Role of acupuncturists in acupuncture treatment.

Traditional Chinese medicine (TCM) is based on a paradigm of the body different to that of modern biomedicine. Inherent characteristics of TCM necessitate an active and central role of acupuncturists in acupuncture treatment. The author looks at acupuncture in the practical context and analyzes the role of acupuncturists in diagnostic process and treatment delivery. Acupuncture as a complex non-pharmacological therapy depends solely on the acupuncturists' skills, competence and understanding of TCM theory to work. More attention should be given to this important role of acupuncturists in either clinical practice or research on acupuncture.

Introduction

Acupuncture, as one of treatment modalities of traditional Chinese medicine (TCM) that develops a different conceptual and theoretical basis to modern biomedicine, is widely used without adequate evidence supporting its efficacy (1). Given that the validity of randomized controlled trials (RCTs) in evaluating acupuncture is open to severe criticism (2–5) and the biological mechanism of acupuncture is still unclear (6,7), it will continue to be a problem on how to access the effectiveness of acupuncture. Acupuncture treatment extends far beyond needling with acupuncturists being a component in or contributor to the treatment. Increased attention given to the role of acupuncturists in acupuncture treatment may help better understand TCM theory and improve the validity of clinical trials of acupuncture.

Characteristics of TCM

Biomedicine believes that ‘what is to be most accurate must be shielded from the bias of human observation’; conversely, ‘Chinese medicine relies on the veracity of the senses, the person-centered experience either as reported by the patient or perceived by an observant practitioner’ (8). TCM and biomedicine focus on different ends of the spectrum—objectivity and subjectivity—of any medical entity respectively; that is why TCM may complement biomedicine well in its distinct approaches to some medical conditions without clear biomedical pathogenesis, such as the functional somatic syndromes (9). TCM develops a set of well-established theories whereby to categorize symptoms to elicit TCM diagnosis, and at the same time classify available treatment options (usually, Chinese herbs, acupuncture or a combination of both) to form a corresponding treatment plan. To ensure efficacy, TCM diagnosis and the subsequent treatment should be one-to-one corresponding to each other strictly. However, a particular TCM diagnosis—a kind of pattern diagnosis—is at most probable, but never definitive.

Modern biomedicine uses RCTs as ‘gold standard’ to judge the effectiveness of an intervention. Efficacy of an appropriately standardized treatment protocol justified by RCTs can be generalized within a well-defined patient group. But this standard does not apply to TCM. TCM practitioners tend to believe in inconsistent, disparate and anecdotal ‘miracles’ that can only be explainable by TCM. While biomedicine places emphasis on ‘standardization’ and ‘generalization’, and disparages ‘anecdote’ (10), TCM considers any individual patient as a new ‘anecdote’ different from other patients. One effective treatment protocol therefore ‘belongs’ to one particular patient individually; it should not be generalized to other patients. This individualization in the diagnostic process and treatment delivery is highly valued and encouraged by TCM. TCM is therefore remarkably characterized by the ambiguity in its theory presentation, the subjectivity in its diagnostic process, and the flexibility and individualization in its clinical application. These characteristics result in almost all problems met in the evaluation of acupuncture efficacy.

Unlike modern biomedicine emphasizing identification of specific diseases over analysis of general symptom patterns to explain symptoms, TCM develops a ‘holistic’ method to identify and analyze symptoms. According to TCM, different coexisting symptoms are interdisciplinary and interactive, so any individual symptom is rarely studied in isolation. Instead, it is investigated in context of its relationships with other concurrent symptoms, as well as with symptom modifiers and other clinical observations such as the tongue coat and pulse diagnosis, to identify the most probable pattern of disorders (9). This pattern diagnosis is then used to determine a subsequent treatment plan. Since TCM relies solely upon those subjective entities either reported by patients or perceived by practitioners, obtaining adequate information with defining meanings is therefore a prerequisite for an effective TCM treatment. This determines the key role of acupuncturists in acupuncture treatment.

Communication Plays a Key Role in the Acupuncture Treatment

Acupuncturists play an active and central role in acupuncture treatment. All the information used to make a diagnosis can only be obtained from acupuncturists' ‘looking’, ‘listening’, ‘feeling’ and ‘thinking’. These subjective processes are inextricably linked and embedded in the comprehensive communication between the acupuncturist and the patient. This characteristic of TCM underpins the predominant role of acupuncturists in the treatment. A particular acupuncture treatment session is characterized, except for needle insertion itself, by the elaborate and comprehensive communication between the acupuncturist and the patient. In contrast to biomedicine usually relying on biological diagnostic markers beyond symptoms when making diagnosis, TCM depends solely upon subjective medical entities—patients' reported symptoms, information obtained form pulse taking and sometimes other relevant aspects including mind, spirit and lifestyle factors. A good relationship and successful valid communication with a patient are therefore essential to ensuring the quality and quantity of information correctly depicting patient's health status, hence an accurate diagnosis. To obtain significant and relevant information, communication with a patient can be prolonged and enhanced and is focused on details of some particular aspects that are important and not yet explicit for a diagnosis to be made, when, for example, the patient presents complex symptoms; what the patient wants to say is not what the acupuncturist wants to know; and the acupuncturist gets information conflicting in quality and needs to confirm and support his or her judgment until it is meaningful and explicit enough to draw a conclusion.

