How Difficult it is to be Good at Acupuncture
At least once a month I get the question from a patient: “So… did you have to go to school to do this?”
No, I think to myself. I was just unemployed, and it was between this, Starbucks barista, or yoga studio receptionist. I’d never handled a needle before, nor studied physiology, but who needs to know physiology, am I right? This is just acupuncture.
“Yes,” I answer aloud. “To do this we need a Master’s degree in Science and Chinese Medicine. It’s four years of school – five if you’re like me and had to work concurrently as a Starbucks barista (while also pursuing an artistic passion). Then there are quarterly boards and national exams.”
“Really?!” the patient is astonished, predictably so in consideration of the question in the first place, and it takes all of my patience to not make the next point hurt just a tad bit more.
I kid. But it is a blow to the ego, to realize what percentage of the population figures what we do doesn’t require any education, let alone a Master’s degree. My wife is an MD, which means people meet her and assume she’s an amazing person of great brilliance. When they meet me they assume I am a fine person of great faith.
“Does that stuff actually work?” they ask. Then they ask my wife if she can offer any insight on some recent medical issue they’re having. Then she recommends acupuncture, because she happens to be an amazing person of great brilliance.
(Obviously) I’ve put enough thought into all this to have an idea where peoples’ shock and frustrating inquiries come from. (Almost) nobody understands what acupuncture is, or more specifically what it is not.
First, acupuncture is not a “new modality used just to treat pain,” which is closer to the definition of chiropractic, which might explain why society erroneously lumps us together, in spite of the two practices coming from different ages in history, opposite sides of the planet, and different paradigms of thought.
Acupuncture is an ancient modality, over 2000 years old, used to treat much more than just neck and back pain, and it is only one of the many parts of Traditional Chinese Medicine. Other parts are herbal medicine and moxibustion, Tui Na massage, cupping, and Qi Gong exercise, all to combine to form a profession that in my opinion gets rather sold short by the simplified title, “Acupuncturist.”
“Acupuncture” is one of the many forms of holistic medicine, but what does that even mean? Few people are able to define “holistic medicine,” most figuring it to imply not pharmaceuticals. It’s true, holistic medicine might employ herbs, vitamins and supplements instead of drugs, however this has nothing to do with its distinction.
“HOLISM” means we diagnose and treat the whole person instead of a biomedical diagnosis. This doesn’t mean biomedical diagnoses don’t offer helpful information, but for us they are only a starting point. We must spend time getting to know each patient’s unique physiological “pattern” in order to get an idea of how to treat. Five people with asthma may show five different patterns and get five different treatments. Believe it or not, the lungs are their problem only part of the time, whereas other times they are only the branch/victim of the root issue, which may be the kidneys, stomach, liver, or any combination of the four. There is no such thing as “the acupuncture point for asthma,” nor “the herb for weight loss,” etc. etc. This is why prescribing some “natural herb” for any one disease, such as turmeric for arthritis or ginger for indigestion, is not at all holistic medicine, as it disregards our primary principle – the treatment of patterns, as opposed to symptoms. The bad news is this is more challenging to practice. The good news is it means there is always hope, no matter the diagnosis.
My second favorite question from laypeople is: “Can acupuncture treat…?” and I enjoy always cutting them off with an emphatic: “Yes!”
My answer is not a business move, nor is it pie-in-the-sky naiveté, but instead based on logic. Every condition, whether the common cold or Parkinson’s disease, must exist within some physiological pattern, so the question is never whether or not something is treatable, but simply to what degree.
How severe is the case?
When did it start?
How often is the person coming for treatment?
How well do they take care of themselves in daily life?
Most importantly, how good is the acupuncturist?
In my first year out of school I used to treat a 60-year old woman whose chief complaint was panic attacks, recent onset, though her health was otherwise poor, which should tell any health care professional that this had been brewing under the surface for quite a while. She was anemic, pre-Diabetic and overweight, but her main concern was this newly constant, terrifying anxiety.
In spite of holistic pattern diagnoses, there are admittedly certain conditions that are easier than others to treat (with Chinese Medicine). Gynecology and orthopedics, for example, are relatively straightforward, whereas psychology is at the opposite end of the spectrum. It requires an exceptional practitioner with extensive experience, which did not describe me at the time. Still, we owe it to ourselves (and our employers) to try our best with every patient who walks through our door, just as we owe them our full transparency and a referral for a “second opinion” whenever we are unable to help.
Over the few months that this patient came to me she had a few improved weeks of relief, but most weeks were bad, symptoms unchanged.
Finally I conceded confusion and recommended she visit another practitioner. She glared back at me in utter confusion and despair. “You don’t want to see me anymore?” she asked, as if I were breaking up with her.
“No, it’s not that,” I explained. “But we’ve been working together long enough now that you should be improved. I just think you should give someone else a try.”
She looked as if I’d told her what we have to do is travel to the moon and engage in some ancient mud wrestling ritual to heal her condition.
“What is somebody else going to do that you’re not doing?”
Ahh, of course, I realized… she doesn’t understand Chinese Medicine – and why should she? She thinks I’ve been doing “the anxiety points,” or the panic attack protocol, and it’s “just not working.”
One of my teachers used to say Western medical school is much harder than Eastern medical school, but Eastern medicine is much harder (in practice). This is not to suggest that any doctor’s job is easy; but most people don’t realize how much their acupuncturist has to do right in order for it to “work.”
Ascertain a correct pattern diagnosis, which is subjective in the first place, hence harder than getting the results of blood tests or some other fancy technology that doesn’t exist in most Chinese Medical offices. It does very little for me to simply know you have an elevated A1C or ANA factor. I then have to determine whether it’s a result of your kidney channel, stomach, liver, a combination of those, or none of the above. I also have to decide whether your body is suffering more from blood stagnation, organ weakness, or fluid inflammation; or again and most commonly, a combination of a few.
