Roots and Branches

Another Post – from an ongoing conversation.

ewolfk — Thu, 27 Oct 2011 21:10:48 +0000

Elaine wrote ” It is too bad that so many of these conversations become arguments and folks give up and we get no closer to figuring out how to navigate these competing desires within the profession and how to serve the public best. While I can appreciate the thought of community acupuncture clinics available to all I know that that possibility is just as disturbing to many within our profession as Medicare coverage would be.” AND…”We continue to have no working mechanism to 1) get advice and assistance from experienced and knowledgeable professionals who could answer our questions and help us understand the implications of various choices…”

Steve Wrote “Elaine – I hope you will go a bit further and explain the thoughts underlying your comments about the dilemma of widespread CAN clinics being disturbing to many other LAcs AND who might be the experienced and knowledgeable professionals who can help LAcs understand the ins and outs of Medicare. I would think you are referring to physicians. I honestly do not understand how the CAN approach disturbs so I am hoping you will illuminate me. I remain of the opinion that acupuncturists simply do not understand how the health system works.”

Elaine writing –

I’m going to speak to what I’ve observed in my colleagues’ reactions to change within the profession. I believe I’m representing significant currents within the acupuncture community, though of course there are many who would disagree. In general, much “political” activity within the profession is driven by fear (and the related issue of feeling threatened) and outrage. (I don’t, personally, share all of the opinions I am stating

here.)

For the practitioner with a private-room-relatively-expensive business model (known by some as a BA practice), a CAN clinic on every corner can feel like a direct economic threat. If clients can go there for $15.00 (perhaps with a more convenient schedule) they won’t come to me for $85.00. Also, if I do participate with insurance, I know that reimbursement levels are based on “usual and customary” fees. If the going rate averages out to $80.00, the reimbursement level is such that I can practice the way I would like and still make a decent hourly wage. If there are enough CAN clinics out there to impact the usual and customary calculation, then “my” reimbursement level goes down and my practice model is no longer sustainable.

In addition, certain aspects of the CAN model, such as the tendency to label lifestyle advice and discussion of the philosophy of behind AOM as classist or out-of-place, is, for some, a threat to the integrity of the medicine.

Some of my teachers, for instance, spoke of the needle as being merely an anchor to the energetic teaching that was an integral part of the acupuncture treatment. Over the years many battles with the medical establishment centered on the difference between acupuncture and sticking needles in. The CAN focus on sticking needles in undermines the long held position that what we do is different, and that an MD with a 200 hour course is not capable of doing what we do. We spent a lot of years and dollars learning a system we believe is valuable, and it’s not comfortable to consider whether it was, in fact, a big waste. (I believe this also contributes to a lack of interest in research for some of us.)

So, the fear of the economic impact and the threat to “our” belief system about the medicine, combined with a reaction to the harsh voices of a subset in the CAN community proclaiming that the BA practitioner and the “acu-establishment” have made a conscious decision to deprive the working class access to care and to steal the future of the unwitting acupuncture students, means that many of my colleagues would be/are less than sanguine about a CAN clinic on every corner.

As for the experienced and knowledgeable professionals who could help us understand the ins and outs of Medicare, physicians may be part of that group, but I was actually thinking of experts in health policy or other fields who could advise as to how to mitigate or avoid some of the negative impacts of “the system” on health care delivery. Steve, while I don’t disagree that many of us don’t understand how the health system works, I would stress that many of us DO understand that the current system does not work WELL. Many of us, practitioners and patients alike, are outside of the system because we’ve seen over the years the negative impact it has had on the delivery of health care and the emphasis on disease care (and, in some cases, creation).

I believe that an underlying factor (perhaps subconscious for many of us) in our conflicted feelings about inclusion in the system is that it is comfortable to commiserate with our clients, yup, it is a real shame that the Man doesn’t respect us and so we’re stuck with you paying me out-of-pocket. If only times would change. It feeds into our story about us against the world, and, I care, so I’ll give you a discount. If the system does accept us, but we don’t feel we can work within it and still do what we consider to be good work, we become the greedy provider who isn’t accepting Medicare patients because it isn’t worth it.

