Chapter 71 Evidence-Based Medicine

Evan and Simon turn from clinical experience to the evidence behind a treatment.

What is evidence-based medicine?

Medicine that follows the evidence.^[1]

And medicine based on experience? That is experience passed from one generation to the next. A teacher uses a medicine to treat a disease, and it works. He passes that experience to his apprentice, who treats it the same way.

Evidence-based medicine is skeptical of this. Why? Because there isn't enough evidence. Individual cases don't provide enough objective clinical support.

What proportion of patients improve with this medicine? How many are cured? How often do adverse reactions occur? Without complete clinical records, there is not enough evidence.

That is why evidence-based medicine has always regarded inherited medical experience as unreliable. What if the experience being passed down is wrong? It has to be tested clinically, with enough evidence to support it.

And that is why so many Western drug research institutes have been putting so much effort into studying Chinese medicines in recent years.

Back in the private dining room.

Evan smiled faintly. “Evidence-based medicine… Heh. So you gave Evie Ma Xing Shi Gan Tang and Yinqiao San because there was clinical evidence for those two formulas?”

Simon paused, then nodded. “That was part of the reason. Both work very well, particularly against influenza A. They work even better than oseltamivir. There is evidence-based research behind that.”

Evan knew the research Simon meant.

Influenza A—H1N1. Parents would probably remember it. When it swept through a few years earlier, everyone had rushed to buy the specific treatment, oseltamivir, better known as Tamiflu. Supplies ran out in many places, and prices were driven up to 700 or 800 yuan a box.

What people didn't realize was that Chinese medicine had a specific treatment too. It was even on the market as a ready-made preparation: Jinhua Qinggan Granules.^[2]

It was developed by combining and modifying Ma Xing Shi Gan Tang and Yinqiao San.

And there was evidence-based research behind it.

In 2011, the internationally respected medical journal Annals of Internal Medicine published the study. Anyone with a background in Western medicine would know how much authority that journal carried.

It was one of the most authoritative medical journals in the world, regarded as the leading journal in internal medicine.

That August, it published a clinical study of influenza A conducted by Chinese researchers using evidence-based methods. They had recruited 410 patients with mild influenza A and randomly assigned them to four groups: a control group, a Tamiflu group, a Chinese medicine group, and a Chinese medicine plus Tamiflu group.

The control group received no medication, and their fevers lasted 26 hours. The figure was 20 hours for the Tamiflu group, 16 for the Chinese medicine group, and 15 for the combined-treatment group.^[3]

The Chinese medicine was a modified combination of Ma Xing Shi Gan Tang and Yinqiao San. It worked much better than Tamiflu. The advantage was obvious. Approval for production in China followed immediately: the commercial preparation Jinhua Qinggan Granules.

Instead of scrambling for Tamiflu, people would have been better off scrambling for that.

This was evidence-based medicine. Scientific, supported by clinical trials: controls, comparisons, experimental data, a theoretical basis. Western medicine accepted the results.

The study had made quite an impact internationally because Annals of Internal Medicine was so authoritative. Yet few people in China knew about it, or even knew the medicine existed.

Chinese medicine was particularly good at diagnosing and treating respiratory diseases, especially epidemic respiratory illnesses. And some people still claimed it only got in the way during epidemics. They had no idea what it could do!

…

“I know about that study,” Evan told Simon. “After it came out, enthusiasm for Chinese medicine research grew even stronger. Huge amounts of money went into it. Yet very few Chinese medicines have stood up to evidence-based testing.”

Simon nodded. “That's what puzzles me most.”

“I have nothing against evidence-based medicine. Experience should be questioned. We should look for enough evidence to demonstrate that a treatment works. The thinking is perfectly sound.”

Simon was surprised. He had expected Evan to dismiss evidence-based medicine, not praise it so highly.

“Don't look so surprised,” Evan said. “Evidence-based medicine is a good thing. Chinese medicine should use it too. But something has gone wrong in the way it's applied to Chinese medicine.”

Simon paused again. “What has gone wrong?”

“Do you know why Ma Xing Shi Gan Tang combined with Yinqiao San can treat influenza A?”

“Experiments show that it effectively inhibits viral replication. And in Chinese medicine terms, it clears heat, resolves toxins, frees Lung qi, and vents the pathogen.”^[4]

“Wrong.”

Simon stared.

