By Lonny S. Jarrett & Z’ev Rosenberg
For Chinese medicine (CM) in America today it is the best of times and, it is the worst of times. On the one hand, CM is increasingly accepted, and practitioners are finding opportunities to work in more venues than ever before. On the other hand, the cost of education has skyrocketed and many practitioners find it difficult to support themselves working in the field, let alone repay their loans.
We recognize that CM is a rigorous qualitative science of function based on a worldview that places consciousness within the context of psychology, physiology, ecology, culture, and ultimately the cosmos. It is this ecological perspective that makes CM so valuable to humanity at this point in its history. Our concern is that the educational and regulatory institutions that serve as a vehicle for the establishment and conveyance of our medicine have bent too far in the face of the forces of cultural assimilation and that the fundamental integrity of the medicine, and therefore the profession, have been compromised.
Here we examine where we are as a profession, how we got here, and a clear way forward that best protects the integrity of the medicine and profession. Our value is to establish a culture of CM that reflects the holistic and ecological values inherent within the medicine itself. It is our conviction that CM is best cultivated and learned in a way consistent with the values that have presided over its 2000 years of evolution. And, that this is the only way in which the medicine, its practitioners, and the profession will thrive. It is our hope that the medicine is not yet so embedded in the cultural status quo that there may still be time left to create the CM that could, and should be.
Chinese medicine has come of age in America at precisely the moment when our political, social, economic, educational, military, and medical systems, all based in the values of modernity, have become antiquated in the face of the pressures of a global world. It is our belief that the advanced systems thinking in Chinese medicine’s ecological perspective are desperately needed at this point in history and that the medicine will thrive if we have the courage to meet this challenge by standing up for our own integrity and the integrity of the medicine which, in the end, are one.
Chinese medicine has grown quickly in America since its public introduction in 1972 when James Reston first wrote about it in the New York Times on his return from China. The founders of the original schools and organizations in our field had brief educations in CM at the time they enthusiastically created the institutions and organizations necessary to establish a culture of CM in the United States. Most of the founders had learned some version of modern TCM and a minority practiced traditions such as Worsley Five-Element Acupuncture.
While those in minority traditions consistently advocated to create institutions and regulations that promoted diversity, the majority ruled and successfully instituted a framework that favored TCM and the standardized modern values it is predicated upon. While there was no necessity to follow the status quo, it seemed to many to be the path of least resistance to successfully establish their schools and give CM a foothold in the culture. Chinese medicine has come far relatively quickly, yet the current First Professional Doctorate (FPD) with its emphasis on integrative medicine (not Chinese medicine) seems a deal with the status quo devil that appears to many of us who are scholars and senior practitioners as having gone what may be an irrevocable step to far in compromising the principles of our medicine.
One of our fundamental values is that, ideally, no non-lifesaving intervention should ever be preformed prior to the application of a reasonable course of CM. The question is, how do we best position CM so that the full complement of its capacities are respected and utilized? The answer is that this can only be accomplished if we are willing to create an academic and regulatory environment that both respects, and engenders respect, for the authentic nature of the medicine as it is based in holistic and ecological principles.
Choices define outcomes and are based on values that are either consciously or unconsciously held. One only has to compare a page of written classical Chinese to a page of modern English to be immediately impressed that each language reflects a very different way of viewing, thinking, and speaking about life. It is well established that CM and the reductionist and materialistic sciences are based on complementary value systems.1 It is of the utmost importance that as we create CM in the West, we do so according to consciously held values that reflect the strengths of our medicine. Ideally, institutional values, regulations, and laws would reflect the holistic and ecological values that are inherent within our medicine. Instead what has happened, is that CM has been forced, like hammering a round peg into a square hole, to bend itself to accommodate values that reflect the reductionism and ultimately the materialism of modernity as they pervade Western culture.
The values of materialism and reductionism helped to establish the educational, regulatory, and delivery systems for Western biomedicine making it the dominant paradigm in Western culture in the modern era. Yet, yesterday’s innovations when institutionalized often create their own problems as culture evolves, and the medical system and science upon which it is based that emerged with the advent of modernism are now compromised and suffering under the weight of the very values that engendered them. Despite the theoretical and bureaucratic failings inherent in current medical education, research, delivery, and the insurance industry, the forces pushing the assimilation of CM into the current culture of medicine have not relented.
While CM itself predates modern materialistic values, the majority of its practitioners in the West are at a postmodern level of development and hold values that are very different from those of the corporatism and materialism that underlie the current medical system.
