MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Whenever we consider alternative medicine, we think of therapeutic interventions and tend to forget that alternative practitioners frequently employ diagnostic methods which are alien to mainstream health care. Acupuncturists, iridologists, spiritual healers, massage therapists, reflexologists, applied kinesiologists, homeopaths, chiropractors, osteopaths and many other types of alternative practitioners all have their very own ways of diagnosing what might be wrong  with their patients.

The purpose of a diagnostic test or technique is, of course, to establish the presence or absence of an abnormality, condition or disease. Conventional doctors use all sorts of validated diagnostic methods, from physical examination to laboratory tests, from blood pressure measurements to X-rays. Alternative practitioners use mostly alternative methods for arriving at a diagnosis, and we should ask: how reliable are these techniques?

Anyone trying to answer this question, will be surprised to find how very little reliable information on this topic exists. Scientific tests of the validity of alternative diagnostic tests are a bit like gold dust. And this is why a recently published article is, in my view, of particular importance and value.

The aim of this study was to evaluate the inter-rater reliability of pulse-diagnosis as performed by Traditional Korean Medicine (TKM) clinicians. A total 658 patients with stroke who were admitted into Korean oriental medical university hospitals were included. Each patient was seen by two TKM-experts for an examination of the pulse signs – pulse diagnosis is regularly used by practitioners of TKM and Traditional Chinese Medicine (TCM), and is entirely different from what conventional doctors do when they feel the pulse of a patient. Inter-observer reliability was assessed using three methods: simple percentage agreement, the kappa value, and the AC(1) statistic. The kappa value indicated that the inter-observer reliability in evaluating the pulse signs ranged from poor to moderate, whereas the AC(1) analysis suggested that agreement between the two experts was generally high (with the exception of ‘slippery pulse’). The kappa value indicated that the inter-observer reliability was generally moderate to good (with the exceptions of ‘rough pulse’ and ‘sunken pulse’) and that the AC(1) measure of agreement between the two experts was generally high.

Based on these findings, the authors drew the following conclusion: “Pulse diagnosis is regarded as one of the most important procedures in TKM… This study reveals that the inter-observer reliability in making a pulse diagnosis in stroke patients is not particularly high when objectively quantified. Additional research is needed to help reduce this lack of reliability for various portions of the pulse diagnosis.”

This indicates, I think, that the researchers (who are themselves practitioners of TCM!) are not impressed with the inter-rater reliability of the most commonly used diagnostic tool in TCM/TKM. Imagine this to be true for a commonly used test in conventional medicine; imagine, for instance, that one doctor measuring your blood pressure produces entirely different readings than the next one. Hardly acceptable, don’t you think?

And, of course, inter-rater reliability would be only one of several preconditions for their diagnostic methods to be valid. Other essential preconditions for diagnostic tests to be of value are their specificity and their sensitivity; do they discriminate between healthy and unhealthy, and are they capable of differentiating between severely abnormal findings and those that are just a little out of the normal range?

Until we have answers to all the open questions about each specific alternative diagnostic method, it would be unwise to pretend these tests are valid. Imagine a doctor prescribing a life-long anti-hypertensive therapy on the basis of a blood pressure reading that is little more than guess-work!

Since non-validated diagnostic tests can generate both false positive and false negative results, the danger of using them should not be under-estimated. In a way, invalid diagnostic tests are akin to bogus bomb-detectors (which made headlines recently): both are techniques to identify a problem. If the method generates a false positive result, an alert will be issued in vain, people will get anxious for nothing, time and money will be lost, etc. If the method generates a false negative result, we will assume to be safe while, in fact, we are not. In extreme cases, such an error will cost lives.

It is difficult to call those ‘experts’ who advocate using such tests anything else than irresponsible, I’d say. And it is even more difficult to have any confidence in the treatments that might be administered on the basis of such diagnostic methods, wouldn’t you agree?

27 Responses to Alternative diagnostic techniques: like bogus bomb-detectors?

  • I think “irresponsible” is a too gentle word.
    Putting others onrisk in despite of better knowledge, acquired by study, is often considered as criminal.
    Ideological blindness does not excuse negligent action.
    And ensuring effectiveness to a proven totally nonsense method as a physician to a patient (as a layman in terms of medicine) might also be a property-crime.

    Just imagine an engineer who builds bridges with too few pillars, as he is pretty sure to “strengthen the construction” by “electroacupuncture according to Voll”. I think the engineers insurance would want the money back from him ;D

    Or imagine that engineer to construct a house. To raise his income, he offers “vibration measurement for local structural analysy” with a bogus machine and after detecting a “dangerous condition” he promises to spill some fixating fluids to stabilize the fundament. He then sells special homemade stabilization glue for 5k Pound/Euro/Dollar and spilles the water on the building site using a watering can (homeopathy).

