A Look At Flexner to Obamacare and the "Rhyme of History"
By Christian Nix
The 20th century was an astonishing period of advances in medical technology and the application of bio-chemistry and surgery. There is an old saying I am fond of and it seems appropriate to the point I wish to make in this piece: "History may not repeat itself, but it sure does rhyme."
There is a curious parallel between the advances in bio-medicine during the 20th century and the opportunity now open to acupuncturists and the Chinese medical community in North America during the current epoch of change within medicine and healthcare delivery.
The rhyme of history regarding this parallel is one that currently receives little, if any, consideration in any of the debate that I read and hear; and yet understanding this parallel is essential to the success of both individual practitioners and to the profession as a whole.
I would like to examine the decisions and actions of the conventional medical community in the early 20th century that led to the overwhelming progress, prowess and influence – not to say the advances and outcomes – of bio-medicine since the Flexner Report imposed serious standards and the adoption of best-practices in an attempt to discover if history is trying to rhyme once again.
The parallel I seek to investigate and uncover is one that seems largely ignored within the Chinese medical world where the internal debate continues regarding Classical Chinese Medicine vs. Traditional Chinese Medicine with much of the discussion focused on the "dangers of allowing TCM to depart from its classical antecedents in favor of a new and – to the chagrin of its classical proponents and adherents – untried model that offers concessions to the bio-medical notions of research and analysis."
Heiner Fruehauf in his book Chinese Medicine in Crisis: Science, Politics, and the Making of "TCM" noted"An urgent call for a re-evaluation of the direction and the fundamental convictions that we set for ourselves as individual Oriental medicine practitioners. Otherwise we may become thoroughly entrapped in 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."
I understand this internal debate well and I can grasp and appreciate the points made by such elder spokesmen as Z'ev Rosenburg and Heiner Fruehauf.
However, there may indeed be an important point or two regarding the rhyme of history and a certain inevitability regarding the necessity of our current historical moment and the shift (and chaos) prompted by the Affordable Care Act.
It is still somewhat de riguer within holistic medical circles in general (and certainly within some portion of the Chinese medical world in particular) to malign conventional medicine for both its excesses (too focused on prescribing drugs and too quick to promote expensive surgery); and its perceived shortcomings (same refrain).
Yet even the hardest critic would – in good conscience – be forced to admit that something good and positive was achieved during the grand sweep of 20th century medical advancement.
Many holistic and Chinese medical professionals who know and have read about Abraham Flexner's famous report in 1910 are quick to deride it as the ill-begotten result of America's wealthy industrial class seeking to outlaw homeopathy and the other forms and styles of healing and folk medicine that existed prior to the rise, creation and consolidation of the American Medical Association's nefarious power.
But the flip-side of this argument holds an equally relevant and essential point for contemplation; namely that the charlatanism of the "snake oil" salesmen of that era took them something of a back-seat to a more organized approach.
The question that naturally arises (at least in my mind) is: How willing are we as a profession to admit the existence of a considerable presence of new-age, snake oil practitioners within our own ranks; and what really is being done to guard against the wanna-be shamanic guru types who flatly and roundly reject the idea that there even can or should be standards and best-practices within holistic Chinese medicine? Are you starting to hear the rhyme of history?
The net effect of the Flexner Report was to declare the need for and (at least attempt) to define some standards by which medical practice would be taught, preformed and analyzed retrospectively. Yes, the uber-emphasis on biochemistry and physics very predictably created a bias and the very glass ceiling that many authors and thinkers have noted and commented upon. Here are some opinions:
"Crisis ... 'a crucial or decisive point or situation: a turning point ... an unstable condition ... involving an impending abrupt or decisive change ... which aptly describes the transition taking place in science today. In physics, biology, chemistry ... experts concur on the fact that the traditionally western dependence upon reductionism ... has reached its limits." 4
"Medicine more and more has come to be a science, or more accurately the application of one science, namely biochemistry. Medical techniques have come to be tested as much against current concepts in biochemistry as against their empirical results. Techniques that don't fit such chemical concepts - even if they seem to work – have been abandoned as pseudoscientific or downright fraudulent." 1
"Even Classical Greece had a notion of the inherent dangers of an epistemology that elevated physics at the cost of the subjective experience. Oswald Spengler nails this point with great erudition and detail in his 1928 classic, The Decline of the West. He even devotes an entire chapter in explanation of the glass ceiling of physics as it was then understood and practiced in Western science, descrying the very crisis now so evident to those individuals not in the employ of institutions to toe the line of the status quo." 3
But, the fact of progress remains and the incredible legacy of achievement that resulted from this decision to standardize bio-medicine is a very large elephant in the living room to be ignored or diminished by even the most irate and vehement of holistic zealots.
