An Interview with Bob Flaws

Bob Flaws began his study of Chinese medicine in 1977, and has since become one of the best-known English-language teachers, authors and practitioners of Chinese medicine. A champion of both the paradigm and process of Chinese medicine, Bob has written, translated and/or published over 80 books and hundreds of articles on the subject. As the primary instructor of the Blue Poppy Institute, Bob teaches postgraduate courses to practitioners worldwide. I recently sat down with Bob to discuss the practice of Chinese herbal medicine in the U.S.

Elizabeth Liddell (EL): What do you see as the key differences between the practice of Chinese herbal medicine in China and here in the West?

Bob Flaws (BF): I think the first key difference is that ready-made medicines are rarely used by professional practitioners in China. Ready-made or so-called "patent" medicines are sold over the counter, and typically patients buy them themselves in the same way that someone here might go to a health food store or a pharmacy and buy an over-the-counter preparation without necessarily seeing a doctor. So, the first difference is that rarely would a Chinese doctor prescribe a ready-made medicine. It's always an individually written, water-based decoction in China.

The second difference is an extension of the first - the difference in dosage. The dosage that is typically prescribed here in the U.S. is much smaller than the standard daily dose in China. If an American practitioner uses the little black ready-made pills from China according to the directions on the box, the patient may only be getting 3-4 grams of medicinals per day, whereas in China, that patient may be getting 200 or more grams of medicinals, which are then decocted in water. In my experience, many of the failures of Western practitioners are not necessarily failures in diagnosis, or even failures in picking the right prescription, but rather failure in prescribing a high enough dosage. It is difficult to get a therapeutically appropriate dose from ready-made medicines unless they are high potency extracts; by high potency, I mean 10:1 extracts or higher. At some point, it actually becomes cheaper to take the bulk-dispensed, water-based decoctions. I think Western practitioners of Chinese medicine need to take the issue of dose into more serious account. In my experience, at the moment, many practitioners are not even asking the question about comparative potency of different forms of Chinese medicinals.

EL: How integrated are Chinese and Western medicine in China, and how concerned are doctors in China with interactions between Western drugs and Chinese medicinals?

BF: There are three separate health care delivery systems in China. There is pure Western medicine, pure Chinese medicine, and there is what's called integrated Chinese-Western medicine. In the integrated system, every patient typically gets both the standard Western treatment based on his or her Western medical diagnosis, and then they'll get the Chinese treatment based on his or her pattern discrimination. However, even in the so-called pure Chinese medicine, the doctors make a lot of use of Western diagnostic procedures. So I would say, overall, Chinese medicine is much more integrated with Western medicine in China than it is here in the West.

As to how concerned Chinese doctors are over drug-herb interactions, this does not seem to be a big concern. I read a dozen or so Chinese medical journals every month, and authors of the articles in most of those journals do not appear to be overly concerned with potentially adverse interactions between Western drugs and Chinese herbs. It's pretty routine in China for patients to be taking both Western pharmaceuticals and Chinese herbs. I've translated literally scores of research articles where patients are taking both without any particular discussion of toxicity, or interaction, or adverse reactions due to this combination.

EL: In your opinion, what benefits does such an integrative model offer?

BF: My overall impression from personal clinical experience and from the Chinese medical literature is that the combination of Western medicinals and Chinese medicinals is, for many disease processes, better than either of them individually. Typically, you get a better therapeutic effect with a smaller dosage of Western meds and have to take the Western meds for a shorter period of time. Clinicians know that most of the side-effects of Western drugs are dose-related and that, if you can keep the dosage minimal and the duration as short as possible, you'll get the therapeutic result without the adverse reactions. Chinese medicinals taken with Western medicines seem, in many cases, to achieve that therapeutic goal.

Further, it has been demonstrated in many published pieces of research and case histories that Chinese herbs can eliminate many of the side-effects of Western drugs. For instance, ACE inhibitors, a class of Western hypotensive medicine, produce the side-effect of a dry cough in 10 percent of people who take them. I've translated Chinese research showing that, if one prescribes yin-supplementing, lung-moistening Chinese medicinals in conjunction with ACE inhibitors, this can eliminate this dry cough while still getting the hypotensive effect. So, if Western medicines cause side-effects, very commonly Chinese medicines can eliminate those side-effects. This is true of corticosteroids. It's true with chemotherapy. It's true with radiation, antibiotics, and with various psychotropic and neuroleptic drugs. I've included a lot of this research in books such as Chinese Medical Psychiatry and The Treatment of Modern Western Medical Diseases with Chinese Medicine, but this is just a tiny fraction of what exists in the Chinese literature.

