The Good, The Bad and the Masterful - Researching Practice
In a research-focused issue of EJOM ten years ago David St George, epidemiologist and outspoken champion of alternative medicine, declared that complementary and alternative medicine (CAM) should avoid biomedical agendas and instead do their own research. He rated orthodox medicine’s methods as over-quantitative, insufficiently tuned to the subjective experiences of patients and practitioners, blind to healing phenomena based on vital forces, and in any case the servants of an establishment whose main interest in CAM is to swallow the bits it finds attractive and spit out the rest (St George, 2000). In the same EJOM issue Scheid and Bensky chided Fitter (and to some degree all of us) for ‘Orientalism’ (re-shaping Chinese medicine in order to assimilate it into Western culture) when he suggested that Chinese medicine should be grounded in contemporary culture and make use of a range of Western research methods (Scheid and Bensky, 2000). Fitter was not advocating the ‘hard evidence’ end of the research spectrum: he had focused particularly on approaches used in psychology and the various forms of reflective practice (Fitter, 2000).
This debate came out of Scheid and Bensky’s article on yi, ‘Medicine as signification’, which cautioned against applying positivist research methods to Chinese medicine on the basis that knowledge about healing power cannot be captured or represented in numbers, words or even concepts (Scheid and Bensky, 1998); indeed, the understanding and consequent actions deployed by superior practitioners may not be communicable at all – it is not explicit knowledge. They also warned that importing ideas and methodologies from holism, systems theory or psychotherapies may be equally inappropriate for this purpose, though there are contrary opinions even amongst anthropologists and sinologists (Shea, 2006). Much of the apparently most progressive CAM research of the last decade, striving to move beyond the normal biomedical framework, has drawn heavily on holism and systems theory. Whole systems research has a flexible, adaptive, non-hierarchical outlook, mixes quantitative and qualitative methods and particularly attempts to mesh with the unique theories and practices of the intervention, be it traditional acupuncture, homoeopathy or whatever (Verhoef et al., 2005).
How then did Scheid and Bensky propose to research practice? In their article, investigational methods ‘suited to the demands of medicine as yi’ were as yet undefined. However, Scheid has subsequently developed a four-stage approach and applied it to a esearch project on menopause (Scheid, 2010): i) an examination of current and historical literature ii) a survey of menopausal women iii) action research to apply the findings from i) and ii) and determine what works best in the clinic iv) (yet to be started) a conventional clinical trial.
Action research comes from the same stable of social sciences inquiry techniques recommended by Fitter for the professional evelopment of practitioners. Literature reviews, surveys and clinical trials are of course part and parcel of orthodox medical pproaches. The critical distinction (for Scheid and Bensky) seems to be whether such alien methods are assimilated into the culture of Chinese medicine, and moulded to fit its traditions, or whether Chinese medicine is moulded to fit the alien methods. This is not necessarily straightforward to determine.
St George suggested two types of research for the acupuncture profession, one pragmatic and one speculative (St George, 2000). The former embraces techniques such as audit, before-and-after/outcome studies and case studies, ie, monitoring realworld clinical practice, primarily for our own professional development but also providing indicative data about our capabilities for outsiders. For the second, he looks to investigate the underlying phenomena behind our healing work: qi, universal consciousness, vital forces etc. What has happened in both of these areas since then?
Pragmatic research for practice development There have been numerous outcome studies of various sizes (up to tens of thousands), with selected groups of patients or patients in general, measuring wellbeing and quality of life and/or specific symptom scores, and carried out by practitioners,colleges or professional researchers. These have been run for avariety of reasons, such as piloting a future randomised controlled trial (RCT), or to support the marketing of a service, but very few have been done in order to help improve the repertoire of practitioner skills and probably even fewer have actually achieved this. In China, by contrast, there have been innumerable outcome studies designed to compare different points/needling techniques/modalities for treating patients with particular conditions.
