My Journey of Thinking: From Experience-Based Medicine to Evidence-Based Medicine

My study of Chinese medicine has roughly gone through three stages.

In the earliest stage, I read works such as Huangdi Neijing and Yijing, feeling that these books were very reasonable, with a sense that "all the principles of medicine in the world are exhausted here!" I thought Chinese medicine was beautiful, and I even wrote some pieces interpreting Huangdi Neijing and Yijing. Later I felt such writing was not rigorous and would invite ridicule; even I myself felt ashamed reading it, so I deleted all those writings.

After I began treating patients myself, I gradually came to prefer practical clinical works such as Shanghan Lun, Jingui Yaolue, Wenbing Tiaobian, Waitai Miyao, and Qianjin Fang, because to truly solve patients' problems one must rely on the concrete treatment methods mentioned in these books.

After treating more patients, I found these two types of books still not practical enough; the most practical are medical case records. The ancients said: "Reading Wang Shuhe thoroughly is not as good as having much clinical practice." Medical case records are other doctors' clinical experience; reading them can make up for one's own lack of clinical experience. Most case records do not treat patients mechanically according to the classics. Some clinically experienced Chinese medicine practitioners have unique experience in treating a certain disease or category; the formulas they use for similar diseases are much the same, and when I put them to use, they also had considerable efficacy.

For example, the case records of the late Dr. Sun Bingyan treating cancer, Dr. Zhu Yongxian treating skin diseases, and Wang Weide treating carbuncles and abscesses. When they treated a certain category of disease, their prescriptions were basically unchanged, with good reproducibility of efficacy—rather like precision medicine. In fact, these doctors' case records are very much in line with the ideas of modern evidence-based medicine. If these doctors had been trained in evidence-based medicine and clinical epidemiology, they could entirely have designed scientific controlled clinical trials, accumulated convincing data, and reduced medical uncertainty.

Many Chinese medicine practitioners get headaches and take offense as soon as they hear the modern medical concept of evidence-based medicine, emphasizing the differences between Chinese medicine and modern medicine. In fact, evidence-based medicine is merely a way of thinking and a philosophy for improving clinical efficacy. Its soul is: "problem-based research, evidence-following decision-making, attention to practical outcomes, post-hoc evaluation, and striving for perfection." It is usable not only in modern medicine but equally in Chinese medicine. If one is only a Chinese-medicine enthusiast, one need not care too much about evaluating clinical efficacy; but a clinical Chinese medicine practitioner cannot afford not to care.

Those who merely love Chinese medicine, grandstand about its theory without treating patients, mostly remain at the beginner stage of learning it. At this beginner stage, some ideas in Huangdi Neijing and Yijing are useful—not in clinical efficacy, but in disease prevention. So we may also call them fairly good ancient preventive-medicine readings.

But Chinese literati from ancient times to the present have a common failing: they love grand talk and belittle empirical evidence. The writings of ancient literati are permeated with this ethos. For example, our ancestors often spoke of "inner sagehood and outer kingship," believing that when personal cultivation reaches the highest realm, one is a true king, and ruling with kingly ways will surely bring enduring prosperity. Flip through Chinese history and one sees how absurd such wishful ideals are. Those who reached the realm of "inner sagehood" never actually became kings; rather, they were used by later "kings" as tools to rule and delude the people—Confucius is the most typical example. As for rulers who reached "inner sagehood," there have been none from antiquity to today; they ruled through force—Zhu Yuanzhang and Liu Bang could scarcely even be called more than ruffians.

This ethos of "loving grand talk and belittling empirical evidence" also influenced Chinese medicine. Reasoning by deduction from Huangdi Neijing and Yijing, there is almost no disease under heaven that cannot be cured by medicine. So many enthusiasts of Chinese medicine have long held the illusion that once a Chinese medicine master has mastered heaven and man, he becomes so supernatural that he can cure any disease. I often meet such enthusiasts; they do not regard the difficulty of treating disease as an objective fact, but believe that Chinese medicine has declined, that today's Chinese medicine practitioners are too poor to reach the supernatural level, and that if one reached it, so many would not die.

