In my now prolonged dialogue with physicians, one question emerges with enough regularity to deserve mention and naming: what is a discipline?
In medicine, a discipline must include and involve the professional in certain steps or a certain process. This process is nothing neither more nor less than the process – the discipline – to self-reflect, self-assess and self-improve.
The purpose of making your medical practice into a discipline as I am defining it is to engage in the process of self-critical analysis of:
Many licensed acupuncturists insist that their clinical applications are legitimate and that, "my patients improve and I get results." But, what specifically is causing that perceived improvement? How do you know the patient is improving?
The Practical, How-to of Your Discipline
In the simplest terms, the process that creates your discipline is documentation – the more, the better. The work of creating your discipline is the work of collecting data.
This data comes in three forms or categories:
Why Should You Care?
The value of structuring your medical practice as a discipline is two-fold. First, it is what big-time medical practice respects.
"This is . . . arguably, the single most important contribution of Hellenic culture to Western culture as a whole – in a nutshell, systematic rationality. The notion that best and most profitable and truest and most useful means of making sense both of the natural world and the human world is not recourse to tradition, not even recourse to revealed texts; but systematic examination of and reflection upon evidence in rational terms. That, to us . . . seems self-evident. 'How could anyone ever have imagined otherwise?' But, in fact, most societies at most times and places have imagined otherwise and are led by gnomos, by custom, by convention – by the way things have been done. What you are taught is what you believe. These Ionians are the first to contest that; and this is – in effect – the birth of systematic rationality, the birth of philosophy, the birth of science, the birth of history and historiography – all of the above," said Timothy Shutt, Professor of Hellenic Studies on the contribution of Greek thought to modern science.
One of my colleagues often derides me good-naturedly about the relative brash and wet-behind-the-ears naivety of acupuncturists and Chinese medical professionals and of holistic medicine in general, saying that, "in real medicine, this is how we roll."
The Real Gem of Conventional Medicine
My impression of my now considerable collaboration with mainstream medical professionals is that the real expertise and genuinely admirable strength of that system and the physicians who work within it can be reduced to three specific characteristics.
The first and most obvious is this element of self-critical analysis and reflection – which can only come from the extensive and exhaustive data collected from a sample population over a significant period of time. (Consider who within the acupuncture and Chinese medical world is actually doing this.)
The common criticism from such luminaries as Z'ev Rosenberg and even Heiner Fruehauf is that analysis of copious data does not tell the full tale of a truly holistic model.2,3
But, it seems clear to me that collection and analysis of data is certainly not harmful to the practice of acupuncture and holistic Chinese medicine either. The crux of the argument and legitimate concern from the holistic point of view is the same liability that Carl Jung described regarding the methodology of modern medicine in its zeal to prove its truths within the artificial laboratory setting – viz. that the aim of laboratory research is to reduce and (insofar as possible) control and remove any extraneous factors that may affect an outcome; and to instead refine, define and specify a single discrete cause for that outcome.
I agree with Jung and this, of course, is both the boon and bane – or at least the strength and the glass ceiling of reductionism.
In other words, so many factors influence a given patient's cause of health/illness/recovery that one must be cautious not to blindly accept any given conclusion in a research model that seeks to control and diminish the complicating factors of this thing called life.
Nonetheless, the reluctance of the Chinese medical world to adhere to the minimal discipline of simply using a validated and professionally accepted intake and patient demographic form that documents the specific treatment protocol and therapeutic application performed for the patients given (documented) diagnosis and then – ultimately – the collection and review of those outcomes as well as the tracking over time of the patient or patient population's long-term benefit from treatment (if any); this is a glaring omission that smacks simply of a general lack of focus and even – at this point – almost petulant apathy within our profession.
Stop and consider what it would really take? All that is required is a few forms and a standard system to collect and analyze basic data.
