How Do I Treat Patients Using Acupuncture?

Over the years students have enquired as to how I treat my patients. Since this is quite difficult to answer in a brief manner I have often given them little snippets here and there. Well I decided to write the entire lot down and post it here on my blog. It is quite detailed but hopefully quite interesting and engaging. Perhaps you should grab a beer, wine or a coffee, put your feet up and take it all in at a casual pace?

POTENTIAL NEW PATIENT

Typically I get new patients via phone calls, walk-ins or from friend’s gatherings. The first thing I need to do is to convince the person that acupuncture can help them with their complaint. Sometimes this isn’t hard because the person has had acupuncture before from someone else or because they have been referred to me by an existing patient.

Sometimes, however, it’s difficult to convince them about the benefits of acupuncture. They could be worried about the needles hurting. They might be convinced (by who, I have no idea) that Chinese medicine only requires one treatment and their complaint will be healed. They might even be concerned about the cost of the treatment.

I’m not sure what your experience has been in other countries, but I have found that in Australia these are the typical concerns that potential new patients have when deciding whether to try acupuncture. But I don’t shy away from these questions.

For starters we know that acupuncture doesn’t hurt very much, and I often tell them that an acupuncture needle is thinner than a strand of hair. I also mention that about one in every ten needles might bite a little – like a mosquito bite, but that the sensation goes away almost immediately.

As for cost, the Chinese medicine community in Australia charges very little compared to other medicines; and we are way down the list when we compare other careers and their high costs. If they need further explanation then I might discuss the call out costs of plumbers and electricians. Or I might mention the costs of seeing a naturopath initially and then ongoing. I may even discuss the ongoing costs of visiting a GP.

The number of treatments that a new patient might need is not that simple to answer. For starters it really is educated guesswork on our part. We can’t be 100% certain that, for example, five weekly treatments will effectively treat a chronic cough they have had for six years. There are so many factors, known and unknown, which will determine if five treatments is the magic number for that patient.

But we can draw on our experience in order to make our estimate more accurate. I never tell my patient they could be completely healed after one treatment. In fact I tend to aim on the higher side when it comes to predicting the number of treatments they will need. I’d rather they got better inside my estimate than still only be 50% improved when we reach that number.

I don’t want to shy away from the sometimes brutal reality of their complaint. If a potential patient has had a problem for over twenty years then it’s just not ethical for me to say they could be better in a couple of months. I’d much prefer to explain the chronic nature of their complaint and advise a series of treatments across several treatment blocks. I would focus on their newer signs and symptoms and explain that these should improve faster than the chronic ones. I would also talk to them about targeting these small victories throughout the treatment blocks because each of these improvements gets them closer to the BIG heal. I like metaphors and so this is where I get them to visualise us both climbing a mountain with the healing of their body the climb up, but is also the descent down the other side.

The climb up is the hardest bit and is the bit we have to do first. The climb is where we focus on the little improvements – these are generally the more recent complaints that a patient has. The newer/acute disorders are almost always easier to treat than the old/chronic ones.

The same applies when we climb a mountain. We focus on the enjoyable little experiences along the way – the gorgeous flower bouquet on the hillside; the subtle breeze sensuously rubbing the side of our face; the brief rest and snack under a shaded rocky outcrop; a pause to turn back and stare at the stunning view; even the feeling that we are achieving something of critical importance as we get closer to the top of the climb; the knowing in the back of our minds that it’s going to be so much easier on the way back down.

As we climb the metaphorical mountain together, we tough it out together. We celebrate improvements in our patient’s complaints. We know that as each of these complaints clear away we are getting closer to the big heal – the top of the mountain. All these toxic little complaints should be celebrated as they disappear.

Assuming I do a good job then we get to the top of the mountain and the patient has the big heal. This is often accompanied by a healing crisis (where the patient feels like we went backwards rather than forwards) but this is rarely a bad thing – well as long as the patient knows it could occur (and they always do with me).

Similarly on our trek up the mountain, when we finally reach the top and our exhaustion is mixed in with our euphoria, it can all be a little much and we find ourselves slumping to the ground. This is the healing crisis; but in good news it rarely lasts for long and before you know it, you are standing back up and taking in the splendour of the view; and you are fortified for the trip back down.