“Because influenza A is a wind-heat invasion of the exterior—a heat pattern. Of course pungent, cool medicines that release the exterior work! Why didn't the same medicine cure Evie? Because she had wind-cold invading the exterior.

“I cured Evie. She had adenovirus pneumonia, didn't she? And my treatment worked quickly, didn't it? Following evidence-based medicine's logic, you would gather a lot of patients with adenovirus pneumonia, randomly divide them into groups, and give one group the medicine I prescribed.

“I can tell you that very few would respond. Why? Because you can't guarantee that every patient's condition is the same as Evie's. I mean the underlying pattern and disease mechanism in Chinese medicine, not the diagnosis of adenovirus pneumonia.^[5]

“I don't treat adenovirus pneumonia. I treat the condition identified through Chinese medicine pattern differentiation. Wind-cold was constraining her exterior. She had a Guizhi Tang pattern, along with breathlessness, so I used Guizhi Jia Houpo Xingzi Tang. You have to find patients who meet those conditions.”

Simon looked distracted, almost dazed.

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“Let me give you another simple example,” Evan continued. “A while ago, I cured a patient who had suffered from mouth ulcers for years. He had Spleen–Stomach deficiency-cold. Earth couldn't contain Fire. I used Lizhong Tang, and it worked quickly. Afterward, I prescribed Fuzi Lizhong Wan to consolidate the improvement.^[6]

“By that reasoning, I cured his mouth ulcers with Lizhong Tang. To prove that Lizhong Tang works for mouth ulcers, should we find a large number of patients with mouth ulcers and give them the formula in a clinical trial?

“I'm telling you, it won't work. Why? Because Chinese medicine treats patterns, not symptoms.^[5]

“You can't match Lizhong Tang to mouth ulcers alone. Too many different conditions can cause them.

“Lizhong Tang treats Spleen–Stomach deficiency-cold. If you want to prove it works, find a group of patients with Spleen–Stomach deficiency-cold and conduct a controlled clinical trial.

“But they'll tell you, ‘Sorry, modern medicine doesn't recognize Spleen–Stomach deficiency-cold. What deficiency-cold? We can't find it. You can't prove it exists.’

“You've rejected my theory, and then you ask me to prove my treatment? I say Lizhong Tang treats Spleen–Stomach deficiency-cold. You tell me that condition doesn't exist and demand that I prove something else.

“What am I supposed to do? This is a classic case of ‘abolish the medicine, test the drugs.’ Reject Chinese medicine's theory completely, then test its medicines by Western medicine's rules. How can that produce results?

“Even if we fund our own research into the relationship between Spleen–Stomach deficiency-cold and Lizhong Tang, and get results, they won't recognize them. The authoritative medical journals won't accept them either. I'm telling you, influenza A was a lucky break. Those patients had a single pattern. They were all heat patterns.

“The problem isn't that Chinese medicines don't work. How can you use them without understanding Chinese medicine's theory? You want to master some peerless sword technique, but you dismiss the sword manual as unscientific and fill your head with machine-gun shooting techniques instead. What are you going to do—aim down a sword and fire it in bursts or on full automatic?”

Simon was stunned. For a long time, he could not speak.

Evan sighed softly and looked at him. “Machine-gun theory can't teach you swordsmanship. The more pharmacology reports you read, the more modern interpretations of Chinese medicine you study, the less capable you'll become of treating patients with Chinese medicines.

“You know Mr. Zhang Xiaotong? He opened a clinic in Beijing that practices Chinese medicine alone. The doctors there are very good.

“He says medical miracles happen at their clinic every few days. They've cured many illnesses that Western medicine couldn't cure.

“But even when you cure someone, Western medicine won't recognize it. An individual cured case doesn't have evidence-based research behind it. The reason is the same.

“It doesn't really matter to us. All we're doing is treating illness and saving lives. But if you want to save lives with Chinese medicine, you have to think in Chinese medicine terms. If you want to save lives with Western medicine, be a proper Western medicine doctor.

“Western medicine is very powerful too. It can cure many illnesses that we Chinese medicine doctors can't. The world is richer for its differences. Forcing the two together the way you do makes them weaker, not stronger. You're destroying Chinese medicine and the advantages those differences give us.

“I won't tell you what to do, but you need to understand this for yourself. That's all I can say. I won't force you to practice Chinese medicine alone, even though it would benefit me.”

