Charles Williams – Internship Report Spring 2012

Ethnography of an Acupuncture Clinic

Introduction

During the spring semester, I completed an internship at San Marcos Community

Acupuncture Clinic. I took on the duties of a regular volunteer, but was also extended

privileges of observing and participating in different forms of traditional Chinese medicine.

My interest in traditional medicine and healing in different cultures led me to the

acupuncture clinic to gain a better understanding of what is involved in non-biomedical or

western healing. I experienced the modality by both observing treatments as they took

place and by participating in every opportunity I was offered. Besides receiving

acupuncture, I also received herbal therapy and was bled. I learned a tremendous amount

throughout my internship, especially better people skills. I will describe my job at the

clinic, explain the clinics model for treatment, discuss some basics of traditional Chinese

medicine, as well as give some personal experiences and examples from my research.

My Internship Responsibility

My daily routine included arriving at the office before opening, illuminating the

open sign and placing a sandwich board outside to attract sidewalk traffic. I made sure that

all patients’ charts are out for the day and the ones from the day before were put away, and

I was expected to watch the list of patients for any last minute appointments made online. I

made sure the patients’ tea area was stocked. My responsibility also included greeting

patients, checking them in, taking payment information, gathering any specific requests

(for example, if a patient needed to leave by a certain time, if they needed a blanket or a

heating pad, etc.), and most of all I prepared patients for their treatment. Occasionally the

clinic had new patients, which required a tremendous amount of work compared to

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processing existing patients. The newcomers always go through an orientation so that they

know how our clinics set up. The orientation includes what we expect patients to do when

they arrive, how to set up payment plans, properly fill out the paperwork, answer

questions, and show them around the clinic.

During my internship, I did many more sporadic small tasks. I found myself walking

to the copy store to restock the clinic’s necessary papers. I watched patients’ treatments

when the opportunity arose. Also, I was able to handle herbal formulas and look up their

uses in the many traditional medicine books available at the clinic. It gave me a glimpse of

what it is like to run an acupuncture clinic as well as a chance to evaluate the science as a

whole.

POCA

The clinic belongs to People’s Organization for Community Acupuncture (POCA), a

movement began by Lisa Rohleder in a small clinic outside Portland, Oregon. The clinic

model is a low-priced, high-volume acupuncture that is a response to the expensive cost of

acupuncture school as well as the client limitations most acupuncture clinics have due to

high treatment prices. She created a model where patients are allowed to choose what

they can pay within certain boundaries ($15-$35). This payment plan allows individuals

who are unable to either afford health insurance or people who cannot afford to go to an

acupuncturist who charges upwards of the normal seventy dollar treatment. Basically, the

people who pay the higher price allow the clinics to offer such a low minimum payment.

Mrs. Rohleder is the president, as well as an acupuncturist herself, who still runs the

clinic in Portland. There are clinics sprouting up in every major American city that follow

her model. The clinics pay a yearly fee to be a part of the organization, which then lists

their clinic and allows them access to forums and resources linking the clinics’ staff

together. There are also dues for acupuncture students and patients that allow them access

to their respective forums and resources. Members have the perks of not paying the new

patient fee when visiting another community clinic and access to online resources. Visit

the webpage, www.pocacoop.com, to explore their forums and blogs.

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Although the acupuncturists are trained in acupuncture, moxibustion (mugwart

burnt on patients skin or on acupuncture needle ends), oriental medicine, tui na

(therapeutic massage), gua sha (scraping therapy), bleeding, cupping, and a variety of

biomedical diagnostics, the POCA model only allows for acupuncture to be performed. The

POCA model allows for the acupuncturist to spend about five minutes before each session

to discuss treatment and progress. Each acupuncturist is trained in Chinese pulse

diagnosis, as well as being able to examine the tongue and physical symptoms. All the

combined information they receive creates the diagnosis and treatment for the patient.

The only factor preventing the practitioners from treating every patient with a regimen of

differing Chinese medical techniques is time and the restrictions imposed by POCA.

