By Zev Rosenberg on February 1, 2007
“This term ‘philosophy,’ therefore, describes the entirety of intuitive
insight, intellectual knowledge, and all concrete activities associated with
the art of nourishing life. Medicine, from the perspective of the Neijing, is the science of how to safeguard one’s body through the wisdom of the ages — philosophy.”
– Zhang Xi-chun, translated by Heiner Fruehauf
The Chinese medical profession appears to be at a crossroads, one requiring some definition of purpose. Practitioners who want to practice a more open-ended, classically inspired form of Chinese medicine, need to develop a vision of what needs to be accomplished. The historical basis of modern Chinese medicine needs to be studied and absorbed, and educational models need to be developed and expanded. If we cannot define what is unique in our field, the tools and technology of our medicine will eventually be subsumed into biomedicine and the underlying principles and theory will be lost.
Although there are many potential bridges of collaboration between Chinese medicine and biomedicine, I think we need to ask ourselves, do we wish to be technicians, or scholar-physicians?
I. What do we mean by ‘scholar-physician?
Chinese medicine is based largely on scholarship and a literary tradition, with the requirement to study essential classical texts, quote and debate them. The foundations of Chinese medicine are based on principles (yin yang, five phase, six channels) that require a philosophical and philological approach to the body of knowledge. Traditionally, a physician-in-training needed to study such texts as the Su Wen/Simple Questions, Ling Shu/Divine Pivot, and Nan Jing/Classic of Difficulties to understand channel/connecting vessel theory, the Shang Han Za Bing Lun/Treatise on Cold Damage and Miscellaneous Diseases to diagnose progressions of disease parts and practice internal medicine.
In China, the concept of the scholar physician largely was developed during the 12th century Song dynasty through the encouragement of the emperor Huizhong. Huizong initiated the compilation of classical medical texts, established printing presses and academies to teach medicine. For the first time, the practice of medicine was elevated to a higher social status, making it more attractive for Confucian scholars who didn’t want to be limited to being government officials. Medicine continued to develop during the Jin-Yuan dynasties that followed in the works of the great Jin-Yuan dynasty physicians Li Dong-yuan, Zhang Zhe-he, Liu Wan-su and Zhu Dan-xi. This era was considered to be a ‘renaissance’ in Chinese medicine, so great were the developments of the four schools associated with these men. Under the Mongols, much eclectic knowledge was shared across the vast lands of the new empire, and an eclectic approach to knowledge was encouraged.
While the modern era has eroded the ideal of the scholar/physician to some degree in China, the importance of scholarship together with clinical practice has survived relatively intact. In the West, however, where the development of Chinese medicine is largely in an embryonic stage, there is still confusion about what direction we should go, in terms of the role of an acupuncturist in the existing health care systems, within or without.
II. The crossroads of modern medicine and its future
The modern biomedical world has seen vast changes in the last fifty years, as vast institutions of hospital chains, pharmaceutical companies, insurance providers, research institutions have centralized resources and largely usurped the power once in the hands of doctors. According to Paul Unschuld, present era medical doctors have largely had their role reduced to that of technicians, because they have lost control over their sources of information, fees, or decision-making. Much of the essential data of biomedicine has been outsourced to the fields of organic chemistry, biology, pharmacology, and physiology, which are separate professions and fields of study. The insurance industry largely determines physician fees, what services will be covered, and for how long. Doctors rely largely on information gained from expensive technological testing apparatus, again reinforced by the insurance industry which demands ‘definitive’ diagnoses, leaving little room for physician judgments based on knowledge and experience.
Many people interested in health provider careers were and are drawn to Chinese medicine as a clear alternative to the present biomedical establishment, in the hope of having a relative degree of independence in day-to-day practice. Most practitioners of Chinese medicine are still independent providers, largely with cash practices, in small offices with relatively low overhead. Some practitioners do work in hospitals, medical clinics and chiropractic offices, usually as limited providers of health care under the auspices of an M.D., D.O. or D.C. Many practitioners, however, are disappointed by a lack of a clear vision on what we should be; therapists or physicians, primary or secondary care, independent providers or not. The present-day Chinese medical schools in the West are also struggling with these issues, which are not clearly defined by any means at this point.
Modern medicine has also lost the integrity of the physician-patient relationship to a large extent. HMO’s and insurance companies often choose the physicians/specialists for patients, determine fees, treatments, timing of visits, and duration of treatment. Physicians have ceded control of their materia medica to pharmaceutical companies, who pressure physicians to prescribe their medications and avoid ‘unproven’ treatments such as herbal medicines. Gargantuan legal institutions such as the FDA, AMA, research foundations, and the HMO/insurance complex render the physician as a highly paid employee of a mega-corporation, unable to control even their own information sources in the medical schools.
III. What are our choices?
There is great pressure on the Chinese medical field to follow suit, to subsume and integrate into the biomedical world. If this should happen, many of the strengths of Chinese medicine could be threatened, because much of what makes Chinese medicine strong could not easily survive in this environment:
1) Individualization of treatment based on physician judgment
2) Control of medicines and preparations
3) Determining compatibility of patients and practitioners
4) Negotiable fees based on cash practice or profession-based insurance
5) More time, attention and care given to patients
6) Traditional diagnostic methods and flexible, creative treatment modalities
Already there are insurance programs that match acupuncturist/herbalists with patients, approve and review diagnosis and treatment codes, sell herbs to the patients, determine fees and hold the practitioners responsible for large amounts of paperwork that take time away from the patient/practitioner relationship. While I do encourage new graduates to work with other health care providers in both private offices and hospitals, it is also important for us to develop clinical environments that are conducive to the practice of a full-spectrum Chinese medicine. This may also mean we need to develop patient in-care facilities, including hospitals where herbal medicine is used, as in China.
IV. A Medicine Based on Philosophy, Not Data Sets
Chinese medicine is based on study of philosophy and principle, the cornerstone of clinical practice. Chinese medical practitioners are also encouraged to have a broad knowledge of the arts and humanities, so that they may have the greatest possible empathy with their patients. The modern trends in medical studies have moved away from philosophical approaches and the humanities to total immersion in the hard sciences. This trend also colors the training of Chinese medical doctors in China, where studies in Confucian doctrine and philosophy (“the Classics”) has largely been abandoned. In the West, if one reads the works of Sir William Osler, one can see the emphasis on philosophy and the humanities in medical training less than a century ago.
In conclusion, a scholar-physician embodies and lives the knowledge that is taught to him/her, The knowledge base belongs to each individual practitioner, instead of a centralized knowledge source based on data from studies and large institutions. Each practitioner’s experience is potentially innovative and creative. The knowledge based is stored in the historical and modern Chinese medical literature, which includes natural philosophy and the clinical case studies of generations of physicians with their prescriptions. In order for us to have a healthy future, we need to recognize the roots of our philosophy and practice, and create environments where we can both cultivate the strengths of our profession, and interact with other medical providers and systems from a position of strength and knowledge.