Blue Beryl Blog
Knowledge and Skill Defined: Medical modes of attention, word and action
“Everyone who aspires to be a great physician must be intimately familiar with the following classics: the Simple Questions (Huangdi neijing suwen), the Systematic Classic of Acupuncture and Moxibustion (Zhenjiu jiayi jing), the Yellow Emperor’s Needle Classic (Huangdi neijing lingshu), and the Laws of Energy Circulation from the Hall of Enlightenment (Mingtang liuzhu). Furthermore, one must master the twelve channel systems, the three locations and nine positions of pulse diagnosis, the system of the five zang and the six fu organs, the concept of surface and interior, the acumoxa points, as well as the materia medica in the form of single herbs, herb pairs, and the classic formulas presented in the writings of Zhang Zhongjing (fl.150-219, author of the Shanghan zabing lun), Wang Shuhe (fl.210-286, author of the Maijing), Ruan Henan (4th century, author of the Ruan Henan yaofang), Fan Dongyang (fl.308-372, author of the Fan Dongyang fang), Zhang Miao (4th century), Jin Shao (4th century) and other masters.
In addition, one should have a masterful grasp of the science of determining the Yin-Yang of destiny (yinyang lu ming), all schools of physiognomy (xiangfa), and the divinatory technique of interpreting the five omens in fire-cracked turtle shells (shaogui wuzhao), as well as the skill of Book of Change divination utilizing the system of the heavenly stems and earthly branches forming a cycle of sixty years (Zhouyi liuren). It is imperative that one masters all of these methods with the depth of an expert, only then can one become a great physician. Without this knowledge, it will be like having no eyes or stumbling around at night—one will be destined to fall down and be done at the outset.
Sun Simiao, How a Great Physician Should Train for the Practice of Medicine. Tr. Fruehauf, Heiner
The famed medical authority Sun Simiao is discussing the contents and breadth of knowledge, as well as the arduous discipline of learning, that fosters medical expertise. Having penned these words in the Tang dynasty, his statement attests to the rapid development of an extensive medical corpus in just a few centuries after the Han dynasty. The historical personage of Sun Simiao remains a cultural symbol for medical expertise and a wisdom that is almost revelatory in nature. He is esteemed for his medical virtuosity, envisioned as an accomplished physician and healer whose inquiry plunged the depths of learning and medical investigation, and emerged with great insight into the workings of the universe and the courses and causes of disease and their rectification. This inquiry into the “medical”—an epistemological, existential and clinical reflective process, informed by a body of traditional experience that has encountered the face of suffering for millennia—serves as a model for aspiring students and clinicians. It frames the development of knowledge and skill, and forms the basis of experience (jing yan) and consummate or profound medical knowledge (shen’ ao) (Hsu, 1999:227).
The rather lofty ideals and extensive list of areas of medical knowledge offered above could only be compounded by further centuries of investigation and experience, leaving a contemporary practitioner bewildered by the question of just what constitutes knowledge in Chinese medical practice. Of course, Sun Simiao’s statement is meant to be instructive and serve as an admonition for future generations to persevere while maintaining a healthy perspective on individual levels of attainment in knowledge and expertise, whilst continuing to reference traditional norms in their course of personal development.
“Knowing Chinese medicine meant acquiring profound knowledge by memorizing the ‘experience’ (jing yan) of the ancients in the text and combining it with one’s own experience in medical practice.” Yet texts are full of apparent contradictions and complexities with regard to Chinese medical theory (Farquhar,1994: 37). Even in the case of the seminal classic, Nei Jing (Inner Cannon) early medical authorities found the need to clarify central points of medical doctrine. Hence the publication of the Nan Jing (Classic of Difficulties) and its many commentaries, a work itself meant to elaborate upon and clarify terse passages and inconsistencies in the foundational medical texts of Chinese tradition. Are these to be proverbially resolved in effective clinical practice? Farquhar offers, “The two most usual responses to these contradictions have been to generalize to a point that transcends the difficulty but leaves medicine looking a lot like mysticism or superstition or to resolve the perceived contradictions with reference to a few carefully selected loci of authority in the classical texts, thereby creating new theory in an attempt to rectify or purify an essential Chinese medicine.” When challenged with extreme confusion or limitation, scholar physicians such as Ye Tian Shi developed and vocalized their own ideas, simply because they knew the diseases they were treating could not be effaced by irrelevant models of disease causation.
