Cook times for Patients: They're Done When the Little Red Button Pops Out

When Less is More

I know that we were all taught in school that "Qi takes 20 minutes to circulate through the body". This has lead to the idea that everyone needs 20 minutes with the needles and then get them up and send them on their way. Many community acupuncturists (contrarians that they are!) leave people for as long as they don't need the chair for someone else, leading to two hour cook times. 

Some of my colleagues and I have noticed that, again, one size does NOT fit all. Many patients will do better with a shorter "cook" time. In my experience, those patients who have low blood sugar, are more frail, are elderly, those going through chemo and those who are fighting off external invasions generally do better with less time. Just like "it takes money to make money", it takes Qi to move Qi around. If you don't have much Qi to begin with, you don't want to go using it up by leaving someone too long with needles. 

One of my SWAC instructors taught that tonification must be done in many short bursts over a long period of treatment. This seemed counter-intuitive to me at the time, but now I get it. I, myself, have had several experiences of having acupuncture before lunch that left me wiped out. (This is an example of having your blood sugar too low for acupuncture.) I felt really relaxed, but also like I needed to go home and take a three hour nap. If your patient feels this tired after acupuncture, they have been over-treated. Next time use fewer needles or less time or both. 

Communication is Key

There are some people who don't fit any of these criteria who still do better with less time. One of my patients seemed like a very "excess" case at first: heat, phlegm, Qi stagnation. My inclination: sedate! Use lots of needles! One hour cook time! Said patient complained of feeling exhausted and foggy-headed. After working with this individual for a couple months, we narrowed it down to no more that 12 needles for no more than 2 minutes. Basically, I put the needles in, stand quietly for a moment, remove the needles, and my patient feels fantastic. I had another patient who said she felt like she was taking off in an airplane after just 15 minutes. It was an uncomfortable sensation for her. We shortened her time to 10 minutes and she felt relaxed and refreshed. 

On the flip side, I have had people ask me to leave them for a longer period of time. One of my patients told me he feels like he needs about an hour for his body to "hear the story the needles are telling". Folks who are more excess and those who take a while to calm down seem to do better with a longer time with the needles. 

Cook times can change, too. One of my regulars who tends to crash out for 45 minutes got very agitated 20 minutes into a treatment. He got angry, in fact. After I pulled the needles he calmed down and said that he just felt like "he needed to get up and go!" Patients who are more sensitive will learn to tune in to their bodies. The cues are different for everyone. Feeling antsy, suddenly awake, and energized are the ones I've encountered most often in clinic. 

Setting Expectations

I referred a friend of mine to a community clinic in another state. She's 80 and suffering from arthritis and fatigue. The acupuncturist told her to lay back and relax. The room was full of other patients when she received her treatment and she dosed off to sleep. When she came to, it was an hour and a half later and there was no patient or acupuncturist in sight. She began to get frightened and didn't know if she should call out. Had she been forgotten? When I heard this, I was upset for a number of reasons. First, you should always let your patient know what to expect. Second, (in my opinion) no acupuncturist has any business leaving an 80 year old with needles for that long! 

I let all my new patients know that I will come check on them in 30 minutes. After their first visit I let them know they are welcome to stay longer or shorter if they wish. I tell them I usually see people become deeply relaxed or doze off and then become wakeful for seemingly no reason. I think this is the body's way of saying: "Got the message, thanks! I'm done!" On average, I leave folks for 45 minutes, but I always let the patient tell me what's better for him or her. I never let anyone go longer than an hour and 15 minutes. Sometimes, I'll pull the needles out and let my patient continue their nap.

Wireless Doorbells

My thanks to Jen Alberti at South Shore Community acupuncture for pointing out the wonder of wireless doorbells. These little guys only cost a few dollars and can be picked up by a wireless receiver in your office or charting area. They are especially nice for patients that you have left facedown on a massage table. There's nothing worse than needing to use the restroom, feeling claustrophobic or realizing you need to pick your son up from daycare in 5 minutes when you're helpless and full of needles. At Left Hand, we leave one with almost every patient. That way they can ring us when they're done. If you're low tech, you can let your patients know that coughing repeatedly will bring you running. 

