The Sequence of TCM Treatment: Differentiating Pattern, Disease, and Constitution, Then Choosing Method and Herbs

How exactly should TCM improve its clinical efficacy? I believe this is a question every clinically practicing TCM physician is earnestly seeking to answer. Patients, patient families, and even TCM colleagues are always consulting me on such questions. I myself am only a half-filled bucket and dare not act the teacher, so I can only share some views based on my own years of clinical experience following my masters.

Pattern differentiation and treatment determination (bian zheng lun zhi) is the basic principle of TCM treatment. It has quite a few features of modern evidence-based medicine. But because TCM pattern differentiation is vague, without very detailed, replicable efficacy data to refer to, clinical effect often depends on the individual physician's medical literacy and clinical experience. From my years of quietly observing domestic TCM colleagues' treatments through their patients, many TCM physicians are quite good when expounding theory, but their clinical results are mediocre. There are two possible reasons: one is that the physician's own level of applying what he has learned is low; the other is that TCM basic theory itself still has much open to question.

So the method of pattern differentiation is hard to master, and its theoretical system still has areas to be perfected. It is necessary for us, under new historical conditions, to re-standardize the reference system of pattern differentiation and treatment.

Now we have entered an era in which Chinese and Western medicine coexist. Modern technology's advantages in clinical diagnosis far exceed those of traditional TCM. So modern TCM, in disease differentiation and treatment, has great advantages over traditional TCM. For some major diseases—various malignant tumors and the like—we may in the past have been unable to find the cause; now, with modern technology, we can find the patient's cause, which helps guide our clinical medication. Moreover, traditional TCM also has a tradition of disease differentiation and treatment. There are also many research results in modern TCM pharmacology, which further clarify the mechanisms by which Chinese medicine treats disease. Some people who value TCM traditional theory and disparage modern research may dismiss all this; I personally think that is irrational.

Ancient TCM also had a tradition of disease differentiation and treatment, but the "disease" in ancient TCM disease differentiation differs from the concept I mentioned above of using modern technological means to diagnose disease and then treat it. From the perspective of modern medicine, the "disease" in ancient TCM disease differentiation is often still only a symptom rather than a disease. Take "jaundice" (huang dan): in ancient times it was considered a disease, but in modern medicine it is a symptom, and the causes producing jaundice may be multiple. When we study TCM and treat diseases like jaundice according to TCM disease differentiation, we must use TCM thinking to work out the prescription logic.

Constitution differentiation and treatment (bian zhi lun zhi) is a formulation of some scholars and is also of great clinical significance. "Constitution" refers to the patient's physical constitution—the innate constitutional characteristics—and is one of the bases for our clinical medication. To achieve constitution differentiation, the physician must patiently communicate with the patient, understanding the past medical history and physical constitutional features. A general visual glance and a few brief sentences are hardly enough to grasp the patient's constitution. In my own diagnosis and treatment, physical examination and inquiry are extremely detailed; I often need to communicate with a patient for more than an hour, and I continue to follow up on the patient's situation, because trying to understand a patient's constitutional features in a short time is quite difficult.

The benefit of constitution differentiation is that one will not make major clinical errors. If a physician can be patient and meticulous, clinical efficacy is relatively more assured. One point to note in constitution differentiation: a patient's constitution often has familial and hereditary features, so understanding the patient's family medical history is also of great reference value.

These three methods of treatment determination are not isolated. In clinical practice we need to weigh them repeatedly, choose the relatively more reliable standard of treatment determination, and then prescribe. No physician is a divine healer who is effective 100 percent of the time, but if one can think more rigorously and examine patients more carefully, the average clinical effective rate will still rise considerably.

Improving the level of treatment determination depends on improving basic medical literacy, so in ordinary times one must read more books, think more, and practice more clinically. In the process of reading, thinking, and treating, one gradually raises one's own judgment.

After treatment determination comes choosing the therapeutic method. Broadly speaking, one must choose whether to use acupuncture, moxibustion, cupping and other auxiliary therapies, or to treat with herbs. Generally, once the corresponding method is chosen, one adopts the corresponding clinical management plan.

If herbs are used to treat disease, the question of herb selection arises. Herb selection is extremely important. The physician's two afflictions are, first, not knowing the disease, and second, not knowing the herbs. Herb selection requires us to repeatedly read the various books of Chinese materia medica; in recent years I myself have paid special attention to the clinical experience of folk herbal medicine.

From practice I have seen some patients who, treated with single folk herbal remedies, achieved results far better than those of famous professors at major hospitals. Some of my own family's inherited folk herbal experience is also nearly 100 percent effective. Professor Tu Youyou's invention of artemisinin was in fact inspired by the medication experience of folk herbal medicine.

So when we study TCM, we must not, after learning some TCM theory, look down on this field-and-plot medication experience. In coming years I may repeatedly travel between the library and the fields, taking actual efficacy as my first principle, and delve into TCM methods for treating cancer, hepatitis B, asthma, and other diseases. I also hope that colleagues who wish to inherit and carry forward TCM will, in a spirit of seeking truth, return to the mountains, forests, fields, and marshes, and seek breakthrough discoveries at the true source of TCM, rather than sitting in an air-conditioned room treating patients from books.

Much of TCM theory has sunk into abstract speculation; when used to guide clinical practice, results are not ideal and the effective rate is barely passable. Pursuing 100 percent efficacy is an impossible goal, but is not every physician's lifelong wish to draw as close as possible to that goal? I personally believe that a truth-seeking scholarly attitude and an indefatigable spirit of inquiry are the key to improving our clinical efficacy. Scholarship and medical practice should be grounded in reality and free of empty talk.