Building Your Treatment Strategy - Pt3, Communication

[00:00:02] Speaker A: Hi, everyone, and welcome to the nervous Herbalist, a podcast for chinese medicine practitioners who like herbs and want to learn more about their function, their history, and treatment strategies to use in the clinic. Let's get into it. All right, so we are back. I am Travis Kern. [00:00:24] Speaker B: And I'm Travis Cunningham. [00:00:25] Speaker A: And we're here to talk to you today about communicating with the patient. Now that you've done all the work, you've done all the work, right? It's all done now. So you. [00:00:37] Speaker B: So you think. [00:00:38] Speaker A: So you think. So you've diagnosed, you've established a pattern, you've thought through a formula, you've built it, you've dosed it, and now it's time to hand it over to the patient. So let's just start there. So t, what, this is a new patient you've never seen before. The patient's never taken herbs. You've now got the formula ready. What is your next step? How do you talk to them about it? [00:01:01] Speaker B: So I talk to them. So it comes before I would actually think about writing a formula. When somebody's coming in for the first time or the first time that I think they might need herbs, I would start the, the appointment by saying the main way we need to intervene to address this issue is with herbs. So making that very clear from the start that, because if you don't do that, then it's like, not clear. Is it the acupuncture working on it? Is it the herbs working on it? Is it both? And it might be both. Most of the time it's both. But there's plenty of things that we treat here that if I just had acupuncture to treat, I wouldn't feel comfortable telling the patient that we're legitimately trying to move in terms of a symptom or a pattern or something like that. [00:02:00] Speaker A: Because the type of condition is one that, in your experience, and mine, too, I suppose acupuncture alone might not be able to get us where we need. [00:02:09] Speaker B: To go, or my acupuncture won't be able to get there. Like, I don't feel like the acupuncture that I do, in my experience, can get the patient there. I also think even if it is both, it's wise in conversation to lean heavily on the emphasis that the herbs are doing the pushing. Because if you have everything equal, if you walk into a situation, the patient comes in, they get acupuncture, which is a long experience, and then they get an herbal prescription, and there's not much discussion about it. It's almost like the time, like the majority of the time in the experience is devoted to the acupuncture. And then the patient's mindset is, oh, I'm really here for the acupuncture. And the herbs are just kind of extra, a little extra, which is not how I see it. In fact, in many cases, that's the opposite of how it is, how it's going. Right. The opposite of our strategy. So I try to make clear in the language that the main way we're going to try to influence this particular part of their case is with herbs. And that's because herbs can be taken every day. We don't typically do acupuncture every day in this country. It can be very expensive, etcetera, etcetera. And herbs work. I usually say to people, acupuncture works from the outside in, where herbs work from the inside out. [00:03:43] Speaker A: That's a good phrase. [00:03:44] Speaker B: I like that. That's another way to kind of explain it. And people are like, oh, yeah, that makes sense. [00:03:49] Speaker A: Yeah, it's a simple little image. [00:03:51] Speaker B: Right? [00:03:51] Speaker A: Yeah. I think it's also worth pointing out that we have a lot of colleagues who, you know, are starting to prescribe herbs, or they maybe, you know, sell a bottle of patent pills here and there or what have you. And almost everyone I know who doesn't sell a lot of herbs, even if they want to prescribe more, they usually ask their patient if they're interested in making herbs. [00:04:14] Speaker B: Don't do that. [00:04:15] Speaker A: Yeah, I know. It's funny. People are here to say that. They'll be like, wait, I don't understand. It's like, look, we're not, like, pouring them down people's throats, but you're the expert. I in the room, like, you tell the patient what it is that you think they need. [00:04:29] Speaker B: Right. [00:04:29] Speaker A: And it's not optional insofar as, like, oh, we're mostly like, the treatment is the acupuncture. But, you know, how do you feel about maybe trying some herbs? No, no, no. Because this is what will happen. The patient will say, no, thank you. [00:04:43] Speaker B: Right, right. [00:04:44] Speaker A: Almost every time they'll say, no, thank you. Even if you know that this is really the thing, you're going to need to push hard because of your phrasing, because of the way you approached it, because you made it seem like, you know, you know, maybe you should drink some more water. Like, just a light hearted, not a big deal thing. They're going to walk away from it. [00:05:02] Speaker B: Right. [00:05:02] Speaker A: They're going to say no. So I think it's important like you said, to point out the importance of the herbs in the treatment structure and to not. It's not optional. Like, if you think the patient needs herbs, right. They need to take the herbs. [00:05:14] Speaker B: Right? [00:05:15] Speaker A: Right. Now, let's say the patient's got some financial considerations. They can't afford the herbs. That's. That's a conversation you need to have with them, and it needs to be a frank one. Right. That's like, look, this is what the cost is here. You know, we might be able to adjust dose this way or this way, but we can't really get much lower than this number. Right. [00:05:36] Speaker B: Well, and if. If it's a. If it's an herbal case, like, if it's in my mind we're treating this with herbs, I would. I would rather have them come in for acupuncture less and have them continue to take the herbs. Right. [00:05:50] Speaker A: Like, if they're cash and they need to save some money. [00:05:52] Speaker B: If they need to save some money, I'm gonna say, like, okay, well, then let's strategize around, finding you a good herbal formula and then having you take the herbs consistently and come in for acupuncture less. [00:06:03] Speaker A: At the right dosage. [00:06:04] Speaker B: At the right dosage, yeah. [00:06:05] Speaker A: Cause here's the, here's the, like, a terrible outcome in my mind. So the patient has some financial considerations. You want to get them herbs because you know that they're gonna be helpful. So you reduce your dosage by a third, or you pull out a really important ingredient that's kind of expensive. And, you know, sometimes you can substitute things for sure, but, like, in this case, it's an ingredient that the patient really needs to take, but it's expensive. So the patient, instead of spending $40 a week on herbs, now spends dollar 25 a week on herbs, which is more functional for their budget, and then they don't get anything out of it. And that is a nightmare in my mind. [00:06:45] Speaker B: Right. [00:06:45] Speaker A: Because they're still out $25, and you didn't give them what they needed. Right. [00:06:49] Speaker B: Yeah. And the more we do this, I think the more you and I feel this way. We don't want to undercut the power of the treatment. So, like, if you're. If I'm, like, not sure that the patient's gonna need herbs, let's say somebody comes in for an orthopedic problem, and I think I can handle it with acupuncture. Or somebody comes in for. I don't know, they're like, they have an acute anxiety thing, but it's not chronic. And it's like, not a big deal or whatever. And I just don't, I don't think it. I need to write an herbal formula. I think we can address, you know, with acupuncture reasonably well. I won't give them herbs, and I, like, I'll just make that distinction. If I want to give them herbs, then you emphasize the herbs, right. And you do the whole thing at a therapeutic dosage. Like, you don't undercut the power of the treatment. You don't undercut the power of the treatment in the patient's mind either. Like, yeah, you can take herbs and they can help. No, like, the herbs are doing the pushing. The herbs are what we're using to intervene here. It's a really important part of the intervention. Even if you're doing acupuncture and herbs and you really feel like your acupuncture is doing a big part of the pushing, you want to make sure that the herbs in the patient's mind are a central part of the strategy and that that's known. [00:08:19] Speaker A: I literally had a case of this this morning. So I have a patient that I've been seeing for plantar fasciitis, and we've been working together for a while. Plantar fasciitis, down from like a nine, like, could not walk on their feet at all. Down to, like, a one and a half, right. Pretty nice reduction almost exclusively with acupuncture. A little bit foot soaking, a little bit gua sha in the calves, right. But now we've been hovering at this, like two out of ten, one and a half out of ten. And the patient's frustrated. They can't get back to everything that they wanted to do. So last week, I was like, okay, let's. We need to, we need to add some herbs into this, right? I mean, we've, we've done all the heavy lifting that I can do with the acupuncture. We've got to start working from the inside. Patient was like, okay. I mean, you know, I don't know that that's necessary. I was like, I think it is. Like, I just, I think it is. This is what we need to do. So I wrote the formula, patient took the formula, just a week's worth, came back today, and the pain is less. Right. And so I'm like, oh, that's great. I'm glad that the herbs are working out. You know, the patient didn't have any digestive issues. Well tolerated, able to take it, took it at full dosage, and the pain is down you know, it's hard when you're in those lower numbers. It's hard exactly to, like, capture, but based on. Based on how she described her activity and the discomfort level that she was dealing with, I'd say it's probably down, I don't know, 30, 40%, like, a significant reduction. And she says to me, well, I mean, you did leave the needles in a bit longer last time, so how do you know that it's the herbs? And I was like, well, because I wrote the formula to do exactly what happened to, like, we reduced pain in your feet, specifically in your heels. Right. Within a week. Well, but couldn't it have been the longer needles? Well, sure it could have been, but also that, like, we've done longer treatments in the past before. The major change here was this formula that I wrote for this purpose. And she wasn't arguing with me exactly, but I had to, like, stand some ground and be like, no, the herbs are valuable. It's not placebo. It's not fluff. In your mind. Like, I wrote a formula for a purpose. You took it, and it worked. [00:10:24] Speaker B: Right? [00:10:25] Speaker A: Great. That's exactly what I wanted to happen. But the patient, again, this was their first time with herbs. We had done all of this heavy lifting with needles and gua sha, and I think that maybe in my initial sale, I might not have emphasized as concretely the value of what the herbs were for, which, you know, circumstance. I don't know. Just maybe I didn't. And so here they come back to me with, like, well, I don't know how impactful those were. And I'm looking at the chart being like, wow, what a great formula. It's going really well, you know? So it's funny to see, like, managing the patient's relationship to the treatments and what you're choosing and why really, really matters. [00:11:09] Speaker B: It does, and it also matters. The reason that I think we're putting so much emphasis on this now is because compliance really depends on those. It's not only like getting the person to buy the herbs or take the first formula, it's also getting the person to think that it's important enough so that they continue to take the herbs once they're not around you. So then they come back and you find out that, oh, yeah, I have half a week's worth of herbs left over, you know, and you're like, well, okay, did the herbs help, or were they not dosed high enough to really know? [00:11:50] Speaker A: Yeah, especially because the patient was supposed to be taking 6 grams or 8 grams twice a day. And they took it once every other day. [00:11:58] Speaker B: Exactly. Yeah. Then you can't know. Yeah, yeah. [00:12:01] Speaker A: I mean, I have a headache. I only took half an ibuprofen. I don't think ibuprofen really helps my headaches. [00:12:06] Speaker B: Right. [00:12:06] Speaker A: It's like, well, that's not the dosage for ibuprofen. Like, we don't know. Maybe you're right, but we actually don't know because you didn't take the herbs. I think it's also worth mentioning that a not insignificant number of people have issues with the taste of herbs. [00:12:22] Speaker B: Yeah. [00:12:22] Speaker A: Right? [00:12:22] Speaker B: So that's one thing that I always say to people, is the herbs don't taste good. Can you handle that? Is it okay, like, is it. Can you take the herbs if they don't taste good? I actually make people say yes the first time before I give them herbs. Right. [00:12:40] Speaker A: I think that's a good. I haven't done that before. I like that idea of forcing their compliance. I tell them, like, the herbs are going to take, like, taste like this. That's. It's medicine. What are you going to do? It's not supposed to be pleasant. Drink it. You know, I have a very, like. You know me, I don't like to be paternalistic with my patients. Like, I'm not your. Your parent, right? So I'm here to give you advice. But you are an adult in most cases, obviously, we treat some younger people, but you know what I mean? Like, you're an adult. You make your decisions. I'm not gonna, like, fuss at you or, like, be like, you know. But at the same time, I have so little tolerance for the herbs taste bad excuse for why I didn't take them. Because firstly, we