Chinese Medicine in the West 2009 Journal of Chinese Medicine. Number 90. June 2009 Chinese Medicine in the West 2009 n January 1985 The Journal of Chinese Medicine c Chinese go to o the British Acupuncture published an edited transcript of a discussion Council conference, and conferences of some called ' Acupuncture in the West between Peter other associations, such as the association for Hugh Deadman, Ted Kaptchuk, Giovanni Maciocia and Traditional Chinese Medicine, are pred MacPherson, Felicity Moir. It was a particularly popular article Chinese Daniel Maxwell,! and to celebrate the 30th anniversary of the jCM we Felicity Moir decided to convene another discussion, in London in PD: And that's also rooted in history isn'tit Chinese and Volker March 2009. Present this time were Peter Deadman medicine is strong in Australia because there gh MacPherson(HM), Daniel Maxwell has been a Chinese medical presence since the (DM), Felicity Moir(FM) and Volker Scheid(VS) 19th century at least. I remember hearing that in All are past or present practitioners of acupuncture the 19th century a lot of the bush doctors who and/or herbal medicine. For brief biographies of the went around treating remote communities were participants, please see the end of the article Chinese doctors, carrying their boxes of herbs And also, as you mention, Britain and China ck by the fact that we have no have a history! person here in the discussion. You know, we in 2009; herbal medicine has almost been taken VS: I know that the Chinese medicine organisations over by China in the UK, in terms of the physical Australia made a political decision They presence of all the shops in UK high streets. And wanted not to have this separation, so they in terms of discussing Chinese medicine in the worked really hard at it, from both sides West, there's the enduring problem of what it means for us, as Westerners, to claim ownership PD: This is one form of separatism, and there of something that comes from somewhere else are others. some of which weve overcome history of this process- associated with there was a time when so-called "traditional erialism and with translation- all these acupuncturists" from different schools issues have interested me for the last 20 years rouldn't talk to each other, and we' ve mostly overcome that. but as well as the eparatsn PD: To answer your first question, that's my fault. between Westerners and Chinese in britain there is an equal separation between traditional HM: I think it's partly that what's happening in the UK is different from what's happening in other practise acupuncture, or doctors who practise countries; because of our history. In the 1970s acupuncture. There seems to be ething specially, we had styles of acupuncture that about this profession, like many professions, were the import of TCM, and that relied where people love the differences more tha on the charisma of the individuals who started the similarities those schools, and who actually didn't want too much Chinese medicine to come in, because FM: It's on the political level with upcoming that would become quite confrontational, regulation that people are coming together-the and so a dynamic was set up here of separate British Acupuncture Council with the Chinese development. If you go to Australia, for example, professional bodies, the physiotherapists and to their big conferences, it is 50-50 Chinese and the doctors. It seems to be that it's only when Westerners, whereas over here in Britain there have a threat from the outside that we all come re separate conferences. For example relatively
6 Chinese Medicine in the West 2009 Journal of Chinese Medicine • Number 90 • June 2009 I n January 1985 The Journal of Chinese Medicine published an edited transcript of a discussion called ‘Acupuncture in the West’ between Peter Deadman, Ted Kaptchuk, Giovanni Maciocia and Felicity Moir. It was a particularly popular article and to celebrate the 30th anniversary of the JCM we decided to convene another discussion, in London in March 2009. Present this time were Peter Deadman (PD), Hugh MacPherson (HM), Daniel Maxwell (DM), Felicity Moir (FM) and Volker Scheid (VS). All are past or present practitioners of acupuncture and/or herbal medicine. For brief biographies of the participants, please see the end of the article. VS: I’m struck by the fact that we have no Chinese person here in the discussion. You know, we are in 2009; herbal medicine has almost been taken over by China in the UK, in terms of the physical presence of all the shops in UK high streets. And in terms of discussing Chinese medicine in the West, there’s the enduring problem of what it means for us, as Westerners, to claim ownership of something that comes from somewhere else; the history of this process ‑ associated with imperialism and with translation ‑ all these issues have interested me for the last 20 years. PD: To answer your first question, that’s my fault. HM: I think it’s partly that what’s happening in the UK is different from what’s happening in other countries; because of our history. In the 1970’s especially, we had styles of acupuncture that were pre‑ the import of TCM, and that relied on the charisma of the individuals who started those schools, and who actually didn’t want too much Chinese medicine to come in, because that would become quite confrontational, and so a dynamic was set up here of separate development. If you go to Australia, for example, to their big conferences, it is 50‑50 Chinese and Westerners, whereas over here in Britain, there are separate conferences. For example relatively few ethnic Chinese go to the British Acupuncture Council conference, and conferences of some other associations, such as the Association for Traditional Chinese Medicine, are predominantly Chinese. PD: And that’s also rooted in history isn’t it. Chinese medicine is strong in Australia because there has been a Chinese medical presence since the 19th century at least. I remember hearing that in the 19th century a lot of the bush doctors who went around treating remote communities were Chinese doctors, carrying