Office Hours with Angelique and Toby, episode 32. Released October 28, 2026. 26 minutes. This episode is sponsored by Classical Pearls.
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About this episode
Acupuncturists Angelique Britt and Toby Daly talk through the business and the bedside of a Chinese medicine practice. Angelique explains why she stopped accepting MassHealth and other Medicaid plans, how she transferred those patients to nearby practices, and what late cancellations and no-shows cost a solo practitioner. The two compare cancellation policies, discuss the hard step of discharging a patient who repeatedly misses appointments, and reflect on starting a practice from scratch.
The second half turns clinical. Angelique describes a patient with long-standing insomnia whose sleep, and rosacea, shifted most when she was treated on the bladder channel in the Saam tradition. Toby explains how he chooses between two Classical Pearls sleep formulas, Peace Pearls and Spirit Pearls, and how Heiner Fruehauf changed his view of Fu Zi (prepared aconite). The episode closes with a patient facing a third recurrence of colorectal cancer who hopes to avoid surgery and further chemotherapy. Drawing on her years as an oncology and hospice nurse, Angelique offers a framework for that conversation built around the patient's own goals.
Topics
00:00 Introduction
02:00 Leaving Medicaid plans and transferring patients
04:08 Late cancellations and practice policies
05:55 Training patients on cancellation rules
08:05 Discharging a patient after repeated no-shows
09:59 Bringing on a new practitioner without a top-down model
12:05 Starting a solo practice
14:09 Surprising outcomes in clinic
16:11 Insomnia, the Saam tradition, and the bladder channel
19:50 Peace Pearls, Spirit Pearls, and Fu Zi
22:06 The Classical Pearls clinical reference guide
23:53 A patient with recurrent colorectal cancer
25:51 Patient goals, quality of life, and hospice principles
Key terms
Saam acupuncture (舍岩): a Korean Buddhist monastic acupuncture tradition that treats imbalance on one channel system at a time, using combinations of the five transport points.
Sanjiao (三焦): the "triple burner," one of the six fu organs and its channel.
Fu Zi (附子): prepared lateral root of aconite, a warming herb in the Chinese materia medica.
Suan Zao Ren Tang (酸棗仁湯): Sour Jujube Decoction, a classical formula for insomnia from the Jin Gui Yao Lue.
A note for listeners: this is a conversation between licensed practitioners, offered for education, not as medical advice. Fu Zi (aconite) is toxic if improperly processed or dosed and should be prescribed only by a trained, licensed herbalist. Anyone considering changes to cancer treatment should talk with their oncology team. Patient details have been kept general to protect privacy.
Transcript
This transcript was generated automatically and lightly edited for readability.
Toby: Thanks so much to Classical Pearls for sponsoring this episode.
Angelique: Tomorrow is the last day that I'm accepting MassHealth in my practice, like all the Medicaid plans. It's a bittersweet situation. On the one hand, I don't have to deal with the administrative piece of it anymore: keeping track of referrals, dealing with no-shows and late cancels, and all of that. Not to mention that the compensation's not the best. But if I could have eliminated all of the administrative part, I could deal with the reimbursement. Quite honestly, it would have been fine. So that's the silver lining. The hard part is that it closes the door to some folks, because they don't have the access. For folks on Medicaid plans there's no copay; it's essentially free for them. There are usually twenty visits per calendar year, with the ability to advocate for more. For example, there's a patient I've been seeing for over a year now, almost every week, for chronic pain and other issues that have responded really, really well to acupuncture. They're going to go to another practice, but I will miss that person. So there are some patients I'm going to lose that I'm going to miss.
Toby: At least you have practitioners near you that take it.
Angelique: Yeah. There's one practice that takes one of the plans, and another practice that takes all of them. So I referred most of my patients to the practitioner who took all the same plans I did, just for ease of transition. Some of the other folks I sent to the practice that takes one of the plans, to distribute them evenly so I wasn't dumping a bunch of people into one practice at one time.
Toby: That's a nice way to do it. How did you make your final decision?
Angelique: I got really frustrated with so much of it: having to keep track of payment, having claims denied, not having any recourse with patients who late cancel or no-show, because one of the rules is you can't charge them. I'm a small practice. It's just me, and I have a limited number of spots. So I was starting to feel the hit of late cancels with no recourse. For everyone else I have a late cancellation policy; it's fifty percent of their fee. I know you think I should increase that to the entire fee. Maybe I will at some point. I remember there was a day where I had three late cancellations, and that's three patient spots I couldn't fill. So I had to make that decision.
Toby: You really tried. For me, late cancellations drive me insane. But with Stephanie, a late cancellation means we take a hundred percent of the fee. And a lot of times, if it's that day, we have a wait list, so she just puts somebody else in. It's actually financially really great if somebody late cancels.