Hello again

It's been a long time and I feel guilty for not keeping up this blog as I had intended. Part of why I started writing it was I had things to share that I felt would benefit other people. I find myself having things that I want to share again. They say that life is what happens when you're making plans. It's also what happens when you're not writing blogs! So, welcome back.

Balance Method Made Easier

Hey all you Dr. Tan fans! 

My buddy Eric Sherrell (http://www.sherrellacupuncture.com/) presented a webinar yesterday on an easier way to remember the balance method through ELotus seminars. I'm hoping they will put it up on their free TCM Wisdom Tube archive soon. Check to see if they haven't posted it by next week, if they haven't, bug them! You will have to register, but it's free and totally worth it. 
http://www.elotus.org/tcm-wisdom-tube

It's hard for me to get away from my business for continuing education, and ELotus makes it easy to get at least some new learning in on a lunch hour.

In his brief presentation, Eric shows how (yes) there is a pattern to Dr. Tan's first five systems. He shows an easier way to remember the systems and makes it kinesthetic. It will still take some learning on your part, but definitely better than rote memorization.

I figure I will commit the Yang Leg and Arm portions to memory first seeing as Yang channel arm, shoulder, back and leg pain are a good deal of what I treat. 

Hometown Wyoming, pop. 25,000

Unknown asks:

"I am going back to my hometown in Wyoming (population 25,000). Just curious why you think starting a practice in a place like this (Nome was your example) is a bad idea?"

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As Joe Friday in Dragnet says: “Just the facts, ma’am...”

1. What other towns are in close proximity to Home Town, WY? Can you poach of off them? Will they drive to come see you?
2. Are you planning on joining an established practice with a chiropractor or massage therapist? This could work to your advantage. 
3. How many other established chiropractors, acupuncturists, massage therapists are there in town? How many of them will be willing to refer to you? (See also my post “A Tale of Two Cities”) 
4. How well liked are you in Home Town?  If you are well liked, assume you can attract a few more people to your practice.
5. How many people in Home Town, WY are going to think that what you do is voodoo and will never come to see you no matter how poorly they are sleeping or how bad their back is hurting?
6. What is the median income of the folks in Home Town? I ran the numbers for  what I considered to be an average four-person family through http://www.disposableincome.net/. It was quite humbling to see that this family would need to be making $65K a year to afford weekly acupuncture for one family member. Also keep in mind most folks don’t have an “acupuncture budget”, a chiropractic budget and massage budget, they just have X number of dollars at the end of the month to spend on their health and wellness. (or clothes or video games or mini golf)
7. How hard are you willing to work to promote your business? Nights, weekends?
8. Do you want to do acupuncture full-time or part-time? Would it be acceptable to work at the bank two days a week and work at your practice three days a week to live in the place you love?
9. Based on the information you’ve assembled above, how many patients do you think you can get in the door each week? How much are you planning to charge each patient? Are you planning on starting a community clinic? If so, you will need to get 3 or 4 times as many butts in chairs as a conventional acupuncture practice!
10. How much money per month can you survive on? (rent, food, utilities, necessities) Are you going to be living alone? Are you going to be living with your life partner, that happens to be a much sought-after video game designer making triple digits? 
11. How much money are you going to be spending on overhead? Rent, utilities, supplies, general and professional liability insurance, taxes, advertising (to name a few)

Now crunch the numbers and tell me if starting your dream practice in Home Town, WY  looks like a great business idea, or a poor one. I hope it still looks like a great one!

A Tale of Two Cities

Will your new practice be welcomed with open arms? That depends...

City #1
My business partner and I opened our community acupuncture practice in 2010. A month after opening, we held a grand opening party. I was astounded by the number of local acupuncturists who showed up. I braced myself for being dragged into a corner. I thought surely one of them would tell me "you have until sundown to get out of town, or else!". Instead they shook my hand and told me how glad they were to see me in town and that they would be referring patients to me.

