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An Open Letter to Interns and Practitioners about TCM Acupuncture

by Todd Luger, L.Ac.

There has been much talk in recent years of the merits of so called TCM acupuncture versus pre or non TCM styles. And with good reason, I believe. However, this entire discussion has been one that lacks clarity and definition. What follows are the personal opinions of one who has wrestled with this topic for a long time. There is much to be read on various sides of this issue, with the likes of Dan Bensky, Bob Flaws, Steven Birch, Mark Seem, Ted Kaptchuk, Giovanni Maciocia and numerous others all staking out their positions. And practitioners such as Kiko Matsumoto, Miriam Lee, Harriet Beinfeld and Diane Connelly, while not overtly arguing in this battle, have long promoted so called non TCM styles of practice. Why would it be desirable to practice a non TCM style of acupuncture and, almost more importantly, what is this monolithic TCM to which everyone refers?

TCM is the term used to describe the modern practice of the traditional healing arts of ancient China. As Flaws and others have noted, TCM is part of a continuation of the tradition in Chinese medicine of recommending treatment based on the discrimination of patterns (Chinese: bian zheng lun zhi). It is thus to be distinguished from purely empirical, symptomatic or disease oriented approach to therapeutics, in that it attempts to seek out and treat underlying "causes" of illness. Clinically speaking, this means one disease may have many treatments and one treatment may be applicable to many diseases. TCM is also a system of education that introduces students to all the major methods of pattern differentiation used in Chinese medicine (five phase, six channel, four level, channel and collateral, eight extraordinary vessels, zang fu, triple burner, six evils). However, in the modern Chinese clinic, the main method used in the differentiation of chronic diseases has been zang fu or organ diagnosis. This is due to several cultural and historical factors.

In the last fifty years (i.e. the entire modern era of Chinese medicine), the Chinese people have mainly used acupuncture for serious organic diseases, not for the milder conditions that many Americans present with. While acupuncture has a reputation as being good preventive medicine, it has not often been used this way in modern China (though this is changing in recent years). Because of the nature of their patient load, Chinese doctors have focused on zang fu patterns, as organic disease is often rooted at that level. The situation is quite different in Japan. It is thought that many Japanese seek out "traditional" acupuncture for the same quality of life issues that Americans often do. Thus, some Japanese acupuncturists (who are not doctors or herbalists) have focused on channel and collateral and five phase patterns, finding them more applicable to their patients. Others emphasize careful palpation of channels or just the abdomen in order to determine treatment. There is no doubt much to learn from studying these different styles, as well as studying the classics that inspired them, such as the Nei Jing, Nan Jing, Zhen Jiu Da Cheng, Jia Yi Jing, etc. The modern French practice of acupuncture, rooted in the works of Soulie de Morant and exemplified in modern works by Yves Requena is also a fascinating and relevant field of study.

Because of the TCM emphasis on zang fu differentiation, it has been harshly criticized and even completely dismissed by some lecturers. But the real problem is not TCM, but the relevance of zang fu acupuncture to an American private practice. There are, I believe, some serious misconceptions about zang fu acupuncture. First, it is highly effective when applied at frequent intervals, up to15 times per month. It also has a history of use that far predates the communist era. Zang fu acupuncture has been derogatorily called herbal acupuncture because many of the principles of internal medicine were developed and applied by herbalists over the centuries, but it was never their exclusive domain. Giovanni Maciocia has identified so called "herbalized" descriptions of acupuncture point functions from the 14th century and earlier. Zang fu acupuncture has its place and its legacy in history and will become more and more relevant in America as acupuncturists are allowed entry to mainstream healthcare settings. Having said that, zang fu acupuncture is probably not the best style for Americans with low grade psychosomatic, stress induced, musculoskeletal and psychospiritual syndromes or those looking for preventive care. But this is hardly an indictment of TCM. TCM is bian zheng lun zhi, nothing more, nothing less.