Sound medical knowledge, located in actual clinical modes of practice, is guided by textual study. “Profound” knowledge was not verbally explicated, yet was to emerge through years of rigorous study and extensive clinical practice. Mentorship or discipleship would require the student to become grounded in the principles of medicine and the style of treatment of one’s teacher, and might open the way to access “private techniques of diagnosing and prescribing (Scheid, 2007:278), perhaps only alluded to in texts, or developed incidentally, through trial and error. Texts later became didactic tools for transmission of forms of knowledge meant to be expressed in action, rather than knowledge divorced from discrete methods of treatment and practice. A contradiction stands that there are numerous traditional methods and principles that have no embodiment in known or extant forms of contemporary practice, while clinicians may continue to source from traditional lore, claiming to adhere to traditional norms in a desire to appear consistent with tradition, having their work substantiated by canonical authority. Medical practice is a separate discipline then archaeology.
Farquhar explains, “A focus on the clinical work of Chinese medicine that privileges the practical and the temporal reveals Chinese medical classification as a method of deploying material from the medical archive within specific projects of healing, a continuing subordination of formalized knowledge to the concrete demands of the moment.” (p.38) She raises the question of whether in this system of epistemological checks and balances if practice is “disembodied (p.39) and continues on to point out that “flexibility and responsiveness of knowledge constructs are more valued in Chinese medical practice than are explanatory ‘rigor’ or generalized predictive power (p. 39).”
Knowledge in Chinese medicine is neither absolutely fixed, as evidence in countless interpretive approaches abound in the commentarial literature. Nor is it disembodied. Theory and practice are enjoined in observable clinical behaviors, demonstrated in practical clinical skills and interventions. Nor is it bound to traditional models found in canonical lore. Modern clinicians draw knowledge from clinical studies, epidemiology, and contemporary case records to guide decision-making processes for modern conditions. Traditional knowledge based in canonical texts and transmitted through social networks and relationships, is reworked and transformed in an active discourse amidst contemporary health care settings, delimited by scope of practice within professional fields, and embodied in kan bing and temporal sequence of decision-making processes of modern practitioners.
Skill can be classified along lines of craftsmanship, artistry and mastery, stemming from a reliance on technical performances, to decision-making capacities involving flexibility and improvisation, to profound knowledge, which stems from learning and vast clinical experience. There is a fine line between skill and notions of efficacy, virtuosity, and personal style.
Scheid (2007) speaks of the medical style of Fei Boxiong, who emphasized gentle and harmonizing methods, which steered away from dramatic results and side effects due to toxicity, and prescribed formulas that were cost effective and able to be consumed over longer periods of time. Using the phrase “medicine of the refined” (based on a translation of a title of one of his works), he describes Fei Boxiong as a clinician and teacher who emphasized personal understanding cultivated from a rooting in canonical principles and methods, arduous toiling in study, but emerged with a responsiveness and subtlety to the needs of his (her) patient base.
Hence skill is knowledge cultivated and performed. Aspects of skill pertain to tacit knowledge, and require disciplined performance. At first observation, emulation and repetition constitute a large portion of practical endeavors, while reflection and study are components which, over time, shape the way a practitioner molds their experience and personal understanding in ways that forge a unique style of practice.
Proverbially, skill is the cultivation of a therapeutic method, ideologically to the point that it becomes inseparable from the individual clinician and their experiential base of knowledge. Applied knowledge is not purely objective or subjective in this regard, but an interplay of dynamic processes of analysis, reflection, attention and action. Practitioners cultivate knowledge of traditional methods to assist them in dealing with clinical situations, and yet there is a private sense of knowing by which therapeutic methods are not treated as external measures, but are themselves expressions of an intrinsic capacity of not only comprehending but also acting upon specific disease courses in manners that become available from an internal resource. While skill and knowledge can be said to be modes of medical attention and action, cultivation here takes on a meaning by which a sense of resourcefulness is accessed, whereby outward behaviors or drugs of choice become secondary. These manners and means of medicine are secondary to the internal development of a medical practitioner. In these ways study, ethical rigor and contemplation formed essential components of medical discipline, seen as a personal journey to intuit and overcome sources of suffering phenomenologically—as if to contact the heart of illness and directly experience it in one’s self and to direct treatment from a place of connection, compassion an inner knowing.
