Office Hours with Angelique and Toby, episode 7. Released August 1, 2025. 30 minutes.
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About this episode
Toby Daly and Angelique Britt start light, with what they wear in clinic and why, then turn to joint pain in the Saam framework: tracing the channel the pain follows, weighing heat, swelling, and blood stasis, when those qualities take priority over the channels around the joint, and what to reconsider when early improvement fades.
Toby explains how he uses a patient's response over roughly three acupuncture visits to decide whether herbs are needed and how to tailor the formula, and the two compare raw herbs and patent formulas, including displaying herbs and lending herb cookers. They close with running a sustainable clinic: assistants and trial shifts, swings in patient volume, protecting recovery time, and Sun Simiao's advice to keep a small heart and a large gallbladder.
Topics
What to wear in clinic
Joint pain: channel trajectory, heat, swelling, and blood stasis
When early improvement fades
Using acupuncture response to guide herbal prescribing
Raw herbs versus patent formulas
Clinic assistants and trial shifts
Patient volume and sustainable schedules
Sun Simiao: a small heart and a large gallbladder
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.
Sun Simiao (孫思邈): Tang dynasty physician and author of Qian Jin Yao Fang, known for his teachings on medical ethics.
Blood stasis (血瘀, xue yu): impaired circulation of blood, often associated with fixed, stabbing pain.
A note for listeners: this is a conversation between licensed practitioners, offered for education, not as medical advice. Patient details have been kept general to protect privacy.
Transcript
This transcript was generated automatically from the published audio and lightly edited for readability. It may contain errors in names and terms.
Welcome to Office Hours. Whether you're new to the acupuncture profession or have been at it for decades, this is the place where we discuss all things Chinese medicine and more. Join Toby Daly, a seasoned acupuncturist of the Saam tradition, and Angelique Britt, a nurse-turned acupuncturist who is brand new to the field as they explore topics in and around the world of acupuncture and Chinese medicine. There's something for everyone here. Drop in anytime. I'm doing pretty good today, Toby. How are you doing?
Toby: Hey Angelique, how are you doing? Everything's going pretty well with me. I was gonna ask start off asking you a really practical clinical question. Do you mind? Sure.
Angelique: A little scared, but let's go.
Toby: Okay. I think this is not a scary one. What do you wear in clinic and why?
Angelique: I wear scrubs and I like scrubs for multiple reasons. One is it helps me transition from my role as a human being person, mother, all the things I do at home, into being a professional. It's almost it's like, you putting on a uniform. And the other piece that I like about it is that I'm not at all worried if it gets gross. So if I end up getting balms or salves or something gross on me, it doesn't matter. I'm not really worried or thinking about my clothing at all. And there's no decision. It's like it's one less thing to have to decide in a day. I have several sets of black scrubs and I just grab a set and go in the morning. So it's easy in that way as well.
Toby: D w what about for your patients?
Angelique: I think I think it helps in a medical profession to wear medical appearing garb, but I only have the experience of having been a nurse working in hospitals and home care where scrubs were a requirement. It weren't they weren't optional. So I think that's also a part of my comfort level with it is that it's something I've worn for a very, very long time. And so in a medical professional role it's comfortable. But I do I think I think that patients equate scrubs and medicine and security. As long as they don't have some kind of medical trauma attached to scrubs. I think that could go the other way, although I haven't encountered that yet. But it's possible.
Toby: Okay. Yeah, I th I think it's it's so interesting how we present ourselves, right? Because we don't have a longstanding role in this culture, right, acupuncturists. So it's fascinating. I've wor I've worked with so many different acupuncturists, right? From shorts and Tevas, right, to like shirt and tie with a white coat and things like that. So I just always think it's really interesting. How acupunctures dress because we don't have a full dress code that you were expected to have and then the reasons for it. So anyways, th thanks for sharing that. I think that's really interesting. That's a that's a good reason for scrubs for me. That's a good argument because I don't like to think about what I'm gonna wear. So that's I'll I'll consider going in that direction. All right. What about your clinical work right now? Any especially outstanding challenges or successes with your clinical work?
