Read, See Patients, Think (2012-12-23)
Xiao Xiangru
23 December 2012
The fundamental question of medicine is clinical effect. However beautifully one speaks, if problems cannot be solved, the medicine will be cast out. How to raise effect? Famous doctors East and West, present and past, became famous and got results by doing only two things their whole lives: read and see patients.
Without reading, one cannot become a great physician
Looking at TCM's current state: the quality of result ties directly to how much the doctor reads.
China TCM Press's Hundred-Year Hundred-Master TCM Clinical Series basically covers the 20th-century TCM names. Their lives differ, each has his own experience and field — but the path is one: reading and seeing patients. Of the two, reading is decisive. Whether in medical skill, medical ethic, or vocational spirit — all are proportional to the quality and quantity of reading. At the present stage of TCM, cultivating reading ability, cultivating interest in TCM, creating an environment for reading — is in fact more important than seeing patients.
Build the ability to read, build the environment for reading
TCM is rooted in Chinese tradition; its essence lives in the classics. But how many today can read the classics? The basis on which one treats — what direction, what guiding thought — matters. The famed scholar Ren Yingqiu of Beijing TCM College — the greatest theorist of modern TCM — held that, at this stage, TCM's theoretical problem is more complex than the clinical problem, because few have solid TCM foundation.
Why is TCM in trouble today, why must it be revived? The known reason: results have fallen. The deep reason: today's TCM doctors read too little. Why so little? Reading ability is insufficient. Are we lazy? No. Many work over ten hours a day; many die early because of it. Hard-working TCM is plentiful. But our country issued the simplified-character plan in 1960; everyone born after the 1950s was taught in vernacular and simplified script, and learned pinyin. Our TCM works are in classical Chinese. Same Chinese, different across the millennia. In my own days as a student we had to test in classical Chinese; one could choose foreign-language instead, and many did, finding classical Chinese no easier than English. Few today can really read traditional characters, really read literary Chinese. Speaking for myself: at least one-third of the Neijing I still do not understand, though I have read it many times and been taught by many famous professors.
And where is today's reading environment? Walk into any TCM university, research academy, or hospital — what are people doing? Not "how is the classics study, how is the clinical effect?" — but "Do you have grants? funding? prizes?" Without those, you cannot become professor or director; you cannot survive. But energy is limited; grants and prizes are hard work — where is the time for the classics? Yet real TCM needs the classics. Without reading, how can effect rise?
One of my doctoral students applied at Tianjin University of TCM. They told him: Mr. Xiao is famous, well-known to us; but we want researchers — only reading old books won't do. So it is not that today's people don't want to read; there is no environment, no energy, no chance. The one place where TCM can now grow is, roughly, the classics-teaching offices in TCM universities, especially the Shanghan teaching offices. Better-known doctors today are mostly teachers of classics in such offices. Because to teach classics you must learn them, else you cannot teach. Crooked road brings straight result.
When I finished my doctorate in 1990 — when PhDs were few and kidney-disease PhDs fewer still (I was the first) — many big hospitals invited me. I chose to be a university teacher. Why? Because under the present medical system, doctors in big hospitals cannot really grow, cannot really lift their skill. Why? Hospitals live on the doctor's earnings. Whose money? The patient's. If I were department chief, then the staff's salaries, bonuses, plus hospital fees, all from somewhere. The hospital thinks money daily, the doctor thinks money daily — how can doctor-patient relations be good? More: how does the doctor have time and energy to raise his skill? As a university teacher I can see patients in spare hours; teaching is my work; if I am a fit teacher, livelihood is no issue. So I see patients without burden, only for joy; I think only how to cure. Sometimes for free. Only this gives one a doctor's bearing and feel.
Read the classics again and again; embrace all schools
What to read? Consensus: classics. Neijing, Nanjing, Shanghan Lun, Jinkui Yaolüe, Shennong Bencao Jing. Plus the Four Great Masters of Jin-Yuan, the Wenbing school, the bencao works through the ages — these every fit TCM doctor must read.
