Harmonizing the paradigms

[Guest guest]

Emmanuel,

 

Sorry it took so long to reply.

 

> Perhaps Ken, Bob Felt, Z'ev and Fernando would also like to

> add their input into how these paradigms might find the path to a

> dynamic harmony.

 

I think harmony would be easier to achieve if we could be open and a little

yeilding, as well as patient enough to wait for a fuller view. I do not doubt

that 200 hour courses for physicians are a valid political concern, but I do

not think they are matters of integrated medicine per se. Proposing the

integration of Chinese and biomedicine is not the same as marketing classes

to physicians. Integration is the proposal that better health care can be

delivered to more people if these practices are in some way mutually

available not the proposition that biomedical physicians have so little to

learn that they can practice with trivial instruction.

 

I think we also need to recognize that the circumstances of TCM in China

that people identify as problems of integration are neither new nor the

result of integration. It is more that integration is a response to health care

issues in the PRC. TCM could not exist in China without practically and

theoretically accomodating to biomedicine. What has changed is only that

we are paying attention to facts about TCM that we have previously ignored.

 

I am grateful that Volker Scheid has expressed the realities of Chinese

practice in ways that people can accept but it is not " breaking news. " The

Chinese are doing what they have been doing since the first minute of the

Communist Party, trying to provide health care too many people with too

few resources. If SARS proves anything, it proves that China still does not

have the medical infrastructure it needs. As Rey's post noted, the tension

between preserving Chinese medicine as a political aim and the deeply-

rooted bias toward science in Maoist thought (and in the Chinese

population) could not help but be expressed other than by the adaptation of

TCM to scientific method in general and specifically to laboratory and

clinical research.

 

I also feel that we cannot even think about harmonizing the paradigms until

we get past the naïve view promoted in the '80's that there is some unitary

TCM that is " what they do in China. " China is so big and so various that

without a grasp of someone's family background, eduation, wealth, postion

in the family, whether they were blacks or reds, where they trained, where

they work, and a host of other variables, it is impossible to understand even

an individual's view. Thus, I think we need to be patient, to get a broader

view of Chinese opinion, to find what facts there are, and not rush to

judgement.

 

I am not claiming expertise, but what I am reading from the PRC does not

seem all that horrible. I don't think it is necessarily an either/or

disease/pattern propostion. For example, a " Modern Therapuetics " text I

am reading divides clinical information into macrocosmic and microcosmic

and describes combinational patterns that take information from all clinical

observation -- traditional or biomedical -- and uses it to compose a therapy.

The writer uses urinary stones as an example:

 

Take a patient suffering from renal colic due to urinary stones, prior to

their excretion, employing macroscopic pattern differentiation it is

impossible to know for certain what the exact causes are; based on the

principles of “pain is representative of stoppage”, if one employed liver

coursing and qi movement methods it would be possible to relieve the

pain, and one would assume that the condition had been cured. However

from

the point of view of disease pattern combination, whilst the calculi have

yet to be excreted or dispersed the disease actually still exists, and

treatment to ensure that the calculi are either dissolved or excreted

should be continued. At the same time the understanding of the condition

may be taken one step further; calculi occurring in the kidneys, are

connected with the viscera and are predominantly yin and are a

transformation due to cold, they are actually caused by cold congealing

due to yang vacuity; calculi occurring in the ureter or bladder are

connected with the bowels and are predominantly Yang, and are a

transformation due to heat, they are actually caused by the brewing and

scorching of damp heat. In the case of calculi that remain static, this is

mainly due to qi stagnation and congealing blood. If one prescribes drugs

on these principles in non-surgical cases of urinary stones, and also

recommends beneficial activities such as leaping [about] and drinking

water, the therapeutic effects will generally be very satisfactory.

 

I don't see that this as anti-traditional or lacking in respect for the

capacities of pattern logic. I suppose you could argue that were China full

of expert pulse diagnosticians you would not need X-Rays to know if the

stones had dissolved. I do not deny that such skill is possible, I believe I

know people who have that skill. However, there are not now, nor have

their even been, enough of such brilliance to serve entire populations. So,

what are we to do? Wait until there are? If I were the patient, I would

want the expert pattern diagnosis and the consequent treatment but I would

also want the microcosmic information - XRay's, scans, blood assays, etc. -

to be considered.

 

Theoretically, I think looking at clinical information as clinical information

rather than as either Chinese or Western, makes sense and achieves a

certain low-level harmony by viewing clinical data in the clinical context

rather than in the political context of who controls it. If we are to be

patient

centered, as Alon suggests, then I think we must answer the question, " What

can we do that makes the most of CM's benefits available to the largest

number of people in our own societies. " In that light, I think that even a

less than ideal integration that helps a lot of people is a long term positive

for the field as a whole. I've written about this aspect of the issue at length

so I will leave it at that.

