All posts by drmorris

Thoughts on Ernst’s Review of Reviews: Acupuncture and Pain

Politics of Evidence

Curious, I read the Pain® journal article by Edzard Ernst et al: Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews (1). Their conclusion: “Although acupuncture is commonly used for pain control, doubts about its effectiveness and safety remain.” And, that, “Acupuncture remains associated with serious adverse effects. One might argue that, in view of the popularity of acupuncture, the number of serious adverse effects is minute. We would counter, however, that even one avoidable adverse event is one too many.”

The reviewed data were collected internationally and represent ten years of studies, identifying only 38 cases of infection, 42 traumas, 13 adverse effects and five deaths claimed to be related to acupuncture. Ernst et al. listed 165 references. 32 seemed to be systematic reviews. Most are anecdotal case reports of complications. There were 17 negative reviews between 1989-2000 and 57 positive later reviews.

 Safety in Medicine

Ernst et al. did not examine iatrogenic deaths due to conventional drugs, chemotherapy, radiotherapy and surgery. They focused on the safety and efficacy of acupuncture. Ernst is chair of Complimentary and Alternative Medicine at Exiter, so while it would be interesting to see results an in-depth ‘review of reviews’ on the safety and efficacy of conventional medicine and surgery, that is not likely the scope and mission of the department.

Consider the 41,000 ulcers and 3,300 deaths caused by nonsteroidal anti-inflammatory drugs in one year (2). Also, the 16,000 injuries from auto crashes each year connected with psychoactive drugs such as benzodiazepines and tricyclic antidepressants (3). The magnitude of drug related deaths internationally over a 10-year period, while not their topic, would provide context. This is not tu quoque – erroneous logic, based upon the argument that: “If you did it, so can I”. Rather, I concur that avoidable injuries and death are unacceptable.

To their credit Ernst et al. recommend, “The key to making progress would be to train all acupuncturists to a high level of competency.” Ernst et al. called it malpractice rather than any real risk of acupuncture. I couldn’t agree more. Abbreviated acupuncture programs pose a risk to the patient and to society.

Rogers reached a similar conclusion 30 years earlier, “It is shown that serious complications can arise only from the improper use of acupuncture or from its gross abuse by incompetent practitioners. The safety of a technique must be judged on its results in the hands of competent practitioners who use it properly. If this criterion is accepted, acupuncture is seen as an extremely safe therapeutic system whose complications are very rare and are easily avoided or rectified(4).

The Science

Ernst et al. do not reference previous studies showing acupuncture as safe. Take for instance, the 2003 article by Brian Berman and Lixing Lao, Is Acupuncture Safe a Systematic Review of Case Reports (5). That article clearly demonstrates that acupuncture is a safe practice.  Further, Edzard doesn’t identify other complications such as fainting, vomiting or bruising, which are the more common side effects seen with this intervention. More importantly, the number of adverse events per treatment is not stated. In order to assess risk, one must know the number of times acupuncture was performed during the studies. Edzard does not provide the number of patients, treatments, or needles inserted. Without that, no conclusion can be drawn on safety.

The methods section also is weak and lacking in detail. For data on efficacy, he doesn’t provide information about how the studies were controlled. Was it acupuncture alone, skin penetrating, non-penetrating or adjacent to the point location? I don’t see any of that here. It leaves the reader wanting to know more about the studies that he used.

In systematic reviews, there is also a danger of pulling information without getting the context of the meaning. These authors seem to pull sentences, describing study findings, out of the larger context of the reviews. Further, lack of detail as to how Ernst et al. quantified the quality of the studies brings into question the validity of their conclusion.

Ernst et al. continue: “In many of the case reports, causality was uncertain… not least because of a lack of sufficient detail. Yet, most of the authors seemed confident about causality.” It is not clear how a conclusion can be drawn from conflicted propositions such as these.

The field has standards such as STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) (9).  Further, a new tool has been developed by Hammerschlag et al. that assesses reporting quality and combines STRICTA and CONSORT (Consolidated Standards of Reporting Trials) (10). Enrnst et al. have cast the net wide and have included an impressive number of citations. It would be useful to have them more focused in terms of time frames and qualifications.

In Closing

It appears that Ernst et al. do not provide a secure theoretical or evidential basis for their argument, and have used analytical tools inadequate to achieve objective and reliable conclusions. Their argument relies heavily on preconceptions, variable definitions and opinion, a problem exacerbated by a tendency to confirmation bias on the authors’ part. In their attempt to link acupuncture to adverse events, they included hearsay and unverified data (“most of the authors seemed confident about causality”). Pain can be treated effectively with acupuncture and at a lower cost of care.