Many of us are rooted in a pluralistic and holistic perspective and are able to hold multiple perspectives simultaneously and can rank each in relevance according to context. To us, the assimilation of CM into the rank and file of biomedicine is an anathema whose precepts while complementary, are the antithesis or our own method. Further, the constraints of the institutions that uphold the linear, reductionist, and materialistic perspective make it difficult to impossible to practice our own medicine with autonomy and integrity in a way that patients might maximally benefit.
The cultural forces of materialism have attempted to shape CM into a medicine practiced and regulated in an environment possessing very different values than those inherent within it. If we continue to follow this path, CM will no longer represent a medical science of equal sophistication that complements the weaknesses of the predominant healthcare model in the West. Rather, it will be just another adjunctive therapy applied symptomatically that reinforces the cultural status quo. On its current course, CM runs the risk of becoming another institutionalized medicine that consumers will seek an alternative to.
Integration and Assimilation Vs. Creative Engagement
The values that gave rise to WM and its cultural and institutional structures arose out of modernism and the pursuit of rational and objective knowledge in the face of 4000 years of myth and superstition inherent in the great traditions. Such developmental leaps occur in the face of certain survival challenges and yet, in time when taken as absolute principles, inevitably create their own problems which in turn new steps must be taken to overcome.
We live in a unique time where the confluence of all knowledge and culture imparts a top down perspective on history that allows us to appreciate the weaknesses and strengths of various perspectives in a way that hasn’t been possible before when cultures were significantly isolated from each other. The emerging global perspective is congruent with the advent of an integral perspective on medicine. This integral perspective appreciates the weaknesses and strengths of CM and biomedicine recognizing that each has a complementary domain of application. From an integral perspective we recognize that biomedicine is most efficacious in treating the exterior physical dimension of the human being when critical life saving intervention is needed. Chinese medicine, on the other hand, addresses the interior functional dimension of the human being comprised of spirit, mind, and all the non-physical dimensions of the self. It is best applied preventively, in long term care, and in any case where lifesaving intervention is not called for. Of course, CM also shares a great interest in more ‘physical’ medicine when necessary, including acute and life-saving interventions. It just never had the technology to do in the pre-modern era beyond certain limits.
These days, “integrative medicine” is all the rage. The implication is that Western medicine (WM) and Chinese medicine are being integrated in some cutting edge way. However “integrative” can mean many things to many people. Often, “integrative” is little more than a slogan used to pitch an individual or a group practice like the words “natural,” “organic,” or “holistic.” It can also mean when applied to an individual’s practice, “I study some of this and some of that.” While the pretense might be “cutting edge,” in fact, the reality too often may be that the application of all methods is diluted.
When “integrative” is applied to a group practice it often means, “We have physicians, acupuncturists, nutritionists, and Vedic astrologers and we all talk to each other.” While certainly multiple perspectives are the way to go in order to form an integrated diagnosis, the fact remains, that due to the unnatural hierarchy of power in clinical practice physicians will always have the lion’s share of liability as well as legal authority to determine treatment strategy. As a profession we have to consider how much legal liability we want to take on because with prescriptive rights (ordering and interpreting biomedical tests) come both increased liability and external controls. We should also remember that Chinese medicine itself is capable of multiple perspectives, as it contains different methods of pattern differentiation, from channel, viscera/bowel, yin/yang, or five phase perspectives for example.
Prevailing thought seems to be that by conforming to the conventions of the culture that has risen out of the principals and perspectives that shaped the practice of WM, we will rise to the point of receiving the same respect and therefore income and job security of those in biomedicine. It seems to us unlikely, however, that this this will be so or that conforming to the culture of biomedicine is the best path to achieve such status. The more logical outcome is that licensed acupuncturists will become second or third tier providers working under the direction of physicians and relying on their diagnosis and treatment directives, just as physical therapists and RNs work within the present system.
It’s also important to note that even physicians no longer control their sources of information, fees, diagnoses, or treatments. Rather, these are controlled by outside forces such as insurance companies, regulatory boards, and government agencies. Hence even physicians are employees of a hierarchical system that begins with forces, such as insurance adjusters that simply don’t necessarily have the integrated practice of medicine as a significant motive.
The responsibility of schools is to impart a value of depth rooted in the capacity of each student to create his or her own synthesis and to lay the foundation for a lifetime of learning by giving basic tools. Becoming a mature practitioner is always going to take a lifetime of work after graduation. The question is, “to what degree are the values and perspectives being imparted by schools consciously held or just unconscious reflections of the culture at large?” That schools are by and large failing to invest students with a satisfactory basis is reflected in several ways.
