The Three Distinctions of TCM Treatment: Treating the Person, Treating the Pattern, Treating the Disease

This is some of what I tell my students in class; I now set it down as an essay for everyone's correction.

First, the doctor treats the patient, not the disease. So the first checkpoint in treating illness is treating the person (bian ren lun zhi).

For the same disease, different patients may receive entirely different prescriptions and entirely different advice. If one uses a single formula for a thousand people, one cannot achieve good results.

Chinese patients have always tended to value the medicine over the doctor, so in clinic the question we hear most often is: Doctor, what medicine should I take for this condition?

Many patients and families are unwilling to see a doctor at all; they just want to ask by phone or online: I feel such-and-such discomfort today—what should I take? Someone in my family has such-and-such disease—what should they take? Or simply: Doctor, do you think such-and-such medicine can solve my problem?

I encounter countless such enquirers every day. If you do not reply, they grow anxious; some directly accuse you of poor medical ethics. The term "medical ethics" has been abused beyond imagination.

The state legislates that doctors must not prescribe without seeing the patient, precisely for the patient's safety.

Nowadays some patients register but never appear; family members bring their test reports straight to the doctor, or simply ask by communication tool and demand a prescription. This puts the doctor in a difficult position.

If you cannot even see the patient, how can you treat the person?

The same cold, in different people, presents differently; the robust and the frail cannot be given the same herbs. Even an in-person consultation may not get the medicine right, let alone prescribing blindly without seeing the patient—you could easily do the patient serious harm.

So the first checkpoint for a doctor is: one must see the patient before treating and prescribing. Without seeing the patient, do not lightly offer medication advice, lest you harm their life and health.

Many medical textbooks say that medicine is not purely a technical matter; it is also closely tied to the patient's education, social background, personal beliefs and even personality. When treating, the doctor should first form an intuitive impression and have a basic grasp of the patient's occupation, habits and character.

For example, the same disease, in people of different occupations, requires different treatment plans.

Take cancer: a busy person who, after falling ill, does not rest but keeps rushing about, easily relapses while being treated. Then, while treating, we must urge the patient to rest more and keep regular hours.

Many patients have heavy social engagements and often stay up late; unless we urge good habits, even if controlled in the short term it will soon relapse. For such patients it may even be necessary to prescribe sedating, sleep-promoting herbs, because business pressure leaves them anxious and sleep-deprived.

But for retired or resigned patients who have cancer, with ample time to recuperate, we should instead urge them to take part in social activities, even to find some meaningful work, and not just idle at home "convalescing."

Why? Because, in my experience, once such a patient idles at home fixating on his illness, he lives in daily worry and pressure, which easily triggers relapse.

Again, whether a patient lives in a hot or a cold climate matters; the external climate differs and affects the body differently, and TCM prescribing must take this into account. Likewise, patients long resident in humid regions differ from those in dry regions.

Male and female patients need different medication; the optimistic and the pessimistic differ; the elderly and the young differ; the constitutionally robust and the chronically frail differ.

So without seeing the patient, without direct contact, without the four examinations (inspection, auscultation-olfaction, inquiry, palpation), one must not prescribe.

Ideally, the doctor should know the patient's basic situation thoroughly before treating. Abroad, almost every member of society has a family doctor who knows the patient well.

Treating the person has another meaning, which I repeatedly stress to my students: the doctor should use his own life experience to judge the patient's character and the risk involved in a given medical act.

Some patients or families may bring enormous professional risk to the doctor; such patients require special caution during treatment.

I once worked under an old physician. On my first day he told me: in treating disease, safety comes first—first the patient's safety, second the doctor's own safety.

Our domestic climate overemphasizes medical ethics and rarely discusses the skill of handling doctor-patient relations; I think that is a defect.

TCM circles especially emphasize the "Great Physician's Sincerity" spirit of the Medicine King Sun Simiao; his chapters "Great Physician's Sincerity" and "Great Physician's Learning" are traditionally taught as the first lesson.

I personally do not do this. What I repeatedly tell my students is: ensure both the patient's safety and your own; do not just talk blindly of compassion and benevolence, but recognize the enormous risks of our profession.

Frankly, I do not want myself or my students, because of the inherent risks of medicine, to fall into doctor-patient disputes.

A doctor must learn to control risk; a doctor who cannot control risk is not a good doctor. The cost of training a doctor is high, and an innocent sacrifice is a great loss to society.

Now let me discuss pattern differentiation and treatment (bian zheng lun zhi).

