HealthCMi (Healthcare Medicine Institute) actively supports the environmentally sound and sustainable production of Chinese medicinal herbs in the United States in an effort to preserve endangered plant species. Recently, I was able to discuss domestic cultivation with one of the pioneers in the field, Peg Schafer.
What was your inspiration for starting the Chinese Medicinal Herb Farm?
The Chinese Medicinal Herb Farm was created for a couple of reasons. As a farmer, I was looking for a niche crop that would be a viable venture on small acreage. I was also looking for something of a right livelihood, something where I could ‘be part of the solution’ as well as make a living.
My background is in nursery and greenhouse management. Chinese herbs were a natural choice because they were already tools in my personal medicine chest. In 1997, I started with containerized Chinese herb plants. A few years later I moved into field production.
Robert Newman was maintaining an herb garden at the American College of Traditional Chinese Medicine (ACTCM) and later moved to China working as the guest curator of the medicinal herb collection at Nanjing Botanical Garden. Before he left the US, Robert bestowed his collection of rare seed and plant materials to a few US growers. That was a major infusion of known-origin germplasm and was instrumental in the early days of domestic production and the Chinese Medicine Herb Farm.
We have grown out over 270 different Asian medicinal plants and have worked to maintain a diverse collection that continues to be evaluated. Currently, we maintain a mostly unique collection of over 400 Asian medicinal plants. Many currently reside in our demonstration gardens, nursery, medicinal orchard, and in storage as seed stock. The collection requires ongoing stewardship to maintain its level of quality.
What is your main form of outreach concerning Chinese medicinals?
Educating students, practitioners, and growers on current issues facing Chinese medicinal herbs and cultivation practices is our primary focus. In an effort to reach more people than our workshops and internship program could accommodate in 2011, I wrote a book called the Chinese Medicinal Herb Farm: A Cultivator’s Guide to Small-Scale Organic Herb Production published by Chelsea Green Publishing.
What are some of the greatest challenges facing production of traditional herbal medicine plants worldwide and domestically?
Chinese herbs were traditionally wildcollected in China. Now, the carrying capacity in China has been exceeded for many botanicals. In response to modern sustainability pressures, many Chinese medicinals have recently shifted from wild harvesting to cultivation. In a reversal of traditional collection methods, the most commonly used herbs are now almost entirely cultivated varieties.
What are some of the pressures impacting the sustainability of Chinese medicinals?
Climate change, over-harvesting, habitat loss, and a host of other pressures affect the continued availability of Chinese medicinals. Chinese herbal medicines have become very popular not only throughout Asia but also in North America, Europe, and Africa. On a basic level, there is simply not enough of Chinese origin herbal material, farmed or collected from the wild, to fulfill world market demand. Many herbs originating from China will be exported for the foreseeable future, especially those that are not commonly used, require a long time under cultivation, or have complicated life cycles.
What differentiates medicinal herb farming from food cultivation?
Learning to grow undomesticated and largely unselected plants and bring them under cultivation has been surprisingly difficult with some species. The tendency is to grow them as if they were vegetables. That method will often serve when growing superior or food grade herbs—herbs that are food stuffs. Chinese herbal medicine is historically based on the qualities of wild origin herbs that have been subjected to the stressors of nature. Plants that are stressed release chemicals in response to the availability of nutrition, quality of soil, water distribution, the effects of UV, pest pressures, etc. Ignoring that some herbs are regionally specific and to further provide an easy life for them by providing optimal food grade growing conditions impacts the potency of their medicinal actions and does not tend to imbue them with the expected clinical outcomes.
What are some common obstacles to growing Chinese medicinals for farmers?
Chinese medicine is relatively new in the US and has little agricultural precedence and information. The occupation of a non-industrial farmer, although gaining in respectability, is physically demanding and requires long hours working in all kinds of weather. Historically, it is a low paying profession and becoming certified organic adds administrative responsibilities to the long row that was already hoed that day. With the average age of farmers at around sixty, the US government is initiating incentives for up and coming farmers.
On another note, quality seed stock, or germplasm, is greatly needed in China and the rest of the world. The seed currently exported from China is of notoriously poor quality. Germination rates tend to be very low. There is no way of ascertaining that the seed stock was maintained with integrity, if it was originally from a good medicinal variety, or if there is sufficient genetic diversity to allay species vulnerability.
While the domestic Chinese medicinal plant market is garnering a large amount of interest, the market has no history and requires significant development. It is different from the current import market and a new system needs to be created. This is not a quick and easy task. Support from all stakeholders is crucial to make a comprehensive and effective domestic industry.
How do people get involved to help protect, preserve, and strengthen the availability of Chinese medicinals?
Lonicera hypoglauca, Jin Yin Hua, Honeysuckle
All herb using people, from herb companies and herbalists as well as growers and patients, are stakeholders and ought to be interested in where the products they consume come from. Ultimately, we all need to foster the well-being of not only the herbs but endeavor to sustain the world that nurtures the environment so that the herbs can naturally and effortlessly flourish. Ah, such lofty goals!
The most obvious way to protect beleaguered resources is to not engage in trade of wild-origin materials. There are a plethora of policies, however, the Convention on Trade of Endangered Species of Wild Fauna and Flora (CITES) treaty is the most effective and important tool for regulating international trade. The wildlife trade monitoring network, TRAFFIC, has an active East Asian presence and an informative email newsletter. There are a few nascent sustainable MAP (medicinal and aromatic plant) projects in China supported by wild plant collectors, pharmaceutical companies, government organizations, and international support groups.
We can also support in-situ and ex-situ conservation in ecological preserves, parks, and botanical gardens. Important plant areas (Chinese IPAs) will serve an increasingly important function as genetic reservoirs. For conservation purposes, it is always easier to preserve what already exists rather than to recreate intact viable biodiverse populations. However, protection is difficult unless we know the range of the different herbal materials. Conservation and legal protective strategies are based on research. Data is limited, fragmented, and incomplete due, in part, to the vastness of the project and extensive rural geography. A comprehensive list of endangered wild medicinal herb plants does not exist. An attempt was made, specific to Chinese medicinal plants, and there is a table in chapter 5 in the Chinese Medicinal Herb Farm A Cultivator’s Guide to Small-Scale Organic Herb Production. In cases where more than one species represents any one given herb, consideration of which herbal material to use might make a difference and lessen the pressure on a species experiencing survivability stress. Mending the Web by Elizabeth Call et al. offers some assistance to herbal practitioners.