Skill is also meted out in tangible realms. Skill involves intimate and personal understanding surrounding how to address aspects of individual circumstance relevant to life processes and phases, including age, sex, and socio-economic conditions relevant to patient concerns, and according to specific sub-disciplines of medical practice, for example—geriatrics or obstetrics and gynecology. The analytic power of any medical mode of attention, classical or modern, is engaged differently according to each set of circumstances regarding individual patient’s lives and health status.
Skill has as much to do with personal style and efficacy as it does with the application of learned knowledge, whether acquired through academic endeavors, private mentorship, secret transmission, or through experience gained through trial and error. Ultimately skill is inseparable from one’s own cognitive style, perceptual aptitude and depth of training, as well as the embodiment of all of these in therapeutic intervention. Skill is found in word, action, thought and reasoning, yet emerges from intention and awareness.
 Sun Simiao is perhaps the most famed of medical figures in Chinese history. The above quote is quite telling in that one finds that his notion of a great physician encompasses shaman, scholar, sage and diviner. In particular culturo-historical contexts this change in role mirrored the social and political influences that shaped medicine in various periods and local contexts. One of the earliest canonical works mentioned was the Nei Jing. Attributed to the Huang Lao school or syncretism. Prior to this time, Chinese dynastic civilization was preceded by the Shang and Chou, whose understanding of suffering and ill health preceded the pragmatic, and “rational medicine” established in the classics of the Han dynasty. Among causes of illness characteristic upheld by the Shang was (Unschuld, 25) an evil wind, which could be cast aside by the wu-shaman, who practiced a form of “demonic medicine” (Unschuld, 26). Ancestral ties were also primary causes of disease. This ideology was maintained in the Chou culture and even to this day, Unschuld notes a common consideration of reciprocity lending to the health of a family and community (Unschuld, 27), part of folk religious ideas that stemmed from Shang kings propitiation of ancestors to maintain their political power. As is commonly noted, kinship ties extend the influence into the medical and also at a larger level, in state societies, largely define what is medicine and who can practice it. The Han Dynasty is the bedrock from which Chinese medical history arose, and the Inner Cannon (Nei Jing) and Treatise on Febrile Disorders due to Cold Damage, of Zhang Zhong Jing (Shang Han Zha Bing Lun) are a reference point for establishing canonical authority in Chinese medical history. The Nan Jing followed, as an elaboration on difficult medical issues, a testament to the commentarial tradition that would follow. The Han medical works form the foundation for establishing innovation, elaboration, as well as modernization, that mark the epochal and cyclic transformations of tradition.
The sage healers of ancient times were able to heal the heart of humanity, and thus prevent disease from arising. Today’s doctors only know how to treat disease when it has already manifested in physical form, and don’t know anymore how to work with the heart. This situation can be compared to the process of pruning tree branches while neglecting the tap root, or to working downstream without awareness of the properties of the wellspring. Is this not an ignorant way to go about the business of medicine? If you wish to bring about real healing, you must first and foremost treat a person’s heart. You must bring the heart on the right path, so that it can be filled and sustained by a universal sense of truth. You must get it to a place where it can safely abandon all doubting and worrying and obsessing in senselessly looping patterns, where it can let go of any anxiety provoking imbalances, and where it is willing to surrender all “me, me, me” and all “this is his/her fault!” Try and awaken the heart to acknowledge and regret all the wrong that one has done, to lay down all selfish attachments, and to transform one’s small and self-centered world for the glorious universe wherein we are all one, and wherein there is nothing to do but praise its existence. This is the master method of the enlightened physician–healing through the heart. Or, in different words from the ancient record: the enlightened doctor intervenes before physical disease manifests, while the average physician springs into action only after disease has become apparent. To treat before this stage, this is the terrain of healing the core—the heart; to treat afterwards, this is the realm of dietary therapy, herbal therapy, acupuncture, and moxibustion. Although there are these two types of therapeutic paths, there is really only one core law of healing: All disease comes from the heart.
