This is an extract of the keynote debate which took place at the British Acupuncture Council’s Conference in October 2004, which was chaired by Mike O’Farrell, Chief Executive Officer of the BAcC. The three keynote speakers were Stephen Birch who has co-authored seven books on acupuncture and regularly contributes to the debate on the use of scientific methods in the integration of Traditional East Asian Medicine (TEAM) in the West, Peter Deadman who is Publisher and Editor of the Journal of Chinese Medicine and co-authored the major acupuncture textbook A Manual of Acupuncture, and Felicity Moir who is a Course Leader and Principal Lecturer at the University of Westminster, School of Integrated Health. Questions or comments follow the introductory views of the keynote speakers, together with the responses of the speakers.
Stephen Birch Diversity has always been an inherent part of the acupuncture profession, but how do we preserve it? Well, it turns out that in the US there were all kinds of problems that came up. For various political and educational needs diversity was challenged. First of all, how to get licenses in the US? It was decided that one way of facilitating licensing in each State was to eliminate the cost of developing an exam, so they developed their own national exam which the States could then hire out not at their expense but at the expense of the examinees. So the States were freed from having to pay big bills for having to develop exams which are expensive. These exams then inadvertently set in stone a model of acupuncture and TCM that was known by the mid-1980s and it’s still pretty much the same thing today. It forced all of the schools into teaching the same thing; all of those schools who like to do something that was not TCM had to start teaching TCM or eliminate these other things that they wanted to teach, because otherwise you cannot pass the exams. So there was an inadvertent restriction on diversity because of this. In California they passed a law that basically said that there is no acupuncture, it’s only acupuncture and herbal medicine and you have to learn both of these things which means that you go to school and get this full heavy TCM training and if you want to do something different - tough, too bad. There are several other States that follow this model as well. Also, in line with this in California several individuals came forward to the state regulatory authorities and said look we have got a list of unproven medical techniques and they gave a list of these Japanese, German and other European origin acupuncture methods and they said we think you should regulate these things. These things are now all illegal in California and have been for 10 years. Diversity was limited yet again.
The discussion about the nature of acupuncture got frantic in the US because of the problem around the question are we TCM or are we acupuncture. That is, is it acupuncture, herbs, qi gong, diet, all these other things, or is it just acupuncture. It caused a huge division in the US and in fact the national organisation The American Association of Acupuncture and Oriental Medicine took the stand that there is no such thing as acupuncture, there is only oriental medicine and changed their name to The American Association of Oriental Medicine, AAOM. In fact, when States were dealing with acupuncture licensesure problems if they didn’t put in the licensing requirements ‘training in herbal medicine’ the AAOM wouldn’t support their efforts. States struggled for years to get licensed because of this problem. This was quite difficult. So we had these kind of difficulties in the US that were partly inadvertent, partly a kind of dirty politics, but anyway there was a restriction on diversity that happened in the US.
So one thing that we can think about when we are talking about diversity is what is it that the general public thinks is important in our training? What are they looking for? In terms of the public face we have to have a uniformity of public appearance, we have to look a certain way so that they take us seriously. We have to have uniformity in our training and testing and licensing procedures but these are difficult issues because they can undermine this diversity that I have said is an integral part of the whole tradition of acupuncture and East Asian medicine.
So if we look at what happens from a patient perspective I suggest that what they want to know is are we able to help them with their problems, which relates to our training as an acupuncturist. Are we able to handle their problems, do we understand the legal, ethical and professional issues about behaviour with patients, handling patients and so on and are we able to make recommendations as to when they should go back to the doctor and when we shouldn’t treat because the condition is serious. I believe that these are implicit assumptions that patients come in with when they come to see us as acupuncturists. But if we look to mainstream medical perspectives, which is the group that tends to want to regulate us whether we like it or not, they want to know are we safe, are we able to make medical recommendations to recommend patients go to the doctor because it is not something I should treat. That, I believe, is the number one priority and something we have seen come up in the UK. They also want to know do we have any indication or evidence that we can treat the conditions that we claim we want to treat. This is to do with research. Again, the issue about handling patients, the legal, ethical and professional issues are the main things that the regulatory agencies and the medical profession are going to want to concern themselves with. In fact, what I suggest happens is that mainstream medicine is not really very concerned with the details about what we do in the acupuncture training. They want to know that we are able to turn people out that can function safely on their own , which requires knowledge of anatomy, physiology, pathophysiology etc., and that they are trained in management of patients and things like this. I believe that these are skills that anyone who is handling patients probably should have, and certainly from the perspective of mainstream medicine and regulation of medical practices these are skills that pretty much everyone should have.
