Specialty board development is an area that I have actively supported. Yet, specialization is not an area that interests me; I don't specialize, at least not now. Curiously, I see the value in generalism as well as specialism. Further, I see them as yin and yang components, mutually defining each other, transforming, opposing, generating and consuming each other. There are advantages and disadvantages for each perspective.
In this piece, we will examine some assumptions, as well as explore various points of view. My concerns are related to process and development. They come from sociological and professional perspectives. As a pragmatist, it seems we can work together while appreciating the current state of affairs in a way that is inclusive of the interested parties.
Terms
We must resolve stasis of definition. Beginning with Webster's New World Medical Dictionary, "Board-certified in medicine means a physician has taken and passed a medical specialty examination."1 However, this is the realm of conventional medicine. The acupuncture and Oriental medical (AOM) profession needs to develop its own understanding and definitions. A common definition of "board" is a committee with supervisory powers. But Wu identifies the term zhuanjia, which falls into the range between the ideas of "specialist" and "expert." Zhuan indicates deep, profound, complete and wholehearted focus. The term zhuan also is considered to be narrow and is contrasted with bo, indicating broad. "Zhuan is also knowledge that is focused as opposed to that which it scattered or miscellaneous and thus superficial (za)."2
Some History
The debate about specialism is not new. Let's explore it through a historical review of family medical practices in China. Confucian values conceive generalization as a virtue. The "gentleman is not a tool." Wu Yi-Li discusses medical specialization and family lineage, as well as generalism and specialism, in Chinese culture.2
Wu suggests that generalist values maintained by Chinese officials were accompanied by the "valorization of the amateur ideal." This resulted in the cloaking of expertise in a discipline with Confucian generalist respectability. But this was not limited to medical practice. It was considered to be socially unacceptable to focus on any given profession, since one could easily be then classified as a technician. Medicine as a discipline was a vocational option if one failed to enter the elite government service. A gentleman might have skills in medicine but did not make this a livelihood. Upper-class doctors might align themselves ideologically with statesmen and scholars who were benevolent medical amateurs. The Confucian gentleman avoided existence as a tool, but also argued that one needed to develop expertise in a particular subject. Otherwise, there is a risk of dissipating one's intellectual resources.2
The cultural value of the generalist, Confucian gentleman did not preclude these upper-class individuals from careers as legal experts. Neither did ideals of medical generalism preclude doctors from devoting their practices to the treatment of specific conditions. The imperial medical service was divided into departments that included medicine for women, children, external diseases and febrile conditions. Beyond the state-approved specializations that supported publications, medical families provided sources of hereditary specialization. As long as they didn't sacrifice their moral principles, government officials could adopt roles as "gentleman specialists." The earliest of the four great gynecological families of the Zhejiang Province included the Chen of Jiaxing, the Qian family of Shaoxing, the Song family of Ningbo and the monks of the Bamboo Grove Monastery in Xiaoshan. In addition, there is the Guo family of Hangzhou. All claimed gynecological expertise from the 12th century. These families each claim descendants practicing in the 20th century. The texts generated from these specialist lineages were used by both medical literati and laity.2
The distinction between the scholar-doctor and the hereditary doctor diminished over time. By the Qing Dynasty (1644-1911), the social class and legal differences between these roles had diminished. Family lineages engaged in literati traditions and classically absorbed practitioners engaged the practical family knowledge.
The Chen family has practiced women's health since the Song (1008-1017). Their proud emblem of this is a fan displayed on the wall at the clinic. It is imprinted with recognition for their women's health specialty from the Song court. Just like the Chen family, the Guo family traces its specialization roots back to the Song. Guo Zhaoquan left Henan at the beginning of the Song. He gave shelter to an "unusual person (yi ren)," whereupon he was gifted with three peony blossoms. On one of the petals was written 13 formulas for treating women's ailments. Zhaoquan became a doctor of women's medicine, passing the knowledge down through his family lineage. His descendants used these formulas to treat the Empress Dowager Meng.2
Holism and the Argument against Specialization
Holism is one concept that we must address in the debate between generalist and specialist practices. I will contrast specialization against holism, but not in support of specialization. Rather, it is in order to gain perspective and create space around the terms generalism and specialism.
The term holism was introduced by the South African statesman Jan Smuts in his 1926 book, Holism and Evolution. According to the Oxford English Dictionary, Smuts defined holism as "The tendency in nature to form wholes that are greater than the sum of the parts through creative evolution." He derived holism from the Greek word, holos, meaning all, entire or total. All the properties of a given system, whether it is biological, chemical, social, economic, mental or linguistic, cannot be determined or explained by the sum of its component parts alone.
