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Programme-by-programme
Introduction: About the series
Programme 1. Why is CAM so popular?
Programme 2. How do we know if they work?
Programme 3. Does it matter how it works?
Programme 4. First, do no harm
Programme 5. Fit to practise
Programme 6. A marriage made in heaven?
Programme 1. Why is CAM so popular?
Programme 2. How do we know if they work?
Programme 3. Does it matter how it works?
Programme 4. First, do no harm
Programme 5. Fit to practise
Programme 6. A marriage made in heaven?
Transcript: How Do We Know If It Works?
First broadcast on BBC Radio 4
Tuesday 28/09/04 2100-2130
PRESENTER:
ANNA FORD
CONTRIBUTORS:
NANCY HOLROYDE-DOWNING
KATE THOMAS
IAIN CHALMERS
PETER MORRELL
EDZARD ERNST
ANDREW VICKERS
GEORGE LEWITH
HUGH MCPHERSON
RICHARD SMITH
PRODUCER:
RAMI TZABAR
ACTUALITY - ACUPUNCTURE CLINIC
Okay so now I'm going to have a look first at your tongue, if you don't mind …
I did brush it this morning.
That's quite good. Okay now can you tip it up, so I can see beneath and back down? And back out again. Alright. So when you - when I look at your tongue I've noticed three things when you put it out - one, it's somewhat pale, it's not desperately pale but somewhat, it is somewhat wet - meaning it's not a dry tongue, it's not cracked, it doesn't have a thick coat on it - and it's also somewhat swollen - it has little ridges along the side. So all of these …
FORD
I've come to see Nancy Holroyde-Downing at the Traditional Acupuncture Centre in London. She's been practising acupuncture for 20 years and over the course of an hour we talk about my general health, my likes and dislikes, my sleeping patterns, the night cramp in my left leg, whether I feel hot or cold, and even how many siblings I have. At the end, she tells me, that I might have what she calls post-menopausal yin deficiency. So then it was time to lie on the table and check my pulses…
ACTUALITY - ACUPUNCTURE CLINIC
Is this a pulse that feels thick like a rope or thin like a piece of cotton? Is it a pulse that feels soft or is it something that's more like a guitar string - very wiry?
These are quite poetic descriptions of what you're feeling.
They tend to be. Chinese medicine has a lot of resonance with what they call the entire universe, the celestial world - the mountains, the valleys, the rivers, the lay of the land really. Much of Chinese medicine is going to depend upon a dialogue and a sharing of the experiences of the practitioner and the patient. I want you, at the end of a treatment, to have a pulse that is nicely balanced, quite even, not too hard, not too soft, not too tight, not too flaccid, not too big, not too deep - nice, even all the way.
And can you do that in one session?
Ah well probably not. I mean yes, I can make a difference in the pulse if I cannot I've obviously not given you good treatment. Whether it will hold is another question. So I'm going to now put the needles in, the first of them will be something called stomach 36 in Western parlance and in Chinese it would [Chinese name] and the other one is on the inside above the ankle [Chinese name] or a spleen 6. So here we go with the first point, I will locate it by palpating. Now it's going in. Do you feel that?
Yes.
Now is there another sensation?
Oh yes, there we go.
Now that would be the arrival of the chi - has it dissipated now, it's gone off?
It's gone off, it's like an ache.
That's it.
Yes, it's really not like anything …
FORD
Acupuncture is one facet of traditional Chinese medicine, which also includes herbalism. Its origins date back several thousand years and like many complementary and alternative medicines or CAMs, its practices and enticing metaphors seem a million miles away from the concerns of Western science. However, science is catching up in its understanding.
In this programme, we'll explore the issues around how scientists go about testing something which at first glance, appears very unscientific. Perhaps the millions of Britons using complementary therapy don't need convincing that they work - and by the way my leg cramps haven't returned since that acupuncture. But evidence is a slippery concept, which few in this field of research agree on.
MONTAGE
In every generation there are scientists who dismiss Newton, there are scientists who dismiss relativity and all the other theories that then become accepted later.
With complementary medicine the whole approach of it is about individualised care.
I think that's just a cliché - a tired cliché on top of it.
You can get any rubbish published, you just go down and down and down and down the food chain, as we call it.
You've got to be sophisticated, you can't treat acupuncture just as if it's some kind of drug.
It's a whole bogus question this thing about evidence - homeopathy works.
FORD
We live in an age of evidence-based medicine. It's the buzz word of the medical profession. It may sound like a tautology - I mean, if medicine is not based on evidence, what is it based on? But the fact is that estimates by the medical profession of the percentage of procedures that have been subject to scientific trials vary between 20 and 80%. Enough to suggest that there is still much to be done to test the theories underlying orthodox medicine.
