OK, I’ve Built It; Now Where the Heck Are They? (On Growing a Patient Base, with a Bit of Reflection on Somerset Maugham)

This is a blog post I've been meaning to write ever since our trip to San Francisco; it's a subject that came up in lots of conversations there with different practitioners. I've been feeling bad that writing this post kept getting displaced by other things I've been doing, because I know that attracting patients is the number one issue for new clinics. It's what everybody worries about. And new clinics succeeding is more important to me than anything else; I would never want to give anybody the impression that talking to the "leaders" (whoever they are) is more important or more interesting to me than the basics of this revolution, which is acupuncturists making a living by treating ordinary people. Because that would mean my priorities have gotten screwed up. And if my priorites ever get screwed up, I'm counting on my comrades to call me on it. What are friends for, right?

Happily, however, I can see that everything really is connected: the leadership of this profession (or the lack thereof); the leadership's priorities, or lack thereof; and where the rubber meets the road -- the success on the ground of new clinics. Right now seems like the most opportune moment for this long-delayed post.

WCA has been open for five and a half years (Good Lord!) and I have had lots of opportunities to reflect on the dynamics of how the schedule book fills up or empties out. Some of those opportunities occurred early on when there was nobody there for me to treat, the phone wasn't ringing, and there was pretty much nothing else for me to think about. It's hard to think about anything else when you are staring at the possibility of failure at uncomfortably close range.

As far as I can tell, an empty appointment book is caused by three categories of potential issues, with one general qualification.

Let's get the general qualification out of the way first: life is cyclical. Things change. Things go up and down. If you don't believe me, ask the I Ching. No matter what else is going on, there will be some oscillation of patient numbers in any practice. There will be slow times and peak times. That's just how it is. If you want to eliminate that element of fluctuation, you are going to need to find another dimension of reality to put your practice in.

For those of us who will be staying in this dimension, the question really is -- how slow is slow? How do I arrange things so that "slow" is not an economic crisis? This is where I think the three categories of causes-of-an-empty-appointment-book come in, and they are:

1. Energy (Yours)

2. Ambivalence (Also yours)

3. Structure (which is really a combination of the first two, and still yours.)

The general qualification, that patient numbers will oscillate, has to do with other people's energy, other people's ambivalence, and other people's structure. Practicing medicine, unless you are a veterinarian, means dealing with people, and people are an unreliable lot. If they were more reliable, they would have less need of healers. So your patients' inability to focus their energy, clarify their intentions, resolve their ambivalence, and organize their lives -- everything that leads them to not make appointments with you -- is just what you signed on to deal with when you decided you wanted to be a healer. Hey, nobody said this was a glamorous job (well, actually, some people have kind of implied that, but they are full of ****.)

Okay, back to the categories. Number one: energy. If you are tired, divided, or distracted, you will have fewer patients. If you're VERY tired, divided, or distracted, you will probably have no patients at all. Many new practitioners are very tired at exactly the time when their clinics open -- because they've been doing all the work to get their clinics ready. Or they have just graduated from school. They're tapped out. The only remedy for this is rest. (Hard to do when you are worried about money, I know, but there it is.) If I teach a weekend workshop and try to see patients on Monday morning, I'll be looking at a lot of empty slots. Recently we changed the schedule at WCA so that I don't work Monday mornings anymore -- it was kind of pointless.

Similarly for divided or distracted -- if something else has major claims on your physical, emotional, or mental energy, your patient numbers, or lack thereof, will reflect that. Every year in the fall, Skip's patient numbers take a big dip on Wednesday mornings -- it's as reliable as the almanac. That's because cross country season starts in the fall, and 2 of our 3 kids have been cross country runners. Wednesday afternoons are when the meets happen, and Skip goes to all of them, like the very supportive dad he is. On Wednesday morning, his energy is not really in the clinic -- it's already directed toward the Franklin High Cross Country Team. So patients don't show up.

If you're like me, you may not really realize that you are tired, divided, or distracted, until you look at your mysteriously empty schedule. Then you may say, aha.

Now for #2, ambivalence. This is a tough one to talk about -- it's hard to be honest enough without making people angry or frustrated. This is where Somerset Maugham's book The Razor's Edge comes in handy. I read this book because my meditation teacher recommended it, and it's not just because the title comes from the Katha Upanishad; it's because the conclusion of the book is that in life, people basically get whatever it is that they truly want. One reason that you might not be attracting patients is because you don't really want them. Don't scream; let me explain.

This is where some seemingly disparate issues come together. Many students were taught in acupuncture school that doing a good job with patients means doing things that in their heart of hearts they don't really want to do. Furthermore, a lot of patients don't really want you to do them either. But that is a bit of an aside, because what matters here is what you want. If you really believe that to do a good job with a patient, to give him what he really needs, you have to spend an hour talking to him, carefully pore over his medical history, come up with a perfect Zang-Fu diagnosis, do half an hour of Tui Na, and write up a brilliant herbal prescription, all the while fluffing his pillows attentively, do you still want to see him? How about him, his wife, and all their friends and relatives? Really? Do you feel a tiny internal cringe when you think about what it would really mean to do treatments like that over and over? For years? I feel more than a tiny cringe, I feel a wave of exhaustion and hopelessness engulf me when I think about practicing like that. The hopelessness comes from knowing that a whole lot of patients don't really even need all that -- not to mention can't pay for it --but if I really believed that's what a "good treatment" is, I'd feel compelled to do it.