In Acupuncture is like Noodles by Lisa Rohleder, she gives a quote to illustrate how

practitioners should use the community acupuncture model to practice. The quote is by

Sun Simiao, a 6th century acupuncturist:

Whenever a great physician treats diseases, he has to be mentally calm and his disposition firm. He should not give any way to wishes and desires, but has to develop first a marked attitude of compassion. . . If someone seeks help because of illness, or on the ground of another difficulty, a great physician should not pay attention to status, wealth, or age; neither should he question whether the particular person is attractive or unattractive, whether he is an enemy or a friend, whether he is Chinese or a foreigner, or finally whether he is educated or uneducated. He should meet everyone on equal grounds. . .”

This quote pertains to the clinic in a variety of ways. The main point is that everyone

should have equal access to healthcare and the practitioner should not be the gatekeeper

for medicine. The patients receive the same quality of care that they would at a private

acupuncturist; however, the private clinics have considerably less intimate patient-to-

patient contact in a healing setting. The reason is because private clinics attempt to mimic

doctor’s offices, with individual treatment rooms versus the community model where

treatments take place in one room with multiple recliners. Private clinics charge more so

that a patient gets a private setting; however, the treatment between the two is almost

identical.

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Currently, this is the closest acupuncture can get to Western medicines outpatient

clinic mixed with a general practitioner, and it is the model that seems most fitting to mix

with biomedicine. The mixing can be done due to the low cost of handling acupuncture in a

community setting, as well as increasing the hospital ward appearance to allow patients

the ability to watch others go through their treatments. The New England School of

Acupuncture conducted a trial where they set up a free clinic in Boston University’s

Medical Center. This ward was only operational for limited hours, and was only able to

treat around five hundred different patients. Despite the problems, this experiment

exposed that people will come to an open ward-like clinic, and that the patients level of

success was increased by either the acupuncture or the intimate setting provided

(Highfield et al., 2008).

About the Clinic

(Photo from inside the treatment area)

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(Haicam standing at the kitchen area. My internship desk as

well as the herb shelf are also pictured.)

When walking down the sidewalk on North LBJ Drive, at the corner of Hopkins and

LBJ, there is an old building. A yellow sign directs you through a doorway and down a long

hall. The floor is creaky and loud, and combined with the lights bouncing off the metal

ceiling, it makes you feel like you are stepping back in time. A neon-green open sign hangs

about halfway down the hall. Creaking along, red, green, yellow, white, and blue Tibetan

prayer flags flutter above the clinic doorway.

As the door opens, a soft jingle lets the acupuncturist know someone has arrived.

You notice the loud, creaky floor and the reflective metal ceiling tiles continues throughout

the clinic. Two small windows near the ceiling allow a generous amount of natural light

into the space, so the clinic to keep its lights off most of the time. Large white draped

curtains hang from the ceiling to separate the treatment area from a space that presents

itself as a hallway to the office. Patients walk down this makeshift hallway until they reach

the wall on the other side of the room. To the patient’s right is a stain-glass door leading to

the office.

The office is an extremely small room compared to the clinic, only about eight or

nine feet long and half that across. Despite the restrictions, the room fits a small kitchen-

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like area, reception desk and a few chairs, as well as a large shelf full of herbs and

uncommon acupuncture tools. A large window, four or five times the size of the windows

in the treatment area, allows a view of the next building and a small amount of sky and the

flood of natural light completely eliminates the need for artificial lights. The office is where

patients check in and pay, receive herbal prescriptions, and have confidential consultations

with the acupuncturist. Once the patient has taken care of any office business, they walk

through a small break in the curtains that make up the hallway which leads into the

treatment area.

The treatment area has eight recliners fit perfectly along the walls, caddy cornered

of course to keep away any regimental design. Each recliner has a sheet over it, and all the

sheets are natural colors (brown, dark green, tan, apricot, and white) that add a peaceful

feel to the room. There is always meditative background music being played from

Pandora.com, which occasionally switches to rock or some other upbeat genre sending the

acupuncturist running to keep a relaxed mood in the clinic.

About every two chairs, there is a small table with a selection of different sized

needles, alcohol and cotton balls, and hand sanitizer. Either beside this table or under it,

there are a few different blankets and towels for patients to choose from. The treatment

area also has two treatment tables. One in a private room created by a floor to ceiling style

armoire and two tri-folding room separators with bamboo artwork for treatments that

could disrupt the patients or treatments that require the patient to disrobe.

