By Andy Ho
THE Singapore Medical Association (SMA) desires that doctors here be permitted to refer patients to traditional Chinese medicine (TCM) practitioners.
If this suggestion is accepted by the Singapore Medical Council, I believe the practice of evidence-based medicine - and patient interests - will suffer a blow.
Of late, some doctors seem to have embraced even disproven remedies. Take, for instance, a review of acupuncture research that appeared last July in the New England Journal of Medicine. This highly respected journal is one of the most widely read by doctors across specialities.
In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which 'showed that real acupuncture treatments were no more effective than sham acupuncture treatments'.
The authors then editorialised: 'There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.'
First, they admit that pooled clinical trials of the best sort show that real acupuncture does no better than sham acupuncture. This should mean that acupuncture does not work - full stop. But then they say that both sham and real acupuncture work as well as the other and thus is useful. Translation: Please use acupuncture as a placebo on your patients; just don't let them know it is a placebo.
The authors trotted out the same conclusion after they reviewed an important German trial which also showed acupuncture to be merely a placebo.
In any randomised and blinded clinical trial of any mode of treatment for any condition, the finding that the treatment is no better than a placebo always leads to one conclusion only: It is therapeutically useless. Acupuncture, it would seem, is excepted from this rule.
A final study chosen for review was a 'pragmatic' trial that was bereft of any use because, as the authors said, 'neither providers nor patients were blinded to treatment. Therefore, a bias due to unblinding cannot be ruled out'. In fact, such a 'trial' is inherently biased.
Then, as spinmeisters, the authors concluded with a flourish: 'Acupuncture... has not been established to be superior to sham acupuncture... However, (it) may be more effective than usual care, (so) it is not unreasonable to... incorporate acupuncture into... the management of chronic low back pain.'
I should add that I am not criticising TCM per se. Only acupuncture, a facet of TCM, albeit its most dramatic, is being scrutinised here. Chinese herbology must be analysed on its own merits.
Interestingly, although acupuncture may be TCM's poster boy today, the Chinese physician in days of yore would have looked askance at it. Instead, his practice and prestige were based upon his grasp of the Chinese pharmacopoeia.
Acupuncture was left to the shamans and blood letters. After all, it was grounded, not in the knowledge of which herbs were best for what conditions, but astrology.
In Giovanni Maciocia's 2005 book, The Foundations Of Chinese Medicine: A Comprehensive Text For Acupuncturists And Herbalists, there is a chart showing the astrological provenance of acupuncture. The chart shows how the 12 main acupuncture meridians and the 12 main body segments correspond to the 12 Houses of the Chinese zodiac.
In Chinese cosmology, all life is animated by a numinous force called qi, the flow of which mirrors the sun's apparent 'movement' during the year through the ecliptic. (The ecliptic is the imaginary plane of the earth's orbit around the sun).
Moreover, everything in the Chinese zodiac is mirrored on Earth and in Man. This was taught even in the earliest systematised TCM text, the Yellow Emperor's Canon Of Medicine, thus: 'Heaven is covered with constellations, Earth with waterways, and man with channels.'
This 'as above, so below' doctrine means that if there is qi flowing around in the imaginary closed loop of the zodiac, there is qi flowing correspondingly in the body's closed loop of imaginary meridians as well.
These meridians run from head to toe to form a network interlinking 361 points on the skin. But why are there 361 points? Since the earth takes three minutes under 24 hours to rotate 360 degrees on its axis, the sun appears to revolve through 361 degrees on the ecliptic every 24 hours. Hence 361 points. This factoid alone is sufficient to nail down the acupuncture-astrology linkage.
Since qi flows around in a closed loop, needles can be inserted at one of these points far removed from your site of pain to rechannel qi. If done well, this supposedly can cure your spot of trouble.
Note that not only is acupuncture astrological in origin but also the astrology is based on a model of the universe which has the earth at its centre. This geocentric model was an erroneous idea widely accepted before the Copernican revolution.
Today, no one believes the earth is at the centre of the universe. [Not true! ST Feb 10, 2011: Third of Russians think sun revolves around earth: Poll*] But the ancient Chinese saw this geocentric principle organising all of nature as well. From its accompanying astrological system, acupuncture was birthed.
So should doctors check the daily horoscopes of their patients?
[*I wrote to Dr Ho to point out that his sweeping statement was not quite correct. His reply: "No reasonable person believes in a geocentric universe. If the Russians do, they are just living in the past."]
[The SMA wrote in reply a few days later.]
Feb 15, 2011
Unwise to criticise alternative medicine, says SMA
DR ANDY Ho wrote that he was disappointed with the local medical profession for not warning the public about the dangers of chiropractic neck manipulation ("Perils of chiropractic neck manipulation"; Jan 21) and criticised homeopathy ("Indefensible ideas behind homeopathy"; Jan 22).
His scathing commentary on acupuncture criticises the Singapore Medical Association (SMA) for suggesting that the ethical code of the Singapore Medical Council (SMC) be amended to allow medical practitioners to refer to traditional Chinese medicine (TCM) practitioners and acupuncturists ("Pinning down acupuncture: It's a placebo"; Saturday).
While Western-trained doctors do warn their patients about the risk and safety profile of what they prescribe and voice their opinions on various kinds of alternative medicine to their patients, it is another thing to advocate that the local medical profession collectively criticise alternative medicine groups.
This is especially so when doctors and alternative medicine practitioners are seen to be competitors and criticising alternative medicine can be construed as self-serving.
Dr Ho's column on Saturday failed to take SMA's proposal to amend the SMC ethical code in context. When the current code was introduced, TCM practitioners and acupuncturists were not state-registered. They are now.
