Conference Keynote: Breaking the Ceiling
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The theme for this conference is “Breaking Barriers”. You know, there are so many barriers to break in acupuncture that it was really hard to choose which ones to talk about for this speech. But since I've spent so much time talking about classism as a barrier, I thought it might be fun to shift gears a little and talk about numbers.
That, I have to say, is one of the things I really love about community acupuncturists. We talk openly about numbers. Because numbers are an important way to be connected to reality. This seems like a good time to thank all of the people who worked on the 2010CAN Survey, especially Justine Deutsch. Thank you all.
One of the things that we at WCA have observed over time, watching other clinics, is that 100 treatments a week is a kind of ceiling.100 treatments a week sounds like a LOT of treatments to most acupuncturists at first, something that it's hard to imagine doing.But almost all clinics really need to break through that ceiling in order to be successful and sustainable. Ideally, each acupuncturist in a clinic is able to provide 100 treatments a week as a matter of course, consistently, no big deal. One of the main things we wantedto do with this conference was to provide some help and some resources for acupuncturists in breaking that ceiling, breaking through the 100 treatments a week barrier. I want to use this talk to frame WHY breaking that ceiling is so important, what it means for individual clinics and also what it means for community acupuncturein general.
But first I want to back up a little and talk about sizing, or right-sizing, of businesses.
There's a famous business and marketing blogger, Seth Godin, and his blog is where I heard about right-sizing. Actually, another acupuncturist, Elaine Wolf-Komarow, sent me a link to his blog,because she's much better on keeping up with Internet stuff than Iam. And I was really grateful, because the idea of right-sizing fits so well with this conference. So let me summarize Seth Godin's blog post of February 24, which he titled “an atomic theory ofbusiness size”.
In chemistry, the point of the periodic table of the elements is to define elements by the size of their atoms: the number of protons,neutrons and electrons that they each have. An oxygen atom always has 8 protons, and a titanium atom always has 22, and so on, and that's their atomic number. You don't have an element that is part oxygen and part titanium, you just can't. The elements are what they are. And the electrons that orbit the nucleus are where they are,depending on their quantum numbers. According to Seth Godin,businesses have an elemental size: a size where they are supposed to be, a size where they really work, where they are stable and successful and sustainable. He says: businesses that exist, exist because the marketplace allows them to function at the right size.
He says a mom and pop business is just the right size for mom and for pop. The rent and the overhead are probably relatively low, so it works out, it's stable. A mom and pop business doesn't need,say, its own advertising department that costs hundreds of thousands of dollars a year – if you added one of those to a mom and pop,it's out of scale, and the business isn't stable anymore.
He says the next level of business up from mom and pop feels different – different furnishings, different payroll, different everything. It's not an incremental step, it's a quantum leap.
So what does all that have to do with us? Well, there are individual implications, and there are professional implications.Let's start with the individual implications.
One of the big things that keeps community acupuncturists from breaking that 100 treatments per week barrier is a problem with right-sizing. We have an image of an acupuncture practice in our minds, but that image isn't the right size. It's way out of scale. It's like our mental setting for an acupuncture practice is at hydrogen, which has an atomic number of 1; but really the elemental size for an acupuncture practice is closer to, say, tungsten, which has an atomic number of 74. It doesn't work at hydrogen, it works at tungsten. But we keep picturing hydrogen. We've got our attention inthe wrong place.
One of the funny things for me about giving this talk is that it's almost 9 years to the day – today – that I gave my first “community acupuncture” treatments. It's almost exactly 9 years ago that we started the clinic that would end up being Working Class Acupuncture. I remember that we got the keys to the space sometime inmid-March of 2002 and we started seeing patients there in early April. So it's almost exactly 9 years ago that we started using the community acupuncture business model, though of course we weren't calling it that at the time. We didn't actually have a name for what we were trying to do. We were flailing around, trying to figure out how to make a living doing acupuncture.