It seems to me that one solution to preserve this kind of diversity in the field is a kind of paramedical training and there is a model for this. For example, in Germany if you are not a medical doctor and you want to do some form of complementary therapy you have to go to Heilpraktiker School. The Heilpraktiker School teaches you anatomy, physiology, pathophysiology, how to identify serious diseases, make the appropriate referrals and after that you can go and learn herbal medicine, massage, acupuncture, homoeopathy or any combination of things; that is secondary. The first training is in paramedical training, the knowledge of what the current regulatory authorities and the mainstream medical authorities believe is most important for handling patients.
Acupuncture training in Japan is similar. Most of the acupuncture school training is in anatomy, physiology and pathophysiology, then techniques. You learn how to do needling and moxibustion but you do not learn systems of acupuncture usually. You have to wait until post-graduate education to learn a stylised system of practice. The training there is much more broad so that individuals can have a life-long license to treat patients. That is, they are expected to be safe in the market place. If we have this kind of approach where everyone who is going to do some kind of complementary therapy, in this case acupuncture, has as their background this kind of training in anatomy, physiology and pathophysiology it will satisfy the demands of the medical authorities because this is one of the main things they are concerned about, and it will allow diversity to be preserved. That will allow us to focus what we do in acupuncture schools on the models of training that we do, instead of being forced to teach everything and be regulated by the government. We have much more right over what we do. It will allow us to use our best teachers to teach what they do and the models of practice that they use. You could have one level of accreditation and testing overseen by government regulatory agencies that dealt with the paramedical training, and then another level of accreditation and testing that focused on technical acupuncture skills and knowledge which was set up in consultation with the British Acupuncture Accreditation Board (BAAB) or other independent educational authorities. If you consult with universities here they are more concerned with how you test and evaluate your students than with the actual content of what you teach them. It is up to us as the experts to decide what the content is of what we teach our students. We should not be told by some government body what we should teach them. I believe that this will allow diversity to flourish. I do not know if this is relevant to what is going on in the UK. This is one thing I thought would be interesting to talk about given the discussions that are going on in the profession right now.
Peter Deadman I wanted to say a few words about diversity but from a different angle. I am also going to mention Volker Scheid, who will get a lot of publicity today. I read - or to be more honest, I looked through - his latest book Chinese Medicine in China: Plurality and Synthesis. Plurality means diversity, and one of the key points he makes is that there really is not one internally consistent system within Chinese medicine. There is a lot of overlapping of complementary traditions both in the present day and historically, and he either quotes or states the example of a patient visiting ten herbalists and coming away with ten completely different or somewhat different prescriptions. This is an example of diversity in practice.
I would say this example pales into comparison with what happens in the case of acupuncture. A patient who visits ten different acupuncturists within this country or world-wide might not only have ten different selections of acupuncture points, but just about everything about the treatment could vary from practitioner to practitioner. Unknown to the patient the practitioner may be selecting acupuncture points according to a TCM pattern, to a Five Element CF, or using a classical or modern combination of points. They might be selecting points according to the symptom or according to the disease. They may have very individualistic opinions about what the acupuncture points do. They might be choosing points according to the time of day, the date and time of the patient’s birth, and so on, and in fact it can get even more extreme than that, with practitioners selecting points by intuition or dowsing and so on.