EL: So, in your view, this integrated strategy could benefit patients and even their Western medical doctors.

BF: For sure, I think such integration would benefit patients. There's no question about that in my mind. As somebody who's been in practice for 23 years, I believe that the combination of Chinese and Western medicine is better than either of them alone. You have the disease specificity of Western medicine and the power of their techniques, and then you have the holistic wisdom of our medicine - the ability to see the bigger picture - and the holistic treatment methods that we use.

The prescriptive methodology of Chinese medicine certainly could benefit practitioners of Western medicine in terms of the precision of their practice. If Western drugs could be prescribed on the basis of Chinese medical pattern discrimination, the Western docs could do a much better job of determining who should and should not get a particular Western drug. As a Chinese doctor, my experience is that often I can predict that a particular patient will have problems with a particular Western drug given their pattern discrimination. For instance, we know that corticosteroids tend to create a qi and yin vacuity, and then eventually a yin and yang vacuity. Well, we can predict then that patients with a severe qi vacuity or a severe yin vacuity are not going to do well long-term on high doses of corticosteroids; they are going to be more likely to have side-effects. Or take Clomid, one of the medicines that promotes ovulation. If we understand that Clomid is a warm or hot-natured medicinal, we can predict ahead of time that patients who suffer from anovulation due to yin vacuity may very well develop - and in fact, clinically, they commonly do develop - vacuity heat in response to Clomid, whereas those patients who suffer from uterine cold infertility are particularly good candidates for Clomid.

EL: Do you see any downside for us if we become overly involved in the Western medical paradigm, such as losing our focus on pattern discrimination?

BF: That's kind of an ironic question, because my experience is that a very large number of people who think they're doing Chinese medicine are really already practicing Western medicine using acupuncture and Chinese medicinals. Until we start talking about patterns, until we start treating based primarily on pattern, and until we start thinking primarily in terms of pattern, then we're not doing Chinese medicine. We're doing Western medicine using Chinese modalities. So, first of all, I think we need to begin practicing Chinese medicine. And I'm not sure that as a profession, as a whole group, we're there yet. As long as we keep patterns primary in our focus, my experience is that you can reframe Western medicine into our medicine quite nicely. In any case, it's important when talking to Western doctors to very consciously and deliberately articulate this philosophy of treatment based on pattern discrimination.

As an example of this, I've spent the last three years working on three books, two of which were co-authored by Western MDs, Chinese Medical Psychiatry, The Treatment of Modern Western Medical Diseases with Chinese Medicine, and The Treatment of Diabetes Mellitus with Chinese Medicine. All three books are about the treatment of modern Western disease categories, but when it comes to the Chinese medical treatment sections of those books, treatment is still primarily based on pattern discrimination.

EL: What are you working on now, and what are your plans for the future?

BF: I'm working on two main projects at the moment in terms of Blue Poppy. Simon Becker and I are working on a book on cardiovascular disease that will be similar in outline to the diabetes and psychiatry books, and David Frierman and Dr. Li Wei from Oregon are doing a nephrology book for us, patterned on the same model. So we're trying to create high-quality textbooks using an integrated Chinese-Western medical approach for each of the main medical specialties. I'm also continuing to research and write formulas of high-potency extracts.

In terms of the future, I'd like to have more time to ride my motorcycles. I have some other hobbies and volunteer organizations I'm involved with. Exactly when I'm going to want to depart from Blue Poppy is hard to say, but I am actively looking around for somebody that might be interested in becoming the editor-in-chief and research and development manager here - a successor to my part, if you will.

EL: Those might be big shoes to fill. What are you looking for in a successor?

BF: Well, certainly they'd have to be able or willing to learn to read modern medical Chinese. We would be looking for somebody with hopefully 10 years of clinical experience, but absolutely not less than five. We'd need somebody to be bright and articulate, and a hard worker. I'm assuming some type of training period would go on during which the baton would slowly be passed from hand to hand, but definitely somebody who is either willing to learn medical Chinese or knows medical Chinese. It's just not possible to do what I do every day without being able to read Chinese.

EL: Well, how and where would someone apply if they were interested in "carrying the baton" forward?

BF: Ha! Good question. I guess anyone brave or foolish enough could call me. There are already a few practitioners busy learning to read Chinese who have begun publishing regularly at the Blue Poppy websites, like Simon Becker and Robert Helmer. Although I've got a couple of eggs that I'm sitting on, I'd love to hear from more potential successors. You could always fax a resume (303-245-8362). We're probably talking about a three-to-five year project.