The cultivation of medicinal plants is underway in China and domestically. As wild medicinal crops become scarcer, the efforts expended to collect them will start to fall more in line with the increased efforts and costs of farm land, labor and inputs. Increased awareness through media exposure also supports action. Exposure of Chinese agricultural practices utilizing excessive inputs of fertilizer and pesticides and farming in soils that carry the burden of heavy industrialization reveals that these activities threaten the integrity of Chinese cultivated medicinal plants. Domestically speaking, cultivating to conserve and grow for local markets facilitates a shorter supply chain. A supply chain that has fewer changes of hands experiences fewer quality failures. Shorter travel distances and smaller businesses combined with a culture of openness and accountability usually results in fresher products.
Domestic products have lower travel miles from field and farm to customer, which benefits the environment and brings the botanicals to the end user in an expeditious manner. Supporting domestic medicinal plant production also defends access to herbs by avoiding import and export bans thereby ensuring practitioners access to the herbs. For a favorable situation where growers and consumers support each other and the environment, the cultivated herbs need to be clean, efficacious and available in sufficient quantities. Naturally, the buyers must afford the cost of producing them.
Large industrial monotypic agricultural systems do not support ecological diversity and have a history of producing lower quality products. These types of operations are increasingly common for food and medicinal plants and are more about the bottom line than they are about healthful food and medicine. The same business model is used for genetically modified and engineered crops (GMO and GE). While I am not opposed to the concepts per se, it is the realities that concern me. Specifically addressing Chinese herbal medicine, if we change the biological foundations of an herb we may change its function. Once altered genes work their way into the genetics of non-GMO cultivated and wild plants there is no way to get back to the original genetics. This goes against one of the most lauded of scientific codes – the precautionary principle. However, GMO and GE crops are patentable and are therefore attractive to companies beholden to their stockholders for the creation of wealth.
Dao-di herbs refers to Chinese herbs that are grown by traditional methods. This includes everything from seed stock, planting and harvesting time, geographic location, cultivation practices, and processing. Given the shift from mainland China to the USA, how do you view cultivation in relation to dao-di herbs?
The concept of dao-di, or geo-authentic, herbs comes up from time to time. Many herbs have regionally specific affinities that we should adhere to as best we can but we should also explore and assay all herbs as Chinese herbal medicine is not a static system. Soils and climates vary but it is interesting to note that most of China and the USA share the same latitudes. The majority of new Chinese herb farms are in Western China and for some herbs outside their indigenous extent. There is also the interesting case for the preference in China for American grown herbal material of Xī Yáng Shēn (American Ginseng). Indeed, roughly 20% of the herbs included in the Chinese materia medica are plants from other regions of the world. To the best of my knowledge, domestically cultivated herbs that have been tested either organoleptically by trained Chinese herbal professionals or biochemically via HPTLC or HPLC have demonstrated comparable flavors or bioactive compounds commonly accepted to represent herb quality. How fresh are the aromatic herbs in the pharmacy? For example, does Bò Hé (Mentha haplocalyx Briq. or M. arvensis L.) have a strong mint smell?
Salvia miltiorrhiza, Dan Shen, Red Sage root
Transparency and accountability are of utmost importance. We, as consumers, are motivation factors in commerce. Worldwide the herbal medicine industry is working to come into compliance with the mandated Current Good Manufacturing Practices (cGMP) and the recommended Good Agricultural Practices (GAP). Specifically, in reference to labeling, many questions arise. Is the genus and species of an herb stated on the label or does it only state the pinyin medicinal name? The pinyin name is the name of the medicine not the name of the herb. Is the specific origin listed and not merely the generic “made in China” label? There are several things to look for. A unique lot number is most often listed; traceability is key. Ask suppliers and pharmacists for the Certificate of Analysis (COA) or herb specification sheet, which will give more detailed information such as what form the herb is in like a powder or whole root, etc. Date of harvest is not listed unless the product is domestic; this may be very important. Requesting accompanying documents helps to catch fraudulent herbs and sends a message that you care about quality.
Recently the American Botanical Council, an herbal industry watchdog, identified adulteration as the most significant problem in the herbal supplement industry. This may be due to ignorance, deception for financial gain, or for other reasons. It is an especially pervasive problem with Chinese originated botanicals. This is due, in part, to the sheer vastness of China including language barriers and regional herb preferences utilizing identical pinyin names for differing medicinals. This leads to a lack of compliance with cGMP and GAP. As a result, it is common to have more than one species present for any given herb lot.
Traceability is complicated by longstanding wild collection practices, middlemen, and herb transportation carriers to regional herb market hubs. Scarcity leads to increased prices and is also a trigger for adulterations due to economic motivators. In the USA, we must also be vigilant to make sure that herbs are true to species.
Species confusion leads to many types of complications. Well intentioned individuals often import seeds based upon the pinyin name but later find that the seed is not what they expected. For one example, my farm encountered unexpected obstacles after receiving seeds some years ago for Bǎn Lán Gēn. I grew the seed out and it turned out to be southern Bǎn Lán Gēn (Baphicacanthis cusia (Nees) Bremek). I was looking for the standard species for Bǎn Lán Gēn (Isatis indigotica Fortune ex Lindl. or Woad). It turned out that I did not have the proper growing conditions for Baphicacanthis.
Chinese botanical medicine is on the rise worldwide. It is clear that a combination of cultivation as well as collection of wild medicinal plants will be necessary to satisfy global market needs. We can engage in conservation and meet the demand for Asian medicinal plants with applied agro-ecological cultivation, sustainable wild collection practices, and responsible trade. The future of Asian botanical medicine and consequently the health of the people who utilize it are depending on it.
Thank you Peg. I enjoyed our discussion and greatly appreciate your strident efforts to foster sustainable and ecological solutions. Look forward to our support from the Healthcare Medicine Institute, including our grant program for the development of domestically sustainable organic Chinese medicinal herb cultivation.
Adam White LAc is the CEO of the Healthcare Medicine Institute (HealthCMi) and is a licensed acupuncturist in California. HealthCMi (Healthcare Medicine Institute) is best known for acupuncturist news and research publications along with our continuing education courses.
Peg Schafer’s main endeavor is the 18 year old Chinese Medicinal Herb Farm near Petaluma, California currently operating as an educational and research farm. Peg is the author of The Chinese Medicinal Herb Farm A Cultivator’s Guide to Small-Scale Organic Herb Production published by Chelsea Green. She often addresses herb quality, ecological cultivation practices, conservation and other issues affecting herbs at Oriental Medicine colleges, conferences, and community events. Consultations are available for farm operations, grower/practitioner enterprises, herbal companies, research institutions and other stakeholder industries.
