The Ethic of Collegiality

When I graduated from the New England School of Acupuncture in 1998 and moved to Portland, Maine, to set up practice, I viewed other acupuncturists in that town as competition for scarce acupuncture dollars. Because I was new, scared and broke, I wanted my business cards and brochures to be the only ones in the local health food store and elsewhere.

Despite several months of that kind of negative thinking, I began to meet fellow practitioners. A group of six of us formed the Portland Acupuncture Network and met monthly to work on and accomplish various projects: an Acupuncture Day in the rotunda at the state Capitol to educate legislators about our profession; an acupuncture booth at the popular Common Ground Fair; joint-effort health fair tables; and peer review on difficult cases. I quickly discovered that these other practitioners were not only truly interesting people, but also good sources of information, support, ideas and friendship.

I'd also resisted joining the Maine Association of Acupuncture and Oriental Medicine (MAAOM). But after a few years in practice, I got talked into not only joining, but also serving on the board as secretary. I thought it would be a piece-of-cake job, but the association immediately launched the biggest, most strenuous legislative campaign in the history of Maine acupuncture in order to get an improved, expanded scope-of-practice bill passed, and I got swept along.

What an education we all got! It was a long, uphill battle against numerous groups that opposed our bill, including physicians, chiropractors, naturopaths, dieticians and even massage therapists. Over the course of more than a year and many meetings on this bill, which passed successfully two years ago, I learned that professional community and collegiality are worth a whole lot. I got to know fellow practitioners as earnest, dedicated, generous, talented and supportive friends. We all learned from each other.

For years, the Maine association was a rather fractured, contentious group; but in pulling together to get the legislation passed, we formed bonds and generated bold new energy and cooperation for working on things such as closely located CEU classes; regional group meetings in a very large state; new practitioner advocates; discounted rates for supplies, classes and malpractice insurance; an improved Web site; an e-mail newsletter; a Web-based information center; and monitoring of both the acupuncture licensing board and workers' comp meetings. Not all efforts met with entire success, but the enthusiasm was infectious and spilled over into my own practice. I felt renewed energy and a sense of support and community.

I moved to the Northwest before my term as secretary of the MAAOM was finished, and in the two-plus years of building my practice here, I've felt the loss of those relationships with my Maine colleagues. To be part of my new state's professional organization would require a four-hour round-trip car ride, and that has seemed daunting. But I've met several of my friendly local fellow practitioners and plan to work toward building a small regional group here, just as we did in Maine, because without such professional connections, I will begin to feel isolated and burned out in my work.

In the meantime, I feel distressed by occasional stories of fractious, undermining, and possibly unethical behavior within the acupuncture community. A newly graduated acupuncturist, working hard to establish her new practice, received a call from a woman asking about her services and approach to the healing process. The two had a warm and productive conversation, and the woman ended up booking an appointment, saying she'd been seeing another acupuncturist for some time, but was ready to try a new approach to resolve her symptoms. Without naming the acupuncturist, she said she felt he'd sometimes rushed her through the sessions, was often arrogant, and didn't always listen to her. In addition, she felt she'd be more comfortable seeing a female practitioner.

Within days, the woman called back to cancel the appointment. She'd talked with her previous acupuncturist about terminating with him, and he called into question the wisdom of the patient's transferring to the new acupuncturist. He strenuously pointed out to the patient that he himself was much more experienced, had been a faculty member of an acupuncture teaching facility, and treated several locally well-known people as patients, whom he named. He said that the other practitioner was brand-new in the field and didn't have much experience, and that this woman would really be taking a chance with the quality of her health care.

The woman, flustered, decided that the more established, better-known acupuncturist was a safer bet, even while expressing regret to the new acupuncturist for not having the opportunity to work with her, because, she said, "I thought we clicked on the phone. I truly felt as if you heard what I was saying and that what you do would help me."

