On Barefoot Medicine: a solution for holistic practitioners

 

The term Barefoot doctor describes that solitary physician healer who strolled village to village, roaming the land to offer succor to those in need. Such an image is as quaint as it is an anachronistic. Yet there is a gem in this idea. In this article, as an exercise in finding solutions for the beleaguered U.S. health care system and its less than adequate care of the US patient population, allow me to uncover that jewel, to shake off the dust and encrustation and to reveal the wisdom such an approach contains for 21st Century healthcare.

As the Barefoot Dr. provided primary care and management of ongoing illness, so too the modern holistic practitioner is suited to exactly this task. When I say primary care, I mean prevention. 

 

“The respective strengths and weaknesses of Chinese and Western medicine overlap in a way that makes Western medicine seem best suited to coping with (acute) infectious diseases and Chinese medicine with those functional disorders and chronic illness in which discrete or long-term physical symptoms have not yet become apparent. (Porkert, 1988).

 

 

The idea that one has to be ill in order to seek care is a result of the crisis oriented approach that comes from the conventional medical model. Most lay patients understand that stress will eventually cause illness. They feel it in themselves and see it in those around them - friends, family, co-workers and colleagues. If the modern barefoot doctor simply treated stress, the results would be significant, interest in their service high and the breadth of their possible clientele enormous. What U.S. adult isn't stressed? Add to this the fact that holistic practice is the approach for treating stress par excellance and you have nearly all the elements in place to reintroduce that most simple of approaches, the (modern) barefoot doctor.

Consider also that conventional medicine in U.S. healthcare is almost exclusively aimed at acute and traumatic illness of injury. Thank heaven such technology exists! I know where I'm going if I have a dramatic illness or injury. But such occurrences are rare, especially when compared to the disproportionately overwhelming prevalence of chronic disease. In 2005 the WHO published its report on chronic disease, stating that 8 out of 10 people in all countries all around the world will die prematurely of chronic disease in the 21st century (WHO, 2005). Ouch!

Conventional medicine -- which is based on a single, all pervading premise of reductionism -- is not really blind to the plague of chronic disease. It is simply not well suited to address illness for which no cure yet exists - i.e. chronic disease. Ah, but what about holism?  Holism is -- not coincidently -- inherently suited to the treatment of chronic disease. The holistic tenet which acknowledges the mind-body connection and within which there exists a bias of mind-body inseparability (Flaws, p. 263) is the obvious choice for managing chronic disease. Why? Because as Ken Cohen points out, cure and healing are not the same. (Cohen, 2003)

The American Institutes of Stress estimates that “between 75 and 90 percent of visits to primary care physicians in the United States are motivated simply by stress.” (Rohleder, p. 56). What is stress related illness save mind-body illness? What are physical signs and symptoms of dis-ease caused by worry, anxiety, frustration, sorrow and anger, save the very issues inherently treated by holistic medicine. Many holistic practitioners doubtless grasp this essential truth which looms like a large and proverbial elephant in the living room of the conventional medical establishment. What therefore are the steps one might take as a practitioner to better infuse one's skills and knowledge where they are needed most? What model of delivery is going to leverage our strengths as holistic healing practitioners? What changes must one consider before set setting out as a Barefoot Dr.?

Since holistic medicine is inherently suited to the treatment and management of chronic disease - the bane of modern life, driven as it is by the ubiquitous malevolence that is stress - one need not add a whole new clinical skill set in order to build a significant practice. Whether you practice massage or acupuncture or most any-other physical medicine, if you are competent in-clinic, you will be able to alleviate stress. Most practitioners already grasp their role in mitigating stress, so what's all the fuss? It is in the delivery of your services that the Barefoot model reveals its the currency of influence within your community. Simply stated, the spa model of catering to wealthy clientele is a limiting model. Not many stressed out ordinary working folks can afford $75 - $150 for hour long treatments in order to relax. If they had that kind of time and money they wouldn't need treatment for stress. So who are the demographic treated by the Barefoot Dr. and how can you reach them?

