Convergent Points Volume 1 Issue 1

The Essence of Chinese Medicine: Teaching and Learning from Cases

Interviews with Dr. Yu Guo-Jun, Sharon Weizenbaum, and Valerie Hobbs

Please note the term “case studies" was used in these interviews, as they were discussing historical as well as modern cases, but their observations would apply to contemporary case reports as well, such as those that appear in this journal.

Since the Han Dynasty, What Works and What Doesn’t Work: An Interview with Dr. Yu Guo-Jun

Sarah E. Rivkin (SER): Reading the introduction to your book, it was interesting to see how much the works of famous physicians were important in your study of Chinese medicine, how you progressed from the classics to cases, reading what famous physicians did. Can you talk more about the role that case studies played in your education?

Dr. Yu Guo-Jun, as translated by Michael FitzGerald (YGJ/MF): Case studies are the essence of Chinese medicine—all the good stuff brought into reality. They are an essential part of studying Chinese medicine. Case studies are the most pragmatic and useful part of Chinese medicine. There's so much theory in Chinese medicine; there's so much debate on what that theory means. Case studies are where it's all put into practice, reality and practicality.

My favorite thing to read is case studies, and there have been case studies since the Han Dynasty, all the way through history and up to modern times. Case studies are so important because that’s the place where we see all the methodology and the formula prescribing and the pairing of herbs. It’s how we learn all the rules about making formulas, and the clinician’s thought process is there for us to see. They're valuable because they can tell us what works, and they can also tell us what didn't work. It’s where we put things into practice. Reading case studies, we get to see how each individual doctor approached a particular problem and their thought process.

SER: Could you talk a bit more about the importance of writing up and publishing cases from your clinical practice? What have you learned from this? And more broadly, how does it advance the field of Chinese medicine when you share information?

YGJ/MF: When I was younger, I wrote some articles. For example, I wrote an article on the use of Si Ni Tang plus ya dan zi (Fructus Brucae Javanicae) to treat diarrhea. I didn't have a lot of experience, so I stopped writing and just focused on seeing patients and keeping good records about what worked and what didn’t. And if an interesting case came in, I'd write it down. Then somebody from a well-known Chinese medicine magazine asked teachers and professors throughout China if they would be willing to develop courses to teach countryside doctors who were not strong in theory. To help them be able to be better doctors, they devised this idea to write it in the fashion of a dialogue, with a teacher and students and asking questions. We were trying to make something much more practical and replicable.

MF: The goal was to develop something that students out in the middle of the country could read and learn Dr. Yu’s thinking process. Giving them something better than the book where it was all laid out. The problem with the old way was when it didn’t work, the doctors didn't know what to do because they didn’t really have a thought process. The publisher’s request was that you could understand it easily. It needed to be useful: I look at it, I understand, I use it, it works! That was their goal.

This magazine went around and asked all these well-known doctors, Can you develop this or write about this? But they declined, saying, “Oh, I don't want to do that, then I’d have to explain everything I do." They were intimidated. But Dr. Yu accepted it, and he worked for the magazine for almost 18 years.

YGJ/MF: The book, A Walk Along the River, that we translated came from this project. It became a really popular thing in China. This project recorded many, many case studies from Dr. Jiang, Dr. Yu’s teacher, and also his case studies, and it went through the process of explaining their thinking.

SER: Dr. Yu, in your writing and teaching, you raise an issue that I've been thinking about a lot: You have to trust the person who's telling the story or writing the case. I'd love to hear more of your thoughts on the reliability and authenticity of case studies.

MF: Dr. Yu raised the issue of a case study that fooled him. It was a report of using Dang Gui Shao Yao San and Gui Zhi Fu Ling Wan to treat asthma, or at least to keep it under control. Dr. Yu was excited because even though he really likes Jin Fei Cao San, as he mentioned in his book, xuan fu hua (Inulae Flos) is really bad tasting, and some people feel sick from drinking it. He was excited by this formula. It doesn't taste too bad, and he tried it on about 30 different people. But it didn't get any results.

