Hello, I’m Virginia Doran. And this week’s show title is modern language, ancient knowledge using acupuncture research to communicate acupuncture’s evidence. The guest today is Sandro Graca, who is just doing amazing things for this field. We really need to thank him and people like Mel hopper, Koppelman, who are doing things through the evidence based acupuncture, uh, organization, and other things. Sandro originally from Portugal, though, he graduated from the Irish college of TCM.
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He’s a fellow with a bar and practices in Dublin fertility medicine at the Sims clinic. He’s also a member of evidence-based acupuncture board and is an avid and a speaker and promoter of acupuncture research. Additionally, he teaches at the Northern college of acupuncture in New York and UK, and sits on the board of the obstetrical acupuncture association. So Sandro, thank you for being a guest. Thank you for having me here. It’s a pleasure to be here with you having a chance to chat and thanks to the American acupuncture council for having me.
It’s a pleasure. Yeah. And we all want to thank the American Acupuncture Council for so generously, you know, supporting these shows and producing them. Um, so I wanted to start by asking, how did you get into research? It’s not a path everybody takes in acupuncture. Yeah. It’s um, I suppose it’s a, it’s a follow on from the acupuncture, right? The, um, and it’s funny when you, when you asked me that my brain was like, Oh, a few years ago, people used to ask me and we all used to this in the clinic. How’d you get into acupuncture in the first place. And now it’s, how do I get into, um, to research? And actually the answer is pretty simple. And I, I started reading the papers after qualifying and, you know, you read all the books and you’re in college and you have your teachers and you start practicing in the clinic. And eventually
It just led to my field being, you know, more into, um, acupuncture for fertility and pregnancy. And I just started to read papers, you know, studies that were out. And at the time, I honestly, I didn’t know how to, or you know, that there was a way of reading them. I would just jump straight into the methods.
Well, that’s encouraging because for a lot of us, it’s a challenge too. We haven’t had sufficient training in school to really read and analyze research papers.
It’s, it’s a different, it’s a different language, isn’t it? And then, you know, it’s a different language, but here I am, you know, from Portugal and studying Chinese medicine in Ireland. So I guess I’m missing the different languages. Right. But, but yeah, I would just, you know, initially it would be like, what you’re saying it is, it is, it is a more complicated language. Like academic writing is different and from what we’re used to from a book, for example, and I was just, yeah, I was just jumping to that method section because I wanted to see what points they were using for the studies and almost like a compare and contrast on what I was using in the clinic as well.
So why do you think acupuncture’s should be research literate even if they don’t plan to use it and they just intend to be a practitioner clinical practitioner.
Yeah. So, so kind of like the same principle. So first of all, to keep up to date and there’s, there’s that, there’s that difference between, you know, how much do you need to know about research and do you just want to be able to read and know how to read it and interpret the paper and get the, I suppose, the juice from the paper, or are you really interested in doing research because that’s way further down the line, right? So for, for a practitioner in the clinic and independent of specializing in one particular field, or, or just being more general practitioner, just to keep up to date, because, you know, unfortunately, you know, books are written, it could be five years plus before there’s a second edition of that book. And in terms of getting like what’s up to date, you know, getting it from from research is the quickest way to, um, to learn, you know, and to keep up to date and then you start getting into, you know, why, and, and really why it matters for the profession as well.
And not just for the individual is because of trying to learn how to use that language and whether we want it or not. The reality is that for most of the other medical fields, they understand that language. They like to communicate in that language. And they like to use research for argument, you know, argumentation between people, right? So learning how to, again, get the information from it and know how to use it, you know, get familiar with the language just means that you will be able to then communicate with people. I I’ll give you one very quick example. And it’s like, I’m very practical in terms of telling people why and giving them examples. If you’re going to be talking to someone, it being a new patient, just a member of the public, a consultant, or even a healthcare policy maker. If you’re going to talk to them about what you do, if you have that chance of like the five minutes, you know, golden ticket to tell them what you do, if you use terminology that we would use to one another, because we’re both practitioners, they don’t understand it. Right. And sometimes people think about this and go like, Oh, but it’s what we do. And if you’re good at explaining, and I always say, no,
Know your audience,
Think about how you felt during the first day in TCM school. Think about how you were during that first week, during that first month with all the different terminology, you know, there was she and Shen and jingle. It, it, it was all new to you. And it took you a little bit of time to understand the concepts, to get, you know, it’s a new way of looking at things, right? It’s like a new reality. It’s like the new lens to look at it. Right. You only have five minutes with these people. They don’t know the terminology, but there’s other terminology that they’re familiar with. Right. And if you use that, you just going to engage with them and you’re going to be able to communicate with them.
