The Middle Way Model

Hello and welcome to those of you who have been reading my series in Acupuncture Today and want to learn more about the Middle Way model and the support for applying that model I am offering here. I still treat 15-25 patients a day 5 days a week so I just ask that you be patient with me in getting back to you on any questions you have. I will reply – it just may take me a day of so. 

I plan on getting creative in building a support system although there will undoubtedly be some bumps in the road.  Feel free to ask your questions here I don’t require anyone to have read my book “Making Acupuncture Pay” to be able to participate here but I devoted a lot of time going into detail about many subjects in that book so it was meant to provide the foundation that we could build on and discuss from. 

We will see what transpires and I look forward to your feedback. 

Matthew Bauer

Matthew,

What do you think about mixing a middle way model and community acupuncture model?  I know of some practitioners who feature community style treatments on certain days for certain hours.  I know educating patients about the differences would be important as the perceived value and price variation could cause questions.  Just wondering if you had any opinions on this and could talk about this option to possibly bring in more patients covering a wider spectrum of affordability.  As always, thanks so much and I am enjoying reading all of the posts and feedback!

Zu San Li

I just read a good blog post on the Community Acupuncture blog from someone talking about how he tried a hybrid-type practice and then went to true community style. I give the link to that post below. As you can see from this post, the CA model is meant to be more than a type of business model. I have great respect for what the CA people are doing but I know (and they know too) that the goals of the CA movement are not going to be ones that every acupuncturist will have the same passion for. I am trying to offer an alternative model with a similar support system for those applying it. Just a little note though about this blogger’s post:  He mentions working in many different settings such as a holistic center, chiropractor’s office, and a home practice – all of those types I do not recommend. Most of those settings do not work well and that is why I focus on private practice and especially solo-private practice in a professional office. Just as if you try a Community type practice but don’t understand the many details needed to do it right, you also need to know the right way to build a solo private practice and that is what I am trying to detail and support with my Middle Way model and this site. Needle on.    

https://www.pocacoop.com/prick-prod-provoke/post/ive-been-asked-to-write-a-blog-about-my-ca-journey

Matthew Bauer

Matthew,

Thank you for both of your replies.  I read the blog post and I see what it is that you are mentioning.  In your book you talk about the emperor’s method and the peasant’s method as both ends of the spectrum from a low volume, high fee to a high volume, low fee type practice.  So to further discuss the middle way practice as I understand, it works as a moderate volume with moderate fee clinic.  The treatments are all done in individual rooms but can be occurring simultaneously.  Can you speak about your structure?  I don’t recall if you have separate times for new patients.  Do you have walk-in times available?  Have you discovered any things with this method that makes the treatments flow better?  At a rate of 15-25 patients per day you must have an efficient system to keep things moving.  I forgot how many treatment rooms you have?  

Zu San Li

Matthew,

Thank you very much for the valuable information.  I like all those suggestions as they would seem to make the whole system work more effectively.  You are being very generous with sharing this information and I know everyone appreciates it very much.  You are giving new patients 45 minutes and returning patients are given 15 minutes of treatment and then left in the rooms with needles?  I like the idea of the kitchen timers and the baby monitors.  If a patient shows up late does that throw the whole flow off or are they asked to return another time?  Also, are you having new patients fill out forms before showing up?  I know you had mentioned presenting workshops, is this something that is being scheduled?  Or a webinar or online discussion? Thanks!

Zu San Li

Matthew,

Just read your post in the section on Appointment Times, sorry did not see that earlier.  Thanks!

Zu San Li

No problem, I forgot I did that other post but now, between these two threads, it covers the subject better. We usually don’t take new patient walk-ins just because we seldom would have enough time for that. We sometimes will take an existing patient if they popped-in. As far as people arriving late or on the wrong day , when I was just working out of 2 rooms that was much more of a problem but now with 4 treatment rooms it gives me more ability to accommodate things like that.  As for any seminars or similar I do have a one day live seminar with Evergreen (Lotus) herbs for a Saturday, June 8^th and a free one hour webinar on Wednesday, May 29^th at 12:30 Pacific.  I will be letting people know about this on the Facebook page and this Forum as that time gets closer. I may also look to schedule some conference calls if enough people are interested. I may start doing that after the Lotus seminar. I am really happy you are finding this a good resource and hope others do and will too! 