their boxes of herbs. And also, as you mention, Britain and China have a history! VS: I know that the Chinese medicine organisations in Australia made a political decision They wanted not to have this separation, so they worked really hard at it, from both sides. PD: This is one form of separatism, and there are others, some of which we’ve overcome: there was a time when so‑called “traditional acupuncturists” from different schools wouldn’t talk to each other, and we’ve mostly overcome that. But as well as the separatism between Westerners and Chinese in Britain, there is an equal separation between traditional acupuncturists and physiotherapists who practise acupuncture, or doctors who practise acupuncture. There seems to be something about this profession, like many professions, where people love the differences more than the similarities. FM: It’s on the political level with upcoming regulation that people are coming together ‑ the British Acupuncture Council with the Chinese professional bodies, the physiotherapists and the doctors. It seems to be that it’s only when we have a threat from the outside that we all come together. Chinese Medicine in the West 2009 By: Peter Deadman, Hugh MacPherson, Daniel Maxwell, Felicity Moir and Volker Scheid
Journal of chinese Medicine. Number 90. June 2009 Chinese Medicine in the West 2009 VS: That happened in China, too. The only reason Chinese and that' s key to me. And although nowadays I dont medicine became Chinese medicine-in a certainse think that's always why students are doing Chinese is because of this threat of extinction before the medicine, that passion still emerges. You really see it early 20th century there was no"Chinese medicine. in their understanding of the whole diagnostic and Only lots of factions practising"medicine", all at each pathological process. And the acupuncture is one part others throats. It was only when they were faced with of that; it's the qi of acupuncture that's so important the real threat of extinction in 1929 that they started So I think that is still alive and well, and that' s what to organise politically as one group. So those things keeps me going in terms of education and in terms have nothing to do with Chinese medicine, they are what I want to teach which is a true alternative just professional po PD: Well I have to say I'm not convinced that that is still PD: Anyway, my apologies for the lack of a Chinese alive, because i teach in a lot of different countries presence.I'd like to start us off by thinking about and I'm really surprised how Chinese medicine how we would like to see this profession-that we education seems to be increasingly divorced from might call Chinese medicine, or Oriental medicine those roots and several essential steps seem to be unfold. how we think it's going to unfold, or how missing. I remember teaching in America, analysing we fear it's going to unfold in the future. To start off cases, and doing what is very natural to me-its how I would say that the use of an acupuncture needle I was taught -trying to relate what is happening to to stick in an acupuncture point is not a rootless the patient to the causes of disease. I always felt that thing. For me it has deep roots in what I understand if somebody is sick, what we must do, as well as offer of Chinese medicine- I've not studied Japanese, treatment, is look back and try to understand how Vietnamese, Korean acupuncture- and even more this has come about. It's logical that if how it has come in what I understand of Chinese philosophy, which about is a present factor in their lives they may not I feel is the ultimate root of this practice. What we get better until they change it. But I heard Ame have, more with acupuncture than herbal medicine, students tell me that this is not something that is a lot of people practising, learning and researching were taught, and that their approach to the patient acupuncture in a way that does not connect with those starts with differentiation of patterns and leads on to roots. So one question is how important do we feel treatment, and anything else is background that they those roots are, and is that how we would like to see were not taught. I've seen this in other places,and this medicine develop, deeply rooted, or re-rooted, this to me is part of the Westernisation of Chinese are we happy for it to go in another direction -do we think it will go in another direction, or are we afraid that it will go in another direction. DM: In the last discussion 23 years ago, Ted Kaptchuk was saying that at some point Western acupuncture VS: I think the crucial issue here has to do with the names would make a"declaration of independence China, and Chinese. A lot of people in the medical But what I've observed recently -at least an world would say that acupuncture has nothing to traditional practitioners-is that it seems to be do with China, it's just sticking needles, and most of the opposite. Apart from research and more modern the current research doesn't say" Chinese medicin inventions like electroacupuncture, there seems to be it says"acupuncture". So I'm interested in whether more of a cleaving to the older texts and especially there is really anything Chinese about Chinese lineages. There is much more interest in finding medicine? Is it acupuncture when you just stick lineages from China rather than just broad spectrum needles? What's the difference between doing it in " TCM"or"Chinese medicine". So it is not becoming a Chinese way, or a medical acupuncture way, or a more independent; it is becoming more Chinese Japanese way? VS: I think all these things are happening at the same FM: Your question brings me right back to why I wanted time. I would suggest that the Westernising process to study Chinese medicine -as a true alternative. To is actually something in which China is involved, me having one system of medicine in a country, a too. It comes from the West going to China, then monoculture, is an absolute danger. That was always the Chinese taking it up and repackaging their my concern, and therefore I went into Chinese own medicine in a way that they think appeals to medicine And to me that's what Chinese medicine is us but also that they think is systematic, and they all about, it offers society a true alternative, another ship it over here and we call it Westernisation. But ray ofunderstanding how the body works, a different another way of looking at it is actually as a Chinese narrative for patients, a different process altogether, interpretation of the West sold back to us. So I think
