In the medical magazine Patient Management, Denis Dutton last year presented a tongue-in-cheek account of how GPs might incorporate alternative techniques into their practices. The article generated an interesting exchange.
Dr Denis Dutton’s original article in the March edition (“Increasing Your Income While Appeasing Your Patients”, pp. 9-11), and his more recent reply to Dr Campbell’s letter in the June edition (“One rule for Orthodoxy, Another for the Rest of Us”, p. 7) raise several interesting issues.
Our society comprises Western-trained doctors who study and practise acupuncture. For many of us, enthusiasm was first sparked by noticing the beneficial effects of acupuncture in the clinical setting. Most of our members are experienced clinicians and in their opinion, the effects of acupuncture amount to more than the sum of willing, motivated doctors enhancing a placebo response.
Many have been motivated to study the philosophies and pathophysiology of Eastern medicine, in particular traditional Chinese medicine. The collection of clinical material has been meticulously recorded by the Chinese for centuries, but it is only in the last 15 years that textbooks have been available to us, showing the logic and complexity of this study of medicine.
The marriage of Eastern and Western medicines is an exciting and vital factor in many parts of the world. The double-blind crossover trial, which all doctors would agree has been a cornerstone for the development of safe, effective Western medicine, is, however, an inappropriate measure of acupuncture. The reasond for this become obvious when Western doctors study the basics of acupuncture. The observations of the Chinese seem to fit in with modern advances in biophysics and it is ultimately the advancement of these basic sciences which will make the who subject more understandable to non- clinicians like Denis Dutton.
By reacting to acupuncture and claiming Chinese medicine is based on primitive and fanciful concepts, the American NCAHF exposes itself as being either unaware of the complexities of the subject, or worse still, threatened by them.
The medical profession, if it is to continue to earn the respect of the public, should study both Western and Eastern medicine with open minds.
Only then can valued judgements be made.
Dr Robin Kelly, President, Medical Acupunture Society (NZ)
Dr Dutton’s Reply
According to Dr Kelly, modern advances in biophysics will make acupuncture finally understandable to stubbornly sceptical non- clinicians like me. Wrong: the mechanism of the treatment is not the issue. I don’t know how Panadeine works, but I accept that it does. It is not the failure of acupuncture’s supporters to demonstrate an intelligible mechanism that is in question, but the straightforward clinical claims made on its behalf. The history of medicine is littered with episodes of “willing, motivated doctors enhancing a placebo response”. There need be nothing the least bit stupid or venal about this; in their eagerness to help their patients, an intelligent doctor can develop a sincere faith in an ineffective treatment modality. Blind testing routines are our best defence agaist this possibility.
On the subject of mechanism, it is worth remarking that I am aware of two local medical practitioners who were trained in acupuncture (one in Beijing, the other in Auckland) and who have used it extensively. Becoming increasingly suspicious, both of these practitioners had the idea of intentionally placing their needles at the wrong points, according to the Chinese charts (which don’t all agree with one another, incidentally). They found no difference in the perceived effect. One of these doctors has stopped using acupuncture, and the other continues to use it in the opinion that it is the time and attention he is giving the patient that produces the benefit, rather than a psychological effect of turning the patient into a pin-cushion.
Claim and counter-claim about the clinical effectiveness of acupuncture is all fair enough, and I hope doctors interested in these issues will consult both sides of the debate [start with P. Skrabanek, Lancet 1: 1169-1171, 1984; Irish Med J 79(12): 334-335, 1986]. What I find deeply disturbing is that Dr Kelly would claim that blind trials, though they are a cornerstone of safe, effective Western medicine, are “an inappropriate measure of acupuncture”.
This is a claim frequently made on behalf of alternative treatments and I believe it should be regarded with the utmost contempt. When a patient asks about the symptoms that might be alleviated by acupuncture, a definite answer is forthcoming; no one ever says “Oh, we have no idea what symptoms acupuncture is good for”. When the patient asks how much it costs, again a definite answer is immediately ascertainable. But in the present case, when we further ask if the modality has been shown through blind testing to be clinically effective, we’re told by the President of the Medical Acupuncture Society of New Zealand that this would be inappropriate. Not that it hasn’t been done, or that the results have been in his view indecisive, but that it would be inappropriate. Why? His society’s members deem acupuncture appropriate for the patient’s symptoms, which are demonstrably real. Real money is deemed appropriate for the demonstrably real account the doctor sends out. Why shouldn’t the paying patient demand that her treatment be just as real, as demonstrated by scientific tests? How can anything else be “appropriate” except the magic question: is acupuncture clinically effective beyond the usual placebo responses?
The “exciting and vital” marriage Dr Kelly describes looks to me like one in which Western medicine has taken Eastern superstition as a mail-order bride.
Dr Denis Dutton, School of Fine Arts, University of Canterbury