Stephen Barrett, M.D.
Traditional Chinese medicine (TCM) is based on fanciful notions that ill health is caused by "imbalances" of the flow of "vital energy" (Chi or qi) through alleged pathways called "meridians." The diagnoses made by its practitioners have very little to do with people's actual health problems. One study has found that acupuncture literature does not provide a consistent framework for evaluating patients, and at least seven studies have found that when multiple practitioners see the same patient, their TCM diagnoses vary considerably. This is not surprising because TCM concepts have little relationship to anatomy and physiology and the body processes that TCM postulates cannot be measured by scientific instruments.
A Personal Anecdote
In 1998, following a lecture I attended at a local college, an experienced TCM practitioner diagnosed me by taking my pulse and looking at my tongue. He stated that my pulse showed signs of "stress" and that my tongue indicated I was suffering from "congestion of the blood." He was mistaken. I do not suffer from stress, and my blood circulates normally. A few minutes later, the acupuncturist told a woman that her pulse showed premature ventricular contractions (a disturbance of the heart's rhythm that could be harmless or significant, depending on whether the individual has underlying heart disease). He suggested that both of us undergo treatment with acupuncture and herbs—which would have cost about $90 per visit. I took the woman's pulse and found that it was completely normal.
Researchers who examined 16 TCM acupuncture texts or treatment articles to determine the consistency of diagnosis and recommended treatment for chronic low-back pain. Although 24 diagnostic patterns were described by one or more texts, only 4 patterns were described by at least half of them. Most texts (12/16) described only 3 or 4 patterns. The patterns could be categorized into 3 broad types:
- Cold, damp, wind, heat channel obstruction patterns
- Kidney vacuity patterns (sometimes differentiated into yang and yin patterns)
- blood (or blood and qi) stasis patterns.
Several acupuncture points were recommended by most texts regardless of the diagnosis, whereas other acupoints were recommended for specific diagnostic patterns. There was, however, substantial variation between texts in recommended acupoints, with fewer than 20% of all acupoints recommended by half or more of the texts .
In a study published in 2001, a 40-year-old woman with chronic back pain who visited seven acupuncturists during a 2-week period was diagnosed with "Qi stagnation" by 6 of them, "blood stagnation" by 5 , "kidney Qi deficiency" by 2, "yin deficiency" by 1, and "liver Qi deficiency" by 1. The proposed treatments varied even more. Among the six who recorded their recommendations, the practitioners planned to use between 7 and 26 needles inserted into 4 to 16 specific "acupuncture points" in the back, leg, hand, and foot. Of 28 acupuncture points selected, only 4 (14%) were prescribed by two or more acupuncturists. . The study appears to have been designed to make the results as consistent as possible. All of the acupuncturists had been trained at a school of traditional Chinese medicine (TCM). Six other volunteers were excluded because they "used highly atypical practices," and three were excluded because they had been in practice for less than three years. The study's authors stated that the diagnostic findings showed "considerable consistency" because nearly all of the practitioners found Qi or blood stagnation. However, the most likely explanation was that these are diagnosed in nearly everyone.
In another study, six TCM acupuncturists evaluated the same six patients on the same day. Twenty diagnoses and 65 acupoints were used at least once. The diagnosis of "Qi/Blood Stagnation with Kidney Deficiency" and the acupoint UB23 were used for every patient by most acupuncturists. However, consistency across acupuncturists regarding diagnostic details and other acupoints was poor. No diagnoses, and only one acupoint, were used preferentially for a subgroup of patients. Some diagnoses and treatment recommendations were dependent more on the practitioner than on the patient. Fine-grained diagnoses and most acupoints were unrelated to either patient or practitioner. The researchers concluded that TCM diagnoses and treatment recommendations for specific patients with chronic low back pain vary widely from one practitioner to another .
Another study examined TCM diagnoses and treatments for patients with chronic low-back pain using two separate sets of treatment records. Information from more than 150 initial visits was available for analysis. A diagnosis of "Qi and Blood Stagnation" or "Qi Stagnation" was made for 85% of patients. A diagnosis of kidney deficiency (or one of its three subtypes) was made for 33%-51% of patients. Other specific diagnoses were made for less than 20% of the patients. An average of 12-13 needles was used in each treatment. Although more than 85 different acupoints were used in each data set, only 5 or 6 acupoints were used in more than 20 of the treatments in each data set. Only two of those acupoints (UB23, UB40) were the same for both sources of data. More than half of the patients received adjunctive treatments, including heat (36%-67%), and cupping (16%-21%). There was substantial variability in treatments among providers .
