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
Journal of chinese Medicine. Number 90. June 2009 Chinese Medicine in the West 2009 VS: But then what you are actually finding out is doctor someone you go to when you have a problem something much more generic; what it is that makes and you want the problem fixed, like a technician. a good healer or a good practitioner. Maybe being Or is a doctor somebody you go to for medicine but a good Chinese medicine doctor helps you become also in the hope that you might receive information, a good healer, but then maybe dealing with lots knowledge, advice, even wisdom and inspiration. of antibiotics might also make you a very good Does a doctor model, for example, a more integrated doctor, or maybe interaction with people. One way and healthy approach to life? And this is something of answering the question that we raised before that I feel idealistic about -that on a level of individual simply to look at Chinese medicine through history, sickness the doctor practising within the tradition and then kind of strip away all of the contextual we are concerned with, does have knowledge and factors, such as what is typical about Sung dynasty wisdom that relates to leading a healthy life. And Chinese medicine in southern China, what is typical looking at the bigger picture, on a society level we about Ming dynasty medicine in another place, what know we are beset by health problems, we have is typical about acupuncturists in England, so if you a vast rise in obesity and diabetes, and all kinds of had enough data and looked at it in a very de chronic diseases. I believe Chinese medicine in the fashion then maybe you could find out there are wider sense has knowledge about how to live that certain things about Chinese medicine- when it can help with these problems And broader still,in works-and they are always there. a world where we are ultimately in danger of great suffering or extinction because our relationship with PD: I'd like to revisit something you said because I thought the natural world has gone so badly wrong, I believe it was important to pin it down. One thing that we all there are teachings within these traditions that offer discovered when we studied Chinese medicine is how solutions on a planetary level. Daoism and Buddhism flexibleitis, how flexible the thinking is, and that can be particularly, which have been strong influences disturbing. A piece of theory or an idea will be brought on Chinese medicine, teach and model restraint in up to explain something that is happening, and that desire for material consumption and harmony with piece of theory may be contradictory to another piece the natural world of theory which is not called upon at that moment And so it seems to me that you're suggesting that Vs: But I think that you also have to see the shortcomings e of the special qualities of Chinese medicine is this One of the biggest sho relationship, between what we might call systematic is that it is individualistic. It is focused on the knowledge and spontaneity of practice. individual and not on the group, not on society, at least not how it has developed. It was because of VS: That would be one special quality; its like yin and social medicine that Western medicine won out in China itself. Because a Western-trained doctor named Wu Liande knew how to impose quarantine PD: Yes, they re integrated. The spontaneity of practice during a plague epidemic in Manchuria in 1910, not separate from-it has to be rooted in, some form and because this proved to be more effective than of systematic knowledge. actually treating plague patients with Chinese medicine. Western medicine became the Chinese VS: Also, one of the things we really don t know enoug states preferred medical system. And that's what is about yet historically, is what was the daily life like, really lacking in Chinese medicine. It is very good at how did these famous doctors practise, apart from treating individuals, but it simply hasn't got a very writing out a formula. Maybe they meditated-some developed social understanding of disease of them were Buddhist monks; or maybe they wrote nsive that integrating the Heart-Mind means you become VS: I think you need to differentiate between Chinese clearer, more precise, focused, in your actions in medicine and our own aspirations. Maybe Chinese medicine, and as a result, in all your actions, your medicine can help us, but I don' t see the green agenda daily life. This is an intellectual tradition, but also a as being very Chinese medicine at present. At least medical tradition from a historical perspective I can't see that Maybe now you want to develop it, and maybe it gives you PD: When I teach health preservation, I start off and I ask the tools to think about it what is a doctor, what role does he or she have? Is a
Journal of Chinese Medicine • Number 90 • June 2009 Chinese Medicine in the West 2009 11 VS: But then what you are actually finding out is something much more generic; what it is that makes a good healer or a good practitioner. Maybe being a good Chinese medicine doctor helps you become a good healer, but then maybe dealing with lots of antibiotics might also make you a very good doctor, or maybe interaction with people. One way of answering the question that we raised before is simply to look at Chinese medicine through history, and then kind of strip away all of the contextual factors, such as what is typical about Sung dynasty Chinese medicine in southern China, what is typical about Ming dynasty medicine in another place, what is typical about acupuncturists in England, so if you had enough data and looked at it in a very detailed fashion then maybe you could find out there are certain things about Chinese medicine ‑ when it works – and they are always there. PD: I’d like to revisit something you said because I thought it was important to pin it down. One thing that we all discovered when we studied Chinese medicine is how flexible it is, how flexible the thinking is, and that can be disturbing. A piece of theory or an idea will be brought up to explain something that is happening, and that piece of theory may be contradictory to another piece of theory which is not called upon at that