What Does a "Right-Sized" Practice Mean?

As I've been building my business, I keep running up against a wall: my clinic can't look like the traditional clinic. And, instead of questioning the wall itself, I kept judging myself for falling short.

The wall is the way our profession "normally" runs. For acupuncturists, it's higher volume (two or more patients an hour), a receptionist at the front, several rooms running at once. Sometimes it's having multiple practitioners. Often, it's expecting a full-time income from clinical work alone.

There's nothing wrong with that model, necessarily. People run it well and love it. But if you can't meet it, where does that leave you?

The Standard Isn't the Standard

I want to show you some numbers that I wish someone had shown to me sooner.

NCCAOM ran a Job Analysis survey in 2024 with over 4,400 licensed acupuncturists responding. Here's some of what it found:

💡 Only 31% of respondents spend 40 or more hours a week in clinical practice. Everyone else is below that line. And note how low the bar is: the report counts anything under 40 hours as part-time (which is a strange standard for a job where you're on your feet with your hands on people all day).

💡 In 2023, 22% of respondents grossed $25,000 or less as acupuncturists. Another 17% grossed between $25,001 and $50,000. Only about one in five grossed over $100,000. And that's gross - money before rent, supplies, insurance, and everything else.

💡 Of the 3,066 respondents not working full-time, the top reason was personal preference (44%), followed by family obligations (26%). "Other" came in at 23%, and the most common write-in there was retirement, semi-retirement, or teaching. Only 21% said the reason was not having enough new or returning patients.

Just think about that last one for a second. Roughly four out of five part-time acupuncturists are not part-time because they can't fill a schedule. They're part-time because of the rest of their life, or because they chose it.

So the busy full-time clinic that comes up when you google "is acupuncture a good career" describes about a third of us at most, and the six-figure version describes about one in five*.

(*The survey respondents also cluster heavily in a handful of states, with California and New York alone making up 22% of respondents, and those markets look nothing like mine in Iowa.)

What Happened in My Clinic

I realized quickly after starting my practice that seeing multiple people per hour wasn't going to work for me. I physically don't have the mobility to make that happen, and I mentally don't have the capacity to task switch that often and still provide good patient care.

And, I don't have support staff to pick up where I fall short. More people per hour means more laundry, more admin, more cleaning. I can't afford support staff without higher volume, and there simply aren't other acupuncturists to hire in Des Moines even if I wanted to.

But here's the part that took me longer to admit: I also like it this way. I like not rushing from room to room. My patients appreciate the extra few minutes here and there to slow down and chat. I don't want to manage people, and I don't want employees.

For a long time I blamed myself for not being able to stretch to fit the imagined standard - I still lapse into that feeling sometimes! But, the longer I practice, the more I realize I can (and should!) build my practice around what I can actually do, rather than punish myself for something that just can't exist.

So What Does "Right-Sized" Actually Mean?

A right-sized practice is one designed to fit the capacity you actually have, rather than the capacity you'd need to match somebody else's clinic.

That's it. It isn't a smaller version of the real thing. It's a different design entirely.

And I keep using the word designed intentionally, because it's a practice that you have purposely created. Most of us end up somewhere in between: we picked a few things on purpose and let the rest accumulate. Right-sizing is the work of going back through and deciding which parts were choices, evaluating what is working, and slowly beginning to divest the things that aren't.

Three Budgets, Not One

One day, I had a bit of a lightbulb moment that shifted my mindset around how I allocate my time and energy.

We talk about capacity like it's one tank. You're out of energy, or you aren't. But when I actually looked at how I was feeling during the week, I wasn't out of all my energy. I would be exhausted from appointments, but still have energy to write. I could have a certain number of hours of follow-up appointments, but throwing in new patient appointments left me more tired - even with the same number of contact hours.

So, I've started to think about my capacity as at least three separate budgets:

• Physical. Using my hands, mobility, standing, turning over rooms, laundry, cleaning. This energy is spent per treatment, but also in maintenance tasks. It also is slow to refill and requires physically resting; short breaks are necessary, but also won't replenish things completely.

