Each time I attempt to modify a formula, I think to myself, is this the correct way? Do I choose my modifying herbs based on the system that I am trained in, the newest research results of Chinese herbs (e.g. Coumarin containing herbs as anti-cancer herb) or the presenting pattern? Or all the above? Or is there something that I have to consider such as the season, the constitution, past medical history and current Western medication.
These thoughts generated the desire to ask other practitioners and find out what their approach and experience are. Also, dispensing formulas for other practitioners tells me that not everyone is using the same ‘system’. Some formulas are very large, say up to 25 single ingredients and some are little and contain only 4 ingredients. In some instances, I recognize a formula like Liu Wei Di Huang Tang that has been tweaked with a few other herbs…
I am thankful that a highly regarded anonymous practitioner as well as Shelley Beer, Robin Marchment and Greg Bantick have answered my call and given us their opinions and insights. Hopefully, their answers and approaches will help you, that’s if help is needed, to make even better decisions about modifying classical formulas.
If there is enough interest, we are happily organizing a webinar on this topic. If you could briefly email your interest, that would be great!
Question 1: As Chinese herbalists and confronted with various systems, are we in a state of confusion?
Anonymous: As much as a tradie (trades person) is confused by the various tools in his toolbox.
Shelley Beer: No
Robin Marchment: I am not. I fear that dogmatism is worse than confusion because confusion at least suggests the consideration of various avenues. There is nothing confusing about Chinese medicine if we look at it logically, and utilize the appropriate knowledge for each patient.
Greg Bantick: Some maybe confused. Chinese medicine is such a rich field that confusion, may at times, just be a part of studying it. The more we learn about our medicine, the more we will learn of the many different approaches to using herbs. Schools generally teach individual herbs and formulas, which leads to a familiarity with a wide range of formulas. They often don’t teach much depth about the approaches the various formulas came from. Some practitioners continue with this approach. Others go on to study with a teacher of a particular approach. I found it useful to immerse myself in a particular approach. Take the time to really get to know it, and develop the clinical confidence that comes from the focus. At some point I found it useful to add other approaches. Even within one tradition, such as the Shang Han Lun, there are many different approaches to using the same text and its formulas. We can learn a lot from how other practitioners have thought about and clinically applied the principles embodied in a text like the Shang Han Lun.
Confidence can come from really digging deeply into one approach and finding how it can be used to treat a wide variety of conditions. Having done that, learning how other practitioners of the same approach, through their clinical experience and personal interests, have developed their own style helps. We can also develop familiarity with the depth and richness of the many, other approaches. Being curious about the various approaches all have something to offer, and can break down pride in a particular approach. It can lead to mutual respect and understanding toward our colleagues.
Question 2: When do we modify a herbal formula and when don’t we?
Anonymous: There are some formulas that work better without modification. There is usually a traditional indication that this is so, or the composer (e.g. Fu Qing Zhu) says “Don’t change the formula!!”. Other formulas are more like strategies, and the actual herbs employed are flexible. For example Xiao Yao San is the strategy of tonifying Liver blood while ensuring Spleen is supported to continue the Liver blood supply, and on the basis of sufficient Liver blood a tiny amount of Liver qi moving herbs will suffice to move Liver qi. One can use the strategy without sticking to the same herbs.
OR take Li Dong-Yuan’s formula structure as another example, used for many of his formulas. It employs groups:
a) Huang Qi, Ren Shen, Gan Cao
b) blood tonifying (eg Dang Gui, or Bai Shao)
c) a bitter cold herb or two (eg Huang Bai or Zhi Mu)
d) herbs that lift (could be Sheng Ma, Chai Hu, Ge Gen, Jie Geng or a selection of wind-moving herbs in small doses, e.g. Qiang Huo, Du Huo, Fang Feng)
As a good example, see Yi Qi Cong Ming Tang, or Sheng Yang Yi Wei Tang, or his version of Ban Xia Bai Zhu Tian Ma Tang. Bu Zhong Yi Qi Tang has the structure without the bitter-cold herb, while Sheng Yang San Huo Tang deletes Huang Qi, which again is instructive–the formula structure is adaptable!
Shelley Beer: I modify all the time, unless I am forced to dispense capsules or pills.
Robin Marchment: Zhang Zhong Jing advocated that we look at the signs and treat accordingly – and also look at the signs in order to understand what mistakes have been made. He did not advocate adhering dogmatically to one formula – in fact he offered hundreds of examples of modification according to individual circumstances. The study of Wen Bing formulas and other famous formulas found in good formula books too, shows that many are variations of each other.
Greg Bantick: Each approach has its own criteria for when to modify. Initially be guided by these. They provide a model for how to think about modifications according to different clinical presentations. Over time I think we develop our “favorite” reliable modifications. Another modification approach is taking a component of several formulas and combining them. I use both. If a patient closely conforms to a formula I prescribe it without modification. If I know the formula will adequately treat the problem, but it may take some time, and they have some particularly distressing symptoms, I may modify the formula to help with the quick relief of those symptoms. In doing this the modifications still need to harmonize with the intent of the formula.
Question 3: In your opinion, how do we best modify?
Anonymous: From experience, either our own or a teacher’s.
Shelley Beer: Keep in mind the Chinese diagnosis, Choose a base to match as closely as possible, and when critical discomforts are not covered by the base formula, follow the typical subtractions/additions stated in basic formula references , or handed done via oral tradition to be useful or seen clinically to be effective.
