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— updated 1998-01-19
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— updated 1998-01-19
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Modest proposals for improving traditional Chinese herbology educationAmerican herbalists' realpolitik, essay #2. Discover the secrets to achieving clinical results with Chinese (TCM) herbology. Know the attributes of a successful student. Curriculum requirements include a firm foundation in TCM case history analysis (patterns of disharmony), skills in tongue and pulse examination, materia medica, tailoring herbal formulas to individual needs, diet and addictions counseling, environmental health, law and ethics of health care, interpreting scientific research... by Roger W. Wicke, Ph.D., and C.S. Cheung, M.D. |
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Subtopics on this page…
IntroductionMost genuine learning results from one's desire to know; it is self-initiated rather than imposed. Often, this is the only way to obtain knowledge and wisdom that endures. Externally imposed knowledge is more quickly forgotten because the motivation for retaining it may be absent. Millions of college graduates know that the data they have crammed into their heads for the next day's exam leaks out rapidly during the months afterward. In spite of this, many continue to endure this process for the tenuous rewards held out by society: first, the good grades; then, a gold-embossed piece of paper; followed by status and the satisfaction of having fulfilled society's expectations. Moreover, these expectations are becoming increasingly difficult to predict, let alone fulfill, as our society disintegrates into conflicting factions ruled by the twin spirits of venality and quick profit. As the educational standards of the status quo become increasingly removed from practical needs, and as educational costs increase, increasing numbers of students are questioning whether the educational process serves either their own goals or those of their future clients. Many students may not even know what their goals are, beyond becoming certified, licensed, classified, and pigeonholed into a comfortable bourgeois niche. This article outlines a proper set of goals for an aspiring TCM herbalist and scrutinizes how well American students of TCM are meeting them. Many of the issues touched upon in this article require lengthier discussion to do them justice. However, the authors' purpose in including them here is not to resolve these issues and problems, but only to convince the reader that they represent subject areas worthy of inclusion in a curriculum for future TCM herbalists. The need for understanding of diet, environmental and social factors in healthThe first set of goals for any health care provider should be to aid his or her fellow humans to improve their health, to alleviate their suffering, and to avoid harming them. Recognizing that such suffering may arise from physical, social, political, mental, and spiritual sources, one must be cognizant of these larger issues while practicing specific techniques such as herbology. Such an awareness allows one to identify sources of ill health that may be beyond one's skills and to refer clients to obtain appropriate help. Failure of the health care provider to recognize the influence of poor diet, environmental pollution, poor sanitation, mental stress, and political oppression and poverty in the lives of clients may often result in clinical failure to achieve results in improving their physical health. In the authors' experience, these factors may account for 80% of the illnesses seen at this time in America; in these cases the herbalist should use herbs in a supporting role, focusing on assisting the client in removing the sources of aggravation. Poor diet, food sensitivities, and pollution together may account for a majority of failures of otherwise experienced and competent TCM herbalists. The lone individual cannot hope to solve many of these problems, but we as a health care providers must commit to integrating our respective methods in a manner that works toward solving these ultimate sources of suffering. The student of TCM herbal science should also study non-herbal subjects such as ecology; chemical and other sources of pollution and their health effects; non-toxic alternatives for use in home construction, gardening, cleaning and sanitation; the politics of health care; the role of social breakdown in deteriorating health; understanding addictions and other self-destructive processes; counseling skills; food and nutrition science and how to avoid the plethora of harmful food products and additives. It is the rare TCM college or teaching clinic that does discuss these non-herbal issues with clinic clients and with students. More typically, students graduate with few clues how to integrate these important issues into their practices. If one does not address them, one risks giving herbal formulas month after month with little effect, because some simple but overwhelming factor has remained hidden and unresolved. For example, people who suffer from "Wind Damp" in the muscle meridians (which characterizes many arthritis sufferers) often experience chronic aggravation when they consume margarine and hydrogenated oils •[1a, 1b, 1c]•, which are notorious for aggravating circulatory disorders and inflammatory conditions due to their tendency to create free radicals. From a TCM perspective, hydrogenated oils often create toxic Heat in the body, and may aggravate Organ systems already weakened or predisposed to disharmony in an individual. Some TCM herbalists dispense long-term herbal formulas with no attempt to uncover dietary hazards during the health history. When simple remedies are available, such as not eating toxic food products, it is inexcusable that the herbalist fail to mention them. While selling clients herbal formulas month after month may seem good business, it is terrible ethics, and one who takes this course risks exposing his or her profession to the same contempt and ridicule being heaped upon the medical profession for similar sins. The core curriculum: health assessment, pulse palpation, tongue assessment, materia medica, and herbal formulationAs discussed in a previous article in this series •[2]•, Chinese herbal methodology comprises a body of knowledge inherently distinct from that of acupuncture, although both traditional Chinese herbology and acupuncture are rooted in the philosophies of Yin and Yang, the Five Elements (Wu Xing) and the principle that correct assessment of symptom-sign complexes will lead to appropriate clinical strategies. Similar systems of herbal health care based on detailed symptom-sign pattern differentiation arose in ancient India (Ayurveda) and Persia (Unani), where acupuncture never became established to a significant extent. Therefore, the goals of an aspiring TCM herbalist should include acquiring the specific knowledge and experience of traditional Chinese health care necessary to use herbs effectively and safely. Educational and legal systems that muddle the boundaries between herbal science and acupuncture and fail to acknowledge their distinctness may result in inappropriate standards for both disciplines. It is difficult to become expert in many disciplines. No one can do everything and one risks becoming a dilettante if one does not choose a few subjects to study thoroughly. A Chinese proverb admonishes the person who "has many knives, but none of them are sharp." To determine what TCM herbal subjects a student would benefit