As far as the treatment is concerned there could be thirty, twelve, eight needles, one needle. The needles might be thick or thin. They might penetrate deeply causing intense sensations, or the needle might barely penetrate the skin causing no discernible sensation whatsoever. The needles may be retained for a matter of seconds or for periods of up to half an hour or even longer, and even this diversity does not include interventions such as cupping, moxibustion and bleeding. After the treatment the practitioner might be expecting to see changes in the patient’s physical condition, their mental and emotional condition or even their spiritual condition. So the question I find myself asking myself more and more is ‘What on earth is acupuncture? What is it that we do?’ In considering this question I am perhaps artificially separating the administration of acupuncture from its clinical context. As we know, one acupuncturist might make the patient feel safe and warm, listened to and confident in the success of the treatment. Another practitioner might impress or even overwhelm the patient with their presence, their power, their focus. A third practitioner might be cold and distant. Of course, all of these things make a difference, as does the simple fact of the patient presenting for treatment at all. Yet none of these seem to me to be unique to acupuncture. All of these might be found in the clinic of a homoeopath, an osteopath, a GP or even a surgeon.
The question I am asking, ‘What is acupuncture’, leaves all of these things to the side. It is not that they are not important, but the question I am asking is independent of them. If all the acupuncture approaches that I have mentioned are effective, especially if they are equally effective, what does this say about acupuncture? Does it matter what points we choose? Does it matter how we needle? If these are not important then I do not see a very bright future for acupuncture colleges. A lot of people are going to be out of work. If it does matter then I feel that something that we could do in the West - and the subject today is ‘Acupuncture in the West’, which should perhaps be ‘Acupuncture in the West: What now, what is the way forward?’ - is to integrate the objective observation of western science at its best, and I stress at its best. It is a very courageous position to take, to objectively examine phenomenon and be prepared to drop long-held and fondly-held beliefs. That is objective western science at its best I would say, and it combines well with the historical Chinese philosophical sceptical approach. What I would like to see going on, the way forward, is for us to start examining what we do. Does it make a difference? Are some methods of practice better than others? Is it important to obtain deqi or is it unimportant? Millions of questions that we need to know if we want to decide what acupuncture is and to further our practice, improve our practice and the outcomes of that practice.
Now this can be done in various ways; one way I would say – and it very encouraging to see more and more of this happening world-wide – is research into acupuncture. I think we should very much welcome research even when it throws up conclusions that we do not like, which it often does. Research sometimes seems to indicate that acupuncture is not effective in conditions that we always thought acupuncture was effective for. That does not mean that the research is right, but our immediate response should not be to reject the conclusion out of hand, but to really reflect on it. So, I think we should welcome research and particularly encourage research that we as practitioners can learn from, especially research that follows the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) guidelines. The STRICTA guidelines emphasise things like the acupuncture rationale; how was the treatment given chosen, the details of needling, how many needles, retention, was deqi obtained, the treatment regimen, other interventions apart from acupuncture, and practitioner background. The idea is, and it is obvious, that without offering this information it is impossible to evaluate research.
You see a piece of research on acupuncture and back pain, but if you do not know the type of needling and the type of point selection you really cannot evaluate the research. In order to encourage research as much as possible along these guidelines and to particularly encourage research that answers the questions that acupuncturists have, rather than focus research predominantly on trying to prove to the medical world or the government that acupuncture is effective, we should start to design research to answer some of the questions that we have about what is the most effective acupuncture. Beyond formal research I feel that we need to cultivate in our profession a very questioning attitude to our own practice. We all tend to believe what we were taught and this applies as much in China and the Orient as it does in the West. We find it very difficult to give up our fondly held beliefs.
Felicity Moir I wish to start by describing three factors that form the basis of my angle on this debate. One is that we practise our medicine in the West and therefore in a western political and legal framework. Our patients are mostly westerners and therefore consult with us with a knowledge base that comes out of a western culture, an NHS and biomedical inheritance often, and not forgetting a steady input from a western media. We view our practise through personal, often western determined filters. It is the meanings that phenomena have for us and the values we put on them that determine what we see, what we understand and how we act. Much has changed in medicine within this country over the last few years, led by a new political agenda, some of which I understand and much of which I don’t and despair of. There is also the rise of patient as consumer, the informed patient. Because professionalism includes an intrinsic relation of trust between the patient/client and the professional it is more and more being expected that professionals be accountable for their action. This is involving things such as league tables (I don’t know about the one in The Independent, and look forward to seeing it) - league table successes within universities, for instance, statistics on hospital waiting lists and the development of evidence based medicine. Doctors are now expected to practise what is shown, through research, to be effective. This is all impacting on us.
