Transforming the Health Care System

Transcription

1 Response to HPRAC Consultation Interprofessional Collaborations Transforming the Health Care System Introducing and Integrating Traditional Chinese Medicine into the Health Care System to help reduce waiting time, lower expenditures and improve health May 2008 Mary Xiumei Wu MD. (China, TCM), M.Sc., Dipl. OM., R.Ac. President Toronto School of Traditional Chinese Medicine 2010 Eglinton Avenue West, Suite 302 Toronto, Ontario, Canada. M6E 2K3 Tel: ; Fax: Website:

2 Executive Summery Traditional Chinese Medicine (TCM) is an ancient natural Oriental medicine that is getting more and more accepted and used in the modern technological Western world. TCM is a distinct and comprehensive medical paradigm composed of fundamental theory, unique diagnostic methods and a variety of treatment modalities primarily including acupuncture, Chinese herbal medicine, tuina massage and taiji qigong exercise. Sufficient knowledge, understanding of its theory, diagnostic methods and differentiation of syndromes, and comprehensive holistic treatment modalities are essential for safe, effective and high standard of TCM care and services. With proper regulation and government support, TCM will contribute more significantly to the improvement of the health and quality of life especially the aging population, shorten the waiting list, and reduction of our health care costs in Ontario. With the upcoming regulation of TCM profession and the creation of the regulatory body, Transitional Council of the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario (CTCMPAO), requirements of training and competence, standard and scope of practice will be established. As a new health profession to be regulated, we are excited and concerned at the same time. We appreciate the government s commitment in regulating TCM and other new health professions to protect the public and ensure safe, effective and high quality health care services. We hope that with the interprofessional collaboration, TCM will be introduced and integrated into our health care system, College of TCMA will work with all other regulatory colleges to develop policies and procedures of interprofessional collaboration, the government will develop legislations that is effective in protecting the public, fair to the professions and to the public, respect to different philosophy and culture, and support new health professions. Recommendations for the mechanisms to facilitate and support interprofessional collaboration Public protection, quality of care, access, accountability are the four inter-related objectives of RHPA. To ensure these objectives are fulfilled when the same or similar controlled acts are shared or performed by various professions, the following are our suggestions: 1. Government initiated and funded education for interprofessional collaboration: o Educate the public: Health care serves the public and paid by the consumers. The public has to be well informed about the services available to them, the professions that serve them, the laws and regulations that protect them, and the parties that pay for them. o Educate future practitioners in the professional training programs:

3 To make it a requirement, through legislation, in the course curriculum to equip students with the awareness and knowledge regarding the health care system and interprofessional collaborations o Educate registered practitioners: through continue education o Educate regulators: through programs initiated and funded by government o Educate payers: design and organize educational workshops to discuss and design programs/procedures and policies regarding interprofessional collaboration o Mechanisms for education and promotion of interprofessional collaboration: Establish a program within the Ministry of Health and Long Term Care by appointing a program coordinator responsible for the promotion, education, regulation and improvement of interprofessional collaboration. 2. Regulation and interprofessional collaboration should focus on quality, accessibility and choices of services provided to the public by qualified practitioners only with fair share. For example: if massage therapists, physiotherapist, chiropractors, naturopaths, occupational therapist, midwife, podiatrists with 300 hours of training in acupuncture are allowed to practice acupuncture, bill the insurance companies, claim and advertise for acupuncture, then TCM practitioners / acupuncturists with 300 hours of training should also be allowed to practice, bill, advertise and claim for massage, physio, chiro and naturopaths and so on. 3. Controlled acts, modalities, procedures performed by various professions have to be clearly defined, documented, all stakeholders be well informed at legislative, regulatory and practitioners levels. 4. Specific modalities/procedures performed at different levels with different standard of training, practice with different scopes, requires precise, accurate and applicable regulation and implementation. 5. Advertising, claims should be differentiated and limited. 6. Choices be clearly presented to the consumers for informed choices. For example: Definition: Training: TCM acupuncture Anatomical acupuncture TCM Ac hours Ana. Acu. 300 hours for MD, Dentists, DC, ND, physio