On the flip side of that coin, the validity of the holistic zealot's position is also worthy of consideration. The most notable characteristic of this "glass-ceiling" is that conventional medicine – with its reductionist bent – has been hard-pressed to explain and therefore accept and validate the bidirectional relationship between the mind and body (even though this barrier too has now largely been overcome by the fields of psychoneuroimmunology and psychoneuroendocrinology and the branches of conventional medicine that study and report on brain chemistry and psychiatric conditions).
Since the current epidemiology of chronic functional illness and disease arising from stress and life-style etiologies does not respond as well to the conventional body-as-machine approach as does say incidence of acute infectious disease and trauma, the current need for an approach that includes a professional model of mind-body holism is of paramount importance to any attempt to revise medicine – to say nothing about issues of cost when using conventional care for managing this increasing prevalence of chronic disease.
This is the basic situation as many are already aware. But, to return to Flexner: The successful effort to create and define standards and – in the course of time – to develop best-practices in conventional medicine was perhaps the single biggest and most momentous effect of Flexner's famous, (or infamous depending on your loyalties) report. But whether or not Flexner was a savior or "Satan," it is the rhyme of history that I wish to illuminate.
Opportunity and Solutions
The parallel to our current situation in the Chinese medical community in North America and especially as it pertains to the new healthcare legislation is nearly palpable.
The argument by Chinese medical purists goes something like this: "Chinese medicine cannot and must not be studied according to bio-medical criteria because to do so diminishes the eclectic nature of its many classically validated approaches and we risk sacrificing tradition on the altar of acceptance into the club of modern science. It (Chinese medicine) is too diverse to be studied through the cold and narrow lens of reductionist science."
But is this really the case?
With all the many ways to demonstrate and document both methodology and (hopefully) substantiate efficacy, I suspect more and more that the above lament is increasingly a kind of excuse arising from a segment of the Chinese medical industry that would simply be less stressed and more content not to have to do the work of self-criticism, reflection and analysis. Other research methodologies exist than randomized controlled trials and these too have legitimacy within conventional circles and among conventional medicine professionals. Why should we as a profession not employ some other research methodologies to our collective work? Why not lay aside the fervor of an argument that can only ever be short-sighted and – at best – offer a losing proposition that degrades and denigrates rather than acclaims and elevates?
The price of neglecting this task is higher than many might at first believe; so if you're thinking, "who cares?" The truth is, you do care. Remember that ultimate legitimacy in medicine comes when a group of professionals arrives at something resembling 'best-practices' – howsoever these might change as new data, evidence, applications and thinking develops and evolves. But to ignore the opportunity and importance of arriving at a profession-wide set of standards and best-practices is to ignore utterly the rhyme of history.
The incredible advances of 20th century conventional medicine were the result of a serious attempt to define what the mainstream held to be true about its own epistemology and methodology of inquiry into the natural world as well as the clinical applications it could study and review in eradicating disease and affecting healing.
However flawed this attempt might appear to us from our 21st century parapet of 20/20 hindsight, it is nonetheless worthy of respect and consideration when seen within the context of its own era and historical necessity.
My own investigation into this matter and 9 plus years of traveling and teaching has shown me there is precious little in the way of agreement regarding best-practices within either holism in general or acupuncture and Chinese medicine in particular. The system of Chinese internal medicine is somewhat more defined by the rigors and parameters of pattern discrimination; but even still it is rare to find practitioners who have studied and grasped that system to a degree sufficient to offer consensus in either diagnosis or treatment. Try to find acupuncturists who adhere to a discipline or who even agree about whether or not needle sensation is required as part of therapeutic efficacy and it becomes clear that nothing like best-practices exist within the acupuncture world.
