Utilize Chinese Medical Terminology

While some sources may relate acupuncture, medicinals, or formulas to Western diseases, the key texts emphasize Chinese medical actions—clearing heat or drying dampness, for example—and Chinese medical indications like lumbar soreness or headache rather than indications for any Western medical conditions.  To use Chinese medicine effectively, one must scrupulously stick to Chinese medical terms and concepts;  in diagnosis, this requires largely limiting oneself to data derived from the traditional Four Examinations.  The findings from these investigations lead directly to treatment methods which, in turn, correlate with the actions of acupoints, medicinals, and formulas.  Adhering to this methodology maximizes clarity, maintains the professional standard-of-care, and improves efficiency.

Identify the Chinese Medical Disease

Regardless of the Western medical diagnosis, the goal is to first pinpoint the main complaint, reframe it as a Chinese medical disease whenever possible, and identify the pattern that has resulted in the disease.  Many Western medical conditions will present with a wide variety of different types of symptoms;  endometriosis, for example, will often primarily manifest as dysmenorrhea, menorrhagia, or infertility.  In this example, if the patient’s main complaint is dysmenorrhea, the more experienced Chinese medical clinician might reframe the condition as either lesser or lower abdominal pain and then utilize data from the Four Examinations to differentiate the primary pattern which, according to Chinese anatomy and physiology, would logically result in the symptomatology. 

For pattern identification, Chinese medical theory should be the starting point.  Based on the statement of fact, “With flow, there is no pain; pain is caused by lack of flow”, one is able to deduce that, in our hypothetical example, the free flow of qi and blood in the abdomen is impaired.  Common causes are primary obstruction of qi and blood or secondary obstruction arising from cold or heat.  Liver qi depression and binding or qi stagnation and blood stasis are commonly seen primary causes;  typical secondary causes include either vacuity or repletion cold or damp-heat or toxic heat that obstruct and block the normal flow of qi and blood.  Differentiation of the correct pattern relies on skillful use of the Four Examinations to confirm or deny diagnostic hypotheses.

Dynamically Collect Data to Differentiate Patterns

In our training, the Four Examinations are usually taught separately, and every examination is further broken down into constituent parts.  While this might be necessary in the classroom, clinical diagnosis should smoothly integrate all components of diagnosis (四诊合参 si zhen he can “correlate all of the Four Examinations”). In China, skillful diagnosis is usually learned through mentorship from veteran clinicians, but many Westerner practitioners will not have the opportunity to shadow clinicians with extensive experience.

To illustrate the difference between the cohesive process utilized by the more experienced clinicians and the type of less integrated method often used by novice practitioners, we can consider a hypothetical case. The patient, a 62-year-old male diagnosed with rheumatoid arthritis, sees two different practitioners of Chinese medicine for a consultation.  The first one is a practitioner who graduated about 5 years ago from an accredited American school of traditional Asian medicine. The second practitioner was born in China, received a degree in the United States over twenty years ago, and continues her studies with post-graduate work in Guangzhou.

Examination by First Practitioner

For the initial visit, the practitioner fills out forms similar to those he has seen in mainstream medical clinics.  In the treatment space, the practitioner skips the inspection and listening and smelling examinations to begin the inquiry part of the Four Examinations.  The initial interview is lengthy and exhaustive—including all of the Ten Questions as taught in school—and covers many areas of his health ranging from what he dreams about to the infectious diseases of his childhood.  When the comprehensive interview is finished, the practitioner palpates the pulse but is unsure of the accuracy of his findings.  He thanks the patient and asks him to schedule for acupuncture.

Upon reviewing the case, the practitioner encounters what some have termed “the paralysis of analysis”.  In other words, his exhaustive inquiry has actually led to a glut of information, making it difficult to accurately isolate primary pathologies and craft a streamlined treatment plan.  He considers the Western medical diagnosis of RA and several patterns identified but does not include treatment methods in his charting.  His point protocol includes empirical points for joint pain, along with points added for the spleen qi vacuity, liver qi depression, and damp-heat in the lower burner, but in no specific order. Based on the observation that the patient seems “shen disturbed”, he adds points to quiet the spirit.

Examination by Second Practitioner

The next practitioner also requests that the patient complete first office call documents, but her bespoke intake forms explore the patient’s subjective health experiences more than any formal medical history.  When she brings the patient into the treatment area, the practitioner utilizes her mentor training from China which emphasizes the inspection examination.  She observes that the patient is obese and presents a tai yang body type (i.e., abdominal and lower body obesity), directly confirming a phlegm-damp obstruction pattern.  Based on the statement “the spleen is the source of the engenderment of phlegm [while the lung is merely the receptacle]”, the practitioner hypothesizes that the patient may present spleen qi vacuity. She observes that he is easily winded and asks about and confirms fatigue, corroborating her diagnostic hypothesis of spleen qi vacuity.

The basic TCM model for impediment disease—marked by joint pain and inhibited bending and stretching—is that the decline of qi and blood in the channels and network vessels due to aging has allowed wind, cold, and damp evils to invade and obstruct the joints.  The spleen qi vacuity pattern, expected with aging and confirmed by signs and symptoms has led to splenic failure to engender qi and blood.  Furthermore, inquiry reveals a lengthy history of hunting, fishing, and hiking in cold, damp weather, explaining how external evils invaded and lodged in vacuous channels and network vessels.

The pale tongue with white fur corroborates qi vacuity with dampness, while a sunken, tight pulse indicates qi stagnation in the channels owing to cold and dampness.  Palpation finds cold joints generally and redness of the joints of the hands specifically complicated by phlegm nodules and harder blood stasis lumps.  When asked about his arthritis, the patient reports using heat on his shoulders and knees, while he resorts to ice on his fingers and hands when they become inflamed.  Applying heat and cold to the painful areas, however, only provides temporary relief, and he notes that the hand joints have become increasingly deformed.

Rather than the Western diagnosis, this practitioner will build her treatment plan around the Chinese medical disease of impediment.  Based on the palpatory examination confirmed by data from the other examinations, the primary evils are cold and dampness, complicated by phlegm-stasis and occasional transformative heat.  The doctor uses the treatment methods, in order of their priority, of dispelling wind-cold-damp and disinhibiting joints, transforming phlegm and dissipating nodulations, quickening blood and transforming stasis, and resolving depression and clearing heat. These methods are supported by supplementing qi and blood to treat the root, preventing further invasion by any external evils.

Build Treatments on Solid Diagnostic Foundations

It has been said that the Chinese medical process can be likened to a snake passing through a hollow bamboo tube.  The mouth of the tube represents the diagnosis, and it determines all of the subsequent steps, from selection of the treatment methods to the choice of formulas and points, that will be used.  Without careful diagnosis, good clinical outcomes can elude us.

Great doctors are great diagnosticians.  One can only master Chinese medical diagnosis by remaining true to the intrinsic ideas and language developed by generations of doctors over millennia.  Once there is a firm foundation of theory and terminology, the secret lies in years of earnest and mindful practice to facilitate the creation of treatment plans which can restore harmony and alleviate the suffering of our patients.