Diagnosing: The Clinic Versus The Textbook

As I am "aging" in my practice of Chinese Medicine, I am always looking for ways to improve my clinical outcomes—and adhere to what I was taught about our medicine: one will always be a student of Traditional Chinese Medicine. That's an upside for me, as learning ways to more effectively and efficiently treat my patients is what inspires me.

With learning in mind, I recently took Sharon Weizenbaum's online seminar entitled, "Clarifying Diagnosis." I researched the seminar and figured that at my eight years into practice it would be a great time to have a refresher on my diagnostic skills. Sharon's teachings—as many of you know—are deep and profound and enlightening. She approaches Chinese Medicine much like a romantic detective: looking under every rock to find signs and symptoms, properly categorizing them all the while staying rooted in the spirit of our medicine. I'd like to imagine I do the same in my clinic day in and day out. However, her teachings have reminded me that at times—I can fall into the pattern of, as Sharon puts it, "jumping to conclusions."

For example—is heat at night always a yin deficiency? Are cold hands and feet always a yang deficiency? As I was reminded—no, not always.

What we see in the clinic, doesn't always line up with what we learned from the textbook. As practitioners—our most important job is to look at the symptoms and ask, "why?" Why is this patient experiencing heat at night? What is the root of this condition? What are the other symptoms that are in line with my diagnosis? Do the tongue and pulse make sense? Am I looking to the pulse as confirmation of my diagnosis or am I using it as a way to explain my diagnosis? For me, the pondering of these questions is imperative to the practice of Chinese Medicine.

To continuously ask the question, "why?" when we see a symptom will keep us from "jumping to conclusions" and quickly deciding a patient has, say, "kidney yin deficiency" or "liver qi stagnation." When we ask the "why" behind the symptom—we might for example realize that the heat at night is just heat not being able to descend and that could be due to excess or deficiency or a little of both. Discernment, as Sharon reminded me, is key. Our diagnoses should be more focused on the right relationships of qi, yin and yang and on what we deem is causing the presenting pathology. Of course I knew that, of course I've heard that hundreds of times over the course of my study. But, it's really refreshing to be reminded once in a while.

One of the things that Sharon stated that really got me thinking was when she discussed Polycystic Ovarian Syndrome (PCOS)—and how clinically she mainly sees cases of PCOS caused by blood stagnation. She points out that we are taught in school that PCOS is typically the result of phlegm-dampness. Right, we were taught: cysts=damp phlegm accumulation. OK, so your treatment plan is to resolve the dampness, and the cysts will go away. But, is that really what we always see clinically? I don't always see that. And, are these "cysts" really cysts? No. They are actually follicles that have not fully matured. They're not cysts (most of you know this but it bares repeating) and they're actually not filled with fluid. Rather they are developing follicles that for some reason or another were stopped in their tracks.

Is it that there's not enough yang energy to cause the expulsion of the egg from the follicle; is it a blockage of qi or blood causing the cessation of ovulation; is there heat drying things up and preventing this normal biological process from moving forward? And, if we don't know the right reason for the blockage of ovulation—we can't properly treat. If our main goal is just to restore ovulation (by, say, using electrical stimulation on xi gong xue or a strong herbal formula to induce ovulation), are we really getting to the root of the problem? And furthermore—if we "force" ovulation, are we causing the body to ovulate a poor quality egg? I think that answer is yes. Rather, when we focus on resolving the deeper issue—the result will be hormonal balance, optimal follicle-developing conditions and efficient ovulation.

Clinically, we see quite different presentations than what are taught to us via the textbook—and, it's always important to remember to step back, collect all the data and draw your diagnosis from all the presenting symptoms. It's important to remember that when a patient appears in your office they are probably NOT going to be textbook. Now, that would just be too easy. And, we all know that our medicine is simply beautiful, but it's not always simple.

As I mature as a practitioner, I am constantly intrigued by the medicine I practice. And, as I learn and study more—I am always reminded that each case is different and therefore my approach to each patient must be different. Yes, my point prescription may be the same but my intention may be different. I may use similar herbal formulas, but my dosages will vary. And, most importantly, my diagnosis must be focused on the root.

So, as I grow and learn from my clinical experience, I will always continue to look at symptoms and ask, "why?" until it leads me down the correct path of a clear diagnosis and hopefully very effective and timely treatment for my patients.