色中色

By Amanda J. Kreiss, DiplOM, MSTOM, MA

Teachers I admire at my alma mater (Steve Bonzak) and in our profession-at-large (Dr. Huang and Sharon Weizenbaum) speak decisively about raw herbal medicinals as the time-tested, irreplaceable gold standard. Pioneering veteran farmers Jean Giblette and Peg Schafer emphasize that a demonstrated, steady demand by herbal clinicians for ecologically cultivated raw medicinals is imperative to the confidence North American farmers need to risk growing these specialty crops.

Inspired by these and other valued influences, I understand that my day-to-day clinical choices have a powerful impact on the nature of my patients’ healing. Alongside those of my peers, these choices likewise have broad implications for the preservation of our age-old medicine and for the safe and sustainable re-rooting into North American soils that is vital to its ongoing evolution. Consequently, when I entered private practice, I made the commitment to “go it raw.”

I now craft custom formulae for nearly every patient, and typically order raw for over 90 percent of them on a weekly basis. I nearly always order for internal consumption. Infrequently, I order for external application or integration into congees, soups, or other foods. Less often, I order powdered-at-source for a draft or for honey-pill-making. The latter I find ideal for Winter Solstice celebrations, when Er Zhi Wan honey pills pair fabulously, in the way of tradition, as complement to red wine!

I understand my choice is unusual amongst US-trained herbal clinicians, and I want to share some of my lessons learned with you. For your ease of reference, I have numbered these germinal insights and kept them brief.

Key Lessons from a Herbal Clinician’s Journey with Raw Medicinals

Lesson #1: Superb Source Selection Matters to Patients and Inspires Healing

This decade we’ve watched the local food movement blossom. The First Lady tends a White House garden.? Alice Waters, Michael Pollan and Will Allen garner celebrity status. Terms like “farm-to-table”, “community food security”, and “foodshed”—once but seeds themselves—have flowered into everyday vocabulary. Meanwhile, the news highlights tale after tale of untrustworthy products and raging pollution within China.

Amidst all this, I recognize that my patients deserve the right to ask about the safety and quality of the herbal medicine they consume, in much the same way they have learned to do for food. As their clinician, I in turn have the responsibility to do my due diligence to seek meaningful answers. In large part, I answer by choosing to order their formulae from a source I know deserves their trust and can embrace their curiosity because it is committed entirely to the detailed art, science, and skill of source herbology.

This source, Inner Ecology?, dedicates its full time and resources to responsible, multi-faceted medicinals research; smart sourcing, both internationally and now domestically; fastidious compounding, compatible with current Good Manufacturing Processes (cGMP); education for patients, clinicians, farmers, and the public; and advancement in access to supply to ecologically cultivated medicinals of the highest quality. It does all of this because patients of our shared medicine deserve it and because it’s unreasonable for herbal clinicians, who are rightly busy applying their skills to patient care, to do this due diligence. I founded Inner Ecology, quite simply, because no other option existed that met my criteria. It now has the distinct privilege of serving many of you, on behalf of your patients, across the continent.

Over time, the patients in my clinical practice have come to understand clinical herbology as distinct from, yet interdependent with, source herbology—just as their primary care physician’s expertise is distinct from yet interdependent with that of their pharmacist. Picking up formulae (or receiving a bicycle delivery or a shipment, for those who are not local) from Inner Ecology further professionalizes the experience for them. Since most grew up heading to the neighborhood pharmacy, it feels familiar. Yet they routinely express delight and relief to receive formulas of vibrant herbs, not generic bottles of pills or powders.

Lesson #2:? Each Formula’s Flavor Array is Distinct and Each Patient’s Palate is Unique

When introducing new patients to decocting and imbibing, I frequently mention the value of what I call “palate maturation”. If they ask what flavors to anticipate, I speak with equal parts candor and wonder about the thousands of herbal medicinals in the Materia Medica.

Just as each meal is unique, so each herbal formula showcases its own fusion of flavors, textures, and temperatures. These flavors, harmonized through interactive symphony during decoction, heal by educating the immature palate. Each taster, quite naturally, experiences them differently. This seems only reasonable: an individual reared with a native Indian palate may not experience the lingonberries, rye bread, and pickled herring of my own Swedish ancestors the same way they surely did. An herbal decoction opens, in essence, a whole new cuisine to a patient.

I am careful not to voice my assumptions, particularly when ordering a patient a formula similar to one that challenged my own personal palate. While I may mention flavor names (bitter, acrid, sweet, salty) to them, I tell my patients that I look forward to hearing what they taste in the recipe I built just for them. Experience teaches me that what Dr. Huang asserts is true: tastes evolve as healing happens. So, to a patient who needs bitter, bitter will be a delight, until the need for bitter extinguishes itself.

The importance of withholding assumptions has been reinforced on myriad occasions, including one that was especially clarifying. I ordered a modified Wen Jing Tang for a patient. It’s a formula I’ve taken myself, thanks only to sheer willpower, meted out dose-by-dose. Yet with her I never shared my own poignant aversion. I spoke, instead, about the adventures of palate maturation.