    I assume, the engineer would go into jail in the first case and would at least have serious problems with the prosecutor in the second example.
    With alternative techniques in medicine, this behavior often seems to be the preferred model of business.

  • Just a note of information. While osteopaths in the UK are woo based practitioners, in the US their training is essentially the same as that of MDs. They do have some odd training in a kind of manipulation but that is not the center of their practice. When I lived in Maine my GP was a DO since he had an office in the same building. I had no somatic problems and my interactions with him were identical with those with MDs.

    • this is correct; and in continental Europe, osteopaths are even more woo than in the UK, as far as i can see.

      • Many UK osteopaths reject the wackier elements of their profession during training or with clinical experience, as they are exposed to research and the world beyond the history of their profession. Many reject woo — but certainly not all, and possibly not even the majority.

        • yes, that may well be so, i don’t doubt it for a minute. but don’t you think it is time for your professional organisations to take a clear position on unproven or disproven aspects of osteopathy? think of cranial osteopathy, for instance, and the claims your colleagues are making about it.

          • Some of us want exactly that. Politics, fear, and misunderstanding seem to grind the process to a halt, resulting in weak “middle-ground” positions. In my personal opinion.

          • i am very pleased to hear that some of you are rational. try to convince more of your position!!! because, until a clear majority is on your side, osteopathy will remain woo.

          • It is becoming increasingly clear that professional organisations (both chiro and osteo) are not in the slightest bit interested in tackling this problem; they are, of course, there to represent the best interests of their members and if the majority believe in, and want to sell, woo then it would seem unlikely there would ever be the impetus to change. Indeed, without the backing of their statutory regulator, any such stance would simply fragment registrants and draw battle lines.

            However, the statutory regulators are charged with protecting the public and it is they who should be leading their registrants towards ensuring all practice is evidence based. There are several ways of doing this including ensuring their registrants only advertise and practice according to the robust evidence but, more importantly, they must ensure that the training establishments do not teach beyond that robust evidence. Only then will we see the public being properly protected.

            At present, I see no signs that they are even willing to consider that.

  • In Germany nearly everybody must be member of a health insurance company and pay the insurance premium.
    Since the last few years, nearly all insurance companies have been paying for a lot of diagnostics, treatments and prescribed drugs of CAM physicians. These include homoeopathic, phytotherapeutic and anthroposophical drugs but also osteopathy and acupuncture (the latter only for some indications I think).

    This is remarkable and in my opinion a scandal with respect to the payment of drugs, particularly those homeopathic ones.

    In german law it says, services must be sufficient but must not excess the necessary level.
    And in german law it says, one must pay for (normal) OTC-drugs on its own.
    (Even if the normal OTC-drugs are prescribed and show proven efficiency. Only in severely threatening situations, insurances do pay for those OTC-drugs.)

    As the law must be consistent, the patient’s health is regarded as sufficient without getting the OTC-drugs as long as he is not in a severely threatening condition.

    Within the range of professional quality, insurances are allowed to pay for some treatments and other things in addition to the normal guaranteed services.
    When insurances pay for homeopathic drugs, they do regard this as “of professional quality” and “necessary”.

    Absurd: A homeopathic drug is considered as necessary as long as a homeopathic physician prescribes it, whereas a drug of proven efficiency can only be regarded as necessary on exception in severly threatening situations.
    And for necessary and efficient drugs like antibiotics, the patients must pay a small amount on their own. About 6 Euros. Guess what? Homeopathic drugs are payed 100% by the insurances (up to 100 Euro per year.).

    Remember: These insurances are paid by duty insurance premium. You must pay the same amount regardless of your insurance. And as a marketing action to attract members, they promise to pay for bogus business models, raising the costs for all patients in the health system:
    Practitioners using bogus diagnostics and treatment, the pharmacist selling bogus drugs and the industry producing bogus drugs. All get paid in principle by taxes.

    Encomium of Germany 😀

    • Unfortunately the private health insurers in Australia do the same things. I have repeatedly written to my insurer, complaining that they are covering services and medicines that have no proven effectiveness, but I have yet to recieve an answer, and I continue to pay premiums which reflect the cost of these bogus therapies and drugs. They were even covering reiki and Bowen therapy for Dog’s sake. It makes my blood boil.

  • One westerner promoted as a ‘master’ of Chinese Pulse Diagnosis wrote a large textbook by that name. I didn’t find any serious references in it (i.e. to actual research studies confirming the claims), but instead many claims such as:

    “A Flat pulse in the Distal position may result from a birth delivery complicated by the
    presence of the umbilical cord around the neck after the head is out side of the mothers body. With this scenario the left proximal Kidney position would probably be Feeble-Absent. A search for history of birth trauma is frequently fruitful.”

