The following is a recent e-mail from my friend Amy:
I have had migraine/sinus headaches for a number of years. It is funny that they happen mostly on weekends, and I have tried several kinds of Chinese doctors such as herbal doctors, “chi-kung” massage/herbal doctors, and acupuncture/herbal doctors as well. Not much has helped until recently. I went back to the herbal doctor who treated me years ago (I did not get better then). He said my kidney is a bit weak, thus making my hormones imbalanced—I am not sure if this is the right term. Well, this time I am getting a bit better because my weekly headaches are not as severe as before. I asked the herbal doctor if I am close to menopause, but he answered not quite yet.
If you ask me why I do not go to a doctor who practices Western medicine, the answer is I have been to my family doctor and all he prescribes for headaches are painkillers, with the dosages getting higher. I have had an MRI and CAT scan done; nothing was wrong. That is why I turned to Chinese herbal doctors instead.
Amy’s plight is common to many patients with conditions for which mainstream Western medicine lacks satisfactory answers. The MRI and CAT scans were not helpful in either defining her condition or directing her doctor toward effective treatment. Her doctor prescribed stronger and stronger analgesics, but Amy wanted a cure, not just temporary pain relief. Her only recourse was to seek alternative caregivers without involving her primary care physician. Not knowing which type of practitioner would meet her needs, she sought a series of them. When she found one practitioner who seemed to help her, she was unsure of what he meant when he told her that her “kidneys were weak,” and there was no one to translate.
What began for me as a small family practice that additionally offered TCM in a sublet office space evolved into a busy practice. Patients like Amy were desperate for a Western physician sympathetic to and knowledgeable about alternative treatments. Although I could not subscribe to extreme deviations from allopathic medicine such as the Candida theory of disease or the environmental allergists’ approach of totally isolating patients from their environment, I did offer reasonable alternatives. I still used allopathic remedies for the majority of patients. For treating hypertension, I found that drugs were easier than herbs to titrate, but I sometimes supplemented a drug regimen with antihypertensive herbs. Over the years, various herbal teas came in and out of favor for lowering cholesterol, but when I let my patients take them and monitored their blood cholesterols, I found most were ineffective in changing their lab measurements. My patients with advanced coronary artery disease still underwent bypass surgery. After surgery, I would maintain them on the usual aspirin and cholesterol-lowering drugs and also supplement the drugs with herbs that promote blood flow. My diabetics still received diabetes teaching and drugs, but I prescribed Spleen tonifying herbs and also mobilizing-blood herbs to help with all the complications that accompany their disease. For women with severe menopausal symptoms, I prescribed hormone replacement for short-term relief at modest doses and supplemented with herbs for lowering Deficiency Fire (see chapter 2).
The challenge I faced was how to find ways to adapt ancient TCM treatments to a busy modern practice. I continued to use standard Western diagnostic methods, and if I recognized conditions for which I felt a TCM approach would be preferable, I presented patients with options and informed them of the respective pros and cons of each treatment plan. I pointed out that TCM would require more commitment of time and expense. In the early 1990s, it was rare for insurance companies to cover such treatments. I began to discover what a difference there was between TCM and allopathic medicine in terms of their demand on a practitioner’s time and energy. For acupuncture, the patient occupied one of my three treatment rooms for forty minutes. A steroid injection would have taken ten minutes at most. Clearly, my motive for continuing to use TCM was not profit-driven. I used it because I believed in its effectiveness and safety. I could write an allopathic prescription in a matter of seconds; if I used a TCM approach, I had to wait until the end of the day when I had the time to laboriously write a twelve- to fourteen-ingredient herbal prescription using Chinese script, which I would then mail to the patient. I really appreciated the advent of the fax machine, which eliminated a lot of mailing. Once, though, I dialed the wrong number and, much to their bewilderment, people working at a bank, instead of my patient, received the Chinese prescription.
As to the creed of mainstream medicine that steroids are the drugs of choice for joint injections, I had become an apostate. I had seen too many adverse effects and therefore looked for alternatives. A podiatrist, who practiced sports medicine using a complementary approach, told me he used a homeopathic solution for injecting soft tissue (Subotnick 1991, 199). When I began using it for injecting soft tissue inflammation, I was impressed with the results, and it became my injectable solution of choice. With steroids, after the local anesthetic wears off, the patient has an intensification of pain for the first one or two days before relief finally sets in. This did not occur with the homeopathic injection.
Another colleague, a physician acupuncturist, said that he succeeded in treating allergic rhinitis by using a vitamin B12 injection at acupuncture points around the nose. I adopted his technique. My results were unexpected and inexplicable. The best responders to this treatment were young males. For females and older men, the treatment had no effect. Every spring, a number of my younger male patients would come in for their injection into the Bitong acupuncture point for their hay fever, and they would be asymptomatic for the season.
I had discovered an herbalist who concentrated herbal formulas into tinctures. One of his tinctures was for colds and the flu. If taken early, at the first warning sign of the flu, when there was just a slight sore throat, it would stop the progression to full-blown symptoms. This led to another tradition among my patients. In the fall, about the time I began giving flu shots, mothers would come in to get a supply of the tincture to protect their families against the onslaught of the flu.
