In the June 2008 issue of AT, Leon Hammer wrote an impassioned essay decrying our profession's current fascination with specialization. While he shed welcome light on the professional insecurity that motivates some to adopt modern specialties, he didn't focus on the enduring value of historical specialties, which differ from their modern counterparts.
Rather than simplistically categorizing patients according to the expression of their pathologies, as Dr. Hammer rightly criticized, historical specialties differentiate patients by the source of their ailments.
While Chinese medicine practitioners certainly can benefit by learning a little Western medicine, we sacrifice our medicine's strengths when we substitute their specialties for our historical ones. Although we can learn more specifics of anatomy and physiology and the meaning and use of various diagnostic tests in courses focused on (Western) medical specialties, that training often reinforces a physical bias in our perceptions and beliefs. That physical bias treats accumulations as given and tries to mitigate their experiential impact, rather than seeking to individually stimulate patients to disentangle from those accumulations. Why accept the limited standards of efficacy measured by Western medicine when our practice can aspire to transformational healing?
More information, even technologically enhanced information, won't rectify the deficiencies of modern Chinese medical training. Neither computer databases nor advanced diagnostic tests fill the gaps in our differential diagnosis. We must face the central flaw of modern TCM; while it discriminates patterns of disease expression and can sort patients into broad diagnostic categories, it offers practitioners precious little guidance individuating treatment strategies. We must learn to peer into each patient's "black box" in order to sort out their specific blocks. Those blocks provide the key to effective treatment far more than any amount of information, no matter how technologically enhanced.
Strange as it might seem to those of us who spent hundreds of hours learning to distinguish symptom-sign complexes, and thousands of hours memorizing symptoms indicated for hundreds of points and herbs, the wealth of Chinese medicine can't be found in its information. Those textbooks full of information are only a point of reference. Our real work in practicing must focus on identifying and sorting out complex and entangled individual factors. Standard treatments generally provide average results; the embodied spirit can do better.
The wondrous nature of Chinese medicine emanates from its poetic language and simple yet profound theories. It is an inquiry into the nature of life - both in general and, specifically, each individual's specific health challenges. Our work with Chinese medicine exceeds the potential of Western medicine when we incisively stimulate our patients to make profound transformations that liberate their innate potential for healing. We unblock their intrinsic responsiveness and our patients do the healing, which can carry them far beyond pharmaceutical maintenance. How can we learn to use Chinese medicine more incisively?
The historical specialties of Chinese medicine help practitioners sort out and disentangle the subtle dynamics leading to their patients' accumulations. Each specialty focuses on a single facet of the complex prism of life. The embodied spirit engages various key functions in maintaining individual life, and each was the focus of a historical specialty of the Imperial Academy of Medicine. These include:
maintaining the profusion of wei qi through the superficial layers (zhou li) - waike (external medicine specialty);
ingesting and digesting physical and experiential input, and combining the product with kong qi (air) to generate postnatal qi (qi and blood) - chang weike (digestion specialty); and
regulating the interface between blood and both jin and ye fluids, including their support by jing (essence) in managing the internal environment - "gynecology."
So, waike is about more than treating patients with ailments that appear on the exterior, though many people with skin or orthopedic ailments can be treated with this approach. Waike focuses on facilitating wei qi to release or expel stagnations to the exterior. That can be important for patients struggling with any kind of condition. This historical specialty focuses on unblocking stagnations, rather than balancing deficiencies and excesses. It stimulates catharsis, which "resets" intrinsic wei qi mechanisms, rather than directly attempting to restore harmony.
The digestion specialty is not just for patients with ailments that appear in the digestive tract. Patients develop a wide variety of disease because of dysfunctions in their generation of postnatal qi from digesting input. Likewise, the gynecology specialty is not just for women with ailments of their monthly cycles or after menopause. Chinese medicine gynecologists historically treated patients with a wide variety of ailments, including wind-damp painful obstruction, with herb formulas such as San Bi Tang for "Three Painful Obstructions" in Fine Formulas for Women (1237, Chen Zi-Ming). Indeed, any patient - even men - whose disease arises from failure to maintain the internal relationship between fluids and blood can benefit from this specialty. Of course, I don't tell men these herbal formulas have been informed by the "gynecology" specialty; I suspect most of them wouldn't take that very well!
One ironic feature of current Chinese medical training renders learning specialties an extension of our general training, as in Western medicine, rather than an inherent part of the initial curriculum. Most acupuncture and Oriental medicine schools teach (and licensing tests examine) a single tradition of Chinese medicine, which was dubbed "traditional Chinese medicine (TCM)" for our consumption. Much of our training process is devoted to learning its relatively consistent doctrine, rather than exploring Chinese medicine's philosophical roots in classical thought to develop clinical problem solving. The theories of historical specialties have explicit differences from each other; learning them can deepen a practitioner's understanding of the complexity and competing urges of individual life.
Each embodied spirit expresses primal urges in personal ways. These individual specifics make each patient different, even though many may have the same collection of symptoms or disease presentation. The historical specialties of Chinese medicine provide detailed energetic templates for different facets of human life. These can aid practitioners in developing individual treatment strategies for their patients. Historical specialties don't limit the range of patients a practitioner might treat; they reduce the complexity of practitioners' analysis that helps them discover insightful treatments.
Beyond the standard TCM doctrine imported from the People's Republic of China, American practitioners have been influenced by a few other recent traditions. Most notably, many have been inspired by Japanese traditions, the Worsley tradition based on Nanjing (Classic of Difficulties), and empirical traditions like the ones conveyed by Master Tung or Dr. Su. While each of these traditions enriches modern TCM, our nascent community of Oriental medicine lacks the intellectual vitality and ferment of China's 2,000-year historical tradition, which consists of competing schools of thought based in part on different passages in the enigmatic Neijing (Inner Classic).
We've been taught to classify excesses and deficiencies that accumulate around blocks, rather than pursuing the more subtle work of sorting out the individual causes of those blocks. Chinese medicine is an inquiry into the entanglements and accumulations of each embodied spirit. Can we learn to recognize and support the intrinsic vital processes of life and trust its wisdom to transform health, rather than trying to manage the expression of disease or insert control in the face of dysfunction?
Most of Dr. Hammer's points concerning the corrosive impact of our profession's current fascination with boards of specialization were well-taken. He was correct that standard biomedical research methodologies cannot evaluate Chinese medicine accurately. Their inadequacy derives from a core inconsistency between those research methodologies and our individualized approach to medicine. We know that patients can't be meaningfully classified into experimental classes according to their presenting conditions.
One patient with arthritis, vaginal hemorrhage or any other ailment isn't the same as any other! Randomizing patients into experimental classes and treating them as though they were the same doesn't serve the vitality and growth of Chinese medicine. At best that "research" may help us control disease expression. It cannot support our work to focus, stimulate and nurture resolution through profound transformational healing.
Our current TCM specialties are exemplified by concentrated studies in numerous doctoral programs and boards of specialization. How do these varied programs extend our understanding of Chinese medicine? Is there a single one that penetrates through the systematic weakness of modern Chinese medicine? Do any transcend clinical doctrine to uncover the subtle classical and historical thinking processes? Do they teach the "radical healing" principles of historical specialties like waike or develop TCM protocols to fit into specialties defined by Western medicine?
The shortsighted focus of trying to professionally "fit in" limits the potential of Chinese medicine. We see and understand phenomena differently from modern "scientific" medicine and have different goals. We strengthen our practice by explicitly exploring those philosophical differences. Historical specialties provide practitioners one way to engage the practical application of Chinese medicine's rich philosophical tradition assisting practitioners in refining their ability to individualize treatment strategies.
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