My experience has advised me that the healing crisis is the body reaching the point where health COULD take over from disease. I say ‘could’ rather than ‘will’ or ‘should’ because this is often where a patient decides they have improved enough and stop coming for treatment. The problem here is that the patient is still not completely healed and needs additional treatments. If they stay the course then the rest of the treatments are easier than the previous ones, in the same way that the trip back down the mountain is far easier than the climb. Their body should be healed, and be stronger than it’s been in years. Strong enough to fight to stay healthy.

Regardless of whether my patients have healed quickly or slowly, from acute complaints or chronic disorders, I always encourage regular appointments into the future. These are what I call ‘top-ups’. Prevention is better than cure after all.

Most of all I make sure that my patients understand that Chinese medicine helps their body heal itself, and to heal itself much faster than it could have managed on its own.

HOW I CHOOSE MY POINTS

In part this is done via my Chinese medicine diagnosis; it is also done via the patients Qi telling me (discussed shortly); and part of this is done via point combinations.

My point combinations are designed to tonify together, sedate together, move stagnations together; no matter what the diagnosis is I can construct a treatment that has the points working together for optimal benefit.

I don’t lift and thrust a needle to tonify or sedate; I don’t twirl or shake the needle a certain way to tonify or sedate. It’s the sum of the parts that will tonify together, sedate together, and/or move stagnations together. It’s the combination of points performing a function together that I am interested in. This will be discussed in a lot more detail throughout the point combination book that I am writing – in fact that is what the book is all about!

I can even construct a treatment where some points tonify and some points sedate.

One of my favourite point combinations is when I am treating a patient with a common cold resulting from an external pathogenic factor (EPF) invasion. In that instance I have combinations of points that can tonify Wei Qi, some that can clear the EPF, and some that can do both. This fascinating treatment construct will be discussed in the point combination book.

NUMBER OF NEEDLES

The typical number of needles I use ranges from 8-16. My view is that either side of those numbers I am either doing too much or not enough. This view is based on my 20+ years of experience as well as extensive research and reading.

I don’t have a problem with other acupuncturists needling outside of those numbers. In fact, the acupuncturist that I currently frequent uses between 30-40 needles.

The other reason I have a range of 8-16 needles is for the point combinations to be most effective. I will discuss this concept shortly, but the sum of the parts are more important than individual point function. I find that if I do less than eight needles I haven’t been able to get a good enough combination of points which may negatively impact on the success of the treatment.

On the other hand, if I go beyond 16 needles I feel like I’m moving beyond my preferred targeted approach. The combinations of points can therefore get diluted, and the purpose of the treatment may even get lost within the vast function list of each point used.

I want to target my treatments – I don’t want to put stacks of needles in and hope that some of them will have an effect; and that is why my current preference is to use between 8-16 needles. This range allows me to give each point a job to do and a point partner/s to help.

Lastly, the number of needles used is almost always an odd number. This is because my favourite channel (Ren Mai) usually has 1-3 needles included in the treatment (discussed later).

BILATERAL NEEDLING

I almost always do bilateral needling. I am of the view that if there are two of the same point then I should needle both. It’s like a double-shot benefit – as in, two LI 4 (He Gu) points are far better than one.

I have experimented with this in the past and found my treatments to be less effective as a result. I have also found that my point combinations typically rely on bilateral needling for a more rounded effect.

DELIBERATE SCATTERING

The deliberate, but planned, scattering of needles is very important to me and for each treatment I look to cover some/all the areas of head/face, trunk (front or back), arms/hands, and legs/feet. Over the years I have found that this ensures the best chance of breaking through any stagnations. If I stack my needles in one area then I line myself up for failure.

None of us can be 100% sure that we know where blockages are located. Therefore I take that out of the equation and deliberately ‘scatter shot’ my points. These are across a wide area of the body, using a range of different channels that travel in different directions. The points and channels chosen are deliberate and combine well with one another. It’s not random stabbing of points. My point combination book will teach you how to do this too.

PATIENT POSITIONING

Once I have decided on the diagnosis I must then decide on whether my patient will lie prone or supine (face-down or face-up). I don’t flip my patient mid-way through a treatment. I don’t like it when practitioners have done that to me in the past. Plus my patients have commented to me that they lose that sense of relaxation right at the point where they were relaxing; and they don’t get that relaxed feeling back after they have been flipped. They comment that their brain starts going a million miles an hour and they get restless. A restless brain isn’t conducive to good treatment results.