Many TCM schools seem to emphasize teaching technique and information rather than imparting an overarching philosophical framework that emphasizes the importance of qualitative diagnosis, and the synthetic mode of inquiry upon which it is based. Chinese diagnosis entails a deep understanding of the processes that underlie manifestation. Ideally, emphasis is placed on looking at phenomena through multiple perspectives and the creation of a unique synthesis that includes all relationships that are central to the patient’s life. This synthesis comprises a living and evolving picture including the patient’s past, present, and potential futures. Instead of focusing on imparting a context of depth, schools have been forced to teach to a test that primarily values the modern tradition of TCM practice integrated with a high percentage of WM. Hence, students are less taught the principles of medicine and are instead taught how to pass an exam.
This conclusion is validated by the fact that so many practitioners are foundering after graduation failing to run successful practices. It is true that many schools do not offer sufficient training in business and practice building and management. However, we suspect that the difficulty new graduates face in supporting themselves lies elsewhere. People have simply not been placed on a path of inquiry. They have been given a fish, but not taught to fish. Any practitioner who has gained an authentic basis in the medicine will have a foundation into which he may easily integrate anything new learned. Without a sufficient foundation, all one can ever have is facts and techniques that remain unrelated to each other.
Another significant issue is that many school teaching clinics provide patients for the students. This has two disadvantages. The first is that students are handed patients and do not build their own practice while in school under the guidance of the faculties mentorship. The second significant disadvantage is that students are not responsible for overseeing the ongoing treatment of individual patients over time. Rather, they see patients for only one session every now and then so have little cultivated appreciation for how the natural progression of treatment unfolds over time. This unsatisfactory scenario continues after graduation, as practitioners sign up with HMO’s, PPO’s, and work ‘in network’. Insurance companies refer the patient, pay the acupuncturist an hourly fee, require specific treatment and diagnostic codes, and determine how many treatments a patient will receive. Many other practitioners work at health spas where patients come for only a few days or a week precluding the possibility of long term treatment planning and follow up.
The two most significant dimensions of education that schools often fail to impart are an adequate basis in pulse diagnosis and an appreciation for the Chinese language. Both Chinese pulse diagnosis and language have both inner and outer dimensions to impart to the developing practitioner. Pulse diagnosis has its practical application in terms of diagnosis and treatment planning and is one of the defining features of the practice of CM as a preventive and long term care complement to the critical care application of biomedicine. In its inner dimension, pulse diagnosis is a vehicle for having an embodied relationship to Chinese physiology, one that transcends abstraction. A firm foundation in pulse diagnosis imparts to the practitioner a body of not just knowledge, but of experience into which all future clinical observations may be integrated.
Similarly, having a basis in the Chinese language has its own inner and outer benefits and is essential for students if we are to create a culture based in the deepest capacities the medicine has to offer culture. Externally, learning the language grants students access to the historical medical literature that is a vehicle for the medicine’s transmission from the past to the present. At least just as importantly, learning the language is perhaps the fastest route for appreciating the holistic and synthetic nature of the medicine. The Chinese language is based on a wholly different quality of mind and mode of inquiry than is Western linear thought and learning to read classical Chinese instills this perspective, so essential to the basis of the medicine, in a way that merely memorizing the functions and locations of acupuncture points and herb formulas cannot.
Sadly, most schools have greatly compromised their teaching of pulse and language and prioritized instead courses and prerequisites in the biosciences. This in the name of the notion that having such expertise will better position graduates for jobs in “integrative” medical settings. While this may be true and of economic benefit, it wont be authentic CM that they will be practicing or “integrating.” And, this means that the results of treatment and all subsequent study on the efficacy of “Chinese medicine” will be compromised. We realize that some biosciences must be learned in order to produce practitioners of an integral medicine who appreciate the complementary natures of CM and WM. However, we feel that far too much emphasis has been place on “integrating” and that the Chinese medicine component of any such integration is too often significantly left by the wayside.
It is our strong feeling that, the doctorate level of education must involve advanced study and demonstration of competency in the foundations of CM itself and that focusing the advanced degree on “integrative medicine” is a critical mistake. The best path forward is to consciously define the ideals at the heart of our medicine, instill these within students, and create institutions within our own field that gives rise to a culture of medicine based on our own higher values.