from learning, we need to consider the practical problems encountered in typical herbalist's daily experience. The major problem is how to match up the client's complaints and symptom with herbs from a list of herbs available to the practitioner. This is usually broken down into two halves: (1) accurately characterizing the state of the client in a way that will be useful in choosing herbs; (2) accurately characterizing the properties of the herbs in such a way that the appropriate ones can be matched to the condition of the client. The first half of the problem is client health assessment, which traditionally includes a health history and symptom complaints, plus pulse palpation and tongue inspection according to traditional Chinese methods. Once an accurate assessment is made, it will point toward possible herbs and herbal formulas. TCM materia medica entries include descriptions of the functions of each herb using the same terminology as the health assessments. For example, if one assesses a client as having Damp Heat of the Liver, one looks for herbs and herbal formulas that drain and clear Damp Heat from the Liver. To most TCM herbalists, the need for coherency between the system of health assessment and the manner in which herbs are described may seem obvious, but there are modern systems of herbal practice for which this is not the case. Lacking a coherent foundation of assessment terminology and descriptions of herbal properties, Western, or so-called "eclectic", herbalists have constructed a Tower of Babel on which flights of fancy and theoretical speculation have replaced common sense and careful observation. •[3]• In eclectic herbology, the physiological properties of herbs are usually listed, perhaps together with certain esoteric, astrological, or other folklore information; the problem arises in attempting to match the herbs to people whose symptoms and signs are known, but whose physiological characteristics can only be speculated upon, without expensive biomedical testing. •[4]• Failure to define herbal properties to facilitate matching with corresponding symptom-sign patterns invariably leads to much guess work and poor results. In real life, client health assessment is usually a more difficult problem than determining proper herbs. The difficulty arises because most clients fail to neatly match textbook definitions of disharmonies, which are the labels used to describe an individual's health imbalances. Usually, a given individual with health complaints will present with a combination or hybrid of several TCM textbook patterns. Some of these may predominate to a greater degree than others. Often the most difficult job of the clinical herbalist is to judge which ones predominate, and to design an herbal formula that simultaneously resolves most of the client's disharmonies, each to the corresponding magnitude to which it is present. For example, a client might have a predominance of an acute Wet Heat of the Three Burners, superimposed on a chronic pattern of Deficiency of Kidney Yin and Deficiency of Spleen Qi. Such combinations may overwhelm the skills of students whose training has emphasized memorization of textbook definitions and passing of simplistic multiple choice exams, at the expense of assignments designed to cultivate problem-solving ability. It is this problem of accurately assessing clients with multiple disharmonies that many graduates of TCM colleges are ill-prepared to solve. TCM colleges are not unique in failing to turn out graduates who are effective problem-solvers. The failing is increasingly endemic to American higher education, modeled after an obsessive-compulsive educational ideal of inserting a requisite volume of facts and data into students' minds, and when the student is capable of barking out the data stored in his neurons, decreeing that he is educated. Such people make excellent workers in factories, where robotic behavior is necessary, and deviation from standard procedure often disastrous. Creativity, free-thought, active curiosity, and inquiry under such conditions are dangerous and threaten the carefully established order. However, such people make terrible problem solvers. When the situation does not match that in the textbook, regulation, or procedural manual, the robotic worker is paralyzed to inaction. He is dependent on a higher authority to define and standardize the anomaly, so that he, the robot, can be successfully programmed for handling the new situation. The health problems of real people rarely conform to the tidy definitions found in TCM textbooks. Therefore, robotic styles of education are ineffective in training TCM herbalists to successfully deal with the unpredictable combinations and permutations of problems arising in any typical American practice. This is not a reflection of any inaccuracy or defect of these definitions, but rather results from the complexities of life. The classical TCM disharmonies are like colors on a painter's palette. A knowledge of the properties and characteristics of individual colors, while necessary, does not guarantee success as a painter; it is merely a first step. Many TCM colleges continue to measure skill as an herbalist by the ability to regurgitate definitions on exams. Standards in pulse palpation are minimal among the TCM profession at large. The primary reason for this is a tendency to use classical pulse terminology in an idiosyncratic manner, which may serve as mnemonics to the practitioner who uses them, but results in a breakdown of communication between practitioners, educators, and students. There are approximately 28 classical pulse types commonly discussed in textbooks of TCM. These pulse types are defined in terms of basic pulse parameters such as the pulse rate, rhythm irregularities, strength, depth at which it is felt most strongly, width, pulse beat duration, edge qualities, and pulse waveform profile characteristics. (The significant correlation of pulse qualities to patterns of health disharmony is discussed in detail in many TCM textbooks. •[5a, 5b]•) Assuming, conservatively, that each of these parameters has an average of three clinically useful values (e.g., strength may be weak, normal, or strong), there will be a total of 6561 (3 to the 8th power) possible pulse types. Yet there are only 28 classical pulse types defined. In reality, one may feel pulses that fall between the cracks of the 28 classical types. However, the classical pulse types have been given special attention because they tend to appear more commonly or to appear in specific disharmonies, which increases their instructive value. The problem for new students is that they typically feel a pulse and then attempt to force fit their perceptions into one of the 28 classical pulse types. Just as an individual may suffer simultaneously from several classically defined disharmonies, his or her pulse may manifest aspects of several classical pulse types simultaneously; one must relate each aspect of the pulse to components of the client's symptom-sign complex. Modern TCM practitioners tend to focus on the classical pulse type that seems most predominant or significant (depending upon the judgment of the practitioner) in describing the client's pulse, ignoring most secondary features and ignoring differences between the pulses in the six positions and the three levels or depths of the radial pulses. In consequence, when even experienced practitioners palpate a complicated pulse with numerous unusual features, each may report a different classical pulse type. One is reminded of the three blind men exploring an elephant: the first feels the trunk and declares that it is a snake, the second feels the feet and declares it a tree, and the third holds onto its tail and declares the others both in error; it is a rope. A better and more instructive method of teaching pulses is to train new students to focus one specific parameter of the pulse at a time, at each pulse position. After students learn correct pulse taking positions and mechanics, it is easy to determine rate by using a stop watch and to acquire an internal reference standard for strength by having students feel a range of pulses while the instructor points out the strong, normal, and weakened pulses. Likewise, pulse width is relatively easy to teach by having students compare narrow and wide pulses. Instead of encouraging new students to jump to conclusions about which classical pulse type most closely describes the pulse being palpated, they should be required to write down, systematically, each of the basic pulse parameters that they feel at each position. Then, and only then, are they ready to review the characteristics of the classical pulse types to determine which one or ones might coincide with certain characteristics of the palpated pulse. If this method is practiced, with frequent and detailed correction by the instructor, pulse techniques cease to be a mystery and can be learned in a much shorter time than is currently the experience of most TCM students. To reiterate, passing a multiple choice exam on the 28 classical pulse types is not equivalent to skill in pulse palpation, and can be so confusing to the new student that it is worse than useless. Students should study classical pulse types only after they feel and recognize the basic pulse parameters. Tongue inspection, in contrast to pulse palpation, is easier to learn as it relies less upon careful technique and sensitivity. •[6]• However, good quality lighting and color spectrum balance is essential to reveal subtler qualities of the tongue. •[7]• Many clinics and schools either have inadequate lighting or have fluorescent lighting with such deranged color balance as to make even the healthiest tongue look sickly. This is not acceptable for professional practice. In conditions of poor lighting, the most frequently overlooked are subtle shades of grayish or dusky coloration that may indicate Qi Stagnation or mild Blood Stagnation. Relatively healthy people with mild disharmonies and few complaints (e.g., athletes wanting to take herbs to improve performance) may require more careful analysis to avoid mistaken assessments. Good lighting and thorough tongue inspection and pulse palpation are essential in such cases. The importance of practice and clinical experienceAfter a student has acquired the basic knowledge of health assessment, pulse and tongue techniques, materia medica, and herbal formulation, it is vital that he or she engage in active practice of clinical herbology. Passive observation of a good clinician is valuable in the early phases of training, but is no substitute for the school of hard knocks in which one tries to make the textbook knowledge of TCM herbal science work in the real world. Too many recent graduates of the robotic style of learning are terrified when facing their first client. People are so complicated. The robotic mind is helpless. The thought of facing one's first client frequently induces such helplessness, that some postpone this day indefinitely by returning to school in the hopes that more precise robotic programming will give them the courage to face the world. And of course, we have a gargantuan educational industry ready and eager to take advantage of this dependency. Students most likely to take this route tend to be overeducated academics indoctrinated at the graduate level. Whenever they encounter unpredictable and untidy phenomena in the world, they have been trained to return to the classroom to receive imparted wisdom from the high priests of science. After the high priests bestow the approved knowledge and blessing in the form of a gold-embossed paper, the students are sent back into the world to attempt another try. Some of them become so discouraged by the untidiness of the world that they retreat permanently to academia and become high priests themselves, never admitting to their students that they too are afraid of the real world. Others who hesitate to face the problems of their first clients retreat into mysticism, in the hope that they can overcome the difficulties of life and their own limitations by magic. The holistic health professions are littered with such thinking. The TV sitcom mentality has created several generations of Americans who want a solution to their problems within 30 minutes. Special mantras and pills blessed by one's guru, electronic gizmos that enhance one's brain waves, and other pseudo-religious flotsam substitute for hard work, courage, intellectual rigor, and true creativity. Environmental pollution, social deterioration, and general apathy are other factors that lead some of us to escape into mysticism. These problems require persistent effort and time to solve, and the magnitude of the task discourages many. Retreat from the world for the right reasons is not always undesirable, and mysticism, when followed by a return to the world with increased understanding of the inner self, may lead to major advances in civilization during times of crisis. •[8]• An ancient Chinese saying states that times of crisis are also times of great opportunity. Shock brings success. After retreating, one must return to the world with calm, so that the sacrificial spoon and chalice do not fall to the ground. However, retreat out of fear of confronting the truth will not lead to success. All knowledge, to become wisdom, must eventually become grounded in experience. Otherwise such knowledge never escapes the domain of the dilettante: impressive and high-sounding, but easily misguided. America is overrun by people who know a lot, but do not pay attention to the consequences of their actions. Observe how many people take nutritional supplements and herbal products after hearing scientific or even pseudo-scientific reasons for why they should take them, never stopping to observe possible bad reactions. These people's actions are robotic and non-reflective, never questioning the ideas and commands of the "experts". The authors have heard of cases in which individuals took numerous daily capsules of cayenne pepper for years, creating so much intestinal inflammation that a physician determined that a colostomy had to be performed. One wonders whether such individuals ever questioned the wisdom of either the "experts" who recommended cayenne in the first instance or the physicians who recommended a colostomy. How many students of TCM are trained to reflect and ask questions, rather than to blindly accept dogma from officially certified experts in their own profession? Passing multiple choice exams does not result in the independence of mind required to solve real problems. The only way to acquire this skill is to plunge in and practice solving problems! Just DO IT. Practice. Ask lots of questions. Think and reflect. Ask experts for help when you are stuck or uncertain. Passively absorbing data and indoctrination from others is no substitute for practice. The attributes of a successful student of Chinese herbologyPrevious academic achievement and scientific training is no guarantee of success as a TCM herbalist. What now passes for education is often merely indoctrination, and since indoctrination in scientific materialism blinds the student to other