Download this page in PDF formatFirst there is a mountain
Then there is no mountain
Then there is.
–Donovan
I suspect many natural medicine practitioners get stuck in the second part of Donovan’s spiritual journey. When “there is no mountain” everything appears mystical and magical. However, things that should be obvious may not be seen at all.
I feel like I’m coming down “the other side” of a mountain. There may be other mountains I have to climb in the future. I’m not claiming to be finished, complete, perfect, or enlightened. For a while there was no mountain. And now there is. The only thing that sucks is that it hurts worse walking downhill, partly due to physics and partly because I’m 20 years older than when I started up the opposite side.
Patients want treatments which are safe. It seems obvious, but please think about it in more depth. This is why so many people choose “natural medicine” in the first place. Mainstream medicine doesn’t have a great reputation for being safe. Drug side effects and surgical errors terrify people, including me. This often leads people to reject “western medicine” or at least put it further down the list, which may look something like this:
- Do nothing for a while
- Try that stuff I saw on TV
- Go to the chiropractor
- Try doing nothing again, that’s cheap
- Go to an acupuncturist
- OK, OK, I’ll go to a regular Doctor.
With luck, the problem will resolve in stage 1. For colds, back pain, stress headaches, and many other normal aches and pains, Dr. Time will often offer a safe cure. One of the big challenges in life is to know when Dr. Time is not on your side.
As an acupuncturist, I often hear patients tell me they don’t like doctors, pills, surgery, etc. While the expense may be a factor, I think it’s really the safety that concerns them. I share that concern, and am very aware of the well-documented damage and death caused by prescription drugs and botched surgeries.
Still, I’m a fan of science. Science isn’t the cause of mainstream medicine’s failures. In fact, most of the drawbacks of the mainstream medical system can be traced to institutionalized corruption which has allowed corporate criminals to usurp science and law for tremendous financial gains. Sucks, doesn’t it?
So the mainstream system is largely broken and patients look for alternatives which they perceive as having less risk. That is where natural medicine (or “complementary and alternative medicine”) comes in. The notion that Natural=Safe=Good is still one of the main reasons people choose herbs and supplements. In most cases, they are correct–herbs and supplements cause far less harm than most prescription drugs, according to the basic statistics.
My formal training is in Chinese medicine. Acupuncture and Chinese herbs are traditions with centuries of history and many happy customers. Acupuncture is generally safe, research has confirmed, when practiced by professionals who use sterile needles and don’t put them in too deep around the lungs. Chinese herbs overlap with foods. Much of Chinese dietary lore it tied up with Chinese medical theory and herbal practice. There is a spectrum of ingredients from foods like rice, garlic, and ginger which are regularly used by billions of humans with a fabulous track record of safety and tastiness to very unusual medicinal substances like Aconite, Aristolochia, and Arsenic which only start the alphabet of potentially toxic substances (perhaps it ends with Zoopharmacotoxicology, the study of toxic animals used as medicines).
Chinese herbal medicine, much like Chinese dog food, doesn’t have the best track record and public perception as a safe group of products. The clientele of acupuncturists are self-selected as trusting of the traditional Chinese medical system (or trusting of the individual practitioner based on a referral). The dog food from China that was adulterated with melamine in such quantities that American dogs were dropping dead certainly led many people to swear they would never take any medicines made in China, or give them to their pets. Acupuncturists probably don’t see these people in their clinics very much. Likewise, people who read about Aristolochic Acid and Chinese Herb Nephropathy in USA Today understandably make a mental note to be very careful selecting treatments from China. Heavy metals in Ayurvedic and Chinese medicines, both intentionally and unintentionally included, are a real issue that is unfortunately not ancient history. Even highly regarded current academic texts on Chinese herbal medicine give mixed messages about Cinnabar (Mercury sulfide/Zhu Sha), Realgar (Arsenic sulfide/Xiong Huang), and Lead Oxide (Minium/Qing Dan).