Hur Jun (Chinese: Xu Jun) All Disease Comes From the Heart, from Dongyi baojian (Precious Reflections by an Eastern Physician). Tr. Fruehauf, Heiner
The heart of Chinese medical practice lies is in the transformation of suffering. Self-cultivation is acknowledged as the means by which one can enter into the root of disease, which paradoxically, is also wellspring of health. One of the earliest dialectics forming therapeutic intervention is known as root and branch determination, or ben and biao respectively. The Korean physician Hur Jun plays on the metaphor of the heart as the root of suffering, and by treating at the level of the heart, or addressing any limited sense of self, one can eradicate disease at its source, and engage a process of “core healing.”
The extent to which self-cultivation serves a role in the cultivation of medical knowledge and skill in medical arts depends upon each practitioner’s disposition or proclivity. The role and parameters upon which personal development can be measured is subject to personal validation, yet that themes of self-cultivation have a long precedence in medical discipline is unquestionable.
The philosophical origins of Chinese medical tradition include Daoist and pre-Buddhist influences, yet through the ages Buddhist, Confucian and Neo-confucian values came to shape the orientation of practitioners in individual approaches to self-cultivation. Historically, many of the scholar physicians of whom Scheid offers biographical sketches were influenced by Neo-confucian values of self-cultivation and the development of sincerity (cheng) as a primary virtue. For many notable medical authorities, their affiliation with the ethical, religious and contemplative traditions of China guided their medical careers. Among them, Fei Boxiong advocated empathizing and connecting with the suffering of the patient, as a manner to maintain conscientiousness, and stressed the ethical cultivation at the heart of medicine. (Scheid, 106).
Hsu clarifies that for qigong healers, wellbeing is transmitted and that methods are trained in which a healer may become able to alter physiological states via transmission or working upon the vital energy of the patient. Hsu’s informant, Qiu di spoke of “nurturing the primordial qi through herbs, diet and meditation.” (Hsu, 71) These ideas have been prevalent since antiquity, in vogue primarily in Taoist religious contexts, including the adherence to alchemical practices and philosophies in the pursuit of longevity and immortality. Aside from clinical medicine, many noted medical authorities were concerned with these realms of quasi-religious practice and inner alchemy (nei dan), including Li Shi Zhen, in whose Qi Jing Ba Mai Kao (Exposition on the Eight Extraordinary Vessels) one finds a conscious inclusion of alchemical ideas and principles in discussing the core meridian systems of the body. While the “medical body” of the Inner Cannon had us glimpse the potentials of medicine in terms of preserving and extending life, further evidence of alchemical thought can be gleaned even in Shen Nong Ben Cao Jing, an early systematic presentation of herbal pharmacology. The concerns of medicine and that of religion arbitrated notions of physiology and bodily existence, such that the context for transforming suffering into wisdom took on varied directions.
Zhang Zhongjing’s art stems from academic learning, while Hua Tuo’s was the gift of enlightenment. When the heart awakens, the waves of change become maneuverable--this way of practicing is unique and may appear strange to others, and only a few may be able to follow the likes of Hua Tuo when studying his techniques. Realistically, therefore, academic instruction needs to begin with those essential details that can be a standard for generations of physicians. The archetype for this style of transmission is, of course, Zhang Zhongjing. His way within the Dao of medicine is the way of the constant. Hua Tuo, on the other hand, exemplifies the way of change that puts the constant to use. -Guo Yong, “Supplementation of What Has Been Lost from the Shanghan lun” (Shanghan buwang lun, 1181) tr. Fruehauf, Heiner.
