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Marcello Costa & Hubertus Jersmann: Chinese paradox

Marcello Costa and Hubertus Jersmann
Monday, 2 April, 2012
Marcello Costa & Hubertus Jersmann: Chinese paradox cover image

FROM July this year, all traditional Chinese medicine practitioners must register with the new national Chinese Medicine Board of Australia, a new member of the Australian Health Practitioner Regulation Agency.

This extends nationwide a process adopted in Victoria in 2000.

Traditional Chinese medicine (TCM) claims to be a complete diagnostic and treatment system dating back thousands of years. It claims to be based on an understanding of health and illness which differs substantially from that of scientific medicine.

In Australia, TCM is included under the general term “complementary and alternative medicine” (CAM) and refers to the three modalities whose practitioners will be included in the register — acupuncture, Chinese medical diagnosis and Chinese herbal dispensing.

TCM is based on a non-scientific concept of imbalances of “essential elements” — wood, fire, earth, metal and water. It is similar to ancient beliefs in other cultures in India and the Mediterranean.

Until well after the scientific revolution of the 16th and 17th centuries, the Greeks, Romans and then all of Europe believed that diseases were due to an imbalance of four bodily fluids (humours), corresponding to the world’s four “fundamental elements” — earth, water, air and fire.

With the advent of scientific medicine, these theories were proven baseless.

So, what are the implications of registering TCM practitioners?

As far as mere process is concerned, there is some evidence from Victoria that registration has a beneficial impact on tightening standards and that dealing with complaints was somewhat improved. However, we need to look beyond mere process.

As far as the ability to practice is concerned, this new status would entitle registered TCM practitioners to make diagnoses and recommend treatment. That would place them on a par with medical practitioners practising scientific, evidence-based medicine.

While the differences in diagnoses and therapies would be (hopefully) clearly obvious to the public, it will be far less clear whether a TCM practitioner has adequate knowledge to be a safe diagnostician.

The TCM board lists a range of courses and institutions that train practitioners. While all Australian medical schools are closely scrutinised by the Australian Medical Council, both initially and on an ongoing basis, we do not know what criteria have been used to determine the quality of TCM courses and institutions.

The therapies advocated by TCM need to be regulated by the Therapeutic Goods Administration (TGA) to ensure patient safety. Evidence that these therapies are safe and efficacious is currently sparse.

We welcome the enormous recent efforts of the Chinese government to fund scientific research into TCM therapies and are looking forward to seeing the results.

However, the registration of TCM practitioners is missing the woods for the trees. It seems to be based on the merits of process alone.

Medically and from a public health standpoint, registration of TCM is contraindicated for four reasons:

  1. There is no objective evidence supporting Chinese diagnostics. Indeed, the theories underlying the diagnostic approach of TCM are directly contradicted by scientific knowledge.
  2. There is no point in registering, and thereby giving an official imprimatur to training courses, which are based in unscientific, disproven theories of disease causation.
  3. Evidence for the efficacy and safety of the treatments advocated needs to be demonstrated.
  4. The therapies put forward need TGA approval with a similar rigour that is applied to all therapies prescribed by medical practitioners.

      Short of fulfilling these minimal essential requirements, TCM practitioners should not be labelled “health practitioners” and should not be privileged with national registration through AHPRA.

      Those who believe that regulation is a substitute for evidence will find that even the most meticulous regulation of nonsense must still result in nonsense.” (Edzard Ernst, the world’s first professor of complementary medicine, at the University of Exeter, England.)

      Professor Marcello Costa has a personal chair in neurophysiology at Flinders University, Adelaide, South Australia, and is a Fellow of the Australian Academy of Science. Associate Professor Hubertus Jersmann is a senior academic at the School of Medicine, University of Adelaide, and is a respiratory physician at the Royal Adelaide Hospital.

      Information for potential conflict of interest: Professor Costa is a founding member of the Friends of Science in Medicine (FSM). Associate Professor Jersmann is a member of FSM.

      Posted 2 April 2012

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      Comments

      Regardless of national registration status, the public does not perceive difference between types of complementary and alternative medicine, nor between individual practitioners. Therefore a "privilege" with APHRA registration is in effect no privilege in practise. However the registration does place those who are registered under more scrutiny, and hopefully in future there will be better legislation to hold them accountable, should any adverse effect of therapy occur.

      To what extent is this decision by the Australian Health Practitioner Regulation Agency tainted by their own conflict of interest? More registrants, more income, more staff, higher fees. I doubt compulsory registration of lay Chinese health practitioners will do anything to improve health (I presume practitioners who are medically qualified are already registered). But I do not think it will do much harm; nor do I think that lack of scientific evidence equals evidence of lack of benefit. I think some lay Chinese medicine practitioners probably do quite a lot of good, just as many GPs can benefit patients without providing medication or surgery. Good listening can be very therapeutic, though clearly a good health practitioner needs to recognise circumstances when listening is not enough. And some Chinese therapies are likely to have physiological effects, some of which are likely to be beneficial.