YGJ/MF: This is a universal problem, right? A lot of famous doctors in China have similar problems. They will write a case study or write an article about something they did or treated and sometimes it's successful and sometimes what was written doesn't work very well at all. They're publishing these things under the name of a famous doctor and they're misleading the young people.

SER: It speaks to something, Dr. Yu, that you discussed a lot, which is not only truthfulness but the necessity that what you do can be reproduced by other people.

YGJ/MF: Yes, to know that you can trust what’s in a case, you need to be able to replicate the results, provided conditions are what they should be. If it's something that’s not repeatable, it's just an interesting one-time thing, and you shouldn't really write about it. I’ve been taken in by these kinds of case studies, and I’ve made mistakes because the things that I’ve read about didn't work. I’ve gone down a lot of dead-end roads and learned things the hard way.

Things don't always work. It became very important for me to say, “I'm not going to lead people astray." It's important that if I do write something, I'm going to explain my thought process on it, and I'm only going to write about things that I know are reproducible and that I've had a lot of experience with already. I’ve been cheated, or whatever the proper word is, by some of these sorts of things. You have to present things factually in a way that people can use them. When we talk about passing something on, the people we’re passing knowledge to want to be able to see something or read something and then take it in and use it and make it real, make it their own. That's the whole meaning of passing something on to a different generation or to your students.

SER: Do you think it's a mistake to publish single cases for that reason?

YGJ/MF: From a scientific standpoint it may or may not be meaningful if you only have one example, but it could be interesting. You should really be able to repeat that at least 30 times before you write about it. And within that 30 times, the treatment should be 90% effective. They don't have to be cured, but at least for 90% of the people that you did this method or this idea with, they should have some positive effect before you publish it.

SER: Is there anything else, any other thoughts about case studies?

MF: One thing he's saying is that what you should be doing as a doctor is seeing patients in the day and going home at night and writing something down about them and keeping records. Of course, it should all be true and straightforward and honest—real, active, useful information. And truthfully keep a record of all that. Truthfulness is the lifeblood of case studies. Case studies should be truthful, based on real things. Factual is probably a better word. They should be complete or take in all aspects of things, and not just be narrow-minded or too narrowly focused. They should have a new meaning. They should provide some fresh perspective, because if you have a case study that says, “I use Gui Zhi Fu Ling Wan to treat some blood stasis in the lower jiao," yeah, who cares? I mean we already know that. So, to help people get it, I would say they should offer a new perspective on something, a fresh insight on how something might be useful. Being, again, reproducible.

Yu Yi Cao and Ye Tian Shi wrote a directory on clinical practice, which is actually written by a student and is full of case studies in which they say, “I did this and it didn't work." Dr. Yu said these are honest books.

A famous doctor, a Jing Fang practitioner, Dr. Xu Ling Tai was criticized because he wrote a commentary on Ye Tian Shi's book and criticized him for saying he’s confused. But Dr. Yu said, he’s not confused, he's being honest, and nobody's perfect. And the fact that he wrote it was a valuable thing. Doctors who are honest, that is really valuable. And he also said he has two cases in his book where he says, “I did this, it didn't work out." He included these because being honest has meaning in a case study. Honesty and reproducibility are of great value. New or fresh ideas and reproducibility. Those are his four standards for good case studies. There are a lot of case studies that you look at them and you think, “Wow, this is super awesome"! But then when you use it, it's not so awesome. Basically, they're not what they seem: people report the good parts and not the bad.

YGJ/MF: These things that we've been talking about are very important.

MF: And also part of the problem is that we are actually not really taught how to think in Chinese medicine, we're taught to imitate, and I imitate you and it doesn't work. I couldn't think my way out of a paper bag to what to do next. You're never taught to say, “Okay, here's a case study, or here's something where we use this." Because some of the theory is disconnected, it's just a thing that might inspire you to get an idea. It's not actually attached to anything. It's just an abstract concept that might inspire you.

So much of our education is based on a philosophy of the wise people who know far more than we do and are saying something which we don't get. Our goal is to get there.

Where Theory Comes Alive, an Interview with Sharon Weizenbaum

SER: When do you first remember encountering case studies? Can you tell me something about your relationship with them?