This is how we get to an impasse. We want the respect of the system, we want acupuncture/AOM in its fullest sense, to be available to everyone, and we, for the most part, want to be independent professionals with “reasonable” incomes and a healthy lifestyle, and most of us don’t see a viable way, either within or outside the system to do all of those things.

It is easy to sign a petition to save the Sagebrush Lizard –except for a handful of property owners the only impact is a few pennies of our tax money. For every decision about the future of acupuncture in the US medical system, though, there are winners and losers and philosophies challenged.

Does that help?

Finally, a post.

ewolfk — Mon, 10 Oct 2011 21:09:19 +0000

I do loads of writing, mostly on listserves. I often feel like I put my best efforts there, and then have no steam for real posts here. This time, I tried to write something that would work here too. Some of the context is missing, and it isn’t the best writing I’ve ever done, but it is part of a discussion about things that could be done to help the acupuncture profession and the folks that would like to be a part of it.

Complicated and Divisive vs. Straightforward and Uniting

….. All this talk about lack of research and failures of our training seems to be little more than another example of a few voices promoting particular paths, convinced that going in that direction would be the thing that would make the difference for our profession. Our history and our current circumstances have been shaped by certain of these voices gaining power and making changes in line with their vision and, in my experience, these changes often have serious unintended consequences and often don’t have the intended outcomes. If you look at the factors contributing to the high cost of acupuncture training you’ll see a road littered with good intentions. And, having just lived through the great FPD brouhaha the article Jim posted (thanks Jim) came as no surprise.

How is it that our profession can be successful with very difficult changes and yet time and again can’t manage the most simple and straightforward actions that might have a real and immediate impact on the profession.

The cost of an education in ANY field is a hot topic these days, and I am not sure, given the current economy, that there are many degree programs in which future salaries are commensurate with the debt incurred. That being said, some months ago we came up with some fixes that could begin making a difference relatively quickly –

1) Make sure that potential students have easy access to data on costs, graduation rates, graduate success, expected incomes, licensure limitations, etc. A drop in applicants will be sure to get a school’s attention.

2) Change any requirements (or pressure schools to change any requirements if it comes from them) that the biomedicine portion of an acupuncture degree be obtained from an acupuncture school. There has been universal agreement in this group that these classes are poorly done. Having students take them at other institutions will likely save money, give them a better class – the credits of which are more likely transferrable, and increase their contact with future allied health professionals.

3) Pressure the schools to provide decent business classes, including a focus on picking a location, choosing a business model, learning how those two are intimitely connected, having successful practitioners from a variety of models come in and speak, etc. (As an aside, I haven’t yet watched the CAN documentary – I will soon, I hope. CAN, and their attention to looking at the impact of pricing, schedule, location, and office vibe, and its impact on potential customer base, has had a huge impact on my practice. I do want to point out to Steve, in particular, that a significant part of what makes a CAN clinic owner see their clinic as a success, in my view, is a focus on social justice, making a difference in the world, serving the community. I don’t believe that, as a rule, a CAN clinic is more financially rewarding for the average practitioner than a moderately successful “boutique” practice. Which is fine. However I think it does provide some limit to the view of the CAN model as the future of acupuncture.)

I honestly don’t think it should be that hard to make some small changes that would have a big impact. I wish we could focus on those and get them done before we considered much bigger and more difficult changes.

Recently I’ve heard a few practitioners talk about loan forgiveness — that will make the difference. Leaving aside the reality that this is not going to happen any time in the forseeable future given this country’s budget reality, and leaving aside the question of whether we could even make a case for this being the best use of tax dollars, think of the impact this would have on the cost of education. There goes any downward pressure. On another note, look at the number of active licensees who appear to be practicing in West Virginia — a state with very easy and generous regulations.