For the classics — read continually, repeatedly. By the pillow, on the desk, in the hand. The more you study, the less you feel you have understood; the more you study, the more there is.
Once well-grounded in the classics, you can judge which of the historical famous works carry the essence. The finest fixed; the aim is reached.
The works of historical famous figures — we cannot read all. So read by plan: the Four Masters; the Wenbing school. Representative masters — Zhang Jingyue, Sun Simiao — read by plan.
Reading includes specialist books. Whether TCM should be divided into specialties is debated. I hold: dividing too fine or too early is bad for the doctor's growth. But one's energy is finite; in medicine, one should still have an area of focus. Before specializing, build a sound overall foundation; then research from a more focused field.
Reading also includes Western-medicine books. In China we have both Western and TCM — an inevitable thing. It is also good: more medical resources. Many things Western cannot solve, TCM can; and the reverse — many things TCM cannot solve, Western is better. Hold to fact. Western is not all bad, not the source of TCM's decline. Its development has reason. TCM's existence does not turn on this or that person's will; the one criterion is effect. If TCM does its own work well, no one can do anything; many chances will come to show what TCM can do.
In China today, to be a fit TCM doctor, learn Western. TCM through history was always an open system; we must be broad-minded, embrace, gather, draw — what holds is great. Why study Western? Not to compete; not to earn a living. As a doctor, know all medicine as much as possible — including Western theory, method, knowledge. The Neijing: "What is said to be untreatable is what has not yet found the method." For a disease, in theory there must be a way; not having found the method has two readings — humanity-wide we have not yet (e.g., cancer, AIDS — not the doctor's fault); or others can treat and you cannot — also not having found. For some diseases Western is in fact better; why not know?
Zhang Zhongjing, author of the Shanghan Zabing Lun, founded TCM's clinical theory system. All the theory and methods used in TCM today come from the Shanghan Lun and Jinkui Yaolüe. TCM works are vast as the sea; but the most important are the four great classics. Within the four, most important are the Huangdi Neijing and the Shanghan Zabing Lun. The Neijing discusses theory and does not treat; the Shanghan Zabing Lun treats and does not discuss theory. The Neijing has only 13 formulas, too few for clinic. The Neijing's gift is the basic principles — vital. Cannot read the Neijing, no TCM thinking — cannot become a real TCM doctor. The Shanghan Zabing Lun: this disease, this formula. E.g., article 379 of Shanghan: "Vomiting with fever: master with Xiao Chaihu Tang." You do not need to know why — just remember it and use it. That is Shanghan's strength: memorize it, you can use it. Repeated understanding premises memorization; understanding alone is useless. If you want to read the classics, read the originals; Shanghan and Jinkui must be committed to memory.
Read and treat — drop all distractions
Among contemporary masters, in my view the greatest are Pu Fuzhou and Yue Meizhong. Founders of the China Academy of TCM, models of reading and clinical work — most studious of all.
Pu, after his 1955 transfer to the Academy, spent the rest of his life reading the books and seeing patients, with all distractions cast off. He valued most Shanghan, Jinkui, Wenbing Tiaobian, Shanghan Wenyi Tiaobian. He said: "The Neijing and Nanjing are the basis; without a sound theoretical base, no clinic. If one only reads formulary books and pharmacology and treats by them, that is rootless tree." And: "Shanghan and Wenbing are about externally-contracted heat — one stresses cold, one heat; Wenbing develops on Shanghan. Jinkui is internal-medicine; though chapters like jing, shi, ye are externally-contracted, the heart of it is internal. All later schools develop on this. For Shanghan and Jinkui, first read the originals — don't reach for commentaries too soon, lest you scatter." Pu was a hereditary TCM doctor, famous young, with many patients; but he felt some cases were not handled well. The reason? Books not well read. He closed his door for three years; Neijing, Nanjing, Shanghan, Jinkui, Wenbing Tiaobian, Wenre Jingwei — read deeply, thought repeatedly. After that, his clinical handling was much surer. He said: "Many people did not understand my mood, thought my closing the clinic was to raise my price." They did not see the value of the classics. In Pu's home, except for materials issued by his unit, all books are medical books. He said: "Learning prizes focus; one's energy is finite; my intelligence is at most middling. If I split now this way, now that, in the end nothing will be done." For decades Pu, on lute, chess, calligraphy, painting — never glanced. "Lifelong love of medicine; focus on medicine; refined in medicine." — only so does one become a generation's master.