Journal of Chinese Medicine • Number 90 • June 2009 Chinese Medicine in the West 2009 7 VS: That happened in China, too. The only reason Chinese medicine became Chinese medicine ‑ in a certain sense ‑ is because of this threat of extinction. Before the early 20th century there was no “Chinese medicine.” Only lots of factions practising “medicine”, all at each others’ throats. It was only when they were faced with the real threat of extinction in 1929 that they started to organise politically as one group. So those things have nothing to do with Chinese medicine, they are just professional politics. PD: Anyway, my apologies for the lack of a Chinese presence ... I’d like to start us off by thinking about how we would like to see this profession ‑ that we might call Chinese medicine, or Oriental medicine ‑ unfold ... how we think it’s going to unfold, or how we fear it’s going to unfold in the future. To start off I would say that the use of an acupuncture needle to stick in an acupuncture point is not a rootless thing. For me it has deep roots in what I understand of Chinese medicine ‑ I’ve not studied Japanese, Vietnamese, Korean acupuncture – and even more in what I understand of Chinese philosophy, which I feel is the ultimate root of this practice. What we have, more with acupuncture than herbal medicine, is a lot of people practising, learning and researching acupuncture in a way that does not connect with those roots. So one question is how important do we feel those roots are, and is that how we would like to see this medicine develop, deeply rooted, or re‑rooted, or are we happy for it to go in another direction – do we think it will go in another direction, or are we afraid that it will go in another direction. VS: I think the crucial issue here has to do with the names China, and Chinese. A lot of people in the medical world would say that acupuncture has nothing to do with China, it’s just sticking needles, and most of the current research doesn’t say “Chinese medicine” it says “acupuncture”. So I’m interested in whether there is really anything Chinese about Chinese medicine? Is it acupuncture when you just stick needles? What’s the difference between doing it in a Chinese way, or a medical acupuncture way, or a Japanese way? FM: Your question brings me right back to why I wanted to study Chinese medicine ‑ as a true alternative. To me having one system of medicine in a country, a monoculture, is an absolute danger. That was always my concern, and therefore I went into Chinese medicine. And to me that’s what Chinese medicine is all about, it offers society a true alternative, another way of understanding how the body works, a different narrative for patients, a different process altogether, and that’s key to me. And although nowadays I don’t think that’s always why students are doing Chinese medicine, that passion still emerges. You really see it in their understanding of the whole diagnostic and pathological process. And the acupuncture is one part of that; it’s the qi of acupuncture that’s so important. So I think that is still alive and well, and that’s what keeps me going in terms of education and in terms of what I want to teach, which is a true alternative. PD: Well I have to say I’m not convinced that that is still alive, because I teach in a lot of different countries, and I’m really surprised how Chinese medicine education seems to be increasingly divorced from those roots and several essential steps seem to be missing. I remember teaching in America, analysing cases, and doing what is very natural to me – it’s how I was taught – trying to relate what is happening to the patient to the causes of disease. I always felt that if somebody is sick, what we must do, as well as offer treatment, is look back and try to understand how this has come about. It’s logical that if how it has come about is a present factor in their lives they may not get better until they change it. But I heard American students tell me that this is not something that they were taught, and that their approach to the patient starts with differentiation of patterns and leads on to treatment, and anything else is background that they were not taught. I’ve seen this in other places, and this to me is part of the Westernisation of Chinese medicine. DM: In the last discussion 23 years ago, Ted Kaptchuk was saying that at some point Western acupuncture would make a “declaration of independence”. But what I’ve observed recently ‑ at least among traditional practitioners ‑ is that it seems to be quite the opposite. Apart from research and more modern inventions like electroacupuncture, there seems to be more of a cleaving to the older texts and especially lineages. There is much more interest in finding lineages from China rather than just broad spectrum “TCM” or “Chinese medicine”. So it is not becoming more independent; it is becoming more Chinese. VS: I think all these things are happening at the same time. I would suggest that the Westernising process is actually something in which China is involved, too. It comes from the West going to China, then the Chinese taking it up and repackaging their own medicine in a way that they think appeals to us but also that they think is systematic, and they ship it over here and we call it Westernisation. But another way of looking at it is actually as a Chinese interpretation of the West sold back to us. So I think