I wish we would just do a better job of focusing on the basics and put less energy into grand visions of how to remake the profession.

New Research – Acupuncture Effective against Depression during Pregnancy

ewolfk — Fri, 05 Feb 2010 22:08:34 +0000

Web address:
http://www.sciencedaily.com/releases/2010/02/100204075105.htm

Acupuncture Found Effective Against Depression During Pregnancy

ScienceDaily (Feb. 4, 2010) — In a study to be presented February 4 at the Society for Maternal-Fetal Medicine’s (SMFM) annual meeting, The Pregnancy Meeting ™, in Chicago, researchers will unveil findings that show that acupuncture may be an effective treatment for depression during pregnancy.

“Depression during pregnancy is an issue of concern because it has negative effects on both the mother and the baby as well as the rest of the family,” said Dr. Schnyer, one of the study’s authors.

About 10% of pregnant women meet criteria for major depression and almost 20% have increased symptoms of depression during pregnancy. The rates of depression in pregnant women are comparable to rates seen among similarly aged non-pregnant women and among women during the postpartum period, but there are far fewer treatment studies of depression during pregnancy than during the postpartum period.

Dealing with depression is difficult for pregnant women because the use of anti-depressants poses concerns to the developing fetus and women are reluctant to take medications during pregnancy.

In the study, an evaluator-blinded randomized trial, 150 participants who met the Diagnostic & Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for Major Depressive Disorder were randomized to receive either acupuncture specific for depression (SPEC, n=52) or one of two active controls: control acupuncture (CTRL, n=49) or massage (MSSG, n=49). Treatments lasted eight weeks (12 sessions). Junior acupuncturists masked to treatment assignment needled participants at points prescribed by senior acupuncturists. Massage therapists and patients were not blinded. The primary outcome was the Hamilton Rating Scale for Depression, administered by blinded raters at baseline and after four and eight weeks of treatment. Data were analyzed using mixed effects models and by intent-to-treat.

The results showed that the women who received SPEC experienced a significantly greater decrease in depression severity (p<0.05) compared to the combined controls (d=0.39, 95% CI [-1.31, 1.65]) or CTRL acupuncture alone (p<0.05; Cohen´s-d = 0.46, 95% CI [-1.24, 2.31]). They also had a higher response rate (63.0%) than the combined controls (44.3%; p<.05; NNT=5.3, 95% CI [2.8, 75.0]) or CTRL acupuncture alone (37.5%; p<0.05; NNT=3.9, 95% CI [2.2, 19.8]). Symptom reduction and response rates did not differ significantly between controls (CTRL 37.5% and MSSG 50.0%). Mild and transient side effects were reported by 43/150 participants (4 in MSSG; 19 in CTRL, 20 in SPEC). Significantly fewer participants reported side-effects in MSSG than the two acupuncture groups (p<0.01).

“The results of our study show that the acupuncture protocol we tested could be a viable treatment option for depression during pregnancy” said Dr. Schnyer.

Why I love acupuncture

ewolfk — Wed, 03 Feb 2010 23:36:13 +0000

The following article first appeared in the Winter 2002 Newsletter of the AOMAlliance

THE MIDDLE LAND

By Matthew D. Bauer,L.Ac.

The name “China” comes from “Chin”, the name of the state whose Emperor first unified China after conquering the fighting independent states bringing an end to the “Warring States” period (423-221 BCE). Before that term began to be applied to that region and its people, the Chinese referred to their region as the “Middle Land” or the “Central Territory”. Many historians believe the ancient Chinese called their homeland the Middle Land because they thought China was the center of the earth. While some Chinese may have thought this way, I feel it more likely this practice had a much deeper, and very ancient, meaning.

…Ancient Taoist philosophy is full of references to a mysterious middle ground, a state of being “in between” one reality and another. This concept was known by several different names including “divine door”, “heavenly gate”, “mystical pass”, “divine pivot”, etc. When you consider that gates and doors are passageways between one thing and another, it is obvious this concept is not concerned with a physical or geographic “middle” but rather, the potential for transformation. The traditional names of dozens of acupuncture points have terms that reflect this concept such as Life Gate (GV-4), Jade Pivot (CV-21), Stone Pass (KI-18), and the somewhat redundant Pass Gate (ST-22).