ways of viewing the world •[10]•, it is an obstacle to be overcome rather than an advantage. The ideal student of Chinese herbology possesses a keen sense of the natural world, an ability to observe without bias or preconceived notions, skills of reasoning and logic, experience of a wide range of human situations and circumstances, and a practical outlook that values solutions to problems over high-sounding theories. Students with experience gardening or tending animals will be able to understand the practical essence of Yin and Yang, the Pernicious Evils, and the qualities of Qi, Blood, Essence (Jing), and Shen better than those who have spent their lives cloistered in libraries and classrooms. Skills of reasoning and logic are also necessary to make correct clinical decisions, but such skills are not necessarily learned in school or at university. People who work with their hands making complex creations, such as machinists and carpenters, often possess greater common sense and reasoning ability that university graduates with specialized indoctrination as scientists, medical researchers, psychologists, or economists. The quest for knowledge, or true scientific inquiry, is frequently mistaken for the religion of science. Massage therapy and other health professions requiring a high degree of hands-on work foster the intuition so valuable to an herbalist. Such constant interaction with clients enhances skills of observation needed by herbalists to obtain accurate and complete health histories. That massage therapists and herbalists have historically lacked high social status is an additional factor promoting the appeal of each for the other. Health professions with higher social prestige and status are less likely to relinquish the orthodoxy that supports their status. Physicians who stray from orthodoxy risk provoking the jealous discipline of medical boards and professional societies. The rare physician who ventures into a sincere study of herbal health care should be commended for courage. Finally, there is no better motivation for the student herbalist than poor health for which all other health modalities have failed. This factor alone can stimulate one to overcome prior indoctrination, peer pressure, status-quo control of the health professions, and nay-saying of friends and relatives. It is no accident that many of the most committed alternative health professionals arise from the ranks of sick people for whom the medical system has provided no answers and no relief. According to Chinese folk wisdom, "If one is on the right course, even thunder and lightning cannot divert him." The need for support networks among newly graduated traditional Chinese herbalistsThe relative lack of professional support networks creates additional stress on herbalists beginning to practice. A young herbalist usually finds that he or she must create opportunities for practice and making a living. Even more than in other professions, an entrepreneurial spirit is essential because of the lack of support by mainstream institutions and because of a resistance many Americans may have toward trying health care methods considered non-standard in this country. Too often TCM herbal schools offer technical training with no clues how to begin a business, which in turn prevents new herbalists from gaining the clinical experience necessary for their continuing development. Mentor relationships with older and established herbalists would ensure that new practitioners receive advice and encouragement when needed. •[11]• Here are several ways for new herbalists to become known and established in a community:
Avoiding the temptation to shirk disciplined study and to indulge in magical thinkingBecause of the time and commitment necessary to learning traditional Chinese herbal science, some students are tempted to take shortcuts or diversions into medieval hocus-pocus to compensate for their lack of true knowledge and experience. This may explain the current popularity of semi-mystical systems among such herbalists as those who limit their knowledge to simplistic "Five-Element" theory, and who ignore the advances of TCM within the last 2000 years. Any sophisticated system of scientific thought, including modern Chinese herbology, may seem like magic to primitives or to the uninitiated individual of another culture. Throughout human history, primitive peoples have tried to explain natural phenomena by the activities of gods or by unseen forces. Deterioration and corruption of religious thought lead to a short-circuiting of reasoning ability and a fascination with symbolism and simplistic representations of reality. The Five Element theory is an ancient Chinese philosophy that applied to all natural phenomena; its application to human health is first recorded in the Yellow Emperor's Classic of Internal Medicine. •[12]• From these texts, there is no indication that the Five Element philosophy was intended to be any more than a system of mnemonic correspondence to aid in describing interesting relationships between natural phenomena. The qualities of wood, fire, metal, water, and earth were useful as metaphors for many natural, social, and political processes. The strength and yielding quality of wood, the quick and consuming nature of fire, and the fluidity and coolness of water evoke qualities that we can see in many activities of life. One's intuitive faculties may focus on these elemental qualities to sharpen the perceptions and enhance pattern recognition, both valuable skills in traditional Chinese health care. However, when one attempts to explain all phenomena of human health by using ad hoc Five Elements rationalizations, one stretches the limits of credibility and fosters the evolution of a semi-religious system increasingly distanced from common sense and reality. To ignore the historical developments that followed the Five Element philosophy during the next 2000 years, such as the theory of Organ disharmonies (Zang-Fu), the theory of Cold-induced Feverish illnesses (Shang Han Lun), and the theory of Virulent Heat illnesses (We Re Lun), would be sheer folly. These later theories added considerable refinement and precision to traditional Chinese health assessment methods, resulting in more effective herbal formulas. Without them, modern Chinese herbal practice would have remained a crude and primitive system. All the segments of TCM are linked by a common thread. Throughout the history of Chinese herbology, different schools of thought have arisen, each competing with each other for dominance. Rather than engage in futile debate over which of these theories is superior, we should attempt to understand how they complement each other and enhance the level of precision of Chinese herbology as a whole. The Five Element philosophy as applied to Chinese herbology, though dangerously simplistic, is quickly grasped even by impatient and superficial people, accounting for its popularity in America. Quick, simplistic, and pseudo-spiritual nostrums for our many difficult and tenacious problems may allow us to feel OK about postponing the day of reckoning with our polluted environment, the junk food we consume, and our addictions to sugar, alcohol, smoking, TV, and sex. The effectiveness of placebos further complicates the matter, because the placebo effect is really due to potent influences of one's own mind. However, when one confuses the effects of one's own mind with the powers of a remedy or action by another person, one has given away personal power to this outside influence and can be manipulated and controlled by it. This is why many