Adults have found relief in acupuncture for over two thousand years, but American practitioners have traditionally been adverse to actively seek out and treat children, as evidenced by the small niche that pediatric acupuncture occupies. However, treating children with acupuncture, using appropriate techniques, is safe and effective. Additionally, more and more adults are realizing the benefits of acupuncture for themselves, so it is logical that they might also use acupuncture to treat their children. In the last decade I’ve witnessed tremendous growth in the pediatrics specialty brought about by greater demand by parents and a growing number of acupuncturists seeking training.
When I first became licensed in 2003, I never imagined that I’d end up becoming a pediatric acupuncture specialist. My journey to this specialty started simply from the desire to help my infant son heal from a severe case of eczema that wasn’t responding to Western medical treatments. Only after I began treating him with acupuncture, herbal medicine, and dietary changes did his eczema begin to resolve. As I shared my son’s story with my patients, I found that many of their children suffered from conditions that could be treated with acupuncture such as colic, constipation, cough, and ear infections to name a few. Inspired by my son’s story, my patients began to bring their kids in for treatment, too. As word spread about how acupuncture helped these kids, I began seeing even more children and this is how my family practice was born. Today, my practice is comprised of approximately 30 percent babies, children, and teens.
The most surprising thing I found about pediatric acupuncture is that, contrary to what many adults think, kids actually like getting acupuncture. I’ve had babies use sign language to sign for “more” and children that aren’t feeling well ask their moms to schedule a visit with me. Children like acupuncture when they know it helps them feel better. I really enjoy treating kids because the treatments are more playful and spontaneous. They are gratifying to treat because they respond so well and quickly to acupuncture. Recently, I treated a little boy with pneumonia and persistent wet cough. His mother called the next day to tell me that after his session he finally stopped coughing and was able to sleep through the night. Parents are so grateful to me for helping heal their kids by augmenting Western medical treatments.
The key to helping kids learn to like acupuncture is how you approach and honor each child and their receptivity to needles. In this article, I will share some of my practical pearls of wisdom for explaining acupuncture to kids, approaching them with needles, and my painless needling technique. Pediatric acupuncture takes an entirely different approach than when you’re working with adults. When treating an adult there’s an order and routine to the treatment, the needles stay in much longer and they can tell you if something you’re doing is uncomfortable or isn’t working for them. However, working with kids can be challenging because they are often unaware of their physical needs and how to verbally express their symptoms. Sometimes, they are unsure about the process of acupuncture and why it will help them. It’s very important to bring positive energy to each treatment—kids can tell if you’re not feeling connected or are uncomfortable.
Through trial and error I have learned how to treat kids with acupuncture successfully. Just about every child I work with tries acupuncture because of the systematic way I introduce it to them and their parents. From my experience I have developed a philosophy about pediatric acupuncture that I know helps my patients find success with the course of treatment. There are four cornerstones to my philosophy:
Building trust with kids is the most important thing you can do. If kids trust you they will be more willing to try something you ask, even if they’re a little afraid. Tricking a child or using distraction to needle them without their permission is not recommended. You can trick them once, but they probably won’t want to come back again. Be patient and eventually they will try acupuncture needles. In the mean time, you can use other non-needle techniques to stimulate the acupuncture points such as microcurrent, laser, shonishen, or tuina massage.
2) Respect
You’re treating a human being in a child’s body, and you should treat her with the same respect for her body and emotions as you would an adult. Many children have been hurt or traumatized by medical providers. Even if it was necessary in the course of treatment, it is still traumatic. That’s why it’s important to make sure you have permission before you touch or treat them with acupuncture. Be gentle and firm and always start by asking them to try acupuncture first before giving other options. If they’re absolutely adamant about not getting acupuncture, respect their decision.
3) Flexibility
With adults there is not much variation in treatment flow, but with kids it’s totally different. To be successful in delivering pediatric treatments, let go of rigid ideas of how you think a pediatric visit should be and go with the child’s flow. If what you’re doing is not working, then do it differently—change it up!
You can change it up by:
Changing the point you’re working on
Moving location of treatment—mom’s lap, on the table, standing up, or on their belly.
Switching to a different modality— massage, microcurrent, shonishen, or laser.
As you do the treatment, communicate with the parents but also talk to the kids about their own bodies. You’re interaction should be guided by the child. In other words, meet the child where they’re at. Are they shy? Outgoing? Fearful? Curious? Ready? Need mom close by? Need distraction? Pay attention to what they need even if they’re not able to verbalize it.
4) Connection and Play
In TCM, we use the Five Elements to understand the unique way of being each child has that shapes his behavior, temperament, and how he interacts with his environment. The Five Elements are Wood, Fire, Earth, Metal, and Water. Each Element represents an archetype that corresponds to a certain way of being in the world. Once you determine a child’s Five Element type, you can use this knowledge as a guide for connecting with treating him in a way that honors his true nature. For example, you may want to challenge a Wood child, bring singing and playfulness into your treatment for a Fire child, talk about friends or pets with an Earth child, explain what you’re doing step-by-step with the Metal child, and allow the Water child to read a book instead of chatting with you. Each Element requires a different approach and this increases your chances of successful treatment.
Using play is a great way to make treatments fun. Just be sure not to bring too much excitement or you may lose control of the session. Singing, jokes, toys, and drawing are examples of how you can use play in your treatments. Do whatever feels natural to you to connect with kids.
What are kids commonly treated for?
In my practice, I typically see babies and children for chronic rhinitis, upper respiratory tract infections, acute and chronic otitis media, allergies, asthma, eczema, and digestive disorders. For teens, I also treat acne, anxiety, depression, and pain conditions. Overall, I treat kids for the many of the same conditions as adults. For a complete list of the most commonly treated pediatric conditions see Table 1.
How do you explain acupuncture to kids?
The biggest obstacle to treating kids is the word needle. It conjures up images of shots, blood draws, being poked, and memories of being hurt. Acupuncture needles are nothing like hypodermic needles, but once the word needle is out there you can’t take it back. You may lose a patient that you could otherwise treat if they become fearful you’ll hurt them. To avoid the fear and apprehension that is commonly associated with the word needle I coined the term “tap” to refer to acupuncture needles. Children don’t have a frame of reference for “taps” and the term sounds harmless. Who’s afraid of a little tap? I started using this term because I rub and tap the acupuncture point before insertion and I tap the needle in. If children ask if it’s a needle I will tell them the truth, but I’ll make sure to differentiate between a hypodermic needle and an acupuncture needle.
Explaining Acupuncture to Children
Before I show a child “taps” I make sure they understand that I won’t do anything to their body unless I have their permission. I make it clear that I won’t trick them or treat them against their will. I also give them permission to tell me if they’re scared or if something I’m doing is uncomfortable. Since building trust is my primary goal, it allows me to go at the child’s pace so we can continue the treatments long-term if necessary. Many kids visibly relax once they know they won’t be forced to do something they don’t want to do, making them more receptive to trying acupuncture.
