Tuesday, February 26, 2013

A Simple Way to Contact MD Practitioners in Your City

Your patients' MDs, both General Practitioners and Specialists, need to know that you are participating in their patients' care. As our medicine is more and more tied into the electronic records' system and more of us are billing insurance, this is a logical step. However, in the meantime, I suggest you make this process part of your standard procedures when possible. This begins with a place on your history forms where patients are requested to:
• list any other care providers that they are seeing currently or
• any doctors who are a long term part of their health care team (i.e., their "regular doctor" or primary care provider [PCP]) 

With each new patient who has actually agreed to a course of therapy, ask for permission to send a letter/fax to their main PCP stating who you are and about the care you'll be providing, and requesting a copy of their patient records. It is, of course, a HIPAA requirement that you request permission to contact any other healthcare providers. This is a separate piece of paper that you present if the patient actually has listed other providers on your history taking forms. While some patients may not have an MD and some may not wish their MD to know about you, others will think it quite professional that you want to be in contact with their other care givers. Furthermore, in some cases it will be absolutely mandatory that you stay in touch with patients' MDs.

So what to say to these MDs, PTs, NDs, DCs, or whomever?  First of all, my suggestion is that, like any marketing process, this simply needs to be part of your standard procedures, and that this letter is a prewritten digital file that you revise as needed for each case. That means you are not writing it from scratch every time. Below is a sample letter that I might write, but it is only one idea.

To:  Sarah Jones, MD., Boulder Gynecology Clinic
Dear Dr. Jones, 

Your patient, Mary Smith, has recently begun acupuncture care at my clinic, WomanCare Acupuncture Clinic. I will be treating Mary with acupuncture for premenstrual pain and related symptoms. It is my expectation that Mary will require three-four treatments per month for three months to see significant and lasting improvement in her condition. I will also be counseling her on diet and exercise to help her take care of herself long term.

Mary has given permission for and I am happy to provide you with updates or a final report at the end of the treatment protocol for your files, should that be helpful for maintaining thorough records in her case. I am able to send those records to your electronically if you prefer.

Enclosed for your interest and information you will find:
• a signed release of records so that our clinic may see Mary's recent medical history with your office
• some research about acupuncture therapy for cases similar to Mary's
• a general brochure about WomanCare Acupuncture Clinic and the services we offer that may be of use to other patients
• a copy of my Curriculum Vitae showing my credentials and experience in the field of acupuncture and Chinese medicine
• several of my business cards

If you have any questions or concerns at all about Mary's care at my clinic, I am happy to speak with you or communicate by email at any mutually convenient time. As a specialist is gynecological care, I would also like to know if your clinic is willing and able to receive appropriate referrals from my clinic.
Thank you for your time.

Yours truly,
Honora Lee Wolfe

You may sometimes need to add a paragraph explaining that you are aware that the patient is taking XYZ drug(s).

You may need a paragraph about Chinese herbal medicine that the patient is taking while under your care.

At the closure of Mary's care, if appropriate and especially if it is a positive outcome, send another letter explaining that Mary's treatments are for the moment completed and that her XYZ symptoms are significantly improved. Even if Mary is going to stay under your care longer, it may be useful to update her MD on any significant improvements or changes in her care or condition.
If you were to open this type of professional communication with three-or-five-or-ten MDs and you have faith in your treatments, you may find these doctors will slowly begin to refer a patient here or there to your care. Over a period of time,  this can become significant, especially if you are referring patients back to these MDs from time to time. I believe that we do not need to fear these communications or relationships and that with attention and respect we can create open professional communication with appropriate Western medical practitioners.

Thanks for reading and best wishes!

Monday, February 25, 2013

Need a few more appointments this week or next week?

Practice a little slow this week? One powerful way to add a few names in your appointment book is to do patient re-activation phone calls. It's way easier than cold calling (calling people who don't know you) and it's a tried and true method to get a positive response from the universe in growing your practice.

You don't need to have a huge agenda for these calls, but it is certainly easier if you write a few "scripts" for them before you start. This is helpful too, since you will inevitably be leaving messages on the phones of many of these patients. Here are some ideas:

1. For patients where you parted ways after treatment success: "I saw a recent article about your condition (which I'd be happy to email to you if you're interested) and it made me think of you. How are you doing? Still no more symptoms?" Then listen to the patient and see what they say. If they are still better, you have at least reminded them of your ongoing care for them as a patient. You might suggest a "tune-up" appointment or two at the next change of season to maintain their health.

2. For the patient that cancelled and disappeared: "I see you cancelled your last appointment and then we never heard from you after that. Can you tell me how you are doing? I was just wondering if you disappeared because you were feeling great, or was there something that did not work for you at our clinic...something that we could have done better? I hope you might be willing to share that if it was the case. I appreciate your taking this call and I hope you are feeling better."

