TCM Education in Crisis — A Letter to the Bureau Leadership (Excerpt)
(August 1995)
1. The present crisis of Chinese medicine — self-subordination
Before Liberation, Chinese medicine was slighted, discriminated against, and pushed aside. After Liberation, Chinese medicine has been in a subordinate position. Only after the founding of the State Administration of TCM in 1986 did that subordinate position begin to change, and TCM's enterprise — treatment, education, research — began to develop across the board, with no small achievements. Unfortunately the subordinate position once imposed from outside has quietly become self-subordination. Self-subordination shows itself most clearly in the clinical care of TCM hospitals: the ratio of Chinese-medicine treatment in the wards is not gradually rising but gradually falling. Is Chinese medicine useless, or do we not know how to use it, or do we not want to? This is a grave question, a crisis. If this trend is not reversed, things will only get worse and worse, until Chinese medicine is reduced to something that may or may not be — and so loses any reason to exist. TCM education would then have no reason to exist either. Reversing this is worth deep study.
2. The roots of self-subordination
In the last decade-plus, many articles on innovation have been written; many try to reshape Chinese medicine's systemic theory. One senior practitioner even doubts pattern-discernment and treatment. Some are eager to use Western theory to guide TCM treatment. Loss of trust in TCM theory is the greatest crisis. Every country has traditional medicine — but all the others are gone. Only Chinese medicine remains standing, because Chinese medicine has a body of theory that can guide practice. This body has its dross, but the essence is the main thing; and much of its content is ahead of its time. We need to vigorously mine it, develop Chinese medicine, and renew world medicine.
Zhang Zhongjing's age already had when the spleen flourishes through the four seasons, evil cannot strike. That modern medicine has come to see the spleen as a key immune organ is only some thirty years old. Some replace the heart rules the spirit-bright with the brain rules the spirit-bright — not realizing that Chinese medicine's zàng-xiàng is systems theory, which has long united heart and brain. Why do they not see that TCM treatment of Japanese encephalitis B leaves almost no sequelae? In the 1970s I told Western-trained colleagues: the heart is not just a blood pump — it must produce a hormone, and a hormone that influences the cerebral nerves. Of course no neural-system hormone has yet been found — but ANP and others were found in the 1980s. Chinese medicine's systemic theory must be developed with new technology. Do not try to reshape TCM theory with today's-and-before Western achievements. Chinese-medical theory contains much truth ahead of its time. As the new-technology revolution is only beginning, let us not rush to clean up the dross — let us hurry to mine the essence.
The popularity of "self-subordination" in TCM hospitals has many causes — pursuit of revenue is one. But the biggest cause, I hold, is lack of confidence in TCM's technical mastery and in TCM as a great treasure-house. I graduated from Guangdong's TCM specialty school at a level far below today's bachelor's, yet I have used Chinese medicine alone in clinical practice for decades — because patients forced me to keep lifting my craft. Today many TCM practitioners under the banner of "integration" use Western and Chinese for any disease — and lose confidence when they cannot use a Western drug. What is real integration? Worth deep study. If we dare not use Chinese medicine, and then cannot use it — and Chinese medicine itself is gone — what is left to integrate? I do not oppose using Western medicine and drugs when needed; Western medicine is often good at the manifest, fast-acting, with its strengths. But for a given patient, under what guiding thought, what theory and method, in the main — is the key question. We should also have a goal: step by step, replace, with comprehensive TCM care, those diseases now held to require Western drugs and surgery. Sum up honestly, write up, repeat across the field, refine, set as standard, write into textbooks — could Chinese medicine then not develop?
3. Independent thinking — walk our own road
In medical education, our country founded its medical universities earliest (Sui-Tang). But over the past century, as Chinese medicine was disdained, it was excluded from the education system from the 20th century onward. In the 20s and 30s a few TCM schools were founded — but not well. After Liberation, with TCM higher education built up, education, treatment, and research all took Western medicine as blueprint — unavoidable. But TCM and Western medicine are two different systems, of different roots and developments. Chinese medicine has its character. Since the TCM colleges were founded in 1956, almost forty years on — I propose a deep summing-up, and on the basis of investigation, plan our own road. We cannot copy the Western pattern; we must create our own.
(1) In pre-clinical Western medicine, lab work matters. Do we copy this? TCM theory comes from practice — black-box-like, drawing conclusions from countless information feedbacks. So TCM's foundational theory is tightly tied to clinical practice. I think it is best to enter the clinic early, run experiments through the hospital, take patients and case records as the laboratory class. With research outputs accumulating, some animal experiments will be fine — e.g., experimental study of wind-pathogenesis. But for now I hold this is secondary. The road we walked was not animal experiment — it was working with patients. The earlier and more students see patients, and verify theory on patients, the better. TCM theory is simple — sometimes hard to believe. Through cases the difficulty falls away. To force experiments is too hard. Many pre-clinical teachers today are detached from clinic — a pity. How can they let students believe what they themselves do not? Teachers of Shanghan and Jinkui who do not see patients — who have never used Guizhi Tang — can they teach well? I have always held that Shanghan and Jinkui are clinical courses, not foundational. Wenbing of course is clinical too. When students have Shanghan and Wenbing well, and use them in clinic, they will not become so blindly devoted to antibiotics. I also bring my medical-history graduate students to the clinic; through clinic they see Chinese medicine really solves problems, and so will not draw careless conclusions about history — will not call Li Dongyuan's sweet-warm-resists-great-heat method wrong. Pharmacology and formula classes can spend some hours in the pharmacy as lab.