Bio-medical research criteria seem to be leading the research within acupuncture, but there is more and more evidence of effectiveness that is accepted as valid within western research criteria and also accepted by ourselves. Something like MacPherson’s pragmatic control clinical trial on lower back pain is an example - accepted by both western medical criteria and acceptable to many of us. Much of our evidence is also coming from our new colleagues in the British Medical Acupuncture Society and Acupuncture Association of Chartered Physiotherapists. Whatever we may say about their style of acupuncture and understanding of qi they are showing clear evidence of effectiveness, of patients getting better, and I would propose we are benefiting from the higher profile. We might say that this is not important to us; we have a 2,000 year old tradition and that is what we base our medicine on. But there are a couple of ideas that come to me whenever I think of this. Many of us do not read Chinese and so much of the knowledge is hidden from us. We are relying on the few texts that have been translated. Reality is that we cannot hide from the political drive, nor from expectations from patients. Further, Chinese medicine has always been about change and adaptation. That is why is has lasted 2,000 years. It is a very pragmatic medicine.
Moving onto some other perspectives, in his introduction to his book The Doctor, His Patient and the Illness, Michael Balint presents a prospect that by far the most frequently used drug in general practice is the doctor himself. It is not only the bottle of medicine or the box of pills that mattered but the way the doctor gave them to his patient. In fact the whole atmosphere in which the drug was given and taken. Professor Onora O’Neil, when she gave the 2002 Reith Lecture last year, said that more accountability would not necessarily produce trust between the practitioner and the patient. And quoting a little liberally from Phillip Larkin, a comment he made when he was on the Booker panel (he was describing it in relation to books and I to doctors) - we couldn’t describe a good doctor but we’d know one when we found one. If this is the case then it is critical that we make sure that evidence is not all on the disease or the treatment side but that we turn our focus on the practitioner.
Scheid and Bensky said in EJOM 1998 that the healing power develops out of and through the dialectic between fa, which loosely translates as method, and yi, intention. In the intimate relationship between practitioner and patient the concept of intention yi is critical. They describe yi as ‘the ability to enter into the totality of a clinical situation, view it from different angles simultaneously, match it with ideas already present in the mind, compare and contrast them, weigh up different possibilities for action and then and only then do exactly what is appropriate’. Healing power, they consider, is grounded in an understanding which involves thinking and deliberation, like bio-medicine, but this knowledge is context specific, personal and not readily communicated similar they consider to romanticist art.
Many people would say that what goes on in practice is largely intuitive, which I think often translates unable to be communicated, something Polanyi in education calls tacit knowledge. But what we have to think of here is: is it knowledge which is not communicated or which cannot be communicated? Is it an attribute of the knowledge or of the knower? It is back to being accountable. If we are going to maintain the right to practise as much from the yi as from the fa then we are going to have to find some way of showing that we do. Fish and Coles have an interesting perspective on this. They flipped this concept around so that rather than being accountable they propose that what professionals need to do is give an account of their practise, both the day-to-day but also the complexities of their practice. If others are to benefit we will need to articulate, write down what it is we do and why we do it. Interestingly, Scheid and Bensky quote a lovely passage from a Chinese doctor and acupuncturist, Guo Yu, of the Han Dynasty - the Han Dynasty! Listen to this, the first person in literature to elaborate on the importance of yi: ‘Now when it comes to treating nobles, they look down on me from the heights of the distinguished places, and I am filled with anxiety that I might not please them. Though the acupuncture needles demand precise measure, with them I am often in error. I am burdened with a heart full of trepidation, compounded by a will reduced in strength. Thus intention is not fully there. Consider what influence this has on treating the disorder. This is the reason I cannot bring about a cure.’
