Will Chinese Medicine Disappear in the 21st Century?
— A TCM enthusiast on TCM education
Cheng Ge
If in the 21st century there is no batch of young, capable TCM practitioners, it will be a loss for Chinese traditional culture, a loss for humanity's medical-health world, a disappointment to medicine, a disappointment to the world.
— Cui Yueli
Do TCM colleges train TCM doctors, or Western doctors?
Mr. Liu is a graduate student at a TCM college in Hunan. In conversation with me he kept stressing that he studies "integrated medicine," not TCM, and tried to avoid being identified with TCM. On TCM's look, listen, ask, palpate, he actually said, "That is not a scientific diagnostic method". I was stunned for a moment: this is what a TCM graduate program produces?
Recent figures: at Beijing University of Chinese Medicine, the TCM-major total class hours are 3,697, with TCM-to-Western ratio 65.2:34.8. At the TCM College of Beijing Union University, total class hours (excluding internship) are 3,048, ratio 64.15:35.85. Nationally, TCM courses make less than 70% of class hours, and Western more than 30%. By this ratio, four years of classroom: TCM in fact only 2.6 years, Western about 1.4 years. The graduate's level is roughly that of two mid-level technical-school students — one in TCM, one in Western.
Surveys show: many students, in self-study, put more energy into Western medicine and foreign languages; the one-year clinical internship is mostly Western. So in the TCM college, TCM and Western come even at best — or Western edges ahead. Practical-skill class hours in TCM courses are being cut, and clinical-course practical hours shrunk.
The TCM-to-Western class-hour ratio is hotly debated in the TCM colleges. But in Western-medical colleges, TCM is only about 2% of total class hours. In March 1996, former Minister of Health Cui Yueli, in a letter to the CPPCC Committee on Science, Education, Culture, Health, and Sports, asked: why can't TCM courses in TCM colleges also be 2%?
There is also dispute over the sequence of TCM and Western: Western first, TCM first, or in parallel.
At Beijing University of Chinese Medicine, the two run in parallel; at the TCM College of Beijing Union University, Western first then TCM — two stages.
Beijing Union holds Western-first works better in practice. But former Beijing TCM College president Prof. Wang Mianzhi held: TCM is grounded in deep Chinese tradition, and Chinese and Western are two medicines built in two different modes of thinking. If a TCM student first learns Western, the prior occupation of the mind is hard to avoid — judging TCM by Western thinking, which is bad for the whole later course of TCM learning.
Prof. Li Zhichao of the China Academy of TCM holds: Chinese and Western come to life from two different roads. Facts also show Western science cannot fully explain TCM's way of knowing life. At present, then, Western cannot explain TCM, and neither side need try to remake the other.
Today's TCM colleges have two main majors: TCM proper and TCM-pharmacy. TCM-major graduates become TCM physicians; in writing prescriptions, they use processed sliced herbs. TCM-pharmacy graduates mostly go to pharma plants or drug-inspection bureaus; few staff TCM dispensaries. In school they get neither the practical training of processing or compounding nor focused study of the four qi, five flavors, ruler-minister-aide-courier, channel-entry of TCM materia medica — most of their time is spent on chemical analysis. The pharmacy program seems set to train pharmacists for Western medicine.
China founded its TCM colleges to train senior TCM physicians; whether this goal is reached, judging by the current education, looks doubtful. Prof. Wang Mianzhi also held: both TCM and Western are science; broadly speaking, both should be studied. But for higher medical institutions there is clear teaching division — TCM and Western colleges must design courses around their training objectives. If a TCM-college graduate cannot independently and correctly use TCM theory to guide treatment, that is the greatest failure. TCM-college education cannot be Western-first-TCM-later, nor can the two be split — TCM must be principal, Western auxiliary. Only so can senior TCM physicians be trained.
Do we really not need the Huangdi Neijing anymore?
Data show: at one Beijing TCM college, classroom hours for the Huangdi Neijing — TCM's basic-theory course — have been cut in half over the past decade. In 1983 the plan set 144 hours; in 1987, 108; in the new edition of textbook, only 72. Selected chapters dropped from 61 (1983) to 30 today. Under such conditions, raising basic-theory level is empty talk.
Surveys show many TCM undergrads must wait until graduate school to study the Neijing. Students who love TCM are deeply disappointed in classroom teaching; they seek out look-listen-ask-palpate, acupuncture, tuina, and pharmacology on their own. They attend lectures on Chinese tradition, apprentice on their own, practice qigong. One fourth-year student at a Beijing TCM college told me: the classics taught — Neijing, Shanghan, Jinkui — were taught in disconnected snippets, useless. Reading the books on his own, the difficult questions he raised the teachers themselves did not know.
Many junior-stage teachers at TCM colleges are detached from the clinic — they do not believe what they teach and cannot understand it. Teachers of Shanghan and Jinkui have never even prescribed Guizhi Tang. How can they teach?