Published audits for traditional acupuncture and East Asian medicine (TEAM) are extremely scarce. Most have been done by practitioners working for/with the NHS (for example, Blacker, 2008), as part of their job specification, or for defining a role for the therapy. Many of the studies described as audits do not actually comprise a cyclical process. They may gather practice data but do not compare it to explicit criteria, nor use it to implement change and drive up standards.
A few diagnostic studies have been published in the West in the last 10 years (and many in East Asia) and some at least have had an influence on practice, or at least the teaching of practice. Most have been carried out by university researchers to examine the reliability of the various diagnostic techniques, for example the pulses (King et al., 2002), the tongue (Li et al., 2009), three of the four main TCM diagnostic methods (O’Brien et al., 2009a), overall TCM pattern diagnosis (Mist et al., 2009), overall Toyohari meridian therapy diagnosis (O’Brien et al., 2009b) and a review of all TEAM methods (O’Brien and Birch, 2009). Mechanising and quantifying tongue and pulse diagnosis has been a major strand of TCM research programmes in China (Zhou and Zhang, 2006; Xu et al., 2007 and 2008; Dong et al., 2008). Perhaps the most exciting project is that looking at correlations between TCM diagnoses and biomarkers (Schroen, 2010).
Speculative research St George said in 2000 that many people had tried to measure qi, or healing forces, but none had succeeded. This is still the case. St George suggested this was because researchers had been trying to measure the wrong thing, for example the strength of electromagnetic signals rather than frequency and pattern. Also he said that those who did the research needed to be steeped in the tradition they were investigating. This is perhaps more to the point than which electromagnetic characteristics are investigated. It seems unlikely that any attempt to measure qi in those terms will be successful, given the enormity of the concept: its transformations generate ‘that which fills out the entire universe’ (Barnes, 2009). It is hard enough to define it, let alone measure it (Birch et al., in preparation; Birch and Bovey, in preparation).
In a series of papers Tiller argues for the existence of a system of largely unseen psycho-energetic forces that will in due course be seen to provide the technical underpinnings for CAM. These are magnetic rather than electrically-based (Tiller, 2010). Electromagnetic phenomena provide one of the main explanatory models for qi flow along meridians for both Western (Napadow et al., 2008) and Chinese researchers (Li et al., 2008). Tiller also employs entanglement theories (Tiller, 2006). This is an idea derived from quantum theory that posits correlated behaviour between two or more elements of a system without any interchange of energy or matter (Hyland, 2004; Walach, 2005). It has been applied to CAM most often for homoeopathy but is pertinent across the board, including conventional medicine, to provide an explanation for why verum and sham treatment groups in clinical trials tend to improve in the same way, to the same extent (Walach, 2005). Quantum terminology also appears quite frequently now in Chinese papers on qi mechanisms (Li et al., 2008). However, much as we would like to have theoretical physics in our corner the physicists tend to be sceptical that quantum mechanics can be applied at the macro level of human interaction (Greenland, 2010). Spirited, if somewhat incomprehensible, arguments on this subject persist (Hankey, 2008).
It would be easy to feel some sympathy for Scheid and Bensky’s charge of Orientalism at this point, except that the whole of CAM is targeted, not just TEAM. Explanations of healing with TEAM may call upon current knowledge of physics or psychology but should also fit with traditional knowledge of the medicine. It is not impossible to research qi-related phenomena but this should be approached in ways true to the characteristics of qi known from the historical literature (Birch and Bovey, in preparation; Mayor, in press).
Physiological mechanisms Investigating healing phenomena may have practice implications in St George’s schema but he himself admitted that it is not generally the sort of research that practitioners can do themselves. Also, at one end of the spectrum it metamorphoses into the highly medicalised approaches that use laboratory animals (animal ‘models’, in the parlance) to investigate physiological mechanisms underlying acupuncture, whether for specific diseases, body systems or general effects such as analgesia. Most of this work takes place in China, indeed it appears to account for a substantial proportion of the Chinese acupuncture research output. South Korea and the US are also major contributors. One problem with the use of animal models is that they readily yield positive results of specific physiological actions for true vs sham acupuncture, results that are not matched in clinical trials. (See Wayne et al., 2009, for further discussion.)