3.  For the patient where their written contact information no longer works: "I'm calling for two reasons...one just to check in and see if you are still feeling improvement from your treatment through my clinic. Second, I see that your email address as changed. Did you still wish to be on our mailing list? We really hope so, but we need an updated email address!"

4. The patient where your interaction was OK, but you don't know why they stopped coming: "Hi Jane. It's been awhile since I saw you and I just wanted to say hello and see how you are. I know you had ...(you divorce finalization, our son's graduation, your mother's serious illness, your new job, whatever). I know that was stressful for you and I wondered how you are doing."

After each of these possible openers to the conversation, then be quiet and see where the patient will take the conversation. If they haven't much to say, you can ask if they'd like to continue to receive your email newsletter; you can offer to send them a coupon for 1/2 off the next time they might want to come in for a visit; you can let them know about a new class you are teaching or a new skill you have acquired; you can tell them about a free lecture you are giving somewhere; you can remind them that regular tune-up treatments can keep them symptom free. Whatever feels appropriate.

After the call, you might follow up with a card or a personalized email and include a piece of research or an article on their condition if you can find one (check out our TCM Infoline here at Blue Poppy for lots of free research: see the search mechanism in the center at the top of our home page). If you send a regualr piece of snail mail (what a concept), include a copy of your biz card as well.

Does this take a little courage? You bet, but then if you were a wimp you probably would not be running your own business anyway. Plus, you don't know what fruit this will bear. For every ten phone calls you make, you will likely get one patient to make an appointment right away and another one to call back for an appointment within a few weeks, or to refer a friend since they have now been reminded about you and your services. Or perhaps one of them will call and ask if you will come and give a talk for their special group. You just don't know.

Also, these same scripts can be used for the inevitable messages that you will leave for people...likely over 50% of the calls won't reach a real person. Even so, you've reached out is some non-threatening, not-necessarily-commercial way, which is more than more other types of practitioners ever do.

So don't abandon your inactive patients. Make it a monthly task to call six-or-eight-or-ten of them...you don't need to make this a gargantuan task! The more you do, the easier they become (and what's the worst that could happen anyway?). It's easier to get your old patients back into your clinic than to develop new ones who have never been there before!

I have a live class coming up at National College of Naturopathic Medicine in Portland, OR on April 17th, 5 PM! If you think it sounds helpful, hope to see you there! I'll also be attending the Great River Festival at Northwest Health Sciences U. in Bloomington, MN the first weekend in April and speaking to the practice management classes there on April 4th.  If you work at a school or are a student at a school and would like me to come and give a free lecture, feel free to email me at honora@bluepoppy.com. Thanks for reading.

Tuesday, February 19, 2013

How to create a brochure that someone will actually read!

As the teacher of Practice Management at Southwest Acupuncture College for a decade, I've looked at lots of projects: websites, presentation folders, business plans, biz cards, and patient information brochures. The last of these, patient info or educational brochures are always useful to have in a clinic, take to talks that you are doing, or send out with any other promotional literature or letters to potential sources of referral.

I read and grade a lot of these and the most common mistake that is made is putting too much emphasis on yourself and your clinic and not enough emphasis on what’s in for the potential patient and why will they want to read your brochure?

For example, if you place the name of your clinic and contact information as the featured information on the front of your brochure, why should I as a potential patient, really care? What’s in it for me to pick it up and read?

However, if you put something like this on the front:
"Migraine headaches don't have to keep you from enjoying life."
"Allergy season got you down? Real relief begins here!"
"Insomnia sufferers need relief now!"
"PMS got you breathing fire?"
"Maintaining healthy blood pressure is important for everyone."

Underneath or to the side of any one of these headlines, you put a relevant photo that you can buy cheaply from any one of many "royalty-free" photo services such as iStock.com. If I have one of these conditions, I might just wish to read the brochure!

Then, on the inside, put some quick data from relevant research on your topic, (which you can find  doing a word search right here at BluePoppy.com by searching the TCMInfoline...but you have to create a login to access this) or on WebMD, Acufinder, Acupuncture Today, and many other sites.
You could add the WHO list of conditions that acupuncture is considered effective for treating. (Yes, I know it is outdated and incomplete, but it still lets your patients know a lot of things acupuncture can treat besides pain?)

Then add some pictures of you working in your clinic (or a professionally done portraint) and bio on the inside bottom right.

On the back side, include a map or picture of your clinic, directions and contact information. Your website and phone number should be reasonably bold and prominent.

This is a good recipe for brochure design and you can spin headlines and content for any condition you want to treat. So get to work out there and design some great brochures to help you promote your clinic and your work! Use them at live events, when you visit other professional offices, or if you do a booth at a Health Fair. Put up a sign encouraging patients to take them to friends and colleagues.
This is only one part of your overall marketing strategy, but not an unimportant link in your marketing chain.
Good Luck!

