Examples

[Guest guest]

Hi Everyone -

 

Apologies for not chiming in, I have been on the road and dealing with the

Little Hoover Commission amongst other things. My time is short for the list

these days. However - Unschuld was nothing less than remarkable... a true

academician.

 

The notion of patents vs individualized prescriptions is interesting. When

formulas preexist in fancy bottles, pharmacists control the market. When they

are individualized, the physician controls the market. This issue went to such

extremes the physicians would require the patient to fill the prescription at

many different pharmacies piecemeal. This practice protected the formula

conception and the often secret family traditions. In that respect, I am

greatful to

have been exposed to the Tong family tradition through Drs Shen and Hammer;

the texture and richness of the Tong family style is a different soup than TCM.

 

Will

 

> How can you (or Unschuld) say that individualized prescription

> writing has no substance in the history, while at the same time

> acknowledging that the trend toward recording this type of practice

> started one thousand years ago, and acknowledging that it existed far

> longer than that? That seems like a reasonable chunk of time to

> establish a history.

>

 

 

William R. Morris, OMD

Secretary, AAOM

Academic Dean

Emperor's College of TOM

310-453-8383

 

 

 

 

[Guest guest]

Bob,

 

Thanks for filling in some detail for us. I realize that you are

presenting someone else's ideas here, so forgive me questioning you

about them. It may be that I am missing the point of what Unschuld is

saying, so please set me straight if this is so.

 

At 6:14 PM -0600 9/25/03, Robert L. Felt wrote:

>I think that what Paul has been getting at, not just " in the Woods, "

>is that we

>have institutionalized so much about Chinese medicine that has no

>substance in the subject's history, that we are failing to understand how and

>how not to apply it in our own societies.

 

--

How can you (or Unschuld) say that individualized prescription

writing has no substance in the history, while at the same time

acknowledging that the trend toward recording this type of practice

started one thousand years ago, and acknowledging that it existed far

longer than that? That seems like a reasonable chunk of time to

establish a history.

 

Of course, although there was a scant record of this practice during

the previous one thousand years does not prove it's absence. To take

one example, si ni san, the shang han lun gives several adaptations

to this formula for different conditions. Presumably these

adjustments were established by adapting the formula to individuals,

and at some point recording the most useful of them. Xiao yao san,

which is a derivation of si ni san, was recorded several hundred

years later, in the 11th century. How would the authors of xiao yao

san have arrived at that formula had they not made adjustments in

individual cases to si ni san?

 

Another example are the records of Hua Tuo (~AD 200), which according

to summaries (eg in Elizabeth Hsu, 2001),provided highly

individualized treatment to his patients.

 

You say, " consider what has been rejected by the field because we

have been sold the idea that the standard for the field must be

individualized prescription. " I'm not sure what has been rejected,

since most of the alternatives, such as kampo, are in fact practiced

by those who are interested in those systems, and trainings are

available for those who wish to learn them. There is no restriction

of their practice, so far as I know. My training, both here and in

China, included the use of so called " patents " , and in practice I use

these as well as individualized prescriptions. I choose what I

consider to be the most appropriate treatment available for the

individual patient. I've studied with some very highly regarded

Chinese practitioners, and they all used both types of prescribing.

Of course, had I not been trained in individualized prescribing, I

would not be able to offer this flexibility to my patients. So

exactly who has rejected what here?

 

You say, " Consider how often we read on these lists about

non-compliance with decocted formulas and practice with foreign and

domestic prepared products that are understood primarily through

commercial literature.

Was it fair to not give people the choice rather than make a standard

of an elite medicine... " . Surely this is a false claim. You are

describing a situation that doesn't exist; or if it does, very

rarely. I know of no practitioners well trained in individualized

prescribing, who cannot offer both, or who would refuse the choice of

alternative methods of delivery if circumstances demanded it.

 

In setting minimum standards for training and licensure examination,

choices have to be made. Frankly, I think the choices made have

allowed the greatest flexibility in our practice, and the greatest

freedom we could get from outside restrictions. Imagine if we were

only trained in the use of standardized formulae -- we would have

little justification for doing individualized prescribing even if we

wanted to, whereas the reverse is not so. I don't think anyone who

engages in the process of setting standards believes that they are

creating a comprehensive definition of Chinese medicine in doing so.

 

Rory

--

 

 

 

[Guest guest]

Rory,

 

No doubt Bob will reply to the questions you

raised to him. I think he's much more of a fan

of history than I am anyhow.