Robin Marchment: By treating the patient. By careful diagnosis of the individual. By knowing all the actions of the herbs and the channels they enter, and by employing flexible thinking in their application. By considering the principle rather than strictly adhering to the ingredients. By using all resources, not just one school. And not by trying to fit our patient into a single pattern. Jing Fang clinical (note I say ‘clinical’) specialists make significant modifications.
Greg Bantick: According to the approach that the formula is from. Modifications should follow prescribing guidelines of enhancing the main herbs, countering harshness and so on. If a formula fully covers the presenting pattern or patterns we don’t need to modify it. If however, it is the closest formula, but does not address all the patterns or symptoms, I go outside the approaches modifications and use my own. Most of them come as familiar combinations of two or three herbs, that I know will help with the symptoms. Modifications should still conform to the intent of the formula. They should enhance it for this particular patient. Modifications are not just adding together various herbs for all the different symptoms. They should follow from a good diagnosis and differentiation.
Question 4: In your opinion, is the scientific approach (evidence based herbs) a curse or a blessing?
Anonymous: It is tossing out everything that has been learned about how these substances interact with human physiology and deciding to start again at the beginning.
Shelley Beer: It’s a curse- it risks the beauty of the Chinese diagnosis system being usurped.
Robin Marchment: All of our herbs are evidence based – clinical observation etc. Modern trials do not duplicate the clinical experience – nor do they cover all herbs. So, it is useful to consider the findings, but not rely on them as the be all and end all in selecting herbs for the prescription. First, treat the patient’s pattern. Without that results will be poor.
Greg Bantick: This is a big question that I have strong feelings about. Briefly, our medicine is a whole, complete system of medicine. It is part of the indigenous science of China. It has its own theories, anatomy, physiology, and the other facets we assume make up a medicine. It has confidence in non-material qi, tastes, smells, consciousness, value, meaning, taiji, meditation, prayer, ritual, that are currently denied by modern science. Australian practitioners, even in our reductionist scientific materialist conditioned society, practice these with good clinical results. The denial of them by our cultures science, has for decades blocked access for many, to good, safe and inexpensive health care.
The Chinese were very good at recording vast amounts of empirical observations in a wide range of areas. We can develop that tradition by taking good, objective patient records, utilizing patient outcome surveys and other ways of measuring, to more objectively develop our skills. We can learn different measuring techniques from our cultures science to help develop our own medical science. Much of our cultures science is based on reductive materialism, given that material is what is most amenable to measurement. From measuring we have learnt to value the derived data as more objective, more reliable evidence. This has some validity, but it also denies our inescapable human subjectivity and learning to work with it. Even those that originally championed evidence based medicine are now questioning it. Not because the approach is bad, but the way it has been used as a weapon to promote one view or product, while squashing another, is a good example of our subjectivity. The belief that only our cultures scientific method is valid and other ways of knowing are invalid, is a belief system. It is called scientism. It is not benign. It has been the instrument of the destruction of many indigenous sciences, arts and cultures. It is not our cultures scientific method, as much as it the individuals that use it as a form of cultural imperialism. There are many other valid, and certainly some more useful ways of knowing. Only recently has our cultures science, begun to investigate consciousness, even reaching out to meditators. Our medicine teaches subjective skills, how to use them well, and how to develop objective checks and balances to those skills. We are in an interesting time where indigenous views are contending with the modern scientific, reductionist, materialist view.
Question 5: What’s your clinical experience with modifying herbal formulas?
Anonymous: I do it all the time.
Shelley Beer: 26 years
Robin Marchment: I am now semi-retired but I used to see 30-40 patients a week. And I had the advantage of working with an excellent herbalist with 30 years’ experience in China. When I write a prescription I rely on the patient’s needs and so it is generally based very loosely on one or more formulas – using those to guide and inspire rather than to specify the exact ingredients.
Appropriate modification demonstrates our deeper knowledge and is the key to efficacy. Where do we find a patient that mirrors a patient from 200AD Han Dynasty? Do those etiological factors exist in Australia? Or anywhere in the modern world? (But in Australia least of all.) Patterns are an important feature of diagnostics – but in most cases the formula can be improved to fit the patient’ exact presentation with at least some modification. Few people present with one formula pattern. The true etiology must be considered. Relying on one pattern might get some results, but not the best results.
Greg Bantick: I learnt the Nei Jing and Shang Han Lun from a variety of teachers, who, naturally all had different approaches. I also spent time in the same way with the Wen Bing, Zhu Dan Xi, Qin Bo Wei, and Li Gao. These largely because I had access to teachers of these approaches. So my personal approach is using the one that seems best for the particular patient. I experiment, try things, and keep good notes about what I did and why. I check myself on subsequent visits, to see if my thinking was accurate. If there were changes, what in particular changed, would that change reasonably be from the formula? Do I need to now change the formula, modify or adjust doses, because of those changes? If there were no changes, did I diagnose correctly and comprehensively? Did the choice of formula and modifications adequately fit the pattern? If I am confident the formula is correct, do I need to be patient, or change the dose? These are some examples of my thinking.
Shelley Beer works in Daylesford & Castlemaine (Victoria)
Robin Marchment works in Surrey Hills (Victoria)
Greg Bantick works in Wooloowin (Queensland)