Makes sense. Absolutely. I always don’t, it’s like, don’t explain it in Chinese medical terminology because you know, for a lot of people they’re not going to understand, and they’re either going to think you’re trying to fool them or they’re going to think, Oh, that’s very poetic, but it sounds like gobbledygook, you know, talk to them at the level they’re at. So if it’s a doctor using research language, if it’s just a lay person, you know, keeping it scientific, but simple enough for them to understand.
Yeah. There’s different levels, right? Unlike again, if we go to the different levels and the extreme of like the healthcare policy maker, a lot of the times healthcare policy makers don’t even come from a medical background that could be from a law background. So not only that person might not have the medical background, they definitely don’t have your own medical paradigm background because they’re not TCM. They’re not even, you know, biomedical, how are you going to communicate with them? Right. So I always say like, as you pointed out, you know, it’s have that in your head about know your audience. Who are you talking to? You might only have a few minutes if you’re talking to another practitioner. Absolutely. I love talking about the classics. I love talking about Chinese medicine. Love talking about acupuncture, use the terminology with your colleagues, but when you’re talking to other people, they might not know it and you’re just going to, you’re going to lose.
Right. Right. Now, what would be your advice for starting into some sort of knowledge of research literacy? Like where would somebody start assuming they didn’t have a good program in school for that practice?
Yeah. You know, this is the, this is the lecture in me. Can just go, you have to practice more. Um, yeah, it’s true. I it’s difficult because you know, a lot of the times you don’t even, you don’t even learn it in school as such like the basic research skills of, you know, where to find the papers, how to go about finding them. And then there’s the whole thing about, you know, what’s the quality and how do I know that this is a good paper or not? And I would say, just start and get to it. So go online. Pub med is the easiest way to do it. It’s free, you know, indexes, most of the papers there. And again, think about the levels and think about the steps. There’s, you know, whenever, whenever we hear the word research, we’re thinking about, you know, lab coats and run the mice control trials.
And, you know, for those, and, you know, can look at the pyramid and think that you’re all the way up the top of the pyramid, but, you know, think about lower down the pyramid because it needs that space too. So, you know, start reading about case studies case reports, learn how you learn, what are the different types of studies that go up that pyramid of evidence and get familiar with it because there is, it’s really difficult to jump ahead and think that you just, you have to read all the RCTs. It’s difficult. It’s like trying to learn how to drive in a Ferrari, you know, get your little binder car first and get familiar with it. And then once you’re, once you’re more comfortable, then you get your next car and so on and so on. So pub med will be my first recommendation, you know, Google scholar as well.
Um, the results from Google scholar, just because it includes more stuff. And it just it’s a lot like there’s chapters of books and books and stuff like that. I prefer pub med. And I would always say to colleagues, start there and look at, you know, different years, different publications, you will start to know as well. You might have a particular author that you read the book from college or that, you know, from before and just try and follow and see what other publications that particular author has and, and just practice really, you know, it’s it’s, you gotta get used to it. It’s a different language, but again, look, we’re TCM practitioners. We are used to different languages, right. We can study Chinese medicine. So yeah, practice scholar would be the key ones.
I was surprised when you really encouraged, uh, when we spoke yesterday about, uh, practitioners doing case reports that that really filled a need. I just thought I didn’t really see the value in it until you explained it to me.
I think that, you know, it’s, it’s a big passion of mine and with evidence-based acupuncture, both Mel and I have spoken about this before in public and in our own work and trying to how to approach this in a way to, again, having those five minutes and getting people involved with us. And I always mentioned too, when, when I’m doing my presentations, I always say that I love to put it out there because that’s, you know, the standing on the shoulders of giants and you see something and you try to improve on that and build up on that. But it always breaks my heart a little bit to see that you read the research paper and independent of the results you look at who was doing the treatment, who was doing the acupuncture. And a lot of the times it’s not acupuncturist.