Matthew Bauer

Matthew —

 Thank you for making this forum available.  I have read your book and read all of the CA literature as well.  I am leaning more towards the Middle Way business model for my planned practice.  My fees will not be sliding scale but is expected to be appropriate for my market and I am looking into accepting insurance in a way that makes it economically worthwhile.

Nonetheless, one thing I really like about the CA model as a patron of such clinics is the ability to “stew” with the needles as long as I want.  Thus the multi-bed semi-private space is very appealing to me.  Do you think a Middle Way practice could work with a semi-open space where I have more beds than expected treatments in any one hour.  In other words I would not have separate treatment rooms (except one room for initial visits and any follow-up visits that may require more privacy.)  What do you think?

Johanne

Thanks for posting and welcome to the Forum. The Middle Way model I promote tries to find the right balance between underdoing and overdoing many things involved with a practice. On one hand, it promotes a modest fee (but not Community Acupuncture-like low fee), moderate patient-load (8-10 a day) with a low average out of pocket cost to the patient by means such as accepting insurance. As far as how you arrange the treatment tables/chairs and how long you leave the needles in, that is very flexible and up to you. If you like leaving needles in for as long as a patient wants to stew – great! You just want to be able to accommodate 8-10 patients a day to get the patient volume you would need but as long as you can swing that in that type of setting you should follow what your passions dictate.  

Matthew Bauer

Thank you for your detailed and thought through response. It cleared a lot up for me. Just to understand this further. If you are recommended 6 visits per say, in an initial acute pain situation, you are doing them either daily, or three times a day twice a week. If the response is favorable, you are moving down to 1 to 2 visits a week for three weeks.

If all is still responding well, what are your recommendations for a follow up, maintenance?

Regarding the patients whom you are getting stuck with, stubborn cases, with little variation to the pain, if you feel they can be helped further (improvement on the other diagnostic criteria), what is your general continuance rate with patients and do you recommend an additional 5 to 6 visits to continue? 

I find the latter two criteria supremely helpful in helping to predict if they are going to do better or not.

Thanks again for all your time posting.

Joshua

Acujosh

Thanks for you well thought out response. So to clarify, in chronic pain cases , arthritis, long term lower back pain, CTS etc, cases do you see recommending 5-6 visits to see if there is any change? If you were seeing a fibromyalgia patient, ALS,  stroke patient, wouldn’t it make sense to ask for 8-10 visits, you used the example of peripheral neuropathy in your talk at lotus, stating that it could take even 10 visits until you see if it will give you a result. So the number has to vary between giving you a fair shot at getting the body to start it’s healing process vs. immediate relief treatment wanted by the patient.

Can you clarify your consultation vs examination. What do you charge for the exam? is it scheduled another day along with the acupuncture? When are you going over your approach with explaining and laying out in advanced, the groundwork you use to manage patients? At the consultation or evaluation? In terms of a rough stat  or percentage, what percentage of people “convert” from a  free consultation to a paying evaluation (from your practice)?  

Thanks again,

Acujosh

Dear Matt:

Your information is clear,well thought out, methodical. Thanks for educating us and helping to save our profession!

More on the consult/eval: So if you do the consultation, take their symptoms, tell them that you can help them and then give them the acupuncture explanation and your initial recommendations and rationale for the recommendations, are you scheduling an eval and a treatment for them the next visit? Additionally, do you set aside more time to talk to them after the 5 or 6 visits at the re-evaluation?  

In terms of percentages, those are really great stats to work from. As you said it isn’t what you can measure in any re-evaluation, it has to do with perceived patient satisfaction. In order to have high patient satisfaction you need to set the context for them by explaining how acupuncture works, that the needles are safe. Secondly, you need to explain what they should and should not expect so you can manage the expectation factor. Thirdly, you need to talk to them if they are missing visits or are engaging in activities that re-aggravate their condition as well. Some patients make the worst patients, others have no choice and have to continue to re-aggravate their conditions to their job, that too needs to be taken into consideration.

Fourthly, I think documentation is critical because when you do an re-exam/re-eval, you need to refer to what the patient told you in the beginning. So do you have a format for keeping that documentation handy in an organized fashion?

Additionally, I find that regarding documentation, that males typically are the hardest to treat because they won’t divulge much of the info you need, you need to really pry it out of them so you can have a comparative to work with.

Sincerely,

Joshua

Acujosh

Matt,

Excellent detailed explanation. I always have to manage my idealistic generalist approach vs my pragmatic side. Your helping to bridge the gap, so thank you.

I think the analogy of the troop surge is great and I see how it can relate to their health issue so they can really open up.

