Here are some questions for our readers:
- How many American acupuncturists prescribe Chinese herbs? Some schools offer programs that teach only acupuncture, not herbal medicine.
- How many are well-trained in herbs? The California licensing exam is much more rigorous than the national herbal exam.
- How many use preformulated patents instead of personalized prescriptions?
I'm not aware of any good statistics to answer these questions. I also won't quote how many people have the national herbal license, because I know acupuncturists who decided not to take it since their states only recognize the acupuncture license, anyway.
The Best and Worst Herbs
I'm going to continue with my controversial streak here, only because someone has to say something, right or wrong, before everyone else can disagree and discuss it, with the ultimate goal being some kind of consensus.
What's the best kind of herbal medicine? Forgetting that some cases may not absolutely require herbs, but thinking from the ideal, traditional medical perspective, I suggest that the kinds of herbal medicine, from best to worst, are:
- Personalized prescriptions: Prescribing each patient a personalized raw/powder formula that addresses all or most of their zang-fu patterns with minimal side-effects, and is modified as the patient's condition changes. This is the way of all great herbal doctors. It is fraught with peril for the student who can't tolerate making occasional mistakes; patients may not get better as quickly, may spend more money, and may even discontinue treatment. But it is the only answer for complicated diseases, or when the appropriate formula is not commonly manufactured.
- Classical combos: Combining multiple patent formulas to address all or most of the patient's zang-fu patterns with minimal side-effects, changing the formulas chosen as the patient's condition changes. This technique has been employed in Taiwan (with KPC-type granular formulas) for decades with good results. Similar to this is the practice of prescribing several patents to be taken simultaneously (e.g., a bottle of bu zhong yi qi tang and a bottle of xiao yao san).
- Single patent: Prescribing only one patent formula that addresses the patient's major or root zang-fu pattern.
- Nada: No herbs.
- Oops: The wrong formulas for the patient. First, do no harm. Stick with the previous one if you don't know what you're doing.
What You Learned in School
From what I saw in school, most students did not graduate with the confidence or ability to write a personalized prescription for every patient. Most used patent medicines in the clinic. Add to this habit the problems of starting your own practice: time management; rapport; questioning; analysis; accurate charting; promotion; and the busy-ness of the rest of your life, and the likelihood that you'll learn to write personalized prescriptions is quite low. In fact, if you've learned it only in part, you might abandon it once in practice.
By the time I received my master's degree, I was just getting the hang of how to proceed from:
- Symptom and sign intake, to
- A complete zang-fu picture with pathomechanisms, to
- Representative formulas for all those patterns, to
- Assembling that into one not-too-big formula that still worked. (Thanks to Dr. Jiang Zheng!)
Now that I'm in practice, I find the prospect of classical combos much more palatable: I understand that only with practice will I become great at personalized prescriptions, but I have a lot on my mind! It makes you wonder if it wouldn't be smart to follow the Chinese way - specialize in either acupuncture or herbal medicine - but most of us try to do it all, and I'm no exception.
Classical Combos
Since they're so attractive, let's look at classical combos in more detail. When you put several classical formulas together, you get:
- Reliability. Each of these formulas has proven over time to work well. If it ain't broke...
- Simplicity. No worries about subtracting the wrong single herb. When you fiddle with your personal prescription, eliminating various seemingly redundant herbs, you sometimes thwart the whole prescription: Problems pop up, and the whole thing becomes an incomprehensible puzzle.
- Comprehensiveness. Instead of just prescribing one patent for one or two patterns, you address the whole person. Most patients have between two and four patterns of imbalance, which are mutually reinforcing and creating, so if you only treat one pattern, you may worsen another, and/or decrease the chances your changes will last. Of course, there are the typical treatment issues, such as you can't only boost the yin if there's also Spleen vacuity dampness - you can prescribe liu wei di huang wan and liu jun zi tang.
- Convenience. They're quicker and easier to prescribe and fill.