As I show kids a “tap”, I open up an acupuncture needle and take it out of the package. I hold it up in the air and I talk about how tiny it is and how it’s barely visible in the tube. I tell them about the hundreds of other kids that were a little scared of “taps” until they tried them and realized how easy and painless they were. Then I explain how “taps” help the body heal itself when I place them at special points on the body.
I make sure to show the child how the taps are placed. I pretend my massage table is a child and I show them how I rub and tap the point and then tap it in. Then I ask the child if they want to try it. Many children will say “yes” at this point. If the child is still a little apprehensive, then I’ll demonstrate the “taps” on their mother or father, so the parents can reassure their child how easy and painless it really is. If the child still refuses, acts afraid, or cries then, at this point, I switch to other non-needle techniques.
What are the guidelines for pediatric needle technique?
First, I use extremely small gauge needles for pediatric acupuncture, which allows for a virtually painless experience. The small gauge allows me to insert needles even at sensitive points such as Bitang or LR 3. In babies and toddlers, I most often use 46 gauge half-inch needles. In small children, I use 44 gauge half-inch needles and for teens, I’ll use 42 gauge half-inch or one-inch needles. In my experience smaller gauge needles are just as effective as larger gauge needles in children.
Second, I always apply pressure, rub, or tap the acupuncture point with my finger before inserting the needle. This “warms up” or desensitizes the point before the needle is inserted. I also use this time to engage with child, check in with their body language and make sure they’re ready. If they are cringing, tensing or pulling away, then I stop and see what’s going on and reassure them that it will be okay. Distractions, such as having the child wiggle their toes or eyebrows, can help them relax if they’re feeling a little nervous. Needling when the child is scared or tense may increase needle sensation during insertion. Once I know the child is absolutely ready, I press my finger down next to the tube to provide added pressure as I tap the needle in. This also helps desensitize the point and provides a virtually pain-free experience.
For babies, I use an in/out needle technique, which means the needle is inserted and immediately removed. In my experience, I have found that this works for babies and kids up to approximately age eight. After age four, I encourage kids to retain the needles for anywhere from 10 seconds to several minutes. Most kids ages eight and up can retain that needles anywhere from one to 15 minutes depending on their age and comfort level.
What is the recommended treatment frequency?
How often I treat a child depends on the nature and severity of their health condition. For example, if I’m treating a baby for painful acute otitis media, I may recommend treatment three treatments in the same week to help reduce the pain and treat the infection. For a case of asthma that is exacerbated and has required several recent emergency room visits, I would start with twice weekly for two weeks, then weekly for twelve weeks. Once symptoms improve the frequency is reduced to twice monthly depending on how the illness is resolving, but total treatment time for chronic asthma may be six months to one year. On average, I recommend a course of six to twelve treatments and then reevaluate the child’s progress. Many mild cases resolve within one course of treatment, although chronic cases may need treatment at varying frequencies for up to a year.
Children enjoy acupuncture and it’s a viable treatment options for many kids with conditions such as ear infections, digestive problems, pain, allergies, and asthma. It can augment or support Western medical treatments and improve clinical outcomes. To help kids learn to like acupuncture, be sure to build trust, be flexible, go with the child’s flow, and use play to connect with them. Explain and demonstrate acupuncture in a way that allays their fears. Use the term “tap” instead of “needle” for kids that are apprehensive about getting treatment. When properly introduced to acupuncture, kids are open and receptive and can benefit from acupuncture treatments throughout childhood.
Outside of Thailand, Thai massage is perhaps the most widely known and practiced aspect of Traditional Thai Medicine (TTM). However, this relatively small component of the TTM system is often misunderstood or misrepresented. Unaware of the full scope of practice TTM offers and the medical theory in which Thai massage is based, many Thai massage practitioners are limited in making the most effective treatment choices for their patients.
Stemming from issues of geography to timing and language barriers to changing political priorities, there are many reasons TTM as a complete system is not as globally well known or practiced as some other traditional medical systems, such as Ayurveda and Traditional Chinese Medicine. Like other medical systems, Thai Medicine continues to remain a living tradition while it adapts as information is transmitted from teacher to student and as human environments and our global landscape change. In fact, the essential theories of Thai Medicine are based on the knowledge that everything is constantly shifting. And while human lives and maladies may appear very different in our modern time than for those living thousands of years ago, Thai medicine has remained applicable in diagnosis and treatment because fundamentally, wind continues to move, fire continues to transform, water still holds things together and earth still provides structure.
History and Context
Traditional Thai Medicine comes from Thailand. Despite popular belief, TTM theories and practices have not been transplanted from China or India or Taiwan; rather, TTM comes from the land that is Thailand and from the people living there, and their ancestors before them. While it is true that some of these ancestors interacted with and exchanged ideas with the early peoples of both India and China—particularly India, as medicine from the Buddhist tradition came to Thailand from India along with Buddhism—these influences were from the systems that would become Ayurveda and Traditional Chinese Medicine (TCM), as they are respectively known today, and were integrated into what would become Traditional Thai Medicine as it is known today. Though these three individual systems may share some similar ideas and concepts, it cannot be stressed enough that they are in no way interchangeable and one cannot simply exchange Ayurvedic or TCM theory for TTM theory. Each system is unique in its theory and in application and part of what makes each medical system unique is the geography, plants, and climate in which the system developed as well as the needs of the peoples developing medicinal knowledge in that region. The primary early peoples moving into and inhabiting the region known today as Thailand were the Malay in the South, the Khmer in the East and the Mon in the North. Later, the T’ai people moved into Central Thailand from Southern China and Northeast Vietnam. Together, with other early peoples already inhabiting the land, these groups connected and clashed, bringing various influences into a common knowledge and system that continues to be codified into Traditional Thai Medicine of today.
Historically, much of the traditional medical practices of Thailand have been preserved locally, with some variation in information and focus based on region and lineage. The Thailand Ministry of Public Health has been collecting the multiple streams of textual knowledge from these various lineages in order to create a singular system, which is presented in a four-year traditional medicine program offering government licensure in one of four areas: Traditional Pharmacist, Traditional Doctor, Traditional Midwife and, most recently, Traditional Massage.1While all practitioners, regardless of the level of previous training and experience, are encouraged to complete the degree program to earn licensure to practice, there are still doctors practicing within their individual lineages and systems of knowledge that exist locally and regionally across Thailand. While there is overlap and common theory among these various local systems, each lineage is considered whole unto itself.
