An exploration of what it means to be an acupuncturist, with reflections on how and why the profession has changed over the last twenty-five years, and the development of professionalism. The article examines how far an acupuncturist is born and how far they can be grown, with particular reference to the means whereby suitable students can be selected for training. Also considered are the roles of the therapeutic relationship in successful practice and that of continuing professional development in the never-ending journey towards mastery of Chinese medicine.
Then and Now In the halcyon days of the late seventies, when I first trained as a practitioner, an acupuncturist was one small spell short of a witch; ‘aquapuncher’ was probably done under water, and lentils and sandals were endemic. Whilst we tended to see ourselves as the free thinkers of our generation, one of the practitioners local to me was an eccentric even by our standards. An example of his more nefarious practices was to take the needles out of his patient and stick them in the pillow next to the patient’s head, ready for insertion into the subsequent willing victim. Needless to say he was NOT a member of MY professional body! But in spite of this and other strange behaviours, unaccountably, his practice flourished and his patients, by and large, got better. So did mine which, to me, was equally astonishing.
How times have changed since then! At that point we were all still in the anarchic wood phase of our profession – often rather more energetic than directed. Now, many of us work from purpose-built clinics; our hygiene is scrupulous and we work on a daily basis with a Code of Safe Practice which confines pillow needles and other horrors to the bad old days. Gone are the ubiquitous lentils, the only pulses in evidence being those on the wrists of our patients. We work hard to balance the demands of holism with trying to ‘get it right’ for those whose job it is to check up on us. And our patients, by and large, still get better.
How did this miraculous transformation happen? How did we draw together these separate strands into a coherent, patterned whole and move into the fire stage of our development where we have really begun to blossom? Were we responsible for our own progress, or were we just in the right place at the right time? To find the answer, it is necessary to go back to basics; to explore what it means to be an acupuncturist.
What is An Acupuncturist? In considering this question should we be looking solely at the therapeutic use of needles or should we be looking at a broader description of an acupuncturist, encompassing the whole of the treatment experience and including the broad sweep of the therapeutic relationship? Do we consider whether an acupuncturist needs to be capable of running a practice (premises, promotion, finances and all!), or whether it is enough simply to be able to do the treatment? My take on this would always be that an acupuncturist in this day and age is a professional, and as such the broad definition has to be the most appropriate – we have to include Mitchell and Cormack’s ‘four aspects of treatment’ (techniques, therapeutic relationship, explanation and understanding, practical action and self-help activities (Mitchell and Cormack, 1998), as well as the ability to establish and run a professional practice, the commitment to audit, research and continued professional development: in fact, the whole picture.
In general, acupuncturists are a very different breed today from those of two or three decades ago. This is not in question. And yet I have no hesitation in still calling myself an acupuncturist. Neither do any of my colleagues. But in this day and age where professionalism is new and shiny, and statutory regulation looms large, who or what is an acupuncturist is still very much open to discussion. In truth, the definitions of the term are almost as legion as the points we use. According to the British Acupuncture Council (BAcC) website, ‘Acupuncture … is an holistic approach to health based on over 2000 years of developments and refinements in the Far East. … The skill of an acupuncturist lies in their ability to make a traditional diagnosis from what is often a complex pattern of disharmony. The exact pattern and degree of disharmony is unique to each individual and with traditional acupuncture will be treated as such with a personalised treatment plan.’ Whereas ‘Western-style or medical acupuncture is a more recent development practised predominantly by doctors and physiotherapists which uses a more limited range of acupuncture techniques on the basis of a western medical diagnosis.’
So where exactly do I fit if I insert needles for pain relief? What sort of an acupuncturist am I if I use a four-needle formula to detox drug addicts? Or if I relax mothers in labour, treat localised sprains and strains for footballers or assist patients to give up smoking? The British Medical Acupuncture Society (BMAS) website says: ‘BMAS has always looked at acupuncture from a western, medical, neurophysiological and scientific point of view.’ Endorsing a comment in the House of Lords report it also says: ‘The ideal promoted by the BMAS is that acupuncture should be fully incorporated into orthodox medicine and used as one of the therapeutic tools available in treatment of a defined range of conditions.’ Clearly, from the BMAS standpoint, it is not only the definition of acupuncture that is still open to discussion: so also is its future.