moment. And so it seems to me that you’re suggesting that one of the special qualities of Chinese medicine is this relationship, between what we might call systematic knowledge and spontaneity of practice. VS: That would be one special quality; its like yin and yang isn’t it. PD: Yes, they’re integrated. The spontaneity of practice is not separate from – it has to be rooted in, some form of systematic knowledge. VS: Also, one of the things we really don’t know enough about yet historically, is what was the daily life like, how did these famous doctors practise, apart from writing out a formula. Maybe they meditated ‑ some of them were Buddhist monks; or maybe they wrote extensive self‑reflecting diaries – some Confucianists when they go to bed, every night, reflect on what they could have done better today. There is the idea that integrating the Heart‑Mind means you become clearer, more precise, focused, in your actions in medicine, and as a result, in all your actions, your daily life. This is an intellectual tradition, but also a medical tradition. PD: When I teach health preservation, I start off and I ask what is a doctor, what role does he or she have? Is a doctor someone you go to when you have a problem and you want the problem fixed, like a technician. Or is a doctor somebody you go to for medicine but also in the hope that you might receive information, knowledge, advice, even wisdom and inspiration. Does a doctor model, for example, a more integrated and healthy approach to life? And this is something that I feel idealistic about ‑ that on a level of individual sickness the doctor practising within the tradition we are concerned with, does have knowledge and wisdom that relates to leading a healthy life. And looking at the bigger picture, on a society level we know we are beset by health problems, we have a vast rise in obesity and diabetes, and all kinds of chronic diseases. I believe Chinese medicine in the wider sense has knowledge about how to live that can help with these problems. And broader still, in a world where we are ultimately in danger of great suffering or extinction because our relationship with the natural world has gone so badly wrong, I believe there are teachings within these traditions that offer solutions on a planetary level. Daoism and Buddhism particularly, which have been strong influences on Chinese medicine, teach and model restraint in desire for material consumption and harmony with the natural world. VS: But I think that you also have to see the shortcomings. One of the biggest shortcomings of Chinese medicine is that it is individualistic. It is focused on the individual and not on the group, not on society, at least not how it has developed. It was because of social medicine that Western medicine won out in China itself. Because a Western‑trained doctor named Wu Liande knew how to impose quarantine during a plague epidemic in Manchuria in 1910, and because this proved to be more effective than actually treating plague patients with Chinese medicine, Western medicine became the Chinese state’s preferred medical system. And that’s what is really lacking in Chinese medicine. It is very good at treating individuals, but it simply hasn’t got a very developed social understanding of disease. FM: That’s why I think Chinese medicine and biomedicine can integrate so well. VS: I think you need to differentiate between Chinese medicine and our own aspirations. Maybe Chinese medicine can help us, but I don’t see the green agenda as being very Chinese medicine at present. At least from a historical perspective I can’t see that. Maybe now you want to develop it, and maybe it gives you the tools to think about it
Chinese Medicine in the West 2009 Journal of Chinese Medicine. Number 90. June 2009 PD: Well I've been reading Joseph Needham recently, in a world that is de and I'm very interested in his observation that the solutions for how to live. i see within what i know of reason the Chinese developed so much science and Chinese traditions and Chinese philosophy, as good technology, centuries earlier than the West-and answers as I see anywhere else-a philosophy-based within that we can include chinese medicine- is alternative to unbridled consumerism and that the Taoists were observers of nature- without fundamentalist belief preconceptions. There was this simple observation of the natural world unmediated by restricting theories DM: Although to a certain degree, that intelligence about or beliefs, in the way that Christianity obstructed the the world, and balance and nature, and all of that, is development of science in the West. It was a kind of a quality of other traditional pre-industrial societies accelerated learning through accurate and flexible You know if you look at native American tradition, or bservation Celtic paganism, they all seem to share that kind of FM: But don't you think that Confucianism put a stop to that for quite a period of time? VS: But then you have environments like the Easter Islands that were destroyed by traditional societies VS: I think that's too simplistic. this whole thing that What I like about Chinese medicine, is it goes against Confucianism, Buddhism, Taoism are three totally essentialism. You always have to come back to what separate things. They always integrate. Theres a is specific in this moment, in this specific context, famous saying in China,"People are a Confucian here and now... you cannot uphold just one principle in office and Daoist out of office, "and when they sometimes you use more yin-yang, sometimes you prepare for death they may become Buddhist too. use more five phases-so you have to be flexible. That You know you can flip between these traditions very to me connects to where we come from. I conscious flexibly, and they share a common cultural frame of try to always make connections to my being in the reference, like almost everything we do in the west is West, and my being in the West very much comes connected to Platonism in some way, so it's the same from the 60,s, 70s, the counter-culture movement for them that's where we come from and I think the most important thing about that time was going against HM: I think one of the dangers though, with this idealising essentialism