Getting back to basics, here’s my theory: patients want safe medicines. No patient wants permanent kidney damage from medicines intended to shorten a cold or ease pain from a back injury. No parent wants their infant to suffer mental retardation in exchange for being less fussy during teething. These two examples from traditional medicines (Aristolochic Acid-containing herbs in the first, and lead oxide teething powders in the second) just scratch the surface, and there are plenty of examples from western medicine as well (one of my favorite words is “rhabdomyolisis,” which can occur due to cholesterol medications making your body eat its own muscle tissues, showing up as leg pain and dark urine with kidney damage).
“Safe” is more important than “natural.” Not all natural medicines are safe, not all unnatural medicines are unsafe. The ancient Chinese doctors didn’t have it all figured out, even the legendary Divine Farmer (Shen Nong) who taste-tested toxic herbs until his face turned black. Despite his dedication to personal experimentation and divine status, Shen Nong missed a few things. Only modern chemistry has significantly added to the experimental results of Taoist alchemists and early Chinese doctors by revealing the brain-damaging effects of lead and the extreme difficulty of turning it into gold. We are still coming out of the dark ages, as dedication to the old ideas (Old=Natural=Safe=Good) still leads many to confidently poison themselves, their patients, and their children.
Please do no misconstrue my pointing out a few lingering bad ideas as dismissing the entirety of Traditional Chinese Medicine or other natural medical systems. But make no mistake on my conclusion: good quality scientific research is the best tool to provide adequate proof that a treatment is safe. Good quality science means it is not corrupt or biased: not corrupted by profit-motivated corporations or biased by cultures who have “face to gain” by showing their traditions have great value.
A partner theory is that the more commonly used a substance is, the safer it is likely to be. Ginger and garlic are prime examples of medicinal herbs which are common foods. If they caused kidney failure, we would know about it. Many Chinese herbs are very uncommonly used, and never as foods. They should ideally be used short-term and researched to see if any new properties have been discovered, good or bad. The best of Chinese herb books are still a few years behind the online databases such as Dr. Duke’s Phytobotanical Database and the National Library of Medicine (PubMed) abstracts. Not every abstract on PubMed is worth the pixels it’s printed on, but it’s better than an outdated textbook with no footnotes when looking for research.
Acupuncturists, you should be aware that most intelligent patients will go home and use the internet to research any herbal treatment you give them. This means that you should do that, too. This isn’t just about price, but about claims, recalls, toxicity, and research.
I suspect, dear reader, that you have already deduced the Yang to the Yin of “safety” in this post. Like “salt and pepper,” “safe and effective” go together. They are the peak of the medical mountain that perhaps go unseen when “there is no mountain.”
For most simple conditions, it is more important for a medicine to be safe than effective. First, we should define effective as “more effective than placebo.” This is different than “more effective than doing nothing.” The placebo effect is strong: for conditions where patient perception is the measure of efficacy (pain & nausea are the two top categories), placebos can easily have a 40-60% efficacy rate, depending largely on the confidence and kindness with which they’re prescribed. Being on a “waiting list” often leads to a 20-30% improvement in the same time frame.
The older generation of American acupuncturists have done some amazing work. They translated and published many books about Chinese medicine, they lobbied to gain the legal right to practice acupuncture and herbal medicine, and they set up schools to teach more aspiring acupuncturists. One thing they haven’t done is produce much good quality research. Research can be expensive, complicated, and time consuming. But it’s not out of reach, even on a grassroots level. Good research is mostly created by attention to detail and meticulous record-keeping. It generally doesn’t cost more to do good research than bad research. Bad research, however, is a WOMBAT: Waste Of Money, Brains, and Time.
I keep looking for good quality research on acupuncture and Chinese herbal medicine. There’s not much of it out there. Unfortunately, much of the high quality research says these TCM therapies aren’t much, if any, better than placebo. Acupuncture is somewhat (a better sounding word than “slightly“) better than placebo for some types of musculoskeletal and arthritis pain, and nausea, according to the best research. But when studied for conditions like uterine fibroids or asthma, TCM hasn’t convincingly been shown to be better than placebo, partly due to poor quality research. There are many powerful Chinese herbs, but not that much great research on them. Some herbs definitely “work”–rhubarb root and magnesium sulfate are both quite effective laxatives, though neither should be used too frequently. Oyster shell and cow bones are both effective calcium supplements, so will effectively treat the anxiety, heart palpitations, and insomnia caused by calcium deficiency. Other sorts of anxiety may not respond as well to powdered oyster shells.
