The Yin and Yang of Integrative Clinical Care, Education, and Research

Yin and yang 

Medical students, residents, and patients who are unfamiliar with traditional Chinese medicine recognize and readily understand the traditional symbol for yin and yang, which visually represents the concept of equal opposites (Figure 1). This familiar symbol has even been used by Western researchers and scientific writers.1, 2 Examples of these opposites are summarized in Table 1.

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Figure 1. The yin-yang symbol.

Table 1. Summary of Chinese Yang and Yin Concepts

	Yang	Yin
	Up	Down
	Light	Darkness
	Out	In
	Specific	Global
	Explicit	Implicit
	Male	Female
	Dominant	Submissive
	Objective	Subjective
	Rigid	Yielding
	Science	Art

Although both sides of the traditional yin-yang symbol are considered equal in Traditional Chinese Medicine, different cultures may prefer and thus emphasize and elevate one or the other. Generally in Western medicine, greater status, greater opportunities, greater salaries, and greater power are associated with being male, dominant, narrowly focused, and having explicit, specific goals. Despite this cultural predilection for yang-type values, many patients and clinicians recognize that yin-type values are also necessary for a balanced approach. These values include the value of being present for, of nurturing, and yielding to the patient.

Clinical care 

Patients’ reasons for seeking healthcare can also be divided into yang-type and yin-type goals. Table 2 lists examples of yang and yin reasons for seeking healthcare.

Table 2. Yang and Yin Reasons for Seeking Healthcare

	Yang	Yin
	Cure (eg, cure infection or cancer)	Overall well-being
	Symptom management (eg, corrective lenses, pain medicine)	Enhanced resilience
	Prevent specific disease (eg, polio vaccine)	Health promotion and stress management
	Eliminate specific toxin (eg, lead poisoning)	Autonomy/reduced reliance on technology or medications/enhanced coping
	Early detection of disease (eg, cancer screening)	Connection/trust/support/respect
	Biomedical information	Transcendence/meaning

Often, patients have more than one reason for seeking healthcare, but at times, they may not realize or express it.3, 4, 5, 6 Typically, in a yang-dominated culture, they are often discouraged from expressing more than one goal (chief complaint) per visit. Yet, if most or all their goals, especially the yin-type goals, are not addressed, patients may feel dissatisfied with their medical care or feel like they have not been heard.7, 8

Poor bedside manner often reflects a clinician’s lack of attention to yin-type goals for respect, support, and connection. This is usually not because the clinician is hard-hearted or inhumane, but because clinicians in our culture have been trained that the best way to serve the patient is to focus on achieving yang-type goals in a short period of time.9 A physician who spends a culturally disproportionate amount of attention to yin-type goals may be viewed as nice but technically incompetent.10 On the other hand, physicians who can incorporate both yin and yang goals in their practices may be considered truly holistic. I have spoken with many clinicians who are burned out on mainstream medicine and who are interested in learning new knowledge and skills in the field of complementary medicine; frequently, they express the lack of ability to fulfill their own and their patients’ needs for meeting yin-type goals as a reason for seeking something new. This observation may lead to fruitful research on models of medical education that better meet both yin and yang goals. For example, courses that enhance students’ mindfulness and innate capacity to express compassion verbally and nonverbally may result in enhanced patient care and in less burnout among clinicians.11, 12

Medical education 

Over the past 20 years, there have been enormous efforts to enhance the teaching of humanism and professionalism in medicine.13, 14, 15, 16, 17 The yin and yang model can also make a useful contribution to this ongoing effort (Table 3). Because we live in a yang-dominant culture, yang-type teaching is the norm in medical education, particularly during clinical training (the third year of medical school through residency and clinical fellowships). Although medical schools select students who have demonstrated great intelligence and aptitude for solving problems, the bulk of our educational efforts have focused on enhancing biomedical knowledge of physiology, pathophysiology, pharmacology, and specific skills and procedures rather than on enhancing or developing yin-type ways of being with patients, relieving suffering, and extending compassion (sometimes included under the rubric of biopsychosocial care). In mainstream, yang-oriented medicine, biomedical knowledge and being able to practice specific, measurable skills are highly valued, with written tests and structured clinical exams to evaluate students’ proficiency in these areas. There is less emphasis on the yin skills of learning and evaluating a student’s ability to be present with patients and to relieve suffering with compassionate intentionality.18