of Chinese medicine, is that it's a fantasy. I worry about looking back into the past and having these HM: I talk to the scientists in my department and they'll idealised images of Chinese doctors who meditated be saying exactly the same things about flexibility and did their calligraphy -setting them up on a open-mindedness, willingness to be flexible and pedestal as if this is the real Chinese medicine or seeing the bigger picture the real doctors, as though somehow we should emulate them, or we would do good medicine if we VS: Totally, but I would also agree that there is somet did those sorts of things. Or importing the grand about Chinese thinking that allows you to see story of Chinese medicine, about being at one with connections that exist, patterns in the world. I'm not nature, and how that can inform the green agenda. saying it's the only way that you can discover them My experience, especially working in the university, because mathematicians might also be very good at is that the acupuncture world is a very small world discovering patterns. But I think Chinese medicine, in the UK. I feel marginal in the university and as a Chinese thinking, trains you in discovering patterns, community we are marginal. And lots of the ideas that discovering connections that are responsible for we discuss in Chinese medicine are also discussed in causing certain effects my department, about clinical judgement, clinical easoning, about how to be a good doctor and FM: One of the things I find in the clinic, the turning point so forth. The sorts of things that we attach to our for students, is when they start to understand how ised Chinese doctor, are actually issues that to be flexible. When they study, they get fixated on le wrestle with in the West as well. So I think zangfu differentiation primarily, and everything that it's a much more complicated picture. We shouldnt we do to try to shift them away from that doesnt overly romanticise it so that we end seem to work, so its only once theyre in the clinic fantasy land. that we can say now just look at the person what is the best way that you can understand what PD: I'm not idealising the Chinese doctor or Chinese is going on . don't try putting them into a box medicine. I'm only saying that from my perception, it channel theory that will help you, qi, blood, body
12 Chinese Medicine in the West 2009 Journal of Chinese Medicine • Number 90 • June 2009 PD: Well I’ve been reading Joseph Needham recently, and I’m very interested in his observation that the reason the Chinese developed so much science and technology, centuries earlier than the West ‑ and within that we can include Chinese medicine ‑ is that the Taoists were observers of nature ‑ without preconceptions. There was this simple observation of the natural world unmediated by restricting theories or beliefs, in the way that Christianity obstructed the development of science in the West. It was a kind of accelerated learning through accurate and flexible observation. FM: But don’t you think that Confucianism put a stop to that for quite a period of time? VS: I think that’s too simplistic… this whole thing that Confucianism, Buddhism, Taoism are three totally separate things. They always integrate. There’s a famous saying in China, “People are a Confucian in office and Daoist out of office,” and when they prepare for death they may become Buddhist too. You know you can flip between these traditions very flexibly, and they share a common cultural frame of reference, like almost everything we do in the West is connected to Platonism in some way, so it’s the same for them. HM: I think one of the dangers though, with this idealising of Chinese medicine, is that it’s a fantasy. I worry about looking back into the past and having these idealised images of Chinese doctors who meditated and did their calligraphy ‑ setting them up on a pedestal as if this is the real Chinese medicine or the real doctors, as though somehow we should emulate them, or we would do good medicine if we did those sorts of things. Or importing the grand story of Chinese medicine, about being at one with nature, and how that can inform the green agenda. My experience, especially working in the university, is that the acupuncture world is a very small world in the UK. I feel marginal in the university and as a community we are marginal. And lots of the ideas that we discuss in Chinese medicine are also discussed in my department, about clinical judgement, clinical reasoning, about how to be a good doctor and so forth. The sorts of things that we attach to our idealised Chinese doctor, are actually issues that people wrestle with in the West as well. So I think it’s a much more complicated picture. We shouldn’t overly romaticise it so that we end up living in a fantasy land. PD: I’m not idealising the Chinese doctor or Chinese medicine. I’m only saying that from my perception, in a world that is desperately looking for meaningful solutions for how to live, I see within what I know of Chinese traditions and Chinese philosophy, as good answers as I see anywhere else ‑ a philosophy‑based alternative to unbridled consumerism and fundamentalist belief. DM: Although to a certain degree, that intelligence about the world, and balance and nature, and all of that, is a quality of other traditional pre‑industrial societies. You know if you look at native American tradition, or Celtic paganism, they all seem to share that kind of knowledge about living. VS: But then you have environments like the Easter Islands that were destroyed by traditional societies. What I like about Chinese medicine, is it goes against essentialism. You always have to come back to what is specific in this moment, in this specific context, here and now… you cannot uphold just one principle – sometimes you use more yin‑yang, sometimes you use more five phases – so you have to be flexible. That to me connects to where we come from. I consciously try to always make connections to my being in the West, and my being in the West very much comes from the 60’s, 70’s, the counter‑culture movement ... that’s where we come from, and I think the most important thing about that time was going against essentialism. HM: I talk to the scientists in my