Some serious flaws in the scientific reporting of two acupuncture clinical trials, for the treatment of infertility and allergic rhinitis, were recently published on Prof Edzard Ernst’s blog. The overly positive way in which the researchers made their mostly negative results public was also of concern. Both these studies were published by the researcher of the year, Prof Caroline Smith, of the National Institute of Complementary Medicine (NICM), Australia. The stream of comments and discussions that followed made me think of another commonly overlooked aspect when it comes to acupuncture clinical trials. Conflict of interest! In both these studies the authors declared to have no conflicts of interest and in other similar studies by this author this also seems to be the case. The question can be asked; If you are a practicing acupuncturist conducting a clinical trial in acupuncture, isn’t that, by default, a serious conflict of interest? The intention of this article is not an in-depth discussion of what a conflict of interest is, but rather to compare medical doctors with acupuncturists turned researchers. Let me explain.
Some medical doctors (GPs, surgeons etc.) decide to leave their practice after practicing 10-20 years to become full time researchers (and visa versa). Universities accept these people with open arms because they bring with them a wealth of knowledge regarding the practical side of medicine and healthcare in general. They are thus seen as an asset to any medical research project including clinical trials. Can the same be said about an acupuncturist? They also bring with them years of experience and thus they should also be a major asset to any acupuncture clinical trial. But I am afraid not!
Why? Medical doctors have a multitude of tools (drugs, surgical procedures, diagnostic kits etc.) at their disposal to diagnose and treat all types of medical conditions. Yes, there is medical conditions that cannot be treated and to say nothing about the issue of misdiagnosis. But when will it now be a conflict of interest? When they publish a positive clinical trial of a specific medical intervention in which they have a vested interest. e.g owning shares in the company producing the medical intervention (financial interest) or if they have been staunch supporters of this intervention during their years of practice (emotional interest). Just imagine that you have been prescribing a specific intervention to hundreds of patients over a long period of time, and now you have to face them with a negative clinical trial result – that will be difficult. The former is easy to declare whilst the latter might be slightly more difficult.
Doctors also tend to focus on a specific disease e.g. cancer and will perform research with the existing tools at their disposal but also try to find new tools in order to improve the risk-benefit profile of the disease treatment. Thus, for a doctor there is the possibility that they might run into a conflict of interest but due to the multitude of medical interventions this is by no means a given.
What about acupuncture practitioners turned researchers? An acupuncturist only has one tool at their disposal to treat all medical conditions. I can hear them say; but we stick needles in different places and depths etc. depending on the medical condition! Yes, but the fact remains that they can only stick needles into people – and that is a single intervention. So is this a conflict of interest by default? I would argue, yes, it is like having a single drug, packaged differently or in different doses, to treat all medical conditions. If you have treated hundreds of patients for various medical conditions and now suddenly you publish a negative clinical trial, you will not only be red faced when you run into your former (current) patients – who paid for their treatment – they might even sue you for misleading them. As an acupuncturist you cannot allow acupuncture to be ineffective for a specific medical condition otherwise people might start to query the effectiveness, in general, of the only tool you have. And not only that, they might start to question the unscientific principles that acupuncture is based on! And this, no acupuncturist want and hence they will have a conflict of interest by default – no matter what medical condition they aim to treat.
Likewise, if you have been emotionally and financially invested in acupuncture as a cure-all for 10-20 years it will be very difficult, if not impossible, to publish a negative result. In addition, the acupuncture fraternity is a very tight knit community, where negative results are frowned upon because of vested interests – surely they will expel you from this community if you publish negative results and thereby question the only tool that they have?
Keeping the above in mind, how do acupuncture researchers go about conducting clinical trials? An example: Prof Smith and Bensoussan, both at the NICM, are currently registered as practicing acupuncturists. This means that they can legally practice acupuncture and because they have been active for decades they are also well known and respected in the acupuncture fraternity. It is unknown if they’re still actively practicing or maybe practicing part-time in someone else’s practice, or if they have a financial stake in their former or someone else’s practice. Based on the fact that they are still registered it can be expected that they have a current emotional and/or financial interest in the positive outcome of their acupuncture clinical trials.
Because of this inherent conflict of interest and due to the current strict clinical trial regulations, which makes it quite difficult (although not impossible) to fabricate or falsify data, they target the next best thing which is the design of their clinical trial e.g. the A+B versus B design. But it doesn’t stop there. As soon as the clinical trial give a neutral (and thus negative) result, which in their books doesn’t happen very often, the results will be inflated to make it sound positive (another example here). Why? because they must protect the single tool that they have, they must keep the acupuncture fraternity happy and they must protect themselves against potential lawsuits from former (current) patients or a decrease in patient numbers (and thus financial income). On top of that – how would the media and the public react to an acupuncture clinical trial if the lead researcher declare that they have their own acupuncture clinic? Surely this is a conflict of interest and it must be declared as such?
So what is the main difference between a doctor and an acupuncturist? A doctor has a multitude of medical interventions and might have a conflict of interest – but this is not a given. An acupuncturist has one intervention only and therefore they have a conflict of interest by default – this is a given and one which they never seem to declare!
Forthcoming attractions: Currently the biggest ever complementary medicine clinical trial in Australia is being conducted by Prof Smith. This large trial is looking at the effectiveness of acupuncture on IVF outcomes and was branded a waste of money in the media when the NHMRC announced that they granted $600k for this project. Question is; when they publish the (inevitably positive) results will they also declare to have a conflict of interest? For some reason, I strongly doubt it.