POINTS ON PAPER

The points I start with on paper almost always end up slightly different by the time all the needles have been inserted. As therapists I feel we need to be conduits of energy, or Qi, if you like. That’s the patients Qi and Universal Qi (discussed further below). This Qi tells us a lot, and in regards to treatment, it tells us what points need special attention, and which ones don’t.

I don’t get a full sense of that when I am sitting across a table from someone. I get a bit but I get the rest once I start touching their aura and their body. If you are sensitive to this Qi you can pick up a lot on what the person really needs. This sensitivity bypasses the patients (and my) rational brain. With the rational brain out of the way we can get to the deeper layer of healing energy – one that neither the patient, nor I, have any real idea about. In my view this is the area where the best healing occurs.

WHAT ORDER DO I NEEDLE MY POINTS?

For the most part I don’t needle points in a particular order. As I said earlier, I consider the sum of the parts to be more important than the individual points. I know that once all my needles are in that the treatment will start its healing journey; and it’s the collective that will achieve that.

There are exceptions to this rule and I will give a few examples here:

If my patient is incredibly stressed and anxious (for whatever reason) then I like to ‘Open the Four Gates’ before I do anything else. These are LI 4 (He Gu) and LR 3 (Tai Chong) needled bilaterally. As some of you would know, this is a great point combination to calm the patient down.

Another great treatment for calming a patient is GV 20 (Bai Hui) and Yin Tang and so I may put those two points in before any others.

The other scenario where I put the points in a certain order are when I open the Eight Extraordinary Vessels. In that instance I will always start with the Opening Point, then use the Coupled Point and then put at least one point in the vessel I am opening.

For example, if I were wanting to open the Chong Mai I would first needle SP 4 (Gong Sun) bilaterally; then I would needle PC 6 (Nei Guan) bilaterally; then I would put a point in the Chong Mai, such as KI 14 (Si Man) bilaterally. This makes it completely clear what I am trying to achieve with my treatment (open the Chong Mai) because SP 4 (Gong Sun), PC 6 (Nei Guan) and KI 14 (Si Man) perform multiple functions in the body, and the last thing I want is for the points to be confused about why they are being used. Yes, that can really happen!

I’m not saying that the body wouldn’t work it out, but in this situation I want the treatment to start working as quickly as possible. There will be a more thorough explanation on these three scenario’s later in the book.

So because I don’t have to needle points in a particular order I tend to choose the sequence of my needling in other ways. Therefore the points that are likely to hurt the most are needled last. I want to limit the stressful experience that a lot of people feel when they know needles are about to penetrate their skin. I have found that the best way to do this is to keep the nasty points till the end.

I have experimented with this over the years by either doing the nasty points first, or trying to hide them in the middle of the treatment. I even went through a phase where I left them out altogether and chose other, less effective, points to limit the pain potential for my patients (obviously this wasn’t the most sensible decision I have made in my Chinese medicine career – but we learn from our mistakes just as much as we learn from our successes).

I also tend to leave the points on the feet until the end of the treatment. This is partly because they can be a bit nasty, but mostly it’s a hygienic reason. After I touch the feet I need to wash my hands before I touch their body again. This can get a little stop-start if I am having to wash my hands multiple times in a treatment. So if I leave all my feet points until the end I only have to wash my hands after all the needles have been inserted.

HOW DO I NEEDLE?

Before I answer I do need to caveat it first. Over the past 20+ years of treating patients I have tried a range of different techniques. Some have been very traditional Chinese and some have been more Japanese style. My needle types have ranged from 0.35 by 40mm down to 0.12 by 15mm. My stimulation methods have ranged from strong stimulation to obtain De Qi down to barely inserting the needle at all.

In the end I have come to a middle ground. I now almost always use 0.20 by 15mm, 0.20 by 30mm, or 0.20 by 40mm needles. Sometimes I need to use longer ones and they may end up 0.30 thick by 75mm long, but for the most part the needles mentioned above are the ones I use.