Why, you know, why can’t I get involved in this? Why can’t we as a profession? You know, it should be us doing this. So again, thinking about the different steps and jumping ahead and thinking that, you know, someone is going to arrive with a bunch of money and get us to do a big, huge RCT. Yeah. Let’s keep our fingers crossed and hope that that’s going to happen, but probably won’t. So let’s start somewhere else. And that was something that recently we started to put that together and get that point across of let’s build that bottom of the pyramid of the case studies and the case reports and just write them and write them according to the guidelines. So you can go online and you can find it’s care, hyphen, a statement, care, hyphen statement.org, and you can get the guideline. It’s like a roadmap that you follow those, you know, those guidelines, those principles to write your case report, that’s where the name comes from.
Just kind of keep it in your head it’s care because it’s for case reports, CA R E. Yeah. So, um, you know, research, we love acronyms. It’s amazing. And, but, but it’s, it’s going to, a lot of the times it’s going to turn people’s head because it’s like a case studies case reports are at the bottom of the pyramid. But last year I was doing a day, it was a pre symposium lecture in a, in Portugal. And that came about, and I just had those few seconds when someone asked a question in the audience about a case reports and I was like, but hang on a minute, look at the pyramid. It doesn’t matter how much you look at the top of the pyramid. If the bottom of it is not strong and full, the whole thing is going to collapse. It’s like the house, right?
So for us to be thinking that as, as starting in research and has not having enough funding and all that start aiming and thinking about our CTS, I think in my opinion, that it’s just going to take a lot of energy and we’re just not going to get there. Let’s get familiar with the case studies and the case reports. And look at the time that we’re going through right now, where there’s, the virus is going around. There is no time for RCTs. There is no time for huge literature reviews and studies. We’re going on case reports, we’re going on case studies, right until the month start building up. And then you start putting that amount of work together. And eventually there will be trials, right? Right. We can do this. Right. We have the guidelines. It doesn’t matter how much training you had in school.
You’re doing this all the time. You’re treating patients, you’re in clinic, you’re treating patients, you’re taking notes, put those notes into those guidelines, start producing case studies, start putting case reports out there, you know, try and get them published. You know, you get your name out there. It looks good on your CV. And eventually you just start building up that bottom of the pyramid and Hey, some of those case studies and those case reports might end up being a pilot trial. They might end up being an RCT at some stage, you know, fingers crossed. Yeah.
How can a practitioner, uh, incorporate the knowledge from the existing literature in their practice?
Well, I’ll give you a very, very, again, an example that was like, wow. So if I can’t remember exactly how many years ago, but a few years ago in Australia, when the legislation changed, one of the things that came out for the acupuncturist is that they couldn’t do any direct advertising of any kind. So they couldn’t even, it’s almost like they can’t even talk about what they do. Right. And, and yeah, you know, it’s a bit like I do this, but I can’t tell you anything. And you know, there’s different levels of advertising, right? So that, wasn’t the point of it. The point was what some practitioners then started to develop and credit to the first person I heard saying, and then using it this way, it was Deborah bets. And she was like, well, you can’t talk about what you do, but you can talk about the research that is out there.
Right? So instead of writing on your website about what you do, and these are the conditions that you see, and then having hassle with people saying, Oh, you can’t say this. You can’t say that. Why don’t you start talking about the papers that are out there and start saying something like, Hey, here’s a paper from the study and 2019. And Hey, there were 10 people. It was a small trial, but isn’t it funny that even from that small trial, they found that blah, blah, blah. And at point they can’t come to you and say that, Oh, you can’t write that because it’s advertising because you’re saying I’m not advertising. I’m just talking about what they found from the paper.
Yeah. There’s always a work around isn’t there.
I shouldn’t be saying this life. Yes. But you know what I mean? Like if you’re reporting and if you’re talking about stuff that is in the study, number one, you’re informing the public. So you can use that as a training for you for when you’re talking to the person in the clinic, you can use it for your website. Right. You can use it for your blog. You can use it for your social media and, you know, for the public it’s information, you’re not selling that, Hey, come to my clinic because I do this. You’re just saying, I’m an acupuncturist. Here’s what, you know, a study from last year, I found about acupuncture and this, I do this type of acupuncture in my clinic, you know, work with us. Um, that would be, you know, that would be kind of like the main thing also remember, and I keep saying this all the time, stay up to date, right. If there is, you know, you’re doing, you’re doing
Well these days, that’s hard. There’s so much coming out.
