The Eastern Cultural Signature of Traditional Chinese Medicine : Empirical Evidence and Theoretical Perspectives

Background: Holistic thinking, which is rooted in Eastern culture, is assumed to be the core of traditional Chinese medicine (TCM). Recently, such holistic thinking has been proposed to be applicable to Western medicine practices for alleviating serious side effects; however, the obscure and often ill-defined terms of TCM, such as qi, yin yang, and wuxing, pose considerable obstacles for further understanding TCM. In the present study, we explored whether and how TCM is actually related to the scientific construct of holistic thinking, to elucidate the particular cultural signature of TCM. Methods: A random sample of 101 college students majoring in TCM and 93 non-medical college students was recruited for the study. Two psychological scales—the Chinese Holistic Thinking Scale and the TCM Competence Scale were used respectively to measure the holistic thinking and participants’ ability to apply the TCM in practice. Results: We found that individuals who thought more holistically were better at applying TCM to modern medical problems. Interestingly, TCM was associated with holistic thinking in both TCM and non-medical students, suggesting that this association is intrinsic. Further exploration revealed that the association and variability facets of Eastern holistic thinking—which emphasize that the world is interconnected and ever-changing, respectively—significantly accounted for the individual differences in competence in utilizing TCM in practice. Conclusion: In short, our study provides the first empirical evidence linking TCM to the Eastern holistic thinking style, which not only deepens the understanding of TCM from a scientific perspective but also promotes dialogue between TCM and Western medicine for building safer and more effective health care systems.


Introduction
Traditional Chinese medicine (TCM) is a complete and independent medical system, which has been used to diagnose, treat, and prevent illnesses for thousands of years.Ever since the World Health Organization began exploring TCM in the 1950s, interest in it has been growing rapidly beyond China because of its particular therapeutic methods and effects.Currently, in many countries, TCM is practiced alongside Western medicine, providing patients with a wide array of therapeutic options.Thus, the integration of two medical traditions can take advantage of the strong points of both traditions to facilitate safer, faster, and more effective health care [1][2][3][4].
Because Western medicine and TCM arise in different cultural backgrounds, they show different characteristics, especially in the thinking styles for making diagnoses [1].Western medicine primarily examines the material aspects of the body and treats illnesses by using drugs, radiation, and surgery, relying on a wide body of scientific evidence.In contrast, TCM emphasizes a more holistic approach and aims to cure and maintain balance in the body through more natural treatments [5][6][7].In other words, TCM treats patients as an integrated whole, while Western medicine focuses on the specific symptoms associated with illness [3,8].Therefore, although Western medicine is generally more effective in treating acute diseases than TCM, such treatment is usually accompanied by serious side effects, such as fatigue, nausea, or hair loss [9,10].Therefore, Western medicine may bene-fit from the acquisition of a more holistic approach, which can be obtained by using the techniques and thinking style of TCM to alleviate or even eliminate the unpleasant side effects of drugs and radiation therapy [2,3].
As a discipline rooted in Eastern traditional culture, TCM is not just a medical system, but also an important branch of Eastern philosophy and the Chinese healing arts.Therefore, TCM uses symbolic concepts to emphasize the integration of the body and mind.According to TCM terminology, health is thought to result from a delicate balance between yin (negativity) and yang (positivity) in the body.The body is thought to be constituted of qi (vital energy) and blood instead of tissues and organs.Furthermore, the body is divided into five functional sub-systems-liver, heart, spleen, lungs, and kidneys, corresponding to the Taoist concept of wuxing (five elements) [1].However, these obscure concepts are often regarded as inaccurate descriptions of the human body in the eyes of Western medical practitioners [11]; this notion greatly interferes with appropriate understanding of TCM from a Western medicine perspective.Therefore, in the present study, we explore the particular cultural characteristics of TCM by using a well-established scale assessing Eastern holistic thinking style in an empirical study.
Despite theories assuming that TCM is rooted in holistic thinking, to our knowledge, no empirical study has directly examined the relationship between holistic thinking and TCM.To fill this gap, we investigated whether and how TCM relates to Eastern holistic thinking style by using two psychological scales-the Chinese Holistic Thinking Scale (CHTS) [42][43][44][45] and the Traditional Chinese Medicine Competence Scale (TCMCS), which was designed for this study.We investigated whether individuals who scored higher on the CHTS possessed greater competence in TCM practice, as measured by the TCMCS.In addition, we tested both students of TCM and non-medical students to examine whether the rela-tionship between TCM and holistic thinking, if observed, is intrinsic, and therefore independent of TCM education.

Participants
One hundred and one college students majoring in TCM at the Beijing University of Chinese Medicine (67 women; mean age = 20.86,SD = 0.61) and 93 non-medical college students at Beijing Normal University (64 females; mean age = 20.54,SD = 0.59) participated in the study.At the time of testing, the TCM students had already taken at least one year of core courses on TCM and had been trained in clinical practices such as acupuncture and moxibustion.The non-medical students had no history of any medical training.The study was approved by the institutional review board of Beijing Normal University.All subjects were informed that they were participating in a social and behavioral survey, and that their answers would be used only for the purposes of scientific research and would be kept strictly confidential.Before testing, written informed consent was obtained from all participants.

