# In Singapore, the TCM Practitioners Board shows why quacks shouldn’t self-regulate

I’ve probably mentioned this before, but I’ll mention it again. I have a bunch of Google Alerts set up for various key words and phrases. I mention this not because it’s in any way unique or even particularly unusual blogger to do this, but rather to explain how I’m ending up today writing about a case of traditional Chinese medicine gone wrong in, of all places, Singapore. Of course, I do deconstruct the claims of TCM and TCM practitioners on a semi-regular basis, and Singapore is in Asia, meaning that it is not unusual to find TCM practitioners getting into trouble there, given the popularity of TCM in many areas in Asia even outside of China. (Heck, the World Health Organization has shown a disturbing credulity towards TCM.) It’s also not surprising that Singapore would have a TCM Practitioners Board. (At least I didn’t find it so.) It’s also not surprising that such a board set up to regulate quacks is tolerant of quackery, given that its members are quacks who believe in the same quackery. In other words, quacks shouldn’t self-regulate. This is how I came across the story of Lee Miing Chong, a TCM practitioner in Singapore and the damage he did to one patient that led to sanctioning by the TCM Practitioners Board. Google done it. Google led me to it.

Specifically, Google led me to a letter to the editor of the The Straits Times, What is TCM diagnosis based on? by Dr. Ong Siew Chey. It’s a response to a chain of letters about a diabetic patient who lost part of his leg thanks to the quackery that is TCM. Yes, it’s just one story. Yes, it’s in a nation far, far away from here. However, it’s a case that, I can almost guarantee, no one in the US medical blogosphere is discussing that gives insight into how TCM is practiced—and not just in the Western nations into which it has insinuated itself, thanks to an active effort of WHO and the Chinese government. So let’s go to the original news story that provoked Dr. Ong’s response, TCM practitioner suspended after treatments caused patient to lose part of leg:

A traditional Chinese medicine (TCM) practitioner has been suspended for three years and fined \$5,000 after his treatments caused a diabetic patient to subsequently lose part of his left leg to amputation.

Mr Lee Miing Chong treated the 59-year-old patient on two occasions in 2015 for poor sensation in both feet, the TCM Practitioners Board said in a statement on Wednesday (March 13).

On Jan 3 that year, Mr Lee used heat lamp therapy on the soles of the patient. However, after the treatment, blisters developed and burst when the man walked. The patient returned to the clinic immediately.

Despite Mr Lee cleaning his wounds, applying medication and bandaging his feet, the patient ran a high fever that lasted until the next day.

Anyone who’s done primary care or, as I have during my training, vascular surgery (in other words, anyone who’s had to deal with diabetic feet, not exclusive of those two specialties) knows that it’s a terrible idea to apply a heating lamp to a diabetic foot, particularly the foot of someone who is already complaining of decreased sensation in that foot. Diabetes, as many of you know, causes damage to the microvasculature of the foot as well to the nerves. It’s a frequently deadly combination. The reason is that compromised blood flow to the foot means that in diabetics minimal injuries, injuries that you or I might not even notice and that for you or me would heal without incident, don’t heal as fast or might not heal at all. They can fester and become infected, to the point that the infection threatens the limb. These infections can be very difficult to treat because compromised blood flow means that antibiotics don’t penetrate as well and don’t heal as well after the debridement of dead tissue. Speaking of dead tissue, compromised blood flow can even lead directly to tissue death by itself. Now, add to that decreased sensation, and the danger is even worse. The diabetic can’t tell when he’s suffered an injury and therefore doesn’t care for it, leading to its getting infected and not being discovered until it’s much further along. That’s why meticulous foot care is absolutely essential for diabetics, especially ones already complaining of decreased sensation indicative of nerve damage (neuropathy).

You can see why applying a heating lamp to the foot of a diabetic like this is a horrible idea. What happened to the patient was completely foreseeable to anyone with a basic understanding of diabetes and its effect on feet. If Lee had applied a heating lamp to my soles, for instance, I’d be able to tell him when it got too hot and pull my foot away before it blistered. Even if I did get blisters, they’d almost certainly heal without incident, because I’m not diabetic, and I don’t have diabetic vasculopathy or neuropathy. Mr. Lee’s patient needed immediate treatment by someone who knows diabetic feet, preferably a vascular surgeon.

What he didn’t need was this:

When the patient went to see Mr Lee the next day, he was given acupuncture and electric pulse treatment. But as his condition worsened, he had to be admitted to hospital on the same day for severe burn wounds on his feet.

As he had diabetes, the burns did not heal. Four months later, his left leg was amputated below the knee.

