Risk, Entrepreneurship, and Acupuncture Schools
Like a lot of other people, I’m fascinated by the federal trial of Elizabeth Holmes, the former head of once-lauded blood testing company Theranos (see: “Bad Blood”, the book and the podcast by journalist John Carreyrou). I’m particularly interested in the way that the trial may turn out to be a judgement on a certain kind of Silicon Valley entrepreneurship; I’m interested in entrepreneurship generally but also, I’m seeing a lot of similarities with themes of entrepreneurship in the acupuncture profession -- especially acupuncture schools.
What kind of entrepreneurship are we talking about? The “fake it ’til you make it” kind, the kind where the entrepreneur makes lofty promises as a way of generating enough money and commitment in order to -- they hope -- make those promises come true. This kind of entrepreneurship worked out well for a number of tech companies but badly for Theranos, which after all was in the business of healthcare. Faking it isn’t something you should ever do with blood tests -- that’s the prosecutors’ point of view.
It’s complicated, though, because entrepreneurship by its very nature involves believing in something before it exists, in order to get other people to believe in it too -- and thus make it real. Every start-up community acupuncture clinic setting up a treatment room with six or eight or, hell, twenty chairs (that would be WCA) before there are enough patients to fill them is participating in that dynamic. The reality of my clinic now (even battered by the pandemic, we’re averaging around 100 treatments a day, none of them done by me) is what I longed for back in 2004 -- when it felt like a fever dream, when it felt unattainable, when anybody I told about it thought I was hallucinating.
I’m thinking a lot about how the “fake it ’til you make it” dynamic has applied to the process of the professionalization of acupuncture, or the creation of the acupuncture profession, and what part acupuncture schools play in it. Two weekends ago was the first module for Cohort 8 at POCA Tech (which is kind of unbelievable -- one of my friends said, “What? Didn’t you just start the school last week or something?”). Fifteen new students, all showing up to class in the midst of a pandemic because they really, really want to become community acupuncturists. (We hope.)
During the admissions process, we try hard to determine whether POCA Tech represents a mutually good investment. Is acupuncture school, particularly THIS acupuncture school, a good use of the student’s time, energy, and money at this moment in their lives? And does educating this student represent a good use of the school’s time, energy, and resources? Both sides are taking a risk, because nobody knows how it’s going to turn out. Every year people drop out of the program because they realize once they’re here that being a community acupuncturist isn’t actually their cup of tea. There’s only so much you can anticipate, as a student, before you’re actually tasked with memorizing 500+ points and putting needles in other humans. On some level you can’t know until you’re doing it.
We introduce the topic of risk a lot earlier in the POCA Tech program than we used to -- as in, immediately, in the first module. I talked about risk in some detail with Cohort 8, both in the context of the extracurricular needling policy, but also as part of orienting them to the school itself. It’s hard to have a conversation with people you’ve just met about the economic risks of entering the acupuncture profession, but I felt like we had to try.
Back in the early 90s, when my acupuncture school promised me a career, I didn’t think that meant “a job that I’d have to make for myself out of thin air”. I was 22 when I decided to go to acupuncture school, I was working class, I didn’t know anything about business or money let alone acupuncture. To say I wasn’t fully informed about the financial risk I was taking is a spectacular understatement. But I sure was able to sign on the dotted line on the student loan forms, and my school encouraged me to do so. In my case, the investment in acupuncture school -- even with the student loans -- turned out to be a good one. I did, in fact, get a career out of it (okay, a really weird career). But it could have easily been otherwise. For a lot of people, it’s been otherwise.
Recently I spoke with someone who attended the same acupuncture school that I did, but 18 years later, when it cost a lot more. They said that they had about $310,000 in student loan debt, most of it from acupuncture school. They said they had tried to practice for about 3 years, after which they’d realized they were struggling to make $18,000 annually, and so they left the acupuncture profession. They expect to never pay off their debt. This person is a competent, successful professional in another field, but their debt is an albatross. They’re contemplating applying for forgiveness under the “Defense to Repayment” provision, on the grounds that our mutual alma mater grossly misled them. We talked about how acupuncture schools routinely promise students that they’ll make $100K a year, no problem. (Every cohort that enters POCA Tech has at least one student in it who’s heard that promise from another acupuncture school.) I think schools have learned not to put that promise in writing, but it doesn’t mean they’re not finding ways to say it anyway. And prospective students are believing it.