We do not think doctors will refer widely to TCM practitioners even if the code is amended. However, patients do request from their doctors medical reports and summaries when they seek care from TCM practitioners. The present code disallows such formal communication. Amending the code will facilitate better communication between a patient's various caregivers so that the patient's interest is best served.
The SMA does not encourage its members to refer to alternative medicine practitioners. But we have to be realistic. They exist and are here to stay. Most public hospitals already offer acupuncture services. Several have TCM clinics on their premises.
[And herein lies my concern and confusion. By offering TCM and acupuncture in public hospital, we are paying public money for sham treatments.]
Continuing this "iron curtain" of no formal communication between doctors and alternative medicine practitioners is impractical and anachronistic.
Finally, many alternative medicine forms are steeped in cultural and religious beliefs, such as TCM and ayurvedic medicine.
From the perspective of safeguarding social cohesion in Singapore, getting the local medical profession to collectively criticise various alternative medicine modalities is unwise.
[Cultural sensitivity taken a little too far, perhaps? Then what next? Bioresonance? Or we only criticise the new-fangled shams, but we lay off the culturally based, traditionally hyped alternative treatments? Or only Chinese doctors can dismiss TCM, and Indian doctors dismiss ayurvedic medicine? What if someone brings in a bomoh?]
In Singapore's social context, journalists should not try to pit one group of caregivers against another. It is best for an impartial and respected body such as the Government to step forward to decide what is safe and unsafe for patients.
Dr Abdul Razakjr Omar
Singapore Medical Association (SMA)
A prickly issue
By Melissa Pang
AT A specialist clinic in Paragon Medical, it is not unusual to see patients seated in the waiting area with needles poking various parts of their bodies.
Ear, nose and throat (ENT) surgeon Tan Nam Guan is also an acupuncturist, and he administers this alternative medicine to his patients as a treatment option. 'I never promise that acupuncture will treat them 100 per cent, but that it may help.'
Dr Tan is one of 97 doctors here who are certified acupuncturists, according to the Traditional Chinese Medicine Practitioners Board (TCMPB).
Although 88 of these doctors hold valid practising certificates, it is not known how many of them actually use acupuncture as a form of treatment. Among the Western-trained doctor-acupuncturists are three licensed TCM physicians.
TCM practitioners incorporate the use of herbal medicine and acupuncture to treat patients, while acupuncturists can practise only acupuncture. It takes a part-time course of seven years to be a TCM physician and a one-year part-time course to be an acupuncturist.
In 2006, the Singapore College of TCM, a privately run institution, launched an English-language graduate diploma for Western-trained doctors keen to be acupuncturists. The part-time course attracted 49 doctors, all of whom graduated the following year. In 2008, 22 doctors took up the course and passed; the number dropped to 12 in 2009.
The course teaches the theoretical and practical aspects of acupuncture and how to use it to manage diseases. Doctors have to complete clinical attachments and sit a test by the TCMPB.
Acupuncture made the news earlier this month, when Straits Times senior writer Andy Ho wrote an opinion piece questioning the Singapore Medical Association's proposal to permit doctors here to refer patients to TCM practitioners. He cited a study that found real acupuncture treatments to be no more effective than sham ones, and said that acupuncture was based on astrology. A debate in the Forum page ensued, with physicians and patients from both camps speaking out.
Dr Derrick Aw, a dermatologist who practises acupuncture at National University Hospital (NUH), commented that it may not achieve the gold standard of scientific evidence to be positioned as a first-line or efficacy-credible form of treatment.
'But it remains a safe option for patients who seek complementary modalities of treatment for their chronic conditions,' he said.
Those qualified in both Eastern and Western medicine point out a lack of understanding of TCM as the main cause of conflict.
Dr Tan said: 'Previously, there was a high chance I would have said the same of TCM. But the training I received helped me to appreciate and understand acupuncture. I believe they may have a different perspective if they have undergone TCM training.'
It is a view shared by Dr Swee Yong Peng, a general practitioner and a qualified TCM physician. Dr Swee, who teaches a compulsory two-day TCM module at the Duke-NUS Graduate Medical School, said the subject may not interest all students, but it is nevertheless an 'eye-opener' for those who appreciate an explanation of another mode of treatment.
Whatever their view, doctors cannot ignore how more patients are turning to acupuncture as a complementary treatment or for help on ailments that Western medicine has no answers for.
One of them is private banker Charlie Bigard, 27, who suffers from sinusitis which leaves her with migraines and a perpetually blocked nose. 'Acupuncture alleviated my headaches while Western drugs helped clear the nose,' she said.
Clinics like Tan Tock Seng Hospital's Complementary Integrative Medicine (CIM) centre have seen a 10 per cent year-on-year growth over the last three years. The clinic is manned by two doctors trained in acupuncture and five TCM physicians. Last year, it had 21,000 visits by patients, said its head Kong Keng He.
These East-West physicians stressed the importance of acupuncture as a complement to Western medicine.
'Acupuncture is seen as a complementary treatment at the CIM clinic. Most patients would have been evaluated by a medical doctor before seeking acupuncture treatment,' said Dr Kong, who is a doctor-cum-acupuncturist.
Dr Tan emphasised that he uses his knowledge of Western medicine to diagnose patients, while acupuncture is meant to augment treatment.
A Ministry of Health spokesman said doctors are free to study TCM to become qualified TCM physicians or acupuncturists, but the two fields are separate.
Registered doctors can combine acupuncture with Western medicine, but combining TCM and Western medicine in the same clinic is not allowed as it would be 'misleading to patients'. The doctor would have to set up a separate TCM clinic to be regulated by the TCMPB.
'Patients then make a conscious choice about whether they are coming for a Western doctor consultation or a TCM consultation,' said the spokesman.