Unexpected outcomes

Want to know one of my favorite things about being an acupuncturist? Watching people experience healing in unexpected ways. Someone comes in for shoulder pain, right? I treat her for a few weeks with LI 4, LI 11, TB 14, SI 10, TB 10, SI 11, and a few ashi points and her shoulder gets better. She’s happy about this, obviously, but then as we’re chatting about preventive care and other things, she says “Look at the nail on my index finger! It’s finally better.” This nail had been a nuisance to her for a long time because of a really gnarly crack right down the middle. Now it was growing normally. What a treat to share in her excitement. What a treat to watch people walk away with more healing than they had thought possible

And, of course, fellow professional acupuncturists will just nod their heads, because although the details of unexpected outcomes such as this can’t be predicted beforehand, the occurrence is by no means a surprise. I never explicitly said this to her, but I wasn’t directly treating her main symptom, shoulder pain. I was treating qi and blood stagnation in the TB, SI and LI channels for her shoulder but also liver qi stagnation, which is a common diagnosis and if treated properly will create a lot of change for the patient. Sometimes this is referred to as the root and the branch. The root cause is a fundamental imbalance that needs addressing, the branch is the specific symptom. If I am successful in resolving the root cause, the “main complaint,” or branch, will respond. But removing the root cause unleashes the possibility of an effect on any number of symptoms for which the patient wasn’t seeking treatment.

The phenomenon of fingernail healing

The patient’s surprise became my surprise when I was reading an article by Daniel Schulman in The Journal of Alternative and Complementary Medicine (abstract; sorry, you’ll have to go to the library to see the entire article). His article is titled The Unexpected Outcomes of Acupuncture: Case Reports in Support of Refocusing Research Designs. His main focus is on research (and I’ll get back to that myself in a minute), and he describes two clinical cases of unexpected results. Guess what one of them is. You’re right, a fingernail healed. This time, a thumbnail. A woman who had come in for treatment of acid reflux and headaches, among other things, never mentioned her thumbnail until one day she happily reported that this longstanding problem was gone.

Unexpected outcomes as a challenge in research methods

The existence of unexpected results such as these points to one of the difficulties that the scientific community is having in designing relevant tests – particularly when comparing the results of acupuncture to conventional biomedical treatments – for the effects of acupuncture. If either my patient or Daniel Schulman’s had been in a clinical trial for effectiveness of acupuncture in the treatment of their “main complaint,” would unexpected outcomes such as these even be documented? I haven’t read a case in which they have. Even more of a puzzle presents itself if a clinical trial reveals no statistical difference between treatment and no-treatment for a symptom. What if my patient still experienced shoulder pain, but slept better, was happier in general, and experienced any number of other unexpected outcomes?

I’m not a scientist, but I’m aware that the so-called “gold standard” of clinical research, randomized, controlled trials (RCT’s) have their inherent limitations and there are many challenges facing those in the research community who are interested in comparing different treatment modalities. I’ve just begun reading some of what Ted Kaptchuk has been writing about all of this (here’s his amazing bibliography) and look forward to learning more.

Until then, what to make of this fingernail phenomenon? How common is it?

Healing alliances

How can I optimize the treatment of my patients? How can I provide the best healing experience possible? It begins with a partnership with each patient – a unique healing alliance. How does this alliance develop?

Listening

It begins with listening. Listening for a patient’s personal understanding of whatever symptoms brought him or her to me. Dealing with illness or pain can be as emotionally draining as it is physically trying. So I also ask about expectations and anxieties. I listen for small details that might convey meaning. It isn’t uncommon for a patient’s needs to be greater than what can be objectively diagnosed. How else to discover this than by listening?

What follows

The result is shared communication. Shared attention. Shared concern. And how could it stop there? Compassion follows automatically. As does a shared vision of what this person’s life would be like without whatever symptom has initiated this interaction.

This is what it means to say I strive to treat the person, rather than the symptom. This is certainly one of the things that drew me to Chinese medicine in the first place.

The unexpected power of the therapeutic alliance

What I now realize is that this interaction has healing power in and of itself. Progress on the road to healing can begin even before acupuncture, before herbs, or before any kind of treatment. Several clinical studies have demonstrated that there is therapeutic value to this healer-patient interaction. This is why randomized clinical trials are needed, after all. Researchers attempt to control for this phenomenon when testing the efficacy of a new drug or treatment. Otherwise, how would we know when a new treatment was effective beyond this important baseline?

All of this is true for Western medicine, too. There even have been instances in which once-orthodox drugs and treatments were abandoned later because subsequent controlled studies demonstrated that the main variable bringing about the positive outcome was the interaction with the doctor, not the treatment itself. Isn’t that amazing? It’s even true for some surgical procedures, believe it or not. Patients were experiencing healing for reasons other than the specifics of the operation. Doctor and patient expectations can have such dramatic effects on treatment outcomes.

