This is the first in a series of articles designed to offer advice on various aspects of clinical practice. The aim of these articles is to share some of the lessons I have learned, often from mistakes I have made, in my 16 years of private practice.I will not address issues relating to diagnostic and treatment theories, as there are many good sources for learning such matters. I also will not address business aspects of practice management such as insurance billing issues, etc. as there are also resources available for those subjects. Instead, I plan to focus on some of the subtle issues that acupuncturists working in the real world of clinical (especially private clinical) practice face: issues that fall between the cracks of Oriental medical theory and practice management concerns.
The advice I give in these columns will be just that - advice from my own experience. Others may have different ideas or experiences, and I invite them to write Acupuncture Today if they would like to share. While what I offer in these columns is geared primarily toward helping those newer to acupuncture practice, I hope that experienced practitioners may also pick up an occasional pointer or two.
Working as an acupuncturist brings many rewards (and a few disappointments). One of the more frustrating aspects of practicing acupuncture and Oriental medicine is that we are not always given the opportunity to help our patients as much as our training makes possible. Some patients will simply stop coming in for treatment, often without a word, if they do not see dramatic improvements after their first few treatments. Many of these patients would have started to see improvements had they only given the therapy a little more time. To begin this series of articles, I will offer suggestions on how you can get more treatment opportunities to help your patients.
While many acupuncture patients enjoy substantial relief of their symptoms after just one or two treatments, others - especially those who have complex, chronic conditions - require several treatments before even modest improvement occurs. Many of these patients have little or no insurance coverage; are not convinced acupuncture is a legitimate form of therapy; and, despite claims to the contrary, are secretly hoping for a miracle. This combination of factors puts acupuncturists under pressure to produce results with as few treatments as possible.
In addition to honing your skills in treatment techniques that may provide faster results and utilizing objective tests such as range of motion tests, it is also very helpful to hone your skills in measuring your patient's subjective complaints. This is important both to help you, the practitioner, measure the effectiveness of your treatment approach, and to help your patients realize when they are making progress.
Patients are often poor judges of their own progress. This being the case, you will encounter patients who, during the course of treatment, tell you they are not feeling any better when in fact their condition has improved. Many times, a patient has told me they were feeling no better since the time of their previous treatment, only to have their spouse cut in and insist that the patient has been noticeably better and able to do much more than they had before.
When taking your patient's history, ask what makes their condition worse. Do certain positions, activities or other factors aggravate the patient's symptoms? Make sure you note these factors and refer to your notes when seeing the patient for follow-up treatments. A patient with low back pain, for example, tells you that their back bothers them after sitting or standing for long periods, causing them to lose sleep at night. When you see the patient again for follow-up treatment and ask how they have been feeling since you last treated them, they tell you they are "the same." When you ask about each aggravating factor, the patients tells you that standing and sitting is still causing pain, but reveals that they are now sleeping well. The patient has improved, but doesn't realize it. Gently reminding the patient what they originally had told you about their condition helps them to realize they are making progress. This realization can make the difference in a patient's decision to continue treatment.
When describing the healing effects of acupuncture to my patients, I use the analogy that facilitating healing is like growing a plant. First, you must get the seed to germinate and sprout. This is like seeing even modest improvement in any of the patient's aggravating factors. The next phase is nurturing the sprout to grow. It is important to be able to measure any improvement in these factors, because it indicates the treatments are beginning to work and should be continued to help the improvement to grow.
In addition to identifying aggravating factors, I tell my patients we need to pay attention to five characteristics of their symptom(s):
- Intensity. This is the most obvious factor, and often the only one your patients will focus on.
- Frequency. How often do symptoms become aggravated?
- Capacity. How much of an aggravating factor does it take before symptoms are aggravated?
- Rebound capability. How quickly can a patient get back to normal functioning after symptoms are aggravated?
- Medication levels. Has the patient reduced their medication levels?
often explain to my patients that because acupuncture helps the body to heal itself naturally, they may not feel anything "healing" any more than they can feel a cut healing. I ask them to pay close attention to changes in these five characteristics in any of their aggravating factors, and to report these changes to me. I explain that any improvement represents a sprout I hope to make grow. I also warn them that the effect of treatment usually takes place day of (or the day following) treatment and may only last a day or so. This is important, especially if you are seeing a patient once a week or less. By the time you see them next, the patient may have had some improvement for a day or two, then regressed to their old levels. I make sure my patients understand that even a day or two of improvement is a much better sign than no improvement at all, and it gives us something to build on.
Because many patients see noticeable improvements in the first couple of treatments, I don't go through the trouble to explain the above until such time I sense a patient may be getting worried they are not progressing. I am also careful not to put words in my patient's mouths or suggest that a possible tiny improvement in their condition is a sure-fire sign they will be cured. I have found, however, that keeping careful track of my patient's subjective complaints and encouraging them to do the same can be the pivotal factor that convinces them to continue treatment.
Click here for previous articles by Matthew Bauer, LAc.