Hello, ambivalence.

It's ironic that, in general, the people in the acupuncture profession who define what a "good treatment" is are not actually practicing full time. They are teaching in schools, or on the CEU circuit, and they're teaching a mode of practice that is impractical and unsustainable. They're being paid to create standards which they have no intention of upholding themselves -- except sporadically, in the tiny private practices that they don't need to depend on to make their living. Sometimes they sprinkle a little salt in the wound by commenting gravely and sadly on how many acupuncturists burn out over the long term.

Then there's ambivalence part two, which I thought about as I was talking to a new CAN practitioner who was worried about her lack of patients. "The other thing is that there are so many other acupuncturists around here, " she said sadly. "I don't know if I can even break in."

The important thing to remember here is that the patients that you really want are not the patients who would be thinking of going to an acupuncturist. They are not the people who are concerned about their health, who are investigating their options, who are hanging out in natural food stores and surfing the Internet for information about whatever condition they have. Well, you might get a few of those. But they are not your patient base. Your patient base is made up of people who are in pain, who are stressed, who are desperately worried about being able to get better so that they can go back to work, who couldn't care less whether what helps them is "natural", unnatural, or polka dotted with green stripes. They just want to feel better. Those are the people who really need you.

When Michael Smith of NADA called me last week about the open letter, he waxed poetic about the troubles of our profession, and among them he included the problem of "treating groupies". I wouldn't have thought of it like this, but I thought that was a great term. He mentioned a patient at a student clinic who said she had seen FIFTY SEVEN DIFFERENT ACUPUNCTURISTS. "How can you possibly evaluate a patient like that?" Michael said. "They're too busy evaluating you." When I was in school, this was what I learned too -- that I needed to target the patients who were savvy enough to know that they needed me, who were sophisticated enough to really value my services. What I learned later was that those were the patients whom I was least likely to be able to help -- in part because they weren't really sick, they were mostly bored. "Natural medicine" is a hobby for a certain group of patients; it's a lifestyle accoutrement. It has nothing to do with need, or pain, or really, with medicine. If that is who I thought I was supposed to be treating, my schedule book would be empty too. Because I don't want to be a lifestyle accoutrement, I want to be a healer.

One thing here that you have to know is that building a patient base out of people who really need you does not happen over night. Because they don't know anything about you; they haven't seen 57 people like you and it will take time for them to understand what you have to offer. Once they figure it out, though, they will overwhelm you with their devotion, their goodwill, and their commitment to your practice.

If your schedule book is chronically on the empty side, it's worth doing a really thorough internal inventory of what you think a good treatment is, who you think you are supposed to be treating, and whether, honestly, you really want to do those things and see those people. It's damn hard to manifest work that you don't really like. (Thank you, Somerset Maugham.) To figure out what you do like and what you can do, you may have to spend some serious time and energy de-programming yourself. Think about where you got your ideas about what acupuncture is. Was it from someone who was actually doing acupuncture? How much acupuncture? For how long?

Okay, on to structure. Structure has to do with what happens once you have attracted a patient to your clinic. I learned my big lesson about structure when I was working in my practice pretty much alone (Skip was still paying our mortgage by doing public health.) I had gotten up to a steady 30 patients a week and I couldn't get beyond that. The day that I figured out why, I had one patient waiting for me to treat them, I was trying to schedule another patient for next week, I knew that we had just run out of toilet paper in the bathroom, my landlord was coming in ten minutes to try to fix a problem with our electrical panel, I had a stack of filing that was spilling all over my desk, and the plants needed to be watered -- dead leaves were falling on my pile of filing. And then the phone rang. I picked it up and snarled, "What! What do YOU want!"

That night I begged Ilse, my neighbor, to come in and answer the phones for me. I thought she'd be great at it, and she was -- but it really didn't matter, as she certainly could not have been worse than me.

If the structure of how your clinic handles patients is exhausting for you, you will have trouble attracting patients, because on some level you won't really want to see them. If having patients in your clinic means that you have to do things that you really, really don't want to do -- like, in my case, answering the phone or otherwise multitasking-- you will not attract patients. Not because you don't like doing acupuncture, but because you don't like doing what goes along with doing acupuncture.

For your structure to attract patients to your clinic, the structure itself needs to feel simple, pleasant, and easy both to you and to your patients. Ask yourself -- do you like your structure? Really? Are you expecting too much of yourself or of anyone else? Is it time to ask for help?

I would love it if other CAN practitioners who have seen their patient base grow would contribute comments about the process. I'm sure I left out things that would be really important to folks in the start up stage, and as I said in the beginning, I'm counting on all of you to notice any lapses from me.