 

But I wanted to follow up on your final comment.

 

>I don't think anyone who

> engages in the process of setting standards believes that they are

> creating a comprehensive definition of Chinese medicine in doing so.

>

> Rory

 

Who are talking about? Certainly

the folks in the PRC who work at setting

standards are very self-consciously at the

task of creating a comrephensive definition of

Chinese medicine. The current initiative

under way there, funded last year to the tune

of some $18 million is aimed directly at doing

this and specifically by the establishment of

standards of quality for herbal medicines,

research standards, etc.

 

They are even engaged in a terminological

standards project in China that is aimed at

development of an international standard

for translation into English and other non-Chinese

languages as well.

 

And if someone is working at setting standards

elsewhere and not intending to provide

comprehensive definitions, what are they

all about?

 

Do you agree that we currently have a set of

defacto standards in the USA, as well as

other non-Chinese areas, in the form of

requirements to sit for and pass licensing

exams?

 

And are these exams based on certain texts

that reflect certain standards and definitions

that have been developed by a certain group

of authors and other authorities?

 

We can certainly debate and discuss the

extent to which the extant standards are

" comprehensive " as well as whether they

came about as the result of someone's or

some ones' intention(s).

 

But it seems far fetched to imagine that

the current situation is all the result of

unintentional acts by people who were

setting standards without envisioning...

 

....well, gee, what were they envisioning anyhow?

 

I think it's high time that we find out the

answers to some of these questions.

 

Ken

[Guest guest]

At 7:37 PM +0000 9/27/03, kenrose2008 wrote:

>Do you agree that we currently have a set of

>defacto standards in the USA, as well as

>other non-Chinese areas, in the form of

>requirements to sit for and pass licensing

>exams?

>

>And are these exams based on certain texts

>that reflect certain standards and definitions

>that have been developed by a certain group

>of authors and other authorities?

>

>We can certainly debate and discuss the

>extent to which the extant standards are

> " comprehensive " as well as whether they

>came about as the result of someone's or

>some ones' intention(s).

>

>But it seems far fetched to imagine that

>the current situation is all the result of

>unintentional acts by people who were

>setting standards without envisioning...

--

 

Well, no one has suggested the acts were unintentional, so I'm not

sure why you are throwing that into the discussion.

 

And setting standards for licensing, eg in California, does not

require a comprehensive definition of Chinese medicine, only a

definition of the scope of practice and training that is felt

necessary in that jurisdiction. Note that the regulations in

California do not preclude any of the practices that Unschuld, or

you, or I, would associate with Chinese medicine or it's broader East

Asian relatives. So, I do agree with you that we have de facto

standards, but those standards do not define Chinese medicine; those

standards are informed by Chinese medicine, which is different. They

are also informed by a lot of other things. To get hot under the

collar about the acupuncture regulations because they present a

particular set of minimum criteria for training seems like a huge

waste of time, because, in fact, any institution accredited to offer

training is free to include anything in addition to those minimums

that they wish, within legal bounds. If someone wants to add a year

of Chinese medical history, or kampo, or botany, or Chinese pharmacy,

no-one is saying they can't do that.

 

At 7:37 PM +0000 9/27/03, kenrose2008 wrote:

>Certainly

>the folks in the PRC who work at setting

>standards are very self-consciously at the

>task of creating a comrephensive definition of

>Chinese medicine. The current initiative

>under way there, funded last year to the tune

>of some $18 million is aimed directly at doing

>this and specifically by the establishment of

>standards of quality for herbal medicines,

>research standards, etc.

--

Well, according to historians such as Unschuld, this is far from the

first attempt at such a thing. Take for example the nei jing...

 

More importantly, how do we get our hands on some of that money?

 

Rory

--

 

 

 

[Guest guest]

Ken

I was thinking about your dislike of the use of energy together with the word

Qi. Considering the wider definition of energy can you give an example in

chinese medicine where Qi describes something that does not have some type of

energy (or kinetic quality) to it?

Alon

 

 

[Guest guest]

At 5:15 PM -0400 9/27/03, WMorris116 wrote:

>The notion of patents vs individualized prescriptions is interesting. When

>formulas preexist in fancy bottles, pharmacists control the market. When they

>are individualized, the physician controls the market. This issue went to such

>extremes the physicians would require the patient to fill the prescription at

>many different pharmacies piecemeal. This practice protected the formula

>conception and the often secret family traditions.

--

 

Hmmm...given the historical evidence, does Paul recommend we include

these business practices in our definition of what is Chinese

medicine?