Curiously, historian Paul U. Unschuld proceeds in his discussion on pragmatic drug therapy in Chinese medicine, in his foundational work Medicine in China: A History of Ideas, without referencing the works of Zhang Zhongjing. Rather, he begins his historical overview in this chapter with reference to Shen Nong Ben Cao Jing and the Nei Jing. The former is one of the earliest foundational works on Chinese pharmacology, the latter the seminal classic on acupuncture and Chinese medical theory in general. Zhang Zhongjing’s works form the foundations of Chinese internal medicine and herbal pharmacology. The two works annotated as the Shang Han Za Bing Lun was one of the earliest systematic treatments of herbal medicine, and serves as a basis of treatment in the classical method. His approach can be said to be a decisive move towards pragmatic, clinical framing of medical methods.
medical knowledge stems from the clinical methods and interventions discussed
in the canonical literature. The advent of printing in the Song dynasty paved
the way for further refinements of medical discourse among literate circles,
while the elaboration of medical ideas and practices have been prevalent amidst
a thriving commentarial traditions for centuries. The scholarly activity in the
medical traditions of China, witnessed in developments during the Tang, Song,
Jin Yuan period, Ming and Qing dynasties, were also followed by modernization
and development of standardized curriculum since the middle of the twentieth
Formal academic learning based upon institutionalized models or frameworks serve as standards in modern and contemporary education in Chinese medicine. Aside from secret transmission whose arbitrary method has involved processes of imitation and repetition, and learning of personal styles of practice through proximity with accomplished and experience teacher/clinicians, the transmission of standard knowledge involves explanation (jieshi) as its key component (Hsu, 1999:165).
Hsu remarks, “The formulation of a theory that can be comprehended more or less in isolation from medical practice is among the most important steps in the standardization of knowledge. In theory, standards are easily established. (1999:228). This is also a difficulty in the standardization of practice, just as individualized treatment, at the heart of traditional Chinese medical rationale, stands in contrast with the modern emphasis on formulaic treatment based on standard protocols. Hsu continues, “In medical practice, even if it is institutionalized in clinics and thereby becomes more standardized, the particular problems a practitioner is faced with slow down any process of standardization.” Pragmatism and sophistication go hand in hand in actual clinical decision-making.
Hsu offers that (1999:128) standardization is related to institutionalization, professionalization and modernization of medical knowledge. Through didactic training according to modern models of education, alongside practical clinical methods, clinicians are trained in traditional and contemporary methods. The line between what is traditional and what may be deemed modern is blurred by the fact that tradition is always based on interpretation and application of theories and methodologies in the present (p.167). Standardized modes of transmission are based on explanatory models that are represented in modern TCM medical education.
Standard knowledge appears public (Hsu, 1999:164), yet there is an intention of a way of life being shared, and that is private. “The standardized transmission of knowledge is based on the belief that the complexities of knowing can be ‘explained; and that there is a ‘method’ of learning. (p.167).” This method involves explanation and concrete demonstration of clinical skills, memorization of texts, information and theories. It is learned through didactic models and classroom education, standardized in the formal curriculum of contemporary medical institutions. Didactic modes of education are public by nature, qualifications to acquire such are predominantly professional. (p.127).
All of these modes of acquiring knowledge deal with private to extended social networks.
Scheid’s (2007) recent work sheds light on the development of contemporary Chinese medical practice, situating as it were, the struggle of major individuals involved in updating and transforming medical traditions that have a direct influence on the training of professionals in present day educational institutions. He mentions Zhang Cigong who explicitly leaned toward modernization and engagement with modern scientific and technological developments. Alternately he mentions, Qin Bowei, who was gifted with extraordinary talents in classical scholarship and exegesis, as well as being one of contemporary China’s most gifted clinicians. Qin Bowei contributed to the shaping of modern education by relying on the canonical heritage as a fresh source of clinical inspiration. In either case, both influenced the standardization of contemporary Chinese medical education and the “remodeling of tradition.” Clinicians must exercise practicality. Demonstration of classical norms can never supercede patient needs.
Standardized medical knowledge itself was the result of cultural and political forces and was meant to synopsize various currents and perspectives on medical treatment. Modern students may take up a flatland approach to medical decision-making, and miss the various shades and depths of which a clinical presentation is revealed and can be understood and engaged. Scheid cites Fei Boxiong(1800-1879), a renowned menghe physician, “You must enter [Chinese medicine] via all the different schools [of thought] and then leave them behind. Grasp their quintessence and merge them into one single treatment [strategy that is appropriate the presenting condition](2007:160).” Such was the aspiration of many pioneers who were engaged in the standardization of Chinese medical knowledge, a fact that may not be clearly visible through reading modern textbooks on various subjects.