Chinese Medicine in the West 2009 Journal of Chinese Medicine. Number 90. June 2009 it is really quite complicated. On the one hand good lifestyle advice, that style shou you have what Peter describes, then you have the become more dominant over time fact that some Westerners have been in China for a long time and come up with all these names like PD: When we say "lifestyle advice", that in itself is a very big subject isn'tit? I'm particularly interested in health medicine and so on, all competing with each other, preservation, which intersects with the practice of and then you have the development of acupuncture Chinese medicine. That is one of the great strengths for purely commercial reasons, so that it is not so of the tradition that i feel connected to, as much much about medicine any more, but more and more the actual practical delivery of the medicine. And the about"wellness"and"well-being", such as cosmetic tyle advice that is given by someone rooted in acupuncture, and IVE. These developments turn Chinese health preservation and Chinese medicine, away from medicine as being concerned with curing is going to be different from the advice given by a disease, and that could be seen as one aspect of doctor, or a physiotherapist for example. It also goes losing ones roots, or losing ones claims to being an a little bit beyond lifestyle advice, because it implies alternative. Though on theother hand, you could also a particular understanding of what human life is say that the entire notion of"alternative medicine For example regulation of the emotions, certainly was wrapped up from the beginning already in this within Confucianism, Taoism and Buddhism, is an white middle-class concern for well-being, and what absolutely fundamental part of being healthy. I'm some call the psychologisation of acupuncture has not sure necessarily that what people offer as lifestyle been well-documented, of course, by Linda barnes advice really connects with those traditions and others HM: I think it's very varied, people bring to their FM: That is something that concerns me, the inclusion relationship with their patient their experiences and of Chinese medicine into "Complementary and their background, and hopefully, if they are good, Alternative Medicine"-often called "therapie they find some way of connecting with the patient rather than medicine. I still think that it is not where that patient needs some help. That's the ideal, understood what Chinese medicine is, that it is a true and that's different for each patient, and different medical system in its own right, that can understand practitioners have different levels of skill. Maybe and treat serious disease. So the"acupuncture for lifestyle advice"is too broad a term, but if they are health and well-being"that is out there does worry thinking"how can I help that patient maintain any me, because there is this idea that we are not treating mprovements that might come from the treatment there are all sorts of things that could be in there, it's very difficult to map in any systematic way, HM: If you look at the membership of the British because it is so varied Acupuncture Council, and I think it is similar for the physiotherapists and the doctors in the UK VS: We talk about complex interventions very often and and I'm doing a big survey right now to track if you look at what the practitioner does in the clinic, down what is actually out there- if you look at there what practitioners treat, they are treating health medicine an many different parts to it, and Chinese conditions. We actually looked at"well-being all cross-fertilise each other and affect each other in we had a well-being question-and less than five different ways. One of the easiest ways to see it is per cent are what may be called"maintenance in terms of herbal medicine, so that you've got some treatments. Almost everyone who is coming to herbs that are also foods and spices, like yams root see us has problems, and we are on the front line which you might eat every day, and then you have of how to address them. And I'd like to pick up on got really very toxic herbs. You have a very wide the lifestyle advice that Peter was talking about, spectrum, so where is the boundary between eating that's always been something that is important to d taking herbs-it doesn't, on a certain level exist me. Actually we did a trial of acupuncture for back So what is the difference between regulating you pain in York, and we asked practitioners about what breath and meditating or just focusing on where you kind of lifestyle advice they gave and why, and all stick the needles in. So we have to talk in a way that of the practitioners thought that the lifestyle advice goes beyond just talking like when we do research was the key factor in terms of long-term sustained we have to frame the questions really carefully. One change. So I think hopefully, as Chinese medicine question would be, what is so specific about this thing becomes more integrated into the West, becomes that we call Chinese medicine that makes it different more part of Western culture, if we are getting goo And how is that different to, say, other forms of very
8 Chinese Medicine in the West 2009 Journal of Chinese Medicine • Number 90 • June 2009 it is really quite complicated. On the one hand you have what Peter describes, then you have the fact that some Westerners have been in China for a long time and come up with all these names like “Classical” Chinese medicine, “Canonical” Chinese medicine and so on, all competing with each other, and then you have the development of acupuncture for purely commercial reasons, so that it is not so much about medicine any more, but more and more about “wellness” and “well‑being”, such as cosmetic acupuncture, and IVF. These developments turn away from medicine as being concerned with curing disease, and that could be seen as one aspect of losing one’s roots, or losing one’s claims to being an alternative. Though on the other hand, you could also say that the entire notion of “alternative medicine” was wrapped up from the beginning already in this white middle‑class concern for well‑being, and what some call the psychologisation of acupuncture has been well‑documented, of course, by Linda Barnes1 and others. FM: That is something that concerns me, the inclusion of Chinese medicine into “Complementary and Alternative Medicine” ‑ often called “therapies” rather than medicine. I still think that it is not understood what Chinese medicine is, that it is a true medical system in its own right, that can understand and treat serious disease. So the “acupuncture for health and well‑being” that is out there does worry me, because there is this idea that we are not treating serious illness. HM: If you look at the membership of the British Acupuncture Council, and I think it is similar for the physiotherapists and the doctors in the UK – and I’m doing a big survey right now to track down what is actually out there – if you look at what practitioners treat, they are treating health conditions. We actually looked at “well‑being” – we had a well‑being question ‑ and less than five per cent are what may be called “maintenance” treatments. Almost everyone who is coming to see us has problems, and we are on the front line of how to address them. And I’d like to pick up on the lifestyle advice that Peter was talking about, that’s always been something that is important to me. Actually we did a trial of acupuncture for back pain in York, and we asked practitioners about what kind of lifestyle advice they gave and why, and all of the practitioners thought that the lifestyle advice was the key factor in terms of long‑term sustained change. So I think hopefully, as Chinese medicine becomes more integrated into the West, becomes more part of Western culture, if we are getting good results with good lifestyle advice, that style should become more dominant over time. PD: When we say “lifestyle advice”, that in itself is a very big subject isn’t it? I’m particularly interested in health preservation, which intersects with the practice of Chinese medicine. That is one of the great strengths of the tradition that I feel connected to, as much as the actual practical delivery of the medicine. And the lifestyle advice that is given by someone rooted in Chinese health preservation and Chinese medicine, is going to be different from the advice given by a doctor, or a physiotherapist for example. It also goes a little bit beyond lifestyle advice, because it implies a particular understanding of what human life is. For example regulation of the emotions, certainly within Confucianism, Taoism and Buddhism, is an absolutely fundamental part of being healthy. I’m not sure necessarily that what people offer as lifestyle advice really connects with those traditions. HM: I think it’s very varied, people bring to their relationship with their patient their experiences and their background, and hopefully, if they are good, they find some way of connecting with the patient where that patient needs some help. That’s the ideal, and that’s different for each patient, and different practitioners have different levels of skill. Maybe “lifestyle advice” is too broad a term, but if they are thinking “how can I help that patient maintain any improvements that might come from the treatment”, there are all sorts of things that could be in there, and it’s very difficult to map in any systematic way, because it is so varied. VS: We talk about complex interventions very often and if you look at what the practitioner does in the clinic, there are so many different parts to it, and Chinese medicine and acupuncture is only one part, and they all cross‑fertilise each other and affect each other in different ways. One of the easiest ways to see it is in terms of herbal medicine, so that you’ve got some herbs that are also foods and spices, like yam’s root which you might eat every day, and then you have got really very toxic herbs. You have a very wide spectrum, so where is the boundary between eating and taking herbs – it doesn’t, on a certain level exist. So what is the difference between regulating your breath and meditating or just focusing on where you stick the needles in. So we have to talk in a way that goes beyond just talking; like when we do research we have to frame the questions really carefully. One question would be, what is so specific about this thing that we call Chinese medicine that makes it different. And how is that different to, say, other forms of very
Journal of chinese Medicine. Number 90. June 2009 Chinese Medicine in the West 2009 good medicine, because there are things that we do it becomes very difficult to draw boundaries because and a doctor does and even a shaman does that are these different systems are connected to each other. just generic to medicine Even more, there is an approach to practice that is really difficult to put into words, because it concerns PD: So the question is, what is unique about Chinese how you become an effective practitioner, how you medicine make judgements, how you learn to discover patterns and to take effective action VS: Yes that would be one of the questions D: I remember from your talk at a recent conference PD: Well I think we are pretty clear that it is not just that your view of Chinese medicine is much more sticking in a needle. It's not giving a herb. It's concerned with the skill and experience and wisdom something deeper than that. I would suggest, as a of the individual practitioner, rather than commonly starting point, that what is unique about Chinese agreed practices medicine is its understanding of the human organism as an integrated whole-this seems to me to be quite VS: That's part of it. But I do also want to point out that special to Chinese medicine-and the understanding biomedical doctors sometimes use pattern diagnosis of the microcosmic human organism as related to the For example they have different treatments for hypertension, and as far as I know there are different patterns of hypertension and doctors develop way VS: OK, but for the first bit you could have systems of typing different Western medicines to these biology, or various systems approaches in Western medicine: they would very much also look at the FM: Including lifestyle advice body as an integrated whole VS: But Chinese medicine is better at doing that because PD: Well it may be that any part that we pick and say is it teaches