Deciding to take insurance has been a big step for me. I was idealistically against it while I was in school and then I was administratively against it after hearing about the headache that the paperwork could be. Yet the reality of earning a living at acupuncture and the challenge of figuring it out became pretty attractive after a while. In addition, the new health insurance laws have created a situation in which many patients are only wanting to see me if I can take their insurance.

Being a mama, I can tend to over-prepare and over-research for trips and as you can see, I’ve spent many months applying this energy towards the logistics of making all of this run smoothly in my business. I’ve looked at a number of cloud-based Practice Management solutions and accounting software, I’ve been reading everything I can get my hands on and I’ve been emailing, talking with and meeting up with colleagues and mentors to figure out how best to go about laying the groundwork for my success. I understand that if I can’t be successful in this business stuff, then my dream of offering healthcare to the folks in my community just isn’t going to happen. It’s a big motivator for me. I really believe in this medicine and it is requiring me to believe in myself and make this work.

As I’m taking insurance, and particular, being in-network with medicaid, gone are the days when I could charge whatever I wanted to whomever I wanted. Everything has to be setup in a consistent fee schedule. Over the last few months, I have realized that the fee schedule and the discounts that we’d like to give within it, are highly controversial. If I ask 20 different people the same question about offering discounts (whether student, hardship, time-of-service, senior, etc) I get 20 different answers and many of those answers directly contradict one another. Yikes! Much of the reasoning behind this has to do with the basic idea that this medicine is an art, every single part of it, and we are all working our own niche in the scene. And, thankfully so!

Since the fee schedule has been a bit of a headache and a bit of a fun challenge for me, I’m going to write out the process that I used to come up with my fee schedule. As I learned this year, price fixing is a very serious charge and so practitioners avoid talking about their actual fees (which I am going to do here as well.) Yet, in all of the literature and power points and emails and forums – I didn’t find anything that detailed the process for me, other than using multiples of the Medicare Physician Fee Schedule. This all seemed very arbitrary and not based in the reality of what I need to charge in order to pay my bills and make sure that patients can afford my treatments.

I’ve used two pretty great books to get some idea of what to do here. The first, Playing the Game: A Step-by-Step Approach to Accepting Insurance as an Acupuncturist has been really helpful to me in setting everything up. They’ve got a great website with tons of resources there to help.  The second, Making Acupuncture Pay, was recommended to me by the awesome guys at Shift Wellness PDX when I went to look at a space in their clinic. Prior to reading Making Acupuncture Pay, I was starting to define my fees pretty arbitrarily on what I was seeing around me and on what I have been charged for acupuncture in the past. But, in his Chapter 5, “Establishing Your Fees,” Matthew Bauer really breaks it down and reminds us that it’s about choosing a fee that will support you while also taking into account what the market in your area can support. And, most importantly:

If you charge higher rates, you greatly compound the stress to produce results that your patients feel are worth the costs unless you are servicing a rich clientele who expect to pay inflated prices. The higher your rates, the more valuable each treatment will need to be. If you charge $120 per treatment, will you be able to make your treatments at least three times more valuable than the acupuncturist across town who charges $40 per treatment? Are you ready to take on this extra pressure?

[...] If you charge on the upper end of your markets norm, you put yourself under greater stress to produce more results with fewer treatments. Think of it like going to a restaurant. If you go to a small Mom and Pop restaurant and they serve pretty good food at reasonable prices, you tend to be happy with the experience even if everything was not perfect. Go to a swank, high-priced restaurant and even if the food is great you might come away disappointed if the waiter didn’t keep your water glass filled fast enough.

Bauer is working in California and his rates are much, much lower than what I’ve seen in this area. He goes through an equation for getting at a certain gross income level and you can always check out his book if you want to read more about that. Ultimately, he says that making acupuncture pay is more about squeezing the most benefit out of the least number of treatments. I guess we could just say that in a different way: Be good at what you do.

So, on that note, I sat myself down with pencil and paper and went to work figuring out some equations so that I could set my fee schedule. Maybe this was a whack way to go about it…but I just couldn’t justify the arbitrary drawing of a number out of a hat based on what everybody else around me is charging. Here’s how I did it:

1) Monthly Expenditures

I listed out all my monthly expenditures. To make this work, I had to get all my licensing fees, get an average CEU cost per month (I just went with 15 CEUs/year), etc. These are not startup costs for a business, these are the monthly expenditures (overhead) that I have to pay (or be saving) every month to keep my head above water.

  • Professional Fees and Licensure (State licensure, NCCAOM certification, Continuing education credits, CPR class)
  • General administrative (EMR/Practice management software, electronic filing fees, accounting software, fax, files, paper, stamps, etc)
  • Marketing costs (rack cards, brochures, cross-promotional materials, social media, website, signs, etc.)
  • Malpractice insurance
  • Rent and utilities
  • Needles and other supplies
  • Childcare costs
  • My share of the living expenses (I took a percentage of this based on the percentage of work I’m doing since I am only able to work part-time right now with my kids)
  • Amount I would like to pay on my student loans each month
  • Miscellaneous other costs

Add all of these monthly costs up. Make them equal to A.

2) Cover monthly expenditures after taxes

Where I live, I need to save at least 30% for taxes. A is the amount that I need to bring home each month….which means that A is going to be 70% of what I am actually grossing (let’s call that gross amount B).

B = A/.70

3) Minimum hourly wage

Now, I looked at my schedule to figure out how many hours I’m able to work each week and then multiplied by 4. (Technically, it should be multiplied by 4.3, but I’m not doing that because using a bit of a lower number for hours gives me a little cushion.) I’m calling this hours (I know, it’s almost too clever, right?)

Now divide B by hours. This is the absolute minimum hourly wage that I need to make to break even. I’m going to call it D (my lowest hourly wage.) I rounded this up by a couple of bucks to make it a multiple of 5 and also because I always worry that I’ve forgotten something in my monthly costs, or maybe I’ll have a sick kid one day and have to cancel an appointment while I figure out care, or what if, or what if, or what if.

4) Define the cost of an adult and child visit

At this point, I’m going to define my fees based on this hourly wage. But, I’m also going to take a little bit of advice from Michael Bower about offering free, half hour consults for people who are new to acupuncture, or even just new to me. I know that most of the EAM practitioners in my area offer a 1.5 hr initial visit/consult and then a 1 hour follow-up appointment. That initial visit tends to cost quite a bit more and it’s something I feel has caused issues for prospective patients in my community because they don’t want to spend more money to jump into something that they don’t even know is the right fit for them.

Since I already offer a free half hour consult for new patients, I’m just going to go ahead and build that into the initial treatment and charge my follow-up rate. If a patient came for the free consult, then I would allow them to schedule a follow-up at a later time. Because of this, it doesn’t make much sense for me to charge a patient for the consult if they book them together as an initial appointment (which actually saves me some time over the previous scenario.) If it really bothers me, I can write these half hour visits off as “marketing” because that’s essentially what it is, and then limit them to a certain amount of my practice each month. This also keeps it really simple for me because I just have a few visit fees:

An adult visit = 100% of an hour
A child visit = 75% of an hour

D is my absolute lowest hourly wage and so I’m letting that wage define the 40% discount that I give for hardship. I’ve decided not to use hardship paperwork myself, but to use medicare or for SNAP benefits as my qualifier. That way, I just have to get a copy of the patients medicare or SNAP card on file and I let the state do the work of determining that they are a low-income patient. My Discounted hourly wage is equal to 60% of my actual hourly wage (W).

W = H/.6

The fee for an adult visit = W.

The fee for a child visit = .75 W = C

5) Define the CPT codes to make this happen

My main codes are going to be 97810 and 97811 and I’m going to make my regular, adult visit equate to a unit of 97810 and two units of 97811. A child visit is going to equate to one unit of each or, with no needles, to two units of 97410.

I need to use two equations to solve for these values. I’m going to say that 97810 = X while 97811 = Y.

X + 2Y = W
X + Y = C = .75W

Going through and solving these equations gives the figures for both 97810 and 97811. I will tell you that my figures are both lower than anything I’ve been hearing or seeing (to make a rate that is 40% more than what I need to pay all my monthly expenses and living expenses) – but they are pretty spot on to what Making Acupuncture Pay gives as examples of practice fees. Granted, they also require that I fill my visits, which requires that I do a really good job…or, like Bauer says, treat the patient’s issue in the least amount of visits so that they are referring their friends.

I went ahead and did similar things to this with the rest of my codes so that I set up a consistent situation for my fees and I’m giving a 40% discount for hardship and a 20% discount for students, etc. I coded 99202/99203 at a reasonable rate so that if I bill insurance for spending that extra time with a patient, it is a reasonable thing to do.

I’m just learning at this stuff – so if anybody has any other advice to throw in here for me (or something I may be seriously over looking) please share!

I just finished my demo with PunctureNote, which is the last system that I had on my list this month to look at before deciding about and jumping into one of these EMRs. I have spent some time with Practice Fusion, Charm EHR, Dr. Chrono, AcuSimple and Jasmine these last couple of weeks.

This post details my understanding and my opinion on the two systems that I liked the best. I am not a representative for either of these systems – I’m just an EAM provider who has participated in the 15-day free trial for AcuSimple and gone through the hour long demo for PunctureNote and I’m letting you know what I think. I don’t fully know/understand the features in these systems and I don’t know everything on the list for the developers in the future (nor what they are actually working on right now.) So, please note that this is just me making lists and figuring out which one I’m going to go with for myself. 

I am excited about EMR software that is made for us as acupuncturists. I also know that these systems are new, which means they are adapting to the folks who are going to support them. Please don’t expect that right now, in this moment, that you will find the “perfect” EMR system for you. It’s not out there. And, it will never be out there if you don’t support the systems that are showing promise.

There are a lot more MDs and Western practitioners in the country right now. They are all helping to direct Practice Fusion and Charm EHR and Dr. Chrono and those systems are starting to work really well for them. As East Asian Medicine providers, we can support developers in the same way, so that they can make kick-ass systems for us. If you want to use an EMR that’s made for your East Asian Medicine/Acupuncture practice and you want to use it NOW, that means you are going to benefit from a number of great features while also being part of the support network that helps to build that system.

Navigating the EMR/EHR field is like trying to surf on an ocean of new information and can feel frustrating. None of us would choose the same surfboard for the real ocean. The right tool for the job is going to be different for everybody and is highly based on each of our intuition, taste, practice needs etc. So, if you’re interested in an EMR, I urge you to go through the free trial periods or demos for yourself.

Some of you may like Jasmine, but it wasn’t for me so I’m not going to talk about it here. I didn’t like the long drop down lists that gave me a ton of options for pulse or tongue that are outside the range of what I use while not including some of the options I do use. I also wasn’t super keen on the calendar, the ad banner at the top of my screen or the Facebook like feel (which literally allows you and your patients to “like” each others comments.) So, I have to admit that after a couple of days, I walked away from that one, not because of the functionality, but because it just didn’t feel right to me.

