Uechi-Ryu.com

Many studies of acupuncture have shown it not to be different than a placebo (sham) treatment. I'll go so far as to say that most of what acupuncture is used for in the East has no proven benefit. But now and then, the treatment proves to be effective.

This is the result of an AHRQ-funded study, published in the prestigious ACOG journal. The most important thing to note here is that treating pregnant women with acupuncture is probably preferable to the standard Rx (SSRI) treatment, as we don't really know if those drugs are good for the fetus. So here's where the Eastern therapy actually excels.

From the Wall Street Journal (since I don't have a subscription to the original medical journal).

- Bill

The placebo effect isn't sham. The palcebo effect is a documented change in the patient. If there was no change then they'd call it the placebo no effect.

Acupuncture works on a number on conditions not just a few. From drug addiction to depression to knee pain to fatigue to nausea from chemo therapy to anxiety to dysmenorrhea, to back pain....the list goes on and on. There are multiple reports of statistically significant outcomes in peer-reviewed literature with none of the life threatening or addictive side effects of many pharmaceuticals. Avandia anyone?

How many peer-reviewed results are necessary to establish acupuncture as a viable treatment approach for multiple conditions? 500? 1,000? 10,000?

http://scholar.google.com/scholar?q=acu ... as_sdtp=on

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Dana

A sham treatment is different from the vernacular sham. Basically it means a treatment very much like the one being studied, but "the good stuff" has been eliminated. In this study, the sham was sticking needles in spots not expected to give the treatment effect.

One expects a placebo effect from the sham. The placebo effect is very real, and has to do with the mind-body effect of "belief." That needs to be removed in a study to understand the true efficacy of the treatment. If the treatment and sham are both beneficial but no different, then what you are observing is the placebo effect in the treatment. In other words... it doesn't add anything to the power of good bedside manner or the patient's own ability to heal him/herself.

- Bill

Family bias aside...

From the standpoint of the FDA and of institutions (insurers, the government) paying for care, the operative word is Missouri.

Acupuncture needs to be treated like any other therapy. It must prove itself in a properly designed research protocol. And it must do it one specific therapy at a time. Just because Listerine is good for bad breath doesn't mean it prevents colds - even though it was once advertised as good for just that.

At the end of the day, some things are shown to work and many things don't. Same for drug therapy. Same for chiropractic. Same for a lot of Western medicine for that matter.

That's why they pay us scientists. Showing what works and what doesn't (e.g. the development of evidence-based medicine) is a very important part of giving the average person financial access to quality, affordable health care.

Those on the leading edge of this very old therapy understand their responsibilities to the medical community. All who practice the art and science of acupuncture benefit when the evidence for a specific therapy is documented.

- Bill

Until very recently, Western medicine has done a terrible job of investigating what can support a patient's own ability to heal himself while at the same time offhandedly dismissing the possibility that the knowledge might already exist.

In an age when we're rushing headlong into national bankruptcy over health care, if a few needles and a few words can get people to significantly improve their mental and physical health at a very low cost shouldn't everyone be paying attention to that approach?

There's a big difference between a critical review and outright bias in either direction.

If one SSRI doesn't work then the prescribing physician tries another one. There's no bruhaha over it because we know that not every treatment works for every person. So if one set of acupuncture points designated for a condition doesn't generate change, then the practitioner tries another, related set of points.

I fully anticipate that the body of peer-reviewed literature for acupuncture (and eventually herbal treatments and tui na) will eventually be developed and clarify the treatments that work from those that don't.

That being said, I think it important to keep in mind that Prozac didn't end depression--so it would be unfair to hold acupuncture to a higher standard than what is accepted to be good science.

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That's a very rich post, Dana. It deserves a careful, thoughtful response.

Your philosophical argument is actually one that's been batted around by very smart people in influential places.

The reason why we have the gold standard RCT (randomized, controlled trial) and blinding or double blinding is because we scientists KNOW that the mind-body effect is very real. And quite frankly this is what separates the science of medicine from the art of medicine. Any doctor with any amount of experience and half an EQ understands the importance of putting a hand on the shoulder and simply saying "I can help you." We call it lots of things (bedside manner, people skills, etc.). But a good doctor needs it in spades.