At the clinic, not all services at the clinic cost money. Once a week, and soon-to-be

twice a week, there is a free treatment offered to veterans from the area that suffer from

post-traumatic stress disorder. The veterans do not receive full acupuncture treatments,

but rather a style called “5NP”. 5NP is an acupuncture method that uses five points on the

ear, and is coupled with a very basic four-needle technique (also known as ‘Four Gates’ in

Chinese medicine) where one needle is inserted in each hand and foot in between the first

and second phalange. Using acupuncture for PTSD is a product of El Paso’s Fort Bliss. The

Army has been pioneering the use of alternative treatments for soldiers since our service

members began returning home from the recent invasions.

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Experience with Chinese Medicine

(Me in the private room of the clinic with acupuncture needles

in the points Yin Tang (forehead) and Large Intestine-20(nose))

During my time at the clinic, I received the luxury of having acupuncture whenever I

chose. Sometimes I would even go in on my days off for stress relief or anything else that

bothered me. This gave me the opportunity to experience exactly what the patients went

through when receiving treatments.

An acupuncturist is most well known for inserting needles into patients. These

needles are extremely fine, and nowhere near the size of a needle used in biomedicine.

Biomedicines needles are hollow and used for injection, where as Chinese medicine uses

needles as instruments to be placed under the skin for a period of time. The needles are

inserted into particular points on fourteen meridians or channels that qi (energy) flows

through. Some meridians are shorter than others, such as the heart meridian which reaches

from the armpit to the tip of the thumb.Then there is the urinary bladder meridian, which

runs the longest course, from the top of the head to the tip of the big toe. The acupuncturist

measures the qi and inserts the needles accordingly to balance the meridians and restore a

normal balance.

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Once in one of the recliners, a patient’s shoes and socks are taken off, their pant legs

rolled up to the knee, and they’re ready to get poked. The acupuncturist usually shows up

about the time they get everything ready and comfortable. She takes the radial pulse, and

then looks at the tongue, both of which allow her to make a proper diagnosis and

treatment. Chinese medicine has a long history of diagnosing using visual ques. At the

clinic, the acupuncturist uses tongue diagnosis, which is essentially taking a peek inside the

patient’s internal organs since the tongue is the only muscle we can view without breaking

skin. Pulse diagnosis is taken on the radial artery, in three different places (using the first,

second, and third fingers at the same time). While the pulse is being taken at each point,

the acupuncturist can also delve deeper into the pulse by measuring it at three different

depths (deep, medium, and superficial). Each different finger and each depth correspond

to a different organ or chi-system that will help the practitioner glimpse what is internally

upset.

After the acupuncturist has done the diagnosis, the patient lays back and gets

comfortable. They use cotton swabs with a bit of alcohol on the areas where the needles

will go, and this is truly the worst part. The cold alcohol is dabbed in places that are about

to get stuck draws your attention to those areas, and the feeling is intensely enhanced.

Then the needling comes. The acupuncturist finds the points as she works in a

counterclockwise/ clockwise (depending on which side she starts on) motion around the

body. When the needles are inserted, the only sign that they are going in is a zing! sound

made by the needle scraping against the plastic guider-tube that is used to deliver the

needle.

When the needles are in place, it takes a few minutes to feel the effects; however

when this happens, your limbs go a bit numb and you may feel tired. I generally get a

spinning sensation and my limbs feel weightless and functionless. These sensations send

me to a far off wonderland between sleep and being awake, yet some who get acupuncture

sit up and look around the whole time. One of the oddest experiences for me occurs when I

am in a deeply meditative state, in which all the creaks and noises around me disappear

and don’t bother me though I am acutely aware of everything going on in my mind.

When the treatment is finished, usually after a half an hour to an hour, the needles

come out. You simply look up at the acupuncturist and she comes and removes the

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needles. How do you know you are done? This is a common question I get while working,

and as a participant, I usually answer that “you will just know”. I say this because, for me, I

get anxious and my thoughts begin to race along with the needles no longer feeling

comfortable. Once the needles are out, the feeling is like being recharged, reawakened, and

almost reborn if you will.