A humble suggestion regarding medical research priorities

Dear mainstream and alternative medicine researchers, please focus more investigative energy on that part of your research that is normally referred to only by way of comparison with a main treatment group — that phenomenal baseline of healing. Please discover more about how all practitioners can be better healers, regardless of the types of treatment involved. What mind-body phenomena are at work when patients and doctors interact, and how can we enhance these effects? What physiological interactions between the nervous, immune, and endocrine systems are taking place when a healer and a patient establish an alliance?

Until we’ve discovered more, I’ll keep listening for clues from my patients.

Road to Gotham

Starting this business has been one of the best experiences of my life. And whenever I’m in danger of losing sight of this, I pull out one of my business cards, put it on the table and have another look at it. And there it is, Sarah Hayes, LAc, Acupuncture Northwest, The Gotham Building, Suite 171, Portland, Oregon. Yes!

While I was on that long road from graduate school to practicing acupuncturist, I initially had only vague notions of how I was going to reach my professional goals. I had no idea how many business questions I would be asking, or how many people I would be relying on to help me know what questions I should ask. Three and a half years of medical training had me ready to treat patients, but the two business classes (two!) left me feeling like a babe in the woods.

Looking back, we were all so wrapped up with our studies that the business ahead of us was the last thing on our minds. We were focused on learning the medicine. If I thought about it at all, I thought I might join another practitioner, or maybe a group of alternative care practitioners, or maybe purchase an established practice. Like I say, it wasn’t exactly clear during my student days. In the end I decided the way I would ultimately be the happiest was on my own. I wanted to go it alone. Looking back, it was the right choice for me.

First questions

How much rent could I afford to pay? How much should I charge my patients? How many patients will I need in order to break even? What part of Portland would be best to locate in? Is off-street parking important? What should my business cards look like? How much do they cost? How else to advertise? Should I create a web site? What insurance companies should I contact for liability insurance? How do I become eligible to charge patients’ insurance companies? What kinds of treatments are covered by insurance companies? Who are the best medical suppliers? Should I build my own inventory of herbs? What software would be best for bookkeeping? On that glorious day when I have my own treatment room and a treatment table, should I use sheets or a paper roller to save on laundry?

Finding a business manager

So what I really needed was someone to put these questions in their proper order, tell me which ones to answer first. I remember thinking “Shoot, what I need is a business manager.” Followed by “Oh my gosh, that would be me.” I was about to become a business- managing/landlord-contacting/insurance-calling/bookkeeping/ laundering acupuncturist. Last thought that night before going to sleep: “Oh my god.”

A comparative study looking at CAM practitioners

How many times has this realization occurred to someone like me? Many, many times, as it turns out. The Sept-Oct, 2002, issue of the Journal of the American Board of Family Practice has this article in it: Characteristics of Licensed Acupuncturists, Chiropractors, Massage Therapists, and Naturopathic Physicians. The authors (Cherkin et al.) wanted to compare practitioners of the four main branches of complementary and alternative medicine (CAM) with conventional physicians. The result that caught my eye was that more than 60% of the acupuncturists in their survey practiced solo. This compares with about 25% for conventional physicians.

Also mentioned in this article is the fact that although there is increasing interest in and use of CAM, there is still a good deal of separation between differing healthcare services in general. CAM practitioners, when they do work in clinics, tend to associate with other CAM professionals, and likewise for conventional physicians. Acquiring integrated care, at least by this measure, is still largely the individual patient’s responsibility.

Feeling lucky

Why I feel lucky to be practicing Chinese medicine

Starting my business — Acupuncture Northwest — has been one of the best experiences of my life. I really think that I am in the right place at the right time, doing the right thing. Attitudes toward complementary medicine (CAM) have been changing dramatically over the past few years, and in addition to success stories such as Portland’s two colleges of Oriental medicine (Oregon College of Oriental Medicine and National College of Natural Medicine), Western doctors are increasingly recognizing the need for complementary therapies.

An interesting CAM study

Medical publications have quantified this trend in various ways. As an example, here is an abstract on the topic from the journal Pediatrician and Adolescent Medicine. Interestingly, studies such as this one often find that a large proportion of Western doctors are interested in learning more, and even being trained in, CAM.

An MD talks about CAM

James Rotchford has written a compelling article that is aimed at his MD colleagues searching for expanded treatment options for their patients. An excerpt (from Medical Acupuncture):

“. . . we uncommonly have the opportunity to see our patients feeling better when they leave our offices than when they arrived. However, patients who have received acupuncture often feel better and have objective signs of improvement even before leaving the office. In part it could be due to the endorphins that are released through acupuncture. Nonetheless, the sense of well being and the immediacy of effect are noteworthy and satisfying to see in patients who have received acupuncture.”

And continuing in his advice to Western doctors he relates:

“For me the medical history comes alive in new and exciting ways as a result of my studying oriental medicine and acupuncture. With oriental medicine not only what the patient tells you but the context in which they tell you is very important. If you enjoy literature or listening to a good story, I’m confident that you will experience a new satisfaction in taking a thorough medical history . . .”

All I can say to that is Amen, Brother. The more all health practitioners can know about context, the more we can really know the person we are treating, the better we are able to offer healing.

Maybe we’re all in the right place at the right time. Wouldn’t that be nice?