Yue is a special case in TCM history — no family teaching, no master, fully self-taught into a great TCM doctor. Why? Because of deep cultural foundation. Yue was once a schoolteacher; at twenty he caught tuberculosis, untreatable, could not teach. He began reading medicine, prescribing for himself; finally cured his own tuberculosis. So he turned to medicine. "A scholar takes to medicine like catching a chicken in a cage." — because the scholar has the cultural base. Much in TCM needs cultural ground; without it, no understanding. Yue read most among us — his way: broad learning, refined research, the three masters. Broad learning: Yue surveyed more than 4,000 medical works, from Neijing and Nanjing down to all schools. Refined research: he reread Shanghan and Jinkui every year; hence his name as the best user of classical formulas. Three masters: Zhang Zhongjing, Li Dongyuan, Ye Tianshi. He said: "These three, across two thousand years, blazed the trail, were of great use; later schools cannot stand beside them."
In his seventies Yue wrote himself a code of self-discipline that fills one with respect:
First, constancy. Every day, save for special things, study at the set time. Diligence makes up for dullness; constancy alone delivers. Lax now and then, in declining years one cannot complete the plan.
Second, focus. Save for special need, do not turn one's eye; finish one before another. Master one without straying — without focus, no refinement, no depth. Refinement also needed — but refinement, too, comes to focus.
Third, enter into detail. In complex serious cases, one sometimes hits a wall. Tracing the cause: study not detailed enough. Skim, you cannot reach. In old age verse-rule grows finer (Du Fu): a lived word. So in medicine. Beware of light-and-shallow (weak — cannot grasp big cases); beware of fragmented (cannot focus, cannot strike the mark).
Fourth, abstain from idle play. Zhang Cigong said his master Zhang Taiyan told him: "Hold to one craft — even verse and song should be set aside."
Fifth, abstain from indulgences. To complete the plan, set aside all useless habits. In dress and food, no rich, no fancy; abide where one is; happy in plainness. Else one frets and cannot reach into depth. Old and modern scholars wore poor cloth and ate coarse fare not to make a show but to put will into learning, with no time for else. Examples abound; one need not throw oneself away. I set down: not only smoking and drinking — even dress is plain, to save the brief light.
Yue's motto: "Working on the heart — when can I forget self? Practicing the art — at any moment I may misdo a person." As a doctor, two things matter: faithful to scholarly truth — even at the price of life; truly responsible to the patient — beyond that, nothing.
This is the great bearing. Each of us should find that one thing we love enough to spend our life on; only then do we work without regret. Else life is bitter. Zengzi: "Each day I examine myself thrice." I hope all can examine ourselves thrice: Am I well? Am I happy? Am I free? That is the level of a life.
Right knowing comes from clinical practice
The aim of medicine is to see patients; how matters. Most TCM doctors today are not using TCM thinking. E.g., for a cold: a doctor prescribes banlangen, yinhuang jiedu, yinqiao jiedu pian, antiviral pills — all Western thinking. Few doctors can say one dose and the cold is gone. The method matters most. Not that using Western is bad; if the way is good, use it. So I repeat: TCM should do its own work well.
E.g., this formula: mahuang 6 g, shigao 30 g, zhimu 10 g, raw Chinese yam 15 g, prepared gancao 6 g, yujin 15 g, yinhua 15 g, gongying 15 g. A formula for acne — but most TCM doctors cannot read what it is doing.