Thursday, February 14, 2013

How & Why to Use Communication Rituals with Your Patients

Recently I was listening to an online marketing presentation about ways to become irresistible to your customers. One of the things they discussed that struck me as really relevant and important for people in the business of healing was to create a series of “business rituals” for how your business communicates with patients...from the very first "touch" (phone call, visit to website, meet at a health fair, whatever) until the final day they leave your practice. Most of us have some of these processes in place intuitively without having labeled them; but what do we mean by this and why should you bother?

First I will discuss why it is valuable for you and your patients. Then I'll give some possible examples.

What can business rituals do for you?
1. You only need to invent the wheel once. The process of designing rituals for your patients as a planning tool for managing all patient and prospective patient interaction. This is valuable to you first because it means you have a created a system that can be repeated in the same way, in the same order, and with relatively predictable results with every patient. Of course your system can be tweaked whenever, as needed, but how you communicate and manage patients becomes built in.
2. Most parts of this process can be delegated. You want and need to focus on treating your patients; it is what you were trained for. So, creating a series of tasks that are all repeated in the same way and same order and then taught to your front desk staff or other subordinate (if you don't ahve such a person, make it a short term goal to hire one!!) frees you up to be the healer that you want to be.
3. Some of your rituals can be designed to increase your patients trust and belief in you, increase their perception of value for your services, or help you tell your unique "story." Let's face it, with only 5% of all Americans using Chinese medicine and acupuncture, what we do is downright weird in some people's minds. We have some work to do to gain the trust of more potential patients. Some of the information we may send/give out or post on our website for the benefit of potential patients (things that all potential patients should receive) should be designed to increase their trust and belief. More on that below.
4. One ritual you can use would be to "pre-qualify" your patients to see if they are a good fit for our services. This can be done with a questionnaire or with a pre-intake free consultation. You may say that you want to simply take every patient who might walk through the door, but it really is not true if you think about it, and it's not even good for your practice or the industry. For example, if a prospective patient shows up with a condition that you have no experience with and you know that someone across town is an expert at this condition, it's probably best for our profession in the long run if you refer that person to the expert. If you make sure they know that you were the source of the referral, perhaps they will return the favor. I've had the question in classes, "What do you say when someone says 'I've tried acupuncture and it did not work'?" Such remarks are very discouraging, but one response might be, "Perhaps you were not with the right practitioner for the condition you have." Also, most of us have had the experience of trying to work with a patient that, for whatever reason, just wasn't right for us and in whose presence we feel uncomfortable. Such pre-qualification rituals can help us know immediately whether a patient is a good fit for us, and probably whether or not we can really help them. I believe it’s a bad idea to take a patient that we don’t think we can help…just for the short-term income. If we are not able to help them, we don’t get any good word of mouth from that interaction and it leaves a bad taste in both our mouth and theirs.
Secondly, the pre-qualification ritual add to a mystique of exclusivity...perhaps making a potential patient really want to become our patient simply because we are not immediately herding them into our treatment room.
5. Follow-up and follow-through rituals are often what make the sale. Let’s say you give a free lecture at the library called “Insomnia? What Can Acupuncture Do For You?”. Fifteen people show up and one actually makes an appointment with you on the spot. Ten others leave you their contact information. What are you going to send them after the lecture to convince them to trust you and come in for care? Whatever the piece is, it should be ready to go before you ever gave the talk. This could be a coupon for a free private 15-minute consult attached to an article you wrote quoting some research and with a current patient testimonial at the bottom of the letter. It could be a phone call thanking them for coming to the talk and asking if they have any other questions they may want to ask in private. Whatever that follow-up looks like, it should be a built-in, standard part of giving public talks…a business ritual. If two more bite, you still have relationship building to do with the other eight that gave you their information. So then what? Perhaps a monthly email with a link to your website articles section? Perhaps a phone call to see if they are still interested in hearing from you?
What could be a list of standard business rituals?
  1. Giving one free talk per month, with appropriate handout literature and follow-up procedures (see above) until your practice is as full as you want it for three months in a row.
  2. Your website includes a free report, a video, an ebook, or some other downloadable educational tool that requires people to leave an email address. Anyone who signs up for this free download gets a thank you note and an offer for a free consult or to have you answer one question for them free of charge. This item is refreshed with new copy at least once per month.
  3. Potential clients are always scheduled for a free consult to see if he or she is a good candidate for your services, or not. If not the right patient for you, have a list of referrals available as a hand-out.
  4. If they are a good potential patient, a simple treatment plan form to give them at the end of the consult so they know what to expect when they come in. This gives patients confidence that they know what is going to happen…no secrets. Also, don’t try to sell 12 treatments if you really think you only need five! If you don’t know, suggest 4-5 treatments and then a review of progress.
  5. When patients first come to your clinic, what info, gift, educational materials, or free samples do they get?
  6. A free tea and cookies service in your waiting area?
  7. A play area for young children?
  8. Send out “haven’t seen you in a while” letters to patients who have not been in for six months. Send out birthday cards for this month’s birthdays with “Get a free Tx on your birthday!” coupons.
  9. Bonding calls to follow up with first-time appointments (‘How are you feeling? Any further question we can answer? Looking forward to seeing you at your next appointment. Please call if you have any questions at all.”…etc.)
  10. You have both morning and evening check-lists for your front desk staff to perform daily, weekly, monthly. (e.g., pull charts at 9 AM, back up the computer at 5 PM, do reminder calls after 3 PM, check needle inventory in all treatment rooms each morning, order needles and herbs on Friday afternoon, etc.).
  11. A monthly promotion for the community…”Come in this Saturday, get an acupuncture treatment for $35; All Proceeds Donated to the Local Homeless Shelter (a different non-profit each month?) When people come in, have handouts, “sign-up for our newsletter” forms, brochures, business cards. A different non-profit every month will draw a different crowd. Get the non-profit to help to promote this.
  12. Asking for a testimonial note whenever a patient says “I feel so much better. Thank you.”
  13. Standard “release from therapy” letter…for patients who are better and have gotten a great result.
So there’s my list. Yours could be completely different…but it’s good to have one. You know what “happens next” with each patient or potential patient.

