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Acupuncture, the Navy, and Faulty Thinking

A Navy neurologist, Capt. Elwood Hopkins, has posted a 3-part article on  “The Power of Acupuncture” on Navy Medicine Live, the official blog of Navy and Marine Corps Health Care. It can serve as a useful lesson in how not to think about medicine. It is a prime example of how an intelligent, educated doctor can be fooled and can fool himself into thinking that a placebo is an effective treatment.

To set the scene: acupuncture has been increasingly accepted in military circles. The Air Force is teaching its doctors “battlefield acupuncture” based on the faulty evidence of one Air Force doctor, Richard Niemtzow.  The Army is using it to treat PTSDThe Navy offers it too.

Hopkins says that after 40 years of practicing neurology, “It was only natural to begin thinking about something else.” (Why? Boredom? And why pick acupuncture?) When he got an e-mail from his Specialty Leader announcing the opportunity for Navy doctors to learn how to do acupuncture, he submitted his application that same day. He was undoubtedly impressed that this training was being offered by the Navy, lending it the imprimatur of authority. His prior impression of acupuncture was that it was a “mysterious tool” that seemed to work; and instead of asking critical questions, he says he was looking for “a fundamental scientific understanding of acupuncture” and asking to see the supporting research and data. 

Mistake #1: Prior prejudice. It sounds like he already had a favorable opinion of acupuncture and was predisposed to accept it.

Mistake #2: Confirmation bias. He was looking only for confirmation rather than also looking for any disconfirming research.

He says his intellect was actively engaged by the teacher, a “charismatic master acupuncturist,” who laid a neurophysiologic foundation for how acupuncture works (never mind showing that it does work!).

Mistake #3: Getting information from a questionable source. A “master” acupuncturist is hardly likely to present a balanced picture of the evidence for and against his source of livelihood. Hopkins himself calls the teacher “charismatic,” so he could have suspected that he might be influenced by that charisma to accept things he would not have accepted as readily from a dry, objective presentation of scientific evidence.

He was told about local physiologic changes in tissues stimulated by needles. He was not told that non-needle “acupuncture” (with electrical stimulation through intact skin or with simple touching with toothpicks) had been shown equally effective, even when acupuncture points are avoided. He was told that needles caused reversal of tissue acidosis. (This is a claim I don’t remember hearing before, and I think it is based on a couple of Chinese studies in animals. Even if true, its clinical relevance would be questionable.) He was told about the “gate control” hypothesis, but was not told that after half a century of investigation it has not been accepted as the explanation for acupuncture’s effects. He was told about MRI findings and endorphin release, but was not told that the same findings can be elicited by placebo pills. I see them as evidence of the mechanism for acupuncture’s placebo effects; he interprets them as evidence that acupuncture “resets normal controls within the autonomic nervous system and maintains CNS homeostasis.” What does that even mean? Sounds to me like typical CAM pseudoscientific doublespeak.

Mistake #4: Cherry-picking the literature. The charismatic master acupuncturist snowed Hopkins with every shred of data that might possibly support a physiologic mechanism for acupuncture, even providing “an extensive reference library.” Did he disclose that it doesn’t matter where you put the needles? Did he list the high-quality trials showing that sham acupuncture works just as well? Did he list all the negative systematic reviews or Edzard Ernst’s recent systematic review of systematic reviews of acupuncture for pain?  It is obvious that he cherry-picked the literature to support his claims. This is easy to do with acupuncture. Many low-quality studies of acupuncture are available.

In part 2 Hopkins actually asks if the clinical effects might be due to placebo. He wonders how we would know, since there is “no honest way” to do a properly controlled double blind study. His teacher says it is better to go by the functional outcome rather than by patient reports of pain levels. So far, so good. But then Hopkins throws science out the window and never mentions placebo again. He actually says

There is nothing like personal experience to convince one of an effect. It is a bit like not requiring a double blind placebo controlled cross-over study to establish that an open parachute is more effective than a closed one.

Wow! Unbelievable! This sounds like it was written by someone ignorant of science and logic rather than by a neurologist. His analogy is a clichéd fallacy: we don’t accept the effectiveness of parachutes because we have had personal experience jumping out of planes. I think he meant to say that not every claim requires proof by placebo-controlled trials, which is true but not pertinent here. We don’t need to do controlled trials to find out if it is effective to do appendectomies for appendicitis or to set broken bones, but we do require controlled trials to find out if acupuncture works. In a way it’s true that personal experience is the best way to convince someone there is an effect, but it’s useless for determining whether there really is an effect. To rephrase his statement, there is nothing like solid scientific data to convince a scientist who knows better than to accept personal experience as evidence.

