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If there’s one lesson that everyone learns very quickly once they start treating, it’s that modern patients have complex conditions that don’t readily fit into any of the ready-made boxes we have formed for them, whether from a Classical or TCM standpoint. Patients usually have multiple ailments all stacked on top of each other like a messy garage. Like said messy garage, some things are new, some things have been there a long time, some things no one knows where they came from, and sometimes there are even animals and insects hiding out. All of this is what you have on your plate the second a patient comes into your clinic, sits in front of you and says “my shoulder hurts” (the ubiquitous ailment).
We’re all familiar with that momentary surge of apprehension (or outright panic) that wells up in this situation, especially if the patient has a Western diagnosis with a scary name like cancer, Lyme disease, autism, etc. However our tools are absolutely equal to the task of even the most complex cases. As the Ling Shu says, “Thorns can be pulled out, even those embedded for a long time; stains can be cleaned, even old ones; knots can be undone, even those formed long ago; accumulation can be demolished, though it be very old.”
One of the keys to successfully treating complex conditions is to be able to competently combine already-extant herbal formulas into a single prescription to match the situation. More accurately, the trick is to use the best tools to perform the right actions at the right times continuously (a subject which I will discuss further in my column on Friday). Over the next few weeks I hope to help those having trouble with formula combining to get a better grasp on it.
So, let’s begin at the beginning.
Reynolds’ First Maxim
There’s one thing that trips up everyone at the beginning (and some folks forever), which is the basis of what I like to call “Reynolds’ First Maxim.” The joke is that I only answer any question my students ask with about five possible responses, so to save time they can be referred to by number. What typically happens is this: a student gets a patient in clinic who comes in with three different “named” diseases like, say, Crohn’s disease, PCOS, and Fibromyalgia. The student gets intimidated, panics, runs through their mandatory battery of questions, needles the Four Gates per supervisor, then calls or emails me with “I have a Crohn’s disease patient. Can you tell me what formula is for that?”
To this I always have the same response:
What are the symptoms?
It’s very easy to get bogged down in the details of what someone else has decided about a patient, whether they are from your side of the healthcare fence or not. We have to be very very careful to not slap names on conditions and try to treat those, whether we are discussing biomedical diagnoses or Zang Fu patterns. Any case that you see is only going to open up to you (like the proverbial flower to the bee) once you start diagnosing, which means using the tools at your disposal to find out what’s really going and making your own judgment. Remember the Four Pillars of Diagnosis? Asking, Looking, Listening, and Touching. These are absolute necessities for any type of case, no matter how easy or difficult. It’s no good just saying “I’m watching this patient for Bob who is on vacation and he says she has Spleen Qi Deficiency so I’m gonna give her Si Jun Zi Tang.” That absolutely won’t cut it. It also won’t do to say “Well, I saw on the internet a study that says Huang Qi is good for autoimmune conditions and since Crohn’s is an autoimmune condition I’ll give her that Huang Qi-based patent we have in the pharmacy.”
You absolutely must do your due diagnostic diligence and find out specifically and systemically what is going on with the patient. Then you can begin to make choices. As long as you are confined to throwing herbs and points at a name, you won’t see results and the patient won’t be sticking with you for very long.
The next step is to make sure that you are using a diagnostic model that is going to steer you in the right direction and provide useful information about what to actually do about the problem, which is what we will discuss next week. For now, remember that the first thing you absolutely must do is find out what is going on with the patient in order to have something to work with.
In other words, what are the symptoms?
Tags: Acupuncture, Herbal Medicine, Diagnosis, Chinese medicine
{ 4 comments… read them below or add one }
now I’m curious what the other 4 Maxims are!
great little article, this is one of my favourite things about our medicine, I am not bound by some crazy sounding WM diagnosis. I notice that patients, once they learn the name of their disease, they feel entirely bound to it, or if WM can’t figure out a name for what’s wrong with them, they feel absolutely lost and helpless. When they come to me and I don’t let a disease name (or lack of one) get in my way, I think it opens up their minds to thinking about their situation in a new way.
Can you say “future article content”?
You make an excellent point about people being tied to their disease name, which is especially bad if said disease’s common definition points everyone in the wrong direction. I just would like to point out that TCM is nearly as bad about this as WM is. I went through a very popular TCM textbook that I hadn’t cracked open in a few years for some article research (no names) and I realized that half the problems people have with diagnosis is that they are being taught to put very specific and narrow syndrome names on what they see. When the modus operandi is “symptoms A=syndrome B and requires point prescription C and formula D” and its unrealistically narrow in scope, what happens when you have a case in front of you with 6 different “patterns” that all require their own point prescription and formula? 60 needles and 6 formulas? This is what TCM students are up against and what I want to fix. Or help to fix.
Fantastic point. I find myself saying this to people all the time, particularly students in the earliest part of their education. You’ve made a good point about the multiple Western disease names, and I do find that the problem is just as bad when someone comes in with a Chinese medicine diagnosis or two. Either they inherit a patient from someone else, or they get attached to their initial diagnosis which, for whatever reason, is not bearing fruit – yet instead of going back to the symptoms, the experience of the patient, they continue to abstract based on that initial diagnosis. What a mess.
I do think some people avoid thinking and discussing symptoms in some cases, because they feel that they don’t want to “focus on the symptoms.” At least that’s the case over in this neck of the woods. People don’t want to be all Xiagong, you know, so they brilliantly jump to a pattern analysis before they even fully reckon with the picture in front of them.
Sometimes folks forget you’ve gotta get through the Xiagong stage to move onward. :)
Thanks for the article!
hmm.. yes I see what you mean. I tend to treat the patient in that moment tho, even if I came up with a diagnosis for them last time, if it’s different TODAY then I treat what’s going on today. For me it’s not a static state of affairs, it’s ever changing and Im just nudging them closer to that balanced midpoint from wherever they happen to be right now. Of course, this is a little easier to do with acupuncture than with herbs..
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