you not just to have three of four set unique to Chinese medicine, you could say ah but patterns like TCM syndromes, but to start from these there is something else like that . so maybe it is the syndromes to look at what is really crucial at that particular combination of these unique factors moment in a persons life VS: I would like to push us to be quite precise, and PD: In terms of treatment it's the"tipping point"-which ask what is the unique configuration. That's where place do you press that will turn things around research is really useful because it forces us not just to develop good methodology, but also to ask precise VS: Yes, you definitely have to be unbelievably flexible. I had a patient I saw recently, I was treating her with herbs and I didn't get anywhere, but I'm a bit stupid PD: Do you have an answer? so I persisted with my herbs until I finally figured out that the crux was to help her change her diet, because VS: I'm still struggling with my own answer, but the way I that's where she was responsive. But concern with think about it is that there is something totally unique diet is still Chinese medicine and valuable about this medicine. You could say it is a unique cultural treasure and if you destroy it you FM: That's why I want to focus on cause of disease, are destroying something like the Amazon rainforest. because I think it's all about-what is the diagnosis, Thats my feeling approach to Chinese medicine. It what is the cause, what is the treatment principle and has grown over 2000 years, and so many people have strategy, and then how that all has to come together put so much effort into it and it is therefore unique to help us understand what is going on and help And just as a cultural phenomenon it deserves to be part preserved. So the next question is, what about it is telling the story to the patient. Chinese medicine has so unique and of course there are different strands a vocabulary that gives patients another narrative to Chinese medicine. When I talk about Chinese and another way of understanding medicine I really mean an elite Chinese medicine, practised maybe for the last 1000 years by a very PD: I absolutely agree. I think one of our roles is to small section of Chinese doctors of Chinese medicine hold a mirror up to our patients so that they can and I would say that it is a unique conjunction of see themselves more clearly. That might involve philosophy, of life, and the understanding of the affirming something they already know about their body as a system, resonating with other systems, and life- but seeing it more clearly. And what we feed
Journal of Chinese Medicine • Number 90 • June 2009 Chinese Medicine in the West 2009 9 good medicine, because there are things that we do and a doctor does and even a shaman does that are just generic to medicine. PD: So the question is, what is unique about Chinese medicine. VS: Yes that would be one of the questions. PD: Well I think we are pretty clear that it is not just sticking in a needle. It’s not giving a herb. It’s something deeper than that. I would suggest, as a starting point, that what is unique about Chinese medicine is its understanding of the human organism as an integrated whole ‑ this seems to me to be quite special to Chinese medicine – and the understanding of the microcosmic human organism as related to the macrocosmic universe. VS: OK, but for the first bit you could have systems biology, or various systems approaches in Western medicine: they would very much also look at the body as an integrated whole. PD: Well it may be that any part that we pick and say is unique to Chinese medicine, you could say ah but there is something else like that … so maybe it is the particular combination of these unique factors. VS: I would like to push us to be quite precise, and ask what is the unique configuration. That’s where research is really useful because it forces us not just to develop good methodology, but also to ask precise questions. PD: Do you have an answer? VS: I’m still struggling with my own answer, but the way I think about it is that there is something totally unique and valuable about this medicine. You could say it is a unique cultural treasure and if you destroy it you are destroying something like the Amazon rainforest. That’s my feeling approach to Chinese medicine. It has grown over 2000 years, and so many people have put so much effort into it and it is therefore unique. And just as a cultural phenomenon it deserves to be preserved. So the next question is, what about it is so unique and of course there are different strands to Chinese medicine. When I talk about Chinese medicine I really mean an elite Chinese medicine, practised maybe for the last 1000 years by a very small section of Chinese doctors of Chinese medicine, and I would say that it is a unique conjunction of philosophy, of life, and the understanding of the body as a system, resonating with other systems, and it becomes very difficult to draw boundaries because these different systems are connected to each other. Even more, there is an approach to practice that is really difficult to put into words, because it concerns how you become an effective practitioner, how you make judgements, how you learn to discover patterns and to take effective action. PD: I remember from your talk at a recent conference that your view of Chinese medicine is much more concerned with the skill and experience and wisdom of the individual practitioner, rather than commonly agreed practices. VS: That’s part of it. But I do also want to point out that biomedical doctors sometimes use pattern diagnosis. For example they have different treatments for hypertension, and as far as I know there are different patterns of hypertension and doctors develop ways of typing different Western medicines to these. FM: Including lifestyle advice. VS: But Chinese medicine is better at doing that because it teaches you not just to have three of four set patterns like TCM syndromes, but to start from these syndromes to look at what is really crucial at that moment in a person’s life. PD: In terms of