By Bob Flaws

I don’t know if I’ve mentioned this before in this blog, but the late great Dr. John Shen once said, “Western medicine is hard to study but easy to practice. Chinese medicine is easy to study by hard to practice.” Personally, I think there is a lot of truth to this statement on a number of different levels. However, today I’d like to talk about just one of those difficulties: that Chinese medicine is a collection of various theories which developed at different times in response to different situations. As the German sinologist Paul U. Unschuld has pointed out in Chinese Medicine: A History of Ideas and elsewhere, Chinese medicine has never developed a single all-encompassing theory. Rather it has developed a whole host of theories, some of which are logically contradictory. For instance, in the realm of correspondence theory, there is yin-yang theory, five phase theory, and eight trigrams theory, each of which attempts to describe the same phenomenal world but divides that world up in different ways. In terms of external contractions, shang han (cold damage) theory and wen bing (warm disease) theory both describe the progression of an externally contracted evil qi through various levels of the body. Cold damage theory posits six levels and warm disease theory posits four. Then we have the several different methods of choosing acupuncture points based on Chinese “astrology.” At least two of these theories are mutually contradictory, saying that different of the extraordinary vessel meeting points are open at the same time. However, it is not that one of these theories is right and the other is wrong. The trick is to know which theory most accurately reflects the exigencies of a particular situation. Thus, one uses the relevant theory in order to achieve a certain therapeutic effect, and one theory does not negate the potential utility of any other theory within the collection of theories known as Chinese medicine.

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As Westerners, we are, as a group, not very comfortable with this epistemological approach. Most Western philosophy and science is based on the search for an all-encompassing ground theory of reality which accounts for all and everything without contradictions or omissions. In general, our Western mind-set has primed us to try to fit all of Chinese medical theories together into one seamless system of thought, and, when there are contradictions, our first response is typically to want to know which theory is right and which is wrong. As a culture, we tend to think ontologically, meaning that we want to now the truth of reality, how things really are. This is also technically referred to in Western philosophy as metaphysics. Interestingly, the late 19th century American philosopher John Dewey suggested that truth is that which works in a given situation, that which achieves the intended effects. Beyond that, any other truth is not knowable. This school of thought is called Pragmatism and is the school of Western philosophy which I believe is the best one for understanding Chinese medical theory – at least how that theory is used in clinical practice.

To me, all the theories of Chinese medicine are like shoes in a shoe store. In a shoe store there are all kinds of different shoes meant for different occasions. Speaking of just men’s shoes, there are loafers, hiking boots, high-top basketball sneakers, running shoes, snow boots, cross-trainers, wing-tips, clogs, sandals, and patent leather dress shoes. There are shoes with shoe-laces and shoes with zippers. There are zippers up the sides, there are zippers up the front, and there are zippers in back. There are Clark’s desert boots (which are way cool) and there are Crocs (which, IMO, aren’t). There are brown shoes, black shoes, smooth leather and suedes. Each of these shoes is meant for its own occasions. On casual Fridays, maybe loafers or desert boots are appropriate, but the rest of the week it’s wing-tips. On snowy days, snow boots are appropriate, but in the summer, hey, sandals are what work. So when you go into a shoe store, you need to know the occasion or use of the shoes you are looking for. It’s not that sandals are good and high-tops are bad. They are only good or bad, right or wrong for a particular occasion. So the trick is to select the right shoe for the occasion. When the occasion is over, you can put the shoes back on the shelf with all the other shoes, and all are equally good, right, potentially useful.

Truth be known, even in China, Chinese medical students have a hard time with this. I have heard third-year students say that they wished they were studying Western medicine where there was one right theory, thus making everything conceptually easier and clear-cut. They longed for the seeming one truth of Western science. In contrast, having to pick and choose between the competing theories of Chinese medicine is a much more difficult and mature conceptual process. Hence, Dr. Shen’s statement, “Chinese medicine is easy to study but difficult to practice.” We don’t have to learn chemistry and physics. We don’t have to half-kill ourselves getting into and staying in medical school. Mostly we just need to read and to memorize a bunch of stuff in relatively easy to understand language (as opposed to the abstruse language of quantum physics or calculus). However, the hard part in Chinese medicine (or at least one of the hard parts) is determining which theory really fits the patient at hand, and, by extension, which other theories to leave on the shelf . In point of fact, the process of Chinese medicine is to make a diagnosis which then allows us to select a treatment which alleviates the patient’s suffering or cures their disease. That end result is actually the most important thing, and making the diagnosis is only a means to that end. It is a tool to achieve a certain pragmatic effect. Once that end has been achieved, the tool has served its purpose and can be put back in its box.

Unfortunately, it takes time and experience to learn which theory to use in a given situation. As a clinical mentor, all too often I see students floundering trying to fit all of a patient’s signs and symptoms into the wrong conceptual theory. They get stuck on a single theory (often based on a single symptom) which then they can’t let go of when everything else doesn’t support that theory or approach. Sometimes, in frustration, they throw up their hands and say, “Chinese medical patterns don’t fit Western patients.” However, in my 30+ years experience, that is absolutely not the case. Instead of trying to force patients into a particular diagnostic box or pattern, we need to select the diagnostic box (or boxes) which truly do describe their situation. For instance, in Chinese medicine, there are 10 different systems of pattern discrimination:

1. Eight principles pattern discrimination
2. Five phase pattern discrimination
3. Viscera & blood pattern discrimination
4. Channel & network vessel pattern discrimination
6. Qi & blood pattern discrimination
6. Fluid & humor pattern discrimination
7. Disease cause pattern discrimination
8. Six aspect pattern discrimination
9. Four aspect pattern discrimination
10. Three burner pattern discrimination

Sometimes, five phase pattern discrimination most accurately describes our patient. Other times, six aspect pattern discrimination most accurately describes our patient. Five phase pattern discrimination and six aspect pattern discrimination are both equally true and right in their own appropriate situations. It is not that one is right and the other is wrong. Rather, it is that, in a given real-life situation, one leads to be better, quicker, more complete therapeutic outcome than the other.

All this means that we need to learn the full range of Chinese medical theories, not limiting ourselves to a single theory or approach. It also means keeping an open, broad, relaxed, and expansive mind about these various theories and approaches. In other words, we shouldn’t become emotionally attached to only one theory since it is important that, should the facts not support a particular theory, we can quickly shift gears and see the case through the lens of some other theory. After all, it is the outcome that is important, not the theory that led to the outcome. In other words, we need to be able to use these theories and concepts flexibly as tools and not be rigidly abused by them.

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