Prescriptions for Virtuosity The Postcolonial Struggle of
Chinese Medicine, 1st Edition
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Prescriptions
for Virtuosity
TH E POSTCO LO N IAL STRU G G LE O F CH I N E SE M E D I CI N E
Eric I. Karchmer
Fordham University Press New York 2022
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support provided for the publication of this book by Appalachian State
University.
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Printed in the United States of America
24 23 22 5 4 3 2 1
First edition
Contents
Introduction 1
1. Efficacies of the State 29
2. Geographies of the Body 69
3. Frail Bodies and the Problem of Diagnosis 107
4. New Textbooks, New Medicine 140
5. Chinese Medicine on the Margins 180
6. Prescriptions for Virtuosity 215
Epilogue 231
Acknowledgments 237
Notes 243
References 253
Index 267
PRESCRI PTIONS FO R VI RTUOSITY
Introduction
It was a gray and chilly November morning in 2002, two years after my grad-
uation from the Beijing University of Chinese Medicine. I had returned to
Dongzhimen Hospital, the main teaching hospital of my alma mater, to
spend a few months studying with several senior physicians. I was walking
briskly toward the hospital entrance, shortly before the outpatient clinic was
to open at 8 a.m. As I approached the hospital, I began to prepare myself
for the intense focus I would need for the next four hours. I was going to be
shadowing an experienced clinician during his morning shift. It would take
my full concentration to follow his clinical work and take good notes as he
efficiently worked through his typical caseload of patients, usually two dozen
or more before lunch.
I was determined to make the most of this opportunity. I wanted to be a
practitioner myself. Although I had completed a five-year medical school de-
gree in Chinese medicine, I still felt distressingly unprepared for the demands
of clinical practice. I envied my Chinese classmates, who could continue to
develop as doctors within the institutional structure of the hospital, gradually
mastering the needed clinical skills as they rose through the ranks of resident,
attending physician, and beyond. After graduation, my opportunities for clini-
cal training in China were limited for a couple reasons. First, foreign students
like me were welcomed at universities of Chinese medicine, but we were not
allowed to work as doctors in China’s state-run hospitals. Some of my Korean
classmates were working around these restrictions by becoming graduate stu-
dents, committing to another three to six years of education as a means to also
get more clinical training from an advisor. Second, I might have been tempted
to follow the lead of my Korean classmates, but I had already started a Ph.D.
1
2 INTRODUCTION
degree in Anthropology at the University of North Carolina. It was because
of that Ph.D. program that I had originally gone to the Beijing University of
Chinese Medicine to conduct my fieldwork. Instead of spending a year or two
conducting fieldwork, however, I had stayed for more than five years, learning
a whole new discipline in the process. I felt incredibly fortunate to have been
able to do so, but I knew I would not be able to write my Ph.D. dissertation un-
less I reimmersed myself in the academic world of anthropology. Feeling torn
by the demands of two professions, frustrated at the challenges of pursuing
both, I had decided that I would return to the University of North Carolina to
finish my Ph.D. But I was determined to not give up on my dreams of clinical
practice. My hope was that through occasional short trips to China, like this
one, I would be able to continue refining my clinical skills.
While I fretted about the feasibility of my convoluted career plans, whether
I could really learn the clinical craft of Chinese medicine and fulfill the de-
mands of an academic career in the U.S., I knew that many of my Chinese
classmates were even more apprehensive about their own futures. A signif-
icant number, in fact, wished to gaihang or “change professions.” I had re-
cently caught up with Chen Shubin, a classmate who had quickly found work
after graduation with the multinational medical nutrition company Nutricia
in its Beijing office. Chen Shubin did not dislike Chinese medicine. Indeed,
like most of our classmates, she had a strong affinity for the profession after
having devoted an entire college career to studying it. But she clearly pre-
ferred the financial benefits of working for a global pharmaceutical firm over
the difficult and poorly compensated work of a doctor of Chinese medicine.
She had been very clear minded about this professional choice long before
we graduated. Even though some of our teachers had discouraged her from
“abandoning her profession,” she had persisted in her ambitions. Now that she
had settled into her job, she was feeling quite pleased about her career choice
and its financial rewards. I caught up with her again in 2008, not long after
she had attended a small get-together with many of our classmates. She told
me then, about eight years since our graduation, that nearly one-third of our
sixty Chinese classmates had now followed in her footsteps and were working
as drug representatives for pharmaceutical companies.
