A Guide to Understanding CAN's Anger, for Any Member of the Acu-Establishment

I can really understand why many different people, reading this blog, would feel hurt, attacked, misunderstood, unfairly maligned, and on top of it all, bewildered. I can imagine that any representative of an acupuncture school or of a mainstream acupuncture organization might be wondering, why are these community acupuncture types so HOSTILE? If all of this anger doesn't make any sense to you, please read on.

(Note: I am not on the Board of CAN and I'm not presuming to speak for CAN as an organization. I did name this blog "Prick, Prod, Provoke", and I did help start CAN. But I am only speaking from my own perspective.)

The first thing you need to know is that all of this anger is not about YOU as an individual, or indeed about any individual; it has nothing to do with whether you or anyone else is a good, caring, honest, hardworking person. The anger is about structures, not about personalities. It's about the many economic disconnections of the acupuncture world. Some of those disconnections involve acupuncturists and some involve patients.

Let's start with the acupuncturists:

1) the disconnection between the cost of an acupuncture education and the typical income of an acupuncturist. According to a recent AAAOM survey, 73% of the acupuncturists surveyed brought in less than $80K gross, annually, from their acupuncture practices. Factoring in overhead and self-employment taxes, this suggests that 73% of acupuncturists are netting less than $40K annually. And while the sample size was small, it reflects my sense of my colleagues' incomes in the 14 years that I have been an L.Ac. A very tiny percentage are doing very well, and a very large number are earning almost nothing from practicing acupuncture. They rely on other jobs or their spouses' incomes to survive. Since I graduated from OCOM in 1994, I have seen the cost and the length and the requirements of an acupuncture education rise relentlessly -- and yet economic prospects for graduates today are no better, and possibly worse, than they were for me. There are still almost no jobs in the field. Most insurance does not cover acupuncture, and many more patients have no insurance at all.

2) The disconnection between institutions and practitioners. The most stable entities in the acupuncture world are not the small businesses run by acupuncturists (because 50% to 80% of acupuncturists are out of business within 5 years) or the state organizations composed of L.Ac.s (mostly tiny and underfunded) but the acupuncture schools and the regulatory agencies such as the NCCAOM, the ACAOM,  the CCAOM, etc.. Acupuncture schools run on federal student loan money taken out by acupuncture students; the regulatory agencies run, directly or indirectly, on fees paid by acupuncturists and acupuncture students. The heads of the larger schools and of the NCCAOM make six-figure salaries. Meanwhile more and more acupuncturists graduate from schools burdened with debt that they may never repay, and a majority watch their businesses fail. For most acupuncturists, our only choice if we want to practice is to take the huge financial risk of starting our own businesses; most of the jobs and the accompanying steady paychecks in the acupuncture world are within the schools or regulatory agencies. In other words, your income = our debt.

Income disparities of this magnitude are what create revolutions.

Now for the economic disconnections that involve patients: 

3) the disconnection between how acupuncture actually works and how you have told us to price it. A single acupuncture treatment almost never creates lasting positive change, especially for chronic conditions; what is effective is a course of treatment, which means frequent and regular acupuncture over a period of time. Even insurance that covers acupuncture almost never pays for a full course of treatment for any really serious problem, and it never pays for preventative care.  The going rate of $65 to $200 for a single acupuncture treatment virtually ensures that no patients with ordinary incomes will get satisfactory clinical results -- they will stop after one or two treatments because they can't afford to continue. And yet those of us who have attempted to price our treatments so that most people can afford them are regularly scolded for "devaluing the profession". Some of us have received threats and intimidation from other practitioners as a result of trying to price our treatments so that our patients will actually get results. It is hard not to draw the conclusion that money matters much more than patients to the acu-establishment.

4) the disconnection between who we are and who we can treat, according to the acu-establishment. Pricing acupuncture at $65 to $200 per treatment limits our patient base to those who are very well off or who have unusually good insurance -- and given what is happening with insurance, those two groups are increasingly not very different.  All of us have been encouraged to find "success" by treating rich people. The problem here is that most of us are not rich ourselves, and to achieve success according to your standards requires that we reject and abandon those people we are most connected to -- our extended families, our friends, our neighbors, the people with whom we have natural relationships -- in favor of the few people who can afford to pay the going rate. The solutions that you generally suggest to this problem -- dedicating part of our practice to charity, reducing fees for a few deserving people, using sliding scales that require income verification -- make us think that none of you have ever been on the receiving end of that kind of "generosity". Having to prove that you are poor enough to deserve help is humiliating. Acupuncturists magnanimously reducing fees for a few people does not solve the problem that we are concerned with, which is making acupuncture genuinely accessible to people like ourselves.