The needles are nothing special, meaning they are no silver bullet. They are

extremely fine filaments of metal, small enough to fit about fifteen into an IV needle, with

pointed end for insertion and a grip side with the filament tightly coiled to make a handle.

Insertion of the needles does not involve any deep puncturing, unless this is the treatment

recommended. Most often, the needles are placed between a half-centimeter and three

centimeters under the skin, usually into tendon or muscle tissue. With other practitioners,

the needles can be inserted much shallower than a centimeter or as deep as seven

centimeters, and in China the needles are considerably larger and much deeper depths are

reached. The needles channel the flow of qi; however, the needles can be placed at 45°, 90°,

and 135° degree angles to the meridian to direct qi flow (Kaptchuk, 1947).

In one particular experience, my stomach had been feeling fairly poor for a few

weeks, and went into the clinic to seek treatment. When I began describing my symptoms,

I was recommended to try bleeding. This is not a treatment common to the clinic and I

believe was offered to me because of my interest in participating.

Bleeding is a traditional operation done for many ailments, from colds to

hemorrhoids. The first mention of bleeding as a treatment in Chinese medical literature

comes from around 200 B.C. (Young, 2008). Bleeding is recommended when there is an

abundance of qi in an area and there are points located mostly on meridians where the

blood should be released. The qi abundance is released when veins are opened and the

pressure allowed to release. The areas that are bled follow the same method of treatment

that an acupuncturist would use for a regular needling treatment.

The treatment took place on the back of my knees. In preparation, I removed my

khakis to keep blood from saturating them, and laid face down on a treatment table in the

only private room in the back of the clinic. I had my feet propped up by a pillow, as well as

a pillow under my chest.

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One of the acupuncturists, Haicam, came into the room and placed warm-moist

towels on each side of my knees, as well as a sheet of plastic under them. I opted to not

watch the procedure since this was the first time I was going to let someone open my veins

to release my blood. She prodded my joint for a while and chose the areas in which she

was going to puncture, asked me if I was ready. The moment before I was punctured was

one of the scariest feelings I have had, mainly from the anticipation. Immediately after the

insertion, I felt waves of heat travelling over my body as well as an urge to get up and run. I

of course stayed, and on the second puncture, my body’s reaction was to throw up. Though

I didn’t, my veins being violated caused me to be nauseous. The next two punctures just

intensified the feelings I had already been having, which gave way after the puncturing was

over.

When the actual punctures were open, I had to lie in the position for about five

minutes and let the wounds bleed and close up. This part of the treatment was not as bad

as the beginning. I could not feel the blood running down my leg due to the warm towels,

which definitely eased my anxiety.

Once the treatment was over, I allowed her to bandage my wounds. She also was

going to give me acupuncture, but first, I had to see what tools she had used. A straw for a

needle (not literally; at most, the needle was a 12 gauge but it no smaller than a 16 gauge.),

about four or so tablespoons of fresh blood, and of course the plastic and towels. I then

was turned onto my back and given an acupuncture treatment, which happened to be one

of the more uncomfortable acupuncture experiences since the back of my knees were so

tender. Overall, the treatment seemed to diminish my stomach discomfort. When I begin

to feel the same illness symptoms, I feel pressure building up in the back of my legs. I relate

this pressure to being psychosomatic.

Another day, I went into the clinic with a list of questions about needling technique.

I happened to get lucky when she told me she would let me put a needle into myself. Now

at first, I was eager to jump into needling myself, but when the needle was actually

presented to me it was harder than I thought. She let me do the needling before a

treatment, which meant I was in a recliner with four or five people in the room. I was given

a small needle and told to place it on point spleen-10. This is a point about an inch and a

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half above the top of the medial part of the kneecap. It is a fleshy area that has a very deep

needling ability, so there was a good chance I wouldn’t hurt myself nor go too deep.

I placed the tube on the point, and did it. I pushed the needle in about a half a

centimeter, with huge resistance from my brain. I thought I was done, but the

acupuncturist told me “now push it in”. “WHAT!?” I replied. So I tried, and tried, yet due to

my natural instincts, I couldn’t push it very far at all. She laughed at me a little bit, and

went on to begin inserting the other needles while I continued to fumble with the one I had

inserted.

