evidence based prescribing

[Guest guest]

With all due respect to everyone, we have to accept the fact that at

least half the effects reported by patients in ANY type of uncontrolled

private practice of medicine are due to placebo (including my

practice). we do EVERY thing we can to insure this. Music, colors,

smells, our length and style of interaction. All these are important

parts of healing and I would hardly suggest we minimize them in our

practices. Quite the contrary. But we are not gong to deliver chinese

herbal medicine to the mainstream of america in this setting. Its just

not cost effective. Keep in mind that I am speaking here from the

perspective of a public health advocate. I want to see CM delivered to

the most people possible in a cost effective way. If spending an hour

with a patient once a week in a idealized setting is necessary to the

treatment of some or all diseases, let's prove it.

 

It may turn out that low dose patents only work reliably when one uses

multiple modalities in such an idealized setting, but not when solely

prescribing herbs after brief consultations. It may turn out that high

dose herb formulas work better than weekly acupuncture plus patents for

many complaints. But if high dose herbs (in any form) are prescribed

once monthly, let's say, the total cost to the patient would be $50 for

the herbal consult and $80 for a months supply of herbs. If the

patient got once weekly acupuncture at $65/tx plus paid another $50 per

month for low dose patents, it would cost more than twice as much to

get the acupuncture. If there is no added benefit to this, no one will

ever pay for it. We may have to accept the possibility that the

primacy of herbology over acupuncture in the modern PRC is the most

cost effective use of CM in mainstream healthcare. What goes on in

some private clinics would considered more like a trip to the dayspa to

most insurers.

 

As an aside, the japanese acupuncture teacher At PCOM used to be an

herbs teacher at PCOM years ago. He is well known for his tongue in

cheek condescension towards chinese herbology. He claims that the type

of patients he typically sees respond better to classical styles of

acupuncture than when using TCM style herbs and acupuncture combined.

So he rarely uses herbs anymore because he finds no added value with

his treatments. However he also admitted that if the patient load we

saw was mostly chronic internal illnesses, then he would actually place

primary importance on the use of herbs integrated with western

medicine. I thought that was quite interesting and have to admit I

pretty much agree. For many patient with stress related functional

nonorganic illness, herbs in large does are overkill. I wonder how

many folks who use patents also fancy themselves more of a classical

style acupuncturist as opposed to TCM style. Perhaps it is your

acupuncture doing it all.

 

So what is evidence to me and what is not? Well, personal anecdotes

about oneself or one's patients in an uncontrolled setting with no long

term followup or statistical analysis do not reveal anything compelling

to me. It could all be placebo effects, as far as most researchers are

concerned. Every single day I have interns tell me their patients are

getting better from their treatments and every day upon close

questioning I find out that many variables other than acupuncture and

herbs are usually at play. Often, the conditions are self-limited or

remittent in nature. Or the patient has altered diet and exercise,

factors I consider more important than herbs and acupuncture. The

evidence that compels me is the following:

 

1. history of mainstream usage - that an idea or usage appears

repeatedly in what are considered mainstream texts

 

2. controlled clinical research - the herb or herbs have been shown in

well designed studies to actually be effective.

 

3. animal physiology research - the herb causes measurable changes in

animal or human physiology, thus allowing the possibility of

therapeutic potential

 

4. pharmacological evidence - the herb contains constituents which can

explain part of its action at standard doses

 

5. current consensus usage in china - that an idea or usage is still

accepted and applied widely today

 

6. anthropological and epidemiological - that societies adhering to

certain dietary and lifestyle practices did so for bonafide medical

reasons and got measurable benefit therefrom

 

 

 

 

Chinese Herbs

 

 

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