Treatment principle: There are hundreds of acupuncture points on the human body. Fortunately most practitioners gravitate to the 50 or so they find most effective. Still, 50 is a big number, and we have to select which combination of a few will be ideal for the patient today. There are many styles of approach. Some practitioners use a lot of points, others use as few as six or even two (there is an elitism amongst minimalists). Some of us use wider, stronger needles (more Chinese style) – others use very thin, gentler ones (more Japanese). I’ve known both awful and awesome practitioners on both sides of these lines.
Point location: I once heard of a clinical study that found when we needle three or more centimeters away from the precise location of an acupuncture point it reduces the efficacy of treatment by at least 40%. Makes sense. Throughout schooling teachers and clinic supervisors would constantly correct us/me: “No, you’re off the point. It’s here,” and point their finger just barely adjacent from where I’d screwed up. Every body in the world is different, and although most intelligent clinicians can perceive point locations relative to every patient’s size and stature, no one bats .1000. I can personally attest to walking out of treatment rooms countless times after needling a patient, shaking my head in disappointment that I just “couldn’t get” a particular point that may have been key to the treatment.
Needle technique: There are free-handers and “tubers,” the former of which do not use the plastic guide tube to help tap the needle through the skin. I’m not sure if it ultimately matters, but most of my teachers whom I most admired didn’t use guide tubes, so I only do so as a last resort. Once the needle gets through the epidural layer there is a particular sensation, whether dull, achy, or radiating, that experienced practitioners intend to affect. This is called the “qi sensation” – that of the needle successfully stimulating the energy along the channel. It is thought by many that without a qi sensation the treatment is worthless. Unfortunately the majority of practitioners are either too afraid or unskilled to go for it.
Adjunctive techniques: To cup or not to cup? Cupping is generally indicated for blood stagnation, which is almost always present in orthopedic cases, but the more advanced practitioner knows when it might be applicable in other cases as well. Will massage or Qi Gong exercises help resolve an issue, and how effective is your acupuncturists’ (Tui Na) massage techniques? Finally, if you went for acupuncture for an extensive period of time and didn’t get desired results and didn’t receive moxibustion therapy then you can almost say you’ve never actually had acupuncture. “Moxa” is a technique of burning mugwort herb over certain points in the body in order to strengthen the corresponding organs and reduce inflammation – especially what we refer to as “cold, damp” inflammation. Basically, if your joints can inform you when it’s going to rain you need moxibustion. At its inception Chinese Medicine’s title was “Acupuncture and Moxibustion,” but most practitioners don’t use it. Why? Usually because they suck.
None of this should be taken as a slight on acupuncturists. Most people suck at their jobs. The majority of architects, fashion designers, writers, on-camera talent, musicians, presidents of the United States, lawyers, and western doctors are awful. However no isolated cases of the aforementioned fails cause any skepticism of the validity of any craft itself. Because of our breadth of experience, after leaving a bad restaurant we don’t doubt whether food itself can be enjoyed. We don’t see a bad TV show and decide we could never be entertained by television, and people surely see doctors for decades without improving and never cast a belief that western medicine does not work. As a matter of fact, most go the opposite direction and choose to believe they themselves do not work. They must be broken, their condition irrevocable, and once it’s progressed for decades and been complicated by the accompanying stress and infinite pharmaceuticals they come to me… and request I fix them in three sessions, lest it serve as evidence that what I do is fake. Nice.
We have to bat close to .1000. We must accurately diagnose, choose the 8-18 points we deem most useful, perfectly locate them, and ensure to get the “qi sensation,” so that the point has the desired effect. We have to determine whether the person needs adjunctive modalities and/or herbs, the latter of which bringing with it another crisis of paradox of choice, as there are many formulas potentially applicable for any one condition. Most patients require a several month long regiment wherein we must carefully peel through layers of the onion that is their pathology. If we accidentally peel an inner layers before an outer layer is resolved we can cause harm. Don’t get me wrong: Not nearly as much harm as do most pharmaceuticals, but the point is we must be more thoughtful with herbs than with acupuncture alone, the latter of which can almost never exacerbate an issue.
With such high demand for thoughtful precision one would expect our educational system to be quite impressive and refined. Unfortunately, as Chinese Medicine is still in practically its infancy stage of widespread acceptance and awareness, most of its academia… how shall I put this… sucks. Colleagues and I agree that we learned about 10% of what we should have relative to time, effort, and money spent in graduate school. For example, in 11 trimesters averaging five classes per the treatment of orthopedic disorders made up only one. Single. Class. Physical pain comprises probably 98% of acupuncture chief complaints and it was 2% of our education. Almost equally criminal were the two measly classes spent on manual needle technique, which is why most (new) acupuncturists can’t needle to save their lives (more importantly, the lives of others). In the financially motivated interest of attaining national accreditation, biomedical classes make up a huge portion of most schools’ curriculum. This leaves us with a more in depth understanding of science than the masses presume us to have, but usually lesser acupuncture skills than the minimal necessity. This is just part of the reason why many of us are constantly taking continuing educational seminars, and why now in my sixth year after graduation I still dedicate one day a week towards apprenticing, working for free in observation of different experts in the field. My wife also jokes that all I ever read is Chinese Medicine literature, as I perpetually feel there is still so much to learn. So please don’t allow one, two, or even ten disappointing experiences with acupuncture cause you skepticism about our paradigm as a whole, nor pessimism for your own prognosis. Chances are you just haven’t yet found the rare unicorn that is a great practitioner.