 

I think we need to be open to information that we have yet to consider and

that we should resist coming to hard and fast positions about integrated

medicine. I think we need to consider the subject of integrated medicine

beyond the issues of political control and to get ahead of everyone by

proposing and prototyping integrations that work both work and extend the

reach of the benefits our profession has to offer.

 

Bob

 

bob Paradigm Publications

www.paradigm-pubs.com 44 Linden Street

Robert L. Felt Brookline MA 02445

617-738-4664

 

 

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[Guest guest]

I do not deny that such skill is possible, I believe I know people who have that skill. However, there are not now, nor have their even been, enough of such brilliance to serve entire populations. So, what are we to do? Wait until there are? If I were the patient, I would want the expert pattern diagnosis and the consequent treatment but I would also want the microcosmic information - XRay's, scans, blood assays, etc. - to be considered. >>>That is a very important point. We always have to conceder training based on what an average graduate is going to be capable of doing. Reality is not perfection, and I have not met a practitioner that to my satisfaction can pick up concrete pathological and verifiable information from pulses in a consistent manner. If any of you can do it I am willing to fly you to SF area and we can go to an inpatient hospital take 30 patients with known diagnosis and have you do a blind pulse reading and written report. I am still wandering why no such study is being done in a controlled manner. We could publish it.

The benefits or hindrance of integration would be different in the west than in china and only time would be informative. The question again is do we want to be apart off or take control of doing it. Are we going to be able to even demonstrate the strengths of OM in a meaningful may if we stay outside the system, I don't think so.

alon

[Guest guest]

, " Alon Marcus " <

alonmarcus@w...> wrote:

> >>>That is a very important point. We always have to conceder training

based on what an average graduate is going to be capable of doing.

 

 

I have been wanting to address this issue as well. Scheid writes on pg. 73

that one impetus for the development of textbook based university training in

TCm was the recognition that " unlike the scholar physicians of previous times

the young recruits for the chinese medical colleges .... did not possess the

intellectual skill necessary to work with medical books written in classical

chinese. "

 

He goes on to explain that the first major textbook, outline of CM (zhongyixue

gailun) only included excerpts from the classics used to illustrate or ground

standard concepts. this has proved the model for all subsequent modern

textbooks. He then states that ADVANCED classes were developed in

various classics, with beijing taking the lead on the nei jing, the SHL in

chengdu, etc.

 

this raise two points:

 

1. are our average students intellectually superior to the average chinese

student. if not, why would we expect our students to get the most benefit from

classical study as opposed to the more pragmatic oriented modern TCM

when their counterparts in China do not.

 

2. where does classical study belong in the program . I have always argued

that it is advanced, not core material. It may be the foundations of TCM, but

it

is not possible to master in its own right by most people (including myself).

so

the classics certainly cannot take precedence over TCM textbooks as core

material for the average student. the emphasis must be on excerpted classics

as in modern china.

 

Now I know some of you will object to this. but you need to ask yourself, do

you really believe the vast majority of your current students would thrive on a

program centered on study of the classics. We can't educate to the lowest

common denominator, but we cannot educate to the highest either. We must

encompass the largest group in our umbrella. If we can train large numbers

of safe effective TCM practitioners this way, then all the better. classical

study

in depth should be reserved for the doctorate. Jack Miller said recently that

he hopes that all PCOM grads tell him they don't need a doctorate to practice

effectively. He hopes those who are interested in research, translation and

advanced clinical specialization will come back for more, not because they

don't know enough to run a general practice.

 

Scholar-physicians will always be an elite few. I think I am reasonably smart,

but will never be any sort of scholar. I don't think it serves any purpose to

bemoan the fact most of us are just average. so you scholars do your job and

we'll do ours and the world will be a better, happy place for all. :-)

 

 

>>>>>If any of you can do it I am willing to fly you to SF area and we can go

to an inpatient hospital take 30 patients with known diagnosis and have you

do a blind pulse reading and written report.

 

I enjoyed that sentence immensely. :-)

 

[Guest guest]

There are two ways of looking at health care in a society. One is

top-down, the other is bottom-up. Top-down is the CDC, national

health, HMO's, institutional. Bottom-up are local, indigenous

practices, alternative methods, individual client-practitioner

interactions, practices of different ethnic and spiritual groups. I

think the media (and our group, to some degree) have tended to focus on

the top-down view of health care. However, a lot of the foundation and

core of healthcare practices is found at the grassroots level, and the

individual practitioner-client relationship shouldn't be ignored.

There is much room for more 'pure' and/or variant practices of Chinese

medicine at the individual practitioner level, and these, for me, are

what will insure the survival of the medicine.