The target demographic is – as mentioned previously – the standard, working, U.S. adult. The Barefoot Dr.. must deliver stress relief in about 15 to 20 minutes for $20-$40. The Barefoot Dr. needs “to bring the mountain to Mohammed” by appearing in one or more satellite locations throughout the week; a weekly circuit from neighborhood to neighborhood. In this way the Barefoot Dr. maintains extraordinary visibility within the community. Not only does such high visibility feed on itself once people start finding your stress clinic, but it also comes in handy if you want to further your growth and career by teaching. How does one minimalize treatment time to 20 minutes? Is it feasible to run several locations simultaneously? These are the essential clinical and logistic considerations for the Barefoot Dr.

First, treatment must be specific. Lose the idea of full-body anything. It takes too long for this model. Learn to charge for results, not for the time you spend with each client. It doesn't matter if you are doing the same treatment again and again to alleviate stress. After all, this is largely what busy chiropractors do. Stress is stress and although it affects different people in slightly different ways, nonetheless the manifestations of stress are largely predictable within certain parameters and easy to recognize and alleviate. Where I work, nearly every client show some of the adverse effects of chronic stress and therefore receives treatment to alleviate stress as part of their treatment protocol. Obviously certain clinical skills lend themselves to this kind of rapid-fire treatment of multiple patients better than others. Acupuncture is king since the needles can do wonders (‘look Ma, no hands’) while the patient relaxes and doesn't even want to fidget or squirm, but simply melts into parasympathetic oblivion. This is a stainless steel induced power-nap. But if you're not legally licensed to work with needles, don't despair. Other techniques will stand you in good stead as a Barefoot Dr. and they will complement your existing skills. In my practice in a western hospital where the overwhelming majority of patients are coming for treatment of pain and stress, the next most useful skill/technique I employ is Teishin. Teishin therapy is ultra-focused acupressure that does not break the skin. It imparts the benefits of meridian therapies and even outshines acupuncture on certain otherwise-excruciating-to-needle areas of the body - the same distal areas which have such wonderful effects alleviating stress. Using teishin on the ears and extremities is a safe, legal, and effective 10 minute treatment for stress. “$20 please.”

If you have previously only worked your massage practice in full body mode, change it to trigger-point work, (check out Janet Travell) or tui-na or some other recognized for of medical massage as this will move you toward that essential specificity that makes competent and viable Barefoot Dr. practice possible. The important issue is to make your treatment specific to a given complaint and not to address the whole body in a spa-like motif. If you already have knowledge of meridian theory, practice shiatsu or some other version of acupressure, then circumscribe the areas of the body most affected by stress. The regions that are no-brainers for stress are: shoulders, nape of the neck and occiput, low back, hips and buttocks, and then arms, hands and face and wherever else a patient complains or indicates. Here are the points I recommend as a general guide for dealing with these regions:

Shoulders: GB 21, LI 11, BL 13, LI 14, TW 10, 15

Nape: GB 20, 21;Liv 2, Lu 7 (teishin)

Occiput: GB 20, BL 10, Ren 24, (teishin)

Low Back: Du 26 (teishin), SI 3, (teishin)

Hips and buttocks: GB 30, 31; ST 25, Bl 23 -- 25

All the points above can be treated with marvelous efficiency and efficacy simply using teishin or trigger point stimulation – to wit, without using needles.