These needles are chosen based on how far I need to insert them. I use a guide tube and tap the needle into the skin. I then push the needle in further and leave it at a certain distance into the body. I don’t generally do any further lifting and thrusting to acquire De Qi. My needle tip will be activating the De Qi because I have needled into the pocket of Qi. This principle applies no matter what angle I insert the needle. A few examples are probably needed here:

For LU 7 (Lie Que) I use a 0.20 by 30mm needle and I angle it transverse along the channel. Needling with the flow of Qi or against it doesn’t bother me too much but is sometimes a consideration. I start the needle tip just proximal or distal to the point and then needle about 0.5 cun transverse.

For SP 6 (San Yin Jiao) I use a 0.20 by 40mm needle and I angle it perpendicular roughly 0.5 cun to 0.8 cun deep.

For BL 15 (Xin Shu) I use a 0.20 by 30mm needle and I angle it oblique roughly 0.5 cun towards the spine, up the channel or down the channel.

I haven’t found any negatives with needling this way. I haven’t seen any lessening of benefit from treatment. In fact, my patients are delighted because acupuncture doesn’t hurt them and more of them continue to attend therapy as a result.

WRITE THE NEEDLE NUMBER DOWN

I write the number of needles used onto the patient file and circle it. Then when I remove the needles I count them to ensure I don’t forget any that might be hidden away. I put needles straight into the sharps container as I remove them.

This was something I started to do consistently when I had a couple of near misses with hidden needles. But it’s something I have been doing for a long time now. I think it probably became a habit pretty soon after I graduated.

When I was in year 11 at school (16 years old) my Mum used to visit an acupuncturist on the Sunshine Coast, Queensland, Australia. I won’t name names but the acupuncturist in question accidentally left HT 7 (Shen Men) in and after her appointment, Mum went straight to the bank (which was virtually next door). As she reached into the hand bag for her bank card she must have dislodged the needle because when Mum tossed the bank card to the bank teller, the needle flew out of her wrist and landed next to her card. It must have been the funniest thing – apparently the female bank teller got the biggest look of shock on her face as she reached for Mum’s card and then paused mid-reach as her brain realised there was a needle on the desk in front of her. This event occurred in 1990 and acupuncture wasn’t particularly well known in Australia (it is now), so Mum thinks that the bank teller thought she was a druggie. Ha!

Needless to say, that story has stuck in my mind and reminds me to always write the number of needles down on the file and to then count those needles upon removal.

PATIENT EXPLANATION

If the patient is interested I will explain what I am doing before, during, and after the treatment. The mind is a powerful tool and can be used to aid us in healing. As I’m explaining the treatment I want my patient to start visualising this in their mind. I’m convinced that this actually helps the patients healing.

I realise that this feeds into the whole placebo argument so I won’t go into any more detail but I do consider it an important part of my treatment.

UNIVERSAL QI

I use Universal Qi in every single treatment. Apart from what I stated above, Universal Qi is also important in other ways. One of those is ensuring that you don’t use your own Qi when treating patients. You must always ensure that you keep some of your own personal Qi supply each day or you will burn out. I’m not suggesting that we don’t give of ourselves in our desire to help the injured and sick. But we must do that with Universal Qi as our partner.

Some of you would have different ways that you keep yourself strong and healthy throughout a busy clinic day. Perhaps you do some Tai Ji Quan (Tai Chi) or Qi Gong? I really like to make sure I have at least three breaks in a busy day. They don’t have to be large – but they need to be there so I can recharge and be ready for my next influx of patients.

ACCESSING UNIVERSAL QI

How do I access and use Universal Qi? First of all I recognise that it’s everywhere and that I can gain access to it immediately because I am in it; and seeing as my patient is also in it, we can both use this Universal Qi to our benefit. Second, when I want to target a specific area I place my hands over the zone (either just above or on the skin), close my eyes and visualise white puffy clouds. I breathe in and draw the white puffy clouds into myself; then as I breathe out I send the white puffy clouds out through my hands and into the patient. I then repeat this 3-5 times.

Sometimes when I am doing this the colour, and image, changes. I could get an image of red fire, blue waterfalls, purple sunsets, or a number of other ones. When this happens I go with it and stay with the new colour and image. One of two things tends to occur during this – either the patient describes the area getting hot, cold, or incredibly energetic; or when I ask them what their favourite colour is, it turns out to be the colour that I’ve been sending into their body. This colour appears to be their Universal Qi colour of choice.