Lanna medicine is an example of a localized traditional medical system that overlaps with TTM in theory and practice, but is considered a separate system from a separate culture. Lanna medicine is the traditional medicine of the Lanna people inhabiting Northern Thailand and is perhaps the oldest and best preserved indigenous medical system of Thailand. Lanna medical texts, written in Lanna script, date back to at least the 13th century, but are likely even older.2
Today, the population of Thailand is more than 90% Buddhist. Though the most common form of Buddhism practiced is Theravada Buddhism, many Animistic practices are still observed and have been blended with Buddhist practices. With such an overwhelming majority of practitioners in the population, it is not hard to imagine that this unique form of Buddhism permeates and informs nearly every aspect of daily life in Thailand, including traditional medicine. In fact, Traditional Thai Medicine is a form of Buddhist Medicine and Buddhism is an entire root of knowledge in TTM. This will be discussed further later, however, it is important to note that for practitioners of TTM, Buddhist concepts and practices both guide conduct in and outside of the treatment room and provide support in caring for patients, community and self.
In TTM, the Buddha is regarded as the ultimate healer and TTM practitioners pay homage to both the Buddha and his physician, Jivaka Kumarabhacca, known to many as The Father Doctor, each day by performing a Wai Khru ceremony. In addition to the Buddha and Jivaka, practitioners of TTM also honor the Reusi tradition in their daily Wai Khru ceremony. Though the Reusi tradition continues in Thailand today, the Reusis of Old are honored for their contribution to the body of medical knowledge, including divination and spiritual practices. Reusis are spiritual ascetics or hermits studying the natural sciences through direct observation, interaction and experimentation in and with nature over time.
In Thai, Wai Khru means respect teacher and this ceremony is about honoring and respecting the practitioner’s lineage of knowledge and connection to all teachers in life. Without teachers, a practitioner would have no understanding, no skills and none of the knowledge needed to practice medicine. Remembering and developing a connection to one’s teachers and lineage means that one is never practicing alone, but rather with the support of all those who have practiced before. Practicing the Wai Khru also aids TTM practitioners in cultivating the Four Boundless States: Metta, Karuna, Mudita and Upekkha. Metta is universal goodwill, Karuna is compassion, Mudita is sympathetic joy and Upekkha is equanimity. From the TTM perspective, cultivating these qualities is a motivating factor in practicing as a doctor.
In addition to practices to cultivate the Four Boundless States, TTM practitioners receive ethical and conduct guidelines from Buddhism. These guidelines are based on the five Buddhist precepts: not killing, not stealing, not engaging in sexual misconduct, not engaging in false speech and not becoming intoxicated. These guidelines are observed for both ethical and practical reasons.
Element Theory and the Roots of Knowledge in Thai Medicine
Thai Element Theory is based on the fact that everything is a composition of earth, water, fire, wind and space. Together, these elements make up all things, animate and inanimate, from a fingernail to an ant to a pond. However, a fingernail and a pond appear and function quite differently because in an fingernail, Earth element is the most active, whereas in a pond, Water element is most active. Variation in all things is based on variations in the level of activity of the elements within each thing, including the body. Along these lines, each person has a unique core constitution, which becomes fixed early in life. This means that the balance of the elements in their mind and body will always lean a certain way, with one element, possibly two, being a bit more prominent than the others, regardless of time of life, season, climate or other external factors. While knowing a patient’s core constitution is valuable, assessment and treatment will primarily focus on current imbalances.
The topic of Thai Element Theory could be discussed at great length and has been in other works. Here, the most basic concepts as related to the body will be presented. The first is that each element has a specific experience, a specific function and a list of specific qualities.
The experience of Earth is solid and its function is to provide resistance and support. The primary qualities of Earth are hard, stable, heavy. Twenty specific structures are enumerated in the texts, but all solid components of the body are Earth element.
The experience of Water is aqueousness and its function is cohesion and fluidity. The primary qualities of Water are moist, fluid, soft. The texts list 12 body parts for Water, however all fluids of the body are Water element.
The experience of Fire is heat and its function is transformation and ripening. The primary qualities of Fire are bright, reactive, sharp. There are four fires of the body listed in the texts. All metabolic processes, aging, decay and heat in the body are Fire element.
The experience of Wind is movement and its function is growth and vibration. The primary qualities of Wind are light (not heavy), mobile, dry. There are six primary winds of the body. Wind is all movement in the body, from thoughts to nerve impulses to muscular contraction.
The experience of Space is unobstructedness and its function is to provide nonresistance and a field upon which all the other elements can play out their activity. The primary qualities of Space are expansive and subtle. The nine orifices in men and 10 in women are associated with Space. Space is also all of the physical space in the body.
Along with Thai Element Theory and Buddhism, the five roots of knowledge form the basis of all medical practices within the Traditional Thai Medicine system. The Five Roots of Knowledge are: Medical Knowledge, Physical Therapies, Divination, Spirit Medicine and Buddhism.
Medical Knowledge is the understanding of how the body works. This root works with herbs, diet, lifestyle guidelines and other types of internal medicine to help balance the elements of the body.
Physical Therapies work primarily with the function and structures of the physical body, focusing on freeing pathways of movement. Therapies include bodywork/ massage, bone setting, cupping, scraping, tok sen and Reusi Da Ton (Thai Yoga), among many others.
Divination looks at a person’s predisposition to disease by gathering and considering information such as where and when a person was born, the season of birth and planetary influences. Methods of divination include astrology, palmistry, numerology and geomancy, among others.
Spirit Medicine primarily works with the unseen forces, such as ghosts, spirits, sorcery and incantations in relation to health. Spirit Medicine helps to alleviate health concerns when they arise and provides preventative care and protection against imbalance with practices such as Sak Yan (magical tattoos), working with amulets and the use of specific incantations.
Buddhism, as mentioned previously, influences all aspects of TTM. As a root of knowledge, Buddhism primarily addresses mental and emotional health, offering practices, such as meditation and other meritorious acts, to help a patient relieve stress and let go of suffering.
These Five Roots of Knowledge are the basis of all medical practices and specialties in Traditional Thai Medicine. All therapies found in TTM require knowledge of the Five Roots to perform correctly, safely a nd effectively.
Traditional Learning in Thai Medicine
To learn Thai Medicine, it is considered necessary to have three things: a body of knowledge; oral transmission and explanation; and experienced practitioners. A body of knowledge could exist in a physical book or manuscript, but could also be an oral text. This information has been developed, tested and proven over time through a lineage of traditional practitioners. The body of knowledge alone does not provide enough information to develop medical knowledge and practice medicine. Without an experienced teacher to provide explanation, texts can easily be misunderstood or seem incomplete. A teacher with sufficient experience as a practitioner is vital to developing medical knowledge, for that person has taken theoretical concepts into practical application and seen the results with a variety of patients. An experienced practitioner is considered to be someone who has received transmission of knowledge from a qualified teacher, has studied the body of knowledge or the texts and has practiced under the guidance of an experienced teacher for a period of time before beginning an individual practice.