Exactly. Right? Like even with research, it’s tough sometimes because there’s so much coming out, but you know, don’t stay in the same place and, you know, I know want to be critical, but you know, it’s not the same points all the time, the same people all the time, it’s everyone is different. And there’s been times when something comes out of a research paper that I go, wow, I actually, I never thought of it, but that’s actually a very good idea to use that particular point prescription for this. Or even not with a point prescription, even with the timing of the treatments, you know, recently there has been a lot of stuff that came out about dosage and considering that, you know, maybe once or twice a week might not be enough for some conditions. Maybe we leave three times a week for condition X. Right. So it’s not about, it’s not about read on the paper and change your practice. It’s about read it on the paper and think about it.
Yeah. I think some of the viewers might be wondering, is there a fast track to learning acupuncture reasons literacy? Well, I know the answer to this. I’m just wanting to hear your response
That look ideally, and this again, going towards what we are exploring with evidence-based acupuncture and what we would like to do. And we’ve done some lectures on this already is just trying to have, start with the basics. Right. And I really mean it. Like, it’s not about trying to teach someone to do RCTs, start with basic research skills and try and talk to the colleges to see can that be incorporated as part of the curriculum. And I know like I’ve been at these meetings and I know that the first thing that the college director is going to say is we don’t have the time we don’t the budget. You know, if you’re going to add something else to the curriculum, what are you going to take? I understand that, but let’s work together. You know, let’s try and find a little bit of space. And, and I can’t say too much about a paper that I’ve been involved with recently and it’s not published yet, but it’s fascinating stuff in terms of how we can get the colleges involved, you know, the associations involved as well. You know, we already have the associations, you know, some of them pushing for practitioners to do ethics CEO’s and to doing, you know, practice CU like proper stuff in terms of ethics and safety, maybe there’s room to incorporate something to do with basic research skills as well.
Right. And, and, and updating it for your, you know, CU or yeah, absolutely.
Absolutely. You know, so, you know, trying to talk, I know it’s very early days to be talking about this, but it would be something that we would really like to explore. And hopefully I’ve been in touch with, with the main authors on that paper. And they did allow me to just say, keep your eyes out for four days, it’s going to be published soon. And hopefully we can engage in this conversation and just say, in my opinion, I think there are a lot of people are just thinking about research as doing research. And I think that we need that little bit of education and say that first, let’s talk about knowing how to find it as you ask, and then how to read us, you know, out to get some points from it. You know, I don’t mean acupuncture points, but points from the paper in terms of how, you know, dosage, what are they doing?
How are they doing it? And ultimately if this doesn’t convince people, ultimately the goal is I, we, as the BA Mel would say the same thing, we would like acupuncturist to be doing the research. We would like to be involved in the design of the trials, right? Because it’s, I’m not the kind of guy to be on the outside saying that that’s wrong and that should change. And the kind of guy that goes, I’ll, I’ll go in and get stuck in and let’s see, can we change it? And I think that the first steps would be that, you know, involve the colleges involved, the associations journal clubs, you know, online education and start, start small, start with the first steps of learning.
Hmm. Now for some people who don’t have access through an institution, uh, they, they may not be able to get anything but abstracts, especially for certain papers. Um, you know, talk about the difference between an abstract and the full text and, uh, why it’s important. If you can to get the full text,
It’s a lot of the times you will hear this, that, you know, you can find a lot of the times they can find the, the, the abstract, you know, the index paper on pub med. And then if you search on Google scholar, you might find the full paper. So when I gave you the example of how I started looking at research, a lot of the times that stuff doesn’t come up on the abstract, you know, abstracts are really condensed in terms of the word count because of publication and to start what you’re, if you’re just starting and you’re reading only the abstract, you’re actually missing out on the, on the, the important thing and kind of like what helps you to build your own confidence, which is go to the method section and see what points were they using? How long were they treating for?
What were they checking for baseline, you know, checkups? Like what were, what did they want to see on the patients first? And then how many months later were they doing and what were they doing again? That sort of information comes up the paper. Sure, absolutely. Yeah. Yeah. So, yeah. So you have, even from, you know, if you go up in that pyramid again, we look at things like, you know, who was the person doing the acupuncture, um, what, what type of training they had and for how many years, a lot of the times, you know, this is encouraged to come up on the paper as well. And if you read the abstract, you’re, you’re missing out on that. You know, the abstract is a little bit like the poster for your movie, right. How they got there, right. It’s just going to tell you the start, like the context of, you know, the context of the story, and then the happy ending for the story, right? That’s your abstract and what you’re missing out from the other one, one of the things that you hear a lot from, and I know, you know this, but for people listening is that it’s very rare that someone actually reads a paper from start to finish. Right? You tend to go through the results first.
