Structured TCM Case Reports – A Great Way Forward

June 27, 2024

In Australia, an estimated of 70% of the population regularly consult with a Complementary medicine practitioner which contributed a significant amount of AU$ 5.2 billion to the economy in 2018 (Complementary Medicines, 2021). Traditional Chinese Medicine (TCM) is part of complementary medicine. The modalities (Acupuncture and Chinese herbal medicine) belong to the category of “mind-body” medicine (Fogaça et al., 2021). Mind-body therapies emphasise the connection between the mind or intellect and the body. However, since TCM is a pre-modern medical system with a complex history and development, our approaches and methods are not always comprehensible to an outsider. Especially in research, where scientific evidence is required, the holistic application of TCM is sometimes neglected. In Randomised Controlled Trials (RCTs), the focus is on identifying one causal factor whereas with many complementary medicine therapies there may be several factors contributing to the treatment outcome.  

Sometimes, the “pre-modern” therapies are subject to harsh criticism because of insufficient scientific evidence. It would be good if TCM were recognised for its “peculiarities”. TCM differs from Western medicine and, therefore, requires a multifaceted approach. I also believe that translating our TCM medical system into the structures of conventional medicine is only applicable to a minimal extent. It would be constructive if doctors and researchers showed that we operate in two paradigms. In Ted J. Kapchuk’s book, The Web That Has No Weaver, he sums up (our problem): “They [Westerners] assume that the current Western science and medicine have a unique handle on truth – all else is superstition.”  

In the following, we will address the topic of case reports. I have completed a thesis on this subject whilst studying for a Master of Research at NICM Western Sydney University. During this project, I have concluded that we can secure a place in TCM research by publishing case reports (as TCM practitioners).  

A Long Tradition for TCM Case Reports and a Preference for Developing Skills  

Case reports accompany us as TCM practitioners during training and later in practice. TCM case reports have existed for several millennia. In the early days, they were engraved on bones and shells or recorded on papyrus (Zeng et al., 2021). Case reports have also been used in other traditional medicine systems. As TCM has developed, case reports have steadily adapted. Case report norms and formats were consolidated during the Ming (1368 – 1644 CE) and Qing (1616 – 1911 CE) dynasties. The most comprehensive collection of case reports was produced by Wang Shixiong, who completed the work of one of his ancestors. He created a compendium with 36 volumes, 350 chapters and 5,000 case reports! This collection remains the most extensive to date. 

Studies have found that TCM practitioners prefer case reports to develop clinical skills. Case reports can fully reflect the individual treatment approach for each patient (Armour et al., 2021). Case reports also bridge the gap between TCM theory and practice (Blalack, 2011). 

The discussion section at the end of a case report allows us practitioners to share our experiences and lessons learned, and we can reflect on strengths/limitations and importance/difficulties for either diagnosis or treatment or both. A well-structured case report provides a testimony to the treatment of a patient. What did everyone experience during the treatment, and what steps led to the result? We know that every patient has a story. Case reports allow us to record these stories in a structured way. Why did the treatment work, what factors were present, why did it not, and what was missing? In conventional medicine, a case report, according to today’s standards, also contains the patient’s perspective (and voice). To do this, it is sufficient to include two short paragraphs written by the patient in each case report. 

Case Reports in Conventional Medicine

Since the prestigious medical journal The Lancet introduced a separate section for case reports in 1995, case reports have generally experienced increasing popularity. This may have had something to do with the “movement” (at about the same time) of general practitioners and psychologists to focus on the individual patient. Historically, case reports in conventional medicine have brought new knowledge about existing diseases, such as the case of human immunodeficiency virus (HIV), which was discovered through a case report. On the other hand, the treatment for infantile hemangioma with propranolol was made known through a case report also (Léauté-Labrèze et al., 2008). Case reports are less commonly indexed in journals today than RCTs, but there are now about 160 publications specialising in case reports (Rison et al., 2017). 

The Research Pyramid

Case reports are positioned at the bottom of the research pyramid because there is no control group, and they have a limited sample size (one). In addition, case reports are not “blinded.” These missing factors are considered limitations in interpreting the results. However, N-of-1 studies or single-subject (a single patient) clinical trials to examine the efficacy and side effect profiles of different treatments (Lillie et al., 2011) are an exciting development. It is thrilling that they recognise the uniqueness of each patient and there is movement towards patient-centred care.  