Anyone who has studied TCM knows that pattern differentiation and disease differentiation are the two great conceptual systems of TCM treatment.

Pattern differentiation is the use of TCM theory to analyze disease data and establish a zheng (pattern), work out therapeutic principles and methods, and put them into practice—a process of thought and action.

TCM pattern differentiation is complex and much debated. But it is precisely TCM pattern differentiation that is closest to the idea of modern evidence-based medicine. I have often stressed: do not neglect TCM theory, but do not over-believe it either. TCM theory is, like any medical theory, only a medical hypothesis with a certain plausibility.

TCM pattern differentiation is highly practical, but to claim it can solve every disease is nonsense.

In broad terms, TCM has six-channel pattern differentiation, eight-principle pattern differentiation, zang-fu pattern differentiation, defense-qi-nutrient-blood (wei-qi-ying-xue) pattern differentiation, and triple-burner (sanjiao) pattern differentiation.

Before discussing disease differentiation, I should introduce a basic feature of TCM reasoning: the "analogous correspondence" (qu lei bi xiang) idea emphasized in TCM books. Strictly speaking, all TCM pattern-differentiation approaches are applications of this idea.

TCM lacks the complete anatomical knowledge of Western medicine; this is its weakness and a frequent target of attack. The ancients knew the interior of the body through "observing the exterior to know the interior."

"Observing the exterior to know the interior" means inferring internal changes from external signs. Its extension is inferring changes in the human body from changes in nature.

This way of knowing has some scientific basis, but it is prone to subjective guesswork.

The Jin-Yuan physician Wang Haogu said: "If the zang-fu organs could speak, the doctors would turn pale." He meant that if organs could talk, the doctors who speak so glibly would be disgraced, because the organs might tell them their judgments were pure nonsense.

So we TCM learners should master pattern differentiation, because it has some scientific basis and can guide us to solve some clinical problems. But we must also stay clear-eyed about its imperfections and not be imprisoned by it. We must always be able to step outside TCM pattern differentiation and solve the patient's problems in a seek-truth-from-facts way.

Now I will outline the content of the various pattern-differentiation systems.

Six-channel differentiation comes from Zhang Zhongjing's Shanghan Lun, honored as the Medical Sage's work. In it, Zhang divided common diseases into six-channel diseases: taiyang, shaoyang, yangming, taiyin, shaoyin, jueyin.

Taiyang qi governs the exterior of the whole body; according to the TCM theory that "the back is yang and the abdomen is yin," the taiyang channel runs along the back. Taiyang disease presents mainly as exterior syndromes: stiff head and neck with aversion to cold.

Yangming governs the interior; its pathology mainly involves the stomach and large intestine, so yangming disease is mainly disease of these two.

The shaoyang channel runs along the sides of the body; later physicians considered shaoyang half-exterior, half-interior, between taiyang and yangming, internally related to the gallbladder and triple burner, hence the simile "shaoyang is the pivot." Shaoyang disease presents mainly as dysfunction of the pivot.

The three yin diseases (shaoyin, taiyin, jueyin) all belong to the interior: taiyin disease is mostly spleen deficiency with cold-dampness; shaoyin disease is mostly heart-kidney yang deficiency with exuberant cold, or kidney yin deficiency with floating heart yang; jueyin disease is mostly wood overacting on earth, attacking the stomach and overacting on the spleen.

This is only a simple division. The body is a complex, interconnected whole: taiyang disease may trigger yangming, yangming may trigger shaoyang; in Shanghan Lun this is called "channel transmission."

Transmission from exterior to interior means worsening; transmission from interior to exterior means the body's resistance has fought the disease and the condition is easing, with possibility of spontaneous recovery.

Incidentally, many patients wonder why TCM insists on treating a cold first and not taking medicines for other diseases during it. By the channel-transmission theory, taking other medicines during a cold can draw the exterior pathogen into the interior, causing unpredictable new problems.

Zhang Zhongjing's greatness lay in systematizing various symptoms into six categories and giving solutions for each.

To this day the prescriptions in Shanghan Lun and Jingui Yaolue remain of great clinical value. I hope, when time permits, to write articles on my years of experience applying six-channel differentiation, for other TCM learners.

But what the six channels actually are has been disputed by physicians of every dynasty. Shanghan Lun holds a place in TCM like the Analects in ancient Chinese philosophy; every dynasty produced armies of annotators, whose commentaries sometimes nearly contradict one another.