• Social. Being present with another person, holding their state, being "on." I use this energy per conversation, not per hour. Longer visits usually mean more talking, so four long appointments can cost me more socially than six short ones would, even though six sounds like more work. It also takes more social energy to work with new patients than return patients, so appointment type matters too. It refills with time alone, not with physical rest.

• Mental. Thinking, writing, planning, problem solving. I can do this type when I am alone, doing asynchronous work, on my own schedule. This also requires recharge time, but taking rests throughout the day usually helps give me more to work with.

I also noticed that some of these pull in opposite directions. For example, six short appointments would be harder on my physical budget and easier on my social one.

I also started to notice that my capacity wasn't the same in each category. I max out my social budget long before I max out my mental one. My physical budget puts a hard cap on my patient hours, even if I have more mental energy. And my mental budget still had room at the end of most weeks, but I wasn't using it on appointments because my other capacities were maxed out.

And, if you're neurodivergent, this may show up in subtle ways. Overspending my social budget doesn't feel like tiredness at the time; it feels like overstimulation on the day of, and then exhaustion a day or two later. This made it very easy to misattribute, and I'd blame the wrong thing and adjust the wrong lever.

Once I started thinking of my capacity this way, I was able to explore different streams of income that match my existing capacities, rather than continuing to try to squeeze more from a non-existent budget (and running myself into the ground).

Streams as Strategy

Here's the part they don't tell you in school: many acupuncturists build their income from more than one place, aka they have "multiple income streams." There are so many possibilities - and once you recognize them, you'll see it in others' practices too. Here are just a few examples:

• Teaching, in person or online, in higher ed or in the community

• Coaching, live or asynchronously

• Renting out space (sublets)

• Bringing on independent contractors or employees

• Consulting and/or mentoring

• Retail, including making products

• Writing, including books, freelance, and other routes

• Research or other work in higher ed

• Corporate events, or providing services in other settings

And, some people keep another job entirely, either because they want to or because they need to, and that doesn't mean they failed. (Remember that NCCAOM study? It reported that 12% of part-timers have another healthcare job and 9% have one outside healthcare.)

Once you can see your capacity budgets separately, you can start seeing the list of additional streams of income as a list you can actually strategically choose from. The question changes shape. Instead of just "what else could I add" and trying all the things, it becomes:

• Which of my budgets has room at the end of the week?

• Which of these draws on that budget and mostly leaves the others alone?

• What does this stream cost me on a bad week, not a good one?

Writing is nearly all mental. Subletting has almost no ongoing draw on any capacity once it's set up (if you pick the right person!). Teaching in person hits all three capacities at once - which doesn't make it a bad choice, just one that needs planning around if you have lower capacity in a certain area.

That's the difference between diversifying because you're scrambling and diversifying because you are being strategic. Sometimes we may need to pick up things that take more of our capacity than we'd like, and that's okay. But, over time, we can become more and more strategic about what income streams we pick.

The Honest Clinic Math

To be clear: lower clinic volume does mean lower income. That is obvious. If we have lower volume in our clinic, for whatever reason, we will likely need to find a way to make that income up in another way.

Raising your rates can help, and if you haven't looked at your rates in a few years, you should. But there's a point where volume is the constraint and changing your pricing can't reach it. This is the point I found myself at in my clinic; no amount of pricing shifts would make up the difference in volume that I am physically capable of producing.

Where That Leaves Me

The problem was blaming myself for this and seeing it as a failure, rather than realizing that this is a situation that the majority of our field is in. Many providers sublet, have contractors, teach, have retail, and any number of other income streams. While my physical capacity is lower than most, that isn't a personal failing; it's just a fact.

Once I started to get real about the math, instead of getting lost in the quagmire of blame, it made getting strategic about my next moves much easier.

Source: NCCAOM 2024 Job Analysis Technical Report (January 2025), available at ncbahm.org.