Two thousand years later we are benefiting from Guo’s reflections on his practice, and in the West in areas such as education, psychology, nursing, medicine, the same desire – that desire to understand the yi of practice – has been discussed and described. It is the desire to understand the difference between our espoused theories of what we do as compared to our theories in action – what is desirable and what is actual. Donald Schon described education (but we can apply it to medicine) as ‘the swampy lowland where situations are confusing messes incapable of technical solution’. But we cannot just leave it and say it cannot be described. If Guo could do it 2,000 years ago so can we. I think it is interesting - another thing the Chinese invented before us.
This is what we have to try and focus on, to articulate and to put equal focus on the yi and the fa, and I would propose that Continuing Professional Development (CPD) is the way we need to be starting on this. It is a western concept, but as we see Guo has done it before. Within this, by using the method of reflective practice, whereby we stand outside ourselves and look at ourselves in an objective way, what Christopher Johns calls ‘mindful practice’, then we might start to be able to articulate what it is that we do. This concept of reflective practice is beautifully described by Johns as ‘a window through which the practitioner can view and focus self within the context of her own lived experience in ways that enabled her to confront, understand and work towards resolving the contradictions within her practice between what is desirable and what is actual practice’. Through this we might be able to support each other and our patients and our society and maybe in that we can change society. It might be possible.
Open Debate Question What research does the panel think that the BAcC should be supporting given our research resource restraints and also that this audience does not necessarily represent the whole of the BAcC membership?
Stephen Birch I think that research is an expensive endeavour and that we need to look realistically at what kind of things you can do, and complex randomised controlled clinical trials are very expensive. It is not something I would recommend the profession to engage in, except in consultation with experts at medical schools who can raise funds for that, or some research centres that can raise funds. You could do research through your own practice, which could involve audits which are an individual thing, where you would keep track of what you are doing in your practice and being more critical of what you are doing in your practice. It should be very easy to develop tools to encourage you and help you to do that. I think that would be a very important thing to do. But this could also be done on a larger scale. If the profession decided to focus on what do we do with migraine patients, for example, and everyone collaborates on this so that it can be put onto a computer database and look at it globally within the profession. This is not horribly expensive to do. These are two simple areas where research can be done within the profession.
Peter Deadman I agree with a lot of that but I think that the single most important area of research should be on deqi or not deqi. I was at the World Federation of Acupuncture Societies’ conference in Oslo where some Italians presented a small, 10 person study where 10 patients were needled at GB 34 without stimulation and a blinded observer looked at changes to the gall bladder. A year later they got the same patients back and needled GB 34 with deqi and again observed changes in the movement of the gall bladder. They found that needling with deqi produced observable changes in the gall bladder function, whilst needling without deqi did not, except in a couple of cases where the needle had accidentally caused pain on insertion and the gall bladder responded. These kinds of studies do not have to be very expensive. Since we are acupuncturists and we are putting a needle into people, if you do not need to cause strong, intense deqi sensation then why do it? If we do need to do it let us be very clear about why we need to do it.
Felicity Moir I would want research to be conducted around ourselves, around the yi part of what we are doing in practice and therefore I would promote reflective practice as a methodology we should all be taking part in, that we could all be doing. We need to write down what it is we do and step back and look at what it is that we have written and engage with supervision, to check with other colleagues that what we are doing is what we think we are doing and why we are doing what we think we are doing. This is something which we could all be doing.
Comment At this very important time is it not also important that we don’t forget our roots and so what you have talked about is very much CPD orientated, what we can do ourselves. But what about where we came from, our diagnostics? If we are not careful we will become more and more westernised.
Peter Deadman I am an interested observer of research, and do not see any reason why we cannot design research to compare treatment according to, for example, pattern differentiation and non-individualised treatment. In principle you can take research methodology and check everything. It does not in any way mean that you abandon core ideas. You simply test whether it makes a difference whether to do A or to do B.