Personally, I lean toward the view that six-channel differentiation is inherently somewhat vague, though strongly practical. It can treat many diseases, but it cannot, as some classical-formula school physicians claim, solve every disease.

Li Dongyuan, one of the four great Jin-Yuan masters, in his prime encountered a great post-war plague. The classical-formula school was helpless; over two thousand coffins were carried out the gates of the capital every day, showing how fierce the epidemic was. The capital's famous physicians debated how to handle the plague using six-channel differentiation but found no strategy; this deeply affected Li.

Some TCM fans believe this was because those doctors lacked the comprehension to grasp TCM's essence. Some fancy that, had they themselves faced the plague, they would have cured it handily. I think that is nonsense.

I also deeply dislike our Chinese habit of invoking "comprehension" as a catch-all, blaming our traditional philosophy and medicine's shortcomings on the learner's insufficient comprehension.

An applied science like medicine should be clear, definite and operable to be truly refined. If one keeps insisting that "medicine is intention," it cannot develop vigorously.

Eight-principle differentiation analyzes the patient's disease by the eight principles: yin, yang, exterior, interior, deficiency, excess, cold, heat, and prescribes accordingly.

The modern physician Shi Jinmo added qi and blood, making ten principles. Some hold it should be two principles and six items: yin and yang are the principles, while exterior, interior, deficiency, excess, cold and heat are the items; these views all have some merit.

Modern people may find the eight principles unfamiliar, but they are the foundation of TCM. They do have plausibility; guided by them, one can indeed solve some patients' problems.

Yin and yang classify the nature of disease. TCM holds that all illness arises from excess or deficiency of yin and yang; the doctor's task, and the patient's taking herbs, is fundamentally to correct this imbalance.

The Huangdi Neijing stresses that treating disease must seek its root. What is the root? TCM says it is yin and yang. Yin and yang here are hard to sum up in one sentence; the learner should read the "Ying Yang Ying Xiang Da Lun" and "Yin Yang Bie Lun" chapters of the Neijing.

In short, yin and yang are a speculative tool of ancient Chinese philosophy for classifying things, a way our ancestors understood nature and themselves.

The ancients observed that everything has an opposite: nature has day and night, sun and moon; people are male and female; directions are south and north; the sun rises and sets. They used the pair yin-yang to split opposites in two and thereby understand the world.

In TCM, excess of yang qi and strong resistance producing heat/excess signs are yang syndromes; yang-syndrome patients have loud voices and an excess of signs. Weak resistance producing deficiency/cold signs is yin syndrome; yin-syndrome patients show signs of insufficient yang qi.

Related to yin-yang, the concepts of "excess" and "insufficiency" are also very important in TCM theory.

A normal body is balanced, in a state of "yin calm and yang secured"; an abnormal body is in imbalance; when yin and yang separate, death is near.

Disease is when one or both of yin and yang are in a state of "excess" or "insufficiency." The doctor corrects this: excess is suppressed, insufficiency is tonified.

This basic idea cannot be wrong; even modern medicine relies on it. For anemia, modern medicine gives transfusions, supplements blood, or boosts hematopoiesis.

Eight-principle differentiation, overall, adjusts these two abnormal states of excess and insufficiency.

Now exterior and interior in the eight principles.

Exterior and interior refer to the depth of disease. TCM holds that pathogen in the channels and on the body surface is exterior syndrome; pathogen involving the zang-fu organs is interior syndrome. By the depth of the lesion, TCM decides whether to release the exterior or drain the interior.

Taiyang exterior syndrome requires sweating to release the exterior; yangming interior syndrome requires clearing and draining interior heat. Some diseases are hard to distinguish as exterior or interior and must be carefully differentiated; some combine both, and one must decide whether to release the exterior or drain the interior first.

These have rules, summarized by physicians over the centuries. In learning TCM one must master and memorize them to avoid being helpless in clinic.

Cold and heat are the nature of the condition. An exuberant, hyperactive tendency with yang pathogen is mostly heat; a quiet, subdued tendency with excess yin pathogen is mostly cold; complex cases have both.

How does one judge whether the condition is hyperactive or subdued? From the pulses, tongue, signs and subjective sensations—the "observing the exterior to know the interior" method.

Spontaneous diarrhea (loose stools, clear long urine) without thirst indicates cold in the viscera; diarrhea with thirst indicates interior heat. A deep, slow pulse indicates cold; a slippery, rapid pulse indicates heat. A pale tongue with white coating indicates cold; a red tongue with yellow coating indicates heat. These signs gathered through the four examinations all help judge cold and heat.

