Reflection: Risk

In preparing acupuncture students to tackle safety issues in their future practices, there’s a category of topics I think of as pre-safety, or concepts to spend some time reflecting on before diving into trying to implement safety by means of policies, manuals, etc. Being an acupuncturist and a small business owner requires you to put yourself out in the world in all sorts of ways; your work is as personal as an artist’s. Creating safety in your practice is like an investment; it helps protect you, your patients, and also your long-term commitment to your work. It’s worth spending the time to develop a solid internal foundation for your approach to safety, as opposed to just going through the motions to be externally compliant.

The next topic on the pre-safety reflection list is risk.

An accreditation mandate for acupuncture schools is that students must be able to “develop risk management and quality assurance programs”. This educational standard most likely originated in other, larger industries where 90% of graduates aren’t self-employed. What does “develop risk management and quality assurance programs” look like in the context of a micro-business, likely owned by a solo practitioner?

I think before you can effectively tackle “risk management”, particularly for a very small, very personal business, you need a certain amount of awareness, ideally an inventory, of your own attitudes toward risk. In my experience, risk is such a charged topic that practitioners’ feelings about risk in general can undermine their ability to navigate any specific instance of risk, let alone develop anything resembling a program to manage it. I’ve observed that some common attitudes toward risk involve judgement, fear, anger, and numbness. (More about all those in a moment.)

And I think what we’re aiming for is a neutral, analytical, non judgmental, safety-positive relationship to risk. To get there, it helps to identify what might be in the way.

I’m grateful that COVID unveiled some of our society’s attitudes toward risk and risk taking, particularly the way it demonstrated how often risk is inversely proportional to resources. The more resources you have, the more you can insulate yourself from risk; the fewer resources you have, the more risks you need to take -- and the more that people will judge you for it.

Early in the pandemic, there was a lot of blame directed at poorer communities where the virus was spreading rapidly, based on the assumption that lower-class people were ignorant and dirty, unable to grasp how to do social distancing or maybe just refusing to wash their hands enough? As more knowledge about the virus emerged, it became clear that the factors driving those higher rates of infection were first, work -- the nature of lower-class people’s jobs didn’t allow them to stay home, so that they were forced into more exposure -- and second, housing -- more crowded living conditions didn’t allow people to put big cushions of space between them. Fewer resources, more risk.

We live in a society with dramatic social inequalities and a scanty social safety net. Another term for this is precarity. I believe this affects our attitudes toward risk; there’s a strong impulse to judge people experiencing any form of precarity because we don’t want to believe it could happen to us.

I wrote at length elsewhere about learning to understand my own relationship to risk taking in light of trauma. I had sky-high risk tolerance because I didn’t care what happened to me (see also, foreshortened future.) I had to learn, over time, how to not be numb in relationship to risk. But for me that all came after my risk taking had paid off and I had become a relatively successful entrepreneur. Then I discovered to my surprise that people who asked me to teach them how to replicate my success were likely to get angry and indignant if I suggested they needed to take similar risks. For some people, the idea that they need to expose themselves to any risk arouses anger. Under that anger is probably fear.

The hard part of course for the 90% of acupuncturists who are self-employed is that small business is inherently risky and precarious, and once again, COVID did a great job of illuminating that. Most entrepreneurs aren’t rich white men in tech who can easily work from home. There are a lot of “necessity entrepreneurs” , or people who start a business because there are no better options for work, rather than because they see the startup as an opportunity. This brings up our society’s skewed attitude toward entrepreneurship. If you’re rich, either via entrepreneurship or any other way, your risk taking is admirable and you’re an American hero. On the other hand, if you’re poor and/or struggling and you have no choice about taking survival-level economic risks, then there’s something wrong with you -- somewhere along the line you must have made bad choices. Most acupuncturists are closer to necessity entrepreneurs than any other kind.

So because most acupuncturists have to grapple with risk not just in relationship to acupuncture safety but also in relationship to entrepreneurship, it’s easy to get overwhelmed and just not want to think about risk management at all. And absorbing ambient social attitudes about risk is not unlike drinking poison -- it will make you want to numb out and/or give up. I think that means it’s even more worthwhile to put effort into developing a neutral, analytical, non judgmental, safety-positive relationship to risk, that you can make use of in both the clinical and the business aspects of your practice.

Personally, I couldn’t tackle that particular task without the concepts of trauma-informed care. Coming to terms with risk without being numb to it meant accepting that everybody wants and deserves safety. However, not only do most people not get enough safety, but being human means that we’re always vulnerable and always at risk, no matter what. (COVID also demonstrated how having a human body is not unlike playing Russian roulette; there’s a certain terrifying randomness at work.) So what can you do?

The only response to risk that reliably makes me feel any better is committing to make more imperfect safety, for myself and everyone else.

And so for students working on risk management, I think the first question is, how does risk make you feel? Angry, fearful, or nothing at all (numb)? Do you have judgements about risk taking? What do you need to do to work through whatever you feel or don’t feel in order to approach the topic of risk from a neutral, curious, safety-positive perspective?

Next up on the pre-safety reflection list: harm reduction.