Tag Archive | "traditional chinese medicine"

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#RealTalk: Cultural Facts & Perspectives that will make you a better doctor-

Posted on 21 August 2016 by Tammy Wong (Meds 2018)

The #RealTalk series allows our fellow students to share their ideas about how healthcare intertwines with their cultural and/or religious background. Check out this interview with 2nd year medical student Tammy Wong:

What is your background?

I was born and raised in Canada by Chinese immigrants from Hong Kong. My parents are Buddhist and raised me with traditional Chinese values.

What aspects of your culture differ from the stereotypical norms?

Family values: Chinese families focus largely on respecting and caring for elders and often decisions are made as a family, especially in relation to healthcare plans for patients. Furthermore, it may be hard to elicit patient wishes from the family’s wishes if they differ, but if physicians were perceived to ‘go behind/around’ the family then it would cause distrust in the system.

Food: One tradition when family members are in hospital or are ill, is that families will bring lots of cultural food to the patient so physicians should keep this in mind if there are diet restrictions for inpatients (i.e. NPO, low salt, etc).

Perspective on death and dying: Many Chinese immigrants, especially elders, are very superstitious. There is an idea that you will jinx something by saying it aloud so often patients avoid talking about death or risks with procedures. As a physician, you need to talk about these so you have to elicit it somehow from the patient. There is also a feeling of duty from remaining family members that they need to do everything that they can to ensure the patient’s survival, so a discussion about palliative care may be harder to approach but is necessary, especially if it coincides with patient wishes.

Perspective on mental health: There is usually a stigma regarding mental health among Chinese families. Many Chinese people do not really believe in the concept and think that you should just ‘get over it’. They also worry about being labelled with a mental health condition and often refuse to address it. This is something that physicians should be aware about and should try to educate to reduce the stigma.

Language barriers: Like with many other cultures, there may be a language barrier when speaking with Chinese patients. Furthermore, in Chinese culture it is common to nod or make sounds of agreement as a symbol to show that the listener is paying attention and as a form of respect. However, in contrast with Western culture, ‘nodding’ doesn’t always mean understanding and agreement; it is just to show respect and listening. Ask if they need clarification and summarize to check if patients actually are understanding.

Paternalistic view of medicine: Particularly with the elderly Chinese patients, they may be used to doctors telling them what to do and not really asking questions about their wishes or opinions because this was the format they were brought up with. Patients are also taught that doctors deserve respect and should know what is best for you. It is important to ask for patients’ wishes and values and to explain risks to help them make informed decisions, rather than just having them follow what you recommend.

Tell us a bit about Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) is still largely used by the Chinese community under the view that it can treat the body holistically and strengthen the body. Often patients will use TCM while also being treated with Western medications. In some cases, private insurance companies may require prescriptions for acupuncture, etc in order for the treatments to be covered. Without the prescription, the treatment can be very expensive and patients may need to go to ‘sketchier’ or unlicensed providers to save money which is more dangerous. Consider prescribing these treatments even if you don’t really believe in it to help out a patient pay for this, especially for a chronic disease that may not be curable with Western Medicine.

When performing a physical exam, what should be done that differs from what we are taught at school?

While there isn’t anything specific to ask about, many Chinese citizens are very modest so proper draping is very important, especially with elders. Ask if the patient would like anyone else in the room (i.e. spouse or family members) and explain what you are doing very clearly.

If you could give one piece of advice to us future doctors on providing care for your population, what would it be?

Always ask for clarification/understanding and take a bit of time to ask if there are any other issues when speaking with Chinese patients. They may not discuss their true fears or opinions until later on in the interview, especially if it is something embarrassing, sensitive or worrying to discuss. Mental health issues also fall into this category because it is often brushed under the rug. Be sure to ask and also suggest lots of supportive resources for these patients.

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Reflections on Chinese Healthcare

Posted on 15 March 2012 by Kenneth Lam

When my friends ask me how medical school is, I explain to them that the human body has been written about with zeal for millennia and that I’m spending a paltry four years catching up on as many stories about the body as I can. In every scientific paper and report and publication I read, I ask myself: what did this researcher observe? How did she come to terms with what she observed? What story is she trying to tell me, and how is she wrapping her head around what she saw?