Mistake #5: Not understanding why science is necessary. It’s hard to believe that this was written by someone who has gone through medical school and residency training. It’s a sad indictment of our educational system.

The instructor asks for volunteers and Hopkins offers himself as a guinea pig. The instructor treats him for his Raynaud’s disease, telling him he believes that it is due to prior cervical injury. As a neurologist, Hopkins should know that the term “Raynaud’s disease” refers only to idiopathic cases and if the condition is secondary to some instigating factor, it is called “Raynaud’s syndrome.” Also, while repetitive trauma from vibrating tools like jackhammers and prior injuries to the hands or feet have been recognized as causes of Raynaud’s, “cervical injury” has not. There are studies showing that acupuncture is more effective for Raynaud’s than drugs or than no treatment, but they are not convincing because they didn’t use placebo control groups. After the treatment, Hopkins’ symptoms resolved, and he became a believer.

Mistake #6: Relying on his personal experience. True believers ask us to “try it yourself” and they say “I saw it with my own eyes.” We have ample evidence that seeing something with our own eyes is often misleading, and that trying something for yourself can interfere with your ability to objectively assess the evidence.

Mistake #7: The post hoc ergo propter hoc fallacy. Hopkins assumes that because his symptoms improved after the treatment, they improved because of the treatment. He doesn’t even consider that there might be other explanations or confounding factors. (For one thing, emotional stress is a known trigger for Raynaud’s symptoms.)

His classmates were treated for various conditions including radiculopathies and interstitial cystitis, and they all “benefitted.” He calls acupuncture a “safe and inexpensive tool that has been time-tested for several thousand years.”

Mistake #8: Relying on the personal experience of others. Testimonials abound for even the quackiest of quack treatments. No matter how many anecdotes we manage to accumulate, the plural of anecdote is not data: that’s why we do science.

Mistake #9: The ancient wisdom fallacy. He is dead wrong about acupuncture being several thousand years old. Even if it was, length of use is no  indication of truth. Astrology has been around for longer than acupuncture: does he think it’s valid because it has been time-tested? Blood-letting was “time-tested” for many centuries, but it turned out to do more harm than good.

In Part 3, Hopkins relates how he has implemented acupuncture in his practice. He has given over 1000 acupuncture treatments for everything from headaches to prostatitis. (One wonders why a neurologist would be treating prostatitis.) He claims a 90% success rate with many spectacular responses. He actually uses the word “miracle.” He admits that some patients don’t respond, saying it is “never clear why.” (I think I can guess why!) He reports improvements in control of diabetes and hypertension, less need for medication, better sleep, etc. He concludes that “It is now evident to me that there truly is a great benefit to acupuncture.” He says it is safe (although the Ernst study documented rare but serious adverse effects including death). He says there are no contraindications, but numerous lists of contraindications are easily found on the Internet both on acupuncture websites and on mainstream medical websites. He says the only time he would not use it was if the patient didn’t want it. He recommends that anyone caring for patients should consider adding this tool to their kit.

Mistake #10: Making uncontrolled observations. His patients improved, but how many of them would have improved without any treatment or with a credible placebo offering some of the non-specific treatment effects of acupuncture?

Mistake #11: Proselytizing on the basis of his own uncontrolled observations. Now that he has convinced himself, he wants to persuade others by simple assertions and by the same kind of unreliable “evidence” that convinced him.

Mistake #12: Not doing his own research. He might have checked PubMed. He might have read a neat new study confirming previous evidence that acupuncture is no more effective than placebo.  It showed that patients were more likely to improve if they believed in acupuncture and believed they got the real thing rather than a placebo, regardless of which they actually got. He might have read what Yale neurologist Steven Novella wrote after actually researching the literature on acupuncture himself. He might have read the many negative systematic reviews, such as the one  showing  that a  “small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias” or the recent systematic review of systematic reviews by Edzard Ernst showing “numerous contradictions and caveats.” He might have read the many skeptical articles on science blogs. He might have read The Skeptic’s Dictionary entry on acupuncture. He might have consulted Quackwatch’s affiliate Acupuncture Watch. Even reading the acupuncture article on Wikipedia might have raised some doubts in his mind.

