Monthly Archives: February 2014

Contradiction and vision

Ted Kaptchuk, in The Web That Has No Weaver, puts forward the notion that Western medicine has more promise for incorporating Eastern ideas than vice versa.  He suggests this difference derives from basic tenets of Western ideology, which put forward fundamental seeming contradictions and ask us to find a greater truth which envelops them.

Western thought, at its most noble and honest, is nourished by the constant tensions between unkown and known, imperfect and perfect.  Western humanity is quickened by a metaphysical dilemma — on the one hand, it was created in the image of the Almighty, and on the other, it was created from dust.

And now I hold these two opposing viewpoints and try to unify them (does that make me the quintessential Westerner?):

1. Unlike the West, Chinese philosophy sees apparent contradictions as part of life.

To be bent is to become straight.
To be empty is to be full.
To be worn out is to be renewed.
To have little is to possess.
– Tao-te Ching, as quoted in Kaptchuk

2. Holding apparent contradictions is fundamental to Western thought (see above).

Perhaps the two trains of thought are not so different after all.  Or perhaps the difference lies in what we choose to do with our perception of contradiction.  Perhaps the Eastern way is to simply notice what is — ‘Ah look, the fabric is all red and all blue’ — and the Western way to search for an underlying greater truth.  For example, fabric is woven from cross-fibers that appear blue when at one angle to the light, and red at another.

In the West, we want a vision of what will be — a vision that is better than what we see in the external world, an unachievable pinnacle to aspire to.  Not Buddha (a human), but Adonai (super-human).  Not just peace on Earth, but the Messiah.  Is this delusional?  Is this the definition of hope?  Is this at the very core of Westerners’ thought patterns?  The 2008 Obama campaign would suggest it is — hope quickens our blood, brings fire and water to our eyes, enlivens our gaze.

Okay, Ted Kaptchuk, I’m on board with this: the Western paradigm is open to change and improvement.  We just need the East to enter with West flare, with vision.

What does this vision look like?

It includes Western primary care physicians embracing other modalities.  Perhaps learning to practice them on their own, otherwise knowing when to refer.  It suggests the importance of the Doctor-patient encounter.  If any specific Western doctor does not want/need/have the capacity do this, they must be required at least to have the analytic capacity to know when it would be beneficial to the patient and respect that.  The notion that healing can take place in a human encounter must be demonstrated and ingrained into Western medical training so that when a patient has such an ailment (and, as I have argued before, these are in fact the most common ailments primary care physicians see), their healing is put first and foremost and they are guided toward the most useful resources.

As I have said, it means changing the system, broadening our view, using our Western ability to sit with opposites and opening medical education to new ideas.  This includes continuing education for practicing doctors.  It also means changing the insurance system to promote people’s health.  And it means educating ourselves, after all, we are the patients, on how we can hope (how quintessentially American!) to achieve health and vitality.

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From knowledge to intuition

Eastern and Western medical paradigms have different uses for knowledge.  In both systems, it is important for novices to use  observable or quantifiable measurements and facts to create treatment plans for patients.  None of us want a 20-something fresh out of med school, be it Eastern or Western, to assume they can take one look at us and understand our deepest  existential quandaries, nor do we probably believe they can heal us with their presence.

The key to good decision making is not knowledge. It is understanding. We are swimming in the former. We are desperately lacking in the latter. … Being able to act intelligently and instinctively in the moment is possible only after a long and rigorous course of education and experience.

-Malcolm Gladwell, Blink

Yet many of us can probably call up the wizened face of some elder in our lives — a grandparent, a rabbi, a psychologist, maybe even a doctor — whose very presence and implicit understanding created space for us to deal with whatever was thrown our way: cancer, depression, war, loss of a limb, or the death of a family member.

Intense communication and intimate recognition automatically resonate and affirm the integrity of a patient’s Qi and Spirit. … Just from being and talking with Dr. Hong [an old, highly respected Chinese doctor], most patients encountered within themselves a depth of humanity deeper than the difficulty or tragedy of any illness.

– Ted Kaptchuk, The Web That Has No Weaver

Achieving this wisdom, this intuition for the vitality of others, is the highest aim for a traditional Chinese medical practitioner (Kaptchuk, 2000).  In contrast, while there are wise Western doctors who practice it, knowingly or not, it is not something that Western medicine, as a system, aims for.  Biomedical research is increasingly recognizing the importance of the doctor-patient encounter and the gaping hole that exists in Western medical training in this regard.

Currently, neither doctors and patients, nor plans have adequate skills in the doctor–patient relationship. (Goold & Lipkin, 1997)

Western doctor training programs that emphasize creating connection and being present with patients are sprouting up (see, for example, the growth of mindfulness-based courses for doctors).  I also put forth that Western doctors and the Western medical system, from med schools to insurance companies, can tap into the available resource of alternative medical practitioners, who were trained in these skills from the beginning.

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Kaptchuk, T. The Web That Has No Weaver. McGraw Hill Professional. 2000.

Gladwell, M. Blink. Little, Brown & Co. 2005.

Goold & Lipkin. “The Doctor-Patient Relationship.” SGIM Symposium on Managed Care. 1997.

