Complementary & Integrative Medicine

I had an opportunity to attend a course on Traditional Chinese Medicine (TCM) at Harvard Medical School recently, which was co-organised by Hong Kong Baptist University (HKBU). HKBU has the a particular school called School of Chinese Medicine, and its objectives are to view TCM according to today's standard, with its improved precision on treatment in area of translational medicine as well as new drug discovery.

Instead of viewing the TCM as something alien, Harvard Medical School acknowledged that TCM is there to stay, especially when the tradition has been around for more than 2500 years,much longer than the current modern understanding of disease.

Certainly there are many differences with the 2 approaches. Modern medicine focus on the aetiology and pathophysiology of diseases, and try to treat disease based on that. Based on what I understand, TCM treatment is based on symptoms. As a perspective, it is estimated that modern medicine has roughly 200-300 presenting symptoms, while TCM has 2000-3000 symptoms in its dictionary. For example, in Rheumatoid Arthritis, while we ask about pain and distribution of pain in the joints, the TCM practitioner would ask about 'cold' or 'hot' or 'warming up' or 'cooling down' type of pain.

Some authors have attempted to marry these 2 concepts together. In series of publications by Zhang Chi et al in 2011 (searchable in pubmed), the author was suggesting that the modern treatment of RA with MTX/SSZ may be more beneficial in patients with 'cold' symptoms instead of 'hot' symptoms. Some theory of what is hot and cold was proposed. For example, 'hot' pattern of disease is more to do with fatty acid metabolism, while cold pattern is to do with JAK-STAT cascade (whatever it is...) or RNA splicing.

While acknowledging that there are more to study, especially in terms of bringing TCM up to the understanding of current modern medical world, we should view the different methodology of treating diseases as complementary and some part as integrated together. To do RCT on TCM can be challenging as TCM uses cocktail of different compounds, instead of 1 persumably active ingredients.

One very successful story of how TCM made an impact in the modern world of medicine is through the formulation of Artemisinin, a 'new' drug for treatment of malaria. Prof Tu was given a Nobel Prize in Medicine for this achievement in 2015. The story of how she manage to make this old medicine up to the current standard deserves a new essay by itself, but what has been told is that she was having difficulty making a stable ingredient. She went back to read a manuscript of thousand years old, and she noticed that the way she extracted it was wrong. Instead of extraction under heat which she has been doing all along, she used 'cold' extract as suggested by the ancient text, and she created a stable compound to treat malaria.

In Malaysia, our plants also have a lot of pharmaceutical potential, but we are lacking behind in terms of making them up to the standard of today's medicine. Learning from this, we should be proud of what we have. And instead of pushing them aside, we should try to investigate and integrate them (once they are scientifically proven) into our daily practice.

Courses vs Distributed Learning

I think attending courses are great ways to sharpen our knowledge and skills. It cramps the whole thing that I should know in 1 day or 1 week, like the BRCU for Nephrologist-to-be. But how much actually we retain from attending courses, way down the line?

Interesting studies were performed to further evaluate this 'mass learning' like attending courses vs 'spaced repetition' like regular CME/attending ward round. Whether we agree or not, studies have consistently shown that spaced learning (learning over period of time) is much better at retention of knowledge and skills.

Moulton Ca et al divided 38 surgical post graduate doctors into 2 groups for learning - 19 in massed group and 19 in distributed learning group. The massed group learnt 4 session in a day of microvascular anatomoses, and the distributed learner groups learnt weekly session for 4 weeks. They were tested 1 month after their last training sessions. The result showed both groups improve their performance, but the one in distributed group learning outperformed the other group almost in every domain that was tested. (Moulton CA et al, Ann Surg 2006).

Another way of studying is to mix different aspect of knowledge instead of of studying one block of knowledge after another, although the superiority of this technique was not consistently shown. For example, when learning chest xray, instead of learning all pleural effusion xray 1st then learning all pneumothorax xrays, it is suggested that learning pleural effusion and pneumothorax and others in a mixed way allow students to compare and perhaps retain it for much longer. Similar thing with ECG learning (Hatala RM, 2003).

Mixed practice allows contrasting different subject, while blocked learning allows looking for similarities. Both are beneficial.

The spaced and interleaving learning have become the mainstream so much so that in the US, the board of anaesthesiology and radiology have change their assessment. Previously, everybody has to resit their exam every 10 years - which essentially means you have to learn for the beginning. Now, they will be doing this in smaller chunk but more regularly.

Another practical example is, instead of blocked nephrology training of 6 months transplant and 6 months PD etc, it can be argued that a mixed approach may help the trainee better. I was tempted to buy a book called "Make It Stick" by Peter Brown (Imprint of Harvard University Press) who wrote it form cognitive psychology perspective.

(https://www.amazon.com/Make-Stick-Science-Succ…/…/0674729013)

The Existence of Evil means there is no God?