4 Ana. Acu. 800h for RMTs. Scope of practice: TCM Ac. For health promotion, and for disease prevention and treatments; Ana. Ac. For pain managements Advertising: TCM Ac. May advertise the title and practice Ana. Ac. May not advertise acupuncture Payments: TCM Ac. Bill under acupuncture and TCM Ana. Ac. Bill under specific practice, i.e. physio, Chiro, massage 7. Fair coverage by OHIP and insurance companies. 8. Special support and promotion for new health professions. 9. Respect and cater the needs of various philosophy, culture and language of the medicines/modalities. 10. Mutual respect and referral. Practitioners know each other s abilities and limitations with mutual respect and referral patients when needed. Introduction to Traditional Chinese Medicine Traditional Chinese Medicine (TCM) is a distinct and comprehensive medical paradigm that is originated and deeply rooted in the Chinese culture for thousands of years. TCM is composed of its fundamental theory, unique diagnostic methods and a variety of treatment modalities including primarily acupuncture, Chinese herbal medicine including nutrition and medicated diet, tuina massage, and taiji-qigong. The philosophy, thinking, language and vocabularies of TCM are very different compare to western medicine. With thousands of years of history, repeated clinical tests, and increased modern research, TCM has been proven to be helpful to a wide range of conditions from minor discomfort to serious illnesses, from chronic to acute conditions, from paediatrics to geriatrics. From health promotion, to disease prevention and treatments. TCM has contributed to the development and strengthening of the Chinese nation and over a quarter of world population has benefited from it. There is an increased interest in using TCM for health benefits and for career among the general public in Canada and around the world. With the upcoming regulation of the profession in Ontario and the standardization of practice, TCM will gain more attention from the public and health professions which likely to lead to the increased acceptance and recognition of this ancient Asian medicine in the modern western world. Characteristic of TCM Holistic approach:

5 TCM takes the entire person and its relation with the universe into consideration when diagnose diseases and differentiate of syndrome, when establish treatment plans and selecting modalities, as well as when administer prevention and treatments. TCM practitioners also take consideration of the body, mind and spirit connections as well as its relation with environmental and social factors. Treatment is based on TCM diagnosis and differentiation of syndromes: TCM treatments focuses on the root cause of diseases that is diagnosed after the overall analysis of the main symptoms and signs summarized from the information collected through the four unique diagnostic methods and differentiation of syndromes based on the fundamental theory. For example, a chronic back pain may caused by the invasion of exogenous pathogenic factors with the obstruction of meridians and collaterals manifested as cold-damp painful obstruction syndrome or heat-damp painful obstruction syndrome. Treatment principles should be dispel cold resolve dampness, warm the channel and stop pain by prescribing herbs that are hot/warm in nature or selecting acupoints that have warm effects with reducing manipulation for colddamp syndrome, and to clear heat resolve dampness, activate the channel and stop pain by prescribing herbs that are cold/cool in nature and needling acupoints that can clear heat with reducing manipulations for heat-damp syndrome. If the back pain is caused by deficiency of kidney essence, then the patient has to be treated with herbs that tonify the kidneys, replenish essence, and/or needle the points that can strengthen the kidneys with tonifying manipulations. Rising of liver yang or sinking of spleen qi both may cause migraine headache. Subdue liver yang should be the treatment principle for liver yang rising. Raising spleen qi should be the treatment principle for headache caused by sinking of spleen qi. Completely different sets of acupuncture points and opposite needling manipulations, and different herbal medicines are used for individual patient although both of them are diagnosed with migraine. Safe and effective TCM treatment is based on precise diagnosis and differentiation of syndrome The most important factor that determines the outcome of TCM treatment is the precise differentiation of syndrome in clinical practice. Briefly speaking, deficient syndrome should be tonified, excess syndrome should be reduced, cold syndrome should be warmed, and heat syndrome should be cold. Adverse reactions and serious consequences may happen when the patient is misdiagnosed especially when differentiation is wrong. It is not hard to think what will happen if a deficient patient if further reduces, or excess patient is tonified, or cold patient is further cooled, or heat patient is warmed.

