Introduction

Even though there is room for more thorough adverse effect reporting in acupuncture trials and a need for more studies about acupuncture safety (Ng et al. 2016; Turner at al. 2011), there already exists evidence concerning the safety of acupuncture. Based on the studies (Witt et al. 2009; Kim et al. 2016; McCulloch et al. 2015; Park et al. 2014; Houzé et al. 2017), we can conclude that generally acupuncture can be seen as a relatively safe practice. The adverse effects from acupuncture are extremely rare compared to reported adverse effects from conventional medicine. The FDA Adverse Event Reporting System (FAERS) Public Dashboard reveals 906,773 serious side effect reports and 164,154 deaths from side effects or malpractice in 2017 alone. This is an unfair comparison as the patient base and seriousness of the conditions treated are often very different, but it gives us a perspective to the safety of acupuncture in comparison with many other medical treatments. And even the most serious side effects like pneumothorax from acupuncture seem to be preventable with sufficient training in acupuncture education (Kim et al. 2016).

In the acupuncture studies about patient safety, the subject has been approached from the point of safety of the treatment itself. There seems to be a lack of studies about the possibility of delayed medical treatment in cancer or other severe medical conditions due to the use of acupuncture. This essay approaches the subject with reflection on a patient case.

Case background

The author first met the patient in 2011. The patient had suffered from recurring, almost constant uveitis for 15 years. Known causes of uveitis had been previously excluded by medical doctors. The only treatment offered to the patient was ophthalmic steroids. Prolonged use of the steroids had increased her intraocular pressure causing glaucoma that threatened her diminishing vision. The ophthalmologist wanted to start a more robust and constant medication for glaucoma with a drug having the side effect of flaring of uveitis. The patient wanted to try acupuncture as an alternative.

After five sessions of acupuncture, the symptoms of uveitis had clearly decreased and she had reduced the use of corticosteroids. She had permission from the ophthalmologist to dose corticosteroids based on need. During the following months, she used them only twice when she felt any peculiar feelings in her eyes. Five months later she visited her ophthalmologist who could not see any signs of uveitis. Due to increased intraocular pressure, they had agreed for regular follow-ups. Beside one occasion in 2012, she has been without corticosteroids and free from uveitis.

In addition to uveitis, she had a medical history of back and joint pains, and Ménière’s disease.

During her initial visits to author’s clinic, she expressed her growing frustration with medicine and how she felt like a test subject. The doctors could not give a reason for her symptoms, and to her it seemed illogical to use medication causing uveitis to treat problems caused by the medication for uveitis. She also felt that some doctors she had met had been unprofessional in their behaviour. Side effects and dissatisfaction to conventional health care are among common reasons for trying acupuncture (Jakes et al., 2014).

Radical change in patient’s health

In 2015, the patient wanted to try acupuncture for fatigue. She had already visited a medical doctor through occupational health care who didn’t find anything alarming. The author performed acupuncture based partly on her previous background information and her current symptoms. Afterwards, she reported a slight initial improvement, but the exhaustion soon returned and was non-responsive to further attempts with acupuncture.

After a third acupuncture treatment she caught a flu and visited another doctor who took a chest X-ray that revealed a cancerous growth in her lungs. The patient was treated with surgical removal of the tumour. Because of inappropriate joking by the operating doctor just before the surgery, she felt mistreated again even though the surgery was successful. Soon after the surgery she contracted pneumonia. During follow-ups later on, her papers were not read properly leading to surgical marks visible in the X-ray to be mistaken as a sign of pulmonary embolism. Two months of unnecessary subcutaneous injections added to her mistrust of the whole medical profession even though the surgery itself had been successful.

During these events the patient contacted the author and told him about the correct diagnosis. She didn’t blame the author for misdiagnosis. But for the author this caused concerns and a need for reflection. How could something this serious be missed even when the cancer was advanced enough to cause serious fatigue? Could this be prevented from happening again?

Meeting in 2017

In 2017, the patient reserved time from the author because of vertigo caused by Ménière’s disease. The prescribed medication was no longer effective. During the meeting she gave a detailed account of her experience with surgery and how she felt afterwards. She was angry and frustrated and said she had little faith left for the health care system even though she had been saved by the medical procedure. During the session she gave permission for using her case as a case study. After giving the permission, she was told that the treatments would be free of charge.