Of course there is also much physiological research done with (consenting) human subjects, the most publicised of which has been the brain imaging work. This is far from practice-based research in terms of the expertise, equipment and money required. There is also a huge gulf between recording transient functional changes in the brain and seeing these translated into sick people getting better. Nevertheless it is a fascinating area with sometimes stunning results, for example the images representing digits returning to normality in carpel tunnel patients (Napadow, 2008).
Differences between practitioners Both St George (2000) and Scheid and Bensky (1998) touched upon the idea that practitioners vary in their capacity to heal and hence in their effectiveness. St George: ‘What makes people good or not-so-good acupuncturists? Is it to do with the needles or is it about being better healers?’ ‘Part of it is being good/not-so-good artists’. ‘A lot of the therapeutic effect is down to the personality of the therapist as well as the patient’.
Scheid and Bensky suggest that intrinsic healing power does not in itself lead to becoming a good physician. Instead they emphasise a process of self-cultivation that comes from the interplay between yi, signification, and fa, the traditional methods, tools and information that we learn and call upon. Nevertheless they concede that practitioners vary innately in both of these components and hence we get ‘superior and inferior craftsmen’.
While it may be self-evident that some of us are better practitioners than others this does raise questions that penetrate to the heart of what we are and what we do as acupuncturists; also that strongly affect how our work is investigated and evaluated by researchers: • To what extent do practitioners vary in their effectiveness at treating patients? • Does this variation stay constant across the range of patients or do particular practitioners suit particular patients? • Is healing power largely an innate characteristic, largely a cultivated one, or a mixture of both? • Can less effective practitioners be identified and can they be helped to improve? • Where do I myself stand in the spectrum and what do I think about this? • Do the best practitioners have the largest practices? • Are the best practitioners more extrovert and do they have larger address books? Are they more famous and better known by their peers? • Do we become better practitioners with more years of experience? • Does the nature/length/style of our training have a significant effect on our healing capacity? • Through what mechanism(s) does the practitioner’s healing power influence the patient’s health? • Should practitioners who are to participate in clinical trials be screened such that only the better ones are used? • Should evaluations of therapies give way to evaluations of therapists?
Some of these questions were addressed in a paper drawing parallels between CAM and psychotherapy (Hyland, 2005). Drawing on data from meta-analyses Hyland found little support for psychotherapies having any great benefit in themselves (specific effects) but noted that the contextual effects were substantial. Such factors might include the nature of the therapist and their relationship with the patient, the patient’s expectancy of the treatment, the setting and reception, the conceptual model used to explain the therapy, and the procedures/rituals engaged in by both participants. The contextual model implies that psychotherapy provides a context that promotes self-healing, rather than that it treats disease. (This is a debatable distinction: promoting self-healing may be the most effective route for addressing chronic illnesses.)
There have been found to be large differences in outcomes between (psycho-) therapists, both in normal practice and in trials (Hyland, 2005). The best therapists achieved positive changes in about 80 per cent of their clients whereas the worst saw on average no change, or a slight worsening in symptoms. Good therapists could be identified by their patients (and peers) quite early on in treatment but there appeared to be no significant effect of type or years of training, theoretical orientation, gender or years of experience. Good therapists were generally good for all patients and bad ones bad for all. Other data indicate that differences between therapists may be more modest in size (Witt et al., 2010).
Hyland drew parallels between psychotherapy and CAM therapies, largely on the basis that both appear to have substantial contextual effects but small specific effects. He went on to suggest that the therapist’s personality may be the most important factor for both (though without any supportive evidence for CAM). Interestingly (for a professor of psychology) he does not favour the usual psychological explanation (therapeutic alliance/placebo) but instead looks to phenomena such as electromagnetic fields or entanglement. However, this is largely conjecture, data are limited and we still do not know what makes a good therapist.