“Neither Donkey Nor Horse”
What is called in the West “Traditional Chinese Medicine” (but rarely in mainland China) is the result of a response to the influx of biomedicine to China in the early 20th century, and pressures to conform to the ‘scientific’ trend, which required the qualitative values of Chinese medicine to be referenced to specific quantities and measurements of anatomy, physiology, biology and other source sciences of biomedicine. This was expressed as bian zheng lun zhi/pattern differentiation and discrimination, which focused diagnosis and treatment on a set/specific number of patterns that related directly or indirectly to modern Western views of the human organism, specifically the zang/fu visceral/bowel approach. Critics of this approach considered it to be politically motivated, a ‘mongrel medicine’ that could not survive on its own; in other words, it became dependent on modern medicine for the primary diagnosis, and sometimes treatment as well. What modern Western practitioners of TCM fail to consider, without adequate historical perspective, that TCM is already an ‘integrated’ medicine for the most part, although there are varying flavors and degrees of biomedicine integrated into it. But in the 1950’s, a new version of this medicine zhong xi yi jie he/integrated eastern-western medicine was developed and taught in Chinese schools. After only a few years, this approach fell apart, as both clinical results and comprehension by graduates declined from former years. There was simply not enough training in either Chinese medicine or biomedicine to be proficient at either, and it became difficult to understand the sources for what was being studied due to a promiscuous mixing of metaphors, sources, and therapeutics.
The situation in Chinese medical education in America is very similar to this. As pressures for ‘integrative medicine’ (at this point not clearly defined, in the authors’ view) increase, and changes in the schools occur rapidly, the curriculum has been greatly altered in the direction of biomedicine, modern research and ‘evidence based medicine’. But all of the ‘evidence’ is considered to be ‘scientific’, based on modern research protocols, which often miss the strengths of Chinese medicine’s more ecological and qualitative approach. The needed depth and focus in Chinese medicine proper has been largely lost, and there is less respect for the classical source texts and vast history of the profession in Asia, which is considered to be ‘anecdotal evidence’ at best. The power has been taken away from the CM physician, and given to researchers (few as they might be), insurance handlers, and the biomedical system of hospitals and doctors’ offices. Graduates are not given the confidence they need in their own medicine, and are told they must practice ‘integrative medicine’ to succeed professionally and financially. Confidence in traditional Chinese/Asian diagnostic methods such as pulse, tongue, palpation and abdominal diagnosis is lacking, and the ability to give an in-depth diagnosis with full nuance and complexity is being replaced with biomedically informed TCM diagnoses that rely on blood tests, physical exams and other staples of the regular medical profession, and add little from the wellspring of Chinese medicine. As a result, many of the primary textbooks used in CM schools are heavily biased in the direction of Western disease description, with a relatively superficial CM pattern differentiation tacked on. In addition, this CM zang-fu pattern differentiation is applied to treatment with acupuncture, even though acupuncture treatments are traditionally chosen according to different criteria based on channel theory (jing/luo).
Fundamentally, many of the institutions are failing to serve the medicine and are instead serving themselves. More seriously, a majority of the schools, and licensing/certification boards, both national and state, are strongly pushing an ‘integrative medicine’ agenda, leaving graduates with an incomplete grounding in either Chinese or biomedicine, leading to confusion. Without access to core Han dynasty texts such as the Su Wen, Ling Shu, Nan Jing, Shang Han Lun or Jin Gui Yao Lue, students are not able to engage in the lively, creative debate that sharpens the intellect to think in the logical system that is encoded in these texts. So the default position for a new graduate is biomedicine with zang-fu pattern differentiation ‘pasted over’ the top.
Fifty percent of Chinese medicine schools in the United States are for profit, meaning they are businesses driven by enrollment and tuition fees. Like a high percentage of higher learning institutions in the U.S. (universities and technical schools), they are being corporatized and pressured to produce technical mastery without experiential or philosophical/cognitive acumen. The precipitous rise in tuition in recent years has led to increasing dependence of students on Federal loans, with steep interest rates. There is pressure on graduates to find immediate income after graduation, but new practices often take a few years to establish, especially in towns where the schools reside and many graduates choose to stay. Meanwhile, teachers’ salaries have largely remained stagnant, even as cost of living indexes rise, so it is often not an economical possibility for successful practitioners of Chinese medicine to teach. Once graduating, new practitioners have to consider rent or leasing offices, cost of supplies, hiring receptionists, and dealing with unpredictable insurance companies and group policies. The attrition rate in our profession is very high, as new practitioners become discouraged by these financial realities, and an intuition that their education is incomplete. Chinese medicine education traditionally never ends, of course. Through practice and study, we are encouraged to hone and improve our skills constantly. Because private institutions are tuition driven, there is less selectivity in student selection than what would be optimal, because of financial pressures for the schools to constantly upgrade their certifications with national and regional certification boards in order to qualify for student loans.
The various CM school programs are also emphasizing standardized testing more and more, based on data sets rather than the flexible, creative diagnostic and treatment methods of the medicine itself, which do not accurately reflect the diversity of traditions within. The end result is a medicine that is largely determined by state and national boards, a frozen, over-simplified version of what originally has existed in a flexible, complex, ever-changing form for millennia.