 

China, as you've noted Bob, is a very complex culture, and still highly

rural. There, too, there is not only much room, but it would appear a

need for local indigenous practices to meet the needs of the

population, not just a nationalized medicine. The nationalized

medicine can serve as an umbrella for local practice, but cannot

replace it.

 

 

On Tuesday, May 6, 2003, at 07:18 AM, Robert L. Felt wrote:

 

> I think we also need to recognize that the circumstances of TCM in

> China

> that people identify as problems of integration are neither new nor the

> result of integration. It is more that integration is a response to

> health care

> issues in the PRC. TCM could not exist in China without practically

> and

> theoretically accomodating to biomedicine. What has changed is only

> that

> we are paying attention to facts about TCM that we have previously

> ignored.

[Guest guest]

I think for us, a middle path is appropriate. Our situation is very

different in the West from China because of language and translation

issues. I agree that a high quality, in-depth textbook-based approach

should be the core of regular TCM college education. However, a

graduated approach to the classics, from simple knowledge that the

texts exist, and what they cover), onward to more complete coverage to

in-depth doctoral study would seem to be the most desirable approach,

in my opinion. Also, different classics have different degrees of

complexity and clinical utility. As you know, I use the SHL as a

supplemental text in the prescriptions classes, since so many of the

prescriptions in the Bensky text are from SHL and JGYL. The Nei Jing

as a body of work is graduate stuff, but again we can give graduated

exposure to it over time. Who will want to study these texts if the

students aren't aware of their existence and what they contain?

 

I look forward to Dan Bensky's lecture at the CHA conference, " Why We

Need to Study the SHL " .

 

 

 

On Tuesday, May 6, 2003, at 10:48 AM, wrote:

 

> this raise two points:

>

> 1. are our average students intellectually superior to the average

> chinese

> student. if not, why would we expect our students to get the most

> benefit from

> classical study as opposed to the more pragmatic oriented modern TCM

> when their counterparts in China do not.

>

> 2. where does classical study belong in the program . I have always

> argued

> that it is advanced, not core material. It may be the foundations of

> TCM, but it

> is not possible to master in its own right by most people (including

> myself). so

> the classics certainly cannot take precedence over TCM textbooks as

> core

> material for the average student. the emphasis must be on excerpted

> classics

> as in modern china.

[Guest guest]

I think we need to consider the subject of integrated medicine beyond the issues of political control and to get ahead of everyone by proposing and prototyping integrations that work both work and extend the reach of the benefits our profession has to offer.Bob

 

Thank you, Bob, for your lengthy, informative and well considered post. It gives me much to consider.

Emmanuel Segmen

[Guest guest]

Z'ev,

 

I think that the issues related to development

of integrated medical education are more complex

than the current discussion takes into account.

 

I want to start by addressing a couple of points

that have been recently made, and hope that I

can proceed from there to address the inevitable

complexity involved here.

 

The Nei Jing

> as a body of work is graduate stuff, but again we can give

graduated

> exposure to it over time. Who will want to study these texts if

the

> students aren't aware of their existence and what they contain?

 

The second sentence is extremely important. Let

me put it this way. How many of the lost medical

texts do we want to study?

 

Now, how do they become lost?

 

And before anyone answers, I suggest you think

it over a few times. It's always hard to find

something that isn't there, even hard to know

when to give up looking. But let's do give some

thoughtful consideration to how traditions die

as we consider how to make them live.

 

Specifically about the Nei Jing, perhaps I'm

not grasping the comparison you're making here.

It seems to me that much of the Nei Jing is

fairly basic material. Handing a copy to

someone and saying, " Learn this, " may indeed

be something that could only happen in a

graduate program in the West or anywhere

for that matter. But teaching it properly

to students of Chinese medicine should be

a part of basic education.

 

What does it mean to teach it properly?

 

Well, I've come to appreciate that one

must take an approach to teaching that

is based on the students as well as on

the material to be taught. I learned this

lesson very clearly in the 1990s while

teaching at Chengdu University of TCM

and later while preparing the materials

that began developing there into Who Can

Ride the Dragon? At one point in that book's

evolution, the manuscript had to be completely

rewritten when I realized that it had been

originally composed for an audience of

Chinese students and was now being published

for a primarily Western audience.

 

If you look at how the Chinese teach

Nei Jing in the early stages of TCM

education, you'll find the often mentioned

Yi Gu Wen course. The standard text introduces

basic considerations related to the ancient

language and texts and then works through

various passages and excerpts from a selection

of texts. The selection of texts is based on

a few criteria. Some relate to teaching the

students the language/literary issues involved,

and some relate to providing them access to

sources for some of the basic theoretical

considerations.

 

As if the didactic question had been, How do

we let students know where this comes from,

how it gets to them, and how they should go

about developing access to the information

and knowledge?