Conclusion? Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews: Are the papers conclusions valid? There remains serious question given the inconsistencies in the document. We must as the question, what is the objective for Pain®, regarded as a prestigious and impartial journal, in publishing this article.

1.           Ernst E, Myeong SL, Choi TY. Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. PAIN®. 2011;152(4).

2.           Ray WA GM, Shorr RI. Adverse drug reactions and the elderly. Health Affairs 1990;9:114-22.

3.           Ray WA FR, Decker MD. Psychoactive drugs and the risk of injurious motor vehicle crashes in elderly drivers.  . American Journal of Epidemiology. 1992;136:873-83.

4.           Rogers P. Serious Complications of Acupuncture … Or Acupuncture Abuses? (An edited version of the original in the American Journal of Acupuncture Oct-Dec 1981: 9(4); 347-351). 1998.

5.           Lao L HG, Fu J, Berman BM. Is acupuncture safe? A systematic review of case reports. Altern Ther Health Med 2003. 2003;9(1):72-83.

6.           H. M. Langevin PMW, H. MacPherson, R. Schnyer, R. M. Milley VN, L. Lao, J. Park, R. E. Harris,, M. Cohen KJS, A. Haramati, and R. Hammerschlag. Paradoxes in Acupuncture Research: Strategies for Moving Forward. Evidence-Based Complementary and Alternative Medicine. 2011.

7.           Kaptchuk TJ, Shaw J, Kerr CE, Conboy LA, Kelley JM, Csordas TJ, et al. “Maybe I made up the whole thing”: placebos and patients’ experiences in a randomized controlled trial. Cult Med Psychiatry. 2009 Sep;33(3):382-411.

8.           Janssens L, Altman S, Rogers P. Respiratory and cardiac arrest under general anaesthesia: treatment by AP of the nasal philtrum. Vet Rec Sep 22 1979;105(12):273-6.

9.           Hugh MacPherson AW, Mike Cummings, Kim Jobst, Ken Rose, Richard Niemtzow, for the STRICTA Group*. Standards for Reporting Interventions in Controlled Trials of Acupuncture: The STRICTA Recommendations. Acupuncture in Medicine. 2002 March 2002;VOL 20(1):Page 22 – 5.

10.         Hammerschlag R, Milley R, Colbert A, Weih J, Yohalem-Ilsley B, Mist S, et al. Randomized Controlled Trials of Acupuncture (1997–2007): An Assessment of Reporting Quality with a CONSORT- and STRICTA-Based Instrument. Evidence-Based Complementary and Alternative Medicine. 2011:25.

 

 

Monoculture Culture of the Mind, a Way Out:

 Knowledge Building through Cases

 

The case as tool for knowledge development sustains primacy if considered as a longitudinal series of data. In Monocultures of the Mind, I established history and advantages of the case in what might be called ‘local knowledge’ – that is, direct clinical experience of master practitioners. Here, the discussion on cases continues!

The field has resources for managing and developing cases. The editors of the journal Global Advances in Health and Medicine have provided, under “For Authors,” a template that can be downloaded for case presentation. This template has been vetted across various portions of the healthcare community and can serve as a starting point for case reporting in all master and doctoral programs within the field.

In this article, the matter of case Based Learning is addressed. When I attended a master’s degree program in medical education at USC, we interviewed Luann Wilkerson who initiated Harvards New Horizons program – one of the first case based approaches to medical education. This set the stage for me.

Case-Based Learning

Case-based learning (CBL) is an approach that challenges learners to learn through engagement in real problems. Adult learners expect a foundation of critical thought and context. This expectation is that learners build their knowledge by combining previous knowledge with current knowledge 1. The teacher serves in the role of facilitator.

Contrary to an expert speaking each piece of information, the case study provides the learner a context for developing problem-solving skills. Further, small group case-based learning encourages collaboration and cultural competencies now expected by members of society for practitioners of medical disciplines 4,5.

A time-honored tradition in Chinese medicine, case-based teaching offers a tool for conveying expert knowledge in service to medical education. Case studies make available the insight, thoughts and methods of expert practitioners by capturing their views on practical applications and theoretical framework. This form of knowledge provides a foundation for the transmission from generation to generation in literary form.