department and they’ll be saying exactly the same things about flexibility and open‑mindedness, willingness to be flexible and seeing the bigger picture. VS: Totally, but I would also agree that there is something about Chinese thinking that allows you to see the connections that exist, patterns in the world. I’m not saying it’s the only way that you can discover them, because mathematicians might also be very good at discovering patterns. But I think Chinese medicine, Chinese thinking, trains you in discovering patterns, discovering connections that are responsible for causing certain effects. FM: One of the things I find in the clinic, the turning point for students, is when they start to understand how to be flexible. When they study, they get fixated on zangfu differentiation primarily, and everything that we do to try to shift them away from that doesn’t seem to work, so its only once they’re in the clinic that we can say ... now just look at the person ... what is the best way that you can understand what is going on ... don’t try putting them into a box – is it channel theory that will help you, qi, blood, body
Journal of chinese Medicine. Number 90. June 2009 Chinese Medicine in the West 2009 fluids, zangfu, trigger point acupuncture? That's the differentiation of patterns, because if a patient has a turning point I always think, for students, when they pounding shi headache from uprising of Liver yang, start to grasp the potential of Chinese medicine; how there are certain types of causes, lifestyle behaviours, to understand the person and the configuration thats that are likely to lead to it that are different to if in front of them they have a dull, permananently aching headache. Differentiation of patterns for me was a brilliant HM: I think that's the key point for me, understanding shortcut to clarifying what factors in a patients life how a person works. That sounds very mechanistic, might contribute to that particular problem, and but i don 't mean it in a mechanistic sense then feeding them back to the patient, being able to say "from the perspective of Chinese medicine, VS: Mechanistic is part of it we would say such and such", and I always found that was important for the patient in two ways. One HM: Yes, but its more than just being mechanistic, its an because it explained something to them that they understanding, and I think that it comes back to the understood pretty quickly, and the other, and this principles and theories that drive the medicine, that was the interesting thing, if the conclusion was for ually have something to offer that really resonates example'you're too tired and you never rest, you're ith patients, when we explain it to them. People doing everything at a stressful level,, they would come to see us when they re stuck- they feel a brick say yes my family is always telling me that, and wall. They have relentless migraines, or an irritable my friends are always telling me that, and yet their bowel that won,'t stop, or whatever it is. We have to friends and family were telling them and it didnt reconfigure our understanding collectively -me and make any difference -it was background noise. It the patient -about what's going on for them, in was only when they came for a consultation and it way that they can suddenly say, aha that's what's was fed back to them in this different setting, that it going on. And this might not take one session, it suddenly had might take a series of sessions, and there will be other factors in a person's life that are feeding that problem VS: But thats an unspecific thing, you know that could in some way. Why else have they hit a brick wall at a shaman, or a biomedical doctor this point in time? PD: I'm suggesting the route to it is through chinese PD: What do you think is unique about Chinese medicine medicine in that process? FM: I like the expression "being forensic". To me Chinese HM: For me it's a combination of the theories of chinese medicine has this forensic component, and thats medicine like zangfu differentiation, as well as what I remember Dr Shen teaching. He absolutely understanding qi and stuckness-what's going on in showed it through his diagnostic methods-he'dlook the body. I do a lot of palpation-hands-on work that at people, feel the pulse and put it together and work brings a persons attention to their body and helps it out, and so could go from the pattern backwards to reconnect the mind and body. When they understand the cause and forwards to the treatment better what's going on, theres theres some PD: Absolutely, it looked like magic. VS: Would that be the same if I was a homoeopath and I FM: But he could explain how he did it, that was the tell them"you're a silica type"? Wouldn,'t that help difference. that was what was so wonderful. Thats them in the same way? when i decided that this is the medicine i want to know about, and I think ' forensic is something I would like to say from my own experience I feel Chinese medicine is able to do. It's as volker differentiation of pattern was always terribly was saying: when you can,'t work it out, when your important because, taking from the old Communist treatment isn't working, it's how you move from text books, it leads forwards to the treatment and there. And I think thats the difference, not just backwards to the cause. We know there are all kinds applying another treatment randomly; you work out of lifestyle problems that can lead to disharmony how you might change your treatment. That to me and disease. The question is, which are the key ones, might be the key to what Chinese medicine has the and one might arrive at that through intuition, one ability to do ght arrive at it through a high level of empathy, but a fairly reliable way to arrive at it is through HM: I think that this 'wow moment can happen in any