health professionals argue that administering placebos is unethical. The act of giving a placebo tricks the client into believing that his or her own power is really coming from an outside source. The political power of religion derives from such deceptions. Perhaps a more subtle reason for the popularity of Five Element philosophy, to the exclusion of subsequent historical refinements of Chinese health care, is the tendency of cultures in decline to indulge in romanticism and self-deception, glorifying the Good Old Days. The historian Toynbee labels this dysfunctional response to cultural decline as archaism. •[13]• Examples include the fundamentalist religious response to modern problems that simplistically assumes a return to former biblical guidelines of a mythical period 3000 years ago will save a dying culture from corruption and extinction. Likewise, a declining Chinese empire over the last 900 years or so has witnessed elements of its own people harking back to the ideals of the ancient Emperor Yao Shun. The limited success of modern Chinese herbal methods by themselves in dealing with contamination by toxic chemicals and poisoned food likewise leads some to yearn for simpler times. The glorification of "classical", primitive philosophies as that of the Five Elements is an archaistic response to a world out of balance. According to Toynbee, effective, life-affirming responses to cultural decline are exceedingly difficult, which leads one to empathize with the many who succumb to dysfunctional responses such as archaism, unrealistic utopianism, stoicism, and hedonism. Such times call for compassionate visionaries who see pathways toward an enlightened future, yet who return from their visions to ground them in the present: a tall order, but one we should strive to fix our gaze upon. While the newly graduated traditional Chinese herbalist may be tempted by the temporary glamour and popularity of health fads and trendy ideas, the money to be made hawking them to a gullible public, and the personal power to be gained over others by deceiving them, the backlash that inevitably happens when the public recognizes these empty promises will destroy one's credibility. The slow, steady path is more secure, and one's karma will not be burdened. The experiences of self-study of Yue Mei Zhong•[14]•
During a period of trial and error, he concluded that many of his formulas were too complex, and he decided to simplify. Yet he still had many clinical failures and questioned the validity of the theory and his understanding of it. At this time, he began reading the Shang Han Lun, a treatise on illnesses induced by Cold, and the Jing Gui (Golden Cabinet). Although these texts emphasize identification of symptom-sign complexes with little discussion of underlying pathology, and they don't discuss the nature of the herbs used in the formulas, these texts establish the cornerstone of TCM and the principles upon which later texts were to expound. Although they are simple, these texts have reached the scientific heights. He then delved more deeply into the Qian Jin (Thousand Ducats). Their simple theories and practical formulas are as effective as those of the Shang Han Lun. Used in appropriate manner, the results are often dramatic. Yue concluded that the pinnacle of TCM development as a medical science occurred during the Han and Tang dynasties, never again to be surpassed. Later dynasties refined and preserved the insights and accumulated knowledge, but never achieved profound new advancements. Still experiencing lack of success in certain cases, Yue decided to review the Shang Han Lun and Jing Gui each year to refine his understanding, although he also recognized the need to be very observant and to be flexible in using ideas from several schools of TCM: Shang Han Lun, the Spleen and Stomach school of Li Dong Yuan, and the Wen Bing school of Ye Tian Si. Formulas need to be tailored to the individual's constitution, designed to target the current symptom-sign complex, and adjusted to the season of the year and geographic location. The effective herbalist recognizes the need to combine one's own clinical experience with a historical understanding of how classical formulas evolved and an awareness of the standard indications and clinical range of each classical formula, tailoring the client's formula to the exact requirements of the moment. By the 1990's many of the ancient classics of TCM have been translated into English and compiled into cross-referenced and indexed volumes, so the modern TCM student's studies are much more convenient than those of aspiring herbalists in ancient China. The five levels of attainment as a TCM herbalist•[15]•
Level-2 herbalists know how to use herbs, have studied some TCM theory, pathophysiology, clinical reasoning and interpretation of symptom-sign complexes, herbal materia medica and classical formulas. However, they cannot apply the theory well, so their effectiveness is limited when confronted by complex health problems characterized by multiple symptom-sign complexes. Their knowledge is superficial, and they lack ability to clearly differentiate patterns of disharmony. Instead, they tend to choose herbs and formulas for single symptoms and are only moderately successful. Level-3, or bian-zheng, herbalists, have usually been trained by old masters and have studied and practiced TCM extensively. They are capable of accurate and comprehensive differential pattern assessment and are skilled in managing clinical cases. However, their abilities are standard for the profession, and they are unable to resolve difficult cases with which other herbalists also have difficulty. They are good herbalists, but not exceptional. Level-4 herbalists are capable of independently analyzing and solving difficult problems, regardless of the roots of the problems, regardless of danger, and can solve almost all problems like untangling knots. Therefore, these herbalists are able to handle intractable cases that many other physicians have failed to resolve. Their formulas are often simple, using ordinary ingredients, but they use them in a confident manner, certain of their properties and effects. Level-5 herbalists are very rare and can solve even the most intractable problems quickly and with confidence. The differential assessment skills of these herbalists are very refined and exact. They tailor their formulas to the individual's needs with precision, using neither more nor less than necessary to achieve the desired result. Ancillary curriculumCounseling skills; history of Chinese health care; legal, political, and ethical studies; Chinese language and classical herbal literature; phytochemistry and pharmacognosy; plant taxonomy; scientific research design. A basic familiarity with anatomy, physiology and pathology, plus the core subjects of traditional Chinese health assessment, materia medica, and herbal formulation provide the foundation for a clinical herbal practice. A working knowledge of such subjects would qualify one to function at a health technician's level. In China this would be the equivalent of a community paramedic, if training in first aid and midwifery were included. In America, the typical herbalist operates relatively independently (since hospitals and clinics generally exclude herbalists), and will require training to successfully deal with practical problems commonly encountered, such as environmentally induced illness, chemical sensitivity, poor diet, and emotional issues. These subjects have been discussed earlier in this article. Counseling skillsMost herbalists would benefit by