The viewpoint of an acupuncturist trained and practising in the eastern world will be very different again. Acupuncture is a tool. It is the particular means whereby we choose to motivate the therapeutic process in our patients. In western society, without a relationship with the patient, acupuncture would still work to a degree but that degree would be limited. Thus runs the viewpoint of the run-of-the-mill western-trained traditional acupuncturist. But it seems likely that this viewpoint is to a degree culture-specific. If you were trained in acupuncture in the East and if your background were oriental, you would probably have a very different viewpoint. Oriental culture does not place the same emphasis on the self-development of the individual that we do in the West. We see personal development, self-awareness, understanding and individual responsibility as central issues in our society and in our approach to our ill health. (Consumer Advisory Panel, 1997). As patients, we often require intellectualisation of our issues and one-to-one contact with our physician in order to develop a personalised treatment plan. We view the personal space to deal with the emotional issues surrounding our ill health as our right. (Radley, 1994)
In China, by contrast, we could expect that privacy would be much less important, we would anticipate less discussion or explanation and there would be an expectation of a higher level of compliance with the physician’s stipulations. We would be expected to accept the outcome of treatment, either good or bad, with relative equanimity. One of the major differences between a western Chinese medicine consultation, and a Chinese acupuncture treatment is likely to be in the area of the therapeutic relationship in general. The stereotypical oriental practitioner would not agonise over the boundary between active listening and counselling, or the fine distinction between giving advice and directing a patient. Masakazu goes so far as to describe his ideal acupuncturist thus: ‘Without asking for the patient’s ailment, this doctor would take the person’s pulse and help the patient heal by needling the meridians as he saw fit. This is truly ideal.’ (Masakazu, 2002). Clearly, the definition of acupuncture and thus of an acupuncturist is very varied.
Is an Acupuncturist Born or Do They Grow? Narrowing our view for the time being to western-trained acupuncturists working with a traditional diagnosis, we can consider the question of whether in fact an acupuncturist is grown or whether, on the other hand, they are born. Is acupuncture a learned skill or an innate talent? Arguably, many of the characteristics which form people into acupuncturists exist (or not) by the time they apply to study. Students learn many skills during their acupuncture training, not least of which are in the area of personal development. Skills are learned and developed to overlay pre-existing abilities. There seems to be a continuum running between skill and ability, with ability as an innate resource to be drawn on and skill as something to be learned later. At enrolment, a mix of the two is the norm, where for instance a student arrives on the course with a well-honed ability to relate to people but still a lot to learn in the skills of establishing an appropriate role distance with a patient. In truth, the answers to the above question are not absolute. There is no doubt that acupuncturists need to possess a measure of both skill and natural ability. Modern-day acupuncturists in private practice must be able to do the treatment, maintain the relationships and run their businesses if they are to survive as practitioners. The pieces that make up the whole do not fit together seamlessly and there are many different routes that lead to the same place. How acupuncturists choose to travel, which route they take, and what resources they use to get there are the things that define them as practitioners; their individuality. As usual in Chinese medicine, there is no right or wrong here.
Recognising a Good Acupuncturist So, how does the world recognise a good acupuncturist from a bad one, and indeed does the world need to recognise them? In theory, this is one of the primary functions of the professional bodies; to sort the novices from the masters. The BAcC and the BMAS help to categorise practitioners and to define which sort of acupuncturist we are dealing with. Different patients look for different things from their practitioner. Some patients cannot trust an acupuncturist unless he or she is also a medical doctor, a member of the BMAS. Some will not be interested unless the practitioner is a member of the BAcC, or has been trained in China, and there will always be a percentage who only trust the ‘born healer’ regardless of professional qualifications or memberships of appropriate professional bodies. And surely all of us look for that indefinable quality – the qi of the practitioner, the quality of awareness, the ability to be present for us, to relate, to meet us on the level of spirit, to heal.