Whether or not the reader finds any of the above either disturbing or even worthy of consideration at all, -- "after all, if patients are willing to pay me, then who cares what science has to say and why should I bother defining my standards?" – It is the rhyme of history and the current opportunity that should be considered and not too quickly dismissed. The opportunity before the Chinese medical community is the chance to begin to impose discipline within its own ranks.
In a subsequent article, I will address this question regarding: What is a Discipline in Medicine? The parallel between our current situation and the Flexner Report of just over a century ago is that by adopting and defining an industry-wide standard of best-practices, we have the potential to gain enormous legitimacy and leverage during a historical era in which literally tens of millions of patients and a nearly bankrupt medical system would derive profound benefit.
Whatever your definition of success and however jaded one might be towards the conventional medical system, such legitimacy smacks of real victory. As Flexner's Report circumscribed what would and would not be considered legitimate, so too the Chinese medical community in North America has a choice to declare what is and is not legitimate practice. What this all comes down to is research; but not merely the kind so abhorred by the Classicists and others within that camp. What is required is the simple collection of data, an attempt at clear documentation of what was performed and the tracking of clinical outcomes so that something like a consensus of best-practices may be outlined and – eventually – adopted on a system-wide basis.
The choice not to design and perform research of its own initiative and devising and according to its own definitions may doom the Chinese medical world to perpetual sub-standard eclecticism and – by extension – perpetual exclusion from the highest levels of mainstream medical practice and delivery.
Even research currently being conducted according to the parameters of bio-medicine and believed to be at odds with our industry's Classicist leanings is still a move to create the preponderance of proof so necessary to substantiate legitimacy of both the efficacy of clinical outcomes and a peer-reviewable methodology and without which no universal acceptance and inclusion will be possible or even considered by the conventional mainstream.
Those who dismiss and deride such bio-medical efforts and evidence as facile and disingenuous should come forward with their own research design and studies. This is the game of science and if the rules of the randomized control trial seem not to fit, then we must choose among the other options – for our own sake if not that of our patients and our potential contribution to the medical system and to society.
I am a big believer that, "if you feel the rules work against you, then by all means make up your own rules." There has never been a situation on such a wide-spread scale (and I suspect there will not come another in our life-time) when the disarray of the status quo has so perfectly set the stage for daring and visionary innovation. We members of the Chinese medical profession have the unprecedented opportunity to write our own ticket right now IF enough people are willing to set our own ship in order first and start to define and raise the level of practice within our own industry to something that could legitimately be considered to include a defined set of best-practices.
There is no shortage of reasons or rewards to get into the game during this historical shift; but the one option that seems to lead nowhere and to no one's benefit is the one that does nothing different.
Conventional medicine and the conventional medical professionals I work with are eager to know more and to adopt what I have tried to offer. There is no reason why more efforts should not focus on this prize of inclusion within mainstream settings and the incredible rewards that exist for those who will for bridge the chasm of understanding between holism and conventional medicine.
If you can hear the rhyme of history, there seems to me to be a note of inevitability to it all.
Becker, Robert; Gary Selden. The Body Electric: electromagnetism and the foundations of life. Morrow. New York, 1985.
Fruehauf, Heiner. Chinese Medicine in Crisis: Science, Politics, and the Making of "TCM"
Nix, Christian. Tao of Integration: Archetype, Medical Systems and a Vision of Medicine in the Age of Chronic Disease. 2010
Pritzker, Sonya. From the Simple to the Complex: what is complexity theory and how does it relate to Chinese medicine? Clinical Acupuncture and Oriental Medicine. Elsevier Science Ltd. Vol. 3. 2002. p. 99-104
Christian Nix has launched the first Hospital Based Acupuncture Residency Training program in North America and his Community Pain and Stress Center is the first private model of community-style practice to be integrated into a major hospital system. His new book, Tao of Integration is a fresh look at much of the misapprehension hindering professional quality integration in medicine. Christian travels and teaches throughout the world.