For patients who had flu that had progressed beyond the initial sore throat, I wrote three standardized prescriptions for different stages of the flu, and would merely copy the appropriate one for each patient. I individualized by adding a few herbs here and there.
Using TCM for a Cancer Patient
I continued to adhere to the standard of practice of the allopathic medical community. Because cancer patients were usually under the care of an oncologist who rarely approved of alternative treatments, I chose not to assume TCM care for those patients. I routinely referred them to Dr. Lai. An exception was Mrs. O. She had chosen me as her primary care physician through her HMO. Her options for health-care providers were limited to the HMO panel. Mrs. O. had a rare cancer of the muscle that had spread to her lungs. It was inoperable, and neither radiation nor chemotherapy was considered effective. In view of these circumstances, her oncologist had no objection to alternative treatments. I ventured to treat Mrs. O. with Chinese herbs using the principle of balancing cleansing herbs to fight the cancer and immune boosting herbs to help her body fight the disease. In her eighties, Mrs. O. remained functional with a good quality of life for her remaining two and a half years. She was an artist and continued to paint, and she was able to take public transportation everywhere.
Each winter, Mrs. O. suffered a bout of respiratory infection. Each time she responded well to an old and inexpensive antibiotic, ampicillin. I knew that with her lung metastases, her demise would most likely be from respiratory problems. I shared my plans for terminal care with her daughter. When the end was near, I would admit her mother not to the acute hospital but to a facility with a hospice-like setting, where she could receive oxygen and an intravenous morphine drip. Mrs. O.’s last days were as I had anticipated. Her daughter sat by her bedside, playing Mrs. O.’s favorite music on a cassette recorder, and in a matter of days, Mrs. O. passed on very peacefully.
Using TCM to Treat Avascular Necrosis of the Hip
Martha, in her late thirties, developed Stevens-Johnson syndrome, a rare allergic-type reaction, from taking an antiseizure drug. She became severely ill with a skin rash, mouth sores, and a high fever. She was hospitalized and treated with high doses of steroids. Two months after her discharge from the hospital, Martha told me she had pain in one hip. A dreaded complication of steroid therapy is avascular necrosis of the hip where the blood supply to the head of the femur (hipbone) becomes inadequate, and the bone disintegrates. I suspected this to be what was wrong, and my diagnosis was confirmed with a bone scan and MRI.
The orthopedist I consulted told me that sometimes even a very small dose of a steroid could cause avascular necrosis. At Martha’s young age, he did not advise a total hip replacement, which usually requires revisions about every ten years. He told me about an operation that involves making tiny holes in the head of the femur to stimulate circulation to this part of the bone, but it was not always successful. The Western options did not sound favorable. I consulted Dr. Lai to see if there were any effective TCM therapies. He advised me to use an herb formula often used for arthritis to increase circulation to the bone. After Martha had been on the formula for four months, the orthopedist repeated the MRI, and it showed some healing of the hip bone. When I retired eight years later, Martha still had not required surgery.
TCM’s Role in Cost Containment
During my later practice, something new in health care became increasingly prevalent: the Health Maintenance Organization (HMO) system. The concept is that health-care providers, including doctors, are paid only a flat fee up front whether the patient requires a lot of care or only a little. This puts the onus on the doctor to keep the patient as healthy as possible. The common goal of maintaining health to contain cost is sound. But I found the HMO’s method of rules and regulations often self-defeating. The ultimate arbiter of how a patient was managed was no longer the patient’s physician but some clerk with no medical background, a clerk who made life and death decisions by using an algorithm from an inert database. It seemed ironic that when I phoned to request approval of a test or treatment, the clerk on the other end of the phone would ask, “How do you spell that diagnosis?”
When I worked under a single HMO system, the rule was that every doctor was allotted enough time to see and treat six patients an hour, which meant ten minutes per patient, regardless of the complexity of the problem. I recall seeing a patient who had already made four visits without having his problem solved. On his fifth visit, I spent an extra five minutes to obtain a more detailed history, and, because of that effort, I was able to solve his problem. Yet I was criticized for spending more than the allotted time. The critics failed to compute the time spent on the patient’s four previous unfruitful visits.
In about the mid-1990s, some HMOs began covering acupuncture services. The medical director of the group I was affiliated with asked if I could help create guidelines for the use of acupuncture. I read the proposed guidelines, which stated, “Acupuncture is covered when all other forms of conventional therapy have been tried and failed.” What a paradox, I thought. HMO’s main goal is cost-effective care. If all other therapies had to be tried before the potentially effective one, acupuncture, is contemplated, the cost of care will escalate rather than being contained. I suggested deleting that guideline and replacing it with a list of conditions for which I knew acupuncture to be effective.
