Abstract:
This is a two part article dealing with the common misunderstandings regarding so-called integration in medicine. More often than not, proponents of integration confuse the fundamental tenets and vicissitudes - seeing and declaring what they want to see rather than seeking to understand the historical moment and the logical basis of integrating TCM and conventional medicine. Part 1 attempts to define integration in medicine in unambiguous terms, dispelling the common misunderstandings propagated by many poorly thought-out adminstrators and teachers. Part 2 deals specifically with the issue of research methodologies in regard to integration and the epistemology that has led to the large-scale dismissal of anything other than the conventional approach.
Christian Nix
October 19, 2009
Myths of Integration
The flurry of new ideas - some brilliant, some less-well-thought-out - and the sheer and harrowing pace of change which characterize American society especially, but also world culture in general, makes for a wonderful and polyphonic symphony. Yet, good-thinking is as rare a commodity as ever it has been. Times characterized by angst and uncertainty - and ours is a most uncertain epoch - seem to spawn a most predictable human trait: people see and hear what they wish - to wit, what they would like to be true without regarding over-much the factors which may confound that cheery picture and without struggling to assimilate those inconvenient aspects which may refute their own ‘positive thinking.’
Regarding integrative medicine, there is a very little well-thought-outness to be found in the literature on this topic - most of it consisting of platitudes and trepidatious meanderings about what not to do. But where is the discussion which abides at that deeper and more inclusive level? This article will attempt to introduce a more utilitarian view of integration and must necessarily comment upon the misperceptions and puerile expostulations which make up the overwhelming majority of the literature on this subject.
In the first place, integration is not an arbitrary concept nor is it the mixing together of various disparate approaches to health and healing – which is the current status quo. Integration is a discernable conceptual and clinical model of medical practice. To be sure, it is not - in-clinic - what it will yet become. But, human endeavors in the material realm forever lag behind the conceptual clarity which proceeds significant action. Therefore, let us begin by looking at a clearly thought-out model of what integration must be in order to minimize the chicanery of poorly thought-out action and application.
In her recent article, ‘Transforming Your Oriental Medical Practice to an Integrative Medical Model,’ Belinda Anderson, PhD states that "Integrative medicine is basically a system of medicine that impresses patient centered care, focuses on prevention and wellness, impresses the significance of life-style, environmental and psycho-social factors as determinants of health, and selects appropriate treatments according to effectiveness based on evidence.” (Anderson, pg.1) This general statement fairly sums up the current level of understanding regarding integration. Dr. Anderson goes on to note several factors which deserve recognition in the quest for integration since each of them seems to evince a specific challenge to the evolution of integration in medicine in the 21st century. (Here I refer specifically to the challenges of communication and research methodologies).
The problem I have with Dr. Anderson’s statements and her appraisals is the ambiguity, lack of perception and manifest lack of insight they evince. Yet I must be restate with emphasis that this is essentially the state of the art regarding integration and her own ambiguity is certainly not deserving of any special notoriety. "Patient centered" care is a cliché (which Anderson does not define); “Life style, environmental and social factors” are certainly important to treatment, but once again these are cliché’s within the literature. All the above have entered the realm of marketing slogans, the rallying-cry of some presumed shift or new vanguard of medical practice. (What would be the opposite of patient centered care? Patient centered care as opposed to what? Some other focus? Precisely how does integrative medicine - as she is “basically” defining it – include life-style, environmental and psycho-social factors into its treatment protocols?)
Here I will venture to clarify what I think Dr. Anderson may be trying to convey. First, she is not describing integrative medicine but actually holistic medicine. It is holistic medicine which inherently contains a focus on prevention and the promotion of wellness, which inherently acknowledges the role of environmental factors, life-style design and psycho-emotional and societal factors. (Porkert, 1988) Though it may come as a real surprise to many, holism is based on holistic science and is thus utterly evidence-based. So Dr. Anderson has not yet arrived at any discussion or understanding of integration - though her appraisal would be a correct assessment if the article were an exposition of holism. This is more significant than and it might it first appear. Why? Because as Bob Flaws, Paul Unschuld and others have ably explained, the generation of students who have brought Chinese medicine to the west have largely done so as a back-lash to their own culture’s perceived short comings. (Flaws, 2009; Unschuld, 1985) This to me seems a case-in-point regarding Dr. Anderson's article.