Taoist holistic philosophy stresses that all creation is interconnected comprising one great whole. Interestingly, modern science has begun to turn from a mechanistic view of nature toward a holistic view. The mechanical view of nature gained prominence with the theories put forth by such great scientists as Newton and Descartes in the 17th and 18th centuries and has been the dominant view of scientists and the general public ever sense. Throughout the later 20th century however, the cutting edge of scientific thought has been quietly developing theories in which all things are seen as interconnected. From the smallest scale of quantum physics to largest scale of astrophysics, holistic interconnectedness is rapidly gaining ground in nearly every field of science.

“A human being is part of the whole, called by us the Universe, a part limited in time and space. He experiences himself, his thoughts and feelings, as something separated from the rest – - a kind of optical illusion in his consciousness.”(Albert Einstein from the Quotation Page.com)

If all creation is interconnected then everything is truly “in between” everything else. All ground is a middle ground – a door or gate connecting it with all else. The ancient Taoists discovered a most important feature of interconnecting gates: they are not all equal. Some gates connect things that are very similar to one another so passing through such a gate is hardly noticeable. Other gates connect things that are so different; passing through these gates is nothing short of a mystical experience.

Modern science has been mystified by some of these gates also. For example, it is well known that water can be changed from a liquid to a solid (ice) or a gas (steam) depending on its temperature. Lowering or raising the temperature of water molecules throughout 99.99% of the range water remains a liquid, changes the nature of those molecules in predictable ways that are proportional to the change in temperature. Yet scientist have not been able to find any mechanism to explain why lowering or raising the temperature of water molecules past their critical threshold (gate) should cause them to suddenly jump from one state of existence to another. Scientists call these mystical jumps “phase transitions” and they represent just one of several phenomena that are forcing scientists to change their mechanical view of nature.

…Another concept of modern science that deals with mysterious gates is known as the “Butterfly Effect”. This term was coined in the 1960’s within the field of meteorology from the following concept: A butterfly flaps its wings in China, causing a chain reaction of meteorological consequences that causes a thunderstorm in Kansas, one month later. The Butterfly Effect describes what scientists call “systems that are sensitive to initial conditions”. In such systems, a tiny stimulus at just the right (pivotal) point can cause a domino effect leading to dramatic changes that are disproportionate (from a mechanical point of view) to the initial stimulus. The idea that a very small stimulus is capable of causing dramatic changes is now considered scientific fact.

The concept that everything is a gate connected to everything else and that some gates wield special influence over a whole system is central to the theory of acupuncture. Chi circulates throughout every cell of the body and thus has the potential to get stuck at any spot, yet the most common or pivotal stuck spots have been singled out and termed “acupuncture points”. Hua Ching Ni has stated that the human body has 36,000 acupuncture points yet the Chinese designated only 360 or so as “regular” points – those most pivotal – while recognizing several hundred relatively less pivotal as “extra” or “extraordinary”. In treatment, acupuncturists select a limited number of points to effect healing and will sometimes chose the less common extra points over regular ones. Point selection therefore, is based on the skill of being able to recognize the most pivotal of the pivotal points at any given time within a dynamic, fluctuating system.

…I believe human beings are systems that are sensitive to initial conditions and that the best acupuncture points are those that cause a Butterfly Effect stimulating a healing phase transition. Not every butterfly in China will cause a thunderstorm in Kansas and not every change in water temperature will cause a phase transition – you have to know how to pick your spots.

…It’s exciting to see modern science developing a holistic view of nature and coming to grips with the concept of mystical doors or gates, but it remains to been seen if this trend will take modern science to where Taoist science has always been focused: Spirituality.