In 2002, my mental picture of an acupuncture practice was, like everybody else's that I knew, pretty much stuck on hydrogen. Stuck on 1. I didn't know tungsten was an option, because I didn't know it existed, or I didn't know it could exist for me – I'd heard the stories of course of great acupuncturists in Asia seeing a hundred people a day, but nobody I knew did that in America. I knew I needed to see more patients than I was seeing if I wanted to support myself as an acupuncturist, but I didn't really know how many. You all weren't around back then, so we didn't have anyone to talk toabout numbers; we didn't have any real support for doing the math. So my attention was on doing one treatment at a time, which is where most American acupuncturists' attention is, which is, of course, the wrong place. I thought if I did one treatment at a time, it would eventually add up to enough treatments, but that isn't actually what happened. Adding up one treatment at a time is taking incremental steps. I don't think anybody can get to 100 treatments a week by adding up one treatment at a time. You don't break through the ceiling incrementally, you break through the ceiling with a quantum leap.
My patients are the ones who catalyzed my quantum leap. They did it by not cooperating with my idea of one treatment at a time. They didn't show up one at a time. They showed up two or three or four at a time; they showed up late or early, they showed up with friends and family members and coworkers. Eventually I got it, that the space I thought was mine, the acupuncture practice I thought was mine, wasn't really mine, it was theirs. Like most acupuncturists, I thought acupuncture was mine and I was doing a good thing by wanting to share it. I learned that acupuncture wasn't mine at all, it wasn't mine to share and it wasn't about me being good. It's about acupuncture being big. Really big. I caught a glimpse of how huge acupuncture really is, and I got it that I was supposed to participate in it rather than control it or own it. That was how I discovered tungsten, or my version of it anyway.
When I say that breaking the 100 treatment per week barrier is a quantum leap, I don't mean that it happens all at once, because it doesn't. It's not like you're seeing 30 people one week and then yougo through a wormhole and you're seeing 100 the next week, it generally happens over time, more time for some people, less time for others. The important thing to understand is that consistently doing 100 or more treatments a week is qualitatively different –not just quantitatively different – from doing 30 or even 50.There's a threshold that you cross where it's not about providing one treatment after another treatment anymore, it's about taking care of a space where a LOT of people come to use acupuncture in the way they want to use it, which might not be the way you think they should use it. There's a point where the space starts to belong to the patients.That's when your practice is elementally different from a conventional acupuncture practice, when it's stable at a level that conventional acupuncture practices can't possibly be stable.Getting there is hard for a lot of acupuncturists because of the way we were trained to think about acupuncture.
In that first week of April 2002, I think about 12 community acupuncture treatments happened. If you look at the numbers from the 2010 CAN survey, these days, 6783 treatments are happening each week in a hundred or so clinics. We know that not everybody answered the survey, and we know that we don't even know about all of the community clinics, so we know the actual number of treatments is probably a lot higher. Maybe it's 10,000, we don't know, but we can say pretty confidently it's not less than 7,000 treatments a week. So 12 treatments a week to 7,000 treatments a week; that's a 58,000 percent increase at least. Pretty good for 9 years. I'd call that evidence that the community acupuncture model likes quantum leaps.
I wouldn't say that we knew or guessed that a 58,000 percent increase in what we were doing was going to happen, because we didn't. But we did know that the hydrogen scale was wrong, and we were flailing around, reaching in the dark for what the right scale was, what the right size was. My point is that we had an inkling that the mindset we inherited in acupuncture school had to be questioned,had to be discarded even. I want to return to the issue of individual acupuncturists making the quantum leap to 100 treatments a week, and how that happens. It has to start with a feeling that the scale you've got is wrong. I don't mean a feeling of panic as in “OMG I'm not going to make enough money!” Lots of conventional acupuncturists have that feeling too, it doesn't have anything really to do with shifting your scale. The feeling I'm talking about isn't about you, it's not personal, it has nothing to do with your success or your failure – it has to do with the nature of acupuncture itself. It's sort of like feeling that maybe the world doesn't work the way you thought it worked, and acupuncture doesn't work like you were taught to think it worked – it's bigger and stranger and more magical than you expected. It can actually shift you out of worrying about yourself and your success, because you're no longer just focused on yourself. You're seeing the big picture with you as a part of it, but not at the center anymore. It's not necessarily a comfortable feeling, there is a kind of uneasiness for sure, but there's also a kind of wonder and curiosity. I remember thinking,wow, I guess I was really wrong about everything, and that's probably good.