At this point, even if he is willing to look at the great mass of disconfirming evidence, he is probably not capable of judging it objectively. Once someone has become a true believer on the basis of personal experience reinforced by grateful patient feedback, there is rarely any hope. He has drunk the Kool-Aid. I just hope he doesn’t go on to seek training from a charismatic homeopath or a reiki master!

I can understand why many doctors are less skeptical than they should be about most of the CAM information they encounter: they are used to having pre-digested, accurate scientific information presented to them by experts. They were (sadly) not taught to question what their teachers said in medical school and residency. They were taught about evidence-based medicine, but they have poor understanding of what we mean by science-based medicine. They rely on published information in medical journals, but they may not realize that half of the studies they read are wrong. Even if they are good at critically evaluating scientific medical information, they may not be used to critically analyzing information from the realm of CAM. They may not have learned to recognize the common logical fallacies and the pitfalls.

The One Big Mistake: Not Following the SkepDoc’s Rule of Thumb. My rule, which applies to critical thinking in every sphere: before accepting any new claim, find out who disagrees with it and why. Once you fully understand the arguments on both sides, only then are you qualified to judge whether the claim is credible. What if a jury listened to the prosecution but not to the defense?

For those of us who have made an effort to develop our critical thinking skills and have not been influenced by personal experience or charismatic apologists, all indications are that acupuncture amounts to an elaborate placebo system. Using placebos on patients is unethical. As a retired Air Force colonel and as a physician, I am saddened to see acupuncture infiltrate the military health care system. And I am saddened to see how Dr.  Hopkins’ faulty thinking led him astray. To salvage a bit of good from the bad, I hope his experience can serve as a bad example for others to learn from.

Posted in: Acupuncture

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19 thoughts on “Acupuncture, the Navy, and Faulty Thinking

  1. daedalus2u says:

    What the phrase “resets normal controls within the autonomic nervous system and maintains CNS homeostasis.” means to me is “it triggers the placebo effect”.

  2. Zetetic says:

    Dr. Hall,

    I noted in his article that Capt Hopkins is a Neurologist at Naval Hospital Bremerton. That’s sort of in your neighborhood, perhaps you could interview him.

  3. Harriet Hall says:

    @Zetetic,

    What would be the point of interviewing him?

  4. DrRobert says:

    In addition to the large number of good points Dr. Hall already mentioned, we have to remember also that these are soldiers that being treated ineffectively with placebo, so they are receiving substandard healthcare. Also, being that its the military, tax payers are funding this sCAM care too.

    I guess we slowly are turning into one of those countries that uses low-cost placebo healthcare over legitimate health care.

  5. “He reports improvements in control of diabetes and hypertension, less need for medication, better sleep, etc. ”

    “He says the only time he would not use it was if the patient didn’t want it. He recommends that anyone caring for patients should consider adding this tool to their kit.”

    Well, if you believe that acupuncture has a specific, physiologic effect beyond placebo, I can see how you might take that position, but in general, I like to have some evidence and science behind any given choice of treatment fro any particular condition. Aspirin has many things for which it is effective, but I wouldn’t use it to treat a staff infection.

    The displacement effect is one of the things most troubling about sCAM. When I see the words “acupuncture”, “diabetes”, and “less need for medication” in the same sentence, it tends to trouble me greatly.

    I can understand why it’s hard to convince some people that acupuncture is nothing more than an elaborate placebo when it comes to subjective outcomes like pain and nausea, but life threatening conditions like diabetes, hypertension, and asthma have relatively easily measured, objective outcomes. Any practitioner who advocates acupuncture for such conditions (unless and until a body of supporting good, scientific evidence emerges) immediately forfeits credibility with me.

    Sure, I suppose it’s possible that a placebo response from just feeling good about your health as a result of acupuncture could have some effect in lowering your blood pressure, but traveling down placebo road without fully understanding that this is the road we’re traveling down is inherently dangerous.

    If the practitioner believes they are providing anything other than an elaborate placebo because they have at least somewhat bought into the elaborate mysticism surrounding their sCAM modality of choice, this is dangerous quackery, pure and simple.

    It is by no stretch unreasonable to speculate such a practitioner would prescribe sCAM alone as a first step in treating milder conditions, which to me would be the equivalent of saying, “Your condition isn’t particularly serious, let’s try hand waving and see if it goes away.”