Stephen Birch I think you have raised a very important issue. Right now there is virtually no evidence that it makes a difference doing some kind of differential diagnosis in treatment. There are almost no clinical trials that have any meaningful results and there are very few studies that have been attempted to show that you can get practitioners to even agree on diagnosis. If you cannot agree on it you cannot do patient selection appropriately. There has to be agreement on which treatment to administer once you start going down that road. It may be that this is a third area of research I would add to what I said before. I think that the profession itself could fund and conduct studies very easily and inexpensively on reliability of diagnosis. Can we agree on anything? What is it we are not agreeing on and why. It is a little frustrating when you are a student and your teachers cannot agree on what is going on with a patient. If we can improve that level of agreement, it provides a better base for us to do such research. The scientific community is not going to do it for us. It is probably something that we have to do ourselves.
Comment I just wanted to respond on the idea of reflective practice and whether it is western or more rooted in our classical traditions. Reflective practice can be engaged in looking at the function of our own Five Elements or our jing, qi and shen as part of our practice. Reflection is looking inwards and we do not have to have a western model. It is up to us as a profession to engage in that and as we do our CPD and as we write our reports we use the substance of our traditions to do that.
Question A comment that Gordon Brown made recently at a conference about what his party needed was not just a programme but a soul made me think that perhaps they might do well coming across and seeing what we are doing in our profession. I have confidence that we have already brought the two together, but as we move forward and as part of the scope of acupuncture looking into the future how do we best continue to keep programme and soul together?
Felicity Moir I think we need to be honest about the difficulties of being in practice and to share that with each other. That is where I would hope the soul would be maintained and revitalised. I recognise in myself when we were talking about research – I think it comes back to this question of diversity – that when someone comes to me as a patient and asks a question about something which I have read about in a research paper that I feel better being able to answer the question. I feel a bit more confident, although it does not change my relationship with my patient. We can allow people who have the funding to conduct research and learn from it while at the same time maintain our own integrity and self-cultivation. Chinese medicine has the power, as in the yi and the fa, to put the two things together. A lot of GPs also do this because it is inherent in practice. We need to recognise that and gain from what is going on within medicine generally.
Comment The thing which came up for me was the word connection. We could take any patient with a condition, and maybe it is of secondary importance what approach we use, as long as we use an approach that we are competent in and feel that we have a connection with. In terms of maintaining soul my concern is that we do not end up ticking lots of boxes because we know what that is about. It is not an awful lot to do with connection with our soul. If we are going to try to keep our soul engaged in our practice then we need to do meaningful things that we connect with. For example, if we are engaged in studies which are meaningful for us, that feed us, something a bit bigger that feeds our practice, such as whether we are Buddhist, Daoist, Christian etc.
Comment There may be a lot of interest in getting involved in research and it is important that the profession uses the resources of the Acupuncture Research Resource Centre (ARRC). Even if there is a negative outcome of a trial and you know a bit about methodology when reading the paper you might find that it was just not a very good design in the first place. But that might lead you on to doing something better. If people could share information that is also a good thing.
Stephen Birch There are probably not many people in the acupuncture profession trained in research methods who can evaluate clinical trials on acupuncture very closely. My comments are mostly addressed to that group who may understand this comment. I think that the problems of interpreting clinical trials on acupuncture are enormous. There are problems with the way studies have been carried out, how they have been implemented, whether the control treatment was appropriate, whether the right research method has been chosen to answer the question they thought they were asking to begin with, which often is not the case. Then how you measure the outcome; these are all very complicated things. When people have looked at clinical trials and tried to judge how effective acupuncture is the conclusion is that you don’t know. The studies are so bad. Occasionally we find something for nausea or vomiting or dental pain you can get some kind of conclusion because the studies were quite well done and were simple designs relatively speaking. When you look at something like asthma, the BMA drew the conclusion which I think was a faulty conclusion, because it misquoted from the original study it was claiming to be quoting from, that acupuncture is not effective for asthma. Does that mean we should all stop treating asthmatic patients? If you look at the qualities of the studies that were done, most were awful. Much more work needs to be carried out on how we conduct such studies.