‘Evidence-based Medicine’ and the erosion of Chinese Medicine criteria
The latest ‘trend’ in Chinese medicine education is EBM, or evidence- based medicine. This means basing one’s clinical practice on modern study models (‘double-blind’, control groups, etc.) rather than on ‘anecdotal’ case histories or principles of medicine recorded in the ‘classical Chinese medical literature. But since Chinese medicine is based on individualized patient diagnoses and patterns, a ‘one size fits all’ approach greatly limits the potential for practicing at the highest level possible. The modern trend in medical studies have moved away from philosophical approaches and the humanities to total immersion in the hard sciences, and this is influencing modern CM curriculums as well. This fragments the knowledge base of Chinese medicine into ‘data sets’, rather than a unified philosophy that can be applied to any clinical situation encountered by the physician.
By focusing only on memorization of data (points, formulas and patterns), the meaning of why these points and formulas work in the first place is lost. Without principle, one cannot develop the creative thinking necessary to individualize treatment, and what is left are ‘treatment protocols’ for biomedically diagnosed and defined conditions. Evidence-based medicine narrows the scope of Chinese medicine tremendously, by relying only on modern studies designed largely by researchers who are not trained in Chinese medical logic and philosophy. Certainly studies can be designed based on yin/yang, five phase or channel theory, by utilizing the criteria already established in Chinese medicine, rather than superimposing ‘scientific’ criteria over the top. Even biomedical treatments have only been confirmed in the thirty percent range, the other seventy percent are ‘unproven’. How scientific, for example, is the use of SSRI’s for depression, when their mechanisms of action are largely unknown? While ‘alternative’ medicine is often considered to be largely ‘placebo’, so are many biomedical treatments. Just because a therapy doesn’t hit you over the head like a hammer doesn’t mean it won’t ‘work’.
There are no reliable studies on either traditional forms of practice in acupuncture/moxabustion therapy, or Chinese herbal formulas. Modern laboratories can analyze and break down single herbs, but cannot measure or track complex formulas with many ingredients and resulting multiple biological pathways in the body. A compounded herbal formula is much more than the sum of its parts, and to try to isolate active ingredients misses the plot entirely. Because of this, ‘evidence’ in Chinese herbal medicine must rely on received texts, cases and philosophy of great Chinese physicians, ancient and modern. In China, 考政 Kao zheng/evidential research or scholarship began in the 17th century, and peaked during the Qing dynasty. It was a cultural movement that attempted to return to the Han dynasty classics as a style of learning, in contrast to Neo-Confucianist trends of the Song/Jin/Yuan dynasties. According to Benjamin Elman, professor of East Asian Studies at Princeton University, evidential learning was an effort by 18th century Chinese scholars to restore ancient medical and mathematical classics, through research and rigorous analysis and evidence drawn from ancient artifacts and documents.
Our concern is that the homogenizing forces of cultural assimilation are so strong that “integrative” medicine, even if it provides jobs, will be a detriment to the further development of CM here in the West. It is our hope that the schools and institutions of CM in America might take heed of the points we’ve made and reconsider their direction in implementing doctoral programs focused on “integrative medicine.” Instead, it is our suggestion that such an emphasis should be only a minor component of any advanced degree and that all programs from entry level through doctorate should endeavor to provide a significantly firmer rooting in Chinese medical theory, history, language, diagnosis, embodied practice, and treatment planning with relatively less emphasis on prerequisites and courses in Western biomedicine.
We realize it is unlikely that our plea will be heeded by those possessing an “integrative” agenda and a “for profit” motive. In this regard we find consolation in knowing that the cream will rise to the top and we are heartened by all the practitioners who are applying themselves ceaselessly to better themselves and the medicine through their continued study and refinement. We acknowledge that learning CM is a lifetime (or many lifetimes!) endeavor yet we can’t help but feel that, for the money spent on an education a deeper foundation in the art and science of CM, on its own terms, should be imparted by educational institutions.
In part II of this article we will examine the national organizations that regulate CM in America and how they might better serve CM by living up to its values at an institutional level.
- Porkert, M. (1983). “The essentials of Chinese diagnostics.” Acta Medicinae Sinensis. Zurich, Switzerland: Chinese Medicine. pp. 1–15.
- Jarrett, LS (1999): Nourishing Destiny: The Inner Tradition of Chinese Medicine. pp-435-453.
- Jarrett, LS: (2003) The Clinical Practice of Chinese Medicine, pp.707-770.