It is up to us to tap the archive of Chinese medicine and discover the patterns that enable us to correctly treat our patients. We need scholar-doctors who will plunge deeply into the study of the classics and discern new insights through practice. But we will always use the main method of TCM: pattern differentiation through palpation, questioning and observation (though we may emphasize one or the other). Whether you are using a Mark Seem technique or a Kiiko technique, you are still identifying a pattern (in this case pain or resistance on palpation) and choosing treatment based on your assessment (is it tense or flaccid; what is the location; shall I use reducing or supplementing manipulation?). Eventually we will have our own textbooks of common ailments in America and side by side with liver qi constraint will be wood/metal imbalance and yangqiao mai excess. Diagnostic signs will typically include palpation alongside tongue and pulse. And this will still be TCM, in my opinion.

TCM acupuncture has also been called bereft of spirit and to this charge there is little argument that can be made. There is much in Chinese medical terminology that is richly suggestive, both psychologically and spiritually, especially point names and five phase relationships. How to integrate this information into education and practice certainly deserves exploration.  There is no doubt that the modern communists played down what was esoteric, demonic, shamanic, metaphysical and even that which was merely psychological or existential. However, it should be remembered that the Confucian/Legalists, who dominated the written transmission of medical lore for two millennia also tended to play down these things. The so called scholarly medicine of imperial China was really very secular and somatic (whether this is good or bad is debatable, but it is a good explanation for the lack of psychospiritual emphasis in modern TCM). Those who wished expertise in psychospiritual matters would pursue Daoist or Buddhist studies to complement their study of medicine. There were no doubt monastic strains of medicine in China that were similar to Tibetan medicine, with its decided psychospiritual emphasis. Unfortunately, almost all of the Buddhist and Daoist canons remain untranslated. However, the revival of qi gong and traditional philosophy in China is beginning to generate interest in these areas once again. Luckily, some Asian philosophy classics are widely available (largely thanks to Thomas Cleary), as well as there being sophisticated discussion of Chinese medical psychology on many fronts (Flaws, Needham, Worsley, Soulie De Morant, Kaptchuk, Rochat De Vallee, Hammer, Requena, Maciocia). Thus, there are endless avenues for exploration in this area. Like modern psychologists and religious leaders, the ancient Chinese never came to much of a consensus on these matters. Will we?

The question remains as to what needs to be done to the existing curriculum to meet the needs of practice in America. Should the acupuncture portion just be scrapped and rebuilt from the ground up? Who will supervise the training in this new American acupuncture? Will students just develop it spontaneously during their internship? Or will you apply your ideas in practice throughout the years and return your insights to the professional community through serious research, education and writing? Can psychology be more systematically integrated into our education and practice (assuming some expert panel of students, practitioners and educators can first come to a consensus on the nature of mind and spirit and how to best facilitate therapeutic transformation at each stage in an individual's development)? There is no doubt that some changes need to made in the way acupuncture is taught and practiced in America, but we are just beginning to have enough conscientious, articulate practitioners to even begin talking about what we need and what we should do about it. It is good that everyone is riled up about these issues. That will foment the necessary change, if all this energy is channeled creatively and constructively. I look forward to what the future educators and innovators will bring to the profession in the form of debate, challenge, real growth and transformation of practice.

For now we must rely on the experience of our teachers. Unfortunately, there are only a handful of American practitioners who have been practicing long enough to have developed unique and effective insights and innovations into the diagnosis and treatment of modern westerners. Luckily, many of these folks write and lecture for our benefit. Unluckily, they are not available to give long term clinical supervision to all of us. Without supervised clinical experience, I do not believe it is possible to gain a high degree of competency, much less mastery, in a given style of practice. Through a long career of trial and error, you might achieve something akin to mastery. But while workshops are helpful, those who truly want to master certain styles have always apprenticed with teachers who specialize in those styles. You have your whole lives to practice as you please, on your own, without scrutiny or comment. During your formal education, you should have the benefit of such a teacher's experience. If they are not available in the school clinic, seek them out in the community and try to do extended internship with such a practitioner. Your colleges can only give you limited credit for observation with private acupuncturists, but this shouldn't limit you. Do as much as you can, even without credit or compensation. Continue after you graduate; you may have some free time as your practice grows. A good long term relationship with a teacher or teachers is worth the sacrifice of time.


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