Sometimes the stories affirm one another, and other times the stories conflict. Here’s an example: in the past, Western medicine used to say that peptic ulcers were caused by stress and excessive acid production. But when Barry Marshall and Robin Warren entered the scene in 1982, they told a different story: peptic ulcers are largely caused by an organism known as Helicobacter pylori. I absolutely believe it to be true, but I also understand that the story they tell is about a small creature that few will ever have the privilege of seeing first hand and that doctors recommend their infected patients to vanquish this little beast by consuming small yellow pills.

The point here is that I take information on faith by the authority of those teaching me, which is the same way my teachers learned from their teachers and how they continue to learn from their colleagues. And so I need to make a disclaimer before I begin this article: I know precious little about medicine of the Western variety and even less of the traditional Chinese variety– only what I have been told and what I have seen.

I spent the past summer in China with four friends on a very non-systematic tour of hospitals and other care facilities in five different cities. On three or four occasions, we saw traditional Chinese medicine (TCM) being practiced. Sometimes, it was in TCM hospitals: six story complexes divided into departments with teaching faculty and nurses and the same aura of legitimacy of any hospital, but devoted to a system of medicine that I had been told lacked evidence. Other times, we visited the TCM department nestled within a larger public hospital or community care centre. These departments seemed just as busy as the outpatient departments providing Western medicine.

The presence of these well-funded and well-visited complexes was evidence with which I grappled. The first thing I conceded was that traditional Chinese medicine was doing something. At the very least, it did enough to get people to change their behavior and spend money. Some patients traveled hours by train to see a doctor. Others were following through on doctor’s recommendations to live closer to the hospital so that the doctor could provide more regular care and update their herbal regiment more closely. And every TCM patient we asked gave us a testimony of how it really worked for them: their asthma was better, their cheeks were less flushed, their hematuria lab results came back negative, their diarrhea was relieved. We had a case where a patient reported having Duchenne’s muscular dystrophy (an irreversible genetic condition) improved with TCM.

Confused, I wanted to learn more about the principles behind TCM, and the opportunity came in our last week. We were shadowing Dr. Sun in his clinic at the Shanghai Children’s Medical Centre and his students brought in some bilingual textbooks on Chinese medicine. They were a series of four books published by the Nanjing University of Traditional Chinese Medicine and translated in Shanghai and they covered the basic theory, diagnostics, science of prescription, and science of curative properties. So in between patients, we each read a little.

Two theories govern Traditional Chinese Medicine, but before I get into them, I need to expose the underlying premises in Western medicine. Western medicine is generally built on a theory of reductionism and causality: we break the body up into systems and then the systems down into organs, tissues, and cells, and we then find out what everything causes in order to predict how we can change things. I’ll give you an example: if someone comes in looking jaundiced (yellowish in colour), our explanation is based on how abnormal function of the smaller parts of the body add up to this overall appearance. Jaundice is caused by the excess build up of bilirubin in the skin, and bilirubin is cleared by the liver and produced when red blood cells are broken down, and so the problem must be with the liver or with the break down of red blood cells. It’s a remarkably systematic and rigorous approach to the body.

By contrast, the theories in Chinese medicine are primarily theories of dynamic equilibrium– that the whole body is in a state of balance that’s established by conflicting forces. That balance is thrown off if one side becomes deficient or too strong. One theory asserts that the balance is always between two forces; the second theory asserts that the balance is a complicated web between five forces. Note that these ways of thinking aren’t foreign to one another. The Western notion of water balance (homeostasis) in the body has the same philosophical underpinning– you’re not drinking enough or you’re sweating too much. Similarly, Chinese medicine does break the body down into different functional systems. But in Chinese medicine, the concept of balance comes first, and the concepts of reductionism and causality occur WITHIN the framework of these forces that need to be balanced.

And so the balance between two forces is known as the Yin-Yang theory, while the balance between five forces is known as the Five Elements theory. All disease always goes back to Yin-Yang or the Five Elements. These are abstract concepts: yin-ness is exemplified by the moon, the shade, the internal, the cold, downward directions, etc. while yang-ness is exemplified by the sun, heat, the external, upwards-ness, etc. So, if you’re too hot and feverish, it goes back to either too much yang or too little yin. And the treatment (whether herbal or pharmaceutical) is, by definition, a yin-strengthener or a yang-inhibitor. The Five Elements are also abstract concepts: fire, water, metal, wood, and earth, and they have a relationship of either strengthening or restraining another element. This is where things got strange for me.