I have spent two weeks with AcuSimple and I really love it. After my demo with Puncture Note today, I have to say that I love that system as well. Both have a number of features on the burner that will make them even better. The developer of PN sent me an email asking me not to share any information about what he said about the future of PN with other developers – which is fair and I will try my best to make sure that I don’t do that here.

I don’t think these two tools need to be competing too much against each other. It seems to me that they have one, very large and obvious difference right now: One system offers more customization for a larger initial time investment on your part. The other system offers ease of use from the beginning with less customization for your individual practice. Both systems are being developed by East Asian Medicine practitioners/Acupuncturists.  Here are the things that were important to me – and what I’ve seen happen with the systems up to today (September 23, 2014):

User Friendly/Intuitive:

AcuSimple:
If you are using WordPress for your website or otherwise know how it works, you’ll be able to get around AcuSimple relatively easily. The main things you’re concerned about will be in the left column (calendar, E-forms, invoices, chart notes, etc). You use a visual or text field to create your forms, letters/emails, invoices, etc, which offers a lot of variability for people who want to customize your stuff.  There is a drop down field of “contacts” above your visual editor where you can select the contact you’re working with. As you slide through the list on the left side, it will correlate with whatever contact you’ve chosen.

Overall, I wouldn’t describe it as an “intuitive” system, though I think it’s user-friendly because I think WordPress is user friendly. It allows for a lot of customization, but you’ll also have to figure a few things out along the way.

Puncture Note:
For PunctureNote, it looks like you login to the system and then go to “Front Desk” to see who is scheduled for that day. You click on the patients name and then have access to a screen that has all of their information on it. Their information is organized with dark grey block headings that make it really easy to navigate the screen. Personally, that feels more intuitive to me.

I would describe the system as intuitive. It’s easy to get around. You don’t have to do a whole lot of work to get started because they have it all setup for you. You won’t be able to customize the system as much, so it depends on whether or not that’s something you want.

Importing/Exporting Data:

Both systems allow the importation and exportation of data. You can import your contacts by using an Excel CSV file. For chart notes, you have to scan those in. I haven’t gone through this process in either, so I’ll have to come back and report on this once I do it this week.

For exporting, AcuSimple exports chart notes as PDF files, contacts as an Excel CVS file and financials to OFX or CSV files. In the demo today, I was told that PunctureNote can also export files to an Excel CVS.

Calendar/Online Scheduler

It’s hard here because I didn’t get to play around myself with the calendar on PunctureNote. However, it appears to be a Google based calendar and the developer said that it’s data can be exported to iCal and Google Cal (though you can’t import data in from your calendar because it’s an encrypted system so it’s not going to allow that.) When patients schedule new appointments, a text is sent to them and an email is sent to you.

On AcuSimple, I’m not sure what the calendar is based on. You can drag and drop calendar events with your mouse or finger (and create them by clicking or dragging as well).  There is a separate scheduler that has a scheduling widget that you insert into your website (this is separate from the patient portal.)

I don’t feel like I have enough information about either calendar or scheduler to feel strongly about a choice here. Both systems allow multiple bookings during the same hour, they allow you to set/limit certain appointment types (like things you’ve offered on Living Social, etc), you can look at the calendar for past/future for one patient or for all your patients, patients can schedule and receive email reminders. 

Patient Portal

PunctureNote allows patients to schedule through the patient portal, in AcuSimple, patients schedule through an online scheduler. PunctureNote allows encrypted communication with patients through the portal.   I’m kinda into the pretty portal on AS because I’m a sucker for that stuff…and it has enough functionality for me to wait for text reminders and everything else that will get added to it (so, no text reminders for patients through AcuSimple right now). It seems like you can add patients or they can add themselves in both systems with email addresses acting as unique identifiers. Again, I’m not really sure what I like best here.

For AcuSimple, there is a separate area where the patient portal is housed. The system gives you code for a widget and you choose from two buttons that you can put onto your website. You find your code and settings for the patient portal by going to “edit profile” and then choosing one of the icons at the top (that wasn’t intuitive for me). The patient portal itself is very pretty and customized with your logo and business name.  The portal allows patients to fill out forms about contact information and insurance as well as customized forms that you’ve made and inserted into the patient portal. You can upload files from you computer into the portal for them. They can also rate and review you.

In PunctureNote, the patients login to the same main area where you login and then they get into their portal. You can message your patients through the patient portal and it’s encrypted communication between the two of you in the system. Patients can look at a lot of their data, but I just had a quick demo so it was hard for me to see all of the features in the one hour. There is also coding for a button that you can insert into you website. You can personalize the button so that it includes your logo.

Patient Check In

On Puncture Note, you have the option of putting an additional screen in the waiting room and having patients check themselves into the system and then fill out the subjective note for you.

Patient Communication

As stated above, PunctureNote allows you to message patients through their encrypted patient portal.

AcuSimple allows you to send out mass group emails to patients through their system (by using an email template) and you can also send emails to a single patient, which are then connected to their file. I believe that these emails go through your regular email address (the one that you’ve identified with the system when you set it up) and so they are not encrypted.

Patient Invoices/Categories

The patient billing was built into PunctureNote and seemed pretty simple to use, but we didn’t spent a whole lot of time on that. Ultimately, it looked really easy and intuitive, partially because the developer was leading us through it and he knows well how the system works. I wish I could say more about the billing here – but I do know that it ultimately ends up in the billing system and gives you a report as you need for your financials. It looked like invoices can be sent to the patient through the encrypted patient portal or printed out for them.

In AcuSimple, like I said, you create a number of categories and define them (and which area they belong to.) For example, if you’re creating an Initial Intake, you can just give it a total cost, or you can insert the various CPT codes that you might be using for that (97202 @ X dollars, 97810 @ Y dollars and 2 units 97811 @ Z dollars). You can do a TOS discount in the category itself or in the invoice when the patient pays. But, you setup your various categories in this way. You setup your inventory, including herbs, as categories too. When it’s time to create the invoice, you insert the various categories that you’re using and ultimately end up with your total cost and an invoice that can be emailed to the patient or printed out.

Herbal Inventory

Right now, there is no herbal inventory on PunctureNote.

On AcuSimple, you create “categories” and sort them into either Income, Expenses or Pharmacy. This was not intuitive to me either – but it’s how you do all your billing and how you run your herbal inventory (or sell anything else) as well as pay your expenses out.

Billing

Both systems give you billing reports. As of this time, the financial reports in AcuSimple are much prettier (there are examples on the website) in terms of color coded visual graphs. AcuSimple lets you export financials so that they can be opened in QuickBooks or other systems. I’m not sure whether financials from PunctureNote can be exported, I’m waiting to hear back about that from the developer. PunctureNote also allows you to export financials.

Templates

In AcuSimple, you have the option of creating templates for your SOAP note, as well as templates for your emails, insurance forms, letterhead and more. All of this can be customized with your logo and the information specific to your clinic. You can create letters, invoices or anything else by using these templates that you’ve setup. It takes a minute to figure out how to make these and there is no tutorial at this time. I can be really dense and I did it after two days, but I also know how to use the WordPress visual editor….

SOAP notes

For PunctureNote, you are going to open a SOAP note and it gives you nice color boxes at the top for “Subjective,” “Objective,” “Assessment,” and “Plan” that you click on. Once inside, the system is pretty automated so you just go through and there are a lot of drop downs and check boxes. You write very little. If you have an extra computer and your patient checked in at your front desk, they can fill out the subjective piece themselves. Then, you can leave any notes on the subjective piece and it becomes very easy for you to see what the patient said and what the practitioner added to that. For the objective piece, you can pick from three different pulse systems and get a drop down. For assessment, you type in what your assessment was (since it’s too much to make a drop box for everybody’s different assessment style.) In the treatment plan, you can select the type of acupuncture you’re doing (TCM, 5-Element, etc) and you are given a number of check boxes and areas that you can fill-in. Once the SOAP note is completed, it looks very organized to go back through and see everything that you selected.

For AcuSimple, there is a pre-made SOAP note template that you can add to and save as you like (it will not be immediately ready for you, but if you like their template you can save it and use it in about 5 seconds) or you can make your own from scratch. If you make your own, you can use the “E-forms” area to create forms that work for whatever you’re doing. For example, if I’m using Kiiko Matsumoto style for my gyn exams, I can make a check box for all of the different abdominal points and reflexes that I’m testing. I can make another E-form for my pulse diagnosis with a drop down or check boxes or simply text fields. Then, I go to the template area and I insert these forms as well as any images, etc, that I want in my basic SOAP template. When I create the patient chart, I can pull up the basic SOAP template OR, I can pull up the various E-forms that I’ve made and insert them into the chart as I feel like it. This is a cool feature because I can create different E-forms for various things that might be going on with the patient, like “headache,” “digestive complaints,” “back pain,” or whatever I tend to see. Then, you can insert these E-forms into the chart note as you need. This allows you to customize your chart/SOAP note to the patient. However, it means that you have to create the various templates that you want to use.

In AcuSimple, you can import formulas from the reference section and click a drop-down menu of your favorite formulas into the SOAP notes. It inserts the formula and then you format it as needed.

Drawing/Pain identification:
In AcuSimple, you can import any images you want and if you pay for the biggest package, you can draw directly on those. For PunctureNote, they have a really beautiful diagram of the body that is color coded in various sections. You just click on the section of the body that you’re talking about and a check-box menu comes up where you can qualify what kind of pain or what’s happening with the palpation. It’s actually one of the most beautiful parts of their system.

ICD-9 or ICD-10 Codes, CPT Codes

PunctureNote allows you to use ICD-9 or ICD-10 codes. AcuSimple allows you to use ICD-9 codes. Both programs allow you to click on a menu and go through a series of inputs to select the codes you want. Both systems add these codes to your chart notes.

As stated above, in AcuSimple you create your categories for treatments with the CPT codes that belong to them. You then chose one of these categories from the drop down menu and it imports your codes into the chart notes. As of right now, CPT coding and super bills are not included in the PunctureNote system.

Reviews and Ratings

AcuSimple allows your patients to review and rate you and you can decide if you want these to be viewable on your scheduler.

Insurance

AcuSimple allows you to fill out CMS-1500 forms and do electronic insurance billing, for the medium priced package. You can also create superbills and email those to your patient or print them out.

Reference

AcuSimple has built in references for Herbal Formulas (over 450), Acupuncture Points, and a Materia Medica reference (for individual herbs, over 400.) Through the reference, you can add herbal formulas to your drop down formula heading (that is where you select formulas for your chart notes.)

Support

I found the demo through PunctureNote to be great today. I got an email a few hours afterwards asking me if I wanted to sign up. I emailed back with about eight questions on the system and am still waiting for a response. I think that it’s normal for them to respond within 24-48 hours…to somebody who isn’t signed up for the system.

With AcuSimple, I have not signed up for the system but I have been emailing with the developer, non-stop, over the last couple of weeks. I have to say that I am extremely impressed with his quick response time and ability to answer my questions. Everyone else I’ve spoken to about this system has said the same thing, that he is amazing. Every small feature I asked about was immediately added even though I’m not paying for the system yet. So, I have to say that I am pretty stoked and feel like he’s got my back if I start using his system.