Peter Deadman I think one thing that is very important for our soul as human beings is to learn to observe accurately. The goal of psychotherapy, for example, is to learn to observe ourselves accurately, to free ourselves from illusion, to see who we really are and it is a terribly difficult thing for us to do. The Chinese have a saying that the last creature to discover water is the fish. It is very hard to see the sea that you swim in. This challenge of accurate observation and willingness to let go of our beliefs is a very difficult thing to do; I would say it is a way to keep our true soul in our practice. It is when we ride on the things which we hold unquestioned in our mind in practice and just repeat ourselves and ignore the challenge of truly observing whether treatment is effective or not, that somehow we can lose our soul in practice. So research is not just about something that gets done that is very expensive, gets done out there; research is about the way which we approach what we do ourselves every day.
I would just like to say that whatever the quality of research that has been conducted into asthma and the fact that it indicates correctly or wrongly that asthma is not effectively treated by acupuncture, it might help us recognise that asthma is very difficult to treat with acupuncture. Our results in most cases are going to be quite moderate. This does not mean that we should not be satisfied with these results. But if we carry in our heads an expectation that acupuncture can always cure asthma then we will see ourselves as failures. What actually happens in practice does not match a false idea we have originally been given. My challenging statement is that we as acupuncturists in the West have our heads full of false ideas.
Question What the speakers are proposing is particularly challenging - to look at our beliefs, and I just want to ask how do we support ourselves so that we can do so with enough self-esteem, enough courage etc. to look at these things? How can we do this without feeling isolated, where we have enough networking and professional support to enable us to look at these difficult issues?
Felicity Moir We all, so many of us, work in isolation and we do have to start working together, which means putting time into being together and challenging each other on what we are doing. So the Regional Groups in the UK are important. I know that often in multi-disciplinary clinics when meetings are arranged people don’t turn up to them which is really a problem that comes from our isolation. The sort of people who have gone into acupuncture are not team players. We are all individuals, which is why it is hard to get people to work together. This is something which we have to change.
Stephen Birch It is really important to get together with your peers and continue studying. I feel a little spoilt myself because I belong to an association that has its roots in Japan and we try to get together once a month to study together. We review everything; we go from theory into point location, needling techniques, diagnosis. Do we agree on anything? What are we finding problems with? When we get together we are constantly evaluating, trying to review these things. It is extremely useful to do that. If systems can be set up to structure that for the general field it would be very helpful.
Question There is a lot of knowledge and experience out there. Is it not the responsibility of the colleges and universities to pull together all of this expertise and experience and share this with the larger body of practitioners, for people who specialise in areas for example. Is specialisation a path we should be taking?
Peter Deadman Personally, I believe that one route to refining our knowledge is specialisation, joint specialisation, and setting up nation-wide, or it could be world-wide, study groups on the treatment of certain conditions using email and the internet. We are general practitioners and our problem is that in a given year we might see five of this, or three of that, so it is very difficult to gain enough clinical experience. If you pool that experience and you agree with people how to evaluate the cases and evaluate the treatment then you are pooling numerous brains to the same end and we can learn an awful lot from this. From my experience of talking to people over 25 years I feel that the majority of acupuncturists spend a very large amount of time feeling inadequate and unconfident, and one of the reasons is that we are sold a false package to start with. We are sold acupuncture as being greater than it is. All this orientalism with its magico-mystery attached actually creates an unattainable virtual perfection of acupuncture that mostly we fail to match up to, and this can result in our feeling unconfident and inadequate. I think it is a curse of our profession. The sooner we get back down to earth and accept that 35% improvement in migraine patients is fantastically good because it is better than any medicine can deliver – or a 25% improvement in back pain – these are realistic targets. But we are sold some fantasy in the early years that actually creates great burdens for us.
Felicity Moir I would say that this is true. I think so many other professions feel like this as well, professions that have that intimate relationship with patients. Educationalists also have it, nurses will talk about it as well. I don't think we are on our own with that. I think many professionals have learned to put on a false image of being fine, but when you get down underneath it and talk to GPs for instance you will find many who feel the same, who feel inadequate. I think we should get support from them as well.