If you are massage professional and are not yet versed in auricular therapy, find a course and add this to your repertoire. The ear has such outstanding effects on the nervous and endocrine systems - the very biomedical systems which run amok when stress gets the better of us - that auricular therapy is an indispensable skill for the Barefoot Dr. Other microsystems like the scalp and hand are simple and effective as well. If you are licensed to use needles, realize that there is a great interest and application of abdominal needling currently being employed in China. Some practitioners ‘poo-poo’ this kind of shotgun approach to treatment where multiple approaches or microsystems are piled one on top of the other. But the mantra of the Barefoot Dr. is to use what works. I can tell you from experience that it is possible to treat 4 to 6 patients per hour without needles, simply using trigger points, tui-na and teishin therapy. Believing that patients need a certain period of time is a fallacy and leads to sloppy treatment and methodology (Flaws, p. 61). When the nervous system is stuck in fight-or-flight long enough, it simply becomes habituated to a kind of cliché response. Interrupt this habit and the patient will ‘come down’ for a period of time (i.e. until the next treatment).  “For chronic illness to maintain itself, the disorder must be accompanied by altered neurological reflexes that transmit pathological messages to higher nervous centers.” (Oleson, p. 59) Inturrupt these reflexes and the negative feeedback loop is broken allowing the patient’s own internal resources to contribute to their recovery.

 

 

I know precious few practitioners -- of massage, TCM or whatever -- who are booked solid five days a week. In fact, most prefer not to be as this takes rather impressive stamina. To add the Barefoot Dr. delivery model to your practice, batch your spa treatments to 1 or 2 days, filling these days as completely as your stamina and sanity will permit. (Don't forget you are required by law not to take more patients than you can competently manage. Being tired is not a viable excuse in front of a judge if you are charged with malpractice). There are two possibilities for extending your sphere of influence.

Number one, find a space for rent and try one to two days per week. It should be clean, with easy street access and signage and cost no more than $85- $120 a day. A per hour rate works to if it's in the $10-$20 per hour range. Your goal is volume. Scout the location and see what businesses or other organizations you can alert to your new endeavor. A quarter-page flyer indicating your services, the fee (sliding scale here) and the location is sufficient. Make 1000 copies and pay someone you can trust to canvass the neighborhood - houses, car windshields and mailboxes. Make announcements at the local church and wherever else you can think. Get a sandwich-board and announce something about pain and stress walk-in clinic, $20 for 20 minutes, and your suite number or office door or an arrow to your door. Make it easy for them.

Set your room in order with three reclining lawn-chairs or massage chairs and a single folding massage table. If you need a screen for privacy, okay; either that or hang a sheet. But the less disrobing the better, as this takes time, yours and theirs. When patients enter, talk softly even if they are the first and/or there is no one else present. Be curt but not brusque and have them in a chair within one minute of their arrival. Keep the chitchat to a minimum and don't be overly effusive about answering questions regarding your setup. Show them you are all business and tell them if they want a treatment with a little more time, they can see you at your regular spa location for an hour-long consultation on such and such day. Don’t spend extra time, no matter how tempted. Get to the heart of the problem as is if you had no time to spare. No unnecessary touchy, feel-good stuff. Once you have made the slightest improvement, the smallest impact or gotten even the most miniscule response or indication of a successful treatment, you are done. Finish and send them along. The sign could be a sigh or a general release in which they settle into the chair more completely; whatever indication you detect as constituting an improvement is sufficient to move along or to move them along and take the next patient. If no one else is waiting get busy with something else -- a phone call, sitting down to write -- maintain an air of urgency. The purpose of this is to clearly demonstrate a model of delivery in which the client pays much less than usual because they are receiving a much more succinct treatment than usual. If your client is clearly enjoying some badly needed relaxation or is drooling on their own short-front, with their head lulling grotesquely, then either call the morgue or let them sleep -- for few minutes -- and charge them for the time. A 20 minute treatment with a 20 minute nap is a $40 treatment. A 10 minute treatment with a noticeable sigh of relief might be a $20 treatment -- or if you so wish $15. I recommend setting the minimum $20 and only make exceptions for real financial hardship cases. Most folks who are employed can fork over $20 for stress relief once a week.