training or experience in counseling. While to some this comes naturally, others may need to develop skills in listening carefully, making comments and asking questions that promote rapport yet elicit useful information, and communicating ideas and instructions clearly to clients. Health history taking is a skill often taken for granted, yet it makes the difference between obtaining a complete clinical assessment and obtaining a confused jumble of symptoms that don't seem to lead anywhere. The health history is also an opportunity for the client to receive insights into the relationships between personal habits and lifestyle to health. Too often the traditional Chinese herbalist will ask only enough questions to determine a TCM assessment of classical disharmonies, failing to proceed the extra step to learn whether diet, personal habits, or other factors are aggravating the health complaints. In such cases, herbal formulas may provide only temporary relief, if at all. The difference between a competent herbal technician and a competent clinical herbalist is that the technician will determine the correct herbal formula and no more, whereas the clinical herbalist will assume the duty to look into the whole life pattern, giving an herbal formula as part of a larger strategy of working with a client to regain health. History of Chinese health careTo attain a higher level of understanding of traditional Chinese herbology, it is necessary to place the knowledge of Chinese herbology into its historical context. For example, two major traditional theories of acute feverish illness (Shang Han Lun and Wen Bing) arose following the period of Eurasian urbanization and epidemics of the 11th through 16th centuries, in an attempt to understand virulent feverish illnesses never seen before to such an extent. Many such advances in TCM methodology arose in response to natural challenges. The appropriateness of toxic heavy metal use can also be understood by juxtaposing historical events, demography, and general cultural milieu. During the Middle Ages and Renaissance period of Europe, as well as in China during the same time, physicians used heavy metals to treat a variety of pernicious illnesses such as syphilis and severe acute febrile conditions. On average, people did not live nearly as long as they do now in modern industrialized countries, and the concern over long-term side effects was either not recognized or was ignored because of generally short life spans. In addition, safer methods, such as penicillin injections for syphilis, had not been discovered. For a modern TCM herbalist to administer arsenic to a client with syphilis would be unforgivable considering the serious long term side effects, yet heavy metal (mercury, arsenic, lead, etc.) preparations are listed in many books of Chinese materia medica. Many of these books fail to emphasize that these preparations are included for historical interest and completeness, and should no longer be used in all but the most exceptional circumstances. Certain dogmatically-inclined traditional Chinese herbalists insist that these preparations are OK simply because the ancient masters list them in their texts. Such attitudes are striking for their simpleminded faith in ancient masters and lack of historical perspective. Rather than perceive science and medicine as an evolution and devolution of ideas, the archaist grasps for that indeterminate past time where great masters were all-knowing and the world was tidy. Periods of overall cultural decline are reflected in the scientific world by an increasingly slavish devotion to dogmas and ideas of the past, whereas periods of cultural advancement promote scientific and intellectual expansion by means of vigorous and often heated debates. In such periods, the old masters are scrutinized and admired for their wisdom, but their theories are improved and modified without apology. Legal, political, and ethical studiesUnfortunately, our present world is frequently chaotic, rude, and often insane. In more peaceful and perfect times, the herbalist might be respected for his or her skills and left alone to focus upon perfecting the art. In these times, the shrewd herbalist knows that it is necessary to protect one's backside. A working, practical knowledge of legal and political issues affecting herbalists is a necessity, as previous articles in this series discuss. •[16a, 16b]• Well-meaning, but naive alternative health practitioners assume that the medical industries and professions are generally altruistic agencies that may at worst be suffering from a shortsightedness or lack of understanding. Such people are astonished when they find themselves confronting a vicious, profit-motivated empire that cynically engages in character assasination, fraud, murder, and genocide to gain and hold power. •[17a-17c]• One does not overcome these obstacles without studying one's opponents and learning how to defeat their strategies. Chinese language and classical herbal literatureA minimal knowledge of Chinese medical terminology is important to understand the difficulties in translating ideas for which there are no direct English equivalents. Yin and Yang are two obvious examples, and they are generally not translated into English counterparts for lack of any words or short phrases that capture the full range of their meaning. Most TCM schools offer some courses in Chinese traditional medical terminology, but many fail to discuss the philosophy and philology of the terminology. Chinese character-syllables are pictographs that can represent archetypal ideas or qualities, groups of functions, or more concrete everyday things such as objects and actions. In traditional Chinese health theory, many terms represent functional complexes, rather than concrete physical objects. For example, Pi, which is often translated as Spleen for lack of a better alternative, represents the functions of assimilation of nutrients, the production of metabolic energy from food, protection of the body from invasion by pathogens, the maintenance of blood flow within its proper pathways, and the holding of the Organs in the proper places; one can immediately see that this is not quite the same spleen of Western medicine. Many students of TCM are told to memorize lists of TCM terms together with their standard English translations, completely missing a major point of the exercise, which is to arrive at an appreciation for the oddities and misunderstandings that can arise in translating terms that have no precise counterparts in English. For those interested in pursuing research of classical literature and writing, a knowledge of Chinese language and classical herbal literature is necessary. Translating Chinese, especially ancient Chinese literature, into English is fraught with difficulties, and many poor translations of TCM texts garble the intended meaning so badly as to be of dubious value. Some of the worst translations are achieved by academics who view traditional Chinese health practices as superstitious relics and cultural curiosities; their questionable motivation in translating such texts leads to English versions that overflow with nonsense. According to Bob Flaws •[18]•, one must possess an extensive fluency in both Chinese and English, plus a working knowledge of TCM health care to achieve accurate translations of traditional Chinese health literature. A recommended glossary of TCM terminology (English-Chinese) is one compiled by Nigel Wiseman. •[19]• Phytochemistry and pharmacognosyIt is perfectly possible to practice as an herbalist without any knowledge of