Though there is now a Traditional Thai Medicine degree program offered through the Thai Ministry of Public Health, as mentioned earlier, traditionally, Thai Medicine has been learned and taught through apprenticeship starting at a young age. Sometimes, this apprenticeship happens within a family, but this is not always the case. Entering a student teacher relationship is a lifelong commitment on the part of both parties and therefore, in their lifetime, a teacher may only accept a few students as apprentices. When a teacher accepts a student, they are also accepting that student into their medical lineage, meaning that the knowledge can be traced to a source, practitioner to practitioner, and therefore each practitioner has the full support of the knowledge and experience of all those who have practiced before; this body of knowledge and transmission is the legacy of the lineage, is exceptionally powerful and is not to be taken lightly. To maintain and honor this connection, it is important to always offer gratitude and respect to teachers in a number of ways. This is a primary reason to practice the daily Wai Khru, discussed earlier.
Typically, an apprenticeship consists of copying the teacher’s medical texts, observing treatments, assisting the doctor, lessons, discussions and hands-on practice under the supervision of the teacher. The pace and rhythm of this transmission varies from teacher to teacher and student to student, and it is the teacher that decides when the student is ready to begin a practice. Traditionally, a student will practice under supervision for a period of time before beginning to practice independently. For students, an apprenticeship model is central to developing a relationship with the body of knowledge being transmitted, with the teacher offering the transmission and with the lineage of practitioners who tested, preserved and passed the knowledge generation to generation.
Conclusion
When learned as a complete system, the care available to patients through Traditional Thai Medicine is comprehensive and specific, working with the natural systems of the body in the context of nature to find balance. The traditional method of learning this system is also extremely valuable in that it requires practitioners to develop relationships with teachers and the knowledge they receive, providing true understanding and the support necessary to practice with kindness, compassion and confidence.
This paper has been written and presented with gratitude to my primary teachers Nephyr Jacobsen of The Naga Center, LLC and Tevijjo Yogi.
Sources/Resources
Haddad, Bob. 2013. Thai Massage & Thai Healing Arts: Practice, Culture and Spirituality. Forres, Scotland: Findhorn Press. Jacobsen, Nephyr. 2015. Seven Peppercorns: Traditional Thai Medical Theory For Bodyworkers. Forres, Scotland: Findhorn Press.
Jacobsen, Nephyr and Salguero, Pierce. 2014. Thai Herbal Medicine: Traditional Recipes for Health and Harmony. Forres, Scotland: Findhorn Press.
References
1. Over the past several hundred years or more, various efforts have been made, regionally and nationally, to collect, condense and preserve traditional medical knowledge.
2. Though it is important to note the regional and cultural differences between the local medical systems of Thailand, such as Lanna medicine, for ease of reference, use of the term Traditional Thai Medicine or TTM in this paper encompass all of the medical systems of Thailand, past and present.
The purpose of this case study is to encourage the modern acupuncturist to perform a thorough History & Physical exam (H & P), approach each patient with kindness and honesty, admit when there are unfamiliar concepts and findings, know when to treat, how to treat, and when to refer. The importance of a thorough and detailed H & P cannot be over emphasized. Question-Asking, Observation, and Palpation are some of the diagnostic techniques taught in Chinese Medical Schools. As basic as these techniques are, they are some of the most crucial skills to incorporate with each patient interaction. Even the most astute clinician needs to be focused on the full set of data points prior to making a diagnosis and pursuing a treatment strategy. The Law of the Instrument is often well appreciated and understood in the medical community. The surgeon recommends surgery. The homeopath recommends homeopathic remedies. The acupuncturist recommends acupuncture. Of course, as clinicians we can be biased to use tools that are within our own “tool box.” When choosing a tool to use, how wonderful to choose one with which we are not only familiar, but one we already possess! Upon examining the contents of your tool box, it is important to not only see what IS there, but to see what IS NOT there. To illustrate this concept in action, let’s meet Katie.
“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” – Abraham H. Maslow (1966)i
THE FIRST PATIENT ENCOUNTER
Email is often my first interaction with a potential new patient. It was January 7, 2015 at 09:06am when I received an email from Katie:
“Hi Amy,
I was hoping to set-up an appointment with you at your earliest availability. Here’s my situation: Last month, I was working out rather strenuously as I was participating in a 30-day workout challenge. The nature of the exercise is barre (Dailey Method). I’ve been doing this for about 4.5 years, and have never experienced any issues. A few weeks ago, I had a particularly intense workout, and found that both of my knees and ankles felt really tight afterwards. The tightness continued, but this was rather normal and I expected it would subside in a few days. Over the past week, the situation has accelerated into really swollen ankles (particularly on the left side), and has made walking rather unbearable. I went to see a traditional doctor to make sure I didn’t injure my ankle/s, but they were rather dismissive and just said to rest. I would love another opinion, especially one that encompasses a natural healing process. I have never tried acupuncture, but am absolutely open to whatever seems like the right course of action. Please let me know when you might be able to see me. I am working from home today, and can easily get there if there is any availability.
Thanks much,
Katie M.”
There were many details in Katie’s email that immediately engaged my attention. First of all, she was a good historian. I noticed that she had been experiencing symptoms for a few weeks, worsening in intensity. This fact demonstrated to me that this was not an acutely life threatening injury, and possibly a good fit for me as a clinician. She explained that the pain was in her knees and ankles and feels “tight.” The symptoms were progressing, and she reported swelling that was increasing, L>R, and that walking had become “rather unbearable.” That language caught my attention. “Unbearable” is obviously a subjective descriptor, however it illustrates the intensity of the pain. Katie also explained that she had already seen a traditional doctor, which I later discovered was a medical doctor (MD). This fact was “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” – Abraham H. Maslow (1966)i OM CLINICAL MEDICINE also reassuring to me. Lastly, I knew that if she was experiencing anything really serious or concerning that the MD surely would have diagnosed and treated accordingly. Of course, I agreed to see her later that same day.
Now that you have been introduced to Katie, let’s get back to the toolbox.
THE TOOLBOX
What clinical tools do you have that are most familiar, accessible, and valuable to you? As an acupuncturist, you may answer this question by listing:
Acupuncture needles
Electric stimulation
Moxibustion
Cupping
The Materia Medica
This list, although not exhaustive, is an appropriate answer to the question. However – this list is also a list of potential interventions. In other words, these interventions are therapeutic tools.