  6. Regarding accupunture and Raynaud’s – I get mild to moderate Raynaud’s symptoms almost everyday in the winter months (start a couple of years ago). I had no idea that stress could effect it, mine seems to be mostly triggered by being cold, although I suppose that makes sense, the way that stress seems to effect ones circulation. Was Capt. Hopkin suggesting that accupunture effected the overall vasospasms tendency or just that it stops an episode, how did he track his improvement (if he did)? Sorry, I could find the part of the article where he talks about this.

    Maybe I’m being naive, but my Raynaud’s epidsode seem pretty reliable, it seems like it would be pretty easy to test something like that with a real accupunture vs sham accupunture vs medication and exposures to cold.

  7. couldN’T find it, that is

  8. Harriet Hall says:

    Michele: go to http://navymedicine.navylive.dodlive.mil/archives/1577 and read the next-to-the-last paragraph as well as the one just above.

    A controlled study such as you suggest would provide useful evidence. An uncontrolled study like this http://www.ncbi.nlm.nih.gov/pubmed/9077368 would not. Presenting a single informal observation like Dr. Hopkins’ as “evidence” is laughable.

  9. daedalus2u says:

    micheleinmichigan, vasodilation is mediated through nitric oxide, and stress is a low nitric oxide state which (under some circumstances) produces peripheral vasoconstriction. In many kinds of stress, your body “wants” to drive blood away from the periphery so there is more to support the major organs, heart, liver, brain which you need to survive more than you need blood delivered to your fingers.

    Anything that “resets normal controls within the autonomic nervous system and maintains CNS homeostasis” should help to reduce peripheral vasoconstriction when vasoconstriction is inappropriate. Any and every sufficiently effective placebo should do that.

    Under circumstances of severe blood loss, peripheral vasoconstriction is a “feature”, and so “normal controls within the autonomic nervous system” should trigger peripheral vasoconstriction.

  10. jt512 says:

    Fantastic deconstruction of the process of self-delusion. This post should be on every skeptics must-read list.

    My only nit is the repetition of the poorly justified claim by Ioannidis that most (you actually said “half”) published research is wrong.

    Jay

  11. Quill says:

    Dr. Hall wonders: “One wonders why a neurologist would be treating prostatitis.”

    No wonder at all. A lot of people have their head up their ass.

    In terms of faulty thinking and schooling, according to the California Medical Board’s website, Dr. Hopkins is a 1972 graduate of Duke University Medical School, is a board-certified neurologist and lists two secondary practice areas: Aerospace Medicine and Complementary & Alternative Medicine.

    sCAM and space? sCAM in space? Well, it would save the next big NASA project, say a Mars mission, a lot of baggage if they didn’t have to haul along a full “allopathic” medical facility but rather could get by with a bag of needles, some sugar pills and perhaps a meridian map. They could even staff Reiki people in ground control and perform healing at a distance.

  12. @Harriet Hall, thanks for the link! That is a very dramatic anecdote, My symptoms are not near so bad as the captain’s, but I’d certainly be willing to get stuck with some needles for several months of normal cold tolerance (whether the results are due to actual poking or some mysterious placebo effect matters little to me).

    Unfortunately, it sort of begs the question, “if acupuncture is so great for Raynaud’s, why doesn’t some CAM doctor get off their rear, get some of that NCAAM money, and do a good study to show off the results?”

    Actually, it kinda ticks me off. It looks like they are either avoiding doing research because they suspect they’ll get less than stellar results or they are just lazy bums, unwilling to pay their dues.

    @DU2, I can’t say that I really understood your post fully, but most of the drugs used for Raynaud’s have been test against placebos and the placebo results are not that impressive…I suppose if one’s episode’s were primarily triggered by anxiety or stress, I could understand a bigger placebo response, but my symptoms and the symptoms of the folks I know with Raynaud’s are triggered by cold, constriction and or vibration (power tools), So I’d expect that the placebo response would be pretty well represented in the relevant medication RCTs.

  13. Here is how these things usually go: get excited about the intervention. Then, somewhere along the way, identify what problem or problems it is helpful for.

    This is nuts.

    We (as humans susceptible to physical and psychological maladies) want to prevent and treat various maladies.

    A broad-spectrum intervention is fitting for prevention: eat vegetables and exercise so you avoid a lot of bad outcomes.

    We don’t wander around through life wondering what might treat our various maladies: gee, what one intervention might restore my youthful vigor and at the same time ease my lower back pain?

