by Bob Flaws

As I think I have mentioned previously on this blog, my first teacher of Chinese medicine was Michael Broffman. In one of those early classes, Michael talked about the importance of follow-up. This means getting back in touch with a patient three, six, or 12 months later and finding out what was the net or final result of treatment. For instance, some patients may appear cured only to relapse soon after the cessation of treatment, while others may leave treatment because of a lack of initial results only to have all their symptom disappear not long thereafter. If the practitioner fails to routinely follow-up patients, in the first instance, they will think they are more effective than they truly were and, in the second instance, they will think they are less effective than they thought they were. Michael described how his Taiwanese teacher (a Dr. Li if I remember correctly) required his students to follow-up with patients at regular intervals after treatment so as to really understand what treatment had or had not accomplished.

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Similarly, in clinical studies published in Chinese medical journals, there is often the inclusion of being free from all or part of the patient's original symptoms on follow-up as part of the definition of outcomes criteria. For instance, in some studies you will find the definition of cure as meaning that all the patient's symptoms had disappeared and (3, 6, 12 months) later had not recurred. Likewise, improvement in such studies is often defined as disappearance of some or all of the patients symptoms but, on follow-up after a specified period of time, some or all the symptoms had returned. In these kinds of studies, the length of the follow-up period after the conclusion of treatment is specified and varies depending on the condition being treated. Without the inclusion of such results on follow-up after a specified period of time, a study does not carry much weight.

One also routinely finds statements about follow-up in Chinese case histories published in the contemporary journal literature. The concluding line of the majority of such case histories reads something like, "After three months of treatment, all the patient's symptoms had disappeared, he/she was cured, and, on follow-up after one year, there had been no relapse."

In my experience, it is rare for North American practitioners of acupuncture/Chinese medicine to do this kind of follow-up on a routine basis. Yet, as Michael Broffman stated 30 or more years ago, without doing this kind of follow-up, you really don't know what your outcomes are. It's a fact of life that often patients simply disappear from practice. Commonly, we assume that the patient left because he or she felt no effect from our treatment and decided not to "pour good money after bad." However, from my own experience, this may or may not be a correct assumption. I can't even count the number of women who I treated for infertility and discontinued treatment without informing me they were stopping only to find out at some later date that they had gotten pregnant within months thereafter and definitely attributed their success in conceiving to my treatment. Conversely, I frequently read American case histories published in non-peer-reviewed "journals" where the practitioner describes the patient's treatment, we're told the patient's symptoms improved or disappeared, and the practitioner claims that as a cure. However, without follow-up, that claim is simply unsubstantiated.

In all but the rarest of clinics there are slow days. If you really want to improve your clinical skills, I recommend spending some of that "down time" calling old patients and asking them what the net effect of their treatment with you was. You'll probably be surprised in both directions. Nevertheless, you will have learned something valuable: what actually did or did not work. Only based on that kind of real feedback can we amend what we are doing, making it constantly better and better. In any case, the next time you read a clinical trial, cohort study, or case history, look to see if there is inclusion of follow-up. If there is, great. If not, take what you have read with a very large grain of salt. Similarly, if your teacher in class tells you a case history claiming this or that treatment was effective, ask if he or she did follow-up and what the result of that follow-up was. If the teacher cannot tell you there was follow-up and what the outcomes of that follow-up were, it's probably best to keep your mouth shut, but now you also know how to weight those claims. It's only by asking such "hard" questions of ourselves, our teachers, and our written sources that we as a profession can really move forward. I believe we owe this to our patients, our profession, and ourselves. Based on my reading of the Chinese medical literature, such follow-up is a standard part of professional practice in China.

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