Herbals Herbals Herbals!

Ok, at this point I have either completely lost your attention or you are watering at the mouth. Herbs have that effect on people--you love them, you hate them, mostly though, people just hate loving them. There are problems with the community acupuncture model. There, I said it, and I mean it, so deal. It's a much better solution than the conventional private practice model (but that's really not saying a whole lot, now is it). I'm not going to say much more than that, except to point out that the biggest deficiency in the CA model--for me--is how to fit (real) herbal medicine into 10-15 minute time slots.

There are numerous serious problems with education in this field, many concerning herbal medicine, but the fact remains that most of us have spent large sums of money and heaps of time on our educations, much of which were oriented towards Chinese Herbal medicine. So what's a practitioner to do? Abandon all that education and just stick to the needles? What if, like me, you really like herbs? Tran Viet Dzung is of the opinion that acupuncture and herbs are indeed two separate and complete medicines unto themselves. To try and master both would be akin to trying to master both neurology and histology--too much for most people, himself included. Of course, he's never studied herbs (to my knowledge).

I agree with him, to a point. I honestly believe that acupuncture can treat any condition, given enough time. The same is true for herbal medicine. However, often one is clearly more time/energy/cost effective. Two examples immediately spring to mind: acupuncture is much faster when dealing with pain. Herbs, in my opinion, are generally better suited to gynecology. These are generalizations, but in my limited experience, very true. Have I successfully treated gyn cases with acupuncture? Of course! Have I successfully treated pain with herbs? Of course again. The point is NOT needles vs herbs, just as I don't believe you can say Tung vs TCM--they are both effective, and while there is over-lap, generally they are used in different ways for different things based on the experience of which is more effective within a shorter time frame.

Where I differ with Tran is on the idea that they are so unrelated. Tung and TCM are not that far afield, really, if you understand the one, the other comes to you much more quickly. We get kind of myopic in this field, but think about the shared assumptions between these two different styles, like physiology, theory, even techniques, etc. Acupuncture and herbs are probably further apart than these two styles, but honestly, they are not separate medicines--an acupuncture only practitioner will pick up herbs exponentially faster than a western-trained MD or pharmacologist.

Faculty and mastery are also very different things. Do you have to be a master acupuncturist to be effective? Hell no! I'm living proof of that, for sure. I think you can also be merely proficient with herbs and be very effective. We all know that mastery comes with time and experience. I don't see why you couldn't master both. However, I can't deny that herbs do require more time and effort to become proficient in. Much of the problem here is educational--we are taught herbal medicine with an eye towards mastery, not proficiency. I'd say the reverse is true of acupuncture, which is why most people upon graduating are decent acupuncturists and terrible herbalists.

So what's a CANner to do? Patents you say? Bah! Really, I have gotten results using patents, we all have, but nowhere near the results I have with granules or bulk. Bulk, then, all the Chinese seem to think they're the best! Hmmm, wrong again. While they are the strongest, probably most effective, people do not take them. In my experience, people who are very ill will make their formula for the couple of days required to get over whatever bug they have. On the other end of the spectrum, I have found that cancer patients are very good about keeping up with the bulk process. So we have people of whom it requires very little commitment for very quick results and highly, highly motivated people. The vast swath of our patients will fall in between these extremes, and can't be bothered to deal with making potions. Heck, they're probably making time for the acupuncture as it is! Ahh, so granules!

Here's where people get tripped-up by their training: Granules are the best _delivery system_, now the REAL problem arises--the _method_. At this point, I might use some strange terms that come from my training in Kanpo--which is the Japanese method of herbal medicine. Kanpo represents, to me, the starting point for quick, effective herbal medicine. If ever there was a model for community based herbal medicine it's Kanpo. Don't worry. It may sound weird, but it's just a different perspective and method of doing the things we were (mostly unsuccessfully) taught to do in school.

Why is it that people like using patents? Well, you have a basic symptom, or confirmation (that's "pattern" or zheng in TCMese) and a patent that goes with it. Allergies = Bi Yan Pian. Damp-Heat = Long Dan Xie Gan Tang. Often this is enough to get good results, sometimes you have to look harder or tweak this or that, but for the most part, easy, simple. Bi Yan Pian is not just a pill, it's a FORMULA. You can get this formula in the form of granules. Ah ha! Yeah, that's pretty much the big secret of Kanpo--think in terms of formulas, unmodified, and then give people granules of that formula.

Now, I'm not talking here about mixing it up one herb at a time. No, the Japanese don't stand for that kind of crap. It should be the whole formula decocted together, then made into granules--believe it or not, herbs that are cooked together are more effective than herbs cooked separately and then combined later. I think this is the main reason that Chinese teachers look down on granules as opposed to bulk--they don't account for the fact that the way most dispensaries prepare granule formulae robs them of the synergistic effects of decocting herbs together. You wouldn't cook a chicken, cook some garlic, cook an onion and cook spices all in separate pans, and then throw them all together for "dinner" would you? Just imagine how unsatisfying that would taste! Different flavors come out when various things are cooked together--herbs are no different. Why, then, do most schools use separate granules to build formulas? Heavy modification.

Yeah, Kanpo doesn't play this game either. One of my teachers said that if you're adding or subtracting more than one or two herbs, you've got the wrong formula! You can give someone two different formulas at once, if their confirmations call for that, but you shouldn't go messing with the basic structure of the formula. Writing a formula from the ground up or heavily modified until it barely resembles the supposed "base formula" is for master herbalists--not us! The Chinese faculty at schools can do this because most of them spent _years_ seeing hundreds of patients a week with a broad range of complaints while they were surrounded by already accomplished masters for guidance. Suffice it to say, we do not have those kinds of opportunities, we have to trust in the strength of formulas that have made it down to us through the ages. Would you take your car apart and then decide that this thingy here just isn't necessary, or you know, it'd run better if I added some do-hickies here? If you're a master mechanic you sure can, but again, we don't need to master the mechanics of the car to drive it--you don't need to know enough to fiddle with a formula to use it effectively!

The last problem most people run into with herbs is dosing. Well, Kanpo has the answer to that too--and again, it's simple: Don't mess with a good thing. When the government was assessing herbal medicine as part of the national health system they looked at this. Currently there are about 150 herbal formulas that are covered by the national health system (just like antibiotics or antidepressants). You'll find that traditional dosages are quite low according to modern TCM standards. That is because all Kanpo formulas were evaluated in light of historical scholarship and the dosages were fixed, by the government, to these "new" standards.

When you aren't modify herbs, not changing dosage and using mostly ancient formulas (typically 4-8 herbs) you get a very clear picture of what effects are occurring. With so few variables to keep track of, you can actually learn by _doing_. You see a patient, come up with a confirmation(s), choose the formula(s) that go with the confirmation(s) and simply pull the granule form of that formula(s) off your shelf and hand it to them to take as directed. See what happens. Chances are, you'll start to get a good sense of what such and such a formula is good for, and what might happen regarding side effects, over time you'll develop a sense of _who_ such and such a formula is good for. This is the basic path forward that I see for herbal medicine in this model. Personally, this seems much more "traditional" than the TCM approach, which strikes me as pharmacology with herbs rather than herbal medicine. Herbal medicine has a strong folk tradition and doing things as simply as possible is about as folksy as it gets. Of course, there is way more to Kanpo than this! I mean, you have to come up with the confirmation and that's a big thing, but I have other things to do than just blog--I feel a book coming on!

--Matthew