Looking at the Standardization of Traditional Chinese Medicine from the Nucleic Acid Test

From an operational standpoint, the nasopharyngeal swab nucleic acid test is a fairly simple procedure. Minimal equipment — just a swab — and one to three movements, and you’re done. By any analysis, it ought to be perfectly standardizable. Yet from my own experience of being swabbed countless times over the past three years, the sampling operation has been entirely capricious — each time a different sensation.

National authorities published standard protocols for sampling long ago. The operational difficulty is far lower than a factory worker’s daily routine. From a learning-curve perspective, each testing site should handle no fewer than 1,000 samples per day — meaning 1,000 repetitions of a standardized action every single day. Work 30 days and you’ve completed 30,000 learning cycles. Quality requirements should be entirely achievable.

So standardization ought to be the most attainable direction in medical development. The reasons it isn’t boil down to two:

1. They know how to do it, but can’t be bothered.

2. They know how to do it, but simply can’t execute.

This problem, frankly, has no solution. Some people are just not good at the task — like the cafeteria lady.

Now let’s talk about Traditional Chinese Medicine. The textbook is a quintessential standardized protocol. The pattern differentiation and treatment methodology seems perfectly clear, fully replicable — match the symptoms and signs, and theoretically you should be able to cure the patient according to the framework’s deductions. But in reality, outcomes mostly fall short. Why?

In recent years, numerous clinical pathways and clinical guidelines have been introduced, ostensibly to guide grassroots physicians in raising the overall standard of care. Yet judging by current results, it’s hard to assess their effectiveness. Why?

Again, the reasons boil down to two:

1. A patient’s symptoms and signs are unlikely to match perfectly. A little more here, a little less there, and you’re already off the prescribed pathway.

2. The pathways themselves are products of a statistical game — there will always be a subset of people falling outside the 95% confidence interval.

Anyone who has studied medicine knows that no disease presents exactly as the textbook describes, and no disease follows a clinical pathway to the letter. There are always variations and exceptions. How to achieve standardization against this fundamental backdrop remains an enduring research question.

Set the boundaries too tight and too rigid, and it becomes unworkable — it would greatly diminish TCM’s vitality and undermine its transmission.

Set them too loose, and you’ve effectively got no standard at all.

For instance: this morning I went out to run errands and got caught in a sudden downpour. For some inexplicable reason I also felt an urgent need for the restroom. I happened to be passing by the China Association of Chinese Medicine, but the security guard not only refused to let me in to use the facilities — he solemnly informed me that this was a national institution. Naturally, I wasn’t about to explain my various connections with the association. I could only conclude that he was following standardized procedures. After all, dressed as an ordinary nobody, I presumably didn’t meet the threshold for using their washroom.

鼻咽拭子核酸检测从操作角度看是一个比较简单的过程，装备少，一根棉签，1~3个动作即可完成，无论从什么角度分析都可以实现完全标准化，但从我这三年被捅了无数次的经验看来，鼻咽拭子的采样操作完全是随心所欲，每次都有不同的感受。

如何进行采样，国家早就发布了相关标准流程，操作难度比厂妹的日常工作要低很多；从经验学习看，每个核酸点一天采样量应该不少于1000，也就是说每天都可以重复1000个标准化动作，干上30个工作日就能完成3万次学习，应该完全能够达到质量要求。

所以，标准化是医学发展中最实现的一个方向。原因不外乎以下两点：

1、知道怎么做，但是懒得做。

2、知道怎么做，但是做不到。

这个问题吧，无解，有的同志就是操作不行，譬如食堂阿姨。

再说说中医的问题，教科书就是一个典型的标准化流程，辨证论治思路似乎是很清晰的，完全可以复刻，症状体征对上了按道理说就应该能按照理论的推断治好，但其实结果大多并不能如愿，这是为什么？

近几年推行了诸多临床路径、临床指南，似乎是用来指导基层医生提高整体医疗水平的，但是从目前的收效看似乎无法进行评价，这是为啥？

原因也不外乎有以下两点：

1、病人的症状体征不太可能完全对的上，多一点，少一点，可能就不是那个路径了。

2、路径本来就是统计学游戏的结果，总有一部分人属于5%的置信区间。

学医的都知道，没有什么病是按照课本上长得，也没有什么病能完全按照临床路径去发展，总会有各种各样的情况出现，这种基本背景下的标准化目标究竟该如何实现，是我们一直研究的课题。

限定的死了，太标准，不好执行，会极大削弱中医的能量，不利于传承。

限定的宽了，相当于没有标准。

譬如说，今天上午出门办事突遇大雨，又不知为何突感内急，正好路过中华中医药学会，结果保安小哥不仅不让我进去上厕所，还名正言顺地告诉我这是国家机关。我自然不会说我跟学会的诸多渊源，只会觉得它是按照标准化流程办事，毕竟p民装扮的我看上去就不足以享受他们的净房。