I have a concern about acupuncture research I'd like to share with the acupuncture community.
As acupuncture gains more popularity with the general public, the medical community and the insurance industry, acupuncturists will be called on to justify our existence as credible health care providers. Payment for our services will increasingly be based on scientific research that will verify acupuncture as a valid method for treating various maladies. I recently met with a medical doctor who is in charge of complementary and alternative medicine at a major teaching hospital. He directly criticized acupuncture for its lack of "evidence-based" research.
Over the last several months, I have had exposure to several Western medical institutions that have received grant money to perform research on acupuncture. Other institutions are not using grant money but are conducting research using their own funds. I have discussed research protocols with some of those involved with, or interested in, the studies. This is where my concern originates.
I am concerned that input from acupuncturists trained to make a differential diagnosis is being left out of the basic research design. For instance, suppose a study is being conducted about the efficacy of acupuncture in the treatment of headaches. Most studies have a control group treated with standard Western medication. The acupuncture treatment group tends to get the same acupuncture points regardless of what the TCM differentiation might be. In my TCM training, successful treatment depends on successful diagnosis and proper selection of acupuncture points. Some acupuncture points will be common regardless of the differentiation, but to truly treat the problem we must first discern whether the problem is due to excess or deficiency and further diagnose the problem, i.e., headache due to liver qi deficiency, liver fire, liver yang rising, or dampness. With the current type of research design (i.e., using the same acupuncture points for all headache complaints), I maintain that the results will be skewed and therefore not result in a valid study. Might acupuncture get the short end of the stick in a research design such as this?
Acupuncturists will increasingly be called upon to perform the acupuncture protocol portion of these studies. I urge the acupuncture community to voice its concern about protocols that do not adequately account for differentiation of symptoms. There is the temptation to "fit" Chinese medicine into a Western medicine research design. I think good research can be done on acupuncture provided we, as acupuncturists, honor the strength of our training. That strength comes in being able to extract more information from the patient and creating a treatment tailored exclusively for that patient.
Acupuncture schools must take the lead in research. Few acupuncture schools teach acupuncture students anything about conducting research or research design. Acupuncture schools are poised to provide solid research that could be respected by the Western medical and scientific community, and to prepare acupuncture students to be an integral part of designing research protocols that accurately evaluate the effectiveness of acupuncture.
As individual acupuncturists, we can attempt to assure that acupuncture is adequately evaluated in research protocols by contacting specific departments within major teaching hospitals and inquiring if there are any studies on the horizon in which acupuncture will be one of the treatments being evaluated. If so, inquire if they need acupuncturists to participate in the study. This would be an opportunity to educate our Western medical peers about how acupuncture might be more fairly evaluated in the study by proper TCM diagnosis.
Thanks for allowing me to voice a concern.
Dan Thompson, LAc Pittsburgh, Pennsylvania
"Who represents the acupuncture community?"
It behooves me that Dr. William Rutenberg, chair of the American Academy of Medical Acupuncture, would be the person elected to testify for the acupuncture community at the White House CAM Commission. Dr. Rutenberg represents the medical community in endorsing acupuncture, but who represents the acupuncture community? From Dr. Rutenberg's perspective, the main source of access through which patients could learn about complementary and alternative medicine (particularly acupuncture) is through Western-trained physicians!
Dr. Rutenberg states: "One criterion for full membership in the AAMA is the completion of a minimum of 220 hours of formal training in a medical acupuncture that meets AAMA standards." Why don't doctors and chiropractors do what they do best, and let acupuncturists do what we are trained to do?
When I attended acupuncture school, the requirements for admission were a bachelor's degree from an accredited college, along with one year of pre-medical training. The completion of the acupuncture section alone required in excess of 2,500 hours of formal training - not 220 hours, 2,500 hours! The next stop in order to be state licensed was to pass the NCCAOM exam. Without passing the national exam, a person cannot receive a license to practice acupuncture in the state of Maine. Competency levels are certainly reached if all these levels of education are met.
