MDs sceptical as BC gives stamp of approval to traditional Chinese medicine

When Henry Lu arrived in British Columbia from his native Taiwan in 1971, traditional Chinese medicine (TCM) was widely considered a form of quackery. Now, says Lu, principal of the 14-year-old International College of Traditional Chinese Medicine of Vancouver, the province boasts an estimated 600 TCM practitioners and even some Western-trained doctors are using acupuncture in their practices.

This summer, the BC government formally recognized this growing popularity; on June 21, it became the first in Canada to regulate the full range of TCM therapies. "By regulating traditional Chinese medicine, the provincial government recognizes it as an important and valued health option in our society," then BC Premier Glen Clark said in announcing the decision. He even suggested that TCM practitioners might soon be brought into the province's Medical Services Plan.

But critics say the move was based more on political considerations than medical considerations. "It's a case of willful blindness," says Dr. Lloyd Oppel, an assistant professor of clinical medicine at the University of British Columbia and acting president of Canadians for Rational Health Policy.1 This year-old lobby group is opposed to the adoption of alternative, scientifically unproven forms of medical treatment. Oppel says the province made no effort to evaluate the effectiveness of TCM and simply disregarded its superstitious underpinnings in an effort to curry favour among BC's large ethnic Chinese population. He argues that giving TCM the status of a health profession is a dangerous "leap of faith" that misleads the public.

TCM theory clearly contradicts accepted Western ideas concerning anatomy and physiology. According to Lu, TCM is a complete system of medicine, with its own methods of diagnosis and treatment. It is based on the belief that disease and illness are caused by blockages or imbalances in qi, a mysterious vital force found in all living things. In humans, says Lu, qi is believed to flow through 12 head-to-toe "meridians" or pathways, each linked to a particular organ.

Although TCM practitioners often make use of diagnoses made by medical doctors, they also examine the patient's tongue and take a pulse to develop an individualized course of treatment (TCM practitioners claim to be able to distinguish between 15 different kinds of pulse). TCM-style treatments include acupuncture, cupping (the placing of heated, inverted cups on the skin to draw out stagnant blood or qi), moxibustion (the burning of herbs above specific acupuncture points on the body), herbal medicine, massage and physical manipulation, and traditional exercise.

In BC, interest in TCM has been fuelled by recent immigration from China, where it is practised widely and officially endorsed. In the Greater Vancouver area alone there are now 300 000 ethnic Chinese residents, who account for one-sixth of the region's population. But a growing number of non-Chinese patients, many of them seeking relief from chronic ailments like arthritis, are also experimenting with acupuncture and Chinese herbal remedies.

To meet the burgeoning demand for TCM practitioners, the province now boasts 11 TCM schools. Lu's college alone has 175 full-time students, most of whom are enrolled in a 4-year certificate program that includes a 4- to 6-month practicum at a TCM hospital in China. Only a handful of Lu's students are of Chinese origin.

It's hard to dispute the need for regulation. Many TCM practices are inherently risky. Oppel, a former emergency room physician at the Peace Arch Hospital in White Rock, south of Vancouver, says he has personally treated patients who had burns caused by cupping and lungs punctured by improperly placed acupuncture needles. He suspects that the majority of such adverse effects, especially those related to long-term use of herbal medicines, go unrecognized and unreported.

In response to such concerns, BC had already moved to regulate acupuncture, the best-known and most commonly practised form of Chinese medicine. In 1996, acting on a recommendation from the provincial Health Professions Council (HPC), the BC Ministry of Health established a self-regulating College of Acupuncturists. But the college, charged with determining licensing requirements, was hobbled by internal disputes. In 1997, three TCM associations filed a joint application to the HPC asking that acupuncture instead be included among the responsibilities of a new, broader college of TCM. In July 1998, after a series of public hearings, the HPC agreed and forwarded its recommendation to the minister of health.

As a result of this summer's announcement, TCM will become a recognized health profession in BC. Only members of the new College of Traditional Chinese Medicine and Acupuncture Practitioners of BC will be allowed to practise acupuncture, make TCM-based diagnoses or prescribe Chinese herbal medicines determined to carry a high risk of harm. (Physicians and other health professionals may continue to provide TCM treatments if these fall within their accepted scope of practice.)

Over the next 3 years, the college's newly appointed 9-member Board of Directors will draw up bylaws establishing educational requirements and professional standards for TCM practitioners. The existing College of Acupuncturists will immediately begin licensing qualified acupuncturists before being wound down.

"Regulation can only be supported," says Dr. Morris van Andel, deputy registrar of the College of Physicians and Surgeons of BC. "There are a significant number of people who access alternative practitioners and they have the right to choose the treatment they want. But these practitioners should at least have to meet certain professional standards."

Still, TCM's new status worries many physicians. Some elements of TCM have demonstrated merit, and there is evidence that acupuncture, for example, might be a useful adjunct treatment for certain kinds of pain, drug-withdrawal symptoms and postchemotherapy nausea. But the province's decision to designate TCM a self-regulating health profession means that doctors and medical scientists will have little if any role to play in determining if and when TCM treatment is warranted.

According to Oppel, this gives TCM de facto status as a form of primary health care. In Alberta and Quebec, where acupuncture is regulated, patients must consult a medical doctor before seeking acupuncture treatment, and again if acupuncture doesn't alleviate their symptoms. But in BC, says Oppel, doctors could be "left out of the loop" entirely. Although self-regulation will reduce the number of complications associated with untrained or unqualified practitioners, it also suggests that provincial health authorities have concluded that TCM works. This may increase the danger that patients will delay seeking appropriate or effective medical care.

The HPC, notes Oppel, made no effort to evaluate the effectiveness of TCM treatment or to identify what types of medical conditions TCM practitioners could diagnose reliably. HPC officials confirm that they focused only on the narrower question of whether the establishment of a licensing system would reduce risks to the public posed by unqualified practitioners. But James Knights, a Victoria-area TCM practitioner and president of the Association of Traditional Chinese Medicine of British Columbia, dismisses suggestions that TCM should be subjected to scientific scrutiny. He maintains that it has already proven its value through 5000 years of clinical experience.

Knights says medical doctors should simply respect the professional judgement of qualified TCM practitioners, even if their methods seem alien. He thinks establishment of the new college will hasten this process. "TCM practitioners understand their limitations," Knights argues. "Western medicine is better suited to dealing with acute health problems. We advise patients to seek Western medical treatment when required."

He says TCM's new professional status should encourage Western-trained doctors to reciprocate and refer patients with chronic ailments better treated by TCM to these practitioners.

But this will likely be a more trouble-prone relationship than Knights suggests. The BC college had opposed TCM's designation as a health profession precisely because of the lack of scientific evidence for the efficacy of TCM treatment and concerns about the appropriateness of TCM training based on metaphysical principles such as qi. It is now drawing up a draft policy to guide doctors through the ethical problems associated with TCM and other alternative treatments. "It's OK to recommend these therapies if you've tried everything else and it's for the patient's psychological comfort," says Oppel. "But we also have to be honest. We need to tell patients there is no proof these therapies will work and that they may not be safe."