So the pillow-needle man may have had a talent (indeed, his patients got better) but since we assume he was not a member of a professional body, he instantly lost credibility with the people who were looking for formal professional credibility. But to those who were content with spirit and charisma, he did the job splendidly.
The Development of Professionalism In the time since pillow-needle man behaved as he did and now, what has happened? What has changed? We have become professionals. Over a period of three decades we have dragged ourselves up by our hippie bootstraps, and rushed into the twenty-first century, pristine in our white-coated correctness, brandishing a needle in one hand and a degree in the other. And this transition from outcast to inboard has cost us on the one hand, and paid us huge dividends on the other. What some practitioners fear is that somewhere in the transition we have lost our way: that holism and the essential spirit of our treatment may have gone by the board to be replaced by a focus on accountability and evidence base. Or that we have forgotten the patient in our efforts to ‘get it right’ for external agencies. If there is any truth in this, we must also recognise our gain – orthodoxy: professional and academic recognition and respect. Sometimes we dream of a world where all patients and all practitioners are considered equal, and where all treatment sees the patient as an individual and the needs of the patient as paramount. As Lao-Tzu said: ‘the journey of a thousand miles begins with a single step.’
Exploring the base-line for training So we have looked at how the world sees acupuncturists, but almost more importantly to me, as a college principal, is the ability to recognise the potential to become a good acupuncturist in an applicant or a student. There may not be easily identifiable characteristics that define an acupuncturist, let alone make a ‘good’ one. Nevertheless, at LCTA (London College of Traditional Acupuncture and Oriental Medicine) over the years, we have identified certain characteristics that determine the bottom line for students who enrol onto our courses. In other words there are specific attributes that a student needs to have in place at the very start of the course in order for them to have a good chance of success, both within the course itself, and in subsequent practice. To this extent, acupuncturists are born, or at least they reach the College with the right attributes, whether they were born with them, or developed them along the way.
It is where a student’s pre-existing abilities do not fit the basic profile that we can run into trouble. For instance, if a good degree of self-awareness is not apparent in a student at enrolment, a training in acupuncture is probably not going to be sufficient to make a significant enough change. Another pre-requisite is a degree of humility and the ability to empathise – what Masakazu calls the ability to ‘cry with one’s patients’ (Masakazu 2002). Yet another is an accepting attitude, the willingness to view another person as different without finding the person in some way wrong. Interviewing for these abilities is a challenging and very interesting process. It is with a certain reluctance that we shake off the ‘commitment is all you need’ attitude and replace it with strict entry requirements, of various types. It is sobering to have to accept that some people just cannot be grown into our modern-day definition of acupuncturists, no matter how much they may have the heart and desire to be!
Developing a Student Selection Tool Based on a process of constant evaluation of the results of our decisions, year by year, we have developed a sophisticated tool, known as the C Score, that is highly effective in assessing these abilities and skills already apparent in applicants at interview. We have divided them broadly into four categories, each of which is further subdivided. For example, the first category is ‘Commitment to Chinese Medicine’, and assesses applicants’ previous exposure to the subject, their clarity of decision-making, their strength of vision of themselves as a practitioner and the practical and emotional support and resources already in place to help them undertake the journey. The second area breaks down the applicant’s ability to study at higher education level, the third their life experience and the fourth their ability to work with people and the quality of their own spirits. After an in-depth interview it normally takes no more than five to ten minutes for the two interviewers to produce a score on this assessment. Over years we have determined by observing students’ progress what C Score applicants need to be able to complete the course successfully.
After a while this C Score, as we call it (the origins of the name are definitely not worth relating!) takes on a life of its own. We can begin to see students in the light of their overall abilities and potential, rather than being side-tracked by the more conventional markers of educational qualifications and high IQ on the one hand and charisma on the other. Insofar as applicants are ‘born’ acupuncturists, the C Score measures this before they ever arrive on the course.