Many of these people are patients or their families, and I can understand their feelings. But I must also point out that this thinking is very ignorant. Just flip through history and it is not hard to see that the miracle doctors they revere actually did not reach the realm they imagine. The medicine-king Sun Simiao was deified by the people, but in his own writings he frankly admitted that many patients died in his hands; for certain specific diseases, the fatality rate was as high as seventy or eighty percent ("seven or eight out of ten died in my hands").

Others think a good Chinese medicine practitioner is equivalent to a general hospital; this idea is also unrealistic. In modern medicine, general practitioners generally can only treat common minor ailments while triaging patients with difficult, complicated, or severe conditions. This is because there are simply too many diseases for one doctor to master fully; once you become a general practitioner it is hard to do deep research on specialized diseases—time and energy do not allow. In today's increasingly refined division of labor, a doctor who claims to cure all diseases is undoubtedly highly irresponsible to patients. My own mother was delayed by such a "generalist miracle doctor"; had it not been for him, her gastric cancer could have been discovered earlier and the cure success rate would have been much higher.

When I began studying Chinese medicine, I also thought I would treat every kind of disease in the future. But after engaging in clinical practice, I realized that my energy and time are limited, and I should focus on choosing one field to research deeply.

I do not want to prattle about how "gifted" people can grasp everything and reach the level of treating all diseases. Back in high school, I ranked first in the school in every subject, could score full marks in math, physics, and chemistry, and my writing was also the best in the school; my total score was several tens of points above the second in the school, and on my best occasion over a hundred points above. I say this not to boast, but to say that if someone like me lacks so-called "giftedness," then few people in China can be said to have it. If Chinese medicine requires such demanding conditions to master well, then it is impractical and not worth promoting.

To be factual, I do not have that miraculous giftedness and cannot reach the level of treating all diseases; even within one specialized disease, my efficacy is quite limited. Over these years I have studied extremely hard, yet can only improve my skill little by little, far from the state of curing disease with a single touch. In earlier years I searched everywhere for extraordinary masters, but most of those I met were swindlers and charlatans. Many who brag about their mystical "giftedness" can barely read classical Chinese.

Most rigorous Chinese medicine practitioners are quite honest. I have met many good teachers who have constantly pointed out my shortcomings; some, wanting me to grow better, often criticize me until I am torn to pieces. With each such criticism, I can clearly feel that I have taken another big step forward.

Now I deeply realize that studying medicine and treating disease is very hard work. A doctor must be sincere toward patients and society, and must be rigorous and factual at work. If not, we will mislead patients and delay their illness—a grave fault. The frequent doctor-patient disputes are also related to this. To go far and steady, a Chinese medicine practitioner must not take the road of "loving grand talk and belittling empirical evidence."

Medicine has kept advancing to this day. The reason humanity chose evidence-based medicine as today's mainstream medical thought is that it pools the experience and wisdom of many. For Chinese medicine to transition from experience-based to evidence-based will require a great deal of foundational work, but doing this work benefits—without any downside—Chinese medicine itself, the community of Chinese medicine practitioners, and the public at large.

Many people mock Chinese medicine, saying it lacks controlled clinical studies, is unscientific, and relies entirely on guessing. I do not quite agree. What I most like to read now are the case records of specialists—especially those with complete medical records that can be followed up to real patients, rather than cases fabricated by some doctors to attract business. I see many specialists who have devoted a lifetime of effort to one or a limited number of disease categories, refining their treatment protocols and producing valuable results. From an evidence-based medicine perspective, their clinical work can be used as high-credibility evidence.

Of course, saying this is not to deny those general-practice Chinese medicine practitioners. They do have important significance in diagnosing and treating common diseases. Western medicine also has general practitioners and specialists; this is a difference in the division of labor in the medical system. General practitioners and specialists are complementary, and both are important in the system. Moreover, a specialist must first receive a comprehensive medical education before conducting research in a specialty; otherwise it is easy to see the leopard through a tube, with a narrow field of vision.

But we must also see that so-called general practitioners are actually skilled only in a limited number of common diseases, most of which already have mature treatment protocols. Infinitely exaggerating the role of Chinese medicine or a particular doctor's comprehensive ability does not accord with facts. Most people who study medicine must eventually move toward specialization and refinement. The further one goes in specialization and refinement, the more one appreciates the benefits of evidence-based medicine. After all, more precise treatment is both what patients need and what doctors hope for.