So first you need to get into a kind of creative discomfort, a kind of suspicion that maybe everything you think you know is wrong,and the truth is actually going to be a relief when you finally find it. The ceiling is first and foremost a ceiling in your mind. If you know you're blocked, if you can't break that ceiling, instead of fighting the block, it's generally more productive to be curious about it, to work off the theory that you're confused about something and you don't even know what it is that you're confused about, but once you figure it out, you'll be much happier. If you're on the wrong side of that quantum leap, you have to start by just being open to a qualitative solution instead of a quantitative one. A quantum solution instead of an incremental one.
The next step, I'd say, is to really think about how people work,and how acupuncture works, and how they work together in the real world, which is extremely different from how they work in textbooks.In textbooks, if you do the right treatment, the patient gets results; if you're smart enough, you should be able to make a living as an acupuncturist. It's all about your knowledge and your skill. If you start from that premise, you are looking at your practice as a hydrogen atom, atomic number one. It's all about one treatment at a time, because you can only do one treatment at a time, and this is all about you, right? So if you just do enough single treatments they should eventually add up to the point where you can pay your bills,and it's OK to have relatively low numbers of patients, as long as you are smart enough to help ALL of them.
The problem with having a low atomic number for your practice is that low numbers are not a good fit with how people actually behave,and so your practice is not ever going to be stable if the numbers are low. Different people can stick with a treatment plan to different degrees; there are a lot of people who, even if you're helping them, are going to stop coming in, because they can't be consistent about anything in their lives, including acupuncture.Other people can be consistent in short bursts, and then they get inconsistent again. People drop in and drop out of getting acupuncture. They get busy, they get better, they move away, they come back. These are trends that are very obvious to anyone who's had a community acupuncture clinic for five years or so – you get to see the way people flow in and out. This means that you have to set your sights on seeing lots and lots and LOTS of people, if yourclinic itself is going to be steady. Sometimes I suggest to acupuncturists with new clinics that they should just focus on tryingto accumulate a thousand files. Once you accumulate a thousand files,you're in the ballpark for having introduced enough people to acupuncture that some of them are going to be consistent. The mos tbrilliant acupuncture treatment in the world is not going to make an inconsistent person into a consistent person, it can't be done. Partof the quantum leap is understanding that and letting go of all your patients as individuals. You can and should care about them asindividuals, of course, but you shouldn't hang on to them as individuals, ever, because you never know what they are going to do.
It's a similar thing for treatments – you have to let go of individual treatments. In the textbooks, individual treatments matter a lot; in real life, not so much. You can't measure the effect of acupuncture in discrete increments; it's more like a big, messy continuum. Acupuncture works unbelievably well for some people – if you went to the documentary screening last night, you'll have some examples immediately coming to mind – and not so well for others.Acupuncture works very slowly over time for chronic conditions and chronic pain; sometimes people can only track the effects by noticing that this month was a lot better than last month. Most of all,acupuncture doesn't work precisely. After 17 years of doing it,I'm pretty convinced that acupuncture is not like a laser, it's like a shotgun. You can try to aim it all you want, but its effects still go everywhere. So acupuncture is not really meaningful in small quantities, with small atomic numbers. As an element, it's only stable when the numbers get larger, and then it's a beautiful,amazing thing. You know what tungsten is used for? Making lightbulb filaments. It shines in the darkness.
OK, so it doesn't make sense to think about acupuncture in terms of individual patients, or in terms of individual treatments. Once you get that, you need to take a look at all of the ways you put yourattention on individuals, and ask yourself if your attention really belongs there. Sometimes it does, and sometimes it doesn't. For example, an acupuncturist who has broken through the 100 treatment ceiling is never scared by a room full of patients; she doesn't get overwhelmed, and she doesn't lose track of people. A full room feels good to her, and it feels good to her patients; everybody is having their own individual experiences, but there's this other thing going on that is much bigger, and she's holding the space for that thing as she's moving from person to person. She's connected to the tungsten element of her practice. But an acupuncturist who hasn't broken through that ceiling has trouble holding that space for tungsten,because she's still trying to hold it for hydrogen, she's still thinking one plus one plus one. She might do something like spending too much time with one patient so that she gets way behind with the next few patients. She can get caught up in what she's doing with a patient, what she's learning, what she wants to think about,and not be able to tune into the room as a whole, what the patients are doing with each other whether they know it or not. She is overwhelmed by a lot of people because she's no longer able to be in total control, and then she can't keep track of everyone. If that's what's going on for her internally, of course she's not going to be able to attract or retain high numbers of patients. If she's made the shift to a sliding scale, she's dependent on high numbers to make a living, but she hasn't really embraced the limits, and the possibilities, of community acupuncture. She's essentially trying to have her practice be partly one element and partly another, and that's about as unstable as you can get.