Sharon Weizenbaum (SW): There were no case studies in English when I was in school. And I didn't read Chinese. Then a book came out a while later, Patterns and Practice from Eastland Press. And that was amazing. You had case studies, acupuncture and herbal. And just to have the authors go through their thinking process in the cases—I just ate those books up! You could learn in a way that you couldn't from, say, Giovanni Maciocia's texts. Giovanni's case studies are a snapshot in time, not really ongoing, and often very simplified. When I later started learning to read and translate Chinese, my relationship with case studies then got really strong.

SER: I recall you were a student of the renowned modern gynecologist, Dr. Qiu Xiao-Mei. When was it you started working on translating her material?

SW: I was pregnant, so it was 28 years ago. I translated a bunch of Dr. Qiu’s text on gynecology. She had a whole chapter-long discussion on bleeding disorders and, in that section, she talked about the different pathological mechanisms, and then she talked about it theoretically and what her treatment protocols were. She followed that up with a bunch of case studies for each section. So it ended up being a whole book of translated case studies that are all about pathological bleeding in gynecology. That really showed me right away how she put her theory into practice.

From reading these cases, I also started to learn about dosages. When you see these cases over and over again, you start to see, for example, when you're using ren don teng (Lonnicerae Caulis) and hong teng (Sargentodoxae Caulis) to treat bleeding due to heat you use twice to three times as much of those herbs as you would use of your standard dose of herbs. You really get a feel for herbs you use a lot of, and when you use a lot of them, and herbs that you don't use so much. For me, it's really that which has transferred into teaching about dosages.

You could see how she artfully worked with dosages, depending on the situation. Even when she was talking about bleeding due to heat as the primary topic, for example, she was always working with deficiency or blood stasis was mixed in. What time during the cycle would she start to move the blood? What time in the cycle would she start to supplement kidney qi? After looking at maybe 50 different case studies, you started to really learn about the timing of giving the herbs: when to give strong stop bleeding herbs and when to use carbonized herbs. (When the bleeding isn't so serious, you don't need to use so many carbonized herbs.)

This is something I emphasize with my students: You need to read case studies in order to learn about dosages. That's the best way to learn about what that doctor did in this kind of situation and what they did in that kind of situation. Through reading all those case studies, you get a feel for the subtleties of treatment that you can't just learn from a textbook. In contrast, the textbook says in order to stop bleeding due to heat, use this formula, but you don't get anything about the subtleties of working with the cycle.

Let's say you have a person who's bleeding heavily, and you give them herbs, and now they stopped bleeding. What do you do now to prevent more bleeding in the future? There's this kind of staging in the case studies. It's the only way you can really teach that subtlety. All these cases are so slightly different: So how do you shift things, and why is that important to treat? There are so many idiosyncrasies; how can you learn that through just theory? You can't. You have to see example after example, and if you can't go to China and sit with a doctor for months on end, reading case studies is the next best thing.

SER: The relationship to time is different in a case study than in a textbook because case studies have the sense of progression and movement.

SW: That's exactly right. The textbook doesn't have that sense of how things progressed through time or staging like I mentioned with bleeding. If somebody is bleeding heavily, the first thing you want to do is stop bleeding. But then, after they stop bleeding, if they’ve bled a lot, you want to build back their blood. And also, it's very common to have leftover blood stasis after someone's been bleeding a long time. So you want to make sure you've cleared away all the blood stasis. The case studies and work of Dr. Qiu Xiao-Mei demonstrate that kind of staging: What do you do after somebody has stopped bleeding? What do you pay attention to? How do you treat it? How do you prevent it from happening again? That can't be demonstrated in a textbook.

I can teach about that staging, but until you get to the case studies, it's not even very real. Someone might be bleeding heavily, for example, a 16 year old who has just started bleeding heavily and is not very weakened yet. Stopping bleeding and restoring the blood is different than if you see a 55 year old who's been bleeding heavily for six months, and then she's really depleted. And so you can give these rules, but the cases show you have to work with that individual patient. Where are they in their menstrual cycle, and where are they in terms of their actual bleeding? All illnesses are like that.