In practice, we might hear horror stories from patients about feeling offended or adversely affected by the behavior of another practitioner. Among the stories are those involving demonstrations of poor boundaries, unprofessional appearance or demeanor, work that is too abrupt, rough or painful, advice-giving on matters outside the scope of practice and prejudicial comments from one practitioner about another practitioner.

Professional ethics dictate that we, as health care providers, have a system for peer review and intervention when fellow practitioners operate in a manner that is unsafe, inappropriate, illegal or unethical. But how do we handle the issues of unwarranted prejudice, badmouthing and unfair competitive practices that occur within the profession? How do we monitor the ethics of an individual practitioner who chooses to ignore the concepts of collegiality and professionalism in favor of economic gain, perhaps at the expense of the patient's right to appropriate services?

Since a power differential exists in any therapeutic relationship, patients will be disposed to respond to their practitioners as they do to other authority figures, no matter how much a practitioner might stress the idea of a partnership in the process of healing. The patient seeks treatment in the hope that the acupuncturist will know what is best, and will therefore defer to the practitioner's judgment. This perception puts the patient in a most vulnerable position. In some cases, it will be difficult for the patient to say no or to question the practitioner's opinion, even if the patient feels uncomfortable or mistreated.

It is the practitioner's ethical responsibility to use his or her power only to serve the patient. Beyond that, however, certain personal qualities of the practitioner appear to facilitate a patient's ability to heal, among them the characteristics of honesty, tolerance of and respect for others, fairness, personal responsibility and empathy. While education, acquisition of information and years of experience are important influences on a practitioner, they are not necessarily correlated with a practitioner's success in producing positive outcomes. Psychotherapist Carl Rogers observed that a therapist's empathy, non-possessive warmth and personal genuineness were the factors most closely related to a patient's behavior change. Similarly, an acupuncturist's ability to connect with and respond to a patient can be much more important than years of practice, teaching credits or fame of patients served.

We acupuncturists have a shared responsibility to strive for the highest standards of professionalism and ethical behavior, including that of collegial respect, regard and support. The profession is faced with encroachment from several "outside pernicious influences," including the American Medical Association's latest efforts to restrict our ability to get licensed and to practice; and then we find sometimes oppositional factions within our own structure: TCM versus Five Element, Japanese versus TCM, established practitioners versus the upstarts. Territoriality often rears its ugly head.

As both catalyst and partner in the healing process, we practitioners must proactively anticipate, identify and effectively meet patients' needs. Our mission as acupuncturists should be to protect and promote the health of our patients and facilitate community and practitioner wellness; to preserve professionalism, autonomy, and the integrity of the practitioner-patient relationship; to maintain a voice concerning all issues related to the profession of acupuncture; to educate the public and the practitioner; to cooperate with other state and professional organizations; to promote economic viability of all practitioners; to promote quality health care; and to encourage collegiality in the acupuncture community.

Collegiality means valuing diversity and recognizing the bare fact that everyone - each practitioner - has something different and important to offer. Collegiality means being open with others, sharing with them and collaborating for the good of the profession, including acting as guides or mentors. Our shared expertise and wealth of knowledge can make our profession strong and much more viable in the field of health care. A focus on the concept of abundance for all, rather than territory or turf, will serve us better than a divisive, suspicious, backbiting approach to practice. The energy we acupuncturists create through association with each other makes us better practitioners individually and stronger as a profession.

The NCCAOM Code of Ethics commits us in general to "continue to work to raise the standards of the profession" and to "use appropriate professional mechanisms to report ethical and professional practice violations." Acupuncturists must realize, however, that without specific guidelines on each issue that arises, it is invariably each practitioner's responsibility to be acutely mindful of the potential ramifications of every action, every remark, every suggestion or piece of advice. We are in a position of influence that must be held with awe and reverence. Derogatory, harsh and belittling comments about another practitioner affect not only the practitioner being maligned, but also the patient and his or her ability to make appropriate choices.

In the spirit of abundance, collegiality and professional strength, we would do well to attend encouragingly to our fellows in practice and to gain, not lose, from the notion of networking, learning from our peers, and renewing ourselves through professional affiliation and support.