Most of what it takes to break through that 100 treatment a week ceiling is not external, it's internal. It's not about marketing o rsignage or what conditions you feel confident about treating. It has to do with your ability to be present for people, and how much space you have inside you for other people's suffering. You can attract and retain people in direct proportion to how much internal space you have for them. Call it the atomic number of your heart. So of course it's harder if, say, you're a new parent, or if you're the parent ofa child who's having any kind of difficulty; lots of your heart space naturally will be taken up by parenting. Similarly, if you have any kind of troubles or worries you can't put aside, you won't be able to attract or retain people in large numbers. And if you have any interests outside of your practice that are seriously competing for your attention, you’ll have trouble attracting and retaining patients in large numbers. You have to be fairly one-pointed in your focus on making space for people. And this, of course, is not what they teach in acupuncture school; they don't teach you how to make space for people in your heart, especially lots of people simultaneously. Community acupuncturists all have to learn how to do that for themselves, by trial and error. Lots and lots of error. It can be done, you can raise the atomic number of your heart, it jus trequires effort and desire and practice. Maybe desire more than anything. You have to want to help a lot of people.
So in the end I think it comes down to looking at yourself, yourpersonal relationship to the numbers. Where do you put you rattention, what's the atomic number of your practice, really? How much space do you have inside you, what is the atomic number ofyour heart, honestly? A few months back we put on a class for Oregon acupuncturists, and a really interesting combination of people showed up: a lot of very new acupuncturists who weren't doing community acupuncture, and a bunch of hardcore community acupuncture comrades.I remember looking out at everyone and thinking you could tell who's who by their faces. Most of the conventional acupuncturists looked kind of shiny. You could tell that they hadn't seen a lot of people,and also that they weren't oriented toward seeing a lot of people.They were oriented towards expressing themselves as acupuncturists,concerned with the individual nature of their practices. The community punks, on the other hand, looked, well, used. Well-used.You could see that they had been seeing a lot of people, and they were kind of worn around the edges, sand-papered down by other people's pain, but also lit up inside. Tungsten filaments.
OK, that's the personal part of the atomic numbers, let's talkabout the profession as a whole. Seth Godin says that rightsizing your business is one of the most important decisions you can make. What if an entire profession hasn't found its elemental number, its correct atomic size? Businesses that exist, exist because themarketplace allows them to function at the right size. What if each of our businesses is also impacted because the profession that they are a part of is not functioning at the right size? Because the profession never actually made a decision about rightsizing,never thought about what size it should be because it was too busy putting all its energy into glorifying individuals being individuals?The acupuncture profession is really good at that: making gurus,making specialists, encouraging people to express their uniqueness asa marketing strategy. Does it work?
Let's look at what it means when only a few people are gettingacupuncture, say 3.1 million in 2007. We'll restrain ourselves andnot start ranting about the fact that most of the professionapparently thought 3.1 million was a great number, even though it'sabout 1% of the population as a whole, which means that 99% of thepopulation in America didn't get acupuncture. That's the size we'reat right now as a profession. What does it mean for our businesses?