Somebody has diarrhea or acute abdominal pain—who is the person who has that abdominal pain, and once the pain stops, what do you want to do then as a follow-up treatment? That's where Dr. Yu’s book is so wonderful, A Walk Along the River, because you walk through a case from beginning to end. You know what he did first and then what he did next.

SER: Speaking of Dr. Yu, something he raised in our discussion was accuracy and truthfulness when it comes to cases. Those that fit exactly what the author's trying to illustrate make me a little suspicious.

SW: Right. You can't believe them, which is disorienting. As a student, you get a feel for it; as a translator, you know those cases that you don't even want to translate. They're too textbook-perfect, and I know from experience, clinic doesn't work that way. There are so many cases on uterine fibroids where they move the blood and crack stasis, and supposedly, it works. It never worked for me! Or cancer treatments, where they use neoplastic or blood moving herbs. I would get bad results following those protocols and feel terrible. I started to get an eye for real case studies versus not-real case studies.

SER: And then there are those perfect little cases you read that make many of us throw up our hands, because when does that patient ever walk through your door?

SW: Right! Like here's a person with vaginal discharge and a greasy tongue coating, and you know they don't also have any food sensitivities or eczema on their elbows or low back pain. All the symptoms fit exactly into the perfect textbook category. Those are the cases not to trust, where the person has nothing else going on except for everything related to the vaginal discharge, period. In contrast to Dr. Yu’s cases, which are complex, with all these little idiosyncratic signs and symptoms, which is what we experience in almost everybody in the clinic.

SER: Can you talk a bit about the importance of writing up and publishing cases from your practice? What have you learned from this? How often do you do it? And how does it help you in terms of your thought process?

SW: In clinic, sometimes the process of processing the information to come up with a diagnosis is very rapid for me, so having to articulate that process is useful. This is also why I like having students in the clinic because I can articulate what my process was and why I am coming to the conclusions that I'm coming to. Articulating it either verbally or in a written case study deconstructs a process that is very automatic for a lot of experienced practitioners, to the point where you sometimes read case studies and there's this information about symptoms, and then there’s the formula. You can’t always understand how the doctor got to their diagnosis. What was the process? When writing a case study, what I want is for the student or reader to be able to understand how I got from here to there.

Sometimes I've even taken case studies, like one article about a case of Qin Bo Wei’s where he doesn't say a whole lot about how he got from the pathology to the formula, and I'll break it down. How did what he saw get him from this set of signs and symptoms to this formula? This is a way to deconstruct a doctor’s process for yourself. Dr. Yu does a lot of that for us, which is so nice. He really deconstructs it and takes us all the way.

And for me, a lot of Feng Shi Lun’s cases don't do that, and they're frustrating for me because I don't see how he got to a formula. There is a gap in the process that I'm not understanding; he has so few signs and symptoms that it's often difficult for me to understand. I'm sure there is something that happened between the signs and symptoms and the formula but something's missing. I feel like I would never get there. It's very important when teaching the student through a case study for that process to be articulated, “How did you get from here to there?" And if there's too big a gap, there's the danger of the student feeling stupid, like they could never do this. “This is beyond me." It's important to not set up people to feel defeated.

SER: Related to that, what do you see as the role of case studies in Chinese medicine more broadly, in terms of the preservation of medical knowledge or clinical thinking? How do they transmit information?

SW: Case studies are the most important teaching tool; they are where the theory comes alive in actual practice. Having my students write up case studies is key to me knowing whether they're understanding what I'm teaching or not. I need my students to write them up in a very detailed, deconstructed manner, so I can see each step that they're taking along the way, to ensure they understand all of those steps.

Case studies are very important, not just for us to read from doctors with a lot of experience, but something for us to practice writing and have evaluated by people who are perhaps more experienced. I'm able to see when my students write up case studies where they are getting sidetracked and help them with that weak area. That is important for learning to feel like they can do it. Reading case studies and writing them.