talked about that, and two, get over it. [00:13:23] Speaker B: Yeah. [00:13:24] Speaker A: Like, take the herbs, you know? Well, I just couldn't take them. Well, you need to, because if you don't, we're not gonna make progress. [00:13:32] Speaker B: Right. Then I can't help you. [00:13:33] Speaker A: I literally say it like that now. [00:13:34] Speaker B: Yeah. [00:13:35] Speaker A: Oh, I couldn't. Oh, the taste was so strong, I couldn't take it. Literal response. Well, you need to take them, otherwise we're not gonna make any progress here. [00:13:42] Speaker B: Yeah. [00:13:43] Speaker A: Right. And then they just kind of look at you. [00:13:45] Speaker B: Yeah. [00:13:45] Speaker A: Like, what did you expect? I was gonna be like, oh, no, it's okay. You don't have to take the medicine I prescribed. No, you have to take it. Take the medicine. Right. And, you know, I've had patients who. Who just couldn't. You know, they're like, I gagged. I almost threw up when I took it. And that's the. Those are harder conversations because now you have to be like, okay, I hear what you're saying. Right. But without these herbs, we're not going to be able to achieve the results that we were trying to achieve. And you need to be aware of that. And you got to tell them that, because again, in this whole conversation about managing patient expectations, if you let them off the hook. Oh, you know, oh, it's okay. You know, whatever. They took a portion of the dose. They didn't take it at all. They took it at the wrong time of day. They took it mixed with orange juice or sweetened with honey or whatever instructions that you didn't give them. You can't reasonably make an assessment about whether that formula was helpful or not. [00:14:44] Speaker B: Right. [00:14:44] Speaker A: Which means your treatment plan is going to stall out. [00:14:46] Speaker B: Yeah. [00:14:47] Speaker A: Right. And the thing is, is that you have to tell the patient that. [00:14:51] Speaker B: Yeah. [00:14:51] Speaker A: Politely. [00:14:52] Speaker B: Yeah. [00:14:53] Speaker A: Professionally, you're not a scold. At least we're not scolds. Maybe that's some people's strategy, but you still. You can't let the patient off the hook just because they don't like the way they taste. [00:15:04] Speaker B: Right. [00:15:04] Speaker A: They need to know that if they don't take the herbs, they're not gonna get the results. [00:15:09] Speaker B: Right. And I would say the majority of people that we deal with, like, I don't know about what your experience is, but the majority of the people we deal with take the herbs. [00:15:19] Speaker A: Oh, yeah. [00:15:20] Speaker B: And they don't complain so much. They might say, like, oh, they don't taste good, but I'll still take them. [00:15:25] Speaker A: My favorite are the people who hated them in the first week. [00:15:28] Speaker B: Yeah. [00:15:28] Speaker A: And later they're like, you know, they don't taste good, but they've kind of just become, like, my ritual. [00:15:33] Speaker B: Yeah. [00:15:34] Speaker A: Just drink them. They tastes like garbage, but I just drank it. I love that response because there's a recognition that the herbs are helping and that there's something to it. [00:15:45] Speaker B: Yeah. [00:15:46] Speaker A: And, you know, like, okay, a lot of western people, we don't have a lot of bitter flavor in our diets. We don't. You know, Americans in particular have a tendency to consume a lot of sweet flavor, a lot of salty flavor, very palatable, easy to consume, huge amounts of flavors. And bitter and acrid are not that. Right. And so you'll get formulas, many of which are bitter and acrid with a little hint of dirt and a little whiff of animal and, like, you know, it's not great, but you know, that mummified silkworm is gonna help your phlegm. I know. It's gross, right? I made. I made a granule for myself last week because I had this little head cold thing. It's like, oh, put the jiangsan in there. And I'm looking at it going, ugh, that's not gonna taste good. But I boiled it, and I drank it because, like, I had phlegm, and I needed to get rid of it, and that was gonna do it. [00:16:42] Speaker B: Yep. [00:16:42] Speaker A: You know, so. Okay, so you've talked to the patient ahead of time. You've explained to them the importance of the herbs. You asked them to say out loud that they can handle the flavor. Right. You give them. They pick up the herbs from the pharmacy. We walk them through how to take it. [00:17:03] Speaker B: Right, right. [00:17:04] Speaker A: So I was just doing this right before we were taping. The usual spiel is, you know, your dosage is in grams. [00:17:13] Speaker B: This is for a granule formula. [00:17:14] Speaker A: For a granule formula. Of course. Yeah. Bulk, of course, is a different game. Right. For granule formula, your dosages and grams, you can weigh the amount of herb that you need to get the most accurate, you know, quantity per dose. But also, we've done a conversion into spoons. We talked about that last time. We don't want to go over it again, but there's no such thing as a 1 gram spoon anyway. And so you put the spoons in the cup, you cover with warm water. You stir to dissolve. You drink like tea. The amount of water that the patient can dissolve it in is up to them. Yep. I think that's a really key piece. [00:17:48] Speaker B: Yes. [00:17:48] Speaker A: You know, I had a patient years ago now. She ate her granules. [00:17:53] Speaker B: Yeah. [00:17:53] Speaker A: She just ate them. [00:17:54] Speaker B: Yeah. [00:17:54] Speaker A: Like, with a spoon. [00:17:55] Speaker B: I know. I know of at least one teacher at Ocom that eats granules. [00:18:02] Speaker A: Eats the granules. Yes. I mean, you know, don't try that at home, kids. I mean, you can. It's not gonna hurt you. But that seems pretty. That seems pretty intense. [00:18:10] Speaker B: Right. [00:18:10] Speaker A: But the point being, what matters is the number of grams, the number of times a day, not the. Not how much water or whatever. [00:18:19] Speaker B: Right, right. [00:18:19] Speaker A: However, there are some ways that you could probably futz with the outcome of a formula by mixing it with some kinds of carriers that maybe would not be ideal in my mind, that would be sweet things in particular and acidic things. So juice is the one thing that comes to mind. And obviously, I mean, I've never heard anybody doing this, but you shouldn't mix your granules with soda. [00:18:45] Speaker B: Right. [00:18:45] Speaker A: Or. You know what I mean? Or, like, also probably not coffee, probably not tea. Mostly because you will you ruin your coffee and your tea? Like, I don't. You know what I mean? Like, if you were gonna enjoy that nice cup of tea, that delicious brew of coffee, it's now just gonna taste, like, vigorous. [00:19:01] Speaker B: Well, and if it's, you know, if it is coffee or tea, and it's a significant amount, it can definitely alter the direction of the formula. [00:19:10] Speaker A: Without a doubt. Yeah. Because coffee and tea themselves are herbs. [00:19:13] Speaker B: Are herbs. [00:19:14] Speaker A: Yeah, for sure. So mix yourself with water. [00:19:16] Speaker B: Yep. [00:19:17] Speaker A: If you have instructions from your practitioner, some formulas can be sweetened. Right. But very mildly. [00:19:22] Speaker B: Yeah. [00:19:23] Speaker A: And, you know, a little bit lemon juice or something. Okay, fine, if you have to. But let's be honest, just mix it with water, drink it down. [00:19:30] Speaker B: Yeah. [00:19:30] Speaker A: Right. Okay. So the patient agrees, they've got the instructions, they go home. What else do you prepare them for before they start taking the formula? What other things are on your mind? Obviously, it's case specific, but what are some of the things you're thinking about? [00:19:47] Speaker B: So the first one is treatment planning in general. When we're talking to somebody about taking herbs for the first time, they're usually at the beginning of a treatment plan. And we do treatment planning with everybody. Even if they come in for, even if they're an insurance patient or something, we do treatment planning. We do it with people who are cash patients. We want to create an expectation that treatment is going to take time for chronic problems. So if somebody has tinnitus for ten years or 30 years and they come in, we don't want to give them the impression that it's going to be better or that it's going to be fixed in two weeks, that is not realistic. [00:20:38] Speaker A: Definitely not. [00:20:39] Speaker B: And even if it's possible, because some cases you have like that. Right. There's a chronic problem. It's a small percentage of people come in, it's a chronic problem. They've had it for 30 or 40 years. Whatever it is. You give them an herbal formula, two weeks later, it's gone. [00:20:56] Speaker A: Gone. [00:20:57] Speaker B: I had headaches for 25 years. I took the herbs. My headaches are gone. You know, it's like what really could. [00:21:05] Speaker A: Just as likely be the alignment of the cosmos as it is the formula. [00:21:10] Speaker B: That you feel is really like, wow. Yeah, that doesn't. [00:21:14] Speaker A: Yeah, that's a lucky outcome. [00:21:16] Speaker B: That's a lucky outcome. But that does happen. But you don't want to create the expectation that that's going to happen. So you want people to be in this headspace of, they're going to be taking herbs and they're going to be taking them for at least a certain amount of time. That's reasonable. That gives you enough time to try a variety of strategies. That's the way that I think about it. So for most cases with us that we see that are going to be chronic disease or chronic problems, I tell them three months, we're going to set our goals for three months from today. That's what I say to them. So the first time they come in, I give them that expectation, we need to work on this for about three months. And so if we're doing a treatment strategy, let's say we're harmonizing with a chihu formula, right. That's often going to be three to six weeks before we move on to the next stage. If it's granules, if it's bulk, maybe we do it faster than that. Two weeks, two to four weeks or something. [00:22:23] Speaker A: And that's just the first stage. [00:22:25] Speaker B: That's just the first stage. And most importantly, then if they're expecting three months, if they have that in their mind for a goal, for treatment, then if you miss the first round, if you give them a formula and it doesn't help, it doesn't work out or it gives them some negative symptoms, right. At least it's put into the context of we need to be at this for three months. [00:22:49] Speaker A: Right. [00:22:50] Speaker B: You know, the first round, if we miss in the first week, it's actually not that big of a deal because it's one out of twelve weeks that we're planning on working on this. [00:23:00] Speaker A: So three months, obviously it'll vary by case, but that's, that's going to be. Well, I mean, inside of your three month start, is that a weekly interaction with the patient? [00:23:11] Speaker B: So usually the way that we've done it here up to now, we've talked about maybe like shifting this a little bit recently, but usually that's, it's dependent upon the case. Right. It's dependent upon the way that they're paying for treatment. So if they're doing acupuncture through insurance and they're coming in for an orthopedic related problem, let's say, then we're going to be doing more acupuncture to address that problem and we need to see them more frequently anyway. So we're going to see them for about once a week, at least in the beginning. If it's more acute than that and it's an orthopedic condition, then we might see them more than once a week. Right. But for herbal assessment, in the beginning, we're going to check in weekly, probably, and then as we get more comfortable, like after the first round, if the herbs are well tolerated and the person's doing well. At this point, for me, I could go two, three, four weeks before I see the patient again if I need to, but I didn't feel like that in the beginning. When I was starting off writing herbs, I wanted to see them a little more frequently to make sure that things were being addressed and moving the right way. I now think that if you see people that frequently, there's an argument for not doing a detailed assessment every time they come in, because sometimes you overthink it and you change the remedy prematurely, when really what it needs is just more time. The patient just needs to take the herbs for more time, another week, another two weeks, and then the case will really shift. [00:24:54] Speaker A: And this is particularly true for chronic disease. [00:24:57] Speaker B: Yes. [00:24:58] Speaker A: Which is much of what we treat in our practice, chronic disease of a wide variety. But things that people have had for five or more years, many of them for 15 or more years. [00:25:09] Speaker B: Right. [00:25:10] Speaker A: You know what I mean? This is a different scenario, say, than an acute problem. [00:25:15] Speaker B: Yes. [00:25:16] Speaker A: Cold and flu, very different. Right. Etcetera. So when you're thinking about treatment planning for chronic disease, we're looking at minimum three months as a starting. This is our starting salvo, initial volley, whatever metaphor you want to pick three months with, likely something close to weekly treatment. [00:25:38] Speaker B: Yes. [00:25:38] Speaker A: Right. Now, if at least in the beginning. At least in the beginning. I think that's really important, too, because also with my own work with chronic disease, even if we're just doing herbs, I want to see this person every week for at least three weeks. [00:25:52] Speaker B: Yeah. [00:25:52] Speaker A: Because I'm writing a formula just one week at a time. I've never seen this person before. I have no idea how their body's going to react. I'm still feeling out their reaction to the dosage