    This type of pulse diagnosis is done to adults, not to the baby with the cord wrapped around the neck. It’s akin to the ‘False Memory Syndrome’ that hypnotherapists do with alien abductions, guiding someone to confirm that they had birth trauma…

    More here: http://www.dragonrises.edu/wp-content/themes/dragon/downloads/articles/hammer-evolvingmethod.pdf

    Also from that link (I can’t resist) is the suggestion that one can diagnose Multiple Personality Disorder and AIDS from the pulse, but if you’re wrong, it may be due to a full bladder or the time of day:

    “New diseases, new problems associated with a modern civilization so very different from the agricultural society which spawned the original Chinese medicine have begun to show consistencies in pulse diagnosis. The `ceiling dripping’ Scattered pulse of Aids and the various Qi Wild pulses related to Multiple Personality and Sexual Abuse are among the few recently identified syndromes which seem to have characteristic pulse pictures. Hopefully with the information provided in this book and the skills developed in pulse workshops, practitioners will be equipped to explore new worlds, expand the purview of Chinese medicine and serve future generations.
    VI. Limitations of Pulse Diagnosis
    What are some of the limitations of pulse diagnosis? The pulse is an individually-
    developed art form, a blend of learning skills, intuition, a form, actually, of meditation, of being in touch simultaneously with the deepest parts of oneself and another. It requires an ability to trust one’s senses and years of practice, especially with a master.
    It is not subject to the western scientific model, and it is, perhaps, in some ways, the most fickle of all the diagnostic modalities. It is more affected by ephemeral influences than the tongue diagnosis or other forms of diagnosis. It can be affected transiently by emotion, by pernicious influences or acute illnesses, by activity, by medication, by diet, a full bladder, an imminent or concurrent menstrual flow, and by the biorhythms, seasons of the year, and even the time of the day. “

    • thank you for this comment!
      what i find particularly irritating is the inevitable remark OUR METHOD IS NOT AMENABLE TO THE WESTERN SCIENTIFIC MODEL…in fact, it means “we do no understand science, we have no evidence to back up our claims, and we want to mislead everyone about all that”.

      • Ernzt, your comments are both ignorant and bias, you are betraying your initial training and are a disgrace to Exeter Uni. How can you possibly say that a diagnostic technique that has been around for 5000 years are less superior to something western medicine says is correct after a few hundred years! Just because western diagnostic tools are not yet refined enough to measure the potency of , say a homeopathic, doesn’t mean it doesn’t work, all it means is that you cannot yet measure it!

        • You want me to moderate the truth??

        • John Smith said:

          Ernzt, your comments are both ignorant and bias [sic]

          Please feel free to point out any gaps in Prof Ernst’s knowledge and examples of his biased comments.

          you are betraying your initial training and are a disgrace to Exeter Uni.

          Ignoring the fact that some of Prof Ernst initial training was in homeopathy, I’m sure critical thinking skills and an inquiring mind are deemed to be very valuable assets at the University of Exeter.

          How can you possibly say that a diagnostic technique that has been around for 5000 years are less superior to something western medicine says is correct after a few hundred years!

          Seriously?

          Just because western diagnostic tools are not yet refined enough to measure the potency of , say a homeopathic, doesn’t mean it doesn’t work, all it means is that you cannot yet measure it!

          So, when do you believe someone will be able to measure the ‘potency’ of a homeopathic product and what will it be measuring?

          But of course, not being able to measure anything in a homeopathic product is not the reason scientists don’t think it works: it’s because there is no good evidence that it works.

          • Thanks for the responses.

            You need only to travel to economically poor countries for evidence of the use and benefits homeopathy can have in a country where the expensive ‘evidence based’ medicines are only available for the rich. In societies such as those in India where hospitals in New Delhi treat up to 13 million patients a year, in rural areas where there are no western medical facilities only homeopathic hospitals which treat the small local communities ONLY with homeopathics, this is evidence, you can’t say this is placebo.

            Open your eyes to the rest of the world and see what is going on. China has operated hospitals only offering Chinese medicine for thousands of years, something must be working to have a population of 1.3 billion!

            Getting so hooked up on ‘evidence based ‘ medicine is both narrow minded and ignorant, look at your history, how did the “Quacks Charter” of 1512 come about and how come it hasn’t been repealed? Because the Barbers and Surgeon (who were considered medical at that time) couldn’t keep the population healthy. Henry V111 had the sense to see this and acknowledged that both have a place. Mind you it took the Barbers and Surgeons hundreds of years to get their act together and now in 2013 think they are the bees knees.