And now, with the GMP [Graduate Mentorship Program], from the very beginning, I’m integrating case studies to illustrate the points that I'm making. This is so important for seeing symptoms for what they tell you for sure. Having case studies as examples also makes sure I don't go off in a weird direction.

SER: Do you have any other thoughts on case studies in terms of how you read them, how you write them, how you teach them, how you have your students use them?

SW: There are so many different kinds of case studies, everything from Ye Tian Shi who says, “I had a patient with lin disorder and I gave them Zhu Ling Tang and the results were great," and that's all you know. What can you learn from that? Not a lot, except that Zhu Ling Tang can be effective sometimes, but it’s extremely cryptic. And then there are those on the other end of the spectrum, like Dr. Yu, where they walk you through their whole thinking process and, where you might have thought something else, explaining why that's not correct and bringing you back on track. His process is extremely deconstructed. This deconstruction and also writing in a way that articulates the whole thought process could be seen to be holding the reader's hand a little bit too much. Maybe they should have figured it out for themselves? However, I think we need more of that.

What I find is that when I go through a process of really consciously proceeding stepwise in a diagnosis, soon those steps become more automatic. I tell my students if you do two case reviews with me where you're doing this meticulous, tedious process, that will serve you in the clinic more than you could imagine. You don't have to do that with every patient you see. But if you're not getting good results, you can go back and look at these steps and see where you can go back and say, “Maybe I should apply this a little bit more for this case." I'd like to see more of this hand-holding and breaking it down into steps. I think it's very useful for up-and-coming practitioners to see that. And you have options for having their hand held so that when they’re alone in the clinic, they feel supported through each step. I think that is very important.

There are also case studies that are written for the glorification of the doctor, designed to show how incredible they are and to create a sense of the unattainability of that level of practice. Those are cases I also don't trust. The information of the case is organized to support the practitioner’s ego, as opposed to helping people learn how to take those steps for themselves or to empower the student. The goal is to set the teacher above the students and make the teacher’s level of skill seem unattainable. And there is also the financial gain part of it or the financial protection. I want to protect my little medical kingdom. And my financial gain for my little medical kingdom. But then there also can be an ego thing, wanting to seem like an amazing person. It's narcissistic. It can be there in the case studies as well, and, in reading case studies, it’s important to develop an ear for that.

Sometimes reading a case study, you have a feeling like, “Wow, that kind of miracle is so unattainable to me." But then you start to feel like there’s something wrong with that case study. This is in contrast to someone like Dr. Yu, who has many miracles in his books, but he makes you feel like you could do that too. He makes it accessible, which is why those books and his teachings are so popular. As if to say, “If you go through the process like I'm telling you, you could do this as well." You don't get any feeling that he's there to make his ego stronger; he’s just trying to help.

I now try to teach the students in this GMP to be aware of their own experience as they’re reading a case study: “Does this make you feel bad about yourself?" Dr. Yu always makes you feel good about yourself. I'm trying to train the GMP students so when they read articles, they are more aware of their own experience during it. They are able to be more critical of the author if they're having a bad experience with the article, if it makes them more confused. And that seems like a really important part of teaching case studies—teach the reader to be aware of their own experience.

It’s amazing to me how much my students just take it for granted that the author is so knowledgeable and so correct. If they're having a bad experience it must be some limitation of theirs. But if you can’t figure out a case, it may be because the author didn't give enough information, rather than it's too complicated and you must not be very good. I think that's wonderful to have those case studies, and there's stuff that we can still learn, but maybe there are also pieces that are not clear.

Case studies are what make things come alive!

 The Start of Something Good, an Interview with Valerie Hobbs

SER: What does it mean that the doctoral program at ACTCM is case-based learning, and how does that work?

Valerie Hobbs (VH): The student assessments in both the transitional doctorate and the DAOM are largely based on the construction of case studies and the submission of academic, publishable case studies.

SER: What it means in your program is writing cases?

VH: Yes. There is quite a lot of presentation of cases along with the material that is being taught, integrated with a clinical internship.

SER: My understanding of case-based learning in allopathic medical schools is it's more about reading cases with particular scenarios. Writing cases comes in later.