chemistry or biochemistry, just as an electrician may be perfectly capable of wiring a home according to established rules and procedures with little knowledge of the physics of electromagnetism. The question is does one wish to remain a technician, or do one's interests extend to learning more about the inner mysteries of herbs and possibly advancing the profession's knowledge and capabilities? Whether one likes it or not, when administering or taking herbal formulas, one is dealing in chemicals: highly complex aggregates of biochemicals produced by plant (and animal) metabolisms. Yet very few, if any TCM colleges in America offer courses in phytochemistry, the study of the secondary metabolites of plants, and pharmacognosy, the study of the physiological effects of these metabolites. Herbalists trained in a Western biomedical tradition tend to focus heavily upon biochemical constituents of plants to explain their physiological actions. Certain herbs that contain significant amounts of a small number of potent chemicals, such as ephedra (ephedrine), belladonna (hyoscyamine, atropine, scopolamine), coca leaf (cocaine), and cinchona bark (quinine), have been used clinically with predictable results based on an understanding of their corresponding potent chemical constituents. The net physiological action of herbs such as Rx Ginseng and Rx Rehmanniae are more difficult to explain biochemically because they contain a large number of nutrients and physiologically active chemicals. For these, a more empirical approach is needed to determine proper clinical application until the complex chemistry of these plants is analyzed more thoroughly; traditional Chinese herbal methods are ideally suited to this task. To advance the Chinese herbal sciences, all relevant disciplines should be explored and nurtured. Unfortunately, certain neo-Luddite factions within the TCM professional community seem to have an almost superstitious aversion to anything scientific. While science, along with other professions in these times, has been guilty of arrogance, fraud, and shortsightedness, does this mean that we should deny ourselves the fruits of reason and proper scientific method? Just because we observe burglars breaking into homes with hammers, screwdrivers, and other useful tools, does this mean that we should deny these tools to ourselves and should build our own houses by shaping boards and pounding in nails with our bare hands? Germany, Switzerland, France, Japan, and China all have active TCM professional communities. In addition, the academic communities in all these countries actively support the sciences of phytochemistry and pharmacognosy as they apply to clinical herbal usage. Some of the best textbooks of phytochemistry have been written by German authors, and Germany has a vigorous professional exchange between clinical herbalists and phytochemists. In the U.S. the pharmaceutical interests carefully control these sciences, and there is sparse professional exchange with clinical herbalists. The few exchanges that do occur are often between pharmacognosists and herbalists with a predominantly biomedical orientation. By failing to encourage studies of phytochemistry and pharmacognosy, TCM herbalists and academic institutions impose a handicap upon themselves. Some institutions have protested that they have no money for research in these areas, so why bother? First, herbalists must see the value. Second, the knowledge is steadily being compiled by other countries; we should at least inform ourselves of what other countries have achieved at no expense to ourselves. This knowledge may prove invaluable in fine-tuning the clinical uses of Chinese herbs, improving preparation methods for manufacturing herbal products such as patent formulas, and improving quality control in selecting species and varieties for breeding, growing, harvesting, drying and preparing bulk herbs. Plant taxonomyFor similar reasons that pharmacognosy and phytochemistry are relevant to herbalists, plant taxonomy is necessary to acquire an appreciation of the raw products upon which clinical herbalists depend. A clinical herbal technician needs to have at least enough ability to distinguish raw plant products by sight, smell, and touch as to be able to detect dangerous or poisonous substitutions. At the crudest level, this type of taxonomy is taught by trial and error in TCM school clinics, as students put together herbal formulas from a typical office materia medica of 300 herbs or more. One learns to recognize and distinguish commonly confused herb products with the help of the master herbalist on duty and fellow students. A more satisfying education should include training in botanical taxonomy, enabling the herbalist to converse intelligently with botanists, who are crucial to the recognition and selection of raw plant products for commercial herb packers and distributors. To be fully functional in taxonomy, an herbalists should have a knowledge of the principles of plant classification and identification by taxonomic phyla, class, order, family, genus, and species, and subspecies. One should also learn the variations of pharmacognostic properties relevant to each entry of the materia medica; in other words, how much intra-species variation or intra-genus variation is allowable before the desired clinical functions vary unacceptably? Presently, the typical clinical TCM herbalist functions on trust of the supplier or wholesaler to accurately label the product. Mislabeling is not infrequent among some suppliers, and the clinical herbalist is forced to learn to identify samples, not only to avoid gross mislabeling and potentially dangerous substitutions, but to simply ensure that the desired species or subspecies is actually what was purchased to ensure optimal clinical results. Some clinical herbalists insist on identifying samples by microscopic taxonomy, which is often a better way to distinguish species identity and quality, incidentally checking for mold content and other impurities. Large-scale herbal manufacturers may also use chemical taxonomic assays to ensure uniformity and quality of herb samples. Scientific research designRegardless of whether the clinical herbalist ever intends to conduct formal research, a familiarity with the basics of good research design will enable one to spot faulty conclusions and poorly designed studies. Rather than being rare creatures, faulty research studies are the rule. Some studies are seriously flawed, making the results invalid or dangerously deceptive; others are merely flawed in less serious ways that merely require the reader to reinterpret the findings or recommendations. Currently, students and graduates of TCM programs are generally no better off than medical students, of which neither group learns to see through the "authoritative research" hype fed to them by pharmaceutical companies and health fad promoters. To give an example of seriously flawed research designs commonly mimicked by TCM herbal researchers, consider the standard two-part experiment where the effectiveness of a particular formula or herb in relieving high blood pressure is being tested. In such an experiment, half of the subjects are given a placebo and the other half the intended test substance in a double blind setup (subjects and researchers who administer the remedies do not know which are the placebos). All subjects' blood pressure is measured at specific times throughout the testing period. After the data is collected, the averages and standard deviations are compared to determine whether the difference is statistically