Journal of Chinese Medicine • Number 90 • June 2009 Chinese Medicine in the West 2009 13 fluids, zangfu, trigger point acupuncture? That’s the turning point I always think, for students, when they start to grasp the potential of Chinese medicine; how to understand the person and the configuration that’s in front of them. HM: I think that’s the key point for me, understanding how a person works. That sounds very mechanistic, but I don’t mean it in a mechanistic sense. VS: Mechanistic is part of it. HM: Yes, but its more than just being mechanistic, its an understanding, and I think that it comes back to the principles and theories that drive the medicine, that actually have something to offer that really resonates with patients, when we explain it to them. People come to see us when they’re stuck – they feel a brick wall. They have relentless migraines, or an irritable bowel that won’t stop, or whatever it is. We have to reconfigure our understanding collectively – me and the patient – about what’s going on for them, in a way that they can suddenly say, ‘aha that’s what’s going on’. And this might not take one session, it might take a series of sessions, and there will be other factors in a person’s life that are feeding that problem in some way. Why else have they hit a brick wall at this point in time? PD: What do you think is unique about Chinese medicine in that process? HM: For me it’s a combination of the theories of Chinese medicine like zangfu differentiation, as well as understanding qi and stuckness ‑ what’s going on in the body. I do a lot of palpation ‑ hands‑on work that brings a person’s attention to their body and helps reconnect the mind and body. When they understand better what’s going on, there’s hope, there’s some way out. VS: Would that be the same if I was a homoeopath and I tell them “you’re a silica type”? Wouldn’t that help them in the same way? PD: I would like to say from my own experience – differentiation of pattern was always terribly important because, taking from the old Communist text books, it leads forwards to the treatment and backwards to the cause. We know there are all kinds of lifestyle problems that can lead to disharmony and disease. The question is, which are the key ones, and one might arrive at that through intuition, one might arrive at it through a high level of empathy, but a fairly reliable way to arrive at it is through differentiation of patterns, because if a patient has a pounding shi headache from uprising of Liver yang, there are certain types of causes, lifestyle behaviours, that are likely to lead to it that are different to if they have a dull, permananently aching headache. Differentiation of patterns for me was a brilliant shortcut to clarifying what factors in a patient’s life might contribute to that particular problem, and then feeding them back to the patient, being able to say “from the perspective of Chinese medicine, we would say such and such”, and I always found that was important for the patient in two ways. One because it explained something to them that they understood pretty quickly, and the other, and this was the interesting thing, if the conclusion was for example ‘you’re too tired and you never rest, you’re doing everything at a stressful level’, they would say yes my family is always telling me that, and my friends are always telling me that, and yet their friends and family were telling them and it didn’t make any difference – it was background noise. It was only when they came for a consultation and it was fed back to them in this different setting, that it suddenly had meaning. VS: But that’s an unspecific thing, you know that could be a shaman, or a biomedical doctor. PD: I’m suggesting the route to it is through Chinese medicine. FM: I like the expression “being forensic”. To me Chinese medicine has this forensic component, and that’s what I remember Dr. Shen teaching. He absolutely showed it through his diagnostic methods – he’d look at people, feel the pulse and put it together and work it out, and so could go from the pattern backwards to the cause, and forwards to the treatment. PD: Absolutely, it looked like magic. FM: But he could explain how he did it, that was the difference, that was what was so wonderful. That’s when I decided that this is the medicine I want to know about, and I think ‘forensic’ is something I feel Chinese medicine is able to do. It’s as Volker was saying; when you can’t work it out, when your treatment isn’t working, it’s how you move from there. And I think that’s the difference, not just applying another treatment randomly; you work out how you might change your treatment. That to me might be the key to what Chinese medicine has the ability to do. HM: I think that this ‘wow’ moment can happen in any
Chinese Medicine in the West 2009 Journal of Chinese Medicine. Number 90. June 2009 sort of consultation The difference is that the content to Hugh, but surely people of your calibre have an of the wow moment in an acupuncture consultation opinion, even if it's subjective. I think that there is is rooted in Chinese medicine theory. I think that in a tendency for practitioners who are longer in the any sort of research we do we have to capture that tooth, some that I've spoken to, to think well maybe the process, because if we lose that-and I think that it's just placebo after al this is the problem with a lot of research where they are mechanistic in the sense of"you should use these VS: No it's not; not from my own experience. I have points"or"these are the parameters of treatment"-they a very special,'old style of practising, which re not allowing practitioners to create that moment or sequential needling, so I will do a point and then I create that experience for the patient. We risk losing will feel the pulse and then I will do another point so much, and I think thats one of the reasons the And I have learned to make predictions on the basis acupuncture trials in Germany or the United States of how the pulse changes. I have found a way of here they constrain the practitioners, were actually knowing: when this happens it's most likely that the chopping off something that is very special person' s going to get better. OK you could say I'm then communicating that to the patient in some kind DM: I think it is interesting, and illustrative that we of placebo way, yes, but my experience constantly are talking a lot about what happens outside the shows me that I do certain things and it works and I acupuncture itself, theories of Chinese medicine such don't do certain things and it doesnt. And for herbs as differentiation and so on, whilst to the patient who s the same thing