Measures
Eastern holistic thinking style was measured with the CHTS [44], a 26-item questionnaire using a 7-point Likert-type scale from "completely disagree" (1) to "completely agree" (7).The CHTS contains three facets: association, variability, and contradiction.The association facet consists of 13 questions such as "I always think about all of the aspects of others," which asserts that everything in the world is interconnected and nothing can be separated from the rest of the world.The contradiction facet consists of nine questions such as "I often do something which I do not really like," which holds that the world is a contradictory entity with old and new, good and bad, strong and weak opposites, coexisting in everything.Finally, the variability facet contains four items such as "I think that a person's habits are difficult to change," which emphasizes that everything in the world is changeable and flexible, and nothing can stand still or remain fixed.The CHTS has excellent reliability and validity [42][43][44][45].Both the total score and the score of each facet were used in the following analyses.
To assess participants' ability to apply TCM theories in tackling medical problems, we created the TCMCS.To conceptualize TCM competence and generate items to assess it, we generated 60 items on the use of TCM to diagnose medical problems by reviewing the literature on TCM.An example item is "In my opinion, illness is related to one's living environment, daily diet, and mood states."Of these 60, 25 were selected by eleven TCM experts from the Beijing University of Chinese Medicine and the Chinese Academy of Traditional Chinese Medicine.A pilot study revealed sixteen items that had high internal consistency and test-retest reliability; these were selected as the items of the TCMCS (see Appendix for all items).All were rated on a 7-point Likert-type scale from "completely disagree" (1) to "completely agree" (7).Individuals who scored higher on the TCMCS were better at applying the TCM in practice.
Nine participants were excluded because of missing items in the questionnaire.Three additional participants (1.5% of the sample) with outlier responses-that is, scoring over three SDs from the group mean-were excluded from further analyses.Therefore, the final sample comprised 182 participants (92 TCM students; 90 nonmedical students).

Results
The CHTS, which was used to measure Eastern holistic thinking style, had high internal consistency reliability (Cronbach's α = 0.73).The reliability of its three subscales was also adequate (association: α = 0.79; variability: α = 0.83; contradiction: α = 0.65).Similarly, the TCMCS, which was used to measure participants' competence in TCM practice, also had high internal consistency reliability (Cronbach's α = 0.75).Participants with TCM training (i.e., TCM students) scored significantly higher on the TCMCS than did the non-medical students; TCM students: mean = 92.9,SD = 9.64; nonmedical students: mean = 82.8,SD = 9.19; t(180) = 7.2, p < 0.001; these data indicate that the TCMCS had high construct validity.Next, we investigated whether participants who preferred to think holistically were better at TCM practice.
First, we examined the relationship between holistic thinking and TCM competence in TCM students.The significant positive correlation found between holistic thinking and TCM competence (r = 0.27, p = 0.009; Figure 1(a)) suggested that individuals who had an Eastern holistic thinking style exhibited greater TCM competence.To further examine whether this association was established through education on TCM, or whether it was an intrinsic property of Eastern culture, we examined the association in a group of non-medical students who had no experience with or knowledge of TCM.Interestingly, in this sample, we observed a similar association (r = 0.38, p < 0.001; Figure 1(b)); this was further confirmed by Fisher's Z-test analysis, in that there was no significant group difference in the correlation (Z < 1).Therefore, we conclude that the association between Eastern holistic thinking and TCM competence is intrinsic, and independent of TCM education.Taken together, our findings indicate that TCM competence is the realization of Eastern holistic thinking in practice.
To further examine which specific facets of Eastern holistic thinking (as measured by the CHTS) affect TCM competence, we performed a stepwise multiple regression analysis.To increase the statistical power, both the TCM and non-medical students were included in the analysis because they showed the same pattern in the association between holistic thinking and TCM competence.In this analysis, we used TCM competence as the dependent variable, and the three facets of Eastern holistic thinking (i.e., association, variability, and contradicttion) as covariates of interest, controlling for gender and age.The regression analysis revealed that both the association and variability facets, not the contradiction facet, significantly predicted TCM competence (Table 1), together accounting for 11.8% of the variance in TCM competence.The finding was further confirmed by correlation analyses between the three facets of Eastern holistic thinking and TCM competence (association: r = 0.17, p = 0.02; variability: r = 0.27, p < 0.001; contradiction: r = −0.01,p = 0.86; Figure 2).