Table 3. Yang and Yin Values in Medical Education

	Yang	Yin
	Knowledge	Presence/patient-focused attention
	Specific skills	Compassionate intention

Although students applying for medical school are usually asked why they are seeking this training, once they have responded “To help other people,” and once admissions committees have scrutinized students’ records to support their claim to altruism (such as volunteer or community service), relatively little curricular time is expended after the first two years of medical school on cultivating students’ innate compassion and positive attitudes toward patients.19 Some attention is paid during the preclinical years through courses devoted to the humanities and professionalism, but students quickly learn that these courses do not count as heavily as courses emphasizing memorization of facts and physiologic pathways.20

Once students reach the hospital wards and clinics, mastery of yang-oriented knowledge and skills is reinforced, while development of yin-type attitudes, knowing, and skills often languishes.16, 21 Students quickly learn from observing their senior role models.22, 23 As one student recently stated, “I’ve often been asked by senior residents and attending physicians whether I’d checked vital signs, blood pressure, and weight, and I’ve been asked about differential diagnoses and lab tests and drugs, but none of them has ever asked me if I was intentionally compassionate and patient-centered when I took a history or what my patient thought of my bedside manner.” Students are often unaware that while they take historical and physical exam data, they also send powerful messages to patients about the kind of healers they are, how much they can be trusted, and what kind of support and connection they might offer to their patients. Many medical educators are working on this problem, but a universal solution has not been recognized or implemented.24, 25, 26, 27

The relative lack of explicit attention to developing yin-type skills in most current clinical curricula may result in a reduced ability to meet patients’ yin-type goals, frustration among physicians sensitive to this unmet need, and eventually burnout. Furthermore, by introducing the yin-yang model and increasing attention on yin-type goals in both preclinical and clinical training, we may create health practitioners who are more satisfied with their practice (because they are better equipped to fulfill their original goals of helping others), and who achieve better clinical outcomes for their patients.28, 29, 30 These types of conceptually based hypotheses can be tested through rigorous research, evaluating the effectiveness of different curricular interventions in developing yin-type attitudes and skills on outcomes for both patients and clinicians.

Yang and yin values in medical research 

Early in my biomedical training, I was offered a simple conceptual model to understand the research process. To conduct effective research, one must pick a specific patient population (defined primarily by a specific disease or symptom), and then select age, gender, and other explicit inclusion and exclusion criteria. Next, one must pick a treatment aimed at reducing that disease or symptom. The primary research outcome is the reduction in the disease or symptom. Secondary outcomes might include changes in the patients’ quality of life, their use of healthcare, the cost of healthcare, satisfaction with care, or the amount of school or work missed (Figure 2). For example, when studying an alternative treatment for jaundice, we picked otherwise healthy newborn infants hospitalized in our medical center, with bilirubin levels in a specific range at a particular age. Subjects were randomized to receive either a specific dose of agar or usual care. The outcomes were bilirubin levels 24, 48, and 72 hours after starting the experimental therapy.31 In a secondary study, we examined the impact of newborn jaundice and our treatments for it on mothers’ senses of their child’s inherent vulnerability.32, 33

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Figure 2. Yang-type research design.

This prototypic design, a randomized controlled trial, might be called the yang model of medical research. The yang model can be applied to complementary treatments, such as the impact of glucosamine on symptoms of osteoarthritis,34 as well as to mainstream treatments. Reversing the order (starting with patients with known outcomes and then looking back at previous exposures) in a case-control study to identify risk factors for disease is also a yang-type research methodology. For example, one might look at patients who have or who have not had a documented myocardial infarction, and then examine their diet, smoking history, or exercise to assess the relative risks of these different factors in developing heart disease.