But TCM also has true cold with false heat: the patient feels great heat yet wants thick clothes and quilts—TCM calls this heat on the skin, cold in the bones. Or the body feels cold yet the patient wants to strip off clothes—cold on the skin, heat in the bones. The former is true interior cold with false exterior heat; the latter is true interior heat with false exterior cold. In such cases one must not be fooled by surface signs; detailed inquiry and deeper judgment are required.

Deficiency and excess refer to the relative strength of upright qi and pathogen. Deficiency is deficiency of the body's upright qi; excess is repleteness of pathogen.

Upright qi builds a strong defense; pathogen is the cause of harm. Ideally the body has enough upright qi so that even with pathogen it does not fall ill; hence the Neijing says: "When upright qi is present internally, pathogen cannot invade."

This gave rise to a key TCM principle: "support upright and expel pathogen." In theory this is fine, but in practice it is not easy, and overemphasizing it leads to empty talk.

Taken together, that is the eight-principle differentiation.

Later physicians added qi and blood differentiation to supplement the eight principles.

This is because TCM holds qi and blood to be the two most vital elements sustaining life. Qi or blood deficiency, or qi stagnation and blood stasis, cause illness; the doctor should restore the normal flow of qi and blood, for when it flows well many diseases resolve on their own.

Zang-fu differentiation is another major TCM system.

TCM divides the body's organs and tissues into zang and fu.

What are TCM zang-fu? There are the five zang and six fu, plus the "extraordinary fu organs."

The five zang are heart, lung, spleen, liver and kidney. The six fu are gallbladder, stomach, small intestine, large intestine, bladder and triple burner. There are three views of the triple burner in TCM history; the one here is the six-fu triple burner. (There is also the regional triple burner, and we will mention the warm-disease school's triple-burner differentiation later.) The six-fu triple burner is generally considered to lie within the abdominal cavity, roughly corresponding to the mesentery, greater and lesser omentum and lymphatic tissues.

The extraordinary fu organs are the brain, marrow, bone, vessels, gallbladder and uterus. The gallbladder is both one of the six fu and one of the extraordinary fu organs.

It must be stressed that although TCM zang-fu share names with many organs in modern science, their actual referents are not identical.

The TCM five zang and six fu are more like high-level summaries of bodily functions. To distinguish them from modern medicine, TCM calls this the "visceral manifestation" (zang xiang) theory.

In general, zang are characterized by "storing without draining," fu by "draining without storing." Zang store the body's essence and should not leak it; if the body's essence leaks out, upright qi becomes deficient.

Fu transport the substances the body needs—food and fluids—and should remain open; "openness is their tonification." If fu lose their transporting function, the body cannot absorb the essence of food or excrete waste, and illness follows.

Zang-fu differentiation infers, from the functional characteristics of each organ, which organ a lesion belongs to, and applies the corresponding principle.

Zang-fu differentiation is also combined with the four seasons and five phases, one of the most criticized parts of TCM differentiation.

TCM holds the four seasons have characters: spring generation, summer growth, autumn harvest, winter storage. Spring's generating nature resembles wood among the five phases and the "liver loves free coursing" among the zang, so spring belongs to liver-wood. Summer heat resembles fire and corresponds to heart-yang, so summer belongs to heart-fire. Similarly, late summer belongs to spleen-earth, autumn to lung-metal, winter to kidney-water.

These one-to-one correspondences are, one might say, forced arguments the ancients used to make their "nature and humanity are one" theory self-consistent; they are not scientific. The Neijing chapter "Sheng Qi Tong Tian Lun" stresses that the body and nature are a whole: the body breathes air and exchanges energy with nature, so every movement is influenced by nature; wind, rain, sunshine and cloudiness all affect the body.

From this idea arose TCM's disease-cause theory. Later TCM summarized three causes of disease; one is external cause, summarized as the six excesses: wind, cold, dryness, dampness, summer-heat and fire.

On this question I think the late Shanghai physician Professor Jiang Chunhua put it well: using five-phase theory for zang-fu differentiation, taken far enough, becomes sophistry. We should take the essence from the reasonable parts and discard the over-theorized, impractical parts.

Space does not allow a full discussion of five-zang and six-fu differentiation; another day I will write on visceral manifestation theory.

There are also triple-burner differentiation and defense-qi-nutrient-blood differentiation, both developed later by the warm-disease school. The classical-formula school has always attacked the warm-disease school, so many classical-formula physicians reject the value of triple-burner and wei-qi-ying-xue differentiation.