is uneducated in terms of these theories the big part HM acebo? "But I think we need to move beyond that of acupuncture is what actually happens when you HM: It's not black and white. Its not"isit placebooris itnot put the needle in and you get movement of qi. To certain extent that eludes explanation or research or proof. When a patient feels certain sensations such as effects", there are in every consultation. a stuck feeling in the stomach or the hypochondrium, and then the needle goes in and they feel qi rising VS: I am talking about specific effects up the leg and something clearing: how much of that is to do with placebo and things like the way we HM: Well for specific effects the evidence now is coming flourish our fingers when we take the needle out, and through more clearly for some conditions. We're how much is the training and skill of the practitioner seeing significantly different results for acupuncture in the manipulation of qi. versus sham acupuncture in the most recent trial evidence, for some conditions, for example PD: I think it's a very big question-perhaps the biggest osteoarthritis of the knee, headache, low back pain, question for acupuncturists now. I'd like to see lots neck pain and rates of pregnancy among women of really good and appropriate acupuncture research undergoing in vitro fertilisation. So we know there has into this, because the thing I'm most interested in to be something specific there, and any practitioner in is does it make any difference whether you stick a clinic or anyone who has experienced acupuncture a needle in an acupuncture point or not, and does knows at an individual level that changes happen it make any difference if you get deqi or not; does The difficulty is to capture-at the population level it make any difference if you use a 36 or 38 gauge those changes and it's especially difficult to do that needle that the patient barely feels, or even whether when you standardise the treatment in any way or you hold the needle above the skin, or whack a great you dont allow the flexibility that we were talking big 30 gauge needle in two inches so that the patient about earlier. So that's why I echo your call for more is transfixed to the couch? You know, these seem to relevant research and that relevance means capturing me pretty essential questions to answer. And thethe flexibility that is characteristic of Chines problem is we can't just rely on practitioners to judge this because one universal rule is that whatever they do, they will invariably report that it works fine, but PD: What nobody has done-I may be wrong- is any theworking might be to do with the generic effects studies which compare different kinds of needling, of the treatment rather than the needling itself. for example mild, Japanese style needling with strong Chinese style needling Actually most acupuncturists, FM: And that's where we come to Hugh? To say how are for good or for ill, are not that bothered about seeing we going to do this? research that says that acupuncture works, most acupuncturists feel confident acupuncture works DM: Well hold on. hold on. Yes that is where we come In a way that's the problem; whatever they do
14 Chinese Medicine in the West 2009 Journal of Chinese Medicine • Number 90 • June 2009 sort of consultation. The difference is that the content of the wow moment in an acupuncture consultation is rooted in Chinese medicine theory. I think that in any sort of research we do we have to capture that in the process, because if we lose that – and I think that this is the problem with a lot of research where they are mechanistic in the sense of “you should use these points” or “these are the parameters of treatment”‑ they are not allowing practitioners to create that moment or create that experience for the patient. We risk losing so much, and I think that’s one of the reasons the acupuncture trials in Germany or the United States where they constrain the practitioners, were actually chopping off something that is very special. DM: I think it is interesting, and illustrative that we are talking a lot about what happens outside the acupuncture itself, theories of Chinese medicine such as differentiation and so on, whilst to the patient who is uneducated in terms of these theories the big part of acupuncture is what actually happens when you put the needle in and you get movement of qi. To a certain extent that eludes explanation or research or proof. When a patient feels certain sensations such as a stuck feeling in the stomach or the hypochondrium, and then the needle goes in and they feel qi rising up the leg and something clearing; how much of that is to do with placebo and things like the way we flourish our fingers when we take the needle out, and how much is the training and skill of the practitioner in the manipulation of qi. PD: I think it’s a very big question ‑ perhaps the biggest question for acupuncturists now. I’d like to see lots of really good and appropriate acupuncture research into this, because the thing I’m most interested in is does it make any difference whether you stick a needle in an acupuncture point or not, and does it make any difference if you get deqi or not; does it make any difference if you use a 36 or 38 gauge needle that the patient barely feels, or even whether you hold the needle above the skin, or whack a great big 30 gauge needle in two inches so that the patient is transfixed to the couch? You know, these seem to me pretty essential questions to answer. And the problem is we can’t just rely on practitioners to judge this because one universal rule is that whatever they do, they will invariably report that it works fine, but the ‘working’ might be to do with the generic effects of the treatment rather than the needling itself. FM: And that’s where we come to Hugh? To say how are we going to do this? DM: Well hold on, hold on. Yes that is where we come to Hugh, but surely people of your calibre have an opinion, even if it’s subjective. I think that there is a tendency for practitioners who are longer in the tooth, some that I’ve spoken to, to think well maybe it’s just placebo after all. VS: No it’s not; not from my own experience. I have a very special, ‘old’ style of practising, which