Data on acupuncturists’ differences in outcomes Despite the fact that numerous clinical trials have used multiple practitioners, scarcely any have reported on the individual differences between these practitioners (presumably this could still be done retrospectively, unless the data have been destroyed). From the large German health insurance trials we know that the length and type of training, time in practice, use of TCM diagnoses and most of the other practitioner details recorded did not significantly affect the results (Witt et al., 2010). Better qualified and more experienced physicians were not more successful. Hence the focus falls on the therapeutic relationship and (unknown) individual qualities of the physicians. These data came from large pragmatic trials where the (2,781 medically qualified) practitioners could treat as normal, though we cannot assume that the results would extrapolate directly to other populations of acupuncturists.
The other Western country to commit huge funding for acupuncture research trials is the USA. Kaptchuk’s team at Harvard has launched a series of studies to investigate placebo effects. In one of these (Kelley et al., 2009), 289 IBS patients were randomised to: a) waiting list, b) sham acupuncture plus a limited/neutral practitioner input (LIM), or c) sham acupuncture plus a full/warm/empathic input (FULL). The sham used a retractable needle device, on 6-8 non-points, left for 20 minutes, with six sessions in three weeks. A second part of this study compared true and sham acupuncture after switching half of the participants at three weeks, but that is another story.
The sham groups outperformed the waiting list by about 11 per cent (LIM) and 20 per cent (FULL), hence the conclusion that there is a graded response with different placebo items adding to the effect. A few patient characteristics (eg, extroversion) affected the outcomes but only to a small extent, and only in the context of the FULL regime. Of particular interest to us here are the individual practitioner effects: these were much larger than any other tested factor, and twice the size of the effect of the therapeutic interaction (LIM v FULL). It is remarkable that such differences exist even when the practitioners’ freedom of expression is constrained by tight trial protocols; also that the differences were apparent in the limited as well as the enhanced therapeutic setting. Of the four practitioners, one achieved poorly throughout, two did well throughout and one did relatively poorly in LIM but quite well in FULL.
In an experiment carried out by the Southampton University CAM research group patients were treated with either real acupuncture, retractable needle sham or mock TENS sham (Lewith, 2009). Again there were two types of interaction: empathic and nonempathic. Neither the type of acupuncture nor the therapeutic interaction affected the outcomes. The only important factor was the individual practitioners (there were three), though again, results had nothing to do with their length of experience. From qualitative interviews it appeared that being sweet-natured and empathic may be less valuable than appearing to know what you’re doing. You can be somewhat ‘doctorish’ as long as you listen, engage and look to have the patient’s best interests at heart. Confidence is important: for the patient in the practitioner and for the practitioner in their craft and their own proficiency in it.
It is important that psychological explanations are again tempered by referring back to TEAM knowledge, for example Scheid and Bensky’s yi model or Birch’s multiple layers of qi that are differentially accessed by basic/good/master acupuncturists (Birch, 2009a). Hsu has considered traditional practices in terms of their ritual efficacy and suggested that the most important role of training is to teach the rituals and inspire confidence in them (Hsu, 2007). She identified de qi as perhaps a critical component of traditional acupuncture’s ritual, a transformative experience shared by practitioner and patient that harnesses the healing power of the former. Much effort has been put into researching de qi,cataloguing patient experiences of it, correlating it with differential patterns of brain activation/deactivation, though there is no good evidence to show that de qi is important for treatment outcomes (Bovey, 2007; Lewith, 2010). It seems very likely that people differ inherently in their capacity to generate, feel or be attuned to de qi but also that it can be cultivated, for example by meditative practices and appropriate exercises. The practice, or not, of qi gong, may turn out to be a better predictor of acupuncturists’ potency than age, gender, training and experience, but I suspect it still would not be a large factor by itself.
