Research
Why are case reports important to evidence based medicine?
Case reports have been written for over a thousand years, for the purpose of increasing medical knowledge. For many years, case reports were deemed ‘anecdotal’, but in recent years, with efforts to make the content of case reports more rigorous and complete, they have become more well-respected as evidence. While they may be missing the statistical significance of a clinical trial, case reports give insight into how to solve difficult, complex problems with multiple variables, which may not be capturable in the context of a clinical trial.
Clinical trial evidence has been instrumental for validating the benefit of acupuncture to biomedical practitioners making referrals, for legislators regulating the practice of acupuncture, and for health care organizations including acupuncture in their scope of offerings. Research has brought us a long way in supporting the public acceptance of acupuncture as a healthcare modality.
Clinical research efficacy trials are often not as valuable in informing acupuncture practice as they are in biomedicine. While clinical investigate problems by isolating straightforward variables, actual patient care is more complex, and proven clinical trial protocols may not be appropriate for all patients.
Why are clinical trials not enough?
Evidence-based medicine presumes that the best information comes from double-blind clinical trials, and yet for acupuncture, these clinical trials are often not the most useful in practice. Clinical research protocols tend to be fixed sets of points applied to large groups. Acupuncture is patient-centered, where the treatment is specifically designed for the individual. Therefore, clinical trial protocols test an approximation of traditional acupuncture where the treatment is not designed to fit the patient. When it comes to patient care, clinical trial evidence is often not the most useful source of knowledge for informing traditional acupuncture treatment because:
- There is an assumption that most patients with a specific condition will respond to the same treatment
- If a patient’s condition doesn’t present typically, they may not respond to a protocol designed for the typical patient
- Research protocols may dilute the treatment effect by addressing a variety of patterns rather than focusing on the individual patient’s characteristics
- Newer research strategies attempting to better approximate actual practice rely on traditional knowledge anyway
- Many of the styles and strategies in common use have not been tested, and there isn’t enough funding to test everything.
The strength of clinical trials is in numbers – it is population-centered research. The strength of case reports is in the specifics – it is patient-centered research, designed to understand how to best treat the individual. If acupuncture is to be practiced in a patient-centered manner, it makes sense to prioritize case reports as important evidence for clinical practice decision making.
What can we learn from case reports?
As there are many diverging perspectives on diagnosis and treatment, it becomes more challenging for acupuncturists to quickly choose the most useful options which will provide quick and efficient relief. While clinical trials are able to answer questions about acupuncture’s generalized clinical efficacy, case reports explore different types of research questions concerning effectiveness at the level of the individual patient:
- How do we tailor acupuncture treatment to meet the needs of an individual case?
- How do we know which treatment strategies or styles might be useful for a given patient?
- What are the most important diagnostic considerations for patients with a specific condition?
- How can traditional theory be used to understand and solve modern health problems?
- What new methods and techniques are being developed that have not yet been researched, and in what ways are they reliant on traditional theory?
Understanding how to make a correct diagnosis and create an effective treatment depends on a different type of evidence, evidence based on experience. Clinical trials don’t make decisions. Practitioners do.
A new way forward
Traditional acupuncture is expanding into new territory, whether it be modern interpretations of ancient theory, or new technologies and techniques. Understanding when and how to take advantage of these innovations and developments is best discussed in a case report. And as an added bonus for the researchers out there – this is a gold mine for hypotheses. Let’s start writing and enrich the mine.
For further exploration of the role of case reports in acupuncture research, click here.