From our perspective, these disconnections look a lot like systematic discrimination -- unintentional no doubt, but systematic just the same.

  5) the disconnection between how simple acupuncture actually is, and how much we paid to learn it. Acupuncture and herbs are not the same thing. You can get excellent clinical results with acupuncture with a minimum of training in Chinese medical theory. After a little time working with real patients in the real world, most of us come to the conclusion that we could have learned what we needed to know about acupuncture, in order to help most people, in eighteen months of schooling, tops. Most of what we spent armloads of money to learn has no direct (or even indirect) usefulness to our patients. That curricula are designed and accredited in this way suggest to us that what patients need does not interest you.

Many acupuncturists have joined CAN because they feel it is the only place they can have honest conversations with other acupuncturists, without an atmosphere of competition and oneupmanship. Many acupuncturists have said that CAN is the only place that they have found real support and information about how to start a practice. CAN was designed to fill a lot of different gaps in the acupuncture world, particularly the gap between who we are and who we can treat according to conventional business models. As a result, CAN has also introduced acupuncture to exponentially increasing numbers of patients.

Oddly enough, CAN's stellar usefulness is another thing that makes me angry. I developed the community acupuncture business model and I helped design CAN. I had no real qualifications to do either of those things: no experience with business or organizing, no real web skills, some experience with acupuncture but not decades of it; no financial resources except credit cards, and no connections. It has not been an especially convenient time in my life, either, since I've been raising children. Everything I have done in terms of CAN and the (now international) community acupuncture movement would have been infinitely easier for someone within the acu-establishment to do; it has been a lot of work but there is absolutely nothing about any of it that is particularly complex. Any number of you have infinitely more experience, resources, and connections than I did, so why didn't somebody else more qualified do this a long time ago? It's really simple, and it's been needed forever.

The short answer is that it was a priority for me, and apparently not for you. I've started to think of myself, with my remarkable lack of qualifications to lead a movement, as a walking indictment of your indifference.

But the long answer is what really explains, I think, the intensity of my anger towards the acu-establishment. In 1999, I started treating a hospice patient with stage 4 lung cancer. He didn't really want acupuncture, but had agreed to it at his wife's urging. He would let me use only a few needles, most of them local; he wouldn't take herbs or change his diet. Almost everything I learned in school was no use at all with him. Over the course of two years, as I treated him, he stopped coughing up blood, regained much of his energy, and got kicked out of hospice. He credited the acupuncture. His lung doctor, the head of pulmonology at the local Kaiser hospital, called me to ask if I could explain why our mutual patient's cancer had apparently stopped spreading. And then I left my public health acupuncture job, and the economic structures to treat this patient disappeared. I was in no position to offer him charity care and he would not have accepted it; he wanted to pay me, but after having had cancer for the better part of a decade, buying groceries was a challenge. If he missed an acupuncture treatment, he started coughing up blood again. I developed the community acupuncture business model because I had to find a way to continue to treat him. His wife believes that regular acupuncture added five years to his life. Perhaps you can understand why I feel that making acupuncture widely accessible to people of ordinary incomes is actually a matter of life and death.

Since then, I have treated patients for whom getting acupuncture is a matter of being able to keep working the jobs that let them support their families. I have treated patients for whom getting acupuncture meant no longer thinking of suicide, because they are no longer crushed by chronic pain and depression. I have treated another patient with terminal lung disease who has stopped coughing up blood and no longer gets pneumonia, whose doctor visits have decreased from every three weeks to every six months. (His doctor said that his asbestosis was no longer a major issue: "I don't understand what you're doing, but whatever it is, just keep doing it.") I have done what I did because these patients' lives MATTER to me. My goal for this blog is for other acupuncturists to understand what's at stake -- people's lives. Honestly, in contrast to the real pain and suffering that so many people are dealing with, and the staggering untapped power of acupuncture to offer real help, the acupuncture profession's preoccupation with status seems petty, trivial, and appallingly selfish. People are suffering and we have the power to help them NOW. If we want to.

Please don't tell me that if we had more status it would help our patients, because the economy is in a nosedive and the healthcare system is going to follow it, straight down. It does not benefit our patients for us to achieve status within a system that is economically unsustainable. Please don't tell me things really aren't that bad, because acupuncturists can get jobs on cruise ships. Please don't tell me that my patient with asbestosis could afford to get acupuncture at market rates (twice a week, for the rest of his life, did I mention that he is raising his grandson?) if he really valued his health. Just as you may be bewildered by all the anger on this blog, i am bewildered that all the economic disconnections of the acupuncture world are not painful to you as they are painful to so many of us. You are in relative positions of power.  You could change all of this. If you wanted to.