A little addendum here. I decided this morning to go with AcuSimple and I’ve signed up. The main reason is that it just feels right for me. It also does the insurance billing right now, and that’s a big deal for me. I know that during the PunctureNote demo, the developer listed a number of things that are on his list, but I need a system now and Dan Axelrod has been amazing about communication and support for the last couple of weeks, so I’m going to go with it.

I really hope that if you’re looking at a Practice Management and EMR system that you support one of these systems because you’re supporting the East Asian Medicine/Acupuncture community and you’re helping to make it stronger.

I’m trying to get this business thing down and it’s not easy. If I had more time to post about the process, I would! I’m learning so much as I progress as an EAM provider and as a business owner. I feel really blessed to have been able to take advantage of some instruction through Mercy Corps NW as well as the generosity of a number of small business owners who have been great mentors.

I am making some time to write about AcuSimple here and that’s because after a week of messing with it (and getting quick and amazing responses from it’s designer, Dan Axelrod), I am feeling like I’m on the way to being a total boss of this EMR system. I was a little scared to dive into electronic records, but I’ve been more scared not to. I do a number of house calls and I don’t want to be carrying paper files around with me. I’m also getting overwhelmed by all of the pieces I’m needing to put together to make everything work (scheduling, billing, inventory, books) and it seems so nice to be able to get most of what I need in one place.

I love the system that my midwife uses, Private Practice, since it’s really iPad friendly, allowing patients to login and update their own profiles and sign in office right on the screen. I wrote to them asking if they could tweak things around for an acupuncturist but the answer was, “not right now.”

I tried asking around about what system would work best for me as an acupuncturist. People referred me to Dr. Chrono, Practice Fusion or Charm EHR. These are all nice systems but they are made for Western care providers and are geared at that type of practice. I also saw that they were either very expensive (and not affordable for me while I’m just starting out as a single practitioner) or FREE. That last bit bothers me because I don’t believe in getting something for nothing. ;-) Regardless, I got the free trial of Dr. Chrono and signed up for Practice Fusion and played with those for a couple of days. The systems are very complicated for what I’m trying to do – there are prescription portals, lab tests, vaccination reports and all kinds of extra things that I don’t need as an acupuncturist (who cannot be a primary care provider because I’m in Oregon.) Dr. Chrono has a pretty system that works well on an iPad, Practice Fusion didn’t feel that pretty to me. During the tests of those systems, I was also working with AcuSimple and I ended up opting to go with that system.

I came to AcuSimple through some web searches and one or two mentions on Facebook. There are no tutorials setup right now and in my research rapture, I asked and googled and couldn’t find much to help me. After a few emails back and forth with the creator, I decided to go for the 15-free-day trial. The first few hours were really frustrating for me as I tried to wrap my mind around what the hell was going on. But, I’m starting to get it now, and I want to share so that if some of you want to give it a go, you know how to get started!! As I find time, I’ll try and post more info about how to use the system.

First thing’s first: you’ll create an account and then login to the system and you’ll get a series of directions:

This ultimately explains the whole process, but for me, it didn’t make a whole lot of sense because I was totally new to the whole thing. The organization of the system is so different than the way we organize our paper files that I had to understand that first. But, I couldn’t understand that until I created enough “stuff” to mess around with it and see what was happening! Catch 22 there….

You’ll see up at the top that it says “Bex” and that’s my profile. So, lets go there first. Click on PROFILE SETTINGS. A logo will come up. Click the top corner: EDIT PROFILE and you’ll get to this screen:

Something I missed my first few times through here is that there are six icons on top of this EDIT PROFILE screen. You will see that my profile is taking up the whole screen as well. That’s because I closed the memos/images sidebar and it’s up in the little icon in the top-right corner by my name. You can do that too by X’ing it out. So, here’s the deal on those six icons, in order from left to right:

  1. Your practice information
  2. Online scheduling setup
  3. Patient portal
  4. Insurance settings
  5. Calendar settings
  6. Data transfer

As you go through these, most are pretty self-explanatory. The online scheduling setup includes code for a couple different button designs that you can put on your website. Let’s look at the PATIENT PORTAL though (cause it’s one of my favorite parts!):

This is all pretty self-explanatory on the back end. You can activate the portal by checking it’s box and you can decide whether or not you want your patient’s reviews of you to show up or not. It also gives you the option of putting the code for the portal into your website with a button. But above the button, you’ll see the code for the link. You can copy and paste that into your browser to see what that looks like and then create a fake account to try out the system. I’m going to make an account for Heather Doe.

Once you’re inside, you’ll see that there are a couple of forms that your patient can choose to fill out. The contact information is locked. Once they make that account, only you can edit that for them.  In order to have more forms show up here (intake, health history, etc) you’ll have to create those forms and add them to the portal.

So how do we do that? We gotta go back to where we are logged into our AcuSimple system. In the sidebar, click on E-FORMS.

On the top left, you’ll see a drop down – mine says “-Contacts-” If I click on that, I’ll also see a list of my patients. On the right, there is a blue button that says “New Form,” and that’s what we’re going to click. (Ignore all of my templates, we’ll get to that later – maybe not tonight, depends on how tired I am!)

Now you’ll see that you can create a form for your patient portal. You can also create templates for your chart notes, insurance stuff or other forms that you might want. You simply “Add new field” by clicking on one of the green options and then fill in the blanks as necessary. One thing I did learn is that for “checkboxes” you can check multiple choices while for “radio buttons” you are only allowed one choice out of the set.

The “signature” field is nice if you’re using an iPad. You can put it on your HIPPA forms and Consent to treatment forms and then have them sign them in office or on their iPad or iPhone when they are logged into the patient portal!!!

Here I’ve created a form called “Consent to Treatment” and added some custom text at the top and a signature field at the bottom. I checked “Include in Patient Portal.” That’s going to show up like this:

The patient can sign that with their mouse or with their finger on their tablet or phone. Once they submit the form, AcuSimple will send you an email to let you know that you’ve received a new form from a patient. If you login to the system and click on E-FORMS again, you can choose the patient’s name from the drop down menu.

All forms that have been submitted by this patient will be listed here with the orange “Submission” mark on them. You can click on the form to check it out.

Once you select a patient in that contacts drop down menu, every item you select in the black sidebar on the left will correspond to that patient.

Now, I’m getting tired. But, to finish off this first piece, lets say that you want to create a chart note for Heather Doe here. You can use a pre-made SOAP note that’s included in the templates (scroll down the menu on the left and you’ll find it), or you can make your own little templates to throw into your notes. It might seem confusing, but it’s just like legos! You’re going to make pieces of a chart and then you’re going to build your chart note to each individual patient, k?

First, I went to E-FORMS and made a little template for the “subjective” part of my chart. And another where I can have Siri add a little “objective” note for myself. These are here:

I’ve also got a form for my gynecological intake. I used a number of checkboxes for that because I’m using a Kiiko Matsumoto style system for that, but you can use the E-forms boxes to make it however you want.

You need to make sure that on these forms, you UNCHECK “INCLUDE IN PATIENT PORTAL.” 

So here’s how I put my lego pieces together to make a chart note for a patient who comes in with gynecological concerns:

Go to PATIENT NOTES and then choose your patient from the “contacts” drop down. Click “New Note.”

Here you can click on the “Forms” drop down and choose the template you made. Each template you choose will be added under the previous one to create a chart.

Here I’ve added the “Gyn Form” chart. Now all I have to do is check the boxes for the reflexes I’m looking for. You could have fields here to fill in.

The AWESOME thing about this is that Siri loves it. And more than me, Siri is like a boss. You can dictate all the fields while you’re talking to the patient. Just repeat their stuff back, “Pain on the left side of your head?” And it will fill in the blanks for you.

I’m tired and need to go do something other than take and upload screenshots with descriptions so I’m off….but I have to say that the more I play with AcuSimple, the more I’m loving it for the work that we do as acupuncturists.

This system is made for us! And it’s made by one of us. And it’s pretty affordable at $40 a month. You can add a few extra features on and rack it up to $60 if you want to get into the more hefty insurance billing features. Alright….I’ll be back for more later. <3

 

I am giddy right now. My nose is filled with the waft from sugar pop candy crunch fried and puffed dough bombs. There are donuts under lights, dancing around poles while an old juke box plays Pearl Jam in the background. 

It’s all the Voodoo, stick a pin in it and paint it pink. I am toppled over with the generosity in this town, this big fat city of bridges. This is exactly what I needed this week. 

I was feeling bored and overwhelmed in Portland. I’ve been here for 15 years and have loved it for most of those years. But, the long lines and road raging and other things that have come with the with the influx of so many people have taken their toll on me. When I saw the new freeway sign, proclaiming wait times to various destinations, I got claustrophobic. I started to think that maybe Portland and I were done with our love affair. I swore it to my husband. I saw the crackling dried grass and told myself that I was drying up here too. I started fantasizing about the salty Puget Sound up North, about moving back to Olympia.  I decided that my destiny was to buy a kayak and drink my morning tea with the seals, between the bay and the Olympics.

In all of it, I’ve been trying to start a business, take care of my children and fundraise for this upcoming trip to Nepal. The trip itself terrifies me and I haven’t allowed myself to really sit with it, since I feel like I’ve got to raise the money before I can relax. Asking people for their hard earned dollars has become the topic of many therapy sessions for me. It squeezes me hard in discomfort and brings up all of my issues around worth and money and more.

Like all places that aren’t comfortable, the fundraising has caused some change in me. It’s forcing me to rely on other people and to accept gifts. It’s shining a light on some emotional parts of myself that I have avoided looking at before. And today, well, today it opened my heart up in a way that I’m not used to. I felt it this morning when I arrived at The Give and Take and Chelsea handed me a stack of her business cards and a beautiful handmade broom.

See, I sent out a number of emails this week, to local Portland companies, asking them for donations for a silent auction that I’m planning for the end of October. I didn’t expect anybody to reply. But the majority of people did. And every who replied said yes. And more than that, they said that this trip to Nepal and the work it involves sounds amazing to them.

I have to say that I was caught off guard. There is a part of me that tells me that I’m unworthy and undeserving and that people don’t help each other. Though I spend the majority of my time helping other people, somehow, I let myself listen to that part and believe in it. And this week, the world showed up, with her sassy self, to prove me wrong. 

Tonight, I found myself at Voodoo Donuts, helping to direct one of their customers, a new Portland transplant, “down to the docks.” When I finally got up to the counter, I asked for the box that was left for me. Inside were three t-shirts and a gift certificate. I got in my car so pumped that I felt like I might explode. Why am I so happy???

There’s a story I read a while back that I think explains a lot of this. In The Continuum Concept, Jean Leidloff is living with a group of Yaqui. Three of the men take her on a seven-mile journey, to translate for them while they pick up nine building poles. After the exchange, the first man picks up three of the heavy poles and stacks them on his shoulder. The second man does the same. The third, however, only picks up two poles, leaving one for Jean. She is appalled that he expects her to carry this heavy pole along a rough trail for seven miles, but she grudgingly picks it up and starts the walk.