Angelique: Trying to think I don't think I have anything super remarkable in terms of remarkable cases, successes, failures. Nothing is coming up for me at this particular time. I've had a lot of orthopaedic cases lately, and those are admittedly not my favorite. But it actually reminds me of a question that I wanted to ask you about Som and Pain, which is I have shied away from treating pain with Som. I was treating a woman that had knee pain with good effect for a couple of weeks and then it seemed to stop working. So I probably I'm gonna take the blame and the hit here. It was probably a misdiagnosis issue, perhaps, but it just seemed to kinda wear off. And so I and then they had the case that I talked about a few episodes ago with the carpal tunnels issue where the fist she couldn't make a fist after I did wrong I did the treatment on the channel that I shouldn't have. But found out it was the wrong channel through doing the treatment and then reversed it and it got a little bit better. So I've kind of shied away and I've stuck to the orthopedic style needling I learned in school as well as traditional Chinese medicine style acupuncture. So I'm curious how you approach like if someone comes into you and has, you know, they've sprained their ankle or they have shoulder pain, you know, what how you approach it with some and how your efficacy has been versus going in like Directly needling into the joints, etcetera.
Toby: Yeah, I still use the framework that my teacher provided, right? Sometimes channels, sometimes quality. So let's say sprained ankle, right? If it's swollen, if it's hot, th those are the qualities and then all the channel trajectories and the counterbalancing channels that are going through the ankle. I tend to have the patient wherever the most pain is, I like I like to have them trace it wherever you know, over wherever the pain is and that helps me to I tend to for pain cases. To focus on the patient telling me exactly where the most pain is. That's where I like to start use if I take a channel trajectory. So basically for treating ankle pain, you know, we probably have eight different channels that we can choose from based on the channel trajectory and the qualities through there. So I always just base that. I wanted to ask you about for that pain that was helping with the knee pain and then it started to not work. Were you rotating different channels and it still didn't work or were you kind of We're tending to do the same things.
Angelique: I was I was rotating so this person had medial knee pain and so I was kinda going I went back and forth between at the liver and the spleen and then one day she had more lateral knee pain and so it was more on the stomach channel but didn't seem to last as long as when I used electro. So when she was one of my first patients from back in the early aughts of months ago and I felt really confident about electro and treating knee pain because I did a bunch in the student clinic at NESA and so I went right for the electro And had like supremely good results with that. And then I got brave with her. And as I was embarking further into the Saam journey, I was like, let's try this thing. And it worked great. I think it was like three weeks. I think I was able to do each of those channels. I think I did spleen, liver, and stomach, and I'm not sure if I did it in that order. Based on what her other imbalances are. She tends to be a lung excess type person. But it was after whatever the third one was, and I can't remember it. She was kind of like It didn't really work.
Toby: That third one was a new channel you hadn't taken before, like that's the first time you supplemented the stomach?
Angelique: I think so. I'd have to look back to know for sure.
Toby: But that's but the usually the problem is then you if you keep going to the same thing, definitely it stops working. Usually you were doing the right switching to different channels, but I think maybe you're just missing something. Like if it's i extreme pain and sometimes even if it's not on the kidney channel, then supplement small intestines fantastic for that. You know, if there's there's a lot of heat involved, supplement bladder can be really helpful, things like that. So it's not like you were really focused on the channel part. Maybe if there was some other qualities, do you remember?
Angelique: The pain as was more of an aching and the medial knee and it was worse going downstairs and she liked to walk in the woods so when she had to traverse roots and things that was causing her discomfort there. And the knee itself was warm. I remember being normal color, you know, she runs a little on the pale side. Kind of puffy in general, a little on the puffier side. So with that being said, did not consider doing Well, I don't think I could have she's I was did I supplement no. Yeah, it was a little on the puffier side. Sorry I'm being a little tangential 'cause I'm trying to remember if I supplemented large intestine for her ever. Anyway, she was puffy and but not like edema, like just she kinda had a puffy quality to her flesh in general. So the knee itself was kind of puffy. There wasn't anything descript along the medial knee that I could find. It was tender on palpation. Like around liver eight, I remember that, and again around spleen nine.
Toby: Before that you worked with the spleen, did you did you supplement large intestine or supplement spleen, do you remember?
