Editor's Note: Cogita is an group of European researchers who have explored the role of gut feelings in medical decision-making for primary care physicians.1 This article uses their published glossary of terms to explore the AOM diagnostic process.
Like primary care physicians (PCP), AOM practitioners see patients from all walks of life, seeking treatment for a wide variety of medical concerns. We see patients for both chronic and acute conditions and for preventive care. This broad range of clinical presentations can be diagnostically challenging. Exploring the variety of influences that contribute to treatment decisions can help us to balance our analytical and non-analytical reasoning, and to integrate formal education with the tacit knowledge of clinical experience.
Pattern recognition provides AOM practitioners with a useful starting point in the domain of non-analytical reasoning. The "patterns of disharmony of the zangfu, or organs" is one of many categories of pattern recognition, and the preferred category of TCM. Other categories include the five elements, the channels, the substances, and pathogenic factors.
Pattern Recognition
Five Element traditions are known for pattern recognition of the Five Elements. Treatment-blocks from the Worsley Five Element tradition can be said to provide pattern recognition of the acupuncture channels.2 Japanese meridian therapies also prioritize the channels. Each tradition has its preferred categories of pattern recognition.
Pattern recognition is an attractive method of diagnosis for common presentations, because it allows us to move quickly toward a treatment approach, especially with routine care. But pattern recognition does not always force us to explore the etiology of a disease process.
Although common etiologies are provided with patterns of disharmony,3 in a busy practice, we may be drawn to treat the branch without fully understanding its root cause. Clinical experience has taught us that when we identify liver yang rising, we can resolve our patient's headache by choosing from a handful of points. But to address the underlying cause of this common pattern, a more analytical approach is needed.
Pathophysiology
The Cogita group reports that diagnosis based on pathophysiology is seen as the highest level of diagnosis. In the field of AOM, it offers the greatest potential for restoring health rather than masking or repressing pathology. We know from basic theory that long-term yin deficiency and heat can lead to serious illness, including autoimmune disease and cancer. Drawing on a comprehensive knowledge of Oriental medical theory, we may choose to explore the interplay between the elements, the organs, and the channels as they work together to manage the body's resources and deal with pathogens.
As we shift our focus away from pattern recognition toward the body's natural mechanisms for healing, our point selections also shift. Incorporating channel physiology during this phase of the treatment planning process facilitates the selection of points based on the location of symptoms in the body.
Pathophysiology of the channel systems is an important area of AOM theory, where, like the organs, the channels are seen as anatomical structures with their own unique and independent physiological functions.4 The AOM specialty of waike or external medicine also calls for a detailed analysis of the disease process and the mechanisms available for restoring health.5
Contextual knowledge about a patient also supports the diagnostic process. The etiology of blood deficiency in a female patient with heavy menses as compared with an elderly patient with weak digestion is a good example of this. Although we confirm our diagnosis with pulse and tongue findings, the patient context limits what we look for.
The Constitutional Factor
Context is provided in a significant way when we diagnose a patient's constitutional type (or CF for Constitutional Factor). The CF corresponds with commonly observed patterns of disharmony, behaviors, strengths and weaknesses. The context of elemental type prioritizes treatment of the corresponding zangfu and channels when signs and symptoms support multiple patterns of disharmony.6
Borrowing from the field of clinical psychology, we might describe constitutional acupuncture is transpersonal acupuncture, since it addresses transcendent aspects of the human experience. From a Taoist perspective, the diagnosis of constitutional type prioritizes the lessons associated with one's destiny. Pattern diagnosis of a patient's CF is a nuanced skill. Although based on observable phenomena, an experienced practitioner may engage gut feelings, since the patient's behavior is strongly influenced by the patient-practitioner relationship.
In general, gut feelings play an important role in the presence of any uncertainty. We may act on a sense of alarm or a sense of reassurance when faced with incomplete or conflicting information. In medical problem solving, "close enough" may be especially acceptable with a heuristic approach. Here the practitioner is able to try an intervention and then see if it works, allowing the patient's response to confirm or challenge a diagnosis.
With heuristics, an important distinction can be made between acupuncture and other therapies. Acupuncture allows us to immediately observe the response to treatment by way of subtle changes to the patient's tongue, pulse, facial expressions, and what they report. In a clinical setting, an entire session may be spent interacting with a patient in this way, arriving at an effective treatment in a step-by-step fashion. The insurance industry recognizes this approach to acupuncture treatment, allowing reimbursement for time spent interacting with a patient.
Each AOM tradition is characterized by its treatment protocols and preferred categories of pattern identification. An exploration of the diagnostic process on a deeper level reveals the foundational theories that all of us share, supporting the interplay between the elements, the organs, and the channels as they work together to manage the body's resources and deal with pathogens.
Collaborating with practitioners of other traditions deepens our understanding of these basic principles and calls us to a broader view of the mechanisms available to us as clinicians. And from our PCP colleagues, we are called to the nuance of medical decision-making, from its most analytical to its most intuitive.
References
- Barais M, Hauswaldt J, et al. COGITA network has constructed a glossary of diagnostic reasoning terms. The European Journal of General Practice, 2017;23(1):53–56.
- Homan C. Understanding Channel Theory through the Clinical Application of Leamington Acupuncture. Meridians: The Journal of Acupuncture & Oriental Medicine, 2016;3(4), 5–9.
- Giovanni M. The Foundations of Chinese Medicine (2nd ed.). Philadelphia: Elsevier Press, 2005.
- Juyi W. Applied channel theory in Chinese medicine. Seattle: Eastland Press, 2008.
- Cecil-Sterman A. Advanced acupuncture: A clinic manual. New York: Classical Wellness Press, 2012.
- Hicks A. Five element constitutional acupuncture. Philadelphia: Elsevier Press, 2004.