Comparing a novel treatment with usual care in a nonrandomized fashion (a prospective cohort study) is another yang-type design, as long as it adheres to the rules identifying specific patient and disease populations, interventions, and yang-type outcomes (cure, symptom management, preventing specific disease, or eliminating a specific toxin). This type of design is particularly useful for lifestyle choices that are difficult to control in a randomized controlled trial (eg, studies of the impact of breastfeeding on the development of eczema or allergies).35, 36

In yang-oriented research, a treatment is considered successful if it reduces the primary disease or specific symptom; effects on quality of life, healthcare costs, utilization, and satisfaction with care are considered secondary. Biomedical researchers know that in order to maximize statistical power, it pays to focus on one narrow, well-defined outcome and leave other considerations for future, larger, and longer-term trials. Therefore, most yang-type researchers are parsimonious in identifying treatment outcomes. For example, in the early studies of the effects of bone marrow transplants, researchers focused primarily on whether or not the transplanted marrow engrafted, not on the rate of graft-versus-host disease, the cost of care, or even mortality.37 Once research had established the ability to get a bone marrow transplant to “take,” additional research was needed to determine the best ways to enhance survival and reduce morbidity.38

On the other hand, some complementary therapies are aimed at more global, yin-type outcomes (Figure 3). Research designed to evaluate their effects would more appropriately focus on yin-type outcomes such as overall well-being, resilience, a sense of connection, trust or support, a greater sense of the meaning of one’s illness and treatment, autonomy or reduced dependence on drugs or technology to cope, or transcendence.39

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Figure 3. Yin-type research design.

For evaluations of yin-type therapies, outcomes such as mortality, disease, and symptoms are secondary. Trying to force yin-type therapies and goals into yang-type research designs is like trying to pound a round peg into a square hole. It could also be likened to trying to achieve yin-type clinical outcomes (trust, connection, support) by using yang-type skills (biomedical knowledge).

Because we exist in a yang-dominant culture, yin-type outcomes have not been well specified and are more difficult to measure and report than yang-type outcomes. In fact, they are inherently more nonspecific or global than yang outcomes. Some work has been done to define and measure quality of life,40, 41, 42 trust,43 social support,44, 45 and satisfaction with care.46, 47 But there are fewer validated, reliable, widely used instruments that measure overall well-being, resilience, autonomy, or transcendence.48, 49, 50, 51, 52, 53 This is particularly true for patient populations with limited abilities to communicate these abstract concepts with researchers (such as children, patients who speak other languages, patients with speech or language deficits, or those who are cognitively disabled). Better delineation of these yin-type outcomes is an important challenge for integrative medical researchers.

The concept of primary versus secondary outcomes is important for clinician-researchers who are interested in yin-type therapies. For example, if the primary goal of a therapy such as Healing Touch is to improve overall well-being, statistical power to detect a meaningful improvement is enhanced if the outcome measures focus on overall well-being, not secondary outcomes such as improved sleep, decreased anxiety, decreased pain, or remission of cancer. Similarly, if the primary goal of acupuncture is to restore a balanced and harmonious flow of Qi, outcomes should focus more on assessing the flow of Qi (through traditional or novel proxy measures) rather than on the reduction of specific symptoms such as pain or nausea.26

Although in yang-type studies, researchers try to minimize the role of “nonspecific effects” of therapy (sometimes referred to as placebo effects), in yin-type studies, these nonspecific or global effects may be of paramount importance.54 Regardless of which type of research study is being done, in my experience understanding of this basic model clarifies the goals and values underlying proposed research and facilitates communication among practitioners and scientists from different traditions.

Summary 

This simple yin-yang model is accessible to patients, students, and researchers and is applicable across the domains of clinical care, medical education, and research on conventional therapies and holistic medicine. However, the benefit of incorporating more yin-type values into standard clinical models is not broadly understood or accepted by major insurance companies, who focus on paying for yang-oriented diagnostic codes and procedures. Despite this limitation, patients are turning to yin-oriented therapies in ever-greater numbers to fill their unmet needs for healing. Although medical education has traditionally focused on achieving yang-type goals by providing tools such as biomedical knowledge and manual skills, educators of the past 20 years have tried to promote yin-type values and skills such as humanism and professionalism, particularly during the preclinical years. With respect to research, better delineation of yin-type outcomes is an important challenge for integrative medical researchers who include collaborators from diverse clinical backgrounds and traditions; it may also be helpful in developing research that is patient-centered rather than disease or treatment-centered. This model may be helpful in all these domains, as medical pluralism—incorporating both yin and yang traditions—flourishes in the modern world.