At each level of learning, case narratives provide physicians with tools to communicate their knowledge about patients, their medical problems and the interventions. More than storage-retrieval devices, formative discourse of the case shapes the reflections, thoughts, talk and actions of learners and their teachers. Further, reform of the medical record is central to the improvement of medical education, patient care and clinical research 6.

 

One type of case-based teaching, called ‘problem-based learning’ (PBL), reveals information in stages and at critical moments in the development of the case. The problem-based learning model requires extensive faculty and economic resources in comparison to the more minimal case-based learning presentation model. There are several distinct features that define the PBL approach 7:

 

  • Real tasks, issues, and problems provide a context for the learning experience.
  • PBL learning is an ‘emergent’ learning process as faculty and learners are involved in a participatory and co-operative model for learning, planning, production, and evaluation while designing, implementing, and refining the curricula.
  • The PBL approach is grounded in academic research on learning 8.
  • PBL can be used to demonstrate competencies relative to life-long learning since it can be used to stimulate learners to take responsibility for their own learning. The faculty members typically facilitate and there are few lectures and less structure of content.
  • PBL also provides a tool for collaborative care competencies among learners, stresses the development of problem solving skills within the context of professional practice, promotes effective reasoning and self-directed learning, and is aimed at increasing motivation for life-long learning.

 

Case-based and problem-based learning methods are not without detractors. There are studies showing that active problem solving for junior learners is less effective than studying examples that experts have already solved 9,10. Active problem solving tends to be better suited to senior learners who have memorized the vocabularies of practice. Thus, the case vignette is often more suited to early learners while active problem solving is more relevant in later portions of a program. Many of the PBL strengths are shared in case-based learning.

 

Case presentation can be used throughout a range of teaching methods; for example, case vignettes can be used during a lecture to highlight experience. Cases also provide seeds for rich critical thought-based dialogues within small groups. The dynamics can be shifted so that the learner presents the case. The latter method can be used to demonstrate summative assessment of competencies at important milestones within a program.

 

“Cases stimulate the imagination, open up possibilities, provoke us, and perhaps disturb us. They fill in the gaps left by powerful generalizations, reminding us that every illness is unique in the same way,” opines Ian R. McWhinney who believes case studies have played an important part in the annals of Western medical practice—as can be seem in Edward Jenner’s case reports on his discovery of the small pox vaccination 12.

 

Case Study as Program Evaluation Tool

Portfolios are increasing as a valuable evaluation tool for medical education. The Accreditation Council for Graduate Medical Education (ACGME) supports the development of the portfolio as a “web-based professional development tool for residents to record, organize, reflect on, and seek feedback on their learning experiences.” The expectation is that the methods will become an integral portion of the next accreditation cycle for ACGME 13.

Cases are commonly used artifacts in the portfolio presentation. There are several reasons for this. The case is an excellent tool for summative evaluation of program level competencies. This is partly due to the ability of program leaders to use the case to assess competencies across the curriculum. The well-constructed case may be suitable for publication and can be used for promoting the professional development of the learner. Such works in publication reflect well upon the program.

Conclusion

Cases provide access to knowledge that is connected to its origins. Exploring cases highlights the thought of significant physicians throughout the literate history of Chinese medicine. The value of local knowledge over general knowledge is realized through the case, in particular the essence of expertise.

 

 

 

