I have probably one of the toughest jobs in medicine. I am a small-town acupuncturist. I was unprepared for small-town acupuncture at first. The idea had never even crossed my mind. No one taught me about it in school, and much of the practice advice I read in the journals does not apply if you live in an area of only 5,000 souls, as I do.

One of the big surprises of small-town life is the survival of the quaint concept called the "reputation." In the city, you can probably be a chain-smoking, Satanic, Communist gangster on the weekends and still enjoy a busy practice during the week. Not so in a small town. Everyone will find out. I don't care how clever you think you are.

Reputation means that if you believe (as I do) that doctors should be good examples for their patients, and you find yourself having a Big Mac attack, you can drive 40 miles away to another town. Otherwise, you will have to risk explaining to a patient (who shouldn't be there, either) why they can't eat this junk, but you can. To many of your small-town patients, doing is endorsing, and if you can't walk your talk, your authority as a nutritional advisor will probably take a hit.

Same thing in the grocery store. I sometimes amuse myself by observing what people put on the conveyor and marveling that they can survive on all that crap. However, I also know that goes both ways. Fortunately, my grocery choices are normally above reproach. When I encounter a patient at the store, I can see them examining my purchases and putting a mark on the scoreboard.

If your indiscretions run a little wilder than, say, the occasional bag of Fritos, you'll probably have to leave town to amuse yourself, anyway. I don't think you can even buy an X-rated magazine in our town.

In a small town, a nice neat line does not divide "friends" and "patients." Contrary to the lessons of ethics class, you will be fraternizing with your patients - period. Many of your patients will have been friends and acquaintances first, and they will often stop you in the supermarket and at parties to loudly announce how much better their hemorrhoids are. So much for confidentiality. My husband, often with me in public, has perfected the art of meandering off at the first sign of full disclosure. I usually try to change the subject or lead them off to a secluded spot, in hopes of protecting at least a vestige of their privacy.

Many of my patients are each other's friends and relatives and have referred each other to me. I get married couples, brothers and sisters, and I'm seeing three generations of one particular family. My waiting room sometimes sounds like a party, as friends and neighbors "run into each other" coming and going for treatment. Often, these people have known all the details about each other's health for years and are quite concerned for each other. The sense of connection is heartwarming. It also requires the vigilance of the palace guard to protect everyone's privacy from snoops.

"So, how's Edna's weak bladder doin'?" is the sort of thing I often hear. Believe me, you haven't been pried until you've been pried by a small-town prier with five or six decades of experience.

"Well golly, you have to ask her when ya see her," delivered with a grin, has become my canned answer - repeated as many times as necessary. I am an oyster in training.

While going for acupuncture in almost every big city is no longer any weirder than seeing the dentist, it is still looked at sideways by some people in my small town. This makes my patients even more special to me because they don't have the luxury of anonymity. Not only must they build up the courage to come in and pay me to poke them with pins, they also face the risk of being labeled a sucker or a weirdo for buying into "that voodoo stuff."

So I try to honor my patients by being careful of my "image." No green Mohawks, hot pants or dog collars in public. In a small town, as a public figure, you are under the microscope every time you go out. On the odd occasion I need to run into town looking like one of the Clampetts, I find myself lurking and wearing sunglasses. I'm probably overreacting.

I'm not saying I try to be perfect. I don't come to work in pearls and pantyhose. I dress comfortably - lots of loose or stretchy stuff that I can move in. I also like crazy shoes, especially since people laying face down on the table spend lots of time looking at them. If it is nice weather out, I will ride my motorcycle to work. My little senior ladies think that is very cool.

Most rural American towns are economically depressed, so the whole fee thing is a little more complex. Sure, we have people with money, but not nearly the pool you could depend upon in a city. Also, many of our people are uninsured.

Well, since I don't want to take insurance anyway, I offer two clinics to give everyone a chance to get what they want. I have a fairly large treatment room, so I divide it up hospital-style (semi-private) two days a week, and treat two people at a time for a sliding fee. The other two days, I do private treatments.

I even developed a totally private, self-scheduling and payment system, because those are two things I'd rather not do. Everyone has an envelope that stays with their file and has their patient number on it, which is their initial and a number, such as M-11, for example. I give it to them when they come in, and after the treatment, they go schedule themselves using that number and then drop it in the payment box. This has solved so many problems. If they misschedule, it's not my fault. It's theirs. They can stand there all day looking at their calendar, making phone calls, whatever they need to do to schedule themselves. Meanwhile, I waste zero time waiting for them. It also offers better privacy protection than traditional scheduling. The patient's name never appears on paper for prying eyes to pick out.

I also don't have to handle the money. I know, I should accept it from the universe with great, glad openness, blah blah, and I do. However, something feels tacky to me about treating sick people and then putting my hand out. Anyway, problem solved. I leave a change envelope out there for anyone who needs it. One of the perks of a small town is that you can do stuff like that. The system also frees me up to prep the room between patients and keeps me on time. It does, however, confuse some of my seniors, so I help them along.

Speaking of money, since many of my patients may also start out as acquaintances, I sometimes get the, "What kinda discount ya gonna give me?" wink-wink. Believe me, it doesn't get any more discounted than the bottom of my sliding fee, and I make that clear.

Here's another small-town issue that's not an issue for me, but was for my office mate, a nurse practitioner. One of her patients, a tiny elderly lady, was the victim of very inappropriate and weird sexually aggressive behavior from her physical therapist. The patient, being polite, well-bred and of another era, was reluctant to report it. My colleague was also debating whether to report it. Should she report it without the patient's consent? She knows the guy. Does she want to ruin his career without more evidence? I felt that not only would I report it, but that I'd probably go kick his butt around the block and paint "pervert" on his forehead, and that's about as diplomatic as I could get. In the end, unable to convince the patient to get on board, it went unreported.

While most practices depend on word-of-mouth, it is of geometric importance to the small-town practice. One bad day or big slip up and you can be really screwed if the word gets around. I try to make sure everyone goes home happy and I take really good care of my top referrers, sending them the occasional, very elaborate gift certificate for a private treatment. I cannot buy the kind of press they are giving me for free. I think display ads for small-town practices are a waste of money, anyway.

In exchange for behaving myself, I receive the admiration and gratitude of my community, sort of the "country-doc fuzzies." People often brag about me to their friends in my presence, and I often hear, "Oh, you're the acupuncturist! Fred said you really helped his back. Ya gotta card?" or, "I can't tell you how great it is that you do that sliding fee clinic thing. My sister could never afford care without that." I'm not just another face in a sea of acupuncturists, and I get to be a part of the shift that my town is making to a more integrated medical model through education and awareness. I also get to live in the forest with moose and bears for neighbors, and I have never sat in a traffic jam during my commute. I know who my neighbors are and we chop wood, hike, share dinners, raise walls and party together. If I want to stroll around my property, stark naked, I can.

This is my second small-town practice and I continue to learn more about this animal every day. It is an odd beast, and it requires adaptability. You have to be really clear about why you are doing this - is it about you, or the patients? Inside, I might be a cigar-smoking, hot-pants-wearing kind of gal (not really), but if I put people off by "being me," they won't risk coming in for treatment, and then what have I accomplished (except being a drama queen)? So I compromise.

And maybe when I'm out of town on a motorcycle trip, I might order fries once in a while. I don't have to be perfect, but I do want to be an inspiration.

Julie Crist is a 1996 graduate of Northwest Institute of Acupuncture and Oriental Medicine in Seattle. Her first small-town practice was in Brookings, Ore., and she currently practices in Colville, Wash. She can be contacted at .