6 When liver yang rising patient gets more headache or even eye bleeding after acupuncture treatment, it may be caused by misdiagnose without differentiation or with wrong differentiation of the syndrome. When back pain patient have heavy bleeding after acupuncture treatment, it may be caused by improper needling or used the improper acupoints without TCM diagnosis and differentiation. More seriously, if a pregnant patient with back pain or migraine receiving acupuncture or Chinese herbal medicine without correct TCM diagnosis, miscarriage may be caused as a result. In order to ensure the safe and effective acupuncture, tuina massage and Chinese herbal medicine treatments, all practitioners must master TCM diagnosis and correct differentiation of syndromes. TCM terminology and language Developed thousand years ago based on a distinct philosophy and culture, TCM as a distinct medical paradigm, that has its own vocabulary and language regarding its theory, diagnostics, differentiation of syndromes and treatments that is very different compare to western medicine. Heart fire may refer to insomnia, anxiety, palpitation, mouth/tongue ulcer, and frequent painful urination that are commonly seen with patients diagnosed as mental disorder, heart disease, oral inflammation and bladder infection. Liver wind may refer to hemiplegia, tremor, and vertigo, cramping of muscles, which are commonly seen in patients who are diagnosed with stroke, Parkinson s disease, MSA, MS, Memoir Syndrome. Qi and blood deficiency refers to tiredness, dizziness, palpitation, headache, scanty menstruation with pale tongue, pale lips, pale nails and deep, weak and thin pulse, that are usually seen in patients with anaemia, leukemia, migraine and infertility. Liver qi stagnation refers to chest oppression, signing, hypochondriac and lower abdominal distension and pain, irritability with a wiry and taut pulse, that may be seen in patients with depression and PMS. Patients diagnosed with the same disease according to western medicine, may be diagnosed and differentiated with different TCM syndromes. For example, stroke patients with hemiplegia may be differentiated as excess conditions such liver fire and liver wind, phlegm heat (or phlegm cold) obstructing the channels; or as deficiency conditions such as qi and blood deficiency, or liver and kidney yin deficiency with empty heat; or as a combination of excess and deficiency such as spleen and kidney yang deficiency with phlegm obstruction. Therefore, the same western disease can be treated differently according to TCM diagnosis and differentiation. On the other hand, patients with different western diagnosis may be treated the same according to TCM if these patients are diagnosed and differentiated with the same TCM syndrome. For example, patients may be diagnosed with migraine, chronic fatigue, postpartum depression, infertility, stroke, leukemia, breast cancer may all represent a qi and blood deficiency syndrome, therefore,

7 they all should be treated the same with the principle of tonify qi and blood with acupuncture the tonifying points use reinforcing manipulations, or with qi and blood tonic herbs. Comprehensive treatments Doctors of TCM are trained with systematic and comprehensive theory and diagnostic methods, and a variety of modalities may function as general practitioners or specialists. As a general TCM practitioner, one or more modalities may be used for treatment of all departments such as internal medicine, external medicine, paediatrics, gynaecology and obstetrics, oncology and immunology. A combination of modalities such as acupuncture and herbs, acupuncture and tuina massage, or all three modalities may be used for the same patient. Medicated diet and nutrition, taiji-qigong exercise, and self-tuina may be combined for self-healing. With the comprehensive treatments, patients usually get better and lasting results. A TCM specialist may focus on the practice of one modality (i.e. acupuncture, or herbal medicine) for prevention and treatments, or focus on a specific department (paediatrics or gynaecology, or oncology) using a variety of modalities. This comprehensive and holistic approach usually brings better and longer lasting results. It is more effective for treatment and for prevention. TCM is preventative TCM always emphasize prevention of disease by nourishing life and reserving essence, protecting the body from the attack of exterior pathogens and disturbance by improper emotions. TCM also emphasizes the prevention of disease from further development. As the famous TCM saying stated: when the liver is diseased, you know that it will affect the spleen. Therefore, one should strengthen the spleen. TCM can identify the energy imbalances of health problems at early stage and to restore balances naturally Many serious illnesses are the accumulation and development of minor conditions and imbalances with chronic and persistent stress from the mind and the body. Many people may have presented health problems with minor symptoms and signs (although sometimes can be obvious and serious symptoms and signs) that can t be diagnosed and treated by western medicine. Whereas TCM doctors are able to diagnose and differentiate these conditions and imbalances at energy levels, and be able to restore balance and to improve health. In such case, TCM may be able to prevent more serious conditions that may otherwise happened to the patient. TCM complement with western medicine