BTW, Blue Poppy is offering a BOGO deal on books today, Valentine's Day 2013! Check it out.

Wednesday, February 13, 2013

Five Ways to Be the Life of the Party at Every Networking Event

by Honora Lee Wolfe
We always hear that we have to “network” to build our practice. “Join the Chamber of Commerce, Kiwanis, the PTA, and Toast Masters,” business teachers say. I myself have said that you should go to every fundraiser, party, speech, seminar, Chamber of Commerce class, PTA meeting, church dinner, book-signing, or other event where there will be people to meet and greet. So, okay, you might say to me, what if I do go? How do I “work” such events to actually become better known in the community and turn that into patients and referrals? How do I do that without being a jerk or overly pushy?
Here are my best ideas to get the most out of every event you attend.

1. Be the first in and last out. As a rule, the best networking opportunities happen in the 20 minutes prior to the start of the event and the 20 minutes after the function ends. If you main objective is to make as many contacts as possible, the always arrive as early as possible. You can even think of yourself as one of the hosts and greet and speak to as many people as possible and then say goodbye and “gee, wasn’t it interesting when the speaker said…” at the end. Mostly, people won’t care that you aren’t really the host, but will be thankful that someone was kind enough to greet them and make them feel more comfortable and welcome in a new environment.

2. What’s in a name (tag)? Okay so this one is a little hokey, but it works. Create your own name tag and put your name and then a quote or message underneath, either something inspiring enough to start a conversation or relevant to what you do and interesting enough that people will ask about it.
Or, if they will have their own nametags, open yours up and write your message on it. You can try something inspiring like, “The average human heart beats 100,000 times per day; make those beats count.” or “Choose a positive thought; the human brain can only hold one thought at a time!” or something humorous like “Needle little pick me up?” or  “Got health?”  This will start a number of conversations; I guarantee it.

3. Be a brilliant conversationalist. You can control any conversation by asking all the questions and then just sit and listen attentively. Don’t interrupt or talk much about yourself. People will believe you carry on the best conversation they ever had. Toward the end of the conversation or when it’s time to go, offer them your card with a simple comment such as, “It was great to talk with you; appreciate you sharing about yourself. Here’s my business card; I don’t know that you’ll ever need my services, but if you do, here’s how to find me.” Then offer your hand and a smile and move on.

4. Be a door prize. Offering your product or service as one of the door-prizes at any event that has such things, or as part of a silent auction for any and every community fundraiser, is always a good way to get publicity for being a real participant. If you can arrange it, try to trade the door prize for a copy of the attendee mailing list. Do this regularly for any clubs and associations of which you are a member and watch your mailing list grow.

5. Creative Introductions. You can make a memorable impact on everyone you meet by developing a more creative verbal introduction. So, instead of saying: “I’m an acupuncturist.” you might say:
“I relieve the full range of human suffering using very small sharp metal implements.”
“I help people run faster, jump higher, and recover faster from any and all physical activity and exertion.”
“I help husbands love their wives more every week of the month.”
“I make it possible for more people to get a better night’s sleep.”
You get the idea. As these examples illustrate, the way you introduce yourself can be dead serious and dead boring, or a little more fun and a lot more interesting. Your message should be a conversation starter, memorable, and help you market yourself and your services in a lighthearted way. Remember that you never get a second chance to make a first impression.