The eval/re-eval options make it more flexible too. I like that idea a lot. I  see you can build in the flexibility to the schedule which can be very forgiving to your schedule. I think that is a very practical method for scheduling.

You mentioned in the lecture about giving herbs out to patients, wit the Lotus information sheet on it. So when do you raise the issue about herbs with the patients in your scheduling? 

Thanks for all the information and for your input.

Joshua

Acujosh

If I think the patient will benefit from using herbs, I will mention this in the initial consultation but often will tell them we can discuss the details of this later after the first couple treatments. It really depends on the patient’s condition and so the type of herbs I will be using. My goal is to always keep the costs down so,in some cases, I will be telling them the herbs should be the primary treatment and the acupuncture the secondary. I do that for most cases of sinus issues, for example, as the herbs work so well and are inexpensive. In other cases, I let them know that the acupuncture is the primary therapy but they could benefit from taking herbs also. It really just depends on the condition and how I think we can get the best result for the least cost.    

Matthew Bauer

Dear Matt,

THank you for answering. It makes a lot of sense in your last reply, If we hit patients with too many things, it makes it harder for them to accept the care. Do you have a way to introduce the herbs to your patients . Do you link it with sparking the body’s resources, riding the wave type of education or is there another rationale that you tend to employ for that. 

Joshua

Acujosh

Matt,

Since we have covered a lot of ground fleshing out the middle way model for patients, I wanted to shift the flow to how to practice the middle way model for PRACTITIONERS. What do you find is the optimal flow that you can handle,on a daily basis.What are your clinic hours? Do you take new patients in the evening? What things can you recommend for practitioner rejuvenation?

Sincerely,

Joshua

Acujosh

Hi Josh  – I wanted to answer your questions regarding herbs first as they help reinforce what we had been discussing. I explain that different Chinese herbs span the whole spectrum of being like acupuncture helping the body to better use its own resources to being like drugs that take over for the body’s resources and influence the problem from the outside-in. This being the case, one needs to know the difference between the different herbs and how to use them the right way as needed. The vast majority of Chinese herbs are the very safe type that help the body to help itself. Others are potent outside resources that can be quite effective but carry greater risks of side effects like any type of outside resource does. I stress that the first priority is to use the safest remedies first and only use the stronger but higher risk ones if the gentler ones are not doing the job. I call this “Going up the risk ladder.” 

By explaining things this way you make several points at once. You reinforce that Chinese medicine is very safe in well trained hands and you also start to let them know that while they may have heard that Chinese herbs can be dangerous, you are trained to know how to use them in such a way that greatly reduces any danger.  Ma-huang is a good example of an herb that is perfectly safe in the right hands but carries real risks if used improperly.

I plan to write more about addressing the concerns over the safety of Chinese herbs before long but letting people know that there is the wide range of safety profiles within the vast array of Chinese herbs helps to defuse people’s concerns over safety.

Matthew Bauer

In a sense drugs and herbs are the same in this regard. In explaining it gentler to harsher you help to manage patient expectations too. Very clear and helpful. Thank you once again!

Acujosh

Dear Matt,

Many times when it is slow, you stay the extra hour or two but when you have a busy practice, you need to cut back at some point. That might mean losing some of the evening patients. I work 9-7:30 and I was finding that that last hour or so really put me over  the edge, so I cut back to two nights a week doing that, only to find that more people wanted evening. Eventually, you need to make a clear demarcation, a line you don’t cross, otherwise you don’t have a sustainable practice but a runaway practice and that includes learning how to say one simple but hard word, as healers who want to help everyone. The word is “no” I cannot take you that late.

So I work in 4 rooms and it is demanding on you so you need to pace yourself. 

So in addition to getting practitioners to revitalize their practice there is the other aspect of maintaining the practitioner so he/she can continue in their practice on a continual basis.

Can you please tell me when you actually go over the acupuncture education itself? Do you do it all on one day?Do you draw it out or diagram it as you discuss it with them? OR do you explain it as you needle?

Acujosh

Hi Josh  – Sorry I missed this post somehow. Pacing yourself is important. As for the education process – I have my rap down pretty pat to give the basics during the initial consultation but, depending on the circumstances, I also end-up doing some with each treatment as needed. I usually don’t have to carve-out any more time just for that except if I am using herbs alone. In some of those cases we set-up additional consults and I may charge a small fee for that.

Thanks again for all your interest and great questions. 

Matthew Bauer