that I've chosen, the herbs that I've picked, etcetera. And so I need to see you weekly to tweak this formula. And then, you know, as soon as assuming we've gathered all the necessary data and things are trending in the right direction. When I write that formula on week three, I'm probably going to write it for two or three weeks, depending on how good the formula has been going. If it's going really well, I do three weeks if it's pretty good, but kind of mixed two weeks, and then at that next round, if it's still going really well, I'm then probably going to write it for another three weeks or a month, and that's going to take us through those three months. So it's very close together. One, two, three weeks, then two or three weeks out, and then three or four weeks out, which is roughly three months. Right. When we get through that whole set. And so if acupuncture is in there, different game, because, yeah, we're treating the orthopedic problem. We're probably seeing them at least once a week. If we are lucky and they have a good enough benefit, then we can see them twice a week and we can be a little bit more agile. With acute cold and flu, though, it's a different game. [00:27:06] Speaker B: Totally different. [00:27:06] Speaker A: Totally. Why is it different? [00:27:08] Speaker B: The picture changes really quickly. [00:27:11] Speaker A: It's. [00:27:11] Speaker B: And it's the same for, like, let's say Utis, you know, or it's, you know, not just cold and flu. [00:27:18] Speaker A: Shingles. [00:27:18] Speaker B: Shingles. [00:27:19] Speaker A: That's been one that we had been agile. [00:27:21] Speaker B: There's been cases that we've had where people have had, like, acute vertigo. [00:27:25] Speaker A: Yeah. [00:27:26] Speaker B: Where we've wanted to see people, you know, more quickly. [00:27:29] Speaker A: Also some topical infection. [00:27:31] Speaker B: Yeah, topical infection. [00:27:32] Speaker A: Skin. [00:27:33] Speaker B: Skin stuff like poison oak, poison ivy kind of. [00:27:37] Speaker A: Yeah. [00:27:38] Speaker B: Thing. [00:27:38] Speaker A: That's some wound care stuff that I was doing. Yeah. You gotta be. You gotta be agile with that. [00:27:42] Speaker B: Or even like, gout. [00:27:44] Speaker A: Gout. [00:27:44] Speaker B: Gout flares can be. Yeah. So in those cases, things change really quickly. So usually we wanna see people like, so for me, with those cases, that's often gonna be a bulk remedy versus a granule remedy. If we're doing granules, I'm going to give them another third of the dosage on top of what I would normally give. So let's say eight twice a day, 8 grams twice a day for granules, I would do eight, three times a day or maybe even eight, four times a day for certain conditions. And that's just like, that is just because of experience. We've found, like, if you give that lower dosage with certain kinds of things, it helps, but it kind of seems like they could use a little more. Right. And then, like, you go through the case and the person's like, yeah, you know, the herbs really did help me, but it took like a week to get the thing totally resolved. And it really could, like, with more experience, you realize, like, oh, it could be like two or three days. Like, it doesn't need to be a week or a week and a half. You know, it doesn't need, like, the cold doesn't need to go into their chest and like, have, they don't need to be congested. Like, you know, like these kinds of. [00:29:10] Speaker A: Things you can do before it goes. [00:29:12] Speaker B: There, you can stop it before it goes there, but you got to intervene quickly and powerfully. So for me, that that more necessitates a bulk remedy or if we're doing granules, it would be a higher dose of remedy. What about you with that one? [00:29:27] Speaker A: Yeah, I mean, it's the same. I think one of the challenges here is very few of us practitioners live in a small village setting. True, we live in cities or rural areas even. But even towns where, you know, you're not the person can't just pop over like, oh, take this and call me in the morning. Like that sort of stereotypical kind of thing. In many ways, for a lot of acute conditions, that would actually be ideal. Especially, you know, some herbs like purgative formulas, things, you know, like, I would love for you to take this literally for one day. Strong, strong formula for one day, and then call me and tell me what happened. So it's tough to figure out how to do that in a sort of modern urban or suburban or even a rural setting where we don't share our personal contact information, for example, with patients. I don't really want my patients texting me on my personal phone. [00:30:30] Speaker B: Same. [00:30:30] Speaker A: Yeah. Not everybody feels that way. Some people, no problem, or they have a Google voice or whatever. So your personal circumstances might make the management of acute conditions easier, right. Because you don't mind fielding that question at 08:00 p.m. on your personal phone. I don't want to do that. So we had to figure out other ways to do that. So in our clinic, we built this phone call check in model where it's literally a five minute conversation. It goes on the calendar so that it's in the flow of my day. And I tell the patient, this is the key piece about communicating the expectations here. So chronic disease, take this formula for a week or two weeks or a month. They know how long. They know what we're going to check in on. We told them what the formula is supposed to do and what they need to report back. It's exactly the same, I think, with acute stuff, but in a much shorter time frame. So here's this bulk formula. It's two, two days worth. On the morning of the third day, I'm going to call you and I'm going to ask you, how's the phlegm in your throat? Or I'm going to ask you, has the burning subsided during urination? Has the pressure reduced, whatever it is. Right? I'm going to tell them. These are the questions I'm going to ask you. This is what I want you to report back to me for. And then I can quickly and agile with agility, shift the formula as necessary, turn up the dose, turn down the dose, pull out the dahuang, add the dahuang, whatever it is that we need to do. The thing is about that is you gotta be careful because we don't charge for that. [00:32:06] Speaker B: Right. [00:32:06] Speaker A: Like the phone call. I mean, you know, we're pretty good at it now. So it really is like a five minute phone call, but there's no fee. Like, I don't ask someone to pay me to check in on it. Right. But in the early days of doing that, and if you use it in different circumstances, you can find yourself in a ten minute, 15 minutes, 20 minutes conversation where you effectively do all of your diagnosis, like your ten questions and stuff over the phone. And then you prescribe the formula and you didn't get paid for your consultation and, okay, every now and then, for long time patients, friends of the clinic, whatever, okay, no big deal. But as a policy, as a position to take, as a practitioner who needs to keep the lights on and pay your bills and make money, you have to be mindful of that. Yeah. So I want to say, like, for my purpose, I use phone call check in a lot for, like, acute cases because I want to be agile with the formula and I want to knock this thing out in four days instead of two weeks. And a lot of acute conditions, also very painful. Right. Like patients in the agony. [00:33:15] Speaker B: Yeah. And so very uncomfortable, even if it's not pain. [00:33:19] Speaker A: Yeah, just super uncomfortable. So you gotta. You want to be there for them, obviously, to make sure that they're getting. They're feeling better. And also, frankly, it's just. It's good for the clinic, it's good for your practice to be available and to be supportive, but you don't want to let yourself get exploited and you don't want to give away too much free stuff. [00:33:39] Speaker B: True. [00:33:40] Speaker A: Right. So I say, for me, using the phone call check in is great, but you have to keep it short and you gotta be mindful of it. And I think that's a really key piece to being good with dealing with acute stuff, because if someone's got an acute problem, you write the most a week long formula, ten day formula. The pattern might not be at all the same three days after you wrote that formula. [00:34:03] Speaker B: Sure, sure. Yeah. [00:34:06] Speaker A: So then they spend money on something that isn't useful. They take it doesn't help. Could make something worse. Could be any number of things. So, you know, a lot of practices, too, though, you know, for the listeners out there. Like, if you, if your practice is mostly orthopedic medicine and you don't treat a lot of this kind of stuff, it's kind of a moot point because nobody comes into your clinic for their UTI. [00:34:31] Speaker B: Right. [00:34:31] Speaker A: You know what I mean? Because we're an internal medicine clinic, because we've been doing a lot of patient training these last five years, because we are in all of our marketing, on the website, this podcast, everything that we do, we're like, you know, chinese medicine could really help with that condition. Like, we're just constantly telling people about all the things that chinese medicine is good for, specifically in the internal medicine space. And so we do have people that call us, you know, also because we have the pharmacy, and the pharmacy is public facing, random people who googled natural remedy for UTI and find their way to a blog post we have about Utis, they'll call us. [00:35:11] Speaker B: Right? [00:35:11] Speaker A: What can I do? What can I do for UTI? Right? And so, you know, we deal with that a little bit more than other people. But, you know, that's another thing. While we're talking about patient management and patient discussion, the random phone call person, the, the off the street inquiry, how do you deal with that? What do you say to someone who's like, so what do you got for sleep problems? And maybe that's in your clinic? Or more likely, if you don't have a public facing thing like our pharmacy, it's probably like at a dinner party or at thanksgiving, your uncle's like, so what do you got for the gout? It's like this really open ended kind of thing. And talking about that can be a little bit challenging. And it's even still challenging for us. People call and we've got our little spiel. The whole, well, you know, chinese medicine is customized medicine. Specific to the person, requires a lot of information. And you go through that thing that you've said a million times, but it's usually really unsatisfying for the person who called because what they wanted you to say was, oh, I've got this bottle of pills here, right? That's great for insomnia. [00:36:20] Speaker B: Right? [00:36:20] Speaker A: Everybody swears by it, puts you right to sleep. But of course, we know that that's not really how it works. And so you have to thread the needle between what kinds of conditions can you rapidly give advice for? Since we were talking about Uti. Uti is a good one. Pretty easy to just write an off the cuff Bajang San modification for UTI, but other stuff. Excuse me. Like sleep or anxiety, depression, irritable bowel, you know? What do you got for irritable bowel? Oof. I mean, come on. Like, that's. That's a complicated question. So you need to make sure that patients know that and play around with language is my recommendation. Like, someone's on the phone, hey, what do you have for insomnia? Take a stab at explaining to them why they should come in and see you for a consultation. [00:37:07] Speaker B: Yeah. [00:37:07] Speaker A: Right. What is it about chinese medicine? What is it that we can do for you that. [00:37:11] Speaker B: That. [00:37:12] Speaker A: That is actually excellent? Do we have things for insomnia? Absolutely, we do. We want to make sure that we get you the perfect thing just for you. So I need you to come in and talk to me. [00:37:21] Speaker B: Yeah. [00:37:22] Speaker A: If you've never done that spiel, practice it. The first time you do it, it'll be awkward, and you'll sound dumb. Right? You'll be like, oh, my God, I can't believe I just said that to that person. And the next time it'll be better. And the next time it'll be better until eventually you'll have, like, your own little script. [00:37:37] Speaker B: Right? [00:37:37] Speaker A: You know? And you'll know how to set the expectations for the patient, how to communicate the treatment plan, how to say, hey, this is good for you, and this is why. Right? And you have to sell that. Right? You know, people. People in our field get so nervous about sales, enos, right? Oh, salesy. I don't want to. I don't want to be a salesman. Yeah, like, who does? I mean, I guess there's a handful of assholes out there who really like love. Oh, I just want a sell anything to anybody. But, like, who wants to be a creeper about it, right? But that doesn't mean that you sell yourself short, that you don't tell people about the amazing things that you have to offer, and that you don't communicate why the medicine is so valuable, because you don't want to be salesy. Like, come on. You're really just, like, you're setting yourself up for a situation where you're going to leave patient care on the table. You're going to leave someone in discomfort, and if we're being frank, you're also going to leave money on the table for yourself, and there's no reason to, because you have a quality product, you have amazing knowledge, the patient wants it and needs it, give it to them. [00:38:41] Speaker B: Yeah. [00:38:42] Speaker A: If that means you have to, quote, be salesy about it, then okay. But that's really just a headspace. [00:38:48] Speaker B: Yeah. So when somebody calls like that, like, hey, what do you got for insomnia? What's your pitch currently? Maybe you can give them yours and I can give them mine. So people know, like, what it looks like now, you know? [00:39:03] Speaker A: Yeah. So I