Proof or Faith?
During my medical training in Liverpool, we attended a debating competition in a prestigious centre of learning and culture - Oxford University. We were seen as being the poor relations from the North of England. Liverpool had, and still has, a reputation for humour and certain irreverence. The debating team from Liverpool proceeded to bring the house down with their storytelling and debating skills. At the end of the competition, a formal and rather stuffy professor began by saying, ' Of course, anyone can be funny....' to be met with a rapid riposte from the back, 'Well, go on then!'.
I was reminded of this when I saw a recent programme on television about acupuncture. The programme began with a scene of open heart surgery performed under acupuncture anaesthesia. The patient was fully conscious and was able to talk to the surgical team throughout the procedure. She made a full recovery and left hospital much quicker than if she were to have conventional anaesthesia. The presenter then asked whether acupuncture actually works or not. This invites the comment, 'Go on then, you do it!'.
I saw similar things in China when I trained in acupuncture. A man had a brain tumour removed under acupuncture anaesthesia and was conscious throughout. At the end of the operation, his head was bandaged, he sat up, waved to us all and walked out of the operating theatre. Whatever we may think personally about such events, and our reactions are always based upon what our previous experience tells us, there is no escaping the fact that something quite unusual was happening.
In today's world, 'scientific proof' is the buzz word to see if any treatment is effective or not. The word 'science' is often used in quite a narrow way and can be intended to disprove effective treatments rather than as a genuine attempt to be open-minded. I had a conversation with a statistician once about medical research. She said that there was a great difference between those who undertake pure research and those who undertake medical research. Pure scientific researchers ask the question, 'How can I find out what happens when I do A?'. A medical researcher tends to ask, 'How can I show that when I do A, B happens?'.
The gold standard of conventional medical research is the ‘controlled clinical trial’ (CCT) or ‘randomised clinical trial (RCT) which has been in increasingly common use only since the 1960’s. Prior to that time, the effectiveness of treatments was mainly determined by recommendations from a small number of doctors. Harris Coulter, who has studied CCT's and how they are used, wrote The Controlled Clinical Trial: An Analysis by Harris L Coulter (Batus, 1991) which I would recommend to anyone interested into how these developed to their current pre-eminent position in conventional medicine.
In controlled clinical trials neither the person nor the doctor knows whether a ‘real’ or a ‘sham’ treatment is being applied. For example, if a drug is being studied, some people will be given the drug and others will be given tablets containing no active substance. In this way, differences in the outcome of the two groups can be attributed to the effects of the drug - all subjective elements are accounted for and negated.
The basic problem begins with trying to define a particular illness. There are so many variations within ‘normal’ and these variations become more numerous when people start to develop symptoms. It is notoriously difficult for doctors to agree on definitions of disease let alone agreeing on what is an effective treatment. This is a natural function of the complexity of human beings and their individuality. It is nigh impossible to categorise people into rational and easily definable groups and any ‘generalisation’ must ignore significant aspects of the rich variety of human experience.
If it is difficult to define a disease clearly, how much more difficult is it to state whether a particular treatment is effective or not? It is impossible to gather together a sufficiently homogenous group to enable such trials to be meaningful. One key example is the previous medical history. One would think that this would be of over-riding importance when considering individual variation. However, no clinical trial has ever considered the importance of prior medical history!
Is it possible for the subjective element to be removed completely? A consultant rheumatologist I know was always being asked to perform clinical trials for new anti-arthritis medication but became interested in acupuncture for the treatment of arthritis. His senior registrar was in charge of the day-to-day conduct of the drug trials and many pieces of research were done. As the consultant became more and more involved in acupuncture, he became more and more disillusioned with the efficacy of the conventional medication. The results of the trials became less and less favourable for the drugs until eventually the pharmaceutical companies stopped using his unit for research. It was as if his mental attitude were affecting the trials even though he was not personally involved in them.
We hear phrases such as 'evidence-based medicine'. In reality, such requests for scientific evidence are frequently used as a stick to beat up treatments or practitioners where trials are inappropriate. Any other 'evidence' is seen as being less worthy, less scientific, of less value. Indeed, individual stories and case histories are actively dismissed and called 'anecdotal', a term used pejoratively by the conventional medical profession.
In his book, Coulter points out that what we think is a logical, scientific method of analysis is nothing of the sort. People are pre-selected to exclude those people who may 'interfere' with the final conclusion which is desired. This is why drug trials consistently have very significant degrees of claimed success in treating a particular condition. When the drug enters the 'real world', the success rate is much less. This is the story with statins. Initial drug trials were amazing in the percentage rates of claimed improvement. Real patients rarely behave as people do in drug trials and so success is less dramatic and adverse effects become more obvious.
I would encourage us all to consider anew the question of case histories and their value to us as practitioners. Whenever I read a text about Chinese medicine, I always look at the case histories. This is the way in which academic theory becomes real and practical. We can only be sure that our work is of benefit by putting theory into practice in this way . Do we need research trials for this? Do we need placebo groups where we withhold treatment? Do we need large groups of people to be analysed and studied by statisticians before we can decide whether a treatment is 'proven'? Certainly, we need to consider what we do and the effectiveness of our treatments but we already know that Chinese medicine is effective. Surely the challenge for us is how to translate those ancient wisdoms into practical and effective applications for the 21st century.
We should never underestimate the power of hearing people's stories and the positive effect this can have upon our patients and ourselves. Listening to someone's account of overcoming adversity and suffering is very inspiring. It gives people hope. It gives us hope that perhaps we can do something to benefit others!
In this column, I intend to bring you case histories from my own practice. These will be used to illustrate how the practice of Chinese medicine can achieve benefits for others and ourselves. We all know the awesome power of Chinese medicine, yet I am continually inspired by people and the stories they bring to me. I hope that I can share some of this with you in forthcoming issues.
Stephen Gascoigne qualified in medicine in 1976 in Liverpool, UK and worked for 6 years in hospital and general practice. Stephen trained in acupuncture in China and subsequently in Chinese herbal medicine in London with the esteemed Vietnamese practitioner, Tinh Thong Nguyen. Stephen is the author of The Chinese Way to Health (Connections, 2000), an introduction to Chinese medicine and its methods for the general public and two textbooks for students and practitioners of holistic medicine - The Clinical Medicine Guide (Jigme Press, 2001) and The Prescribed Drug Guide (Jigme Press, 2003).