A little way into the hike, Jean realized that she is the only one who was pissed about the whole deal. She had gotten used to hiking with a couple of Italians who wouldn’t wait for her. She always had to rush to keep up. With the three Yaqui though, they speed up or slow down with her pace, but none of them seeme to be paying much attention to her. She starts to relax into the hike and go at a pace that works for her. Nobody else seems in a hurry and the hike becomes enjoyable. A little while after this, it dawns on her why the pole had been left for her to carry: The Yaqui wanted her to be included in the shared work they were participating in. It wasn’t out of an expectation that she “do her fair share,” (as she was used to) but it was an inclusive gesture.

In most of the work I’ve done in my life, I’ve tried to take on more than my share, thinking that this illustrated a good work ethic. I thought that having other people give to me, or help me, was a sign of my weakness and inability. Having to fundraise this trip to Nepal has dredged up feelings of inadequacy, since I know that I cannot do this all on my own. And that is the perfect thing for me in this moment.

I have an opportunity to provide healthcare to these folks in Nepal who really need and really deserve it. And I simply cannot do it alone. My community here is totally engaged in this work with me. Every person who has spurred me on, donated to this campaign or to this silent auction is carrying part of the load to get me there. It makes me feel so confident and strong to know that I am merely one small piece in the chain that is going to link my home and my community to the people of Nepal and the good work that we are all doing there, together.

We are amazing beings. And from it, I have relearned a truth: We are all one. It’s only by going down the rabbit hole that I ever learn any of these things about myself. So I guess I’ve learned another truth too. The magic is in the hole.

The little marsh pheasant
Must hop ten times
To get a bite of grain.

She must run a hundred steps
Before she takes a sip of water.
Yet she does not ask
To be kept in a hen run
Though she might have all she desired
Set before her.

She would rather run
And seek her own little living
Uncaged.

The Way of Chuang Tzu, Thomas Merton

In 2006, I sat with an eight-month old baby at a breakfast spot on Alberta Street in Portland. Like most popular breakfast spots, we’d been wait listed and were hoping for the waitress to seat us soon. They had provided a couple of extra chairs in the area by the door, as well as small cups for a self-serve pot of coffee. A slightly balding man sat in one of the chairs, intently looking at some paperwork. I sat next to him and started nursing the baby while my husband went outside.

Trying to be friendly, I asked him what he was working on. It had something to do with acupuncture and we got into a conversation about schools. I had recently been accepted to OCOM and was planning to start soon. After he shared his very strong opinion with me, I ended up applying and switching to go to NCNM. I kept Jonathan Schell’s card in case I’d like to check in with him about the Classics someday.

In my second year of school, I ran into the same man at Townshend’s Tea House on Alberta. He told me that he was creating a Chinese Medicine Database (CMD) that would support and store the English translations of Chinese medical texts for us. It would cost a practitioner money to be a part of it, but ultimately, it would be a place for these texts to be shared freely among members to promote access to the knowledge. The project sounded exciting, but the price tag was out of my reach at the time, so I never looked into it.

The idea of CMD is one that I have heartily supported until recently. I thought that it represented an exchange of knowledge similar to what I’ve experienced through wikipedia (albeit, with more respect to female contributors.)

I have seen a number of great scholars associated with the CMD and I have thought of joining and contributing at some point. Yet, I logged into a social networking site this week to find out about something that made me totally bummed out about how we are treating each other as professionals and as knowledge-searchers.

Translating from Classical Chinese to English is hard work. It takes hundreds or thousands of hours to produce a minimal amount of work that is understandable and readable to a modern English speaker. Having two kids and trying to run a business makes translation time into a pretty decadent occurrence in my life. When I do find that time, I do it because I love it. There is a soul-opening, heart-melting thing that happens for me when I get to sit down and connect to these people who lived thousands of years ago. I don’t know anything else like it. And it is fun to play with the words when I can see some potential to bring an aspect of that living language into the modern day. I’ve got a long way to go with my skill level, but even that is exciting to me. Each step on the path brings beauty into my life and I cherish it.

I imagine that each translator gets something unique out of their work, but I know that most do it because they love it. There isn’t a great payday for translating and so to put in that number of hours means that it is work that comes from the heart.

When a translation is shared, it never feels finished because the text that it was created from is a living text that’s been fitted into a language that is much less living. By that, I mean that Classical Chinese has a lot of space within which the imagination, intuition and even the intellect, gets to breath. Modern English has so many identifiers, pronouns and other specifiers that it does not contain that kind of breath, or space, within which the reader can play. It’s important that a translator has the ability to correct mistakes or otherwise fine tune her work as necessary, over time, to make sure that the reader has a version that is following any changes in the translator’s understanding.

The idea of intellectual property gets tricky. I do believe that when we quote an ancient text by using modern English, we need to cite the ancient text and the translator that produced that. Each translator’s work is different and it’s important for a reader and a practitioner to know where that’s coming from so that they know how to take it. I love my Ursula K. Le Guin translation of the Tao Te Ching, but I also understand that she doesn’t know a lick of Classical Chinese and she used a intuitive process with the help of a Chinese speaker to put it together. It is important that we understand that we are holding an artistic rendering of a Classical text and that we have an idea of what the artist was aiming for. In this way, we know how and when to use it.

Unfortunately, there are some areas in which greed has entered the picture and the ownership of this intellectual property is not based on helping us to better understand a tool. I know that we live in a world of both darkness and light, but I do think that there is a greater good that can direct us as human beings. We can think above base urges like greed and jealously and make decisions for the benefit of humanity. That’s why I got into this career in the first place, to help people feel better. It’s why these books were written and ultimately, why we need to translate them. We’ve got to stop making it about our egos.

Sabine Wilms is a brilliant translator and I appreciate that she has spent a great deal of time to bring Classical gynecological, obstetric and pediatric texts into existence for modern English speakers and practitioners. Her work benefits women, pregnant and postpartum women, mothers and their babies. She just published a translation of a 7th Century pediatric text called Venerating the Root I. Even though this text was self-published outside of any contract or financial obligation to the Chinese Medicine Database (who previously published her translations), she is being sued for damages by them. Sabine has started a Kickstarter campaign to cover the costs of her arbitration in this matter. If you’d like to read more about it, you can find it here.

I’m going to go back to my day now. I’m going to remember to breath and love and concentrate on the things that are important, the things that help me to cultivate the character I’d like to have and the type of healer, person, woman and mother that I want to be. Sometimes, existing inside an unrestrained capitalist mentality can be hard, but a good challenge can be the best way to find out who we are.

昔者莊周夢為蝴蝶,栩栩然蝴蝶也,自喻適志與,不知周也。俄然覺,則蘧蘧然周也。不知周之夢為蝴蝶與,蝴蝶之夢為周與?周與蝴蝶則必有分矣。此之謂物化。

Once upon a time, I dreamt I was a butterfly, fluttering hither and thither, to all intents and purposes a butterfly. I was conscious only of my happiness as a butterfly, unaware that I was myself. Soon I awaked, and there I was, veritably myself again. Now I do not know whether I was then a man dreaming I was a butterfly, or whether I am now a butterfly, dreaming I am a man.
                                                         Zhuangzi, Translation by Kuang-Ming Wu

When I was 26, I  dated Justin Delk for  four months. We’d been friends for a couple of years, since meeting at a Halloween party where he was dressed like Hunter S. Thompson and I, like Joan of Arc. We both chain-smoked and drank too much. He talked far more than I did, usually having an audience that couldn’t help from rolling on the floor as they ate up his jokes. I remember taking him home for Thanksgiving, to my family, where sitting at the table usually felt tight and strained. He told story after story that brought tears to the eyes of my aunt and mom, who would try to wipe them away between their laughing fits. He filled our meal with light and love, and he knew it.

Before he came to Portland, he had worked as a wilderness guide for kids, a climbing instructor and an EMT. Here, he worked as a carpenter, building fancy houses in the Salem area. He lived alone, in a small apartment on the East side of Portland, near a little dive bar. I’d go to the Speak Easy to eat Reuben sandwiches and do my physics homework. He would meet me there after work, to write or draw in one of his journals or work on putting together a chap book that he wanted to publish at Powells. When we got bored, we’d play a game of pool with one of the regulars we’d started to friend.

I knew that his jokes and stories were mainly a show. I knew that he was fighting something inside. I could read it in his poetry and see it in his drawings. I saw it in the way he swallowed six packs and fell asleep with a burning cigarette in his hand. I could see a great chasm of loneliness when I looked into his eyes. I recognized all of it because I had it too. It felt good to be in the darkness together and to have a friend to share the pain of a cruel world with.

One cold night in early January, 2004, the city was covered in snow and we walked across the Morrison Bridge to check out what was going on downtown. Crazy Portlanders were skiing, snowshoeing and building five foot high snow cairns. We joined the mail carriers for a kraut-covered sausage and headed home in the setting sun. He told me that every time he walked across the bridge, it was all he could do not to jump off it. I shook my head in understanding and made a joke. The bridge is only 60 feet above the water and the river was far too cold for me to ever consider doing such a thing. Since it wasn’t something that I considered a reality for me, I just didn’t have it in me to see it as a reality for him. He was an excellent swimmer and had plenty of experience cliff diving. It would be silly to jump off such a low bridge. He had two young children in Texas that he talked about incessantly, and I concentrated on that, telling myself he would never leave them.

Almost a month later, we celebrated his birthday by watching Super Bowl XXXVIII at our friend’s house. He brought sweet potatoes and made his “famous fire chili.” He was rooting for the Carolina Panthers, which he considered to be his “Bad News Bears” for the season. He loved the underdog and wanted to see them win. I remember Jake Delhomme throwing an 85-yard pass for a touchdown and the whooping that ensued. He was the happiest I’d seen him in a long time.

The next week, he told me about some windows he’d put into a home in Salem. He’d gone out of his way to make sure they were framed and insulated correctly, but his boss had gotten upset with him for doing “too good a job.” Justin had used nicer materials than his boss wanted and in the end, to prove a point, his boss made him remove the windows and re-do the job in an inferior way with cheaper materials. I knew he was upset about it because he kept talking about quitting. He told me that his dad (also a carpenter/contractor) never would have done such an inferior job for the caliber of home he was working on. Inside of all his justification, I could tell that the power struggle he had with his boss made him doubt his abilities and question whether or not he had done the right thing. Shortly afterwards, he made photocopies of his chap book, titled Slow Funeral, and passed it out to friends.

I tried to make him feel better by getting tickets to see his favorite Austin group, The Asylum Street Spankers. I excitedly picked his downtrodden self up, grabbed another friend, and we made our way to the Fez Ballroom on February 6th, 2004. The show was perfect and I drank two PBRs while I listened to Christina Marrs’ sweet voice. The band told us they were heading over to the East side for some drinks and we should all join them there. It was about 12:30 and we decided to go. The three of us headed out to the car, only two blocks away, but Justin got ahead of us. When we arrived at the car, he wasn’t there. We waited for a while, but when he never came, we decided to drive around and look for him.