Discussion
Holistic thinking and TCM are arguably the most representative markers of Eastern culture.Many theorists believe that TCM naturally embeds holistic thinking in medical practice [5,7,19].Our study used the individual differences approach to provide the first empirical evidence supporting this speculation.That is, individuals who preferred to think holistically were more competent in putting TCM into practice.Importantly, this link was observed even in individuals who had no knowledge of TCM, suggesting that the link is intrinsic, and independent of education on TCM.
Our study not only adds to the findings of previous cross-culture studies on thinking style but also deepens the understanding of TCM.In previous studies on the differences in thinking style between people from Eastern and Western cultures, researchers focused on cultural influences on cognitions as tested in laboratories, such as attention, categorization, and attribution, and rarely on Table1.Multiple regression analysis testing the relationship between TCM competence and the three facets of holistic thinking.Copyright © 2013 SciRes.CM  daily activities or common practices [20,21,28,[46][47][48][49][50].
Chinese philosophy and culture could improve students' differences approach to pirical evidence linking TCM to the inking style.That is, individuals who y was funded by the National Social Science 187) and the National Baa (2011CB505402).
inese Medicine and Western Medicine," European Review, Vol. 11,No. 2 The link between holistic thinking and TCM observed in this study thus provides a new platform for further investigation of how Eastern culture affects daily behaviors through thinking in general, and of the culture difference between TCM and Western medicine in particular.Furthermore, our study aids in understanding the obscure concepts in TCM such as yin yang, wuxing, and qi by making the thinking style through which they were formed more accessible to scientific study.In TCM, yin and yang are complementary opposites that are interdependent; wuxing emphasizes dynamic interactions and the balance of organs; and qi is regarded as the ultimate constituent of the world, the nature of the cosmic movement, and the medium that connects everything in the universe [7,51,52].Our finding that the association and variability facets of CHTS were correlated with TCM competence confirmed the hypothesis that the yin yang, wuxing, and qi concepts in TCM derive from the associative and flexible nature of Eastern holistic thinking [7,51].
Why is there an association between holistic thinking and TCM?One possible reason is that both originate from the agrarian culture of Eastern societies and philosophy [5,7,15,19].In Eastern societies, irrigated agriculture and changeable climatic conditions require cooperation and coordination with a substantial number of individuals for effective economic activities.Therefore, individuals living in such an interdependent social environment may have needed to attend more to interpersonal relationships and to emphasize the harmony between human and nature, which are core tenets of Eastern holistic thinking [15,19].In parallel, TCM, which stems from practices in agricultural production, uses metaphors to understand the body (e.g., liver, heart, spleen, lungs, and kidneys) in terms of natural phenomena (e.g., metal, wood, water, fire, and earth), and thus integrates the body and nature into a unified whole.From the perspective of Eastern philosophy, the Yi Jing (the Book of Changes), the first Chinese philosophy book written during the Zhou Dynasty (1111-721 BC), offers a comprehensive view on the interconnected and everchanging nature of the universe and human societies.Therefore, the holistic thinking style suggested by Chinese philosophy likely serves as a cognitive schema in TCM practice, where TCM doctors are more likely to search for integrated patterns among seemingly fragmented elements.Taken together, because of the shared source of the agrarian culture and the common root of Chinese philosophy, it is not surprising that the link between holistic thinking and TCM competence was also found in individuals who were naïve to TCM.This observation has considerable implications in practice.In medical schools that teach TCM, education on traditional TCM competence.Conversely, studying TCM may help people master Eastern holistic thinking styles [8,53].
Our study further demonstrated that the association and variability facets, and not the contradiction facet, of the CHTS were correlated with TCM competence, which may help enrich the thinking style of Western medicine.In terms of the association facet, diseases are not only caused by particular types of viruses, but also by lifestyles or emotion states.That is to suggest, therapy should focus more on the person with the disease, instead of the disease itself.Similarly, the variability facet suggests the benefits of individualized therapy based on a combination of treating symptoms and monitoring patients' physical conditions, and even their psychological traits.With future studies on the relation between Western analytical thinking and Western medicine, we can deepen our understanding of the cultural signatures of both TCM and Western medicine, which may help in building a safer and more effective system to promote physical health and well-being.

Conclusion
Our study used the individual provide the first em Eastern holistic th preferred to think holistically were more competent in applying TCM in practice.Importantly, this link was observed even in individuals who had no knowledge of TCM, suggesting that the link is intrinsic, and independent of education on TCM, which not only deepens the understanding of TCM from a scientific perspective but also promotes dialogue between TCM and Western medicine for building safer and more effective health care systems.

Figure 1 .
Figure 1.Binned scatter plots between TCM competence and Eastern holistic thinking in (a) TCM students, (b) non-medical students.The x-axis denotes participants' scores on the Chinese Holistic Thinking Scale (CHTS), with higher scores indicating preference for holistic thinking.The y-axis denotes participants' scores on the Traditional Chinese Medicine Competence Scale (TCMCS), with higher scores indicating higher competence in TCM practice.To avoid overlap between participants with similar scores, participants were binned into groups according to holistic thinking scores.Dot size is proportional to the number of observations, which are listed next to each dot.Error bars indicate standard errors of the mean.

Figure 2 .
Figure 2. Binned scatter plots between TCM competence and the three facets of Eastern holistic thinking: (a) association, (b) variability, and (c) contradiction.To avoid overlap between participants with similar scores, participants were binned into groups according to scores for association, variability, and contradiction facets.Dot size is proportional to the number of bservations, which are listed next to each dot.Error bars indicate standard errors of the mean.o