usually start with this. I'll say yes. So chinese medicine has a lot to offer for conditions like insomnia. The thing is, is that not all insomnia is caused by the same root problem. And so we usually have to figure out what kind of insomnia do you have? Right. Difficulty following, falling asleep, staying asleep, feeling rested in the morning. There's a lot of conditions and variations, and the only way to really know that is to talk to you more about it. Right. So the best way for us to really get moving on insomnia is to get you in here for a consultation. And, you know, there are things that I could sell you, but it would be a complete shot in the dark. [00:39:45] Speaker B: Right. [00:39:45] Speaker A: You know, and there's a lot of things you can find online, a lot of things you can buy on Amazon. But to be honest, sleep is a complex human process, and figuring out a way to get you what you need is really going to take some expert insight. And really, the only way to get there is with a conversation. So, you know, let me give you our website, rootingbranchpdx.com. you can read a little bit more about it. We've got some information specifically about insomnia, but if you're interested, I'd love to get you on the calendar right now. [00:40:15] Speaker B: Yep. [00:40:16] Speaker A: So I always, I always include, no matter what the condition is, an insomnia, interestingly, is one. I feel like we get a lot of calls about insomnia and about energy. Like, in general, what do I get for my energy? [00:40:28] Speaker B: Right. [00:40:29] Speaker A: Course, obviously those things tend to be related. [00:40:30] Speaker B: I've been taking the, what do people take? The Ashwagandha or whatever. [00:40:36] Speaker A: Oh, yes, Ashwagandha. Got this great blend from Costco for the energy. [00:40:40] Speaker B: What do you think about. And then they list off like a, like a weird supplement or weird. [00:40:46] Speaker A: Always some western herb, you know, that somebody put into something with some green tea extract. [00:40:51] Speaker B: Right. [00:40:51] Speaker A: Whatever, yeah. I mean, no matter the condition, when I give my pitch, I always hit on, yes, there's something we can do about that. It's usually a complex problem that requires more information than you currently have. The only way to get that information is for me to talk to you about it in detail. Right. So why don't we get you on the calendar? [00:41:12] Speaker B: Right. [00:41:13] Speaker A: I always pitch scheduling. Right now. Yeah, absolutely. [00:41:17] Speaker B: Yeah. [00:41:18] Speaker A: And if they're like, oh, yeah, I mean, you know, it seems like a good idea, then always make sure they have the website. [00:41:26] Speaker B: Right. [00:41:26] Speaker A: Right. Go read more about it. [00:41:28] Speaker B: Right. [00:41:29] Speaker A: Send us, you know, call us if you have any questions. [00:41:32] Speaker B: Sure. [00:41:32] Speaker A: Right. And depending on how that conversation is going, like, if there's a little, there's some interest, but like some trepidation about scheduling or cost or whatever in our clinic because we accept a lot of insurance. One of the successful conversion metrics from that conversation into a patient, an actual patient visit, is to say, you know, hey, do you have health insurance? Yes, we do. Well, a lot of health insurances can cover some of the consultation costs in the form of acupuncture and other things. So what you can do is send me a picture of your insurance card front and back with your name and date of birth, and I give them the clinic email address and we'll do some research and get back to you. Right. People love that. [00:42:15] Speaker B: Yeah. [00:42:15] Speaker A: Because they hate talking to their insurance company. [00:42:18] Speaker B: Yeah. [00:42:19] Speaker A: As anybody who takes insurance out there knows, talking to insurance companies sucks massively. So it's a great way for them to offload that initial check to us. It also gives me an email address. So now I'm going to get an email from that person. I've got a point of contact, I do the check, and if they have a benefit, send it back to them. We're probably 75 or 85% conversion from that process to an appointment. If the person has a benefit. [00:42:50] Speaker B: Yeah. [00:42:51] Speaker A: Almost always. Almost always. So that I like a lot. So, yes, there's something we can do. It's going to require more information. The only way to get that is to do a consultation. Let me get you on the schedule. Can I check your insurance? That's kind of my. Those are the themes. [00:43:07] Speaker B: Yeah, yeah. [00:43:08] Speaker A: And then I just play around with the language specific to the. To the condition that they asked me about. [00:43:12] Speaker B: Yeah. My process would be almost exactly the same. [00:43:16] Speaker A: Yeah, yeah. It's a missed opportunity for anyone calling you who's local to wherever you are practicing. It is absolutely a missed opportunity to not pitch those people on an appointment. [00:43:26] Speaker B: Right, right. [00:43:27] Speaker A: 100%. [00:43:28] Speaker B: Yeah. [00:43:28] Speaker A: And if there is a way to talk to those people to create a secondary follow up. Right. Because, you know, maybe they're in the car, they like, called you while they're waiting for their kid at soccer practice. Sure, maybe they're not ready to schedule an appointment right now, but they really want to. But those people are busy and they will forget about the conversation that they had or it'll slip down their calendar. So if you can get a secondary point of contact with, hey, send me an email because they're sitting in their car, let's say in my example, they can take the picture right now. They can sit, send it to you right now from their phone. Now you've got it. Take a day or two to do the research, send them back an email. Now you've established not only that you are a professional, that you know what you're doing, that you're reliable because you got back to them. And also now you've given them useful information, you've provided a service already for them free. And so many, many. In fact, the vast majority of people respond to that outreach. If they have a benefit, with scheduling an appointment right now, if they don't have a benefit, it's a complete mixed bag. Some people are like, oh, yeah, no, I'll definitely still come in for cash. Some people are like, oh, I'll find someone in my network, you know, whatever. But if they have a benefit and we take their insurance, almost always, right? Yeah. Okay. So the patient has all the information about how to take it, what the treatment plan is, what to report back on. What do you talk to, how do you talk to them about potential side effects? [00:44:55] Speaker B: Yeah. So a lot of this is going to depend on how much time you have to spend to spend time with your patient. So if you have a high volume clinic and you don't have that much time to explain, I think the best, like, you lean on the essentials, which are these herbs. This formula is to work on x condition that they're coming in for the chief complaint. Right. We're working on this. You don't have to explain how. And you just sort of link it to the idea that this is working on this condition. If you experience any symptoms that are startling to you, discontinue the formula, send me an email or give me a call and let me know what's going on. And then we'll talk. And we'll talk about what to do next is kind of how I would leave it. In our practice, we have a little more time to talk to people just because how we have our appointments set up. So I usually talk to the patient about what the formula is doing. And I think that if you can do that, if you have the time for that, it actually really helps because then people can. It helps with compliance. It helps people to see. It also involves the placebo effect idea a little bit. Like, you know, we learned that from one of our teachers at OcOM, who is big on that. Like, explain this thing. Oh, yeah. You get the blood going and, and, and it really makes you, you know, it'll open this up and it'll do this kind of thing. Any kind of language like that can be really helpful because then the person sees why you're doing what you're doing. They get a sense for the difference in perspective of the medicine as well, which is the advantage. The main advantage we have is our perspective. [00:46:54] Speaker A: Yeah. [00:46:55] Speaker B: The difference in our perspective than western medicine on a condition is why our medicine is valuable. So I always try to explain that whenever it's possible. Sometimes conditions are very difficult to describe, like describing xiaoyang patterns, which are very common to patients. That can be challenging. [00:47:19] Speaker A: Well, because you need a lot of layers of chinese medicine knowledge in order to understand it. Right. Like, just that there are these things called confirmations or stages, and that we think about the body in this way from one to the other. Like, yeah, that's pretty rabbit. Holy that. [00:47:35] Speaker B: It is. [00:47:36] Speaker A: You know what I mean? [00:47:36] Speaker B: It is. [00:47:37] Speaker A: But you can still talk about, like, transition or movement shift, moving shift. You can use these kinds of words to describe xiaoyang, pathology and the goal of the herbs in a way that's comprehensible to the patient. I don't, you know, I use chinese medicine terminology all the time. [00:47:57] Speaker B: Yeah. [00:47:57] Speaker A: Right. I don't. There's, there's a school of thought out there that, like, you know, we shouldn't say chi to the patient and, you know, body fluids and blood and whatever. I disagree with that. Yeah, strongly. You know, the argument isn't, isn't crazy, right? It's like, well, this stuff sounds weird to people and, you know, it can be off putting and make it sound like woo woo and hoaxy and like, whatever. And I just push back against that hard. Firstly to say that, like, it only is going to. First of all, some people love woo woo, so it depends on your market, right? Like, if you're dealing with, like, woo, like, I don't know, Santa Monica hippies like you, you might want to lean into it. [00:48:40] Speaker B: Right? [00:48:40] Speaker A: Right. In fact, that's gonna work for your demographic. But the quality of sort of new agey vibes, so to speak, to the way you describe a condition in chinese medicine terms, has nothing at all to do with the chinese medicine terms. Nothing at all that has to do with your presentation your discussion, your lens bias perspective, what have you, that may bring to it a new agey tone, but I couldn't possibly be less new age as a person. Yeah, that's true. I use chinese medicine terminology all the time, constantly with people. Because it's just a system. [00:49:23] Speaker B: Yeah. [00:49:24] Speaker A: Chinese medicine is science. Right. It's not western biomedical science, reductionist based science, but it's science. Right. It's observation based science. And so we're just using a different set of terms. And I think that it's important to give people exposure to those terms because like you said, it's our perspective on physiological and pathological processes that makes chinese medicine valuable, because it gives us a set of intervention tools that are not available to our biomed counterparts. [00:49:56] Speaker B: Right. [00:49:57] Speaker A: And I'm going to include in that biomed counterpart list other alternative medicine practitioners who are essentially biomedical naturopaths, chiropractors, osteopaths, etcetera. Right. Those people are different than the biomed doctors, but their perspective is still fundamentally biomedical. [00:50:15] Speaker B: Yeah. [00:50:16] Speaker A: Right. And that is different from what we do. [00:50:19] Speaker B: Right. [00:50:19] Speaker A: So talk to the patient about it. I use the language all the time. I love, you know, our teacher referred to it as enhancing the placebo effect. [00:50:29] Speaker B: Right. [00:50:29] Speaker A: I, he, of course, is a chiropractor as well as an acupuncturist. But I would say I'm going to put that in chinese medicine terms. I want to shift that because, you know, people hear placebo effect and they're like, you mean the fake part, right. And I think that's a disservice, actually, to what it is at its core, because health narrative is a phrase that you might read or see in places, right. People have a narrative about their health, but I think in our terms, it has a lot to do with the interaction between different kinds of qi, right. So you, the practitioner, walk into the treatment room, and this is stuff we were just talking about, about telling the patient what the treatment goals are, explaining what the outcome is, telling them that these herbs and the needles are important. This is your qi. As the practitioner, you walk into it, you've shaped it a certain way, it exudes from you, right. And when you sit in the patient room, in the treatment room with the patient, they have their own QI that is shaped in exactly the same way from their experience, their discomfort, what they've read, what they've seen, what they know about their family, what their 23 andme said, what their astrologer told them. It's literally, they're just like a human, just like you. Their Qi is being shaped by all of the outside influences. And in the moment that you are explaining treatment and process with them, your chi is now interacting with theirs, and you are now another factor in the influence and shape of their, shall we call it? Qi bubble. Right? And so what our teacher called, you know, his whole thing was like, oh, you put the needle in, and when you get the D chi, like, you know, you've got it. You're like, oh, yeah. So you feel, oh, that's it there, right? You got it there. [00:52:16] Speaker B: That looks good. [00:52:17] Speaker A: That looks good. Right? You're confirming out loud to the patient. You're very vocal, you're