Becoming a drug rep was one way out of the profession made possible
by the rapid growth of the pharmaceutical industry in China beginning in
the mid-1990s (Karchmer, Driver, and Kroeber 1998). I also watched friends
pursue more intricate and ambitious paths to other professions. For example,
some of the graduate students that I met at the Beijing University of Chinese
Medicine were hoping to leverage their graduate training, which often had a
strong focus on biomedical research techniques, to become outright biomed-
INTRODUCTION 3
ical researchers. Huang Yao, the teaching assistant for my biochemistry class,
was one such example. She and her husband had both studied Chinese med-
icine as undergraduates at the Beijing University of Chinese Medicine. Their
excellent grades gave them automatic entrance into the graduate programs of
their choice at their alma mater. I got to know Huang Yao because she had
chosen to get a master’s degree in biochemistry, and she had been assigned
to be the lab assistant for my biochemistry course. I was struggling in the
course, overwhelmed by a whole new vocabulary of chemistry terms in Chi-
nese. I was able to convince Huang Yao to tutor me privately. She patiently
and steadfastly guided me through the course textbook, and without her help
I could not have passed the course. A little more than a year later, she and her
husband had both completed their master’s degrees and were moving to New
York City. Her husband had been accepted into a Ph.D. program for oncology
research at New York University. The last time I caught up with Huang Yao
in New York, she was happily working as a computer programmer, having
left behind the worlds of Chinese medicine, biochemistry, and perhaps even
China. The ambivalence of young doctors like Chen Shubin and Huang Yao
about pursuing a career in Chinese medicine was pervasive. As we will see,
even those who stayed in the profession to work as doctors often had misgiv-
ings about their careers. This ambivalence is one of the defining traits of what
I call the “postcolonial condition” of Chinese medicine.1
Although I was keenly aware of the mixed emotions of my classmates, I
also knew that there were still many excellent physicians working at hospitals
of Chinese medicine such as Dongzhimen Hospital, and I was rushing to see
one of them in action. I hustled through the waiting room of the outpatient
clinic, pulling off my winter jacket and slipping into my white doctor’s coat,
standard attire for all doctors and hospital technicians, just before striding into
the consultation room a few minutes before 8 a.m. On this day, I had arranged
to work with Dr. Sun. Three years ago, he had been the main lecturer for our
fourth-year medical school class in Chinese Internal Medicine, the key course
for that year of medical school. In a pedagogic environment where most pro-
fessors rarely strayed from the textbooks, Dr. Sun had stood out with his care-
fully researched lectures, dynamic speaking style, and memorable anecdotes
from his own clinical cases. I was hoping that his clinical skills would indeed
match his rhetorical talents.
Established in 1958, Dongzhimen Hospital is one of the oldest hospitals
of Chinese medicine in China. The hospital consisted of an interconnect-
ing series of well-trod concrete buildings. Despite its dour appearance, I had
developed a deep fondness for this complex and the clinical excitement that
transpired within its walls. Dr. Sun’s consultation hours were being held in
4 INTRODUCTION
a small, narrow room on the second floor, where the internal medicine out-
patient clinic was located. The room had almost certainly been converted
from some other use to a consultation space, and I didn’t remember ever
entering it as a student. Dr. Sun sat at a yellow desk, the same basic wooden
work desk found in all the consultation rooms, positioned halfway between
the hallway door and a tiny window on the far wall. A stack of stools, a small
cabinet, and a dusty examination table had been pushed to this far end under-
neath the window. The room was so narrow that when Dr. Sun sat at his desk,
I would have to awkwardly squeeze between the wall and his chair to get past
him. Unlike most of my own experiences as a patient in the U.S., where the
clinical exam is centered on the examination table, the desk was always the
site of the clinical encounter for an herbal medicine consultation. Dr. Sun
would spend the entire morning seated in front of it, conducting consultations
and writing prescriptions, too busy on most days to even stand up for a break.
The patient would enter from his left and take a seat at a small, three-legged
stool at the side of the desk nearest the entrance. Students like me would sit to
his right, huddling around the far side of the desk as we took notes.
On this morning, I was sharing the far end of the desk with another medical
student, who turned out to be a distant cousin of Dr. Sun. We were participat-
ing in the time-honored tradition of “copying prescriptions” (chao fangzi), in
which a student follows a senior doctor, making notes about the consultation
Figure 1. Dongzhimen Hospital, viewed from nearby street, 2002.
INTRODUCTION 5
and recording the doctor’s prescription for later study. As this expression sug-
gests, the prescription lies at the heart of this training method. Far more than
a record of the doctor’s treatment for an individual patient, the prescription
is a condensation of the doctor’s therapeutic strategy, both with respect to
a specific disorder and his overall clinical style. Unlike Western medicine
prescriptions, Chinese medicine prescriptions often contain a dozen or more
herbs that the patient usually cooks together in water to make a decoction.
Doctors of Chinese medicine assert that the clinical efficacy of a prescription
depends not so much on the properties of any single item but on the collective
action of the herbs. Moreover, prescriptions are not standardized for medical
conditions. Indeed, physicians generally try to individualize the prescription,
tailoring it to the patient’s unique presentation to the greatest degree possible.
Writing a prescription is therefore an art. Some doctors celebrate this fact by
writing them out with graceful penmanship. The prescription brings together
the physician’s skill at identifying the patient’s underlying condition, a mastery
of hundreds of Chinese medicinal herbs and their multiple clinical uses, and
a command of centuries of formulary scholarship about how to best combine
the herbs. By copying a doctor’s prescriptions, the student hopes to inscribe
and ultimately embody the teacher’s virtuosity.
A Clinical Encounter
On most days, the rush of patients is so overwhelming that doctors and stu-
dents have little opportunity to discuss prescriptions and treatment strategies.