Hope these ideas help you make the best use of any and all your networking opportunities. My next networking events include a class this Sunday, Feb 17th, for San Diego Pacific College of OM Alumni and the Great River Symposium at Northwestern Health Sciences U in Bloomington MN (April 4-6) and  Maybe I’ll see you there!

Tuesday, February 12, 2013

Handling Difficult Communications with Patients

My friend and colleague Nancy Bilello wrote a book for us a number of years ago that I have always liked. We titled it, perhaps inauspiciously, Understanding the Difficult Patient. It should be called something like "Dealing with Problem Patients!" It is all about problematic patient communication, dealing with all those moments where you don't know how to handle a patient: when they are angry, non-compliant, needy, overly-familiar, seductive, don't show up or don't pay, or all the other weird moments that we hate as practitioners but which do happen. It's a wonderful book but it never got the attention we thought it deserved. We are now making it available as an ebook for a very reasonable price and here is the first chapter for those of you who actually have experienced these problems and know that any advice we can get for these is hugely helpful!difficult patient-chapter1.pdf
Please enjoy.
Here's a link for purchasing this ebook as well for anyone interested in this excellent little book.

Monday, February 11, 2013

12 Brain Rules for Better Presentations

Most people have some trepidation about giving lectures and live presentations. Even after years of being in front of every kind of group you can think of, I still get butterflies and I'm always looking for ways to do it better. Here are some interesting tips from author John Medina that can at least give you the assurance that you've done your best to be prepared. His thesis?...knowing how the brain works can help you create and deliver more effective presentations. John Medina's Brain Rules really gave me some things to think about to make my presentations better...
1. Exercise boosts brain power. Got writer's block? Get your body moving and your brain will perk up.
2. The human brain evolved to ensure our survival. It works better when we feel safe. Put your audience at ease and they'll listen.
3. Every brain is wired differently. You may need to say things in a variety of ways to reach all the different brains in your audience.
4. We don't pay attention to boring things. And we're easily distracted. Add an emotional element and we tune in better.
5. Repeat to remember. Your audience is more likely to remember repeated elements.
6. Remember to repeat. Remember to review important information at the end of your talk to stimulate your audience's memory.
7. Your brain needs sleep to function properly. Get a good night's rest before you present, and don't be afraid to take a nap.
8. Too much stress makes brains less effective. Having a happy home life can actually make you a better presenter!
9. Stimulate more of the senses (especially smell), and people will remember more.
10. Vision trumps all other senses. We're more likely to remember pictures than words. Time to revamp your PowerPoints!
11. Male and female brains are different. You may want to tailor your message to the main gender of your audience.
12. We are natural explorers. We learn more by experimenting than by listening passively, so try to get your audience involved.

Intrigued? Presentation guru Garr Reynolds was so inspired by Medina's book that he created a whole Brain Rules presentation about them.
Check out more details about successful presentations at Garr's blog: http://www.garrreynolds.com/Presentations/index.html


Thursday, February 7, 2013

She Dou (Sp 17) "Food Hole"...a Forgotten Acupoint we should use!