The next obvious step forward for Chinese medicine is to find out which therapies work best for which conditions, and to also admit which ones don’t work. This step requires a dedication to discovering truth and using the scientific method. Americans in the past have made some great strides in science and medicine. Currently, the scientific literacy in our country is low. Chinese research is still notoriously biased. So this is our opportunity as Westerners practicing Oriental medicine: combine our desire to use safe, effective TCM with enough cultural detachment to avoid the biases that plague Asian research on traditional Asian medicine.
Acupuncturists must confront the ethical dilemma of promoting placebo treatments. When I think about it from the consumer’s point of view, it is fairly obvious that most people would feel duped to pay for a treatment that is no better than a sugar pill. Through medical history, untold numbers of patients have been happy with the results of placebo treatments (Chinese talismanic medicine, “high potency” homeopathics, and Mesmerism come to mind). In the era of the internet, promoting a placebo treatment is not only less ethical, but less likely to go undetected. Hundreds of years ago, when the doctor was more like a priest with exclusive access to and understanding of the “holy books,” the patient had virtually no chance of figuring out that a treatment was a sham. Now, however, research is just one search query away for any literate person. There is more acupuncture and natural medicine research available online today than in all the books in the library when I was a TCM student in the 1990′s. And it’s available to my patients, too.
If you start looking for good research on various Chinese medicine topics (the Cochrane collection is the best place to start for highly respected systematic reviews; PubMed will pull up a huge assortment, some without abstracts and many of poor quality), you’ll see that there is very little truly good research out there. Some of the best research shows little or no effect for conditions which most acupuncture students are taught to treat with confidence. If you disagree with the research that is out there, try to figure out a better way to state and test your claims. Becoming anti-science isn’t the right move, unless you want to limit your customer base to the most gullible. If you don’t want “mainstream scientists” to have the final say on what in TCM works and what doesn’t, it is up to practitioners, TCM companies, and schools to do good research to prove which claims are true.
Unfortunately, many TCM companies are not troubled in the least by selling placebo treatments, and will be unmotivated to spend time and money to show the things they promote are no better than placebo. Chinese medicine schools, which should be interested in research to promote the profession, are often promoting a dogmatic style or just trying to attract more students with a “feel good” approach. Many authors are also promoting their lineage, or simply translating Chinese sources. It is the few practitioners who got into natural medicine in pursuit of the “truth” about what works and how it works who have the chance to shape an evidence-based natural medicine from inside the profession.
The placebo effect increases with the confidence (and caring) with which a therapy is promoted. It is easier for me to be confident about evidence-based therapies. The other options are to fake confidence or go for self-delusion with good intentions. Many practitioners build financially successful practices based on their personality and belief in their system, even if the system is no better than placebo. Most modern patients, however, would prefer medicine based on evidence rather than blind faith.
Wanting to offer excellent customer service, I am motivated to recommend natural therapies which are better than placebo. Even if a therapy is just 5% better than placebo, I feel better about making the best recommendation rather than being ignorant and promoting a baseless treatment. Ultimately we will have good data comparing natural medicines to conventional medicines, and when the data is in favor of traditional natural medicines, they should be willingly accepted into the medical system of the future. If we don’t push to produce that data, only the mainstream medicine will be “proven.”
The good news is that the wide range of traditional Chinese medical practices will always offer some sensible protocols, even if research shows the fringes are without merit: exercise for a healthy mind and body, a balanced diet for prevention of many diseases, acupuncture & massage for musculoskeletal pain and stress-related conditions, and some traditional herbal treatments modern research confirms as safe and effective.
Ultimately, that’s what it’s all about. Patients want safe and effective treatments and practitioners want to have confidence that’s what we are prescribing. Mount Evidence is the next mountain to climb.