In clinical practice, there are some other tools in your toolbox that will also serve you well—diagnostic tools. Some of the most dependable diagnostic tools you already possess include:
Question-Asking
History Taking
Physical exam including palpation, listening, observation, and data collection
Intuition
The benefits of using each of these tools mindfully cannot be overemphasized. Whether you are a new acupuncturist or a seasoned acupuncturist, proper use of diagnostic tools will always help you choose from the therapeutic tools with more ease and effectiveness.
The differentiation between diagnostic and therapeutic tools may seem obvious and completely unnecessary. However – in my experience—I have found this exact differentiation to be critical in identifying who needs treatment, and what treatment they require.
MAVERICKS OF MEDICINE
In my career, I have had the privilege of working in some of the most prestigious teaching hospitals in the nation.
Here is an anecdote that demonstrates this concept quite well from my experience working as a clinical instructor for the paramedic program in 2003. Each shift, I was assigned three paramedic students to train in the emergency department at the level-one trauma center in San Francisco, California. Each time I would ask, “What would you like to learn today?” And the answer would always be, “IV’s!” (intravenous catheter placement.) Every trauma nurse and paramedic eventually masters this skill. It is indeed an important and potentially life-saving intervention for many a patient. And, I knew that each of these paramedic mavericks would master it in six to eight months no matter what I taught them on this particular day. With this in mind I would then softly explain, “Placing an IV is a skill you will soon master, but what good is this skill if you don’t know which patient actually needs an IV?”
Complete silence. Every time.
Instead of placing IV’s for ten hours, I would always recommend that we spend our time more thoughtfully by assessing patients, asking questions, auscultating lung and heart sounds, and paying attention to other subtle findings such as moist skin and a mild grimace on the face. Oftentimes, these data points collected through a history and physical exam are the most revealing when determining what interventions are not only appropriate, but actually indicated.
I share this story because focusing on assessing a patient properly will facilitate the clinician to reach for the right tool at the right time. Whatever the credentials or licenses you may hold, having good assessment skills will always serve you well. Performing a thorough history and physical exam is a critical step for both seasoned and inexperienced clinicians.
KATIE’S VISIT
Fortunately, I was able to see Katie sameday, and offered her an appointment for consultation and treatment at my BiaoHealth clinic in San Francisco.
Katie is a 45-year old female with no previous medical history. She is in good physical shape, and exercises daily. She is alert, articulate, and well-appearing upon initial observation. Her breathing is even and unlabored. Her skin is appropriately pink. She looks well-nourished and seems to be an appropriate weight for her height. She makes eye-contact and answers questions appropriately. As we used to say in the hospital setting, “She eyeballs well,” meaning—she looks good. She does not look ill or sick. That being the case, we proceed with the formal consultation.
The history taking reveals some further details about her relationship to exercise, when the pain started, and the actual physical activity of the barre 30-day challenge (Dailey Method). I was previously unfamiliar with this type of exercise—and this of course prompted me to inquire more about the routine. This exercise sounds rigorous and challenging; a type of cardioaerobics workout with some impact from body weight and gravity—but definitely not the type of clinical picture that leads to an injury, per se.
After completing her consultation, I escorted Katie to the acupuncture treatment suite. Once she was settled comfortably onto the table, I proceeded to obtain pulse and tongue diagnosis data points. Her pulse was wiry. The tongue was red, slightly dry, and without a substantial fur coating. The red color a bit more beefy red than I expected to find. I documented her resting heart rate at 80-BPM. I then continued onward with my physical assessment. I explained that I would be exposing her legs to assess her knees and ankles.
As I lifted up the sheet and blanket to expose her lower extremities, my jaw dropped. I was stunned by what I found. Physical exam revealed two very abnormal appearing lower extremities. There were multiple erythematous swollen nodules of various sizes—from marble size to golf-ball size scattered about her lower extremities, bilaterally, below the knees. They had the consistency of lipomas, dense, but movable. They varied in size but also in the color of red. Some were more of a sunburn-red erythema, and others had “faded” almost to a purplish-red typical of a bruise. Not only were there erythematous nodules, but I also found that her legs were especially swollen, edematous and tight, the left more-so than the right. As I began to assess this situation further, I placed my hand on her left ankle. Hot to the touch. This was definitely the most concerning, as I was sure there was some type of inflammation, and perhaps even infection. It was not clear. But one thing that was clear: These were NOT the legs I was expecting to find.
I paused. I was thinking so many different things all at once. I wanted to reassure Katie that I could help her. She must have been in a lot of pain! These legs looked painful! Very painful! She is most definitely a stoic person, and I was trying to understand how she had been walking on those legs at all. She explained that it felt like “handcuffs around her ankles.” It took me no time at all to realize that her story didn’t match the physical findings. There was no way that those legs were simply the result of a strenuous workout. There was something much more systemic underlying the presentation. The entire exercise story, although a true recount of historical events, may have had nothing to do with this patient’s presentation.
I still had my hand on her left ankle, proceeding with lower extremity pulse assessments, as I asked, “You mentioned that you saw a medical doctor just two days ago. Is that right? Did your legs look like this two days ago when you saw the doctor?” She tells me yes. I next mentioned the red nodules on her legs. She honestly replied that this was not her focus, that really the ankles were the most painful. She then explained to me that the doctor did not look at her legs. The doctor instead told her that she should rest and perhaps take some ibuprofen to reduce the swelling and pain.
Photo courtesy of BiaoHealth, LLC.
The doctor didn’t assess her legs? I was shocked. I immediately understood my assumption that nothing serious could be going on because she had been evaluated by a medical doctor was not necessarily reliable.
INTUITION – THE VISCERAL TOOL
I have seen many legs over the years – many legs on many people, and I can tell you that I had never seen any legs that looked just like Katie’s legs. So, that being said, I wasn’t sure “what” my physical assessment had revealed.
I will always be grateful that my intuition has been so available and reliable. Even though it was not clear to me what the underlying manifestation of Katie’s condition was, I was confident that acupuncture was not appropriate in this case.
THE SHARPEST TOOL
I explained to Katie that I felt that a medical doctor (MD) needed to examine her legs and that she likely required a thorough work-up for this presentation. “Our bodies give us symptoms for a reason,” I explained. “We have an opportunity to listen to our bodies. And right now, your body is proclaiming that something is wrong.” I also explained to Katie that I was determined to help her, and with that being said, I felt that acupuncture was completely out of the question on that visit. I explained that we could very likely do acupuncture at some time in the future but today was not the day. This was of course a delicate matter because I did not want to disappoint her.