Implications for Biomedicine and Anthropology

San Marcos Community Acupuncture Clinic is an extremely interesting case of how

alternative healthcare is moving into the United States. The approach is focuses on the

social aspect of receiving treatment. Each patient is directly responsible for others

treatment, by way of paying an extra five dollars or having donated a recliner. The ability

to see the extra money patients give put back into the clinic allows them to feel good about

what they are doing as well as being interested in the clinic’s progress. Of course this is not

applicable to all patients, because some pay the minimum and expect a complete spa

treatment, but they don’t notice the acupuncturist and don’t contribute to the spaces family

atmosphere.

In traditional Chinese medicine, the depletion or influx of a person’s energy is the

factor that makes one sick. This makes for an interesting biomedicine and traditional

medicine debate. Their polar opposite perspectives leads each other to think that the other

practitioner is doing harm. I do not see this distinction quite as clearly, they both have so

much to offer as well as teach each other. Eastern medicine is very good at listening and

having a patient centered approach, making the patient feel more relaxed and taken care of.

Western medicine has the scientific basis to lean on, which provides patients comfort with

a diagnosis using expensive tests. As a proponent of both science and patient-centered

healing, I believe these two systems have a lot to learn from each other. Integration is a

difficult task, not because patients would not be receptive to a choice in healing, but

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because each doctrine needs a way to integrate with other without losing fundamental

tenants.

There are many differences between traditional Chinese medicine and western

biomedicine, but the most noticeable one is the mind-body split in western medicine,

where in Chinese medicine, the split never happened. Acupuncturists embrace the idea

that the body can heal itself, and they recognize that the needles are assisting the body’s

natural healing mechanisms (Kaptchuk, 1947). Biomedicine, however, calls medicine that

acts without cause a ‘placebo’. The placebo, in western culture, means one of two things:

there was nothing wrong in the first place or it was a psychological problem. Neither of the

two explanations are what acupuncture embraces, because in the biomedical model, there

is no recognition of the mind being an active part in healing the body.

When reading about an attempt at creating a free-care clinic in the Boston

University teaching hospital, I was stunned at how in such a large and racially diverse city

the university was unable to recruit more than five hundred minority patients. It was not

until I read the appendix, on how the patients were chosen, that the tension between

western physicians and traditional medicine practitioners became visible. The only

recommendation to the clinic that was allowed was from a Boston Medical University staff

physician. This physician must have had two hundred hours with experience in

acupuncture, three letters of recommendation from acupuncturist vouching for the

knowledge of the physician, and thirty continuing education hours over acupuncture.

These criteria are extremely hard to meet, and it seems that only a handful of staff

members could comply. Also, in the report, the methods state that the clinic was only

operational between 5:30pm and 8:30pm, and it even states that the cost to the hospital

“would be minimal” (Highfield et al., 2008). Both systems have been opposed to each

other’s ideas, yet eastern practitioners seem to have a better hold on integrating western

medicine.

Kampo is a system of traditional medicine that has already gone through integration

in Japan. Kampo arrived in Japan around the eighth century from China, and introduced

crude acupuncture and Chinese herbals. Since its introduction to the island, it has gone

through many transformations. First, it melded with the Shinto animist beliefs and took on

the herbal practices of the priests. It was then established as the dominant medicine of

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Japan. Later, in the 18th and 19th centuries, the practice was pushed underground by an

imperialist Japanese government looking to eradicate superstition and implement ‘rational’

western medicine. Western medicine took on the role of primary care in Japan until a

revitalization of Japaneseness following World War II, leading to a reintroduction of

traditional ideas into the dominant society. In the 1950s, Kampo was officially recognized

by Japans National Health Administration, which led to the standardization of medicines,

acupuncture, and practitioner training (Akira 1991).