What a surprise! The acupuncture didn’t help a serious burn on the soles of a diabetic feet! Who’d have thought it? So what recourse did this patient, now missing the lower part of his leg unnecessarily, have? It’s not good. He complained to the TCM Practitioners Board. Did the Board do anything? Not really. Not much:

After an inquiry, the investigation committee concluded that while using the heat lamp was appropriate and generally accepted in treating the man’s condition of general weakness and chills, Mr Lee did not inform his patient about the risks or other available treatment options.

It also found that Mr Lee failed to take adequate precautions and care when providing the heat treatment. Instead, he placed the heat lamp too close – a palm’s length – to the soles of the patient’s feet and for an extended period of time.

He did this despite the patient telling him that both his feet had poor sensation and asking him to be careful.

A heat lamp is an “appropriate and generally accepted” TCM treatment for general weakness and chills? Well, as I’ve discussed many times before, TCM is basically a vitalistic system based on prescientific beliefs not unlike those of humoral theory. Where in humoral theory there are the four humors that need to be balanced, in TCM there are five elements, and various diagnoses balancing fire (heat) with cold. There are also treatments involving actual fire, such as the one I described before during which an alcohol-soaked cloth is draped over a patient and set alight to warm the skin and “open the pores,” after which an herb-infused oil is applied. I asked at the time whether a heating pad would have made more sense, but putting a heating pad on a diabetic foot would be just as bad as a heating lamp.

In any case, notice how the TCM Practitioners Board doesn’t question what Lee did. It only blames him for being sloppy about doing it. Hilariously (at least it would be hilarious if not so infuriating and harmful to patients), the board then continued:

In addition, the investigation committee noted that Mr Lee failed to provide an appropriate and generally accepted method of TCM treatment after the patient’s soles suffered burns.

Why hilarious? Apparently there is no accepted TCM treatment of burns, at least not according to the Singapore TCM Practitioners Board:

He gave his patient acupuncture and electric impulse treatment when he should have advised the man to seek immediate medical attention, given the seriousness of his injuries.

This led to a delay in the patient seeking appropriate medical treatment.

So what was the punishment? Nothing more than a \$5,000 fine, a three year suspension, and a censure, even though apparently Lee Miing Chong fell back on the ever popular quack tactic of blaming the patient.

Now here’s where Dr. Ong Siew Chew comes in with a letter to the editor, Clarifications on TCM treatment:

Initially, Mr Lee used heat lamp therapy on the soles of the patient’s feet for the man’s condition of general weakness and chills.

This part of the treatment was considered “appropriate” by the TCM Practitioners Board even though numbness of the feet in a diabetic patient is usually caused by neuropathy or ischemia, and neither situation should be treated with the application of heat.

Precisely. Applying heat to the soles of the feet to treat “weakness and chills” is not just quackery, it’s dangerous quackery. It cost this man his foot. Dr. Ong Siew Chey, I note, is pretty well-known in Singapore as a retired Professor of Surgery at the University of Singapore. I like the way he thinks, too, based on this interview with him published by the Singapore Medical Association from 2010:

Surgeons of my generation were the last of the general surgeons who had to do everything from head to toe. Of course, the Chinese have a saying…The English equivalent is “Jack of all trades but master of none.” For sub-specialisation, the Chinese have another saying… meaning that if you look at a leopard through a tube, all you see is one spot. General practice and sub- specialisation both have their good and bad points. There seems to be no perfect solution to our dilemma.

The main problem arises when patients have multi-organ conditions. When you have some six consultants coming in for one single case, disorganisation, conflict and confusion may be unavoidable. You need somebody with broad knowledge and experience in charge, someone who knows what is going on.

Yep. And I say this as someone who started as a general surgeon and then subspecialized. In any case, This is the core issue, which is why I sarcastically said that apparently TCM has no accepted treatment for burns. This eminent retired surgeon in Singapore zeroed in on this issue, too:

The board said that Mr Lee failed to provide “an appropriate method of TCM treatment for the patient’s burns”, and that he should have advised the patient to “seek immediate medical attention”.

The TCM Practitioners Board should clarify what the “appropriate method of TCM treatment” here refers to.

It should also indicate whether “immediate medical attention” means Western medical treatment.

And if so, at what stage of the treatment does the board favour a switch to Western treatment?

All excellent questions.

Two weeks later, having received no response, Dr. Ong Siew Chey noted that there had been no response to his letter from the TCM Practitioners Board and reiterated his questions. So the Executive Secretary of the TCM Practitioners Board, Quah Ai Mui, finally responded:

The patient had first consulted Mr Lee for his condition – general weakness and chills.

The diagnosis based on TCM syndrome differentiation was deficiency in “yang” energy.

Treatment with a heat lamp is appropriate and is one of the generally accepted methods of TCM treatment for this condition.

However, Mr Lee failed to take adequate precaution and care when he was administering the heat lamp treatment to avoid inflicting burns or injury to the patient’s feet.