Well, it means that a lot of people may have heard aboutacupuncture, but the odds are overwhelming that they don't knowanybody who's actually using it regularly. Furthermore, thatsituation seems normal not just to them but to us as a profession. Ifwe think 3.1 million is a great number, that's what we're saying,right? That we're OK with 99% of the population not gettingacupuncture. It means acupuncture is supposed to be sort of a secret.Acupuncture is supposed to be reserved for special occasions, ormaybe special people? How are we supposed to market something that isalso meant to be a secret? Now, I'm not saying that acupuncturists ingeneral are OK with the fact that the majority of them are unable tomake a living. But I'm going to stick with what I said earlier, thatthe discomfort of “OMG I'm not making any money” is not the kindof useful, creative discomfort of really feeling that we're at thewrong scale for our businesses. I think a lot of acupuncturists wouldbe fine with acupuncture being a secret if they were also able tomake a lot of money at the same time, but of course business doesn'twork like that. People can't rave about something they don't knowabout. If a secret goes viral it's not a secret anymore. But I'mafraid a lot of acupuncturists actually got into the professionbecause not a lot of peopleknew about acupuncture. Not in spite of it, because of it. Thesecrecy and the specialness are part of the romance of being ahealer, right? If you've got a lot of ordinary people gettingacupuncture anytime they feel like it, it loses that specialness. Andthe healers lose their specialness. The whole thing becomescommonplace.
That leaves out, of course, the reality that for each of thoseordinary patients getting acupuncture, the experience itself is oftenmagical, amazing, anything but commonplace. People say things like,acupuncture has given me back my life. They say, I had forgotten whatit was like to feel really good. They say, I feel like myself again.There’s the difference between the patients’ reality and theacupuncturists’.
Patients are quite capable of picking up on the fact that, nomatter what the profession is saying, acupuncturists don't reallywant them to get acupuncture in large numbers. It's pretty clearthat, as a profession, we're just not that into them; we’re notthat interested in them getting their lives back or feeling likethemselves again, unfortunately. So they respond in kind. When wehave no enthusiasm, they have no enthusiasm. You can't fakeenthusiasm. And where there's no enthusiasm, there's no momentum. Intheory, there are more than 20,000 licensed acupuncturists in theU.S., and there have been for a while. And yet only 3.1 millionpeople got acupuncture in 2007. If every licensed acupuncturist weretreating 1,000 individual patients a year – some of those peopleconsistently, some more of them inconsistently, because that's howpeople are – there should be more than 20 million individualsgetting acupuncture each year. And of course that's in addition toall of the people who might be getting acupuncture from someone otherthan a licensed acupuncturist, someone like a medical doctor or achiropractor or a physical therapist or whoever. If you had more than20 million people getting acupuncture a year, we would start to seesome real momentum. The more people get acupuncture, the morepeople get acupuncture. Youcan say those words with a few different meanings, and all of themare true. That is what we should be seeing. Instead we're seeing isthe opposite – numbers of licensed acupuncturists arestagnating, and in some places they're actually declining. So theless people get acupuncture, the less people get acupuncture.
Maybe the profession hasn't made the sizing decision consciously,but it's made it nonetheless: we have chosen the atomic size thatmakes us feel special. And it's a very small size indeed.Unfortunately, due to the realities of how acupuncture works, and howhuman beings work, you don't get to be special as an acupuncturistand also be able to make a living.
So I'm going to advocate that we revisit that decision aboutsizing the profession, and this time we do it consciously andrationally. What does it mean if lots and lots and LOTS of people getacupuncture?
If every one of those 20,000 licensed acupuncturists managed tobreak the 100 treatment per week ceiling – and let's say we giveeverybody 2 weeks of vacation a year – that would be 100 milliontreatments a year. And it's hard to say how many patients exactlythat would be, because some of them would be consistent and somewould be inconsistent, but it's probably more than our previous 20million calculation – because a lot more people would be tryingacupuncture for the first time, because they would finally have heardabout it from someone they knew. Acupuncture would start to bean ordinary thing for lots of ordinary people. We would start to getthe momentum we needed.
And then the marketplace would change. Businesses that exist,exist because the marketplace allows them to function at the rightsize. Currently we have a lot ofacupuncture “businesses” that don't really exist; they don'tfunction as businesses, they function as hobbies. Because they don'thave enough patients, there's no incentive for them to keep regularhours. So their patient flow is unstable, and then their hours areunstable, and then their revenues are unstable, which ultimatelymakes the job itself unstable; and that all culminates in making thepatient flow even more unstable. That's the elemental nature of asmall acupuncture practice in a wrong-sized profession: unstable. Butall that changes if we collectively decide to right-size theprofession. We commit to a stable flow of patients at a high volume;we commit to stable hours; we start to reap the benefits of stablerevenues and stable jobs, and every year we see the patient flow getmore and more stable. That's what we've seen at WCA, these last 9years. If we collectively decide to rightsize our own businesses andto rightsize the profession as a whole, what the marketplace allowsus to do will change.