Personally, I think all of these—six-channel, eight-principle, zang-fu, triple-burner and wei-qi-ying-xue—are precious experiences left by TCM's development, tools for understanding disease and guiding prescribing. Each has value, yet none is complete truth. The learner should study them, master their use, and yet not be imprisoned by them.

Besides these, each TCM specialty has its own differentiation; for example, the external-medicine physician's differentiation by well-abscess and cellulitis (yong ju) is also very practical.

So much for pattern differentiation. Now disease differentiation.

Disease differentiation is the physician's method of analyzing the features of a specific disease and treating accordingly.

TCM classifies diseases into "men" (categories). The idiom "a dazzling array" understates the number of TCM "men"; open any TCM monograph and you may find dozens or hundreds of them. These "men" are disease classifications according to disease differentiation.

Disease differentiation began with Zhang Zhongjing's Jingui Yaolue. Unlike Shanghan Lun, it divides human disease into twenty-four major categories.

This classification lets TCM physicians look up solutions by disease type. Jingui's classification is rather coarse; later physicians refined it, though some refinements became forced.

In short, disease differentiation is a "specific disease, specific formula" approach. But disease differentiation contains pattern differentiation, and pattern differentiation contains disease differentiation; the two are inseparable.

In Jingui Yaolue, each specific disease has many formulas; which approach suits which subtype must be distinguished by pattern differentiation.

An ideal TCM physician should master all three methods to a high degree. This demands great theoretical, cultural and social cultivation.

Fundamentally, when a person falls ill, both psychological and physiological factors may be at work, and the psychological factors are tied to education and character.

A good TCM physician should be able to solve not only the patient's physical illness but also his psychological problems. As a Buddhist scripture says: the mind is like the overseer; when the overseer stops, all attendants stop. Many human troubles have their root in the mind.

For example, some patients love to stay up late; staying up, they eventually develop cancer. If the doctor does not point out and enforce this bad habit and only treats the cancer, even if the tumor temporarily vanishes, as long as the habit continues it will recur.

Why does a person love staying up late? Reasons vary. One lymphoma patient I have stayed up all night playing cards because he had to entertain clients. Another stayed up late because he was a policeman. Another because he was a programmer who often worked overtime.

If, as a doctor, I cannot persuade the patient to stop staying up late, my treatment is half-failed from the start. And to persuade him, I need skill: for the first patient, to persuade him to care less for fame and gain; for the second, to persuade him to change his post; for the third, to change his work habits.

So a doctor is not just a doctor; in some sense he is a lighthouse to the patient, able to influence the patient's thinking and behavior. Without social experience and depth, one cannot do this.

The Qing physician Ye Tianshu, besides practicing, was reportedly a respected local squire; when neighbors had disputes and needed an arbiter, they went to Ye Tianshu.

This shows Ye was respected not only for medical skill but for learning and standing, so people trusted him to judge fairly.

In the past, a doctor was regarded as an "elder." What is an "elder"? He can be summed up by eight words: "learning a teacher to all, conduct a model to the age"—like Ye Tianshu, whose learning and character commanded respect, so that people accepted his treatment and regarded him as a life guide.

By that standard, most of us would not pass. This profession carries high social expectations; as the saying goes, studying medicine consumes a person. Even a learned person must exert himself to solve problems of physical and mental health.

Medicine is never purely technical. For good results the doctor needs not only exceptional ability but to toil day and night for the patient's well-being.

Because one lapse can kill. Once a person dies, public opinion will thunder down on the doctor, and overwrought families may even threaten the doctor's person. Can one be too careful?

I think a doctor, while doing all this, should also maintain a skeptical attitude toward everything he has learned.

Medicine is an imperfect science, whether Chinese or Western. Every clinician knows: we cannot cure all who come to us; some patients will die under our care.

Professionally, the grieving families are also people we inevitably meet. Besides treating the patient, properly comforting the bereaved family is part of our duty.

Doing so fulfills our humanistic duty and lubricates the doctor-patient relationship, reducing disputes.

Before a patient dies, the doctor should also provide death education to the family.

We must admit that facing a family member's death is one of life's hardest trials. Major disputes often arise shortly after death, when the family is immersed in grief.

Necessary death education helps families overcome the acute shock, recognize death as an unavoidable natural law, and ease pain, fear and panic.

The doctor's work is truly hard, but one general principle helps resist professional risk: toward patients and families, the correct attitude is—tell people the facts as they are, and act with reason and fairness.