Angelique: Well, one day when I grow up to be like you, I can do that too. There are some people on my wait list, and a couple of times someone has late canceled and I've been able to slot somebody right in. But I don't have a continuous wait list every day that I practice, so that happened to be a day where it didn't work out.
Toby: But it's nice financially, right? You collect the full fee for the late cancellation, and then you get to see another patient in that slot too. So it's win-win.
Angelique: I think I'll have to get frustrated before I change my policy.
Toby: It's also great for training patients. Stephanie just lays down the rule: you have to cancel within twenty-four hours, otherwise it's the full fee. Everyone knows that. Someone might do it once or twice, and then they realize we're serious. That really trains the patient. Then everything else moves around their acupuncture appointment, rather than swapping the appointment out for something else.
Angelique: Does she collect a credit card at the time of booking?
Toby: For some patients she does. Otherwise, when they come back to reschedule, she charges them for the missed appointment and that appointment.
Angelique: So if someone you don't have a card for drops off the radar and never comes back, you don't get the fee.
Toby: Yeah, that's possible too. But someone who no-shows and then doesn't pay for it, that's a nice filter for your practice too.
Angelique: That's true. It's a hard thing. I had a patient situation where I had to, how do you say it, fire a patient. I don't know if there's a better term for that.
Toby: It's called patient abandonment.
Angelique: Firing a patient is called patient abandonment?
Toby: I think if you do it wrong, it's called patient abandonment. My bad for assuming, sorry.
Angelique: No, it was a patient who had multiple late cancellations and a couple of no-shows. I have a three-strike policy in place, and I had given them way beyond that, and had face-to-face conversations with them. They would sometimes arrive twenty minutes late to their visits, and at one point I sent them away because I couldn't treat them; my schedule had gotten more full, so I didn't have the wiggle room I had initially. I was direct but kind. I was frank that it's a disservice to them and a disservice to me to show up late or late cancel, and I said I'd been really lenient with my policy, so if it happened again I would put them on same-day booking. I didn't boot them fully out of the practice. If I had an opening that worked for them, they could have it. They wrote an email asking for more leniency, and I said they could book the night before. I moved the bar slightly, and that's as far as I could go, because it had happened so many times. I felt badly, because I knew the person was having a rough time, and it was also a pattern that kept repeating. I didn't enjoy that experience, but it helped me stick to my guns a little more and value my own time a little more, because I tend to be a sucker about certain things.
Toby: It's a tough balance, right? You want to care for the patient, but if they don't let you care for them, you have to do something. How did it end up?
Angelique: I let them know they could book the night before instead of same day, and I just never saw them again. I had referred them to other providers and let them know who else they could see. I was kind about it. I explained that it was hard for me, and I'm sure it was hard for them, but this is what I need to do to preserve my livelihood. I don't have an acupuncture empire. It's just my own little self.
Toby: Not yet.
Angelique: I have no desire to have an acupuncture empire. Colleagues have shared stories with me about places they work where I feel for the business owner in a big way: hiring people off the street and dealing with whatever comes. I have no desire for that. The acupuncturist who will hopefully be joining me sooner rather than later is someone I know; we've known each other for a little while, and she's a really wonderful person. The way I'm going to do things is not "you're working under me, so you have to do all of these things." She'll be working for me, but I'm trying to give her as much agency over her work-life balance as possible. I'm not requiring scheduling every half hour. She can see however many patients she wants, however many days a week. There will be some minimum, because taking someone on adds overhead like the electronic medical record and payroll. But I won't be cracking a whip or creating stress beyond what's inherent in being a new practitioner treating patients on your own. I'm trying to do it a little differently from what I've seen others do. I don't want a million people working for me with me as the boss. At least not now. But life does weird things, and things change.
Toby: From my experience, being a solo practitioner is the ideal situation.
Angelique: I remember you sharing that with me. Initially I was going to start with another person and rent space, and that didn't work out. You said it was probably the best thing that could have happened, even though starting my own business from scratch was stressful at first.
Toby: Starting your own practice is horrible initially and then great as you go along. Working for somebody else is really easy at first and then probably gets horrible as you go along. You jumped in with both feet into, I think, the best possible model.
Angelique: So far it's been working out. Removing insurance plans was scary, because I had seen many people on those plans, so it was a leap of faith. I didn't know whether I'd end up half full. But as I've found in life, when you take leaps forward with faith and work hard, things seem to work out. I ended up with an influx of patients who pay cash or have the other private insurance plans I still take. So I've been fortunate that the hand has risen up to catch me.
Toby: That's great. People need care, and if you can provide good care, they will seek you out. It sounds like you're getting that reputation, and that will serve you for the rest of your career.