Sometimes I think that acupuncture in America is trying toright-size itself through us. It's huge, it knows it's huge; it's theacupuncturists who haven't realized that it should be huge. For lotsof the last 9 years, I've had this feeling that I'm just takingdirections from something that knows what it wants, somethingenormous that already exists somewhere that I can't quite see. I'mtrying to run errands for it, get things set up the way it wants themto be set up so that it can do what it already knows how to do.
So I want to read something that Brent Ottley wrote recently aboutthe progress of community acupuncture over the last few years.
CAN has grown beyond being simply a counter-movement to theacupuncture status quo in America.
(The organization) has moved into a period where questionsabout philosophy and the basic viability of the model are beingovertaken by questions about sustainability and organizationalidentity. Translating the raw energy of first principles intopractice without becoming entangled in bureaucracy and rules isalways tricky. Implementing necessary structure without inducingstasis is probably the biggest challenge that any young organizationfaces. It’s heady and exciting territory, rich with potential, butit’s also thickly strewn with landmines. Great care anddeliberation are warranted.
A short few years ago, CAN barreled out of the Northwest likesome scruffy, brilliant lovechild of Dorothy Day and The Dude,pricking, prodding, provoking, kicking, scratching, screaming,stamping its feet, holding its breath, taking it on the chin, jumpinggleefully on alphabet-festooned grenades, playing the skunk atacademic garden parties and relentlessly broadcasting theinconvenient truth that despite all the preening andself-congratulation, the American incarnation of the Emperor remainsin many ways as naked as a jaybird. All along the way, CAN hasgathered kindred spirits, a fast growing cadre of committedpractitioners and support staffers, and an army of patients. For awhile, CAN could be dismissed by the rest of the profession as abunch of frothing radicals too extreme to be taken seriously. Butthen something tipped, and all of a sudden it was impossible for therest of the acuworld, like it or not, to deny that CAN had builtsomething; a simple, stable and philosophically consistent whole thatactually does what it claims to do. Something that works on theground, again and again, everywhere, right where the rubber and theroad collide, something that proves that putting patients first whilesupporting acupuncturists really is possible,and that the limit is nowhere in sight. And most importantly, it’ssomething that acupuncturists and patients are flocking to. Someonewrote once that the first purposes of any revolutionary movement areto comfort the afflicted and to afflict the comfortable, and if theresponses CAN is getting now are any indication, by that measurewe’re doing pretty well.
Larry, in his excellent blog of last month called it “the endof the beginning”, and I agree with him. We are participants in andwitnesses to the emergence of a new species of acupuncturist, ahybrid that’s never quite existed in modern memory; birthed,inspired and nourished by the immense cultural riches of Asia,mentored by the legacies of Bangladeshi economists, Catholicradicals and contemporary social theorists, and yet still raised andindelibly marked in the context of modern American commercialculture. Community acupuncturists are by now nearly as different fromthe conventionally established definition of what a U.S.acupuncturist is as they are from acupuncturists in Asia. With someused furniture and a fundamental healthcare technique created halfwayacross the world millennia ago, community acupuncture is crafting anew synthesis of healthcare, social entrepreneurship and basic humanjustice. In the process it’s accomplishing what the establishedacupuncture profession, in Larry’s words, has “utterly failed”to do, and that’s building the foundation from which acupuncturegenuinely enters the whole society to become the fundamental,affordable and accessible primary care resource it has the capacityto be.
We've made a quantum leap. And because of that, we have become,elementally, a different kind of acupuncturist.
There are lots of implications for that, but I want to spend therest of my time here talking about just one of them, which is theimplication for how we organize ourselves.
The Community Acupuncture Network is a 501c6 nonprofit, a businessleague, which means, basically, an organization for people with acommon business interest, that promotes a particular industry. A501c6 is an organization for professionals, in our case, licensedacupuncturists. Just like when I opened my clinic 9 years ago, I wasstuck on a hydrogen atomic model, because that’s all I knew, whenwe created CAN in 2006, we used the only organizational model that weknew about. We basically created the community acupuncture equivalentof the AAAOM.