Angelique: I think I think I did I think I did large intestine for her. I'd have to look back if we're being totally honest. Yeah. I know that I worked with those channels. There was the spleen channel, the liver channel, and the large intestine I'm sorry, the stomach channel. And I know I know that for the stomach channel sh for I did supplement stomach 'cause she's more of a lung excess person. And I can't remember if I s I think I know I wouldn't have supplemented spleen for her because of how damp on the inside she was. So I think I probably did the large intestine at one point, if I'm thinking back correctly. And then for her, she tends to be more on the Sanjiao excess side versus liver excess side. So I'm almost positive I did a Sanjiao supplementation. But I can't remember which one was effective and which you know what I mean? I can't go back and remember to be able to clinically discuss this with you. So my apologies there. I should bring my little tablet with me. So yeah, I just What are you saying? What are you what are we getting down to here?
Toby: I would s I would still recommend anyways, always w whatever y is most effective for the patient, that's the top priority for us to do. But from the Saam perspective, right, it's possible supplementing small intestine or supplementing bladder might have been helpful for that. Small intestine to move any kind of blood stasis through there and a bladder to bring that heat down. Sometimes we as we bring down inflammation, that can be a really long standing effect for pain, especially in the joint.
Angelique: That makes sense. Would you do bladder even for somebody who tends to run cold constitutionally, like if they were kind of chilly?
Toby: Yes. Especially in the summer and especially if the knee itself felt hot. So
Angelique: When so when you're evaluating when you're evaluating let's say joints because people come in with the joint pain. I know with the back you look at kind of what shoe the pain's near. And I've been I've done back pain with some better than I have with joint pain. Do you find basically you just whatever channels are surrounding the joint, you narrow it down to those and then try to find whichever imbalance fits best, whichever is most out of balance among that collection of channels. Is that your approach generally? Or what do you do?
Toby: Yes, and then if it feels cr if the joint feels crazy hot, then sometimes I'll just ignore the channels, right? And then just focus on supplementing UB or maybe even liver, even if it has nothing to do with that joint. I if I feel like it's it's just really warm, that's the grossest thing in that in the around the joint pain. Or say there's like a whole bunch of varicosities around it, then I'll kind of ignore whatever else is going on and then supplement the small intestine to deal with any of that blood stasis. So D if the if the quality that's presented in the joint is really gross, then I go for that. Or sometimes the channel the patient will they have no idea about acumoncture channels and they'll trace exactly the channel for where the pain is. They'll say the pain's just along this channel. And so then for me then that really tips me towards working with the channel. Either that channel or the counterbalancing channel for the for the one they just traced.
Angelique: I've that happen. I often have people t show me like where that hurts and have them do that very same thing with the tracing and that's been super helpful in that regard. Just be like, of course. Like a lot of people like will trace their gallbladder channel perfectly inside of their leg, you it's like it runs down here. Thank you so much. It's like a channel.
Toby: Yes. Yes. I feel like they've they've studied a textbook just before they came in to sh to show us. But yeah. Yeah. I feel like I feel like it's really valuable. You and I were talking a little bit offline too, about treating monastics and monastics tend to be able to trace things really clearly on the channel. So we have to take that into account too. They're so they spend so much time in meditation that anything that's going on with their body, they can really you know, tell us in minute detail where it's going on. So sometimes that's really helpful, but also that can be sometimes pull us off. Regular lay people, right? If they trace the channel, fantastic. Then that's a good sign. Sometimes monastics, right? No body aware that they c they can show us exactly the channel. Sometimes with the low channel coming off it, i it's amazing. So but anyways that has a little bit less clinical weight if you end up working with monastics because they're they're aware their body awareness is so high.
Angelique: So another question that I that I had for you, Toby, especially now as I'm preparing like to go forward with my raw herbs. Like I've actually got them I'm starting to grind them. I've got patients asking for herbs. Like I've got four different patients that I can think of right now that very much want to take the raw herbs that I have. And I've been kind of dragging my feet a little bit. If we're being honest, both because I'm a little afraid. And because of the amount of work that I it's currently taking to get them ready for the raw herb dispensing. I'm curious how many how do I ask this, how often you use herbs with your patients? Does every patient have an herbal component? Do you use it for a quarter? And how do you decide? Yeah.