So it's no wonder that some quarters are calling for more research into CAM, but how should it be done? Dr Kate Thomas is Deputy Director of the Medical Care Research Unit at Sheffield University. She's spent 20 years searching for the fairest way of testing a therapy.
THOMAS
There's certainly no single measure that we could possibly use, I think there's a whole range of different things that we can use and I think the very popularity of these therapies tells us an awful lot about their success from the patient's perspective. Patients are clearly going, we know, that well over 20 million visits a year for these major therapies and to put that in context I always think it's quite helpful to do that - about 14 million visits are made to an A&E department in a year. These aren't people who are going once and then not going again. And the fact that they're going again suggests to me that it's one very good measure of perceived success. Of course that's very different from what we think about in terms of scientific success.
FORD
And scientific success, the so-called 'gold standard' for the evaluation of medical treatments, is the RCT - the randomised controlled trial. A system designed to get the most objective result possible.
THOMAS
The principles of a randomised controlled trial are that you allocate people to a treatment and compare it to another treatment or to a placebo fake treatment and that people are allocated at random, so that you don't influence the outcome by people choosing the treatment that they're getting. And you're looking for a difference between the two groups, at the end of the day, that you feel confident is not due to who was in the two groups but to the treatments that they actually received.
FORD
One of the earliest pioneers of the RCT was an 18th Century doctor called James Lind. His legacy lives on in the James Lind Library, which documents the evolution of fair tests in medical treatments. Its editor is Sir Iain Chalmers.
CHALMERS
The only defining feature of a randomised trial is the word randomised. You use a technique to try and ensure that you compare like with like. So if you've got two treatments that you want to compare, Treatment A and Treatment B and the people that you give Treatment A to tend to be rather iller than the people you give Treatment B to and Treatment B looks a lot better, how do you know then that the difference isn't in fact just a reflection of the fact that the people were different going into the two groups initially? Clearly you can make mistakes in that way, as indeed we have done recently in advising women who've been taking hormone replacement therapy that taking it would reduce their chances of heart attack and stroke, it's only since the randomised trials have been done, which are designed to ensure that like will be compared with like that we now know that the advice that was being given to women was precisely the opposite of what in fact the truth is - that in fact hormone replacement therapy increases your chances of having a heart attack and stroke.
FORD
Tell me about the early history of randomised controlled trials - why did people begin to think that this was an important issue?
CHALMERS
Well I think it was because doctors started to ask questions about whether their treatments were doing more harm than good. I mean one of the earliest controlled trials was to test whether or not bleeding and purging people when they were poorly was better than leaving them alone and nature to cure them and in fact that particular controlled trial confirmed what we in these days could guess that bleeding and purging's not a very good idea. But that was what was being done by mainstream medicine in those days.
First broadcast on BBC Radio 4
Tuesday 28/09/04 2100-2130
PRESENTER:
ANNA FORD
CONTRIBUTORS:
NANCY HOLROYDE-DOWNING
KATE THOMAS
IAIN CHALMERS
PETER MORRELL
EDZARD ERNST
ANDREW VICKERS
GEORGE LEWITH
HUGH MCPHERSON
RICHARD SMITH
PRODUCER:
RAMI TZABAR
ACTUALITY - ACUPUNCTURE CLINIC
Okay so now I'm going to have a look first at your tongue, if you don't mind …
I did brush it this morning.
That's quite good. Okay now can you tip it up, so I can see beneath and back down? And back out again. Alright. So when you - when I look at your tongue I've noticed three things when you put it out - one, it's somewhat pale, it's not desperately pale but somewhat, it is somewhat wet - meaning it's not a dry tongue, it's not cracked, it doesn't have a thick coat on it - and it's also somewhat swollen - it has little ridges along the side. So all of these …
FORD
I've come to see Nancy Holroyde-Downing at the Traditional Acupuncture Centre in London. She's been practising acupuncture for 20 years and over the course of an hour we talk about my general health, my likes and dislikes, my sleeping patterns, the night cramp in my left leg, whether I feel hot or cold, and even how many siblings I have. At the end, she tells me, that I might have what she calls post-menopausal yin deficiency. So then it was time to lie on the table and check my pulses…
ACTUALITY - ACUPUNCTURE CLINIC
Is this a pulse that feels thick like a rope or thin like a piece of cotton? Is it a pulse that feels soft or is it something that's more like a guitar string - very wiry?
These are quite poetic descriptions of what you're feeling.
They tend to be. Chinese medicine has a lot of resonance with what they call the entire universe, the celestial world - the mountains, the valleys, the rivers, the lay of the land really. Much of Chinese medicine is going to depend upon a dialogue and a sharing of the experiences of the practitioner and the patient. I want you, at the end of a treatment, to have a pulse that is nicely balanced, quite even, not too hard, not too soft, not too tight, not too flaccid, not too big, not too deep - nice, even all the way.