Interactions between patients and therapists will invariably cause non-specific effects—placebo effects—that will affect treatment outcomes to various extents. Acupuncture treatment involves a broad amalgam of non-specific placebo factors resulted from intimate patient–acupuncturist relationship presented in the treatment ‘including attention, communication of concern, intense monitoring, diagnostic procedures, labeling of complaint and alterations produced in a patient's expectancy, anxiety and relationship to the illness’ (11). They may result in more belief and higher expectation of the treatment, and more importantly, make patients feel they have more control over their illness (12). Acupuncture treatment characterized by the enhanced interaction between patients and acupuncturists is therefore known to be a powerful and successful placebo-generating treatment, to such an extent that its specific effects can hardly be divided from the placebo effects it causes. But one point should be acknowledged that the whole process of communicating with patients happens naturally, but not deliberately. Acupuncturists focus on communication with patients not to exert influence on them to reap placebo effects, but to obtain as much information as possible whereby to construct a correct diagnosis. TCM does not intentionally create placebo effects, though it actually causes enhanced placebo effects.

For Any Individual Complaint, No Standard Acupuncture Treatment Exists Independent of Therapist Factors

Acupuncturists are absolutely a component of and contributor to the treatment (3). The diagnosis and delivery of acupuncture treatment depends solely on the acupuncturists' skills, competence and understanding of TCM theory. Acupuncturists initiate and dominate communication with patients, and focus on questions thought to have defining meanings for making a correct diagnosis; acupuncturists create a collaborative atmosphere working with patients as a partner and take on various styles approaching diverse patients emphasizing on their minds, spirits and lifestyle factors; the same patient can be diagnosed and treated differently by acupuncturists with varied clinical experience and understanding of TCM theory. For any individual complaint, no standard acupuncture treatment exists independent of therapist factors.

Nevertheless, this key role of acupuncturists faces many challenges. First, TCM diagnosis actually results from a process of philosophical thinking without relying upon any objective support, and both the diagnosis and treatment are highly individualized not only to a particular patient but also to a particular acupuncturist, so therapist factors may profoundly affect treatment outcomes. Second, TCM theory is not presented explicitly, and individuals may have a different understanding of it. For instance, the meaning of deqi as described: ‘like a fish biting on a fishing line’ (13)—if it is translated with fidelity—defies an accurate understanding. In fact, unless experiencing the needle insertion on one's own body, one will never know what deqi is. Third, different acupuncturists' competence and skill to communicate with patients varies considerably, and that affects the quality and quantity of information obtained in order to make a diagnosis. Fourth, TCM diagnosis and treatment are not fixed during the whole treatment course, but woven into each treatment session with emergent and contingent adjustments according to repeated pulse taking and feedback about the effects of needle insertion (3). Therefore, the diagnosis conducted in the first session according to TCM principles will have evolved into another one after many treatment sessions. Fifth, acupuncture is a complex therapy with various technical contributing factors being able to affect treatment outcomes including, for example, depth of the needle insertion, skill of needle manipulation, duration of the needle in place and schedule of treatments. These factors, in addition to the difficult setting of a reasonable placebo control, pose formidable barriers for evaluating the efficacy of acupuncture with RCTs.

Difficulties Inherent in the Flexibility and Subjectivity of Acupuncture Treatment

The flexibility and subjectivity involved in acupuncture treatment lead to an increased likelihood of inaccuracy, or even mistakes, which are inherent and unavoidable for TCM, both in the diagnostic process and treatment delivery. Due to all of these uncertainties concerning acupuncture treatment, an acupuncturist is always ready to adjust and improve treatment protocol whenever necessary during the treatment course, especially for the initial several sessions, to form a relatively fixed treatment plan. Any patient seeking acupuncture treatment should be advised not to quit treatment within the initial several sessions due to the reasons that it will take some time to show treatment effects, and the acupuncturist may need some time as well to optimize treatment protocols.

TCM Doctors Tend to Rely on Personal Experience

TCM is virtually experience-based medicine; TCM theory and practical experience combined makes a TCM doctor. Experience, which can only be obtained from long-time practicing, can contradict and compensate for shortcomings of TCM outlined above. Though experience is important for both TCM and biomedicine, biomedicine tends to rely more on objective evidence than personal experience, while experience is much more valued in TCM. Compared with acupuncturists with little experience, more experience means better communicating skills essential to keeping good relationships with patients to ensure a correct diagnosis, more in-depth understanding of TCM theory after a long time verifying it through practicing, more safety and less adverse effects of treatment, and more experience in some senses means more mistakes conducted in the past and probably fewer mistakes in the future. All in all, experience guarantees an acupuncturist's competence to offer optimal acupuncture treatment. An acupuncturist's competence and skillfulness are more achieved from long time practicing than a certain period of training; that is to say, a period of training does not guarantee the professional and technical competence to offer an optimal acupuncture treatment, though training is important and necessary.

Conclusion

Acupuncture treatment features a predominant role of acupuncturists in determining to what extent patients are involved in acupuncture treatment and how to perform needling procedure appropriately (Fig. 1). It has been argued that acupuncture extends beyond needling with multiple therapist-related non-specific factors being integral to the treatment, which can potentially influence treatment outcomes (4). The key role of acupuncturists in acupuncture treatment justifies this assumption. Acupuncturists' active role in acupuncture treatment demands an active corporation of patients, which greatly enhances involvement of patients in acupuncture treatment; the whole course of a particular acupuncture treatment session is actually that of mutual interaction between the acupuncturist and the patient. A comprehensive look at the role of acupuncturists provides a new perspective to analyze acupuncture treatment, which is of great importance for both clinical practice and research on acupuncture.

Figure 1.

Role of acupuncturists in acupuncture treatment.