Toby: I have some basic frameworks that I work. Then I always do like a little bit of flexibility, right? I don't have to follow this, but in general, what I like to do is I like to see a patient for three acupuncture visits. Based on how the response to those three visits, then I'll prescribe herbs based on, you know, if they respond really well but on all the way to Assam treatment, then I know that they can really hand cool in supplementing blood. Say for example I supplement liver. It doesn't resolve everything, then I'll I'll I'll c incorporate that into the herbal formula. Or like let's say I supplement heart and it really helps but it doesn't resolve all the way, then that opens up like foodsa formulas for me and things like that. So it's really guiding for me, how they respond to acupuncture. I remember during COVID I was just treating a whole bunch of new patients and at that time I was only dispensing herbal medicine. I wasn't seeing anybody in the office. And it was I At that moment I realize just how much I rely on that, how much I rely on the patient's response to acupuncture to help guide my herbal prescribing. Because again, it's it's all kind of theoretical to you put those needles in and see how they respond. So normally what I do is I see patients three acupuncture visits and then a lot of times things are resolved. If it's resolved it's resolved. If not, if there's anything still lingering. Then I've seen them partially respond to some of those ideas. So I tend to translate that into classical formulas and then prescribe that. That's that's my basic idea. So in general, I would do like this three acumuncture visits, herbs for two to three weeks, and then check back in. I would s consider that like a course of treatment, like a standard course of treatment, something like that. Okay. Yeah, do you do you want to ask me any specific questions about that?
Angelique: Do you use raw herbs? Do you use patents? Do you use both?
Toby: Yeah, everything. So I do raw herbs. I use a lot of locally grown Chinese herbs, so I can use that for raw herbs. And then I use those same raw herbs to make tinctures and then I have a lot of patents. I tend to use a lot of like classical pearls or sun tan. That's my main patent ones.
Angelique: How frequently you're using the patents. I have found it challenging. I got a stock of patents when I first started, so I thought I'll just start there with patents, you know how they had us do that in school. So I was like, Yeah. But I was struggling to f I wasn't I don't know if it's probably just the whole newness of it, but I was having a hard time like folks weren't exact weren't fitting up weren't fitting the pattern enough that I felt confident enough to describe a patent. Do you know what I mean?
Toby: I try to talk patients into raw herb formulas because that I feel like that's we have the most control between swapping herbs in and out and dosage. I feel like we can just put w whatever they need, we can put that, you know, if you don't mind a baseball analogy, right? Right across the plate, right in the strike zone, right? It's fantastic. And then patents, I think about gets into the into that ballpark, right? So it's it's it's in that area, those ideas. But like a raw herb formula, classically based with modifications, I feel like, wow, we can really dial that in. And then I try to make it so it's enticing for the patients to want to do cook raw herbs. I know it's so much extra effort. So the setup I have at my clinic is when patients first come in, my assistant's assembling herb formulas right there on that table as they come in. So every patient as they come in the clinic, they often see my assistant making formulas. So I've heard from other colleagues it's hard to for them to you know, you know, have people cook raw f herb formulas. But especially you come in and you see like, you know, seven trays of r these amazing herbs, almost everyone's curious about that. And they often ask me, when can I get something like that? So I feel like that's a inadvertent marketing for herbs thing. People coming in and seeing these raw these beautiful You know, with some local raw some locally grown Chinese herbs, you know, just beautiful formulas being made, they kinda wanna get in on the action. So that tends to be really helpful. And sometimes they're even eager to take the raw herb formulas before even before I give them the three acupuncture treatments. So yeah, it that goes well. One other thing that I think really helps with me for cooking for doing the raw herbs is I loan out electric cookers so that it basically cooks it for them. So we sign out a herb cooker for them, they cook their formula with it. Whenever they're done with their formula, they bring that cooker back. So that seems to be work really well. Displaying the herbs and then giving them a cooker. Some patients just will refuse, so that's where the tinctures of the patents come in. Mm-hmm. Okay. Great. And this is something I k I know you're just getting started, but just to put in your back pocket, This would be fantastic at some point to get someone to help you out in the clinic. You can do a one man show for a while, especially getting started, I think it's great, but then consider going forward getting an assistant. It's so valuable to have somebody else take money, make arrangements for the patients, give you a little buffer between the patients to write the my assistant, you know, takes calls in real time, which almost no you almost can never get an acupuncturist on the phone. So my assistant does. If it's something really urgent, she'll come get me even when I'm in the treatment room. So I can answer things right away. So i it's really valuable again, nothing to rush towards, but it's really valuable to get an assistant. And then, you know, just monetarily too it's nice because then your assistant could be making up formulas while you're seeing other patients. So it becomes a little bit A little bit more affordable, right? I if they're actually putting, you know, they're raw herbs, you can make you can charge more for knowing what the formula is and putting it together and then that can offset your cost for having an assistant.