As early as July 1962, after the first batch of regular TCM-college students graduated, five teachers at Beijing TCM College (now BUCM) — Qin Bowei, Yu Daoji, Chen Shenwu, Ren Yingqiu, and Li Zhongren — put forward A Few Comments on Revising the TCM-College Teaching Plan.
The Comments bluntly noted that these graduates "are still found short in TCM scholarly level," especially in reading TCM classics, and that in applying li-fa-fang-yao (principle-method-formula-herb) and biàn zhèng lùn zhì their grasp was incomplete: "the basic skills are far from solid." They proposed: Neijing hours from 120 up to 488; about 100 selected original passages from Suwen and Lingshu. To give students an outline of the classical medicine of the fatherland, to strengthen their ability to read ancient works, and to give them a key to the future research.
The five teachers also proposed the apprenticeship method of teaching TCM: the master selects his pupil — first, the pupil must write well; first two years, recitation — memorize Neijing, Shanghan, Jinkui, pulse-verses, drug-natures, formula-verses; from the third year, assist-in-diagnosis; five years done and out — but many still must consult with famous TCM masters afterward.
The famed Qing physician Ye Tianshi studied under 17 teachers. In sum: to study TCM, one must have considerable command of Chinese. All things develop only on the basis of inheritance — TCM is no exception. Today, 38 years on, we are still arguing over the same questions — this can only be called a great regret for TCM teaching.
The TCM classics handed down are vast as the sea. Yet today's basic-theory text Foundational Theories of TCM is only 300,000 characters, mixing yin-yang and five-phase, jingluo and zàng-xiàng, etiology and mechanism, diagnostic-and-treatment principles — all in one book. To rely on this and produce "senior TCM physicians" is fool's-dream.
TCM colleges now mostly recruit students strong in math-science. They are weak in Chinese tradition, history, and philosophy. If across four-or-five years the deficit is not made up and ability to read TCM classics not raised, the result is foreseeable.
TCM education needs reflection and rebuilding
In interviews I found Chinese views on TCM today fall roughly into these: (1) Worth a try; (2) Chinese herbs won't cure but won't kill either; (3) If Western has no way, try TCM; (4) Trust TCM, but rarely find a good one.
There are 30 higher TCM colleges in the country, with roughly 200,000 students; the TCM workforce is said to number 1 million. "Never in TCM history have ranks been so large, and the level so low." The view is a bit one-sided, but it does name the crisis.
Mr. Liu, after junior high, entered Shandong TCM College for 8 years of TCM study. For his doctorate, he chose integrated-medicine cardiology. Honestly: "If I had stayed pure TCM, I'd never find a good job." From this we see: since the 1950s, integration has shown a tendency to Westernize — replace TCM with Western. With shortages in TCM transmission of both people and skills, TCM has become near a substitute or auxiliary to Western.
In daily life, Western culture has given many visible benefits and satisfied many desires; Western medicine, built on Western culture and thinking, is taken in indiscriminately. Prof. Deng Tietao notes: the present mistrust of TCM theory is the greatest crisis. People mistrust because they see TCM cure rates not rising but dropping. The culprit, no surprise, is TCM education.
Ms. Li now dreads taking Chinese herbs. Two years ago she had recurrent red rashes; lots of Western medicine to no effect. She turned to TCM at a hospital, by appointment with a director-level physician. To no avail — 70-plus doses of bitter decoction, no effect. She gave up.
Such cases are everywhere, dragging TCM's reputation through the mud.
But Ms. Zhang, of Western-medical background, came to revere TCM. After her daughter was born she fell into deep weakness — two or three li and she was breathless. All her Western indicators were normal; Western medicine had no good options. A colleague introduced an octogenarian TCM doctor. One week of medicine and she felt much better; two months and full recovery. She still keeps the old doctor's prescription, but the old doctor has long since passed.
If even half of today's TCM doctors had that old doctor's level, public opinion would change. No one who cares about TCM wants to see this vicious cycle: the harder it is to find a good TCM doctor, the less people trust TCM; the less people trust, the less they study; the less they study, the fewer good doctors.
There is still vast room for TCM growth.
Prof. Deng Tietao of Guangzhou University of TCM holds: TCM clinical practice is the weakest link. TCM has many schools, many lineages — not yet sifted, researched, and organized into workable, effective common practice. TCM clinic cannot copy Western. Besides treating critical, difficult, severe disease, building common clinical norms for common diseases is one of today's main jobs — and through such norms, raise TCM cure rates.
Cui Yueli often said while alive: Japan once abolished Kampo by administrative fiat and now studies TCM to make up for that mistake. If we do not work to train senior talent, in a few years TCM may be digested by Western, with only scraps of formula left.
In August 1998, Deng Tietao, Ren Jixue (Changchun TCM College), Lu Zhizheng (China Academy of TCM) and five other senior professors jointly wrote to Premier Zhu Rongji: the tendency in TCM education and TCM hospitals to weight Western over TCM is daily more serious; left unchanged, TCM will see many die and few born.
Indeed, if our TCM education can no longer train competent TCM doctors, TCM may, before too long, vanish slowly from our view.