VH: Right. That's why I don't think it's quite the model of case-based learning you’re referring to.

SER: My research is focused on the reading and transmission of information through cases. It seems like the students are doing that in your program as well.

VH: They are. In the transitional program in particular, in order to be able to produce a case study, you read a lot of case studies. But it’s not the only way that the learning is delivered.

SER: They are specifically reading and analyzing case studies as part of the curriculum?

VH: Yes. So in the transitional program, there are actually two courses where the title of the courses is Clinical Case Analysis. The entire focus of that particular course is how to look at a case study, how to extract information from a case study. Then the students’ assessment is to produce a written case study of their own. Ultimately, a significant minority of our students end up publishing those cases.

In our doctoral programs, there is a course of study on research and research literature and literacy. We have to examine how we know what we know. In our field, case studies are probably more of the literature that's out there. And yet the acceptance within the US healthcare system is more geared toward the meta-analysis. That sort of statistical analysis is how you prove efficacy. What our students learn is that while that might be the normal course of things if we're talking about a disease that is well studied, what do you do when there's nothing in English? Or how do you present a unique viewpoint? The way that is done first is through the case study—just like the first reports of the occurrence of AIDS ended up being published as case studies. We look at that in a historical way, as well as a really good way to present new information.

We had a student in our DAOM program whose capstone ended up being a case series. What he was reporting on was a unique way to needle SP4 (Gong Sun) and how he used it in infertility cases. He's not going to have the resources to design a randomized controlled trial, and there are so many things that go into infertility, conducting an RCT wasn't likely to happen. But he could report that out as a case series. In this way, the case study can be the start of something good.

SER: That's one way that case studies function.

VH: Right, and it's an important function. As we’d discussed, think how important it was for the world to discover that there was a condition called AIDS—and it started with a case study report! A lot of things in our medicine are like that: For example, I did a case study on acupuncture and preeclampsia [Kocher & Hobbs, 2019], there's nothing else printed in English on that. We looked at it and said, “Well, we can wait for an institution to do a retrospective study but that's going to take a while. Why don't we start with a case study?"

SER: It's interesting to see how the case study brings us into the 21st century, how it paves the way for our acceptance, or our further acceptance, in the contemporary medical world.

VH: Or how cases can pose additional questions. In the discussion section of that case study, we were able to show that what the acupuncture may be doing is actually a mechanism that hasn't been talked about very much, deserving of more research into its particular application. There's almost no way to get something like that into print without a lot of financial backing, except through a case study. It's a way to promote a new idea or mechanism, something other researchers could then incorporate into larger work.

SER: Case studies can function as a springboard for further research, bigger trials, and things like that.

VH: You also have the opportunity to analyze the literature a little bit when you're introducing your case. You can focus the point of the case to influence further research. And you have an opportunity to curate the sources brought in from other languages as well. You're the conduit for that, for what now gets mentioned for the first time in the English-language literature.

SER: Is there anything else that you would want to tell me in terms of the program or your own research?

VH: I wish we had better skills for our practitioners to write a lot more cases because I think you learn quite a bit, and you can talk about different things, like what your management of a case really is. You can talk about difficulties with patients in the case study. It doesn't always have to be “Wow, it was a miracle that acupuncture worked!" There is an opportunity to make them [case reports] a lot more clinically relevant sometimes than a randomized controlled trial; because the nature of having to do a randomized controlled trial is that you have to fit stuff in a box in which it doesn't really fit right. And you almost step away from having relevance in a clinical encounter because you're trying to do this format that is better accepted by the Western science world.

SER: It sounds like you see the case as being a bit more flexible.

VH: Not only more flexible to our needs but more clinically relevant. I'm not so sure in a case study that I can say this needling technique on SP4 really works—I don't really know that in a case study—but I sure can read it and see somebody else's experience. Then the next time I go into the clinic, I can try it. Some of the random control trials are interesting to get me into a setting, but it's not necessarily interesting for my clinical practice.