Focusing on cost containment, modern health delivery systems need to realize that time plays an important role in determining how patient care evolves. In earlier days, a common scenario was that when a patient called the doctor at night, the doctor would say, “Take two aspirins and call me in the morning.” There is more wisdom to this advice than first appears. If the body is given a chance, many conditions spontaneously resolve. For instance, when a patient first has a cough without fever, and his physical examination shows his lungs to be clear, a doctor will most likely wait a week or ten days to see if the symptoms resolve before launching into a costly workup. Often, if the cause of the symptoms is a common viral respiratory infection, the patient will get better on his or her own. If the symptoms persist, then the wheels of costly workup begin to roll, including X-rays, CT scans, and bronchoscopy. Depending on the condition, sometimes the test results are helpful but sometimes they are not.
A common example of how the cost of working up a persistent problem escalates can be seen with patients who suffer from soft tissue inflammation such as tendonitis and cervical or lumbar discitis. If the patient can be treated early with acupuncture and the symptoms resolve, no further workup is necessary. On the other hand, if initial treatment using Western modalities proves ineffective, the inevitable next step is costly imaging, such as an MRI. Often the MRI gives no definitive answers. I have repeatedly seen patients who have already spent thousands of dollars on tests that failed to point the way to definitive treatment before finally coming for acupuncture, which finally helped them.
The following three cases are examples of how using TCM resulted in considerable medical cost savings.
A Case of Cervical Disc Disease
Brenda, a patient in her mid-fifties, complained of one-sided neck pain radiating down the arm on the same side. I suspected she had a degenerative cervical disc, partially herniating and pinching the nerve to her arm. I planned to confirm my diagnosis with an X-ray and then treat with acupuncture. I told Brenda to go downstairs to the X-ray department. About twenty minutes later, Brenda returned saying the line in the X-ray department was very long and she would rather get the treatment first. I proceeded to acupuncture her for cervical disc disease. After the treatment, Brenda arose from the table. “I don’t need to go for the X-ray; my neck already feels much better,” she told me. I then gave Brenda a series of six treatments at weekly intervals, and she had no recurrences of her symptoms.
A Case of PMS and Infertility
Terry, in her late thirties, came to see me for acupuncture to treat severe PMS. Once, during that time of the month, her mind was so clouded that she drove into a parked car. She also had severe menstrual cramps. Suspecting she might have endometriosis, a condition that can involve severe menstrual pain, I asked if she had received a gynecology workup. She said she was considering it but wanted to try acupuncture first. After ten sessions, she improved greatly. She felt good before her periods, and they were no longer painful. Terry then told me that she had been married for four years and had never conceived despite not using contraception. I again asked if she had received a Western workup, and she again said she preferred to try acupuncture first. I continued acupuncturing her, and four months later, Terry became pregnant and later gave birth to a beautiful baby girl. When you consider the cost of today’s high-tech fertility treatments, acupuncture certainly is a viable option.
A Case of Obstructive Pulmonary Disease
My friend Irene was diagnosed with lung cancer twice. She was a nonsmoker who had no previous lung problems. The first time, she had surgery and two lobes of her right lung were removed. She was fine until two years later, when another cancer developed in her left lung. For that, the chest surgeon removed a wedge of lung tissue. Less than a week after she was discharged, she became extremely short of breath and was readmitted to the hospital with the complication of an empyema (an infection between the two layers of membranes covering her lung). The surgeon inserted a tube to drain the pus. After the procedure, her shortness of breath was no better. Because the infection was not responding to antibiotics, she underwent another operation called decortication, to remove the infected lung membrane. Her shortness of breath continued. She could not cough up her thick sputum. Her lung specialist felt that she had developed obstructive pulmonary disease after her surgeries, but he faced a dilemma. He was already treating with around-the-clock inhaled beta agonists to dilate her bronchial tubes without much improvement. With her complicated infection, he feared that using steroids for bronchodilation might weaken her ability to fight infection. When I visited her, Irene was barely able to walk ten feet around the hospital ward without being winded. She had already spent a month in the hospital. She reluctantly agreed to take the herbs I offered to brew for her after I promised her it would not taste too awful. The formula was one that I had often used for post-flu bronchitis. Because the prescription did not contain bitter tasting cold-cleansing herbs, the concoction was palatable. After two doses, she was able to walk around the hospital ward, and in less than a week, she was able to go home. She continued herbal therapy for three months. She has since felt well enough to fly to Virginia to babysit her granddaughter and fly to Hawaii to see her son. She was even able to participate in an antiwar march.
If anyone asks me whether TCM is cost effective, my answer would be, “If used appropriately, a resounding yes!” When subjected to HMO scrutiny, my practice was at the high end for cost-effectiveness. I used acupuncture in about 20 percent of my practice. I probably ordered fewer expensive imaging tests than any other physician with a comparable practice. I did not need to when I saw my patients responding to the TCM approach.
In later years, it was gratifying to see more of my medical colleagues becoming interested in what I was doing. Even the chiefs of family practice, internal medicine, and orthopedics at my hospital referred patients with musculoskeletal soft tissue disorders to me for acupuncture treatment. I was invited to speak both to medical colleagues and to the lay public about TCM. I was delighted at the opportunity to inform both doctors and patients about what options were available and the conditions for which I found TCM effective. There seemed to be a general awakening to the vision I had so distantly seen long ago as a third-year medical student. Indeed, TCM has a role in modern times.