treatment it’s the “tipping point” – which place do you press that will turn things around. VS: Yes, you definitely have to be unbelievably flexible. I had a patient I saw recently, I was treating her with herbs and I didn’t get anywhere, but I’m a bit stupid so I persisted with my herbs until I finally figured out that the crux was to help her change her diet, because that’s where she was responsive. But concern with diet is still Chinese medicine. FM: That’s why I want to focus on cause of disease, because I think it’s all about ‑ what is the diagnosis, what is the cause, what is the treatment principle and strategy, and then how that all has to come together to help us understand what is going on and help the patient to see the links. And part of that is also telling the story to the patient. Chinese medicine has a vocabulary that gives patients another narrative and another way of understanding. PD: I absolutely agree. I think one of our roles is to hold a mirror up to our patients so that they can see themselves more clearly. That might involve affirming something they already know about their life ‑ but seeing it more clearly. And what we feed
Chinese Medicine in the West 2009 Journal of Chinese Medicine. Number 90. June 2009 back to them is quite likely to be something that their What's so good about the theory is its flexibility and friends and family have always told them but they also the fact that the diagnosis tells you something have never clearly heard before, like you need to that you then implement in the treatment and also relax, or'should you eat that fifth helping? in the lifestyle advice, so it's an integrated approach which Western medicine doesnt have. So I think we HM: I want to come back to this question about what is have to discuss what the principles are that underlie unique about Chinese medicine, because when we Chinese medicine, because they drive the theory design clinical trials, we need to have a protocol. So which drives the actual techniques that you use theres a dilemma. We know that out there in the field people are giving all sorts of different treatments, so DM: Well one of those, and you almost touched on it there, should you impose a particular protocol in a trial-one is the"Q"word, "qi, which is one of the reasons why that you think is the best or results from some kind of acupuncture can elude research and elude definition. consensus decision that this is the best treatment, or do It ties into what Volker has said about dealing with you do what might be called a field trial or pragmatic practitioners than a system. Thereis adifference trial where you allow practitioners to practise in their between somebody who has been trained extensively own unique way. I think thats much better for a very in qigong using a needle and doing a diagnosis, and complex intervention-to trust the judgement of the someone who has been trained in an intellectual sens practitioners. Luckily there is a tradition, especially like a computer doing acupuncture -this would in the UK, of doing pragmatic trials in health services be very different in terms of the healing interaction research, and I'm lucky to be in the department that and the results that happen In this sense it is a very specialises in pragmatic trials so I get lots of support living" system-it is about a particular moment and to do that. But then we have to define the parameters a particular person, and for me the thing that really of treatment in order to capture the essential qualities ties all this together is the chinese internal arts, in You have to write it up so that when it comes out the sense that you can intellectually know all about in the BM] or whatever, you have an acceptable yin and yang, and you can know all about qi, and rationale And the key issue in this process is that you you can also do 30 years worth of practice and still dont want to lose anything thats specific or unique not really get anywhere, because to a certain degree to acupuncture, so how can you define this? You some of this stuff is counter-intuitive and has to be have to write it up so that it looks good within the shown, and the only way to get anywhere is to have field- what we call ecological validity -but can also a teacher pass it on to you be accepted from the outside as being sufficiently standardised, with the parameters of treatment well FM: One of the things that interests me, and Hugh you enough defined What weve come up with in York is might be able to help here, are the GERaC studie n approach that says that lots of the components of in Germany. There were certain practitioners there a consultation are generic, like taking the case, giving ho got better results than others, and I believe that explanations about lifestyle and so forth. But within they ve been trying to find out why, and it wasn't that generic label, some of the content is very specific about how long they had been training. I remember to acupuncture, so the actual discussion you might thinking, it if it wasn't their training or years of have with the patient will be different because it is experience, what was it got people better? Have they an acupuncture consultation, and the lifestyle advice done any more work on that you would give would be different because it's an acupuncture consultation. The best way we ve come HM: Yes, they checked everything that they measured, and up with is to say that if it is driven by a theoretical plugged that into the analysis, and out came the fact framework thats acupuncture-specific then you can thatlength of training made no difference and years of allow people to do whatever they want to implement practice made no difference, age made no difference, that theory in an individualised way. Then you have gender made no difference, but, some practitioners to ask what are the theoretical principles that drive were better than others. So what theyre doing now acupuncture or Chinese medicine, and I think there is going back to the key doctors, the doctors who got are some overarching principles, with theoretical rery good results, to interview them to find out what frameworks within them that can be defined for do they do that makes a difference. Because we know example you can write up that they used zang that there are some people that we would like to go syndromes, or they used yin and yang, or they used to see for a treatment and there are some people who eight principles or whatever. You can therefore define we wouldn't go and see; we instinctively know that, what people do, but it's all driven by these broader but to measure that is quite elusive principles, like mind-body integration and so forth