I had already used the most valuable tool in my toolbox, physical assessment and taking a good history I had also already decided which tool I was NOT using: Acupuncture. Fortunately, I had some other accessible tools, and offered Katie some sound therapy and guided imagery meditation for fifteen or twenty minutes. She had already come all this way to see me and finally lying on the table must have been a brief respite from the pain—so this solution made sense to me. Katie agreed.
During Katie’s guided imagery session, I was engrossed in my literature scrub on the internet and in my textbooks trying to determine what this assessment finding was that I had never seen before. Fortunately for me, the answer actually came very quickly – and I was fairly confident that I had found the answer: Erythema Nodosum (EN).
Photo courtesy of BiaoHealth, LLC.
ERYTHEMA NODOSUM
Erythema Nodosum – (definition) Red, painful nodules on the legs.ii I read the description of EN in Taber’s Medical dictionary—and realized at this point, EN is not a disease, but an assessment finding.
[Generally, EN is idiopathic, although the most common identifiable cause is streptococcal pharyngitis. Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, bacterial or deep fungal infection, sarcoidosis, inflammatory bowel disease, or cancer. Certain drugs, including oral contraceptives and some antibiotics, also may be etiologic. The hallmark of erythema nodosum is tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities. Erythema nodosum does not ulcerate and usually resolves without atrophy or scarring. Most direct and indirect evidence supports the involvement of a type IV delayed hypersensitivity response to numerous antigens.]iii
It would be comparable to seeing hives for the first time. Hives is an assessment finding that indicates a histamine release of a nonspecific etiology. EN is an assessment finding, and requires investigation. Sometimes the etiology is unknown, and in any case it does require an extensive workup.
I knew that the best way for me to help Katie was to refer. I explained to her the importance of requesting additional examination and testing by an MD as well as the importance of following up immediately— meaning tomorrow morning. I prepared a letter for her to take to her doctor for her convenience. I explained to Katie that sometimes I never know exactly how I’m going to help someone—the “how” reveals itself later. But for Katie, the answer was clear. She needed me to do a good physical assessment and refer her to an MD.
THE REFERRAL
In the referral letter for Katie’s doctor, I conveyed the subjective and objective assessment findings and encouraged a comprehensive evaluation and diagnostic work-up. I shared that I was concerned that it was a presentation of Erythema Nodosum with the hopes that she would be evaluated thoroughly for her symptoms and underlying etiology. I accompanied the letter with the following recommendations to be included in her diagnostic work-up:
CBC with differential
CXR
Stool examination
ESR
CRP
Serum CA++
ACE
Coagulation Panel
THE DIAGNOSIS & TREATMENT
Katie was well received by the medical doctors at her primary care clinic. In fact, she was seen immediately—the following day after meeting with me. She tells me that the doctor was appreciative of the letter I had written and proceeded to order not only the bloodwork and radiological studies I had recommended, but also included a 3-view x-ray series of her left ankle, an x-ray and CT scan of the chest, a referral to a Rheumatologist, and eventually an Ophthalmologist. Katie was started on a pharmaceutical called meloxicam to reduce the swelling. Additionally, a steroid, prednisone was prescribed, although Katie was resistant to using the steroid unless absolutely necessary. For those readers that may be interested in the detailed results of the bloodwork; her chemistry panel was unremarkable, the Complete Blood Count (CBC) was also unremarkable, aside from an elevated platelet count at 469. Her C-Reactive protein (CRP) however was elevated at 13.4, which was significant. Liver Function Tests (LFTs) completely normal. The results of the radiologic studies were thorough and conclusive.
Katie continued her diagnostic work-up and was eventually diagnosed with Erythema Nodosum consistent with Sarcoidosis.
She was in complete remission after several weeks of our initial encounter. Her chest CT was negative, and she ruled-out for any additional complications. The good news is that it has now been nearly one year since Katie first walked into my clinic, and she routinely sees me for acupuncture in promoting health and wellness, and stress management. Katie still loves the sound therapy and guided imagery as well as the acupuncture treatments. She is considering a full diagnostic evaluation through a Functional Medicine lens, which we will likely pursue together in 2016.
CONCLUSION
An acupuncturist needs to know when NOT to treat with acupuncture. An acupuncturist needs to be mindful of other tools that may be beneficial for the patient. Sometimes this includes listening to a patient’s story, implementing non-needle modalities such as sound therapy or guided imagery, and most importantly—when to refer. Remember, there will always be clinical presentations with which you are unfamiliar. It’s okay not to know everything. But pay attention to your intuition, and it will serve you well.
DISCUSSION
For you, the new or seasoned acupuncturist, I am hopeful that my case study encourages you to examine the tools in your toolbox. Which are you using most often? Which are getting dull? Which need to be sharpened? Do you need some new tools? Do you have more therapeutic tools than diagnostic tools? How much can you rely on your diagnostic tools? What about your own intuition? How often do you refer to other clinical specialists? Do you know when you don’t know? What is the best you can do for each patient with each encounter?
It’s true that experience is valuable. In fact, my clinical experience has created a lot of buoyancy for me in private practice. The truth is that even with twenty years’ experience in emergency nursing, there will always be a clinical presentation in my acupuncture practice that I have never seen. This patient encounter is one I will never forget. I am grateful that I trusted my intuition, that I knew how to help Katie, and that she benefited from my interventions. I am also grateful for the opportunity to share this with you and I hope that this case study benefits you and your patients in some way.
References
i. Abraham Maslow. The Psychology of Science: A Reconnaissance. Chapel Hill, NC: Maurice Bassett Publishing. 1969.
ii. Taber’s Cyclopedic Medical Dictionary, 18th Edition. FA Davis Company. 1997, p. 668.
iii. Robert A. Schwartz, M.D., M.P.H., and Stephen J. Nervi, M.D. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007 Mar 1;75(5):695-700.
About JAIM
For over 30 years, the Journal of Acupuncture & Integrative Medicine (JAIM) has earned a reputation for quality, integrity, and timeliness among the acupuncture and integrative medical community.
Learning to grow undomesticated and largely unselected plants and bring them under cultivation has been surprisingly difficult with some species. The tendency is to grow them as if they were vegetables. That method will often serve when growing superior or food grade herbs—herbs that are food stuffs. Chinese herbal medicine is historically based on the qualities of wild origin herbs that have been subjected to the stressors of nature. Plants that are stressed release chemicals in response to the availability of nutrition, quality of soil, water distribution, the effects of UV, pest pressures, etc. Ignoring that some herbs are regionally specific and to further provide an easy life for them by providing optimal food grade growing conditions impacts the potency of their medicinal actions and does not tend to imbue them with the expected clinical outcomes.