Individualisation and Characteristic (Non-Treatment-Related) Effects

One of the advantages of TCM is the individualisation of TCM treatments. Often, we start the patient with one herbal formula, which we may then adjust and modify several times depending on how the patient’s condition evolves. Is this something that happens in your practice? Some symptoms disappear while others come to the fore. This situation of adaptation and modification requires an adaptable “research format,” and case reports provide an opportunity to capture these details. 

We often advise patients on better nutrition and use complementary treatment components such as moxibustion or Tui Na. All this information is important and impacts the outcome of our treatments. Those factors are difficult to quantify.  

Including this type of information in a case report is essential, and there are several ways to conduct secondary analyses of case reports. We may be able to evaluate and have a clear idea of what factors impact the outcomes most. Quantifying these factors would narrow down the treatment outcomes into individual components. Langevin and colleagues call these factors the characteristic non-needling (non-herbal) components (Langevin et al., 2011). They are called “characteristics” because the theory (Yin, yang, hot, cold, inside, outside, etc.) is grounded in the TCM framework.  

What’s next? 

As TCM practitioner, we need to learn how to write case reports. First, learning how to write structured TCM case reports is an excellent activity for a practitioner, and second, a published case report can be a valuable contribution to our entire industry, if not beyond. Case reports are considered evidence and are part of the research pyramid and evidence-based practice. 

Case reports fit very well with our primary modalities – acupuncture and herbal medicine because the patient is at the centre. The individualisation of our treatments is recognised, and the different practice styles can be accommodated. 

During my research and collaboration with TCM practitioners in various countries, we have created a checklist and case report guideline for Chinese herbal medicine. There is already a guideline for Western medicine (called CARE), which is very popular but is not accommodating for TCM language and frameworks. Another checklist was also created in China, Korea and Taiwan. Still, since TCM therapists often work in hospital-type settings in these countries, it was not suitable to use by TCM practitioners in private practice.

Convergent Points is an established, digital, “open access” platform on which we can publish our (peer-reviewed) TCM case reports. In collaboration with Convergent Points and Bastyr University, we are working for a database solution that can help us evaluate and analyse case reports. This project is still at early development.  

We are planning a webinar for TCM practitioners in Australia who are interested in compiling case reports. You can register your interest with contacts here if you want to hear more about it. 

If this sounds too good to be true, then think again. Publishing TCM case reports is an excellent opportunity to show that TCM is evidence-based and truly deserves a place in the Australian healthcare system. 

References:  

  • Blalack, J. (2011). Utilising Ancient Case Records to Inform Our Clinical Practice. Journal of Chinese Medicine(96).  
  • Fogaça, L. Z., Portella, C. F. S., Ghelman, R., Abdala, C. V. M., & Schveitzer, M. C. (2021). Mind-Body Therapies From Traditional Chinese Medicine: Evidence Map. Front Public Health, 9, 659075. https://doi.org/10.3389/fpubh.2021.659075  
  • Léauté-Labrèze, C., De La Roque, E. D., Hubiche, T., Boralevi, F., Thambo, J.-B., & Taïeb, A. (2008). Propranolol for severe hemangiomas of infancy. New England Journal of Medicine, 358(24), 2649-2651.  
  • Rison, R. A., Shepphird, J. K., & Kidd, M. R. (2017). How to choose the best journal for your case report. Journal of Medical Case Reports, 11(1), 198. https://doi.org/10.1186/s13256-017-1351-y  
Brigitte Linder
Brigitte Linder was born in Zurich and has lived near Melbourne on the south coast of Australia since 2008. She operated Safflower – Chinese Herbs Expertly Dispensed until mid-2023. Safflower is an herbal dispensary business operating under the banner of the Therapeutic Goods Administration (TGA). It was issued a GMP licence. Acuneeds acquired the company in January 2024 and intended to offer all services to practitioners in Australia and New Zealand.Brigitte completed a master's degree in 2023 with NICM Health Research (Western Sydney University). Her thesis involved creating a case report guideline for Chinese herbal medicine. In 2019, she published her first book and has since mentored TCM graduates to better transition to full-fledged practitioners. She has been consulting patients for 20 years and enjoys working with children and patients with complex conditions. She is a diplomat of the Institute of Classics in East Asian Medicine (ICEAM) and prescribes Eastern Han-era herbal formulas, namely Shang Han Lun and Jin Gui Yao Lue. Brigitte has always been interested in uniting a strong, cohesive TCM community. She continues to invest time and effort to ensure practitioners and the profession receive support and recognition.
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