CHINESE DISEASES — THE FORGOTTEN STEP IN WESTERN PRACTICE

More than 10 years ago, the celebrated author, teacher, and practitioner of Chinese medicine, Bob Flaws, visited Tucson to teach a CEU course. Dr. Flaws asked his audience, consisting mostly of licensed practitioners, many with years of experience, to reframe fibromyalgia (FMS) syndrome as a Chinese medical disease. After a few minutes, a student in the back raised a hand and suggested a liver qi pattern. While the instructor praised the student for having the courage to guess, he clarified that Chinese medical diseases and Chinese patterns are two very different categories of pathology. The same question was asked again and, after another awkward silence, I suggested impediment (痹症 bi zheng). Dr. Flaws agreed that impediment would fit as a Chinese disease diagnosis while also proposing a diagnosis of generalized pain (身痛 shen tong literally “body pain) as a possible alternative.

The Problems of Converting Western Diseases to Chinese Patterns

The average North American or European patient with a chronic condition will present 3-10 Chinese patterns. In my two decades in this field, I have come to realize that one of the most common challenges we face in practicing Chinese medicine in translation is how to better organize and prioritize the multiple pattern presentations common in our patient population. The primary obstacle in being able to determine how to determine the relative importance of patterns is a lack of understanding of disease diagnosis.

It is true that in China today both Western medical disease diagnoses and Chinese medical disease diagnoses can be used to help identify the correct Chinese medical patterns. Often, practitioners of Chinese medicine in China are also be trained as Medical Doctors, and many doctors of Chinese medicine are specialists. A Chinese medical rheumatologist, who is also an MD, is both legally permitted and trained to diagnose SLE (systemic lupus erythamatosus) and RA (rheumatoid arthritis), for example. Furthermore, these Chinese specialists know how to convert the Western diseases they diagnose to a Chinese pattern or pattern group, based both on personal experience and the consensus of other experts in the field. This allows for rapid, efficient, and precise identification of the primary pattern associated with the Western disease.

In the West, however, individuals who maintain dual licensure as MDs and acupuncturists are rare, and most Licensed Acupuncturists do not declare clear specialties. Using a Western diagnosis borrowed from another healthcare provider, most Chinese medical practitioners in Europe and North America—who simply cannot be familiar with the common patterns of every Western disease in every specialty as identified by the panels of experts in China—are relegated to using reference texts. This is a laborious, inefficient methodology which is limited by the specialist sources available in English to the practitioner and prone to error. As a result, many Western practitioners attempt to juggle a Western medical diagnosis and a Chinese pattern or patterns as two disparate forms of pathology.

This situation gives rise to the infamous “wrong question” which many Western practitioners ask of experts: “What is the best treatment for this (Western medical) disease"? In China, it is understood that although the disease, whether Western or Chinese, and the main pattern are inextricably, and logically, linked, it is always the pattern which determines the treatment. For example, a patient who suffers from diverticulitis with a presenting pattern of righteous qi vacuity weakness with heat toxins brewing and binding pattern must receive treatment which supports the righteous and expels toxins from the interior, clears heat and relieves pain (or another equivalent treatment). As a system built on the core methodology of 辨证论治 bian zheng lun zhi or “treatment according to pattern differentiation”, Western diseases are only treatable once they are linked with a pattern or pattern group which is rationally derived from the signs and symptoms, and it is the pattern or patterns, not the Chinese or the Western disease, which is used as the guiding criterion for treatment.

Using Chinese Disease Diagnosis to Identify Primary Patterns

Fortunately, Western practitioners who have not memorized the list of standard patterns for every Western disease can utilize the traditional Chinese disease diagnoses. Most traditional diseases coincide with common clinical symptoms such as lumbar pain or headache and are easily learned. Nigel Wiseman and Feng Ye’s Practical Dictionary of Chinese Medicine and Philippe Sionneau and Lu Gang’s comprehensive, seven-volume series, The Treatment of Disease in TCM are both good sources for learning more about Chinese diseases and offer correct nomenclature, definitions, and the disease causes and disease mechanism for each disease.

Breaking down the core Chinese medical process into steps:

1. Make a Chinese disease diagnosis. Frequently, patients will come in with a “laundry list” of complaints which may obscure a clear, chief complaint. In these cases, the practitioner should either ask the patient to prioritize (“which issue most affects your quality of life?”) or, if the patient is unable to choose, then the physician must employ good medical judgment. The latter might involve assessing acuity—blood in the urine would naturally trump occasional right heel pain—or be based on grouping the related symptoms and tabling any outliers, followed by isolating any pathognomonic or primary symptoms in the group to serve as the Chinese disease diagnosis. If, for example, the patient reported lumbar soreness, yang wilting (erectile dysfunction), nocturia, fatigue, cold feet, and a recent increase in leg varicosities, the final symptom might be set aside as a sign of blood stasis, and lumbar soreness, as a key symptom in group of indicators that all point to kidney yang insufficiency, could be selected as the Chinese disease.