excitable. When you get what you've got, that's part of your Qi bubble, and it's now, therefore interacting with theirs. And in some ways, you are reforming the contours of their qi space to more align with the healthy thing that you are trying to promote through your efforts. [00:52:44] Speaker B: Right. [00:52:45] Speaker A: Right. Now, I just got through saying, like, I'm the least woo woo person in the world. And some people listening to that are like, I'm sorry, what? [00:52:54] Speaker B: I think on a more practical level, though, it's not what you say that makes it sound woo woo. It's how you say it. [00:53:01] Speaker A: That's my point. That's exactly what I was gonna say. [00:53:03] Speaker B: Right. [00:53:03] Speaker A: It's like what I just said could be described in a way that makes me sound like I should be living on a hippie commune. [00:53:11] Speaker B: Right. [00:53:12] Speaker A: But it's not intrinsically that. Right, right. This is an observable mechanism that humans see all the time, the way that human energy interacts with itself and other people, and we've all felt it. You've walked into the party, like, I mean, think of the cultural stuff that we talk about. Vibes. The vibes were weird. That guy had bad energy. I just got a creepy feeling, you know, intuition, instinct. There's a lot of words that float around, even in western culture, that describe human attunement to something that is less tangible than another human body. [00:53:51] Speaker B: Right, right. [00:53:52] Speaker A: A feeling, quote, unquote. The thing is, is that chinese medicine and chinese cosmology writ large has quantified this stuff that we just sort of lump in a big bag in the west as, like, not reliable. Oh, it's just a feeling. It's just an instinct. A gut reaction. The vibes, the whatever. It's been quantified in the chinese model. We have names for it and mechanisms for it, and we can observe it in plants and animals and the seasons and the change in the day. So there's no reason to not leverage that knowledge in the treatment space when shaping the patient's expectations. [00:54:30] Speaker B: Yeah. [00:54:30] Speaker A: Right. [00:54:31] Speaker B: Absolutely. [00:54:32] Speaker A: You know it. Right. You can. You can shape it and organize it and push it out there. I think we've all probably heard stories, too, of the practitioners who, like, take on their patients problems. [00:54:42] Speaker B: Oh, sure. [00:54:43] Speaker A: Stories like, I've been treating shoulder pain all week, and, like, now my shoulder hurts. [00:54:47] Speaker B: Yeah. [00:54:48] Speaker A: And there's a really, whoo. Way to describe that energy transfer, blah, blah, blah. Also, it's the same thing, though, with what I just described. Right. It's. It's an interaction of chi. [00:55:00] Speaker B: Yeah. [00:55:01] Speaker A: And your chi has been reshaped by the constant interaction with other chi because your ability to shape it and contain it is being affected. [00:55:11] Speaker B: Right. [00:55:12] Speaker A: It's usually not permanent. It's usually not debilitating, but it can happen. Right. And it happens when you're no longer actively participating with that experience. You're just sort of, like, open and I. And accessible to whatever's around you, which sometimes is good. Sometimes you want to be in that space in a treatment paradigm where you're supposed to be the person leading the plan, setting the stage, putting the expectations together. It's usually, I think, more advisable to be in a more strong, what I would say, metal position. [00:55:42] Speaker B: Oh, yeah. I. [00:55:43] Speaker A: Clear boundaries. [00:55:44] Speaker B: Yeah. I really think that's important. Like the. I mean, we're kind of going off a little bit on a tangent now about treatment with patients and patient practitioner relationship, but I think, like, I think. [00:55:56] Speaker A: It'S valuable here, dive into that a little, because, you know, we've had patients, like, because this gets to setting expectations where they'll try to steer everything. They'll try to take over the treatment and direct it. Talk. Talk a little bit about that. [00:56:08] Speaker B: I think. I think you have to have a stronger mind than your patient when you're in the room. I, like, I think you can't because it's like what you're saying. Whoever's my, like, I'm just using mind as the. As the, you know, the field here. But whoever's mind is stronger, whoever's chi's stronger in the space is going to sort of take over. And I think the reason people come to see us is to be in something other than what they're used to being in. Right. To get to a different kind of experience. And hopefully that experience is therapeutic. Right. I think if we bow sort of, or we yield to the patient's will in some ways too much, we actually create a situation where the patient isn't safe. I really believe that. [00:57:07] Speaker A: What do you mean? Walk me through that. [00:57:08] Speaker B: So if I let the patient decide what the treatment is, the patient doesn't have expertise in what we do. The patient doesn't understand the dynamics that we're interacting with like we should. Right. We're the experts in this field. If they take that over that interaction, it's a little bit like a little kid driving a car or something like that. Right. Handing a gun to an adolescent person or, you know, somebody that doesn't have the same kind of understanding that somebody with more wisdom would have. I also think it becomes really easy to blame the patient when there's not progress. If the patient. If we allow the patient to take up, let's say, your space in the room. Oh, well, they're doing this thing, so I can't really help them. Right. And it also becomes easy to justify not paying attention to our own conduct. If we start to be in this atmosphere where the patient's louder than we are or not louder. It's really not about volume, it's about power. Some kind of power dynamic. If the patient has more power in the treatment space, I really think that it's. It's. If we allow that dynamic to persist, it's unethical. It creates ethical problems. [00:58:41] Speaker A: Right. Because essentially we're kind of letting the patient self treat. [00:58:46] Speaker B: Exactly. [00:58:46] Speaker A: In a lot of ways. And they don't have the knowledge and the skill to do that. And so they could really be harmed. [00:58:51] Speaker B: Yeah. [00:58:52] Speaker A: By a formula that's written in that context, or I. By a needling session that goes awry, either physically or what we might call mental. Emotionally. Right. Yeah. That's an interesting perspective, I think. Something that a lot of people probably haven't considered. I also want to say, too, that the question of that chi interaction is not objectively universal, which is to say I sit in a room with a patient and I sense that there's what I'll call a mismatch between the power dynamics here. Right. It's not in an effort to be the dominant one. I have no interest in being the dominant player. Right. That's not what this is about. But there are circumstances where I know that I'm not going to be able to help this person if there isn't some kind of plasticity to their position. Right. Because they walked in the door with a whole host of problems. And if there isn't a kind of flexibility in shifting their point of view on those things, then I'm not certain that I'm going to be able to help. [01:00:04] Speaker B: Right. [01:00:04] Speaker A: Because the condition of their chi when they walked in the door is the condition of the chi that has all the problems. [01:00:12] Speaker B: Exactly. [01:00:12] Speaker A: Right. So we have to be able to shift the contours of that Qi bubble in order to make change. And we're going to do that with rapport and interaction, the way we talk to the patient, the way we build trust. We're going to do that with needles and Gua Sha and Moxa and whatever. And we're definitely going to do it with herbs. But if there's a rigidity there. Right. That's going to be really hard to make that shift. And that is not because that person just is rigid, and I am me and they are theme. It's the interaction between the two of us. [01:00:42] Speaker B: Right. [01:00:42] Speaker A: That same person can go into a different office with a different practitioner and have a totally different posture and position. Not every patient in the world is your patient. [01:00:53] Speaker B: True. [01:00:54] Speaker A: Right. It's just not. Right. [01:00:55] Speaker B: True. [01:00:56] Speaker A: It's important to find that sort of lock and key relationship. Right. And it's not because the lock is permanently locked. It's just like, you're not the right key. [01:01:06] Speaker B: Right. [01:01:07] Speaker A: Right. And it takes a fair amount of self confidence, I think, to let those patients go. [01:01:16] Speaker B: Yeah. [01:01:16] Speaker A: To let the patient know, like, hey, you know, I'm glad you came in, and this is really interesting information. I have a person I think would be a better fit for what you're working on. Don't just kick them out on the street. [01:01:27] Speaker B: No, no, no. [01:01:28] Speaker A: Sorry, bro. We can't help you. You're out. You got to give a referral, which is why it's important to know people. [01:01:33] Speaker B: Right. [01:01:34] Speaker A: And to keep your colleagues and friends, you know, in. In the medicine near, because you want to make sure that you can ethically treat this person, and then it's not a battle of wills. [01:01:46] Speaker B: No. Yeah, yeah. It shouldn't be a battle of wills. [01:01:49] Speaker A: It shouldn't be a battle of wills. [01:01:50] Speaker B: But if I feel that, like, of the. Maybe three times I've referred a patient to a different practitioner in our own field, like, which is code, perhaps, for me thinking, like, well, they could benefit from our medicine, just not with me. [01:02:07] Speaker A: Right. [01:02:07] Speaker B: I don't want to work for this person. [01:02:09] Speaker A: Right. [01:02:10] Speaker B: It's been because of a dynamic where I think they're, like, they're trying to control the treatment experience to the point where I can't do it. Like, it's not going to work. Their boundaries are so tight around what they will accept from me, what I can give them, won't get them better, from my perspective. So it's not really about Domini. It's not about dominating a patient? [01:02:38] Speaker A: Nope. Not at all. [01:02:39] Speaker B: There's a lot of room for space to be created in the relationship, in the interaction, and checking in. And how is this? And how are you doing with this? And it's a team effort, but I do think people come to see us, to be in a different space, to be in a different. Different than what they're commonly walking around with. Otherwise, why would they come see us? [01:03:03] Speaker A: Yeah, why would they be here? [01:03:04] Speaker B: Why would they be here? [01:03:05] Speaker A: Well, and I'm thinking of one of those referrals that you did to another practitioner who works in our practice, and, like, that patient and that practitioner are getting along great. [01:03:13] Speaker B: Yes. Great. [01:03:14] Speaker A: They're getting progress. Things are moving forward. And that patient isn't any different. No, you know what I mean. Than they were with you. [01:03:22] Speaker B: Right. [01:03:23] Speaker A: But the thing is, is that that other practitioners chi is a better, influential match with the patient, 100%. It's just that simple. And it's not a criticism of her or you or the other practitioner. It's literally just what it is. It has no moral dimension. It's just. This is the circumstance that we're looking at, and you had to make that shift. And it's important to point out that that's all in the interest of patient care. I mean, like, this isn't, like you said, it's not a dominance question. It's not a who's in charge question. It's about finding a kind of synergistic interaction that allows you to really move people in the direction that you're trying to move them in. [01:04:06] Speaker B: Right. [01:04:06] Speaker A: You know? All right. So the patient has been briefed on various outcomes. They especially know that the most common side effects from herbs are digestive in nature. [01:04:19] Speaker B: Yep. [01:04:19] Speaker A: Right. So. And I like the phrase that you had. It was. There's something that was. What'd you say? Not concerning to them. Something that. For them to contact you. [01:04:29] Speaker B: Yeah. What? Did I say. [01:04:32] Speaker A: Something. Now I'm gonna have to go listen back to it and figure it out. We figured out what you said. [01:04:37] Speaker B: Yeah, but concerning could be a word that I. [01:04:40] Speaker A: That's the word that I usually use. Right. If there's something that stands out to you that seems more. [01:04:43] Speaker B: Is anything extreme? I usually say there's some. Some change in bowel movements or, like, some GI changes for the first 24 hours are normal. If those are extreme or continue beyond that point, then contact me. Let me know. [01:05:03] Speaker A: I think that's a good thing to add in there that there is like, because I usually like, could be some grumbles, some upset stomach, mild nausea, all totally normal with the first couple of doses of. [01:05:13] Speaker B: Right, exactly. [01:05:14] Speaker A: But they should level out if they don't contact us. [01:05:18] Speaker B: There are specific remedies that I've given to people that I will prep them for more. Like the first time I give somebody a futsa formula, I will tend to describe like, because I've had negative effects from taking foodsa formulas myself, I know exactly what that experience is like. So I would prep them with. So the. Just so you know, the formula that you're taking here, we're trying to strongly activate your body's vitality. And what can happen with that is this. And then I talk about the positive things. We're going to be moving fluid