You are right that medical schools don't spend enough time teaching this. But frankly who does?

As for "it" being a part of medicine... Here's the thing. We westerners expect someone else to pay for care. The days of doctor visits to the house are over. Medicine is now an industry, and health care practitioners are employees in that big system. And we've arranged things so that MOST doctors operate on a fee-for-service basis. Dr. Smith does something for a patient. Doctor smith can look up in the CPT code book and bill for whatever "it" was. And the government (CMS) or your insurance company will pay the doctor if "the contract" says they'll pay for that service. And what will be paid for is based on years and years of research on what is efficacious and what isn't. All that's based on what we call "medical necessity."

Currently there is no CPT code for "beside manner."

There are other working business paradigms. There are staff model HMOs (e.g. Kaiser) where the doctor gets a salary. There are also IPO HMOs where a doctor gets paid a risk-adjusted amount per member per month for the panel of insurance patients assigned to him/her. With the doctor going at risk, then the incentive to be a good doctor (outside of doing things that are billable) is higher.

At the end of the day, money drives the system. And care won't get paid for if there isn't evidence somewhere that the 3rd party is getting value for those dollars.

Hospitals work a bit differently. Some get paid by number of hospital days. Some get a risk-adjusted case rate (via the DRG system). In other words you get X amount for a birth no matter how long the patient stays, and Y amount for a CABG. You can figure out how all those incentives work.

So what's left? Much of plastic surgery and "alternative" medicine falls under an out-of-pocket reimbursement paradigm. If it isn't in the insurance contract to get breast enhancement, many women will gladly drop the thousands it will cost (from their own money) to get a bigger chest. Given how much money the best cosmetic surgeons make, you can see how well vanity pays. Why won't insurance companies pay for something like that? Well... many will pay for breast reconstruction after a radical mastectomy. Fair enough... Make the woman look as close to "normal" as possible after disfiguring cancer surgery. That falls under the definition of "medical necessity." But paying to give Sally bigger boobs so she can work at a "gentleman's club" isn't considered "medical necessity." Similarly... a lot of (yet) unproven medicine still finds a life in the out-of-pocket market. But believe me... if the evidence ever comes forth that a specific "alternative" therapy is efficacious, well then the government and insurers will pay for it. Then by definition it is no longer "alternative."

Yes and no.

The scientific method was created to protect scientists from their personal biases. If we didn't have preconceived notions, then we wouldn't be good scientists. You should always have at least a cursory guess of how things should come out before you run an experiment. But believe me, Dana. The day you think you will get A and the data tell you it's B, well that is the day that every scientist lives for. Shattering the conventional wisdom is what gives a fellow like me a name.

Just ask Einstein.

Just ask Galileo.

Just ask Copernicus.

There's an old saying that applies very well to medicine - To a hammer, everything looks like a nail.

Managed care created the gatekeeper paradigm because to a surgeon, every patient looks like a surgical opportunity. There's a joke about oncologists... The reason why we put nails on coffins is to keep oncologists from treating dead patients.

The medical community must address the needs of the patient. This means that we don't first think of an opportunity to stick a needle, cut some tissue, or give some medicine. This means that the health care practitioner must first assess the short and long term needs of the patient. THEN the patient is given the appropriate therapy, education, or reassurance. As medicine becomes more and more complex and the number of options grow, the need for that multi-talented first contact becomes more and more important. Sadly, these "primary care" MDs, NPs, PAs and the like get paid the least. And they are in short supply.

If I become czar, that will change.

If a "back cracker" or a "baby doc" can serve as a good PCP, well then medicine welcomes such. This is why many medical plans recognize DOs and OBs as perfectly fine PCPs.

Maybe one day practitioners of acupuncture can take on the PCP role - IF they learn how to manage the entire spectrum of care. Otherwise they'll be relegated to a role of "specialty care." That's not altogether bad. In traditional Western medicine, the specialists make the big bucks.


Often the medical community spends all their time treating the symptoms, and never addressing the cause. A great example is duodenal ulcers. The pharmaceutical community spent a lot of time, effort, and money developing drugs to treat people with that condition. They treated the symptoms with a class of drugs called H2 antagonists. Walk down the stomach aisle in a CVS today and you'll see many of those drugs now appearing over the counter (OTC).