NEEDLE RETENTION TIME

I like to give my patients about 30 minutes with the needles in. That means that the 30 minutes starts once all the needles have been inserted. This isn’t a conscious choice because I want to tonify, sedate or disperse; I do it because experience has shown that a patient has generally been able to relax in that time and that they are just about to get to the point where the brain starts to kick in again and they want to get up. My Mum will regularly yell out “I’m cooked David” at that thirty minute mark of treatment.

I even had a series of treatments from an acupuncturist years ago that had an egg timer attached to the clinic room door. After she inserted the needles she would set the egg timer to 30 minutes. Sure enough, the timer would ring and I would feel like a cooked egg. Ha!!

EXPECTING RESULTS

I expect results! I go into every treatment with the belief that my patient will improve. I have to believe this because to do otherwise could compromise our treatment goals. Positivity and real belief in my medicine is crucial to good results. And if I can get my patients expecting results too then we are even more likely to achieve our goals.

I never tell my patients that they will be cured or fixed as a result of my treatments. I don’t tell them that I can definitely help them get better. My patients choose me and choose acupuncture because I explain what we will be trying to achieve in their healing. I talk about past patient successes with them if they ask me about whether I have treated their particular complaint before. If I have never treated their particular complaint, but if I know about the research associated with their complaint, then I can talk to them about the research successes.

If I don’t think I can help someone then I won’t start treating them. If I know of someone in my field that is far more experienced at treating the persons complaint then I will refer them on. If they have been referred to me, they specifically want to be treated by me, and I know I can treat their complaint, then I will take them on as a patient.

FAVOURITE CHANNEL

Do I have a favourite channel? Definitely! It’s the Ren Mai. I can achieve so much with this channel. Every single organ can be treated using the Ren Mai. It’s a sensational channel to use when you want to link up combinations of points. The Ren Mai can also be used to treat organs in different parts of the San Jiao (Triple Energiser).

For example, if the patient has disharmony between their Lungs and Kidneys, leading to asthma and wheezing, then I can use the Ren Mai to reconnect the Lung/Kidney imbalance. This might include CV 4 (Guan Yuan), CV 6 (Qi Hai), CV 17 (Shan Zhong), and CV 22 (Tian Tu), along with points on other channels and in other areas of the body.

I also like the Ren Mai because I have direct and LOCAL access to each organ. This allows me to use local points and distal points in my treatment for organ based problems. So using the example above, I could include KI 4 (Da Zhong) and LU 9 (Tai Yuan) for a patient with asthma and wheezing as a result of a Lung/Kidney imbalance. I would likely use CV 4 (Guan Yuan), CV 6 (Qi Hai), CV 17 (Shan Zhong), and CV 22 (Tian Tu) as well.

FAVOURITE POINTS

Do I have favourite points? Of course! I’m sure most of you would have too? A lot of these points will be discussed when I write my book.

FOLLOW UP PHONE CALL

It has become common practice for me to call, text or email my patients roughly one-two days after their treatment. This does two things:

The first is that it shows that I care for my patients even when they are not in my clinic. The second is that it often guides when the next appointment should be. I’m not a fan of booking patients in every week and sticking to the schedule rigidly. This is because patient’s signs and symptoms change at different speeds and on different days. As they change, this should then dictate when they need their next appointment.

So what I do for my patients is to set out a treatment plan. This might very well be one treatment a week for six weeks. But my patients know that this could change somewhat based on how they respond to their treatment. They may end up coming in again three days later and then it might be ten days before the following appointment.

My point is that I am sticking to the framework of treating my patient and not the disease. So as my patient changes then I must change too.

I must admit that this has been very popular with my patients since I introduced it about ten years ago.

SUMMARY

The time it took for you to read this is far longer than it takes me to perform it. All of these processes just happen for me as a result of my 24 years in clinical practice.

The one thing I didn’t mention was just how much I love Chinese medicine. I couldn’t think of doing anything else in my life. It’s a serious passion that engulfs my life and I wouldn’t want it any other way.

Hopefully you felt that passion as you read this. It should because I put just as much love into my writing as I do with my healing.

As always I am keen to hear back from you.

Love and light to you all

David Hartmann