The suffering of a child in this world, for what sin that he/she was punished? If God is all loving and caring, why is there such suffering in this world?

This is a good question, that philosophers have been struggling to answer. But to think about it, the very fact that this question was asked means that the questioners have feelings of empathy, that something was not right. In Islam, that is called fitrah, which cannot happen if we exist into being by fluke or by random distribution of matters.

We tend to view evil from our perspective as human being, and it is more difficult to comprehend the existence of evil in this world without a belief in afterlife. Only in the afterlife that every wrong will be made right. The suffering of a person in this world will be his/her reward in the afterlife.

We also believe in a world without suffering and pain, only that, we call that world 'paradise' or jannah. And we live in this world to combat injustice and spread good, and it is a stepping stone for us. It is arrogant to view this world as 'paradise' when in fact, we are being tested.

Having evil gives us opportunity to connect with God. It is of human nature that when difficulties come, we return to the Creator of this world. It gives us a reminder that this is not the end, that we will never achieve complete peace and satisfaction in this world.

And the fact that this world is a test for us, it can be argued that 'evil' is necessary to sift the good from the bad. A teacher knows which students are better by giving them test.

What is good, without knowing what is evil? How are we going to show compassion to the poor, help the needy if everything in this world is all nice and beautiful? As to the poor and needy person, we believe that they will be rewarded and compensated by God appropriately in the world after.

We believe that there is no pure evil. When an evil happens, the sum of that will be good. Now, we may not know as our view is limited, but we put our trust in God, the All-Knowing that there will be a greater good.

For Muslim, God gives us some glance of how some evil bring about some good, in the Quran through the 3 stories of Musa and Khidr. We believe that when a door is shut, another door opens. Anything that happens is an opportunity for us to be closer to God.

Finally, denying the EXISTENCE of God by blaming the existence of evil is phillosophically flawed. One technically may question the WISDOM of God (why certain things happen the way it is), but not actually His existence. And to God we put our trust that it is in His ultimate wisdom thing happens the way it is.

A note from Dr Yasir Qadhi's lecture.

Effective Learning

When I was a medical student, I remember Yurzi used to comment on my style of learning - bring a book in front of TV where he and Muhammad Khanji were around and I would start reading, recalling, summarising and asking them about what I was reading. They were like a wall where I need to throw a ball and it bounced back to me.

I came across recently an article about what are strategies that effective and not effective in learning, by John Dunlosky. He reviewed 10 techniques of learning of variable effectiveness:

HIGH UTILITY
- Practice Testing: active, non-formal recall of material read
- Distributed practice: learning over a distributed period of time

MODERATE UTILITY
- Elaborative interrogation: asking why certain facts is as it is
- Self-explanation: we or others explain the steps taken on solving problem
- Interleaving: mixing different kind of material to be learnt within study session

LOW UTILITY
- summarisation: writing summary of the read subject
- imagery use: forming mental image while reading text
- keyword mnemonic: using keyword to associate with materials
- rereading: restudying text material after initial reading
- highlighting: marking potentially important portion of text while reading

So we know now that having that extra effort to generate and recall that knowledge that we have just read, it will better than rereading and highlighting. Other measures that works include:

1. Give a good spacing and interleaving
Instead of reading the same material many times in one go, try to give some time in between the reading. Do something else in between and go back to the material (interleaving). It will probably double the ability to retain the information.

2. Link the new knowledge to previous knowledge that we already know well
Our minds are not like video camera whereby we remember everything that we read. We have to actively engage the new information, and one way of doing it is by linking to the pre-existing knowledge. I also notice that if I am learning a new concept, I will read it once and try to grasp the core/basic concept. The second time I read the material, I will build a new knowledge on that pre existing materials. Reading from multiple sources will certainly help as your mind will actively compare the pre-existing knowledge and the nw ones - whether they are the same or not.

3. Retrieve knowledge instead of re-reading it.
Try to remember how to say good morning in arabic will impact you much more than reading in the book that says good morning = sobahal khair, even if you read it 10 times more, without actually testing that you could recall it. Retrieving knowledge has been shown to be the most effective method of learning.

4. Understand the material
People who understand the material has better ability to recall it. We don't want to be like the writer in the court, where he/she can write every single word mentioned but has no idea at the end of the day what they meant. Similarly in a class room, you don't want to take notes of everything that the lecturer said. Perhaps you want to read it again - but that will be a double job for you. Try to understand and write down the summary of what being said. The book/internet will give you better explanation on certain things sometimes.

Students who did not perform well sometimes truly did spend a lot of times reading book and re-reading books. Without having to test yourself whether you could generate the knowledge, you have no idea whether what you read or see in the book really stick into your mind or not.

"Put less effort on input and more effort on output"

http://journals.sagepub.com/stoken/rbtfl/Z10jaVH/60XQM/full