significant. The conclusion is either that the test substance "works" or that it "doesn't work". If it does work, then some clever researcher attempts to track down the "active" chemical constituent responsible for the effect. These types of articles appear in TCM research journals constantly. The typical TCM clinical herbalist sees nothing wrong with such a study; after all, this is how respected medical research is done every day all over the world. However, its design violates the very philosophy of traditional Chinese herbal science and is deeply flawed logically. TCM herbal science is founded on the assumption that matching herbal formulas to the whole pattern of a person's disharmony or disharmonies is superior to choosing remedies for individual symptoms, independently of the context of other symptoms. The experiment just described blithely assumes that the Western biomedical model is just fine for answering questions of a TCM nature and proving its efficacy. Let's examine the previous experiment more closely. First, is the question that is answered by the experiment a useful question? The question answered by such an experiment is: Does the substance of interest significantly relieve high blood pressure, taking into account placebo effect? Eliminating placebo effects is important, and this part of the experimental design is appropriate; too many TCM research studies do not even attempt to eliminate this factor! The problem is are we interested in high blood pressure, or in high blood pressure that is part of a clinical picture of Liver Yang Ascending, for example? Suppose that the substance or herb might be useful for Deficiency-of-Kidney-Yang types of high blood pressure, but a disaster for Liver Yang Ascending. This is not an unreasonable assumption, since such distinctions and contraindications are common in the TCM materia medica! Our original question is too vague, which is the very criticism leveled at Western medicine, and which is what causes clients to seek out TCM herbalists: the Western biomedical model is not capable, in spite of its seeming sophistication, of providing precise solutions to vague questions. To choose herbs for an individual with high blood pressure, one requires more information. Proper TCM research must account for multiple symptom variables (patterns of disharmony) when testing the effects of remedies, or it will often be useless to clinicians. The solution to this problem is not the subject of this article and has been outlined elsewhere •[20]•, but it is a proper subject for the training of clinical TCM herbalists. If it is not taught, the volume of bad and useless research will continue to confuse people, to waste their time, and to waste thousands of tons of paper each year. The superiority of an individually tailored curriculumThere is no rational excuse for enduring sub-standard instruction solely to obtain a certified piece of paper with your name on it, unless you are so lacking in self-confidence that you need other people's permission to plan your life. Many herbalists practice without licenses throughout the U.S. and Canada, and as long as one obeys the laws and avoids the practice of medicine •[21]•, one is free to educate people and assist them in improving their health by using herbs and herbal formulas, by tailoring their food intake to their needs, and by eliminating environmental poisons and hazards. The current educational bureaucracy, created in the early 20th century to promote American industrial leadership and the interests of its capitalist owners, is characterized by "inflexibility, unresponsiveness, the absence of customer focus, an obsession with activity rather than result, bureaucratic paralysis, lack of innovation, high overhead". •[22]• It often functions more to keep creative people under control than to educate, and keeps the oligarchy in control of "education". Colleges and universities are accredited if they are endowed with significant amounts of money, place politically well-connected bureaucrats on their board of directors, and have a standardized curriculum. Curriculum quality alone is not enough to become accredited, and more than a few schools have failed financially after establishing the requisite bureaucracy (president, vice president, registrar, dean of students, provost, development fund officers, administrative assistants, admissions officers and committees, etc.) and paying the accrediting agencies their ton of flesh. After paying the accrediting agencies and the salaries of the requisite bureaucrats, a school may have gone into debt, forcing the administration to fire many of the teachers so that recently graduated students may fill their jobs at lower pay. Colleges and universities around the country are currently experiencing this dilemma. •[23]• Private industry, dissatisfied with the skills of many college graduates, has been increasingly forced to provide its workers the education that colleges and universities have failed to provide. There is no reason to tolerate instruction from graduate students whose primary skills include their recently demonstrated ability to do well on multiple choice exams. Design your own education. There are many qualified, experienced TCM herbalists, scholars, phytochemists, and pharmacognosists who are available to offer their instruction to private groups of individuals. Because accredited educational institutions require such large overhead, professors and teachers in these institutions often earn less than their counterparts in the private sector. Many competent herbalists, scientists, and herbal industry consultants are overjoyed to teach independently motivated students whose primary goal is to learn, in contrast to university students whose most frequent concerns are "Do we really have to learn this, will it be on the final exam, and what must I do to get an 'A'?" Additionally, political infighting among university hierarchies over a shrinking shares of financial resources can be hazardous to ones' health. By eliminating the considerable bureaucratic overhead, both students and instructors can come out ahead. If you discover a well-taught course at an accredited college or university, contact the instructor directly to discover whether you can take the course by itself, without any extra baggage attached, like having to enroll as a student and pay excessive fees. The superiority of self-directed education beyond the age of 10 or so has been thoroughly documented. •[24a, 24b]• People (and TCM herbalists) do not learn to think and to solve problems by being force-fed facts to regurgitate on multiple choice exams. Instead, they learn to think and to solve problems by being challenged with new dilemmas and problems at appropriate phases in their lives. •[25]• Yet most educational curricula focus on how many facts and data they can force into students' heads. This is perhaps the primary reason why many newly graduated students of TCM, after successfully passing certification and licensing exams, are frustrated by the intricacies of designing herbal formulas for their first clients. SummaryThe aspiring TCM herbalist who prefers a quality education rather than merely a collection of gold-embossed papers should seek out his or her own plan of action, choosing knowledgeable instructors in each field rather than committing oneself to confinement in any single education institution for several years. The following subjects are recommended in the order listed, with some variation depending upon one's goals and intended specialization.
References
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