onsdag 20 april 2011

The skilful doctor

A saying by Zhang Zhongjing:
"The skilful doctor knows by observation, the mediocre doctor by interrogation, the ordinary doctor by palpation."

Zhang Zhongjing wrote the Shang Han Lun, the Treatise on Cold Disorders during the Han dynasty, 200 AD. The book is one of the Chinese medical classics. Zhang himself is known for his virtous life and his passion for becoming ever more skilled at Chinese medicine so that he could serve his patients better. In the Preface to the Shang Han Lun, he exhorts his contemporary doctors to work harder, saying that many of them are criminally lazy in their work 1800 years ago.

Observing (wang zhen) is the highly trained and precise method of looking at a patient to see their health. The more skilled a doctor becomes over the years, the more he or she sees within seconds of meeting a patient, or seeing a shift in a patient since last time. This is trained (like I talked about in a previous post about airports) and trained and trained. This blends with the skill called Tingjin, or Listening Energy, of the Internal Martial Arts of Baguazhang, Taiji, and Xingyi, but in chinese medical practice it inhabits the middle ground between martial skills and the tingjin that a Daoist adept would use to read much more in a person than that which is visible.

Interrogation is usually a little more mildly called Asking (wen zhen) when translated. Here, the doctor asks questions that elicit specific views into the patients health. There is a youtube clip of Peter Deadman, a well-known acupuncturist, talking about seeing one of his teachers, a laoyisheng, a senior doctor, diagnose patients. He would usually ask them one, maybe two questions while taking their pulse, then treat with a very small number of needles and get an incredible effect. But that doctor had been actively training and practicing his skills for 40 years.

Palpation, or touching, (qie zhen), covers both taking the pulse and sometimes touching and diagnosing a patient´s body, organs and skin. The pulse is a tool that the doctor uses to verify information already gained through looking and asking. This later transfers into the ability to feel points through touch, a skill that is getting more and more lost in acupuncture today, as it depends on the doctor or practitioner having good, stable qigong-skills, and these are rarely taught nor emphasized today. Acupoints move, both sideways and in depth, so knowing only a physical placement - ”In the center of the flesh between the 1st and 2nd metacarpal bones, slightly closer to the 2nd metacarpal bone. If the transverse crease of the interphalangeal joint of the thumb of one hand is lined up with the margin of the web between the thumb and the index fingers of the other hand, the point is where the tip of the thumb touches” - for Large Intestine 4, Hegu, placed in the middle of what is called Hukou or the Tiger´s Mouth in qigong and the Internal Martial Arts is not enough. Hegu is a point that has been quite popularized and misunderstood in the West. Knowing the language for where it is in physiological terms doesn´t mean the practitioner will feel where the point actually is and truly activate it with a needle.

With years of training and clinical practice, a skilled doctor picks up most of the information with the trained skill of a actively looking at the patient. Then this is verified by specific questions, tounge, and verified yet again in depth by carefully taking the pulse. All are techniques aimed at getting a diagnostic view of the organic system and organic change that is a living, breathing, human being.