Suwen — Sheng-Qi Tong-Tian Lun: "Sweating from exertion meets wind; cold shrinks, presses, the zha forms; pent it becomes pimple." Here is the Neijing's account of acne — sweat blocked by cold-evil, i.e., acne with infection. Shanghan Lun article 219, Baihu Tang: "Three-yang combined disease — belly full, body heavy, hard to turn; mouth deaf, face dirty, delirium, incontinent urine. Sweat? — delirium; purge? — sweat on forehead, hands-feet cold-counterflow. If sweating spontaneously, master with Baihu Tang." Baihu Tang resolves yangming heat, stomach-heat blazing. Stomach-heat blazing shows: belly-full, body-heavy, hard to turn, mouth deaf, face dirty, delirium, incontinent urine, sweating. The above formula: Baihu Tang plus mahuang, yujin; Baihu clears yangming heat; mahuang relieves the cold-bound surface (han-bo); yujin moves stasis; yinhua and gongying relieve heat-toxin. TCM is not simple; without classical guidance, no rise in effect. Few use this formula — because few have read these articles.
Another: Wenbing Tiaobian Upper Jiao article 28: "Hand-taiyin summer-warmth, cough without phlegm, clear-high cough — master with Qingluo Yin plus gancao, jiegeng, sweet apricot kernel, maidong, zhimu." I once had a nephritis patient with chronic cough; first I used clear-heat resolve-toxin throat-relieving herbs — some help, but always recurring. Then I found this formula; few doses cleared it. Catch the points — cough without phlegm, clear-high cough, summer-time cough — use, and it works. So if you want to study TCM: memorize Shanghan, Jinkui, Wenbing Tiaobian — three books — and the formulas are enough.
Clinical work is the final aim of medicine, and the most primal. The doctor's level depends much on how rich his clinical experience is. A disease never seen, one is at a loss; once met, one is at home.
In 1981, just graduated, I was posted to the Maozui Commune health-house in Mianyang County, Hubei — just as the Hubei outbreak of hemorrhagic fever came. 40 beds, 39 had hemorrhagic fever. Hemorrhagic fever is a severe infection: fever, widespread skin-and-mucous bleeding. In its course it readily produces low-pressure shock, oliguric renal failure, heart failure, pulmonary edema, cerebral edema — all life-threatening. We met a critically ill pregnant patient and invited a 60-something Prof. He from the Wuhan Medical School's infectious-disease department who specialized in hemorrhagic fever. Faced with this scene, he was scared; he had never seen so many cases of hemorrhagic fever. We were seeing dozens a day — and felt it ordinary, no different from cold. Without the chance to fear, fear is what it is.
So doctors must see many patients. I especially advocate going to the base; there, we not only see many diseases, but truly feel a doctor's duty — to use what we have learned for the people at the base. Our countryside really lacks doctors and medicine; they welcome good doctors. With only Beijing, Shanghai, Shenzhen developing, China is not truly developed. The advantage of developed Western countries: no city-rural gap; their countryside is more beautiful than the city.
The Neijing's many theoretical lines guide clinical thinking; we verify in the clinic. I once treated a man in his 30s, infertile, very heavy, with a whole ring of white hair around the ears; very timid — in his 30s and afraid to sleep alone. Much phlegm. Treated with Sheng Qi Zhi Bai Dihuang Tang plus Wuzi Yanzong Wan; two-plus months: first, fertility resolved, white hair gone; second, fear gone; third, weight dropped 10 kg, phlegm reduced. All these ties to kidney: TCM's kidney is master of essence-and-reproduction, stores essence; its emotion is fear. We often say coward (literally: gall-small); fear ties to gall, but more to kidney-vacuity. Kidney shows its flower in the hair — hair-problem is kidney-problem. The deeper theoretical issue is phlegm — its root in the kidney, because water-metabolism is kidney's basic function. TCM: the lung is the storehouse of phlegm; the kidney is the source of phlegm. With kidney-water-metabolism off, phlegm is much. By clinical cases, TCM theory is grounded in fact, not in imagination.