Proton pump inhibitors was the next generation of these stomach drugs.

Then some crazy guy at UVa proposed that H Pilori caused most ulcers, and you could actually CURE someone of ulcers if you killed the bug. Wow... That suked for the pharmaceutical industry. But the patients got rid of their ulcers forever. What's not to like about that?

We can't always "cure" diseases like chronic depression. But we scientists should be working on that paradigm. Reactive medicine may make a lot of money for shareholders of Pharma, but it isn't always the best medicine.

And "alternative" therapy gets no break in my book when it comes to such. If at all possible, get at the root cause and eliminate it. Don't just treat symptoms and send them out the door.

- Bill

hmmm...some of those "alternative" folks methinks.



All that is old is new again...

"...in healing, one must grasp the root of the disharmony..."

"The principles of healing and medicine in general are difficult to grasp because many changes occur in illness, and the healing process must adapt to that. It becomes difficult to know the root. The origin of illness can be so small and vague, in fact, so elusive, but the illness can still become substantial over time.”

"Seeking emotional excitement and momentary pleasures, people disregard the natural rhythm of the universe. They fail to regulate their lifestyle and diet, and sleep improperly. So it is not surprising that they look old at fifty and die soon after.”

The Yellow Emperor’s Classic of Medicine (the Neijing Suwen)
~240 B.C.
http://www.five-element.com/graphics/neijing.pdf

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Good post and not enough time to respond as this subject deserves..but I think Bill and I have discussed some of this in other posts as well. Dana, I agree there are many alternative medicines and techniques that support the patient's ability to heal themselves and look at the issue holistically..not just at treating the symptoms.

The reason most clinical "gold standard" studies have not been done? They don't make money.

Why research capacin or curcumin when it's available in the spice aisle? Eventhough some preliminary (and scientifically mild studies) have been on tumeric and cumin with some interesting possibilities.

Just because the studies have not been done, doesn't mean the therapies and older medicinals don't have value.

Does it mean all wise old herbal remedies are good or safe? ABSOLUTELY NOT!

But many medicines today came from old folk remedies (aspirin...willow) in some form or another.

I think....like all things...an open mind is best...with a wary awareness to protect yourself as well. Knowledge, always the best path...but sometimes you have to trust your owne instincts and research when big medicine doesn't have the time/interest.

Again...this subject deserves more response than I can put here...just scratching the surface of a larger issue.

Thanks Bill and Dana for an interesting topic!

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Shana

Bill,
In a quick review of the original posts, I see a lot of discussion about cost and profit as the importance in asessing value and benefit. I see little discussion about side effects, patient choice, the benefit to patient AND practitioner of quality interaction...not all incentives are or should be based on money or balancing an accounting equation.

It also sounds like you are saying alternative medecine only treats symptoms..and I think that is a possible bias and misjudgement on your part...unless I'm misreading your intent? In my experience,serious herbal and alternative practitoners take a holistic and long term view of treatment...in part because illness can be changeable and caused by body and mind issues at the same time...and..to be honest, some alternative and herbal therapies take time to be effective.

I value modern medecine and it's strengths and benefits. But I think the mentality of quick fixes, miracle pills, pay for procedures vs results (quantity vs quality in some cases), and majority efficiency over individualized care eliminate some effective tools from the health toolbox. Alternative medecine should not replace modern medicine..nor the reverse. But a strong bias...almost reflexive and without thought..prevents many physicians and scientist from giving...imho..some valid therapies a second glance..for fear of being kicked out of the serious scientist club..and so tools are tossed aside without a serious look.

Also, to Dana's point..not all Pharma works 100% but it appears alternative therapies are expected to show higher successes before they are taken seriously by modern medecine. Again, why not keep both sets of tools and be more concerned with what works for each individua lpatient than how much you can bill for it?

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Shana

The Institute of Medicine agrees with you. Several landmark papers on quality in medicine have come out in the last decade.

When I use terms like "evidence-based medicine" and "medical necessity", I'm dealing with process quality issues. Quality opportunities involve the over-use, under-use, and mis-use of health care services (as defined by the IOM).