This Barefoot approach accomplishes several significant things. First and not least important, your clinical skills become razor sharp. If you are versed in Chinese medical diagnosis, your speed and clarity will greatly benefit from your self-imposed time-limit as well as the repetition you will be called to perform. This model, if you're worth your salt, will let folks in your neighborhood know that there is no-kidding, affordable and (therefore frequent) help for stress, insomnia, anxiety, nervous stomach, headache, etc. Be sure to select the hours of the day best suited to catch people. I suggest lunch time to just before dinnertime, say 12 noon to 6 or 7 pm. This allows working folks to see you on their lunch hour or on their way home from work. It also allows you the best chance of success since folks on the way home are ready and willing to chill out. Lastly, this model of delivery will feed your existing practice. The barefoot model is not meant to replace but augment your existing business. In this way, folks who come for a low risk $20 trial will know that you can deliver should they choose to schedule an hour appointment.

As an afterthought, I mention also that such intrepid practice is truly a service to the community. There is no question that helping the working folks of the world better bear their burden of stress, keeping them laughing with their heads high, will bring you a lot of good mojo from the people who come to rely on your skills and service. This is superior to any advertising, any flyer or any business card. The next part of this article will explain some strategies and techniques for approaching and gaining entrance to conventional medical establishment at the hospital or other allopathic practice.

 

 

In part 1 of this article, I reviewed and clarified the prevalence of chronic disease in the 21st century, along with a model of the delivery -- Barefoot medicine -- that is ideally suited to this current need. Specific guidelines were given as to how a holistic practitioner might successfully treat multiple patients in a single room setting to alleviate the all pervasive complaints of stress. Part one detailed how to establish a community stress clinic as a satellite to one's existing practice. In part 2, I will outline in detail the skills required to gain access to an existing conventional medical clinic or Western hospital style setting. These skills are not as difficult as one might at first believe; many practitioners dismiss the possibility of working in a western setting before setting out to try. Many more will be daunted to give-up, thinking erroneously that there is too much, too-stiff-competition. In reality few holistic practitioners seek to build a bridge to conventional settings and professionals. This article will explain the obstacles to building such a bridge as well as the myriad reasons - not to say favorable factors - which make such outreach worth the effort.

In the first place, U.S. health care is a disappointment – absent as it is from the lives of nearly 1/6 of the population. The costs of failing to maintain a healthy population may now outweigh the cost of extending coverage to all. Chronic disease is epidemic and conventional medicine is at a loss to respond largely because it’s great strength and efficacy lies in its ability to treat acute infectious disease and traumatic illness or injury – to wit, not chronic disease. Holistic medicine with its inability to separate the mind and body is the clear choice for treating chronic disease. So why the disconnect?  What obstacles are leaving holistic medicine and holistic practitioners out in the cold, preventing access to the very medicine that helps patients to help themselves? I offer the following anecdote.

I attended a conference in Portland, Oregon in 2006. At that conference a woman named Jeanette Painovich spoke about her groundbreaking success in creating a full-blown acupuncture treatment program at Good Samaritan Hospital in Los Angeles. This program is now providing a study and peer reviewable literature about how acupuncture can save the hospital money and help patients with serious illness or surgery recover more quickly. Before her talk was 15 minutes old, she had plunged into the matter of ‘language,’ explaining how to communicate with Western medical folks about holistic Chinese medicine. What a storm this affected. For nearly half an hour as I recall, Painovich had to field comments and objections about the way she had conveyed the efficacy of holism to the conventional establishment. With professionalism and unflappable poise, she dealt with each objection in turn, reciting at intervals what nearly became a chant, “I just want to reiterate that this is only one way to communicate with people who don’t know what holistic Chinese medicine is or how it works.” She repeated this phrase – or something nearly identical – nearly a dozen times. My impression as an audience member was that many were deaf to her justification. The disgruntlement stemmed from a sense of belief that talking about holistic TCM in terms other than those used for 2500 years by folks on the other side of the globe was somehow derogatory, traitorous. The sub-text of her plea for understanding and her subsequent message was not lost on all. What Painovich was trying to communicate was that what we have, as holistic practitioners, is a valuable gift by virtue of the way holism organizes the reality of health and illness and may thus treat modern complaints with great efficacy. What we have is an opportunity and even an obligation to reach out to some very educated and intelligent folks who -- because of their own training and medical reality -- don't know what they don't know about holism.