Understanding the classics must come from clinic. E.g., Shanghan Lun article 293: "Shaoyin disease, eight or nine days, the whole body, hands, and feet all hot — heat is in the bladder; there must be blood-stool." Our textbooks and many doctors hold this is shaoyin yin-pattern turning yang, storehouse-evil returning to the bowel — from cold-pattern to heat-pattern is yin to yang; from shaoyin to taiyang-bladder is storehouse-evil to bowel. Many call it a sign of recovery from shaoyin disease. But this picture is very common in nephrology — a kidney-yin-vacuity person who develops urinary infection: fever with blood-urine. By wenbing theory, blood in urine is heat entering blood-aspect. The Shanghan Lun's textbook clearly differs from clinic. So right knowing must come from clinical practice.
Another important practice: verify others' theories. Many doctors' books contain good things, but some are not right; you must judge. A popular doctor named Li Ke writes that for kidney-vacuity low-back pain, use Shen Si Wei: gouqi zi 30 g, tusi zi 30 g, bajitian 30 g, yinyanghuo 30 g. Many take it as treasure. But not everyone is helped. Why? All four are kidney-yang-warming; for yang-vacuity back-pain it works, but many cases are qi-and-yin-vacuity, very common. So we must verify — judge what is good where, and in what case best used.
To learn without thinking is muddled; to think without learning is dangerous
Confucius, Analects — On Government: "To learn without thinking is muddled; to think without learning is dangerous." A doctor must think continually; thought is woven through reading and seeing patients.
TCM's state is long unabolished, long unrevived. Abolishing TCM began late Qing — about a hundred years; not yet abolished. Reviving TCM has gone for decades; not yet revived. Those who want to abolish TCM are of two kinds: those with private interest (e.g., for show of achievement); and the simply idle. Whether TCM lives is not by anyone's will — only by effect. TCM still has effect; some doctors still have effect. So how can it be abolished? Take our Pingxin Tang: it is fully TCM, the government did not invest a single yuan, and yet it works well. Why do many government-built TCM hospitals not work? Because we still have doctors who get results. So TCM cannot truly be abolished; just shrunk a bit. Many young people still wish to devote themselves to TCM. There will always be such people.
But TCM cannot rise back to its peak — its ecology has completely changed. TCM is rooted in Chinese tradition; if tradition is gone, TCM's ground is gone. In the Republic and earlier Qing, when ill people went to TCM; first, no choice; more, that was the cultural education. Today our mainstream culture? Children learn English from kindergarten, math-science-language; Chinese-language is optional. And the country's machinery, every facet, runs on Western systems — including TCM administration and TCM-university teaching. So the real conditions for TCM are gone. How many really love TCM today? Few. Not because TCM is bad — because people no longer know it. The good, when not known, will be cast aside. TCM market-need is shrinking, because fewer and fewer know TCM is an option.
To revive TCM is simple: do our own work well; raise effect; results follow people. Demand the classical TCM — pass the classics or don't graduate. But Shanghan in our teaching-reform class is only 72 hours, three days — can one learn Shanghan? Henan, home of Zhang Zhongjing, at Henan TCM College — Jinkui, Shanghan, Wenbing together a mere 60 hours; a little of each — students say they got nothing.
So is TCM worth learning? In this state, real TCM again has hope. When none can treat, a little better is a good doctor. This is the real chance for those who really wish to learn.
I am odd at the TCM university — I don't do research; my students don't do research; my ideal is to be the best teacher and the best doctor at Beijing TCM University. I will not bend my soul for fame and gain; I do only what makes me glad. As a good doctor, can one starve? As a good teacher, also not. In any field, do your work a little better and food is not lacking. Many wealthy people come to me with worry — no good investment, banks devalue. My earnings are just enough; not worried about money, not worried about bank devaluation — that is the free state. Life should have aim; where is the question. In this state, has TCM a road? Yes — and the better you study, the better the road, with no need to rely on anyone. Most of my graduate students go out and work on their own; I encourage that. One of mine in Handan asked me what to do; I said, if you have the means, go home and work. Now in Handan he has his own clinic, a community health-care center gave him the TCM department; from Monday to Friday community TCM, weekends his own clinic, seventy to eighty patients a day. That is learning for use. In old China, famous doctors had their own clinic; people from miles around came.
Use what one has learned to solve a little for the people — that is what a doctor should do.