THE square diamond ring on the patient
s manicured hand is striking in size.
She
s here to see Dr Im Quah-Smith because she is tired. She lies back, happily chatting about her 40th birthday plans, while the Sydney GP holds her wrist. She monitors the woman
s pulse while running a small piece of plastic slowly across her ear, adhering tiny round magnetic dots when the pulse strengthens.
Quah-Smith is focused, but asks about the venue and party dress. It
s at one of
Sydney
s most impressive seafood restaurants but there is a problem with the outfit. It
s all bad timing
the woman
s period is due and her bloated stomach will be unsightly in her new slim-fitting dress.
Quah-Smith empathises and deftly slots an acupuncture needle into each of the woman
s legs. Not a flinch. The patient smiles. The potential fashion nightmare is over.
Dealing with the worried well is a small but quietly satisfying part of Quah-Smith
s day. At the other extreme is her depression research, supported by the Black Dog Institute, which thrills her to the core.
She is using laser acupuncture to treat depression, beaming low-level infrared light onto the acupuncture sites that Traditional Chinese Medicine uses to treat depression. And she
s using functional magnetic resonance imaging (fMRI) to track what part of the brain is activated by the treatment.
Quah-Smith has her sceptics, but in many ways her medical background makes her one too, particularly when it comes to acupuncturists who don
t have a clinical background. She considers herself a GP first and foremost, having practised for 25 years before giving it up to focus entirely on acupuncture four years ago.
The important thing is that you have to be a good GP before you can be a good medical acupuncturist,
”
she says.
She cites the example of a patient who came to her with headaches. She gave him three sessions of acupuncture but he showed no improvement.
That was very concerning to me,
”
says Quah Smith.
Even though he
d had a brain scan six months [prior to seeing me], he had a tumour in the back of the brain. A lay acupuncturist would have said,
Sometimes these things take longer
, gone for three months and by that time this poor fellow would have had his brain pushed out of his skull,
”
she says.
While working in general practice she prescribed anti-depressants, but not often.
I
m not a fan of anti-depressants in the majority of people with depression, because I think they have reactive depression or secondary depression [having not coped with a life event],
”
she says.
The majority are struggling with
financial distress, difficult children, [or are] carers with an unwell member of the family.
”
Now, patients with depression make up more than half of her patient load, and she
s confident her acupuncture gets results. But she
s driven to understand why and won
t be content until she sees the evidence herself.
Quah-Smith decided laser acupuncture was the only way she could conduct blinded research
something that would be impossible using needles. It felt like a significant compromise because she doubted a beam of light, devoid of sensation, would be anywhere near as effective.
But her small study gave statistically significant results (see box, page 13) and helped her win support for further research. She took an early draft of her findings to Professor Perminder Sachdev, a neuropsychiatrist from
Sydney
s Prince of Wales Hospital who is openly sceptical about acupuncture. Quah-Smith knew she needed his help in order to introduce fMRI to track the parts of the brain activated by laser treatment.
Professor Sachdev was less than enthused. He suggested she invest in a $150 textbook on research methodology in fMRI, read it and get back to him.
He said,
If I see you again, I
ll know you are interested and if I don
t see you again, I
ll know it was all too hard
”
Quah-Smith says.
I did read that book. I was really excited.
”
Professor Sachdev took her on and they tracked 10 healthy subjects, lasering four acupuncture points and a sham point.
What we found was that the acupuncture for depression worked at the points of the brain involved in depression,
”
Quah-Smith says.
It activated brain areas involved in mood disorder.
”
Professor Sachdev hadn
t expected to see any specific response within the brain for several reasons, but now says
the results look interesting
”
We are seeing brain effects and they seem to vary according to where the stimulation point is,
”
he says.
So one can probably speculate from this that maybe they are responsible for a therapeutic effect. We can
t explain the mechanism by which these changes occur. That
s more difficult.
”
While Quah-Smith
s work might sound kooky to some, the latest round of her research has attracted support from the Black Dog Institute, which is helping her recruit 100 depressed patients. Each patient will receive 12 sessions of laser acupuncture, and a sub-group will
also receive fMRI before and after the sessions.
This is the first time we are doing a proper treatment and a before and after scan,
”
Quah-Smith says.
My hypothesis is the change in activation [shown in her previous study of well patients] will be larger in depressed patients.
It will actually put medical acupuncture on the map for medicine in
Australia
. And hopefully more people realise there is validity in acupuncture, validity in laser acupuncture and
consider acupuncture in some of their patients.
”
The Black Dog Institute
s executive director, Professor Gordon Parker, is more reserved, but open-minded about the upcoming research.
Acupuncture is something that is used by people and rated as having modest benefits so therefore it is worthy of study,
”
he says.
He has faith that Quah-Smith is not proselytising and says she
s running quite a risk, given her confidence in acupuncture
s therapeutic effects.
Some people want to prove something they believe in,
”
he says.
[But] if she got a negative result, she
d go with that negative result. She
does respect the parameters of science.
”
He says the institute will facilitate the study and ensure it is conducted properly.
If it turns out to be brilliant material, we
ll claim a much higher contribution,
”
he jokes.