2. Utilize disease diagnosis, along with the signs and symptoms, to identify a primary pattern or patterns. This is, of course, the basic diagnostic process taught in Western schools of traditional Asian medicine. The difference between the standard method in China and the reality of clinical practice in the West is the fact that the use of disease diagnosis in China narrows down the possibilities of patterns to those typically ascribed to the disease and/or logically causal for that disease. Using the previous example, only certain patterns can rationally give rise to lumbar pain, so liver wind stirring internally, for instance, would not be considered as a primary pattern in a case of lumbar soreness. In the absence of a good disease diagnosis, the clinician embarks on a fishing expedition, collecting data and trying to make sense of how it can be organized into 3-10 potential patterns which all have differing degrees of relevance to the patient’s primary complaint.

3. Select the treatment methods that pair with the primary pattern and any additional patterns, organizing them according to priority. Treatment methods are intimately associated to patterns. As an example, consider disquietude of spirit. Often reframed as the sloppy and inaccurate “shen disturbed” diagnosis prevalent in school clinics and, unfortunately, carried into some professional practices, the actual Chinese diagnosis is often 神不安 shen bu an, literally “spirit not quiet”. Unlike the ersatz Western diagnosis of “shen disturbance”, disquietude of spirit naturally generates the treatment method of 安神 an shen quieting the spirit which is, in fact, nothing more than a rearrangement of the characters in the diagnosis with “not” omitted. Following the Chinese process here, diagnosing the patient with disquietude of spirit simultaneously provides a diagnosis and a treatment plan, whereas “shen disturbed” merely implies a potentially frustrating case with a patient who may be non-compliant and respond poorly to care.

   In other words, pattern identification not only pinpoints a pathology, it also indicates the necessary treatment methods. A patient who presents a spleen qi vacuity must receive treatment that supplements the qi and fortifies the spleen, or a similar treatment method, for a good clinical outcome. Conversely, clearing heat or quieting the spirit will not only be ineffective in resolving the main pattern of spleen qi vacuity, these other, unwarranted methods could even make things worse.

   Given the fact that multiple pattern presentations are the rule rather than the exception in North American outpatient practice, it may seem like many different treatment methods may actually be warranted for each case. While this may be true, disease diagnosis and identification of a chief pattern along with methodical prioritization of the other patterns will mandate the importance of each treatment method. If the primary pattern is spleen qi vacuity, the majority of acupoints and/or medicinals must supplement qi and fortify the spleen. Any other treatment methods must not only be warranted by other patterns with supporting signs and symptoms, the clinician should also avoid treatment which could compromise the effectiveness of the primary treatment.

4. Choose treatment that is congruent with the treatment methods and appropriate for the patterns. If a patient requests treatment for difficult, painful urination (strangury or 淋正 lin zheng) and the primary pattern is damp-heat pouring downward, the correct treatment method is clearing heat and disinhibiting water or its equivalent. Due to the aforementioned prevalence of multi-pattern presentations in Western outpatient clinics, the same individual might also present liver qi depression and binding concomitant with spleen vacuity manifesting as irritability, pain with the menstrual movement, depression, fatigue, cold hands and feet, and a liking for sweets, in conjunction with the tongue and pulse indicators of these patterns. If, rather than clearing heat and disinhibiting water, the treatment coursed the liver and rectified qi primarily and, secondarily, supplemented qi and fortified the spleen, the patient may report temporary feelings of wellness, but the chief complaint of strangury is unlikely to improve. Especially if the modality were an internally administered formula, the use of sweet, warm spleen-supplementing agents would likely make a damp-heat pattern even worse.

5. Assess the response to treatment and respond appropriately. If the treatment has been correctly chosen and administered, the patient may report a good outcome. On the other hand, if there is no improvement or the condition has worsened, the clinician needs to review the treatment plan. Has the course been sufficient for a good effect? If positive results are expected after the initial course of care, does the treatment meet the goals set in the treatment methods? Have correct treatment methods been chosen for the pattern or patterns identified and the disease diagnosed? Do the diagnostic data warrant the disease diagnosed and the patterns identified? Make necessary changes to any part of the process, treat again, and review the results. This process is repeated until either the treatment goals of the patient have been met, the patient’s condition markedly changes, or the patient is no longer improving.