And then we get to patient choice. Indeed that is another vector to consider in the multi-dimensional space we use to evaluate health care services. I've done studies which show that the dimensions of quality, cost, and satisfaction sometimes align, and sometimes they don't. For example... If you put a gatekeeper MD in-between a group of individuals with low back pain and the orthopedic surgeons (or not), you get the following.

WITH GATEKEEPER (restricting choice)
* Lower cost (factor of 4)
* Higher quality and better outcome (as measured by patient-reported health status via a survey tool like the SF-36)
* Lower patient satisfaction

WITHOUT GATEKEEPER (giving patient complete freedom)
* Higher cost (because surgeons LOVE to cut and patients get what they ask for)
* Lower quality (higher pain scores on the SF-36)
* Higher patient satisfaction (because they got what they wanted)

So which is better??? The truth is that in some cases, choice for the uneducated consumer isn't necessarily a good thing for that consumer as measured either by cost or by clinical outcome. And yet of all things about our health care system, we Americans love our choice. So... we get what we get.

Be careful what you ask for...

Nope...

I was trying to address the issue of addressing the patient's needs before picking the therapy rather than look for a way that any given therapy (whether it be surgery, Rx, acupuncture, herbs, or whatever) can treat a patient. But often this doesn't happen. To a hammer, everything looks like a nail.

EVERY branch of medicine has issues with treating the symptoms rather than getting at root causes. I could treat Mrs. Jones' mild hypertension with an anti-hypertensive. Or... I might see if losing 50 pounds will decrease all metabolic syndrome symptoms (hypertension, hyperlipidemia, Type II diabetes, etc.).

In my book, NO branch of medicine (West or East) gets a break. It's all medical care. It all should be evaluated based on the needs of the patient. And we should be trying to get at root causes first rather than trying to make any particular therapist or therapeutic modality reap more profit. Profit should come naturally from a system where the customer has his/her needs met.

If all that makes sense...

As for "alternative" medicine, well... This reminds me of a friend of mine (Tara Lane) who used to be lead singer and songwriter for several local bands (e.g. In Clover). Tara used to joke about the "alternative" label given to her music. As she used to joke, "What happens if my music becomes mainstream? Does that mean I can't call it alternative anymore?"

It's a sloppy label, Shana. IMO we should throw it away.

There's medical care that works, and medical care that doesn't work.

There is evolved medical care, and medical care still evolving.

There are myriad sources of care (Europe, Asia, the Americas, etc.).

There's allopathic medicine, osteopathic medicine, etc.

Just remember that money is the mother's milk of the health care system. Without it, things don't happen.

As for herbs... Just remember that all that fits into the broader class of pharmaceutical intervention. The thing about herbs (both good and bad) is that you're dealing with the active ingredients in a more raw form, and sometimes existing in a family of compounds. Modern Pharma tends to be inspired by herbal medicine, but takes it a few steps further. Folks working supercomputers in Pharma labs will isolate the active ingredients in herbs, figure out how they work, manipulate the active sites of the compound or compounds, purify it, standardize the concentration to make dosing more precise, etc., etc. Meanwhile, an herbalist is dealing with a lot of variability and unknown. There's a random element to what they are doing, and that isn't always good.

But it's ALL pharmaceutical intervention in my book.

Just ask the oncologist who prescribes medical marijuana to help a chemotherapy patient improve his/her appetite.

We could go on and on about this. But my bottom line is I like to be agnostic about medical care from any venue. It should address the needs of the patient, the patient should be made happy and healthy (if possible), it should be timely and accessible, and cost should be reasonable.

But...

Americans want what they want. And the libertarian in me says "Go for it!"

Caveat emptor.

- Bill

[quote="Bill Glasheen"]
The truth is that in some cases, choice for the uneducated consumer isn't necessarily a good thing for that consumer as measured either by cost or by clinical outcome. And yet of all things about our health care system, we Americans love our choice. So... we get what we get.[/quote="Bill Glasheen"]

I don't disagree with a lot in your post, and I think this statement is the most interesting. My single biggest frustration with the general population is a lack of personal responsibility and a desire to hand your personal decisions over to "experts". Experts are good, but they are another tool to evaluate and question if need be. THEN one must analyze and make one's own decision. Just like voting, your personal healthcare should be an active participation experience. Buyer beware indeed...

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Shana