In alternative medicine, a holistic approach to healing recognizes that the emotional, mental, spiritual and physical elements of each person comprise a system, and attempts to treat the whole person in its context, concentrating on the cause of the illness as well as the symptoms. From a holist's perspective, the context of a particular event is important because the character of any given part is largely conditioned by the whole to which it belongs, and by its particular function and location in the larger system. Thus, reality for holists is viewed as a process of evolutionary change driven by the dynamic interaction between the parts and the whole.
Some practitioners state that specialization is not holistic. However, many professionals who specialize claim that they practice integrally and engage holism in patient care. They choose to specialize, while still using the holistic concepts of Chinese medicine. The objective is to develop deep skills in the treatment of certain conditions. Further, there are others who approach care from an East-West perspective, applying what might be called "paradigmatic holism," wherein they are functioning integrally between the knowledge systems of biomedicine and Chinese medicine. This also could be called "transdisciplinarity." They do not specialize in a particular cultural perspective, but rather, they synthesize medical thought, arriving at conclusions outside, between and within the domains of the individual disciplines.
Many practitioners who claim roots in Europe, Japan and Korea choose a single paradigm that is holistic, holographic and fractal-like, such as the five-agents doctrine. They then apply this whole system of thinking to a generalist practice. This is clearly a form of holism. There are those who choose a general practice but use a single intervention such as acupuncture, qigung, diet therapies or Chinese pharmacopoeia. This technical specialization has a holistic basis for patient selection.
In my opinion, specialization is an individualizing feature of "holarchical" systems. It is similar to a cell membrane or mitochondria within a cell, or the eight trigrams within the 64 hexagrams of the whole Yi Jing. It could be fire within the system of five agents, where holistic theories place all five agents within the domain of fire. For auricular therapists, it is similar to selecting a spinal segment in auricle. Take any system from galactic to plant or animal, as well as biological or chemical systems. In each of these instances, specialized components contribute unique qualities, functions and structures to the whole.
Some may fear specialties as a morbid dualism that has the potential to create dominator hierarchies, closing out those who have not sought certification. The resulting adversarial relations could lead to alienation - an individual or groups' estrangement from their labour, resources or power. It is the oppositional conception of yin and yang theory. This set of concerns has been conflated with specialization. However, the generalist has the right to engage in the standards of practice that the entire field of AOM enjoys within any given legal jurisdiction.
Issues and Solutions
Paradigms begin to shift with changes in perspective. Further, urgent problems require us to step away from the subject of our concern in order to develop the principles of knowledge. We can revise our process by avoiding simplification and reductionism in our approach to the polarized state of the profession around generalist and specialist practices. It is both a complex and a simple problem, as are the solutions.
U.S. specialty boards in Oriental medicine are a new subject, in comparison to Chinese practices. The National Board of Acupuncture Orthopedics (NBAO) has been active since 1987. However, the debate is emergent in 2007 - the question of whether there should be specialty boards is now arising. But, how do we engage such a question when specialty boards are a current reality? An inclusive forum for such an inquiry might be fostered by the American Association of Acupuncture and Oriental Medicine, with partners such as the National Certification Commission for Acupuncture and Oriental Medicine and the Council of Colleges of Acupuncture and Oriental Medicine. It would necessarily and most importantly include members of the profession and the state associations.
From a pragmatist's point of view, if we agree on an effective definition of the term "specialty board" for AOM and can agree that those who want to pursue specialty certification may, then it seems that the time is ripe to develop specialty board oversight. Such oversight would be autonomous, remaining at arms length from any agency that would provide certification examinations or conduct trainings.
In closing, it is important that we engage our dialogues with respect. We are a community with both diverse and common purposes. And in the spirit of the Dao De Jing, we can make our way (dao) non-coercively focused (de)3.
References
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In the past five years of my clinical practice, I have seen an astonishing upsurge in the chronic use of proton-pump inhibitor (PPI) medications for the gastrointestinal issue diagnosed by allopathic medicine as GERD. It is not uncommon to encounter patients taking these prescriptions for five-plus years.
Working with chronically ill patients entails acknowledging the reality that not all patients will survive their diagnosis. Chinese medicine and acupuncture play a crucial role in palliative and end-of-life care, addressing medication and disease side effects, alleviating pain associated with death, reducing anxiety and stress, and helping patients find peace during the dying process.