8 Both western medicine and traditional Chinese medicine has its strengths and weaknesses. The combination of these medicines usually complementary to each other and can provide better care to patients in many cases. Following are just a few examples: 1. Improve patient care and facilitate better results for cancer patients: Surgery, chemotherapy and radiation therapy are the three may treatments for cancer. However, they cause serious side effects and weaken the patients. TCM may help cancer patients to reduce the side effects of invasive western treatments such as nausea, vomiting, heat and burning sensations, tiredness, weight loss, depression and hair loss. TCM also may help to improve the function of the immune system. TCM helps to prepare cancer patients and enable them to be able to handle chemotherapy or surgery, and to recover faster from surgery. Acupuncture has been shown is effective for arthritis and pain of the knee and hip. Where thousands of people are waiting the knee and hip replacement for months, acupuncture could play an important role in helping patients with pan managements and emotional stress from the pain during the waiting period. Acupuncture may even be able to relieve the pain and improve the condition to the extent where surgery may not be needed any more of can be postponed. As a result, the waiting time for those who need the surgery may be shortened. TCM helps reduce the cost of health care system People who have used TCM have already reduced the cost of our health care system because TCM took care of their problem completely or partially. TCM also may have prevented some other more serious chronic diseases of these patients. In addition, people who receive regular TCM treatments usually get healthier and happier so that they do not get sick as often or become seriously ill. $600 million may be saved if acupuncture is used for stroke patients in Canada a simple calculation Stroke in Canada Stroke is the 4 th leading cause of death in Canada and 60% of stroke victims will be left with disability. There are 40,000-50,000 new strokes reported in Canada annually, about 200, ,000 Canadians are stroke survivors, living with an increase risk of subsequent stroke. Stroke costs Canadian economy $2.5billion annually. The average acute care cost is estimated to be $27,500 per stroke. Stroke counted for 71,808 Canadian hospital discharges. The average hospital stay for stroke is 37 days and hospital

9 cost for stroke is $600/day. 3 million days of hospital care are due to stroke each year. (Canadian Stroke Foundation, 2000) Effect of Acupuncture for the Treatment of Stroke: Controlled clinical trials from United States, Sweden, Taiwan and Norway has reported the following: 1. Acupuncture provided faster recovery and a greater extent of walking and balancing ability 2. Acupuncture increases the effectiveness of physical therapy 3. Acupuncture shortened the number of days in hospital and nursing homes: 161 days for control group patients and 88 days for acupuncture treated patients. The estimated savings was $26,000 per acupuncture patient. $600 Million can be saved if acupuncture is used for stroke patients in Canada every year: A simple math: According to the study provided above, stroke patients who receive acupuncture treatment will shorten their hospital stay from 161 days to 88 days that is approximately half of the time normally required. Lets assume that 30% of the time can be shortened for hospitalization when a stroke patient is treated with acupuncture. The 3 million days of hospital care for stroke patient each year will be reduced by 1 million days. The hospital cost for stroke is $600/day and therefore the total savings will be $600 million/year. Additional benefit will be faster and better recovery, less disabled patients and less home care will be required for stroke patients and some patients may even be able to recover completely and get back to work if acupuncture is used. Therefore the $600 million saving will be increases significantly. Summary of the benefit of TCM 1. Complement to western medicine a. Improve patient care by bring better results for treatment b. Promote and maintaining good health c. Prevent disease 2. Help shorten the waiting list such as surgery of knee and hip replacement 3. Help reduce the cost of health care - $600 million may be saved annually if acupuncture is used for stroke patients in Canada