  1.             Holtorf CJ. Radical Constructivism: Knowing Beyond Epistemology 2000-2007. https://tspace.library.utoronto.ca/citd/holtorf/3.8.html. Accessed September 22, 2008.
  2.             Piaget J. The Moral Judgment of the Child. 1997 ed. New York: Simon and Shcuster; 1997.
  3.             von Glasersfeld E. Constructivism in Education. In: Husen T, Postlethwaite TN, eds. International Encyclopedia of Education. Vol 1. Oxford/New York, NY: Pergamon Press; 1989:162-163.
  4.             Education ACfGM. The ACGME Learning Portfolio. 2012; http://www.acgme.org/acWebsite/portfolio/learn_alp_welcome.asp, 2012.
  5.           Benjamin Kligler M, MPH, Victoria Maizes, MD, Steven Schachter, MD, Constance M. Park, MD, PhD,, Tracy Gaudet M, Rita Benn, PhD, Roberta Lee, MD, and Rachel Naomi Remen, MD. Core Competencies in Integrative Medicine for Medical School Curricula: A Proposal. Academic Medicine. June 2004;79(6).
  6.             Donnelly WJ. The Language of Medical Case Histories. Annals of Internal Medicine. December 1, 1997 1997;127(11):1045-1048.
  7.             Barrows HSI. Problem-based Learning in Medicine and Beyond: A Brief Overview. In: Wilkerson L, Gijselaers WH, eds. New Directions for Teaching and Learning. Bringing Problem-based Learning to Higher Education: Theory and Practice. Vol 68. San Francisco, CA: Jossey-Bass; 1996:3-13.
  8.             Hmelo-Silver CE. Problem-based Learning: What and How Do Students Learn? Educational Psychology Review. 2004;16(3):235-266.
  9.             Sweller J. The Worked Example Effect and Human Cognition. Learning and Instruction. 2006;16(2):165-169.
  10.          Sweller J. Cognitive Load During Problem Solving: Effects on Learning. Cognitive Science. 1988;12(2):257-258.
  11.         Mezirow J. Transformative Dimensions of Adult Learning. San Francisco, CA: Jossey-Bass; 1991.
  12.          Fisk D. Dr. Jenner of Berkeley. London: Wm. Heinemann; 1959.
  13.          (ACGME) ACfGME. The ACGME Learning Portfolio. 2012; http://www.acgme.org/acWebsite/portfolio/learn_alp_welcome.asp, 2012.

 

 

Monoculture Culture of the Mind, a Way Out: Knowledge Building through Cases

Research, Acupuncture, Herbal Medicine, Pulse Diagnosis

The case as tool for knowledge development sustains primacy if considered as a longitudinal series of data. In Monocultures of the Mind, I established history and advantages of the case in what might be called ‘local knowledge’ – that is, direct clinical experience of master practitioners. Here, the discussion on cases continues!

The field has resources for managing and developing cases. The editors of the journal Global Advances in Health and Medicine have provided, under “For Authors,” a template that can be downloaded for case presentation. This template has been vetted ass various portions of the healthcare community and can serve as a starting point for case reporting in all master and doctoral programs within the field.

In this article, the matter of case Based Learning is addressed. When I attended a master’s degree program in medical education at USC, we interviewed Luann Wilkerson who initiated Harvards New Horizons program – one of the first case based approaches to medical education. This set the stage for me.

Case-Based Learning

Case-based learning (CBL) is an approach that challenges learners to learn through engagement in real problems. Adult learners expect a foundation of critical thought and context. This expectation is that learners build their knowledge by combining previous knowledge with current knowledge 1. The teacher serves in the role of facilitator.

Contrary to an expert speaking each piece of information, the case study provides the learner a context for developing problem-solving skills. Further, small group case-based learning encourages collaboration and cultural competencies now expected by members of society for practitioners of medical disciplines 4,5.

A time-honored tradition in Chinese medicine, case-based teaching offers a tool for conveying expert knowledge in service to medical education. Case studies make available the insight, thoughts and methods of expert practitioners by capturing their views on practical applications and theoretical framework. This form of knowledge provides a foundation for the transmission from generation to generation in literary form.

At each level of learning, case narratives provide physicians with tools to communicate their knowledge about patients, their medical problems and the interventions. More than storage-retrieval devices, formative discourse of the case shapes the reflections, thoughts, talk and actions of learners and their teachers. Further, reform of the medical record is central to the improvement of medical education, patient care and clinical research 6.

 

One type of case-based teaching, called ‘problem-based learning’ (PBL), reveals information in stages and at critical moments in the development of the case. The problem-based learning model requires extensive faculty and economic resources in comparison to the more minimal case-based learning presentation model. There are several distinct features that define the PBL approach 7:

  • Real tasks, issues, and problems provide a context for the learning experience.
  • PBL learning is an ‘emergent’ learning process as faculty and learners are involved in a participatory and co-operative model for learning, planning, production, and evaluation while designing, implementing, and refining the curricula.
  • The PBL approach is grounded in academic research on learning 8.
  • PBL can be used to demonstrate competencies relative to life-long learning since it can be used to stimulate learners to take responsibility for their own learning. The faculty members typically facilitate and there are few lectures and less structure of content.
  • PBL also provides a tool for collaborative care competencies among learners, stresses the development of problem solving skills within the context of professional practice, promotes effective reasoning and self-directed learning, and is aimed at increasing motivation for life-long learning.