Angelique: Yeah, I would love to have somebody at some point someday. Just how do you how do you go about finding that right person?
Toby: My method for finding the right person is luck, right? And so trying a whole bunch of other people and then really lucking out on somebody good. My assistant's fantastic. She's been with me now for almost fifteen years. She's been fantastic. But I had a lot of assistance that did not work out well before
Angelique: So how long of a trial period do you tend to did you give people the ones that did not stick? Like how long did you before you knew that it was like this isn't this isn't gonna do it?
Toby: I'm I'm not a great manager of other people. So I gave those people way too long time and it's quite a few major mistakes and major problems. I had one assistant that was more work to manage the assistant than I could have just done everything myself and that went on for months, before I had to f let that person go. I'm I'm not a great manager. That's what I was saying. My method is luck, right? Just finding somebody amazing and just being lucky out on it. I in general if people are thinking about doing this, I think it's great to g there's almost everyone agrees like interviews are useless. Because you can so easily fool people can do anything they you know, put a inc incredible presentation for forty-five minutes or however long that interview is for. It's best to bring somebody in temporarily into your office. I did that a little bit before when my assistant just wasn't available. I brought two people in and told them it was just a really temporary thing for one day. And in that day I could really tell. One was amazing, one needed a lot of help. So then later on when I need when I needed help, that person that was amazing I was able to bring back. So I think yeah, that's a great th it's impossible to know in the interview, but bring somebody in temporarily and if they work out amazing, then you can hire full time. You know, if you if you can manage something like that.
Angelique: Solid advice. I've got to I've got to make sure that I'm full up enough in terms of patient visits to be able to substantiate it. I've I'm I've let's see, I've hit twenty six patients in a week. Closer to twenty. So that's good. Great. Yeah, that's good. But I think I need to get s fuller before I can say, let's come on in. Let's hire some help. I have I have my son helping me.
Toby: Fantastic.
Angelique: One day a week sometimes, you know, if it's gonna be particularly busy and he does the checking in and checking out and dealing with the money part and w cleans the beds, does that kind of thing. That's helpful just to have that minimal you know, that little bit of extra breathing room and not having to deal with, you know, treating somebody and then being like, Ann How would you like to pay today? You know, having to be the salesperson part of it also
Toby: Yeah. I was gonna say one other thing too. Just don't forget the for your clinical work, it tends to come in waves like that, right? So like you crested with twenty six and then now back to twenty and then it'll go thirty, right? And then might even go down to like thirteen for a week. But just th that you should you should expect that. I remember I spent a lot of my first year or two panicked that I didn't have enough people and then panicked I had too many people. So just there's gonna be ebbs and flows for that. So when you're really busy, try and put stuff aside and not do it. And then knowing that there'll be a little bit of an ebb, and then you'll be able to get all those things done that you were gonna do. So yeah, try to hopefully that's comforting. Nobody told me that, and I was just like, my god, I'm overwhelmed. My god, no one's coming, overwhelmed, no one's coming, and it was so th those i if you have a typical office it'll be like that, those c those kind of ways.
