Gold prospecting in Chinese medicine
The Lantern: Volume II, Issue 3 - Article #1
While engaged in putting together several of the smaller appendices in the report entitled "Towards a Safer Choice", a government-funded study of the practice of Chinese medicine in Australia, I had a conversation with a well-known cardiologist in Melbourne who was responsible for critiquing the quality of the research to date on Chinese medicine. I remarked that it was important for Chinese medicine that we have better research, that we had to aim at the gold standard: better controlled double-blind trials for efficacy. “And why would you want to do that?” he enquired, to my surprise.
"Well," I blustered, "to show that Chinese medicine works!”
“You mean you don’t know whether it works or not? How can you face your patients?”
Now he had me on the back foot. “I know it works,” I said. “But we have to have proof.”
“For whom?” he said. “If your patients get better, that’s proof to them, and if you’re sure from your clinical experience that you can help the majority of patients, that’s proof to you. Who else are you trying to convince?”
At the time I thought he was just being deliberately difficult, but over the intervening years his viewpoint has become clear to me. It is not so important to us to show whether a herb or acupuncture point works as described traditionally – this can be demonstrated daily in our own experience. What we really need to know is this: how can it work better? Will it work better in a different preparation (pao zhi)? Perhaps in combination with different than usual herbs or points its effect increases dramatically. This is the focus of much of the clinical reports from China: improved clinical efficacy. No wonder they don’t match up to our "gold standard" – it’s the wrong standard. Chinese medicine research needs a standard of design that gives us the results we need – not just a copy of what large-scale pharmaceutical companies need to patent a chemical drug.
This is a typical comment: “Unfortunately, from the Western perspective, traditional Chinese remedies fail to inspire confidence. The claims rely on anecdotal evidence instead of the requisite ‘randomised, double-blind, placebo-controlled trials’ that’s considered the gold standard for Western medicine. Edzard Ernst, professor of alternative medicine at the University of Exeter, UK, and colleagues at the Chinese University of Hong Kong (CUHK) reviewed more than 2000 clinical trials reported in mainland Chinese journals and found them almost universally flawed.”1
Comments like these choose terms that appear objective but are biased in a way that devalues the topic under discussion: “unfortunately” (why unfortunately?) “from the Western perspective” (whose perspective? I am a Westerner, and it’s not my perspective), “fail to inspire confidence” (fail for whom? We all see numerous patients that seem quite happy to come back for more), and so on.
Readers may object “But what about the skeptics? Shouldn’t we have evidence from controlled double-blind trials in order to convince them?” Yes, indeed; if they are true skeptics, ie those with a healthy skepticism who will look at the evidence (ie. all the evidence, including their own experience) before making up their mind. Then there are the fanatic skeptics whose cry “Humbug!” is their assertion of tribal self-definition. I am not suggesting that we discourage those who wish to put resources into establishing the efficacy of Chinese treatment methods – but we should remember that there are other types of research which may serve the needs of our profession better, and we should encourage the design and implementation of these kinds of trials.
The nasty placebo
One of the damaging side-effects of the infatuation with the double-blind controlled trial has been the disparaging of the placebo. I recall reading a study concerning transcutaneous nerve stimulation (TENS), in which the conclusion stated that in the researcher’s estimation, there was little difference between the analgesic effect of real-TENS and sham-TENS, so the analgesic effect was due to placebo – and therefore it should not be used.
There is serious confusion here between research and clinic, a transference of the negative implication of placebo in research where trial designers try as hard as they can to eliminate all incidence of that distressing tendency for patients to heal themselves. What is concerning is that medical students seem to pick this attitude up and carry it into clinic as practicing doctors, ie they try to avoid placebo activity when they are treating patients.
What they – and we – should be doing, of course, is encouraging by all means possible the tendency for patients to heal themselves. When you combine that with an effective therapy (ie. effective whether the patient believes it or not) it is not at all surprising if the patient improves – and is that not the point?
Endnotes
1. www.annieappleseedproject.org/globchinmed.html