Most Chinese-trained acupuncturists rarely use the point Shi Dou. It is not considered an important or particularly useful point according to current Chinese acupuncture education. In fact, it is probable that most Western acupuncturists promptly forget everything about this point after taking their licensure exams and would be more likely to use its neighbor, Da Bao (Sp 21) if a local point in this region were required.
However, according to the Bian Que Xin Shu (Bian Que’s Heart Writings), a Song dynasty text by Dou Cai as interpreted by Sung Baek in his book Classical Moxibustion Skills in Contemporary Clinical Practice,1 direct moxibustion of this point with tiny threads of high grade mugwort moxa is singularly useful in many if not most cases of spleen qi vacuity, liver-spleen disharmony, spleen dampness, and especially where the qi mechanism (upbearing and downbearing) is impaired due to a combination of liver depression, qi vacuity, dampness, and heat existing all at the same time.  In fact, when reading author Sung Baek’s description of this point’s uses, what he appears to be describing is Li Dong-yuan’s yin fire theory. There are several sites in his book that support this idea.
In one case, Baek states that moxa on this point is of vital importance in cases of edema with urinary retention and the inability to breath when lying down. This symptom picture suggests that  treatment must downbear turbid counterflow qi and also supplement the lung qi (by supplementing the spleen qi) so that is can properly depurate and downbear both qi and body fluids.
In another case, he suggests using Shi Dou for the treatment of spleen stomach damage with dry heat above due to excessive consumption of cold food causing loss of communication between the three warmers. This again suggests that moxa on this point promotes qi rectification, clearing of heat, and spleen qi supplementation.
In a third case, the same author suggests applying 300-500 threads of moxa on Sp 17 in case of chronic malaria in order “to balance hot and cold within the body” by fortifying the spleen.
Finally, he suggests the use of moxibustion on this point for all types of edema due to inadequate engenderment of latter-heaven qi by the spleen, in cases of high fever but where the lower limbs are cold, in cases of diarrhea due to spleen qi vacuity, nue-type diseases with alternating fever and chills, vomiting and loss of appetite, yellow jaundice with red-colored urine and yellow eyes due to cold damage, and chest and rib-side pain due to poor digestion. Also, he insists that  these complex disorders must be treated first by fortifying spleen qi. He further states that treating Shi Dou on the left is for specifically for supplementing the spleen, while, on the right, it is for soothing the liver.
In searching for other views on the use of this point, I found that Felix Mann’s The Treatment of Disease by Acupuncture, which is a translation of the treatment formulary section of the Zhen Jiu Da Cheng (Great Compendium of Acupuncture & Moxibustion), states that Shi Dou can be used to treat chest and limb heaviness, diaphragmatic pain, intermittent fever of the spleen, paralysis and numbness, ascites, and pulmonary congestion. Again, if we look at these symptoms, we see the disease mechanisms of spleen qi vacuity, blood vacuity, dampness, and liver depression qi stagnation with possible damp heat.
According to Li Dong-yuan, the disease mechanisms of yin fire include spleen qi vacuity, liver depression, damp heat, yin and/or blood vacuity with vacuity heat, and stirring of ministerial fire. If one analyzes his treat protocols, it becomes clear that, to treat this kind of complex disease mechanisms, one must, at the very least, supplement the spleen, rectify the qi, and clear heat, as well as doing whatever else is necessary in each patient’s case. Based on Baek’s and Mann’s description of this point’s effects, we see that it is exactly these disease mechanisms which are being treated. We also see that they are discussing difficult-to-treat, complicated conditions similarly to Li Dong-yuan.
As a final note, it is my own clinical experience that this point will be tender, often exquisitely so, when it is most needed. I also agree that it is necessary to burn many, but very tiny, moxa threads on the point, usually at least 50 and often as many as 200. Needling the point is not suggested as a replacement for moxibustion since the two types of therapy do not perform the same functions as well as the fact that it is just over the lateral lung in a very slender person. If time does not permit you to treat both sides with moxa, I suggest using the right side, since it is away from the heart and prevents the possiblity adding unwanted heat to that organ (although I have not had that happen in actual clinic practice). I have used this point with excellent results on many patients and hope you will consider it the next time you encounter a patient with a similar complex condition. Knowing the type of patients that most of us see every day, you may find yourself treating this point on a regular basis.
For more information about moxibustion, see Lorraine Wilcox’s Moxibustion: Modern Clinical Handbook and Moxibustion: The Power of Mugwort Fire. For more on yin fire theory, see Bob Flaws translation of The Treatise on the Spleen and Stomach and his one-hour online course, Li Dong-yuan’s Theories on Internal Damage Disorders.

1 Baek, Sung, Classical Moxibustion Skills in Contemporary Clinical Practice, Blue Poppy Press, 1990. Out of Print

Tuesday, February 5, 2013

Cannnot Burn Moxa in Your Office??

Problems with burning moxibustion in modern Western practice
Zhen jiu is translated into English as acupuncture and moxibustion, which means that moxibustion is half of of our art. Unfortunately, many practitioners here is the West feel they cannot use burning Mugwort moxa in their practice. Either it is too smoky for clinics in modern, multi-tenant office buildings, or it is too time-consuming…or both! I've certainly worked in offices where I could not burn smoky moxa over the years of my practice. However, needles and moxa are not interchangeable. They do not do the same things, and sometimes moxibustion must be used to get the right response. For instance, the Nei Jing says that moxa is simply stronger than needles and should be used when needles are not strong enough to treat the disease (regardless of whether the condition is hot or cold). Because so many Western patients come with chronic, enduring "difficult to treat" conditions, moxibustion is not always merely optional.

More than one kind of "moxibustion"
Fortunately, translating the word jiu as moxibustion is not exactly correct (or at least not complete), and therein lies the solution to this problem. Moxibustion means the burning of mugusa, the Japanese word for Mugwort or Folium Artemisiae Arygii (Ai Ye). However, this is only one kind of jiu, specifically ai jiu. The word jiu is actually a much more generalized term meaning "heat therapy." Other types of jiu described in the Chinese medical literature include burning Medulla Junci Effusi (deng xin jiu), using hot wax, various types of electric heat (called dian jiu in Chinese), various types of herbal fumigation, and various types of chemical heat (called yao fu jiu or applied medicinal heat therapy). So when the Nei Jing says to use moxibustion for conditions acupuncture "needles don’t reach," it does not mean that you have to burn Mugwort in your office.