is sequential needling, so I will do a point and then I will feel the pulse and then I will do another point. And I have learned to make predictions on the basis of how the pulse changes. I have found a way of knowing: when this happens it’s most likely that the person’s going to get better. OK you could say I’m then communicating that to the patient in some kind of placebo way, yes, but my experience constantly shows me that I do certain things and it works and I don’t do certain things and it doesn’t. And for herbs it’s the same thing. HM: It’s not black and white. Its not “is it placebo or is it not placebo?” But I think we need to move beyond that today, clearly there is placebo, so‑called “non‑specific effects”, there are in every consultation. VS: I am talking about specific effects. HM: Well for specific effects the evidence now is coming through more clearly for some conditions. We’re seeing significantly different results for acupuncture versus sham acupuncture in the most recent trial evidence, for some conditions, for example osteoarthritis of the knee, headache, low back pain, neck pain and rates of pregnancy among women undergoing in vitro fertilisation. So we know there has to be something specific there, and any practitioner in a clinic or anyone who has experienced acupuncture knows at an individual level that changes happen. The difficulty is to capture ‑ at the population level ‑ those changes and it’s especially difficult to do that when you standardise the treatment in any way or you don’t allow the flexibility that we were talking about earlier. So that’s why I echo your call for more relevant research and that relevance means capturing the flexibility that is characteristic of Chinese medicine. PD: What nobody has done ‑ I may be wrong ‑ is any studies which compare different kinds of needling, for example mild, Japanese style needling with strong Chinese style needling. Actually most acupuncturists, for good or for ill, are not that bothered about seeing research that says that acupuncture works, most acupuncturists feel confident acupuncture works. In a way that’s the problem; whatever they do
Journal of chinese Medicine. Number 90. June 2009 Chinese Medicine in the West 2009 whatever system of acupuncture they practise, they you ask, "is a 36 gauge needle better than a 20 gauge all say"well it works!".What I'm interested in is, is needle", but I could say that in this patient I'm using there a difference? Are some techniques of needling a 36 gauge and in that patient I'm using a 20, and here more effective than others? Im focusing on five phases and here I'm focusing on that, and then I'm putting them together. So to HM: It's actually very difficult to get funding to do that me,one of the shortcomings of any kind of research kind of research for two reasons: one is that its hard is that you need numbers of patients and numbers enough to get funding just for a single acupuncture of practitioners. And as long as you need numbers trial. To get a head to head with two acupuncture of patients and numbers of practitioners you need arms of different styles is even more difficult. So, one groups, groups who are defined through something, reason is no-ones going to want to fund you. The through an illness, say, or through a style of practice. second reason isif you put any two types acupuncture So if you configure your questions in that way, you into the trial, the difference between the effects is are creating certain social realities, people who suffer not likely to be very big. The size of the trial has to from asthma, vis a vis, people who are individuals be absolutely huge if you want to find a difference, who have all kinds of different symptoms Or people and even if you did find a difference it would only who always use 36 gauge needles, vis a vis, Japanese probably be very small, in which case you'd say well acupuncturists who never insert the needle that's not clinically meaningful. So I would think it would actually be a big waste of resources if you PD: I've often thought of acupuncture as old fashioned tried to do that. But the problem remains-we don't medicine, and I don't think old fashioned medicine have a clue if thick needles or thin needles are better was ever particularly nice- you know, whatever you had to have done to you was probably pretty PD: Well that's just a hypothesis that the difference will unpleasant, including acupuncture. And they yweren't be tiny. That would imply that the specific effects making these fantastically fine needles, thats modern of needling are only a very small part of the overall technology. Acupuncture was probably nasty, brutish effects? and painful, in the same way scarring moxibustion was. At some stage acupuncture be HM: No. The specific effects for five element acupuncture became soft and gentle and you didn't really feel are different from the specific effects of another very much. And that to me is a crucial issue that I'm intervention, say TCM acupuncture. What you really interested in. We can philosophise as much looking at is the difference between two lots of we like, but in the end, I'm really interested in what specific plus non-specific effects. What it doesn't sticking a needle in the body should feel like? tell you is the relative proportion of specific and non-specific effects. The non-specific effects may FM: Well there are lots of different ideas and theoretical may not be relatively large, but that's not the issu models, like the neurological idea that comes from when you're comparing head to head with two medical acupuncture and the muscle chain idea, yles of acupuncture. Because they've got different and then theres the more ethereal side of what is theoretical models, theyre harnessing different qi, especially if you're putting qigong into the mix. specific effects, so they could both be strong So it's quite complex. The theoretical models of how acupuncture might work are out there. PD: Although the five element interview is substantially different from the non-five element interview, which HM: Peter I think your question is better answered in a you would call a non-specific effect. more experimental context, where we don't try to do these field trials or "in the wild" type