Case-based and problem-based learning methods are not without detractors. There are studies showing that active problem solving for junior learners is less effective than studying examples that experts have already solved 9,10. Active problem solving tends to be better suited to senior learners who have memorized the vocabularies of practice. Thus, the case vignette is often more suited to early learners while active problem solving is more relevant in later portions of a program. Many of the PBL strengths are shared in case-based learning.

Case presentation can be used throughout a range of teaching methods; for example, case vignettes can be used during a lecture to highlight experience. Cases also provide seeds for rich critical thought-based dialogues within small groups. The dynamics can be shifted so that the learner presents the case. The latter method can be used to demonstrate summative assessment of competencies at important milestones within a program.

 

“Cases stimulate the imagination, open up possibilities, provoke us, and perhaps disturb us. They fill in the gaps left by powerful generalizations, reminding us that every illness is unique in the same way,” opines Ian R. McWhinney who believes case studies have played an important part in the annals of Western medical practice—as can be seem in Edward Jenner’s case reports on his discovery of the small pox vaccination 12.

 

Case Study as Program Evaluation Tool

Portfolios are increasing as a valuable evaluation tool for medical education. The Accreditation Council for Graduate Medical Education (ACGME) supports the development of the portfolio as a “web-based professional development tool for residents to record, organize, reflect on, and seek feedback on their learning experiences.” The expectation is that the methods will become an integral portion of the next accreditation cycle for ACGME 13.

Cases are commonly used artifacts in the portfolio presentation. There are several reasons for this. The case is an excellent tool for summative evaluation of program level competencies. This is partly due to the ability of program leaders to use the case to assess competencies across the curriculum. The well-constructed case may be suitable for publication and can be used for promoting the professional development of the learner. Such works in publication reflect well upon the program.

Conclusion

Cases provide access to knowledge that is connected to its origins. Exploring cases highlights the thought of significant physicians throughout the literate history of Chinese medicine. The value of local knowledge over general knowledge is realized through the case, in particular the essence of expertise.

 

 

  1.            Holtorf CJ. Radical Constructivism: Knowing Beyond Epistemology 2000-2007. https://tspace.library.utoronto.ca/citd/holtorf/3.8.html. Accessed September 22, 2008.
  2.             Piaget J. The Moral Judgment of the Child. 1997 ed. New York: Simon and Shcuster; 1997.
  3.             von Glasersfeld E. Constructivism in Education. In: Husen T, Postlethwaite TN, eds. International Encyclopedia of Education. Vol 1. Oxford/New York, NY: Pergamon Press; 1989:162-163.
  4.             Education ACfGM. The ACGME Learning Portfolio. 2012; http://www.acgme.org/acWebsite/portfolio/learn_alp_welcome.asp, 2012.
  5.           Benjamin Kligler M, MPH, Victoria Maizes, MD, Steven Schachter, MD, Constance M. Park, MD, PhD,, Tracy Gaudet M, Rita Benn, PhD, Roberta Lee, MD, and Rachel Naomi Remen, MD. Core Competencies in                    Integrative Medicine for Medical School Curricula: A Proposal. Academic Medicine. June 2004;79(6).
  6.             Donnelly WJ. The Language of Medical Case Histories. Annals of Internal Medicine. December 1, 1997 1997;127(11):1045-1048.
  7.             Barrows HSI. Problem-based Learning in Medicine and Beyond: A Brief Overview. In: Wilkerson L, Gijselaers WH, eds. New Directions for Teaching and Learning. Bringing Problem-based Learning to Higher Education: Theory and Practice. Vol 68. San Francisco, CA: Jossey-Bass; 1996:3-13.
  8.             Hmelo-Silver CE. Problem-based Learning: What and How Do Students Learn? Educational Psychology Review. 2004;16(3):235-266.
  9.             Sweller J. The Worked Example Effect and Human Cognition. Learning and Instruction. 2006;16(2):165-169.
  10.          Sweller J. Cognitive Load During Problem Solving: Effects on Learning. Cognitive Science. 1988;12(2):257-258.
  11.         Mezirow J. Transformative Dimensions of Adult Learning. San Francisco, CA: Jossey-Bass; 1991.
  12.          Fisk D. Dr. Jenner of Berkeley. London: Wm. Heinemann; 1959.
  13.          (ACGME) ACfGME. The ACGME Learning Portfolio. 2012; http://www.acgme.org/acWebsite/portfolio/learn_alp_welcome.asp, 2012.