I recount this episode at length precisely because it is so mimics my own experience. After toiling for several years, I have brought to fruition an acupuncture program in a tiny western hospital in rural Guatemala. My joy comes not only from making an impact on the health of people in the pueblo, nor even from bringing students and externs from the U.S. and elsewhere to study and practice in the hospital alongside me. Rather my greatest insight and satisfaction arise from recognizing ways the in which holism can augment existing conventional care and how one may communicate about holism with conventional medical professionals.

My odyssey has led me to clarify for myself this riddle of how conventional reductionism and holism cognize differently their respective realities of health and illness. In this process of clarification, I have realized good, better and best ways to reach out to conventional medical professionals. If my knowledge and lessons help to further the construction of this bridge called integration, then I am content that these years have been well spent.

 

Everything that follows can rightly be called communication. The essence of bridge-building is nothing more nor less. However, empty rhetoric alone bears none of the weight as that statement which may be taught - experientially.  It may be overstatement but I’ll say it anyway: If you are practicing holistic medicine in North America - or any western culture - you simply will be called upon to teach. The paradox is that the people who will most benefit from holistic medicine and the inherent strengths contained therein, are also the ones who don't know what they don't know. The people I refer to are not just patients and physicians, both of whom are frustrated by lack of patient-physician interaction and physical touch, but also the hospital administrators. The task of the holistic practitioner is to explain and communicate what holism is and is not and then deliver an experience, a lesson, something immediate and direct that provides the audience insight greater than mere verbiage can compass.

Communicating about holism isn't difficult. Where I see people in trouble is in the erroneously held belief that holism is somehow a spiritual club whose superior members have achieved some important illumination and who therefore peer down their noses contemptuously at those mediocre souls still stuck in reductionist science. Hordes of holistic practitioners criticize conventional medicine (and vice-versa for that matter) due to a misunderstanding of inherent characteristics and the fundamental presuppositions about reality that exist as the bedrock of each of these dominant medical systems. Holism is no more a spiritual practice than anything else and at the professional level, there are good reasons to leave one’s spiritual beliefs out of the clinical interaction with patients.

Holism is about the ineluctable connection between the mind and body. Communicating about holism isn't difficult and should not be made so. The implications of mind-body inseparability are profound enough that one may simply start there and explain those implication. When I speak about holism, I deliver the above point as concisely as possible and then explain that – in-clinic - this gives rise to an emphasis on discriminating patterns of imbalance. The holistic professional who truly grasps this seminal point need go no further when communicating with MD’s or hospital administrators or even lay patients.  Consider the kinds of questions such folks ask: does acupuncture and Chinese medicine treat nausea? (Fill in the blank with any named disease entity).

“In TCM that's actually a non-question,” I respond politely. I seldom give a yes no answer because the moment someone asks such a question, I've just been given the go-ahead to explain the essential gift of holism. “Holistic medicine treats patterns of imbalance, not diseases. This is why it's effective at treating and managing chronic disease and also why side effects are virtually nonexistent.” The temptation to say, “yes, needle Pericardium 6 on the medial forearm” is a mistake when communicating with western medical professionals and must be resisted. Not only does communication with MD’s and administrators depend on not answering yes or no questions about what diseases are treated by holistic medicine, your own credibility will exist (or not) based on your ability succinctly turn such questions into educational opportunities. What I've actually said when I replied that question X is a non-question for holism is, “there is a different way of make sense of health and illness and I can explain it if you like.” Imperious arrogance is never useful nor is pretense. I usually follow my response with something like, “holistic TCM is based on some dirt-simple metaphors about things which exist in nature. When you hear these metaphors, they make sense and one can have a kind of ‘aha, of course!’ moment.”