around. We're going to be alleviating the feeling of heaviness in your body. We're going to be trying to get more mobility in your tissues and you should warm up. Something like that, depending on the formula, could be different. Right. And then I'll say, but if you experience anything like the following, like you take the formula and you start getting headaches, or you take the formula and you feel like your tongue is getting numb or you feel kind of feverish after taking it and you just kind of feel off, if any of that stuff starts to happen, then just discontinue the formula and contact me, let me know what's going on and we'll take it from there. All that means is that we're adding fuel to the fire too quickly and we need to spend more time clearing the pathway before we do that. That, and we can do that later, but we need to do something else first. [01:07:01] Speaker A: There's a key piece in that description that I want to point out for the listener that I think is important. So a lot of the beginning part of it is textbook and I think anybody would have heard about that. So we're using this herb. This is what we're doing, and this is what's great. These are some things to watch out for. If you notice any of these things, discontinue and let me know. The next part of that, though, is the thing that I want to highlight for the listener, which is that if you just stop there, discontinue, let me know. There's a kind of tacit fear. [01:07:33] Speaker B: Yes. [01:07:33] Speaker A: That's left in the mind of the patient. Like I have damaged myself. [01:07:38] Speaker B: Right. [01:07:38] Speaker A: Something has gone wrong. [01:07:39] Speaker B: Right. [01:07:40] Speaker A: I'm in danger. [01:07:41] Speaker B: Right. [01:07:41] Speaker A: Right. Which, I mean, on some level could be true. Right. If you continue taking the formula and the symptoms got worse, it could be dangerous because herbs are not. They're not a joke. Right. But more importantly, because the patient is prepared because they know what to think of, you've followed up with this other piece that says, hey, don't worry, you've done exactly what you needed to do. This information is helpful because we're basically putting the fuel on the fire a little too quickly. The fire is growing a little bit out of control, and all we need to do is just pull it back a little bit. [01:08:16] Speaker B: Yeah, we need to clear the pathway for it first. [01:08:19] Speaker A: No problem. We'll pull it back. We'll reset. Reset the stones in our metaphorical bonfire, clear everything out so the embers don't go right, and then we'll get going again. It provides a kind of a distinct level of comfort to the patient that though this outcome is less than ideal, it's not catastrophic, it's useful information, and we're not behind. [01:08:44] Speaker B: And we might even be able to go back to it later, which is actually the case with a lot of those. A lot of those cases, like sometimes you give a futza formula a little too quickly or something and you need to do a little more harmonizing. You go back to do the harmonizing, it clears the thing, and then you go back to the futsa networks. Well, you know, so it's. It's also true. Yeah. [01:09:07] Speaker A: It's not. It's not. That's. I mean, the best things in life are also true. [01:09:12] Speaker B: Yeah. [01:09:13] Speaker A: They are convincing and also true. Yes. But I just. I think that's important because I think a lot of new practitioners might only leave or new herbalists might only leave the practitioner with the warning. [01:09:24] Speaker B: Yes. [01:09:24] Speaker A: And not with a little. Just snippet of expectation. And you know what? Look, is the patient going to remember the details of what you told I them, almost certainly not. But what you did, you gave them, again, is this tacit transmission of the notion that this is not. It's not a fear based response. It's an intentional, methodical response to a potential outcome. [01:09:48] Speaker B: True. [01:09:48] Speaker A: You know, and I think that that's. That's really, really valuable because, again, shaping patient expectations is not only about what the positive outcomes are and what the risks are, but about how this whole thing is part of a larger treatment plan that has specific goals that we're going to evaluate progressively over time. [01:10:06] Speaker B: Yes. [01:10:07] Speaker A: Right. Okay. So the patient takes the formula. It goes well, they had a little bit stomach grumbles settled out after a day, they come in. After a week, you're like, this is great. We're making the progress. Refill it. Feel comfortable doing two or three weeks. Right. The patient takes it, and now they're back. They're a month or more in. Right. And the situation, the primary set of symptoms that you're working on have resolved. How do you talk to the patient now? You know, let's put this in the context of our three month treatment plan. [01:10:40] Speaker B: Yeah. [01:10:41] Speaker A: The primary, the big bad, so to speak, we have not yet solved. But you've peeled off the first layer of the onion. That gives you more ability to solve that larger problem. How do you talk to the patient about now transitioning from the thing that we were working on to the next stage of your treatment plan? [01:10:59] Speaker B: Yeah, you would do it a lot like what you just said. Like, we. We've resolved the first part of the, sort of the thing that we're working on, and now we're going to go a little deeper. So that's the next stage of the treatment. Sometimes I'll tell people it's a little bit like you have a couple, like, four different circuits in your body, and one of them is right in front and the other three are behind the first one. So there's power moving through all four circuits. Or sometimes I'll say six, because of the six confirmations and because the power is moving through all of them. If the damage is mostly to the third, 3rd out of the fourth one, but there's 30% damage in the first circuit. If we can optimize the first circuit, that's easier to reach, then it'll be much easier to get to the one at level three. Right. So sometimes I'll give a metaphor like that. In the beginning, they'll be like, oh, yeah, that makes sense. So then when we get to that point in the treatment, I can be like, okay, now we're done with that first circuit, we can go down to the second or third one, and we can really start working on that, and it'll look a little differently. We may have to go back and forth. That's often the case with a lot of treatments where we treat, like, yin confirmations, and then we pop back out and treat yang confirmations, and then we go back into treating yin confirmations. But the progression of the case should be that over time, the person feels better and better and better. And so that's what I say. We're onto the next stage. We're going to shift the formula, and the things that you'll experience now are a little different. [01:12:47] Speaker A: I like the circuit metaphor. I use onion metaphor a lot. Peeling back layers. Like, you know, the problem that you've described is really a deep problem, and I can't quite get at solving it until we peel back some of this other stuff and be able to see it. I also, similar to the circuit one, I'll use a sort of, like, deep in the valley metaphor. So, like the problem, you know, we're way up here at the surface and your problem is way down there. [01:13:12] Speaker B: Yep. [01:13:13] Speaker A: And unfortunately, the path from here to there has been kind of eroded and destroyed. And if we just, you know, start going, we are going to slide and we will probably miss the mark. [01:13:24] Speaker B: Right. [01:13:25] Speaker A: End up in a different place than we want it to be, and it may not be great. So we've got to rebuild a lot of this pathway so that we can actually get down to where the real problem is. Right. I think metaphors are helpful. [01:13:39] Speaker B: Yes. [01:13:40] Speaker A: Feel free, listener, to use any of these and make up your own. You can see the theme, right. The theme is that the problem is further away than I can immediately reach. And we got to do some building, shifting, clearing, whatever it is to get from where I am to where I need to go. And so you can use whatever handy metaphor matches your audience, matches your disposition, your personal experience. But it's helpful. People really respond well to a nicely crafted metaphor to explain what we're doing next. [01:14:12] Speaker B: Absolutely. [01:14:13] Speaker A: So I think it's a strong recommendation to consider it. Okay, so I want to talk about a key piece here, which is. [01:14:23] Speaker B: The. [01:14:24] Speaker A: End of a treatment plan, either with a successful outcome, which, of course, is ideal, or a less successful outcome, or a complete failure. [01:14:36] Speaker B: Yeah. [01:14:37] Speaker A: Right. Complete failure maybe is extreme. I don't know how often we've seen, like, a complete, complete failure, but in terms of resolving the primary issue, we just didn't achieve it. And kind of looking at those three things, because I think a lot of people who have had chinese medicine or used acupuncture herbs or work in our field or whatever are often, like, we know a lot about the sort of open ended treatment schedule that doesn't ever really have a plan and doesn't really have an end and just sort of goes on in perpetuity. And I know that both of us have had experiences where, especially with outcomes that are. We've gotten some progress, but it's not resolved. You're in this kind of in between spot. [01:15:17] Speaker B: Yeah, yeah, yeah. [01:15:18] Speaker A: Where treatment will fizzle out. [01:15:20] Speaker B: Yeah. [01:15:21] Speaker A: You'll have a patient on the calendar you think you've got another treatment plan in place, and the patient will cancel or they'll no show. And they're just gone from your schedule. [01:15:33] Speaker B: Yeah, poof. [01:15:34] Speaker A: No resolution. Whatever happened with that plantar fasciitis problem. Right. And that can be really demoralizing. [01:15:42] Speaker B: It can be, yeah. [01:15:44] Speaker A: And so I want to talk a little bit about that. So let's start with the. Let's talk about successful completion first. So things went well. How do you, how do you, what do you do at that point? Is it a. Are you ending a relationship and setting them up? Hey, if something else comes up or do you put them on a maintenance plan or what? What's your deal? [01:16:04] Speaker B: So I. I will often tell people like it. Okay, so we've achieved the thing that we wanted to achieve. There's kind of an understanding that you get over time when you work with herbs about what a person's going to need to not backslide. So. Right. The issue is resolved, but will it stay resolved if they go off of the herbs? Right. Or stop treatment entirely? And you never really know. Even with a lot of experience, you never really know, I think. So my strategy is to talk to them about that. Like, all right, we achieved the thing we wanted to achieve. You're at a place where it's reasonable to assume that if we pull you off of the herbs, off of the treatment, you'll be good for a while, and you may not need treatment in the future for the same problem. What my preference is at this stage is to put an appointment on the schedule month, two months from now, something like that, where you come back in, we do another, like, kind of a checkup treatment just to see how things are going. But we don't do any herbs, and then we can kind of see how you're doing. And if you're good, then we don't need to put another one on the calendar. Like, you're just good. And a lot of times what will happen with that is people will come back in just because they like coming in, and they'll see you again, and it'll be good. And then, you know, you'll discontinue treatment, or they'll cancel. Right. And then you talk to them, like, a year later because they're in for another problem, and they're like, yeah, I just, I, you know, my schedule got messed up, and I couldn't, and I was already feeling better. The problem hadn't occurred. Remember, Ming would talk about that thing about treating the patient until they, like, cancel the appointment to, like, volunteer. [01:18:00] Speaker A: Oh, yeah. [01:18:01] Speaker B: Right. [01:18:01] Speaker A: Yeah. Yeah. [01:18:02] Speaker B: So their. Their conduct shifts, and that's the evidence that they don't need the treatment anymore for. [01:18:08] Speaker A: Excuse me, for the listener. That's a reference to Liu Ming, who was the founder of an organization called the Da Uin circle down in Berkeley. [01:18:18] Speaker B: Yeah. [01:18:19] Speaker A: Taoist teacher. One of the founding deans of five branches. Chinese medicine school. School. Interesting guy. Look it up. Liu Ming. L I U. Ming. M I n g. Dai yuan. Circle. D a y u a n. Circle. I think it's Dot. You can go read about him and his work. Fascinating guy. [01:18:39] Speaker B: Yeah. [01:18:40] Speaker A: So check that out. But what Travis is talking about here is that, like, actually the end of the treatment plan was that they had a conduct shift. [01:18:47] Speaker B: Exactly. [01:18:48] Speaker A: And conduct here is. We're using the taoist term here again. Demoralize that from your mind. We're not talking about conduct grades. No. Bad conduct. Good conduct. You get an a. Not like that. But that a person's actions and activity has shifted through the interaction with your treatment such that they don't. They don't need it anymore. [01:19:06] Speaker B: Right, right. [01:19:08] Speaker A: I like that. I think I do something similar when we've reached the resolution. Some people, you know, some people's stuff, like, okay, pick a classic acupuncture problem, like low back pain or, I don't know, shoulder pain or something some of those folks will put on. I'll put on a maintenance plan that'll be once every six weeks, and they'll come in and it'll be a little bit achy, but