My first exposure to case studies was this book that had a green cover, Essentials of Contemporary Chinese Acupuncturists’ Clinical Experiences [Chen and Deng, 1989]. I had a wonderful teacher who would teach out of that book. It had the worst index of any book ever, so it was impossible to find things in there. When reading the book, you had to start somewhere, and then you’d read something because you were interested in it. In the course of reading, you would find this clinical gem that you'd immediately want to try. Maybe that's why I think of case studies in that way.

Case studies are what I end up using and reading when I want to know how others are treating a particular condition that is not necessarily well known in the field. I do a lot of gynecology, so I would say, “Okay, how about this case for vulvodynia. How do I treat that? Because it's not in any textbook and it's not in curriculums. How do I find the case studies where people are talking about it?"

I think it's really vital that people publish. After a little while, practitioners end up having something that they get really good at—or they have an experience with something you're not going to see very many times in a professional practice. This is when writing and publishing become very important. I think that that's probably true for everybody.

You had a question about textbooks versus case studies: I always think that the rubber meets the road in testing. If I'm teaching an upper-level course, I should be able to put a case study on a test and have my students be able to make sense of it. But we still need the basic textbooks because that’s where we learn how to speak the language of East Asian medicine. However, when we're trying to describe the poetry that is clinical practice in our medicine, it's about the case study. In a case, you can put a lot of different complex conditions together, you can personalize it, and then you have to figure out how to analyze it and put together a treatment plan. It's mirroring the real life of a practitioner in a way that the textbook stuff doesn't do.

The limitation I see in case studies is this: We tend to think that because something has worked for one person, it's going to work for the next person. We always have to keep in mind what the level of evidence is in a case study. It may show promise, but for us to say for certain that something in the case study really works, I don't know that we know that from that format.

SER: When I was talking to Dr. Yu Guo-Jun, one of the things he kept saying over and over again is that he generally didn't publish until he'd done something 20 times and had predictable results. His criteria for cases were they had to be true. He didn't feel like a treatment had value if someone couldn't reproduce it.

VH: That's interesting. But then it brings up the question: Can we reproduce any research? Reproducibility is a whole other topic, but we want to know within some range that if I use this herb 60%, 70% of the time, I'm gonna have this result. Those things are never going to end up being 100% but there is going to be some percent of success. And he's right that you don't want to do it only once or twice. I appreciate that. But there are some things that are worth writing a case study about before you've treated it 20 times. And you can't control everything, even if you're doing 20 cases of something. Maybe all those people went on an exercise program, and that's why they got better?

Another consideration with case studies is to consider how much do you know from any clinical encounter? Also, the things that you remember are not unbiased. Recall bias could be an issue. You just have to have that as a given. That's the backdrop. When I hear practitioners talking about how they're going to approach something because they read all these cases, I get a little concerned when they put a little too much emphasis on that. But I think if you understand that about case studies, they are still probably more clinically relevant than a lot of other kinds of research.

SER: One thing that interests me as an herbalist is there are so many different variables about dosage and administration, various choices you can make that you're just not going to get from a textbook.

VH: Right, and you're not going to get it from random controlled trials because there are not a lot of sources in English for that. So we can find a bunch of sources in English for acupuncture, but we're not going to find a whole lot about the herbal part of our medicine at all. The other topic we haven't touched on that I think is really important in a case report is talking about adverse events. Those are some of the most instructive case reports. That might lead you to a lot of needed scrutiny for patient safety. Sometimes when the case studies are very negative, I think those are the most instructive.

SER: And those are also the ones that you remember.

VH: Yes, don't do this, right?

This is something I think about case studies: You have a Cochrane report on low back pain and the use of acupuncture for arthritis of the knee or use of acupuncture for migraines, and all of a sudden a whole lot more people are getting treated with acupuncture for those things, and that's great. I firmly believe that case studies are improving the medicine, and that when they're negative, they're actually keeping a lot of people safe. But it's more like dropping a pebble in a pond; you don't really know how far that influence goes. I know that when I'm teaching about case studies is when students really come alive. I can tell them about a pattern, or I can tell them about how to treat something, but then when I start to tell them this story, that's when I think they remember it.

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