Meeting her after the incident produced conflicting thoughts. Because of her past, the current condition felt more alarming. Why did her medication suddenly stop working? Was the dizziness caused by Ménière’s disease, a simple benign positional vertigo or was it something more severe? What if this was somehow connected to her previous condition? There was also curiosity and a need to ask questions about her previous health concerns that might shed some light to the author’s wrong diagnosis.

She had already seen her physician to screen out anything serious but still the situation stirred some insecurity in the author. During the discussion and diagnosis she revealed that she had recently lost her job and was now unemployed. So she was particularly happy to receive free treatments. Lack of money combined with free treatments might also increase the possibility of an already vulnerable patient to feel more dependent on the acupuncturist or it could produce a feeling of groundless gratitude. Having less money might also mean that she might be less willing to see a doctor in case the acupuncture treatment did not work, especially with her experiences with the public health care.

While describing her experiences and expressing her mistrust with the medical profession, she didn’t seem to consider the author to be part of the medical profession. In Finland, the author is a registered health care professional due to being a licensed masseur, but an acupuncturist is not an accepted health care professional nor is there any legal regulation about the profession. The professional associations are working to self-regulate the field, set educational criteria, enforce the following of ethical guidelines, and ensure that the professionals have proper insurances.

For the author, it was important to meet the patient face to face after making a wrong diagnosis. There were no signs of blaming or mistrust from the patient. Her patient records had been reviewed in 2015 and again before the appointment. There was no evidence of neglecting of symptoms, and she had already visited a medical doctor beforehand. It was crucial for the improvement of practice for the author to become more aware of possible consequences. It made the author question his own responsibilities and also the boundaries of his practice.

Analysing the case

During 2015, the author had failed to recognize lung cancer. The examination and questions asked during the visit could have been more thorough. Owing to the fact that the patient was previously known, there was a possibility of using information gathered during earlier visits. This combined with the shorter time reserved for returning patients might have made it harder to be cautious enough. The TCM diagnosis based on the discussion, pulse, and tongue during the visit revealed what is known in Chinese medicine as a deficiency of blood and a weakness of lung qi. Relying on the patient history while formulating a picture of the current situation might have affected the understanding of the real reason for exhaustion and how serious her case was. The medical expertise of the author did not enable him to recognise the underlying reason. A similar mistake was probably made by the medical doctor in occupational health care who failed to see cause for further tests. Given the patient’s earlier bad experiences with health care, she probably might not easily go back for a second opinion. In this case, it was pure luck that the patient caught the flu and was sent to x-ray.

The seriousness of the situation also raises other concerns. What if the patient had gotten better results from the acupuncture treatment? In that case, could the better results have delayed a proper diagnosis and medical treatment? And what role does the therapeutic relationship play in a possible delay of proper treatment?

There exists some evidence that acupuncture is effective in treating cancer-related fatigue (Duong et al. 2017; Zhang et al. 2018; Zick et al. 2016). These studies focus on fatigue in connection with conventional cancer treatments, but acupuncture might also diminish the fatigue caused by cancer itself. Definite scientific evidence for the effectiveness of acupuncture for cancer pain is still lacking (Wu et al. 2015), but there is reason to believe that acupuncture might provide some relief from cancer pain (Hu et al. 2016; Chiu et al. 2017). So there is a possibility that acupuncture might prolong the time before the patient goes to see a doctor. An acupuncturist might see diminished fatigue and/or pain as evidence of successful treatment, which might in reality delay proper medical treatment. However, in case of pain, the same could easily happen with self-administered and commonly available pain killers. The fatigue might also diminish with energy drinks (Warnock et al. 2017), but the effects wouldn’t probably last for long. However, it could also be possible that by visiting an acupuncturist frequently, the acupuncturist could notice if there was no response to treatment or that the results were not as long-lasting as they should be. At least the acupuncturist would notice if the condition of the patient seemed to deteriorate despite the treatments. This could easily alarm a professional acupuncturist so, in this way, the acupuncturist would provide an extra pair of eyes watching for the patient’s health. In Finland, the acupuncture associations require the signing of ethical conduct which states that all acupuncturists refer cases to medical doctors when medical treatment is needed.

A study by Shorofi and Arbon (2017) offered some reasons why patients are opting to use CAM therapies instead of medical therapies. In the study, in all the people opting for CAM therapies, the most relevant reasons for this case study were that the problem was not seen serious enough to see a doctor (21.4%), a belief that these alternative treatments have fewer side effects than conventional ones (16.9%), and dissatisfaction with conventional treatments (6.8%). Combining these percentages with those of people who felt that CAM therapies were more fitting to their personal lifestyle or philosophy (37.7%), there is some evidence of a group of people who might not prefer to see a medical doctor in the first place. The study was done among hospitalised patients in Australia, but the author is in agreement over these patient groups and confirms similar numbers based on his own patient records and experience.