Two days later she called, wondrous and wanting to share the startlingly immediate results she’d experienced and to ask just what that mysterious ingredient was. Waxing more poetic with each passing phrase, she said it tasted to her like the most delicious, intoxicating, spicy, soul-stirringly delectable chocolate she’d ever had. When I explained that E Jiao is actually gelatinous glue from an ass’s hide, this past vegetarian of many years didn’t miss a beat; she was too enthralled by the delights of her taste buds. She and many other patients have taught me to mind my own tongue – quite literally!

Lesson #3:? Raw Decoction Provides a Tool for Ongoing Learning

The reason raw decoction has been the delivery method over the course of millennia is not for lack of technical prowess. It is, quite simply, the most clinically effective method available – a status that has been upheld over thousands of years through the daily empirical results of herbal clinicians.

Its superiority, I have learned, also makes it an unparalleled teaching tool. The legacy of the centuries, now partially transmitted through our primary medical textbooks, assumes raw medicinal usage. No other method of herbal delivery provides the immediacy, the potency, and the able-to-be-anticipated effects necessary to test diagnostic accuracy and refine dosing. Whether I read a patient well, do well enough but need improvement, or miss the mark entirely, it comes vividly clear.? A dosage shift of a few grams in a raw formula can have substantial implications for results.

This simply isn’t true to the same extent with granules, for example. Despite the modifiability of granules, they comparatively lack as teaching tools in clinical practice. I do not observe the clarity of results I do with raw; even significant shifts in dosage can come to disappointingly little avail. My patients are often the first to report the difference. Whether it may be due to inferior grade raw materials, the extremes of manufacturing processes, the dulling effects of excipients on taste, the lack of connection patients have via granular powders to the medicinals themselves, or another factor that has not made itself otherwise known to me, granules simply do not offer the same potency.

I still order granular formulae when needed. I am grateful that they exist as a delivery method; I just adjust expectations of clinical results and dependable feedback when I choose them. After all, I would likewise not expect a cup of processed, instant, mass-produced coffee to have the heart-enlivening effects that a cup of freshly ground, French-pressed, shade-grown coffee has!

Lesson #4: Patients Prefer Raw When Given an Informed Choice

There is a firmly entrenched, passionately defended myth perpetuated in our professional community—a myth beginning, quite sadly, with our academic institutions—that assumes people prefer ready-made, processed medicinals to custom-modified raw formulae. ?I have learned the truth to be radically opposite: nearly all patients staunchly prefer raw medicinals to other delivery methods when proffered an informed choice.

My patients have shared numerous reasons for their preference for raw formulas. They sincerely care to know that the compounding source for their herbal formulas fastidiously researches seed-to-shelf stories; they understand that the same detailed research, due in no small part to lack of transparency, is presently impossible to the same degree for other delivery methods. They prefer the clean taste and texture of decocted medicine, as well as the enhanced ease of digestion and absorption it offers. My patients also report that they really care that I custom-craft their herbal prescription. They enjoy practicing the rites and rituals of “slow medicine”–the sensual experience that touches sight, smell, and sometimes sound, just as much as full-bodied taste—along with the pleasures of its results.

My most intimate debunking of the unfortunate preference myth came in the form of someone gratefully not my patient. For years, my husband Brian saw a respected clinical herbologist who, time and again, ordered him granular formulae. We had near-daily battles about his lack of discipline in taking them. His dislike for them rather approximated disdain. Even when, actively grimacing and gagging, he followed her directions for stretches of weeks, he noticed no results.

One day he asked me to order his formula raw. As he’s a kinesthetic learner, we decocted it together at home. It took only one dose for him to look at me wide-eyed. As if betrayed, he said, “Why on earth didn’t you tell me how much better this was?”

A former manager of high-end restaurants in Manhattan, Brian has a keen palate and is as attuned to texture as he is to flavor. As a native Midwesterner, I take free license to comment that he is a typical New York snob when it comes to demanding quality. The dulled, processed taste of granules combined with the particular murkiness of the granule brand chosen by his clinician had contributed to his ongoing lack of compliance. Now an aficionado of raw, Brian decocts himself and imbibes regularly to resulting twinned benefits for his personal and our marriage’s wellbeing!

Lesson #5:? Patient Compliance is Easiest with Raw Decoction

My patients are more compliant with raw decoction than with other delivery methods I have tried. Though they are busy professionals, battle-weary educators, athletes in training, brand new parents, serious students, and the unemployed too, they are real people living amidst the speed and stimulation of the 21st century.

What initially surprised me before rarely does now? For example, whole families manage decocting for various members – quite often simultaneously. Parents model taking their “potions,” and kids imitate with ease; at times, in reverse, kids inspire their parents’ compliance. Families who decoct for human members often seek out veterinarians trained in Chinese herbology to do likewise for animal members. Many take compliance even further by specifically seeking travel destinations, whether for pleasure or for work, with kitchen access!