I have given now given dozens of presentations to western medical folks about the benefits of holism and I am utterly convinced that they hunger for more of this holistic approach. The strengths of holism are inherently suited to the management of chronic disease. There is no need to foster any pretense about spirituality within holistic science. My experience is that holistic professionals who come to rely on some New Age notion of spirit in order to practice their craft have simply yet to define and clarify what they do, what holistic science is and is not.

I never talk about qi unless asked. Even then, I deflect such queries by simply equating qi to aspects of function. For example:

 

Me: what is the function of the lungs?

Western M.D.: to breathe, respiration.

Me: so then lung qi vacuity or lung qi deficiency would present as difficulty breathing.

 

Next question.  This is simple, succinct, accurate and requires no pissing-contest.  

 

Inevitably the next question has to do with the issue of proof, research and peer-reviewed study. This too can seem a touchy subject. As with other queries, short and concise responses avoid confrontation and long discussion. Even more-so with this line of inquiry one need not respond with dazzling and mysterious explanations. The simple answer to the question of literature on Chinese medical studies is that Medline – the largest biomedical database - only sources a few Chinese medical journals and is thus inadequate. (Fan, p.148). The new best source and the one I refer people to use is TCMLARS (Traditional Chinese Medical Literature Analysis and Retrieval System). Make yourself familiar with not only specific studies you can use to back you in a presentation or conversation, but also with the methodology of those studies. In other articles, I explain why holism requires a different methodology from conventional medicine. (Please see: The Burden of Proof in Holistic Medicine)

The kinds of questions and answers likely to take place in an interaction with Western MD’s, hospital administrators or clinic directors are utterly predictable. Learn how to respond to a stock set of questions without sounding like you are giving stock answers and you will prove a masterful presenter. I have a legitimate and thorough presentation down to just under 20 minutes. Circumscribe your expertise and draw upon existing peer-reviewed sources as proof that holistic medicine will greatly enhance any existing conventional practice. Ultimately your goal is not discussion but rather the opportunity to demonstrate what you can do. If you make it that far – and you should propose a trial period after you finish your pitch -- deliver like a pro and it will be hard for anyone to deny your value. Remember that the ex-factors of chronic disease and skyrocketing medical costs favor holistic therapies like acupuncture, acupressure and Chinese internal medicine. As such, leave all gods, spirits and New Age mumbo-jumbo outside. Holistic science does not require such meanderings anyway, and if you have clarified the importance and methodology of pattern discrimination, you won't need to call upon any spiritual chicanery to make your case. Am I saying the gods have no role in health and illness? Never. No one can out run the will of heaven. But recall that conventional folks are taught to focus on material, physical reality. Nothing makes such people more queasy than references to disembodied entities. Don't do it. Even if you disagree, think of the bridge first and leave your personal gods in the lobby.

Seen from above, there are two forces for change; or, two parties, each responsible for obstructing the process of integration. On the one hand there is a hegemon gatekeeper that is conventional medicine and that gatekeeper is less than receptive to anything outside its own logical confines. All established institutions are hierarchies and they too are merely protecting their interests. But the obstacle of which holistic medical professionals need to be especially aware is a self-imposed subjugation. The need for good quality holistic medical practice in the west is staggering. Rather than waiting for the bestowal of legitimacy by a failing medical system or institution, seek ways to infuse your talents and gifts. Seek rather to bestow upon those in need that which you can offer, bringing relief from stress and its myriad effects to those millions who need it.

 

 

T. Roosevelt

 

Works Cited

¨      Cohen, Ken. Honoring the Medicine: the essential guide to Native American healing. Random House, New York New York, 2003.

¨      Flaws, Bob. Blue Poppy Essays 1988. Blue Poppy Press, Boulder Colorado, 1988.

¨      Porkert, Manfred. Chinese Medicine.  Henry Holt and Company, New York, NY. 1988

¨      Rohleder, Lisa. The Remedy: integrating acupuncture into American healthcare. Working Class Acupuncture, Portland Oregon. 2006.