But as Brent wrote, CAN has grown beyond being simply acounter-movement to the acupuncture status quo in America. Some ofwhat we do is still to prick, prod and provoke, certainly, but whenyou look at the totality of what we are at this point, we’re notthe equivalent of the AAAOM. We do different things, we needdifferent things. So that means, if we want to continue to bestable, we need an organizational quantum leap. We need anelemental structure that is bigger, because a 501c6 nonprofit can’treally support us for what we have become. And just like the space in our clinics belongs to the patients and not just to us, we need an organization that belongs to the patients and not just to us.
Let me say a few things about that before I get more specificabout the quantum leap. There were two figures that blew me away inthe 2010 CAN survey: first, that 102 clinics gave 353,000 treatmentslast year, and second, that those 102 clinics had collective revenuesof between 6 and 7 million dollars.
Let’s start with the treatments. Again, not every clinicanswered the survey, and we know that there are clinics out thereoffering community acupuncture who aren’t part of CAN. So what isthe actual figure for community acupuncture treatments last year?500,000? Probably not less than that, if we can actually document353,000 of them. And how many individual patients is that? I thinkit’s safe to estimate that, at this point, the communityacupuncture movement involves at least a hundred thousand peopleevery year. Probably if you look at the last few years, severalhundred thousand people coming and going in community acupunctureclinics all over the country, patients and practitioners.
And just as we are a different species of acupuncturist, with a different elemental structure, in many cases, our patients area different species as well, with a different atomic number. Thereare a lot of community acupuncture patients out there who bearabsolutely no resemblance to the passive consumers of healthcare thatour culture expects. A great many community acupunctureclinics, including mine, are thriving primarily because some of ourpatients took enormous initiative in getting the word out about us.They made sure that everyone they knew came in and got acupuncture atleast once. They got us in the paper, on the radio, on TV. Theypainted our walls and built our bike racks and organized our offices.We wouldn’t exist without them. And yet we have no formal role forthem in the structure that we’ve got, because technically theydon’t “share a common business interest” with us. That doesn’tmake any sense.
The community acupuncture business model has never fit neatly intothe for-profit category, because we make so many decisions that arenot about profit. And yet we don’t fit into the non-profit categoryeither, because we make our own money and we don’t depend on grantsor donations. For-profit businesses have consumers; non-profitcharities have clients and volunteers; we have our amazing patients,and neither the non-profit structure nor the for-profit structure hasany category that explains them. It would be a really good thing ifwe had a way to organize them, to track and to recognize all theircontributions in a consistent, structured way. At least once a monthI get a phone call or an email from a patient asking how they canhelp start a community acupuncture clinic in their hometown – Iwish I had something to tell them.
OK, on to the money. 102 clinics with combined revenues of 6.5million dollars. To return to Seth Godin’s blog, the vast majorityof those clinics would qualify as mom and pop businesses. Unlike arandom collection of mom and pops, however, we are all doing almostexactly the same thing, and we’re trying to do it together. So manyof our systems are the same. And collectively, we have revenues thatdefinitely are out of the mom and pop range. It would be a reallygood thing if we could find a way to coordinate our interestseconomically, to access the economies of scale that are available toa business with millions of dollars in revenue.
CAN acupuncturists are not just a collection of individuals,anymore than the patients who come to our clinics to get treatedtogether are just a collection of individuals, and what connects usis so much more than “a common business interest”. Just like aclinic that has broken the 100 treatment a week barrier has thatelement of tungsten in its operations – there’s an awful lotgoing on between patients that you can’t necessarily see – we’vegotten to the tungsten element as an organization. There’s so muchgoing on between all of us that is at an entirely different level.And yet we’ve still got an organizational structure, a 501c6, thatis only meant to work for a collection of individual acupuncturists,a bunch of hydrogen atoms, who maybe can work together,incrementally, to get things done, incrementally – but weneed a structure that recognizes that we’ve gotten past theincremental stage, we are already taking quantum leaps together, andwe need to take more of them.