The way that I model and explain decoction may play a role in the level of compliance I witness.? My patients see me with my personal liquid herbal medicine regularly.? When I prepare to describe decoction to new patients, I ask first about their dominant learning style – verbal, visual, kinesthetic. ?I then pick from the tools—including step-by-step decoction instructional videos—that Inner Ecology has developed to make it easy for herbal clinicians to communicate with patients in order to resonate with their individual learning style.? I let them know that, in the end, it’s really as easy as simmering water. I regularly decoct for myself and have guided many patients through the process. I feel very comfortable identifying creative solutions when they’re needed to work with a given patient’s lifestyle.

Whenever it won’t compromise effectiveness, I ask patients to decoct every other or every third day; modern refrigeration makes this possible. I explain that this is a proportional medicine—that it can be concentrated or diluted as long as directions are followed. I describe how to divide decocted liquid evenly into mason jars so that each jar contains a day’s worth of medicine that can be further divided into doses. It’s then ready to be warmed, and easily carried along for the day’s pursuits.? There’s no need for them to find water of any kind; there are no pills to swallow or granules to dissolve.

The Importance of Customized Herbal Medicine

I’ve learned how much it matters to my patients that I apply skill and take time to custom-craft their herbal formulae and introduce them to a more vibrant form of self-care. It’s meaningful to them that their medicine is personalized and that I am not attached to a brand or to handing them a bottle that sells trite titles. Maybe most importantly, patients feel connected with what they have cooked.? Connection—whether through custom-crafting or through cooking—inspires compliance.

For patients of East Asian herbology:

• Ask your clinical herbologist questions about your herbal formulae. Why does s/he choose a particular delivery method for you? What does s/he know about the source of your herbs?? Were they grown with pesticides and herbicides? Were they mass-farmed or grown with integrated methods? Were they sulfured? Was your formula compounded in a cGMP compatible facility? You deserve to know the answers to these and other relevant questions about the substances you take into your body.
• If your current clinician does not yet choose to prescribe customized raw formulae for you, request that s/he does so on your behalf.? You’ll see the results and understand in a very embodied way why it matters.
• If you are seeking a clinical herbologist, identify one who not only prescribes customized raw formulae, but also who uses a professional compounding service with the integrity, fastidiousness, and efforts at sustainability you expect.
• Seek out clinic supervisors and mentors who are experienced in prescribing customized raw herbal formulae for their own patients. These clinicians will be best able to help you with accurate diagnosis, effective dosing, as well as patient education.
• As a patient yourself, choose a clinician who will prescribe customized raw herbal formulae for you. Decocting for yourself is one of the very best ways to build a sensual relationship with the herbs you study, to know their potency at work within you, and to gain confidence in the basic skills that you’ll want to share with your future patients.
• Become accustomed to asking the important questions you ask about your food’s safety and integrity about your herbal medicinals now while you are still in school. Take the opportunity you have to start asking these questions of your school’s dispensary.
• Plan to prescribe raw formulae as soon as you receive your board certification. You’ve been trained well. Don’t allow those skills to atrophy; develop them through practice. Choose the compounding service you will use with great care.

For students of clinical herbology:

For herbal clinicians:

• Don’t forget how important self-care is. Give yourself the gift of decocting raw formulae for yourself on a regular basis. Doing so will keep you connected with the plants, animals, and minerals that comprise our traditional medicinals and it will enhance your comfort in communicating with your patients. As we all know well, modeling matters.
• Trust your training. If you have graduated from PCOM or another institution with a strong emphasis on herbal training, you already have a scaffold of knowledge available for your reference. Use it, in full, for the benefit of all your patients by writing customized raw prescriptions for them.
• Choose to study with continuing education teachers and to associate with colleagues who themselves regularly prescribe raw formulae. You’ll find fans of raw medicinals in all corners; particularly if your passion is for the classics, you will discover that your satisfaction only grows as you go-it-raw, just like the beloved doctors of old.
• Be fastidious about your source selection. Opt for an entity that is committed to professionalism, uncompromising quality, clinician support, and the long-term sustainability of the medicine. Your ordering, formula by formula, from a reputable compounding source is the most regular, rhythmic contribution in your daily power to make toward the big picture of our medicine’s viability.
• Require that all students decoct a certain number of raw formulae before graduating from your clinical herbology program. A surprising number of students today leave school never having developed fluency in these most basic skills.
• Be certain that decoction of raw herbal formulae is actively demonstrated in herbal classes.? This increases student confidence, and it may help instructors revive skills that have become less fresh.
• Integrate concrete information about cGMP requirements and how to evaluate prospective compounding services for herbal formulae into curricula as students approach graduation.
• Demonstrate means of talking with patients about decoction throughout the sequence of herbology courses. Be certain that this is thoughtfully reinforced in practice management courses, and that it is witnessed during clinical supervision for all herbology students.
• Require raw prescribing for advancement and graduation. Do not allow students to advance through clinical stages toward graduation who have not had demonstrated experience in prescribing customized raw formulae to their patients. Allowing this advancement not only does a disservice to the student; it negatively affects that emergent clinician’s future patients and undermines the profession at large.
• Inspire both students and teachers to love these traditional medicinals that have cultivated wellness for billions of people across millennia.

For academic institutions of East Asian Medicine:?

It takes all of us in cooperative support to make a movement – in this case one that brings all of us closer to the roots of our medicine.

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