think through how we did everything. Although we lost quite a few staff either because of our own downsizing or because of life changes for them that the pandemic set in motion, those of us who are still here are bonded in a whole new way and we’re much better at working together, at sharing responsibility, and particularly at accepting and navigating uncertainty.
Hope is a discipline and survival is a triumph. Both happen in increments. A day, a week, a month at a time. A lot of our patients know that and now we know it too, in a deeper way.
So for some acupuncturists, COVID did mean the end of their community acupuncture practice (or their individual acupuncture practice) but for us at WCA it meant a joyful, determined recommitment to it and to each other and to showing up for our community in all the ways that we do. It’s hard to be responsible for a small business and it’s hard to face how much pain, suffering, and precarity there is in the world. COVID reminded me, though, how the commitment to doing those hard things is so, so worth the effort. I wouldn’t want to live through a pandemic in any other way.
Thank you. (And cheers!)