10 Introduce and integrate TCM into Ontario health care system Consider introducing and integrating TCM including acupuncture, herbal medicine, tuina massage, taiji-qigong into hospitals and health facilities for patients with conditions that acupuncture/tcm have proven benefits such as acupuncture for patients with stroke, cancer, and pains of the knee, hip, shoulder and back. Promote Inter-professional collaboration: In order to ensure safe and effective treatments for high quality and lose cost health care, all professions have to work collaboratively with mutual respect, clearly defined scope of practice, sufficiency of knowledge and competencies. TCM is a distinct medical paradigm and a new health profession. It needs to be promoted, accepted, recognized, and then introduced to and supported by the health care system. Following are the brief principle recommendations: 1. Respect the distinct philosophy and culture of TCM as well as its specific vocabularies and terminologies 2. Introduce TCM to other health professions as a medical science and as a new health profession by offering inter-professional collaborations education with the combined effort and resources of the government and regulatory colleges 3. Include TCM treatments including acupuncture, herbal medicine, tuina massage, taiji qigong into treatment protocols and administered by qualified TCM practitioners in public health facilities and in private practices 4. Educate the general public about the concept and benefit of TCM, and the scope of practice of the TCM profession 5. Clarify at legislative and regulatory level the overlapped modalities for safe and effective care provided by health professions and for informed and fair choice of the general public Acupuncture Acupuncture is part of traditional Chinese medicine. It was originated and created according to the philosophy of TCM. Safe and effective acupuncture treatment depends on correct TCM diagnosis and differentiation of syndromes. Acupuncture has a very wide range of clinical applications. As a procedure, acupuncture belongs to the controlled act of performing a procedure on tissue below the dermas in RHPA, however it was exempted from the controlled acts and had been left in the public domain without regulation prior to the passing of TCM legislation. Although the exemption is removed now, over 10 professions are allowed to practice acupuncture in Ontario. This has caused

11 tremendous concerns among the TCMA practitioners and it may cause more serious adverse reactions if it is not regulated properly and practiced outside of TCM contents. The fact of different professions will regulate its own members and set up its own standards may cause tremendous confusions to the public. Professions within the system and covered by OHIP/insurance may take the advantage of performing the procedure with very limited training and competency. As a result, performing acupuncture without adequate understanding of the energy of the body, may cause adverse reactions and serious body damage. The public, the practitioners and the regulators all should know this. In order to protect the public, ensure the high standards, safe, effective and quality acupuncture practice, ensure the public informed, fair and choices to acupuncture, ensure the equality among health care professions and with the respect to the philosophy and integrity of TCM, two types of acupuncture should be clearly defined. We recommend: Define two types of acupuncture and restrict to qualified members of authorized health professions: TCM acupuncture: Definition: Performing a procedure on tissue below the dermis, below the surface of the mucous membrane for the purpose of acupuncture and its related modalities according to the theory and diagnosis of traditional Chinese medicine for health promotion, disease prevention and treatments. Educational requirements: Minimum 2 years of post-secondary education as pre-requesit for entering the professional program 3 years of professional training with minimum of 2200 hours of direct contact including minimum of 600 hours of clinical training Restricted title: acupuncturist TCM acupuncture be authorized to acupuncturists, TCM practitioners and doctor of TCM Anatomical acupuncture: Definition: Performing a procedure on tissue below the dermis, below the surface of the mucous membrane for the purpose of acupuncture pain relieve according to human anatomy and physiology as an adjunct therapy. Educational requirements:

12 Four years of professional training at post graduate level WHO standard for qualified physicians (200hours) Restrictions: Authorized to qualified members of the professions authorized to practice acupuncture within their scope of practice for pain managements. Shorter period of training in TCM (less than one year) carry an adverse event rate double that of practitioners who have studied for four years of more. (HPRAC TCM Report 2001, p13). According to the report, in an extensive report commissioned by two Australian states, New South Sales and Queensland, Bensoussan and Myers report findings about adverse effects of acupuncture based on a survey of practitioners using acupuncture. They reported that the most common adverse events reported were fainting during treatment, increased pain and nausea and vomiting. Serious events were reported to include pneumothorax and convulsions. Other reported events were local skin infection, psychiatric disturbance, headaches, diarrhea, sweating, dizziness and severe asthma. This result can be explained by the lack of understanding of the human body in terms of energy flow, the meridian system, the location and function of the points and the yin/yang balance. With my formal training in TCM (5 years full time), over 30 years of clinical and teaching experience and my understanding of acupuncture and the fundamental theory of traditional Chinese medicine, please let me try to explain. The human body is a complex of organs and tissues connected through a network called meridian system. Energy is circulating smoothly within the meridians along certain directions. Imbalance of energy or obstruction of the meridians and dysfunction of the internal organs are the basic mechanism of disorders and diseases. Acupuncture balances the energy, removes obstruction and regulates the functional activity of the internal organs when it is administered properly. It provides invaluable health benefits and it is effective for a wide range of conditions. The following are some examples: Acupuncture removes obstruction of energy to alleviate pain because pain is caused by energy stagnation Acupuncture also alleviate pain by tonifying the energy because deficiency of the energy can cause pain Acupuncture can alleviate pain by clearing heat because heat can cause pain Acupuncture can alleviate pain by warming the channel, dispel cold because excess cold in the body can cause pain Acupuncture can raise qi when it sinks and therefore to treat prolapse of internal organs.

13 Acupuncture can lower qi when it rebellious and therefore to treat nausea, vomiting, cough and asthma. Acupuncture can draw qi down when qi rises and therefore to treat liver yang rising, a very common pattern of hypertension manifested as headache, dizziness, insomnia, irritability or mental disturbance, red eyes or red face and so on. Acupuncture can raise qi to the head and to treat headaches, dizziness, depression and insomnia caused by qi and blood deficiency when the brain and head do not receive sufficient qi and blood. Acupuncture can clear heat reduce fever and hot flashes. Acupuncture can warm the body, promote blood flow and to treat poor circulation. Although these descriptions may be challenging to understand for many people who do not know TCM, but this is what acupuncture is about (in a very simplified way for explanation only). It is clear that a correct TCM diagnose, precise location and proper selection of acupuncture points and the proper manipulation of the needles is all important for the effectiveness of acupuncture. This is clearly indicated by a comprehensive research quoted on page 15 in the 2000 HPRAC TCM report: The bulk of controlled clinical studies (using sham needling) provide evidence that the observed physiological effects of acupuncture are point (treatment) specific, and not solely a response to the stress of needling. This indicates the acupuncture without TCM is less effective. Less effective or no effect treatment will delay the healing of the patient and wasting of time and money. It is risk and also waste. Acupuncture treatment for pain is a very good example that shows the complex of acupuncture practice as listed above. Pain can be caused by different reasons and the differentiation and TCM diagnosis of pain requires a comprehensive understanding of traditional Chinese medicine and the entire meridian system. The treatment of pain is based on the correct diagnose. The effect of acupuncture for pain relieve is based on the precise location and proper combination of points and proper manipulation of the needles. Just like pain management by medical doctors and physiotherapists. The doctor has to know all the basics of medicine and then be specialized in pain management. The physiotherapist must receive full training in physiotherapy and then be specialized in pain management. A practitioner of acupuncture must first learn all the basics of TCM and acupuncture and basic Western medicine and then be specialized in pain management or sports medicine and so on. Misdiagnose or performing acupuncture without TCM diagnose are very important factors for higher rate of adverse events.