The results first, then you go like, Oh, I want to read a bit more about this. And then, you know, you come to normally the methods, you know, just to see what way they were, what they were using. So it’s, it’s not something it’s not bedtime reading.
No, unless you want to use it for insomnia.
I mean, like, it’s not something that I’m going to read this now and I’m going to get 20 papers and I’ll read them in one day. It’s not like that. You know, I, I would really encourage look at authors that you like in your field and it’s more than like that they have something published and just start reading about it. And for sure read the full paper because it’s, it’s inside. You’re going to get these gems.
Yeah. Is there anything else you want to leave us with,
Um, roll up your sleeves and let’s go, and let’s this look, I like to focus on the positives and I like to encourage people to do things. And that’s how I got, you know, how I got stuck in doing things. And a lot of the times there is this attitude towards research and using the language of science, which we actually have as part of the, the slogan for EBA. And I always say to everyone, look, if it wasn’t for changing the language and adapting the language, I wouldn’t be here. And a lot of my colleagues wouldn’t be here because what was there in terms of Chinese medicine had to be translated. A lot of, you know, this, a lot of the stuff that got to Europe was actually translated from French right into French first. Right. And when I got super enthusiastic about Chinese medicine, the first book that the college got me, like the first big book, the college got me to read was Giovanni’s book, you know, and the great late Giovanni, my church, he took all that knowledge and took all that Chinese medicine and a lot of Chinese writing too.
And put it in that book. And the version that I got first from the college was actually a Portuguese translation. So it was translated again. Right. And yes, we acknowledged that some things are going to be lost in translation is why you go back to the classics and you learn more and you go a little bit deeper changing that now into the language of science is just going to allow for more people to get stuck in. Otherwise you would have to know Chinese to do Chinese medicine. It would never get to the point where I got interested in it and I was reading it. It would never get to the point where I move and I get to study Chinese medicine in English as well. It’s a different language. It’s not changing anything. It’s just changing the way that you’re explaining it to someone else.
So don’t be afraid of the language of science. Don’t be afraid of research. There’s different levels. Read about it, find out a little bit more about it and Hey, get in touch with us having a space occupant. We’re happy to help. And you’re part of a program at the Northern college where there, there is more emphasis on research, right? Yeah. True. Yeah. The Northern college of acupuncture has started that, um, the online MSC. So it allowed for people from all over the world to actually come together and do that. And, you know, the pleasure of being part of that program. And they asked me to stay on and lecture on the program as well. So yeah, the, um, the online MSC, I can tell you, for example, the last it that I was teaching, there was someone in that cohort. Two is from South Africa. There was someone from New Zealand finding the times for everyone be online at the same
Time. And yeah, it’s, it’s fascinating. And it’s fascinating. The amount of work that people that gone through that, you know, practitioners have gone through the, the courses I’ve been able to do quickly, like a colleague of mine was able to create, create something from nothing based on just the, you know, it was one of his ideas from, from the MSC for, for a project for it and took ideas from the MSC, took ideas from EBA and created this new wing in the hospital for treatment. And, you know, based on acupuncture and Chinese medicine and the potential, you know, it’s there, you, you can do it. Like, I didn’t know how to do it either. And it’s just like going to school and learning again. So every one of the Northern college, it is really like being, it’s like my second family and I love them all dearly.
And there’s people from that college involved in research all over the world. So it’s fascinating. It’s a great school. And despite the, there’s always been an emphasis on research with Richard Blackwell. And, um, and yet when I taught there, you know, in person, I was impressed with their clinical skills, more than many schools that I’ve taught at. So, um, they’ve really stuck, struck a good note there on the balance between something like that, didactic and the clinical. So yeah, I recommended the names, you know, you mentioned a couple of names, but people will be familiar with the names from there and you know, it’s, it’s a, it’s a, it’s a second family. Really. I love it. Yeah. Well, thank you so much. Thank you for having, um, you know, we’ll do it again. We’ll get Mel on here too. She’s got time. And, uh, next week our get us, our, our new hosts is Chen Yen. So be sure and catch that and you can find me on luminous beauty.com and, uh, we’ll see you all very soon. Thanks.
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