In serious diseases, like cancer in this case, medical diagnosis and intervention as early as possible is paramount. The symptoms, however, can begin with only minor health complaints. The 21.4% of population who use complementary modalities consider their problems not serious enough (Shorofi and Arbon 2017), but they might still find their way to the acupuncturist who, with adequate training, could be able to recognise the severity of the symptoms and could advise the patient to see a doctor.

The example patient in this essay had a medical diagnosis from her ophthalmologist for her previous condition. But in Finnish acupuncture clinics, it is very common to meet patients with medically unexplained physical symptoms (MUPS). These patients do not have a diagnosis and often feel that in conventional medical care they are misunderstood and their symptoms are not always taken seriously (Lipsitt et al. 2015). This same patient group generally obtains poor clinical outcomes from medical practice (Lipsitt et al. 2015), which might lead them to further avoid medical doctors. Some of these patients might feel more understood by CAM practitioners in general. Depending on the type of therapy, this could partly be due to the duration of initial interview and time used during the treatment, or more cosy clinical settings. It might be the CAM practitioner who first notices that their symptoms start to change or become worse, signalling that there might be a need to see a doctor. However, if the CAM therapist fails to see the alarming signs, the patient might get non-optimal treatment and believe that he gets all the treatment he needs. This could be preventable with proper education and further cooperation with medical doctors.

An even more alarming group than the MUPS patients who often burden health care with their constant visits (Lipsitt et al. 2015), are those who feel very dissatisfied with their medical care and are avoiding seeing doctors. This group is easily left without treatment by their own choice. Some of these patients might still be willing to see an acupuncturist. In that case, more serious and easily recognised problems might become apparent and they could be referred to health care, if they can be persuaded to make an appointment. Within these patient groups, there are people who feel vulnerable and, sometimes, they do not know where they should go and which symptoms they should tell their doctors. In their case, even one bad experience with a medical doctor can lead to further aversion of medical procedures and tests. For them an acupuncturist might be seen as a neutral bridge for communication to conventional health care.

CAM modalities are also often selected because of recommendations or wanting self-control over an illness (Shorofi and Arbon 2017). Many patients from the group who feel CAM therapies are more fitting to their personal way of life may not easily visit a doctor for any minor complaints. Based on the author’s experience, the people from these groups are generally willing to see a doctor when faced with any serious conditions or when told so by an acupuncturist. The problem for these patients is to recognise what is relevant and what is serious enough. Those seeing an acupuncturist with at least a basic education of medicine, could then be told by the acupuncturist to see a doctor if needed.

Conclusions

The failure to recognise lung cancer by the author and by a medical doctor in occupational health care was a human error. The proper acupuncture studies in Finland include a minimum of 14 to 30 ECTS of medicine, depending on the year of graduation, and lung cancer is one of the most difficult forms of cancer to diagnose even for general practitioners (Rankin et al. 2017). Mistakes can happen for any medical professional and CAM practitioner alike, but delays in treatment can lead to disease progression and missed opportunities for cure in a significant subset of patients (Rankin et al. 2017). In conventional care, it is customary to refer the patient to a specialist for diagnosis in case the general practitioner suspects cancer or another more serious disease. A similar attitude is crucial for patient safety among all CAM modalities. Wide cooperation with medical doctors would ensure patient safety and could also encourage some vulnerable patient groups to visit a doctor in time. It might also provide a bridge for communication to patients with MUPS or other patient groups who may feel more understood by CAM practitioners.

Based on these reflections, the author claims that there exists a possibility for certain groups of people to be left without early recognition of serious diseases in conventional health care and in clinics offering CAM modalities. In developed Western countries, most patients already go to a medical doctor in case they suspect anything serious. Those coming to see an acupuncturist or another CAM practitioner have often already visited a medical doctor (Eisenberg et al., 2001). Those who have considered their problems too minor for needing a doctor may still try acupuncture. In case the acupuncturists suspect any more serious health concerns, the professional acupuncturists always ask the patient to visit a doctor. In Chinese medicine education, it is necessary to teach acupuncturists to become aware of their own limitations. In acupuncture education, the students need to be taught to communicate with the patients honestly, if they cannot understand the symptoms or they have any suspicions.