Integration is not the wholesale dismissal of reductionism with its perceived short-comings and its subsequent replacement by holism; it is the correct combining of holism with reductionism in a judicious, prudent, circumspect manner which maximizes the strengths and minimizes the weaknesses of each system. Once one understands the basic epistemological and ontological tenants of holism vis a vis reductionism, this combining of the best of both is actually not all that difficult since the inherent complimentarily of these two systems of cognition is simply self-evident.
As for Dr. Anderson’s statements about the primacy of communication between the practitioners of these different cognitive models and the all important issue of research and evidence-based medical practice, I agree whole heartedly. But these are merely statement of the obvious - and statements about problems at that. The reader is left to ponder what Dr. Anderson’s solutions might actually be. The more worthwhile discussion has to address the specifics of how to communicate, and what the proper research methodologies are and then – most demanding of all - why?
Any further dialogue about integration requires one to at least attempt an understanding of the inherent characteristics of holism vis a vis reductionism.
Reductionism and Holism: separate realities?
Perhaps the greatest test of a practitioner’s ability to conceive of any model of integration lies in his or her ability to understand that epistemology varies from culture to culture. More specifically, the epistemology of conventional medicine is only one approach - and a new and somewhat limiting one at that. Yet conventional medicine is extremely useful in its given area of expertise and anyone with traumatic illness or injury will be well served by it. Conventional medicine is based on one single assumption about reality; namely, that deeper, truer reality may be discovered by reducing any phenomenon to its given constituent parts (and then reducing those parts to their parts and so on). This focus on separating things out into smaller and smaller units is essentially the reductionist methodology; and the ontology it creates and supports has several important implications - the most conspicuous of which is an emphasis on material matter and consequently an inherent preference to separate the mind (non-physical) and body (material).
"Measurement! It is the very foundation of the modern scientific method, the means by which the material world is admitted into existence. Unless we can measure something, science won't concede it exists, which is why science refuses to deal with such "nonthings" as the emotions, the mind, the soul or the spirit.“ (Pert p.21)
If one agrees – tacitly or otherwise – that deeper, truer, more-real reality is revealed by reducing phenomena down to their separate constituent parts, then one must have something to reduce. Thus one arrives at a preference for material reality by default. Reductionism prefers physical reality because measuring and ‘objectively’ quantifying thoughts and feelings is too elusive. Counting and weighing physical matter is a process which may be corroborated. The mind/body split and the disregard for subjective aspects of reality arises as a consequence of this preference.
The fundamental bedrock of holistic reality - and therefore holistic medicine - is that the inner, psychic world of thoughts and emotions is inextricably linked to and influential of - as well as influenced by - physical material reality. That is to say, material reality (body and also the environmental at large) are in a bi-directional relationship with the inner, invisible, non-physical world of thoughts and feelings. That’s it. That’s holism. From this fundamental assumption, several important implications arise; namely that the mind and body are presumed to be inherently inseparable; that treatment addresses the patient’s entire situation (not merely a single aspect like a named disease entity); that factors like lifestyle, sociological situations regarding family relations and one’s roll within society are all taken into account in treatment. Perhaps more significantly, the patient’s roll in creating their own wellness/illness is laid, ‘cards face-up,’ for both the physician and patient to see, ponder and augment. This point is exasperatingly important when dealing with chronic disease. Chronic disease is - by definition - disease for which no cure yet exists. Chronic disease inevitably involves issues of life-style and psycho-social factors. In 2005, the WHO published their report on chronic disease, stating that - in all countries - 8 out of 10 people will die pre-maturely of chronic disease in the 21st century. (WHO, 2005) If holism is inherently suited to the management of chronic disease, then clearly, good-quality holistic practice is something desperately needed in this epoch.