So far we have looked at evidence of practitioner differences from clinical trials, yet outside of these they may be larger (Hyland, 2005). Unfortunately we have virtually no systematic information about this. From a secondary analysis of the MYMOP data gathered by 12 practitioners of the South West Acupuncture Research Group there were found to be differences in outcomes between practitioners and possibly a weak correlation with their years of experience (Chapman, 2006).
Implications for practice It should concern us if increasing experience does not substantially, or perhaps at all, improve our performance. If you are not very good when you qualify then no amount of self-cultivation or experiential wisdom is going to make you better. This appears to fly in the face of accepted wisdom that practising acupuncture is a skill, and skills need to be worked at assiduously to master them. In a recent blog Flaws exhorts Chinese medicine practitioners to go back to basics and rote learn all the standard facts and techniques until they are second nature: ‘mastery is mastery of the basics’ (Flaws, 2010). As most of us have signally failed to do this we are only mediocre craftsmen; masters are few and far between. So could this explain the lack of effect of years in practice on patient outcomes? If only some practitioners get much better with experience but many others do not (and perhaps some even get worse, by losing initial enthusiasm or drifting away from what they were taught) then indeed the correlation between outcomes and experience could be close to zero.
That individual physician effects are the most important explanatory factors in outcomes does not downgrade Chinese medicine, its traditions, theories and procedures: there have always been good and not-so-good practitioners. Unless it is believed that healing power is entirely an innate individual characteristic then the practitioner’s potency arises out of the interaction between themselves and the medical modality they use. Some are surely more suited to this than others but all of us have made the choice to engage with it. It has been suggested that the decision to take up a career in Chinese medicine can be viewed in terms of our xin (heart-mind) functioning (Barnes, 2009) but that level of human-heartedness alone will not always be sufficient to carry us on to mastery.
Implications for research Few practitioners do research and scarcely any do practice-based research for the purpose of developing themselves and their practices. There are good reasons for this (Bovey, 2009) – time pressure, lack of research knowledge or a support structure – but not insuperable ones (Birch, 2009b). It has been suggested (Birch, 2010) that matching acupuncture college dissertation students with practitioner-researchers would provide the former with a ready-made project and access to data from patients, while the latter get a free source of assistance plus some academic affiliation and support. In time this could be rolled out across the whole European TCM Association domain.
Any practitioners can look systematically and honestly at their own results to see how well they’re doing. What changes could they make and do they make a difference? As already pointed out, audit-type projects, incorporating cycles of assessment, reflection and action are sorely lacking in traditional acupuncture (though there may be a repository of incomplete and unpublished data).
Training institutions should be particularly interested in issues of practitioner variability as it impacts on their student recruitment procedures and their educational practices. It would be interesting to know whether degree grades bear any relationship to subsequent practitioner achievements. Do all colleges and styles of acupuncture show similar amounts of practitioner variation (or is there less in those with more formulaic and prescriptive knowledge)?
For the profession as a whole I believe that we should be routinely gathering practice data from a core sample of acupuncturists over a long time period. As part of this we could be looking at the differences between practitioners. Could we learn by studying the best (and the worst) – or is this nonrecordable and non-communicable information (Scheid and Bensky, 1998) that shows up only when we act it out ourselves?
For academic researchers and for sceptical scientists the interest in practitioner and other so-called contextual effects is mainly as part of the argument around sham/placebo and whether acupuncture has any significant specific effects of its own. It is important that TEAM practitioners and their professional bodies engage in these debates, both for better design of future trials and better interpretation of the results of existing ones.