Outpatient clinics work on a first-come-first-serve basis in China. On a typical
day, the waiting room and hallways of the outpatient clinic of a major hos-
pital are filled with patients milling about, anxiously waiting their turn for a
consultation.
But on this day, a light drizzle had begun, thinning out the usual morning
crowd, giving us occasional opportunities to talk. Around 9:30 a.m., an eighty-
four-year-old woman shuffled into the room, her daughter supporting her as
she took a seat. The daughter opened her purse and pulled out her mother’s
outpatient record book, a worn and folded yellow notebook, the size of an
elongated index card. Dr. Sun took the notebook and placed it on the desk,
pushing aside the blood pressure cuff he had used for the last consultation. He
scanned the notes from previous consultations and then looked at the patient:
“What’s bothering you today?” “My whole body aches,” she said in the Beijing
patois, putting her hand to her chest, as if to suggest that it was the greatest
source of discomfort.
While she and her daughter took turns speaking, Dr. Sun began opening
6 INTRODUCTION
the laboratory tests and other exam results that had been folded and stapled
into the record book, adding considerably to its bulk. They included an elec-
trocardiogram from a month ago with a depressed ST section, indicating mild
cardiac ischemia. Blood work from a visit two weeks ago showed that her
white blood cell count had been high (14.3 x 109 cells/ liter) and her neutro-
phil distribution elevated (84 percent), both signs of infection. A biochemical
panel did not indicate conclusively any one problem, but Dr. Sun declared it
“chaotic,” with eight abnormal results. The daughter handed Dr. Sun a recent
chest X-ray. Holding it up to the light and angling it toward us, the students,
Dr. Sun pointed out cobweb-like interstitial markings caused by a pulmonary
infection and drew our attention to the increased spacing of the ribs, a sign
of emphysematous changes. He put down the X-ray and then showed us the
notes from her last hospital visit, in which a different doctor had diagnosed
her with coronary heart disease, chronic nephritis, and interstitial pneumonia.
Turning to a fresh page in the record book, Dr. Sun began writing today’s
entry, asking the patient questions as he wrote. He quickly jotted down addi-
tional complaints about heart palpitations and back pain and then asked her
to stick out her tongue. The tongue exam is one of the distinctive features of
the Chinese medicine exam. Doctors consider it one of the most important
and reliable ways to assess the patient’s overall condition. Dr. Sun carefully
noted the shape and color of the tongue, as well as the texture and color of
the tongue coating. Next, he gestured toward the patient’s wrist to begin the
pulse exam, another distinctive feature of a Chinese medicine consultation.
She extended her arm, palm up. Dr. Sun put three fingers on her radial ar-
tery, letting his fingertips gently roll over the artery, sensing its resilience as he
varied the pressure. He repeated this process with the other wrist. In Chinese
medicine pulse taking, doctors feel for the overall presentation of the pulse
and record its texture according to twenty-eight basic pulse forms. Several
pulse presentations may present simultaneously, and they can also vary across
the three positions on each wrist. Like the tongue exam, the pulse is consid-
ered an excellent indicator of the patient’s overall condition and an essential
part of any consultation (Kuriyama 1999; Farquhar 2014). The pulse exam is
so iconic to Chinese medicine clinical work that patients sometimes turn it
into a test of a doctor’s clinical skills. I observed more than a few patients be-
gin their consultations by silently extending their wrist, with the expectation
that the physician would be able to state the patient’s symptoms based on the
pulse alone.
Having completed his exam, Dr. Sun looked up from his notes and ad-
dressed the two women. He recommended that the patient be admitted to
the hospital. Her condition was too complicated and unstable to be treated
INTRODUCTION 7
Figure 2. Sun Pei checking the blood pressure of a patient, 2002.
on an outpatient basis. Since Dr. Sun has recently joined the nephrology de-
partment, he suggested that the patient be admitted to this ward. It would be
permissible with her chronic nephritis, and he could personally care for her in
that department. They quickly agreed to this plan, and the daughter gathered
up the record book, the X-rays, and other belongings and escorted her mother
out of the room to begin the admissions process.
The next patient did not enter right away, so Dr. Sun turned toward his two
students to discuss this case with the excitement that only a devoted teacher
might have. “What formula would you use for that patient?” he quizzed. Dr.
Sun’s cousin and I looked back at him blankly. I felt overwhelmed by the
complexity of the case. Could a single formula address the patient’s heart,
lung, and kidney problems? Each one alone would be difficult to treat. “First
of all,” Dr. Sun said, breaking the silence, “the patient should be diagnosed
as having Chest Blockage (ᘔ), due to cold and phlegm. In the sixth edi-
tion of the Chinese Internal Medicine (Ѕֵࣨ॓Ѻ) textbook, Chest Blockage
was misleadingly renamed Chest Blockage and Heart Pain (ᘔК)ڔ. But
interstitial pneumonia corresponds perfectly to Chest Blockage, which can
also account for the patient’s mild cardiac ischemia. The proper formula
should be Trichosanthes Fruit, Chinese Garlic, and Pinellia Decoction (Gua
Lou Xie Bai Ban Xia Tang) to ‘invigorate chest yang’ (zhenfen xiongyang).”