A further note about the inherent characteristics of holism; because it necessarily implies the consideration of a multiplicity of factors and because the patients total situation is taken into account, there is also an inherent possibility to bring-to-bear multiple therapeutic applications. This is yet another stroke in holisms favor for managing chronic disease.
With this terse introduction to the primary archetypal modes of cognizing heath and illness, one is ready to begin an under taking of; 1) how to communicate across these cognitive systems (i.e. with someone outside and thus unfamiliar with one’s given system); and 2) endeavoring to understand which model of research is best suited to which type of medicine and why.
On Communication
“For integrative medicine to develop in the Unites States, there is the necessity for education of the both the general public and of health care providers, and for greater communications between medical practitioners and patients.” (Anderson, p. 1)
The above rallying-cry is heard again and again in the quest for integration. Yet there is a glass-ceiling that Dr. Anderson – and the majority of pundits - seem unwilling to acknowledge. It is a curious fact that in the final paragraph of her article, Dr. Anderson also counsels the reader to, “Limit the amount of time you spend on Chinese medicine theories to explain illness and how acupuncture works (the limited amount of time in a talk does not allow for sufficient explanations of Chinese medicine theories and they end up sounding overly simplistic) . . . Western medicine audience responds better to scientific information.” (italics mine; Anderson, p.36)
Here we have one of the most egregious, most pernicious obstacles to integration. At one and the same time, Anderson calls for greater communication and also admonishes about sharing too much about TCM. Add to this the overwhelmingly common misunderstanding she evinces when she clearly associates science exclusively with Western science. It seems that the truth about integration in medicine is that the single greatest obstacle may be holistic TCM practitioners who do not yet understand what they do. Within holistic circles there exists a general unease and even rancor towards the AMA and MD’s with their perceived hegemony. But this is erroneous - or at least partly so.
Dr. Anderson seems not to realize that; 1) holism is rigorously scientific; and 2) clear communication with Western MD's about holistic science is exactly the route and task that TCM professionals must take. It is true that research studies on holistic practices like TCM are under-valued by Western science - obsessed as it is with material reality and ‘objective’ evidence. But, as I will explain in the next section, this is nothing more than the predictable bias arising from the influence of that all-pervasive element of reductionism. It’s not as though rigorous studies on holistic TCM, with its gem of pattern discrimination, do not exist. The issue I see is that teachers like Dr. Anderson are either unaware of them; or - worse still - do not possess the wherewithal to communicate about them to that group who would most benefit from a cogent explanation of the preferred parameters of the holistic cognitive system with regard to research – i.e. western MD’s.
“. . . the question was whether I believe laypeople can understand Chinese medicine on its own terms, and the answer to that question is an unequivocal "Yes, they can." . . . it is my experience over the last 30 years that patients and laypeople in general can understand Chinese medicine on its own terms if it is explained clearly, succinctly, and without apology.” (Flaws, 2009)
Furthermore, some of the most distinguished and pioneering people in TCM in North America concur wholeheartedly that 1) communication with MD’s is the bridge that must be constructed and that indeed this epoch offers an unparalleled opportunity for TCM practitioners to construct that bridge (Painovich, 2007); and 2) explaining TCM and holism to MD’s – or even lay patients – is actually not so tough (so long as one has clarified it for oneself). (Flaws and Frank, 2006)
“Chinese medicine has a much more down to earth and immediately understandable vision of what causes joint pain and what you can do for it. Most of us on hearing that the most probable initial event in OA (osteoarthritis) is the mitosis of the chondrocyte with increased synthesis of proteoglycans and type II collagen, won’t have the foggiest notion of what this means on an everyday level and what we ourselves can do about this. Traditional Chinese Medicine . . . is based on a vision of the human body as a microcosmic miniature of the natural world. Therefore, the language of Chinese medicine is the language we use everyday to describe events in the world around us. More importantly, using this language, we are empowered to take charge of our own lives and well-being so that whether we experience pain and discomfort becomes a function of how we live our life.” (Flaws and Frank, 2006)
As a practitioner and teacher who has successfully explained and presented on TCM to numerous laypersons and western medical professionals, I disagree with Dr. Anderson that one must tiptoe lightly and quickly over this ground. Nothing so elevates one’s legitimacy as a practitioner and teacher as the ability to make the holistic approach intelligible to western medical professionals. Is it so difficult to explain the fundamentals of holistic TCM theory? It is if you haven’t clarified for yourself. Yet the best among us in TCM recognize the simplicity and elegance inherent within the system.