 

In any event, it seems to me I've seen them in operation amongst

practitioners in California, so at least some believe they belong in

the living tradition.

 

Rory

--

 

 

 

[Guest guest]

OK - so I'm jumping in a bit late in this discussion, but I have not been

able to catch up recently. It seems to me that there is somewhat

a disconnect between PUU's published work and his question to the

'wilderness' group. He has always seemed to state that CM is a very

heterogenous system of medicine. In other words, while there was a fairly

standard orthodoxy, one of the interesting things is that new ideas or

new movements could be integrated or at least continue to co-exist

alongside without too much of an issue - and this in fact is where many of the

seemingly paradoxical elements of CM come from. In addition, there has

always been the idea that CM is not a medicine that was " discovered " at the

time of the Nei Jing/Shang Han Lun and never changed but rather has been

very fluid over the centruies, despite the impartance of returning baqck to

the classics.

 

And now, at least from what I can gather, he is saying that by continuing

to adapt and change as culture changes we are no longer practicing CM.

And yet, as Ken pointed out, what Paul is interested in is the impact of

social change on medicine.

 

Is it only appropriate for the social change to occur in the country of

origin, or can it occur elsewhere? What we practice in this country indeed

is not the medicine

of 2nd century China, of 11th century China or even of 20th or 21st century

China. While I read and speak Chinese, and I have studied China for over

20 years, and

I place a high value on learning and understanding the medicine as it is

and was practiced in China, I practice Chinese medicine in 21st century

United States.

Therefore, I have to adapt to my environment, the culture in which I exist

and the practical legalities which exist. Yes, we have, by creating laws

and exams

attempted to define in a narrow fashion what the fundamental basics of CM

are. This is a process, as Unschuld points out, that began long before Mao

in China.

However, I am not sure that this is what is creating the misrepresentation

of Chinese medicine in this country. I think it also has to do with the

american fantasy

of China (both historical and present) and that we act to exploit that

fantasy in our marketing and promotion of CM.

 

 

The use of the term traditional very definitely is a marketing tool - used

both by us and by China (both Taiwan and PRC). We are constantly seeing

practitioners trying to be more " traditional " than thou. Or to have access

to the " true " CM, or to be the 18th generation of a lineage or what have you.

This is all about marketing ourselves to a public that does not have any

idea about any of the issues we are talking about but has an idea of what they

think CM is.

 

So what about the term Chinese medicine? Is what we are doing still

" Chinese medicine " or has it become more universalized? Is it more

" based in the theory of the traditional medicine of China " ?

 

If we look at all of the books that are written more for the public on CM

(Ted Kaptchuk, Efrem Korngold & Harriet Beinfeld, Misha Cohen, Ken Rose,

etc.) they all have very different takes on what is Chinese medicine. Any

lay person reading all of these would be very confused. And many

professionals remain very confused as they

try to explain what they do to their patients. But, should they not be

writing these books? Well....(just kidding). In my very personal opinion,

I think some of these

books represent CM in a more straightforward, less imagined way than

others, but I still own them all, have read them all and can discuss their

ideas with my

patients. Giving both me and my patients the opportunity to talk about the

medicine and to learn from each other.

 

Personally, I have no problem with the movement of the medicine we practice

into the 21st century, however, I feel that we do need to be very careful

to define what we do so that we are not giving the public a false sense of

what we do. Again - it all comes down to definitions.

 

Not sure if I have made complete sense here - but...

 

Marnae

 

At 04:07 PM 9/26/2003 +0000, you wrote:

>Jason,

>

>There's a few things to consider here.

>

> , Jason Robertson

><kentuckyginseng> wrote:

> > With all due respect to Paul and Bob and at the risk of being one

>of those " what they do in China " guys, I think that it is inaccurate

>to imply that prepared herbal formulations are for the common man

>while physician-modified formulations are only for the elite. It

>seems safe to assume that, as a historian, Paul was talking about the

>past.

>

>If I understand Paul's point about the

>comparison of patent and individual formulas

>the gist of it is that our contemporary

>interpretation of " traditional Chinese herbal

>medicine " or some such phrase is based upon

>a misperception of history. It constitutes

>a past-ward projection of a set of values,

>wishes, and most importantly existential fears

>that we layer over more or less random historical

>data in order to construct a context for what

>it is we want to do.

>

>We then legitimize our desires by pointing

>to our historical antecedents and hope that

>the whole enterprise will acquire and sport

>the august mantle of ancient authority.