Applied medicinal moxibustion
For thousands of years, Chinese doctors have been applying various Chinese medicinals directly to the skin as a form of "moxibustion." This can be in the form of a powder, a paste, or a liquid. The medicinals used in applied medicinal moxibustion are typically acrid, warm or hot medicinals which warm the channels, move the qi, and quicken the blood. When applied to the skin, they cause local erythema through chemical irritation. Erythema indicates increased blood flow to the affected area and increased local temperature. If the chemical irritation is very strong, it could actually cause a second degree burn. This means that it can raise a blister similar to strong Mugwort moxa.

The benefits of applied medicinal moxibustion
There are a number of benefits to using "applied medicinal" moxibustion:

● It is not smoky and does not smell. Therefore, it can be used in modern office buildings with smoke detectors other tenants and landlords who know nothing about Chinese medicine.
● There is no danger of accidents to either your patients or your premises from burning moxa rolls, incense sticks, or matches.
● Either the applications can be left on for hours at a time or can be re-applied several times throughout the day, thus extending the duration of stimulation.
● Patients can treat themselves at home between regularly scheduled office visits.
● When applied along with a heat lamp, the warming effect to the patient can be quite comfortable and the treatment effect is strengthened.

Liquid "Moxa"
There are several companies that have created different versions of what is called liquid moxa. Each has different ingredients and practitioners should look at each one and decide which is most useful for the patient in front of them. I personally have three or four different types of liquid moxa in my treatment kit. Some are more like a general pain liniment, some are more warming than others, some quicken the blood and resolve stasis, and they vary in relative mildness or strength. All of them can be used wit a heat lamp. So experiment!

The Blue Poppy version of Liquid Moxa is excellent if you cannot or do not want to use burning mugwort moxa in your practice or with a particular patient. Based on ancient Chinese precedents, it is convenient and easy to use, does not smell up your clinic, and does not set off smoke detectors. It is made from an alcohol tincture of five Chinese herbs, all traditionally used in applied medicinal moxibustion. These are Folium Artemisiae Argyii (Ai Ye), Herba Asari Cum Radice (Xi Xin), Ramulus Cinnamomi Cassiae (Gui Zhi), Fructus Zanthoxyli Bungeani (Chuan Hua Jiao), and Fructus Capsici Frutescentis (La Jiao).

Ai Ye is bitter, warm, and acrid. It enters primarily the liver, spleen, and kidney channels when taken internally, but enters all the channels and vessels when used externally. It warms the channels and scatters cold, moves the qi, quickens the blood, and stops pain.

Xi Xin is acrid and warm. It enters the lungs, spleen, and kidneys when taken internally, but also warms the channels and scatters cold, frees the flow of the network vessels and stops pain when applied externally.

Gui Zhi is acrid, sweet, and warm. It enters the lungs, heart, and urinary bladder when taken internally, but warms all the channels and scatters cold, moves the qi and quickens the blood when applied externally.

Chuan Hua Jiao is also acrid and warm. Some sources says it is even "greatly hot." It enters the spleen, lungs, and kidneys when taken internally. However, when used externally, it strongly warms the channels and scatters cold, moves the qi, quickens the blood, and stops pain.

La Jiao is acrid and hot. When used externally, it treats wind damp pain, low back pain, and muscular pain. It is used in Chinese medicine as a counterirritant.

Functions: Moves the qi and quickens the blood, warms the channels and frees the flow of the network vessels, stops pain

Directions for use: Apply to the affected area or acupuncture points chosen for stimulation similar to regular moxibustion. For best results, use in conjunction with a TDP or heat lamp or hair dryer. Because people’s skin reacts differently, begin by applying to a small test area before applying to larger areas. Most patients will only experience mild heat locally. Some may also experience reddening of the skin. Only a very, very few may experience blisters.

Caution: For external use only. Do not take internally. Do not apply to eyes or genital region. Keep out of the reach of children. If application causes a blister, discontinue use. The therapeutic effect will already have been obtained. Care for the blister as you would normally. Liquid Moxa only causes blisters in a very small percentage of patients with extremely sensitive skin.

Be sure to wash your hands with soap after applying any type of liquid moxa. Keep away from children. Never use liquid moxa internally.

Te Zhong Jiu Fa Lin Chuang Jing Yao (The Clinical Essence of Special Moxa Methods), Chinese National Folk Chinese Medicine & Medicinals Research Association, Chinese National Medicine & Medicinals Press, Beijing, 1994

Ai Jiu Yang Sheng Qu Bing Fa (Mugwort Moxa Life-nourishing, Disease-dispelling Methods), Xi Huo et al., Beijing Physical Culture University Press, Beijing, 1995

Jia Yong Jiu Fa Zhi Bing Xiao Qiao Men (A Small Key to Home Use Moxa Methods for the Treatment of Disease), Liu Jing-yu, Chinese National Chinese Medicine & Medicinals Press, Beijing, 1993

Even if you don't like the sound of the Blue Poppy moxa tincture, I strongly suggest that if you like moxa treatment, it is wise to have some type(s) of liquid moxa in your clinical toolbox. I have founds that there are often patients who need warming therapy but who are sensitive to smoke. So give a couple types of liquid moxa a try in your practice, or make your own version if you like to experiment!