Does the White House CAM Commission understand the difference in the number of required hours of training, or will they endorse medical acupuncture, which will lead health care plans and insurance programs to endorse those who belong to the AAMA rather than those trained entirely in this field?
Celia R. Thibodeau, MAc, Dipl.Ac. Acton, Maine
Referral Letters Redux
I would like to expand on Dr. Kevin McNamee's ideas about referral letters. I agree that letters to our referral sources are important for practice promotion, but would also like to advance the notion that a referral letter is an opportunity to inform as well. I don't think that effusive thanks serves the practitioner nearly as well as the giving of solid information about the referred patient and his/her course in treatment. Referring allopaths are particularly curious about how their patient is faring at the hands of a new treatment paradigm, but they may be hesitant to call and ask.
After a few years of practice on both sides of the fence, my referral letters have been distilled to a few paragraphs that inform, thank, and invite questions or comments:
I have had the opportunity to see and treat Mrs. Jones for complaints referable to arthritis, headaches and poor sleep. Standard medical care has afforded her little relief.
Her Chinese evaluation reveals stagnant qi and blood with liver yang rising. This is a common presentation in our office.
After three acupuncture treatments utilizing Eight Principles theory, she has improved, by her estimation, from an eight to a three on the pain scale, and is sleeping through the night. I plan on seeing her weekly for a months and will then taper her treatments based on her response.
I'll be certain to keep you informed of her progress in our office, and I invite you to call if you have questions or comments.
Thank you for your thoughtful referral of this interesting patient.
Richard J. House, MD, LAc, DABMA
I generally wait until the second or third treatment before sending the referral letter to allow for better understanding of the situation. I am also quick to inform about a poor response to treatment that serves to generate trust and also to increase the awareness of what conditions are likely to respond well to acupuncture.
My referral sources like this general approach, and each year, an increase in our allopathic referrals has been the result. I have one referral source who has twice called to say he is sending us a patient with "bad chi."
It's a start.
Richard J. House, MD, LAc, DABMA Goldsboro, North Carolina
Does De Qi Matter?
I read with interest the article in the February 2002 issue of Acupuncture Today, "Needle Stimulation May Hold Key to Acupuncture's Effects." I commend the author and investigators of this study to examine the effects of needle manipulation, and with the design of their computer-controlled needling system. I anticipate that this type of system may help address research of other aspects of needling in the future.
As the author stated, however, there is no evidence that manipulating the needle to achieve de qi sensation correlates to clinical efficacy of acupuncture treatment. While the Chinese have traditionally held that de qi is an essential part of the acupuncture treatment,1 other traditions of acupuncture, notably the Japanese, have applied much softer needling techniques. Often, very superficial needling without any stimulation is the routine practice; yet, these traditions have yielded significant clinical effects of acupuncture treatment.
I hope that this current study will encourage researchers to look at correlates to clinical efficacy. Is eliciting de qi essential or helpful? Or is acupuncture point selection more important than needling technique to achieve clinical effect? What is the difference in the clinical effects of point selection based on TCM syndrome diagnosis versus energetic traditions of acupuncture such as Japanese meridian therapy or French/Chinese energetics versus pure neuroanatomical point selection? All these traditions have years of reported success by various practitioners.
Clearly, the answers to these important questions will enable acupuncture practitioners of various traditions and paradigms to make better treatment decisions regarding patient care.
I look forward to your future research endeavors.
O'Connor J, Bensky D (eds.) Acupuncture: A Comprehensive Text. Seattle: Eastland Press, 1981.
Bryan L. Frank, MD Immediate Past-President, American Academy of Medical Acupuncture Richardson, Texas
"Thank you for the nice job you are doing"
I wanted to take a moment and thank you for the nice job you are doing. I really appreciate your paper and website. (It's) very informative. I have had two new patients as a direct result of your website. Both stated they had learned about acupuncture and its usefulness for a certain health issue through your website. This is in a small town in Alaska, population about 3,500. Imagine what the response is in large cities. Thanks again, and keep them coming!
Michael Wedge, LAc Palmer, Alaska
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