It’s hard to get good data on the acupuncture profession. We don’t even know for sure how many licensed acupuncturists there are in the US (maybe 37,000?) The data we have, though, suggests that almost all of them are self-employed (91%, according to the last report I was able to find from the NCCAOM). For students, this means that in order to make a living as an acupuncturist, they need to be prepared to start and run a small business -- which is an inherently risky proposition.
It’s hard for humans to get their heads around risk -- COVID has proven that over and over. All the data I’ve seen about what acupuncturists earn (including data that POCA collected in 2017) suggests that the economic risk of entering the acupuncture profession is real and daunting. Yes, a few licensed acupuncturists are making $100K a year, or even $1 million. More are making in the neighborhood of $40K a year. And many more than that are making less than $10K a year. It’s entirely possible to earn nothing as a licensed acupuncturist even when you’re trying your hardest to work. The reality of acupuncturists who are making lots of money -- or even just making a living -- doesn’t cancel out the reality of the acupuncturists who are making nothing.
And it doesn’t mean those people are lazy. Risk isn’t a moral judgement. Risk is risk, and when you enter the acupuncture profession, you’re taking a big one. This is why POCA Tech’s tuition is capped at $25K for the program -- knowing what we know about what acupuncturists earn, that number sounds to us like a reasonable risk for students to take. (Not coincidentally, it’s also about what my acupuncture education cost back in 1994; it’s the economic risk I took that I can honestly say turned out okay for me.) But it’s only reasonable if they know it’s a risk.
This blog post is also an answer to a question I expect I’m going to get at some point, which is, “Why is a member of POCA Tech’s Advisory Board doing a conference presentation titled ‘For the Medicine to Survive, the Profession Must Burn’”? That Advisory Board member would be my friend Tyler Phan Ph.D. If you’d like a preview of his presentation, you can listen to him being interviewed about his research on the creation of the acupuncture profession. It’s not a pretty story.
For the acupuncture profession to come into being, certain people had to believe in it before it existed. Whether they should have done this is up for debate. The very existence of acupuncture schools -- including POCA Tech -- persuades people that there really is an acupuncture profession and they might really have a career in it. But I think we have to ask ourselves, as Tyler is asking: who are the investors in the acupuncture profession, what are these people investing, and what are they getting back? And returning to the example of Theranos, where’s the line between being entrepreneurial and outright lying to your investors and the general public?
If the existence of the acupuncture profession is predicated on students investing their life savings, in advance, in the hopes of having a career that we have reason to believe might never materialize -- yeah, that’s a big problem. If those people are also likely to be predominantly young or female-identified or both, and if they’re investing borrowed money they’ll have to pay back at 8% interest, it’s worse. I’m very aware of how people’s class backgrounds play into their willingness to invest in what looks like a career, but might not be. I’ve often asked myself (and I know other people have wondered!), “Lisa, why are you still mad at your acupuncture school 28 years later? Especially given how much you love your clinic, how successful it's been, not to mention that by your own account community acupuncture saved your life, how can you still be mad?” Well, because my acupuncture school knew I was taking a risk, and I didn’t. Just because that risk turned out okay for me doesn’t mean it wasn’t really a risk.
So yeah, I don’t want to do that to anybody else, especially not some other working class kid with dreams of being an acupuncturist. And judging by the dismayed looks I got from some Cohort 8 students when I shared the economic data we have on what acupuncturists earn, not all of them knew about the risk either, despite our best efforts in the admissions process. We can’t assume that prospective students understand risk, so I think we’ll continue with the practice of making sure that students who enroll get the bad news on their first weekend. Given that acupuncture schools are required to teach risk management to our students, doesn’t talking about the risk of entering the profession seem like the place to start?