            Get over yourselves!!

          • In societies such as those in India where hospitals in New Delhi treat up to 13 million patients a year, in rural areas where there are no western medical facilities only homeopathic hospitals which treat the small local communities ONLY with homeopathics, this is evidence, you can’t say this is placebo.

            That is indeed evidence, but it isn’t evidence that homoeopathy works. It’s evidence that a lot of people without access to medicine have to use homoeopathy.

          • John Smith said:

            Getting so hooked up on ‘evidence based ‘ medicine is both narrow minded and ignorant, look at your history, how did the “Quacks Charter” of 1512 come about and how come it hasn’t been repealed? Because the Barbers and Surgeon (who were considered medical at that time) couldn’t keep the population healthy. Henry V111 had the sense to see this and acknowledged that both have a place. Mind you it took the Barbers and Surgeons hundreds of years to get their act together and now in 2013 think they are the bees knees.

            I’ve often seen apologists for homoeopathy imply that medicine is the same now as it was several hundred years ago, but you’re the first I’ve seen claim that medicine is still practised by barbers. The fact that medicine has taken “hundreds of years to get [its] act together” doesn’t mean that systems that have yet to get their act together are preferable.

            And this brings up, once again, the failure in your arguments. Go back a couple of hundred years, and bloodletting was a routinely used treatment for all sorts of conditions. It was used by large numbers of people across the whole population, and had been in use for hundreds, perhaps thousands, of years. According to the reasoning you have used above, this means that it works. It doesn’t.

          • “China has operated hospitals only offering Chinese medicine for thousands of years, something must be working to have a population of 1.3 billion!”

            “Complementary and Alternative Contraception”, perhaps?

          • Mojo said:

            “Complementary and Alternative Contraception”, perhaps?

            Ha!

          • something must be working to have a population of 1.3 billion

            There are ways to increase a population outside of healing. Much more enjoyable ways. Or how do you think humanity survived the thousands of years befor even the Chinese medicine set in? Just being faster in sex than in dying.

        • How can you possibly say that a diagnostic technique that has been around for 5000 years are less superior to something western medicine says is correct after a few hundred years!

          Because of the evidence.

          Just because western diagnostic tools are not yet refined enough to measure the potency of , say a homeopathic, doesn’t mean it doesn’t work, all it means is that you cannot yet measure it!

          We have an investigatory tool that would be perfectly capable of measuring the effects of homoeopathy if it had any. It is called the controlled trial. It has been used to measure the difference in outcome between patients who have been given homoeopathic treatment and patients who have not. Trials of adequate size and quality have consistently failed to demonstrate that there is any difference. That means it doesn’t work.

          Do you have any “Eastern diagnostic tools” that can “measure the potency of a homeopathic”, by the way? Or even any Northern or Southern ones? Homoeopathy, by the way, is about as Western as it gets, given that it was invented by an 18th century European.

  • To take a good look at the whole picture here, lets take a look at mainstream medicine too. I have included a link to the inter and intra rater reliability of many of the orthopaedic tests that are commonly used surgeons/chiropractors/osteos/physios/gp’s alike. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1635718/

    This was done by an undergraduate at chiropractic college with me. After a history has been taken and many tests done (lets say) an MRI is done. Again, how many of us tell our patients about false positives and false negatives?

    I’m not defending the woo practitioners, but lets look to the uncertainty of the tools we use too before we start pointing fingers.

    • thank you; these are important points, no doubt.
      nevertheless, i’d like to make two points:
      1) the indisputable fact that all is not ok in conventional medicine is a very poor argument for tolerating quackery in alternative medicine.
      2) even though many conventional tests are not sufficiently validated, some diagnostic methods clearly are. as far as i can see, not a single alternative diagnostic method is validated – or can anyone name one that is?

  • Sir, I live in india and just visited a homeopath today recommended to show my wife suffering injuries on her knee, spine and neck from an accident in 2010. The clinic had atleast over 100 paying patients when we arrived. So when our time came i started giving giving a very clear medical history which he wasnt actually interested in listening.He immediately silenced me, made my wife make a fist and read her pulse. I was shocked. He gave the actual pain readings from L-4 and L-5 c1 and C2 out loud and other broken and healed areas as if talking into a recorder. Even mentioned of other intestinal stuff to be careful in the future. !! See I have blood, mri and ct scans of 4 years worth hundreds of dollars to back him up. He saw her tounge and gave medicine worth less than $8 for a week! Hope it helps. The diagnosis was on the bang on head!
    Whats can western science say of that?

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