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Acupuncture Today
April, 2006, Vol. 07, Issue 04
 
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In Defense of Case Studies

By Steven Alpern, LAc

Case studies have a long and distinguished history in Chinese medicine. In 90 BCE, the Imperial historian Sima Qian recorded a case that had been transmitted orally for several hundred years.

It reported the illness of the crown prince of Guo, and his cure after treatment by Bian Que, who has been linked by some later historians with authorship of the Nanjing (The Classic of Difficulties). Following that precedent, innovative physicians through the ages have used cases, in addition to broader discourses on theory, to demonstrate important clinical differentiations. The importance of cases also was reflected in the classical method of training through apprenticeship, which was based on gaining the experience of watching the master work with thousands of cases, as well as receiving and memorizing various texts.

Yet, in our modern, scientific world, case studies generally are dismissed. Many scientific people, especially outside our profession, consider the individual results presented in case studies anecdotal and of limited value. Indeed, the only claim one can rightly make from a truthful case study is that one patient had the reported result at a particular time. To claim that other patients, or even the same patient at another time, with the same named disease, would respond in a similar way clearly is a logical error of induction. Ultimately, we must recognize that case studies are much more about the willingness of "patients" to transform their lives than they are about the power or effectiveness of particular practitioners or treatment methods.

So, what's an acupuncturist to do? Are we to give up case studies in favor of the widely recognized scientific value of double-blind, statistically analyzed experiments?

This path appeals to many in our profession who proclaim the benefits of modernization, especially relative to scientific methodology. They follow the generally accepted standards of scientific medicine, and consider proactive, double-blind, randomized, controlled studies the only legitimate research. However, relative to the 2,000-year written history of Chinese medicine, one also can conduct historical and philosophical research into its wide variety of clinical traditions, and how to apply them with contemporary patients. There is more to Chinese medicine than the modern doctrine.

When considering the use of case studies, we must remain clear that treatments discussed in them are specific to the individual. Any suggestion that they will be effective as protocols for other patients who somehow fit into the same diagnostic category as the patient described in the case study is an inductive error. We don't want to fall into that trap and risk looking simpleminded to our scientific colleagues. The only clear way to avoid that dreaded error is to recognize explicitly that protocols are not an appropriate focus or product of case studies.

Instead of trying to generalize treatment strategies from case studies, we benefit most when we use them to demonstrate clinical thinking. The analysis of an individual's case only begins with sorting symptoms and signs into diagnostic categories. That coarse mesh lumps together many individuals, each with his or her individual life challenges and struggles. We must refine our discrimination and clinical differentiations, and learn to apply Chinese medical ideas creatively, to determine how a specific individual developed his or her particular pathological expression and how to facilitate its resolution.

Response to treatment is individual, and is based on liberating the expression of an individual's intrinsic will to live. Healing work is the creative process of finding ways to stimulate release of entrenched patterns that have led to pathology, and thus allow the being to grow whole. The most effective treatments are the ones that focus most closely on blocks to healing, rather than those that apply the most powerful modalities. The effectiveness of acupuncture and herbs emerges from carefully discriminating what a particular individual needs, and doing no more than necessary! Clear focus on the individual's block(s), rather than his or her disease expression, stimulates the most profound healing.

Clinical symptoms and signs are the expression of the individual's struggle with various emotional and climactic pathogenic factors. Today, we recognize many external factors such as various microbes, chemicals, electromagnetic and nuclear radiation, and the panoply of lifestyle stressors of our fast-paced world, which challenge our physiological responsiveness. Yet, the basic models of pathogenic process developed in the oldest classics of Chinese medicine are still important, because the nature and process of individual embodiment have remained essentially the same during the past 2,000 years.

No matter the specific nature of the challenge, we can always benefit patients by better learning to identify and stimulate individuals to release their specific blocks to healing. Indeed, the Chinese medical "climactic factors" most accurately describe the individual's experience of struggle to resolve or immobilize stressors, rather than providing a specific and accurate description of their physical nature.

Chinese medicine focuses on treating the individual patient, rather than the disease. We do this by probing individuals to optimize their responsiveness to their current physiological challenges. Often, that entails stimulating them to release or expel both internal and external pathogenic factors that impede the free flow of their vitality. Healing asks more of the individual than containing (and thus maintaining) their pathological expression. Independence from further therapy is a truer measure of healing than the patient's satisfaction with a maintenance regime. Case studies can help us learn from each other the subtle and mysterious art of disentangling an individual's diffidence with his or her embodiment, thus allowing them profound and lasting healing.

Of course, the duel dangers of case studies are that some practitioners will present them for the purpose of aggrandizing their egos, while others will uncritically apply their methods to patients. We must use them to teach (and learn) critical thought, or they may promote misdiagnosis and inaccurate application of treatments. We certainly want to guard against that by focusing on the thinking process, rather than the specific methods. Good case studies can help practitioners deepen and refine our understanding of the art of Chinese medicine. That's something you can't get from a double-blind experiment!


Click here for previous articles by Steven Alpern, LAc.

 

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