Why was Kampo so easily integrated? First of all, integration came at a time when

the Japanese people were at a loss for which traditions to hold onto and which ones to

abandon. People wanted the same forms of treatment their mothers and grandmothers

performed, yet in a more medical and scientific setting. The health administration’s

decision also showed that standardization is important for integration. Kampo uses

medicines that are not hand-made for each individual patient, but consist of specific

amounts of herbs (the majority of which are also used in Chinese medicine) in a

predetermined amount. There are about sixty different formulas a physician may

prescribe, available in all Japanese pharmacies, and they come in the same prescription

containers as pharmaceuticals. These herbs as well as visits to a Kampo practitioner are

covered by the national healthcare plan. About half of the physicians in Japan that have

intensive training in Kampo, as well as over forty percent of the population will choose

Kampo medicines over pharmaceuticals if they have the choice (Akira, 1991).

Besides the integration of Chinese medicine into our western biomedical model,

there is also archaeological evidence to show that pre-historic peoples were using

acupuncture-like techniques to cure illnesses. Mummies from Chiribaya Alta, Peru have

been found with circular scars on their necks closely corresponding to a modern cupping

treatment used both in Chinese medicine and pre-modern European medicine (Dorfer,

1999). Also, a Scythian horseman from Western Asia shows a series of dotted lines on each

side of the spinal column, corresponding to the urinary bladder acupuncture meridian

(Dorfer, 1999). The most intriguing evidence for acupuncture-like techniques comes from

a lone mummy, frozen in the Swiss Alps 5,000 years ago.

Otzi the Iceman is a five thousand year old mummy found in Switzerland in 1991.

Otzi’s body had been frozen then preserved when he died on a mountain pass in the Alps.

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My interest of this mummy goes far beyond his copper hatchet, newly constructed animal

skin clothes, lack of a twelfth rib set, or even his precision bow, unlike any discovered. I am

interested in his tattoos. The iceman had a series of tattoo-like markings in very particular

areas, which are still used by acupuncturist today to treat stomach upset and lower back

pain. By tattoo-like, I mean that the widely accepted view is that incisions were made on

the area, and herbs were burnt in the wound which scarred and blackened the area

permanently (Dorfer et al., 1999). The best part about the way this treatment was

conducted is the striking similarity to moxibustion, burning mugwort on acupuncture

points, which are still practiced today.

Otzi gives us a glimpse into European medicine in the distant past. The problem is

that we don’t know if he had a high status or if he was a lone hunter, and there is evidence

to suggest both theories (Dorfer et al., 1999). Regardless of the particular example of Otzi,

it would be fascinating to find another record of this form of healing. Archaeologists and

anthropologists around the world, from labs to the field, need to be aware of the

importance of looking for odd or out of place markings. With this awareness, we may be

able to reconstruct exactly what our ancestors were trying to do in their treatment, as well

as replicate their ancient healing practices.

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References Crow, David 2000 In Search of the Medicine Buddha: A Himalayan Journey. New York: Penguin Putnam, Inc. Dorfer, L., Moser, M., Bahr, F., Spindler, K., Egarter-Vigl, E., Giullen, S., Dohr, G., and T Kenner 1999 A Medical Report From the Stone Age? The Lancet. 354:1023-1025. Highfield, Ellen, Barnes, Linda, Spellman, Lisa, and Robert Sapere 2008 If you build it, will they come? A free-care acupuncture clinic for minority adolescence in an urban hospital. The Journal of Alternative and Complementary Medicine. 14(6):629-636. Institute for Traditional Medicine http://www.itmonline.org/arts/bleeding.htm#figure%201 Kaptchuk, O.M.D., Ted J. 1947 The Web That Has No Weaver – Understanding Chinese Medicine. New York: McGraw Hill. Manaka, M.D., Yoshio, and Ian Urquhart M.D. 1972 The Layman’s Guide to Acupuncture. New York: Weatherhill Inc. Rhodler, Lisa 2009 Acupuncture Is Like Noodles: The Little Red (Cook)Book of Community Acupuncture. Portland: Working Class Acupuncture. Schnorrenberger, M.D., Claus 2003 Chen-Chiu, The Original Acupuncture – A new healing paradigm. Boston: Wisdom Publishing. Tsumura, Akira 1991 Kampo: How the Japanese Updated Traditional Herbal Medicine. Tokyo: Japan Publications, Inc. Young, Wei-Chieh 2008 Lectures on Tung’s Acupuncture: Therapeutic System. American-Chinese Medical Culture Center: Taiwan.

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