City #2 An acquaintance who relocated her family to a resort town of which she was particularly fond. It was not long before she was told by the local acupuncturists in no uncertain terms that the "town wasn't big enough for one more acupuncturist". "You're not welcome here" they said.  Faced with an uphill battle and possible smear campaign from the local practitioners, this woman decided to leave and find another town in which to open a practice. 

Now what's the difference here? Why was my practice welcomed and my acquaintance was ridden out of town on a rail? I think it comes down to perceptions of abundance vs scarcity. 

In our case, our local population numbers at 75,000 people, with additional surrounding populations. The local acupuncturists felt secure in their abilities to get patients in the door. I can't speak for all of them, but they all seem to be as busy in their practices as they want to be. They understand that people who cannot not afford $80 a treatment are not going to come see them more than two or three times anyway. They knew these folks would benefit from regular acupuncture, so they were happy to have a place to refer these patients. Thus, we are viewed as an asset to the community, instead of a drain.

In the case of the resort town, the population was about 21,000 residents. The acupuncturists who were already there knew how hard it was to get enough patients through the door, thus the chilly reception. Maybe these locals were lousy acupuncturists and even worse marketers. I suspect, however, that the local population was just not big enough to keep them busy no matter how stellar they were.  

M is for Marketing

Here's a list of the marketing activities we've tried in the past 2 years

1. free lectures in our clinic and in workplaces 
1. Results: Eh...
2. free acupuncture events
1. Results: One of the top 6 ways we got people in our clinic the first year. We are no longer doing these. There's no money in free acupuncture. 
3. booths at local fairs and farmer's markets
1. Results: One of the top 6 ways we got people in our clinic the first year.
4. gave coupons for free or discounted acupuncture to current patients asking them to pass them on to family and friends
1. Pretty darn good. Don't just ask patients for referrals, give them a tool to use!
5. ads in the local paper (Note to the wise, we only got an article written about our clinic after we started advertising in the local paper, despite months of press releases and contacting the reporters. Just sayin'....)
1. OK, but this needs to be used as a part of a larger marketing plan
6. bulletin board flyering local coffee shops
1. Ugggh... others have had success with it, we found it to be a waste of time.
7. had a friend do active flyering for us at local stores
1. Sometimes we get great results from this, sometimes, not so much. 
8. gave out free treatment cards to local business owners and employees. Basically anyone we came in contact with in our target area while we were out and about. 
9. had giant signage made for our clinic
1. Our #2 patient generator! In spite of what Honora Wolfe says, in the right place, they do work!
2. If I had it to do all over again, I would have added "Affordable sliding scale $20-$45" to it. 
10. used a sidewalk sign
1. I like to use this for messages like: Knee Pain? Acupuncture can help!
11. Posted a website and had SEO done on it 
1. This is just a no brainer in this day and age. If you can't figure out SEO have someone else do it for you. If you have a website, but people can't find it, what good is it?
12. Gave gift certificates to silent auctions
1. Eh, not bad, but no great shakes. Other folks have seen great results. 
13. Did promotions for the local emergency assistance organizations (Donate X amount of dollars to the food bank and get your first treatment for free)
1. Eh, ok. One of our mentor clinic has had great results.
14. Gave free treatments to veterans during the month of November
1. Ugggh... Not many of them came in. Most of them were interested in getting something for nothing. 
15. Participated in the local artwalk
1. Very good! A good way to put yourself in front of your community
16. Treated "first patients free" 
1. Very good! We do this every couple of months. We promote it with print ads, take away flyers for patients, our sidewalk sign and mentions on facebook. 
17. Ran a couple social media campaigns
1. Pick the companies you do a "Groupon" with carefully. My fav: Living Social. This is great as a part of a larger marketing campaign. 
18. Facebook
1. I think this is a must in this day and age. It's a great way to generate buzz about your business. 
19. Twitter
1. I once clicked on a link entitled "How to use Twitter to Market Your Business". It linked to a page that said only: DON'T! I kinda have to agree, unless your demographic is 14-21 year olds. 
20. Phone book (not!)
1. We are not in the phone book. It costs too much, but we often have elderly people who try to find us there. They get frustrated when they can't find you there. 
21. Went to a lot of different networking events
1. OK. Some of them are definitely a big waste of thime.
22. Bring a new person into our clinic and you both get treated for 1/2 price
1. Pretty darn good!
23. Giving gift cards to patients who refer their friends and family to our clinic.
1. OK, mostly a goodwill gesture. 
24. The best marketing.....REFERRALS!
1. Ask your patients for referrals. 