I drove some circles around the Fez but eventually had to drop our friend off. Afterwards, I was crossing the Morrison bridge in the Eastbound lane and I saw Justin. He was standing on the concrete ledge, about two feet up from the street. He had the steel railing pressing into his shins and he was leaning forward with a giggle on his face. He looked like a child, playing in the moonlight, hanging out over the water. I immediately smiled and continued to cross the bridge so that I could turn around and come back in the lane on his side to pick him up. It took me about a minute to turn around and come back, but he was gone. I figured that he must have gotten down and walked to the East side by using the underpass, so I drove to the East side and waited, but he never came.

Something happened to me at that point and I now know it was because I went into shock. I couldn’t understand what I had just seen, or maybe I didn’t want to understand it and so I drove to his apartment and waited outside in my car for an hour. I kept thinking that he would show up so that we could go get drinks with the band. It’s all I could think about. When I looked down and saw it was 2:30 and too late to meet them, I drove home and crawled into bed. I did all of this like a zombie, without thinking, without feeling. I dreamt that he was dead and screaming, a ghostly face too close to my own and I woke up knowing it was true.

I went to our friend Scott’s house, waking him too early and without any greeting, telling him that Justin was dead. He was, obviously, upset with me, but drove me to the police station. After telling an officer my story, she checked the ‘drunk tank’ and saw that he wasn’t there. She offered me a variety of scenarios that included his walking the entirety of the bridge back downtown without my seeing him. I told her he was dead. She told me I was wrong. Scott concurred with the officer. We headed back East across the Morrison bridge, but this time, after seeing something, Scott’s face went white. He drove underneath the bridge and parked and we walked up the stairway to where I said I had last seen Justin. Sitting on the ledge, just under the sign for the suicide hotline, we found his black rimmed glasses.

They wouldn’t send divers into the water, they said it had been too long. His family came and put up missing posters. The officers told me that his body would probably surface around the Rose Festival, when the naval boats churned the water up and released the bodies trapped on the bottom. They wouldn’t advertise what happened because of the risk of “suicide contagion.” Every bald head we saw was Justin, he was the man in pioneer square, the homeless guy on the bank of the Willamette, the bicyclist at PSU.

In mid-February, we rented a canoe and took it to Sauvie’s Island. We got in the water and floated down the Willamette and then the Columbia, almost getting hit by a barge, while we looked for his swollen body. When we didn’t find him, we took flashlights out to the island, ignoring the trespassing signs and looking for him in the swampy tall grass. A helpful officer with a motorboat drove us up and down the Willamette River, from Marine drive to the Morrison Bridge, while we combed the shore, looking for his washed up remains.

I was in so much pain that I couldn’t handle it. Nothing physically hurt and it didn’t seem right not feeling the pain in an identifiable place in my body. I prayed for a broken limb or something to take the pain and make it real for me. One morning, Scott and I had a long jumping competition at Grant Park. I beat him by two feet before landing on a crowbar and going down with two loud pops. Two friends carried me to the car and the next day, we found out I had snapped both my ACL and MCL. I ended up in a wheel chair for the next couple of weeks while I waited for my MCL to heal so that I could have an ACL reconstruction.

At the beginning of March, I gave up on finding him. I thought that perhaps the officers had been right and we’d have to wait until the Rose Festival for any kind of closure. Six weeks after Justin had disappeared, Scott and I headed out to the Arlene Schnitzer to see Henry Rollins. Scott had bought the tickets for Justin’s birthday. We brought another friend in Justin’s place and as the three of us were leaving my front door, an officer pulled up to tell us that his body had just been recovered. A fisherman had pulled him up in the Willamette with his Texas Longhorns shirt on. It was evident that once he reached the water, he had tried to get his boots and clothes off so that he could swim. The current had pulled him as far as the Broadway Bridge before he drowned in the wintry cold river. Knowing that he had tried to get out made me feel sick. I shut down and sat back in my chair while Rollins told jokes about stealing silverware from celebrity parties and having his advances shot down by Sheryl Crow.

Why am I thinking about this story? Probably because I returned from a beautiful camping trip yesterday to find out that Robin Williams had committed suicide. I didn’t know him personally, but I feel so affected by the loss of him. I am saddened that another warrior and light-bringer is gone from the world. I also feel grateful that he has been released from his pain and struggle.

I know that my feelings around this recent suicide bubble up from old places, coming through dark and cold passages in my psyche. I am forced to breathe in my own struggles with trying to bring light into a world where I can so easily be affected by the darkness. I have to remind myself that every day, I am choosing to be here and the choice is one that I make in the faith that I still have enough light in me to make this world shine, or at least, a little corner within it.

A few days after Justin died, I went to the grocery store. I was so stricken by the experience that the world was literally colorless. I squinted at the false light everywhere: the horrible fluorescent tubes hanging from the ceiling, the too bright packaging on basic foodstuffs, the too loud laughter coming out of people who were clueless as to what had just happened to such a beautiful person and all of us who loved him.

The grief from his loss was stabbing every minute of every day. My own urges towards suicide were only staunched because he’d chosen to drown himself, a fate that I could never choose. As much as I wanted to follow him, it didn’t seem right to go out of the world by a different route and I couldn’t get over my fear of heights and cold water to make the plunge. Lucky me.

Some of his friends were angry. There was a lot of talk about how unfair what he did was. There were a lot of people asking how he could take his life when he had young children. People called him an asshole. I didn’t feel that because I recognized his pain, I intimately knew about his ability to numb and I recognized that he was sick. His illness was an illness that, if not caused by modern society, was exacerbated by it. There was no place for him to go for respite and neither of us knew how to break through the million stigmas or the bureaucratic nightmare to get help. I loved him more than life and beyond life and that is what I felt mingling with my grief.

He showed me that I have the capacity to love a person unconditionally, even when I feel that my heart is broken and my whole body is turning inside out. He taught me that not everything is about me and I can’t take shit (especially somebody’s suicide) personally, if I want to continue to live with health and hope.

Before Justin, I spent many hours imagining leaving the Earth and how much better it would be for everyone. I had lamented on how dark and awful everything was and how I would never be able to change it or make it better. Each day, I focused more and more on my own worthlessness and condemned my ordinariness and every way in which I wasn’t good enough. After I came to terms with the fact that I wasn’t going to follow him to the other side, I realized that I made a big choice and it was a choice I would make every day for the rest of my life: To stay.

I see how beautiful and vibrant Justin was, and Robin Williams was, and others that I loved were. The sensitive and caring souls, the warriors who feel a constant, nagging monster inside and whose energy goes to creating the light to fight it away. Every day, they activate the warrior inside themselves, to carry pain and darkness away, and those of us who know them reap the benefits of their brilliant power. The monster isn’t just inside though, it’s outside too, in a world that can be so cruel and so ugly. This problem is not an individual problem, but a cultural problem, and one person cannot fight it alone. An individual light is not strong enough, and eventually, it burns out.

Justin taught me is that I’ve got to spend this life trying to see the beautiful and amazing things about myself and about the world. He taught me to turn my sense of humor towards myself to make myself laugh and open my heart. I have to believe that I’m worth the effort of doing it. But I also learned that culture and society affect our Shen in drastic ways and if we want to address mental health, we must address the culture, rather than merely focusing on the individual.

I thank Robin Williams for the reminder. And to Justin, as always, I forgive you and love you. We all contain a piece of the divine.

When I first see this word, I want to pronounce it “pokey” like the delicious Hawaiian fish salad I used to eat while living on Kaua’i! In this case though, it sounds just like the poke in “poke somebody.” With it, I’m referring to that beautifully amazing plant that is plucked from my neighbor’s yards with agitation:  Phytolacca decandra. 

A few months ago, I was wishing for some fresh poke root to make an oil with. The residents of the few yards where I’d seen it last year had eradicated it. In one spot, somebody had removed a chain link fence and dug out their entire front yard to get rid of it. Most people seem to hate it, and it makes sense because it’s highly toxic. At the same time, it’s one of the best plants for moving the lymphatic system and it’s showing it’s worth against cancer cells that are dependent on hormones for their growth (breast, prostate, ovarian, etc.)

Though I’d given up, I visited a neighbor last week, and while we were sipping on some wine in the secret garden of her yard, I noticed the hugest poke plant I’d ever seen. I excitedly commented on it and she replied, “That thing? That would have been gone long ago if I wasn’t so lazy. I’m taking it out next week.” Poke root is best gathered in the fall or the spring (if you can guarantee that you’re actually gathering Phytollacca decandra) because at that time, most of the energy is in the root. However, this plant was going to be dug up regardless, so I asked her for it. She responded with an emphatic, “Yes! And take all the babies too.” At that point, I saw smaller plants, anywhere from 1-3 feet, covering the gravel walkway and invading almost every section of her backyard oasis. We pulled and plucked for about thirty minutes and I ended up with a big basket of root to take home.

I had enough to make a whole lot of both poke root oil and poke root tincture.  I use the oil to make a breast massage oil that helps to prevent tumors and cysts from forming. It works particularly well for fibrocystic breast conditions and mastitis. It’s also great when used on lumps and bumps that are related to lymphatic or circulatory congestion. I find that the oil works best when the tissue is fattier, while the tincture works best in a more muscular/tendinous region. Internally, the tincture is toxic. NO MORE THAN 2 DROPS (YES, DROPS) ARE TO BE TAKEN AT ONE TIME. This is one of the best and strongest medicines I know of, but I’m not going to go into internal uses in this post. The external uses are so extraordinary, and the oil is so easy to make, that it’s a good starting place.

The little dude and I worked hard to wash all the dirt off the roots. (Mostly, we wore gloves for this.) Then, we sliced the roots very thinly. The larger root was super hard to cut through, so we cut it into smaller chunks and ran it through my food processor with the slicing attachment. Once done, we put it on trays and let it dry off outside for about 4 hours. We didn’t want a bunch of water getting mixed in with our oil and making it go rancid. Because there was enough to fill three quart jars, we used a mix of olive oil, sunflower oil and sesame oil to cover it. In another three quart jars, we tinctured the rest.

In six weeks, we will have some awesome poke root oil. The oil can be used on it’s own or formulated into a nice oil like the one that Donald Yance uses in Herbal Medicine, Healing and Cancer.

Around five years ago, I discovered Lara Koljonen L.Ac’s organization, Essentially Pink. Ever since, I’ve been incredibly thankful and awed by the good work she does on breast health. Using the principles of East Asian Medicine, she re-designed the monthly rituals for women, helping to take us away from the negatively-infused concept of self-breast exams (touching the breast while thinking of disease) and towards much more positive practices. She teaches monthly lymphatic massage and weekly “Tulip Tapping.” These practices make it really accessible for women to increase the circulatory and lymphatic flow in their breast and stimulate and clear the channels. She sells three breast health products, “Boobies Brew,” “Boobies Butter” and “Dreamtime Detox.” The butter works along the same lines as poke root oil, to move the lymphatic tissue in the breast, but it uses castor oil to do this. 