The Value of Good Patient-Practitioner Relationships So if an applicant has a good C Score, what next? We have established which innate qualities they bring to assist them in their development, but how far is it possible for us, as teachers, to have an input into their progress once on the course? In 2000 I completed my Masters degree on the subject of the Maturation of Acupuncture Students. As a phenomenological study this provided a wealth of rich description of students’ process of development. Once a student enrols on a course to study Chinese medicine, it is all too easy for their focus to narrow down and for the study of acupuncture itself to fill their field of vision. As a lecturer at LCTA I do an interesting exercise with students at the start of the course where they consider the five most important components of a ‘good’ practitioner. Almost invariably the initial focus is not on technical skill but on the relationship the practitioner makes with the patient, in all its complexity.
It seems that at the start of a course it is very clear to students that the therapeutic relationship is central, but as time goes on, it is easy for them to become side-tracked by the fascination that the subject of Chinese medicine itself holds for us all. It is only when students have the opportunity to sit back and reflect, as they do on the course and they did in the interviews for my degree dissertation, that the full import of the therapeutic relationship hits home. The view of participants in this study was that reflection on and in practice was key, and central to the development of skill in the therapeutic relationship. For instance, it is not enough to know about the issues that arise from poor handling of role distance: reflection on first-hand experience is necessary for a full understanding of this to grow. The first time we seriously overstep a boundary we learn more about ourselves and the impact on the patient than any classroom teaching can tell us. (Stewart et al, 1995).
No course in Chinese medicine in the western world is adequate without the opportunity for students to reflect extensively on the therapeutic relationship from practical experience and over time. Anecdotal evidence and informal observation seems to suggest a much more direct correlation between students’ skills in the area of the therapeutic relationship and their success as practitioners than between expertise in Chinese medicine and successful practice. This after all is one of the areas where complementary and alternative medicine (CAM) of all kinds scores hugely over conventional medicine. Patients these days want to feel that their needs are treated with the utmost respect. (Usherwood, 1999). As any CAM practitioner knows, carelessness with people’s emotions can readily lose patients. With the use of private healthcare becoming an ever more realistic option for people, they are voting with their feet. Expectations are high and if patients do not get what they need from their practitioner (indeed what they feel they are paying for!) they simply move on.
The Role of Continuing Professional Development So, the Colleges all do their bit to help the fledgling acupuncturists to grow, but when we proudly send them out on their first flight into the skies of private practice, what then? With the best will in the world, alongside the development of expertise, people forget things, they get lazy, they cut corners. Much like learning to drive, everyone develops their own style, their own quirks and their own good and bad habits. So how do we keep learning, keep growing? Surely this is the role and purpose of Continuing Professional Development? The need has been established for practitioners to maintain enquiring minds, to continue growing; to learn forever. Graduates these days have a wealth of opportunity to retain links with their old classmates and to keep learning through post-graduate seminars and short courses. As the profession moves in the direction of specialisms, more and more people are fine-tuning their knowledge – developing their niche and expanding to fill it.
The Never-Ending Journey So there we have it. Would-be acupuncturists seem to arrive at their decision to study Chinese medicine from an unlikely variety of starting points. They are as different as chalk and cheese to the untrained eye, and yet on closer inspection, and observation of their C Score, it becomes apparent that they bring with them a certain set of attributes, qualities, talents (call them what you will) which constitute the ability to become acupuncturists. It is the job of lecturers across the board to coax out of each and every one of these students an individual style of practice that makes a ‘good’ acupuncturist, at the same time as providing fertile ground for development of the individual’s skills and talents. The students become graduates, and the graduates become practitioners and the practitioners sometimes, but not always, become experts in their field; the point being that some acupuncturists recognise the elusiveness of the goal. They recognise that learning to be an acupuncturist is a bit like the Buddhist search for enlightenment – the search is at once frustrating and fascinating, but if you once think you have reached the goal, it is a sure sign that you are mistaken! Growing an acupuncturist therefore, is an impossible task without the commitment and the dedication of the student. It is necessary for both the master and the novice to accept that this is a never-ending journey.
(A Bibliography for this article is printed in the hard copy of The European Journal of Oriental Medicine Vol. 4 No. 2; Winter 2003.)
Susanna Dowie Susanna Dowie has been in private practice since 1982 and is widely engaged in many aspects of the complementary medicine field, including homoeopathy and massage. She has been the principal of the London College of Traditional Acupuncture and Oriental Medicine since 1995.
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