10 Chinese Medicine in the West 2009 Journal of Chinese Medicine • Number 90 • June 2009 back to them is quite likely to be something that their friends and family have always told them but they have never clearly heard before, like ‘you need to relax’, or ‘should you eat that fifth helping?’ HM: I want to come back to this question about what is unique about Chinese medicine, because when we design clinical trials, we need to have a protocol. So there’s a dilemma. We know that out there in the field people are giving all sorts of different treatments, so should you impose a particular protocol in a trial ‑ one that you think is the best or results from some kind of consensus decision that this is the best treatment, or do you do what might be called a field trial or pragmatic trial where you allow practitioners to practise in their own unique way. I think that’s much better for a very complex intervention ‑ to trust the judgement of the practitioners. Luckily there is a tradition, especially in the UK, of doing pragmatic trials in health services research, and I’m lucky to be in the department that specialises in pragmatic trials so I get lots of support to do that. But then we have to define the parameters of treatment in order to capture the essential qualities. You have to write it up so that when it comes out in the BMJ or whatever, you have an acceptable rationale. And the key issue in this process is that you don’t want to lose anything that’s specific or unique to acupuncture, so how can you define this? You have to write it up so that it looks good within the field ‑ what we call ecological validity ‑ but can also be accepted from the outside as being sufficiently standardised, with the parameters of treatment well enough defined. What we’ve come up with in York is an approach that says that lots of the components of a consultation are generic, like taking the case, giving explanations about lifestyle and so forth. But within that generic label, some of the content is very specific to acupuncture, so the actual discussion you might have with the patient will be different because it is an acupuncture consultation, and the lifestyle advice you would give would be different because it’s an acupuncture consultation. The best way we’ve come up with is to say that if it is driven by a theoretical framework that’s acupuncture‑specific then you can allow people to do whatever they want to implement that theory in an individualised way. Then you have to ask what are the theoretical principles that drive acupuncture or Chinese medicine, and I think there are some overarching principles, with theoretical frameworks within them that can be defined, for example you can write up that they used zangfu syndromes, or they used yin and yang, or they used eight principles or whatever. You can therefore define what people do, but it’s all driven by these broader principles, like mind‑body integration and so forth. What’s so good about the theory is its flexibility and also the fact that the diagnosis tells you something that you then implement in the treatment and also in the lifestyle advice, so it’s an integrated approach, which Western medicine doesn’t have. So I think we have to discuss what the principles are that underlie Chinese medicine, because they drive the theory, which drives the actual techniques that you use. DM: Well one of those, and you almost touched on it there, is the “Q” word, “qi”, which is one of the reasons why acupuncture can elude research and elude definition. It ties into what Volker has said about dealing with practitioners rather than a system. There is a difference between somebody who has been trained extensively in qigong using a needle and doing a diagnosis, and someone who has been trained in an intellectual sense – like a computer doing acupuncture – this would be very different in terms of the healing interaction and the results that happen. In this sense it is a very “living” system – it is about a particular moment and a particular person, and for me the thing that really ties all this together is the Chinese internal arts, in the sense that you can intellectually know all about yin and yang, and you can know all about qi, and you can also do 30 years worth of practice and still not really get anywhere, because to a certain degree some of this stuff is counter‑intuitive and has to be shown, and the only way to get anywhere is to have a teacher pass it on to you. FM: One of the things that interests me, and Hugh you might be able to help here, are the GERAC studies in Germany. There were certain practitioners there who got better results than others, and I believe that they’ve been trying to find out why, and it wasn’t about how long they had been training. I remember thinking, it if it wasn’t their training or years of experience, what was it got people better? Have they done any more work on that? HM: Yes, they checked everything that they measured, and plugged that into the analysis, and out came the fact that length of training made no difference and years of practice made no difference, age made no difference, gender made no difference, but, some practitioners were better than others. So what they’re doing now is going back to the key doctors, the doctors who got very good results, to interview them to find out what do they do that makes a difference. Because we know that there are some people that we would like to go to see for a treatment and there are some people who we wouldn’t go and see; we instinctively know that, but to measure that is quite elusive