    Strange how the intervention is the focus, not resolution of illness or symptom.

    BTW: the SBM posts on how Mao promoted acupuncture, as part of the cultural revolution, were awesome.

  14. tomc says:

    A couple of years ago, I read Snake Oil Science by Barker Bausell (who headed a center for Complementary and Alternative Medicine, as I recall) and Trick or Treatment by Ezard Ernst and Simon Singh. Ezard Ernst is the world’s first professor of complementary medicine. I am not a health professional, but this was my take away from these two and the recent Ira Flatow interview with Ted Kaptchuk on NPR’s Science Friday:

    The placebo effect is real. When people take a pill that is a possible treatment, they report they feel better even from an inert pill. Perhaps even the ritual of knowingly taking an inert pill results in some patients reporting that they feel better. It’s not just pills that have this effect. Sham surgery has a placebo effect. People report they feel better after surgery, even though the surgery they received was a sham, not close to the real, intended-effective surgery. A placebo can elicit a physiologic response: a physical change in chemicals released to the blood stream is an example.

    Many studies of inert pills show the placebo effect, and the effect can be lesser or greater depending on many factors. Bigger inert pills have a greater placebo effect than smaller pills, unless the pill is a small green pill. The placebo effect is greater if the physician wears a white coat as opposed to wearing no coat. The placebo effect is even greater if the physician also drapes a stethoscope around his or her neck. Other ways a physician or caregivers interact with the patient affect the amount of placebo effect.

    Random Control Trials (RCTs) are conducted to see if a proposed new medicine or treatment has a greater effect than the placebo effect of a sham treatment. RCT’s are blinded (as best as possible) such that those interacting with the patient don’t know if a patient is receiving the sham (e.g. inert pill or a non-treatment). The patient also does not know or cannot detect, as best as possibly designed, if he received the sham or the real thing. (This is easy for pills and not so easy with other treatments.)

    The assumption of these trials is that all the other things that might have a placebo effect even out over many patients (e.g., how the patient views the interaction with the caregivers). The medicine or treatment “fails” if its effect is no greater than that of the sham administered in a RCT.

    RCTs have been conducted on homeopathic pills vs. inert pills and acupuncture vs. sham acupuncture, as examples. (It took two years to design the sham device that patients would judge as indistinguishable from acupuncture in one RCT.) All proper RCTs show homeopathic pills and acupuncture have no affect in physiologic healing or affect patients’ sense of lower pain or greater well-being. They are no better than their shams; they elicit the same placebo response as their shams; they are shams. They are not “alternative” treatments. I would think no physician recommends any sham as an alternative to a medicine or treatment shown to have a real medical benefit.

    Physicians should impart a placebo effect in their interactions with their patients. This should include a statement to a patient, something like this, “Patients report to me that they feel much better by taking the full course of this prescription or treatment.” And wear that white coat.

    My guess is that some physicians have patients who do not feel better from prescribed medicines or treatments and do not choose to say, “I’m doing everything I know to make you feel better, and it is not helping.” They don’t want to kill the patient’s hope (or lose a patient?). In cases where “feeling better” is the objective, I could envision that some physicians may be passive or even supportive about their patient’s use of non-medical, sham treatments: if the patient believes the treatment “works,” that belief will make them feel better. However, I have a hard time believing that “as many as 50% of physicians” knowingly prescribe inert pills or treatments known as not-medically-effective (shams).

  15. corazon says:

    Dr. Hall,

    Thank you for your comments.

    As a research scientist (M.S, Ph.D.) and a former drug discovery chemist (over a decade with major Pharma), medical treatments based upon unbiased, randomized double-blind placebo controlled studies is very important to furthering our understanding of how the body works and developing ordinary care for the mass population.

    I am also a Traditional Chinese Medicine practitioner and licensed acupuncturist. I am concerned with the dearth of these type of studies in this field and do agree that more scientific research needs to be done to account for “placebo effects” confounding treatment group results. The Society for Acupuncture Research http://www.acupunctureresearch.org/ is striving to work with scientists and clinicians to formulate good research studies that can help further our understanding of this important form of treatment.