We live in a pretty toxic world, but the plants we need to deal with it are rising up everywhere. So long as we pay attention and don’t continue to dig them up and spray them away, we have a plethora of solutions in our neighborhoods and public spaces. As always, remember to be careful in your gathering. As Rebecca Lerner posts on her site:

John Kallas, a Portland, Oregon-based botanist and foraging expert, offers the following safety advice: “Don’t gather within 4 feet of an old house because of lead paint. Don’t gather within 30 feet of a highway — and even then, preferably gather uphill — because of nickel and cadmium from the batteries, petroleum chemicals wearing off tires and washing off the side of the road, coolant, and gasoline. And never, ever, ever gather near railroad tracks. They’ve been putting pesticides and herbicides in those areas for the last 100 years.”

“Who Am I?” The question circled in my head, never finding it’s way out. It swirled in me from the moment I woke and grew bigger until it was time to sleep. As I crawled into darkness and dreams, it’s nagging would be eaten away by some more wise part of myself and I’d wake to a more bearable version of it. Nonetheless, as the days progressed, it gained momentum.

Chapter 1 of the Suwen, Shang Gu Tian Zhen, says that for a woman of twenty-eight, “The tendons and bones are strong, the hair is completely grown and the body is flourishing and robust.” At thirty-five years, “The Yangming vessel begins to weaken. The face begins to have a scorched quality and the hair begins to fall out.”

In thinking about the life cycles here, thirty-five seems to represent the time around high noon. The yang has reached it’s peak and all that is left is for it to decline. We know that the afternoon may be the time at which we feel the most heat, but behind the scenes, the yang is waning.

Here I am in my mid-30’s: a time where a person can look out onto life with the fullness of the light. Between the symbolic age of thirty-five and forty-two, we can survey the landscape that we have created. We are able to access a great deal of warmth as well. This “decline in the yangming” means that there is a turn inward, a more introspective focus, a taking stock of one’s life that is occurring.

For me, in the early part of this year it manifested as an existential crisis. While it was happening, I recognized it for what it was, but naming it did nothing to allay the search for myself. I could see the landscape of my life, in particular, my inner life, and I kept thinking that I could find myself in there if I just searched hard enough.

After six months of this, I was exhausted. I was taking herbs, but still suffered from insomnia, because the question haunted me and no herb could answer it. I discussed it with friends and care providers and no one seemed to know how to deal with it.

One day in April, I drove to the San Juan Islands with a friend to attend the wedding of an old buddy. I was on day three of a pretty gnarly case of food poisoning (avoid the rotisserie chicken at all costs!) and I slowly sipped kombucha as we waited in Anacortes for the ferry. Once on board, we took up four plastic green chairs and stared out the windows at the blackness of the cold night. I told my friend that I felt trapped in the black hole of a question around my identity and I just couldn’t find myself. She talked to me about more practical matters, like how unbelievable it was that she had forgotten her hat and gloves and how she thought she would freeze on the island. I resigned myself to listening as I realized that my thoughts were unanswerable and not great fodder for conversation.

The next morning, we had a breakfast of migas and Earl Grey tea, went swimming in the hotel pool and decided to take a nap before getting ready for the wedding. I laid down on the bed and put needles in myself, trying to calm my anxieties. While I was there, incapacitated by 34 gauge Seirin’s, my friend put her laptop on my belly and told me to check what time we needed to show up at the bar. After I did this, I lay there in an acupuncture induced stupor and thought, “I’ll just ask the Google oracle.”

Into the box, I typed, “Who Am I?” The first hit showed a 10-question Oprah survey that was supposed to report back on one’s personality type. The second, however, was much more meaningful. It was an article written by a psychologist who said that he sees a number of patients in existential crisis. He said that the “Who am I?” question poses significant difficulties, as we are not static beings who can somehow pinpoint ourselves. We are dynamic beings who are constantly creating ourselves and according to him, the better question to ask is: “What experiences do I want to have?” It is our experiences that define who we are and while we do not have control over everything we encounter, we can choose some of the events that help to shape us.

Over the next few months, I mulled this idea over with my brain. It certainly did seem reasonable, logical and justifiable. But, what would I do with it? Eventually, I started to get a glimpse of something deeper in myself, somewhere other than the grey matter in my head. I felt pulled towards something, somewhere, and I knew that I needed to leave the country and do some kind of relief work. I could feel an unsatisfied piece of myself that had to assert itself and be in the world.

I searched the internet again, looking in the Middle East, South America and Africa. I found a number of opportunities, but none seemed quite right. Eventually, I came to the Acupuncture Relief Project. This non-profit was started by two OCOM alumni, one of which was located in Vancouver, WA, not too far from where I live. My passport was about to expire and I had no childcare available for the foreseeable future, but I went ahead and applied anyway.

Andrew Schlabach scheduled an interview with me and we met at Townshend’s Tea House about a week after I applied. He arrived on a motorcycle with a jacket that had a Good Health Nepal insignia. We drank oolong tea for two hours while he asked me about my interpersonal skills, experience working in groups and history of traveling abroad (for which I have next to none.) After two hours, the interview ended and I was accepted for “Team C,” which I later found out will be at the clinic from January 5th until March 3rd.

I was immediately excited, but also scared about two things: One, I am expected to fundraise the amount it will take for me to fly to Nepal, pay for a medical-interpreter, travel to the clinic, my room and board and the clinical supplies that I will be using. This amounts to about $4500. Secondly, I will need to find affordable childcare for my nine- and two-year old sons for the two months that I am gone. In addition to this, the only time I’ve left the country was a one-month stint in Australia in 1993. I have no experience traveling in a developing nation, nor do I understand how to pack one small backpack for an 8-week-plus trip in rural Nepal with no heat, no electricity and no access to running water.

I am slowly navigating this process. The fundraising has proven to be difficult and is already causing me a good deal of stress. I would simply pay it if I could. I practice East Asian Medicine, part-time, doing mobile visits whenever I can. Yet, caring for my children takes the larger portion of my weekdays and requires a considerable amount of my energy. I don’t get paid for the child rearing work I do and right now, my family is struggling (with lots of love and home-cooked food) on one income, in a large city with a great deal of student debt.

The childcare situation is still working itself out and ultimately, it will simply have to work. It’s more a matter of my partner and I coming up with the $2000 for that piece of the equation. It seems that a number of newly graduated, non-parent practitioners, have tended to frequent the ARP scene in Nepal. A lot of these practitioners still have the option of financial aid to help with funding the trip and they don’t have to orchestrate the details that are required in leaving a family for an extended period of time. Leaving my family comes with it the additional risk of travel in Nepal, which does make me anxious, because I want to make sure I come back, healthy, as a wonderfully changed person, with all of the love that I want to continue to give my kids.

Signing up for this program meant that I would be taking a lot of risks. I have repeatedly asked myself why and tried to understand what it is about this experience that is calling me. I thought through every logical and rational reason why I should go to Nepal, especially when I was trying to put together my fundraising page. I will be treating 20-30 patients every day, and that’s going to make me better at my job when I get home. I will have the experience of being in a developing country and that will give me a bigger perspective on humanity, which will ultimately affect my character and help me to be better a better parent and healer. The list went on and on and while each item is true, I still couldn’t say that it was the major part of the reason that I was choosing the experience.

Today, I had an interaction that made this choice clear to me. In a silly way, it’s the experience of choosing the experience that is important. It isn’t practical for me, as the mother of young children, to choose to do volunteer work that takes me away from them for two months. It isn’t reasonable for me to choose an experience that requires me to go through the stress of fundraising a few thousand dollars or risk having to put myself in debt for it. A number of other things about this experience just aren’t logical, or more importantly, justifiable to the part of me that has gotten the main say for so many years.

The crux of it is that I need to go to Nepal because my heart desires it. My Shen is calling out for the experience and I don’t exactly know why, nor do I need to. Something about jumping off a cliff into the unknown seems to be necessary for the health of my spirit and for the openness in my heart. When this became clear to me today, I realized that I often squash the desires of my heart, I consider them frivolous and unnecessary. I ignore them. I debate with them. I tell them they are not as important as my practicality.

With this trip, I have decided to create myself as a human being who gives a little more weight to the desires of the heart. I have decided to let my heart share in the drivers seat and to experience what that feels like to take risks and to walk an unknown path. I want to know who I can be once I do this. By mid-March of 2015, I will. Until then, I will use this site to report my progress.

Last week, I wrote a post about maternal placentophagy. While it’s not a routine practice in America, I know of a few midwives and mothers here in Portland, Oregon who have begun to practice it. Portland Placenta Services claims that Traditional Chinese Medicine (TCM) has been using placenta for “thousands of years” and that the encapsulated placenta can be used to “increase scanty lactation and tonify Qi, life energy, after the birth. Today, many women look to placenta encapsulation as a natural way to even their hormones after birth and avoid postpartum depression.” PPS says that they “use traditional methods to gently steam, dehydrate, powder and encapsulate the placenta.”

In Aviva Jill Romm’s book, Natural Health after Birth: The Complete Guide to Postpartum Wellness, she states that:

In Chinese medicine, the placenta is traditionally made into a medicine to be taken by the mother in the days postnatally. Bob Flaws, in his book The Path of Pregnancy, writes: ‘Postpartum discharge and tonification can be facilitated through the use of the placenta…. The placenta is full of hormones and other biologically powerful substances. it is very potent and powerful medicine and should not be wasted.’

Although taking the placenta as medicine may not be everyone’s cup of tea, many of my clients over the years have done this and found it very tonifying. The following instructions allow you to dry and preserve the placenta as a powder, which, kept in a dark, cool environment, will keep for years. However the recommendation is to take it during the first week or 10 days postpartum until it is entirely used up.

My other post on placentophagy talked about how researchers can find no history (i.e. tradition) of human mothers eating their own placentas prior to the 1970′s. And, the only “traditional preparation methods” I can think of would be those listed by Li Shizhen in the Renbu chapter of the Bencao Gangmu. The late 16th Century text would be the oldest mention in a Chinese source. In most cases, the placenta is soaked for many days and drained of all blood with needles, then dehydrated and ground to a powder that is usually mixed with herbs. Even so, Mark Kristal has shown that the delicate amino acids and other constituents in the placenta will not retain their integrity once heated over 104 degrees F.

Ultimately, if the practice is positive or even neutral/placebo, that’s great! However, with the number of heavy metals and chemicals humans are exposed to on a daily basis, I worry that this may actually be a harmful practice for a mother (and her breastfeeding infant).  I have to ask:

What is the goal/thinking behind the modern use of placenta during the postpartum and what might be a better or safer choice?

Since there are no proven benefits of maternal placentophagy, nor a reliable account of traditional use in any world medicine (that I can find so far), I am compiling a list based on what I’ve read and heard. I think this covers the attributes given to placenta as a postpartum medicine:

  • Helps with “postpartum discharge” (retention of lochia)
  • Slowing and stopping hemorrhaging after childbirth
  • Balancing postpartum hormones
  • Increasing postpartum energy (replenishing iron levels)
  • Increasing milk supply for breastfeeding
  • Avoiding postpartum depression
  • Helping the uterus regain its pre-pregnancy state

For a healthy, well-nourished woman, many of these issues do not require medication after giving birth. Certainly, a woman who has social support as well as access to bone broths, organic well-prepared grains, nutrient-rich vegetables and healing fats should have the bulk of what she needs to replenish herself during the postpartum month. A spokesperson from the Royal College of Obstetricians and Gynecologists in England told the BBC that:

Animals eat their placenta to get nutrition – but when people are already well-nourished, there is no benefit, there is no reason to do it.