The ability of an acupuncturist to recognise important clues about serious health issues depends on education and clinical experience. Even though Chinese medicine courses are not meant to produce medical doctors or to teach how to make a conventional medical diagnosis, they aim at providing enough understanding when it is necessary to refer the patient to medical care. As the popularity and acceptance of acupuncture is growing fast and more and more research about its effectiveness is emerging, the acupuncturists will receive more and more patients seeking alternatives. With growing public awareness of acupuncture, there will be more and more patients coming with grave illnesses that require conventional medical treatments. The need for basic medical education and continuous education for acupuncturists cannot therefore be stressed enough.

It is also crucial for acupuncturists, and other CAM practitioners, to network themselves with medical doctors whom they can refer the patients to or ask for an opinion. Awareness of these critical situations can also be improved with open discussion and sharing experiences with other acupuncturists or practitioners of other CAM modalities.

Some patients have withheld information from their doctors about their nutraceuticals recommended by their nutritional therapists or herbs recommended by CAM practitioners. In the study by Eisenberg et al. (2001), three fifths of CAM therapy used was not disclosed to doctors. The common reason is that the doctor didn’t ask and some patients were also afraid that the doctors would not agree or understand (Eisenberg et al., 2001). This can be very dangerous considering the potential interactions (Salminen, 2018) with drugs used in cancer treatment, for example. The possibility that the patient uses some CAM modality is ever increasing. According to Eardley et al. (2012) “the prevalence of CAM use varied widely within and across the EU countries” and could be even as high as 86% of the population in some countries. The most commonly used modality is herbal medicines. If the patients sense a strong dichotomy between CAM practitioners and medical professionals, it can cause the patients to withhold vital information. It is important that acupuncturists also recognize these dangers and are able to inform their patients and form patient relationships based on trust. They need to tell their patients to inform their doctors or practitioners of other CAM modalities about any treatments they give, especially if they prescribe any medicinal herbs or products.

The acupuncturists and Chinese medicine practitioners might also hear about the use of falsified medicines that can endanger the patients (Hamilton et al. 2016) or other unregulated and possibly harmful products. The acupuncturists can report these potentially harmful products to local authorities and inform their patients about possible dangers in their use. The author believes that information about the use of unregulated or falsified medicines might be left out during visit to a doctor just as easily as the patients withheld information, such as using CAM modalities, and an acupuncturist can instruct their patients to disclose this information.

With patients having any previous dissatisfaction with medical care, extra caution should be taken. In case of any suspicious symptoms, the patients should be instructed to see a doctor, if they have not already done so, to avoid a late diagnosis of serious medical conditions. Making patients agree to see a doctor probably requires building a good therapeutic relationship. The practitioner of any CAM modality also needs to be aware in his therapeutic relationships that a patient might also easily get a wrong idea of the effectiveness. The patient in this case reserved time to check if acupuncture could help with Ménière’s disease when medicine failed. She had already had made the assumption that vertigo was because of Ménière’s disease and that acupuncture might help. Currently, there is preliminary evidence that acupuncture might work for Ménière’s disease (He et al. 2016) but her expectations were high because of the previous success with uveitis. It is sometimes almost impossible to avoid giving false hope by just agreeing to treat any less commonly treated symptoms. Not treating or overly explaining that the treatment might not work might harm the therapeutic relationship and even prevent the referral to a doctor in case it is needed.

Reflecting upon therapeutic relationships and clinical skills after this incident, the author became more aware of possible consequences of his therapeutic practice. It would be unrealistic to think that these mistakes couldn’t ever happen in the future, but there are always ways to improve the practice. He will now reserve extra time for returning patients if a few years have passed from the last session. With this he tries to ensure that he has enough time to collect information. Even in cases of seemingly minor complaints that do not respond to acupuncture treatments, the patients will from now on be routinely encouraged to see a doctor upon termination of the course of treatment. Before, the patients have already been asked to see doctor if there have been any alarming symptoms, but minor health concerns might have been previously overlooked. The author himself sees the work of an acupuncturist very tightly interwoven with the medical profession and sees further cooperation between different medical modalities as a requirement for patient safety. The author also concludes that it is unlikely that offering acupuncture would generally cause delays in diagnosis and treatment of a serious disease like cancer, but there is definitely a lack of proper studies in this area.

 

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