Scientific rigor off the pharm

Good news!  Here’s a study that is using scientific rigor to test the utility of a non-pharmaceutical therapy.  The existence and prominence of this study is as important as the results.  It was published in The Lancet and highlighted in the BBC’s health section.

Both the original and the BBC report on it are refreshingly honest.  The BBC’s article is entitled “Schizophrenia: Talking therapies moderately effective”.  They do not claim to have cured the world, but simply by publishing the article they underscore its importance.

The authors of the study also reach conclusions with caution, point out the weaknesses of their study and discuss what needs to be done from here on the scientific side.  At the same time, they quietly but forcefully make a profound point: when we test other therapies with the same rigor with which we test pharmaceuticals we can get results that are at least as good, and the side effects are minimal to non-existent.

In their words, “Evidence suggests that the effectiveness of [antipsychotic] drugs has been overestimated, whereas the severity of their adverse effects [has] been underestimated … Although differences in efficacy between antipsychotics and placebo were noted, they were smaller than those for most of the analysed adverse effects.”  In my words, antipsychotics are somewhat effective.  So is cognitive behavioral therapy (CBT).  Antipsychotics have devastating side effects.  CBT has none.

State of the Science

Let’s take a look at the state of the science.  What does western medicine have to offer for the treatment of chronic conditions?  I am going to lay out a framework for how Western biomedicine addresses common, chronic, systemic maladies of everyday life, such as high blood pressure, diabetes, autoimmune diseases, and anxiety (see my last post for more details).  And I am going to suggest, because Western medicine takes a reductionist view rather than a systemic one, it is rare for it to hit upon a solution to these types of maladies.

Okay, here are the three ways in which Western medicine currently addresses systemic problems.

  1. There are the rare cases where a microscopic, singular trigger causes a plethora of systemic, chronic symptoms.  Western medicine searches for these causes and occasionally finds them.An example of this?  One that I have personal experience with: celiac disease. It’s an autoimmune disease. Like all autoimmune diseases, it has a vast array of seemingly unrelated symptoms: stomach aches, fatigue, joint pain, neuropathy, the list goes on.  But it’s unique — it is the only autoimmune disease for which we know the cause, the trigger: gluten.  We found the needle in the haystack, the control parameter that sets the whole system running out of whack.  There may be other diseases, autoimmune or otherwise, with such solutions, and hopefully western biomedical research will find them with time.  Until we do, I say, let’s help people who are dealing with multiple sclerosis, fibromyalgia, depression, anxiety, myasthenia gravis, Type II diabetes (the list goes on!) with the best treatment available to us at the moment, right now.  That is usually going to be something that addresses the whole and rebalances it as best we can.
  2. There are (or may be) diseases that have lots of nonlinearities and feedbacks, don’t have a single cause, but which we understand in enough detail to reliably manipulate.  These are truly rare.  In fact, I can’t think of a fully satisfactory example.  If anyone out there can, please do share!  But to get the ball rolling, here’s somewhere we get kind of close.Many women experience irregular menses and/or painful menstruation.  We have a qualitative picture of the hormonal feedbacks that drive ovulatory and menstrual cycles.  Given that knowledge, we can use exogenous hormones (i.e., birth control pills) to manipulate the cycle and remove the hormonal experiences that generate severe cramping.  However, this example is not satisfactory to me because western biomedicine does not understand the system well enough to rebalance it.  Instead, we can hammer away at it and change it to something different: in fact, it is not an ovulatory cycle at all anymore, as ovulation has ceased to occur.  But it does remove certain undesirable symptoms.
  3. For the smorgasbord of systemic diseases that we really don’t understand — haven’t found the silver bullet, don’t have a good enough grasp to hit over the head with a particular chemical, what tools does Western biomedicine provide?  Shots in the dark.  We adjust parameters that we know affect the system, but they are not key control parameters, ones that restore balance.  So we try. We cross our fingers and hope that luck or trial and error will lead us to a key control parameter for this particular person.Maybe a little more serotonin would do the trick.  Try these pills.  Or maybe you need the slow release version.  Try these ones.  Oh, these make you feel anxious all the time?  Lower your blood pressure to the point where you faint?  Try adding this medication on top!  Sometimes these things help, whether from their inherent chemical properties or people’s faith in biomedicine allowing the placebo effect to be quite strong (citation).  Much of the time, they are frustrating for patient and physician alike.

I believe Western biomedicine can be a powerful force for helping people restore their health.  I have experienced this first-hand watching my father heal from cancer following chemotherapy and a stem cell transplant and survive a heart attack.  And, after ten years of struggling with disparate symptoms, I was I was diagnosed with celiac disease thanks to my mother’s sleuthing into the world of biomedical research combined with medical testing.

But it has limitations too: lifestyle diseases, women’s health issues, mental health, chronic pain.  Many of these limitations line-up with success stories from other medical paradigms.  So let’s be honest about where we are today.  What is western biomedicine ready to treat? And what diseases is it still happily mucking about in the world of primary research?  For those problems that western biomedicine isn’t ready to tackle in a living body (yet!), let’s look to different viewpoints that are ready to treat, paradigms in which the healer’s role is to create space for the patient’s body to heal.