…The ancient Chinese were convinced that in addition to the physical world there exists a spiritual realm and the goal of life on earth was to connect with this realm. To do this one must discover and then pass through the most mystical of all doors – those that connect the temporal, physical world with the eternal, spiritual realm (the ultimate phase transition). In order to transform from physical to spiritual, the physical, mental and spiritual essences (chi) must be perfectly balanced. An important component of achieving this is to harmonize one’s internal environment with one’s external environment. This is why the Chinese referred to their place of birth as the Middle Land. People are a product of their environment thus their environment can serve as a gate leading to the spiritual realm. Taoist folk history told of countless generations of ancient Masters who spiritualized their beings after harmonizing themselves with the chi of the high mountains or deep forests in the Chinese heartland.

…All the Taoist holistic arts and sciences were designed with such transformation as their ultimate goal. In essence, these practices have a dual role, serving physical needs while providing those who master these skills the potential for spiritual breakthroughs. The spiritual aspects of acupuncture have not been emphasized recently in the Middle Land or in other countries where the potential scientific “mechanisms” of acupuncture are the focus. Acupuncture itself is undergoing a type of phase transition as it rapidly evolves from an ancient regional art into a modern worldwide phenomenon. As acupuncture undergoes this transformation, I hope its spiritual roots will not be forgotten and that acupuncturists will continue to learn that the skills used to find the pivotal doors to healing can also be applied in the search for the Mystical Pass between Heaven and Earth.

Insurance

ewolfk — Wed, 27 Jan 2010 02:14:02 +0000

I’ve been thinking a lot about insurance lately — specifically about becoming a preferred provider with an insurance plan. I’ m somewhat tormented about it. It used to be that insurance didn’t cover acupuncture at all, so it wasn’t an issue. Now insurance is more likely to cover acupuncture. Some practitioners are very happy about this and fighting to get more coverage. It raises issues — for one thing, now there is a third party determining how many treatments someone can get and what conditions will be covered. It wouldn’t be such an issue if the industry recognized that acupuncture isn’t just about treating a symptom. When we begin to treat with symptom as the focus in order to please the insurance companies we’ve begun to lose the richness of our tradition.

Here is one of my dilemmas — many companies will only cover treatment for pain and nausea, and a few other things. Let’s say someone comes to me because of insomnia, but, like most of us, they do have some pain somewhere. Since insurance won’t cover acupuncture for insomnia, but will for pain, it makes sense for me and for the patient to put down the pain code. Acupuncture is holistic so it isn’t fraud — if I treat the underlying imbalance the insomnia and the pain will improve. But it isn’t completely accurate either — and since all the data gathered by insurance companies is studied to look at effectiveness of certain treatment, it might have an impact on what people think about the effectiveness or ineffectiveness of acupuncture for certain conditions.

I’ll write about some other issues soon. In the meantime, I’m still figuring out how this Blog software works.

Money

ewolfk — Sun, 24 Jan 2010 18:56:31 +0000

I’m doing a lot of thinking about how to structure my business – I want to do my part to make acupuncture available to all who need it, while also providing a pleasant and positive treatment experience, and also meet my financial needs.

I haven’t figured out any magic answer. I work best if I spend a full hour with each client and don’t have to divide my time between rooms. At the same time, the hourly rate I need to charge in order to do that is more than many people can afford. It’s more than I could afford if I were just starting treatment. Then again, for others it is just a tiny blip in their weekly spending.

I know many of my colleagues are struggling with the same issue, and the solutions we come up with all generate controversy. I’m impressed with the work done by CAN, the Community Acupuncture Network. Others in the acupuncture profession see their work as a travesty. I’m not ready to make such a drastic change in my practice style but they’ve given me a lot of food for thought. In many ways I was lucky to establish my practice during the boom years, but it let me get set in ways that aren’t necessarily suited for the recession years.

My first blog post —

ewolfk — Sun, 24 Jan 2010 15:53:59 +0000

This is mostly a test. I’ve got some good ideas for my first real post, but first I need to figure out how this works. Please check back later!