 

Of course, this is my summation and not a

report on the pedagogy in Chinese schools.

 

I'm trying to make a point that I will

continue below by responding to Todd's

concerns.

 

>

> > this raise two points:

> >

> > 1. are our average students intellectually superior to the

average

> > chinese

> > student. if not, why would we expect our students to get the

most

> > benefit from

> > classical study as opposed to the more pragmatic oriented modern

TCM

> > when their counterparts in China do not.

 

The comparison that needs to be made is

not relative intelligence. The contrast

that exists between Chinese and American

students consists of other, more important

factors. Key among these factors is the

fact of how Chinese students are taught

to study and learn. How do they acquire

and retain data, information, and knowledge?

 

And classical study is not omitted from

their early education in TCM. It is begun

there. In fact, for most of them, it began

back in middle school when they were first

exposed to the traditions of language and

literature which provide the epistemological

foundations for the medical classics. Even

so, as I mentioned above, they are put through

a course in the ancient language that serves

as their introduction to ancient medical texts.

 

So the issue has nothing to do with intelligence

but with how that intelligence has been developed

and cultivated. Western students who have not

had been through such initial stages are every

bit as capable of doing so and benefitting

from it. But someone has to tell them to do

it. And someone has to have done it to be able

to guide them through it.

 

And someone has to have done so with an eye

to recognizing the various points along the way

where perspective, experience, culture, etc.

require that material be presented a different

way for the Western students than it is for

Chinese students.

 

This was the point of Who Can Ride the Dragon?

It was meant to provoke such discussions and

to provide some basic answers to the questions

posed by the above. More importantly, I hope,

it was meant to raise more questions, i.e., to

get people questioning how we approach our

education in the subject and how we can

improve it.

> >

> > 2. where does classical study belong in the program . I have

always

> > argued

> > that it is advanced, not core material.

 

The one big problem with this argument is that

it does not reflect the actual situation.

Classical study is a massive undertaking.

It must be started early if we have both

an understanding of its importance and a

sincere hope to transmit its value to students.

 

To relegate the onset of classical study to

advanced levels is to hypocritcally praise

while practically denying the real value.

 

As has been pointed out many times, the critical

step is the beginning. And students need to

begin the path to the classics when they begin

to travel on the dao of medicine. If not,

they will not have the aim in view when they

set out. And having no sense of where they

are going, how can they do anything but get

lost?

 

Now there is a certain amount of getting lost

along one's way that is unavoidable and

highly valuable when it comes to progressing

on this path. But as Z'ev points out, who will

even want to read these texts if they don't

know they exist and have not been taught enough

about them to recognize their status and

importance?

 

It may be the foundations of

> > TCM, but it

> > is not possible to master in its own right by most people

(including

> > myself). so

> > the classics certainly cannot take precedence over TCM textbooks

as

> > core

> > material for the average student. the emphasis must be on

excerpted

> > classics

> > as in modern china.

 

Well, you seem to have resolved some sort of

presumed conflict here, but I am not sure what

it is or was or if it continues outside the

context of this discussion.

 

What is missing in the general character of

the education is an adequate representation

of the language and literary dimensions of

the subject. This omission could be effectively

addressed with a course or courses that introduce

to students the issues related to transmission

and reception of Chinese medicine such as have

been quite clearly outlined in work by Nigel

Wiseman and to some degree in my own writing

on the subject.

 

As I said above, my own aim has been primarily

to get people asking questions and looking into

the matter more carefully.

 

I am not interested in resolving any conflicts

at this point. Students and teachers should

recognize that these conflicts exist and

should wrestle actively with their causes

and their resolutions. But this is going to

take time.

 

A curriculum needs to emerge that anticipates

the needs of Western students who need, just

as their Chinese counterparts do, to develop

an awareness and understanding of the existence,

status, and importance of the medical classics

in relationship to their training as clinicians.

 

Beyond this, the basic education of clinicians

should include development of adequate intellectual

tools to provide access to all the sources of

information that they will need as they progress

along the dao of medicine.

 

I have always been impressed by the inscription

above the entrance to Royce Hall at UCLA. It

reads, Education is learning to use the tools

that the race has found indidpensable.

 

That's what we need to do with respect to

education in the classics. We must learn

how to teach students to learn to use

those tools that have long been indispensable

to the transmission and practice of Chinese

medicine. These tools are not solely and

only contained in the classical texts.

 

But the classical texts do contain critical

components that cannot be found elsewhere.

And those traditions that stand outside

of the literary transmission are intimately

interconnected with the contents of the

ancient books.

 

These are the books that have not gotten lost

for centuries. And we cannot afford to let

them become lost now that they are in our

hands.

 

How do they become lost?

 

People stop using them.

 

Ken