It seems incredible that state and national associations take money for membership but will not construct the one thing that would both unify and elevate the profession and simultaneously legitimize acupuncture and maybe even Chinese internal medicine in the eyes of the mainstream.
Besides, you can bet your life we would find out some rather interesting insights into who is doing what as well as what is working and what is bad quality practice (not that mere 'feel-good, hand-holding, I love you love me' kind of faith-based practice isn't of some value; but obviously the population and the profession are both hoping for something a bit more).
I mentioned three characteristics as noteworthy in my dealings with conventional physicians. The second is likewise a value worth emulating. Physicians are professional students. Part and parcel of the discipline of self-critical, self-improvement is high-level study over decades and decades in a ceaseless quest for refined and yet more usable understanding. CEU requirements notwithstanding, I sense a pronounced attitude of entitlement within the Chinese medical world regarding such continued high-level study.
The ability to expand beyond (well beyond) your school learning is your responsibility. In other words, just because you graduated and passed the exam doesn't automatically entitle you to respect, good income and a prominent position within the medical field. Medicine is the most serious and businesslike of human pursuits. It is the very vulnerable and crucial intersection of people's suffering and fear regarding the specter of death or survival.
If the acupuncture and Chinese medical world wants clout, it would do no harm to adapt the practices of a medical system that has been at the forefront of such critical interaction with patients for some decades now. There is – in my opinion – little value in dismissing the modern medical system on the grounds that it is too tied to "the spiritless mechanisms of state agencies, insurance companies, and most of all, our modern mind that has been conditioned to fancy the unambiguous, standardized, packaged approach" 3 as somehow useless because 'TCM is all about intuition and so who needs data and documentation?'
What's Next?
The acupuncture and Chinese medical world will ultimately have to decide what it is going to be when it grows up; and even if it chooses not to decide, it will still have made a choice. Documentation, collection and analysis of data need not be debilitatingly difficult. Nor should such practices of rational reflection based on evidence be conveyed as somehow anti-tradition. We must ultimately – as Michelle Buchanan in Madison, Wisconsin puts it – "use the tools of modern medicine to show the efficacy of what we do."
Most of what we need to create such a system – forms, scanning and light-technology to read and analyze patient surveys – already exists and is already in-use. The ultimate purpose of all of this is to define and circumscribe the single factor that is now so nebulous as to be almost gossamer and even mythical within our profession: best-practices. What are the best-practices within acupuncture and Chinese medicine? Even the Chinese physicians in China seem to be unable to tackle this issue beyond a certain point.
The systematic review and retrospective analysis of acupuncture and Chinese medicine need not give up the logic of holism or somehow "sell-out" to biomedical thinking. This a false fear. But some effort – any effort – to define and attempt to bridge the chasm between the functional physiology of holistic TCM and the stringent biochemistry and physics of conventional medicine is bound to produce a positive impact.
In Summary
The real contribution of conventional medical science is – to the degree that adheres to its own code – the rigorous and gospel-like belief that reflection upon and rational analysis of data leads to innovation and revision – i.e. to improvement and best-practices.
The decision to make even baby-steps in this direction would revolutionize both medicine in general and the acupuncture in Chinese medical world in particular. It is not as if there are not excellent examples in the Chinese medical world of how this chasm has already been bridged. The Pine Street Foundation is one such example. Consider the impact this small operation has had and continues to have even with minimal resources simply by virtue of its adoption of the kind of rigor and discipline that makes it irrefutably valuable both as a shining example to the Chinese medical world and also within mainstream medicine where its various findings and publications have now reached a world-wide audience.
Do we have the luxury not to choose? Not – in my opinion – if we expect to get what we want – i.e. legitimacy, professional inclusion and better income.
References:
Did any of you ever get the feeling in school that it simply was not OK to speak about wanting to be successful? To get into the nitty gritty details of how to make money in practice? Maybe you were even someone like me who was directly told by someone in a position of power that I needed to take what I could get because in private practice, I wouldn’t make money.
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