Obviously, Mark Kristal has shown that animals eat their placenta for more than just nutrition – it helps with pain relief and maternal bonding. But, humans (and camels) do not participate in this mammalian practice and researchers are working to determine why.

Social support is paramount in helping a postpartum women in understanding her new role as a mother, how to breastfeed her child, assisting with routine work done, etc. When there is support/education combined with nutrition, the new mother will be at lowered risk for postpartum depression and her body should heal well after a normal birth.

Taking placenta pills is not only unproven, but it’s simply not enough to address issues that go above and beyond normal levels for postpartum recovery. In addition, the postpartum placenta pill can satisfy our cultural urges for a quick-fix. For instance, numerous studies have shown that breastfed babies do not necessarily benefits over formula fed babies, due to a lack of nutrition in the mother’s diet. Western mothers often feel pressure to return to their pre-pregnancy weight quickly and end up avoiding a number of foods that would be nourishing for them. If these mothers think that they can get the same benefits by taking a low-calorie placenta wonder pill, they are even less likely to invest in the thinking and lifestyle changes needed to accommodate healthy breastfeeding.

Someday soon, I can go into more specifics about the postpartum recovery period, what each week after birth entails. For now, what do we do with these issues above?

Retention of Lochia/Stopping the Bleeding

In his 17th Century text, Fu Qingzhu Nuke, Dr. Fu recommended the use of Shenghua Tang in the postpartum. The Paojiang stops the bleeding while the other herbs move the blood and help to clear the uterus/lochia and any swelling. (Benson Huang, L.Ac, recommended that this formula can be used right away after a natural birth (no interventions), but that we need to wait for three days after a hospital birth so that any drugs are cleared from the system. If there has been a cesarean, it is best to wait seven days before the woman starts the formula.)

Another teacher recommends using SHT but said that for a more classical approach, a practitioner could look at Danggui Jianzhong Tang plus Taoren and Mudanpi. The DGJZT is going to help tonify the Earth and relieve pain. The Taoren and Mudanpi will move any blood that is stagnating in the uterus and reduce the swelling. I would probably add Paojiang as well – though I have tended to stick with the Shenghua Tang. Western herbalists use postpartum combinations of Capsella bursa-pastoris (Shepherd’s Purse) and achillea millefolium (Yarrow) to staunch bleeding and clear the uterus and the idea behind the combination is similar. If I were to go that route, I would likely add a bit of licorice to harmonize the formula and the Earth.

For the first week, the mother should be eating relatively light foods and avoiding heavy foods. Before tonification, the uterus must be cleared and the Earth organs allowed to rest. Putting undue stress on her digestion will result in delayed healing, fatigue, lowered production of blood and breastmilk, insomnia and many of the other disorders that placenta can supposedly treat. The body just went through a huge ordeal and it needs a little time to breath before supplementation can begin. This is really, really important, but it seems to get lost in the conversation sometimes. Here, think about highly nutritive bone broths with some very overcooked grains and possibly some easily digested and well cooked vegetable soups. I have used simple congees, miyuk gook, peanut jujube soup and warming fish or chicken soups. The mother should avoid hard-to-digest foods such as muscle meats, raw vegetables and overly fatty substances. The foods chosen are going to be different depending on the season, the constitution of the mother and how she’s doing afterwards. 

If the mother shows a more severe yang deficiency that cannot wait, consider Danggui Shengjiang Yangrou Tang.

This is a time of rest and the mother needs to concentrate on keeping a quiet mind (guarding the Shen), nurturing her baby and making sure she is getting plenty of sleep and fluids.

Lactation/Building Blood

This is a huge topic that will require it’s own post. However, as noted above, it’s not simply the quantity of breast milk, but the quality, that matters. I love the way that Hilary Jacobson breaks it down in Motherfood, though it’s based on Ayurveda and not East Asian medicine. She identifies the three Ayuvedic constitutions and the issues they tend towards (people can be a mix of any of these types). It helps me think about the three main problems with the blood like this:

  • The more Earth-Water type (earth in Ayurveda, kapha) tends to be able to produce enough milk and high quality milk, but if social support is lacking, this type can run into problems with apathy and depression. The blood needs to be light enough to house the Shen. Laughter and joy give lightness to the blood, social connection and support are highly important here.
  • The Wood-Fire type (fiery in Ayurveda, pitta) person tends to be highly active (sometimes excessively), drinks a fair amount of alcohol, craves spicy foods, etc. This type may have issues with the quantity of blood but more defining is the toxicity/quality of the blood. Babies breastfed from these mothers can tend towards colic. The blood needs to be high-quality and free from toxins. The Spleen and Stomach need to be functioning well to make this happen. The liver is a major player in the quality of the blood. 
  • The Fire-Metal type (airy in Ayuveda, vata) person tends to be more intellectual and reliant on thinking. This person is the “least vital” of all the types. They are very changeable, with bursts of energy and sudden bouts of fatigue. The nervous exhaustion that can come on in the postpartum is a characteristic of this type. The milk supply for this constitution can be quite low. The vessels need to be filled with high-quality blood so that they can overflow to make milk. Again, the digestive organs need to be functioning well to make sure this happens. The person needs to avoid over-thinking and reserve their energy.  

Placenta pills are just not enough to cut it for some of these issues. A woman needs to modify her behavior, her lifestyle and her diet to include foods that are replenishing for the digestive organs. Depending on her nature, other recommendations to build the blood or clean the blood can follow, as well as meditations, exercises and social recommendations.

Building the blood can be as simple as a couple of cups of blackstrap molasses “coffee” each day, or it can require complex herbal formulas in addition to dietary and lifestyle changes. As stated above, a healthy woman would do well to eat only light foods the first week after birth (to allow the digestive organs to rest and regenerate) and to follow that with traditional food recommendations. These continue to include bone broths, fish congees, miyuk gook and warming chicken soups as well as Sangjisheng egg, lotus soup and red yeast rice cakes.

An avoidance of things that deplete and toxify the blood is very important. This includes alcohol, overly spicy foods, GMO foods, sugar, fried foods, meat imitations, highly processed foods and commonly allergenic foods until it is known that the baby can tolerate them (eggs, soy, dairy, etc.)

Iron

Once the mother’s spleen function is looking good and the baby has shown that she can tolerate some of the more allergenic foods, boost the iron with eggs, dark leafy greens, prunes, meat, chickpeas, lentils, fish, pumpkin seeds, quinoa, etc. Tofu is made with shigao and can be considered too cold for a newly postpartum woman. However, tofu skin (the film that rises to the top while the milk is boiling) is neutral in flavor, high in protein and delicious in soup, while being much easier to digest than tofu itself.

All of these foods work well for replenishing the mother’s energy, but more must be done. The mother must have a good social support network. If she is estranged from her family, this can be difficult, especially if she has a hard time asking for help and doesn’t have the money to pay for services. A new mother needs at least a month off from house work and worries other than her new baby. Worrying and overworking herself will further deplete the spleen, resulting in blood deficiency and toxicity.

In our modern world, it’s easy to become overstimulated by technology. A new mother might post pictures of her new baby on Facebook and then check in often through the social network, especially if she isn’t getting a lot of “real life” support. The stomach channel begins at the eye and we can think about the myriad of ways in which we drain ourselves through the eye – television, reading, social media, playing on our Smartphones, etc. In addition, some of us tend to overthink or become really passionate about ideas or possibilities. All of these things take energy from our digestive function and draw on the resources in our blood in order to feed the overworked brain. A new mother can work to find a meditative state that is more heart-centered and heart-feeding, that builds the blood while it allows her to slow down and focus on her baby and her own healing. Our modern lives are fast-paced, and we tend to sleep too little and think too much. Taking placenta pills three times a day won’t remedy this. We have to change our behavior to keep our reserves strong and add to our energetic bank accounts.

Hormonal Imbalances

Taking care of the digestive function is foremost in every condition listed here, including hormonal imbalances. During pregnancy, the placenta is producing high levels of progesterone. Once the placenta is delivered, the progesterone levels drop and a woman is left in a state of estrogen dominance. Progesterone tends to elevate the mood, while estrogen dominance can result in fluid retention and mood related symptoms. If a woman is following a healthy postpartum diet (good fats, organic fruits, veggies, whole grains and high quality protein) with plenty of fiber, drinking plenty of water and avoiding caffeine, sugar and alcohol, her hormone levels should regulate themselves. Estrogen is excreted through the bowel when it attaches to fiber.

Kombu and kelp can be used to relieve hormone imbalances, if a safe source can be found and they are prepared in a way that warms them for a postpartum mother (like miyuk gook). Soups made with angelica sinensis (danggui) root are very effective for regulating hormones and Danggui Shengjiang Yangrou Tang can be considered if there are signs that an imbalance is not righting itself.

Postpartum Depression

Again, a number of posts can be dedicated to the topic of postpartum depression. There are too many formulas that are too varied and individualized for me to list them here – though ultimately the idea is typically to calm the Shen, smooth the liver, tonify the digestion and kidney, promote sleep and build blood and energy. A Western combination of herbs could be used to do this as well. If postpartum depression is an issue, it’s going to take more than placenta pills to remedy – as it requires individualized treatment and social support.

It seems to me that there are a considerable number of options for us, as EAM providers, that do not rely on placenta. In fact, after typing just this small percentage of remedies out, I realize that placenta pales in comparison to the other resources that we have!

 

Earlier this week, a friend forwarded a New York Times article to me, asking if I’d read it yet. It was an interesting read that focused on the microbiome of the placenta and whether or not it plays a role in the development of an infant’s gut bacteria. I was almost inspired into writing up a blog post, but I got sidetracked, as usual.

A few days later, Sabine Wilms posted some thoughts about the placenta on a Facebook page.  She wanted “to clarify the use of human placenta in the context of postpartum recovery in classical Chinese medicine.” She pointed out that placenta is not mentioned in the Jingui Yaolue (Han Dynasty, 25-220AD) nor the Beiji Qianjin Yaofang (Tang Dynasty, 618-907AD.) This got me to thinking about the many health care providers and mothers I know who recommend the practice.

I have heard and read many times that “maternal placentophagy” (whereby the placenta is eaten by the mother who birthed it) is a practice dating back thousands of years in China. These types of claims are repeated over, and over, and over and over, across the internet. In lesser cases, people or organizations claim that general placentophagy (which just means that the placenta was eaten by somebody, at some point, after the mother birthed it) has been going on for hundreds or thousands of years, implying that there was an ancient practice in which human mothers ate their placentas. With the veritable void of research on the topic, it seems easy enough for misinformation to spread across the human sphere like wildfire.