    I also am a a skeptic. I find over 60% of my patients are taking pharmaceutical drugs for diagnoses where there are no randomized, double-blind placebo controlled studies backing up the treatment strategy and many times the FDA has not approved the drug for the specific application that the drug is being prescribed for. Many times drugs are given to negate side-effects of the initial drug profile. Frequently, the follow-up clinical testing has not been done to validate that the treatment has measurable efficacy. Is this good science? Certainly not-

    I would submit that if you are indeed worried about the scientific research and are a skeptic, we would see blogs examining and testing whether the “gold standard” of unbiased (non-Pharma sponsored), scientific research and testing, FDA approval have been done with respect to the use of the most common prescription medications, surgical procedures and knee-jerk ordinary care protocols in the allopathic community.

    As for the the Navy and their use of acupuncture in ameliorating PTSD, I would suggest you examine the science behind this further. The method the Navy is employing is based upon the NADA protocol using auricular acupuncture. Among many sources, the article in Medical Acupuncture (authors MDs) http://www.medicalacupuncture.com/aama_marf/journal/vol13_2/article1.html concludes that auricular acupuncture does show some effect in the brain as analyzed by FMri. As with most good research, this does raise more questions.
    I personally used this NADA protocol to treat victims of the Katrina and Haiti disasters for emotional trauma. While an FMri was not available and placebo effects not accounted for, the emotional pain and suffering of these patients was relieved.

    I would like to invite you and your skeptical colleagues to be a part of the positive dialogue to help examine and suggest means of studying the “placebo effect” and other unexplained beneficial health effects that have not yet been validated by the “gold standard” methods.

    Best-

    1. Harriet Hall says:

      @ corazon,
      There have been many articles on this blog addressing the evidence behind mainstream medical treatments, and anyway, that has nothing to do with the question of whether acupuncture is effective. It is a fallacious “tu quoque” argument.

      I have examined the evidence for acupuncture and so have a lot of good scientists and systematic reviews. Acupuncture certainly does “work” to relieve pain and suffering, but taken as a whole, the body of evidence is consistent with it being an elaborate placebo system. Studies like the MRI one you cite only show the placebo effect at work in the brain, not any specific effect of acupuncture. Placebos “work” but their place in medical practice is questionable, to say the least. And we are already “part of the positive dialogue” about placebos.

      Since you are yourself an acupuncturist, I suspect that you are subject to confirmation bias. As I pointed out, it is easy to find supporting articles in the literature, but it is harder to stand back and critically examine the whole.

      I suspect the victims of Katrina and Haiti would have benefited as much or more from counseling or from placebo treatments that didn’t involve sticking needles in their ears.

  16. WilliamLawrenceUtridge says:

    Wow, twice in one day. Corazon, have a look at my comment here. In particular, I suggest clicking on the two links. Also, if patients are taking drugs for off-label indications, that’s borderline bad. However, what is acupuncture indicated for? And more particularly, is it ever used for anything but those indications? Based on the reviews I’ve seen, the only conditions it’s considered to be demonstrated as “working” for are pain and nausea. I’ve seen no indication it “works” for PTSD. Please link to pubmed-indexed review articles or meta-analyses.

    If you do research on acupuncture, what sort, and how many variables do you control for? Among the issues that muddy acupuncture are:
    - do needles have to penetrate the skin?
    - if so, what depth?
    - do specific locations matter?
    - does the consultation, more specifically the TCM system used to select points, matter?
    - is there any reason to train people in the TCM concepts?
    - do different systems give different results?
    - what conditions?
    - do practitioner characteristics matter?

    And a personal question – do you believe qi exists? Do you believe acupuncture “manipulates” it?

    Consider these two scenarios for a patient with pain or nausea:
    1) The acupuncturist has spent four years training in TCM. The patient engages in a full TCM consutation using pulse and tongue diagnosis. The acupuncturist explains their findings in terms of the manipulation of qi through the needling of specific points located on specific meridians. They use needles that penetrate the skin up to a depth of several inches on various locations, including over the heart, liver and other internal organs.

    2) A physician has received eight hours of training on acupuncture, focusing on the importance of sterilization and safety. Their patient has a consultation involving measuring blood pressure, heart rate, skin tone, temperature and other conventional signs and symptoms. The doctor explains that acupuncture might help with their symptoms, noting they have tried it in the past and recommend it as a possible course of action along with conventional treatment – but patients in the past have had their symptoms reduced through acupuncture. They choose needling locations that are deliberately far from any organs, blood vessels or nerves, and use nonpenetrating needles that retract into the head.

    Assuming both these interventions get the same results, which should be used? Which is closer to your own practice?

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