When Ernst says (in a review of acupuncture for labour pain) ‘Our analyses show that the effects of acupuncture perceived by women are largely due to placebo’ (Ernst, 2010) then we can refute this on several fronts: the inadequacy and inappropriateness of some of the trials included in the review, the authors’ selective use of data for drawing conclusions and their selective choice of explanatory models, the lack of any workable intervention that is truly a placebo for acupuncture, the absence of knowledge on basic mechanisms underlying acupuncture, and the conceptual and practical difficulties in distinguishing specific, non-specific and placebo components. When Hyland maintains (Hyland, 2005) that the therapy itself does not do the work, which is achieved instead by the processes around its delivery (the contextual effects), I believe he is over-simplistic and perhaps not well-informed about specific therapies. As practitioners of East Asian medicine we would consider that appropriate therapeutic relationships are part and parcel of the therapy; indeed, the therapist’s approach may vary with his/her specific diagnosis of the individual patient. Likewise the clinical decisions made within the therapy are integral to the person who is making them, so the practitioner context and the specific therapy effects cannot be separated. This argument may have less force for more symptom- and protocol-driven styles of practice, which are thus more vulnerable to ‘placebo attack’. Yet acupuncture trial reviewers frequently plead for complete standardisation, so as to make meta-analysis more straightforward and conclusions more clear-cut.
Evidence – of a sort Here are recent examples of the systematic reviewers at work. I have taken the lists of acupuncture reviews for the last two years (February 2008-10) compiled for the NHS CAM evidence website (NHS a & b) and added any further examples up to the end of April 2010 (Cao et al., 2010; Cho & Hwang, 2010; Cho & Kim, 2010; Cho et al., 2010; Cho & Whang, 2010; Kim & Zhu, 2010; La Touche et al., 2010; Lee et al., a, b, c & d, 2010; Lim & Wong, 2010; Rubinstein et al., 2010; Wang et al., 2009; Wu et al., 2010; Zhang et al., 2010). Depending on the wording of their conclusions I have graded each one A to D. Those graded A concluded that acupuncture is effective, or appears to be, even if hedged around with caveats about the poor quality of the data (a more or less universal refrain). Those graded D said that there is no/insufficient evidence to support acupuncture’s effectiveness. Grades B and C are intermediate levels. The list of complaints covered, with grade and number of trials reviewed, is presented in Table 1.
The sheer number (86) published in two years and two months is impressive. Note that for 21 of the 53 conditions there has been more than one review on the same subject in the time period – and that these are not always consistent (e.g. depression, assisted conception). There are 28 A’s, 17 B’s, 16 C’s and 25 D’s. The nationalities of the lead reviewers are heavily weighted to a few countries: China and Taiwan 29, S. Korea 21, US 11, UK 8, others 17.
Unfortunately these gradings, from the bare conclusions on their own, are not very reliable, for there are huge differences between reviews in type, quality and number of included trials, in methodology employed, and particularly in interpretation of the results. The headlines should not be taken at face value, not necessarily even the whole abstract; sometimes you must read the complete paper and consider all of the details.
Table 1. Systematic review conclusions, by condition, Feb 2008 – April 2010*
Other Chronic fatigue syndrome A28 Hypertension C20, D11 Restless leg syndrome D2 Obesity A8, A29 Pain/Post-operative A15, B9 Acne A17 Dermatitis D3 Hot flushes/chemotherapy D6 Hot flushes/menopause C11, D6 Dry eye C6 Rhinitis B12, A12, D7 Common cold prevention C5
Notes • Letters A-D are grades based on the degree of positivity of the conclusions. • Figures in superscript are the total number of studies included in the review. • Where there is more than one review per subject they are presented in reverse chronological order. * All reviews from the NHS annual acupuncture review lists (NHS a & b), Feb 2008-9 and Feb 2009-10, were included, as long as they relatedto a particular condition, reported on at least two studies, allowed the separation of acupuncture from any herbal or laser data, and were systematic reviews. Medline was accessed on 27 May 2010 to locate any further such reviews published up until 30 April 2010.