      I support the 4 points stated above why TCM should not be registered until they are also trained in scientic medicine equivalent to our medical courses. Sure there are a few Chinese medicine which may stand up to scientific evaluation and we should have an open mind on it. For example acupuncture has been is proven scientifically by our medical profession to be benefitial for many conditions especially in the management of acute and chronic pain. However I believe it can be combined safely in trained medical doctors. It is safer to be practised by qualified medical doctors in Australia and even in China than so-called "traditional Chinese herbal practitioners" who have no proper scientific medical training as required by modern society. The public thus may be placed in a harm way if they are allowed to be registered and practise like a trained medical doctor.

      I agree with the 4 points made by Costa and Jersmann. In regard to the comments by HW, Colin Butler and Anonymous I would like to make the following observations.
      "Regulation" of each group such as TCM practitioners is overseen by other practitioners of the same group. An example is the recent case of a blind chiropractor whose patient died during treatment (although not caused by the treatment). The complaint against him was heard by a tribunal of chiropractors who decided his performance required no sanctions.
      I doubt very much that AHPRA employees have a conflict of interest. I think they are the victims of having to oversee a very poorly thought out piece of legislation. As far as TCM practitioners being useful for listening, I know of no evidence that TCM training would fit practitioners for counselling. Any beneficial effects of TCM therapies, being based on a completely flawed system of diagnosis, are purely by chance. That includes acupuncture for which there is little if any strong scientific evidence.

      I don't see how a medical doctor who has done a 6 week course in acupuncture could possibly practice acupuncture in a safer way than someone with 5 years acupuncture training. Perhaps you should ask your patients if they find acupuncture or Chinese Medicine useful? A Chinese Medicine practitioner does not diagnose disease in the same way as a Biomedical Doctor. They diagnose according to Traditional Chinese Medicine, yes, very different, but no, not without merit. People usually seek Chinese Medicine treatment when Western Medicine hasn't helped them for some reason or another. Rather than throwing the baby out with the bath water, perhaps you should find out from your patients what benefits they receive from Chinese Medical treatment, because more and more sure are using it. Do you really think it's all just in their mind?

      Traditional Chinese diagnosis has not been shown to have merit. Asking patients whether or not they felt better after a therapy is not evidence it is anecdotal only. Certainly not evidence that should be accepted by any person capable of critical thinking.

      We do not train our western scientific doctors just to oppose the use of all traditional medicine including Chinese traditional medicine. We must be critical but have an open mind. Any traditional medicine, for example penicillins and medical acupuncture proven to enhance our modern scientific medicine, can be incorporated into our properly trained medical courses. Otherwise they are a waste of time and money. Some patients of 'traditional medicine' become psychological hostages and can be harmed in delaying diagnosis and proper treatments.

      I use medical acupuncture in my practice as distinct from traditional acupuncture practice because not all traditional acupuncture practice are effective and useful and should be used with care by properly trained doctors. Registration of traditional 'doctors' is a first step to see if they are really useful doctors in our society because we can eventually access their patient records and do some research data on them. Time will then tell if they really play a useful role in our society. This should apply to China too. Recent reports from Singapore showed that Chinese traditional doctors/medicine is gradually closing shops as educated Singaporeans do not in general trust them in their health care. The Singapore government is also controlling and evaluating the use of many Chinese herbal medicine because they can be harmful.

      As a trained medical doctor in Australia with a family background of traditional Chinese medicine and with over 35 years of general medical practice, I have come to the above scientific conclusion for the common good of the human society.

      Andy's accusation of turf-protection are commonly-heard but misguided. There is hardly a shortage of work for the medical profession! As Ka Sing Chua pointed out, people from all over the world who have access to orthodox medicine use it - whether it be China, INdia or Europe. There is no "eastern" vs "western" - there is therapy that has been shown to work beyond placebo, there is placebo, and there is completely ineffective therapy. By and large, minor illnesses and discomforts will resolve over time, with no therapy.

      In all the experiences I and my family have had with either TCM or with naturopaths (started using them about 2-4 yrs ago), they have all fixed conditions which my traditional GP's couldn't - or more to the point they just kept prescribing pharmaceutical drugs which ultimately had no effect. This includes chest infections to bad eczema. This is after 35+ years of going to traditional western GPs.
      So when I read comments like those from richard gordon 'Asking patients whether or not they felt better after a therapy is not evidence it is anecdotal only. Certainly not evidence that should be accepted by any person capable of critical thinking' is very insulting. Patients like myself who know they have benefited from treatment from TCM do so after finding traditional medicine could not deal with the root of the problem in the first place and have experienced the how the wholistic approach works. I think richards comments reflect someone trying to protect their own position in society and is resorting to denigrating percieved threats without attempting to understand a different approach. There are thousands of people that know they have benefitted from TCM where traditional medical practise has only gone so far - to not at least want to investigate a practise that may be beneficial to humans and that has less (if any)side effects reflects a closed mind and unfortunately doesn't reflect wanting what is best for patients, it's just protecting one's own position.

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