TCM believes that the Five Elements get mapped to five systems in the body based on traditional abstraction. The Fire element is mapped to the Heart– but not just the anatomical heart. The Heart includes the blood, the vessels, and the tongue. So perhaps it is better to say that the Fire inside the body is manifested in the blood, the vessels and the tongue. Metal in the body is mapped to the Lungs: but the Lungs also include the hair, the skin, the nose, and sweat. So far so good– maybe TCM simply regroups organ systems along different categories. But I balked when the book made an assertion about the relationships between these categories. Why should Fire necessarily restrain Metal? Sure, I could interpret the sweating from a heart attack as Metal becoming overactive once Fire failed to restrain it, but it didn’t seem like a particularly rigorous or well-founded association.

I tried to put my skepticism aside as I watched Dr. Sun apply these theories to his practice. Like a primary care physician during a routine checkup, he’d ask questions about how the patient was doing and whether there have been any changes recently. But I wondered about the credibility of his diagnoses when I saw that his physical exam consisted chiefly of inspecting a patient’s tongue. The reasoning goes as follows: childhood illnesses tend to be problems of too much yang, the Heart is a yang organ, and the tongue is a window into the Heart. From there, he’d make a conclusion (many of which were lost in translation and understanding), and then he’d tailor a herbal recipe based on each herb’s yin or yang property and its elemental attribute. After that, the next patient.

So over this backdrop of a very unfamiliar medical system and cultural and language barriers, I watched as patients poured into Dr. Sun’s office and sometimes paid a little extra to get a bit more time and attention from him. I mean, what was he doing for them? Was he improving their health? Or if not their health, was he improving their wellness? Was he offering the reassurance of his white coat? And if so, was the reassurance powerful enough to make them well? I grappled with the possibility that he was a charlatan and a quack, selling them the promise of better health but being unable to deliver it.

Calling Dr. Sun a quack is a heavy criticism on both the integrity of his character and his beliefs, and there are a few things that keep me from laying down such a pronouncement on him and by extension, TCM practitioners in general:

Firstly, as squeamish as I am about the theories behind TCM, it could be a working medicine of inaccurate theory but accurate associations. There is some evidence where traditional remedies outperform placebo: Chinese herbal medicine works for irritable bowel syndrome (Bensoussan 1998), and acupuncture is indicated for chronic pain (Manheimer 2005). In this situation, it may be that certain treatments were documented to have a positive effect on certain conditions and out of a desire to create a unified system of thinking, TCM used opposing elemental categories to record which treatment was effective against which condition. And when I reflect on the history of Western medicine, I concede that oftentimes, we are also a medicine based on association rather than bulletproof theory, but still we practice.

Secondly, I found that the TCM students were just as motivated by altruism as I was, and putting myself in their shoes, I couldn’t accuse them of any insincerity or quackery. They gave the same response that I would give if I were asked why I wanted to study medicine– they want to help people. And it’s hard for me to fault them for what they believe: the same way I usually don’t question whether clarithromycin works against H. pylori so long as my professor tells me it works, I imagine they don’t question the usefulness of a herbal remedy when Dr. Sun tells them it works. My convictions regarding the efficacy of Western medicine are founded on the trust I have for my teachers. If Western medicine is superior to TCM, then isn’t the validity of my belief only the result of my privilege to be told true stories about what makes people healthy and sick?

Thirdly, TCM is neither a small nor static field of study. Dr. Sun’s students will be learning TCM for the next four years. Just as they respectfully acknowledged that their field is complementary to the massive body of knowledge that is Western medicine, I have to admit that there is so much about TCM that I don’t know and never will. The total index of herbs is in the thousands (though less than a hundred are used regularly). They pick up new techniques from other naturopathic schools. And they are starting to use Western diagnostics to quantify their practice.

So, as China continues to grow economically, it will be interesting to see how their medical system negotiates between TCM and Western medicine. If patients substantially switch over to Western medicine as the medicine of preference, perhaps it suggests that traditional medicines were a compassionate cushion for those who couldn’t afford better care. But at present, I’m more inclined to withhold passing judgment on TCM. I think it is easy to pick on alternative medicines from within a North American medical fortress, to come to a rash conclusion, and to develop a hostile us versus them mentality and in doing so, create conflicts where there are none.

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