Look for example at Ménière’s, which gets an A grade. The inclusion criteria were much wider than with any other review, with uncontrolled trials, observational and case studies and even qualitative studies. Only three of the 27 reviewed studies were RCTs. It is perfectly legitimate to spread the net this wide, admirable even, but you need to know that then you are comparing apples and pears. Most reviewers restrict themselves to RCTs and some just to placebo controlled RCTs.
A more widespread difficulty is that Chinese-authored reviews, though they now largely conform to similar methodology, and offer the same cautions over trial quality, do produce more positive conclusions than would Western authors. Also the Chinese reviews are more reliant on Chinese studies, which are usually of lower quality and more likely to be biased. Hence the following conditions, though apparently good candidates for promoting in acupuncture’s evidence base, still have question marks over them: acne, chronic fatigue, dementia, insomnia, obesity, prostatitis, stroke dysphagia.
It is instructive to take an example such as depression and compare the widely different outcomes of different reviews. Zhang et al. (2009), from the University of Hong Kong, included 20 RCTs on major depressive disorder and found acupuncture to be as good as anti-depressants but no better than sham. It was concluded: ‘Acupuncture therapy is safe and effective in treating major depressive disorder..., and could be considered an alternative option...’ Smith et al. (2009), for the Cochrane group, on depression as a whole, produced the same comparative results, but concluded: ‘We found insufficient evidence to recommend the use of acupuncture for people with depression.’
There are some common illnesses not covered in these recent reviews. I have assigned them a grade from past reviews: general anxiety (C) (Pilkington et al., 2007), situational anxiety (B) (Pilkington et al., 2007), asthma (D) (McCarney et al., 2003), IBS (D) (Lim et al., 2006), shoulder pain (C) (Green et al., 2005), tennis elbow (A) (Trinh et al., 2004).
If, then, we wished to populate our A-list with the best-evidenced conditions, which would they be? The list would be not dissimilar to those put together 10 years ago, though the evidence is considerably more solid: back pain, breech presentation, migraine, nausea and vomiting, neck pain, osteoarthritis, post-operative pain, tennis elbow, tension headache.
Much more focus nowadays falls on cost-effectiveness, with potential benefits already identified for back pain, headache, osteoarthritis, dysmenorrhoea and allergic rhinitis (McDaid, 2010). Even better is cost-saving. From a US systematic review of CAM economic evaluations nine therapies covering 21 conditions showed evidence of cost-savings (Weeks, 2009). For acupuncture it was low back pain, oocyte removal, migraine and post-transurethral prostate resection symptoms! In the workplace too there is some evidence, especially coming out of the integrative medicine movement in the US. Ford employees with back pain who received acupuncture (traditional Chinese) and relaxation/ meditation CDs used 58 per cent less pain medication and hence saved money for the company (Kimbrough et al., 2010).
End note In all the discussion on individual practitioner effects we have by-passed that favourite old subject, what are the differences between different types of acupuncture? In a series of qualitative studies Hughes documented the similarities and differences in approach and outlook of traditional and Western-style acupuncturists who were treating patients with rheumatoid arthritis (Hughes, 2009). Most patients experienced benefits from the treatment but there was some perception that traditional acupuncture may provide more pronounced relief for the main complaint as well as an increase in secondary effects (eg, wellbeing and energy). There is some support for this from another qualitative study (Paterson and Britten, 2008) but as yet no quantitative backing.
Comparisons of different traditionally-based styles are even scarcer: there is one small study of TCM v. Japanese-style acupuncture for diabetic neuropathy (Ahn et al., 2007). The relative merits of different traditions, schools and styles can be a contentious subject but this sort of affiliation may not be particularly important in defining how individual practitioners operate in their own clinics in respect of such fundamental concepts as (Ryan, 2005): • taking an individualised approach • treating the root as well as the branch • channeling energies to promote self-healing • educating and supporting the patient to empower them • being flexible and negotiable rather than directive.
The direction that we each take as TEAM practitioners is hard to predict; the journey is a challenging one and mastery is certainly not guaranteed.
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