Stimulated by Ko et al 2023.[1]
PPI – patient–practitioner interactions
key to acronyms
WM – Western medicine
CM – Chinese medicine
PoPS – principles of point selection
WMA – Western medical acupuncture
RI – Royal Institution (the place where they do the Christmas Lectures)
OA – osteoarthritis
NDI – Nepean Dyspepsia Index (Korean version used in this trial)
AI – artificial intelligence
I have been interested in the practitioner effect ever since a Norwegian colleague presented his data on acupuncture in menopausal hot flushes at a BMAS meeting held in the RI in 2008.[2,3] At some point during that day, he happened to comment to me that it was curious that there was a 3-fold difference in positive outcomes between two of the ten practitioners. Even more intriguing was that all three of his team, who were blind to the data at the time, guessed independently and correctly the identity of these outlying practitioners. I did a quick calculation of the likelihood of that happening by chance and came up with 1/90x90x90 ie 0.0000001.
The empathic female practitioner achieved a success rate of around 71% compared with the less empathic male practitioner who could only manage 22%. The other 8 practitioners ranged from 40% to 69% success.
Around the same time as this, Kaptchuk et al published in the BMJ on the effects of sham acupuncture in IBS with an augmented interaction compared with a limited one and a waiting list.[4] Patients reporting moderate or substantial improvement were 37% (augmented), 20% (limited), and 3% (waiting list). Subsequently, it became clear that that the difference between practitioners was twice as big as the difference between consultation style in this trial.[5]
A few years later, a trial on 221 patients with OA knee found that the senior paternalistic experienced male practitioner was over 3 times more effective in terms of mean pain relief than one of his junior colleagues.[6]
The highlighted trial is published in the journal Patient Education and Counselling, which is the journal of EACH: the International Association for Communication in Healthcare; and ACH: the Academy of Communication in Healthcare. The journal has been published since 2005 and has an impact factor of 3.5.
So, what does the latest research tell us? Well, this trial comes from Korea, and the results are rather different to those of Kaptchuk et al from 2008. 73 patients with functional dyspepsia were randomized to receive 8 sessions of real acupuncture over 4 weeks with either an augmented, patient-centred (Western-style) approach or a limited, disease-focussed (Eastern-style) approach. The acupuncture protocol was the same in both groups – 12 needles in 6 bilateral points: LI4, ST36, LR3, PC3, SP4, ST34.
The augmented approach was significantly worse in the primary outcome. Apparently, Korean patients do not expect warm, supportive relationships with physicians and consider it almost unrealistic in the present Korean medical setting.
The trial was rather small, and there was a difference at baseline in one of the subscales of the primary outcome (NDI frequency). Having said that, the difference between groups in the primary outcome (NDI sum) doubled from baseline to the end of treatment, and the difference was not only significant statistically, but also clinically relevant in the size of the effect.
What should we make of all this? It is a bit confusing. Whilst there are cultural differences between the East and the West, surely there are also marked individual differences between patients as well. No doubt the future AI practitioner will have consultation modes that can be selected based on patient preference.
Personally, I suspect that non-verbal communication is particularly important during the process of acupuncture treatment, but I have little to support that hunch at this stage.
References
1 Ko S-J, Kim K, Kaptchuk TJ, et al. Influence of patient-clinician relationship style on acupuncture outcomes in functional dyspepsia: A multi-site randomized controlled trial in Korea. Patient Educ Couns. 2023;121:108133.
2 Borud EK, Alraek T, White A, et al. The effect of TCM acupuncture on hot flushes among menopausal women (ACUFLASH) study: A study protocol of an ongoing multi-centre randomised controlled clinical trial. BMC Complement Altern Med. 2007;7:6.
3 Borud EK, Alraek T, White A, et al. The Acupuncture on Hot Flashes Among Menopausal Women study. Menopause. 2010;17:262–8.
4 Kaptchuk TJ, Kelley JM, Conboy LA, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ. 2008;336:999–1003.
5 Kelley JM, Lembo AJ, Ablon JS, et al. Patient and practitioner influences on the placebo effect in irritable bowel syndrome. Psychosom Med. 2009;71:789–97.
6 White P, Bishop FL, Prescott P, et al. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain. 2012;153:455–62.
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