Our busiest months in the clinic have come after multiple marketing activities. Here's an example of the way multiple marketing activities work. From an actual patient quote: "Well I saw your ad in the paper and I met you at the farmer's market. Then my friend in yoga class gave me one of your coupons and here I am." Each of those things helped to contribute to get this person through the door, 

Do Over

What would you do differently if you could start all over again?

Ah! The ol' shoulda woulda coulda! 

A) I would look at demographics much more carefully. I would pick a large city further away from Boulder with media outlets targeted to that city. Great examples of this type of city: Albuquerque and Colorado Springs to name two. Much easier to market your practice. You will get to profitability quicker. Any of you thinking of going back to Nome Alaska or Botkins Ohio to start up a thriving practice, think again!

B) I would have chosen as close to a free-standing office as I could have. To my way of thinking the more control you have over your space the happier you are. 

C) On that same vein, I would have looked a little longer for the right space. When you go to the lease signing and water is dripping through the ceiling in great quantities, don’t assume that the landlord is going to hop right on that problem. Our first office had leaks in the ceiling, wasp nests in the walls, little scurrying creatures in the attic, insulation material that fell down from the ceiling, air conditioning that made our part of the office freezing cold, and a lack of acoustical insulation so that we could hear way too much of our neighbors’ noise. That being said, it was dirt cheap and certainly helped us to pay the bills (and ourselves!) the first 1.5 years we were in business.  

D) I would have started off with more screened off tables. Nothing like having patients fighting over the tables. Unless, of course, you count or stripping down to their bra and laying on a table in front of another patient. 

E) I would have paid to have an enclosed office space from the git go. Yes, we were so stupid and thrifty at the beginning that we did not have an office that was separate from our treatment space. Yeah, uh, this makes it impossible to answer your phone while someone is being treated. That's just plain dumb!

F) Make sure you hire the right person, even if it means going through several people. My business partner and I hired a lawyer who was a member of a local networking group. She talked, we listened and took notes, we got back to the office and compared notes. We still did not understand what she was talking about. We called her back and talked some more. We still didn't understand what she was talking about. This is a bad sign. Get an lawyer/accountant/marketing coach that can explain things in a way that you understand them. We later learned that this person gave detrimental advice other members of the group and yet no one would openly acknowledge this. Very frustrating... Then, we hired a lawyer (a friend of a friend) who wanted to draw up our business operating documents in exchange for lots of free acupuncture. Great, right? It turns out that his speciality was estate law, not business law. Later we learned that he was trying to draw up an operating agreement, yet I think he knew he wasn’t up to the task. Eventually, HE fired US. Probably the best thing for us!

G) Back up your computer! When we started our business, my partner and I used her old laptop from school as our work computer. We installed Quickbooks on it and saved all our financial data on it. We were smart enough to purchase an online back up system for it, but alas, did not pay enough attention to whether or not we were backing up the right data. The hard drive went kablooey one day, taking all our Quickbooks files with it. It took a long time to reconstruct all our financial data. I shudder to think what would have happened had we been several years into business. It would have been catastrophic! Back up your computer in two places. 

H) One of our mentor clinics has used the technique of offering free treatments to anyone who donates to the local a local charity to bring in new patients. We made the mistake of 1) offering this deal to all patients, not just new patients 2) doing this for the entire month C) incidentally doing this the same month that our computer died and we had to buy a new one. We gave nearly $1K to a local charity and did not pay ourselves. If you want to do this, I suggest donating the profits on one day to a charity. Be generous, just not that generous!