Classical Combos vs. Personalized Prescriptions
I'm not going to quit writing personalized prescriptions. I'm on the right track, and there is just no better option for some diseases, or for formulas not typically manufactured. Philippe Sionneau and others have translated modern Chinese formulas for modern diseases that combine pattern differentiation and pharmacology. They have yet to make it into the patent industry, but they work so well, I have to use them!
I believe combinations of classical formulas are the best answer for most acupuncturists. If you look at the first list in this article (best to worst in ideal herbal medicine), you'll see I put personalized prescriptions first. The learning curve, the unwillingness of most acupuncturists to commit to them, and the perils to the patient's health and pocketbook knock them down a notch for most.
In fact, I use classical combos when the personalized prescription seems too complicated, or if I suspect the patient's health might be too sensitive to accommodate an imperfect formula. I also rely on classical combos in cases where the diagnosis is not clear after the initial intake and treatment, and I expect we may go through a bit of "diagnosis by treatment." I do that because the effect of these time-tested formulas is better known, so the risk of a negative response is lower. If the results aren't great, I at least know it's not a problem of formula design, but of diagnosis, and I can use their response to refine my diagnosis.
The One Remaining Problem with Classical Combos ...
If you don't have your own herbal pharmacy, when you prescribe your patients more than one formula at the time, you have to send them home with two or three bottles of herbs and complicated instructions for how many to take and when to take them. Unfortunately, as the complexity of the instructions increases, patient compliance decreases. If you could give them just one formula, they'd be more likely to take their herbs as directed.
Another problem is that patients end up with a cabinet full of partly used herbs. They either never use them again and throw them away (a waste), or unwisely give them to someone else (perhaps harming that person).
... And the Answer
The ultimate answer for classic combinations would be to get your prescription in one bottle. Sounds impossible without your own pharmacy, doesn't it?
The good news is that about a year ago, a virtual pharmacy was created for just this type of situation. This way, if your patient needs two-thirds bu zhong yi qi tang and one-third xiao yao san, you can get it in a regular two-ounce bottle or four-ounce bottle. Formulas are drop-shipped directly to you or your patient, and the formulas can reach anyone in the continental U.S. in three days or less. Granular formulas can also filled be for those of you who write personalized prescriptions. To learn more about this virtual pharmacy, visit www.tcmformulas.com, or call (866) 206-9069 x 5284.
Why Not Keep Your Own Pharmacy?
You've probably heard gurus tell you that an herb pharmacy is a great moneymaker. That can be true, and it's up to you to decide, but first think about a few of the downsides:
- It costs money. A full liquid pharmacy costs from $5,000 to $10,000, and a granular pharmacy of 400 single herbs about $2,000. If you want 100 granular classic formulas to combine, that will cost an additional $1,000 or so.
- How long will it take you to use the herbs, and how long is their shelf life?
- It's time-consuming. Ordering, unpacking, pricing and restocking takes time away from treating patients (or costs you money for employees - subtract this from your profit). Filling a granular formula from single herbs can take 15 minutes.
- You have to get a resale license to avoid taxes and financial risks. You must keep records of these sales separate from your office visit records to calculate and file your yearly sales tax.
- Having only one form of herbs or one set of formulas limits how effective you can be for your patients.
Virtual Pharmacy and Instant Profits
If you don't want to maintain your own pharmacy, a virtual pharmacy of liquid combos and granular personal prescriptions is your solution. It makes a lot of sense for newly licensed acupuncturists. A really nice perk is that you collect the total cost (including your profit) from the patient first, and then you pay the pharmacy the cost of herbs and shipping. That means you have your profit in your hands before the herbs have been filled.
As you may know, some herb companies keep your profits in their bank accounts for months at a time. Ask yourself: Do you want your cash now or later? Who should be earning interest on your profit?
Click here for previous articles by Brian Carter, MSCi, LAc.