Angelique: I care a lot, and I think people feel that. I've got a lot to learn. And I still have anxiety every day driving in. This is real talk. Am I going to know what to do? Am I going to know how to take care of people? Seriously, every day, because I've got about a forty-minute drive from where I live out in the woods. It's this odd little psychological battle: is today the day everyone comes in and says nothing helped? Sometimes people do say that, but the vast majority report some benefit, and I find myself surprised. Does that ever happen to you still, or does it fade at some point? I'm like, whoa, really?
Toby: I'm still surprised at times. It's amazing. We're always trying to knock it out of the park, but sometimes something has been there for a decade, and then it just dislodges and resolves for the patient. Maybe surprise is the right word. I'll have a prognosis that something will take this much time, and sometimes it just sweeps away. The patient and I are both pleasantly surprised. It's amazing that biology can turn on a dime like that.
Angelique: It's pretty wild. There's a patient I've been seeing for insomnia. I'm hit or miss with insomnia. I'm better now that I'm doing Saam, because it works really well for insomnia for a lot of people, though not everyone. There's someone I was striking out with who didn't like the Saam style and wanted to go back to a more conventional Chinese medicine style. But this particular patient was getting maybe four hours of sleep a night for about a year. She overworks quite a bit and has a very radiant presence, very loving and caring, very heart excess, but also sanjiao excess, kind of both. Just a lovely person. The first time I treated her, she wasn't presenting as heart excess. She was telling me all the details of her life, down to the minutiae, and I thought, she needs liver. So I treated liver and she slept really well for a couple of nights. We also talked about sleep hygiene, because acupuncture alone can only do so much if you're staying up all hours or engaging your brain too long before bed. The second time, she came in a bit irritated with some gallbladder channel neck pain, which was a thank-you gift from the Saam gods: okay, let's treat the pericardium. So I supplemented the pericardium, and that helped. She was having incremental gains. Then one day she came in with a flare of rosacea. Her face was redder and she was warm, but she's also just a very loving person. It dawned on me that she needed a bladder channel treatment, so I did it. When she came back, she said there was something different about that treatment. The redness was gone from her face, the rosacea was much better, and she talked about how much better she slept and how easy it was to fall asleep. It clicked for me. She'd gotten some gains from liver and some from pericardium, but with bladder there was a big shift. That's probably what I should have treated first, had my thinking cap been on.
Toby: It's so interesting. I feel like two or three visits in, I suddenly realize what their body's been trying to tell me. It's been shouting at me, and then I'm like, okay, I got it now. It's always fascinating. I remember reading a study that humans sleep much better when it's cold. So if you can cool off that inflammation and agitation inside with bladder, they can drop into a deep sleep.
Angelique: Is bladder in your repertoire of channels you consider right away when people come in with insomnia?
Toby: I'm not sure I'd say that. My experience with insomnia so far is: whatever the biggest gap is, close that, and they sleep better.
Angelique: That's the thing with the system in general. Whatever the biggest gap is, close it and it helps.
Toby: Yes, but especially for insomnia. With some other things you have to close the small gaps first, but with insomnia there's usually something gaping. Especially four hours a night for a year; that was a big thing that needed to be closed.
Angelique: Is there a Classical Pearls formula you use for folks who come in with insomnia?
Toby: They have two main insomnia formulas, Peace and Spirit. I feel like Peace has a little more punch. It has Fu Zi in it. Spirit is a little calmer. So if the patient is really exhausted and can't sleep, Peace is really good. If they're a little agitated, Spirit is a little better. Have you used either one?
Angelique: I've used Spirit for one patient who was having a lot of anxiety related to sleeping, and it helped some. I'm wondering if I should have used Peace. So that's for empty heat rising, and you give them a big dose of Fu Zi in the Peace Pearls?
Toby: I'm not sure it's necessarily empty heat. They're exhausted. They're so tired that they can't sleep.
Angelique: So it gives them a little energy to be able to sleep.
Toby: Yes. I think people can push so far that they actually lose the capacity to sleep. They're so exhausted that they don't have that mechanism available. That's why it's such a valuable formula: Suan Zao Ren Tang plus Fu Zi. I don't think I would have come up with that on my own. It's really nice to have that in Classical Pearls.
Angelique: Can you talk a little about Fu Zi for those of us who might be nervous about it?
Toby: I was taught in Chinese medical school that it would kill you if you took it yourself or gave it to patients. Dr. Fruehauf really changed that around for me. He even uses it with heat conditions. He has another formula called Guan Yin Pearls that he uses for hot flash presentations, and it also has a high dose of Fu Zi. He feels that high-quality Fu Zi, especially from the region where it's traditionally grown, is enough to bring, in his words, the energy back into the battery. In school, everyone said prescribing Fu Zi was like killing your patients, and using it in a heat condition like hot flashes was completely foreign. But those strategies are really helpful. Some postmenopausal women with debilitating hot flashes are releasing all that energy and losing it all the time. A Fu Zi based formula can help lock that back in, so they're not harassed by the heat. That heat is good heat, and being able to pull it back into the battery, as Dr. Fruehauf says, can be really valuable.