In a larger study published in 2004, three TCM practitioners examined the same 39 rheumatoid arthritis (RA) patients separately at the University of Maryland General Clinical Research Center. Each patient filled out a questionnaire and underwent a physical examination that included tongue and pulse diagnosis. Then each practitioner provided both a TCM diagnosis and a herbal prescription. Agreement on TCM diagnoses among the 3 pairs of TCM practitioners ranged from 25.6% to 33.3%. The degree to which the herbal prescriptions agreed with textbook recommended practice of each TCM diagnosis ranged from 87.2% to 100%. The study's authors concluded:
The total agreement on TCM diagnosis on RA patients among 3 TCM practitioners was low. When less stringent, but theoretically justifiable, criteria were employed, greater consensus was obtained. . . . The correspondence between the TCM diagnosis and the herbal formula prescribed for that diagnosis was high, although there was little agreement among the 3 practitioners with respect to the herbal formulas prescribed for individual patients .
The University of Maryland researchers then repeated the above study using 40 RA patients and three practitioners who had had at least five years of experience. The results were nearly identical to the previous findings .
In another study, 37 participants with frequent headaches were independently evaluated by three licensed acupuncturists said to be highly trained in TCM. The acupuncturists identified the meridians and type of dysfunction they believed were contributing to the participants' symptoms. The acupuncturists also ascribed one or more TCM diagnoses to each participant and selected eight acupuncture points for needling. Some variation in TCM pattern diagnosis and point selection was observed for all subjects. "Liver Yang" and "Qi dysfunction" were diagnosed in more than two thirds of subjects. Acupuncture points Liver 3, Large Intestine 4, and Governing Vessel (DU) 20 were the most commonly selected points for treatment .
In a "laboratory" study of tongue diagnosis, 30 TCM practitioners wer asked to examine 10 high quality images in each of two sessions. For each omage, if at least 24 (80%) of the practitioners agreed on a diagnosis, the result was considred significant. This occured only 17.3% in the first session and 19.1% in the second session when the practitititioners were given two choices to pick from. But when the chices were more complex, they agreed among themselves less than 5%. The researchers concluded that "TCM tongue inspection for specific characteristics examined was not a reliable diagnostic method, at least for the group of TCM practitioners involved in this study." 
The Bottom Line
TCM theory and practice are not based upon the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community. TCM practitioners disagree among themselves about how to diagnose patients and which treatments should go with which diagnoses. Even if they could agree, the TCM theories are so nebulous that no amount of scientific study will enable TCM to offer rational care.
- Birch S, Sherman K. Zhong Yi acupuncture and low-back pain: Traditional Chinese medical acupuncture differential diagnoses and treatments for chronic lumbar pain. Alternative and Complementary Medicine 5:4150425, 1999.
- Kalauokalani D and others. Acupuncture for chronic low back pain: Diagnosis and treatment patterns among acupuncturists evaluating the same patient. Southern Medical Journal 94:486-492, 2001.
- Hogeboom CJ and others. Variation in diagnosis and treatment of chronic low back pain by traditional Chinese medicine acupuncturists. Complementary Therapies in Medicine 9:154-166, 2001.
- Sherman KJ and others. The diagnosis and treatment of patients with chronic low-back pain by traditional Chinese medical acupuncturists. Alternative and Complementary Medicine 7:641-650, 2001.
- Zhang GG and others. The variability of TCM pattern diagnosis and herbal prescription on rheumatoid arthritis patients. Alternative Therapies in Health and Medicine 10:58-63, 2004.
- Zhang GG and others. Variability in the traditional Chinese medicine (TCM) diagnoses and herbal prescriptions provided by three TCM practitioners for 40 patients with rheumatoid arthritis. Alternative Therapies in Health and Medicine 11:415-421, 2005.
- Coetaux RR and others. Variability in the diagnosis and point selection for persons with frequent headache by traditional Chinese medicine acupuncturists. Alternative and Complementary Medicine 12:863-872, 2006.
- Kim M and others. Traditional Chinese medicine tongue inspection: An examination of the inter- and intrapractitioner reliability for specific tongue characteristics. Journal of Alternative and Complementary Medicine 14:527-536, 2008.
This article was revised on February 2, 2014.