Angelique: No, I appreciate that. I that's it's nice to hear that's normal, that things ebb and flow and they come and they go. And you just gotta ride the wave. It's yeah. I it's it's so hard to fathom being panicked for having too many patients. When that day happens, if I'm lucky, you'll be the first to know. Great. Right now I'm just I'm grateful that I have, you know, enough of a stream of new folks that as other folks complete their course of treatment there seems to be some replacements. So it's it's sustainable, do you know? It's sustainable at this time where I can pay all my bills and I can pay myself some and so it's as long as it maintains and kind of increases, I'll I'll be all right. And that three day a week schedule, mint. I love that so much. It is so nice to be able to go into work for a clinic day and then give everything that you got and then not have to worry about that for the next day. And so like for example, today is my admin day. So I go to yoga class in the morning and then I come home and I do a bunch of administrative tasks, reconcile insurance and all of that baloney. And then well this Tuesday now we're doing this, but then you know, usually I'll yeah make dinner for my kids. I did that before now. I just it's a much more relaxed pace and I know tomorrow, okay, I'm gonna go in and I'm gonna see a full day of patients. Wednesday seems to be my busier day, so I think I've got 10 patients booked for tomorrow. And I'll go through and I'll do that and then I have Thursday where I could just be it's there's just there's there's a lot of comfort in knowing that there's rest after that I don't have to do consecutive days. That's great. Highly recommend.
Toby: Again, th that's from my teacher, Dr. Wu, that model. I found it amazing for myself. And I don't know any acupunctures that work like five or six days a week that are really successful, right? I think it's just too exhausting this work. You have to chunk it out like that.
Angelique: Now you see if other medical professions were that way as well, you know? Like if there was more of if there was more of a break in that way, if things were scheduled for nurses, for example. Like sure, you can do three twelve hour shifts, but you don't always have agency around when those shifts are and if they were spread out it probably would be better. I don't know. I just think if there was more space in general and giving pr in caregiving professions in particular, I think there'd be a lot better outcomes overall for everybody. If people weren't having to crank out so many patients per day and having to do it five days a week.
Toby: Those professions are famous for burnout, right? So that's I mean, obviously it's not working. But w we have this sev several millennia of ideas about self cultivation and doing things in season. Also I tend to like in the summer see patients much later in the evening and then I really pull that back in the winter, right? Again, just to reflect Chinese medicine understanding of our energy, right? Much more energy in the summer, so you can go later when it's still bright, everything's nice. Whereas it starts getting dark at five, it's really nice to be out of your clinic by
Angelique: I like that. That's also a nice way to do it. I'm going to give that very serious consideration 'cause I stay until six and then on Wednesdays sometimes later because I've got a couple of patients that like to come later and it's okay, like you said, it's light outside. But when it starts getting dark it's gonna be a drag to be at the clinic. 'Cause of course there's always the breakdown cleanup part, so you're there past you know, a little ways past your last patient anyway. So leaving the clinic at seven, seven fifteen might be a drag in the winter.
Toby: The nice thing is you have full control of your schedule too. Again, there's no hospital to negotiate with, right? You can decide, so it's really nice. And again, that I just slowly implemented that and I loved it. Because I yeah, I used to be at the office till eight, eight thirty at night in December and I hated it and I thought, I better since I'm in charge here, I better I better make things a little bit better. Angelique, anything else you want to discuss today?
Angelique: Think so. Is there anything else that's on your mind in particular?
Toby: Yeah, I wanna I wanna ask you what are the two things that Sun Sumiao recommends every practitioner should have?
Angelique: What are the two things that Sun Semia recommended? That every practitioner should have? Lord, I don't know.
Toby: He said everyone every practitioner should have a small heart in a large gallbladder.
Angelique: A small heart and a large a small heart and a large gallbladder.
Toby: Yes. Why do you say that, Angelique? Do you do you know much about Chinese culture to s to know what he was meaning?
Angelique: No. I could guess but no.
Toby: This fits in well with the psalm system too, right? So for the large gallbladder, that's courage and decisiveness and being a little bit aggressive in the clinic to really go after things. And then for the psalm system too, we say someone has a small heart, heart deficient, then they're really cautious. So he felt like practitioners should have these two qualities depending upon what's presented in front of you. Right. If you're sure and you really gotta help that patient, then that gallbladder should come on. If you're so unsure, you gotta be really careful and slowly go. Again, case by case, each one of those organs dominates what needs to be done for the patient. So he felt like e each practitioner should have those two qualities in them.
Angelique: I like that. That makes sense.
Toby: It's really guiding for me. Okay. Let's leave it there for now. And I'll put on the screen if I can figure out how to do it, the email if anyone wants to get in touch with us about anything. Otherwise I appreciate everyone's time, spending a little bit of time with Angelique and I. Okay, everyone who take care, okay? Bye for now.
Angelique: Yes, good to see every. Take care. Bye.