Thanks for reading.

Monday, February 4, 2013

Periarthritis of the Shoulder: Acupuncture vs. Tuina?

abstracted & translated by Honora Lee Wolfe, Lic. Ac., FNAAOM (USA)

Introduction: This two-wing comparison study is interesting in that it studies patients whose condition is relatively acute and those whose condition was older or chronic. In the more acute cases, contra-lateral acupuncture on Zu San Li (St 36) was quite effective and tuina was less so. However on the more chronic cases, tuina was more effective than acupuncture. Since many of the patients that arrive in our clinics have been to numerous practitioners and have chronic pain conditions that have not been successfully treated, this information is good to know. In my personal experience, I would add moxibustion and liniments to the treatments, along with the tuina for more complete resolution of this type of pain. Check it out.
On pages 604-605 of issue #10, 2004 of the Shan Dong Zhong Yi Za Zhi (Shandong Journal of Chinese Medicine), Bao Tie-zhou published an article titled, “The Treatment of 80 Cases of Periarthritis of the Shoulder by Acupuncturing Zu San Li (St 36).” A summary of this study is presented below.

Cohort description: Altogether, there were 130 patients in this two-wing comparison study. These 130 patients were randomly divided into two groups, an acupuncture group and a tuina group. There were 80 patients in the acupuncture group, 41 males and 39 females 20-65 years of age, with an average age of 43 years. These patients had been suffering from this condition for 1-12 months. There were 50 patients in the tuina group, 26 males and 24 females 22-68 years of age, with an average age of 46 years. These patients had had periarthritis of the shoulder for 2-12 months. Therefore, in terms of sex, age, and disease duration, it was judged that these two groups were statistically comparable. In addition, these patients’ disease was divided into three stages, early, middle, and late. In the early stage, there was mainly aching and pain of the shoulder region, but movement and use were not affected, even though use may have made the pain worse. In the middle stage, the aching and pain of the early stage had remitted. However, there was pressure point point and function was affected by adhesions. This was also called the joint stiffness stage. In the late stage, also called the frozen and bound stage, there was drooping of the shoulder and both motion and use or function were definitely affected to the point of causing disability in lifestyle and work.
Treatment method: Members of the acupuncture group were needled at the contralateral Zu San Li (St 36) with a 28 gauge, 2-5 inch needle and large amplitude twisting and turning technique. At the same time, the patient was asked to mobilize the affected joint. The needle was retained for 20 minutes, during which the patient continued mobilizing the shoulder joint. Strong patients received one such treatment per day, but aged and weak patients were treated only once every other day. Seven treatments equaled one course of therapy in any case. Members of the tuina group received standard tuina therapy for shoulder pain once per day.
Study outcomes: Outcomes were divided into four grades: excellent, good, ok, and poor. Excellent meant that the shoulder pain disappeared and function returned to normal. Good meant that the shoulder pain disappeared but that function was still a little less than normal. In other words, range of motion was 10% less than normal. Ok meant that the pain was less but range of motion was more than 10% less than normal. Poor meant that there was basically no change in the symptoms or range of motion. The following tables show the outcomes based on these criteria. The first chart shows the outcomes only in those with early stage disease. The second table shows the outcomes in those with middle and late stage disease.

Total effect.
Excel. & good

Total effect.
Excel. & good
These outcomes suggest that this acupuncture protocol is more effective than tuina for those with early stage disease, but tuina is more effective than this acupuncture protocol for middle and late stage disease.
Discussion: Dr. Bao says that, when the yang ming becomes depleted and vacuous, it is not able to nourish the sinews and bones and disinhibit the joints. Zu San Li is a point on the foot yang ming stomach channel, and needling it is able to promote the strengthening and securing of the body’s latter heaven root. Thus the righteous qi is able to obtain banking and nourishment. This then results in the disinhibition of the joints and the outward expulsion of evils. According to the Nei Jing (Inner Classic), “If the righteous qi exists internally, evils cannot strike.”  As to why the acupuncture is effective in the early stage and less effective in the middle and late stages, Dr. Bao says that, although acupuncture can disperse inflammation, its effect is poor when adhesions have caused freezing and binding of the joints. In such cases, tuina is able to break up those adhesions as well as disperse inflammation.  Therefore, acupuncture should mainly be used in early stage cases, and tuina should mainly be used in late and middle stage cases.
For more musculo-skeletal treatment ideas, see The Treatment of External Diseases with Acupuncture and Moxibustion. by Yan Cui-lan & Zhu Yun-long