On the advice of my natural health care provider, I had my placenta encapsulated with my second son in 2012. I actually experienced negative effects while taking it, that included muscle fatigue, a minor tremor and mood swings. Taking it may have contributed to problems with my milk supply. In the time since, I’ve heard and read similar stories from other women, though of course, this is all anecdotal (and individuals respond differently to medicinals -which is why we individualize our treatments in EAM, right?) Even so, these types of experiences have prompted me to wonder:  In a mess of unreliable information combined with a lack of research around maternal placentophagy, how do we know how to best advise our patients on this matter?

Maternal placentophagy does not seem to be found in any of the Classical texts of East Asian medicine (that we have found so far). We have no record of it’s use in the Shennong Bencao (~200 BC), Zhang Zhongjing’s Jingui Yaolue (~200 AD) or Sun Simiao’s Beiji Qian Jin Yao Fang (7th Century). Li Shizhen lists it in the Bencao Gangmu (1578) in his chapter on Renbu, but it appears to be used as a medicine, whereby it was thoroughly cleaned of blood, dried in the sun, pulverized and mixed with herbs (except in the case of an eye wash) and then served to somebody other than the mother.

I find no mention whatsoever about the use of placenta, postpartum or otherwise, in Fu Qingzhu’s Gynecology text (17th/18th Century). It is mentioned in Miao Xiyong’s Shennong Bencao Jingshu (1625and said to be “a medicinal that tonifies dual deficiency of yin and yang, with the ability to restore the root and return the primal [qi]” (Bensky, Clavey, Stoger). Zhang Luzhuan mentions it in the Benjing Fengyuan (1670) and Zhao Xuemin tells us in the Bencao Gangmu Shiyi (1800) that it treats emaciation and facial pigmentation. Again, none of these authors appears to mention a woman eating her own placenta. Instead, it is treated as a medicine that is used to treat disorders of people other than the mother. It is possible that a postpartum mother might be the recipient of one of these medicinals, but the point is that placenta is not a general tonic that is given to all postpartum women after birth. It seems that it is never mentioned as a substance for postpartum tonification in the Classical Chinese literature.

Mark Kristal has been studying maternal placentophagy since the 1970′s. I am not very excited about the ethics in his research, since it involves torturing a vast number of animals. (I believe we can use more creative methods that define our human character in a more positive way.)  However, due to the lack of research in the field, I am including some of the more important points he has made here.

Kristal showedwith rats, that there is a biological mechanism behind their consumption of both amniotic fluid and the placenta. When rats lick their amniotic fluid during birth, they get a dose of something his team termed Placental Opioid-Enhancing Factor (POEF). The POEF works as an analgesic, reducing the pain that the animal is experiencing during labor. In addition to this, his team noticed that the consumption of amniotic fluid and placenta by the mother helped to initiate the mothering instinct towards the newborns. This idea can be used with rats who have never been pregnant, to help them initiate mothering behaviors (to adoptee rats) sooner than they normally would. The mechanisms of all of this are quite interesting and you can read more about them in the article, Placentophagia in Humans and Non-Human Mammals: Causes and Consequences. At the end of the article, Kristal tells us:

The complementary question to “Why do mammals eat placenta at parturition?” is “Why don’t humans eat placenta at parturition?” Strictly speaking, if placentophagia is not a biologically determined behavior in humans, we should assume that there must be a good adaptive reason for its elimination.

Wait, but haven’t humans been eating their placentas for hundreds, if not thousands of years (in China) like all these people are saying? The answer is a big fat NO, according to Sharon Young and Daniel Benyshek. In 2010, they searched the Human Relations Area Files database that has been kept at Yale University since 1949. The purpose of the database is to contribute to an understanding of world cultures by offering a forum for the collection of cultural, behavioral and background information on peoples across the world. At the time that Young and Benyshek did their search, they looked at the 179 cultures currently in the database for any mentions of maternal placentophagy. Here’s what they foundOnly ONE record in the entire search mentioned the practice of maternal placentophagy.

“One Anglo mother, known by two midwives, was reported to have roasted the placenta and supposedly received a surge of energy after its consumption.” Given that the description of maternal placentophagy refers to an “Anglo” mother in the U.S.-Mexico borderland, and, due to the lack of additional corroborating accounts regarding the practice in the larger Chicano literature, the description may be a reference to the recent practice of placentophagy as advocated by some midwives in Mexico and the U.S. first noted in the 1970s, rather than a longstanding Chicano tradition.

Of course, Kristal pointed out William Cowper’s observation that “Absence of proof is not proof of absence.” Yet, why is it that the routine practice of fringe activities that go against major taboos (like cannabalism) can be found in the database without any other mention of maternal placentophagy? If some human culture on Earth had practiced it, would it not be easier to find than routinely practiced cannabalism? According to the search, what do humans do with their placentas? They bury it (55%), put it in a specific location (14.8%), incinerate it (9.4%), hang it in a tree (8.3%), discard it to be eaten by animals (7.7%), use it as medicine to be given to somebody other than the mother later (1.8%) or wrap, hang or or symbolize it in some other, unique manner (3%). Of the 4000 known land mammals, every species practices maternal placentophagy except for camelids and humans.

Although the placenta is known to be readily and eagerly ingested by nearly all other mammalian mothers, including our closest primate relatives, few, if any known human cultures appear to promote or allow its consumption, even in a ritualized context. We suggest that, in the face of many detailed ethnographic descriptions of cultural beliefs and practices regarding the placenta, including its proper treatment/disposal, the lack of a single unambiguous account of a well documented cultural tradition of maternal placentophagy is good evidence that it is absent (or at most, extremely rare) as a customary or learned practice in human societies cross-culturally, and that its postpartum consumption by the mother may even constitute something akin to a universal cultural avoidance.

Taboos against placentophagy seem to be more universal than taboos against cannibalism. Why would human beings have such a homogenous cultural avoidance to this behavior? Kristal put forward a possible theory in his article. It’s based on Desmond Morris’s theories in The Naked Ape. Morris argues that non-procreative sex in human beings happens to satisfy social bonds - those bonds being a large piece of why humans have known such success on the planet. Kristal postulates that perhaps by not utilizing the analgesic effects of the placenta through consumption, a mother makes herself more reliant on her social group for assistance during the birth, which has the additional benefit of helping to ensure the successful birth of an infant with a large head size (in comparison to other mammals.)

This theory is interesting, but in my (anthropologically uneducated) opinion, it’s a big stretch. At this point, until we have more research into why human mothers have traditionally avoided eating their placentas, it can all be one whack theory after another. But, in a 2012 article, Young, Benyshek and Lienard put forward a pretty amazing supposition. I imagine that it took a few beers for them to come up with their idea, and it is also a pretty big stretch, but it’s a more believable stretch, at least for me. More importantly, their idea brings with it some pretty strong potential health implications that health care providers need to consider.

THE FIRE HYPOTHESIS

(I am still lost in the awesomeness of this idea and imagining the three authors camping out next to a river somewhere. One of them is cooking a hot dog on a stick and the smoke keeps following her as she tries to find a nice place to breathe. And viola! The solution to why human women do not eat their placentas! Ha!)

The absence of human placentophagy, the maternal consumption of the afterbirth, is puzzling given its ubiquity and probable adaptive value in other mammals. We propose that human fire use may have led to placentophagy avoidance in our species. In our environment of evolutionary adaptedness, gravid women would likely have been regularly exposed to smoke and ash, which is known to contain harmful substances. Because the placenta filters some toxicants which then accumulate there across pregnancy, maternal placentophagy may have had deleterious consequences for the overall fitness of mother, offspring, or both, leading to its elimination from our species’ behavioral repertoire.

While cooking with fire substantially increases the availability of energy and can eliminate many pathogens and toxins found in raw foods, open fires also increase exposure to specific environmental metals and other toxic substances through smoke inhalation.

If I go back to my college bio classes, I remember all those cool bits about natural selection and this theory starts to make some serious sense. It’s simple, right? If we participate in a behavior that impairs our ability to reproduce (or more importantly, to live), that behavior will be eliminated through a die-off of those who practice it.

The placenta acts as a filter between mother and child and there are a few heavy metals that scientists know it tends to filter out completely. This means that it becomes a sponge for some types of toxicity. And, as we know, toxicity can affect the reproductive organs.

Unlike many other metals, cadmium, inorganic mercury, and trivalent chromium are trapped by the placental barrier in pregnant mothers and accumulate across pregnancy.

Due to natural processes in the prehistoric world, heavy metals were released and uptaken by plants that humans then burned for warmth and cooking. The authors surmise, from modern day scenarios, that women were particularly vulnerable to smoke inhalation and thus, incurred a build-up of heavy metals in their bodies. Cadmium buildup, in particular, can affect the reproductive fitness of an individual. The Fire Hypothesis paper lists several research studies showing cadmium to have a negative impact on the production and function of reproductive hormones. It also acts as an endocrine disruptor. Smokers tend to have high levels of cadmium buildup in their placentas and the authors have used smokers as a modern day analogue for their study.

Since cadmium has a long half-life of about 20 years, multiple births in which the placenta is eaten, in addition to accumulation from chronic smoke exposure, would cause increasingly higher accumulations of the metal before the mother’s body would have been able to excrete significant amounts of the toxicant.

Under such circumstances, consuming this now heavy-metal-laden organ could then have caused damage to the mother’s health, and the health of her offspring through breastfeeding, since breast milk contains approximately 10% of maternal blood levels of cadmium, and eventually threaten the long-term reproductive fitness of mother, offspring, or both.

Regardless of whether The Fire Hypothesis is true, it points us to some problems around the consumption of human flesh, especially when we are talking about an organ that acts as a filter. We live in a world where we even healthy people cook in teflon coated pans, use new PVC piping for our water transfer, have lead paint chipping off into our outdoor soils, drink from bleached paper coffee mugs, eat foods stored in BPA coated cans and go inside buildings that are off gassing chemicals. While we may not cook over wood fires anymore, we do live in close proximity to roads and freeways, where we are subject to the pollution spewing out of automobiles. And from over us, jet fuel rains down into our water and soil.

Harvard published a study in 2011 that measured 87 environmental chemicals in 2000 pregnant women in the Faroe Islands (Denmark). Almost all of the chemicals were found in both maternal and fetal tissues. The same year, UCSF looked at almost 300 American women, and found BPA, lead, cadmium, flame retardants, rocket fuel  (perchlorate) and other chemicals in their tissues. We still don’t understand the full role of the placenta, nor all the constituents that it includes. What is highly likely is that human beings have avoided maternal placentophagy for a good reason. In the modern day, it’s more important than ever that we look at the toxicity in the foods we are eating. In addition to our toxic exposure, we are at the top of the food chain, eating animals who have concentrated any chemicals that plants are up taking.

Is it really in the best interest of mother and child for a woman to consume human flesh, in particular, a filtering organ, while she is attempting to recover from pregnancy and breastfeed a child? Based on the information that I was able to find, combined with the number of food, lifestyle and medicinal tools that we have at our disposal, I really can’t justify recommending the practice. As we begin to understand more about the role of the placenta and why humans have avoided it (until the 1970′s in America), I may change my opinion.

How can we address postpartum tonification through food, diet and lifestyle?  I’ll investigate that more next week.