Stephen Birch Many clinicians don't want to write because they feel they don't have the skills. There are a lot of people who have good cases to share but they are afraid of writing. As a writer I have noticed this a lot. As you know, I am not afraid of writing, which may be a good thing or a bad thing for all of you. Perhaps the BAcC could put together an editorial committee who would be willing to work with contributors who have interesting cases, to help get them written up in a form where they could be published in the European Journal of Oriental Medicine, which is the BAcC's Journal. A proposal for you.
Peter Deadman As the editor of the JCM we would welcome such cases, in any form, which we would be willing to work on.
Mike O'Farrell On behalf of Jasmine Uddin, the editor of EJOM, I would like to say that EJOM has great difficulty in receiving articles from people in any form, and would welcome receiving cases from members.
Comment The BAcC Research Committee is actually encouraging the profession to submit case studies which will be published in EJOM if they pass the editorial requirements of EJOM and we are encouraging them by offering them £50 if they are published, so that will become a regular thing. So there are at least two vehicles out there for people to submit their cases to. I myself have benefited from years of supervision and one of the lovely things to have grown out of that is group supervision and my group has continued to support each other, to share clinical treatment problems. This is a resource that practitioners can really make use of.
Question I set up a practice 4 months ago. A lot of money is being spent on the CPD programme at the moment and there have been times when I would have liked to have contacted someone. Would the BAcC consider having someone with some experience available that members like myself could contact, via email or telephone? Perhaps the Regional Groups are not working as well as they should because those involved are in competition with each other. I know that has affected my desire to talk to fellow practitioners in my area.
Felicity Moir One of the things we usually promote on the course at the University of Westminster is having peer groups following graduation, to work within such a critical group. We all act as supervisors if someone approaches us individually, but this is more informal and is up to the individual. Perhaps we need to take this on more on a formal basis, and make that move.
Comment It has been a tremendous experience being part of the Acupuncture Childbirth Team. We decided to set up our group within the parameters of our county, and what it has meant is that all of us who are particularly interested in treating pregnancy with acupuncture is to pool our knowledge and make very effective connections within the medical system within the county. I absolutely encourage people to get together and discuss what it is that interests them with people in their locality. We have had recent graduates join our group who have been very expressive in the field of pregnancy.
Comment Going back to an earlier comment by Peter Deadman on asthma, I would just like to say that I have had huge success with treating asthma, also looking at food and changing people's diets. One of the difficulties with the research carried out on asthma is that they have not continued to carry on for long enough, probably because of funding they have only carried it out for two to three weeks at a time. I believe that if you take serious diseases, having worked in the medical profession myself as a physiotherapist, you have to allow yourself a long-term period of time to get good results. If this was looked at progressively over a whole year you would get much different results.
Peter Deadman I did not say that acupuncture was not effective for asthma, I said that it was difficult. I would agree with you; a year is a realistic time.
Question I would like to know whether there is an idea of promoting research through the BAcC and ARRC, so that it is the profession suggesting which areas needed to be researched, the profession would put together interested people, would actively promote these areas, and perhaps even reward them at the end. Is that part of the discussion that is going on at the moment?
Mike O'Farrell The Research Committee has now been granted a small sum by the Executive Committee, around £5,000, to encourage practitioners to participate in research activity. They have to apply for this. We have had a series of applications this year, which the Committee has vetted, and will announce soon who has won those awards. £5,000 is not very much money but it is a first step and it is a structure. The BAcC has also been discussing with the acupuncture institutions about how we might develop this still further so that is the second part. On a wider scale, the government has come to some recognition that some money needs to be spent on research by awarding five fellowships into complementary medicine this year. Hugh MacPherson was lucky enough to be awarded one of those, and they are going to have another five next year. If our research activity proves to be successful and we have got the structure right, we are going to try to expand that and hopefully persuade the Finance Committee to agree to another £5,000, and perhaps more. Gently we are trying to get there.