An acupuncture colleague just quoted HIPAA regulations to get "Mr. Joe Six-Pack" out of the treatment room so she could work with his wife after he demanded "needle those points to make my wife lose weight and increase her libido."
A Shiatsu colleague managed to get the wife of his client to stop rubbing her husband's head and leave the room during a house call, by telling her that two sets of hands working simultaneously on a client just fragmented Qi. "I don't even allow two of my students to work on the same person at the same time," he told her.
Clinical Characters
When I taught in Montreal Canada, the husband of one of our students stormed into the school one day and threatened to beat up the owner because "whatever you are teaching my wife is changing her personality." We all guessed he was losing control over her.
Certainly there's an art in dealing with the "spouse" in clinical practice beyond just suggesting they pop out for tea with reading material about Asian medicine. Generally I never allow a spouse, parent, sibling or offspring of a client to observe a session unless they are caregivers who could learn some specific acupoints to help ease a physical challenge or chronic pain. But I'm mindful of the dynamic in the relationship.
I use these examples along with a fistful of other clinic characters in my ethics classes so students can role play or brainstorm potentially complex situations. Other clinic characters include "Ren One Ronnie," "Inner Thigh Theo," "Ken/Kate-30-minutes-late," "Early Ernie/Enid," and "Phone-Therapy Phil." We have fun discussing resolutions for such potential scenarios before diving into deeper cases, which I get students to select out of a bag.
Such as what to do when a terminally ill client in severe pain asks you to focus on points to hasten his/her end. Or what to do when a client suddenly becomes aggressive, or flirtatious in the treatment room. Our role playing/or brainstorming helps students think fast on their feet and prepare for the unexpected.
Prepping for Clinic
How far should clinic prepping go? What sort of psychosocial training did you have to prep you for student clinic, and for your future professional clinic? Those of us who trained several decades ago had no such formal training said, Yolanda Asher, Chair of the AOBTA (r) Ethics Committee. "But instructors did speak about difficult scenarios with clients, and that was helpful." The CEU training in ethics in such issues she finds "quite valuable and important."
Do you feel our ethics requirements for NCCAOM Diplomate renewal or to renew a state license are sufficient? Do all of your students have access to a list of community resources and hotlines for adults and teens for vital referrals when necessary?
Hopefully those of us with several decades of clinic experience under our belts are among instructors who teach such topics in schools of acupuncture and ABT. And share experiences widely and generously with peers. Certainly it's what inspired me to select scores of real life examples from my own experience, and the experiences of licensed acupuncturists and ABT colleagues to weave into global ethics classes and discussions. I've addressed this and extreme cases in AT columns in the past decade.1-3 But I am expanding the topic now because time and again colleagues and graduates – here, and in Europe – ask my advice over cases they have found difficult to resolve.
Consult a Social Worker
I always advise graduates to seek out a streetwise social worker when grappling with gray areas or situations of concern in clinic. AOMA's students reap the benefit of Julia Aziz who is a licensed clinical social worker and supervisor, who has a holistic psychotherapy practice. She teaches 96 hours in AOMA's Integral Studies department, which includes Ethics, Clinical Communications, and Case Management. Her extensive background includes individual and family counseling, rape crisis, hospice, community outreach, domestic violence, and counseling survivors of child abuse.
The first course Aziz designed at AOMA is called Psychology and Clinical Communications in direct response to some of the challenges she saw students facing in clinic. She spends the first half of every class "exploring a relevant topic, for example, developing trust, professional boundaries, grief and loss with chronic pain." She adds, "students look at current scientific research, theoretical perspectives in psychology and alternative ideas on the topic, while also examining their own clinical experiences thus far." In the second half of the class, Julia focuses on challenging cases from student clinics with each student taking turns presenting a case.
We agree that other schools contemplating expanding similar programs, should be encouraged to: a) Maximize case study material for students to brainstorm/or role play, or b) Appoint someone from outside of Asian Medicine – or with a combo of social work/psychology and Asian Medicine - to run such programs.
Aziz added, "I consult with other health care professionals all the time, and I think the time is ripe for developing a new model of compassionate, empowering patient care. I think it would be great for clinic supervisors to have annual training on these issues, to give them an opportunity to consult with mental health practitioners on challenging situations."
Her advice is mirrored by Debra Persinger PhD, executive director of the Federation of State Massage Therapy Boards (FSMTB) who said, "its important to seek out interactions with peers to share challenging clinical scenarios. Often the best learning comes not from what to do but what not to do. People underestimate the need for professional training in handling both simple and complex psychosocial clinical presentations."
What if Students and Supervisors Disagree?
Ah yes, this does happen, especially if some supervisors did not receive in depth psychosocial instruction at school. I remember the time a student in another school where I taught was concerned about a depressed client who appeared in clinic, only to be told by the supervisor, "Why are you depressed? You have a wonderful son," as though that was the gold standard for happiness.
In another case a student argued with a supervisor about a senior client he suspected was being physically abused by a daughter, but the supervisor said the bruising on the client's arm was caused by blood thinners. The student insisted he picked up on clues because he spent more time in the treatment room whereas the supervisor just popped in and out. A delicate situation, resolved when the student talked to the clinic's dean.
One general suggestion is for students and supervisors to plan brown bag lunches for open and hearty discussions about complex issues in clinic. The worst thing is for a student to feel silenced or alone with unresolved concerns.
References
Ferguson PE. Troubled Patients. Acupuncture Today, July 2012.
As modern medical standardization continues, the field of traditional Chinese medicine has the advantage of comprehensive personalization. For rare or complex cases, deeper consideration of constitution is invaluable. Proper constitutional assessment, especially with first-time clients, can guide desirable and predictable outcomes. This leads to a higher rate of return, and greater trust between you and your patient.
Though the creation of a financially sustainable, health-promoting model feels far away today, we are casting a vision for a full return on health, believing that this compels us to keep one foot firmly rooted in caring for the sick and the other foot firmly founded in maintaining health. Shifting from a fee-for-service model to value-based care using a phased approach is paramount.
Traditional Chinese medicine and the Vedic traditions both offer rich frameworks for understanding human health, emphasizing the balance of physical, mental, and spiritual aspects. The concept of "souls" or spiritual components in TCM, namely Hun, Po, Shen, Yi, and Zhi, bears significant similarities to the yogic concept of koshas. Their similarities and differences provide insights into how these systems contribute to holistic health practices.