work with HM: I think that goes back to my point earlier, that ar large populations with very mixed conditions which interview is generically non-specific, but you have to weve been talking about quite a bit this afternoon. define"specific"as those aspects within the content What we need to do is much more tightly controlled that are specific to acupuncture theory. Theres a lot experiments, where we actually try to check what of things that happen in an interview with a five happens physiologically when you put a needle in. element practitioner that are specific You can see very clear differences between using a real needle and a sham needle in physiological PD:Though enthusiasm is the actual needling isn'tit? studies, big differences with regard to needle location and needle depth; we' ve got lots of information about VS: My fantasy about the ideal practitioner is that he that. The trouble is, although we can get correlations actually transcends all these issues of styles. Because with physiological changes in the here and now, its
Journal of Chinese Medicine • Number 90 • June 2009 Chinese Medicine in the West 2009 15 whatever system of acupuncture they practise, they all say “well it works!”. What I’m interested in is, is there a difference? Are some techniques of needling more effective than others? HM: It’s actually very difficult to get funding to do that kind of research for two reasons: one is that its hard enough to get funding just for a single acupuncture trial. To get a head to head with two acupuncture arms of different styles is even more difficult. So, one reason is no‑one’s going to want to fund you. The second reason is if you put any two types acupuncture into the trial, the difference between the effects is not likely to be very big. The size of the trial has to be absolutely huge if you want to find a difference, and even if you did find a difference it would only probably be very small, in which case you’d say well that’s not clinically meaningful. So I would think it would actually be a big waste of resources if you tried to do that. But the problem remains ‑ we don’t have a clue if thick needles or thin needles are better. PD: Well that’s just a hypothesis that the difference will be tiny. That would imply that the specific effects of needling are only a very small part of the overall effects? HM: No. The specific effects for five element acupuncture are different from the specific effects of another intervention, say TCM acupuncture. What you’re looking at is the difference between two lots of specific plus non‑specific effects. What it doesn’t tell you is the relative proportion of specific and non‑specific effects. The non‑specific effects may or may not be relatively large, but that’s not the issue when you’re comparing head to head with two styles of acupuncture. Because they’ve got different theoretical models, they’re harnessing different specific effects, so they could both be strong. PD: Although the five element interview is substantially different from the non‑five element interview, which you would call a non‑specific effect. HM: I think that goes back to my point earlier, that an interview is generically non‑specific, but you have to define “specific” as those aspects within the content that are specific to acupuncture theory. There’s a lot of things that happen in an interview with a five element practitioner that are specific. PD: Though our enthusiasm is the actual needling isn’t it? VS: My fantasy about the ideal practitioner is that he actually transcends all these issues of styles. Because you ask, “is a 36 gauge needle better than a 20 gauge needle”, but I could say that in this patient I’m using a 36 gauge and in that patient I’m using a 20, and here I’m focusing on five phases and here I’m focusing on that, and then I’m putting them together … So to me, one of the shortcomings of any kind of research is that you need numbers of patients and numbers of practitioners. And as long as you need numbers of patients and numbers of practitioners you need groups, groups who are defined through something, through an illness, say, or through a style of practice. So if you configure your questions in that way, you are creating certain social realities, people who suffer from asthma, vis a vis, people who are individuals who have all kinds of different symptoms. Or people who always use 36 gauge needles, vis a vis, Japanese acupuncturists who never insert the needle. PD: I’ve often thought of acupuncture as old fashioned medicine, and I don’t think old fashioned medicine was ever particularly nice – you know, whatever you had to have done to you was probably pretty unpleasant, including acupuncture. And they weren’t making these fantastically fine needles, that’s modern technology. Acupuncture was probably nasty, brutish and painful, in the same way scarring moxibustion was. At some stage acupuncture became nice, became soft and gentle and you didn’t really feel very much. And that to me is a crucial issue that I’m really interested in. We can philosophise as much as we like, but in the end, I’m really interested in what sticking a needle in the body should feel like? FM: Well there are lots of different ideas and theoretical models, like the neurological idea that comes from medical acupuncture and the muscle chain idea, and then there’s the more ethereal side of what is qi, especially if you’re putting qigong into the mix. So it’s quite complex. The theoretical models of how acupuncture might work are out there. HM: Peter I think your question is better answered in a more experimental context, where we don’t try to do these field trials or “in the wild” type work with large populations with very mixed conditions which we’ve been talking about quite a bit this afternoon. What we need to do is much more tightly controlled experiments, where we actually try to check what happens physiologically when you put a needle in. You can see very clear differences between using a real needle and a sham needle in physiological studies, big differences with regard to needle location and needle depth; we’ve got lots of information about that. The trouble is, although we can get correlations with physiological changes in the here and now, its