And can you do that in one session?
Ah well probably not. I mean yes, I can make a difference in the pulse if I cannot I've obviously not given you good treatment. Whether it will hold is another question. So I'm going to now put the needles in, the first of them will be something called stomach 36 in Western parlance and in Chinese it would [Chinese name] and the other one is on the inside above the ankle [Chinese name] or a spleen 6. So here we go with the first point, I will locate it by palpating. Now it's going in. Do you feel that?
Yes.
Now is there another sensation?
Oh yes, there we go.
Now that would be the arrival of the chi - has it dissipated now, it's gone off?
It's gone off, it's like an ache.
That's it.
Yes, it's really not like anything …
FORD
Acupuncture is one facet of traditional Chinese medicine, which also includes herbalism. Its origins date back several thousand years and like many complementary and alternative medicines or CAMs, its practices and enticing metaphors seem a million miles away from the concerns of Western science. However, science is catching up in its understanding.
In this programme, we'll explore the issues around how scientists go about testing something which at first glance, appears very unscientific. Perhaps the millions of Britons using complementary therapy don't need convincing that they work - and by the way my leg cramps haven't returned since that acupuncture. But evidence is a slippery concept, which few in this field of research agree on.
MONTAGE
In every generation there are scientists who dismiss Newton, there are scientists who dismiss relativity and all the other theories that then become accepted later.
With complementary medicine the whole approach of it is about individualised care.
I think that's just a cliché - a tired cliché on top of it.
You can get any rubbish published, you just go down and down and down and down the food chain, as we call it.
You've got to be sophisticated, you can't treat acupuncture just as if it's some kind of drug.
It's a whole bogus question this thing about evidence - homeopathy works.
FORD
We live in an age of evidence-based medicine. It's the buzz word of the medical profession. It may sound like a tautology - I mean, if medicine is not based on evidence, what is it based on? But the fact is that estimates by the medical profession of the percentage of procedures that have been subject to scientific trials vary between 20 and 80%. Enough to suggest that there is still much to be done to test the theories underlying orthodox medicine.
So it's no wonder that some quarters are calling for more research into CAM, but how should it be done? Dr Kate Thomas is Deputy Director of the Medical Care Research Unit at Sheffield University. She's spent 20 years searching for the fairest way of testing a therapy.
THOMAS
There's certainly no single measure that we could possibly use, I think there's a whole range of different things that we can use and I think the very popularity of these therapies tells us an awful lot about their success from the patient's perspective. Patients are clearly going, we know, that well over 20 million visits a year for these major therapies and to put that in context I always think it's quite helpful to do that - about 14 million visits are made to an A&E department in a year. These aren't people who are going once and then not going again. And the fact that they're going again suggests to me that it's one very good measure of perceived success. Of course that's very different from what we think about in terms of scientific success.
FORD
And scientific success, the so-called 'gold standard' for the evaluation of medical treatments, is the RCT - the randomised controlled trial. A system designed to get the most objective result possible.
THOMAS
The principles of a randomised controlled trial are that you allocate people to a treatment and compare it to another treatment or to a placebo fake treatment and that people are allocated at random, so that you don't influence the outcome by people choosing the treatment that they're getting. And you're looking for a difference between the two groups, at the end of the day, that you feel confident is not due to who was in the two groups but to the treatments that they actually received.
FORD
One of the earliest pioneers of the RCT was an 18th Century doctor called James Lind. His legacy lives on in the James Lind Library, which documents the evolution of fair tests in medical treatments. Its editor is Sir Iain Chalmers.
CHALMERS
The only defining feature of a randomised trial is the word randomised. You use a technique to try and ensure that you compare like with like. So if you've got two treatments that you want to compare, Treatment A and Treatment B and the people that you give Treatment A to tend to be rather iller than the people you give Treatment B to and Treatment B looks a lot better, how do you know then that the difference isn't in fact just a reflection of the fact that the people were different going into the two groups initially? Clearly you can make mistakes in that way, as indeed we have done recently in advising women who've been taking hormone replacement therapy that taking it would reduce their chances of heart attack and stroke, it's only since the randomised trials have been done, which are designed to ensure that like will be compared with like that we now know that the advice that was being given to women was precisely the opposite of what in fact the truth is - that in fact hormone replacement therapy increases your chances of having a heart attack and stroke.
FORD
Tell me about the early history of randomised controlled trials - why did people begin to think that this was an important issue?
CHALMERS
Well I think it was because doctors started to ask questions about whether their treatments were doing more harm than good. I mean one of the earliest controlled trials was to test whether or not bleeding and purging people when they were poorly was better than leaving them alone and nature to cure them and in fact that particular controlled trial confirmed what we in these days could guess that bleeding and purging's not a very good idea. But that was what was being done by mainstream medicine in those days.
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