The Herbalist’s Corner
Jake Paul Fratkin, OMD, L.Ac.
This question should actually be divided into several questions. First, what level of Western medical training is appropriate for the TCM herbalist? Second, if the patient does not come with important lab tests, should we be ordering them? And if so, which ones?
While skilled acupuncturists might go about their work without deeper medical training, relying on their hands as their chief diagnostic tool, herbalists are more often treating patients with significant medical conditions and history. Certainly, there are many TCM herbalists who prefer the classical approach, that despite (or in ignorance of) medical diagnosis, they will prescribe herbs based on pulse, tongue and history alone, and of course get good results. My feeling, however, is that without knowledge of their medical diagnosis, they are working in the dark. They cannot make accurate predictions as to the course of the illness. They may be missing something quite important that would affect their own prescribing, or more importantly, the need for medical intervention.
How much Western medical training is necessary for the American TCM herbalist? Here, I defer to the experience of our colleagues in China. My advanced training was in China, and the herbalists there go through 2 years of medical sciences prior to training in TCM. Although not to the degree of Western medical doctors, in the TCM urban hospitals doctors will often order blood tests and imaging to diagnose infections, autoimmune illness, organ involvement, etc; they also use those tests to monitor improvement. In America, training in medical sciences and diagnosis is reaching good levels at certain TCM schools in the West coast and Texas, but most of the schools offer sub-standard training for a Master-degree health practitioner program.
We need to accept the fact that TCM practitioners in the field are primary care providers for many of their patients. This will only increase as health insurance rates skyrocket. Burdened with exorbitantly high deductibles, people will use TCM practitioners for interventions and therapies that offer real improvement early on.
As primary care providers, how many of us can say that we have the medical level of a nurse practitioner, a physician’s assistant, a naturopath, a physical therapist? The future will see medical doctors gravitating towards specializations, while NP, PA and PTs will become the primary care givers and gatekeepers. This should be our role as well, and we will need to know what and when to refer. My argument leads us to consider a medical training that equals that of a nurse practitioner or physician’s assistant. This should be given by bona-fide health science centers, not casually as is currently offered in the acupuncture schools.
I would like to talk about the importance of medical diagnosis for influencing the choices of the TCM herbalist. Our patients may or may not come with a medical diagnosis, but when they do, it helps guide treatment and monitor progress for many conditions. I am thinking of GERDS, diabetes type 2, bacterial infection, prostatic hypertrophy, mononucleosis, autoimmune disease, heart disease, ulcerative bowel disease, gallstones, uterine fibroid, ovarian cyst, etc. In these conditions, when the patient arrives without a diagnosis, we are truly lost. The prudent thing is to send them for medical evaluation. If we obtain a targeted medical condition, we can focus on treatment more appropriately.
Since 1990, the newer generation of English language TCM textbooks from China (People’s Medical Publishing House, Shanghai College of TCM Press, Higher Education Press, Academy Press, etc), have included the treatment of medical conditions using TCM differentiations and herbal treatments. For example, People’s Medical Publishing House and Shanghai College of TCM Press offer individual textbooks on the treatment of diabetes, ulcerative colitis, nephritis, hepatitis etc. We wallow in ignorance if we do not avail ourselves of the current treatment approaches offered in China.
Besides having a medical diagnosis from an MD, there are various medical diagnostic tools that we need to familiarize ourselves with. You do not need to be able to read MRIs or CT scans, but you should be comfortable reading written reports from radiologists, surgeons, GI specialists, gynecologists, orthopedic surgeons etc. If the patient comes in without a medical diagnosis, it is your responsibility to refer them for proper evaluation.
For example, when a patient comes in with epigastric or abdominal pain, it’s important to know if patients have been diagnosed with gallstones, kidney stones, ulcerations, fibroids, tumors, endometriosis, pancreatitis, etc. This directs your herbal treatment. If the diagnosis is pancreatitis, for example, our herbal treatments will be quite different than if the patient has a duodenal ulcer or gallstone. On the other hand, if medical diagnosis has ruled out any perceived organic problem, it shows a functional disturbance allowing us to proceed with herbal formulas based on TCM differentiation. In spite of a diagnosis of a serious condition, however, the experienced herbalist should not assume that medical intervention is required or preferable. TCM herbal medicine is effective for the following epigastric and abdominal disorders: gallstones, gallbladder inflammation, appendicitis, uterine fibroid (when small), ulcerations, pancreatitis, kidney stones, etc.
Although ordering diagnostic imagery may be beyond our expertise, there is no excuse for not being familiar with common blood tests, and having the lab privilege to order them. I see no reason to expect our patients to have to make a special trip to a medical doctor, with its added expense, inconvenience and delay. In many cases, also, the medical doctor decides that he/she does not want to run that test, or questions the presumption of an alternative healer.
What level of blood testing is appropriate for the TCM herbalist? At the very least, we should be familiar with the general chemistry panel, lipid profile and CBC (complete blood count). The chemistry panel, for example, can show us elevated liver enzymes, which indicate liver inflammation and may flag the presence of undiagnosed Hepatitis C. BUN, creatinine and uric acid can point us to kidney insufficiency.
Lipid testing allows us to advise on dietary control as well as offer herbal solutions. In addition, we can ask for circulatory inflammatory markers that are more indicative of heart disease risk than lipids alone. These include highly sensitive C-reactive protein, homocysteine, fibrinogen etc.
In infectious disorders, the use of a CBC blood test can flag viral and bacterial infections. For those who feel that bacterial infections are the domain of medical doctors, I disagree. Epithelial infections of the nose, throat, lung, skin and bladder are better treated with Chinese herbs then antibiotics, while deep infections may require referral to MDs for antibiotics or even hospitalization.
In addition to the basic chem panel, lipids and CBC, other important tests include thyroid panels (TSH, free T3 and free T4), glucose tolerance, insulin, PSA (prostate specific antigen) as well as possible protozoan infections such as Giardia. Chinese medicine, again, offers good intervention for early and middle stage imbalances.
The other use of lab testing that is appropriate for herbalists are the functional medicine tests that conventional MDs are unaware of. These include saliva testing for endocrine and hormone imbalances, stool tests for dysbiosis, intestinal inflammation and “leaky gut”; and blood tests for food allergies. I commonly use these. Many might say that this is the role of naturopaths and holistic MDs and DCs, but I think there is an argument for TCM herbalists to learn functional medicine. Our herbal solutions are often more effective and cheaper than the nutritional supplement solution. However, functional medicine labs will not extend accounts to licensed acupuncturists unless their state allows them to have lab privileges.
Towards this end, state acupuncture associations should actively lobby their state regulatory agencies to grant lab privileges. This, in turn, will mandate the acupuncture schools to upgrade their curriculums as well as providing continuing education opportunities for under-trained herbalists. Bear in mind that herbalists in China’s TCM hospitals are trained in ordering and interpreting blood and imagery tests, which they frequently do. If we are to achieve primary care status in this country (which already exists in California, New Mexico and Florida), we need to modernize to the China model, and obtain professional level training in Western medical sciences and diagnosis. To those who wish to retain the pre-20th century classical TCM posture, I say, remove your blinders, expand your knowledge base, and be available to your patients at the most professional level. In no way does this diminish your ability to use classical diagnosis to prescribe herbal formulas, but it will flag you to the potential seriousness of a patient’s condition, as well as allow you to predict more accurately the course of an illness.