“such a common-sense, every-day description of the body and its diseases is very empowering. While you may not have the first foggiest notion of what to do for yourself if you are told that you have, for instance, the swine flu virus, if I tell you that your lungs are too wet and that certain foods are prone to engender too much dampness in your lungs, then you immediately know not to eat too many of those foods. Most patients like being empowered to understand and to actually do something for their own health, and the Chinese medical map does exactly that in a very rational way.” (Flaws, 2009)
Without condescension, the same explanations may be employed to enlighten MD's as may be used to empower lay patients. Dr. Anderson’s stance is the greater part of the problem and hindrance to integration. As Jeannette Painovich recognized, ‘it is our (TCM practitioner’s) responsibility to build a bridge to the western medical community.’ (Painovich, 2007) That means learning how to sort through the culturally-bound concepts which do not ‘translate’ (or at least not easily and neatly), as well as the concepts which bear some kind of analogous structure within each given cognitive system (e.g. Chinese medicine has an utterly logical explanation of the relationship between stress and immunity and yet these western biomedical terms and concepts need not be employed to accurately explain the theoretical model of TCM). The treasure of insight one discovers in striving to build this bridge - whether or not MD’s ‘get it’ - is it’s own reward.”
“It is in a comparative way that one can learn from another tradition to see an aspect of one’s own that one had not been paying attention to; and a kind of illumination goes up.” (Campbell, 1997)
Apologetically ducking the issue - for fear that western MD’s won’t approve – is precisely what keeps TCM and the inevitable tide of its integration into the main-stream, sidelined and marginalized.
How may one convey the concept of qi? How express the exquisite elegance of pattern discrimination for managing chronic disease? In my experience, all of this and more is not only palatable to western MD’s but leaves many hungry for more of this almost bucolic and common sense approach. Yes, there must be increased communication between medical professionals of different modalities; no it cannot be passed over and no indeed should TCM professionals shrink from this opportunity. But where and how may one find and learn the particulars of medical-speech for integration – a field that attempts every day to further define and clarify its own mission and existence? I know of no other program which allows medical professionals to ‘cut through the Gordian Knot’ of medical epistemology and the culturally-bound cognitive models which result – the misunderstanding of which hampers progress in communication - save Barefoot Medicine Training as this skill-set is certainly not going to be taught in schools; indeed, it is not even addressed or understood by PhD’s like Belinda Anderson and yet it can and must be done. The next part of this article will focus specifically On Research Methodologies
Works cited:
- Anderson, Belinda. Transforming Your Oriental Medical Practice to an Integrative Medical Model, American Acupuncturist. Oriental Medicine: Pacific College of Oriental Medicine, summer 2009. (p.1,4,36,38)
- Campbell, Joseph. From and audio recording; The Wisdom of Joseph Campbell with Michael Toms. New Dimensions Radio. 1997. Copyright, Hay House Incorporated, 2004
- Flaws, Bob. Explaining Chinese Medicine to Laypeople. Blue Poppy Blog. April 28, 2009.
- Flaws, Bob and Douglas Frank. Curing Arthritis Naturally with Chinese Medicine. Blue Poppy Press. Boulder, Colorado, 2006.
- Painovich, Jeannette. AAAOM Conference 2007, Portaland Oregon. From a talk on her successful integration of Acupuncture in a western medical hospital in Los Angeles).
- Pert, Candace. Molecules of Emotion – why you feel the way you do. Touchstone Press, New York, NY. 1999
- Porkert, Manfred. Chinese Medicine. Henry Holt and Company, New York, NY. 1988
- Unschuld, Paul. Medicine in China: a History of Ideas. University of California Press, Berkeley and Los Angeles, California. 1985.
- World Health Organization. Preventing chronic diseases: a vital investment. WHO press, Geneva Suisse. 2005