(2) Clinical-course teaching — from the self-subordination of the wards, one can see TCM clinical teaching is the weakest link. Most students report that teaching and practice are severely disconnected; resolving this should be a project for the clinical curriculum. This concerns both wards and research. Western medicine, after several centuries, has mature clinical departments; textbook and ward routines closely match, so Western research focuses on the leading edge. TCM is many flowers and many schools, not yet screened, researched, and ordered into workable, effective routines. So the quality of clinical-curriculum textbooks is tied tightly to clinical and research work. Our research cannot copy Western's; aside from attacking critical/difficult diseases, common-disease standard routines should be a current project — across east, south, west, north, center pilot sites — to serve textbook construction. We can lift TCM treatment rate via standardization.
(3) Disease names in clinical disciplines. Take internal medicine: I hold the original TCM disease-pattern names should be the upper half and Western names the lower half; Western diagnosis can be detailed, but TCM diagnosis and treatment is the focus. Western diseases need not be comprehensively covered — only those with current TCM research and good outcomes should be in. As research deepens, gradually add — never force fit. TCM patterns often cover many Western diseases; Western diseases also relate to TCM patterns; let them echo each other.
(4) Basic TCM skills must be trained. Herb properties, formulas, four examinations, pattern-discernment — strengthen training, recite the rhymes; do not slight them as old. This is a fine tradition of TCM education and should be valued.
(5) I propose, on TCM's character, organizing research on subject-teaching methods, with senior TCM masters as advisors.
4. The dialectical unity of inheritance and development
Inheritance and development are a unity of opposites — without inheritance, there is no development; without development, there is decline. This is truth. But within the TCM community in recent decades the disputes are not few. Recently there are repeated reformist articles. One senior practitioner speaks always of reform — yet in his articles the destroy is plenty and the build very thin, almost zero. For the sake of reform he discards the old; his own outcomes drop. A great pity.
Some say in the 1970s-80s we had already surpassed Zhang Zhongjing; some shout when will the punctuating of old medical books end? These comrades, perhaps seeing slow TCM progress, with good intent, want to move faster. But we must look from historical materialism: every thing's development has cause and consequence. Chinese medicine has millennia of continuous development. This ancient thing knew nothing of bacteria or viruses, yet used the li-fa-fang-yao of Shanghan and Wenbing to treat hemorrhagic fever, leptospirosis, encephalitis B — all reaching world-class level. Dialectical materialism teaches: practice is the sole criterion of truth, not whether a thing is new or old. Chinese medicine is sometimes startlingly new. After the Song there was another great leap in Chinese medicine; we owe gratitude to Lin Yi and his forebears for collating the old books. After the Party led a great collation of pre-modern medical books, later students have reliable editions to summarize the predecessors' material — surely the foundation of the 21st-century takeoff. Sun Tzu long said know yourself and know the enemy, and you will not be in danger in a hundred battles. I have read many anxious reformist articles — and on knowing oneself they are too thin. To talk reform without knowing oneself: their proposed methods are only to use Chinese medicine to fill Western medicine's gaps.
The Party and State's directives on TCM begin with Chinese medicine must not be lost. They point to the main side of inheritance vs development today: Chinese medicine is at risk of loss. In this century too much has been lost. So in 1990 the Two Ministries and One Bureau's program — five hundred senior practitioners nationally raising over seven hundred academic successors — was a fine, major decision. Within inheritance is the seed of development; many seniors take their successors into research, summarize experience, lift theory. Pity that some do not look kindly on even this good thing. May the seven-hundred-plus successors' work be sifted, and the essence written into new textbooks.
We also should not forget the 1958 promotion of Western doctors learning Chinese medicine; senior masters were then more numerous than now, and a fine generation of Chinese-Western integrators were trained, with century-exceeding outcomes. Their teaching material was the Four Great Classics. To put the Neijing now as an elective is improper — it should be a required course of theoretical lift. The non-surgical treatment of acute abdomen — the prized result of Western-doctors-learning-TCM in those days — has, in the past twenty years, not seen many further advances. This should have been carried forward by TCM hospitals — yet I see many TCM hospitals' surgical departments have almost wholly westernized; TCM has retreated from that ground. Has TCM surgery no future for lack of advanced surgical methods? The jolting therapy invented by a Western doctor for treating intestinal volvulus — I checked the Zhouhou Fang's "Sudden Abdominal Pain" chapter and found this method already there, with spinal pinching added (showing spinal-pinching therapy began in the Jin). The Zhouhou Fang's "sudden abdominal pain" did not specify intestinal volvulus — I only mean Chinese medicine is a great treasure-house, and inheritance is tightly tied to development. There are many such unknown treasures awaiting our mining. Could TCM's millennia of theory and experience — battered and torn over more than a century — have been sorted in the past two or three decades? If we do more rescuing and inheriting today — do a great collation, a great summing-up of all of TCM — alongside development will surely come. Time in this century is short; with the half-rescue of Chinese medicine, prepare the ground, lay the foundation; the 21st century will be TCM's takeoff.
A qualitative leap in TCM theory must rest on help from the new-technology revolution. And the results of joining TCM with new technology will in turn drive the new revolution. This is my view of TCM's future. By that time (probably one or two dozen generations of work), the Shanghan Lun and Neijing can enter the museum of history.
The most important point at present is — in treatment, teaching, research alike — do not force TCM into the Western mold. Always, while borrowing, start from one's own character and find one's own road. Otherwise TCM will go astray.
I propose: soft-science exploration of TCM's development — but never let those without TCM clinical experience be the backbone. Multi-disciplinary, mixing old-middle-young — I always fear those without deep TCM understanding will coin terms and lead TCM down a side road. I hold we must guide with historical materialism and dialectical materialism, draw on the "three theories" (information theory, control theory, systems theory) for reference, and let multi-disciplinary research move TCM forward. The newer the thing, the more it can develop TCM — that is my view. The above ramble may be hot at points, but it comes from sincere love of Chinese medicine. May errors be corrected.