When the patient developed blisters on his feet due to thermal burn, Mr Lee should have referred the patient for Western medical treatment.

When the patient subsequently developed a high fever which persisted, Mr Lee should have referred the patient to the hospital for further treatment without delay.

I can only conclude two things from this. First, “yang energy deficiency” is utter nonsense, a fake diagnosis based on superstitious prescientific vitalism. Second, apparently TCM is only good for treating fake diagnoses like “yang energy deficiency,” because, according to the TCM Board, once the patient developed a real medical problem (significant burns on the soles of his feet and sepsis), TCM should be abandoned.

Dr. Ong Siew Chey would not be deterred. (I’m really starting to like this guy.) In another letter, What is TCM diagnosis based on?, he responded:

According to the board, the diabetic patient’s initial complaints were “weakness and chills”.

Whether the symptoms were systemic or confined to only the feet is not clear.

If the symptoms were systemic, the cause could be anaemia or infection.

If only the legs and feet were affected, the cause could be lack of blood supply to the lower extremities or diabetic neuropathy.

There could have been other causes that required scientific investigation.

Why did the board call it a “deficiency of yang energy” and agree that heat lamp application to the feet was “appropriate” treatment?

What is the patho-physiological basis of “yang energy”?

Singapore is now a First World country and is able to provide scientific, evidence-based medical treatment to its people. Why is there still a need for treatment based on 2,500-year-old concepts?

I couldn’t have said it better myself (although I could have taken longer to say it).

Fans of TCM were not pleased, however. For instance, Amos Wu Pom Hin wrote that “one mistake by a TCM practitioner does not justify throwing the baby out with the bathwater” and then went on:

To leap from this complaint of the uncertain utility of TCM to the conviction that it must then be useless is, according to physicist Carlo Rovelli, the failure to grasp the utility of uncertainty, bringing about the “origin of much silliness in our society”. Is science-based medicine the iron-clad practice that it is made out to be? Albert Einstein was humble enough to proffer that “if we knew what it was we were doing, it would not be called research”.

While experts revel in their scientifically proven practices, people should acknowledge that they do not know everything.

Thus, to denigrate TCM just because it had its roots in primitive and herbal cures is to commit the fallacy of argumentum ad ignorantiam, or arguing from ignorance, that something is false simply because it has not been proven true.

This comment merits the Godzilla facepalm:

The “utility of uncertainty”? Um, sir, there’s no uncertainty here. TCM does not have a basis in science. It’s prescientific quackery. Also, seriously, this guy needs to learn his logical fallacies. Or maybe not, given that he himself just demonstrated a logical fallacy of his own while projecting it onto TCM critics. I mean, seriously. How does one go from appealing to ignorance, saying that just because we don’t know for sure it’s not true doesn’t mean it’s not true (“people should acknowledge that they do not know everything”) to accusing TCM critics of basically the same sort of thinking? The cognitive dissonance must be astonishing. At least he admitted that TCM had its roots in “primitive and herbal cures,” although he does conveniently ignore a lot of the religion and prescientific vitalism that are also the basis of TCM.

Finally, Tan Jun You invokes the “your science can’t explain my TCM” fallacy, even as he commits the argumentum ad populum (appeal to popularity) logical fallacy:

Traditional Chinese medicine (TCM), in a very quick and general view, is based on the black box theory, in which one sees the signs that manifest on a patient’s “exterior body” through the “inner body’s” complex system with many possibilities.

It also takes into account a holistic view of the environment and the body, as well as the subjective feelings of the patient’s own body condition.

It requires a huge paradigm shift in perspective as TCM methodology cannot be explained in scientific terms, as concluded by many scholars and researchers worldwide.

To quote from the website of the National Centre for Complementary and Integrative Health, the US Federal Government’s lead agency for scientific research on complementary and alternative medicine: “TCM can be difficult for researchers to study because its treatments are often complex and are based on ideas very different from those of modern Western medicine.”

How convenient. If science doesn’t support your quackery, say that it requires a “paradigm shift” because your quackery can’t be explained “in scientific terms.” To be honest, I wouldnt’ care that much that TCM is “based on ideas very different from those of modern Western medicine” if those ideas could be tested scientifically. Of course, many of them can, and nearly all of them failed. The only useful remedies to come out of TCM are few and far between and virtually all herbal remedies that don’t need the mystical vitalistic edifice of TCM to explain their utility and could be discovered by pharmacognosy, the branch of pharmacology that studies the medicinal properties of natural products.

Perusing this story and the subsequent exchange of letters to the editor, I can’t help but be depressed. The arguments for pseudoscience are the same all over the world. It also shows us that boards regulating quack specialties are also the same all over the world, which is why quacks can’t be trusted to self-regulate.