Angelique: That's good. We talked about the book last time: the clinical reference guide, which has a great description of each formula along with indications and applications. I use both the spiral-bound copy you can purchase from them and the free ebook. I have the ebook on my computer and leave the hard copy at my office, so on a home visit I've pulled up the clinical guide in people's homes. When I visited you, that was the book we were looking through, where I was describing the patient profiles and thinking, my goodness, I recognize this person in this formula. It's a really great reference.
Toby: I don't know if you remember, but my physical guide is falling apart because I reference it so much.
Angelique: Do you have lots of notes in there from all the continuing education you've done?
Toby: Yes. It's been a really valuable guide, and I highly recommend it. I'll put a link with the YouTube version if you're interested.
Angelique: The ebook is free to download, and the printed reference guide is, I think, about fifteen dollars.
Toby: Highly recommended. Okay. I have a patient who contacted me yesterday with colorectal cancer. It was originally resolved with several rounds of chemotherapy. Then they found a metastasis in the liver, which has been treated, and now the original colon cancer has returned. Going forward, the only option they have is surgery with an ostomy bag, and they're really trying to avoid that. They reached out to ask what I might be able to offer. Let's say that reached your office. How would you handle it?
Angelique: Someone who wants to avoid chemotherapy or surgery?
Toby: Surgery and another round of chemotherapy.
Angelique: These are the moral and ethical dilemmas. So the tenor of their question is, can you help me avoid chemotherapy and surgery for a colostomy?
Toby: Yes.
Angelique: I was an oncology and hospice nurse for a long time, so I'm familiar with what chemotherapy does to people, and with the whole ostomy experience. I would probably tell them that there likely isn't something I could do that would replace proceeding with treatment for what sounds like an aggressive cancer. I wouldn't say the word aggressive, but I would imply that this is a third recurrence and this seems to be what's going to save your life. I'd want to ask about their feelings around the ostomy and whether they've had any education about it. But I don't think I could in good faith say, absolutely, come in, get some acupuncture, take some herbs, and don't get surgery and chemotherapy. I feel like that would be detrimental, although I know how hard both of those things are for people. It's a tough one.
Toby: I think that's similar to how I'm going to manage it. I want to see them in person and talk about it. Then we can gauge how opposed they are, and maybe I can educate them a little more. It's nice to be outside the oncology clinic, where the patient can talk more freely, and I can just listen. But it's basically the same as you: there's no guarantee. Especially with a second recurrence. Coming back like that after all those rounds of chemotherapy and the original surgery, that's technically aggressive.
Angelique: I probably wouldn't say aggressive to them, but I think talking in person is good. I might pull in some of my hospice nursing, not in terms of talking about end of life, but because one of the main premises of hospice care is identifying the patient's goals. We identify patients' goals for care when we're giving acupuncture, but in terms of their life: what is most important to you? What do you want to accomplish? What do you want to do? Is this a younger person who might live the rest of their life with an ostomy bag, or someone older? What are their concerns about the ostomy specifically? Do they know that certain things exist, like opaque ostomy bags that help manage odor, and ways to make it less conspicuous? A lot of times folks imagine the worst-case scenario, which is totally normal. I'd find out where they are with that, and help resource them back to the people in their oncology network who know this well, because they don't always talk with the social worker, though there's usually one involved. Probably more of the visit would be talking about things like that. But I couldn't in good faith say, let's just do acupuncture and herbs and hope, unless someone says, I'm not doing this, and I'd rather do something than nothing.
Toby: That's really valuable for me. I didn't have a framework like the one you've developed. Is your goal to never have an ostomy bag, or is your goal to live? That's a big fork in the road. It would be good to discuss that in person.
Angelique: Totally. Cancer is scary, and I get it. They've been through chemotherapy before, so they know what they're getting into. It can be rough.
Toby: It's not theoretical for them.
Angelique: Yeah.
Toby: Thanks so much for the "what's your goal" framework. That will be really valuable.
Angelique: Sometimes, depending on age and goals, not treating is okay too. I know that's controversial, because our society says you need to treat and do all the things. But there comes a point where it's quality of life over quantity of life. Has there been a conversation about prognosis, the likelihood of success, the likelihood of recurrence? If someone says, I really don't want to go through this kind of treatment anymore, and they're more in the realm of palliative or hospice care, then okay, let's do the best we can with what we've got in Chinese medicine. And if you do choose treatment, Chinese medicine can be a great adjunct to help you manage some of the symptoms, maintain some of your resilience, and deal with some of the side effects. It's a tough conversation.
Toby: Thanks so much for that framework. Let's leave it there for today. It's been great talking with you.
Angelique: Good talking to you. Sounds good. Bye.