it's not in a flare. And they can do everything they want to do, and they just have some low back pain. So we do a little bit acupuncture. Boom. It's also a great opportunity to check in with the patient because now, like you said, there's something on the calendar. [01:19:46] Speaker B: Right, right. [01:19:47] Speaker A: It's in their schedule. It comes around. We use an electronic health record, so they get an email confirmation and a text reminder and, you know, all this kind of stuff. And I think that's really valuable just to keep connection to our patients and for them to keep connection to us. For people who have something that has a tendency to flare or that has a cyclical nature, it's not a bad idea to have what I think of as a maintenance check in thing pretty regularly on the calendar. Right, right. But we have a whole host of other patients who are. It's not a thing that's flared. It's some random thing they've never had before. It's now resolved. I love the two month just hey. Making sure everything's good. [01:20:28] Speaker B: Yep. [01:20:28] Speaker A: Right. And then at that point, I always take the opportunity to remind someone, like, okay, so we get to the end of the treatment plan. Everything's good. We're scheduling the two monther. All right. It's on the calendar. And I always take the opportunity to tell the patient, like, hey, this is what's on the calendar for two months. But if anything comes up. [01:20:45] Speaker B: Yes. [01:20:46] Speaker A: Between now and. [01:20:46] Speaker B: I say that, too. [01:20:47] Speaker A: Yeah. Don't. Don't wait. [01:20:49] Speaker B: Yeah. [01:20:49] Speaker A: Right. Just call me. We'll get you on the calendar earlier. We'll find a spot for you. Or if something new shows up. Right. Remember, like, you got cold and flu, you've suddenly got sleep problems. Anxiety goes up with work, call us. You don't have to wait. Right. And I always take the opportunity, in that case, to remind someone, like, we are now a practitioner in their corner. [01:21:14] Speaker B: Right, right. [01:21:14] Speaker A: We're here to help you with whatever it is that comes up. And so, you know, we're in a good spot. I mean, this is the ideal outcome. Right? Like, you did the work. [01:21:24] Speaker B: Yes. [01:21:24] Speaker A: They were compliant. You did the work. You were present with them. You shaped your chi bubble, which reshaped their chi bubble. And now you guys have positive rapport, and they love your clinic, and they love you, and they're telling all their friends about you, because, really, let's remember, that's also part of this game. You got to keep the lights on. You got to see more patients. So that kind of resolution to a case is really important because it feels complete. And when something's complete now, people, you know, they finished the book. They can now loan it to someone else. [01:21:56] Speaker B: Yes. [01:21:56] Speaker A: Right. And that's really. That's really important. That reference to loaning books out is going to be even more dated in, like, ten years when there are no more books and you can't loan them out. But anyway, so, all right, that's the ideal outcome. So, basically, we talk to the patient about how much we've achieved. We set them up for either a check in or some kind of maintenance thing, depending on the condition, if it has tendency to flare. And remind the patient that if something comes up in the meantime, call us. [01:22:25] Speaker B: Right? [01:22:25] Speaker A: Right. Okay. Let's go to the opposite end, because I actually think the one in the middle is the hardest. So go to the opposite end. You get down to three months, you've done all kinds of different formulas. You know, they've gotten a little bit benefit here and there, but ultimately, you have not been able to really move the patient in a direction that you think is significantly meaningful. And you're at the end of the treatment plan. Hopefully. You've been checking up with them throughout the treatment plan. [01:22:53] Speaker B: Of course. [01:22:53] Speaker A: Yeah, of course we're doing this. We're going to pivot here. Okay, this hasn't worked. Let's try this tool. We're not out of tools yet. We're going to try this one. But now you're down. And honestly, you've used the eight formulas that at all make sense to you. You've talked to some colleagues, you've run the case study by some people, you've read the whole internal medicine manual, you've tried all the tricks you've got for acupuncture, and you just haven't been able to do it. [01:23:19] Speaker B: Yeah. [01:23:20] Speaker A: What do you say to the patient now? [01:23:22] Speaker B: I think you have a very matter of fact conversation about, like, you know, I think we've made a little progress here on some things here and there, but we haven't really meaningfully impacted the thing that you came in for. So at this point, I don't think it makes sense to continue with treatment, doing this kind of treatment. But I have some ideas for you about where you could go next to try to resolve the problem, and that would come with a referral list. So I've always given people a referral list whenever that's happened, you know, and building your referral list is really important because you need people that you can refer people to genuinely, like, yeah, I actually think this person could be helpful. And they're usually people from different fields. I don't often refer in those cases. I don't often refer people to somebody in our field. Again, part of that might just be that if I've been treating somebody for that long, the people that I would ask questions about the case to are already people that I've talked to. And so I don't really believe, like, if that patient went to go see them that it would be that much different, maybe, you know, like, I just don't have that much confidence. [01:24:47] Speaker A: Right. Because the person that you would refer to as one of the people you would have consulted, it would be one. [01:24:52] Speaker B: Of the people consulted. Yeah. [01:24:54] Speaker A: In which case, like, there's probably not going to be that much notably different between what they would do and what you've been doing. [01:25:02] Speaker B: Right. [01:25:02] Speaker A: So we might as well refer this person out to a different style modality, what have you. Right. Yeah, that's a, that's a tough one. Right. Because I think a lot of people, you know, and obviously it's case specific. Right. And how long you've been doing the treatment plan and what's going on and whatever. I've had, for example, a couple of orthopedic cases that were very, like, mobility oriented. Like, people would notice it when walking and, like, whatever. And I used all my tricks for, you know, like, hip pain or whatever, and, you know, within, you know, I'm seeing the patient twice a week for four weeks. Right. For a whole month. That is a lot of treatment by american standards, and we haven't really done anything with it. I would refer that patient out to one of our orthopedic colleagues. [01:25:50] Speaker B: Sure. [01:25:50] Speaker A: Who does a lot of orthopedic work. Right. Like, that's all they do, orthopedic work. They know their muscles backwards and forwards. They know all the. The motor points, the trigger points, the whatever. I'm gonna let those folks take a shot, and I'm just gonna tell the patient that. Right. Hey, look, I've tried all the tricks. I've got. We've tried some herbs. I haven't been able to make this work. I've got a colleague who only deals in this space. Let me refer them. Let me refer you to them. Yeah, right. But if it's outside of that, it's an internal medicine thing, and we really have done all the due diligence that we've just described. You're right. The people that I would refer them to are the people I've already talked to. [01:26:25] Speaker B: Exactly. [01:26:26] Speaker A: So it's probably important to, like, give them an opportunity to go somewhere else. [01:26:29] Speaker B: Yeah. [01:26:29] Speaker A: Right. And the referral network thing is huge. That's a conversation for a different day. But for those out there, if you're a new practitioner and you don't have a huge referral network or if you want to expand yours, we can talk more about what that looks like. I don't think we have, like, an immediate how to. I mean, it really does have to do with talking to people, meeting people, getting treatment from those people. You got to really know what it is that you're referring to. And if you don't have a referral network, ask one of your colleagues who might. Yeah, right. It's really not a great idea to discontinue treatment with someone without referral. [01:27:05] Speaker B: No, I never do that for a variety of reasons. [01:27:07] Speaker A: I mean, like, the core one, obviously, is patient care. We want to make sure the patients are getting what they need and that they have a place to go. You don't want it to feel like you're abandoning someone. Right. Just for their own, their own mental health and their own ability to get help in the future. But also there's a very real, like, legal and malpractice consideration as well. Right. You don't want to put yourself or your clinic in a position where someone could reasonably argue in a legal setting that you abandoned them. [01:27:34] Speaker B: Right. [01:27:35] Speaker A: That you were just like, yep, can't do it, sorry. And rolled up shop. Right. So if you have no referral network, Google something. [01:27:44] Speaker B: Yeah. [01:27:44] Speaker A: And find some people who are near to that person who talk a lot about the condition that you're trying to do. That's not great, but you really need to give someone the next step. [01:27:54] Speaker B: Give them another option. [01:27:55] Speaker A: Yeah. They really need to have another option and they can, they can navigate it from there. I mean, you're not responsible for guaranteeing this person's outcome. Right. But you definitely want to give them a referral. [01:28:04] Speaker B: Right. [01:28:05] Speaker A: All right, let's talk about the hardest one. I think the middle position. So in this position, you've achieved, let's say, half of what you expected in the treatment plan in time. Again, three months was an initial test balloon. You didn't guarantee the patient that you could solve their problem in three months. This is just the first foray. But even by our own standards of that, at the first foray, we haven't really gotten it. We've gotten a lot, but we haven't gotten it. How do you think about the next proposal to the patient, the next treatment plan, so to speak? Right. Because trends are good. We're making progress, but not at the rate or pace that we anticipated. How do we, for lack of a better term, sell the patient on the next plan? [01:28:53] Speaker B: So for me, that it's going to look like a combination of the first and the second one, sort of naturally. [01:28:58] Speaker A: It'S in the middle. [01:28:59] Speaker B: It's in the middle, which would be like. So firstly, I would check in with the patient about how they're feeling about their case. [01:29:06] Speaker A: I think that's huge. [01:29:08] Speaker B: So that's what I would say. And I would say exactly that. So before I get started and talk to you about where I see your case, I want to check in with you and ask you how do you feel about your treatment? How do you feel about the case? Where is your, like, how you doing mentally with this whole thing? And really get their perspective? Because if they're like, yeah, I think we've been doing well, but it just feels like things have stalled out and, yeah, it doesn't really feel like we're making much progress anymore. If they come out with that, then I'm like, I'm more leaning toward, okay, they're probably not going to be a good candidate for more treatment right now with us. Right. So I would lean the conversation more in that way. Like, so we've made some good treatment. I think, you know, I think you're right. We didn't hit our goals, but we did make some progress. We got you to benefit. I think moving forward, the best. Like, if we were going to really try to tackle this, we would need to change certain things about how we treated you. We would need more frequent treatment. We would need to do different kinds of herbal intervention. We would need to do more stuff with diet. I'm trying to think of all the things that have come up in the past when this has happened. [01:30:26] Speaker A: Yeah. Exercise, usually lifestyle stuff. [01:30:29] Speaker B: We would need to address more lifestyle stuff. I might have to book you an appointment with my colleague to talk about nutrition and food, because I hate doing that. Send them all to Travis K. Oof. [01:30:44] Speaker A: It's a process. I like the. There's a couple of things that stood out to me when you were saying that one is the next stab. Well, firstly, let's talk about checking in with the patient. [01:30:57] Speaker B: Yeah. [01:30:57] Speaker A: Could not possibly be more important. You gotta do that because fatigue is real. [01:31:03] Speaker B: Yes. [01:31:03] Speaker A: For all kinds of reasons. Taking herbs every day can be exhausting, especially if it's a bulk formula, especially if the flavor is strong. Two times a day, three times a day. Coming to treatment, even if they're coming once a week, you know, the sort of american treatment standard. They've been seeing you once a week for eight weeks, twelve weeks. What have they been taking off? They've been managing their schedule. Something extra to do. I mean, you come to work every day, so you're not really thinking about it. But those people had to make a trip here, like, out of their norm to make that happen, and that's hard to sustain. I mean, these are modern people living modern lives. They have their own demands. You're not the most important thing necessarily in front of them. And I think some practitioners will be like, but it's their health. It should be the most important thing. Yeah, it