14 The adverse events, risk of harm from acupuncture are not just stems from the performance of a procedure on tissue below the dermis. The following are just a few examples of adverse events of acupuncture when it is performed without TCM diagnosis. If a patient has excess energy in the head causing headaches, the proper treatment should be lowing the energy and stop pain. If the practitioner accidentally raises more energy to the head, due to improper selection and combination of points, or due to improper needling manipulations, or the practitioner failed to recognize the imbalance of the energy of the body, as a result, this acupuncture treatment may cause more severe headaches, dizziness, fainting, convulsion or even stroke in severe cases. Sciatica, fibromyalgia, back pain or pains of many kinds are usually treated with a variety of modalities by different health professions including physiotherapists, chiropractors, naturopaths and massage therapists. Acupuncture does have good effect in relieving pain only when used properly. While acupuncture is performed for pain relieving, it also produces other physiological effects such as the regulation of energy. A group of points can be perfect for a sciatica patient according to anatomy and western diagnosis, but the patient may not get any effect. Not only that, acupuncture may also produce some adverse events in some cases. For example, a group of points (UB 23, UB-32, UB 37, UB-40 and UB 60 on the back and leg) are usually used for sciatica and it usually helps the pain. However if the patient has very low energy in the head (may be manifested as slight headache or dizziness, depression, insomnia), this acupuncture treatment will draw the energy downward to the back and leg to cause more deficiency energy in the head. Therefore the patient may suffer from sever headache, worse insomnia, more depression, or fainting, even convulsion). This is why there are twice as much of the adverse events for acupuncture practitioners with shorter period of training compared with practitioners who have studied for four years or more. Acupuncture may cause palpitation and arrhythmia and sweating when it disturbs the heart qi. This may happened when using acupuncture to treat carpal tunnel syndrome or degenerative spinal problems. If a patient has heat in the body and the practitioner uses points and manipulations that warm the body, the patient may feel hotter or burning sensation after treatment. There may even be bleeding (usually nose bleeding) in some cases. This may happen when using acupuncture and associated technique such as moxibustion to treat back pain by following a menu without proper TCM diagnosis.

15 If a patient has cold condition and the practitioner uses points and manipulations that clear heat and cool the body, the patient may feel colder or shivering during, even shock in severe cases. This may happen when using acupuncture to treat neck and arm pain following a menu without differentiating if the patient has cold or hot condition Acupuncture may cause nausea, vomiting or severe asthma (rebellious qi) when it disturbs the normal flow of stomach and lung qi which normally moving downwards. This may happen when acupuncture is used for sciatica or back and leg pain, Fibromyalgia and stroke without proper TCM diagnosis. Selection of acupuncture points and manipulation of needles depend on the treatment principle. The treatment principle is established based on precise diagnosis. Diagnosis is based on TCM theory. It is an art to do acupuncture. The safety and effectiveness of acupuncture depends on the knowledge and understanding of the human body from both TCM and Western medical perspective, and depends on the practical skills of the practitioners. The risk of harm and the effectiveness of acupuncture are closely related to the theoretical basis of the treatment. Lack of understanding of the theory of TCM, misdiagnosis of the patient will result in higher risk of harm as high as 200%. Practicing acupuncture outside the scope of TCM can be very dangerous. Final Words Traditional Chinese Medicine including Acupuncture (TCMA) is an ancient Asian medical paradigm that is getting more and more accepted by modern western world. It s health benefits are proven and well documented. Practice of TCMA is a serous and formal health profession. Proper regulation will ensure the effectiveness of public protection and the further development of TCMA for the optimum health benefits of Ontarians. TCMA deserves its attention for its introduction, and integration into the health care system. It is no doubt that TCMA will contribute to our health more significantly in the future. Acupuncture is part of TCM. Practice outside of the TCM contents with limited training could result in increased adverse events. The regulation of the practice of acupuncture by various health professions needs to be carefully considered regarding the definition, educational standards and scope of practice.