>

>In this way, our contemporary efforts at the

>reception of ancient medical traditions closely

>parallels the conduct of many in China over

>the centuries. A common pose of writers in

>many eras was to affect the voice of ancient

>individuals whose names could lend to the

>text at hand this same aura of authentic

>authority.

>

>If you hold in your hands a Ming reproduction

>of a Tang vase, is it a fake? Is it ancient?

>Is it Chinese?

>

>The association of the various doctrines,

>modes and models of systematic correspondence

>to the practice of herbal medicine is something

>that took place at a particular point in time,

>as described in Bob's earlier post. Whatever

>else it is, it is an historical fact.

>

>To what extent are we beholden to such

>facts? Do they matter?

>

>When someone says he or she is practicing

>traditional Chinese herbal medicine, should

>there be an expectation that the current

>practice exists in some relationship to

>the practices of the past?

>

>If you vary the time spans, the question

>becomes even more interesting.

>

>I more or less insist, as Bob has pointed

>out many times now, that what we are talking

>about is who we are and who we want and aim

>to be.

>

> In modern China public hospitals of TCM provide physician-modified

>formulas at very cheap prices. The hospital of TCM in Chengdu is a

>beehive of relatively poor patients getting fairly cheap medical

>care. In fact, people there aknowledge that TCM is often cheaper

>than their western medical options. Usually, they use physician

>modified formulas in more acute or serious conditions then use

>prepared formulas for maintenance.

>

>On a busy day, something on the order of

>3 - 4,000 patients flow through the clinic

>in that hospital. At least that was the

>order of magnitude of throughput in the

>days when I was there several years ago.

>

>How many herbal pharmacies are there in

>Chengdu? As I recall, it's hard to find

>a street that doesn't have at least one.

>And there are thousands of streets, eh.

>

>How much self-prescribing and self-administration

>of herbal medicines goes on?

>

>And how much of that consists of formulas

>for raw herbs that folks write out for themselves

>and then go and fill and bring home and

>decoct?

>

>And how much of it is the use of prepared

>patents?

>

>I frankly don't know the answers, but my

>general impression from having hung out

>in Chengdu and other Chinese cities for

>much of the past decade or so is that

>there is no comparison between the amount

>of patent formulas and raw herb decoctions

>that are consumed regularly in Chinese

>cities where patients have access to

>doctors or pharmacists who can prescribe.

>

>I guess the numbers could be gotten.

>Probably easier for you there in Beijing.

>So if it's necessary to know the answer

>I think you can find it out.

>

>Paul's point about this comparison is

>that if you scan the history of the

>use of herbs (and others medicinal

>ingredients) as medicine in China you

>find a great preponderance of reliance

>on prepared drugs and relatively little

>historical justification for the

>contemporary emphasis when viewing

>the practice of herbal medicine on

>individualized formulas.

>

>And before anyone freaks out and

>demands to know the specifics, what

>difference does it make?

>

>If we can demonstrate with historical

>records that it was this way or that

>way, what difference does it make?

>

>By the way, this doesn't mean that

>I think it makes no difference. I

>just think that we need to think

>about what difference it does make.

>

>

>

> >

> > I guess what I'm saying is that, whatever has happened in the past,

>the modern socialist regime has helped provide access to what may

>have been more for the elite in previous centuries. Because of this,

>a great deal of experience has been accumulated in the modern era by

>doctors who see 40-60 patients per/day while modifying raw herb

>formulas.

>

>There is no question about this.

>We should understand it in the larger

>context when trying to develop an

>accurate and comprehensive picture

>of the practice of traditional brands

>of medicine in China today. And I'm

>always reminded of those 900,000,000

>farmers.

>

>

> >

> > The great question, of course, is how can these lessons be applied

>by those of us practicing in western countries. I, for one, had

>fairly good patient compliance using granules and creating modified

>teas that patients could drink twice/day.

> >

>

>That's a great one, of course.

>

>Another great question is how can we

>profit from the lessons of history?

>

>Do we need to replicate the behavior

>of past practitioners? And if we aim

>to do so, do we first need to know

>what that behavior actually was?

>And if so, how can and should we

>accomplish that little chore?

>

>Or is it entirely alright to just

>make up an idealized set of images,

>project it onto the past and say

>what we are doing today is valid

>because it resembles these entertainments?

>

>And does any of this matter at all?

>

>After all, all anyone wants to do

>is pay their rent, right?

>

>So, yes, I want to keep the questions

>big.

>

>Ken

>

>

>

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