should. But life is life, man. Like, there are things that people are going to have to deal with that are gonna always take the first spot over your treatment. [01:31:55] Speaker B: Yep. [01:31:55] Speaker A: Right. So that's important to know. It's important to ask them and to be frank about it. [01:32:00] Speaker B: Yes. [01:32:00] Speaker A: Right. And here's the other part. You have to listen to what they actually say. Yeah. You can't just ask for the purpose of asking, you really have to ask and listen. [01:32:10] Speaker B: Right. [01:32:11] Speaker A: And hear what they're telling you. And I think, like you said, you know, if it's, yeah, we got a lot out of it, but everything's stalled, and I'm just, you know, I'm feeling kind of overwhelmed, and there's a lot going on right now. You hear that phrase a lot. It's a lot going on right now. Holidays are coming up, right. You'll hear these sort of consistent refrains around what is basically, I'm busy and I'm feeling like my bandwidth is getting eaten up. And this is one of the things in my bandwidth. You can, in that moment, especially if you've made some progress, you can get that person to agree to another treatment plan. But there is a very high likelihood in my experience, and I think yours as well, that they'll flake before the end of that treatment. [01:32:53] Speaker B: Oh, yeah, right. Yeah. And you don't really want, again, like, you don't want to compromise the power of the treatment. [01:32:59] Speaker A: Right. [01:33:00] Speaker B: Or you're truthfully your own expertise. Right. Like, if you don't think that that next treatment plan could be better than the previous one, don't recommend it. [01:33:13] Speaker A: No. [01:33:14] Speaker B: Right. Like, if you can't see, like, oh, yeah. Like, this person, if we got the nutrition aspect of, like, if we got to that, if we got the meeting better, that would really make this, like, I could see them making a big difference. [01:33:26] Speaker A: Make the proposal right. [01:33:28] Speaker B: Then make that proposal for sure. But if you can't see an option for that, another thing to add, by the way, would be to include another practitioner. So, like, I have my strain counter strain body workers that I like to refer people to that are important. [01:33:46] Speaker A: So, like, at this next stage, I. [01:33:49] Speaker B: Really think we need to work with another person with a little different point of view than me that's also very good at what they do. And both of us working together, which we've worked on many patients together before, this is a person I know and trust. I send people to them all the time. I know them personally. You know, we, I really think we can make better progress if we do these things. [01:34:16] Speaker A: Right. [01:34:17] Speaker B: Right. That would be the next proposal would be like, yeah, I think in this case it's going to look more like this. If we can do these things, if this can be included, we have reason to believe we can get better results and they can be a little faster. It also might be the kind of thing where, depending on the condition, you're never really going to be able to make it move that quickly and a lot, and a lot of the time, like for our experience with treating elderly people, the ideal scenario for me at this stage, if I don't think we can actually, like, it's not ever going to get solved. Right. The condition is not ever going to go away. Probably we can kind of get it to the place where it's slowly getting better all the time. Kind of. Even if it's never like going to be resolved, it's still getting a little better and a little better and a little better. And then we would like treat differently. We would treat more around seasonal changes, for example, and mitigate when dramatic environmental shifts are happening. And then when it's not like that, we would ease off treatment. They don't need to come in as much. [01:35:32] Speaker A: So tell me, do you think this is accurate then from what I'm hearing you say, which. So, okay, you're at the position where you think there is some kind of next step that can legitimately yield quality results. [01:35:46] Speaker B: Right. [01:35:46] Speaker A: Nutrition shift, lifestyle adjustment, combination with another practitioner, or, and you didn't mention this, but there are some cases where like, we just need to keep chipping at it. [01:35:54] Speaker B: Yes. [01:35:54] Speaker A: Like the trajectory keep going is like still at a steep enough slope for me to say, yeah, we did this for eight weeks, but honestly, I think another six is going to really make some big difference. But you, the practitioner, have to determine that for yourself. [01:36:10] Speaker B: Yes. [01:36:10] Speaker A: And you have to legitimately feel like this is actually something that we can achieve. Right. [01:36:16] Speaker B: Absolutely. [01:36:17] Speaker A: And if you don't, don't make that referral or don't make that treatment plan. [01:36:23] Speaker B: Yeah. [01:36:23] Speaker A: Right. Don't insist on a new treatment plan because a couple of things will happen. One, your lack of confidence will be picked up on by the patient even if it's not conscious. That will increase the likelihood that they're going to flake on your treatment plan and then you're going to find yourself unresolved without a reschedule, wondering what happened? Were they frustrated? Did something bad go down? That lack of resolution is an enemy to self confidence. It's an enemy to professional confidence because all of a sudden this thing that you were working on, well, it'll seem all of a sudden, but in reality there were all the signs that said this is how that was going to go. And so if you don't have confidence that this next stage is a legitimate next step, then you need to do what we described in the fail scenario, which is refer up. [01:37:17] Speaker B: Right. [01:37:17] Speaker A: Right. Now I also want to address this cause I think it's important. Why would someone. Rhetorical question here, I guess. Why would someone offer a treatment plan to a patient that they're not all that confident in actually getting results? Right. Money. [01:37:38] Speaker B: Money, right. [01:37:39] Speaker A: Because maybe you're a new patient or a new practitioner. [01:37:42] Speaker B: Or a new practitioner. [01:37:43] Speaker A: Maybe you're worried about the cash flow. Maybe you want to keep your books full. Right? And I'm not saying this is conscious. I don't mean, I mean, I'm sure there's some assholes out there who are consciously, like, you know, milking people for all their words, but there's a kind of headspace that will, and I'm going to call it what I generally refer to as a scarcity mindset, where if I let this patient go, transfer them, refer them, whatever, that I'm not going to have what I need. My schedule won't be full, the cash flow won't be good. And so I got to hold on to this patient, right? And, you know, it's chinese medicine, so just getting acupuncture is good for everybody. So even if it's not completely resolving their problem, I'm not hurting them. I'm not stealing from them. I'm not giving something bad. I want to say definitively that that is a losing headspace. Like, definitively a losing headspace. And the reason is. Well, this is one of my favorite images, is that a scarcity mindset is like a closed fist. Right. You're clenching, holding tightly to everything that's there. And when the fist is closed, by definition, it is not open. [01:38:56] Speaker B: Right. [01:38:56] Speaker A: And therefore cannot accept what is new and possible out there. Right. So I love that image. I wish there were a way to make that a tattoo in some way, because I think that'd be gorgeous. But the idea is you have to. [01:39:13] Speaker B: Talk to sage about that. [01:39:14] Speaker A: I know, right. Treat responsibly, treat ethically, be honest with yourself, and avoid that nagging feeling that you need to clinch. [01:39:25] Speaker B: Yes. [01:39:25] Speaker A: Right. Because it won't work out in the long run. Right. It won't. And what you want is the resolution to a case so that that patient goes out and spreads the gospel of your treatment. [01:39:38] Speaker B: Right. [01:39:38] Speaker A: Right. That's what we want. We want little evangelizers out there in the world telling everyone how great you are, how awesome you are, how professional you are, and making sure that they're doing the heavy lifting of word of mouth referral, which is how the vast majority of us actually get patients in the door is, through word of mouth referral. And that has everything to do with managing the patient case, which is what we've been talking about here. [01:40:03] Speaker B: Right. Or, you know, if you didn't get to the goal. Right. The patient is at a dinner party sometime. Have you ever tried acupuncture? I heard acupuncture was good for my shoulder. Oh, yeah. I did acupuncture for a while. How did it go? Well, we didn't quite meet the treatment goal, but I did get a little better from it. I'd recommend it to other people. [01:40:25] Speaker A: Yeah. Still positive. [01:40:26] Speaker B: Still positive. [01:40:27] Speaker A: Still positive. [01:40:28] Speaker B: They were very professional, you know, like. [01:40:30] Speaker A: Yeah, very positive. Really nice. Their clinic was cool. [01:40:32] Speaker B: Their clinic was cool. I really liked them a lot. You know that, like, that's way better than the scenario of I bought an extra treatment plan. We didn't get much better from that last one. I kind of felt like it was a waste of money. [01:40:49] Speaker A: Not really sure. [01:40:49] Speaker B: I'm not really sure it's worth worth it. And. And then there's this weird thing that happens with people where if they have a negative experience to end, that's all they remember. Right. [01:40:59] Speaker A: Yeah, 100%. [01:41:00] Speaker B: It doesn't matter how well you did in the beginning. Like, yeah, we got this chronic condition, 40% better, you know, in, like, three months, which is pretty good. [01:41:10] Speaker A: Yeah. Actually had it for 15 years. They're no longer pooping blood. [01:41:13] Speaker B: Yeah. But, you know, and then, like, the last interaction they have with you is negative. Yeah. It didn't work. [01:41:20] Speaker A: It didn't work. Yeah. I don't know that it was really valuable. [01:41:23] Speaker B: Yeah. [01:41:23] Speaker A: Yeah, that's. That's the. That's the killing blow, right? I mean, that's. That's the worst case scenario for this to come out of. And look, okay, we've been talking about strategies for managing patient interaction and, like, you can't control everything. [01:41:34] Speaker B: No. [01:41:35] Speaker A: Right. Doesn't matter. You could do everything that we said. You could add your own flair. You can be professional and on top of it. And some of your patients are gonna flake without reason. You're not gonna know why. I. Some people are going to have a negative experience. Hopefully, if you're open and self reflective and listen to that feedback, if you get it, you can minimize that. Yeah, but, I mean, it's going to happen. [01:41:56] Speaker B: It's all about building good systems so that over time, you do. It gets better. [01:42:03] Speaker A: It gets better over time, so. Okay, well, I feel like that's a pretty robust dive into managing the last part of the case. So we've laid out the condition and the pattern, building the formula, setting the dosage, talking to the patient about that formula. And then key with the work we've talked about today is understanding that treatment plan and communicating it to the patient and making sure that they understand what we're working on, how we're going to achieve, what we're going to achieve, what to do when that works, and what to do when that works less well. And so I think that that's a really good spot to sort of close out this little trio of items. So if you've just found yourself on this episode, go back and listen to part one and two, because that's going to lay out the case, the specific case that we use to build this series. And the three of these episodes together really represents a sort of how to, for the new herbalist, someone who has prescribed very little. And it's, you know, the further episodes that we get into in this series are going to be a little bit more wonky, maybe sometimes nerdy. We're going to dive into specific herbs and formulas and different things like that. Sometimes more novice, sometimes more advanced. But this trio of talks are linked together as a group, so that way anybody can listen to it and get a sense of like, okay, where do I begin? How should I get my head space around this? Because like you said, it's about building systems. [01:43:41] Speaker B: Yes. [01:43:42] Speaker A: And these are our systems. They're not the systems. I want to stress that. Right. There's a lot of different ways you can do this medicine, as we know, but these are the ones that we use, and they work pretty well for us. And I'm sure that they'll evolve over time as the ones, you know, we do things differently now than when we started five years ago. And so it's important to remain agile in all of these avenues. And as a key piece to all the listeners out there, just remember, this is a practice. Your medicine is a practice. Your life is a practice. All of it is. Some days are going to be better than others, but you just keep. You keep doing it, right? [01:44:20] Speaker B: Absolutely. [01:44:20] Speaker A: Even if the herbs don't taste good, drink them. [01:44:23] Speaker B: You keep taking them. [01:44:24] Speaker A: Just drink them. [01:44:25] Speaker B: Yeah. I've had a huanglian formula now for, like, the last three months. [01:44:31] Speaker A: Brutal. Every time, brutal. [01:44:32] Speaker B: But every day I take those herbs. [01:44:34] Speaker A: That's right. Making progress. Yep. All righty. Well, let's call it. Thanks, everybody. [01:44:39] Speaker B: All right, see you next time.