Let me give some concrete examples. One of the things that peoplekeep asking us to do is micro-lending. Clinics can start up with abudget of $5,000 or $6,000. And yet it’s harder and harderfor new businesses to qualify for any kind of credit. Doesn’t thatseem like something CAN should do, make small loans to help start newclinics? Absolutely, but a 501c6 is not set up to do microlending.Another thing that keeps coming up is resources for employers. Somany of us have become employers, and yet we don’t know really whatwe are doing. CAN is helpful as a kind of online support group, butwe need more than that. Is that something 501c6s do? Not generally.We need to organize our patients – wouldn’t it be amazing ifpatients who wanted to see a community acupuncture clinic in theirhometown didn’t have to just sit tight and wait for anacupuncturist to find them? Wouldn’t it make a lot of sense if wecould organize a patient base for a clinic BEFORE the clinic opened,instead of after? 501c6s absolutely don’t do that. We don’t needto “promote our industry”, that’s too vague; we need tocoordinate our interests economically, find ways to pool ourresources and access economies of scale.
For those of you who follow the CAN blog, and especially some ofthe arguments we’ve gotten into with the acu-establishment, you’llnote that our opposition has some consistent complaints: not only arewe rude, not only are we scruffy, but we’re not a very good501c6. They want to see our bylaws. They take exception to how ourmembership is set up. The thing is, they’re right. We’re NOT avery good 501c6. We really ought to be something else, something thatlets us organize our patients, and provide resources for employers,and access economies of scale, and create a microlending program.
Lucky for us, there is an organizational structure that allows usto do all of those things. It’s called a multi-stakeholdercooperative. Cooperatives have been around a long time – in factthey have a whole movement of their own, which we are looking forwardto joining – but multi-stakeholder cooperatives are a relativelynew phenomenon. They are more common in Europe and in Canada thanthey are here – in some places they are beginning to replacetraditional social-service nonprofits – but they are starting toappear in the U.S as well, where they are being used to do thingslike reconstruct local food systems in the Midwest. A cooperative is a kind of organizational and business recognition that producers and consumers -- or practitioners and patients --depend on each other.
So I’ve already been talking at you for way too long to get intothe technicalities of how multi-stakeholder cooperatives work. I’mgoing to be doing a breakout presentation on that very topic latertoday and again tomorrow, and if you can’t come to thepresentation, you can certainly get the handouts. Mostly what I wantto do is just to make the official announcement that we have foundour new atomic number, and we know where we will land after our nextquantum leap. We’ve spent the last 6 months or so hammering out ournext organizational structure, which is actually a new organization-- one that CAN itself will join as a member. That’s how amulti-stakeholder cooperative is set up – you can have individualsas members, and they can be practitioners and also they can bepatients; you can have community clinics as members, and you can alsohave institutions or organizations as members – like CAN, likeCLIMB, like a needle company. All linked together as a new economicfoundation for community acupuncture.
Our multi-stakeholder cooperative is called the People’sOrganization of Community Acupuncture, or POCA. Get it? Theactual transition -- into really being able to use POCA foreverything we need it to do -- will probably take us about a year orso. But you can expect that after this weekend, the conversation onCAN is going to be all about POCA. In a month or so, CAN and POCAwill have one website; and in the meantime, POCA has a Facebook pagewhere you can get more information. You should also expect toget emails and phone calls about POCA as we’re getting itestablished. There’s a lot to do.
We’re really thrilled about this. It is a lot of work to move anorganization onto an entirely new foundation – an awful lot oftechnical details – but we feel strongly that it’s a necessaryinvestment in our future. The structure of a cooperative seems to bea really perfect fit with our sensibilities, especially our desirefor self-empowerment and economic self-determination; and there’s alot of exciting potential for connecting with other cooperatives. Wefeel that POCA will really let us all take responsibility forourselves in our communities at a whole new level, and let us createthe future for community acupuncture that we want to see. We think that POCA is ultimately the vehicle that will allow us to collectively right-size the profession -- which means that the marketplace will allow more and more of our individual clinics to function at the right size, to prosper and thrive.
I want to close with a last quote from Seth Godin’s blog post onhis atomic theory of business size:
When in pain, consider your scale. When you’re too big or toosmall for the revenue or the impact you seek, you’ll feel it inyour bones. Leap.
big damn clinic
hierarchy of needs
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