Evan nodded. “I've said my piece. I won't stay for dinner. Goodbye, Dr. Liu.” He picked up his bag, turned, and left.

Simon sat in his chair, looking lost, his mind in confusion.

Outside, Evan took several deep breaths, then slowly let the air out. He badly wanted the system's reward, but he couldn't compromise his principles.

Reader Notes

Reader Notes

1. ↩︎ Evidence and experience. Evidence-based medicine brings clinical expertise together with the best available research evidence in caring for an individual patient. It does not require doctors to discard experience, or treat every patient sharing a disease name identically. Clinical judgment includes assessing whether research applies to a particular patient and considering that patient's circumstances and preferences. The opening presents a sharper opposition between evidence and inherited experience to frame the dispute. Its generalizations, and the arguments that follow, belong to the novel rather than to this definition. Source: Sackett et al. — Evidence based medicine: what it is and what it isn't, p. 71.
2. ↩︎ Formulas, a trial decoction, and granules. Ma Xing Shi Gan Tang and Yinqiao San are traditional formulas, introduced earlier in the serial. Combining and modifying formulas means adjusting a prescription, rather than simply taking two finished products together. The 2011 trial tested a twelve-ingredient decoction. Jinhua Qinggan Granules is the manufactured preparation discussed by the narrator; the study should not be read as testing every preparation sold under that name. The narrative also compresses the approval chronology: the Beijing municipal government's account dates the granules' marketing approval to 2016. Sources: Wang et al. — trial abstract; Beijing municipal government — production history (in Chinese).
3. ↩︎ What the trial measured. This was an unblinded randomized trial in 410 people aged 15–69 with uncomplicated H1N1. The four figures describe median times to fever resolution, not cure rates. The paper's Table 3 gives those medians, but its adjusted comparison did not establish superiority of the herbal treatment alone over oseltamivir. Overall symptom-score improvement did not differ significantly between groups, and missing viral data limited conclusions about viral shedding. The control group received no assigned study treatment, which does not mean all supportive care was withheld. These limits qualify the narrator's broader interpretation. Source: Wang et al. — Annals of Internal Medicine, 2011, abstract and Table 3.
4. ↩︎ Heat, toxins, and the Lung. “Clearing heat,” “resolving toxins,” and “venting the pathogen” describe traditional treatment actions. Here “toxins” belongs to that vocabulary; it does not identify a measured substance or mean that a formula has been proved to remove a particular virus. The capitalized Lung names a traditional functional system. Pungent and cool are medicinal-property categories, while releasing the exterior describes a treatment principle. Simon's separate claim about inhibiting viral replication remains his statement; the cited terminology does not establish it. Sources: WHO — Chinese medicine terminology; Hong Kong Department of Health — Diagnostic Methods and Features.
5. ↩︎ A disease, a pattern, and a symptom. Pattern differentiation considers the combined findings used in Chinese medicine to guide treatment; a pattern is not simply another name for a biomedical diagnosis. “Guizhi Tang pattern” refers to the findings traditionally associated with selecting that formula. Guizhi Jia Houpo Xingzi Tang is the distinct modified formula used earlier in Evie's case. The later line “patterns, not symptoms” also turns on two Chinese words pronounced zheng: 证, a diagnostic pattern, and 症, a symptom. This distinction does not establish Evan's predictions about trial outcomes or classify every H1N1 case as wind-heat. Sources: Hong Kong Department of Health — Diagnostic Methods and Features; WHO — Chinese medicine terminology, entries 546 and 548; HKBU — Guizhi Tang and its additional formulas. ↩︎
6. ↩︎ Earth, Fire, and the Lizhong preparations. Spleen–Stomach deficiency-cold is a traditional pattern, not a measured temperature of those organs. Earth refers here to their traditional functions. Evan's image of Earth failing to contain Fire recalls the mouth-ulcer discussion in Chapter 25; it is not the five-phase relationship in which Water restrains Fire. Lizhong Tang is the decoction named here. Fuzi Lizhong Wan is a related pill formula containing processed fuzi, an aconite-derived medicinal material. Tang and wan distinguish the preparations; this chapter gives no ingredients, doses, or schedule for this patient's treatment. The formula reference explains traditional indications, without verifying this reported cure. Sources: HKBU — Li Zhong Wan, Method and Additional Formulae; Danxi Xinfa — “Mouth and teeth,” section 78 (in Chinese).