In Praise of the Lowly Clinician

I want to express my admiration for the acupuncturist/herbalist who maintains a practice, day-in, day-out, every week, save for those few weeks they can manage to get away. They are unsung heroes, often invisible in their communities, successful in their ability to persevere and keep the practice going. It is very difficult to maintain a clinic without the support of institutionalized medicine, and various stressors constantly challenge the independent practitioner.

First is the stress of keeping the calendar full. As the economy falters, people are holding their dollars close to their pockets. If patients perceive acupuncture/herbal medicine as a luxury, they will forgo it, as they might massage or facials. It is best to remember that we are providing medical services, healing ailments and injuries more effectively and with less expense then our Western medical counterparts. I think that the key to longevity in practice is making the effort to hone one's skills and increase one's knowledge by continually studying and applying what we learn. Another step is to cultivate the belief that the universe, the Dao, will send us those patients we are able to help or are meant to help.

A second stressor, quite significant, is dealing with the expectations and demands of our patients. While most patients are grateful both for the effort made and benefits perceived, we all have to deal with those patients who are either dissatisfied or impatient for results. Several factors have to be acknowledged. First and foremost, patients are paying for a service and should have reasonable expectations of success, and it's important for the practitioner to be clear about outcomes. For myself, I expect an 85 percent success rate for those cases I take on, and I explain to new or potential patients that I expect certain outcomes within a specified number of treatments or time frame. I explain how long I expect this to take and what the costs will be for medicines and lab tests. With acupuncture, I often propose that we try four to six treatments and see if that resolves the problem. These benchmarks offer the patient clear goals.

If I expect less that an 85 percent chance, I am careful to explain this to patients. Then it is their choice whether to proceed or not. If chances are less then 50 percent, I actually try to discourage them from pursuing treatment with me. In no case will I take cases that I feel I have little chance for improvement, and for me, this includes neurological conditions such as Parkinson's, stroke, Alzheimer's or problems due to genetic defects. I also try not to take on patients whose problems are due to over-medication with Western pharmaceuticals, unless they are willing to wean themselves off.

As far as demanding patients, when they are unreasonable, excessive, or time-consuming (such as repeated phone calls or e-mails), one needs to exert diplomatic skill. It is always best to acknowledge their concerns or do your best to respond, even in limiting ways ("We'll talk about in more detail on your next visit"). However, some patients cross a line in their demands, and it is important to set up boundaries. Often, a gentle but clear rebuke is all that is needed to remedy the situation, but occasionally, it will be necessary to terminate the relationship.

I wonder sometimes if patients demand from regular medical doctors some of the things that they demand from me. I know of some practitioners who go overboard in responding to the needs of their patients, and I actually admire them for their patience and willingness to be available. (I don't think I can include myself in this group.) Every practitioner will have to decide what is acceptable, but it usually incurs consequences if you respond rudely. I do know from experience that there are patients who are trouble from the get-go (they gravitate to alternative practitioners because their demands or behavior are not tolerated in the institutionalized or conventional medical world). It might be best to weed them out over the phone before actually seeing them.

Another stressor is the lack of respect offered by the general medical or scientific community. In my 30 years of practice, it is quite rare that I get a referral from a medical doctor. I have cultivated good relationships with several doctors in my town, but if I get a referral, it tends to be for patients who have difficult personalities, rather than difficult conditions. Worse are negative comments from physicians about Chinese medicine.

A woman once brought a two-year old little girl to me. She has a history of eczema, ear infections and wheezing, and the medical approach had been repeated antibiotics and steroid inhalers. The mother was tired of this medical merry-go-round and was pleased that I was able to address her child's case differently and effectively. However, she came in with deep doubts one day when her pediatrician told her that Chinese herbs would cause kidney failure in young children. I was furious and told the patient that I am an authority on Chinese herbal medicine and that if her doctor made such a statement, she should be able to produce scientific evidence that supports it. This sort of doctor relies on urban myths that permeate the medical community without evidence. (Another urban medical myth is that antioxidants and Chinese herbs inhibit the effects of chemotherapy, when the literature shows that they actually enhance the efficacy of chemotherapy.) I reminded the woman that her daughter was improving with my treatments, and the Western treatment had continually made her daughter sick. She had decided to continue working with me.

It is discouraging that the medical community holds us in low esteem. The answer, besides talking directly with medical providers, requires national efforts to bring TCM into the scientific mainstream, but this will be over a long time period. When my work is personally questioned, I respond by citing various scientific articles or books that support the validity of what we do. I will send letters and articles to physicians to try to clarify the situation and this usually results in quieting the criticism. It has not necessarily resulted in actual referrals from those doctors. In fact, conservative physicians won't start referring until they have experienced benefits from TCM treatment for themselves or their family members.

Other stressors plague the dedicated practitioner. Mountains of paperwork that accumulate from faxes, e-mails and post, need to be sorted through. Most of it is neither interesting nor useful, but we still need to go through it for that occasional important notice. Then there are the time requirements of the pharmacy, keeping in stock medicines that we like and managing custom prescriptions. For myself, I have a pharmacy with 500 herbal products from various manufacturers, about 60 of my own tinctures in large 16-oz. bottles, and then 250 individual herbs in extracted powder form that I use for custom prescriptions. When I can, I'll find a student to help make the custom prescriptions, but it is often up to me during my evenings or off-days. I greatly enjoy designing a custom prescription. As an herbalist, I consider my prescriptions to be my works of art. But it can take 15-20 minutes to put together a formula, and much more time keeping the pharmacy in stock. All this takes time away from doing something else.

So yes, my hat is doffed to the "lowly" clinician. I use this adjective in good humor, and proudly include myself in this category. The practitioners in the trenches have my utmost respect. One is often dealing with complicated and challenging medical issues, and patients in discomfort demand our utmost attention and care. We don't have society's enthusiastic support nor do we see the financial rewards that medical doctors earn.

However, our work is effective, and we often achieve our patient's heartfelt gratitude. If it's any consolation, one should remember that our work is more than just providing medical services to our patients. We are also carrying a candle for our art, keeping alive the tradition of the Chinese herbalist. This tradition has historically offered various models: the respected house physician to the aristocracy, the Confucian scholar or the Daoist recluse interpreting the relationship of the macrocosm to the microcosm, the humble shopkeeper with a table in the back for pulse diagnosis, the dedicated barefoot doctor providing health care to rural peasants, the modern hospital physician treating serious disease and injury without Western pharmaceuticals. We are a continuum in a long line of dedicated practitioners of traditional Chinese medicine. That posture, whether recognized by society or not, has deep meaning and offers deep purpose. This is our real reward.