***
THE fMRI scanner has broken down, so Quah-Smith rejigs her schedule and suggests we have a late lunch. Before navigating her Mercedes out of the tight little car park, she reaches for her sunglasses. They
re narrow, with vivid blue shades, but they
re no fashion statement. They
re for her dyslexia.
Quah-Smith realised she w
as dyslexic when her son Alex was diagnosed by a remedial teacher and she discovered the condition was inherited.
All my life when I looked at volumes of black print, all the way through school and uni, I saw the white, not the black. White stood out and black recedes.
”
Quah-Smith has spent a lot of time staring at black print and computer screens. Her latest research is for her PhD, which she aims to finish in the next three years. But she says her computing skills have proven a greater challenge than the dyslexia.
I
ve got shocking IT skills. Gordon [her husband] and the kids have said they will no longer help me with the computer. In the middle of the night I
d be shaking people and saying,
I
ve lost this document
help, help!
”
It
s not only a PhD research project, a family with two teenage children and a busy practice that keeps Quah-Smith interested in life. She is federal secretary of the
Australian
Medical
Acupuncture
College
, presents acupuncture workshops to GP registrars through General Practice Education and Training and is a clinical lecturer for the
University
of
Sydney
, presenting acupuncture to final-year medical students during their community medicine term. She
s also worked with her practice associate, Dr Emily Teo, to establish an acupuncture outpatients department at
Balmain
Hospital
in
Sydney
s inner west.
I exist on six hours [of sleep] a night,
”
Quah-Smith says.
When I
m really busy and juggling school, work and research things I exist on five. I give myself acupuncture to keep going. If you
re feeling a bit tired, you can needle yourself out of it.
”
She
s keen for me to understand more about acupuncture and why it works. And her enthusiasm is hard to ignore. At one stage over lunch, she reaches over, takes my pen from my hand and starts taking notes for me. And, on our first meeting back at her surgery
, she
s pleased to answer my questions but determinedly refers back to a list of
key messages
”
she
s drafted in preparation for our interview.
She does have a ligh
ter side. She has a good laugh as we discuss her distinctive Chinese features and the extent to which her appearance might imply great expertise.
My Caucasian colleagues who practise acupuncture say,
Acupuncture is much easier for you, you are Chinese. People will presume you will do better acupuncture
”
she says.
I don
t think I
m particularly Chinese. I
m a very boring
North
Shore
girl.
”
***
Quah-Smith
s family left
China
about five generations ago and her grandparents were the last generation to read or write Chinese. She spent her early childhood in
Kuala Lumpur
Malaysia
, living in a
very privileged estate
”
because her father was deputy commissioner of road transport.
But the racial riots of 1963 rocked her father
s confidence in
Malaysia
and he decided his three daughters should be educated elsewhere. During the riots he was required to distribute food and monitor the curfew, but he feared leaving his family at home.
My father taught me to use a rifle, just in case we had a home invasion,
”
Quah-Smith says, explaining that her mother refused to touch a gun.
I was 10. That was very scary.
”
At the age of 14, Quah-Smith was sent to Abbotsleigh, a girls
boarding school on
Sydney
s upper
North
Shore
. When she graduated, she took her father
s advice and studied medicine instead of architecture. She initially did anaesthetics training but her parents were concerned the specialty would make it harder for her to have a family.
Chinese parents are very much into their children settling down and having children by a certain age,
”
Quah-Smith says.
So she settled on general practice, discovered she loved it, and headed off to do her first acupuncture course in 1991 at
Royal
North
Shore
Hospital
, inspired by a GP colleague who was going and asked her to keep him company.
I thought,
That
s a nice diversion
, and now I
m doing my PhD in acupuncture
that
s the most hysterical thing,
”
Quah-Smith says.
She
s studied acupuncture extensively, both here and in
France
, and says it takes a long time to be able to tailor treatment to suit each patient. While there are set acupuncture points taught within traditional Chinese medicine, the most effective sites vary from person to person, so it takes both practice and a
natural ability to discern them.
It
s an acquired skill and some people have a natural knack to do it,
”
she says.
I had the natural knack.
”
ACUPUNCTURE AND DEPRESSION
Dr Quah-Smith
s double-blind randomised controlled trial of laser acupuncture in 30 depressed patients used the Beck Depression Inventory at baseline and during and after treatment.
Patients could not tell whether the laser was active during treatment, so half received a sham treatment while the rest received 12 treatments.
At the end of the treatment period, Beck Depression Inventory scores fell from baseline by 16.1 points in the intervention group and by 6.8 points in the sham control group (P<0.001),
”
states Quah-Smith
s paper, published in
Acupuncture in Medicine.
The difference showed only a trend four weeks later, but was again significant after 12 weeks (P=0.007).
”
While only 25 patients completed the study, Quah-Smith was shocked by the results
statistical significance.
I didn
t expect it,
”
she says.
I said to the statistician,
Are you sure?
And he said,
Yes, I checked it three times
. I nearly fell off my chair.
”
Reference
Acupuncture in Medicine
2005; 23(3):103-11.